FRESENIUS TOTAL HEALTH (HMO SNP)

Transcription

1 FRESENIUS TOTAL HEALTH (HMO SNP) 08 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN H60; H6; H4 7447, V This formulary was updated on 0/0/07. For more recent information or other questions, please contact Fresenius Total Health Member Services at TTY 7. Hours: February 5 - September 0, 8 am - pm ET, Monday - Friday. October - February 4, 8 am to pm ET, 7 days a week, or visit Y06_HMO_Formulary_0 CMS Accepted 08//07 Version

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Fresenius Health Plans. When it refers to plan or our plan, it means Fresenius Total Health (HMO SNP). This document includes list of the drugs (formulary) for our plan which is current as of 0/0/07. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 09, and from time to time during the year. What is the Fresenius Total Health Formulary? A formulary is a list of covered drugs selected by Fresenius Total Health in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Fresenius Total Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Fresenius Total Health network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 08 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 08 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60-days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 0/0/07. To get updated information about the drugs covered by Fresenius Total Health, please contact us. Our contact information appears on the front and back cover pages. Every month, we update our printed formulary with a monthly addendum. Please visit our website at or contact Member Services for more information. ii

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 98. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Fresenius Total Health covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Fresenius Total Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Fresenius Total Health before you fill your prescriptions. If you don t get approval, Fresenius Total Health may not cover the drug. Quantity Limits: For certain drugs, Fresenius Total Health limits the amount of the drug that Fresenius Total Health will cover. For example, Fresenius Total Health provides 0 tablets per prescription for Digoxin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Fresenius Total Health requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition Fresenius Total Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Fresenius Total Health will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Fresenius Total Health to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to Fresenius Total Health s formulary? on page iv for information about how to request an exception. iii

4 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Fresenius Total Health does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Fresenius Total Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Fresenius Total Health You can ask Fresenius Total Health to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to Fresenius Total Health s Formulary? You can ask Fresenius Total Health to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Fresenius Total Health limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Fresenius Total Health will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tier, or utilization restriction exception. When you request a formulary, tier, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. iv

5 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0 day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0 day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 98 day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Members who have a change in level of care (setting) will be allowed up to a one-time 0 day transition supply per drug. For example, members who: Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short term planning taken into account (often under 8 hours). Are discharged from a hospital to a home. End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary. End a long-term care facility stay and return to the community. If a member has more than one change in level of care in a month, the pharmacy will have to call our Plan to request an extension of the transition policy. For more information For more detailed information about your Fresenius Health Plans prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Fresenius Health Plans please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit v

6 Fresenius Total Health s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Fresenius Total Health. If you have trouble finding your drug in the list, turn to the Index that begins on page 98. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin). The information in the Requirements/Limits column tells you if Fresenius Total Health has any special requirements for coverage of your drug. List of Abbreviations B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. QL: Quantity Limit. For certain drugs, Fresenius Total Health limits the amount of the drug that Fresenius Total Health will cover. For example, Fresenius Total Health provides twelve tablets per prescription for Sumatriptan Succinate. This may be in addition to a standard one month or three month supply. ST: Step Therapy. In some cases, Fresenius Total Health requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Fresenius Total Health may not cover drug B unless you try Drug A first. If Drug A does not work for you, Fresenius Total Health will then cover Drug B. PA: Prior Authorization. Fresenius Total Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Fresenius Total Health before you fill your prescriptions. If you don t get approval, Fresenius Total Health may not cover the drug. Standard Retail Cost-Sharing TIER ONE-MONTH SUPPLY THREE-MONTH SUPPLY Tier (Preferred Generic) $0 $0 Tier (Generic) 5% of the cost 5% of the cost Tier (Preferred Brand) 5% of the cost 5% of the cost Tier 4 (Non-Preferred Brand) 5% of the cost 5% of the cost Tier 5 (Specialty Tier) 5% of the cost Not Offered vi

7 This information could change Drug Name Drug Tier Requirements/Limits Analgesics Analgesics acetaminophen-codeine oral solution 0- mg/5 ml acetaminophen-codeine oral tablet 00-5 mg, 00-0 mg, mg ASCOMP WITH CODEINE ORAL CAPSULE MG BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE MG butalbital-acetaminop-caf-cod oral capsule mg PA PA PA butalbital-acetaminophen oral tablet 50-5 mg PA butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg carisoprodol-asa-codeine oral tablet mg PA PA PA PA carisoprodol-aspirin oral tablet 00-5 mg PA hydrocodone-acetaminophen oral tablet 0-5 mg,.5-5 mg, 5-5 mg, mg hydrocodone-ibuprofen oral tablet 0-00 mg, 5-00 mg, mg ibuprofen-oxycodone oral tablet mg oxycodone-acetaminophen oral tablet 0-5 mg,.5-5 mg, 5-5 mg, mg oxycodone-aspirin oral tablet mg pentazocine-naloxone oral tablet mg PA tramadol-acetaminophen oral tablet mg

8 Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 00 mg, 00 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release 4 hr 00 mg diclofenac sodium oral tablet,delayed release (dr/ec) 5 mg, 50 mg, 75 mg diclofenac sodium topical gel % diclofenac sodium topical gel % 5 diflunisal oral tablet 500 mg etodolac oral capsule 00 mg, 00 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 4 hr 400 mg, 500 mg, 600 mg flurbiprofen oral tablet 00 mg, 50 mg ibuprofen oral suspension 00 mg/5 ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 5 mg, 50 mg PA indomethacin oral capsule, extended release 75 mg ketoprofen oral capsule 50 mg, 75 mg PA ketorolac oral tablet 0 mg PA; QL (0 EA per 0 days) meclofenamate oral capsule 00 mg, 50 mg meloxicam oral tablet 5 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 5 mg/5 ml naproxen oral tablet 50 mg, 75 mg, 500 mg naproxen oral tablet,delayed release (dr/ec) 75 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 mg piroxicam oral capsule 0 mg, 0 mg sulindac oral tablet 50 mg, 00 mg

9 ZORVOLEX ORAL CAPSULE 8 MG, 5 MG ST Opioid Analgesics, Long-Acting fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 7.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour QL (0 EA per 0 days) methadone oral solution 0 mg/5 ml QL (00 ML per 0 days) methadone oral solution 5 mg/5 ml QL (400 ML per 0 days) methadone oral tablet 0 mg QL (40 EA per 0 days) methadone oral tablet 5 mg QL (80 EA per 0 days) morphine oral tablet extended release 00 mg, 5 mg, 00 mg, 0 mg, 60 mg oxycodone oral tablet,oral only,ext.rel. hr 0 mg, 5 mg, 0 mg, 0 mg, 40 mg, 60 mg, 80 mg Opioid Analgesics, Short-Acting butorphanol tartrate injection solution mg/ml, mg/ml butorphanol tartrate nasal spray,non-aerosol 0 mg/ml DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, MG/ML fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone (pf) injection solution 0 (mg/ml) (5 ml), 0 mg/ml hydromorphone injection syringe mg/ml QL (60 EA per 0 days) PA; QL (60 EA per 0 days) QL (5 ML per 0 days) B/D PA; QL (0 EA per 0 days) hydromorphone oral tablet mg, 4 mg, 8 mg QL (0 EA per 0 days) LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY, 400 MCG/SPRAY PA; QL (600 EA per 0 days) PA; QL (50 EA per 0 days) meperidine oral solution 50 mg/5 ml PA; QL (900 ML per 0 days) meperidine oral tablet 00 mg, 50 mg PA; QL (80 EA per 0 days) morphine oral tablet 5 mg, 0 mg QL (0 EA per 0 days) nalbuphine injection solution 0 mg/ml, 0 mg/ml B/D

10 oxycodone oral solution 5 mg/5 ml QL (5400 ML per 0 days) oxycodone oral tablet 0 mg, 5 mg, 0 mg, 0 mg, 5 mg QL (0 EA per 0 days) tramadol oral tablet 50 mg QL (40 EA per 0 days) Anesthetics Local Anesthetics lidocaine (pf) injection solution 0 mg/ml ( %), 5 mg/ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % PA; QL (90 EA per 0 days) lidocaine topical ointment 5 % lidocaine-prilocaine topical cream.5-.5 % B/D Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/ Anti-Craving acamprosate oral tablet,delayed release (dr/ec) mg disulfiram oral tablet 50 mg, 500 mg naltrexone oral tablet 50 mg Opioid Dependence Treatments buprenorphine hcl sublingual tablet mg, 8 mg buprenorphine-naloxone sublingual tablet -0.5 mg, 8- mg Opioid Reversal Agents naloxone injection solution 0.4 mg/ml naloxone injection syringe mg/ml Smoking Cessation Agents CHANTIX CONTINUING MONTH BOX ORAL TABLET MG QL (6 EA per 65 days) CHANTIX ORAL TABLET 0.5 MG, MG QL (6 EA per 65 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) QL (06 EA per 65 days) 4

11 NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 0 MG/ML Antibacterials Aminoglycosides amikacin injection solution 500 mg/ ml GENTAK OPHTHALMIC OINTMENT 0. % ( MG/GRAM) gentamicin ophthalmic drops 0. % gentamicin sulfate (pf) intravenous solution 00 mg/0 ml gentamicin topical cream 0. % gentamicin topical ointment 0. % neomycin oral tablet 500 mg paromomycin oral capsule 50 mg streptomycin intramuscular recon soln gram TOBRADEX OPHTHALMIC OINTMENT % tobramycin in 0.5 % nacl inhalation solution for nebulization 00 mg/5 ml tobramycin ophthalmic drops 0. % tobramycin sulfate injection solution 0 mg/ml, 40 mg/ml tobramycin-dexamethasone ophthalmic drops,suspension % Antibacterials, Other acetic acid otic solution % bacitracin ophthalmic ointment 500 unit/gram bacitracin-polymyxin b ophthalmic ointment 500-0,000 unit/gram BACTROBAN NASAL NASAL OINTMENT % chloramphenicol sod succinate intravenous recon soln gram B/D 4 5

12 clindamycin hcl oral capsule 50 mg, 00 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 00 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml CLINDAMYCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML clindamycin phosphate injection solution 50 (mg/ml) (6 ml), 50 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin phosphate vaginal cream % clindamycin-benzoyl peroxide topical gel. %( % base) -5 % colistin (colistimethate na) injection recon soln 50 mg daptomycin intravenous recon soln 500 mg lincomycin injection solution 00 mg/ml linezolid intravenous parenteral solution 600 mg/00 ml linezolid oral suspension for reconstitution 00 mg/5 ml linezolid oral tablet 600 mg methenamine hippurate oral tablet gram metronidazole in nacl (iso-os) intravenous piggyback 500 mg/00 ml metronidazole oral capsule 75 mg metronidazole oral tablet 50 mg, 500 mg metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, % metronidazole topical lotion 0.75 % 6

13 metronidazole vaginal gel 0.75 % mupirocin topical ointment % neomycin-bacitracin-poly-hc ophthalmic ointment ,000 mg-unit/g-% neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unit-unit/g neomycin-polymyxin b gu irrigation solution 40 mg-00,000 unit/ml neomycin-polymyxin b-dexameth ophthalmic drops,suspension.5mg/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic ointment.5 mg/g-0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic drops.75 mg-0,000 unit-0.05mg/ml neomycin-polymyxin-hc ophthalmic drops,suspension.5-0,000-0 mg-unit-mg/ml nitrofurantoin macrocrystal oral capsule 00 mg, 5 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 00 mg polymyxin b sulfate injection recon soln 500,000 unit polymyxin b sulf-trimethoprim ophthalmic drops 0,000 unit- mg/ml SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 mg vancomycin intravenous recon soln,000 mg, 0 gram, 500 mg PA; QL (60 EA per 65 days) PA; QL (80 EA per 65 days) B/D vancomycin oral capsule 5 mg, 50 mg 4 PA XIFAXAN ORAL TABLET 00 MG 4 PA; QL (9 EA per days) XIFAXAN ORAL TABLET 550 MG ; QL (60 EA per 0 days) Beta-Lactam, Cephalosporins cefaclor oral capsule 50 mg, 500 mg cefaclor oral tablet extended release hr 500 mg cefadroxil oral capsule 500 mg 7

14 cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet gram cefazolin injection recon soln gram cefdinir oral capsule 00 mg cefdinir oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefepime injection recon soln gram, gram cefotaxime injection recon soln gram, gram, 500 mg cefoxitin intravenous recon soln gram, 0 gram, gram cefpodoxime oral suspension for reconstitution 00 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 00 mg, 00 mg cefprozil oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefprozil oral tablet 50 mg, 500 mg ceftazidime injection recon soln gram, gram, 6 gram ceftriaxone injection recon soln 0 gram, 50 mg, 500 mg ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium intravenous recon soln.5 gram cephalexin oral capsule 50 mg, 500 mg cephalexin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cephalexin oral tablet 50 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG 4 TAZICEF INJECTION RECON SOLN GRAM, GRAM, 6 GRAM TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG 4 PA 8

15 Beta-Lactam, Other aztreonam injection recon soln gram DORIBAX INTRAVENOUS RECON SOLN 500 MG imipenem-cilastatin intravenous recon soln 50 mg, 500 mg 4 PA PA INVANZ INJECTION RECON SOLN GRAM 4 PA meropenem intravenous recon soln 500 mg Beta-Lactam, Penicillins amoxicillin oral capsule 50 mg, 500 mg amoxicillin oral suspension for reconstitution 5 mg/5 ml, 00 mg/5 ml, 50 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 5 mg, 50 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet 50-5 mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release hr, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 50 mg, 500 mg ampicillin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml ampicillin sodium injection recon soln gram, 0 gram, 5 mg ampicillin-sulbactam injection recon soln.5 gram, 5 gram, gram BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50 mg, 500 mg nafcillin injection recon soln gram 4 9

16 penicillin g procaine intramuscular syringe. million unit/ ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 5 mg/5 ml, 50 mg/5 ml penicillin v potassium oral tablet 50 mg, 500 mg piperacillin-tazobactam intravenous recon soln.75 gram, 4.5 gram, 40.5 gram Macrolides azithromycin intravenous recon soln 500 mg azithromycin oral packet gram azithromycin oral suspension for reconstitution 00 mg/5 ml, 00 mg/5 ml azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 500 mg ( pack), 600 mg clarithromycin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml clarithromycin oral tablet 50 mg, 500 mg clarithromycin oral tablet extended release 4 hr 500 mg ERY PADS TOPICAL SWAB % ERYTHROCIN (AS STEARATE) ORAL TABLET 50 MG ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 00 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin ophthalmic ointment 5 mg/gram (0.5 %) erythromycin oral tablet 50 mg, 500 mg erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % Quinolones 4 0

17 AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK 400 MG/50 ML ciprofloxacin (mixture) oral tablet, er multiphase 4 hr,000 mg, 500 mg ciprofloxacin hcl ophthalmic drops 0. % ciprofloxacin hcl oral tablet 00 mg ciprofloxacin hcl oral tablet 50 mg, 500 mg, 750 mg ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/00 ml, 750 mg/50 ml levofloxacin intravenous solution 5 mg/ml levofloxacin oral solution 50 mg/0 ml levofloxacin oral tablet 50 mg, 500 mg levofloxacin oral tablet 750 mg MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % moxifloxacin oral tablet 400 mg moxifloxacin-sod.ace,sul-water intravenous piggyback 400 mg/50 ml ofloxacin ophthalmic drops 0. % ofloxacin oral tablet 00 mg, 400 mg VIGAMOX OPHTHALMIC DROPS 0.5 % Sulfonamides silver sulfadiazine topical cream % SSD TOPICAL CREAM % sulfacetamide sodium (acne) topical suspension 0 % sulfacetamide sodium ophthalmic drops 0 % sulfacetamide sodium ophthalmic ointment 0 % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml 4

18 sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg Tetracyclines demeclocycline oral tablet 50 mg, 00 mg DOXY-00 INTRAVENOUS RECON SOLN 00 MG doxycycline hyclate oral capsule 00 mg, 50 mg doxycycline hyclate oral tablet 00 mg, 0 mg doxycycline monohydrate oral capsule 00 mg, 50 mg doxycycline monohydrate oral tablet 00 mg, 50 mg, 50 mg, 75 mg minocycline oral capsule 00 mg, 50 mg, 75 mg minocycline oral tablet 00 mg, 50 mg, 75 mg MORGIDOX ORAL CAPSULE 50 MG Anticonvulsants Anticonvulsants, Other BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG levetiracetam in nacl (iso-os) intravenous piggyback,000 mg/00 ml,,500 mg/00 ml, 500 mg/00 ml levetiracetam intravenous solution 500 mg/5 ml levetiracetam oral solution 00 mg/ml levetiracetam oral tablet,000 mg, 50 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 4 hr 500 mg, 750 mg ROWEEPRA ORAL TABLET,000 MG, 500 MG, 750 MG

19 SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 50 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 00 MG 4 ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5 ml LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML zonisamide oral capsule 00 mg, 5 mg, 50 mg Gamma-Aminobutyric Acid (Gaba) Augmenting Agents DIASTAT ACUDIAL RECTAL KIT MG DIASTAT ACUDIAL RECTAL KIT MG 4 ST; QL (60 EA per 0 days) 5 ST; QL (0 EA per 0 days) 4 QL (40 EA per 0 days) 4 QL (0 EA per 0 days) DIASTAT RECTAL KIT.5 MG 4 QL (5 EA per 0 days) divalproex oral capsule, delayed rel sprinkle 5 mg divalproex oral tablet extended release 4 hr 50 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 5 mg, 50 mg, 500 mg gabapentin oral capsule 00 mg, 00 mg, 400 mg gabapentin oral solution 50 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET MG, 6 MG 4 ONFI ORAL SUSPENSION.5 MG/ML 4 PA; QL (480 ML per 0 days) ONFI ORAL TABLET 0 MG 4 PA; QL (60 EA per 0 days) ONFI ORAL TABLET 0 MG ; QL (60 EA per 0 days) phenobarbital oral elixir 0 mg/5 ml (4 mg/ml) PA phenobarbital oral tablet 00 mg, 5 mg, 6. mg, 0 mg,.4 mg, 60 mg, 64.8 mg, 97. mg PA

20 primidone oral tablet 50 mg, 50 mg SABRIL ORAL POWDER IN PACKET 500 MG 4 PA SABRIL ORAL TABLET 500 MG 4 PA; QL (80 EA per 0 days) tiagabine oral tablet mg, 4 mg valproate sodium intravenous solution 500 mg/5 ml (00 mg/ml) valproic acid (as sodium salt) oral solution 50 mg/5 ml valproic acid oral capsule 50 mg Glutamate Reducing Agents felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML 4 ST FYCOMPA ORAL TABLET 0 MG, MG, MG, 4 MG, 6 MG, 8 MG lamotrigine oral tablet 00 mg, 50 mg, 00 mg, 5 mg lamotrigine oral tablet extended release 4hr 00 mg, 00 mg, 5 mg, 50 mg, 00 mg, 50 mg lamotrigine oral tablet, chewable dispersible 5 mg, 5 mg topiramate oral capsule, sprinkle 5 mg, 5 mg topiramate oral tablet 00 mg, 00 mg, 5 mg, 50 mg Sodium Channel Agents 4 ST; QL (0 EA per 0 days) APTIOM ORAL TABLET 00 MG 4 ST; QL (0 EA per 0 days) APTIOM ORAL TABLET 400 MG, 800 MG 5 ST; QL (0 EA per 0 days) APTIOM ORAL TABLET 600 MG 4 ST; QL (60 EA per 0 days) BANZEL ORAL SUSPENSION 40 MG/ML ; QL (400 ML per 0 days) BANZEL ORAL TABLET 00 MG 4 PA; QL (40 EA per 0 days) BANZEL ORAL TABLET 400 MG ; QL (40 EA per 0 days) carbamazepine oral capsule, er multiphase hr 00 mg, 00 mg, 00 mg carbamazepine oral suspension 00 mg/5 ml 4

21 carbamazepine oral tablet 00 mg carbamazepine oral tablet extended release hr 00 mg, 00 mg, 400 mg carbamazepine oral tablet,chewable 00 mg DILANTIN ORAL CAPSULE 0 MG 4 EPITOL ORAL TABLET 00 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG, 00 MG, 00 MG fosphenytoin injection solution 00 mg pe/ ml oxcarbazepine oral suspension 00 mg/5 ml (60 mg/ml) oxcarbazepine oral tablet 50 mg, 00 mg, 600 mg PEGANONE ORAL TABLET 50 MG 4 PHENYTEK ORAL CAPSULE 00 MG, 00 MG phenytoin oral suspension 5 mg/5 ml phenytoin oral tablet,chewable 50 mg phenytoin sodium extended oral capsule 00 mg, 00 mg, 00 mg phenytoin sodium intravenous solution 50 mg/ml VIMPAT INTRAVENOUS SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 0 MG/ML 5 ST; QL (00 ML per 0 days) VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG Antidementia Agents Antidementia Agents, Other ergoloid oral tablet mg PA Cholinesterase Inhibitors donepezil oral tablet 0 mg, mg, 5 mg donepezil oral tablet,disintegrating 0 mg, 5 mg rivastigmine tartrate oral capsule.5 mg, mg, 4.5 mg, 6 mg ST; QL (60 EA per 0 days) 5

22 rivastigmine transdermal patch 4 hour. mg/4 hour, 4.6 mg/4 hr, 9.5 mg/4 hr N-Methyl-D-Aspartate (NMDA) Receptor Antagonist memantine oral tablet 0 mg, 5 mg memantine oral tablets,dose pack 5-0 mg NAMENDA XR ORAL CAP,SPRINKLE,ER 4HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 4HR 4 MG, MG, 8 MG, 7 MG Antidepressants Antidepressants, Other bupropion hcl (smoking deter) oral tablet extended release hr 50 mg bupropion hcl oral tablet 00 mg, 75 mg bupropion hcl oral tablet extended release hr 00 mg, 50 mg, 00 mg bupropion hcl oral tablet extended release 4 hr 50 mg, 00 mg FORFIVO XL ORAL TABLET EXTENDED RELEASE 4 HR 450 MG mirtazapine oral tablet 5 mg, 0 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 5 mg, 0 mg, 45 mg nefazodone oral tablet 00 mg, 50 mg, 00 mg, 50 mg, 50 mg perphenazine-amitriptyline oral tablet -0 mg, - 5 mg, 4-0 mg, 4-5 mg, 4-50 mg trazodone oral tablet 00 mg, 50 mg, 00 mg, 50 mg Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL PATCH 4 HOUR MG/4 HR, 6 MG/4 HR, 9 MG/4 HR MARPLAN ORAL TABLET 0 MG 4 phenelzine oral tablet 5 mg 4 ST 4 ST; QL (0 EA per 0 days) 4 PA 4 6

23 tranylcypromine oral tablet 0 mg SSRIs/ SNRIs citalopram oral solution 0 mg/5 ml citalopram oral tablet 0 mg, 0 mg, 40 mg desvenlafaxine succinate oral tablet extended release 4 hr 00 mg, 5 mg, 50 mg duloxetine oral capsule,delayed release(dr/ec) 0 mg, 0 mg, 60 mg escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 0 mg, 0 mg, 5 mg FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK 0 MG ()- 40 MG (6) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 0 MG, 0 MG, 40 MG, 80 MG fluoxetine oral capsule 0 mg, 0 mg, 40 mg fluoxetine oral capsule,delayed release(dr/ec) 90 mg fluoxetine oral solution 0 mg/5 ml (4 mg/ml) fluoxetine oral tablet 0 mg, 0 mg fluvoxamine oral tablet 00 mg, 5 mg, 50 mg maprotiline oral tablet 5 mg, 50 mg, 75 mg paroxetine hcl oral tablet 0 mg, 0 mg, 0 mg, 40 mg paroxetine hcl oral tablet extended release 4 hr.5 mg, 5 mg, 7.5 mg PAXIL ORAL SUSPENSION 0 MG/5 ML 4 sertraline oral concentrate 0 mg/ml sertraline oral tablet 00 mg, 5 mg, 50 mg TRINTELLIX ORAL TABLET 0 MG, 0 MG, 5 MG venlafaxine oral capsule,extended release 4hr 50 mg, 7.5 mg, 75 mg 4 ST 4 ST 4 ST 7

24 venlafaxine oral tablet 00 mg, 5 mg, 7.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 4hr 50 mg, 5 mg, 7.5 mg, 75 mg VIIBRYD ORAL TABLET 0 MG, 0 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 0 MG () Tricyclics amitriptyline oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 5 mg, 50 mg 4 ST 4 ST PA clomipramine oral capsule 5 mg, 50 mg, 75 mg PA desipramine oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg doxepin oral capsule 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg PA doxepin oral concentrate 0 mg/ml PA imipramine hcl oral tablet 0 mg, 5 mg, 50 mg PA imipramine pamoate oral capsule 00 mg, 5 mg, 50 mg, 75 mg nortriptyline oral capsule 0 mg, 5 mg, 50 mg, 75 mg nortriptyline oral solution 0 mg/5 ml protriptyline oral tablet 0 mg, 5 mg PA trimipramine oral capsule 00 mg, 5 mg, 50 mg PA Antiemetics Antiemetics, Other chlorpromazine injection solution 5 mg/ml chlorpromazine oral tablet 0 mg, 00 mg, 00 mg, 5 mg, 50 mg COMPRO RECTAL SUPPOSITORY 5 MG diphenhydramine hcl injection solution 50 mg/ml PA meclizine oral tablet.5 mg, 5 mg 8

25 metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 0 mg, 5 mg perphenazine oral tablet 6 mg, mg, 4 mg, 8 mg PHENADOZ RECTAL SUPPOSITORY.5 MG PA prochlorperazine edisylate injection solution 0 mg/ ml (5 mg/ml) prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 5 mg promethazine oral syrup 6.5 mg/5 ml PA promethazine oral tablet.5 mg, 5 mg, 50 mg PA promethazine rectal suppository.5 mg, 5 mg PA PROMETHEGAN RECTAL SUPPOSITORY 5 MG, 50 MG TRANSDERM-SCOP TRANSDERMAL PATCH DAY.5 MG ( MG OVER DAYS) PA trimethobenzamide oral capsule 00 mg PA Emetogenic Therapy Adjuncts aprepitant oral capsule 5 mg, 40 mg, 80 mg B/D aprepitant oral capsule,dose pack 5 mg ()- 80 mg () 4 B/D dronabinol oral capsule 0 mg,.5 mg, 5 mg B/D EMEND ORAL SUSPENSION FOR RECONSTITUTION 5 MG (5 MG/ ML FINAL CONC.) 4 B/D granisetron (pf) intravenous solution 00 mcg/ml B/D granisetron hcl intravenous solution mg/ml, mg/ml ( ml) B/D granisetron hcl oral tablet mg B/D ondansetron hcl (pf) injection solution 4 mg/ ml ondansetron hcl (pf) injection syringe 4 mg/ ml ondansetron hcl oral solution 4 mg/5 ml B/D ondansetron hcl oral tablet 4 mg B/D; QL (5 EA per 0 days) ondansetron hcl oral tablet 4 mg, 8 mg B/D 9

26 ondansetron oral tablet,disintegrating 4 mg, 8 mg B/D Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG B/D 4 B/D amphotericin b injection recon soln 50 mg B/D CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % clotrimazole mucous membrane troche 0 mg clotrimazole topical cream % clotrimazole topical solution % econazole topical cream % ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 00 MG, 50 MG fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 400 mg/00 ml fluconazole oral suspension for reconstitution 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 00 mg, 50 mg flucytosine oral capsule 50 mg, 500 mg griseofulvin microsize oral suspension 5 mg/5 ml itraconazole oral capsule 00 mg ketoconazole oral tablet 00 mg ketoconazole topical cream % ketoconazole topical shampoo % MENTAX TOPICAL CREAM % 4 4 PA 0

27 MYCAMINE INTRAVENOUS RECON SOLN 00 MG MYCAMINE INTRAVENOUS RECON SOLN 50 MG NOXAFIL ORAL SUSPENSION 00 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG NYAMYC TOPICAL POWDER 00,000 UNIT/GRAM NYATA TOPICAL POWDER 00,000 UNIT/GRAM nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 unit/gram NYSTOP TOPICAL POWDER 00,000 UNIT/GRAM terbinafine hcl oral tablet 50 mg terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg voriconazole intravenous solution 00 mg voriconazole oral suspension for reconstitution 00 mg/5 ml (40 mg/ml) voriconazole oral tablet 00 mg 5 voriconazole oral tablet 50 mg Antigout Agents Antigout Agents allopurinol oral tablet 00 mg, 00 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg 4 PA 4 PA 5

28 ULORIC ORAL TABLET 40 MG, 80 MG ST Anti-Inflammatory Agents Glucocorticoids ALA-CORT TOPICAL CREAM %,.5 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0. % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % clobetasol scalp solution 0.05 % clobetasol topical gel 0.05 % clobetasol topical ointment 0.05 % CORMAX SCALP SOLUTION 0.05 % desonide topical cream 0.05 % desonide topical lotion 0.05 % desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.5 % desoximetasone topical gel 0.05 % desoximetasone topical ointment 0.05 %, 0.5 % DEXAMETHASONE INTENSOL ORAL DROPS MG/ML dexamethasone oral elixir 0.5 mg/5 ml dexamethasone oral tablet 0.5 mg, 0.75 mg, mg,.5 mg, mg, 4 mg, 6 mg

29 dexamethasone sodium phosphate injection solution 0 mg/ml, 4 mg/ml fluocinolone topical cream 0.0 %, 0.05 % fluocinolone topical ointment 0.05 % fluocinolone topical solution 0.0 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % FLUOCINONIDE-E TOPICAL CREAM 0.05 % fluticasone topical cream 0.05 % fluticasone topical lotion 0.05 % fluticasone topical ointment % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocortisone butyrate topical ointment 0. % hydrocortisone butyrate topical solution 0. % hydrocortisone butyr-emollient topical cream 0. % hydrocortisone topical cream %,.5 % hydrocortisone topical lotion.5 % hydrocortisone topical ointment %,.5 % hydrocortisone valerate topical cream 0. % hydrocortisone valerate topical ointment 0. % methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 6 mg, mg, 4 mg, 8 mg methylprednisolone oral tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 40 mg methylprednisolone sodium succ intravenous recon soln,000 mg mometasone topical cream 0. % mometasone topical ointment 0. %

30 mometasone topical solution 0. % prednisolone sodium phosphate oral solution 5 mg/5 ml ( mg/ml), 5 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone oral solution 5 mg/5 ml prednisone oral tablet mg, 0 mg,.5 mg, 0 mg, 5 mg, 50 mg prednisone oral tablets,dose pack 0 mg, 0 mg (48 pack) prednisone oral tablets,dose pack 5 mg, 5 mg (48 pack) RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) MG, MG, 5 MG triamcinolone acetonide topical cream 0.05 %, 0. %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0. % triamcinolone acetonide topical ointment 0.05 %, 0. %, 0.5 % TRIDERM TOPICAL CREAM 0. % Antimigraine Agents Ergot Alkaloids dihydroergotamine injection solution mg/ml PA dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml) ergotamine-caffeine oral tablet -00 mg Serotonin (5-HT) B/D Receptor Agonists 4 QL (8 ML per 0 days) rizatriptan oral tablet 0 mg, 5 mg QL ( EA per 0 days) rizatriptan oral tablet,disintegrating 0 mg, 5 mg QL ( EA per 0 days) sumatriptan nasal spray,non-aerosol 0 mg/actuation, 5 mg/actuation sumatriptan succinate oral tablet 00 mg, 5 mg, 50 mg sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml QL ( EA per 0 days) QL ( EA per 0 days) QL (4 ML per 0 days) 4

31 sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 mg/0.5 ml sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml Antimyasthenic Agents Parasympathomimetics guanidine oral tablet 5 mg pyridostigmine bromide oral tablet 60 mg Antimycobacterials Antimycobacterials, Other dapsone oral tablet 00 mg, 5 mg rifabutin oral capsule 50 mg Antituberculars CAPASTAT INJECTION RECON SOLN GRAM ethambutol oral tablet 00 mg, 400 mg isoniazid injection solution 00 mg/ml isoniazid oral tablet 00 mg, 00 mg PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 50 MG 4 pyrazinamide oral tablet 500 mg rifampin intravenous recon soln 600 mg rifampin oral capsule 50 mg, 00 mg RIFATER ORAL TABLET MG 4 SIRTURO ORAL TABLET 00 MG TRECATOR ORAL TABLET 50 MG 4 Antineoplastics Alkylating Agents BICNU INTRAVENOUS RECON SOLN 00 MG QL (4 ML per 0 days) QL (4 ML per 0 days) QL (4 ML per 0 days) PA 5

32 busulfan intravenous solution 60 mg/0 ml carboplatin intravenous solution 0 mg/ml B/D cisplatin intravenous solution mg/ml B/D cyclophosphamide oral capsule 5 mg, 50 mg B/D dacarbazine intravenous recon soln 00 mg B/D EMCYT ORAL CAPSULE 40 MG 4 PA GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG 4 PA HEXALEN ORAL CAPSULE 50 MG 4 PA ifosfamide intravenous recon soln gram 4 B/D LEUKERAN ORAL TABLET MG MATULANE ORAL CAPSULE 50 MG 4 melphalan hcl intravenous recon soln 50 mg 5 B/D MUSTARGEN INJECTION RECON SOLN 0 MG 4 PA oxaliplatin intravenous solution 00 mg/0 ml B/D thiotepa injection recon soln 5 mg 5 B/D TREANDA INTRAVENOUS RECON SOLN 00 MG VALCHLOR TOPICAL GEL 0.06 % 5 ZANOSAR INTRAVENOUS RECON SOLN GRAM Antiandrogens bicalutamide oral tablet 50 mg flutamide oral capsule 5 mg nilutamide oral tablet 50 mg 4 PA XTANDI ORAL CAPSULE 40 MG ZYTIGA ORAL TABLET 50 MG Antiangiogenic Agents POMALYST ORAL CAPSULE MG, MG, MG, 4 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG ; LA 6

33 THALOMID ORAL CAPSULE 00 MG, 50 MG, 00 MG, 50 MG Antiestrogens/Modifiers DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML 5 4 PA FARESTON ORAL TABLET 60 MG 4 PA SOLTAMOX ORAL SOLUTION 0 MG/5 ML 4 tamoxifen oral tablet 0 mg, 0 mg Antimetabolites ALIMTA INTRAVENOUS RECON SOLN 500 MG ARRANON INTRAVENOUS SOLUTION 50 MG/50 ML cladribine intravenous solution 0 mg/0 ml 5 B/D cytarabine (pf) injection solution gram/0 ml (00 mg/ml) B/D cytarabine injection solution 0 mg/ml B/D DROXIA ORAL CAPSULE 00 MG, 00 MG, 400 MG fludarabine intravenous recon soln 50 mg 4 PA fluorouracil intravenous solution.5 gram/50 ml B/D fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution %, 5 % gemcitabine intravenous recon soln gram 5 B/D hydroxyurea oral capsule 500 mg mercaptopurine oral tablet 50 mg NIPENT INTRAVENOUS RECON SOLN 0 MG PURIXAN ORAL SUSPENSION 0 MG/ML 5 4 TABLOID ORAL TABLET 40 MG 4 PA Antineoplastics ADRIAMYCIN INTRAVENOUS SOLUTION 0 MG/0 ML B/D PICATO TOPICAL GEL 0.05 %, 0.05 % 7

34 Antineoplastics, Other azacitidine injection recon soln 00 mg BELEODAQ INTRAVENOUS RECON SOLN 500 MG bleomycin injection recon soln 0 unit B/D clofarabine intravenous solution 0 mg/0 ml daunorubicin intravenous solution 5 mg/ml B/D decitabine intravenous recon soln 50 mg 5 B/D dexrazoxane hcl intravenous recon soln 50 mg 4 B/D doxorubicin intravenous solution 50 mg/5 ml B/D doxorubicin, peg-liposomal intravenous suspension mg/ml PA epirubicin intravenous solution 00 mg/00 ml 4 B/D ERWINAZE INJECTION RECON SOLN 0,000 UNIT FARYDAK ORAL CAPSULE 0 MG, 5 MG, 0 MG FUSILEV INTRAVENOUS RECON SOLN 50 MG HALAVEN INTRAVENOUS SOLUTION MG/ ML (0.5 MG/ML) 5 B/D idarubicin intravenous solution mg/ml B/D ISTODAX INTRAVENOUS RECON SOLN 0 MG/ ML KADCYLA INTRAVENOUS RECON SOLN 00 MG KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG, 400 MG/DAY(00 MG X )-.5 MG, 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X ), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 60 MG 8

35 leucovorin calcium injection recon soln 00 mg, 50 mg leucovorin calcium oral tablet 0 mg, 5 mg, 5 mg, 5 mg B/D levoleucovorin intravenous solution 0 mg/ml B/D LONSURF ORAL TABLET MG, MG LYNPARZA ORAL CAPSULE 50 MG mesna intravenous solution 00 mg/ml B/D MESNEX ORAL TABLET 400 MG 4 mitomycin intravenous recon soln 0 mg, 40 mg, 5 mg NINLARO ORAL CAPSULE. MG, MG, 4 MG B/D ODOMZO ORAL CAPSULE 00 MG PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT RUBRACA ORAL TABLET 00 MG, 00 MG SYLATRON SUBCUTANEOUS KIT 00 MCG, 00 MCG, 600 MCG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG TRISENOX INTRAVENOUS SOLUTION 0 MG/0 ML 4 PA VELCADE INJECTION RECON SOLN.5 MG VENCLEXTA ORAL TABLET 0 MG, 50 MG 4 PA VENCLEXTA ORAL TABLET 00 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG vinblastine intravenous solution mg/ml B/D vincristine intravenous solution mg/ml B/D vinorelbine intravenous solution 50 mg/5 ml 4 B/D YONDELIS INTRAVENOUS RECON SOLN MG 9

36 ZALTRAP INTRAVENOUS SOLUTION 00 MG/4 ML (5 MG/ML) ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG Aromatase Inhibitors, RD Generation anastrozole oral tablet mg exemestane oral tablet 5 mg letrozole oral tablet.5 mg Enzyme Inhibitors ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG docetaxel intravenous solution 80 mg/4 ml (0 mg/ml), 80 mg/8 ml (0 mg/ml) ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG 4 B/D 4 PA etoposide intravenous solution 0 mg/ml B/D IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG irinotecan intravenous solution 00 mg/5 ml 4 B/D JEVTANA INTRAVENOUS SOLUTION 0 MG/ML (FIRST DILUTION) mitoxantrone intravenous concentrate mg/ml paclitaxel intravenous concentrate 6 mg/ml B/D topotecan intravenous recon soln 4 mg Molecular Target Inhibitors AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG ALUNBRIG ORAL TABLET 0 MG BOSULIF ORAL TABLET 00 MG, 500 MG CABOMETYX ORAL TABLET 0 MG, 40 MG, 60 MG 0

37 CAPRELSA ORAL TABLET 00 MG, 00 MG COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 MG X), 60 MG/DAY (0 MG X /DAY) COTELLIC ORAL TABLET 0 MG ERIVEDGE ORAL CAPSULE 50 MG GILOTRIF ORAL TABLET 0 MG, 0 MG, 40 MG ICLUSIG ORAL TABLET 5 MG, 45 MG imatinib oral tablet 00 mg, 400 mg PA IMBRUVICA ORAL CAPSULE 40 MG INLYTA ORAL TABLET MG, 5 MG IRESSA ORAL TABLET 50 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X), 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (4 MG X ) MEKINIST ORAL TABLET 0.5 MG, MG NEXAVAR ORAL TABLET 00 MG OFEV ORAL CAPSULE 00 MG, 50 MG RYDAPT ORAL CAPSULE 5 MG SPRYCEL ORAL TABLET 00 MG, 40 MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE.5 MG, 5 MG, 7.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG TARCEVA ORAL TABLET 00 MG, 50 MG, 5 MG TASIGNA ORAL CAPSULE 50 MG, 00 MG

38 TORISEL INTRAVENOUS RECON SOLN 0 MG/ ML (0 MG/ML) (FIRST) TYKERB ORAL TABLET 50 MG VOTRIENT ORAL TABLET 00 MG XALKORI ORAL CAPSULE 00 MG, 50 MG ZEJULA ORAL CAPSULE 00 MG ZELBORAF ORAL TABLET 40 MG ZYKADIA ORAL CAPSULE 50 MG Monoclonal Antibodies AVASTIN INTRAVENOUS SOLUTION 5 MG/ML, 5 MG/ML (6 ML) BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML, 0 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 0 MG/ML EMPLICITI INTRAVENOUS RECON SOLN 00 MG, 400 MG ERBITUX INTRAVENOUS SOLUTION 00 MG/50 ML HERCEPTIN INTRAVENOUS RECON SOLN 440 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (0 ML) KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 00 MG/4 ML (5 MG/ML) LARTRUVO INTRAVENOUS SOLUTION 0 MG/ML OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML PERJETA INTRAVENOUS SOLUTION 40 MG/4 ML (0 MG/ML)