2018 年綜合處方一覽表. Centers Plan for Medicare Advantage Care (HMO)

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1 Centers Plan for Medicare Advantage Care (HMO) 08 年綜合處方一覽表 本處方一覽表更新於 07 年 9 月 如需獲得更多最新資訊, 或者如果您有其他問題, 敬請致電以下電話, 聯絡 Centers Plan for Healthy Living: , 聽力障礙電傳使用者請致電 : , 工作時間為 : 每週 7 天, 早 8 點至晚 8 點, 或者請瀏覽 : H6988_ENRC085 Accepted

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3 Centers Plan for Medicaid Advantage Plan (HMO SNP) 08 年處方一覽表 ( 承保藥品清單 ) 請閱讀 : 本文件含有關於本計劃承保藥品的相關資訊 CPHL 08 處方一覽表 ID:803, 版本 :7 本處方一覽表更新於 07 年 9 月 日 如需瞭解更多最新資訊, 或者如果您有其他問題, 敬請致電 聯絡 Centers Plan for Medicare Advantage Plan (HMO), 聽力障礙電傳使用者請致電 , 每週七天早 8 點至晚 8 點, 或者請瀏覽 現有成員注意 : 此處方一覽表自去年以來發生了變更 請閱覽此文件, 確保處方一覽表仍然包含您服用的藥品 本藥品清單 ( 處方一覽表 ) 中的 我們 或 我們的 指代 Centers Plan for Medicare Advantage Care (HMO) 其中的 計劃 或 我們的計劃 指代 Centers Plan for Medicare Advantage Care (HMO) 本文件包含一份用於我們的計劃的藥品清單 ( 處方一覽表 ), 最後更新日期為 07 年 9 月 日 如需獲得最新處方一覽表, 請聯絡我們 我們的聯絡方式和處方一覽表最新更新日期會分別出現在封面和封底 一般情況下, 您必須使用網絡內藥店來使用您的處方藥福利 福利 處方一覽表 藥店網絡和 / 或自付費用 / 共同保險費可能會在 08 年 月 日發生變更, 並在 07 年多次發生變更 Centers Plan for Medicare Advantage Care(HMO) 處方一覽表是什麼? 處方一覽表是 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plan (HMO SNP) 在諮詢醫療保健提供者團隊後選擇的承保藥品清單, 這個清單上列出了有效的治療計劃所必需的處方療法 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plan (HMO SNP) 一般會承保處方一覽表內列出的藥品, 只要這些藥品屬於醫療必需藥品, 且處方由 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Dual Coverage H6988_ENRC085 Accepted i

4 Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plan (HMO SNP) 網絡內的藥房開出, 也符合其他的計劃規則 如想獲得關於如何開處方藥的更多資訊, 請查閱您的承保福利說明 處方一覽表 ( 藥品清單 ) 會發生變更嗎? 一般情況下, 如果您正在服用我們的 08 年處方一覽表上的藥品, 且此藥品年初屬於承保藥品, 我們不會在 08 年保險年期間中斷或減少藥品承保, 除非出現更新更低價的普通藥品或發佈關於該藥品安全性或有效性的新的負面資訊 其他類型的處方一覽表變更, 例如將一種藥品從我們的處方一覽表上移除, 不會對目前正在服用該藥品的會員產生影響 正在服用該藥品的會員能夠在該保險年的剩餘時間以相同的分攤費用獲得該藥品 我們認為讓您在該保險年的剩餘時間繼續獲得您在選擇我們的計劃時能夠從處方一覽表中獲得的藥品是很重要的, 您能夠節省額外費用或我們能夠確保您的安全的情況除外 如果我們將藥品從處方一覽表中移除, 增加了一種藥品的事先核准 數量限制以和 / 或者逐步治療限制, 或將一種藥品移至更高的分攤費用等級, 我們必須在變更生效前至少 60 天內通知受影響的會員這一變更情況, 或在會員要求續開藥品時進行通知, 在這種情況下, 此會員將獲得 60 天的藥品供應量 如果食品與藥物管理局裁定我們處方一覽表上的一種藥品不安全或此藥品的製造商將藥品撤出市場, 我們會立即將此藥品從我們的處方一覽表上移除並通知服用此藥品的會員 隨信附上的處方一覽表最後更新日期為 07 年 9 月 日 如想獲得 Centers Plan for Medicaid Advantage Care (HMO) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plan (HMO SNP) 承保藥物的最新資訊, 請聯絡我們 我們的聯絡資料在封面和封底 如果處方一覽表在年中發生了無需徹底修訂的改動,Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plan (HMO SNP) 將向您寄送一份勘誤表作為對您的紙本一覽表的更新 如何使用處方一覽表? 有兩個方法可以在處方一覽表中尋找您的藥品 : 醫療狀況 處方一覽表從第 頁開始 此處方一覽表中的藥品根據它們用於治療的醫療狀況類型劃分為不同種類 例如, 用於治療心臟狀況的藥品被列於 心血管藥物 種類之下 如果您知道自己藥品的作用, 則可從第 頁開始的清單中查詢種類名稱 然後在這一種類下方查詢您的藥品 字母排列 如果您不確定應該在哪個種類下方查詢, 您應該在從第 I- 頁開始的索引中尋找您的藥品 索引提供了一份清單, 將本文件包含的所有藥品按照字母順序進行排列 品牌藥品和普通藥品都列於 H6988_ENRC085 Accepted ii

5 此索引之中 查詢索引, 找到您的藥品 在您的藥品旁邊, 您將看到承保資訊所在頁面的頁碼 翻至索引中所列頁面, 並在清單第一欄找到您的藥品名稱 什麼是普通藥物? Centers Plan for Medicaid Advantage Care (HMO) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plan (HMO SNP) 承保品牌藥和普通藥 普通藥品是通過 FDA 審核的與品牌藥品具有相同活性成分的藥品 一般情況下, 普通藥品的價格比品牌藥品低 我的受保範圍是否有約束或限制? 部分承保藥品可能有額外承保要求或限制 這些要求和限制可能包括 : 事前核准 :Centers Plan for Medicaid Advantage Plan (HMO) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plan (HMO SNP) 要求您的醫生為某些藥品獲得事前核准 這意味著您領取處方藥之前需要獲得 Centers Plan for Medicaid Advantage Plan (HMO) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plan (HMO SNP) 的核准 如果您未獲得核准,Centers Plan for Medicaid Advantage Plan (HMO) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Advantage Care (HMO SNP) 可能不承保此藥品 數量限制 : 對於一些藥物,Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Advantage Care (HMO) 會限制 Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Advantage Care (HMO) 將承保的藥量 例如,Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 將 sumatriptan 的單次處方量限制為 片 這可能是對標準一個月或三個月供應量的補充 分步治療 : 在某些情況下,Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 會要求您在其承保治療您所患病症的另一種藥物前先試用其他藥物 例如, 如果藥品 A 和藥品 B 都可治療您的疾病情況,Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 可能會要求您先試用藥品 A, 否則就不承保藥品 B 如果藥品 A 對您無效,Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO) Centers H6988_ENRC085 Accepted iii

6 Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 將承保藥品 B 如想瞭解您的藥品是否有其他額外要求或限制, 您可從第 頁開始檢視處方一覽表 您也可以瀏覽我們的網站, 瞭解有關特定承保藥品所受約束的詳細資訊 我們已在網上發佈文件, 解釋我們的事先核准和逐步治療限制 您也可以要求我們向您傳送一份副本 我們的聯絡方式和處方一覽表最新更新日期會分別出現在封面和封底 您可以要求對這些約束和限制作出特例處理, 或對也許能夠治療您的健康狀況的其他類似藥品清單作出特例處理 參見第 v 頁的 如何向 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 請求特例處理 部分, 瞭解請求特例處理的方法 什麼是非處方 (OTC) 藥物? OTC 藥物是 Medicare 處方藥計劃通常不承保的非處方藥 Centers Plan for Medicaid Advantage Care (HMO) 承保某些 OTC 藥物,Centers Plan for Medicaid Advantage Care (HMO) 將為您免費提供這些 OTC 藥物 這些 Centers Plan for Medicaid Advantage Care (HMO) 提供的 OTC 藥物的費用將不計入您的總 D 部分藥物費用中 ( 即您支付的費用不計入保障缺口中 ) 如果我的藥品未納入此處方一覽表該怎麼辦? 如果您的藥品未納入此處方一覽表 ( 承保藥品清單 ), 您首先應該聯絡會員服務部, 詢問您的藥品是否在承保範圍內 我們的聯絡方式和處方一覽表最新更新日期會分別出現在封面和封底 如果您知道 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 不承保您的藥物, 那麼您有兩個選擇 : 您可以向會員服務部索取一份 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 承保的類似藥品清單 當您收到這份清單之後, 將其交給您的醫生檢視並要求醫生開一種與 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) 和 Centers Plan for Nursing Home Care (HMO SNP) 承保藥品類似的藥品 您還可請求 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for H6988_ENRC085 Accepted iv

7 Nursing Home Care (HMO SNP) 進行特例處理並承保您的藥物 參見下方資訊, 瞭解如何請求特例處理 如何向 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 請求處方一覽表特例處理? 您可請求 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) 和 Centers Plan for Nursing Home Care (HMO SNP) 進行承保規定以外的特例處理 您可以向我們請求進行幾類特例處理 即使一種藥品不在我們的處方一覽表之上, 您也可以向我們請求承保此藥品 如果請求被核准, 此藥品將以事先決定的費用分攤水準被承保, 而您無法要求我們提供更低的費用分攤水準 您能夠請求我們以更低的費用分攤水準承保一種處方藥品, 前提為這種藥物不屬於專業級藥品 如果請求被核准, 這將降低您必須支付的藥品費用 您可以向我們請求撤銷對您的藥品承保約束或限制 例如, 對於某些藥品,Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) 和 Centers Plan for Nursing Home Care (HMO SNP) 限制我們承保的藥量 如果您的藥品有藥量限制, 您可以向我們請求撤銷此限制並承保更大藥量 一般情況下, 只有當計劃處方一覽表上包含的替代藥品 更低的費用分攤水準藥品, 或額外使用約束限制對您的治療效果不佳以及 / 或者可能對您產生副作用,Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 才會核准您的特例請求 您應該聯絡我們, 要求獲得一份有關處方一覽表或使用限制特例的初始保險決定 當您請求一份處方一覽表或使用約束特例時, 您應該提交一份您的開藥醫生或醫師出具的支持您請求的聲明 一般情況下, 我們必須在收到您的開藥醫生出具的支持性聲明後的 7 小時內作出決定 如果您或您的醫生認為等待 7 小時才能裁定可能會對您的健康造成嚴重傷害, 您可以請求加急 ( 快速 ) 特例 如果您的加急請求得到許可, 我們必須在收到您的醫生或其他開藥醫生出具的支持性聲明的 4 小時之內告知您我們的決定 H6988_ENRC085 Accepted v

8 在我能夠和我的醫生討論變更我的藥品或請求特例之前我應該做什麼? 作為我們的計劃的新會員或持續會員, 您可能正在服用不在我們的處方一覽表上的藥品 或者, 您可能正在服用我們處方一覽表上的藥品, 但您獲得該藥品的能力受限 例如, 在開處方藥之前, 您可能需要得到我們的事前核准 您應該向您的醫生諮詢, 確認您是否應該更換為我們承保的合適藥品, 或請求處方一覽表特例處理, 要求我們承保您服用的藥品 在您向您的醫生諮詢並決定正確的處理措施之時, 我們可能會在特定情況下在您成為我們的計劃會員的最初 90 天內承保您的藥品 對於您所服用的不在我們處方一覽表上的每一種藥品或如果您獲得您的藥品的能力有限, 我們將暫時承保 30 天的供應藥量 ( 除非您的處方箋上註明的天數更少 ), 您可在網絡內藥房配藥 結束您最初 30 天的供應藥量之後, 我們不會為這些藥品支付費用, 即使您成為本計劃會員的時間不超過 90 天亦如此 如果您在長期護理設施住院, 我們將允許您續配藥一直到您獲得 9 天的過渡供應藥量, 使其與配藥增量保持一致 ( 除非您的處方箋上註明的天數更少 ) 在您成為我們會員的最初 90 天, 我們將承保一次以上的這些藥物續配藥 如果您需要的藥物並不在我們的處方一覽表上或者如果您獲得藥物的能力有限, 而您加入我們計劃成為會員已經超過 90 天, 在您尋求處方一覽表例外處理期間, 我們將承保一次 3 天的急救用藥用量 ( 除非您的處方箋上註明的天數更少 ) 我們會向因護理等級改變而改變治療方式的會員提供過渡期藥物 ( 例如, 從醫院轉入長期護理機構或流動門診的個人 ) 更多資訊 為獲得關於您的 Centers Plan for Medicare Advantage Care(HMO) 處方藥品承保的詳細資訊, 請閱覽您的 承保福利說明 和其他計劃材料 如果您對 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 有疑問, 請聯絡我們 我們的聯絡方式和處方一覽表最新更新日期會分別出現在封面和封底 如果您對 Medicare 處方藥品承保有一般性問題, 請致電 Medicare, 電話是 -800-MEDICARE ( ), 每週 7 天 每天 4 小時開通 聽力障礙電傳使用者應致電 或者訪問 visit H6988_ENRC085 Accepted vi

9 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 處方一覽表 以下處方一覽表列出了 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) 和 Centers Plan for Nursing Home Care (HMO SNP) 所承保藥物的承保訊息 如果您在藥物清單上找藥物有困難, 請翻至 I- 頁, 開始閱讀索引部分 圖表第一列是藥品名稱 品牌藥品名稱大寫 ( 如 :LIPITOR), 普通藥品為斜體小寫 ( 如 : atorvastatin) 要求 / 限制欄中的資訊告知您 Centers Plan for Medicare Advantage Care (HMO) Centers Plan for Medicaid Advantage Plan (HMO SNP) Centers Plan for Dual Coverage Care (HMO SNP) 和 Centers Plan for Nursing Home Care (HMO SNP) 對您的藥品承保是否有任何特殊要求 H6988_ENRC085 Accepted vii

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11 Table of Contents Analgesics... 3 Anesthetics... 8 Anti-Addiction/Substance Abuse Treatment Agents... 8 Antianxiety Agents... 9 Antibacterials... Anticancer Agents... 9 Anticholinergic Agents... 7 Anticonvulsants... 7 Antidementia Agents Antidepressants... 3 Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents... 4 Antiparasite Agents... 4 Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents... 69

12 Contraceptives... 7 Dental And Oral Agents Dermatological Agents Devices... 8 Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents... 9 Heavy Metal Antagonists... 9 Hormonal Agents, Stimulant/Replacement/Modifying... 9 Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations... 0 Respiratory Tract Agents... 3 Skeletal Muscle Relaxants... 7 Sleep Disorder Agents... 7 Vasodilating Agents... 8 Vitamins And Minerals... 9

13 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 0- /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet ascomp with codeine oral capsule BELBUCA BUCCAL FILM 50 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml buprenorphine transdermal patch weekly 0 mcg/hour, 5 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule , butalbital-acetaminophen oral tablet butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HOUR QL (700 per 30 QL (360 per 30 (Tylenol-Codeine #3) QL (360 per 30 (Tylenol-Codeine #4) QL (80 per 30 (Buprenex) 3 PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) QL (60 per 30 (Butrans) QL (4 per 8 PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Marten-Tab) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Zebutal) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Esgic) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) QL (4 per 8

14 capacet oral capsule PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) codeine sulfate oral tablet 5, 30, QL (80 per endocet oral tablet 0-35 QL (40 per 30 endocet oral tablet.5-35, 5-35 QL (360 per 30 endocet oral tablet QL (300 per 30 fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, (Actiq) 4 PA; NDS; QL (0 per mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 (Duragesic) QL (0 per 30 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution QL (700 per /5 ml, 5-63 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (700 per /5 ml hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (360 per hydrocodone-acetaminophen oral tablet (Verdrocet) QL (360 per hydrocodone-acetaminophen oral tablet 5- (Lorcet (hydrocodone)) QL (360 per hydrocodone-acetaminophen oral tablet (Norco) QL (360 per hydrocodone-ibuprofen oral tablet QL (50 per 30 hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone injection solution /ml, 4 /ml hydromorphone injection syringe /ml, (Dilaudid) 4 /ml hydromorphone oral liquid /ml (Dilaudid) QL (00 per 30 hydromorphone oral tablet, 4, 8 (Dilaudid) QL (80 per 30 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.4 HR 00 MG, 0 MG, 0 MG, 30 MG, 40 MG, 60 MG, 80 MG QL (30 per 30 4

15 LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY 5 4 PA; NDS; QL (30 per 30 lorcet (hydrocodone) oral tablet 5-35 QL (360 per 30 lorcet hd oral tablet 0-35 QL (360 per 30 lorcet plus oral tablet QL (360 per 30 methadone injection solution 0 /ml methadone oral solution 0 /5 ml, 5 QL (800 per 30 /5 ml methadone oral tablet 0 (Dolophine) QL (360 per 30 methadone oral tablet 5 (Dolophine) QL (80 per 30 methadose oral tablet,soluble 40 QL (90 per 30 morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml carpuject outer,l/f,p/f, sdv 4 /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 00 QL (80 per 30 /5 ml (0 /ml) morphine intravenous syringe 0 /ml, /ml, 4 /ml, 8 /ml morphine oral solution 0 /5 ml QL (700 per 30 morphine oral solution 0 /5 ml (4 QL (300 per 30 /ml) MORPHINE ORAL TABLET 5 MG 3 QL (80 per 30 MORPHINE ORAL TABLET 30 MG 3 QL (0 per 30 morphine oral tablet extended release 00 (MS Contin) QL (60 per 30, 00, 60 morphine oral tablet extended release 5 (MS Contin) QL (90 per 30, 30 morphine sulfate 0 /ml vial 0 /ml NUCYNTA ER ORAL TABLET EXTENDED RELEASE HR 00 MG, 50 MG, 00 MG, 50 MG, 50 MG QL (60 per 30 NUCYNTA ORAL TABLET 00 MG, 50 QL (8 per 30 MG, 75 MG oxycodone oral concentrate 0 /ml QL (0 per 30 oxycodone oral solution 5 /5 ml QL (300 per 30 oxycodone oral tablet 0 QL (80 per 30 oxycodone oral tablet 5, 30 (Roxicodone) QL (0 per 30 oxycodone oral tablet 0 QL (0 per 30 oxycodone oral tablet 5 (Roxicodone) QL (80 per 30

16 oxycodone oral tablet,oral only,ext.rel. hr 0, 5, 0, 30, 40, 60 oxycodone oral tablet,oral only,ext.rel. hr 80 oxycodone-acetaminophen oral solution 5-35 /5 ml oxycodone-acetaminophen oral tablet 0-35 oxycodone-acetaminophen oral tablet.5-35, 5-35 oxycodone-acetaminophen oral tablet oxycodone-aspirin oral tablet OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL. HR 0 MG, 5 MG, 0 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL. HR 80 MG (OxyContin) QL (60 per 30 (OxyContin) ; QL (0 per 30 QL (800 per 30 (Percocet) QL (40 per 30 (Percocet) QL (360 per 30 (Endocet) QL (300 per 30 QL (360 per 30 QL (60 per 30 QL (0 per 30 oxymorphone oral tablet 0 (Opana) QL (0 per 30 oxymorphone oral tablet 5 (Opana) QL (80 per 30 oxymorphone oral tablet extended release hr 0, 5, 0, 30, 40, 5, 7.5 QL (60 per 30 reprexain oral tablet.5-00 QL (50 per 30 tencon oral tablet PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) tramadol oral tablet 50 (Ultram) QL (40 per 30 tramadol-acetaminophen oral tablet (Ultracet) QL (40 per XTAMPZA ER ORAL QL (60 per 30 CAPSULE,SPRINKLE,ER HR TMPRR 3.5 MG, 8 MG, 9 MG XTAMPZA ER ORAL QL (0 per 30 CAPSULE,SPRINKLE,ER HR TMPRR 7 MG XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER HR TMPRR 36 MG QL (40 per 30 6

17 zebutal oral capsule PA-HRM; QL (80 per 30 ; AGE (Max 64 Years) Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON 3 SOLN 400 MG/4 ML (00 MG/ML) celecoxib oral capsule 00, 00, (Celebrex) QL (60 per , 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 etodolac oral capsule 00, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 flurbiprofen oral tablet 00, 50 ibuprofen oral suspension 00 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 5 PA-HRM; QL (40 per 30 ; AGE (Max 64 Years) indomethacin oral capsule 50 PA-HRM; QL (0 per 30 ; AGE (Max 64 Years) indomethacin oral capsule, extended release 75 indomethacin sodium intravenous recon soln ketoprofen oral capsule 50, 75 PA-HRM; QL (60 per 30 ; AGE (Max 64 Years) 7

18 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac oral tablet 0 PA-HRM; QL (0 per 30 ; AGE (Max 64 Years) mefenamic acid oral capsule 50 (Ponstel) meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral suspension 5 /5 ml (Naprosyn) naproxen oral tablet 50, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 500 piroxicam oral capsule 0, 0 (Feldene) sulindac oral tablet 50, 00 Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (.5 %), 0 /ml ( %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine (pf) injection solution 5 /ml (Xylocaine-MPF) (0.5 %) lidocaine hcl % vial inner,ltx-fr,p/f,sdv (Xylocaine-MPF) 0 /ml ( %) lidocaine hcl injection solution 0 /ml (Xylocaine) ( %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive (Lidoderm) PA; QL (90 per 30 patch,medicated 5 % lidocaine topical ointment 5 % PA; QL (90 per 30 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents 8

19 Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 BUNAVAIL BUCCAL FILM.-0.3 MG QL (30 per 30 BUNAVAIL BUCCAL FILM QL (60 per 30 MG, 6.3- MG buprenorphine hcl sublingual tablet, PA; QL (90 per 30 8 buprenorphine-naloxone sublingual tablet -0.5, 8- QL (90 per 30 bupropion hcl (smoking deter) oral tablet extended release hr 50 (Zyban) CHANTIX CONTINUING MONTH QL (68 per 84 BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, QL (68 per 84 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) QL (53 per 8 disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 (Revia) NARCAN NASAL SPRAY,NON- QL (4 per 30 AEROSOL MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION 3 QL (008 per 90 CARTRIDGE 0 MG SUBOXONE SUBLINGUAL FILM -3 QL (60 per 30 MG, 8- MG SUBOXONE SUBLINGUAL FILM -0.5 QL (30 per 30 MG, 4- MG ZUBSOLV SUBLINGUAL TABLET 0.7- QL (30 per MG, MG,.4-.9 MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG QL (60 per 30 Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, (Xanax) QL (0 per 30 9

20 alprazolam oral tablet (Xanax) QL (50 per 30 buspirone oral tablet 0, 5, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 0, QL (0 per 30 5, 5 clonazepam oral tablet 0.5, (Klonopin) QL (90 per 30 clonazepam oral tablet (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating QL (90 per , 0.5, 0.5, clonazepam oral tablet,disintegrating QL (300 per 30 clorazepate dipotassium oral tablet 5, 3.75 QL (80 per 30 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (80 per 30 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG 3 diazepam injection solution 5 /ml QL (0 per 8 diazepam intensol oral concentrate 5 QL (00 per 30 /ml diazepam oral solution 5 /5 ml ( /ml) QL (00 per 30 diazepam oral tablet 0,, 5 (Valium) QL (0 per 30 diazepam rectal kit , 5- (Diastat AcuDial) diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml, 4 (Ativan) QL ( per 30 /ml lorazepam injection syringe /ml QL ( per 30 lorazepam oral tablet 0.5, (Ativan) QL (90 per 30 lorazepam oral tablet (Ativan) QL (50 per 30 ONFI ORAL SUSPENSION.5 MG/ML 4 PA NSO; NDS; QL (480 per 30 ONFI ORAL TABLET 0 MG, 0 MG 4 PA NSO; NDS; QL (60 per 30 0

21 temazepam oral capsule 5, 30 (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION 4 PA BvD; NDS FOR NEBULIZATION 300 MG/4 ML gentamicin 0 /ml vial sdv 60 /6 ml gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 00 /50 ml, 0 /00 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 40 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 00 /0 ml neomycin oral tablet 500 streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 300 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 0 /ml, 40 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln gram ; QL (4 per 8 (Tobi) 4 PA BvD; NDS (BACiiM) clindamycin 75 /5 ml soln 75 /5 ml (Clindamycin Pediatric)

22 clindamycin hcl oral capsule 50, 300 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous (Cleocin in 5 % piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml dextrose) clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 50 /ml clindamycin phosphate intravenous (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection recon (Coly-Mycin M soln 50 Parenteral) daptomycin intravenous recon soln 500 (Cubicin) linezolid intravenous parenteral solution 600 /300 ml (Zyvox) linezolid oral suspension for reconstitution (Zyvox) 00 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /00 ml metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 00, 5, 50 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (0 per 30 ; AGE (Max 64 Years)

23 nitrofurantoin monohyd/m-cryst oral capsule 00 (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 ; AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 vancomycin in dextrose 5 % intravenous piggyback gram/00 ml, 500 /00 ml, 750 /50 ml vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 vancomycin oral capsule 5, 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG 4 PA; NDS; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG 4 PA; NDS Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 5 /5 ml, 50 /5 ml, 375 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback gram/00 ml cefazolin injection recon soln gram, 0 gram, 500 cefazolin intravenous recon soln gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 (Spectracef) CEFEPIME GM INJECTION GRAM/50 ML 3 3

24 CEFEPIME INJECTION RECON SOLN (Maxipime) 3 GRAM, GRAM CEFEPIME-DEXTROSE GM/50 ML 3 GRAM/50 ML cefotaxime injection recon soln gram, 0 (Claforan) gram, gram cefotaxime injection recon soln 500 cefoxitin gm piggyback bag gram/50 ml cefoxitin intravenous recon soln gram, 0 gram cefoxitin intravenous recon soln gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 400 (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 80 /5 ml ceftriaxone gm piggyback l/g, single use gram/50 ml ceftriaxone gm piggyback l/f, single use gram/50 ml ceftriaxone injection recon soln gram, 0 gram, 50, 500 ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln (Zinacef) 750 cefuroxime sodium intravenous recon soln (Zinacef).5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 4

25 MEFOXIN IN DEXTROSE (ISO-OSM) 3 INTRAVENOUS PIGGYBACK GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 3 SUPRAX ORAL TABLET,CHEWABLE 3 00 MG, 00 MG tazicef injection recon soln gram, gram, 6 gram TEFLARO INTRAVENOUS RECON 3 SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50 (Zithromax Z-Pak) azithromycin oral tablet 50 (6 pack), 500 (3 pack) azithromycin oral tablet 500, 600 (Zithromax) clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 DIFICID ORAL TABLET 00 MG 4 ST; NDS; QL (0 per 0 e.e.s. 400 oral tablet e.e.s. granules oral suspension for 3 reconstitution 00 /5 ml ERYPED 00 ORAL SUSPENSION FOR 3 RECONSTITUTION 00 MG/5 ML ERYPED 400 ORAL SUSPENSION FOR 3 RECONSTITUTION 400 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED 3 RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG, 500 MG 3 5

26 erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 4 LA; NDS imipenem-cilastatin intravenous recon (Primaxin IV) soln 50, 500 INVANZ INJECTION RECON SOLN 3 GRAM meropenem intravenous recon soln (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet 50-5 amoxicillin-pot clavulanate oral tablet (Augmentin) 500-5, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, 500 ampicillin oral suspension for reconstitution 5 /5 ml, 50 /5 ml 6

27 ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn).5 gram, 5 gram, 3 gram BICILLIN C-R INTRAMUSCULAR 3 SYRINGE,00,000 UNIT/ ML(600K/600K),,00,000 UNIT/ ML(900K/300K) BICILLIN L-A INTRAMUSCULAR 3 SYRINGE,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln gram nafcillin injection recon soln 0 gram nafcillin intravenous recon soln gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, gram/50 ml oxacillin injection recon soln 0 gram, gram oxacillin intravenous recon soln gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 5 million unit penicillin g procaine intramuscular syringe. million unit/ ml, 600,000 unit/ml penicillin gk 0 million unit 0 million unit (Pfizerpen-G) penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit 7

28 piperacillin-tazobactam intravenous recon (Zosyn) soln.5 gram, gram, 4.5 gram, 40.5 gram Quinolones ciprofloxacin hcl oral tablet 00, 750 ciprofloxacin hcl oral tablet 50, 500 (Cipro) ciprofloxacin in 5 % dextrose intravenous piggyback 00 /00 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500, (Levaquin) 750 moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 300, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) sulfatrim oral suspension /5 ml Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate oral capsule 00 (Vibramycin) doxycycline hyclate oral capsule 50 (Morgidox) 8

29 doxycycline hyclate oral tablet 00, 0 doxycycline monohydrate oral capsule 00, 50, 75 doxycycline monohydrate oral capsule 50 doxycycline monohydrate oral suspension for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 00 doxycycline monohydrate oral tablet 50, 50, 75 minocycline oral capsule 00, 50, 75 minocycline oral tablet 00, 50, 75 (Mondoxyne NL) (Vibramycin) (Avidoxy) (Minocin) tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG adriamycin intravenous solution 0 /5 PA BvD ml, 0 /0 ml adrucil intravenous solution.5 gram/50 PA BvD ml, 500 /0 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 3 MG, 5 MG 4 PA NSO; NDS; QL ( per 8 AFINITOR ORAL TABLET 0 MG 4 PA NSO; NDS; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 4 PA NSO; NDS; QL (8 per 8 ALECENSA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (40 per 30 ALIMTA INTRAVENOUS RECON SOLN 00 MG, 500 MG ALUNBRIG ORAL TABLET 30 MG 4 PA NSO; NDS; QL (80 per 30 anastrozole oral tablet (Arimidex) AVASTIN INTRAVENOUS SOLUTION 4 PA NSO; NDS 5 MG/ML, 5 MG/ML (6 ML) azacitidine injection recon soln 00 (Vidaza) 9

30 BAVENCIO INTRAVENOUS 4 PA NSO; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON 4 PA NSO; NDS SOLN 500 MG BENDEKA INTRAVENOUS 4 PA NSO; NDS SOLUTION 5 MG/ML bexarotene oral capsule 75 (Targretin) 4 PA NSO; NDS; QL (40 per 30 bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 5 unit (Bleo 5K) PA BvD bleomycin injection recon soln 30 unit PA BvD BLINCYTO INTRAVENOUS KIT 35 MCG 4 PA NSO; NDS; QL (40 per 365 BOSULIF ORAL TABLET 00 MG 4 PA NSO; NDS; QL (0 per 30 BOSULIF ORAL TABLET 500 MG 4 PA NSO; NDS; QL (30 per 30 CABOMETYX ORAL TABLET 0 MG, 60 MG 4 PA NSO; NDS; QL (30 per 30 CABOMETYX ORAL TABLET 40 MG 4 PA NSO; NDS; QL (60 per 30 CAPRELSA ORAL TABLET 00 MG 4 PA NSO; NDS; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG 4 PA NSO; NDS; QL (30 per 30 clofarabine intravenous solution 0 /0 (Clolar) ml COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 4 PA NSO; NDS; QL ( per 8 MG/DAY(80 MG X-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) COTELLIC ORAL TABLET 0 MG 4 PA NSO; LA; NDS; QL (63 per 8 cyclophosphamide intravenous recon soln 4 PA BvD; NDS gram, gram, 500 CYCLOPHOSPHAMIDE ORAL 3 PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 4 PA NSO; NDS SOLUTION 0 MG/ML, 0 MG/ML (50 ML) DARZALEX INTRAVENOUS 4 PA NSO; LA; NDS SOLUTION 0 MG/ML decitabine intravenous recon soln 50 (Dacogen) 0

31 doxorubicin intravenous solution 0 /5 (Adriamycin) PA BvD ml, /ml, 0 /0 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 4 PA BvD; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 300 MG, 400 MG ELIGARD (3 MONTH) 3 SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) 3 SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) 3 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON 4 PA NSO; NDS SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (30 per 30 ETOPOPHOS INTRAVENOUS RECON 3 SOLN 00 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 4 PA NSO; NDS MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil 5,000 /00 ml latex-free 5 (Adrucil) PA BvD gram/00 ml fluorouracil intravenous solution PA BvD gram/0 ml fluorouracil intravenous solution.5 (Adrucil) PA BvD gram/50 ml, 500 /0 ml flutamide oral capsule 5 GAZYVA INTRAVENOUS SOLUTION 4 PA NSO; NDS,000 MG/40 ML GILOTRIF ORAL TABLET 0 MG, 30 MG, 40 MG 4 PA NSO; NDS; QL (30 per 30 GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG 3

32 HERCEPTIN INTRAVENOUS RECON 4 PA NSO; NDS SOLN 50 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG 4 PA NSO; NDS; QL ( per 8 ICLUSIG ORAL TABLET 5 MG 4 PA NSO; NDS; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG 4 PA NSO; NDS; QL (30 per 30 ifosfamide intravenous recon soln gram, (Ifex) PA BvD 3 gram ifosfamide intravenous solution gram/0 PA BvD ml, 3 gram/60 ml ifosfamide-mesna intravenous kit - 4 PA BvD; NDS gram, 3,000-,000 imatinib oral tablet 00 (Gleevec) 4 PA NSO; NDS; QL (90 per 30 imatinib oral tablet 400 (Gleevec) 4 PA NSO; NDS; QL (60 per 30 IMBRUVICA ORAL CAPSULE 40 MG 4 PA NSO; NDS IMFINZI INTRAVENOUS SOLUTION 4 PA NSO; NDS 50 MG/ML, 50 MG/ML (0 ML) IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML 4 PA NSO; NDS; QL (4 per 365 IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML 4 PA NSO; NDS; QL (8 per 8 INLYTA ORAL TABLET MG 4 PA NSO; NDS; QL (80 per 30 INLYTA ORAL TABLET 5 MG 4 PA NSO; NDS; QL (60 per 30 IRESSA ORAL TABLET 50 MG 4 PA NSO; NDS; QL (60 per 30 IXEMPRA INTRAVENOUS RECON SOLN 5 MG, 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG 4 PA NSO; NDS; QL (60 per 30 KEYTRUDA INTRAVENOUS RECON SOLN 50 MG 4 PA NSO; NDS; QL (4 per KEYTRUDA INTRAVENOUS SOLUTION 00 MG/4 ML (5 MG/ML) 4 PA NSO; NDS; QL (8 per

33 KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X 3)-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X ), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 0 MG/ML 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 4 PA NSO; NDS; QL (49 per 8 4 PA NSO; NDS; QL (70 per 8 4 PA NSO; NDS; QL (9 per 8 4 PA NSO; NDS; QL (63 per 8 4 PA NSO; NDS 4 PA NSO; LA; NDS 4 PA NSO; NDS X ) letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG 3 leuprolide subcutaneous kit /0. ml LONSURF ORAL TABLET MG 4 PA NSO; NDS; QL (00 per 8 LONSURF ORAL TABLET MG 4 PA NSO; NDS; QL (80 per 8 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG,.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (448 per 8 3

34 LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 40 PA NSO-HRM; AGE (Max 64 Years) MEKINIST ORAL TABLET 0.5 MG 4 PA NSO; NDS; QL (90 per 30 MEKINIST ORAL TABLET MG 4 PA NSO; NDS; QL (30 per 30 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon PA BvD soln gram methotrexate sodium (pf) injection PA BvD solution 5 /ml methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST mitoxantrone intravenous concentrate /ml NEXAVAR ORAL TABLET 00 MG 4 PA NSO; NDS; QL (0 per 30 nilutamide oral tablet 50 (Nilandron) NINLARO ORAL CAPSULE.3 MG, 3 MG, 4 MG 4 PA NSO; NDS; QL (3 per 8 ODOMZO ORAL CAPSULE 00 MG 4 PA NSO; LA; NDS ONCASPAR INJECTION SOLUTION 4 PA NSO; NDS 750 UNIT/ML ONIVYDE INTRAVENOUS 4 PA BvD; NDS DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS SOLUTION 4 PA NSO; NDS 00 MG/0 ML, 40 MG/4 ML POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG 4 PA NSO; NDS; QL ( per 8 PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (6 MG/ML) 4 PA NSO; NDS; QL (00 per PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG 4 PA NSO; LA; NDS 4

35 RITUXAN HYCELA SUBCUTANEOUS 4 PA NSO; NDS SOLUTION 400 MG/.7 ML (0 MG/ML), 600 MG/3.4 ML (0 MG/ML) RITUXAN INTRAVENOUS 4 PA NSO; NDS CONCENTRATE 0 MG/ML RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG 4 PA NSO; NDS; QL (0 per 30 RYDAPT ORAL CAPSULE 5 MG 4 PA NSO; NDS; QL (4 per 8 SOLTAMOX ORAL SOLUTION 0 3 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG 4 PA NSO; NDS; QL (30 per 30 SPRYCEL ORAL TABLET 0 MG 4 PA NSO; NDS; QL (60 per 30 STIVARGA ORAL TABLET 40 MG 4 PA NSO; NDS; QL (84 per 8 SUTENT ORAL CAPSULE.5 MG, 5 MG, 37.5 MG, 50 MG 4 PA NSO; NDS; QL (30 per 30 SYLVANT INTRAVENOUS RECON 4 PA NSO; NDS SOLN 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG 4 PA NSO; NDS; QL (8 per 8 TABLOID ORAL TABLET 40 MG 3 TAFINLAR ORAL CAPSULE 50 MG, 75 MG 4 PA NSO; NDS; QL (0 per 30 TAGRISSO ORAL TABLET 40 MG, 80 MG 4 PA NSO; LA; NDS; QL (30 per 30 tamoxifen oral tablet 0, 0 TARCEVA ORAL TABLET 00 MG, 5 MG 4 PA NSO; NDS; QL (60 per 30 TARCEVA ORAL TABLET 50 MG 4 PA NSO; NDS; QL (90 per 30 TARGRETIN TOPICAL GEL % 4 PA NSO; NDS; QL (60 per 8 TASIGNA ORAL CAPSULE 50 MG, 00 MG 4 PA NSO; NDS; QL ( per 8 TECENTRIQ INTRAVENOUS SOLUTION,00 MG/0 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 00 MG 4 PA NSO; NDS; QL (0 per 4 PA NSO; NDS 5

36 thiotepa injection recon soln 5 (Tepadina) toposar intravenous solution 0 /ml TREANDA INTRAVENOUS RECON SOLN 00 MG, 5 MG TRELSTAR.5 MG VIAL INNER, ; QL ( per 84 SDV.5 MG TRELSTAR.5 MG VIAL INNER,SDV.5 MG ; QL ( per 68 TRELSTAR 3.75 MG VIAL INNER, SDV 3.75 MG TRELSTAR INTRAMUSCULAR ; QL ( per 84 SYRINGE.5 MG/ ML TRELSTAR INTRAMUSCULAR SYRINGE.5 MG/ ML ; QL ( per 68 TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/ ML tretinoin (chemotherapy) oral capsule 0 TREXALL ORAL TABLET 0 MG, 5 3 PA BvD; ST MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 50 MG UNITUXIN INTRAVENOUS 4 PA NSO; NDS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VELCADE INJECTION RECON SOLN 4 PA NSO; NDS 3.5 MG VENCLEXTA ORAL TABLET 0 MG PA NSO; LA; QL (60 per 30 VENCLEXTA ORAL TABLET 00 MG 4 PA NSO; LA; NDS; QL (0 per 30 VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (30 per 30 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG 4 PA NSO; LA; NDS; QL (4 per 8 vinorelbine intravenous solution 0 /ml, (Navelbine) 50 /5 ml VOTRIENT ORAL TABLET 00 MG 4 PA NSO; NDS; QL (0 per 30 XALKORI ORAL CAPSULE 00 MG, 50 MG 4 PA NSO; NDS; QL (60 per 30 6

37 XATMEP ORAL SOLUTION.5 3 PA BvD; ST MG/ML XTANDI ORAL CAPSULE 40 MG 4 PA NSO; NDS; QL (0 per 30 YERVOY INTRAVENOUS SOLUTION 4 PA NSO; NDS 00 MG/40 ML (5 MG/ML), 50 MG/0 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON 4 PA NSO; NDS SOLN MG ZEJULA ORAL CAPSULE 00 MG 4 PA NSO; NDS; QL (90 per 30 ZELBORAF ORAL TABLET 40 MG 4 PA NSO; NDS; QL (40 per 30 ZOLADEX SUBCUTANEOUS 3 QL ( per 84 IMPLANT 0.8 MG ZOLADEX SUBCUTANEOUS 3 QL ( per 8 IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG 4 PA NSO; NDS; QL (60 per 30 ZYKADIA ORAL CAPSULE 50 MG 4 PA NSO; NDS; QL (40 per 8 ZYTIGA ORAL TABLET 50 MG, 500 MG 4 PA NSO; NDS; QL (0 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0. /ml propantheline oral tablet 5 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 00 MG, 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 MG/ML 4 ST; NDS 4 ST; NDS 4 ST; NDS 3 QL (80 per 30 3 QL (600 per 30 7

38 BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG ; QL (60 per 30 carbamazepine oral capsule, er (Carbatrol) multiphase hr 00, 00, 300 carbamazepine oral suspension 00 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release hr 00, 00, 400 carbamazepine oral tablet,chewable 00 CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 5 divalproex oral tablet extended release 4 (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 5, 50, 500 epitol oral tablet 00 ethosuximide oral capsule 50 (Zarontin) ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 400, 600 (Felbatol) fosphenytoin injection solution 00 pe/ ml, 500 pe/0 ml (Cerebyx) FYCOMPA ORAL SUSPENSION ST MG/ML FYCOMPA ORAL TABLET 0 MG, MG, MG, 4 MG, 6 MG, 8 MG 3 ST gabapentin oral capsule 00, 300, (Neurontin) 400 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) GABITRIL ORAL TABLET MG, 6 MG ST lamotrigine oral tablet 00, 50, (Lamictal) 00, 5 lamotrigine oral tablet extended release 4hr 00, 00, 5, 50, 300, 50 (Lamictal XR) 8

39 lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 levetiracetam intravenous solution 500 (Keppra) /5 ml levetiracetam oral solution 00 /ml (Keppra) levetiracetam oral tablet,000, 50 (Keppra) levetiracetam oral tablet 500, 750 (Roweepra) levetiracetam oral tablet extended release 4 hr 500, 750 (Keppra XR) LYRICA ORAL CAPSULE 00 MG, 50 QL (90 per 30 MG, 00 MG, 5 MG, 5 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML QL (900 per 30 oxcarbazepine oral suspension 300 /5 ml (60 /ml) (Trileptal) oxcarbazepine oral tablet 50, 300, (Trileptal) 600 OXTELLAR XR ORAL TABLET 3 ST EXTENDED RELEASE 4 HR 50 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml (4 /ml) PA NSO-HRM; AGE (Max 64 Years) phenobarbital oral tablet 00, 5, 6., 30, 3.4, 60, 64.8, 97. PA NSO-HRM; AGE (Max 64 Years) phenytoin oral suspension 5 /5 ml (Dilantin-5) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 00 phenytoin sodium extended oral capsule (Phenytek) 00, 300 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml POTIGA ORAL TABLET 00 MG, 300 MG, 400 MG 4 ST; NDS; QL (90 per 30 POTIGA ORAL TABLET 50 MG 4 ST; NDS; QL (70 per 30 primidone oral tablet 50, 50 (Mysoline) 9

40 ROWEEPRA ORAL TABLET,000 MG, 500 MG, 750 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR 3 ST; QL (60 per 30 SUSPENSION,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 50 MG, 500 MG, 750 MG 3 ST; QL (0 per 30 tiagabine oral tablet, 4 (Gabitril) topiramate oral capsule, sprinkle 5, (Topamax) 5 topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) 00, 50, 00, 5, 50 topiramate oral tablet 00, 00, 5, 50 (Topamax) TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 4HR 00 MG, 5 MG, 50 MG 3 ST; QL (30 per 30 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 4HR 00 MG valproate sodium intravenous solution 500 /5 ml (00 /ml) valproic acid (as sodium salt) oral solution 50 /5 ml (Depacon) (Depakene) 4 ST; NDS; QL (60 per 30 valproic acid oral capsule 50 (Depakene) VIMPAT INTRAVENOUS SOLUTION ST; QL (00 per 5 00 MG/0 ML VIMPAT ORAL SOLUTION 0 MG/ML ST; QL (00 per 30 VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG ST; QL (60 per 30 zonisamide oral capsule 00, 5 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 0, 5 (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating 0, QL (30 per

41 galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (30 per 30 4 hr 6, 4, 8 galantamine oral solution 4 /ml QL (00 per 30 galantamine oral tablet, 4, 8 (Razadyne) QL (60 per 30 memantine oral solution /ml QL (360 per 30 memantine oral tablet 0, 5 (Namenda) QL (60 per 30 memantine oral tablets,dose pack 5-0 (Namenda Titration Pak) QL (49 per 8 NAMENDA XR ORAL QL (8 per 8 CAP,SPRINKLE,ER 4HR DOSE PACK MG NAMENDA XR ORAL QL (30 per 30 CAPSULE,SPRINKLE,ER 4HR 4 MG, MG, 8 MG, 7 MG NAMZARIC ORAL CAP,SPRINKLE,ER QL (56 per 365 4HR DOSE PACK 7/4//8 MG-0 MG NAMZARIC ORAL QL (30 per 30 CAPSULE,SPRINKLE,ER 4HR 4-0 MG, -0 MG, 8-0 MG, 7-0 MG rivastigmine tartrate oral capsule.5, 3, 4.5, 6 QL (60 per 30 rivastigmine transdermal patch 4 hour (Exelon) QL (30 per /4 hour, 4.6 /4 hr, 9.5 /4 hr Antidepressants Antidepressants amitriptyline oral tablet 0, 00, 50, 5, 50, 75 PA NSO-HRM; AGE (Max 64 Years) amoxapine oral tablet 00, 50, 5, 50 PA NSO-HRM; AGE (Max 64 Years) bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release (Wellbutrin SR) hr 00, 50, 00 bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr 50, 300 citalopram oral solution 0 /5 ml QL (600 per 30 citalopram oral tablet 0, 0, 40 (Celexa) QL (30 per 30 clomipramine oral capsule 5, 50, 75 (Anafranil) PA NSO-HRM; AGE (Max 64 Years) desipramine oral tablet 0, 5 (Norpramin) PA NSO-HRM; AGE (Max 64 Years) 3

42 desipramine oral tablet 00, 50, 50, 75 PA NSO-HRM; AGE (Max 64 Years) desvenlafaxine succinate oral tablet (Pristiq) QL (30 per 30 extended release 4 hr 00, 5, 50 doxepin oral capsule 0, 00, 50, 5, 50, 75 PA NSO-HRM; AGE (Max 64 Years) doxepin oral concentrate 0 /ml PA NSO-HRM; AGE (Max 64 Years) duloxetine oral capsule,delayed (Cymbalta) QL (60 per 30 release(dr/ec) 0, 60 duloxetine oral capsule,delayed (Cymbalta) QL (30 per 30 release(dr/ec) 30 duloxetine oral capsule,delayed (Irenka) QL (30 per 30 release(dr/ec) 40 EMSAM TRANSDERMAL PATCH 4 HOUR MG/4 HR, 6 MG/4 HR, 9 ; QL (30 per 30 MG/4 HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 0, 0, 5 (Lexapro) 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, 0, 40 fluoxetine oral capsule,delayed release(dr/ec) 90 fluoxetine oral solution 0 /5 ml (4 /ml) (Prozac) 3 ST; QL (56 per ST; QL (30 per 30 (Prozac Weekly) QL (4 per 8 fluoxetine oral tablet 0, 0 (Sarafem) fluvoxamine oral capsule,extended release 4hr 00, 50 fluvoxamine oral tablet 00, 5, 50 imipramine hcl oral tablet 0, 5, 50 (Tofranil) PA NSO-HRM; AGE (Max 64 Years) imipramine pamoate oral capsule 00, 5, 50, 75 PA NSO-HRM; AGE (Max 64 Years)

43 maprotiline oral tablet 5, 50, 75 MARPLAN ORAL TABLET 0 MG 3 mirtazapine oral tablet 5, 30, 45 (Remeron) mirtazapine oral tablet 7.5 mirtazapine oral tablet,disintegrating 5 (Remeron SolTab), 30, 45 nefazodone oral tablet 00, 50, 00, 50, 50 nortriptyline oral capsule 0, 5, 50, 75 (Pamelor) PA NSO-HRM; AGE (Max 64 Years) nortriptyline oral solution 0 /5 ml PA NSO-HRM; AGE (Max 64 Years) paroxetine hcl oral tablet 0, 0, 30, 40 (Paxil) PA NSO-HRM; AGE (Max 64 Years) paroxetine hcl oral tablet extended release 4 hr.5, 5, 37.5 (Paxil CR) PA NSO-HRM; AGE (Max 64 Years) PAXIL ORAL SUSPENSION 0 MG/5 ML 3 PA NSO-HRM; AGE (Max 64 Years) perphenazine-amitriptyline oral tablet - 0, -5, 4-0, 4-5, 4-50 PA NSO-HRM; AGE (Max 64 Years) phenelzine oral tablet 5 (Nardil) protriptyline oral tablet 0, 5 PA NSO-HRM; AGE (Max 64 Years) sertraline oral concentrate 0 /ml (Zoloft) sertraline oral tablet 00, 5, 50 (Zoloft) SURMONTIL ORAL CAPSULE 00 MG, 5 MG, 50 MG 3 PA NSO-HRM; AGE (Max 64 Years) tranylcypromine oral tablet 0 (Parnate) trazodone oral tablet 00, 50, 300, 50 trimipramine oral capsule 00, 5, 50 (Surmontil) PA NSO-HRM; AGE (Max 64 Years) TRINTELLIX ORAL TABLET 0 MG, ST; QL (30 per 30 0 MG, 5 MG venlafaxine oral capsule,extended release (Effexor XR) QL (30 per 30 4hr 50 venlafaxine oral capsule,extended release 4hr 37.5, 75 (Effexor XR) QL (90 per 30 33