Introduction in English..Page II-2. Introduction in Spanish... Page II-11. Introduction in Chinese...Page II-21. Introduction in Korean.

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2 Table of Contents Introduction in English..Page II-2 Introduction in Spanish... Page II-11 Introduction in Chinese...Page II-21 Introduction in Korean.Page II-30 Introduction in Vietnamese.Page II-40 List of Covered Drugs...Page 1 Index. Page I-1 II-1

3 Vitality Health Plan of California is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. This information is not a complete description of benefits. Call (TTY: 711) for more information. Proficiency of Language Assistance Services are Available Hours: 8 a.m. to 8 p.m., seven days a week from October 1 through March 31 and Monday to Friday from April 1 through September 30. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY :711) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY (հեռատիպ) 711): توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. با 711) (TTY: تماس بگیرید. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:711) まで お電話にてご連絡ください ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم هاتف الصم والبكم: 711). ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚ ਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬਧ ਹ (TTY: 711) 'ਤ ਕ ਲ ਕਰ បយ ត ប ស ន អ កន យ ខ រ, ស ជ ន យ ផ ក យម នគ តឈ ល គ ច នស ប ប រ អ ក ច រ ទ រស ព (TTY: 711) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). न द : य द आप ह द ब लत ह त आपक लए म म भ ष सह यत स व ए उपल ह (TTY: 711) पर क ल कर เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711). II-2

4 Discrimination is Against the Law Vitality Health Plan of California complies with applicable Federal civil rights laws and does not discriminate on the basis of race, ethnicity, national origin, religion, gender, sex, age, mental or physical disability, health status, receipt of health care, claims experience, medical history, genetic information, evidence of insurability, or geographic location. Vitality Health Plan of California does not exclude people or treat them differently because of race, ethnicity, national origin, religion, gender, sex, age, mental or physical disability, health status, receipt of health care, claims experience, medical history, genetic information, evidence of insurability, or geographic location. Vitality Health Plan of California: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Vitality Member Service Department at (TTY: 711) to help you. Hours are 8 a.m. to 8 p.m., seven days a week from October 1 through March 31 and Monday to Friday from April 1 through September 30. You can also ask for a Civil Rights Coordinator who works for Vitality Health Plan of California. If you believe that Vitality Health Plan of California has failed to provide these services or discriminated in another way based on race, color, national origin, age, disability, or sex, you can file a grievance with: Vitality Health Plan of California Member Services Department (Complaints) Studebaker Road, Suite 960 Cerritos, CA TTY: 711 FAX: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Vitality Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at II-3

5 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 Vitality Health Plan of California. When it refers to plan or our plan, it means Vitality Choice and Vitality Plus. This document includes list of the drugs (formulary) for our plan which is current as of 8/23/2018. 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 1, 2020, and from time to time during the year. What is the Vitality Health Plan of California Formulary? A formulary is a list of covered drugs selected by Vitality Health Plan of California 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. Vitality Health Plan of California will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Vitality Health Plan of California 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 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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. Below are changes to the drug list that will also affect members currently taking a drug: Drugs removed from the market. 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. 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 30 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 30-day supply of the drug. The enclosed formulary is current as of 8/23/2018. To get updated information about the drugs covered by Vitality Health Plan of California, please contact us. Our contact information appears on the front and back cover pages. Every month Vitality Health Plan of California mails you a report called the Explanation of Benefits, or EOB. The EOB tells you the total amount you have spent on your prescription drugs and the II-4

6 total amount we have paid for each of your prescription drugs during the month. Along with your EOB, we will send you a Formulary Change Notice if there have been any recent changes to our formulary. In addition, all formulary changes will be included on the monthly updated formulary available on our web site at How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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 page 3. 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 I-1. 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? Vitality Health Plan of California 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: Vitality Health Plan of California requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Vitality Health Plan of California before you fill your prescriptions. If you don t get approval, Vitality Health Plan of California may not cover the drug. Quantity Limits: For certain drugs, Vitality Health Plan of California limits the amount of the drug that Vitality Health Plan of California will cover. For example, Vitality Health Plan of California provides 30 tablets per prescription for Rabeprazole oral tablet. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Vitality Health Plan of California 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, Vitality Health Plan of California may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Vitality Health Plan of California 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 3. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explain our prior authorization and step II-5

7 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 Vitality Health Plan of California 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 the Vitality Health Plan of California s formulary? on page II-7 for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Vitality Health Plan of California pays for certain OTC drugs. DRUG NAME STRENGTH DOSAGE FORM CETIRIZINE HCL 5 MG TABLET CETIRIZINE HCL 10 MG TABLET CETIRIZINE HCL 5 MG TAB CHEW CETIRIZINE HCL 10 MG TAB CHEW CETIRIZINE HCL 1 MG/ML ORAL SOLN CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H FEXOFENADINE HCL 30 MG TAB RAPDIS FEXOFENADINE HCL 60 MG TABLET FEXOFENADINE HCL 180 MG TABLET FEXOFENADINE/PSEUDOEPHEDRINE 60MG-120MG TAB ER 12H FEXOFENADINE/PSEUDOEPHEDRINE MG TAB ER 24H FEXOFENADINE HCL 30 MG/5 ML ORAL SUSP LORATADINE 10 MG TABLET LORATADINE 10 MG TAB RAPDIS LORATADINE/PSEUDOEPHEDRINE 10MG-240MG TAB ER 24H LORATADINE/PSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H LORATADINE 5 MG/5 ML ORAL SOLN KETOTIFEN 0.03% OPHT DROPS Vitality Health Plan of California will provide these OTC drugs at no cost to you. The cost to Vitality Health Plan of California of these OTC drugs will not count toward your total Part D drug costs (that is, the cost of the OTC drugs does not count for the coverage gap. 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 Vitality Health Plan of California does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Vitality Health Plan of California. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Vitality Health Plan of California. You can ask Vitality Health Plan of California to make an exception and cover your drug. See below for information about how to request an exception. II-6

8 How do I request an exception to the Vitality Health Plan of California s Formulary? You can ask Vitality Health Plan of California 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 this drug is not on the specialty tier. 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, Vitality Health Plan of California 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, Vitality Health Plan of California 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, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 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 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. 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 31-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 31-day supply of medication. After your first 31-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 and 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 31-day emergency supply of that drug while you pursue a formulary exception. In circumstances where a beneficiary is changing from one treatment setting to another, Vitality Health Plan will ensure a fast process for approving non-formulary Part D drugs. This process shall also apply to formulary Part D drugs that require prior authorization or step-therapy. Examples of level of care changes are: beneficiaries who are discharged from a hospital to a home; beneficiaries who end their skilled nursing facility Medicare Part A stay and who need to revert to their Part D plan formulary; beneficiaries who end a long-term care facility stay and return to the community; and, beneficiaries who are discharged from II-7

9 psychiatric hospitals with medication regimens that are highly individualized. Vitality Health Plans contracted pharmacies can insert an industry standard submission code at the point of sale to override the formulary restrictions. Vitality Health Plans contracted PBM s (MedImpact) after hours service will provide pharmacies with access to representatives who can override pharmacy claims processing issues. This access will allow pharmacies the ability to override claims at the point-of-sale and ensure beneficiaries receive reliable access to medications. For more information For more detailed information about your Vitality Health Plan of California prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Vitality Health Plan of California, 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 MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Vitality Health Plan of California Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Vitality Health Plan of California. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ELIQUIS) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if Vitality Health Plan of California has any special requirements for coverage of your drug. Abbreviation Description Prior PA Authorization Restriction Prior Authorization PA BvD Restriction for Part B vs Part D Determination PA-HRM PA NSO Prior Authorization Restriction for High Risk Medications Prior Authorization Explanation You (or your physician) are required to get prior authorization from Vitality Health Plan before you fill your prescription for this drug. Without prior approval, Vitality Health Plan may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from Vitality Health Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Vitality Health Plan may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 yrs or older are required to get prior authorization from Vitality Health Plan before you fill your prescription for this drug. Without prior approval, Vitality Health Plan may not cover this drug If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from Vitality II-8

10 PA NSO- HRM QL ST EX LA GC NM Restriction for New Starts Only Prior Authorization Restriction for High Risk Medications and for New Starts Only Quantity Limit Restriction Step Therapy Restriction Excluded Part D Drug Limited Access Drug Gap Coverage Non-Mail Order Drug Health Plan before you fill your prescription for this drug. Without prior approval, Vitality Health Plan may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 yrs or older are required to get prior authorization from Vitality Health Plan before you fill your prescription for this drug. Without prior approval, Vitality Health Plan may not cover this drug. Vitality Health Plan limits the amount of this drug that is covered per prescription, or within a specific time frame. Before Vitality Health Plan will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at ,. TTY/TDD users should call We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. You may be able to receive greater than a 1- month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. This drug is not eligible for greater than a 1-month supply per fill. NDS Non-Extended Day Supply HI Home Infusion This prescription drug may be covered under our medical benefit. For Drug more information, call AGE Age limit This prescription drug will be limited to certain age groups. Restriction CB Capped Benefit This drug has a maximum benefit. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Drug Name Drug Tier Requirements/Limits sildenafil oral tablet 100 mg (Viagra) 2 Quantity Limits (maximum 6 tablets per 30 sildenafil oral tablet 50 mg (Viagra) 2 Quantity Limits (maximum 6 tablets per 30 sildenafil oral tablet 25 mg (Viagra) 2 Quantity Limits (maximum 6 tablets per 30 II-9

11 Copayments/Coinsurance for members in Vitality Choice Plan (HMO): Tier Description Copayment/Coinsurance 30 day supply 90 day supply Tier 1 Preferred Generic $0 $0 Tier 2 Generic $5 $10 Tier 3 Preferred Brand $35 $70 Tier 4 Non-Preferred Brand $90 $180 Tier 5 Specialty Tier 33% Not Applicable Copayments/Coinsurance for members in Vitality Plus Plan (HMO): Tier Description Copayment/Coinsurance 30 day supply 90 day supply Tier 1 Preferred Generic $0 $0 Tier 2 Generic 25% 25% Tier 3 Preferred Brand 25% 25% Tier 4 Non-Preferred Brand 25% 25% Tier 5 Specialty Tier 25% Not Applicable II-10

12 Vitality Health Plan of California es un plan Medicare Advantage HMO que tiene un contrato con Medicare. La inscripción en el plan depende de la renovación del contrato. Esta información no es una descripción completa de los beneficios. Llame al (TTY: 711) para obtener más información. Disponibilidad de servicios de asistencia lingüística para personas con dominio limitado del inglés Horario de atención: De 8:00 a. m. a 8:00 p. m., los siete días de la semana desde el 1.º de octubre hasta el 31 de marzo; y de lunes a viernes desde el 1.º de abril hasta el 30 de septiembre. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY :711) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY (հեռատիպ) 711): توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. با 711) (TTY: تماس بگیرید. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:711) まで お電話にてご連絡ください ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم هاتف الصم والبكم: 711). ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚ ਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬਧ ਹ (TTY: 711) 'ਤ ਕ ਲ ਕਰ បយ ត ប ស ន អ កន យ ខ រ, ស ជ ន យ ផ ក យម នគ តឈ ល គ ច នស ប ប រ អ ក ច រ ទ រស ព (TTY: 711) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). न द : य द आप ह द ब लत ह त आपक लए म म भ ष सह यत स व ए उपल ह (TTY: 711) पर क ल कर เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711). II-11

13 La discriminación está prohibida por la ley Vitality Health Plan of California cumple con todas las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, origen étnico, nacionalidad, religión, género, sexo, edad, discapacidad mental o física, condición de salud, recepción de atención médica, experiencia en cuanto a reclamaciones, historia clínica, información genética, prueba de asegurabilidad o ubicación geográfica. Vitality Health Plan of California no excluye a las personas ni las trata diferente por motivos de raza, origen étnico, nacionalidad, religión, género, sexo, edad, discapacidad mental o física, condición de salud, recepción de atención médica, experiencia en cuanto a reclamaciones, historia clínica, información genética, prueba de asegurabilidad o ubicación geográfica. Vitality Health Plan of California: Brinda servicios y ayudas sin cargo a personas con discapacidades para que se puedan comunicar con nosotros de manera eficaz, tales como los siguientes: o Intérpretes calificados en lengua de señas o Información por escrito en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos) Brinda servicios lingüísticos sin cargo a personas cuyo idioma principal no es el inglés, tales como los siguientes: o Intérpretes calificados o Información escrita en otros idiomas Si necesita estos servicios, comuníquese con el Departamento de Servicio para los miembros de Vitality al (TTY: 711) para obtener ayuda. Desde el 1.º de octubre hasta el 31 de marzo, el horario de atención es de 8:00 a. m. a 8:00 p. m., los siete días de la semana; y desde el 1.º de abril hasta el 30 de septiembre, el horario de atención es de lunes a viernes. También puede comunicarse con un coordinador de derechos civiles que trabaja para Vitality Health Plan of California. Si considera que Vitality Health Plan of California no le ha brindado estos servicios o lo ha discriminado de otra forma por motivos de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar una queja usando lo siguientes datos: Vitality Health Plan of California Member Services Department (Complaints) Studebaker Road, Suite 960 Cerritos, CA TTY: 711 FAX: Puede presentar una queja en persona o por correo, fax o correo electrónico. Si necesita ayuda para presentar una queja, un coordinador de derechos civiles de Vitality está disponible para ayudarlo. También puede presentar un reclamo relacionado con los derechos civiles ante la Oficina de Derechos Civiles (Office for Civil Rights) del Departamento de Salud y Servicios Humanos (Department of Health and Human Services) de los EE. UU., por vía electrónica a través del Portal de la Oficina de Derechos Civiles, disponible en o por correo o teléfono: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Los formularios de reclamo están disponibles en II-12

14 Nota para los miembros actuales: Este formulario se modificó desde el año pasado. Para asegurarse de que los medicamentos que usa sigan figurando, revise este documento. Cuando en esta lista de medicamentos (formulario), se menciona nosotros, nos o nuestro/a(s), se hace referencia a Vitality Health Plan of California. Cuando se menciona plan o nuestro plan, se hace referencia a Vitality Choice y Vitality Plus. Este documento incluye la lista de los medicamentos (formulario) para nuestro plan, que tiene vigencia a partir del 8/23/2018. Si necesita un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en la que actualizamos el formulario por última vez, aparece en las páginas de portada y de contraportada. En general, debe ir a farmacias de la red para usar su beneficio de medicamentos con receta. Los beneficios, el formulario, la red de farmacias o los copagos o el coseguro pueden cambiar el 1.º de enero de 2020, así como de vez en cuando durante el año. Qué es el formulario de Vitality Health Plan of California? Un formulario es una lista de medicamentos cubiertos que Vitality Health Plan of California seleccionó con el asesoramiento de un equipo de proveedores de atención médica y que representa las terapias recetadas que se consideran una parte necesaria de un programa de tratamiento de calidad. En general, Vitality Health Plan of California cubre los medicamentos que figuran en el formulario siempre y cuando el medicamento sea necesario por motivos médicos, se abastezca la receta en una farmacia de la red de Vitality Health Plan of California y se cumplan otras reglas del plan. Para obtener más información sobre cómo abastecer una receta, consulte la Evidencia de cobertura. Puede cambiar el formulario (lista de medicamentos)? En general, si está usando un medicamento que figura en el formulario de 2019 y que tenía cobertura al inicio del año, no cancelaremos ni reduciremos la cobertura del medicamento durante el año de cobertura de 2019, salvo cuando haya un medicamento genérico nuevo menos costoso disponible, cuando se publique información nueva sobre la seguridad o la eficacia de un medicamento o cuando se retire el medicamento del mercado. (Para obtener más información sobre los cambios que afectan a los miembros que están usando el medicamento, consulte las viñetas a continuación). Otros tipos de cambio en el formulario, como cuando se quita un medicamento del formulario, no afectarán a los miembros que estén usando el medicamento. Estos medicamentos seguirán estando disponibles con el mismo nivel de costo compartido durante el resto del año de cobertura para los miembros que los estén usando. A continuación, se detallan los cambios en la lista de medicamentos que también afectarán a los miembros que estén usando un medicamento: Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentos (Food and Drug Administration, FDA) considera que un medicamento que figura en nuestro formulario no es seguro o si el fabricante del medicamento retira el medicamento del mercado, quitaremos inmediatamente el medicamento del formulario y les avisaremos a los miembros que lo usen. Otros cambios. Podremos hacer otros cambios que afecten a los miembros que usan un medicamento. Por ejemplo, podremos agregar un medicamento genérico nuevo en reemplazo de un medicamento de marca que está en el formulario o podremos agregar restricciones nuevas a un medicamento de marca o moverlo a otro nivel de costo compartido. O bien, podremos hacer cambios basados en pautas clínicas nuevas. Si quitamos medicamentos del formulario, agregamos requisitos de autorización previa, límites de cantidad o restricciones de terapia escalonada a un medicamento, o movemos un medicamento a un nivel de costo compartido más alto, debemos notificar el cambio a los miembros II-13

15 afectados al menos 30 días antes de que el cambio entre en vigencia, o en el momento en que el miembro solicite un reabastecimiento del medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 30 días. El formulario adjunto está vigente a partir del 8/23/2018. Para obtener información actualizada sobre los medicamentos que cubre Vitality Health Plan of California, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de portada y de contraportada. Todos los meses, Vitality Health Plan of California le envía por correo un informe llamado Explicación de beneficios (EOB, por su sigla en inglés). En la EOB, se le informa el monto total que ha gastado en medicamentos con receta, así como el total que nosotros pagamos por cada medicamento con receta a lo largo del mes. Junto con la EOB, le enviaremos un Aviso de cambio en el formulario en caso de que se haya hecho algún cambio reciente en el formulario. Además, todos los cambios del formulario se incluirán en el formulario que se actualiza mensualmente, disponible en nuestro sitio web, Cómo uso el formulario? Hay dos formas de encontrar un medicamento en el formulario: Afección El formulario empieza en la página 1. En este formulario, los medicamentos están agrupados en categorías según el tipo de afección para la que se usan. Por ejemplo, los medicamentos que se usan para tratar una enfermedad cardíaca figuran en la categoría Agentes cardiovasculares. Si sabe para qué afección se usa el medicamento, busque el nombre de la categoría en la lista que empieza en la página 3. Luego, busque el medicamento en el nombre de la categoría. Lista alfabética Si no está seguro de la categoría en la que debe buscar, busque el medicamento en el Índice, que empieza en la página I-1. El Índice incluye una lista alfabética de todos los medicamentos que figuran en este documento, tanto los medicamentos de marca como los genéricos. Para encontrar el medicamento, busque en el Índice. Al lado del medicamento, verá el número de página en la que podrá encontrar información sobre cobertura. Vaya a la página que figura en el Índice y busque el nombre del medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Vitality Health Plan of California cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la FDA ya que tiene el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los de marca. Hay restricciones en mi cobertura? Algunos medicamentos cubiertos podrían tener requisitos adicionales o límites en la cobertura. Estos requisitos y límites pueden incluir los siguientes: Autorización previa: Vitality Health Plan of California solicita que usted o su médico obtengan una autorización previa para ciertos medicamentos. Esto significa que deberá obtener la aprobación de Vitality Health Plan of California antes de abastecer sus recetas. Si no obtiene la aprobación, es posible que Vitality Health Plan of California no cubra el medicamento. Límites de cantidad: Para ciertos medicamentos, Vitality Health Plan of California limita la cantidad del medicamento que Vitality Health Plan of California cubrirá. Por ejemplo, Vitality Health Plan of II-14

16 California proporciona 30 comprimidos por receta de rabeprazol en comprimidos por vía oral. Esto podría ser aparte de un suministro estándar de un mes o de tres meses. Terapia escalonada: En algunos casos, Vitality Health Plan of California le solicita que pruebe ciertos medicamentos para tratar su afección antes de que cubra otro medicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento B se usan para tratar su afección, Vitality Health Plan of California podría no cubrir el medicamento B, a menos que usted pruebe primero el medicamento A. Si el medicamento A no le resulta eficaz, Vitality Health Plan of California cubrirá el medicamento B. Para averiguar si el medicamento que necesita tiene requisitos o límites adicionales, consulte el formulario, que empieza en la página 3. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos en nuestro sitio web. Allí publicamos un documento en el que se explican las restricciones de terapia escalonada y autorización previa. Si desea una copia, puede pedirnos que le enviemos una. Nuestra información de contacto, junto con la fecha en la que actualizamos el formulario por última vez, aparece en las páginas de portada y de contraportada. Puede pedirle a Vitality Health Plan of California que haga una excepción con respecto a estas restricciones o límites, o para una lista de otros medicamentos similares que puedan usarse para tratar su afección. Para obtener información sobre cómo solicitar una excepción, consulte la sección Cómo solicito una excepción al formulario de Vitality Health Plan of California? en la página II-16. Qué son los medicamentos de venta libre (OTC)? Los medicamentos de venta libre son medicamentos sin receta que no suelen estar cubiertos por un Plan de medicamentos con receta de Medicare. Vitality Health Plan of California paga ciertos medicamentos de venta libre. NOMBRE DEL MEDICAMENTO CONCENTRACIÓN PRESENTACIÓN CETIRIZINE HCL 5 MG COMPRIMIDO CETIRIZINE HCL 10 MG COMPRIMIDO CETIRIZINE HCL 5 MG COMP. MASTICABLE CETIRIZINE HCL 10 MG COMP. MASTICABLE CETIRIZINE HCL 1 MG/ML SOLUC. ORAL CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG COMP. LIB. PROL. 12H FEXOFENADINE HCL 30 MG COMP. DISOL. RÁP. FEXOFENADINE HCL 60 MG COMPRIMIDO FEXOFENADINE HCL 180 MG COMPRIMIDO FEXOFENADINE/PSEUDOEPHEDRINE 60MG-120MG COMP. LIB. PROL. 12H FEXOFENADINE/PSEUDOEPHEDRINE MG COMP. LIB. PROL. 24H FEXOFENADINE HCL 30 MG/5 ML SUSP. ORAL LORATADINE 10 MG COMPRIMIDO LORATADINE 10 MG COMP. DISOL. RÁP. LORATADINE/PSEUDOEPHEDRINE 10MG-240MG COMP. LIB. PROL. 24H LORATADINE/PSEUDOEPHEDRINE 5 MG-120MG COMP. LIB. PROL. 12H LORATADINE 5 MG/5 ML SOLUC. ORAL KETOTIFEN 0.03% GOTAS OFT. Vitality Health Plan of California le proporcionará estos medicamentos de venta libre sin costo alguno. El costo de estos medicamentos de venta libre para Vitality Health Plan of California no se contará para el total II-15

17 de sus costos de medicamentos de la Parte D (es decir, el costo de los medicamentos de venta libre no se cuenta para el periodo sin cobertura). Qué sucede si el medicamento que necesito no está en el formulario? Si el medicamento que necesita no está en este formulario (lista de medicamentos cubiertos), comuníquese primero con Servicios para los miembros y pregunte si el medicamento está cubierto. Si le informan que Vitality Health Plan of California no cubre el medicamento, tiene dos opciones: Puede pedirle a Servicios para los miembros una lista de medicamentos similares que estén cubiertos por Vitality Health Plan of California. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por Vitality Health Plan of California. Puede pedirle a Vitality Health Plan of California que haga una excepción y que le cubra el medicamento. A continuación, se incluye información sobre cómo solicitar una excepción. Cómo solicito una excepción al formulario de Vitality Health Plan of California? Puede pedirle a Vitality Health Plan of California que haga una excepción a nuestras normas de cobertura. Son varios los tipos de excepción que puede pedirnos que hagamos. Puede pedirnos que cubramos un medicamento, incluso si no está en el formulario. Si aprobamos el medicamento, se lo cubrirá con un nivel de costo compartido predeterminado, y usted no podrá pedirnos que proporcionemos el medicamento con un nivel menor de costo compartido. Puede pedirnos que cubramos un medicamento del formulario con un nivel menor de costo compartido si este no está en el nivel de medicamentos especiales. Si lo aprobamos, usted pagará un monto menor por el medicamento. Puede pedirnos que no apliquemos las restricciones de cobertura o los límites en el medicamento. Por ejemplo, para ciertos medicamentos, Vitality Health Plan of California limita la cantidad del medicamento que cubriremos. Si el medicamento que necesita tiene un límite de cantidad, puede pedirnos que no apliquemos el límite y que cubramos una cantidad mayor. En general, Vitality Health Plan of California solo aprobará su solicitud de una excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento con un nivel menor de costo compartido o restricciones de utilización adicionales no tendrían la misma eficacia para tratar su afección o le provocarían efectos médicos adversos. Comuníquese con nosotros para solicitarnos una decisión de cobertura inicial para una excepción a las restricciones de utilización o al formulario. Cuando solicita una excepción a las restricciones de utilización o al formulario, debe enviar una declaración de su médico o del emisor de la receta para respaldar su solicitud. En general, debemos tomar una decisión en el plazo de 72 horas luego de haber recibido la declaración de respaldo del emisor de la receta. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que esperar una decisión hasta 72 horas podría perjudicar seriamente su salud. Si se le otorga la solicitud de acelerar el proceso, debemos proporcionarle una decisión antes de que transcurran 24 horas de haber recibido una declaración de respaldo de su médico o de otro emisor de recetas. Si necesito cambiar un medicamento o solicitar una excepción, qué debo hacer antes de hablar con mi médico al respecto? Como miembro nuevo o que continúa en nuestro plan, podría estar usando medicamentos que no están en nuestro formulario. O bien, podría estar usando un medicamento que está en el formulario, pero su capacidad para obtenerlo es limitada. Por ejemplo, antes de poder abastecer su receta, podría necesitar nuestra II-16

18 autorización previa. Hable con su médico para decidir si debería cambiar por un medicamento adecuado que cubramos o solicitar una excepción al formulario para que cubramos el medicamento que usa. Mientras consulta con su médico para determinar la forma de proceder correcta para usted, podemos cubrir el medicamento en ciertos casos durante los primeros 90 días en los que usted es miembro de nuestro plan. Para cada uno de los medicamentos que no estén en el formulario o si su capacidad de obtener los medicamentos es limitada, cubriremos un suministro temporal de 31 días. Si su receta es por menos días, permitiremos reabastecimientos para proporcionar un suministro máximo de 31 días del medicamento. Después del primer suministro de 31 días, no pagaremos estos medicamentos, incluso en caso de que usted haya sido miembro del plan durante menos de 90 días. Si reside en un centro de atención a largo plazo y necesita un medicamento que no está en el formulario o si su capacidad de obtener los medicamentos es limitada, pero ya pasaron los primeros 90 días de la fecha de inscripción en el plan, cubriremos un suministro de emergencia de 31 días de ese medicamento mientras usted solicita una excepción al formulario. En circunstancias en las que un beneficiario se traslade de un centro de tratamiento a otro, Vitality Health Plan proporcionará un proceso rápido para aprobar los medicamentos de la Parte D que no están en el formulario. Este proceso también se aplicará a medicamentos de la Parte D que están en el formulario y que requieran una autorización previa o una terapia escalonada. Estos son ejemplos de cambio en el nivel de atención: beneficiarios a los que se les da el alta de un hospital para que vayan a un hogar; los beneficiarios que terminan su internación en un centro de enfermería especializada conforme a la Parte A de Medicare o que necesitan volver al formulario del plan de la Parte D; los beneficiarios que terminan una internación en un centro de atención a largo plazo y regresan a la comunidad; y los beneficiarios a los que se les da el alta de hospitales psiquiátricos con regímenes de medicamentos muy individualizados. Las farmacias contratadas por Vitality Health Plans pueden ingresar un código de presentación estándar de la industria en el punto de venta para anular las restricciones en el formulario. El servicio fuera del horario de atención del administrador de beneficios de farmacia (PBM), MedImpact, contratado por Vitality Health Plans brinda a las farmacias acceso a representantes que pueden resolver los problemas de procesamiento de las reclamaciones de farmacia. De esta manera, las farmacias podrán anular las reclamaciones en el punto de venta y asegurarse de que los beneficiarios reciban un acceso confiable a los medicamentos. Para obtener más información Para obtener información más detallada sobre su cobertura de medicamentos con receta de Vitality Health Plan of California, revise la Evidencia de cobertura y otros materiales del plan. Si tiene alguna pregunta sobre Vitality Health Plan of California, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en la que actualizamos el formulario por última vez, aparece en las páginas de portada y de contraportada. Si tiene preguntas generales sobre la cobertura de medicamentos con receta de Medicare, llame a Medicare al MEDICARE ( ) las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al O bien, visite II-17

19 Formulario de Vitality Health Plan of California El formulario, que empieza en la página siguiente, incluye información sobre la cobertura de los medicamentos que cubre Vitality Health Plan of California. Si no puede encontrar un medicamento en la lista, búsquelo en el Índice, que empieza en la página I-1. En la primera columna de la tabla, se detalla el nombre del medicamento. Los medicamentos de marca están en mayúsculas (p. ej., ELIQUIS), y los medicamentos genéricos están en minúscula y en cursiva (p. ej., simvastatina). La información en la columna Requisitos/Límites le indica si Vitality Health Plan of California tiene requisitos especiales para la cobertura del medicamento. Abreviatura Descripción Explicación PA PA BvD PA-HRM PA NSO PA NSO- HRM QL ST Restricción de autorización previa Restricción de autorización previa para determinación de Parte B frente a Parte D Restricción de autorización previa para medicamentos de alto riesgo Restricción de autorización previa para nuevos comienzos únicamente Restricción de autorización previa para medicamentos de alto riesgo y nuevos comienzos únicamente Restricción de límite de cantidad Restricción de terapia escalonada Usted (o su médico) debe obtener una autorización previa de Vitality Health Plan antes de abastecer la receta para este medicamento. Sin la aprobación previa, es posible que Vitality Health Plan no cubra este medicamento. Este medicamento podría ser elegible para pagarse según la Parte B o la Parte D de Medicare. Usted (o su médico) debe obtener una autorización previa de Vitality Health Plan para determinar si este medicamento está cubierto por la Parte D de Medicare antes de abastecer la receta para este medicamento. Sin la aprobación previa, es posible que Vitality Health Plan no cubra este medicamento. Los Centros de Servicios de Medicare y Medicaid (Centers for Medicare and Medicaid Services, CMS) han considerado que este medicamento es potencialmente dañino, por lo que es un medicamento de alto riesgo para los beneficiarios de Medicare de 65 años o más. Los miembros de 65 años o más deben obtener una autorización previa de Vitality Health Plan antes de abastecer la receta para este medicamento. Sin la aprobación previa, es posible que Vitality Health Plan no cubra este medicamento. Si usted es un nuevo miembro o si no ha usado este medicamento antes, usted (o su médico) debe obtener una autorización previa de Vitality Health Plan antes de abastecer la receta para este medicamento. Sin la aprobación previa, es posible que Vitality Health Plan no cubra este medicamento. Los Centros de Servicios de Medicare y Medicaid (Centers for Medicare and Medicaid Services, CMS) han considerado que este medicamento es potencialmente dañino, por lo que es un medicamento de alto riesgo para los beneficiarios de Medicare de 65 años o más. Los miembros de 65 años o más deben obtener una autorización previa de Vitality Health Plan antes de abastecer la receta para este medicamento. Sin la aprobación previa, es posible que Vitality Health Plan no cubra este medicamento. Vitality Health Plan limita la cantidad de este medicamento que se cubre por receta, o en un plazo específico. Antes de que Vitality Health Plan brinde cobertura para este medicamento, usted deberá probar otro u otros medicamentos para tratar su afección. Este medicamento podrá cubrirse solo si los otros medicamentos no le resultan eficaces. II-18

20 EX LA GC NM NDS HI AGE CB Medicamento excluido de la Parte D Medicamento de acceso limitado Periodo sin cobertura Medicamento no disponible a través de venta por correo Suministro de días sin posibilidad de extensión Medicamento de infusión a domicilio Restricción de límite de edad Límite de beneficio Este medicamento con receta no suele estar cubierto por un Plan de medicamentos con receta de Medicare. El monto que usted paga cuando abastece una receta para este medicamento no se cuenta para sus costos totales de medicamentos (es decir, el monto que paga no le ayuda a reunir los requisitos para la cobertura en caso de catástrofe). Además, si recibe ayuda adicional para pagar los medicamentos con receta, no recibirá ayuda adicional para pagar este medicamento. Este medicamento con receta puede estar disponible solo en ciertas farmacias. Para obtener más información, consulte el Directorio de farmacias o llame a Servicios para los miembros al Los usuarios de TTY deben llamar al Brindamos cobertura para este medicamento con receta en el periodo sin cobertura. Consulte la Evidencia de cobertura para obtener más información sobre esta cobertura. Podría recibir un suministro mayor de 1 mes para la mayoría de los medicamentos que figuran en el formulario a través de la venta por correo con un costo compartido menor. Los medicamentos que no están disponibles a través del beneficio de venta por correo se indican con NM en la columna Requisitos/Límites del formulario. Este medicamento no es elegible para un suministro mayor de 1 mes por abastecimiento. Este medicamento podría estar cubierto por el beneficio médico. Para obtener más información, llame. Este medicamento con receta se limitará a ciertos grupos etarios. Este medicamento tiene un beneficio máximo. Este medicamento con receta no suele estar cubierto por un Plan de medicamentos con receta de Medicare. El monto que usted paga cuando abastece una receta para este medicamento no se cuenta para sus costos totales de medicamentos (es decir, el monto que paga no le ayuda a reunir los requisitos para la cobertura en caso de catástrofe). Además, si recibe ayuda adicional para pagar los medicamentos con receta, no recibirá ayuda adicional para pagar este medicamento. Nombre del medicamento sildenafil comprimidos por vía oral 100 mg (Viagra) sildenafil comprimidos por vía oral 50 mg (Viagra) sildenafil comprimidos por vía oral 25 mg (Viagra) Nivel de Requisitos/Límites medicamentos 2 Límites de cantidad (máximo de 6 comprimidos cada 30 días) 2 Límites de cantidad (máximo de 6 comprimidos cada 30 días) 2 Límites de cantidad (máximo de 6 comprimidos cada 30 días) II-19

21 Copagos/Coseguro para miembros en Vitality Choice Plan (HMO): Nivel Descripción Copago/Coseguro Suministro de 30 días Suministro de 90 días Nivel 1 Medicamento genérico preferido $0 $0 Nivel 2 Medicamento genérico $5 $10 Nivel 3 Medicamento de marca preferido $35 $70 Nivel 4 Medicamento de marca no preferido $90 $180 Nivel 5 Nivel de medicamentos especiales 33 % No Aplica Copagos/Coseguro para miembros en Vitality Plus Plan (HMO): Nivel Descripción Copago/Coseguro Suministro de 30 días Suministro de 90 días Nivel 1 Medicamento genérico preferido $0 $0 Nivel 2 Medicamento genérico 25 % 25 % Nivel 3 Medicamento de marca preferido 25 % 25 % Nivel 4 Medicamento de marca no preferido 25 % 25 % Nivel 5 Nivel de medicamentos especiales 25 % No Aplica II-20

22 Vitality Health Plan of California 是一項簽有 Medicare 合約的 Medicare Advantage HMO 計劃 能否在計劃註冊參保視合約續簽情況而定 本資訊並非完整之福利敘述 請致電 ( 聽障專線 :711) 瞭解更多資訊 提供語言協助服務服務時間 :10 月 1 日至 3 月 31 日期間, 每週七天, 上午 8 點至晚上 8 點 ;4 月 1 日至 9 月 30 日期間, 週一至週五, 上午 8 點至晚上 8 點 ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY :711) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY (հեռատիպ) 711): توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. با 711) (TTY: تماس بگیرید. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:711) まで お電話にてご連絡ください ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم هاتف الصم والبكم: 711). ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚ ਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬਧ ਹ (TTY: 711) 'ਤ ਕ ਲ ਕਰ បយ ត ប ស ន អ កន យ ខ រ, ស ជ ន យ ផ ក យម នគ តឈ ល គ ច នស ប ប រ អ ក ច រ ទ រស ព (TTY: 711) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). न द : य द आप ह द ब लत ह त आपक लए म म भ ष सह यत स व ए उपल ह (TTY: 711) पर क ल कर เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711). II-21

23 歧視屬於違法 Vitality Health Plan of California 遵循適用的聯邦民權法, 不會因種族 族群 原國籍 宗教 性別認同 性別 年齡 身心殘障 健康狀況 接受醫療護理情況 索賠經歷 病史 基因資訊 可保性證明或地理位置而歧視任何人 Vitality Health Plan of California 不會因種族 族群 原國籍 宗教 性別認同 性別 年齡 身心殘障 健康狀況 接受醫療護理情況 索賠經歷 病史 基因資訊 可保性證明或地理位置而拒絕或差別對待任何人 Vitality Health Plan of California 承諾 : 向殘障人士提供免費協助和服務, 幫助他們與我們進行有效溝通, 比如 : o 合格的手語翻譯員 o 其他格式的書面資訊 ( 大號字體 音訊 無障礙電子格式 其他格式 ) 向母語並非英語的人士提供免費語言服務, 比如 : o 合格的翻譯員 o 用其他語言書寫的資訊 如果您需要這些服務, 請致電 ( 聽障專線 :711) 聯絡 Vitality 會員服務部獲取協助 服務時間為 10 月 1 日至 3 月 31 日期間, 每週七天, 上午 8 點至晚上 8 點 ;4 月 1 日至 9 月 30 日期間, 週一至週五, 上午 8 點至晚上 8 點 您也可以要求 Vitality Health Plan of California 的民權協調員為您服務 如果您認為 Vitality Health Plan of California 因種族 膚色 原國籍 年齡 殘障或性別而未能提供這些服務或在其他方面存在歧視行為, 您可向以下人員提出申訴 : Vitality Health Plan of California Member Services Department (Complaints) Studebaker Road, Suite 960 Cerritos, CA , 聽障專線 :711, 傳真 : 您可以親自或以郵寄 傳真或電子郵件的方式提出申訴 如果您在提出申訴時需要幫助,Vitality 民權協調員可向您提供幫助 您還可以透過美國衛生與公眾服務部民權辦公室的入口網站 以電子方式向民權辦公室提出民權投訴, 或透過寄送郵件或致電提出投訴 : U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , ( 語障專線 ) 投訴表格可在 取得 II-22

24 現有會員請注意 : 本處方藥一覽表自去年以來已經變更 請閱讀本文件, 確保本藥物表仍然包含您服用的藥物 本藥物清單 ( 處方藥一覽表 ) 中, 凡提述 我們 或 我們的 時, 均指 Vitality Health Plan of California 凡提述 計劃 或 我們的計劃 時, 均指 Vitality Choice 和 Vitality Plus 本文件載有我們計劃截至 2018 年 8 月 23 日的藥物清單 ( 處方藥一覽表 ) 如需獲取最新的處方藥一覽表, 請聯絡我們 我們的聯絡資訊連同最後更新處方藥一覽表的日期載於封面和封底 一般而言, 您必須使用網絡內藥房才能享受處方藥福利 自 2020 年 1 月 1 日起和在該年內, 福利 處方藥一覽表 藥房網絡和 / 或共付額 / 共同保險可能會不時有所調整 什麼是 Vitality Health Plan of California 處方藥一覽表? 處方藥一覽表是 Vitality Health Plan of California 透過諮詢醫療提供者團隊所選出的受保藥物清單, 是高品質治療計劃中不可或缺的處方藥治療 只要具有醫療必要性, 且於 Vitality Health Plan of California 網絡內藥房配藥, 並遵守其他計劃規定,Vitality Health Plan of California 通常會承保列於我們處方藥一覽表中的藥物 要瞭解有關如何按您的處方配藥的更多資訊, 請查閱您的 承保範圍說明書 處方藥一覽表 ( 藥物清單 ) 是否會變更? 一般情況下, 如果您的藥物年初包含在 2019 年處方藥一覽表中, 我們不會在 2019 承保年度中停止承保或減少承保該藥物 例外情況是 : 出現了價格更為低廉的全新普通藥 ; 或某種藥物的安全性或有效性方面出現了新的不良資訊報告 ; 或者藥物退出市場 ( 請參閱下文, 詳細瞭解會影響目前正在使用藥物的會員的變更 ) 其他類型的處方藥一覽表變更 ( 例如從處方藥一覽表中刪除某種藥物 ) 不會對目前正在使用此藥物的會員產生影響 在承保年度剩餘時間內, 將以相同的共付額向使用此藥物的會員提供此藥物 以下藥物清單變更也會影響目前正在使用藥物的會員 : 藥物退出市場 若美國食品及藥物管理局認為我們處方藥一覽表上的某種藥物不安全, 或藥物製造商從市場中撤除該藥物, 我們會立即從我們的處方藥一覽表上刪除該藥物, 並向使用該藥物的會員發出通知 其他變化 我們可能會作出影響目前正在使用藥物的會員的其他更改 例如, 我們可能會添加一種新的普通藥以取代處方藥一覽表上現有的品牌藥, 或對品牌藥添加新的限制條件, 或是將其移至其他費用分攤等級 我們也可能會根據新的臨床指南作出更改 如果我們從處方藥一覽表中移除了某些藥物, 對某個藥物新增了事先授權 數量限制和 / 或階段療法限制, 或提高某個藥物的費用分攤等級, 則我們必須在該更改生效前至少 30 天或在會員要求再次配藥時, 向受影響的會員發出通知 ( 該名會員將收到 30 天份的藥物 ) 本文件內附的處方藥一覽表最後更新於 2018 年 8 月 23 日 如需獲得有關 Vitality Health Plan of California 承保藥物的最新資訊, 請聯絡我們 我們的聯絡資訊載於封面和封底 Vitality Health Plan of California 每個月都會向您郵寄一份名為 福利說明 ( 簡稱 EOB ) 的報告 福利說明會告訴 II-23

25 您當月您已花費在處方藥上的總金額, 以及我們已為您每份處方藥支付的總金額 如果處方藥一覽表近期有所更改, 我們會在寄送福利說明時也向您寄送一份 處方藥一覽表更改通知 此外, 所有的處方藥一覽表更改將包含在處方藥一覽表的每月更新中, 詳見我們的網站 如何使用處方藥一覽表? 有兩種方法在處方藥一覽表中查找您所需的藥物 : 病症處方藥一覽表從第 1 頁開始 本處方藥一覽表中的藥物依照其所治療的病症類別分類 例如, 用來治療心臟病的藥物列在 心血管藥物 類別 若您瞭解藥物的用途, 您可在從第 3 頁開始的清單中查找類別名稱 然後, 在此類別名稱下查找所需的藥物 按字母順序排列的清單如果您不確定要尋找什麼類別, 您可以利用自第 I-1 頁開始的索引來尋找您的藥物 該索引提供一份按字母順序排列的清單, 其中有本文件包含的所有藥物 該索引中列有品牌藥和普通藥 請在該索引中查找所需的藥物 藥物旁邊註有頁碼, 您可以在該頁查找承保範圍資訊 轉到該索引中所列的頁碼, 在清單的第一欄即可找到所需的藥物名稱 什麼是普通藥? Vitality Health Plan of California 同時承保品牌藥和普通藥 普通藥是一種由 FDA 核准, 具有與品牌藥相同活性成分的藥物 通常, 普通藥的費用比品牌藥低 我的承保範圍是否有任何限制? 某些承保藥物可能有其他要求或承保範圍限制 這些要求和限制可能包括 : 事先授權 : 對於某些藥物,Vitality Health Plan of California 要求您或您的醫生取得事先授權 這表示您將需要在配藥前取得 Vitality Health Plan of California 的核准 如果您未取得核准, Vitality Health Plan of California 可能不會承保該藥物 數量限制 : 對於某些藥物,Vitality Health Plan of California 限制了 Vitality Health Plan of California 承保的藥物數量 例如 : 對於 Rabeprazole 口服藥片,Vitality Health Plan of California 會為每份處方提供 30 片 這可以另外附加在標準的一個月或三個月的供藥上 階段療法 : 某些情況下,Vitality Health Plan of California 會要求您先嘗試使用某些藥物治療您的病症, 才會承保您使用另外一種藥物 例如, 假設藥物 A 和藥物 B 都能治療您的病症, 則在您嘗試使用藥物 A 前,Vitality Health Plan of California 可能不會承保藥物 B 藥物 A 對您無效時,Vitality Health Plan of California 才會承保藥物 B 您可以透過第 3 頁開始的處方藥一覽表查詢您的藥物是否有額外的要求或限制 您也可以透過瀏覽我們的網站, 取得更多關於特定承保藥物限制的資訊 我們已在線上刊載文件, 說明我們事先授權 II-24

26 和階段療法的限制 您也可以要求我們寄一份給您 我們的聯絡資訊連同最後更新處方藥一覽表的日期載於封面和封底 您可以要求 Vitality Health Plan of California 對此類限制或使用上限作出例外處理, 或索取可能治療您的病症的其他相似藥物清單 請參見第 II-26 頁的 如何申請 Vitality Health Plan of California 處方藥一覽表例外處理? 章節, 瞭解如何申請例外處理的相關資訊 什麼是非處方 (OTC) 藥? 非處方藥是指無需醫生處方即可獲取的藥物, 通常不受 Medicare 處方藥計劃承保 Vitality Health Plan of California 會為某些非處方藥承保 藥物名稱 規格 藥物劑型 CETIRIZINE HCL 5 MG 片劑 CETIRIZINE HCL 10 MG 片劑 CETIRIZINE HCL 5 MG 咀嚼片 CETIRIZINE HCL 10 MG 咀嚼片 CETIRIZINE HCL 1 MG/ML 口服液 CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG 12 小時緩釋片 FEXOFENADINE HCL 30 MG 速溶片 FEXOFENADINE HCL 60 MG 片劑 FEXOFENADINE HCL 180 MG 片劑 FEXOFENADINE/PSEUDOEPHEDRINE 60MG-120MG 12 小時緩釋片 FEXOFENADINE/PSEUDOEPHEDRINE MG 24 小時緩釋片 FEXOFENADINE HCL 30 MG/5 ML 口服混懸液 LORATADINE 10 MG 片劑 LORATADINE 10 MG 速溶片 LORATADINE/PSEUDOEPHEDRINE 10MG-240MG 24 小時緩釋片 LORATADINE/PSEUDOEPHEDRINE 5 MG-120MG 12 小時緩釋片 LORATADINE 5 MG/5 ML 口服液 KETOTIFEN 0.03% 眼藥水 Vitality Health Plan of California 將免費為您提供這些非處方藥 Vitality Health Plan of California 為這些非處方藥支付的費用將不計入您的 D 部分藥物總費用 ( 即非處方藥的費用不計入達到承保範圍缺口的金額 ) 若我的藥物不在處方藥一覽表上, 該怎麼辦? 如果您的藥物不在此處方藥一覽表 ( 承保藥物清單 ) 上, 那麼您首先應該聯絡會員服務部, 詢問您的藥物是否在承保範圍內 如果您得知 Vitality Health Plan of California 並未承保您的藥物, 則您有兩種選擇 : II-25

27 向會員服務部索要一份由 Vitality Health Plan of California 承保的相似藥物清單 收到該清單後請拿給您的醫生看, 並要求醫生開處由 Vitality Health Plan of California 承保的相似藥物 您可以要求 Vitality Health Plan of California 作出例外處理, 並承保您的藥物 請查看以下關於如何申請例外處理的資訊 如何申請 Vitality Health Plan of California 處方藥一覽表例外處理? 您可以要求 Vitality Health Plan of California 對我們的承保規則作出例外處理 您可以申請多種例外處理 您可以要求我們承保不在我們的處方藥一覽表上的藥物 如經批准, 藥物將按事先確定的分攤費用水平承保, 您無法要求我們為該藥物提供更低的分攤費用水平 如果藥物不屬於特種藥等級, 您可以要求我們以更低的費用分攤水平承保處方藥一覽表中的藥物 如經批准, 您為藥物支付的費用也會更低 您可以要求我們豁免對您的藥物的承保範圍限制 例如, 對於某些藥物,Vitality Health Plan of California 限制了藥物的承保數量 如果您的藥物有數量限制, 則可以要求我們撤銷限制並承保更多數量 通常, 只有在替代藥物處於計劃的處方藥一覽表上時, 或是較低分攤費用的藥物或額外的使用限制對於治療您的病症無法達到相同的效果時, 和 / 或可能造成副作用時,Vitality Health Plan of California 才會批准您的例外處理申請 您應當聯絡我們, 要求我們做出針對處方藥一覽表或使用限制例外處理的初始承保決定 在提出針對處方藥一覽表或使用限制例外處理申請時, 您應提交一份處方醫生或醫生的聲明以支持您的申請 通常, 我們在收到處方醫生的支持聲明後, 必須在 72 小時內做出決定 如果您或您的醫生認為等候 72 小時再作出決定會對您的健康造成嚴重傷害, 您可以申請加急 ( 快速 ) 例外處理 如果您的加急申請獲得批准, 我們在收到您的醫生或其他處方醫生的支持聲明後, 必須在 24 小時內為您做出決定 在向醫生提出變更藥物請求或提交例外處理申請之前, 我應該做什麼? 無論是本計劃的新會員還是老會員, 您可能正在使用我們處方藥一覽表上沒有的藥物 或者, 您正在使用一種在我們處方藥一覽表上的藥物, 但您在獲取該藥物時受到限制 例如, 您在開藥之前可能要獲得我們的事先授權 您應當先和您的醫生談談, 以決定您是否應該換用我們承保的適當藥物, 或提出處方藥一覽表例外處理申請以使我們承保您使用的藥物 在您與醫生討論以確定何種措施適合您時, 我們會在您成為計劃會員後的頭 90 天內針對某些情況為您的藥物提供承保 對於您使用的不在處方藥一覽表上的每種藥物, 或因受限而難以獲取足量的藥物, 我們將為您承保 31 天的藥量 如果為您開具的處方上藥物供應天數較少, 我們將允許補充藥物, 以提供最多 31 天份的供藥 在最初的 31 天供藥後, 即使您成為計劃會員的天數還不足 90 天, 我們將不再為這些藥物付費 II-26

28 如果您居住在長期護理機構且需要的藥物不在處方藥一覽表上, 或您獲取藥物時受到限制, 但您成為我們計劃的會員已超過 90 天, 則在您尋求處方藥一覽表例外處理時, 我們將會對該藥物承保 31 天份的緊急供藥 如果受益人從一種治療環境轉至另一種環境,Vitality Health Plan 將確保遵循快速程序, 以核准不在處方藥一覽表中的 D 部分藥物 此程序還適用於要求事先授權或階段療法的處方藥一覽表 D 部分藥物 護理等級變更的範例有 : 受益人出院回家 ; 受益人結束專業護理機構 Medicare A 部分住院, 需要恢復使用 D 部分的計劃處方藥一覽表的藥物 ; 受益人結束長期護理機構住院, 返回社區中 ; 以及受益人從精神病院出院並使用高度個人化的藥物治療方案 與 Vitality Health Plan 簽有合約的藥房可在銷售點添加行業標準提交代碼, 以免除處方藥一覽表上的限制 與 Vitality Health Plan 簽有合約的 PBM( 藥房福利管理公司,MedImpact) 的非工作時間服務會為藥房提供代表的聯絡方式, 該代表能夠解決藥房索賠處理問題 這項服務能讓藥房能在銷售點解決索賠問題, 確保受益人獲得可靠的藥物補給 瞭解更多資訊 如需瞭解更多關於 Vitality Health Plan of California 處方藥承保的詳細資訊, 請查看您的 承保範圍說明書 及其他計劃資料 如果您對 Vitality Health Plan of California 有任何疑問, 請聯絡我們 我們的聯絡資訊連同最後更新處方藥一覽表的日期載於封面和封底 如果您對 Medicare 處方藥承保範圍有任何疑問, 請致電 Medicare, 電話 :1-800-MEDICARE ( )( 全天候熱線 ) 聽障人士可致電 或瀏覽 Vitality Health Plan of California 處方藥一覽表 從下一頁開始的處方藥一覽表介紹了 Vitality Health Plan of California 承保藥物的承保資訊 若您在清單中尋找藥物時遇到困難, 請閱讀從第 I-1 頁開始的索引 清單的第一欄列出了藥物名稱 品牌藥用大寫字母表示 ( 例如 ELIQUIS), 普通藥則用小寫斜體字母表示 ( 例如 simvastatin) 要求 / 限制欄中的資訊說明了 Vitality Health Plan of California 在承保您的藥物時是否有任何特殊要求 縮寫描述說明 PA 事先授權限制 您 ( 或您的醫生 ) 必須先獲得 Vitality Health Plan 的事先授權, 才可以配取該處方藥 若無事先授權,Vitality Health Plan 不會承保該藥物 II-27

29 PA BvD PA-HRM PA NSO PA NSO- HRM QL B 部分和 D 部分裁決的事先授權限制 高風險藥物的事先授權限制 新會員特有的事先授權限制 高風險藥物和新會員特有的事先授權限制 數量限制 此藥物可能享有 Medicare B 部分或 D 部分承保 您 ( 或您的醫生 ) 必須先獲得 Vitality Health Plan 的事先授權以裁決 Medicare D 部分是否承保此藥物, 才可以配取該處方藥 若無事先授權,Vitality Health Plan 不會承保該藥物 CMS 認為該藥物有潛在危害, 因此將它歸為 Medicare 65 歲或以上受益人的高風險藥物 65 歲或以上的會員必須先獲得 Vitality Health Plan 的事先授權, 才可以配取該處方藥 若無事先授權,Vitality Health Plan 不會承保該藥物 如果您是新會員或您從未服用過此藥物, 則您 ( 或您的醫生 ) 必須先獲得 Vitality Health Plan 的事先授權, 才可以配取該處方藥 若無事先授權,Vitality Health Plan 不會承保該藥物 CMS 認為該藥物有潛在危害, 因此將它歸為 Medicare 65 歲或以上受益人的高風險藥物 65 歲或以上的會員必須先獲得 Vitality Health Plan 的事先授權, 才可以配取該處方藥 若無事先授權,Vitality Health Plan 不會承保該藥物 Vitality Health Plan 限制了每份處方或指定時期內承保的藥物數量 ST EX LA GC NM NDS 階段療法限制 被排除的 D 部分藥物 具有取藥限制的藥物 缺口承保 非郵購藥物 不延長天數的供藥 Vitality Health Plan 為該藥物提供承保前, 您必須先嘗試用其他藥物來治療您的病症 只有當其他藥物對您無效時, 該藥物才可享受承保 本處方藥物通常不由 Medicare 處方藥計劃承保 您在配取此藥物時所支付的金額不計入您的藥物花費總額 ( 這表示您所支付的金額無法幫您取得災難承保資格 ) 此外, 若您有接受額外補助以支付您的處方藥費用, 您將無法為該藥物取得任何額外補助 此處方藥可能只在某些藥房提供 如需更多資訊, 請查看藥房目錄或致電我們的會員服務部, 電話 : 聽障/ 語障人士可致電 我們為該處方藥提供承保缺口期間的承保 請參閱 承保範圍說明書 瞭解有關該承保的更多資訊 您可以透過郵購以優惠價格獲得處方藥一覽表上的大多數藥物, 且配取的藥量大於 1 個月份 不能透過郵購福利獲得的藥物將在處方藥一覽表的要求 / 限制欄中註明 NM 每次配取該藥物時不得超過 1 個月的份量 HI 居家輸液藥物該處方藥可能受我們的醫療福利承保 如需更多資訊, 請致電 AGE 年齡限制 該處方藥只面向某些年齡群體 CB 福利限制 該藥物具有最高福利限制 II-28

30 本處方藥物通常不由 Medicare 處方藥計劃承保 您在配取此藥物時所支付的金額不計入您的藥物花費總額 ( 這表示您所支付的金額無法幫您取得災難承保資格 ) 此外, 若您有接受額外補助以支付您的處方藥費用, 您將無法為該藥物取得任何額外補助 藥物名稱 藥物等級 要求 / 限制 sildenafil oral tablet 100 mg (Viagra) 2 數量限制 ( 每 30 天最多 6 片 ) sildenafil oral tablet 50 mg (Viagra) 2 數量限制 ( 每 30 天最多 6 片 ) sildenafil oral tablet 25 mg (Viagra) 2 數量限制 ( 每 30 天最多 6 片 ) Vitality Choice Plan (HMO) 會員的共付額 / 共同保險 : 等級 描述 共付額 / 共同保險 30 天份的藥量 90 天份的藥量 第 1 級 首選普通藥 $0 $0 第 2 級 普通藥 $5 $10 第 3 級 首選品牌藥 $35 $70 第 4 級 非首選品牌藥 $90 $180 第 5 級 特殊級藥 33% 不適用 Vitality Plus Plan (HMO) 會員的共付額 / 共同保險 : 等級 描述 共付額 / 共同保險 30 天份的藥量 90 天份的藥量 第 1 級 首選普通藥 $0 $0 第 2 級 普通藥 25% 25% 第 3 級 首選品牌藥 25% 25% 第 4 級 非首選品牌藥 25% 25% 第 5 級 特殊級藥 25% 不適用 II-29

31 Vitality Health Plan of California 는 Medicare 와계약된 Medicare Advantage HMO 플랜입니다. 이플랜의가입은계약갱신시에결정됩니다. 이정보는혜택에대한완전한설명이아닙니다 (TTY: 711) 번으로연락하여자세한정보를문의하실수있습니다. 언어지원서비스를이용하실수있습니다시간 : 10 월 1 일부터 3 월 31 일까지는주 7 일오전 8 시부터오후 8 시사이에, 4 월 1 일부터 9 월 30 일까지는월요일 - 금요일, 같은시간대에이용할수있습니다. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY :711) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY (հեռատիպ) 711): توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. با 711) (TTY: تماس بگیرید. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:711) まで お電話にてご連絡ください ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم هاتف الصم والبكم: 711). ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚ ਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬਧ ਹ (TTY: 711) 'ਤ ਕ ਲ ਕਰ បយ ត ប ស ន អ កន យ ខ រ, ស ជ ន យ ផ ក យម នគ តឈ ល គ ច នស ប ប រ អ ក ច រ ទ រស ព (TTY: 711) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). न द : य द आप ह द ब लत ह त आपक लए म म भ ष सह यत स व ए उपल ह (TTY: 711) पर क ल कर เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711). II-30

32 차별은법으로금지되어있습니다 Vitality Health Plan of California 는적용되는연방민권법을준수하며인종, 민족성, 출신국가, 종교, 성별, 연령, 정신또는신체적장애, 건강상태, 의료기록, 청구이력, 병력, 유전자정보, 보험가입에대한증거또는지리적위치등을바탕으로차별을하지않습니다. Vitality Health Plan of California 는인종, 민족성, 출신국가, 종교, 성별, 연령, 정신또는신체적장애, 건강상태, 의료기록, 청구이력, 병력, 유전자정보, 보험가입에대한증거또는지리적위치를이유로사람들을배제시키거나다르게대우하지않습니다. Vitality Health Plan of California 는 : 효과적으로의사소통을하기위해장애인들에게무료로다음과같은지원과서비스를제공합니다. o 유자격수화통역사 o 다른형식의 ( 대형활자, 오디오, 이용가능한전자형식, 기타형식 ) 문서정보 주로사용하는언어가영어가아닌사람들에게는다음과같은무료언어서비스를제공합니다. o 유자격통역사 o 다른언어로작성된정보 이러한서비스가필요하시면 Vitality 가입자서비스부에 (TTY: 711) 번으로연락해주십시오. 10 월 1 일부터 3 월 31 일까지는주 7 일오전 8 시부터오후 8 시사이에, 4 월 1 일부터 9 월 30 일까지는월요일 - 금요일, 같은시간대에이용할수있습니다. 또한 Vitality Health Plan of California 소속민권담당자 (Civil Rights Coordinator) 와의통화를요청하실수있습니다. Vitality Health Plan of California 가이러한서비스를제공하지못했거나인종, 피부색, 출신국가, 나이, 장애여부또는성별에의해다른방식으로차별을했다고생각하시면다음으로불만을제기하실수있습니다. Vitality Health Plan of California Member Services Department (Complaints) Studebaker Road, Suite 960 Cerritos, CA TTY: 711 팩스 : 직접, 또는우편, 팩스, 이메일로불만을제기하실수있습니다. 불만제기접수와관련된도움이필요하시면 Vitality 민권담당자가도와드릴수있습니다. 또한미국보건복지부 (U.S. Department of Health and Human Services), 민권사무국 (Office for Civil Rights) 에온라인으로민권국불만제기포털 ( 을통해민권관련불만사항을접수하시거나, 우편또는전화로접수하실수있습니다. 연락처 : U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) 불만사항접수양식은 에서구하실수있습니다. II-31

33 기존가입자참고사항 : 이처방집은작년이후변경되었습니다. 쓰시는약이처방집에계속포함된상태인지확인하기위해본문서를검토해주십시오. 이의약품목록 ( 처방집 ) 에서 " 저희 " 또는 " 당사 " 라고칭할때그것은 Vitality Health Plan of California 를의미합니다. " 플랜 " 또는 " 저희플랜 " 이라고칭하는것은 Vitality Choice 및 Vitality Plus 를의미합니다. 이문서는 2018 년 8 월 23 일현재최신인의약품목록 ( 처방집 ) 을포함합니다. 업데이트된처방집을원하시면저희에게문의해주십시오. 처방집이마지막으로업데이트되었던날짜와함께저희의연락처정보가앞표지와뒤표지에표시됩니다. 처방약혜택을이용하시려면일반적으로네트워크약국을이용하셔야합니다. 혜택, 처방집, 약국네트워크및 / 또는자기부담금 / 공동보험액은 2020 년 1 월 1 일그리고연중에수시로변경될수있습니다. Vitality Health Plan of California 처방집이란무엇입니까? 처방집 (formulary) 은 Vitality Health Plan of California 가의료제공자팀과협의해선택한보장약목록으로서양질의치료프로그램에서필수적인부분으로여겨지는처방약치료법을나타냅니다. Vitality Health Plan of California 는해당의약품이의학적으로필요하고, 가입자가 Vitality Health Plan of California 네트워크약국에서처방약을조제하고기타플랜규칙을준수하는이상, 일반적으로처방집에수록된의약품을보장합니다. 처방약조제에관한세부정보가궁금하시면보장범위증명 (Evidence of Coverage, EOC) 을검토해주십시오. 처방집 ( 의약품목록 ) 은변경될수있습니까? 일반적으로연초에보장되었던 2019 년처방집의의약품을복용하고계신경우, 저희는 2019 년보장연도동안해당의약품보장을중단하거나줄이지않습니다. 다만, 덜비싼새로운복제약을이용할수있거나의약품의안전성이나효능에대한정보가새롭게공개되거나의약품이시장에서수거되는경우에는제외됩니다. ( 현재해당의약품을복용하고있는가입자에게영향을주는변경사항에대한자세한정보는아래항목을참조해주십시오.) 처방집에서의약품을제외하는등의기타처방집변경은현재해당약을쓰고있는가입자에게영향을미치지않습니다. 해당의약품을복용하시는가입자는남은보장연도동안동일한비용분담액으로계속이용하실수있습니다. 다음은현재특정의약품을복용하는가입자에게영향을주는의약품목록의변경사항입니다. 의약품이시장에서없어지는경우. 식품의약국이처방집의의약품이안전하지않다고여기거나의약품의제조사가시장에서의약품을철수하는경우, 저희는처방집에서해당의약품을즉시제외하고해당의약품을복용중인가입자에게관련안내를합니다. 기타변경사항. 저희는현재특정의약품을복용하는가입자에게영향을줄수있는기타변경조치를취할수있습니다. 예를들어, 현재처방집에있는브랜드약을대체할새로운복제약을추가하거나, 브랜드약에새로운제한사항을추가하거나, 브랜드약을다른비용분담단계로 II-32

34 변경할수있습니다. 또는새로운임상지침을바탕으로변경을할수도있습니다. 저희가처방집에서의약품을없애거나사전승인요건을추가하거나의약품의분량제한및 / 또는단계적치료제한요건을추가하거나의약품을상위의비용분담액군으로이동하는경우, 변경사항이발효되기최소 30 일전또는가입자가해당의약품의리필을요청하는시점에해당변경으로영향을받게되는가입자에게통지해드리며, 이때해당의약품 30 일분을받게됩니다. 동봉된처방집은 2018 년 8 월 23 일현재최신입니다. Vitality Health Plan of California 가보장하는의약품에대한최신정보를원하시면저희에게연락해주십시오. 저희연락처정보는앞표지와뒤표지에나와있습니다. 매월 Vitality Health Plan of California 에서가입자에게 혜택설명서 또는 EOB 라고하는보고서를우편으로보내드립니다. 혜택설명서는해당월에가입자가처방약에지불한총금액과가입자의처방약각각에대해당사가지불한총금액을알려줍니다. 당사의처방집에최근변경이있는경우에는혜택설명서와함께 처방집변경사항통지 를보내드립니다. 또한처방집의모든변경사항은웹사이트 에매월업데이트되어게시되는처방집에수록될것입니다. 처방집은어떻게사용합니까? 처방집안에서의약품을찾는두가지방법이있습니다. 질환처방집은 1 페이지에서시작됩니다. 본처방집의의약품은치료를위해사용되는질환종류에따라범주별로분류됩니다. 예컨대심장질환의치료에사용되는의약품은심혈관계약제아래에수록됩니다. 귀하의의약품이어디에사용되는지알고있다면 3 페이지에서시작되는목록에서범주명을찾으십시오. 그다음범주명아래에서귀하의의약품이있는지찾아보십시오. 알파벳순서의목록찾아야할하위범주가확실치않다면 I-1 페이지에서시작되는색인에서의약품이있는지찾으셔야합니다. 색인은이문서에포함된모든의약품들의알파벳순목록을제공합니다. 브랜드약과복제약모두색인에기재되어있습니다. 색인을살펴보고의약품을찾으십시오. 의약품이름옆에페이지번호가있고그페이지에서보장정보를찾을수있습니다. 색인에기재된페이지로가서목록의첫번째열에서약품명을찾으십시오. 복제약이란무엇인가요? Vitality Health Plan of California 는브랜드약과복제약모두를보장합니다. 복제약은 FDA 가브랜드약과동일한활성성분을가졌다고승인한것입니다. 일반적으로복제약은브랜드약보다가격이낮습니다. II-33

35 제보장에어떤제약이있습니까? 일부보장약에는추가요건이있거나보장제한이있습니다. 이러한요건및제한에는다음사항이포함될수있습니다. 사전허가 : Vitality Health Plan of California 에서귀하나귀하의의사가특정의약품에대해사전허가를받도록규정합니다. 이는처방약을조제받기전 Vitality Health Plan of California 로부터승인을받으셔야한다는의미입니다. 승인을얻지못하면 Vitality Health Plan of California 는약비용을보장하지않을수있습니다. 분량제한 : 특정의약품의경우, Vitality Health Plan of California 는 Vitality Health Plan of California 가보장하게될의약품의양을제한합니다. 예를들어, Vitality Health Plan of California 는 Rabeprazole 경구약을처방전당 30 정을제공합니다. 이것은기본적인한달분또는석달분에추가될수있습니다. 단계적치료법 : 경우에따라, Vitality Health Plan of California 에서해당질환에대해다른약을보장해드리기전에귀하의질환을치료하는특정약을먼저써보셔야합니다. 예를들어 A 약과 B 약모두가귀하의의학적증상을치료하는경우, Vitality Health Plan of California 는귀하가 A 약을먼저써보기전까지는 B 약을보장하지않을수있습니다. A 약이효과가없는경우, Vitality Health Plan of California 는 B 약을보장하게됩니다. 귀하의의약품에어떤추가요건이있는지또는제약이있는지에대해서는 3 페이지에서시작되는처방집을찾아보시면확인하실수있습니다. 또한보장되는특정한의약품에해당되는제약사항에대한세부정보는저희웹사이트를방문하시면확인하실수있습니다. 사전허가와단계적치료법제한에대해설명한온라인문서를게시해두었습니다. 귀하께서는저희에게사본을보내달라고요청하실수도있습니다. 처방집이마지막으로업데이트되었던날짜와함께저희의연락처정보가앞표지와뒤표지에표시됩니다. Vitality Health Plan of California 에이러한제약사항또는제한의예외를요청하시거나귀하의질환을치료할수있는기타유사한의약품목록을요청하실수있습니다. 예외요청방법에대한정보는 II- 35 페이지의 Vitality Health Plan of California 의처방집에대한예외는어떻게요청하나요? 절을참조하십시오. 비처방 (OTC) 의약품이란무엇인가요? OTC 약은 Medicare 처방약플랜에서일반적으로보장하지않는비처방약입니다. Vitality Health Plan of California 는특정 OTC 약에대한비용을지불합니다. 약이름 강도 투여형태 CETIRIZINE HCL 5 MG 정제 CETIRIZINE HCL 10 MG 정제 CETIRIZINE HCL 5 MG 씹어먹는정제 CETIRIZINE HCL 10 MG 씹어먹는정제 CETIRIZINE HCL 1 MG/ML 경구용액 II-34

36 CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG 정제 ER 12H FEXOFENADINE HCL 30 MG 정제 RAPDIS FEXOFENADINE HCL 60 MG 정제 FEXOFENADINE HCL 180 MG 정제 FEXOFENADINE/PSEUDOEPHEDRINE 60MG-120MG 정제 ER 12H FEXOFENADINE/PSEUDOEPHEDRINE MG 정제 ER 24H FEXOFENADINE HCL 30 MG/5 ML 경구현탁액 LORATADINE 10 MG 정제 LORATADINE 10 MG 정제 RAPDIS LORATADINE/PSEUDOEPHEDRINE 10MG-240MG 정제 ER 24H LORATADINE/PSEUDOEPHEDRINE 5 MG-120MG 정제 ER 12H LORATADINE 5 MG/5 ML 경구용액 KETOTIFEN 0.03% OPHT 드롭스 Vitality Health Plan of California 는이러한 OTC 약을가입자의비용부담없이제공해드립니다. Vitality Health Plan of California 에서부담하는이러한 OTC 약의비용은귀하의총파트 D 약비용에산정되지않습니다 ( 즉, OTC 약비용은보장공백에대해누적되지않음 ). 제약이처방집에없으면어떻게하나요? 귀하의의약품이본처방집 ( 보장약목록 ) 에포함되어있지않은경우, 먼저가입자서비스부에연락해귀하의약이보장되는지문의하셔야합니다. Vitality Health Plan of California 가귀하의약을보장하지않는다는것을아셨다면, 두가지선택권이있습니다. 가입자서비스부에 Vitality Health Plan of California 가보장하는유사한의약품목록을요청하실수있습니다. 이목록을받으시면담당의사에게보여주시고, Vitality Health Plan of California 가보장하는유사한의약품을처방하도록요청하십시오. 해당약을보장해달라는예외를적용해달라고 Vitality Health Plan of California 에요청할수있습니다. 예외요청방법에관한정보는아래를참조하십시오. Vitality Health Plan of California 의처방집에대한예외는어떻게요청하나요? 보장규칙에예외를적용해달라고 Vitality Health Plan of California 에요청할수있습니다. 요청하실수있는몇가지유형의예외가있습니다. 약이처방집에없는경우라도의약품보장을요청하실수있습니다. 승인을받으면, 이의약품은사전에결정된비용분담액수준으로보장되어, 더낮은비용분담수준으로의약품을제공하라고요청하실수없을것입니다. 이의약품이특수분류에없다면, 처방집약을더낮은비용분담수준으로보장하도록요청하실수있습니다. 승인된다면, 이러한요청으로귀하가의약품에지불해야하는금액이낮춰질것입니다. II-35

37 저희에게보장제약이나귀하의의약품에대한제한을면제하도록요청하실수있습니다. 예컨대특정의약품의경우, Vitality Health Plan of California 에서는보장할의약품의양을제한합니다. 귀하의의약품에분량제한이있다면, 저희에게제한철회와더많은분량에대한보장을요청하실수있습니다. 일반적으로 Vitality Health Plan of California 의처방집에포함된대안적의약품, 더낮은비용분담액의의약품또는의약품사용에관한추가적제한이질환을치료하는데있어그만큼효과적이지않을수있거나귀하에게부정적인의학적효과를야기할수있다면, 예외요청을승인할것입니다. 저희에게연락해처방집에대한초기보장결정을요청하시거나의약품사용제한예외를요청하셔야합니다. 처방집이나의약품사용제한예외를요청하실때, 그러한요청을뒷받침하는처방자나의사의진술서를제출하셔야합니다. 일반적으로저희는처방자의근거진술서를획득한지 72 시간내에결정을내려야합니다. 귀하또는담당의사가결정에대해 72 시간까지기다리는것이귀하의건강을심각하게해칠수있을것으로믿는경우, 귀하는신속 ( 빠른 ) 예외를요청할수있습니다. 귀하의신속요청이허가되는경우, 저희는담당의사나다른처방자의근거진술서를획득한지늦어도 24 시간내에귀하에게결정내용을전달해야합니다. 저의약을변경하거나예외를요청하는문제에대해의사와상의하기전저는어떻게대처하나요? 저희플랜의신규또는기존가입자로서귀하는처방집에없는의약품을복용하고계실수도있습니다. 또는처방집에있으나이용에제약이있는약을복용하고계실수도있습니다. 예컨대처방전을조제받기전, 저희로부터사전허가를받으셔야하는경우입니다. 귀하께서는보장이되는적절한약으로전환을요청해야하는지아니면복용하시는약을저희가보장해주도록처방집예외요청을해야하는지담당의사와상의하셔야합니다. 어떤조치가올바른지담당의사와상의하시는동안귀하께서저희플랜가입후최초 90 일동안은경우에따라귀하의약을보장해드립니다. 저희처방집에없는의약품이거나, 수령할수있는의약품이제한적일경우임시로 31 일분을보장할것입니다. 처방전이그보다적은기간에대해작성된경우, 최대 31 일치약을제공하기위해여러차례리필을허락할것입니다. 최초 31 일분이제공된후에는귀하가 90 일이안된플랜가입자라도이러한의약품에대해저희가더이상비용지불을하지않습니다. 장기치료시설에거주하고있는가입자로서처방집에없는의약품이필요하시거나의약품이용에제약이있지만, 플랜에가입한지 90 일이지난상태에서처방집예외를요청하시는경우라면저희는 31 일분의의약품응급공급분을보장합니다. 수혜자가치료환경을바꾸는경우, Vitality Health Plan 은처방집에없는파트 D 약을신속히승인할수있도록할것입니다. 사전허가나단계적치료법이필요한처방집파트 D 약에도이절차를적용합니다. 치료수준변경의예 : 병원에서집으로퇴원한수혜자, 전문요양시설 Medicare 파트 A 이용체류가종료되고파트 D 플랜처방집으로복귀해야하는수혜자, 장기치료시설체류가종료되고지역으로돌아오는수혜자, 고도로개별화된약물요법을하는정신병원에서퇴원한 II-36

38 수혜자. Vitality Health Plans 제휴약국은처방집제한사항을우선하기위해판매처에서업계표준제출코드를삽입할수있습니다. Vitality Health Plans 와제휴한 PBM(MedImpact) 의영업시간이후서비스는약국이약국청구처리문제를결정할수있는담당자를이용할수있도록합니다. 이를통해약국은판매처에서청구건에대해최종결정을할수있으며가입자가의약품을신뢰하고이용할수있도록할것입니다. 자세한정보 Vitality Health Plan of California 처방약보장에관한더욱세부적인정보가궁금하시면보장범위증명과기타플랜자료를검토해주십시오. Vitality Health Plan of California 에대한질문은저희에게문의해주십시오. 처방집이마지막으로업데이트되었던날짜와함께저희의연락처정보가앞표지와뒤표지에표시됩니다. Medicare 처방약보장에관한일반적인궁금증은 Medicare 전화 MEDICARE( ) 번으로주 7 일, 하루 24 시간언제든연락해주십시오. TTY 사용자는 번을이용하셔야합니다. 또는 를방문해주십시오. Vitality Health Plan of California 처방집 다음페이지에서시작되는처방집에는 Vitality Health Plan of California 가보장하는일부의약품에대한보장정보가제공됩니다. 이목록에서의약품을찾는데어려움이있는경우, I-1 페이지부터시작되는색인을참조하시기바랍니다. 표의첫번째열에의약품이름이나와있습니다. 브랜드약은대문자로되어있고 ( 예 : ELIQUIS), 복제약은소문자기울임꼴로되어있습니다 ( 가령, simvastatin). 요건 / 제한열에나와있는정보는 Vitality Health Plan of California 에서의약품보장에특별한요건을두는지를알려줍니다. 약어설명설명 PA PA BvD 사전승인제한사항 파트 B 및파트 D 결정에대한사전허가제한사항 가입자는이의약품에대한처방조제를받기전에 Vitality Health Plan으로부터사전승인을받아야합니다. 사전승인을얻지못하면 Vitality Health Plan은이의약품비용을보장하지않을수있습니다. 이의약품은상황에따라 Medicare 파트 B 또는 D에서보장될수있습니다. 가입자 ( 또는주치의 ) 는이의약품에대한처방조제를받기전에 Vitality Health Plan으로부터사전허가를받아야합니다. 사전승인을얻지못하면 Vitality Health Plan은이의약품비용을보장하지않을수있습니다. II-37

39 PA-HRM PA NSO PA NSO- HRM QL ST EX LA GC 고위험의약품에대한사전승인제한사항 신규가입자만해당되는사전승인제한사항 고위험의약품및신규가입자만을위한사전승인제한사항 수량제한사항 단계적치료법제한사항 제외된 Medicare 파트 D 약 이용이제한적인의약품 보장공백보장 이의약품은 CMS가잠정적위험이있는것으로판단했으며 65세이상의 Medicare 수혜자에게고위험의약품으로간주했습니다. 65세이상의가입자는이의약품에대한처방조제를받기전에 Vitality Health Plan으로부터사전허가를받아야합니다. 사전승인을얻지못하면 Vitality Health Plan은이의약품비용을보장하지않을수있습니다. 신규가입자이거나이의약품을복용한적이없다면, 가입자 ( 또는담당의사 ) 는처방약을조제하기전에 Vitality Health Plan의사전승인을받아야합니다. 사전승인을얻지못하면 Vitality Health Plan은이의약품비용을보장하지않을수있습니다. 이의약품은 CMS가잠정적위험이있는것으로판단했으며 65세이상의 Medicare 수혜자에게고위험의약품으로간주했습니다. 65세이상의가입자는이의약품에대한처방조제를받기전에 Vitality Health Plan으로부터사전승인을받아야합니다. 사전승인을얻지못하면 Vitality Health Plan은이의약품비용을보장하지않을수있습니다. Vitality Health Plan은처방전으로보장되는이의약품의양또는기한을제한합니다. Vitality Health Plan이이의약품에대해보장을제공하기전에, 가입자는질병치료를위해다른약을먼저사용해보아야합니다. 다른약이효능이없는경우에만이약이보장됩니다. 이처방약은일반적으로 Medicare 처방약플랜으로보장되지않습니다. 이처방약을조제할때가입자가지불하는금액은총의약품비용에포함되지않습니다 ( 즉, 지불하는금액은재해성보장에포함되지않음 ). 또한처방약비용을지불하기위해추가지원을받고있다면이약비용을위해추가지원을받지못합니다. 이처방약은특정약국에서만구할수있습니다. 보다자세한정보는약국명부를참조하시거나가입자서비스부에 번으로문의해주십시오. TTY/TDD 사용자는 번으로전화하셔야합니다. 보장공백중에이처방약의보장을제공해드립니다. 본보장에대한자세한정보는보장범위증명을참조해주십시오. 처방집에있는대부분의약은 1개월분이상을할인된공동분담액으로 NM 비우편주문우편주문을통해수령할수있습니다. 우편주문혜택으로구입할수의약품없는의약품은처방집의요건 / 제한사항란에 "NM" 으로표시되어 있습니다. NDS 비장기간조제 이의약품은조제할때마다 1개월분이상을수령할수없습니다. HI 가정주입이처방약은당사의의료혜택으로보장을받을수있습니다. 자세한의약품정보는전화로문의하십시오. AGE 연령제한사항이처방약은특정연령그룹으로제한됩니다. CB 혜택한도 이의약품에는최대혜택한도가있습니다. II-38

40 이처방약은일반적으로 Medicare 처방약플랜으로보장되지않습니다. 이처방약을조제할때가입자가지불하는금액은총의약품비용에포함되지않습니다 ( 즉, 지불하는금액은재해성보장에포함되지않음 ). 또한처방약비용을지불하기위해추가지원을받고있다면이약비용을위해추가지원을받지못합니다. 의약품이름 의약품단계 요건 / 제한사항 sildenafil 경구정제 100mg(Viagra) 2 수량한도 (30일마다최대 6정 ) sildenafil 경구정제 50 mg(viagra) 2 수량한도 (30일마다최대 6정 ) sildenafil 경구정제 25 mg(viagra) 2 수량한도 (30일마다최대 6정 ) Vitality Choice Plan(HMO) 가입자의자기부담금 / 공동보험액 : 단계 설명 자기부담금 / 공동보험액 30일치 90일치 1단계 우선적복제약 $0 $0 2단계 복제약 $5 $10 3단계 우선적브랜드약 $35 $70 4단계 비우선적브랜드약 $90 $180 5단계 특수단계 33% 해당사항없음 Vitality Plus Plan(HMO) 가입자의자기부담금 / 공동보험액 : 단계 설명 자기부담금 / 공동보험액 30일치 90일치 1단계 우선적복제약 $0 $0 2단계 복제약 25% 25% 3단계 우선적브랜드약 25% 25% 4단계 비우선적브랜드약 25% 25% 5단계 특수단계 25% 해당사항없음 II-39

41 Vitality Health Plan of California là một chương trình Medicare Advantage HMO có hợp đồng với Medicare. Ghi danh vào chương trình này phụ thuộc vào việc gia hạn hợp đồng. Tờ thông tin này không mô tả đầy đủ về các phúc lợi. Xin gọi (TTY: 711) để biết thêm thông tin. Dịch vụ Hỗ trợ Thành thạo Ngôn ngữ Sẵn có Thời gian: 8 giờ sáng đến 8 giờ tối., bảy ngày mỗi tuần từ ngày 1 tháng 10 đến ngày 31 tháng 3 và từ Thứ Hai đến Thứ Sáu, từ ngày 1 tháng 4 đến ngày 30 tháng 9. ATTENTION: Nếu quý vị nói tiếng Anh, chúng tôi có dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Xin gọi (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711) CHÚ Ý: Nếu quý vị nói Tiếng Việt, quý vị sẽ được cung cấp các dịch vụ hỗ trợ dịch thuật miễn phí. Gọi số (TTY: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY (հեռատիպ) 711): توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. با 711) (TTY: تماس بگیرید. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます ( TTY:711) まで お電話にてご連絡ください ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 711). ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚ ਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬਧ ਹ (TTY: 711) 'ਤ ਕ ਲ ਕਰ បយ ត ប ស ន អ កន យ ខ រ, ស ជ ន យ ផ ក យម នគ តឈ ល គ ច នស ប ប រ អ ក ច រ ទ រស ព (TTY: 711) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). न द : य द आप ह द ब लत ह त आपक लए म म भ ष सह यत स व ए उपल ह (TTY: 711) पर क ल कर เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711). II-40

42 Phân biệt đối xử là Bất hợp pháp Vitality Health Plan of California tuân thủ các luật về quyền công dân hiện hành của Liên bang và không phân biệt đối xử theo chủng tộc, dân tộc, nguồn gốc quốc gia, tôn giáo, giới tính, tuổi tác, khuyết tật về tinh thần hay thể chất, tình trạng sức khỏe, được chăm sóc sức khỏe, lịch sử khiếu nại, tiền sử bệnh lý, thông tin di truyền, bằng chứng về khả năng có thể bảo hiểm, hoặc vị trí địa lý. Vitality Health Plan of California không loại trừ mọi người hoặc đối xử với họ khác đi theo chủng tộc, dân tộc, nguồn gốc quốc gia, tôn giáo, giới tính, tuổi tác, khuyết tật về tinh thần hay thể chất, tình trạng sức khỏe, được chăm sóc sức khỏe, lịch sử khiếu nại, tiền sử bệnh lý, thông tin di truyền, bằng chứng về khả năng có thể bảo hiểm, hoặc vị trí địa lý. Vitality Health Plan of California: Cung cấp các dịch vụ và hỗ trợ miễn phí cho những người khuyết tật để giao tiếp hiệu quả với chúng tôi, chẳng hạn: o Thông dịch viên ngôn ngữ tín hiệu đủ trình độ o Thông tin bằng văn bản bằng các định dạng khác (chữ in lớn, âm thanh, định dạng điện tử có thể truy cập, các định dạng khác) Cung cấp dịch vụ ngôn ngữ miễn phí cho những người có ngôn ngữ chính không phải Tiếng Anh, như: o Thông dịch viên có trình độ o Thông tin bằng văn bản bằng các ngôn ngữ khác Nếu quý vị cần các dịch vụ này, xin liên lạc với Ban Dịch vụ Hội viên của Vitality theo số (TTY: 711) để giúp đỡ quý vị. Chúng tôi làm việc từ 8 giờ sáng đến 8 giờ tối, bảy ngày mỗi tuần từ ngày 1 tháng 10 đến ngày 31 tháng 3 và từ Thứ Hai đến Thứ Sáu, từ ngày 1 tháng 4 đến ngày 30 tháng 9. Quý vị cũng có thể đề nghị gặp Điều phối viên Dân quyền làm việc cho Vitality Health Plan of California. Nếu quý vị cho rằng Vitality Health Plan of California đã không cung cấp được các dịch vụ này hoặc phân biệt đối xử theo hình thức khác về chủng tộc, màu da, nguồn gốc quốc gia, tuổi tác, khuyết tật hoặc giới tính, quý vị có thể nộp khiếu nại đến: Vitality Health Plan of California Member Services Department (Complaints) Studebaker Road, Suite 960 Cerritos, CA TTY: 711 FAX: Quý vị có thể nộp đơn khiếu nại trực tiếp hoặc qua bưu điện, fax, hoặc . Nếu quý vị cần trợ giúp để nộp khiếu nại, Điều phối viên Dân quyền của Vitality luôn sẵn lòng giúp đỡ quý vị. Quý vị có thể gửi khiếu nại về quyền công dân đến Bộ Y tế và Dịch vụ Nhân sinh Hoa Kỳ (U.S. Department of Health and Human Services), Văn phòng Dân quyền (Office for Civil Rights), theo hình thức điện tử thông qua Cổng Thông tin về Khiếu nại của Văn phòng Dân quyền tại địa chỉ hoặc gửi qua bưu điện hoặc gọi điện theo số: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Mẫu đơn khiếu nại có sẵn tại địa chỉ II-41

43 Hội viên hiện tại xin lưu ý: Danh mục thuốc này đã được thay đổi từ năm ngoái. Xin xem lại tài liệu này để bảo đảm nó vẫn chứa các thuốc mà quý vị sử dụng. Trong danh sách thuốc (danh mục thuốc) này, từ "chúng tôi hoặc của chúng tôi có nghĩa là Vitality Health Plan of California. Trong danh sách thuốc này, từ chương trình hoặc chương trình của chúng tôi có nghĩa là Vitality Choice và Vitality Plus. Tài liệu này có chứa danh sách thuốc (danh mục thuốc) cho chương trình chúng tôi, có hiệu lực từ ngày 8/23/2018. Để có được danh mục thuốc mới nhất, xin quý vị liên lạc với chúng tôi. Thông tin liên lạc của chúng tôi, cùng với ngày cập nhật cuối cùng của danh mục thuốc, có in tại bìa trước và bìa sau. Nói chung, quý vị phải sử dụng các nhà thuốc trong mạng lưới để nhận phúc lợi thuốc toa của quý vị. Các phúc lợi, danh mục thuốc, mạng nhà thuốc, và/hoặc tiền đồng trả/đồng bảo hiểm có thể sẽ thay đổi vào ngày 1 tháng 1 năm 2020, và thỉnh thoảng ở trong năm. Danh mục Thuốc của Vitality Health Plan of California là gì? Danh mục Thuốc là danh sách các thuốc được bảo hiểm do Vitality Health Plan of California lựa chọn cùng với sự cố vấn của các nhà cung cấp dịch vụ chăm sóc sức khỏe, nó thể hiện các liệu pháp chỉ định được tin là một bộ phận cần thiết của chương trình điều trị có chất lượng. Nói chung Vitality Health Plan of California sẽ bảo hiểm cho các thuốc trong danh mục của chúng tôi với điều kiện thuốc đó là cần thiết về mặt y tế, được mua tại nhà thuốc trong mạng lưới của Vitality Health Plan of California, và phù hợp với các quy định khác của chương trình. Để biết thêm về cách mua thuốc toa, xin xem Chứng từ Bảo hiểm của quý vị. Danh mục Thuốc (danh sách thuốc) có thể thay đổi không? Thông thường, nếu quý vị đang sử dụng một loại thuốc trong danh mục thuốc 2019 của chúng tôi mà đã được bảo hiểm từ đầu năm, chúng tôi sẽ không ngưng hoặc giảm mức bảo hiểm của thuốc đó trong năm bảo hiểm 2019 trừ khi có một loại thuốc gốc mới, rẻ tiền hơn hoặc khi có thông tin mới về tính an toàn hoặc công hiệu của thuốc, hoặc thuốc bị loại khỏi thị trường. (Xem các chấm đầu dòng bên dưới để biết thêm thông tin về các thay đổi ảnh hưởng đến hội viên đang dùng thuốc.) Các loại thay đổi khác về danh mục thuốc, ví dụ như loại bỏ một loại thuốc ra khỏi danh mục của chúng tôi, sẽ không ảnh hưởng đến những hội viên đang sử dụng thuốc đó. Thuốc đó sẽ vẫn được cung cấp với mức chia sẻ chi phí không thay đổi cho các hội viên đang dùng nó cho phần còn lại của năm đài thọ. Dưới đây là các thay đổi đến danh sách thuốc mà cũng sẽ ảnh hưởng đến các hội viên đang dùng thuốc: Thuốc bị loại khỏi thị trường. Nếu Cơ quan Thực và Dược phẩm (Food and Drug Administration) thấy một loại thuốc trong danh mục của chúng tôi là không an toàn hoặc nhà sản xuất thu hồi thuốc khỏi thị trường, chúng tôi sẽ lập tức loại thuốc đó ra khỏi danh mục của chúng tôi và thông báo cho hội viên dùng thuốc đó biết. Những thay đổi khác. Chúng tôi có thể thực hiện những thay đổi khác ảnh hưởng đến các hội viên đang dùng thuốc. Ví dụ, chúng tôi có thể bổ sung một loại thuốc gốc mới thay thế cho thuốc nhãn hiệu hiện có trên danh mục thuốc hoặc bổ sung các hạn chế mới đến thuốc nhãn hiệu hoặc chuyển nó sang mức chia sẻ chi phí khác. Hoặc chúng tôi có thể thực hiện các thay đổi dựa trên các hướng dẫn lâm sàng mới. Nếu chúng tôi loại bỏ thuốc ra khỏi danh mục, thêm quy định phải xin phép trước, giới hạn số lượng và/hoặc buộc phải điều trị từng bước đối với một loại thuốc hoặc chuyển thuốc đó sang một bậc chia sẻ chi phí cao hơn, chúng tôi phải thông báo cho các hội viên bị ảnh hưởng bởi thay đổi ít nhất 30 ngày trước khi thay đổi đó có hiệu lực, hoặc vào lúc hội viên đó yêu cầu được mua thuốc tiếp cho loại thuốc đó, lúc đó hội viên sẽ được nhận một lượng cấp là 30 ngày của thuốc đó. II-42

44 Danh mục thuốc kèm theo có hiệu lực kể từ ngày 8/23/2018. Để được biết thông tin mới nhất về các loại thuốc được Vitality Health Plan of California bảo hiểm, vui lòng liên hệ với chúng tôi. Thông tin liên lạc của chúng tôi có ghi tại các trang của bìa trước và bìa sau. Hàng tháng Vitality Health Plan of California sẽ gửi qua bưu điện cho quý vị một báo cáo có tên Giải thích về Những Phúc lợi, hay EOB. EOB cho quý vị biết tổng số tiền quý vị đã chi cho thuốc toa của quý vị và tổng số tiền chúng tôi đã trả cho mỗi loại thuốc toa của quý vị trong tháng đó. Cùng với EOB, chúng tôi sẽ gửi cho quý vị "Thông báo Thay đổi Danh mục Thuốc" ( Formulary Change Notice ) nếu mới có thay đổi nào được thực hiện cho danh mục thuốc của chúng tôi. Ngoài ra, tất cả các thay đổi về danh mục thuốc cũng sẽ được cập nhật hàng tháng trên trang mạng của chúng tôi tại Tôi sử dụng Danh mục Thuốc như thế nào? Có hai cách để tìm thuốc của quý vị trong danh mục: Theo Bệnh Danh mục thuốc bắt đầu từ trang 1. Thuốc trong danh mục này được nhóm thành nhóm theo loại bệnh mà chúng được dùng để điều trị. Ví dụ như, thuốc dùng để trị bệnh tim được liệt kê trong nhóm Thuốc tim mạch. Nếu quý vị biết thuốc của quý vị được dùng cho bệnh gì, hãy tìm tên của nhóm bệnh đó trong danh mục bắt đầu từ trang 3. Rồi tìm tiếp thuốc của quý vị ở trong nhóm bệnh này. Theo vần abc Nếu không biết rõ phải tìm nhóm bệnh nào, quý vị nên tìm thuốc của mình trong Bảng chú dẫn bắt đầu từ trang I-1. Bảng chú dẫn này liệt kê theo vần ABC tất cả các loại thuốc có trong tài liệu này. Cả thuốc thương hiệu và thuốc gốc đều được liệt kê trong Bảng Chú dẫn này. Hãy xem trong Bảng chú dẫn để tìm thuốc của quý vị. Kế bên thuốc của mình, quý vị sẽ thấy có số trang, nơi quý vị có thể tìm được thông tin về bảo hiểm thuốc. Lật sang trang được liệt kê trong Bảng Chú dẫn và tìm tên thuốc của quý vị ở cột đầu tiên trong danh sách. Thuốc gốc là gì? Vitality Health Plan of California bảo hiểm cho cả thuốc thương hiệu và thuốc gốc. Thuốc gốc theo phê chuẩn của FDA là thuốc có cùng thành phần hoạt chất với thuốc thương hiệu. Thuốc gốc thường rẻ hơn thuốc thương hiệu. Có hạn chế nào về việc đài thọ cho tôi không? Một số thuốc được đài thọ có thể có thêm các yêu cầu hoặc giới hạn về đài thọ. Các yêu cầu hoặc giới hạn này có thể bao gồm: Xin phép trước: Vitality Health Plan of California yêu cầu quý vị hoặc bác sĩ quý vị phải xin phép trước đối với một số thuốc nào đó. Điều đó có nghĩa là, quý vị phải được Vitality Health Plan of California chấp thuận trước rồi mới được mua thuốc. Nếu không có sự chấp thuận này, Vitality Health Plan of California sẽ không đài thọ thuốc cho quý vị. Giới hạn về số lượng: Với một số thuốc nào đó, Vitality Health Plan of California có giới hạn số lượng thuốc mà Vitality Health Plan of California sẽ đài thọ. Ví dụ, Vitality Health Plan of California cung cấp 30 viên/đơn thuốc đối với thuốc uống Rabeprazole. Đây có thể là một giới hạn khác ngoài quy định về lượng cấp một tháng hoặc ba tháng thông thường. Liệu pháp bước: Trong một số trường hợp, Vitality Health Plan of California yêu cầu quý vị phải thử dùng những loại thuốc nào đó trước để trị bệnh cho quý vị rồi mới đài thọ cho một loại thuốc khác trị bệnh đó. Ví dụ như, Thuốc A và Thuốc B đều trị bệnh của quý vị, Vitality Health Plan of California có II-43

45 thể sẽ không đài thọ cho Thuốc B nếu quý vị không thử dùng Thuốc A trước. Nếu Thuốc A không trị được bệnh cho quý vị, Vitality Health Plan of California sẽ đài thọ cho Thuốc B. Quý vị có thể tìm hiểu xem thuốc của quý vị có yêu cầu hoặc giới hạn nào khác nữa hay không bằng cách xem trong danh mục thuốc bắt đầu từ trang 3. Quý vị cũng có thể tìm xem thêm về các hạn chế được áp dụng cho thuốc được đài thọ cụ thể bằng cách xem trên trang mạng của chúng tôi. Chúng tôi đã đưa lên trang mạng một tài liệu giải thích các hạn chế của chúng tôi về việc xin phép trước và liệu pháp bước. Quý vị cũng có thể yêu cầu chúng tôi gửi cho quý vị một bản sao. Thông tin liên lạc của chúng tôi, cùng với ngày cập nhật cuối cùng của danh mục thuốc, có in tại bìa trước và bìa sau. Quý vị có thể yêu cầu Vitality Health Plan of California cho quý vị hưởng ngoại lệ đối với các hạn chế hoặc giới hạn này hoặc cho quý vị được sử dụng một danh sách các thuốc khác tương tự có thể trị được bệnh của quý vị. Xin quý vị xem mục, Tôi xin hưởng ngoại lệ đối với danh mục thuốc của Vitality Health Plan of California bằng cách nào? trên trang II-45 để biết cách xin hưởng ngoại lệ. Thuốc không cần toa (OTC) là gì? Thuốc OTC là thuốc khi mua không cần phải có toa bác sĩ mà thường Chương trình Thuốc toa Medicare không đài thọ. Vitality Health Plan of California thanh toán cho một số thuốc OTC nhất định. TÊN THUỐC HÀM LƯỢNG DẠNG BÀO CHẾ CETIRIZINE HCL 5 MG VIÊN NÉN CETIRIZINE HCL 10 MG VIÊN NÉN CETIRIZINE HCL 5 MG VIÊN NÉN NHAI CETIRIZINE HCL 10 MG VIÊN NÉN NHAI CETIRIZINE HCL 1 MG/ML SOLN ĐƯỜNG UỐNG CETIRIZINE HCL/PSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H FEXOFENADINE HCL 30 MG TAB RAPDIS FEXOFENADINE HCL 60 MG VIÊN NÉN FEXOFENADINE HCL 180 MG VIÊN NÉN FEXOFENADINE/PSEUDOEPHEDRINE 60MG-120MG TAB ER 12H FEXOFENADINE/PSEUDOEPHEDRINE MG TAB ER 24H FEXOFENADINE HCL 30 MG/5 ML ORAL SUSP LORATADINE 10 MG VIÊN NÉN LORATADINE 10 MG TAB RAPDIS LORATADINE/PSEUDOEPHEDRINE 10MG-240MG TAB ER 24H LORATADINE/PSEUDOEPHEDRINE 5 MG-120MG TAB ER 12H LORATADINE 5 MG/5 ML SOLN ĐƯỜNG UỐNG KETOTIFEN 0,03% THUỐC NHỎ OPHT Vitality Health Plan of California sẽ cung cấp miễn phí cho quý vị các thuốc OTC này. Chi phí mà Vitality Health Plan of California chi trả cho các thuốc OTC này sẽ không được tính vào tổng chi phí thuốc Phần D của quý vị (tức là chi phí thuốc OTC này không dùng để tính giai đoạn không được trả bảo hiểm. Nếu thuốc của tôi không có trong danh mục thì sao? Nếu thuốc của quý vị không có trong danh mục thuốc (danh sách thuốc được đài thọ) này, quý vị hãy liên lạc với Ban Phục vụ Hội viên trước để hỏi xem thuốc của quý vị có được đài thọ hay không. Nếu Vitality Health Plan of California không đài thọ cho thuốc của quý vị, quý vị có hai lựa chọn: II-44

46 Quý vị có thể đề nghị Dịch vụ Hội viên cung cấp một danh sách thuốc tương tự được Vitality Health Plan of California đài thọ. Khi nhận được danh sách đó, quý vị hãy đưa cho bác sĩ của quý vị xem và đề nghị họ kê cho quý vị một loại thuốc tương tự được Vitality Health Plan of California đài thọ. Quý vị có thể đề nghị Vitality Health Plan of California cho quý vị hưởng ngoại lệ là đài thọ cho thuốc của quý vị. Xem dưới đây để biết cách xin hưởng ngoại lệ. Tôi xin hưởng ngoại lệ đối với danh mục thuốc của Vitality Health Plan of California bằng cách nào? Quý vị có thể đề nghị Vitality Health Plan of California cho quý vị hưởng ngoại lệ đối với các quy định về đài thọ của chúng tôi. Có nhiều loại ngoại lệ mà quý vị có thể xin chúng tôi cho hưởng. Quý vị có thể yêu cầu chúng tôi đài thọ cho một loại thuốc ngay cả khi nó không nằm trong danh mục thuốc. Nếu được chấp thuận, thuốc đó sẽ được đài thọ với mức chia sẻ chi phí được xác định trước, và quý vị sẽ không thể yêu cầu chúng tôi cung cấp thuốc đó cho quý vị với mức chia sẻ chi phí thấp hơn. Quý vị có thể yêu cầu chúng tôi đài thọ cho một loại thuốc nằm trong danh mục với mức chia sẻ chi phí thấp hơn nếu thuốc đó không nằm trong bậc thuốc đặc trị. Nếu được chấp thuận, số tiền quý vị phải trả cho thuốc của quý vị sẽ ít hơn. Quý vị có thể yêu cầu chúng tôi bỏ hạn chế hoặc giới hạn đài thọ cho thuốc của quý vị. Ví dụ như, với một số thuốc nhất định, Vitality Health Plan of California có giới hạn số lượng thuốc mà chúng tôi sẽ đài thọ. Nếu thuốc của quý vị có giới hạn về số lượng, quý vị có thể xin chúng tôi bỏ giới hạn đó mà đài thọ cho quý vị số lượng thuốc lớn hơn/ Nói chung, Vitality Health Plan of California sẽ chỉ chấp thuận yêu cầu hưởng ngoại lệ của quý vị nếu thuốc thay thế có trong danh mục thuốc của chương trình, thuốc có mức chia sẻ chi phí thấp hơn hoặc khi các hạn chế về việc sử dụng khác sẽ không có hiệu quả trong việc trị bệnh cho quý vị và/hoặc sẽ gây cho quý vị các tác dụng bất lợi về mặt y tế. Quý vị nên liên lạc với chúng tôi để đề nghị chúng tôi ra quyết định đài thọ lần đầu cho quý vị được hưởng ngoại lệ đối với các hạn chế về danh mục thuốc, sử dụng. Khi quý vị xin hưởng ngoại lệ đối với danh mục hoặc hạn chế sử dụng, quý vị phải nộp giấy xác nhận của người kê thuốc hoặc bác sĩ ủng hộ cho đề nghị của quý vị. Nói chung, chúng tôi phải ra quyết định trong vòng 72 giờ kể từ khi nhận được giấy xác nhận ủng hộ của người kê thuốc cho quý vị. Quý vị có thể xin hưởng ngoại lệ xúc tiến (nhanh) nếu quý vị hoặc bác sĩ của quý vị tin rằng sức khỏe của quý vị có thể bị tổn hại nghiêm trọng khi phải chờ đợi đến 72 giờ để ra quyết định. Nếu yêu cầu xúc tiến của quý vị được chấp nhận, chúng tôi phải ra quyết định cho quý vị trong không quá 24 giờ sau khi chúng tôi nhận được giấy xác nhận ủng hộ của bác sĩ hay người kê thuốc cho quý vị. Tôi sẽ được đối xử ra sao khi chưa bàn được với bác sĩ để đổi thuốc hay xin hưởng ngoại lệ? Dù là hội viên mới hay cũ của chương trình, thuốc mà quý vị đang dùng cũng có thể không có trong danh mục của chúng tôi. Hoặc, thuốc mà quý vị đang dùng có thể có trong danh mục của chúng tôi nhưng quý vị ít có khả năng được nhận thuốc đó. Ví dụ như, quý vị có thể phải xin phép chúng tôi trước thì mới được mua thuốc toa của quý vị. Quý vị nên nói chuyện với bác sĩ của quý vị để quyết định xem quý vị có nên đổi sang dùng một loại thuốc phù hợp được chúng tôi đài thọ hoặc xin hưởng ngoại lệ danh mục thuốc hay không để chúng tôi sẽ đài thọ cho thuốc quý vị dùng. Trong thời gian bàn bạc với bác sĩ để xác định liệu trình điều trị phù hợp cho quý vị, trong một số trường hợp nhất định chúng tôi có thể sẽ đài thọ thuốc của quý vị trong 90 ngày đầu tiên quý vị làm hội viên của chương trình chúng tôi. II-45

47 Với mỗi loại thuốc không nằm trong danh mục của chúng tôi hoặc nếu quý vị ít có khả năng được nhận thuốc, chúng tôi sẽ đài thọ tạm thời một lượng cấp thuốc cho 31 ngày. Nếu toa thuốc của quý vị được kê cho số ngày ít hơn, chúng tôi sẽ cho phép mua lại để có được lượng thuốc tối đa cho 31 ngày. Sau lượng cấp 31 ngày đầu tiên đó, chúng tôi sẽ không thanh toán cho các thuốc này nữa, ngay cả khi quý vị đã làm hội viên của chương trình chúng tôi dưới 90 ngày. Nếu quý vị sống tại một cơ sở chăm sóc dài hạn và cần một loại thuốc không có trong danh mục của chúng tôi hoặc nếu quý vị ít có khả năng được nhận thuốc của quý vị, nhưng quý vị đã làm hội viên của chúng tôi được hơn 90 ngày đầu tiên, chúng tôi sẽ đài thọ một lượng cấp khẩn cấp thuốc đó là 31 ngày trong khi quý vị đang xin hưởng ngoại lệ danh mục thuốc. Trong trường hợp người có bảo hiểm của chương trình sẽ chuyển từ cơ sở điều trị này sang cơ sở khác, Vitality Health Plan of California sẽ bảo đảm sử dụng quy trình chấp thuận nhanh cho các thuốc Phần D không có trong danh mục. Thủ tục này cũng được áp dụng cho các loại thuốc Phần D có trong danh sách thuốc cần phải xin phép trước hoặc phải thực hiện liệu pháp bước. Ví dụ về các mức độ thay đổi trong việc chăm sóc gồm có: người có bảo hiểm của chương trình được xuất viện về nhà; người có bảo hiểm của chương trình không còn ở tại cơ sở điều dưỡng theo Medicare Phần A; người có bảo hiểm cần chuyển về danh sách thuốc phần D; người có bảo hiểm của chương trình không còn ở tại cơ sở chăm sóc lâu dài và trở về cộng đồng; và, người có bảo hiểm của chương trình là người xuất viện từ bệnh viện tâm thần có phác đồ thuốc có tính cá nhân cao. Các nhà thuốc có hợp đồng Vitality Health Plans có thể nhập mã đệ trình tiêu chuẩn của ngành tại điểm bán hàng để hủy bỏ các hạn chế về danh mục thuốc. Dịch vụ sau giờ làm việc (MedImpact) của PMB có hợp đồng với Vitality Health Plans sẽ cung cấp cho các nhà thuốc tiếp xúc với những đại diện có thể giải quyết các vấn đề trong việc xử lý yêu cầu của nhà thuốc. Việc tiếp xúc này sẽ cho phép nhà thuốc giải quyết được các yêu cầu về cấp thuốc ngay tại điểm bán hàng và bảo đảm người có bảo hiểm của chương trình có thể nhận được thuốc theo cách thức đáng tin cậy. Để tìm hiểu thêm Để biết chi tiết hơn về việc Vitality Health Plan of California đài thọ cho thuốc toa của quý vị, xin xem Chứng từ Bảo hiểm của quý vị và các tài liệu khác của chương trình. Nếu quý vị có thắc mắc về Vitality Health Plan of California, xin liên lạc với chúng tôi. Thông tin liên lạc của chúng tôi, cùng với ngày cập nhật cuối cùng của danh mục thuốc, có in tại bìa trước và bìa sau. Nếu quý vị có các thắc mắc chung về việc đài thọ thuốc toa Medicare, xin gọi Medicare theo số MEDICARE ( ) 24 giờ mỗi ngày/7 mỗi tuần. Người dùng TTY xin gọi Hoặc vào Danh mục thuốc của Vitality Health Plan of California Danh mục thuốc bắt đầu từ trang kế tiếp có thông tin về việc đài thọ cho một số loại thuốc được Vitality Health Plan of California đài thọ. Nếu quý vị không tìm được thuốc của quý vị trong danh sách, xin lật sang Bảng chú dẫn bắt đầu từ trang I-1. Cột thứ nhất của bảng này là tên thuốc. Các thuốc thương hiệu được viết hoa (ví dụ, ELIQUIS) và các thuốc gốc được viết thường in nghiêng (ví dụ, simvastatin). II-46

48 Thông tin trong cột Yêu cầu/giới hạn cho quý vị biết Vitality Health Plan of California có yêu cầu đặc biệt nào về việc đài thọ cho thuốc của quý vị hay không. Từ viết tắt Mô tả Giải thích PA PA BvD PA-HRM PA NSO PA NSO- HRM QL ST EX LA Yêu cầu Xin phép trước Yêu cầu Xin phép trước để Xác định của Phần B so với Phần D Yêu cầu Xin phép trước đối với Thuốc có Nguy cơ cao Yêu cầu Xin phép trước chỉ đối với Lần bắt đầu Mới Yêu cầu Xin phép trước đối với Thuốc Nguy cơ cao và Chỉ đối với Lần bắt đầu Mới Giới hạn Số lượng Giới hạn theo Liệu pháp bước Thuốc Phần D Không được bảo hiểm Thuốc Tiếp Cận Giới Hạn Quý vị (hoặc bác sĩ của quý vị) bắt buộc phải xin Vitality Health Plan of California cho phép trước khi quý vị mua thuốc toa của quý vị. Nếu không được chấp thuận trước, Vitality Health Plan of California có thể sẽ không đài thọ cho thuốc này. Thuốc này có thể đủ tiêu chuẩn để được đài thọ theo Medicare Phần B hoặc Phần D. Quý vị (hoặc bác sĩ của quý vị) cần phải xin Vitality Health Plan of California cho phép trước để xác định thuốc này sẽ được đài thọ theo Medicare Phần D trước khi quý vị mua thuốc toa của mình. Nếu không được chấp thuận trước, Vitality Health Plan of California có thể sẽ không đài thọ cho thuốc này. Thuốc này đã được CMS xem là tiềm ẩn nguy hại và do đó, là Thuốc Nguy cơ Cao đối với những người có bảo hiểm Medicare từ 65 tuổi trở lên. Các hội viên từ 65 tuổi trở lên phải xin Vitality Health Plan of California cho phép trước khi quý vị mua thuốc toa của quý vị. Nếu không được chấp thuận trước, Vitality Health Plan of California có thể sẽ không đài thọ cho thuốc này Nếu quý vị là hội viên mới hoặc nếu quy vị chưa dùng loại thuốc này trước đây, quý vị (hoặc bác sĩ của quý vị) phải xin Vitality Health Plan of California cho phép trước khi quý vị mua thuốc toa của quý vị. Nếu không được chấp thuận trước, Vitality Health Plan of California có thể sẽ không đài thọ cho thuốc này. Thuốc này đã được CMS xem là tiềm ẩn nguy hại và do đó, là Thuốc Nguy cơ Cao đối với những người có bảo hiểm Medicare từ 65 tuổi trở lên. Các hội viên từ 65 tuổi trở lên phải xin Vitality Health Plan of California cho phép trước khi quý vị mua thuốc toa của quý vị. Nếu không được chấp thuận trước, Vitality Health Plan of California có thể sẽ không đài thọ cho thuốc này Vitality Health Plan giới hạn số lượng thuốc này được bảo hiểm trên mỗi đơn, hoặc trong khoảng thời gian cụ thể. Trước khi Vitality Health Plan of California đài thọ cho thuốc này, quý vị phải dùng thử (những) loại thuốc khác để điều cho bệnh trạng của mình. Thuốc này chỉ có thể được đài thọ nếu (những) thuốc khác không có hiệu quả với quý vị. Thông thường, thuốc kê đơn này không được bảo hiểm trong Chương trình Thuốc kê đơn của Medicare. Số tiền quý vị phải thanh toán khi mua thuốc theo đơn này không được tính vào tổng chi phí thuốc của quý vị (có nghĩa là số tiền quý vị thanh toán không giúp quý vị đủ điều kiện hưởng bảo hiểm tai họa). Ngoài ra, nếu quý vị đang nhận trợ cấp đặc biệt cho thuốc kê đơn của mình, quý vị sẽ không được nhận bất kỳ trợ cấp đặc biệt nào để thanh toán cho thuốc này. Thuốc toa này có thể chỉ được cung cấp tại những nhà thuốc nào đó thôi. Để tìm hiểu thêm, xin tham khảo Danh mục Nhà thuốc hoặc gọi Dịch vụ Hội viên theo số ,. Người dùng TTY/TDD xin gọi GC Giai Đoạn Không Được Bảo Hiểm Chúng tôi đài thọ thêm cho thuốc toa này trong giai đoạn không được trả bảo hiểm. Xin tham khảo Chứng từ Bảo hiểm để biết thêm về việc đài thọ này. II-47

49 NM NDS HI Thuốc Đặt Không Qua Bưu Điện Lượng Cấp Theo Ngày Không Kéo Dài Thuốc Truyền Tại Quý vị có thể nhận lượng thuốc cấp cho hơn 1 tháng đối với hầu hết các thuốc trên danh mục thuốc thông qua đặt hàng qua bưu điện với mức chia sẻ chi phí thấp. Những thuốc không được cung cấp qua đặt hàng bưu điện được ghi chú là NM trong cột Yêu cầu/giới hạn của danh mục thuốc. Thuốc này được cấp dùng cho không quá 1 tháng mỗi lần mua. Thuốc kê đơn này có thể được bảo hiểm theo phúc lợi y tế của chúng tôi. Để biết thêm thông tin, xin gọi Nhà AGE Giới hạn Tuổi tác Thuốc này sẽ chỉ được cung cấp cho các nhóm tuổi cụ thể. CB Phúc lợi Tối đa Thuốc này có mức phúc lợi tối đa. Thông thường, thuốc kê đơn này không được bảo hiểm trong Chương trình Thuốc kê đơn của Medicare. Số tiền quý vị phải thanh toán khi mua thuốc theo đơn này không được tính vào tổng chi phí thuốc của quý vị (có nghĩa là số tiền quý vị thanh toán không giúp quý vị đủ điều kiện hưởng bảo hiểm tai họa). Ngoài ra, nếu quý vị đang nhận trợ cấp đặc biệt cho thuốc kê đơn của mình, quý vị sẽ không được nhận bất kỳ trợ cấp đặc biệt nào để thanh toán cho thuốc này. Tên Thuốc Bậc Thuốc Yêu cầu/giới hạn sildenafil oral tablet 100 mg (Viagra) 2 Giới hạn Số lượng (6 viên tối đa/30 ngày) sildenafil oral tablet 50 mg (Viagra) 2 Giới hạn Số lượng (6 viên tối đa/30 ngày) sildenafil oral tablet 25 mg (Viagra) 2 Giới hạn Số lượng (6 viên tối đa/30 ngày) Đồng thanh toán/đồng bảo hiểm đối với các hội viên trong chương trình Vitality Choice Plan (HMO): Bậc Mô tả Tiền đồng trả/đồng bảo hiểm Lượng cấp 30 ngày Lượng cấp 90 ngày Bậc 1 Thuốc gốc Được ưu tiên $0 $0 Bậc 2 Thuốc gốc $5 $10 Bậc 3 Biệt dược Được ưu tiên $35 $70 Bậc 4 Biệt dược Không Được ưu tiên $90 $180 Bậc 5 Bậc Đặc biệt 33% Không áp dụng Đồng thanh toán/đồng bảo hiểm đối với các hội viên trong chương trình Vitality Plus Plan (HMO): Bậc Mô tả Tiền đồng trả/đồng bảo hiểm Lượng cấp 30 ngày Lượng cấp 90 ngày Bậc 1 Thuốc gốc Được ưu tiên $0 $0 Bậc 2 Thuốc gốc 25% 25% Bậc 3 Biệt dược Được ưu tiên 25% 25% Bậc 4 Biệt dược Không Được ưu tiên 25% 25% Bậc 5 Bậc Đặc biệt 25% Không áp dụng II-48

50 Table of Contents Analgesics...3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents...12 Antibacterials Anticancer Agents Anticholinergic Agents Anticonvulsants...35 Antidementia Agents...39 Antidepressants Antidiabetic Agents Antifungals...47 Antigout Agents Antihistamines...49 Anti-Infectives (Skin And Mucous Membrane)...50 Antimigraine Agents...50 Antimycobacterials...51 Antinausea Agents...51 Antiparasite Agents...53 Antiparkinsonian Agents...54 Antipsychotic Agents...55 Antivirals (Systemic)...60 Blood Products/Modifiers/Volume Expanders Caloric Agents...69 Cardiovascular Agents Central Nervous System Agents Contraceptives...88 Dental And Oral Agents...94 Dermatological Agents...94 Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying

51 Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals

52 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg ascomp with codeine oral capsule mg buprenorphine hcl injection solution 0.3 mg/ml buprenorphine hcl injection syringe 0.3 mg/ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg butalbital-aspirin-caffeine oral tablet mg ; QL (2700 per 30 ; QL (360 per 30 (Tylenol-Codeine #3) ; QL (360 per 30 (Tylenol-Codeine #4) ; QL (180 per 30 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) (Buprenex) (Butrans) 4 QL (4 per 28 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) (Tencon) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) (Capacet) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) (Esgic) 1 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) (Fiorinal) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) 3

53 butorphanol tartrate nasal spray,nonaerosol ; QL (5 per mg/ml capacet oral capsule mg 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) codeine sulfate oral tablet 15 mg, 30 mg, 60 mg ; QL (180 per 30 EMBEDA ORAL CAPSULE,ORAL 4 QL (60 per 30 ONLY,EXT.REL PELL MG, MG, MG, 50-2 MG, MG, MG endocet oral tablet mg ; QL (180 per 30 endocet oral tablet mg, mg ; QL (360 per 30 endocet oral tablet mg ; QL (240 per 30 fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg (Actiq) 5 PA; NM; NDS; QL (120 per 30 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-ibuprofen oral tablet mg, mg (Duragesic) ; QL (10 per 30 (Hycet) ; QL (2700 per 30 (Vicodin HP) ; QL (180 per 30 (Lorcet HD) ; QL (180 per 30 (Verdrocet) ; QL (240 per 30 (Vicodin) ; QL (240 per 30 (Lorcet (hydrocodone)) ; QL (240 per 30 (Vicodin ES) ; QL (180 per 30 (Lorcet Plus) ; QL (180 per 30 (Ibudone) ; QL (150 per 30 4

54 hydrocodone-ibuprofen oral tablet mg ; QL (150 per 30 hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml hydromorphone oral liquid 1 mg/ml (Dilaudid) ; QL (1200 per 30 hydromorphone oral tablet 2 mg, 4 mg, 8 mg (Dilaudid) ; QL (180 per 30 HYSINGLA ER ORAL 3 QL (30 per 30 TABLET,ORAL ONLY,EXT.REL.24 HR 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, PA; NM; NDS; QL (30 per 30 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet mg ; QL (240 per 30 lorcet hd oral tablet mg ; QL (180 per 30 lorcet plus oral tablet mg ; QL (180 per 30 methadone injection solution 10 mg/ml methadone oral solution 10 mg/5 ml ; QL (600 per 30 methadone oral solution 5 mg/5 ml ; QL (1200 per 30 methadone oral tablet 10 mg (Dolophine) ; QL (120 per 30 methadone oral tablet 5 mg (Dolophine) ; QL (180 per 30 methadose oral tablet,soluble 40 mg ; QL (30 per 30 morphine 10 mg/ml isecure syrg l/f, p/f, suv, inner 10 mg/ml morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) ; QL (180 per 30 morphine injection syringe 10 mg/ml morphine intravenous solution 10 mg/ml morphine oral solution 10 mg/5 ml ; QL (700 per 30 5

55 morphine oral solution 20 mg/5 ml (4 mg/ml) ; QL (300 per 30 MORPHINE ORAL TABLET 15 MG 4 QL (180 per 30 MORPHINE ORAL TABLET 30 MG 4 QL (120 per 30 morphine oral tablet extended release 100 (MS Contin) ; QL (60 per 30 mg, 200 mg, 60 mg morphine oral tablet extended release 15 mg, 30 mg (MS Contin) ; QL (90 per 30 NUCYNTA ER ORAL TABLET 3 QL (60 per 30 EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 3 QL (181 per MG, 75 MG oxycodone oral capsule 5 mg ; QL (180 per 30 oxycodone oral concentrate 20 mg/ml ; QL (120 per 30 oxycodone oral solution 5 mg/5 ml ; QL (1300 per 30 oxycodone oral tablet 10 mg ; QL (180 per 30 oxycodone oral tablet 15 mg, 30 mg (Roxicodone) ; QL (120 per 30 oxycodone oral tablet 20 mg ; QL (120 per 30 oxycodone oral tablet 5 mg (Roxicodone) ; QL (180 per 30 oxycodone oral tablet,oral only,ext.rel.12 (OxyContin) 3 QL (60 per 30 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg oxycodone-acetaminophen oral solution mg/5 ml ; QL (1800 per 30 oxycodone-acetaminophen oral tablet mg (Endocet) ; QL (180 per 30 oxycodone-acetaminophen oral tablet mg, mg (Endocet) ; QL (360 per 30 oxycodone-acetaminophen oral tablet mg (Endocet) ; QL (240 per 30 oxycodone-aspirin oral tablet mg ; QL (360 per 30 6

56 OXYCONTIN ORAL 3 QL (60 per 30 TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG oxymorphone oral tablet 10 mg (Opana) ; QL (120 per 30 oxymorphone oral tablet 5 mg (Opana) ; QL (180 per 30 oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 300 MG/1.5 ML ; QL (60 per 30 tencon oral tablet mg 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) tramadol oral tablet 50 mg (Ultram) ; QL (240 per 30 tramadol-acetaminophen oral tablet mg (Ultracet) ; QL (240 per 30 vicodin es oral tablet mg ; QL (180 per 30 vicodin hp oral tablet mg ; QL (180 per 30 vicodin oral tablet mg ; QL (240 per 30 XTAMPZA ER ORAL 3 QL (60 per 30 CAPSULE,SPRINKLE,ER 12HR TMPRR 13.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL 3 QL (120 per 30 CAPSULE,SPRINKLE,ER 12HR TMPRR 27 MG XTAMPZA ER ORAL 3 QL (240 per 30 CAPSULE,SPRINKLE,ER 12HR TMPRR 36 MG xylon 10 oral tablet mg ; QL (150 per 30 7

57 zebutal oral capsule mg 2 PA-HRM; GC; QL (180 per 30 ; AGE (Max 64 Years) ZOHYDRO ER ORAL CAPSULE, 4 QL (60 per 30 ORAL ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS 4 RECON SOLN 800 MG/8 ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 mg, 50 mg (Celebrex) ; QL (60 per 30 celecoxib oral capsule 400 mg (Celebrex) ; QL (60 per 30 diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac sodium topical drops 1.5 % ; QL (300 per 30 diclofenac sodium topical gel 3 % (Solaraze) 2 PA; GC; QL (100 per 28 diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mgmcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mgmcg diflunisal oral tablet 500 mg DUEXIS ORAL TABLET MG 5 PA; NM; NDS; QL (90 per 30 etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg (Lodine) etodolac oral tablet 500 mg fenoprofen oral tablet 600 mg (ProFeno) FLECTOR TRANSDERMAL 4 PA PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg ibu oral tablet 400 mg, 600 mg, 800 mg ibuprofen oral suspension 100 mg/5 ml (Child Ibuprofen) 8

58 ibuprofen oral tablet 400 mg, 600 mg, (IBU) 800 mg indomethacin oral capsule 25 mg 1 PA-HRM; GC; QL (240 per 30 ; AGE (Max 64 Years) indomethacin oral capsule 50 mg 1 PA-HRM; GC; QL (120 per 30 ; AGE (Max 64 Years) indomethacin oral capsule, extended release 75 mg 2 PA-HRM; GC; QL (60 per 30 ; AGE (Max 64 Years) indomethacin sodium intravenous recon soln 1 mg ketoprofen oral capsule 25 mg, 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac injection cartridge 15 mg/ml 1 PA-HRM; GC; QL (40 per 30 ; AGE (Max 64 Years) ketorolac injection solution 15 mg/ml 1 PA-HRM; GC; QL (40 per 30 ; AGE (Max 64 Years) ketorolac injection solution 30 mg/ml (1 ml) 1 PA-HRM; GC; QL (20 per 30 ; AGE (Max 64 Years) ketorolac injection syringe 15 mg/ml 1 PA-HRM; GC; QL (40 per 30 ; AGE (Max 64 Years) ketorolac injection syringe 30 mg/ml 1 PA-HRM; GC; QL (20 per 30 ; AGE (Max 64 Years) ketorolac intramuscular cartridge 60 mg/2 ml ketorolac intramuscular solution 60 mg/2 ml ketorolac intramuscular syringe 60 mg/2 ml 1 PA-HRM; GC; QL (20 per 30 ; AGE (Max 64 Years) 1 PA-HRM; GC; QL (20 per 30 ; AGE (Max 64 Years) 1 PA-HRM; GC; QL (20 per 30 ; AGE (Max 64 Years) 9

59 ketorolac oral tablet 10 mg 1 PA-HRM; GC; QL (20 per 30 ; AGE (Max 64 Years) mefenamic acid oral capsule 250 mg meloxicam oral suspension 7.5 mg/5 ml 4 meloxicam oral tablet 15 mg, 7.5 mg (Mobic) nabumetone oral tablet 500 mg, 750 mg naproxen oral tablet 250 mg, 375 mg naproxen oral tablet 500 mg (Naprosyn) naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg (EC-Naprosyn) PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MG/GRAM /ACTUATION(2 %) piroxicam oral capsule 10 mg, 20 mg (Feldene) sulindac oral tablet 150 mg, 200 mg tolmetin oral capsule 400 mg tolmetin oral tablet 200 mg, 600 mg VIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC MG, MG 5 PA; NM; NDS; QL (224 per 28 5 PA; NM; NDS; QL (60 per 30 VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % ; QL (30 per 30 lidocaine (pf) injection solution 10 mg/ml (Xylocaine-MPF) (1 %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 15 mg/ml (Xylocaine-MPF) (1.5 %), 20 mg/ml (2 %) lidocaine (pf) injection solution 40 mg/ml (4 %) lidocaine hcl 1% ampul p/f, latex-free,sdv (Xylocaine-MPF) 10 mg/ml (1 %) lidocaine hcl 2% 100 mg/5 ml inner, l/f, (Xylocaine-MPF) p/f, sdv 20 mg/ml (2 %) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 5 mg/ml (0.5 %) (Xylocaine) 10

60 lidocaine hcl mucous membrane jelly 2 % ; QL (30 per 30 lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) 2 PA; GC; QL (90 per 30 lidocaine topical ointment 5 % 2 PA; GC; QL (90 per 30 lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % 2 PA; GC; QL (30 per 30 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg buprenorphine hcl sublingual tablet 2 mg, 8 mg ; QL (90 per 30 buprenorphine-naloxone sublingual tablet mg, 8-2 mg ; QL (90 per 30 bupropion hcl (smoking deter) oral tablet (Zyban) extended release 12 hr 150 mg CHANTIX CONTINUING MONTH 3 QL (336 per 365 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 3 QL (336 per 365 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) 3 QL (106 per 365 disulfiram oral tablet 250 mg, 500 mg (Antabuse) LUCEMYRA ORAL TABLET 0.18 MG ; QL (224 per 14 naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, 1 mg/ml naltrexone oral tablet 50 mg NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION 3 QL (4 per 30 11

61 NICOTROL INHALATION 4 QL (1008 per 90 CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 3 QL (60 per MG, 8-2 MG SUBOXONE SUBLINGUAL FILM 2-3 QL (30 per MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET 3 QL (30 per MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET 3 QL (60 per MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg (Xanax) ; QL (120 per 30 alprazolam oral tablet 2 mg (Xanax) ; QL (150 per 30 alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg (Xanax XR) ; QL (120 per 30 alprazolam oral tablet extended release 24 hr 3 mg (Xanax XR) ; QL (90 per 30 buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg ; QL (120 per 30 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) ; QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) ; QL (300 per 30 clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg ; QL (90 per 30 clonazepam oral tablet,disintegrating 2 mg ; QL (300 per 30 clorazepate dipotassium oral tablet 15 mg, 3.75 mg ; QL (180 per 30 clorazepate dipotassium oral tablet 7.5 mg (Tranxene T-Tab) ; QL (180 per 30 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT 2.5 MG 4 12

62 diazepam injection solution 5 mg/ml ; QL (10 per 28 diazepam injection syringe 5 mg/ml ; QL (10 per 28 diazepam intensol oral concentrate 5 mg/ml ; QL (1200 per 30 diazepam oral solution 5 mg/5 ml (1 mg/ml) ; QL (1200 per 30 diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) ; QL (120 per 30 diazepam rectal kit mg, (Diastat AcuDial) mg diazepam rectal kit 2.5 mg (Diastat) 4 estazolam oral tablet 1 mg 1 PA-HRM; GC; (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 (60 per 30 ; AGE (Max 64 Years) estazolam oral tablet 2 mg 1 PA-HRM; GC; (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) 13

63 flurazepam oral capsule 15 mg 1 PA-HRM; GC; (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 (60 per 30 ; AGE (Max 64 Years) flurazepam oral capsule 30 mg 1 PA-HRM; GC; (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) lorazepam injection solution 2 mg/ml, 4 (Ativan) ; QL (2 per 30 mg/ml lorazepam injection syringe 2 mg/ml, 4 ; QL (2 per 30 mg/ml lorazepam oral concentrate 2 mg/ml (Lorazepam Intensol) ; QL (150 per 30 lorazepam oral tablet 0.5 mg, 1 mg (Ativan) ; QL (90 per 30 lorazepam oral tablet 2 mg (Ativan) ; QL (150 per 30 midazolam oral syrup 2 mg/ml ; QL (10 per 30 ONFI ORAL SUSPENSION 2.5 MG/ML 5 PA NSO; NM; NDS; QL (480 per 30 ONFI ORAL TABLET 10 MG, 20 MG 5 PA NSO; NM; NDS; QL (60 per 30 oxazepam oral capsule 10 mg, 15 mg, 30 mg ; QL (120 per 30 14

64 temazepam oral capsule 15 mg, 30 mg (Restoril) 1 PA-HRM; GC; (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) triazolam oral tablet mg 1 PA-HRM; GC; (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 (120 per 30 ; AGE (Max 64 Years) triazolam oral tablet 0.25 mg (Halcion) 1 PA-HRM; GC; (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 (60 per 30 ; AGE (Max 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML 5 PA BvD; NM; NDS 15

65 gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 120 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 20 mg/2 ml, 40 mg/ml gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml, 60 mg/6 ml, 80 mg/8 ml neomycin oral tablet 500 mg streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin palmitate hcl oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 (mg/ml) (6 ml) ; QL (224 per 28 (Tobi) 5 PA BvD; NM; NDS (BACiiM) (Cleocin HCl) (Cleocin in 5 % dextrose) (Cleocin Pediatric) 16

66 clindamycin phosphate injection solution (Cleocin) 150 mg/ml clindamycin phosphate intravenous (Cleocin) solution 600 mg/4 ml colistin (colistimethate na) injection (Coly-Mycin M 5 PA BvD; NM; NDS recon soln 150 mg Parenteral) daptomycin intravenous recon soln 500 (Cubicin) mg FIRVANQ ORAL RECON SOLN 25 4 MG/ML, 50 MG/ML linezolid 600 mg/300 ml-0.9% nacl 600 mg/300 ml linezolid in dextrose 5% intravenous (Zyvox) piggyback 600 mg/300 ml linezolid oral suspension for (Zyvox) reconstitution 100 mg/5 ml linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml (Metro I.V.) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg (Macrodantin) 1 PA-HRM; GC; (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 (120 per 30 ; AGE (Max 64 Years) nitrofurantoin macrocrystal oral capsule 25 mg (Macrodantin) 2 PA-HRM; GC; (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 (120 per 30 ; AGE (Max 64 Years) 17

67 nitrofurantoin monohyd/m-cryst oral capsule 100 mg (Macrobid) 1 PA-HRM; GC; (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 100 mg vancomycin intravenous recon soln 1,000 2 PA BvD; GC mg, 10 gram, 5 gram vancomycin intravenous recon soln PA BvD; GC mg, 750 mg vancomycin oral capsule 125 mg (Vancocin) vancomycin oral capsule 250 mg (Vancocin) XIFAXAN ORAL TABLET 200 MG 5 PA; NM; NDS; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG 5 PA; NM; NDS Cephalosporins cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous 4 piggyback 2 gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefditoren pivoxil oral tablet 200 mg 18

68 cefditoren pivoxil oral tablet 400 mg (Spectracef) cefepime injection recon soln 1 gram, 2 (Maxipime) 4 gram cefixime oral suspension for (Suprax) reconstitution 100 mg/5 ml, 200 mg/5 ml cefotaxime injection recon soln 1 gram, 500 mg cefotaxime injection recon soln 10 gram, (Claforan) 2 gram cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection recon soln 1 gram (Fortaz) ceftazidime injection recon soln 2 gram, 6 (TAZICEF) gram ceftibuten oral capsule 400 mg 4 ceftibuten oral suspension for 4 reconstitution 180 mg/5 ml ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cephalexin oral capsule 250 mg, 500 mg (Keflex) cephalexin oral capsule 750 mg (Keflex) cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG 4 SUPRAX ORAL SUSPENSION FOR 4 RECONSTITUTION 500 MG/5 ML tazicef injection recon soln 1 gram, 2 gram, 6 gram 19

69 TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) mg azithromycin oral packet 1 gram (Zithromax) 4 azithromycin oral suspension for (Zithromax) reconstitution 100 mg/5 ml azithromycin oral suspension for (Zithromax) reconstitution 200 mg/5 ml azithromycin oral tablet 250 mg (6 pack), 500 mg (3 pack) azithromycin oral tablet 250 mg, 500 mg, (Zithromax) 600 mg clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg clarithromycin oral tablet 500 mg clarithromycin oral tablet extended release 24 hr 500 mg DIFICID ORAL TABLET 200 MG 5 ST; NM; NDS; QL (20 per 10 erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 200 mg/5 ml erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, 2 (Azactam) gram CAYSTON INHALATION 5 NM; LA; NDS SOLUTION FOR NEBULIZATION 75 MG/ML ertapenem injection recon soln 1 gram (Invanz) imipenem-cilastatin intravenous recon soln 250 mg imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 mg INVANZ INJECTION RECON SOLN 4 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg (Merrem) 20

70 Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution mg/5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution mg/5 ml amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet (Augmentin) mg, mg amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, 3 gram BICILLIN L-A INTRAMUSCULAR 4 SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln 1 gram 21

71 nafcillin injection recon soln 10 gram nafcillin intravenous recon soln 2 gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin injection recon soln 1 gram, 10 gram, 2 gram penicillin g potassium injection recon soln (Pfizerpen-G) 20 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous (Zosyn) 2 PA BvD; GC recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram Quinolones BAXDELA ORAL TABLET 450 MG 5 PA; NM; NDS; QL (28 per 14 ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase 24 hr 1,000 mg, 500 mg ciprofloxacin hcl oral tablet 100 mg ciprofloxacin hcl oral tablet 250 mg, 500 (Cipro) mg ciprofloxacin hcl oral tablet 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 mg/200 ml ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml levofloxacin in d5w intravenous piggyback 250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml 22

72 levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg levofloxacin oral tablet 500 mg, 750 mg (Levaquin) moxifloxacin oral tablet 400 mg (Avelox) ofloxacin oral tablet 300 mg, 400 mg Sulfonamides sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension mg/5 ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet mg sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet mg sulfatrim oral suspension mg/5 ml 4 Tetracyclines demeclocycline oral tablet 150 mg, 300 mg doxy-100 intravenous recon soln 100 mg doxycycline hyclate intravenous recon (Doxy-100) soln 100 mg doxycycline hyclate oral capsule 100 mg, (Morgidox) 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 75 mg doxycycline hyclate oral tablet,delayed (Soloxide) release (dr/ec) 150 mg doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 200 mg, 50 mg doxycycline monohydrate oral capsule (Mondoxyne NL) 100 mg, 50 mg doxycycline monohydrate oral capsule 150 mg doxycycline monohydrate oral capsule 75 mg (Mondoxyne NL) 23

73 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) mg doxycycline monohydrate oral tablet 150 mg, 75 mg doxycycline monohydrate oral tablet 50 mg MINOCIN INTRAVENOUS RECON 3 SOLN 100 MG minocycline oral capsule 100 mg, 50 mg (Minocin) minocycline oral capsule 75 mg minocycline oral tablet 100 mg, 50 mg, 75 mg mondoxyne nl oral capsule 100 mg, 50 mg mondoxyne nl oral capsule 75 mg okebo oral capsule 100 mg okebo oral capsule 75 mg soloxide oral tablet,delayed release (dr/ec) 150 mg tetracycline oral capsule 250 mg, 500 mg tigecycline intravenous recon soln 50 mg (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 mg/5 2 PA BvD; GC ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml adrucil intravenous solution 2.5 gram/50 2 PA BvD; GC ml, 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 5 PA NSO; NM; NDS; QL (112 per 28 MG, 5 MG AFINITOR ORAL TABLET 10 MG 5 PA NSO; NM; NDS; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 5 PA NSO; NM; NDS; QL (28 per 28 ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS; QL (240 per 30 24

74 ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG 5 PA NSO; NM; NDS; QL (3 per 28 ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA NSO; NM; NDS; QL (30 per 30 ALUNBRIG ORAL TABLET 30 MG 5 PA NSO; NM; NDS; QL (120 per 30 ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23) 5 PA NSO; NM; NDS; QL (30 per 30 anastrozole oral tablet 1 mg (Arimidex) AVASTIN INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 25 MG/ML azacitidine injection recon soln 100 mg (Vidaza) BAVENCIO INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 20 MG/ML BELEODAQ INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 500 MG BENDEKA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 25 MG/ML BESPONSA INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 0.9 MG (0.25 MG/ML INITIAL) bexarotene oral capsule 75 mg (Targretin) 5 PA NSO; NM; NDS; QL (420 per 30 bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 15 unit, 30 1 PA BvD; GC unit BLINCYTO INTRAVENOUS KIT 35 5 PA NSO; NM; NDS MCG BORTEZOMIB INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 3.5 MG BOSULIF ORAL TABLET 100 MG 5 PA NSO; NM; NDS; QL (90 per 30 BOSULIF ORAL TABLET 400 MG, 500 MG 5 PA NSO; NM; NDS; QL (30 per 30 BRAFTOVI ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (120 per 30 BRAFTOVI ORAL CAPSULE 75 MG 5 PA NSO; NM; NDS; QL (180 per 30 25

75 CABOMETYX ORAL TABLET 20 MG, 60 MG 5 PA NSO; NM; NDS; QL (30 per 30 CABOMETYX ORAL TABLET 40 MG 5 PA NSO; NM; NDS; QL (60 per 30 CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS; QL (60 per 30 CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NM; NDS; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG 5 PA NSO; NM; NDS; QL (30 per 30 carboplatin intravenous solution 10 mg/ml cladribine intravenous solution 10 mg/10 2 PA BvD; GC ml clofarabine intravenous solution 20 mg/20 (Clolar) ml COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) 5 PA NSO; NM; NDS; QL (112 per 28 COTELLIC ORAL TABLET 20 MG 5 PA NSO; NM; LA; NDS; QL (63 per 28 cyclophosphamide intravenous recon soln 5 PA BvD; NM; NDS 1 gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL 2 PA BvD; ST; GC CAPSULE 25 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 10 MG/ML DARZALEX INTRAVENOUS SOLUTION 20 MG/ML 5 PA NSO; NM; LA; NDS decitabine intravenous recon soln 50 mg (Dacogen) docetaxel intravenous solution 20 mg/2 ml (10 mg/ml), 20 mg/ml, 80 mg/8 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ml (Taxotere) (1 ml), 80 mg/4 ml (20 mg/ml) doxorubicin intravenous solution 10 mg/5 (Adriamycin) 2 PA BvD; GC ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml doxorubicin, peg-liposomal intravenous suspension 2 mg/ml (Doxil) 5 PA BvD; NM; NDS 26

76 DROXIA ORAL CAPSULE 200 MG, MG, 400 MG ELIGARD (3 MONTH) 4 SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) 4 SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) 4 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS 4 SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS; QL (30 per 30 ERLEADA ORAL TABLET 60 MG 5 PA NSO; NM; NDS; QL (120 per 30 ETOPOPHOS INTRAVENOUS 4 RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Toposar) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 5 PA NSO; NM; NDS MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram 1 PA BvD; GC fluorouracil intravenous solution 1 2 PA BvD; GC gram/20 ml fluorouracil intravenous solution 5 (Adrucil) 2 PA BvD; GC gram/100 ml, 500 mg/10 ml flutamide oral capsule 125 mg GAZYVA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 1,000 MG/40 ML gemcitabine intravenous recon soln 1 (Gemzar) gram, 200 mg gemcitabine intravenous recon soln 2 gram 27

77 gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 100 mg/ml, 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG 5 PA NSO; NM; NDS; QL (30 per 30 GLEOSTINE ORAL CAPSULE 10 4 MG, 40 MG, 5 MG GLEOSTINE ORAL CAPSULE 100 MG HERCEPTIN INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 150 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 5 PA NSO; NM; NDS; QL (21 per 28 ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NM; NDS; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG 5 PA NSO; NM; NDS; QL (30 per 30 IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA NSO; NM; NDS; QL (30 per 30 ifosfamide intravenous recon soln 1 gram (Ifex) 2 PA BvD; GC ifosfamide intravenous solution 1 gram/20 2 PA BvD; GC ml, 3 gram/60 ml ifosfamide-mesna intravenous kit PA BvD; NM; NDS gram, 3,000-1,000 mg imatinib oral tablet 100 mg (Gleevec) 5 PA NSO; NM; NDS; QL (90 per 30 imatinib oral tablet 400 mg (Gleevec) 5 PA NSO; NM; NDS; QL (60 per 30 IMBRUVICA ORAL CAPSULE 140 MG, 70 MG 5 PA NSO; NM; NDS; QL (28 per 28 IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG 5 PA NSO; NM; NDS; QL (28 per 28 IMFINZI INTRAVENOUS SOLUTION 50 MG/ML 5 PA NSO; NM; NDS IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML 5 PA NSO; NM; NDS; QL (4 per

78 IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML 5 PA NSO; NM; NDS; QL (8 per 28 INLYTA ORAL TABLET 1 MG 5 PA NSO; NM; NDS; QL (180 per 30 INLYTA ORAL TABLET 5 MG 5 PA NSO; NM; NDS; QL (60 per 30 IRESSA ORAL TABLET 250 MG 5 PA NSO; NM; NDS; QL (60 per 30 irinotecan intravenous solution 100 mg/5 (Camptosar) ml, 40 mg/2 ml irinotecan intravenous solution 500 mg/25 ml IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG 5 PA NSO; NM; NDS; QL (60 per 30 KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML 5 PA NSO; NM; NDS; QL (8 per 21 KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1) KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2) KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML 5 PA NSO; NM; NDS; QL (49 per 28 5 PA NSO; NM; NDS; QL (70 per 28 5 PA NSO; NM; NDS; QL (91 per 28 5 PA NSO; NM; NDS; QL (21 per 28 5 PA NSO; NM; NDS; QL (42 per 28 5 PA NSO; NM; NDS; QL (63 per 28 5 PA NSO; NM; NDS 5 PA NSO; NM; LA; NDS 29

79 LENVIMA ORAL CAPSULE 10 5 PA NSO; NM; NDS MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 mg/0.2 ml LONSURF ORAL TABLET MG 5 PA NSO; NM; NDS; QL (100 per 28 LONSURF ORAL TABLET MG 5 PA NSO; NM; NDS; QL (80 per 28 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 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 5 PA NSO; NM; NDS; QL (448 per 28 LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA NSO; NM; NDS; QL (120 per 30 LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 MG/31 ML(0.16 MG/ML) FINAL 5 PA NSO; NM; NDS; QL (4 per 28 MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg 1 PA NSO-HRM; GC; AGE (Max 64 Years) MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NM; NDS; QL (90 per 30 MEKINIST ORAL TABLET 2 MG 5 PA NSO; NM; NDS; QL (30 per 30 30

80 MEKTOVI ORAL TABLET 15 MG 5 PA NSO; NM; NDS; QL (180 per 30 melphalan hcl intravenous recon soln 50 (Alkeran) mg mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection recon 1 PA BvD; GC soln 1 gram methotrexate sodium (pf) injection 1 PA BvD; GC solution 25 mg/ml methotrexate sodium injection solution 25 1 PA BvD; GC mg/ml methotrexate sodium oral tablet 2.5 mg 1 PA BvD; ST; GC mitoxantrone intravenous concentrate 2 mg/ml MYLOTARG INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 4.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG 5 PA NSO; NM; NDS; QL (180 per 30 NEXAVAR ORAL TABLET 200 MG 5 PA NSO; NM; NDS; QL (120 per 30 nilutamide oral tablet 150 mg (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG 5 PA NSO; NM; NDS; QL (3 per 28 ODOMZO ORAL CAPSULE 200 MG 5 PA NSO; NM; LA; NDS ONCASPAR INJECTION 5 PA NSO; NM; NDS SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS 5 PA BvD; NM; NDS DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 100 MG/10 ML, 240 MG/24 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 100 mg, 50 mg oxaliplatin intravenous solution 100 mg/20 ml, 50 mg/10 ml (5 mg/ml) paclitaxel intravenous concentrate 6 mg/ml 2 PA BvD; GC 31

81 PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML (30 MG/ML) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (120 MG/ML), 1600 MG/13.4 ML (120 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (21 per 28 5 PA NSO; NM; NDS; QL (100 per 21 5 PA NSO; NM; LA; NDS; QL (28 per 28 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (120 per 30 RYDAPT ORAL CAPSULE 25 MG 5 PA NSO; NM; NDS; QL (224 per 28 SOLTAMOX ORAL SOLUTION 10 4 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NM; NDS; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG 5 PA NSO; NM; NDS; QL (60 per 30 STIVARGA ORAL TABLET 40 MG 5 PA NSO; NM; NDS; QL (84 per 28 SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG 5 PA NSO; NM; NDS; QL (30 per 30 SYLVANT INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG 5 PA NSO; NM; NDS; QL (28 per 28 TABLOID ORAL TABLET 40 MG 32

82 TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA NSO; NM; NDS; QL (120 per 30 TAGRISSO ORAL TABLET 40 MG, 80 MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 tamoxifen oral tablet 10 mg, 20 mg TARCEVA ORAL TABLET 100 MG, 25 MG 5 PA NSO; NM; NDS; QL (60 per 30 TARCEVA ORAL TABLET 150 MG 5 PA NSO; NM; NDS; QL (90 per 30 TARGRETIN TOPICAL GEL 1 % 5 PA NSO; NM; NDS; QL (60 per 28 TASIGNA ORAL CAPSULE 150 MG, 200 MG 5 PA NSO; NM; NDS; QL (112 per 28 TASIGNA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (120 per 30 TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 5 PA NSO; NM; NDS; QL (20 per 21 MG/ML) TEMODAR INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 100 MG thiotepa injection recon soln 15 mg (Tepadina) TIBSOVO ORAL TABLET 250 MG 5 PA NSO; NM; NDS; QL (60 per 30 toposar intravenous solution 20 mg/ml topotecan intravenous recon soln 4 mg (Hycamtin) topotecan intravenous solution 4 mg/4 ml (1 mg/ml) TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (10 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON SOLN 100 MG, 25 MG TRELSTAR 3.75 MG VIAL INNER, SDV 3.75 MG TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML 5 PA BvD; NM; NDS; QL (4 per 28 ; QL (1 per 84 ; QL (1 per

83 tretinoin (chemotherapy) oral capsule 10 mg TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VECTIBIX INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 100 MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML) VELCADE INJECTION RECON 5 PA NSO; NM; NDS SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG 4 PA NSO; LA; QL (60 per 30 VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; NM; LA; NDS; QL (120 per 30 VENCLEXTA ORAL TABLET 50 MG 4 PA NSO; LA; QL (30 per 30 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 5 PA NSO; NM; LA; NDS; QL (42 per 28 5 PA NSO; NM; NDS; QL (56 per 28 vinblastine intravenous solution 1 mg/ml 2 PA BvD; GC vincasar pfs intravenous solution 1 2 PA BvD; GC mg/ml, 2 mg/2 ml vincristine intravenous solution 1 mg/ml, (Vincasar PFS) 2 PA BvD; GC 2 mg/2 ml vinorelbine intravenous solution 10 (Navelbine) mg/ml, 50 mg/5 ml VOTRIENT ORAL TABLET 200 MG 5 PA NSO; NM; NDS; QL (120 per 30 VYXEOS INTRAVENOUS RECON 5 PA BvD; NM; NDS SOLN MG XALKORI ORAL CAPSULE 200 MG, 250 MG 5 PA NSO; NM; NDS; QL (60 per 30 XATMEP ORAL SOLUTION 2.5 MG/ML 4 PA BvD; ST 34

84 XTANDI ORAL CAPSULE 40 MG 5 PA NSO; NM; NDS; QL (120 per 30 YERVOY INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 1 MG YONSA ORAL TABLET 125 MG 5 PA NSO; NM; NDS; QL (120 per 30 ZALTRAP INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 100 MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML) ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS; QL (90 per 30 ZELBORAF ORAL TABLET 240 MG 5 PA NSO; NM; NDS; QL (240 per 30 ZOLADEX SUBCUTANEOUS 4 QL (1 per 84 IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS 4 QL (1 per 28 IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA NSO; NM; NDS; QL (60 per 30 ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS; QL (90 per 30 ZYTIGA ORAL TABLET 250 MG, 500 MG 5 PA NSO; NM; NDS; QL (120 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 mg/ml, mg/ml propantheline oral tablet 15 mg Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG 35

85 BRIVIACT INTRAVENOUS 4 QL (80 per 30 SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML ; QL (600 per 30 BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG ; QL (60 per 30 carbamazepine oral capsule, er (Carbatrol) multiphase 12 hr 100 mg, 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 (Tegretol) ml carbamazepine oral tablet 200 mg (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 12 hr 100 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 100 mg CELONTIN ORAL CAPSULE MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel sprinkle 125 mg (Depakote Sprinkles) divalproex oral tablet extended release 24 (Depakote ER) hr 250 mg, 500 mg divalproex oral tablet,delayed release (Depakote) (dr/ec) 125 mg, 250 mg, 500 mg epitol oral tablet 200 mg ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 400 mg, 600 mg (Felbatol) fosphenytoin injection solution 100 mg (Cerebyx) pe/2 ml, 500 mg pe/10 ml FYCOMPA ORAL SUSPENSION MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 4 MG, 6 MG, 8 MG FYCOMPA ORAL TABLET 2 MG 4 gabapentin oral capsule 100 mg, 300 mg, (Neurontin) 400 mg gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) 36

86 GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR 300 MG (9)- 600 MG (69) GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 600 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet disintegrating, dose pk 25 mg (21) -50 mg (7) lamotrigine oral tablet disintegrating, dose pk 25 mg(14)-50 mg (14)-100 mg (7) lamotrigine oral tablet disintegrating, dose pk 50 mg (42) -100 mg (14) lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml levetiracetam intravenous solution 500 mg/5 ml (Lamictal) (Lamictal ODT Starter (Blue)) (Lamictal ODT Starter (Orange)) 4 ST; QL (78 per 30 4 ST; QL (90 per 30 (Lamictal ODT Starter (Green)) (Lamictal XR) (Lamictal) (Lamictal ODT) (Keppra) levetiracetam oral solution 100 mg/ml (Keppra) levetiracetam oral tablet 1,000 mg, 250 (Keppra) mg, 500 mg, 750 mg levetiracetam oral tablet extended release (Keppra XR) 24 hr 500 mg, 750 mg LYRICA ORAL CAPSULE 100 MG, 3 QL (90 per MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 3 QL (900 per 30 MG/ML oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) (Trileptal) 37

87 oxcarbazepine oral tablet 150 mg, 300 (Trileptal) mg, 600 mg OXTELLAR XR ORAL TABLET 4 EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET MG phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) 2 PA NSO-HRM; GC; AGE (Max 64 Years) phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, PA NSO-HRM; GC; AGE (Max 64 Years) mg, 97.2 mg phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral tablet,chewable 50 mg (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 100 mg phenytoin sodium extended oral capsule (Phenytek) 200 mg, 300 mg phenytoin sodium intravenous solution 50 mg/ml phenytoin sodium intravenous syringe 50 mg/ml primidone oral tablet 250 mg, 50 mg (Mysoline) ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR 4 ST; QL (60 per 30 SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, ST; QL (120 per 30 MG subvenite oral tablet 100 mg, 150 mg, 200 mg, 25 mg tiagabine oral tablet 12 mg, 16 mg, 2 mg, (Gabitril) 4 mg topiramate oral capsule, sprinkle 15 mg, (Topamax) 25 mg topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) mg, 150 mg, 200 mg, 25 mg, 50 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg (Topamax) 38

88 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) valproic acid (as sodium salt) oral solution 250 mg/5 ml (Depacon) (Depakene) ; QL (60 per 30 valproic acid oral capsule 250 mg (Depakene) vigabatrin oral powder in packet 500 mg (Sabril) vigadrone oral powder in packet 500 mg VIMPAT INTRAVENOUS 3 QL (200 per 5 SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 3 QL (1200 per 30 MG/ML VIMPAT ORAL TABLET 100 MG, 3 QL (60 per MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg (Zonegran) zonisamide oral capsule 50 mg Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 5 mg (Aricept) ; QL (30 per 30 donepezil oral tablet 23 mg (Aricept) ; QL (30 per 30 donepezil oral tablet,disintegrating 10 mg, 5 mg ; QL (30 per 30 galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg (Razadyne ER) ; QL (30 per 30 galantamine oral solution 4 mg/ml ; QL (200 per 30 galantamine oral tablet 12 mg, 4 mg, 8 mg (Razadyne) ; QL (60 per 30 memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, 28 mg, 7 mg (Namenda XR) ; QL (30 per 30 memantine oral solution 2 mg/ml ; QL (360 per 30 memantine oral tablet 10 mg, 5 mg (Namenda) ; QL (60 per 30 memantine oral tablets,dose pack 5-10 mg (Namenda Titration Pak) 4 QL (49 per 28 39

89 NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR MG, MG, MG, 7-10 MG rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amitriptyline-chlordiazepoxide oral tablet mg, mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg 3 QL (56 per QL (30 per 30 ; QL (60 per 30 (Exelon) ; QL (30 per 30 1 PA NSO-HRM; GC; AGE (Max 64 Years) 1 PA NSO-HRM; GC; AGE (Max 64 Years) 1 PA NSO-HRM; GC; AGE (Max 64 Years) bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release (Wellbutrin SR) 12 hr 100 mg, 150 mg, 200 mg bupropion hcl oral tablet extended release (Wellbutrin XL) 24 hr 150 mg, 300 mg citalopram oral solution 10 mg/5 ml ; QL (600 per 30 citalopram oral tablet 10 mg, 20 mg, 40 (Celexa) ; QL (30 per 30 mg clomipramine oral capsule 25 mg, 50 mg, (Anafranil) 2 PA NSO-HRM; GC; 75 mg AGE (Max 64 Years) desipramine oral tablet 10 mg, 25 mg (Norpramin) 2 PA NSO-HRM; GC; AGE (Max 64 Years) desipramine oral tablet 100 mg, 150 mg, 2 PA NSO-HRM; GC; 50 mg, 75 mg AGE (Max 64 Years) desvenlafaxine succinate oral tablet (Pristiq) ; QL (30 per 30 extended release 24 hr 100 mg, 25 mg, 50 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 PA NSO-HRM; GC; AGE (Max 64 Years) 40

90 doxepin oral concentrate 10 mg/ml 1 PA NSO-HRM; GC; AGE (Max 64 Years) duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Cymbalta) ; QL (60 per 30 duloxetine oral capsule,delayed release(dr/ec) 30 mg (Cymbalta) ; QL (30 per 30 duloxetine oral capsule,delayed release(dr/ec) 40 mg ; QL (30 per 30 EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 ; QL (30 per 30 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg (Lexapro) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 40 mg fluoxetine oral solution 20 mg/5 ml (4 mg/ml) fluvoxamine oral tablet 100 mg, 25 mg, 50 mg imipramine hcl oral tablet 10 mg, 25 mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg (Prozac) 4 ST; QL (56 per ST; QL (30 per 30 (Tofranil) 1 PA NSO-HRM; GC; AGE (Max 64 Years) 2 PA NSO-HRM; GC; AGE (Max 64 Years) MARPLAN ORAL TABLET 10 MG 4 mirtazapine oral tablet 15 mg, 30 mg (Remeron) mirtazapine oral tablet 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 15 (Remeron SolTab) mg, 30 mg, 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg 41

91 nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg (Pamelor) 1 PA NSO-HRM; GC; AGE (Max 64 Years) nortriptyline oral solution 10 mg/5 ml 1 PA NSO-HRM; GC; AGE (Max 64 Years) paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg (Paxil) 1 PA NSO-HRM; GC; AGE (Max 64 Years) paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg (Paxil CR) 2 PA NSO-HRM; GC; AGE (Max 64 Years) PAXIL ORAL SUSPENSION 10 MG/5 ML 4 PA NSO-HRM; AGE (Max 64 Years) perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, PA NSO-HRM; GC; AGE (Max 64 Years) mg phenelzine oral tablet 15 mg (Nardil) protriptyline oral tablet 10 mg, 5 mg 2 PA NSO-HRM; GC; AGE (Max 64 Years) sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 25 mg, 50 (Zoloft) mg tranylcypromine oral tablet 10 mg (Parnate) trazodone oral tablet 100 mg, 150 mg, 50 mg trazodone oral tablet 300 mg trimipramine oral capsule 100 mg, 25 mg, (Surmontil) 2 PA NSO-HRM; GC; 50 mg AGE (Max 64 Years) TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 3 ST; QL (30 per 30 venlafaxine oral capsule,extended release 24hr 150 mg (Effexor XR) ; QL (30 per 30 venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg (Effexor XR) ; QL (90 per 30 venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG 3 ST; QL (30 per 30 VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23) 3 ST; QL (30 per

92 Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 25 mg, 50 mg GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 25 MG JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG KAZANO ORAL TABLET ,000 MG, MG (Precose) ; QL (90 per ST; QL (30 per 30 3 ST; QL (60 per 30 3 ST; QL (120 per 30 3 ST; QL (60 per 30 3 ST; QL (60 per 30 3 ST; QL (30 per 30 3 QL (60 per 30 3 QL (30 per 30 3 QL (60 per 30 3 QL (30 per 30 3 ST; QL (30 per 30 3 QL (60 per 30 3 QL (60 per 30 3 QL (30 per 30 4 QL (60 per 30 43

93 KORLYM ORAL TABLET 300 MG 5 PA; NM; NDS; QL (112 per 28 metformin oral tablet 1,000 mg (Glucophage) ; QL (75 per 30 metformin oral tablet 500 mg (Glucophage) ; QL (150 per 30 metformin oral tablet 850 mg (Glucophage) ; QL (90 per 30 metformin oral tablet extended release 24 hr 500 mg (Glucophage XR) ; QL (120 per 30 metformin oral tablet extended release 24 hr 750 mg (Glucophage XR) ; QL (60 per 30 miglitol oral tablet 100 mg, 25 mg, 50 mg (Glyset) ; QL (90 per 30 nateglinide oral tablet 120 mg, 60 mg (Starlix) ; QL (90 per 30 NESINA ORAL TABLET 12.5 MG, 25 4 QL (30 per 30 MG, 6.25 MG OSENI ORAL TABLET MG, 4 QL (30 per MG, MG, MG, MG, MG OZEMPIC SUBCUTANEOUS PEN 3 QL (3 per 28 INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/0.75 ML (2 MG/1.5 ML) pioglitazone oral tablet 15 mg, 30 mg, 45 mg (Actos) ; QL (30 per 30 repaglinide oral tablet 0.5 mg ; QL (240 per 30 repaglinide oral tablet 1 mg, 2 mg (Prandin) ; QL (240 per 30 repaglinide-metformin oral tablet mg, mg ; QL (150 per 30 SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML 5 PA; NM; NDS; QL (10.8 per 28 SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML 5 PA; NM; NDS; QL (10.8 per 28 SYNJARDY ORAL TABLET ,000 MG, MG, 5-1,000 MG, MG 3 ST; QL (60 per 30 44

94 SYNJARDY XR ORAL TABLET, IR 3 ST; QL (30 per 30 - ER, BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG SYNJARDY XR ORAL TABLET, IR 3 ST; QL (60 per 30 - ER, BIPHASIC 24HR ,000 MG, 5-1,000 MG TRADJENTA ORAL TABLET 5 MG 3 QL (30 per 30 TRULICITY SUBCUTANEOUS PEN 3 QL (2 per 28 INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA SUBCUTANEOUS PEN 3 QL (9 per 30 INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) Insulins FIASP FLEXTOUCH U QL (30 per 28 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) FIASP U-100 INSULIN 3 QL (40 per 28 SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) 3 QL (40 per 28 INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) 3 QL (24 per 28 KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) LANTUS SOLOSTAR U QL (30 per 28 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS U-100 INSULIN 3 QL (40 per 28 SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 U-100 INSULIN 3 QL (40 per 28 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N NPH U-100 INSULIN 3 QL (40 per 28 SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML 3 QL (40 per 28 45

95 NOVOLOG FLEXPEN U QL (30 per 28 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX U QL (40 per 28 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U- 3 QL (30 per SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG PENFILL U QL (30 per 28 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN 3 QL (40 per 28 ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML SOLIQUA 100/33 SUBCUTANEOUS 3 ST; QL (30 per 30 INSULIN PEN 100 UNIT-33 MCG/ML TOUJEO MAX U-300 SOLOSTAR 3 QL (18 per 28 SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U QL (13.5 per 28 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) XULTOPHY 100/3.6 3 ST; QL (15 per 28 SUBCUTANEOUS INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg (Amaryl) ; QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) ; QL (60 per 30 glipizide oral tablet 10 mg (Glucotrol) ; QL (120 per 30 glipizide oral tablet 5 mg (Glucotrol) ; QL (60 per 30 glipizide oral tablet extended release 24hr 10 mg (Glucotrol XL) ; QL (60 per 30 glipizide oral tablet extended release 24hr 2.5 mg, 5 mg (Glucotrol XL) ; QL (30 per 30 46

96 glipizide-metformin oral tablet mg ; QL (240 per 30 glipizide-metformin oral tablet mg, mg ; QL (120 per 30 glyburide micronized oral tablet 1.5 mg, 3 (Glynase) 1 PA-HRM; GC; AGE mg, 6 mg (Max 64 Years) glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1 PA-HRM; GC; AGE (Max 64 Years) glyburide-metformin oral tablet mg 1 PA-HRM; GC; AGE (Max 64 Years) glyburide-metformin oral tablet mg, mg (Glucovance) 1 PA-HRM; GC; AGE (Max 64 Years) tolazamide oral tablet 250 mg ; QL (120 per 30 tolazamide oral tablet 500 mg ; QL (60 per 30 tolbutamide oral tablet 500 mg ; QL (180 per 30 Antifungals Antifungals ABELCET INTRAVENOUS 5 PA BvD; NM; NDS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS 5 PA BvD; NM; NDS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg 2 PA BvD; GC caspofungin intravenous recon soln 50 (Cancidas) mg, 70 mg ciclopirox topical cream 0.77 % (Ciclodan) ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Ciclodan) ciclopirox topical suspension 0.77 % (Loprox (as olamine)) clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % (Antifungal (clotrimazole)) clotrimazole topical solution 1 % clotrimazole-betamethasone topical cream % (Lotrisone) 47

97 clotrimazole-betamethasone topical lotion % econazole topical cream 1 % fluconazole in nacl (iso-osm) intravenous 2 PA BvD; GC piggyback 100 mg/50 ml, 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for (Diflucan) reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, (Diflucan) 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg (Ancobon) griseofulvin microsize oral suspension 125 mg/5 ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg itraconazole oral capsule 100 mg (Sporanox) ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % (Nizoral) miconazole-3 vaginal suppository 200 mg NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7 ML NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 (Nyamyc) unit/gram nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% 48

98 nystop topical powder 100,000 unit/gram SPORANOX ORAL SOLUTION 10 MG/ML terbinafine hcl oral tablet 250 mg voriconazole intravenous solution 200 mg (Vfend IV) 5 PA BvD; NM; NDS voriconazole oral suspension for (Vfend) reconstitution 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg (Vfend) Antigout Agents Antigout Agents, Other allopurinol oral tablet 100 mg, 300 mg (Zyloprim) colchicine oral capsule 0.6 mg (Mitigare) colchicine oral tablet 0.6 mg (Colcrys) probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg ULORIC ORAL TABLET 40 MG, 80 MG 3 QL (30 per 30 Antihistamines Antihistamines carbinoxamine maleate oral liquid 4 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years) carbinoxamine maleate oral tablet 4 mg 1 PA-HRM; GC; AGE (Max 64 Years) clemastine oral tablet 2.68 mg 1 PA-HRM; GC; AGE (Max 64 Years) cyproheptadine oral syrup 2 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years) cyproheptadine oral tablet 4 mg 1 PA-HRM; GC; AGE (Max 64 Years) diphenhydramine 50 mg/ml syrng outer,l/f,suv,p/f 50 mg/ml diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe 50 mg/ml diphenhydramine hcl oral elixir 12.5 mg/5 (Children's Allergy 1 PA-HRM; GC; AGE ml (diphenhyd)) (Max 64 Years) hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml 2 PA-HRM; GC; AGE (Max 64 Years) 49

99 hydroxyzine hcl oral solution 10 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years) hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 1 PA-HRM; GC; AGE (Max 64 Years) levocetirizine oral solution 2.5 mg/5 ml (Xyzal) levocetirizine oral tablet 5 mg (24HR Allergy Relief) promethazine oral syrup 6.25 mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years) promethazine vc oral syrup mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years) Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg Antimigraine Agents Antimigraine Agents dihydroergotamine injection solution 1 mg/ml (D.H.E.45) ; QL (24 per 28 dihydroergotamine nasal spray,nonaerosol 0.5 mg/pump act. (4 mg/ml) (Migranal) ; QL (8 per 28 ERGOMAR SUBLINGUAL TABLET 2 MG ; QL (40 per 28 naratriptan oral tablet 1 mg, 2.5 mg (Amerge) ; QL (18 per 28 rizatriptan oral tablet 10 mg (Maxalt) ; QL (18 per 28 rizatriptan oral tablet 5 mg ; QL (18 per 28 rizatriptan oral tablet,disintegrating 10 mg, 5 mg (Maxalt-MLT) ; QL (18 per 28 sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation (Imitrex) ; QL (12 per 28 sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg (Imitrex) ; QL (18 per 28 sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml (Imitrex STATdose Kit Refill) ; QL (4 per 28 50

100 sumatriptan succinate subcutaneous pen (Imitrex STATdose ; QL (4 per 28 injector 4 mg/0.5 ml, 6 mg/0.5 ml Pen) sumatriptan succinate subcutaneous (Imitrex) ; QL (4 per 28 solution 6 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 mg (Zomig) ; QL (12 per 28 zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg (Zomig ZMT) ; QL (12 per 28 Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON 4 SOLN 1 GRAM dapsone oral tablet 100 mg, 25 mg ethambutol oral tablet 100 mg ethambutol oral tablet 400 mg (Myambutol) isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 100 mg, 300 mg PASER ORAL GRANULES DR FOR 4 SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG 4 pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg (Mycobutin) rifampin intravenous recon soln 600 mg (Rifadin) rifampin oral capsule 150 mg, 300 mg (Rifadin) SIRTURO ORAL TABLET 100 MG 5 PA; NM; NDS; QL (188 per 168 TRECATOR ORAL TABLET 250 MG 4 Antinausea Agents Antinausea Agents AKYNZEO (FOSNETUPITANT) 4 INTRAVENOUS RECON SOLN MG AKYNZEO (NETUPITANT) ORAL 4 PA BvD CAPSULE MG aprepitant oral capsule 125 mg (Emend) 2 PA BvD; GC; QL (2 per 28 aprepitant oral capsule 40 mg (Emend) 2 PA BvD; GC; QL (1 per 28 aprepitant oral capsule 80 mg (Emend) 2 PA BvD; GC; QL (4 per 28 51

101 aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) (Emend) 2 PA BvD; GC; QL (6 per 28 CINVANTI INTRAVENOUS 4 QL (36 per 28 EMULSION 7.2 MG/ML compro rectal suppository 25 mg dimenhydrinate injection solution 50 mg/ml dronabinol oral capsule 10 mg, 2.5 mg, 5 (Marinol) 2 PA; GC mg EMEND (FOSAPREPITANT) 4 QL (2 per 28 INTRAVENOUS RECON SOLN 150 MG EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ 4 PA BvD; QL (6 per 28 ML FINAL CONC.) granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml) granisetron hcl oral tablet 1 mg 2 PA BvD; GC meclizine oral tablet 12.5 mg 1 PA-HRM; GC; AGE (Max 64 Years) meclizine oral tablet 25 mg (Dramamine Less Drowsy) 1 PA-HRM; GC; AGE (Max 64 Years) ondansetron hcl (pf) injection solution 4 mg/2 ml ondansetron hcl (pf) injection syringe 4 mg/2 ml ondansetron hcl intravenous solution 2 mg/ml ondansetron hcl oral solution 4 mg/5 ml (Zofran) 2 PA BvD; GC ondansetron hcl oral tablet 24 mg 1 PA BvD; GC ondansetron hcl oral tablet 4 mg, 8 mg (Zofran) 1 PA BvD; GC ondansetron oral tablet,disintegrating 4 (Zofran ODT) 1 PA BvD; GC mg, 8 mg phenadoz rectal suppository 12.5 mg, 25 mg 2 PA-HRM; GC; AGE (Max 64 Years) prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral tablet 10 mg, 5 mg (Compazine) 52

102 prochlorperazine rectal suppository 25 mg (Compazine) promethazine injection solution 25 mg/ml, (Phenergan) 2 PA-HRM; GC; AGE 50 mg/ml (Max 64 Years) promethazine oral tablet 12.5 mg, 25 mg, 50 mg 1 PA-HRM; GC; AGE (Max 64 Years) promethazine rectal suppository 12.5 mg, 25 mg (Phenadoz) 2 PA-HRM; GC; AGE (Max 64 Years) promethazine rectal suppository 50 mg (Phenergan) 2 PA-HRM; GC; AGE (Max 64 Years) promethegan rectal suppository 12.5 mg, 25 mg, 50 mg 2 PA-HRM; GC; AGE (Max 64 Years) scopolamine base transdermal patch 3 day 1 mg over 3 days (Transderm-Scop) 2 PA-HRM; GC; QL (10 per 30 ; AGE (Max 64 Years) SYNDROS ORAL SOLUTION 5 4 PA MG/ML Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml (Mepron) atovaquone-proguanil oral tablet (Malarone) mg atovaquone-proguanil oral tablet (Malarone Pediatric) mg chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG 5 PA; NM; NDS hydroxychloroquine oral tablet 200 mg (Plaquenil) IMPAVIDO ORAL CAPSULE 50 MG 5 PA; NM; NDS; QL (84 per 28 ivermectin oral tablet 3 mg (Stromectol) mefloquine oral tablet 250 mg NEBUPENT INHALATION RECON SOLN 300 MG 4 PA BvD 53

103 paromomycin oral capsule 250 mg PENTAM INJECTION RECON 4 SOLN 300 MG PRIMAQUINE ORAL TABLET 26.3 MG quinine sulfate oral capsule 324 mg (Qualaquin) 2 PA; GC; QL (42 per 7 tinidazole oral tablet 250 mg tinidazole oral tablet 500 mg (Tindamax) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 mg amantadine hcl oral solution 50 mg/5 ml amantadine hcl oral tablet 100 mg APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML ; QL (60 per 30 benztropine injection solution 2 mg/2 ml (Cogentin) 5 PA-HRM; NM; NDS; AGE (Max 64 Years) benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1 PA-HRM; GC; AGE (Max 64 Years) bromocriptine oral capsule 5 mg (Parlodel) bromocriptine oral tablet 2.5 mg (Parlodel) cabergoline oral tablet 0.5 mg carbidopa oral tablet 25 mg (Lodosyn) carbidopa-levodopa oral tablet (Sinemet) mg, mg, mg carbidopa-levodopa oral tablet extended (Sinemet CR) release mg, mg carbidopa-levodopa oral tablet,disintegrating mg, mg, mg carbidopa-levodopa-entacapone oral (Stalevo 50) 4 tablet mg carbidopa-levodopa-entacapone oral (Stalevo 75) 4 tablet mg carbidopa-levodopa-entacapone oral (Stalevo 100) 4 tablet mg carbidopa-levodopa-entacapone oral tablet mg (Stalevo 125) 4 54

104 carbidopa-levodopa-entacapone oral (Stalevo 150) 4 tablet mg carbidopa-levodopa-entacapone oral (Stalevo 200) 4 tablet mg entacapone oral tablet 200 mg (Comtan) GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 137 MG 5 PA; NM; NDS; QL (60 per 30 GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 24HR 68.5 MG NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR OSMOLEX ER ORAL TABLET, IR - ER, BIPHASIC 24HR 129 MG, 193 MG, 258 MG pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg (Mirapex) 5 PA; NM; NDS; QL (30 per 30 3 QL (30 per 30 4 ST; QL (30 per 30 rasagiline oral tablet 0.5 mg, 1 mg (Azilect) ropinirole oral tablet 0.25 mg, 0.5 mg, 1 (Requip) mg, 2 mg, 3 mg, 4 mg, 5 mg ropinirole oral tablet extended release 24 (Requip XL) hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg trihexyphenidyl oral elixir 0.4 mg/ml 1 PA-HRM; GC; AGE (Max 64 Years) trihexyphenidyl oral tablet 2 mg, 5 mg 1 PA-HRM; GC; AGE (Max 64 Years) XADAGO ORAL TABLET 100 MG, 50 MG 5 PA; NM; NDS; QL (30 per 30 Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ; QL (1 per 28 55

105 ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG ; QL (1 per 28 aripiprazole oral solution 1 mg/ml ; QL (900 per 30 aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg (Abilify) ; QL (30 per 30 aripiprazole oral tablet 2 mg (Abilify) ; QL (60 per 30 aripiprazole oral tablet,disintegrating 10 mg 2 ST; GC; QL (90 per 30 aripiprazole oral tablet,disintegrating 15 mg 2 ST; GC; QL (60 per 30 ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML ; QL (4.8 per 365 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution 25 mg/ml chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg ; QL (3.9 per 56 ; QL (1.6 per 28 ; QL (2.4 per 28 ; QL (3.2 per 28 clozapine oral tablet 100 mg (Clozaril) ; QL (270 per 30 clozapine oral tablet 200 mg ; QL (135 per 30 clozapine oral tablet 25 mg (Clozaril) ; QL (90 per 30 56

106 clozapine oral tablet 50 mg ; QL (90 per 30 clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg (FazaClo) 2 ST; GC; QL (90 per 30 clozapine oral tablet,disintegrating 150 mg (FazaClo) 2 ST; GC; QL (180 per 30 clozapine oral tablet,disintegrating 200 mg (FazaClo) 2 ST; GC; QL (120 per 30 FANAPT ORAL TABLET 1 MG, 2 4 ST; QL (60 per 30 MG, 4 MG FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG 5 ST; NM; NDS; QL (60 per 30 FANAPT ORAL TABLETS,DOSE 4 ST; QL (8 per 28 PACK 1MG(2)-2MG(2)- 4MG(2)- 6MG(2) fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR 4 QL (6 per 28 RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol dec 50 mg/ml vial mdv 50 (Haldol Decanoate) mg/ml haloperidol decanoate intramuscular (Haldol Decanoate) solution 100 mg/ml haloperidol decanoate intramuscular solution 100 mg/ml (1 ml) haloperidol decanoate intramuscular (Haldol Decanoate) solution 50 mg/ml haloperidol lactate injection solution 5 (Haldol) mg/ml haloperidol lactate intramuscular syringe 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml 57

107 haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 ; QL (0.75 per 28 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 ; QL (1 per 28 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 ; QL (1.5 per 28 MG/1.5 ML INVEGA SUSTENNA 4 QL (0.25 per 28 INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 ; QL (0.5 per 28 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 ; QL (0.875 per 84 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 ; QL (1.315 per 84 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 ; QL (1.75 per 84 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 ; QL (2.625 per 84 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 3 QL (30 per MG, 40 MG, 60 MG, 80 MG loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg NUPLAZID ORAL CAPSULE 34 MG 5 PA NSO; NM; NDS; QL (30 per 30 NUPLAZID ORAL TABLET 10 MG 5 PA NSO; NM; NDS; QL (30 per 30 NUPLAZID ORAL TABLET 17 MG 5 PA NSO; NM; NDS; QL (60 per 30 olanzapine intramuscular recon soln 10 mg (Zyprexa) ; QL (30 per 30 58

108 olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg (Zyprexa) ; QL (30 per 30 olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg (Zyprexa Zydis) ; QL (30 per 30 paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg (Invega) ; QL (30 per 30 paliperidone oral tablet extended release 24hr 6 mg (Invega) ; QL (60 per 30 perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg pimozide oral tablet 1 mg, 2 mg (Orap) quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg (Seroquel) ; QL (90 per 30 quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 50 mg (Seroquel XR) ; QL (30 per 30 quetiapine oral tablet extended release 24 hr 300 mg, 400 mg (Seroquel XR) ; QL (60 per 30 REXULTI ORAL TABLET 0.25 MG 5 ST; NM; NDS; QL (120 per 30 REXULTI ORAL TABLET 0.5 MG 5 ST; NM; NDS; QL (60 per 30 REXULTI ORAL TABLET 1 MG, 2 MG, 3 MG, 4 MG 5 ST; NM; NDS; QL (30 per 30 RISPERDAL CONSTA 4 QL (4 per 28 INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 ; QL (4 per 28 MG/2 ML, 50 MG/2 ML risperidone oral solution 1 mg/ml (Risperdal) ; QL (480 per 30 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg (Risperdal) ; QL (60 per 30 risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg ; QL (60 per 30 risperidone oral tablet,disintegrating 3 mg, 4 mg ; QL (120 per 30 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG 5 ST; NM; NDS; QL (60 per 30 59

109 thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG 5 ST; NM; NDS; QL (540 per 30 5 ST; NM; NDS; QL (30 per 30 4 ST; QL (14 per 365 (Geodon) ; QL (60 per 30 4 QL (2 per 28 Antivirals (Systemic) Antiretrovirals abacavir oral solution 20 mg/ml (Ziagen) abacavir oral tablet 300 mg (Ziagen) ; QL (2 per 28 ; QL (1 per 28 abacavir-lamivudine oral tablet (Epzicom) mg abacavir-lamivudine-zidovudine oral (Trizivir) tablet mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML atazanavir oral capsule 150 mg, 200 mg, (Reyataz) 300 mg ATRIPLA ORAL TABLET MG BIKTARVY ORAL TABLET MG 60

110 CIMDUO ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed (Videx EC) release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg EDURANT ORAL TABLET 25 MG efavirenz oral capsule 200 mg (Sustiva) efavirenz oral capsule 50 mg (Sustiva) efavirenz oral tablet 600 mg (Sustiva) EMTRIVA ORAL CAPSULE 200 MG 4 EMTRIVA ORAL SOLUTION 10 4 MG/ML EPIVIR HBV ORAL SOLUTION 25 4 MG/5 ML (5 MG/ML) EVOTAZ ORAL TABLET MG fosamprenavir oral tablet 700 mg (Lexiva) FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG, 200 MG INTELENCE ORAL TABLET 25 MG 4 INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN 4 PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL 4 TABLET,CHEWABLE 100 MG, 25 MG JULUCA ORAL TABLET MG 61

111 KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution 10 mg/ml (Epivir) lamivudine oral tablet 100 mg (Epivir HBV) lamivudine oral tablet 150 mg, 300 mg (Epivir) lamivudine-zidovudine oral tablet 150- (Combivir) 300 mg LEXIVA ORAL SUSPENSION 50 4 MG/ML lopinavir-ritonavir oral solution (Kaletra) mg/5 ml nevirapine oral suspension 50 mg/5 ml (Viramune) 3 nevirapine oral tablet 200 mg (Viramune) nevirapine oral tablet extended release 24 (Viramune XR) hr 100 mg, 400 mg NORVIR ORAL CAPSULE 100 MG 4 NORVIR ORAL POWDER IN 4 PACKET 100 MG NORVIR ORAL SOLUTION 80 4 MG/ML ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET MG RESCRIPTOR ORAL TABLET, 4 DISPERSIBLE 100 MG RETROVIR INTRAVENOUS 4 SOLUTION 10 MG/ML REYATAZ ORAL POWDER IN PACKET 50 MG ritonavir oral tablet 100 mg (Norvir) SELZENTRY ORAL SOLUTION 20 MG/ML 4 62

112 SELZENTRY ORAL TABLET 150 MG, 300 MG, 75 MG SELZENTRY ORAL TABLET 25 MG 4 stavudine oral capsule 15 mg, 20 mg, 30 (Zerit) mg, 40 mg stavudine oral recon soln 1 mg/ml (Zerit) STRIBILD ORAL TABLET MG SYMFI LO ORAL TABLET MG SYMFI ORAL TABLET MG SYMTUZA ORAL TABLET MG tenofovir disoproxil fumarate oral tablet (Viread) 300 mg TIVICAY ORAL TABLET 10 MG 4 TIVICAY ORAL TABLET 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TROGARZO INTRAVENOUS SOLUTION 200 MG/1.33 ML (150 MG/ML) TRUVADA ORAL TABLET MG, MG, MG, MG VEMLIDY ORAL TABLET 25 MG ; QL (30 per 30 VIDEX 2 GM PEDIATRIC SOLN 10 4 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL 4 RECON SOLN 10 MG/ML (FINAL) VIDEX EC ORAL 4 CAPSULE,DELAYED RELEASE(DR/EC) 125 MG VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE ORAL SUSPENSION 50 MG/5 ML 4 63

113 VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG ZERIT ORAL RECON SOLN 1 4 MG/ML zidovudine oral capsule 100 mg (Retrovir) zidovudine oral syrup 10 mg/ml (Retrovir) zidovudine oral tablet 300 mg Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml (Foscavir) 2 PA BvD; GC oseltamivir oral capsule 30 mg (Tamiflu) ; QL (84 per 180 oseltamivir oral capsule 45 mg (Tamiflu) ; QL (48 per 180 oseltamivir oral capsule 75 mg (Tamiflu) ; QL (42 per 180 oseltamivir oral suspension for reconstitution 6 mg/ml (Tamiflu) ; QL (540 per 180 PREVYMIS INTRAVENOUS SOLUTION 240 MG/12 ML 5 PA; NM; NDS; QL (336 per 28 PREVYMIS INTRAVENOUS SOLUTION 480 MG/24 ML 5 PA; NM; NDS; QL (672 per 28 PREVYMIS ORAL TABLET 240 MG, 480 MG 5 PA; NM; NDS; QL (28 per 28 RELENZA DISKHALER 4 INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg (Flumadine) SYNAGIS INTRAMUSCULAR 5 PA; NM; NDS SOLUTION 100 MG/ML, 50 MG/0.5 ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG 5 PA; NM; NDS; QL (28 per 28 EPCLUSA ORAL TABLET MG 5 PA; NM; NDS; QL (28 per 28 HARVONI ORAL TABLET MG 5 PA; NM; NDS; QL (30 per 30 MAVYRET ORAL TABLET MG 5 PA; NM; NDS; QL (84 per 28 64

114 SOVALDI ORAL TABLET 400 MG 5 PA; NM; NDS; QL (28 per 28 TECHNIVIE ORAL TABLET MG 5 PA; NM; NDS; QL (56 per 28 VIEKIRA PAK ORAL TABLETS,DOSE PACK 12.5 MG-75 MG -50 MG/250 MG 5 PA; NM; NDS; QL (112 per 28 VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 8.33 MG-50 MG MG-200 MG VOSEVI ORAL TABLET MG ZEPATIER ORAL TABLET MG Interferons INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG 5 PA; NM; NDS; QL (84 per 28 5 PA; NM; NDS; QL (28 per 28 5 PA; NM; NDS; QL (30 per 30 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (4 per 28 Nucleosides And Nucleotides acyclovir oral capsule 200 mg (Zovirax) acyclovir oral suspension 200 mg/5 ml (Zovirax) acyclovir oral tablet 400 mg, 800 mg (Zovirax) acyclovir sodium intravenous recon soln 5 PA BvD; NM; NDS 500 mg acyclovir sodium intravenous solution 50 mg/ml 2 PA BvD; GC 65

115 adefovir oral tablet 10 mg (Hepsera) cidofovir intravenous solution 75 mg/ml entecavir oral tablet 0.5 mg, 1 mg (Baraclude) famciclovir oral tablet 125 mg, 250 mg, 500 mg ganciclovir sodium intravenous recon soln (Cytovene) 1 PA BvD; GC 500 mg ganciclovir sodium intravenous solution 1 PA BvD; GC 50 mg/ml ribasphere oral capsule 200 mg ribasphere oral tablet 200 mg ribasphere oral tablet 400 mg, 600 mg ribasphere ribapak mg 400 mg (7)- 400 mg (7) ribasphere ribapak mg 600 mg (7)- 400 mg (7) ribasphere ribapak mg 600 mg (7)- 600 mg (7) ribasphere ribapak oral tablets,dose pack 200 mg (7)- 400 mg (7), mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) ribavirin inhalation recon soln 6 gram (Virazole) 5 PA BvD; NM; NDS ribavirin oral capsule 200 mg (Ribasphere) ribavirin oral tablet 200 mg (Moderiba) valacyclovir oral tablet 1 gram, 500 mg (Valtrex) valganciclovir oral recon soln 50 mg/ml (Valcyte) valganciclovir oral tablet 450 mg (Valcyte) Blood Products/Modifiers/Volume Expanders Anticoagulants BEVYXXA ORAL CAPSULE 40 MG, 4 QL (43 per MG CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET 2.5 MG, 5 3 MG ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS) 3 66

116 enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml heparin, porcine (pf) injection solution 1,000 unit/ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml IPRIVASK SUBCUTANEOUS RECON SOLN 15 MG jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) DOPTELET ORAL TABLET 20 MG, 20 MG (15 PACK) (Lovenox) (Lovenox) (Arixtra) (Arixtra) (Coumadin) 5 PA; NM; NDS; QL (24 per 28 4 ST; QL (60 per PA; NM; NDS 5 PA; NM; NDS 67

117 EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML EPOGEN INJECTION SOLUTION 20,000 UNIT/ML FULPHILA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT LEUKINE INJECTION RECON SOLN 250 MCG MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 4 PA; QL (12 per 28 5 PA; NM; NDS; QL (12 per 28 5 PA; NM; NDS 5 PA; NM; NDS 5 PA; NM; NDS 5 PA; NM; NDS Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 mg (Agrylin) anagrelide oral capsule 1 mg 3 PA; QL (12 per 28 5 PA; NM; NDS; QL (12 per 28 5 PA; NM; NDS; QL (6 per 28 5 PA; NM; NDS; QL (30 per 30 68

118 protamine intravenous solution 10 mg/ml TAVALISSE ORAL TABLET 100 MG, 150 MG 5 PA; NM; NDS; QL (60 per 30 tranexamic acid intravenous solution (Cyklokapron) 1,000 mg/10 ml (100 mg/ml) tranexamic acid oral tablet 650 mg (Lysteda) ; QL (30 per 30 Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er (Aggrenox) multiphase 12 hr mg BRILINTA ORAL TABLET 60 MG, 3 90 MG cilostazol oral tablet 100 mg, 50 mg clopidogrel oral tablet 300 mg (Plavix) clopidogrel oral tablet 75 mg (Plavix) dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1 PA-HRM; GC; AGE (Max 64 Years) pentoxifylline oral tablet extended release 400 mg prasugrel oral tablet 10 mg, 5 mg (Effient) ; QL (30 per 30 Caloric Agents Caloric Agents AMINOSYN 10 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 10 % AMINOSYN 7 % WITH 4 PA BvD ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %-ELECTROLYTES 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % 4 PA BvD 69

119 AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 70

120 CLINIMIX 5%-D20W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 30 % in water (d30w) intravenous parenteral solution dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback 5 % 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 71

121 dextrose 50 % in water (d50w) 4 PA BvD intravenous parenteral solution dextrose 50 % in water (d50w) 4 PA BvD intravenous syringe dextrose 70 % in water (d70w) 4 PA BvD intravenous parenteral solution FREAMINE HBC 6.9 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 10 % HEPATAMINE 8% INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS 4 PA BvD EMULSION 20 %, 30 % KABIVEN INTRAVENOUS 4 PA BvD EMULSION % NEPHRAMINE 5.4 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS 4 PA BvD EMULSION 20 % PERIKABIVEN INTRAVENOUS 4 PA BvD EMULSION % PROCALAMINE 3% 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION smoflipid intravenous emulsion 20 % 4 PA BvD TRAVASOL 10 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 10 % TROPHAMINE 10 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % 4 PA BvD 72

122 Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1 mg, 0.2 mg, (Catapres) 0.3 mg clonidine transdermal patch weekly 0.1 (Catapres-TTS-1) ; QL (4 per 28 mg/24 hr clonidine transdermal patch weekly 0.2 (Catapres-TTS-2) ; QL (4 per 28 mg/24 hr clonidine transdermal patch weekly 0.3 (Catapres-TTS-3) ; QL (8 per 28 mg/24 hr clorpres oral tablet mg, mg, mg doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 (Cardura) mg guanfacine oral tablet 1 mg, 2 mg 1 PA-HRM; GC; AGE (Max 64 Years) midodrine oral tablet 10 mg, 2.5 mg, 5 mg NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG 5 PA; NM; NDS; QL (180 per 30 phenylephrine hcl injection solution 10 (Vazculep) mg/ml prazosin oral capsule 1 mg, 2 mg, 5 mg (Minipress) Angiotensin Ii Receptor Antagonists candesartan oral tablet 16 mg, 32 mg, 4 (Atacand) mg, 8 mg candesartan-hydrochlorothiazid oral (Atacand HCT) tablet mg, mg, mg EDARBI ORAL TABLET 40 MG, 80 3 MG EDARBYCLOR ORAL TABLET MG, MG ENTRESTO ORAL TABLET QL (60 per 30 MG, MG, MG eprosartan oral tablet 600 mg irbesartan oral tablet 150 mg, 300 mg, 75 (Avapro) mg irbesartan-hydrochlorothiazide oral (Avalide) tablet mg, mg losartan oral tablet 100 mg, 25 mg, 50 mg (Cozaar) 73

123 losartan-hydrochlorothiazide oral tablet (Hyzaar) mg, mg, mg olmesartan oral tablet 20 mg, 40 mg, 5 (Benicar) mg olmesartan-amlodipin-hcthiazid oral (Tribenzor) tablet mg, mg, mg, mg, mg olmesartan-hydrochlorothiazide oral (Benicar HCT) tablet mg, mg, mg telmisartan oral tablet 20 mg, 40 mg, 80 (Micardis) mg telmisartan-amlodipine oral tablet (Twynsta) mg, 40-5 mg, mg, 80-5 mg telmisartan-hydrochlorothiazid oral (Micardis HCT) tablet mg, mg, mg valsartan oral tablet 160 mg, 320 mg, 40 (Diovan) mg, 80 mg valsartan-hydrochlorothiazide oral tablet (Diovan HCT) mg, mg, mg, mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 (Lotensin) mg benazepril oral tablet 5 mg benazepril-hydrochlorothiazide oral (Lotensin HCT) tablet mg, mg, mg benazepril-hydrochlorothiazide oral tablet mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg enalapril maleate oral tablet 10 mg, 2.5 (Vasotec) mg, 20 mg, 5 mg enalaprilat intravenous solution 1.25 mg/ml enalapril-hydrochlorothiazide oral tablet (Vaseretic) mg enalapril-hydrochlorothiazide oral tablet mg 74

124 fosinopril oral tablet 10 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet mg, mg lisinopril oral tablet 10 mg, 20 mg, 5 mg (Prinivil) lisinopril oral tablet 2.5 mg, 30 mg, 40 (Zestril) mg lisinopril-hydrochlorothiazide oral tablet (Zestoretic) mg, mg, mg moexipril oral tablet 15 mg, 7.5 mg moexipril-hydrochlorothiazide oral tablet mg, mg, mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril oral tablet 10 mg, 20 mg, 40 (Accupril) mg, 5 mg quinapril-hydrochlorothiazide oral tablet (Accuretic) mg, mg, mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 (Altace) mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg Antiarrhythmic Agents amiodarone intravenous solution 50 mg/ml amiodarone intravenous syringe 150 mg/3 ml amiodarone oral tablet 100 mg, 400 mg (Pacerone) amiodarone oral tablet 200 mg (Pacerone) disopyramide phosphate oral capsule 100 mg, 150 mg (Norpace) 2 PA-HRM; GC; AGE (Max 64 Years) dofetilide oral capsule 125 mcg, 250 mcg, (Tikosyn) 500 mcg flecainide oral tablet 100 mg, 50 mg flecainide oral tablet 150 mg lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %), 50 mg/5 ml (1 %) mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG 3 pacerone oral tablet 100 mg, 400 mg 75

125 pacerone oral tablet 200 mg procainamide injection solution 100 mg/ml, 500 mg/ml procainamide intravenous syringe 100 mg/ml propafenone oral capsule,extended (Rythmol SR) release 12 hr 225 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg quinidine gluconate oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg (Tenormin) atenolol-chlorthalidone oral tablet (Tenoretic 100) mg atenolol-chlorthalidone oral tablet (Tenoretic 50) mg betaxolol oral tablet 10 mg, 20 mg bisoprolol fumarate oral tablet 10 mg, 5 mg bisoprolol-hydrochlorothiazide oral tablet (Ziac) mg, mg, mg BYSTOLIC ORAL TABLET 10 MG, MG, 20 MG, 5 MG BYVALSON ORAL TABLET MG carvedilol oral tablet 12.5 mg, 25 mg, (Coreg) mg, 6.25 mg esmolol intravenous solution 100 mg/10 (Brevibloc) 5 PA BvD; NM; NDS ml (10 mg/ml) labetalol intravenous solution 5 mg/ml labetalol intravenous syringe 20 mg/4 ml (5 mg/ml) labetalol oral tablet 100 mg, 200 mg, 300 mg metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg (Toprol XL) 76

126 metoprolol ta-hydrochlorothiaz oral tablet mg, mg metoprolol ta-hydrochlorothiaz oral tablet mg (Lopressor HCT) metoprolol tartrate intravenous solution 5 (Lopressor) mg/5 ml metoprolol tartrate intravenous syringe 5 mg/5 ml metoprolol tartrate oral tablet 100 mg, 50 (Lopressor) mg metoprolol tartrate oral tablet 25 mg nadolol oral tablet 20 mg, 40 mg, 80 mg (Corgard) pindolol oral tablet 10 mg, 5 mg propranolol intravenous solution 1 mg/ml propranolol oral capsule,extended release (Inderal LA) 24 hr 120 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral tablet mg, mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol af oral tablet 120 mg, 160 mg, 80 mg sotalol oral tablet 120 mg, 160 mg, 240 (Betapace) mg, 80 mg timolol maleate oral tablet 10 mg, 20 mg, 5 mg Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended (Taztia XT) release 24 hr 360 mg diltiazem hcl oral capsule,extended release 24 hr 420 mg (Tiazac) 77

127 diltiazem hcl oral capsule,extended (Cardizem CD) release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral tablet 120 mg, 30 mg, (Cardizem) 60 mg diltiazem hcl oral tablet 90 mg dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg matzim la oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil intravenous syringe 2.5 mg/ml verapamil oral capsule, 24 hr er pellet ct (Verelan PM) 100 mg, 200 mg, 300 mg verapamil oral capsule,ext rel. pellets 24 (Verelan) hr 120 mg, 180 mg, 240 mg verapamil oral capsule,ext rel. pellets 24 (Verelan) 4 hr 360 mg verapamil oral tablet 120 mg, 80 mg (Calan) verapamil oral tablet 40 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg (Calan SR) Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG 3 PA; QL (60 per 30 DEMSER ORAL CAPSULE 250 MG digitek oral tablet 125 mcg 1 PA-HRM; GC; High Risk Med. PA Required for ages 65 and older and dose is greater than 125mcg per day; QL (30 per 30 ; AGE (Max 64 Years) digitek oral tablet 250 mcg 1 PA-HRM; GC; AGE (Max 64 Years) 78

128 digox oral tablet 125 mcg 1 PA-HRM; GC; High Risk Med. PA Required for ages 65 and older and dose is greater than 125mcg per day; QL (30 per 30 ; AGE (Max 64 Years) digox oral tablet 250 mcg 1 PA-HRM; GC; AGE (Max 64 Years) digoxin injection syringe 250 mcg/ml 1 PA-HRM; GC; AGE (Max 64 Years) DIGOXIN ORAL SOLUTION 50 MCG/ML 4 PA-HRM; AGE (Max 64 Years) digoxin oral tablet 125 mcg (Digitek) 1 PA-HRM; GC; High Risk Med. PA Required for ages 65 and older and dose is greater than 125mcg per day; QL (30 per 30 ; AGE (Max 64 Years) digoxin oral tablet 250 mcg (Digitek) 1 PA-HRM; GC; AGE (Max 64 Years) epinephrine injection auto-injector 0.15 mg/0.3 ml epinephrine injection auto-injector 0.3 mg/0.3 ml (EpiPen Jr) 3 Mylan generic preferred; QL (4 per 30 (Auvi-Q) 3 Mylan generic preferred; QL (4 per 30 ; QL (18 per 30 FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg milrinone in 5 % dextrose intravenous 5 PA BvD; NM; NDS piggyback 20 mg/100 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution 1 mg/ml 5 PA BvD; NM; NDS norepinephrine bitartrate intravenous (Levophed (bitartrate)) 1 PA BvD; GC solution 1 mg/ml 79

129 RANEXA ORAL TABLET 3 EXTENDED RELEASE 12 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 (Norvasc) mg amlodipine-benazepril oral capsule (Lotrel) mg, mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-benazepril oral capsule mg amlodipine-olmesartan oral tablet (Azor) mg, mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet (Exforge) mg, mg, mg, mg amlodipine-valsartan-hcthiazid oral (Exforge HCT) tablet mg, mg, mg, mg, mg felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg nicardipine oral capsule 20 mg, 30 mg nifedipine oral capsule 10 mg (Procardia) 2 PA-HRM; GC; AGE (Max 64 Years) nifedipine oral capsule 20 mg 2 PA-HRM; GC; AGE (Max 64 Years) nifedipine oral tablet extended release (Procardia XL) 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 (Adalat CC) mg, 60 mg, 90 mg Diuretics amiloride oral tablet 5 mg amiloride-hydrochlorothiazide oral tablet 5-50 mg bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, 2 mg chlorothiazide oral tablet 250 mg, 500 mg 80

130 chlorothiazide sodium intravenous recon (Diuril IV) soln 500 mg chlorthalidone oral tablet 25 mg, 50 mg furosemide injection solution 10 mg/ml furosemide injection syringe 10 mg/ml furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 (Lasix) mg hydrochlorothiazide oral capsule 12.5 mg (Microzide) hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg JYNARQUE ORAL TABLETS, SEQUENTIAL 45 MG (AM)/ 15 MG 5 PA; NM; NDS; QL (56 per 28 (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM) methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg, 2.5 mg, 5 mg spironolactone oral tablet 100 mg, 25 mg, (Aldactone) 50 mg spironolacton-hydrochlorothiaz oral (Aldactazide) tablet mg torsemide oral tablet 10 mg, 20 mg (Demadex) torsemide oral tablet 100 mg, 5 mg triamterene-hydrochlorothiazid oral (Dyazide) capsule mg triamterene-hydrochlorothiazid oral capsule mg triamterene-hydrochlorothiazid oral (Maxzide-25mg) tablet mg triamterene-hydrochlorothiazid oral (Maxzide) tablet mg Dyslipidemics amlodipine-atorvastatin oral tablet (Caduet) mg, mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg amlodipine-atorvastatin oral tablet mg, mg, mg 81

131 atorvastatin oral tablet 10 mg, 20 mg, 40 (Lipitor) mg, 80 mg cholestyramine (with sugar) oral powder (Questran) in packet 4 gram cholestyramine light oral powder 4 gram cholestyramine light packet 4 gram colestipol oral packet 5 gram (Colestid) colestipol oral tablet 1 gram (Colestid) ezetimibe oral tablet 10 mg (Zetia) ezetimibe-simvastatin oral tablet (Vytorin 10-10) mg ezetimibe-simvastatin oral tablet (Vytorin 10-20) mg ezetimibe-simvastatin oral tablet (Vytorin 10-40) mg ezetimibe-simvastatin oral tablet (Vytorin 10-80) mg fenofibrate micronized oral capsule 130 mg, 43 mg fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate nanocrystallized oral tablet (Tricor) 145 mg, 48 mg fenofibrate oral tablet 160 mg, 54 mg fenofibric acid (choline) oral (Trilipix) capsule,delayed release(dr/ec) 135 mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg (Fibricor) fluvastatin oral capsule 20 mg, 40 mg (Lescol) gemfibrozil oral tablet 600 mg (Lopid) JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 60 MG 5 PA; NM; NDS; QL (30 per 30 JUXTAPID ORAL CAPSULE 20 MG 5 PA; NM; NDS; QL (90 per 30 JUXTAPID ORAL CAPSULE 5 MG 5 PA; NM; NDS; QL (45 per 30 KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML 5 PA; NM; NDS; QL (4 per 28 LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG 3 QL (30 per 30 82

132 lovastatin oral tablet 10 mg, 20 mg, 40 mg niacin oral tablet extended release 24 hr (Niaspan Extended- 1,000 mg, 500 mg, 750 mg Release) niacor oral tablet 500 mg omega-3 acid ethyl esters oral capsule 1 gram (Lovaza) ; QL (120 per 30 PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 5 PA; NM; NDS; QL (2 per 28 MG/ML pravastatin oral tablet 10 mg pravastatin oral tablet 20 mg, 40 mg, 80 (Pravachol) mg prevalite oral powder in packet 4 gram REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 10 mg, 20 mg, 40 mg (Crestor) (Zocor) 5 PA; NM; NDS; QL (3.5 per 28 5 PA; NM; NDS; QL (3 per 28 5 PA; NM; NDS; QL (3 per 28 simvastatin oral tablet 5 mg simvastatin oral tablet 80 mg (Zocor) ; QL (30 per 30 VASCEPA ORAL CAPSULE QL (240 per 30 GRAM VASCEPA ORAL CAPSULE 1 3 QL (120 per 30 GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 25 mg, 50 mg (Inspra) 83

133 TEKTURNA HCT ORAL TABLET 3 ST MG, MG, MG, MG TEKTURNA ORAL TABLET ST MG, 300 MG Vasodilators BIDIL ORAL TABLET MG 3 isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg isosorbide dinitrate oral tablet 5 mg (Isordil Titradose) isosorbide dinitrate oral tablet extended (ISOCHRON) release 40 mg isosorbide mononitrate oral tablet 10 mg, 20 mg isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr ; QL (30 per 30 minitran transdermal patch 24 hour 0.4 mg/hr ; QL (60 per 30 minoxidil oral tablet 10 mg, 2.5 mg NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 (Nitrostat) mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr (Minitran) ; QL (30 per 30 nitroglycerin transdermal patch 24 hour 0.4 mg/hr Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg AUBAGIO ORAL TABLET 14 MG, 7 MG (Minitran) ; QL (60 per 30 (Strattera) 5 PA; NM; NDS; QL (60 per 30 5 PA; NM; NDS; QL (28 per 28 84

134 AUSTEDO ORAL TABLET 12 MG, 9 MG 5 PA; NM; NDS; QL (120 per 30 AUSTEDO ORAL TABLET 6 MG 5 PA; NM; NDS; QL (60 per 30 AVONEX (WITH ALBUMIN) 5 PA; NM; NDS INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN 5 PA; NM; NDS INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR 5 PA; NM; NDS SYRINGE KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS 5 PA; NM; NDS KIT 0.3 MG caffeine citrate intravenous solution 60 (Cafcit) 2 PA BvD; GC mg/3 ml (20 mg/ml) caffeine citrate oral solution 60 mg/3 ml (20 mg/ml) clonidine hcl oral tablet extended release (Kapvay) 12 hr 0.1 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg (Focalin) ; QL (60 per 30 dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg (Dexedrine Spansule) ; QL (120 per 30 dextroamphetamine oral tablet 10 mg, 5 mg (Zenzedi) ; QL (180 per 30 dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg (Adderall XR) ; QL (30 per 30 dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg EXTAVIA SUBCUTANEOUS KIT 0.3 MG (Adderall XR) ; QL (60 per 30 (Adderall) ; QL (60 per 30 5 PA; NM; NDS flumazenil intravenous solution 0.1 mg/ml GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG 5 PA; NM; NDS; QL (30 per 30 glatiramer subcutaneous syringe 20 mg/ml (Copaxone) 5 PA; NM; NDS; QL (30 per 30 85

135 glatiramer subcutaneous syringe 40 mg/ml (Copaxone) 5 PA; NM; NDS; QL (12 per 28 glatopa subcutaneous syringe 20 mg/ml 5 PA; NM; NDS; QL (30 per 30 glatopa subcutaneous syringe 40 mg/ml 5 PA; NM; NDS; QL (12 per 28 guanfacine oral tablet extended release (Intuniv ER) 24 hr 1 mg, 2 mg, 3 mg, 4 mg INGREZZA ORAL CAPSULE 40 MG, 80 MG 5 PA; NM; NDS; QL (30 per 30 LEMTRADA INTRAVENOUS 5 PA; NM; NDS SOLUTION 12 MG/1.2 ML lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended (Lithobid) release 300 mg lithium carbonate oral tablet extended release 450 mg lithium citrate oral solution 8 meq/5 ml 4 metadate er oral tablet extended release 20 mg ; QL (90 per 30 methylphenidate er 18 mg tab 18 mg (Concerta) ; QL (30 per 30 methylphenidate er 27 mg tab 27 mg (Concerta) ; QL (30 per 30 methylphenidate er 36 mg tab 36 mg (Concerta) ; QL (60 per 30 methylphenidate er 54 mg tab 54 mg (Concerta) ; QL (30 per 30 methylphenidate hcl oral capsule, er biphasic mg, 20 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule, er biphasic mg methylphenidate hcl oral capsule,er biphasic mg, 20 mg, 40 mg methylphenidate hcl oral capsule,er biphasic mg methylphenidate hcl oral capsule,er biphasic mg ; QL (30 per 30 ; QL (60 per 30 (Ritalin LA) ; QL (30 per 30 (Ritalin LA) ; QL (60 per 30 ; QL (30 per 30 86

136 methylphenidate hcl oral solution 10 mg/5 (Methylin) ; QL (900 per 30 ml, 5 mg/5 ml methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg (Ritalin) ; QL (90 per 30 methylphenidate hcl oral tablet extended release 10 mg ; QL (90 per 30 methylphenidate hcl oral tablet extended release 20 mg (Metadate ER) ; QL (90 per 30 methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 54 mg (Concerta) ; QL (30 per 30 methylphenidate hcl oral tablet extended release 24hr 36 mg (Concerta) ; QL (60 per 30 NUEDEXTA ORAL CAPSULE MG 4 PA; QL (60 per 30 OCREVUS INTRAVENOUS SOLUTION 30 MG/ML 5 PA; NM; NDS; QL (20 per 180 PLEGRIDY SUBCUTANEOUS PEN 5 PA; NM; NDS INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS 5 PA; NM; NDS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML RADICAVA INTRAVENOUS PIGGYBACK 30 MG/100 ML 5 PA; NM; NDS; QL (2800 per 28 REBIF (WITH ALBUMIN) 5 PA; NM; NDS SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE 5 PA; NM; NDS SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK 5 PA; NM; NDS SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) riluzole oral tablet 50 mg (Rilutek) SAVELLA ORAL TABLET 100 MG, 3 QL (60 per MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42) 3 QL (60 per 30 87

137 TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG 5 PA; NM; NDS; QL (14 per 30 5 PA; NM; NDS; QL (60 per 30 tetrabenazine oral tablet 12.5 mg, 25 mg (Xenazine) 5 PA; NM; NDS; QL (112 per 28 Contraceptives Contraceptives altavera (28) oral tablet mg alyacen 1/35 (28) oral tablet 1-35 mgmcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) ; QL (91 per 84 amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) ; QL (91 per 84 apri oral tablet mg aranelle (28) oral tablet 0.5/1/ mgmcg ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) aubra oral tablet mg-mcg aviane oral tablet mg-mcg azurette (28) oral tablet mgx21 /0.01 mg x 5 balziva (28) oral tablet mg-mcg bekyree (28) oral tablet mgx21 /0.01 mg x 5 blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) blisovi fe 1.5/30 (28) oral tablet 1.5 mg- 30 mcg (21)/75 mg (7) blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) briellyn oral tablet mg-mcg camila oral tablet 0.35 mg 88

138 caziant (28) oral tablet 0.1/.125/ mg-mcg cryselle (28) oral tablet mg-mcg cyclafem 1/35 (28) oral tablet 1-35 mgmcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg cyred oral tablet mg dasetta 1/35 (28) oral tablet 1-35 mgmcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg daysee oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) ; QL (91 per 84 deblitane oral tablet 0.35 mg delyla (28) oral tablet mg-mcg desog-e.estradiol/e.estradiol oral tablet (Azurette (28)) mgx21 /0.01 mg x 5 desogestrel-ethinyl estradiol oral tablet (Apri) mg drospirenone-ethinyl estradiol oral tablet (Gianvi (28)) mg drospirenone-ethinyl estradiol oral tablet (Ocella) mg elinest oral tablet mg-mcg ELLA ORAL TABLET 30 MG 4 QL (6 per 365 emoquette oral tablet mg enpresse oral tablet (6)/75-40 (5)/125-30(10) enskyce oral tablet mg errin oral tablet 0.35 mg estarylla oral tablet mg-mcg ethynodiol diac-eth estradiol oral tablet (Kelnor 1/35 (28)) 1-35 mg-mcg ethynodiol diac-eth estradiol oral tablet (Kelnor 1-50) 1-50 mg-mcg falmina (28) oral tablet mg-mcg femynor oral tablet mg-mcg gildagia oral tablet mg-mcg heather oral tablet 0.35 mg 89

139 incassia oral tablet 0.35 mg introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg ; QL (91 per 84 isibloom oral tablet mg jencycla oral tablet 0.35 mg jolivette oral tablet 0.35 mg 4 juleber oral tablet mg junel 1.5/30 (21) oral tablet mgmcg junel 1/20 (21) oral tablet 1-20 mg-mcg junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) kariva (28) oral tablet mgx21 /0.01 mg x 5 kelnor 1/35 (28) oral tablet 1-35 mg-mcg kelnor 1-50 oral tablet 1-50 mg-mcg kimidess (28) oral tablet mgx21 /0.01 mg x 5 kurvelo oral tablet mg l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) (Amethia Lo) ; QL (91 per 84 l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) larin 1.5/30 (21) oral tablet mgmcg (Fayosim) ; QL (91 per 84 (Amethia) ; QL (91 per 84 larin 1/20 (21) oral tablet 1-20 mg-mcg larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) 90

140 larissia oral tablet mg-mcg leena 28 oral tablet 0.5/1/ mg-mcg 4 lessina oral tablet mg-mcg levonest (28) oral tablet (6)/75-40 (5)/125-30(10) levonorgestrel-ethinyl estrad oral tablet (Aubra) mg-mcg levonorgestrel-ethinyl estrad oral tablet mg (Altavera (28)) ; QL (91 per 84 levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg levonorg-eth estrad triphasic oral tablet (6)/75-40 (5)/125-30(10) (Introvale) ; QL (91 per 84 (Enpresse) levora-28 oral tablet mg lillow oral tablet mg loryna (28) oral tablet mg low-ogestrel (28) oral tablet mgmcg lutera (28) oral tablet mg-mcg lyza oral tablet 0.35 mg marlissa oral tablet mg microgestin 1.5/30 (21) oral tablet mg-mcg microgestin 1/20 (21) oral tablet 1-20 mg-mcg microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) microgestin fe 1/20 (28) oral tablet 1 mg- 20 mcg (21)/75 mg (7) mili oral tablet mg-mcg mono-linyah oral tablet mg-mcg mononessa (28) oral tablet mgmcg 4 myzilra oral tablet (6)/75-40 (5)/125-30(10) necon 0.5/35 (28) oral tablet mgmcg nikki (28) oral tablet mg nora-be oral tablet 0.35 mg 4 91

141 norethindrone (contraceptive) oral tablet (Camila) 0.35 mg norethindrone ac-eth estradiol oral tablet (Junel 1/20 (21)) 1-20 mg-mcg norethindrone-e.estradiol-iron oral tablet (Blisovi Fe 1/20 (28)) 1 mg-20 mcg (21)/75 mg (7) norethindrone-e.estradiol-iron oral tablet (Blisovi 24 Fe) 1 mg-20 mcg (24)/75 mg (4) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen LO 0.18/0.215/0.25 mg-25 mcg (28)) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen (28)) 0.18/0.215/0.25 mg-35 mcg (28) norgestimate-ethinyl estradiol oral tablet (Estarylla) mg-mcg norlyda oral tablet 0.35 mg norlyroc oral tablet 0.35 mg nortrel 0.5/35 (28) oral tablet mgmcg nortrel 1/35 (21) oral tablet 1-35 mgmcg nortrel 1/35 (28) oral tablet 1-35 mgmcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg NUVARING VAGINAL RING QL (1 per MG/24 HR ogestrel (28) oral tablet mg-mcg orsythia oral tablet mg-mcg philith oral tablet mg-mcg pimtrea (28) oral tablet mgx21 /0.01 mg x 5 pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg portia oral tablet mg previfem oral tablet mg-mcg quasense oral tablets,dose pack,3 month 0.15 mg-30 mcg ; QL (91 per 84 reclipsen (28) oral tablet mg setlakin oral tablets,dose pack,3 month 0.15 mg-30 mcg ; QL (91 per 84 sharobel oral tablet 0.35 mg 92

142 sprintec (28) oral tablet mg-mcg sronyx oral tablet mg-mcg syeda oral tablet mg tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) tilia fe oral tablet 1-20(5)/1-30(7) /1mg- 35mcg (9) tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25 mg- 35 mcg (28) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trinessa (28) oral tablet 0.18/0.215/ mg-35 mcg (28) tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trivora (28) oral tablet (6)/75-40 (5)/125-30(10) tri-vylibra oral tablet 0.18/0.215/0.25 mg- 35 mcg (28) tulana oral tablet 0.35 mg velivet triphasic regimen (28) oral tablet 0.1/.125/ mg-mcg vestura (28) oral tablet mg vienva oral tablet mg-mcg viorele (28) oral tablet mgx21 /0.01 mg x 5 vyfemla (28) oral tablet mg-mcg 93

143 vylibra oral tablet mg-mcg wera (28) oral tablet mg-mcg xulane transdermal patch weekly ; QL (3 per 28 mcg/24 hr zarah oral tablet mg zenchent (28) oral tablet mg-mcg zovia 1/35e (28) oral tablet 1-35 mg-mcg zovia 1/50e (28) oral tablet 1-50 mg-mcg Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg (Evoxac) chlorhexidine gluconate mucous (Paroex Oral Rinse) membrane mouthwash 0.12 % oralone dental paste 0.1 % paroex oral rinse mucous membrane mouthwash 0.12 % periogard mucous membrane mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 mg (Salagen (pilocarpine)) triamcinolone acetonide dental paste 0.1 (Oralone) % Dermatological Agents Dermatological Agents, Other acitretin oral capsule 10 mg, 17.5 mg, 25 (Soriatane) mg acyclovir topical ointment 5 % (Zovirax) ; QL (30 per 30 ALCOHOL PADS TOPICAL PADS, MEDICATED ammonium lactate topical cream 12 % (Geri-Hydrolac) ammonium lactate topical lotion 12 % (AmLactin) calcipotriene scalp solution % calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcitrene) calcitrene topical ointment % calcitriol topical ointment 3 mcg/gram (Vectical) 4 COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML 5 PA; NM; NDS 94

144 COSENTYX PEN (2 PENS) 5 PA; NM; NDS SUBCUTANEOUS PEN INJECTOR 150 MG/ML DENAVIR TOPICAL CREAM 1 % DUPIXENT SUBCUTANEOUS 5 PA; NM; NDS SYRINGE 300 MG/2 ML fluorouracil topical cream 0.5 % (Carac) fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution 2 %, 5 % imiquimod topical cream in packet 5 % (Aldara) 2 PA NSO; GC; QL (24 per 30 methoxsalen oral capsule,liqd-filled,rapid (Oxsoralen Ultra) rel 10 mg PANRETIN TOPICAL GEL 0.1 % PICATO TOPICAL GEL % 3 QL (3 per 56 PICATO TOPICAL GEL 0.05 % 3 QL (2 per 56 podofilox topical solution 0.5 % REGRANEX TOPICAL GEL 0.01 % 5 PA; NM; NDS; QL (30 per 30 SANTYL TOPICAL OINTMENT UNIT/GRAM SILIQ SUBCUTANEOUS SYRINGE 5 PA; NM; NDS 210 MG/1.5 ML TALTZ AUTOINJECTOR 5 PA; NM; NDS SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML TALTZ SYRINGE 5 PA; NM; NDS SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % 4 TREMFYA SUBCUTANEOUS 5 PA; NM; NDS SYRINGE 100 MG/ML VALCHLOR TOPICAL GEL % VEREGEN TOPICAL OINTMENT 15 % zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg ZOVIRAX TOPICAL CREAM 5 % ; QL (5 per 4 Dermatological Antibacterials clindamycin phosphate topical foam 1 % (Evoclin) 95

145 clindamycin phosphate topical solution 1 (Cleocin T) % clindamycin phosphate topical swab 1 % (Cleocin T) clindamycin-benzoyl peroxide topical gel (Duac) 1.2 %(1 % base) -5 % clindamycin-benzoyl peroxide topical gel (Benzaclin) 1-5 % ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % (Erygel) erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 (Ery Pads) % erythromycin-benzoyl peroxide topical (Aktipak) gel 3-5 % gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % metronidazole topical cream 0.75 % (MetroCream) metronidazole topical gel 0.75 % (Rosadan) metronidazole topical gel 1 % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) mupirocin topical ointment 2 % (Centany) neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml neuac topical gel 1.2 %(1 % base) -5 % rosadan topical cream 0.75 % selenium sulfide topical lotion 2.5 % silver sulfadiazine topical cream 1 % (Silvadene) 4 ssd topical cream 1 % 4 sulfacetamide sodium (acne) topical (Klaron) suspension 10 % Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 %, 2.5 % ala-scalp topical lotion 2 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % 96

146 betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0.1 % betamethasone valerate topical foam 0.12 (Luxiq) % betamethasone valerate topical lotion 0.1 % betamethasone valerate topical ointment 0.1 % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical (Diprolene) ointment 0.05 % clobetasol scalp solution 0.05 % (Cormax) clobetasol topical cream 0.05 % (Temovate) clobetasol topical foam 0.05 % (Olux) clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % clobetasol-emollient topical foam 0.05 % (Olux-E) clocortolone pivalate topical cream 0.1 % (Cloderm) 4 cormax scalp solution 0.05 % desonide topical cream 0.05 % (DesOwen) desonide topical lotion 0.05 % (DesOwen) desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, (Topicort) 0.25 % desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, (Topicort) 0.25 % diflorasone topical cream 0.05 % (Psorcon) diflorasone topical ointment 0.05 % ELIDEL TOPICAL CREAM 1 % 3 97

147 EUCRISA TOPICAL OINTMENT 2 3 % fluocinolone topical cream 0.01 % fluocinolone topical cream % (Synalar) fluocinolone topical ointment % (Synalar) fluocinonide topical cream 0.05 % 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 % (Cutivate) fluticasone topical ointment % halobetasol propionate topical cream 0.05 (Ultravate) % halobetasol propionate topical ointment (Ultravate) 0.05 % hydrocort buty 0.1% lipo cream 0.1 % (Locoid Lipocream) hydrocortisone butyrate topical cream 0.1 (Locoid) % hydrocortisone butyrate topical lotion 0.1 (Locoid) % hydrocortisone butyrate topical ointment 0.1 % hydrocortisone butyrate topical solution (Locoid) 0.1 % hydrocortisone topical cream 1 %, 2.5 % (Ala-Cort) hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 % (Anti-Itch (HC)) hydrocortisone topical ointment 2.5 % hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % prednicarbate topical cream 0.1 % 4 prednicarbate topical ointment 0.1 % (Dermatop) procto-med hc topical cream with perineal applicator 2.5 % 98

148 procto-pak topical cream with perineal applicator 1 % proctosol hc topical cream with perineal applicator 2.5 % proctozone-hc topical cream with perineal applicator 2.5 % triamcinolone acetonide topical cream % triamcinolone acetonide topical cream 0.1 (Triderm) %, 0.5 % triamcinolone acetonide topical lotion %, 0.1 % triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % Dermatological Retinoids adapalene topical cream 0.1 % (Differin) adapalene topical gel 0.1 % (Differin) tazarotene topical cream 0.1 % (Avage) TAZORAC TOPICAL CREAM 0.05 % 4 tretinoin topical cream % (Avita) 2 PA; GC tretinoin topical cream 0.05 %, 0.1 % (Retin-A) 2 PA; GC tretinoin topical gel 0.01 % (Retin-A) 2 PA; GC tretinoin topical gel % (Avita) 2 PA; GC tretinoin topical gel 0.05 % (Atralin) 2 PA; GC Scabicides And Pediculicides malathion topical lotion 0.5 % (Ovide) permethrin topical cream 5 % (Elimite) spinosad topical suspension 0.9 % (Natroba) 4 Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" BD UF NANO PEN NEEDLE 4MMX32G 32 GAUGE X 5/32" BD VEO INS 0.3 ML 6MMX31G (1/2) 0.3 ML 31 GAUGE X 15/64" BD VEO INS SYRING 1 ML 6MMX31G 1 ML 31 GAUGE X 15/64" 99

149 BD VEO INS SYRN 0.5 ML 6MMX31G 1/2 ML 31 GAUGE X 15/64" GAUZE PAD TOPICAL BANDAGE 2 X 2 " INSULIN SYRINGE-NEEDLE U-100 (Ultilet Insulin Syringe) SYRINGE 0.3 ML 29 GAUGE INSULIN SYRINGE-NEEDLE U-100 (Advocate Syringes) SYRINGE 1 ML 29 GAUGE X 1/2" INSULIN SYRINGE-NEEDLE U-100 (Lite Touch Insulin SYRINGE 1/2 ML 28 GAUGE Syringe) PEN NEEDLE, DIABETIC NEEDLE (1st Tier Unifine 29 GAUGE X 1/2" Pentips) VGO 40 DISPOSABLE DEVICE Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CERDELGA ORAL CAPSULE 84 5 PA; NM; NDS MG CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL 3 CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG KANUMA INTRAVENOUS 5 PA; NM; NDS SOLUTION 2 MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML 5 PA BvD; NM; NDS 100

150 KUVAN ORAL TABLET,SOLUBLE 100 MG miglustat oral capsule 100 mg (Zavesca) ; QL (90 per 30 NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML NITYR ORAL TABLET 10 MG, 2 5 PA; NM; NDS MG, 5 MG ORFADIN ORAL CAPSULE 10 MG, 5 PA; NM; NDS 2 MG, 20 MG, 5 MG ORFADIN ORAL SUSPENSION 4 5 PA; NM; NDS MG/ML PALYNZIQ SUBCUTANEOUS 5 PA; NM; NDS SYRINGE 10 MG/0.5 ML, 2.5 MG/0.5 ML, 20 MG/ML PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 25 MG, 75 MG PULMOZYME INHALATION 5 PA BvD; NM; NDS SOLUTION 1 MG/ML STRENSIQ SUBCUTANEOUS 5 PA; NM; LA; NDS SOLUTION 100 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS 5 PA; NM; NDS SOLUTION 5 MG/5 ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000-42,000 UNIT, 10,000-34,000-55,000 UNIT, 15,000-47,000-63,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-63,000-84,000 UNIT, 25,000-79, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-14,000-UNIT, 3,000-10,000-16,000 UNIT, 40, , ,000 UNIT, 5,000-17,000-27,000 UNIT, 5,000-17,000-24,000 UNIT 3 101

151 Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous apraclonidine ophthalmic (eye) drops 0.5 (Iopidine) % atropine ophthalmic (eye) drops 1 % (Isopto Atropine) 4 azelastine nasal aerosol,spray 137 mcg (0.1 %) ; QL (30 per 25 azelastine nasal spray,non-aerosol 0.15 % (Astepro) ; QL (30 per 25 (205.5 mcg) azelastine ophthalmic (eye) drops 0.05 % BEPREVE OPHTHALMIC (EYE) 4 ST DROPS 1.5 % cromolyn ophthalmic (eye) drops 4 % cyclopentolate ophthalmic (eye) drops (Cyclogyl) 0.5 %, 1 %, 2 % CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % epinastine ophthalmic (eye) drops 0.05 % (Elestat) ipratropium bromide nasal spray,nonaerosol 0.03 % ; QL (30 per 28 ipratropium bromide nasal spray,nonaerosol 42 mcg (0.06 %) ; QL (15 per 10 olopatadine nasal spray,non-aerosol 0.6 % (Patanase) ; QL (30.5 per 30 olopatadine ophthalmic (eye) drops 0.1 (Patanol) % olopatadine ophthalmic (eye) drops 0.2 (Pataday) % phenylephrine hcl ophthalmic (eye) drops 10 %, 2.5 % proparacaine ophthalmic (eye) drops 0.5 % Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (ear) solution 2 % bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) (AK-Poly-Bac) ointment ,000 unit/gram bleph-10 ophthalmic (eye) drops 10 % 102

152 CILOXAN OPHTHALMIC (EYE) 4 OINTMENT 0.3 % CIPRODEX OTIC (EAR) 3 DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic (eye) drops (Ciloxan) 0.3 % ciprofloxacin hcl otic (ear) dropperette (Cetraxal) % erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) gatifloxacin ophthalmic (eye) drops 0.5 (Zymaxid) % gentak ophthalmic (eye) ointment 0.3 % (3 mg/gram) gentamicin ophthalmic (eye) drops 0.3 % hydrocortisone-acetic acid otic (ear) drops 1-2 % levofloxacin ophthalmic (eye) drops 0.5 % MOXEZA OPHTHALMIC (EYE) 3 DROPS, VISCOUS 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 (Vigamox) % NATACYN OPHTHALMIC (EYE) 4 DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic (Neo-Polycin HC) (eye) ointment ,000 mgunit/g-1% neomycin-bacitracin-polymyxin (Neo-Polycin) ophthalmic (eye) ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) ointment 3.5 mg/g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml 103

153 neomycin-polymyxin-hc ophthalmic (eye) drops,suspension , mg-unit-mg/ml neomycin-polymyxin-hc otic (ear) drops,suspension ,000-1 mg/mlunit/ml-% neomycin-polymyxin-hc otic (ear) solution ,000-1 mg/ml-unit/ml-% neo-polycin hc ophthalmic (eye) ointment ,000 mg-unit/g-1% neo-polycin ophthalmic (eye) ointment ,000 mg-unit-unit/g ofloxacin ophthalmic (eye) drops 0.3 % (Ocuflox) ofloxacin otic (ear) drops 0.3 % polycin ophthalmic (eye) ointment ,000 unit/gram polymyxin b sulf-trimethoprim (Polytrim) ophthalmic (eye) drops 10,000 unit- 1 mg/ml sulfacetamide sodium ophthalmic (eye) (Bleph-10) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) tobramycin ophthalmic (eye) drops 0.3 (Tobrex) % tobramycin-dexamethasone ophthalmic (TobraDex) (eye) drops,suspension % trifluridine ophthalmic (eye) drops 1 % (Viroptic) ZIRGAN OPHTHALMIC (EYE) GEL % ZYLET OPHTHALMIC (EYE) 3 DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC (EYE) 3 ST DROPS,SUSPENSION 0.2 % bromfenac ophthalmic (eye) drops 0.09 % 104

154 BROMSITE OPHTHALMIC (EYE) 3 DROPS % dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % DUREZOL OPHTHALMIC (EYE) 3 DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) ; QL (50 per 25 fluocinolone acetonide oil otic (ear) (DermOtic Oil) drops 0.01 % fluorometholone ophthalmic (eye) (FML Liquifilm) 4 drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops 0.03 % fluticasone nasal spray,suspension 50 (24 Hour Allergy mcg/actuation Relief) ILEVRO OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 0.3 % ketorolac ophthalmic (eye) drops 0.4 % (Acular LS) ketorolac ophthalmic (eye) drops 0.5 % (Acular) LOTEMAX OPHTHALMIC (EYE) 3 DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) 3 OINTMENT 0.5 % prednisolone acetate ophthalmic (eye) (Omnipred) 4 drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % PROLENSA OPHTHALMIC (EYE) 3 DROPS 0.07 % RESTASIS OPHTHALMIC (EYE) 3 QL (60 per 30 DROPPERETTE 0.05 % XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % 4 PA; QL (60 per

155 Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral combo pack mg CARAFATE ORAL SUSPENSION MG/ML cimetidine hcl oral solution 300 mg/5 ml cimetidine oral tablet 200 mg (Acid Reducer (cimetidine)) cimetidine oral tablet 300 mg, 400 mg, 800 mg DEXILANT ORAL 3 ST CAPSULE,BIPHASE DELAYED RELEAS 30 MG, 60 MG esomeprazole sodium intravenous recon soln 20 mg esomeprazole sodium intravenous recon (Nexium IV) soln 40 mg famotidine (pf) intravenous solution 20 mg/2 ml famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50 ml famotidine intravenous solution 10 mg/ml famotidine oral suspension 40 mg/5 ml (8 (Pepcid) mg/ml) famotidine oral tablet 20 mg (Acid Controller) famotidine oral tablet 40 mg (Pepcid) lansoprazole oral capsule,delayed (Heartburn Treatment release(dr/ec) 15 mg 24 Hour) lansoprazole oral capsule,delayed (Prevacid) release(dr/ec) 30 mg misoprostol oral tablet 100 mcg, 200 mcg (Cytotec) nizatidine oral capsule 150 mg, 300 mg nizatidine oral solution 150 mg/10 ml omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg pantoprazole intravenous recon soln 40 (Protonix) mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg (Protonix) 106

156 rabeprazole oral tablet,delayed release (dr/ec) 20 mg (Aciphex) 1 ST; GC; QL (30 per 30 ranitidine hcl injection solution 25 mg/ml, (Zantac) 50 mg/2 ml (25 mg/ml) ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg (Acid Control (ranitidine)) ranitidine hcl oral tablet 300 mg (Zantac) sucralfate oral tablet 1 gram (Carafate) Gastrointestinal Agents, Other AMITIZA ORAL CAPSULE 24 MCG, 3 QL (60 per 30 8 MCG CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 mg/5 ml (Gastrocrom) dicyclomine oral capsule 10 mg dicyclomine oral solution 10 mg/5 ml dicyclomine oral tablet 20 mg diphenoxylate-atropine oral liquid mg/5 ml 1 PA-HRM; GC; AGE (Max 64 Years) diphenoxylate-atropine oral tablet mg (Lomotil) 1 PA-HRM; GC; AGE (Max 64 Years) enulose oral solution 10 gram/15 ml GATTEX 30-VIAL 5 PA; NM; NDS SUBCUTANEOUS KIT 5 MG generlac oral solution 10 gram/15 ml glycopyrrolate injection solution 0.2 (Robinul) mg/ml glycopyrrolate oral tablet 1 mg (Robinul) glycopyrrolate oral tablet 2 mg (Robinul Forte) kionex (with sorbitol) oral suspension gram/60 ml lactulose oral solution 10 gram/15 ml (Constulose) LINZESS ORAL CAPSULE QL (30 per 30 MCG, 290 MCG, 72 MCG loperamide oral capsule 2 mg (Anti-Diarrheal (loperamide)) methscopolamine oral tablet 2.5 mg, 5 mg 107

157 metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl injection syringe 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 (Reglan) mg MOVANTIK ORAL TABLET QL (30 per 30 MG, 25 MG OCALIVA ORAL TABLET 10 MG, 5 MG 5 PA; NM; NDS; QL (30 per 30 RAVICTI ORAL LIQUID PA; NM; NDS GRAM/ML RELISTOR ORAL TABLET 150 MG 5 PA; NM; NDS; QL (90 per 30 RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML 5 PA; NM; NDS; QL (28 per 28 RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML, 8 MG/0.4 5 PA; NM; NDS; QL (28 per 28 ML sod polystyren sulf 15 g/60 ml sorbitol free 15 gram/60 ml sodium phenylbutyrate oral tablet 500 mg (Buphenyl) sodium polystyrene sulfonate oral powder sps (with sorbitol) oral suspension gram/60 ml ursodiol oral capsule 300 mg (Actigall) ursodiol oral tablet 250 mg (URSO 250) ursodiol oral tablet 500 mg (URSO Forte) VELTASSA ORAL POWDER IN 3 QL (30 per 30 PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM VIBERZI ORAL TABLET 100 MG, 75 MG 5 ST; NM; NDS; QL (60 per 30 XERMELO ORAL TABLET 250 MG 5 PA; NM; NDS; QL (90 per 30 Laxatives CLENPIQ ORAL SOLUTION 10 MG- 3.5 GRAM -12 GRAM/160 ML 4 108

158 gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 420 gram MOVIPREP ORAL POWDER IN 3 PACKET GRAM peg 3350-electrolytes oral recon soln 236- (GaviLyte-G) gram peg 3350-electrolytes oral recon soln 240- (Colyte with Flavor gram Packs) polyethylene glycol 3350 oral powder 17 (ClearLax) gram/dose polyethylene glycol 3350 powd 17 gm (ClearLax) packets (rx) 17 gram PREPOPIK ORAL POWDER IN 4 PACKET 10 MG-3.5 GRAM-12 GRAM SUPREP BOWEL PREP KIT ORAL 3 RECON SOLN GRAM trilyte with flavor packets oral recon soln 420 gram Phosphate Binders calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg (Calphron) eliphos oral tablet 667 mg lanthanum oral tablet,chewable 1,000 mg, (Fosrenol) 500 mg, 750 mg PHOSLYRA ORAL SOLUTION MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG 3 sevelamer carbonate oral powder in (Renvela) packet 0.8 gram, 2.4 gram sevelamer carbonate oral tablet 800 mg (Renvela) VELPHORO ORAL 3 TABLET,CHEWABLE 500 MG Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg (Urecholine) 109

159 flavoxate oral tablet 100 mg MYRBETRIQ ORAL TABLET 3 EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended (Ditropan XL) release 24hr 10 mg, 15 mg, 5 mg tolterodine oral capsule,extended release (Detrol LA) 24hr 2 mg, 4 mg tolterodine oral tablet 1 mg, 2 mg (Detrol) TOVIAZ ORAL TABLET 3 EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 24hr 60 mg trospium oral tablet 20 mg Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 (Uroxatral) hr 10 mg dutasteride oral capsule 0.5 mg (Avodart) dutasteride-tamsulosin oral capsule, er multiphase 24 hr mg (Jalyn) ; QL (30 per 30 finasteride oral tablet 5 mg (Proscar) tamsulosin oral capsule 0.4 mg (Flomax) terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists CUPRIMINE ORAL CAPSULE 250 MG 5 PA; NM; NDS deferoxamine injection recon soln 2 gram, (Desferal) 2 PA; GC 500 mg DEPEN TITRATABS ORAL 5 PA; NM; NDS TABLET 250 MG EXJADE ORAL TABLET, 5 PA; NM; NDS DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML 5 PA; NM; NDS 110

160 FERRIPROX ORAL TABLET PA; NM; NDS MG JADENU ORAL TABLET 180 MG, 5 PA; NM; NDS 360 MG, 90 MG JADENU SPRINKLE ORAL 5 PA; NM; NDS GRANULES IN PACKET 180 MG, 360 MG, 90 MG trientine oral capsule 250 mg (Syprine) 5 PA; NM; NDS; QL (240 per 30 Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANADROL-50 ORAL TABLET 50 5 PA; NM; NDS MG ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) 3 PA; QL (150 per 30 ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) danazol oral capsule 100 mg, 200 mg, 50 mg 3 PA; QL (150 per 30 oxandrolone oral tablet 10 mg (Oxandrin) oxandrolone oral tablet 2.5 mg (Oxandrin) testosterone cypionate intramuscular oil (Depo-Testosterone) 1 PA; GC 100 mg/ml testosterone cypionate intramuscular oil (Depo-Testosterone) 1 PA; GC 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml 1 PA; GC; QL (5 per 28 testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 (AndroGel) 2 PA; GC; QL (300 per 30 gram) Estrogens And Antiestrogens amabelz oral tablet mg, mg 2 PA-HRM; GC; AGE (Max 64 Years) DUAVEE ORAL TABLET MG 3 PA-HRM; AGE (Max 64 Years) estradiol oral tablet 0.5 mg, 1 mg, 2 mg (Estrace) 1 PA-HRM; GC; AGE (Max 64 Years) 111

161 estradiol transdermal patch semiweekly mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch semiweekly mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol vaginal cream 0.01 % (0.1 mg/gram) (Alora) 2 PA-HRM; GC; QL (8 per 28 ; AGE (Max 64 Years) (Minivelle) 2 PA-HRM; GC; QL (8 per 28 ; AGE (Max 64 Years) (Climara) 2 PA-HRM; GC; QL (4 per 28 ; AGE (Max 64 Years) (Estrace) estradiol vaginal tablet 10 mcg (Vagifem) ; QL (18 per 28 estradiol valerate intramuscular oil 20 (Delestrogen) mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg (Activella) 2 PA-HRM; GC; AGE (Max 64 Years) estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 1 PA-HRM; GC; AGE (Max 64 Years) FEMRING VAGINAL RING QL (1 per 84 MG/24 HR, 0.1 MG/24 HR fyavolv oral tablet mg-mcg, 1-5 mg-mcg 1 PA-HRM; GC; AGE (Max 64 Years) jinteli oral tablet 1-5 mg-mcg 1 PA-HRM; GC; AGE (Max 64 Years) MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG 2 PA-HRM; GC; AGE (Max 64 Years) mimvey lo oral tablet mg 2 PA-HRM; GC; AGE (Max 64 Years) norethindrone ac-eth estradiol oral tablet mg-mcg (Femhrt Low Dose) 1 PA-HRM; GC; AGE (Max 64 Years) norethindrone ac-eth estradiol oral tablet 1-5 mg-mcg (Fyavolv) 1 PA-HRM; GC; AGE (Max 64 Years) PREMARIN INJECTION RECON 3 SOLN 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, 1.25 MG 3 PA-HRM; AGE (Max 64 Years) PREMARIN VAGINAL CREAM MG/GRAM 3 112

162 PREMPHASE ORAL TABLET MG (14)/ 0.625MG-5MG(14) 3 PA-HRM; AGE (Max 64 Years) PREMPRO ORAL TABLET MG, MG, MG, 3 PA-HRM; AGE (Max 64 Years) MG raloxifene oral tablet 60 mg (Evista) yuvafem vaginal tablet 10 mcg ; QL (18 per 28 Glucocorticoids/Mineralocorticoids a-hydrocort injection recon soln 100 mg betamethasone acet,sod phos injection (Celestone Soluspan) suspension 6 mg/ml cortisone oral tablet 25 mg decadron oral elixir 0.5 mg/5 ml 2 PA BvD; GC dexamethasone oral elixir 0.5 mg/5 ml (Decadron) 2 PA BvD; GC dexamethasone oral tablet 0.5 mg, 0.75 (Decadron) 1 PA BvD; GC mg, 4 mg, 6 mg dexamethasone oral tablet 1 mg, 1.5 mg, 1 PA BvD; GC 2 mg dexamethasone sodium phos (pf) injection solution 10 mg/ml dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml dexamethasone sodium phosphate injection syringe 4 mg/ml EMFLAZA ORAL SUSPENSION MG/ML 5 PA; NM; NDS; QL (104 per 30 EMFLAZA ORAL TABLET 18 MG 5 PA; NM; NDS; QL (30 per 30 EMFLAZA ORAL TABLET 30 MG, 36 MG, 6 MG 5 PA; NM; NDS; QL (60 per 30 fludrocortisone oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 20 mg, (Cortef) 5 mg methylprednisolone acetate injection (Depo-Medrol) suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 16 mg, 32 (Medrol) mg, 4 mg, 8 mg methylprednisolone oral tablets,dose pack 4 mg (Medrol (Pak)) 113

163 methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ (Solu-Medrol) intravenous recon soln 1,000 mg prednisolone 15 mg/5 ml soln a/f, d/f 15 1 PA BvD; GC mg/5 ml (3 mg/ml) prednisolone oral solution 15 mg/5 ml 1 PA BvD; GC prednisolone sodium phosphate oral 1 PA BvD; GC solution 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone oral solution 5 mg/5 ml 2 PA BvD; GC prednisone oral tablet 1 mg, 2.5 mg, 5 1 PA BvD; GC mg, 50 mg prednisone oral tablet 10 mg 1 PA BvD; GC prednisone oral tablet 20 mg (Deltasone) 1 PA BvD; GC prednisone oral tablets,dose pack 10 mg, 10 mg (48 pack), 5 mg, 5 mg (48 pack) SOLU-CORTEF (PF) INJECTION 4 RECON SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250 MG/2 ML, 500 MG/4 ML triamcinolone acetonide injection (Kenalog) suspension 40 mg/ml Pituitary desmopressin 10 mcg/0.1 ml spr 10 (DDAVP) mcg/spray (0.1 ml) desmopressin injection solution 4 mcg/ml (DDAVP) desmopressin nasal solution 0.1 mg/ml (DDAVP) 4 (refrigerate) desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg (DDAVP) GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML 4 PA 114

164 GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT) HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT MG, 15 MG NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 5 MG/1.5 ML (3.3 MG/ML) NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML) octreotide acetate injection solution 1,000 mcg/ml, 200 mcg/ml octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml, 500 mcg/ml 5 PA; NM; NDS 5 PA; NM; NDS 5 PA; NM; NDS 5 PA; NM; NDS 5 PA; NM; NDS 4 PA 5 PA; NM; NDS (Sandostatin) 115

165 octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) OMNITROPE SUBCUTANEOUS 5 PA; NM; NDS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS 5 PA; NM; NDS RECON SOLN 5.8 MG ORILISSA ORAL TABLET 150 MG 5 PA; NM; NDS; QL (28 per 28 ORILISSA ORAL TABLET 200 MG 5 PA; NM; NDS; QL (56 per 28 SAIZEN SAIZENPREP 5 PA; NM; NDS SUBCUTANEOUS CARTRIDGE 8.8 MG/1.51 ML (FINAL CONC.) SAIZEN SUBCUTANEOUS RECON 5 PA; NM; NDS SOLN 5 MG, 8.8 MG SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG 5 PA; NM; NDS SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 20 MG, 25 MG, 30 MG STIMATE NASAL SPRAY,NON- AEROSOL 150 MCG/SPRAY (0.1 ML) SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML ; QL (60 per 30 ; QL (1 per 28 ; QL (1 per

166 TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG ZOMACTON SUBCUTANEOUS RECON SOLN 5 MG ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG Progestins DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 250 mg/ml medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone intramuscular syringe 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg megestrol oral suspension 400 mg/10 ml (40 mg/ml) ; QL (1 per PA; NM; NDS 4 PA 5 PA; NM; NDS 4 QL (10 per 28 5 PA NSO; NM; NDS (Depo-Provera) ; QL (1 per 84 (Depo-Provera) 4 QL (1 per 84 (Provera) 1 PA-HRM; GC; AGE (Max 64 Years) norethindrone acetate oral tablet 5 mg (Aygestin) progesterone in oil intramuscular oil 50 mg/ml progesterone micronized oral capsule 100 (Prometrium) mg, 200 mg Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 mcg, 200 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 112 (Levo-T) mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine intravenous solution 10 mcg/ml (Triostat) liothyronine oral tablet 25 mcg, 5 mcg, 50 (Cytomel) mcg methimazole oral tablet 10 mg, 5 mg (Tapazole) propylthiouracil oral tablet 50 mg 117

167 Immunological Agents Immunological Agents ACTEMRA INTRAVENOUS 5 PA; NM; NDS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS 5 PA; NM; NDS SYRINGE 162 MG/0.9 ML ARCALYST SUBCUTANEOUS RECON SOLN 220 MG azathioprine oral tablet 50 mg (Imuran) 1 PA BvD; GC azathioprine sodium injection recon soln 1 PA BvD; GC 100 mg CARIMUNE NF NANOFILTERED 5 PA BvD; NM; NDS INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM CIMZIA POWDER FOR RECONST 5 PA; NM; NDS SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS 5 PA; NM; NDS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution 250 (Sandimmune) 2 PA BvD; GC mg/5 ml cyclosporine modified oral capsule 100 (Gengraf) 2 PA BvD; GC mg, 25 mg cyclosporine modified oral capsule 50 mg 2 PA BvD; GC cyclosporine modified oral solution 100 (Gengraf) 2 PA BvD; GC mg/ml cyclosporine oral capsule 100 mg, 25 mg (Sandimmune) 2 PA BvD; GC ENBREL SUBCUTANEOUS RECON 5 PA; NM; NDS SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS 5 PA; NM; NDS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK 5 PA; NM; NDS SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 % 5 PA BvD; NM; NDS 118

168 GAMASTAN S/D 4 PA BvD INTRAMUSCULAR SOLUTION % RANGE GAMMAGARD LIQUID 5 PA BvD; NM; NDS INJECTION SOLUTION 10 % GAMMAGARD S-D (IGA < 1 5 PA BvD; NM; NDS MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM GAMMAPLEX (WITH SORBITOL) 5 PA BvD; NM; NDS INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS 5 PA BvD; NM; NDS SOLUTION 10 %, 10 % (100 ML), 10 % (200 ML) GAMUNEX-C INJECTION 5 PA BvD; NM; NDS SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 40 GRAM/400 ML (10 %), 5 GRAM/50 ML (10 %) gengraf oral capsule 100 mg, 25 mg, 50 2 PA BvD; GC mg gengraf oral solution 100 mg/ml 2 PA BvD; GC HUMIRA PEDIATRIC CROHN'S 5 PA; NM; NDS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK), 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA PEN CROHN'S-UC-HS 5 PA; NM; NDS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS 5 PA; NM; NDS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS 5 PA; NM; NDS PEN INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 10 MG/0.2 ML, 20 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML 5 PA; NM; NDS 119

169 HYPERRAB (PF) INTRAMUSCULAR SOLUTION 300 UNIT/ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML INFLECTRA INTRAVENOUS RECON SOLN 100 MG KEDRAB (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG/1.14 ML, 200 MG/1.14 ML KEVZARA SUBCUTANEOUS SYRINGE 150 MG/1.14 ML, 200 MG/1.14 ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML PA BvD; NM; NDS 5 PA; NM; NDS 4 5 PA; NM; NDS 4 5 PA; NM; NDS; QL (2.28 per 28 5 PA; NM; NDS; QL (2.28 per 28 5 PA; NM; NDS; QL (18.76 per 28 leflunomide oral tablet 10 mg, 20 mg (Arava) mycophenolate mofetil hcl intravenous (CellCept Intravenous) 2 PA BvD; GC recon soln 500 mg mycophenolate mofetil oral capsule 250 (CellCept) 1 PA BvD; GC mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml (CellCept) 5 PA BvD; NM; NDS mycophenolate mofetil oral tablet 500 mg (CellCept) 1 PA BvD; GC NULOJIX INTRAVENOUS RECON 5 PA BvD; NM; NDS SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % 5 PA BvD; NM; NDS 120

170 OLUMIANT ORAL TABLET 2 MG 5 PA; NM; NDS; QL (30 per 30 ORENCIA (WITH MALTOSE) 5 PA; NM; NDS INTRAVENOUS RECON SOLN 250 MG ORENCIA CLICKJECT 5 PA; NM; NDS SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS 5 PA; NM; NDS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML OTEZLA ORAL TABLET 30 MG 5 PA; NM; NDS; QL (60 per 30 OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 5 PA; NM; NDS; QL (60 per 30 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) OTREXUP (PF) SUBCUTANEOUS 3 AUTO-INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML PRIVIGEN INTRAVENOUS 5 PA BvD; NM; NDS SOLUTION 10 % PROGRAF INTRAVENOUS 4 PA BvD SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION 1 5 PA BvD; NM; NDS MG/ML RASUVO (PF) SUBCUTANEOUS 3 AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML REMICADE INTRAVENOUS 5 PA; NM; NDS RECON SOLN 100 MG RIDAURA ORAL CAPSULE 3 MG SIMPONI ARIA INTRAVENOUS 5 PA; NM; NDS SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML 5 PA; NM; NDS 121

171 SIMPONI SUBCUTANEOUS 5 PA; NM; NDS SYRINGE 100 MG/ML, 50 MG/0.5 ML sirolimus oral tablet 0.5 mg, 1 mg (Rapamune) 2 PA BvD; GC sirolimus oral tablet 2 mg (Rapamune) 5 PA BvD; NM; NDS STELARA INTRAVENOUS 5 PA; NM; NDS SOLUTION 130 MG/26 ML STELARA SUBCUTANEOUS 5 PA; NM; NDS SOLUTION 45 MG/0.5 ML STELARA SUBCUTANEOUS 5 PA; NM; NDS SYRINGE 45 MG/0.5 ML, 90 MG/ML tacrolimus oral capsule 0.5 mg, 1 mg, 5 (Prograf) 2 PA BvD; GC mg TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML 5 PA; NM; LA; NDS; QL (15 per 28 XELJANZ ORAL TABLET 10 MG, 5 MG 5 PA; NM; NDS; QL (60 per 30 XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF- ( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML 5 PA; NM; NDS; QL (30 per 30 5 PA BvD; NM; NDS PA BvD

172 BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML PA BvD 3 PA BvD 3 PA BvD 3 QL (1.5 per QL (1.5 per PA BvD

173 IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG- 10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT PA BvD 124

174 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML 3 PA BvD 3 PA BvD QL (2 per PA BvD

175 VAQTA (PF) INTRAMUSCULAR 3 SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS 3 QL (2 per 365 SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS 3 SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS 3 QL (1 per 365 SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg (Lotronex) APRISO ORAL 3 CAPSULE,EXTENDED RELEASE 24HR GRAM balsalazide oral capsule 750 mg (Colazal) budesonide oral (Entocort EC) capsule,delayed,extend.release 3 mg CANASA RECTAL SUPPOSITORY 3 1,000 MG colocort rectal enema 100 mg/60 ml DELZICOL ORAL CAPSULE (WITH 3 DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE ST; NM; NDS MG hydrocortisone rectal enema 100 mg/60 (Colocort) ml LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1.2 GRAM mesalamine oral tablet,delayed release (Asacol HD) 4 (dr/ec) 800 mg sulfasalazine oral tablet 500 mg (Azulfidine) sulfasalazine oral tablet,delayed release (dr/ec) 500 mg (Azulfidine EN-tabs) 126

176 UCERIS RECTAL FOAM 2 3 MG/ACTUATION Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % 4 LACTATED RINGERS 4 IRRIGATION SOLUTION sodium chloride irrigation solution 0.9 % (Aqua Care Sodium Chloride) 4 water for irrigation, sterile irrigation solution (Aqua Care Sterile Water) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml ; QL (300 per 28 alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg ; QL (4 per 28 alendronate oral tablet 40 mg alendronate oral tablet 70 mg (Fosamax) ; QL (4 per 28 calcitonin (salmon) nasal spray,nonaerosol 200 unit/actuation ; QL (3.7 per 28 calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 (Hectorol) mcg/2 ml doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg etidronate disodium oral tablet 200 mg, 400 mg FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE MCG/2.4 ML ibandronate intravenous syringe 3 mg/3 ml 4 3 PA; QL (2.4 per 28 (Boniva) ; QL (3 per 84 ibandronate oral tablet 150 mg (Boniva) ; QL (1 per 28 MIACALCIN INJECTION 4 SOLUTION 200 UNIT/ML 127

177 NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous recon soln 30 mg, 90 mg pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml) paricalcitol hemodialysis port injection solution 2 mcg/ml PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCG/ML 5 PA; NM; NDS; QL (2 per 28 paricalcitol oral capsule 1 mcg, 2 mcg (Zemplar) paricalcitol oral capsule 4 mcg PROLIA SUBCUTANEOUS 3 QL (1 per 180 SYRINGE 60 MG/ML RAYALDEE ORAL 3 QL (60 per 30 CAPSULE,EXTENDED RELEASE 24 HR 30 MCG risedronate oral tablet 150 mg (Actonel) ; QL (1 per 28 risedronate oral tablet 30 mg, 5 mg (Actonel) ; QL (30 per 30 risedronate oral tablet 35 mg (Actonel) ; QL (4 per 28 risedronate oral tablet 35 mg (12 pack), ; QL (4 per mg (4 pack) risedronate oral tablet,delayed release (Atelvia) ; QL (4 per 28 (dr/ec) 35 mg SENSIPAR ORAL TABLET 30 MG, 60 MG ; QL (60 per 30 SENSIPAR ORAL TABLET 90 MG ; QL (120 per 30 TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/ PA; QL (1.56 per 30 ML) XGEVA SUBCUTANEOUS 5 PA; NM; NDS SOLUTION 120 MG/1.7 ML (70 MG/ML) zoledronic acid intravenous recon soln 4 mg 128

178 zoledronic acid intravenous solution 4 mg/5 ml zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml zoledronic ac-mannitol-0.9nacl intravenous piggyback 4 mg/100 ml ZOMETA INTRAVENOUS PIGGYBACK 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTHAR H.P. INJECTION GEL 80 UNIT/ML ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML amifostine crystalline intravenous recon soln 500 mg BENLYSTA INTRAVENOUS RECON SOLN 120 MG, 400 MG BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML CETYLEV ORAL TABLET, EFFERVESCENT 2.5 GRAM, 500 MG CYSTADANE ORAL POWDER 1 GRAM/1.7 ML dexrazoxane hcl intravenous recon soln 250 mg, 500 mg (Zometa) (Reclast) ; QL (100 per 300 (Ethyol) 5 PA; NM; NDS; QL (35 per 28 5 PA; NM; NDS 5 PA; NM; NDS; QL (4 per 28 5 PA; NM; NDS; QL (4 per 28 4 (Zinecard (as HCl)) droperidol injection solution 2.5 mg/ml ELMIRON ORAL CAPSULE 100 MG 4 ENDARI ORAL POWDER IN PACKET 5 GRAM 5 PA; NM; NDS; QL (180 per 30 ergoloid oral tablet 1 mg EXONDYS 51 INTRAVENOUS 5 PA; NM; LA; NDS SOLUTION 50 MG/ML fomepizole intravenous solution 1 gram/ml guanidine oral tablet 125 mg 4 hydroxyzine pamoate oral capsule 100 mg 1 PA-HRM; GC; AGE (Max 64 Years) 129

179 hydroxyzine pamoate oral capsule 25 mg, 50 mg (Vistaril) 1 PA-HRM; GC; AGE (Max 64 Years) KEVEYIS ORAL TABLET 50 MG 5 PA; NM; NDS; QL (120 per 30 leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg levocarnitine (with sugar) oral solution (Carnitor) 100 mg/ml levocarnitine oral tablet 330 mg (Carnitor) LEVOLEUCOVORIN 4 INTRAVENOUS RECON SOLN 175 MG levoleucovorin intravenous recon soln 50 (Fusilev) mg mesna intravenous solution 100 mg/ml (Mesnex) MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML methylergonovine injection solution 0.2 mg/ml (1 ml) NPLATE SUBCUTANEOUS RECON SOLN 250 MCG, 500 MCG 5 PA; NM; NDS; QL (8 per 28 PROGLYCEM ORAL SUSPENSION 50 MG/ML pyridostigmine bromide oral tablet 60 mg (Mestinon) pyridostigmine bromide oral tablet (Mestinon Timespan) extended release 180 mg RENFLEXIS INTRAVENOUS 5 PA; NM; NDS RECON SOLN 100 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG 5 PA NSO; NM; NDS; QL (60 per 30 THIOLA ORAL TABLET 100 MG TOTECT INTRAVENOUS RECON SOLN 500 MG TYBOST ORAL TABLET 150 MG 4 QL (30 per 30 VISTOGARD ORAL GRANULES IN PACKET 10 GRAM ; QL (24 per 14 XURIDEN ORAL GRANULES IN PACKET 2 GRAM 5 PA; NM; NDS; QL (120 per

180 Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 125 mg, 250 mg acetazolamide sodium injection recon soln 500 mg ALPHAGAN P OPHTHALMIC 3 (EYE) DROPS 0.1 % AZOPT OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 1 % betaxolol ophthalmic (eye) drops 0.5 % bimatoprost ophthalmic (eye) drops 0.03 % brimonidine ophthalmic (eye) drops 0.15 % (Alphagan P) 4 brimonidine ophthalmic (eye) drops 0.2 % carteolol ophthalmic (eye) drops 1 % COMBIGAN OPHTHALMIC (EYE) 3 DROPS % dorzolamide ophthalmic (eye) drops 2 % (Trusopt) dorzolamide-timolol ophthalmic (eye) drops mg/ml (Cosopt) latanoprost ophthalmic (eye) drops (Xalatan) % levobunolol ophthalmic (eye) drops 0.5 (Betagan) % LUMIGAN OPHTHALMIC (EYE) 3 QL (2.5 per 25 DROPS 0.01 % methazolamide oral tablet 25 mg, 50 mg metipranolol ophthalmic (eye) drops 0.3 % pilocarpine hcl ophthalmic (eye) drops 1 (Isopto Carpine) %, 2 %, 4 % RHOPRESSA OPHTHALMIC (EYE) 3 QL (2.5 per 25 DROPS 0.02 % SIMBRINZA OPHTHALMIC (EYE) 3 DROPS,SUSPENSION % timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % (Timoptic) 131

181 timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) DROPS % Replacement Preparations Replacement Preparations calcium chloride intravenous solution 100 mg/ml (10 %) calcium chloride intravenous syringe 100 mg/ml (10 %) d10 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution electrolyte-48 in d5w intravenous parenteral solution IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq klor-con m20 oral tablet,er particles/crystals 20 meq klor-con sprinkle oral capsule, extended release 10 meq, 8 meq magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml (Timoptic-XE) 3 QL (2.5 per

182 magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R IV SOLUTION L/F, SINGLE-USE NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l, 40 meq/l 1 PA BvD; GC 1 PA BvD; GC 1 PA BvD; GC 1 PA BvD; GC PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 133

183 potassium chloride in water intravenous piggyback 10 meq/100 ml, 10 meq/50 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride intravenous solution 2 meq/ml (20 ml) potassium chloride oral capsule, extended release 10 meq potassium chloride oral capsule, extended release 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq potassium chloride oral tablet,er particles/crystals 10 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 mg) potassium citrate oral tablet extended release 15 meq potassium citrate oral tablet extended release 5 meq (540 mg) sodium acetate intravenous solution 2 meq/ml sodium chloride 0.45 % intravenous parenteral solution 0.45 % 4 PA BvD 1 PA BvD; GC 1 PA BvD; GC (Klor-Con Sprinkle) (K-Tab) (Klor-Con M10) (Klor-Con M20) (Urocit-K 10) (Urocit-K 15) (Urocit-K 5)

184 sodium chloride 0.9 % intravenous parenteral solution sodium chloride 100 meq/40 ml 25's, sdv 2.5 meq/ml sodium chloride intravenous parenteral solution 2.5 meq/ml sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION QL (60 per 30 3 QL (12 per 28 3 QL (30 per 30 3 QL (60 per 30 (Pulmicort) 2 PA BvD; GC 3 QL (13 per 28 3 QL (60 per

185 FLOVENT DISKUS INHALATION 3 QL (120 per 30 BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA 3 QL (12 per 28 AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA 3 QL (24 per 28 AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA 3 QL (21.2 per 28 AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 3 QL (17.4 per 25 MCG/ACTUATION, 80 MCG/ACTUATION QVAR REDIHALER INHALATION 3 QL (21.2 per 30 HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION SYMBICORT MCG 3 QL (12 per 30 INHALER 60 INHALATIONS MCG/ACTUATION SYMBICORT INHALATION HFA 3 QL (10.2 per 30 AEROSOL INHALER MCG/ACTUATION SYMBICORT INHALATION HFA 3 QL (11 per 25 AEROSOL INHALER MCG/ACTUATION Antileukotrienes montelukast oral tablet 10 mg (Singulair) montelukast oral tablet,chewable 4 mg, 5 (Singulair) mg zafirlukast oral tablet 10 mg, 20 mg (Accolate) Bronchodilators albuterol sulfate inhalation solution for 1 PA BvD; GC nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg 136

186 ANORO ELLIPTA INHALATION 3 QL (60 per 30 BLISTER WITH DEVICE MCG/ACTUATION ATROVENT HFA INHALATION 3 QL (25.8 per 28 HFA AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT 3 QL (8 per 30 INHALATION MIST MCG/ACTUATION elixophyllin oral elixir 80 mg/15 ml INCRUSE ELLIPTA INHALATION 3 BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 1 PA BvD; GC 0.02 % levalbuterol tartrate inhalation hfa (Xopenex HFA) 4 QL (30 per 30 aerosol inhaler 45 mcg/actuation LONHALA MAGNAIR STARTER 3 QL (60 per 30 INHALATION SOLUTION FOR NEBULIZATION 25 MCG/ML metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg PROAIR HFA INHALATION HFA 3 AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK 3 INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION 3 QL (60 per 30 BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION 3 MIST 1.25 MCG/ACTUATION SPIRIVA RESPIMAT INHALATION 3 MIST 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG 3 137

187 STIOLTO RESPIMAT 3 QL (4 per 28 INHALATION MIST MCG/ACTUATION STRIVERDI RESPIMAT 3 QL (4 per 28 INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg terbutaline subcutaneous solution 1 mg/ml theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release (Theochron) 12 hr 100 mg, 200 mg theophylline oral tablet extended release (Theochron) 12 hr 300 mg theophylline oral tablet extended release 12 hr 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg TRELEGY ELLIPTA INHALATION 3 BLISTER WITH DEVICE MCG Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 (Acetadote) 2 PA BvD; GC mg/ml (20 %) acetylcysteine solution 100 mg/ml (10 2 PA BvD; GC %), 200 mg/ml (20 %) CINQAIR INTRAVENOUS 5 PA; NM; NDS SOLUTION 10 MG/ML cromolyn inhalation solution for 2 PA BvD; GC nebulization 20 mg/2 ml DALIRESP ORAL TABLET QL (28 per 28 MCG DALIRESP ORAL TABLET QL (30 per 30 MCG ESBRIET ORAL CAPSULE 267 MG 5 PA; NM; NDS; QL (270 per 30 ESBRIET ORAL TABLET 267 MG 5 PA; NM; NDS; QL (270 per 30 ESBRIET ORAL TABLET 801 MG 5 PA; NM; NDS; QL (90 per

188 FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG NUCALA SUBCUTANEOUS RECON SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG SYMDEKO ORAL TABLETS, SEQUENTIAL MG (D)/ 150 MG (N) XOLAIR SUBCUTANEOUS RECON SOLN 150 MG 5 PA; NM; NDS; QL (1 per 28 5 PA; NM; NDS; QL (56 per 28 5 PA; NM; NDS; QL (56 per 28 5 PA; NM; LA; NDS; QL (3 per 28 5 PA; NM; NDS; QL (60 per 30 5 PA; NM; NDS; QL (120 per 30 5 PA BvD; NM; NDS 5 PA; NM; NDS; QL (56 per 28 5 PA; NM; NDS Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg carisoprodol oral tablet 250 mg (Soma) 2 PA-HRM; GC; QL (120 per 30 ; AGE (Max 64 Years) carisoprodol oral tablet 350 mg (Soma) 1 PA-HRM; GC; QL (120 per 30 ; AGE (Max 64 Years) chlorzoxazone oral tablet 500 mg 1 PA-HRM; GC; AGE (Max 64 Years) cyclobenzaprine oral tablet 10 mg, 5 mg 1 PA-HRM; GC; AGE (Max 64 Years) dantrolene oral capsule 100 mg dantrolene oral capsule 25 mg, 50 mg (Dantrium) methocarbamol oral tablet 500 mg (Robaxin) 1 PA-HRM; GC; AGE (Max 64 Years) methocarbamol oral tablet 750 mg (Robaxin-750) 1 PA-HRM; GC; AGE (Max 64 Years) revonto intravenous recon soln 20 mg tizanidine oral tablet 2 mg tizanidine oral tablet 4 mg (Zanaflex) 139

189 Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 200 mg, (Nuvigil) 2 PA; GC 250 mg, 50 mg BELSOMRA ORAL TABLET 10 MG, 3 QL (30 per MG, 20 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) HETLIOZ ORAL CAPSULE 20 MG 5 PA; NM; NDS; QL (30 per 30 SILENOR ORAL TABLET 3 MG, 6 3 QL (30 per 30 MG XYREM ORAL SOLUTION 500 MG/ML 5 NM; LA; NDS; QL (540 per 30 zaleplon oral capsule 10 mg, 5 mg (Sonata) 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 ; AGE (Max 64 Years) 140

190 zolpidem oral tablet 10 mg, 5 mg (Ambien) 1 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg (Ambien CR) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 20 MG 5 PA; NM; NDS; QL (60 per 30 ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG 5 PA; NM; NDS; QL (90 per 30 CIALIS ORAL TABLET 2.5 MG, 5 MG 3 PA; QL (30 per 30 epoprostenol (glycine) intravenous recon (Flolan) 2 PA; GC soln 0.5 mg epoprostenol (glycine) intravenous recon (Flolan) 5 PA; NM; NDS soln 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG 5 PA; NM; NDS; QL (30 per 30 OPSUMIT ORAL TABLET 10 MG 5 PA; NM; NDS; QL (30 per 30 ORENITRAM ORAL TABLET EXTENDED RELEASE MG 3 PA 141

191 ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML sildenafil (antihypertensive) intravenous solution 10 mg/12.5 ml sildenafil (antihypertensive) oral tablet 20 mg sildenafil oral tablet 100 mg, 25 mg, 50 mg TRACLEER ORAL TABLET 125 MG, 62.5 MG TRACLEER ORAL TABLET FOR SUSPENSION 32 MG TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 MG/ML) UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG 5 PA; NM; NDS 5 PA; NM; NDS (Revatio) 5 PA; NM; NDS; QL (37.5 per 1 day) (Revatio) 2 PA; GC; QL (90 per 30 (Viagra) ; EX; CB (6 EA per 30 5 PA; NM; LA; NDS; QL (60 per 30 5 PA; NM; NDS; QL (112 per 28 5 PA; NM; NDS 5 PA; NM; NDS; QL (60 per 30 UPTRAVI ORAL TABLET 200 MCG 5 PA; NM; NDS; QL (240 per 30 UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) 5 PA; NM; NDS; QL (400 per 365 Vitamins And Minerals Vitamins And Minerals pnv prenatal plus multivit tab s/f, glutenfree 27 mg iron- 1 mg prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg 3 ALL RX PRENATAL VITAMINS COVERABLE UNDER PART D 3 ALL RX PRENATAL VITAMINS COVERABLE UNDER PART D 142

192 abacavir...60 abacavir-lamivudine abacavir-lamivudine-zidovudine 60 ABELCET ABILIFY MAINTENA...55, 56 ABRAXANE...24 acamprosate acarbose acebutolol acetaminophen-codeine... 3 acetazolamide acetazolamide sodium acetic acid , 127 acetylcysteine acitretin ACTEMRA ACTHAR H.P ACTHIB (PF) ACTIMMUNE acyclovir... 65, 94 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) ADAGEN adapalene ADCIRCA adefovir ADEMPAS adriamycin...24 adrucil ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR AFINITOR DISPERZ a-hydrocort AKYNZEO (FOSNETUPITANT)...51 INDEX AKYNZEO (NETUPITANT)51 ala-cort...96 ala-scalp ALBENZA albuterol sulfate alclometasone ALCOHOL PADS...94 ALDURAZYME ALECENSA alendronate alfuzosin ALIMTA ALINIA...53 ALIQOPA allopurinol alosetron ALPHAGAN P alprazolam...12 ALREX altavera (28) ALUNBRIG...25 alyacen 1/35 (28) alyacen 7/7/7 (28) amabelz amantadine hcl...54 AMBISOME amethia...88 amethia lo...88 amifostine crystalline amiloride amiloride-hydrochlorothiazide..80 AMINOSYN 10 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 %...69 AMINOSYN II 15 %...69 AMINOSYN II 7 %...69 AMINOSYN II 8.5 %...70 AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 %...70 AMINOSYN-HBC 7%...70 AMINOSYN-PF 10 %...70 AMINOSYN-PF 7 % (SULFITE-FREE)...70 AMINOSYN-RF 5.2 %...70 amiodarone...75 AMITIZA amitriptyline amitriptyline-chlordiazepoxide. 40 amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-olmesartan...80 amlodipine-valsartan...80 amlodipine-valsartan-hcthiazid.80 ammonium lactate...94 amoxapine amoxicil-clarithromy-lansopraz amoxicillin...21 amoxicillin-pot clavulanate amphotericin b ampicillin...21 ampicillin sodium ampicillin-sulbactam AMPYRA...84 ANADROL anagrelide...68 anastrozole ANDROGEL ANORO ELLIPTA APOKYN...54 I-1

193 apraclonidine aprepitant... 51, 52 apri...88 APRISO APTIOM APTIVUS aranelle (28) ARCALYST aripiprazole ARISTADA ARISTADA INITIO...56 armodafinil ARNUITY ELLIPTA ascomp with codeine... 3 ashlyna aspirin-dipyridamole ASSURE ID INSULIN SAFETY...99 atazanavir...60 atenolol...76 atenolol-chlorthalidone...76 atomoxetine...84 atorvastatin atovaquone atovaquone-proguanil...53 ATRIPLA...60 atropine...35, 102 ATROVENT HFA AUBAGIO aubra AUSTEDO AVASTIN aviane AVONEX AVONEX (WITH ALBUMIN)...85 azacitidine azathioprine azathioprine sodium azelastine azithromycin...20 AZOPT aztreonam...20 azurette (28) baciim...16 bacitracin... 16, 102 bacitracin-polymyxin b baclofen balsalazide balziva (28)...88 BANZEL BAVENCIO BAXDELA...22 BCG VACCINE, LIVE (PF) 122 BD ULTRA-FINE NANO PEN NEEDLE BD VEO INSULIN SYR HALF UNIT BD VEO INSULIN SYRINGE UF... 99, 100 bekyree (28)...88 BELEODAQ BELSOMRA benazepril benazepril-hydrochlorothiazide.74 BENDEKA BENLYSTA benztropine BEPREVE BESPONSA...25 betamethasone acet,sod phos betamethasone dipropionate96, 97 betamethasone valerate betamethasone, augmented...97 BETASERON betaxolol... 76, 131 bethanechol chloride BETHKIS...15 BEVYXXA...66 bexarotene...25 BEXSERO bicalutamide BICILLIN L-A BIDIL BIKTARVY bimatoprost bisoprolol fumarate...76 bisoprolol-hydrochlorothiazide. 76 bleomycin bleph BLINCYTO...25 blisovi 24 fe...88 blisovi fe 1.5/30 (28)...88 blisovi fe 1/20 (28) BOOSTRIX TDAP , 123 BORTEZOMIB...25 BOSULIF BRAFTOVI...25 BREO ELLIPTA briellyn BRILINTA...69 brimonidine BRIVIACT bromfenac bromocriptine BROMSITE budesonide...126, 135 bumetanide buprenorphine...3 buprenorphine hcl...3, 11 buprenorphine-naloxone...11 bupropion hcl bupropion hcl (smoking deter). 11 buspirone butalbital compound w/codeine...3 butalbital-acetaminop-caf-cod...3 butalbital-acetaminophen...3 butalbital-acetaminophen-caff...3 butalbital-aspirin-caffeine... 3 butorphanol tartrate... 4 I-2

194 BYSTOLIC...76 BYVALSON...76 cabergoline CABOMETYX...26 caffeine citrate...85 calcipotriene calcitonin (salmon) calcitrene calcitriol...94, 127 calcium acetate calcium chloride CALDOLOR...8 CALQUENCE camila...88 CANASA candesartan candesartan-hydrochlorothiazid73 capacet... 4 CAPASTAT CAPRELSA captopril captopril-hydrochlorothiazide...74 CARAFATE CARBAGLU carbamazepine carbidopa...54 carbidopa-levodopa carbidopa-levodopa-entacapone... 54, 55 carbinoxamine maleate carboplatin CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt...77 carvedilol caspofungin...47 CAYSTON caziant (28) cefaclor...18 cefadroxil cefazolin cefazolin in dextrose (iso-os) cefdinir cefditoren pivoxil...18, 19 cefepime cefixime...19 cefotaxime...19 cefoxitin cefpodoxime cefprozil...19 ceftazidime ceftibuten...19 ceftriaxone cefuroxime axetil cefuroxime sodium celecoxib... 8 CELONTIN cephalexin...19 CEPROTIN (BLUE BAR)...66 CERDELGA CEREZYME CETYLEV cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX...11 CHANTIX STARTING MONTH BOX...11 chloramphenicol sod succinate..16 chlordiazepoxide hcl...12 chlorhexidine gluconate...94 chloroquine phosphate...53 chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone chlorzoxazone cholestyramine (with sugar) cholestyramine light...82 CIALIS ciclopirox...47 cidofovir cilostazol CILOXAN CIMDUO cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINQAIR CINRYZE CINVANTI CIPRODEX ciprofloxacin...22 ciprofloxacin (mixture) ciprofloxacin hcl...22, 103 ciprofloxacin in 5 % dextrose ciprofloxacin lactate citalopram cladribine...26 clarithromycin clemastine...49 CLENPIQ clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl...16 clindamycin phosphate...16, 17, 50, 95, 96 clindamycin-benzoyl peroxide.. 96 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE...70 CLINIMIX 4.25%/D10W SULF FREE...70 I-3

195 CLINIMIX 4.25%/D5W SULFIT FREE...70 CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE...71 CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE...71 CLINIMIX E 5%/D15W SULFIT FREE...71 CLINIMIX E 5%/D20W SULFIT FREE...71 CLINIMIX E 5%/D25W SULFIT FREE...71 clobetasol...97 clobetasol-emollient clocortolone pivalate clofarabine...26 clomipramine clonazepam...12 clonidine clonidine hcl... 73, 85 clopidogrel...69 clorazepate dipotassium clorpres...73 clotrimazole...47 clotrimazole-betamethasone47, 48 clozapine...56, 57 COARTEM codeine sulfate... 4 colchicine...49 colestipol colistin (colistimethate na) colocort COMBIGAN COMBIVENT RESPIMAT. 137 COMETRIQ...26 COMPLERA...61 compro constulose CORLANOR cormax cortisone COSENTYX (2 SYRINGES).94 COSENTYX PEN (2 PENS).. 95 COTELLIC CREON CRIXIVAN cromolyn...102, 107, 138 cryselle (28)...89 CUPRIMINE cyclafem 1/35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE cyclosporine cyclosporine modified cyproheptadine...49 CYRAMZA...26 cyred CYSTADANE CYSTARAN d10 %-0.45 % sodium chloride 132 d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride..132 DAKLINZA...64 DALIRESP danazol dantrolene dapsone...51 DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin DARAPRIM DARZALEX dasetta 1/35 (28)...89 dasetta 7/7/7 (28)...89 daysee...89 deblitane...89 decadron decitabine deferoxamine delyla (28) DELZICOL demeclocycline...23 DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA DESCOVY desipramine desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide...97 desoximetasone...97 desvenlafaxine succinate dexamethasone dexamethasone sodium phos (pf) dexamethasone sodium phosphate , 113 DEXILANT dexmethylphenidate dexrazoxane hcl dextroamphetamine I-4

196 dextroamphetamineamphetamine dextrose 10 % in water (d10w) 71 dextrose 20 % in water (d20w) 71 dextrose 25 % in water (d25w) 71 dextrose 30 % in water (d30w) 71 dextrose 40 % in water (d40w) 71 dextrose 5 % in water (d5w) dextrose 50 % in water (d50w) 72 dextrose 70 % in water (d70w) 72 DIASTAT...12 DIASTAT ACUDIAL diazepam diazepam intensol...13 diclofenac potassium...8 diclofenac sodium... 8, 105 diclofenac-misoprostol... 8 dicloxacillin dicyclomine didanosine...61 DIFICID diflorasone...97 diflunisal...8 digitek digox digoxin DIGOXIN dihydroergotamine DILANTIN diltiazem hcl...77, 78 dilt-xr dimenhydrinate DIPENTUM diphenhydramine hcl diphenoxylate-atropine dipyridamole...69 disopyramide phosphate disulfiram divalproex...36 docetaxel dofetilide...75 donepezil...39 DOPTELET dorzolamide dorzolamide-timolol doxazosin doxepin... 40, 41 doxercalciferol doxorubicin...26 doxorubicin, peg-liposomal...26 doxy doxycycline hyclate...23 doxycycline monohydrate... 23, 24 dronabinol droperidol drospirenone-ethinyl estradiol.. 89 DROXIA...27 DUAVEE DUEXIS...8 DULERA duloxetine...41 DUPIXENT DUREZOL dutasteride dutasteride-tamsulosin econazole...48 EDARBI...73 EDARBYCLOR EDURANT efavirenz ELAPRASE electrolyte-48 in d5w ELIDEL ELIGARD...27 ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) elinest eliphos ELIQUIS ELITEK elixophyllin ELLA...89 ELMIRON EMBEDA...4 EMCYT...27 EMEND EMEND (FOSAPREPITANT) EMFLAZA emoquette EMPLICITI...27 EMSAM EMTRIVA enalapril maleate enalaprilat enalapril-hydrochlorothiazide...74 ENBREL ENBREL SURECLICK ENDARI endocet... 4 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin...67 enpresse enskyce...89 entacapone...55 entecavir ENTRESTO enulose EPCLUSA epinastine epinephrine epitol EPIVIR HBV...61 eplerenone...83 EPOGEN...68 epoprostenol (glycine) eprosartan I-5

197 ergoloid ERGOMAR ERIVEDGE ERLEADA...27 errin ertapenem...20 ery pads erythromycin...20, 103 erythromycin ethylsuccinate...20 erythromycin with ethanol...96 erythromycin-benzoyl peroxide 96 ESBRIET escitalopram oxalate...41 esmolol esomeprazole sodium estarylla...89 estazolam...13 estradiol , 112 estradiol valerate estradiol-norethindrone acet estropipate eszopiclone ethambutol...51 ethosuximide...36 ethynodiol diac-eth estradiol...89 etidronate disodium etodolac...8 ETOPOPHOS...27 etoposide...27 EUCRISA EVOTAZ exemestane EXJADE EXONDYS EXTAVIA ezetimibe ezetimibe-simvastatin...82 FABRAZYME falmina (28)...89 famciclovir...66 famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 106 FANAPT...57 FARESTON...27 FARYDAK...27 FASENRA FASLODEX...27 felbamate...36 felodipine...80 FEMRING femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid...82 fenofibric acid (choline)...82 fenoprofen... 8 fentanyl... 4 fentanyl citrate... 4 FERRIPROX...110, 111 FETZIMA FIASP FLEXTOUCH U-100 INSULIN FIASP U-100 INSULIN...45 finasteride FIRAZYR FIRVANQ...17 flavoxate FLEBOGAMMA DIF flecainide FLECTOR... 8 FLOVENT DISKUS...135, 136 FLOVENT HFA floxuridine fluconazole fluconazole in nacl (iso-osm) flucytosine fludrocortisone flumazenil...85 flunisolide fluocinolone fluocinolone acetonide oil fluocinonide fluocinonide-e fluorometholone fluorouracil... 27, 95 fluoxetine...41 fluphenazine decanoate fluphenazine hcl flurazepam...14 flurbiprofen... 8 flurbiprofen sodium flutamide fluticasone...98, 105 fluvastatin...82 fluvoxamine fomepizole fondaparinux FORTEO fosamprenavir foscarnet...64 fosinopril fosinopril-hydrochlorothiazide..75 fosphenytoin FREAMINE HBC 6.9 %...72 FREAMINE III 10 %...72 FULPHILA...68 furosemide FUZEON fyavolv FYCOMPA gabapentin galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMMAPLEX I-6

198 GAMMAPLEX (WITH SORBITOL) GAMUNEX-C ganciclovir sodium GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GAZYVA gemcitabine...27, 28 gemfibrozil...82 generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK...114, 115 gentak gentamicin... 16, 96, 103 gentamicin in nacl (iso-osm)...16 gentamicin sulfate (ped) (pf).. 16 gentamicin sulfate (pf) GENVOYA GEODON...57 gildagia...89 GILENYA...85 GILOTRIF...28 glatiramer... 85, 86 glatopa GLEOSTINE...28 glimepiride...46 glipizide glipizide-metformin...47 GLUCAGEN HYPOKIT glyburide...47 glyburide micronized...47 glyburide-metformin glycopyrrolate glydo GLYXAMBI GOCOVRI GRALISE...37 GRALISE 30-DAY STARTER PACK granisetron (pf)...52 granisetron hcl GRANIX...68 griseofulvin microsize...48 griseofulvin ultramicrosize guanfacine...73, 86 guanidine HAEGARDA...68 halobetasol propionate haloperidol...58 haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heather heparin (porcine)...67 heparin, porcine (pf)...67 HEPATAMINE 8%...72 HERCEPTIN HETLIOZ HEXALEN...28 HIBERIX (PF) HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S- UC-HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN R U-500 (CONC) INSULIN...45 HUMULIN R U-500 (CONC) KWIKPEN hydralazine hydrochlorothiazide hydrocodone-acetaminophen... 4 hydrocodone-ibuprofen...4, 5 hydrocortisone... 98, 113, 126 hydrocortisone butyrate hydrocortisone butyr-emollient.98 hydrocortisone valerate hydrocortisone-acetic acid hydromorphone...5 hydromorphone (pf)... 5 hydroxychloroquine hydroxyprogesterone caproate117 hydroxyurea hydroxyzine hcl... 49, 50 hydroxyzine pamoate...129, 130 HYPERRAB (PF) HYPERRAB S/D (PF) HYQVIA HYSINGLA ER...5 ibandronate IBRANCE ibu...8 ibuprofen... 8, 9 ICLUSIG...28 IDHIFA...28 ifosfamide...28 ifosfamide-mesna ILARIS (PF) ILEVRO imatinib IMBRUVICA...28 IMFINZI...28 imipenem-cilastatin...20 imipramine hcl imipramine pamoate...41 imiquimod...95 IMLYGIC...28, 29 I-7

199 IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) IMPAVIDO...53 incassia...90 INCRELEX INCRUSE ELLIPTA indapamide indomethacin... 9 indomethacin sodium...9 INFANRIX (DTAP) (PF) INFLECTRA INGREZZA INLYTA...29 INSULIN SYRINGE- NEEDLE U INTELENCE INTRALIPID...72 INTRON A introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR...43 INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL...123, 124 ipratropium bromide , 137 IPRIVASK irbesartan irbesartan-hydrochlorothiazide.73 IRESSA irinotecan...29 ISENTRESS ISENTRESS HD isibloom ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isosorbide dinitrate...84 isosorbide mononitrate isradipine...80 itraconazole ivermectin IXEMPRA IXIARO (PF) JADENU JADENU SPRINKLE JAKAFI...29 jantoven...67 JANUMET...43 JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO...43 JENTADUETO XR...43 jinteli jolivette...90 juleber JULUCA junel 1.5/30 (21)...90 junel 1/20 (21)...90 junel fe 1.5/30 (28) junel fe 1/20 (28)...90 junel fe JUXTAPID JYNARQUE KABIVEN...72 KALETRA...62 KALYDECO KANUMA kariva (28)...90 KAZANO...43 KEDRAB (PF) kelnor 1/35 (28) kelnor ketoconazole...48 ketoprofen... 9 ketorolac... 9, 10, 105 KEVEYIS KEVZARA KEYTRUDA kimidess (28) KINERET KINRIX (PF) kionex (with sorbitol) KISQALI...29 KISQALI FEMARA CO- PACK klor-con m klor-con m klor-con m klor-con sprinkle KORLYM KRYSTEXXA kurvelo KUVAN KYNAMRO...82 KYPROLIS l norgest/e.estradiol-e.estrad...90 labetalol...76 LACTATED RINGERS lactulose lamivudine lamivudine-zidovudine lamotrigine lansoprazole lanthanum LANTUS SOLOSTAR U-100 INSULIN LANTUS U-100 INSULIN...45 larin 1.5/30 (21) larin 1/20 (21)...90 larin 24 fe I-8

200 larin fe 1.5/30 (28) larin fe 1/20 (28) larissia...91 LARTRUVO...29 latanoprost LATUDA LAZANDA... 5 leena leflunomide LEMTRADA LENVIMA lessina...91 LETAIRIS letrozole...30 leucovorin calcium LEUKERAN...30 LEUKINE...68 leuprolide...30 levalbuterol tartrate levetiracetam levetiracetam in nacl (iso-os)...37 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine...50 levofloxacin...23, 103 levofloxacin in d5w LEVOLEUCOVORIN levoleucovorin levonest (28) levonorgestrel-ethinyl estrad...91 levonorg-eth estrad triphasic levora levothyroxine LEXIVA LIALDA lidocaine lidocaine (pf)...10, 75 lidocaine hcl... 10, 11 lidocaine viscous lidocaine-prilocaine...11 lillow linezolid linezolid in dextrose 5% linezolid-0.9% sodium chloride. 17 LINZESS liothyronine lisinopril lisinopril-hydrochlorothiazide...75 lithium carbonate lithium citrate LIVALO LONHALA MAGNAIR STARTER LONSURF loperamide lopinavir-ritonavir...62 lorazepam...14 lorcet (hydrocodone)...5 lorcet hd... 5 lorcet plus...5 loryna (28)...91 losartan losartan-hydrochlorothiazide...74 LOTEMAX lovastatin...83 low-ogestrel (28)...91 loxapine succinate...58 LUCEMYRA LUMIGAN LUPRON DEPOT LUPRON DEPOT (3 MONTH)...30 LUPRON DEPOT (4 MONTH)...30 LUPRON DEPOT (6 MONTH)...30 LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) lutera (28)...91 LYNPARZA LYRICA...37 LYSODREN lyza magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion maprotiline marlissa MARPLAN...41 MARQIBO...30 MATULANE matzim la...78 MAVYRET meclizine...52 medroxyprogesterone mefenamic acid mefloquine megestrol... 30, 117 MEKINIST MEKTOVI meloxicam melphalan hcl...31 memantine MENACTRA (PF) MENEST MENVEO A-C-Y-W-135-DIP (PF) mercaptopurine...31 meropenem mesalamine mesna MESNEX MESTINON metadate er...86 metaproterenol metformin...44 methadone... 5 I-9

201 methadose...5 methazolamide methenamine hippurate methimazole methocarbamol methotrexate sodium...31 methotrexate sodium (pf) methoxsalen...95 methscopolamine methyclothiazide...81 methylergonovine methylphenidate hcl...86, 87 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz 77 metoprolol tartrate...77 metronidazole... 17, 50, 96 metronidazole in nacl (iso-os)..17 mexiletine MIACALCIN miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28)...91 microgestin fe 1/20 (28)...91 midazolam midodrine...73 miglitol miglustat mili...91 milrinone milrinone in 5 % dextrose...79 mimvey lo minitran...84 MINOCIN...24 minocycline...24 minoxidil mirtazapine...41 misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide..75 mometasone...98 mondoxyne nl mono-linyah...91 mononessa (28)...91 montelukast morphine...5, 6 MORPHINE... 6 morphine concentrate...5 MOVANTIK MOVIPREP MOXEZA moxifloxacin... 23, 103 MOZOBIL...68 MULTAQ mupirocin...96 mycophenolate mofetil mycophenolate mofetil hcl MYLOTARG...31 MYRBETRIQ myzilra nabumetone nadolol...77 nafcillin...21, 22 NAGLAZYME naloxone...11 naltrexone NAMZARIC naproxen naratriptan NARCAN...11 NATACYN nateglinide NATPARA NEBUPENT...53 necon 0.5/35 (28) nefazodone...41 neomycin neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b gu...96 neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin neo-polycin hc NEPHRAMINE 5.4 % NERLYNX NESINA...44 neuac NEULASTA...68 NEUPOGEN...68 NEUPRO nevirapine NEXAVAR niacin...83 niacor nicardipine...80 NICOTROL nifedipine...80 nikki (28)...91 nilutamide...31 NINLARO NITRO-BID nitrofurantoin macrocrystal nitrofurantoin monohyd/mcryst nitroglycerin NITYR I-10

202 nizatidine nora-be NORDITROPIN FLEXPRO norepinephrine bitartrate...79 norethindrone (contraceptive)..92 norethindrone acetate norethindrone ac-eth estradiol...92, 112 norethindrone-e.estradiol-iron.. 92 norgestimate-ethinyl estradiol.. 92 norlyda norlyroc...92 NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH NORTHERA nortrel 0.5/35 (28)...92 nortrel 1/35 (21)...92 nortrel 1/35 (28)...92 nortrel 7/7/7 (28)...92 nortriptyline...42 NORVIR NOVOLIN 70/30 U-100 INSULIN NOVOLIN N NPH U-100 INSULIN NOVOLIN R REGULAR U- 100 INSULN NOVOLOG FLEXPEN U- 100 INSULIN...46 NOVOLOG MIX U- 100 INSULN NOVOLOG MIX 70-30FLEXPEN U NOVOLOG PENFILL U-100 INSULIN NOVOLOG U-100 INSULIN ASPART...46 NOXAFIL...48 NPLATE NUCALA NUCYNTA...6 NUCYNTA ER... 6 NUEDEXTA...87 NULOJIX NUPLAZID NUTRILIPID NUTROPIN AQ NUSPIN NUVARING...92 nyamyc...48 nystatin...48 nystatin-triamcinolone nystop...49 OCALIVA OCREVUS OCTAGAM octreotide acetate , 116 ODEFSEY...62 ODOMZO OFEV ofloxacin... 23, 104 ogestrel (28) okebo...24 olanzapine...58, 59 olmesartan...74 olmesartan-amlodipin-hcthiazid74 olmesartan-hydrochlorothiazide74 olopatadine OLUMIANT omega-3 acid ethyl esters omeprazole OMNITROPE ONCASPAR ondansetron ondansetron hcl...52 ondansetron hcl (pf) ONFI ONIVYDE OPDIVO...31 OPSUMIT oralone ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORENITRAM , 142 ORFADIN ORILISSA ORKAMBI orsythia oseltamivir...64 OSENI OSMOLEX ER OTEZLA OTEZLA STARTER OTREXUP (PF) oxacillin...22 oxaliplatin oxandrolone oxazepam oxcarbazepine... 37, 38 OXTELLAR XR...38 oxybutynin chloride oxycodone... 6 oxycodone-acetaminophen... 6 oxycodone-aspirin...6 OXYCONTIN...7 oxymorphone...7 OZEMPIC pacerone...75, 76 paclitaxel...31 paliperidone PALYNZIQ pamidronate PANRETIN pantoprazole paricalcitol PARICALCITOL I-11

203 paroex oral rinse...94 paromomycin paroxetine hcl PASER PAXIL PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE...38 PEGASYS PEGASYS PROCLICK PEGINTRON PEN NEEDLE, DIABETIC.100 penicillin g potassium penicillin g procaine penicillin v potassium PENNSAID...10 PENTACEL (PF) PENTACEL DTAP-IPV COMPNT (PF) PENTAM pentoxifylline...69 PERIKABIVEN...72 perindopril erbumine periogard PERJETA...32 permethrin perphenazine...59 perphenazine-amitriptyline...42 pfizerpen-g...22 phenadoz phenelzine...42 phenobarbital...38 phenylephrine hcl...73, 102 phenytoin...38 phenytoin sodium phenytoin sodium extended...38 philith PHOSLYRA PICATO pilocarpine hcl... 94, 131 pimozide pimtrea (28)...92 pindolol...77 pioglitazone piperacillin-tazobactam...22 pirmella piroxicam PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY podofilox polycin polyethylene glycol polymyxin b sulfate...18 polymyxin b sulf-trimethoprim104 POMALYST portia...92 PORTRAZZA...32 potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex.133 potassium chloride in lr-d potassium chloride in water potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate PRADAXA PRALUENT PEN...83 pramipexole...55 prasugrel...69 pravastatin...83 prazosin...73 prednicarbate...98 prednisolone prednisolone acetate prednisolone sodium phosphate...105, 114 prednisone PREMARIN PREMPHASE PREMPRO prenatal plus (calcium carb) prenatal vitamin plus low iron.142 PREPOPIK prevalite...83 previfem...92 PREVYMIS...64 PREZCOBIX...62 PREZISTA PRIFTIN...51 PRIMAQUINE primidone...38 PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine procainamide PROCALAMINE 3%...72 prochlorperazine prochlorperazine edisylate...52 prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI I-12

204 progesterone in oil progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine...50, 53 promethazine vc promethegan propafenone propantheline proparacaine propranolol propranolol-hydrochlorothiazid 77 propylthiouracil PROQUAD (PF) PROSOL 20 %...72 protamine protriptyline...42 PULMOZYME PURIXAN...32 pyrazinamide pyridostigmine bromide QUADRACEL (PF) quasense quetiapine quinapril quinapril-hydrochlorothiazide...75 quinidine gluconate quinidine sulfate...76 quinine sulfate...54 QVAR QVAR REDIHALER RABAVERT (PF) rabeprazole RADICAVA...87 raloxifene ramipril RANEXA...80 ranitidine hcl RAPAMUNE rasagiline...55 RASUVO (PF) RAVICTI RAYALDEE REBIF (WITH ALBUMIN).. 87 REBIF REBIDOSE...87 REBIF TITRATION PACK..87 reclipsen (28) RECOMBIVAX HB (PF) REGRANEX RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENAGEL RENFLEXIS repaglinide...44 repaglinide-metformin...44 REPATHA PUSHTRONEX. 83 REPATHA SURECLICK...83 REPATHA SYRINGE RESCRIPTOR RESTASIS RETROVIR REVLIMID...32 revonto REXULTI REYATAZ RHOPRESSA ribasphere...66 ribasphere ribapak ribavirin...66 RIDAURA rifabutin...51 rifampin...51 riluzole rimantadine risedronate RISPERDAL CONSTA...59 risperidone...59 ritonavir...62 RITUXAN RITUXAN HYCELA rivastigmine rivastigmine tartrate rizatriptan ropinirole...55 rosadan...96 rosuvastatin ROTARIX ROTATEQ VACCINE ROWEEPRA...38 RUBRACA RYDAPT...32 SABRIL...38 SAIZEN SAIZEN SAIZENPREP SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY)...59 SAVELLA scopolamine base selegiline hcl selenium sulfide...96 SELZENTRY... 62, 63 SENSIPAR SEREVENT DISKUS SEROSTIM sertraline setlakin...92 sevelamer carbonate sharobel...92 SHINGRIX (PF) SIGNIFOR I-13

205 sildenafil sildenafil (antihypertensive) SILENOR SILIQ...95 silver sulfadiazine...96 SIMBRINZA SIMPONI...121, 122 SIMPONI ARIA simvastatin sirolimus SIRTURO smoflipid...72 sodium acetate sodium chloride...127, 135 sodium chloride 0.45 % sodium chloride 0.9 % sodium lactate sodium phenylbutyrate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate..108 SOLIQUA 100/ soloxide SOLTAMOX...32 SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT sorine...77 sotalol...77 sotalol af...77 SOVALDI spinosad...99 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone...81 spironolacton-hydrochlorothiaz 81 SPORANOX sprintec (28) SPRITAM SPRYCEL sps (with sorbitol) sronyx ssd stavudine...63 STELARA STIMATE STIOLTO RESPIMAT STIVARGA...32 STRENSIQ streptomycin STRIBILD...63 STRIVERDI RESPIMAT SUBLOCADE...7 SUBOXONE subvenite...38 sucralfate sulfacetamide sodium sulfacetamide sodium (acne)...96 sulfacetamide-prednisolone sulfadiazine...23 sulfamethoxazole-trimethoprim 23 sulfasalazine sulfatrim...23 sulindac sumatriptan sumatriptan succinate...50, 51 SUPPRELIN LA SUPRAX...19 SUPREP BOWEL PREP KIT SUTENT syeda SYLATRON SYLVANT SYMBICORT SYMDEKO SYMFI SYMFI LO SYMLINPEN SYMLINPEN SYMTUZA SYNAGIS...64 SYNAREL SYNDROS SYNERCID SYNJARDY...44 SYNJARDY XR SYNRIBO TABLOID tacrolimus TAFINLAR TAGRISSO TALTZ AUTOINJECTOR...95 TALTZ SYRINGE tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe 1/20 (28) TASIGNA TAVALISSE...69 tazarotene...99 tazicef...19 TAZORAC...99 taztia xt...78 TECENTRIQ TECFIDERA TECHNIVIE TEFLARO TEKTURNA...84 TEKTURNA HCT...84 telmisartan telmisartan-amlodipine...74 telmisartan-hydrochlorothiazid.74 temazepam TEMODAR...33 tencon...7 TENIVAC (PF) I-14

206 tenofovir disoproxil fumarate terazosin terbinafine hcl...49 terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline...24 THALOMID theophylline THIOLA thioridazine...60 thiotepa thiothixene...60 tiagabine...38 TIBSOVO TICE BCG tigecycline...24 tilia fe...93 timolol maleate... 77, 131, 132 tinidazole...54 TIVICAY tizanidine TOBI PODHALER...16 tobramycin tobramycin in % nacl tobramycin in 0.9 % nacl...16 tobramycin sulfate tobramycin-dexamethasone TOLAK tolazamide tolbutamide...47 tolmetin tolterodine topiramate toposar topotecan...33 TORISEL torsemide...81 TOTECT TOUJEO MAX U-300 SOLOSTAR TOUJEO SOLOSTAR U-300 INSULIN TOVIAZ TRACLEER TRADJENTA tramadol...7 tramadol-acetaminophen...7 trandolapril...75 tranexamic acid tranylcypromine...42 TRAVASOL 10 % TRAVATAN Z trazodone...42 TREANDA TRECATOR TRELEGY ELLIPTA TRELSTAR TREMFYA tretinoin...99 tretinoin (chemotherapy)...34 tri femynor...93 triamcinolone acetonide... 94, 99, 114 triamterene-hydrochlorothiazid 81 triazolam trientine tri-estarylla...93 trifluoperazine trifluridine trihexyphenidyl...55 tri-legest fe tri-linyah...93 tri-lo-estarylla...93 tri-lo-marzia tri-lo-sprintec...93 trilyte with flavor packets trimethoprim...18 tri-mili trimipramine...42 trinessa (28)...93 TRINTELLIX...42 tri-previfem (28) TRIPTODUR tri-sprintec (28)...93 TRIUMEQ trivora (28) tri-vylibra TROGARZO...63 TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA tulana TWINRIX (PF) TYBOST TYKERB...34 TYMLOS TYPHIM VI TYSABRI TYVASO UCERIS ULORIC...49 UNITUXIN UPTRAVI ursodiol valacyclovir...66 VALCHLOR valganciclovir...66 valproate sodium...39 I-15

207 valproic acid valproic acid (as sodium salt).. 39 valsartan...74 valsartan-hydrochlorothiazide.. 74 VALSTAR...34 vancomycin...18 VAQTA (PF)...125, 126 VARIVAX (PF) VASCEPA VECTIBIX VELCADE velivet triphasic regimen (28)...93 VELPHORO VELTASSA VEMLIDY VENCLEXTA...34 VENCLEXTA STARTING PACK venlafaxine verapamil...78 VEREGEN...95 VERSACLOZ...60 VERZENIO...34 vestura (28) VGO VIBERZI vicodin...7 vicodin es...7 vicodin hp... 7 VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC VIEKIRA PAK VIEKIRA XR vienva vigabatrin vigadrone...39 VIIBRYD VIMIZIM VIMOVO...10 VIMPAT...39 vinblastine...34 vincasar pfs...34 vincristine vinorelbine viorele (28) VIRACEPT VIRAMUNE...63 VIREAD...64 VISTOGARD VOLTAREN voriconazole...49 VOSEVI...65 VOTRIENT...34 VPRIV VRAYLAR vyfemla (28) vylibra VYXEOS warfarin...67 water for irrigation, sterile WELCHOL wera (28) XADAGO XALKORI XARELTO XATMEP XELJANZ XELJANZ XR XERMELO XGEVA XIFAXAN XIIDRA XOLAIR XTAMPZA ER... 7 XTANDI xulane...94 XULTOPHY 100/ XURIDEN xylon XYREM YERVOY YF-VAX (PF) YONDELIS...35 YONSA yuvafem zafirlukast zaleplon ZALTRAP...35 zarah ZARXIO...68 zebutal...8 ZEJULA...35 ZELBORAF...35 zenatane zenchent (28) ZENPEP ZEPATIER...65 ZERIT zidovudine...64 ziprasidone hcl ZIRGAN ZOHYDRO ER... 8 ZOLADEX...35 zoledronic acid...128, 129 zoledronic acid-mannitol-water zoledronic ac-mannitol-0.9nacl ZOLINZA zolmitriptan zolpidem ZOMACTON ZOMETA zonisamide...39 ZORBTIVE ZORTRESS I-16

208 ZOSTAVAX (PF) zovia 1/35e (28) zovia 1/50e (28) ZOVIRAX...95 ZUBSOLV...12 ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV...60 ZYTIGA...35 I-17

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