HealthPartners Compass $2850 HSA (Silver) 2016 Formulary. (List of covered drugs)

Transcription

1 HealthPartners Compass $2850 HSA (Silver) 2016 Formulary (List of covered drugs) For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy. Effective: October 1, HealthPartners

2 What s the GenericsAdvantageRx drug list? This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a team of experts every three months for new medicines, safety alerts and other updates. Who decides what s on the drug list? The HealthPartners Pharmacy and Therapeutics Committee manages the list. This team of experts is focused on safety, effectiveness and affordability. Visit healthpartners.com/pharmacy for more information. How do you use the drug list? The medicines on the drug list are listed in alphabetical order by type of medicine starting on page 3. Generic medicines are in lowercase italics (e.g., cephalexin) and are just as safe and effective as brand medicines but cost you less. Some generic medicines are very low-cost. Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines. The Tier Status can be used to determine how much a medicine will cost you. For exact cost information, Find the tier status for your medicine. Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or, Log on to your myhealthpartners account to check your pharmacy benefits. Preventive Generics Preventive Brands All other Formulary Generics & Brands Generics & Brands What s a Medicine? medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases. These medicines usually require more management, have a high price and aren t always stocked at retail pharmacies. Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than non-specialty medicines. Log on to your myhealthpartners account and click on My plan benefits on the Medical Plan tab to check your benefits for specialty medicines. What do the abbreviations in the More details column mean? This column gives special information about the medicine you re searching for. The abbreviations let you know there might be a special program or rule for the medicine. Use this key to help you navigate the drug list: Prior Authorization Required PA Step Therapy Required ST Age Edit AE Gender Edit Female GE Female Gender Edit Male GE Male Quantity Limit Smoking Cessation Benefit SC Trial Drug Program TD Weight Loss Benefit WL Oncology Benefit ONC

3 Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your pharmacy benefits. What s Step Therapy (ST)? Some medicines are on the drug list, but you need to try one or more other medicines first. HealthPartners covers a medicine with step therapy, if you've already tried the other medicine(s). If you haven't, you or your doctor will need to get approval from HealthPartners before the medicine will be covered by your lowest brand, generic or specialty copay or coinsurance. What s an Age Edit (AE)? An age edit means some medicines are only covered if you re within a specific age range. If you're not in the approved age range, you or your doctor will need to request approval from HealthPartners for your medicine to be covered. What s a Gender Edit (GE)? A gender edit means some medicines are covered for males or females only. If you're not in the approved gender group, you or your doctor will need to request approval from HealthPartners for your medicine to be covered. What s a Quantity Limit ()? This means HealthPartners limits the amount of the medicine you'll get each time you fill your prescription. The quantity limit may be less than the days supply listed in your contract or Summary Plan Description. What s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for certain medicines that may not be well tolerated due to: Side effects High cost High potential for waste Your first 6 fills of a trial drug may be limited to less than a month supply. If the medicine works well, you ll get the rest of your month supply. If a copay applies to the medicine, you ll pay no more than one copay for each one month supply. What s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount you get or may not be covered under all plans. Log on to your myhealthpartners account and click on My plan benefits on the Medical Plan tab to check your benefits for weight loss. Weight Loss medicines are listed on the drug list under the Weight Loss medicine category. What s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you re only responsible for your regular generic or brand pharmacy copay or coinsurance. The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (9/15) 2015 HealthPartners

4 List of Covered Drugs Table of Contents Alcohol Dependency... 3 Allergy... 3 Alpha 1 Antitrypsin Deficiency... 4 Anti Addiction/Substance Abuse Treatment Agents... 4 Anti Infective... 4 Arthritis Asthma & Copd Behavioral Health Birth Control Bleeding Disorders Blood Modifier Blood Thinner Bone Health Cancer Corticosteroids Cough & Cold Cystic Fibrosis Dementia Diabetes Ear Conditions Enzyme Replacement Eye Conditions Gout Heart Health Hereditary Angioedema Idiopathic Pulmonary Fibrosis Immune Deficiency Immune Suppressant Kidney Failure Men's Health Migraine Mouth & Throat Multiple Sclerosis Muscle Relaxant Other Conditions Pain Parkinson's Pulmonary Hypertension Seizures / Epilepsy Skin Conditions Sleep Disorders Smoking Cessation Stomach / Gastrointestinal Thyroid Urinary & Bladder Health Vaccines

5 Vitamins And Minerals Weight Loss Women's Health

6 List of Covered Drugs Alcohol Dependency Alcohol Dependency acamprosate oral tablet,delayed release (dr/ec) 333 disulfiram oral tablet 250, 500 naltrexone oral tablet 50 Allergy Allergy, Eye azelastine ophthalmic drops 0.05 % cromolyn ophthalmic drops 4 % epinastine ophthalmic drops 0.05 % olopatadine ophthalmic drops 0.1 % Allergy, Injection AUVI Q INJECTION AUTO INJECTOR 0.15 MG/0.15 ML, 0.3 MG/0.3 ML epinephrine injection auto injector 0.15 /0.15 ml, 0.3 /0.3 ml EPIPEN INJECTION AUTO INJECTOR 0.3 MG/0.3 ML EPIPEN JR 2 PAK INJECTION AUTO INJECTOR 0.15 MG/0.3 ML Allergy, Other Nasal azelastine nasal aerosol,spray 137 mcg (0.1 %) ipratropium bromide nasal spray,non aerosol 0.03 %, 0.06 % Allergy, Other Oral GRASTEK SUBLINGUAL TABLET 2,800 BAU PA RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT PA 3

7 Antihistamines, Oral clemastine oral syrup 0.67 /5 ml cyproheptadine oral syrup 2 /5 ml cyproheptadine oral tablet 4 hydroxyzine hcl oral solution 10 /5 ml ; AE hydroxyzine hcl oral tablet 10, 25, 50 ; AE hydroxyzine pamoate oral capsule 100, 25, 50 ; AE promethazine oral syrup 6.25 /5 ml ; AE promethazine oral tablet 12.5, 25, 50 ; AE Corticosteroids, Nasal flunisolide nasal spray,non aerosol 25 mcg (0.025 %) fluticasone nasal spray,suspension 50 mcg/actuation Alpha 1 Antitrypsin Deficiency Alpha 1 Antitrypsin Deficiency ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, 500 MG GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %) PROLASTIN INTRAVENOUS RECON SOLN 500 MG PROLASTIN C INTRAVENOUS RECON SOLN 1,000 MG ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG Anti Addiction/Substance Abuse Treatment Agents Anti Addiction/Substance Abuse Treatment Agents naloxone injection syringe 1 /ml NARCAN NASAL SPRAY,NON AEROSOL 4 MG/ACTUATION Anti Infective Antibiotics, Cephalosporins cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml 4

8 cefadroxil oral tablet 1 gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefprozil oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML cefuroxime axetil oral tablet 250, 500 cephalexin oral capsule 250, 500 cephalexin oral suspension for reconstitution 125 /5 ml, 250 /5 ml SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET 400 MG Antibiotics, Macrolides azithromycin oral suspension for reconstitution 100 /5 ml, 200 /5 ml azithromycin oral tablet 250, 500, 600 clarithromycin oral suspension for reconstitution 125 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 DIFICID ORAL TABLET 200 MG PA e.e.s. 200 oral suspension for reconstitution 200 /5 ml e.e.s. 400 oral tablet 400 ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 MG/5 ML ery tab oral tablet,delayed release (dr/ec) 250, 500 ERY TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 250 erythromycin ethylsuccinate oral suspension for reconstitution 200 /5 ml erythromycin ethylsuccinate oral tablet 400 erythromycin oral capsule,delayed release(dr/ec) 250 5

9 erythromycin oral tablet 250, 500 erythromycin sulfisoxazole oral suspension for reconstitution /5 ml Antibiotics, Other clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral recon soln 75 /5 ml linezolid oral suspension for reconstitution 100 /5 ml PA linezolid oral tablet 600 PA neomycin oral tablet 500 sulfamethoxazole trimethoprim oral suspension /5 ml sulfamethoxazole trimethoprim oral tablet , trimethoprim oral tablet 100 vancomycin intravenous recon soln 1,000, 10 gram, 5 gram, 500 vancomycin oral capsule 125, 250 XIFAXAN ORAL TABLET 200 MG, 550 MG PA Antibiotics, Penicillins amoxicillin oral capsule 250, 500 amoxicillin oral suspension for reconstitution 125 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 125, 250 amoxicillin pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin pot clavulanate oral tablet , , amoxicillin pot clavulanate oral tablet,chewable , ampicillin oral capsule 250, 500 ampicillin oral suspension for reconstitution 125 /5 ml, 250 /5 ml dicloxacillin oral capsule 250, 500 6

10 penicillin v potassium oral recon soln 125 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 Antibiotics, Quinolones ciprofloxacin hcl oral tablet 100, 250, 500, 750 ciprofloxacin oral suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin oral solution 250 /10 ml levofloxacin oral tablet 250, 500, 750 moxifloxacin oral tablet 400 Antibiotics, Tetracyclines demeclocycline oral tablet 150, 300 doxycycline hyclate oral tablet 20 doxycycline monohydrate oral capsule 100, 50 minocycline oral capsule 100, 50, 75 tetracycline oral capsule 250, 500 Antifungals clotrimazole mucous membrane troche 10 CRESEMBA ORAL CAPSULE 186 MG PA fluconazole oral suspension for reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 griseofulvin microsize oral suspension 125 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 PA ketoconazole oral tablet 200 NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit PA PA 7

11 terbinafine hcl oral tablet 250 voriconazole oral suspension for reconstitution 200 /5 ml (40 /ml) PA voriconazole oral tablet 200, 50 PA Anti Infective, Other ALBENZA ORAL TABLET 200 MG PA atovaquone oral suspension 750 /5 ml BILTRICIDE ORAL TABLET 600 MG dapsone oral tablet 100, 25 ivermectin oral tablet 3 rifabutin oral capsule 150 SIVEXTRO ORAL TABLET 200 MG PA Antiprotozoals ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ST ALINIA ORAL TABLET 500 MG ST atovaquone proguanil oral tablet , chloroquine phosphate oral tablet 250, 500 hydroxychloroquine oral tablet 200 mefloquine oral tablet 250 metronidazole oral tablet 250, 500 YODOXIN ORAL TABLET 210 MG, 650 MG Antiviral, Hepatitis B adefovir oral tablet 10 BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, 1 EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) lamivudine oral tablet 100 TYZEKA ORAL TABLET 600 MG Antiviral, Hepatitis C EPCLUSA ORAL TABLET MG HARVONI ORAL TABLET MG 8

12 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 OLYSIO ORAL CAPSULE 150 MG PEGASYS CONVENIENCE PACK SUBCUTANEOUS KIT 180 MCG/0.5 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 REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML REBETOL ORAL SOLUTION 40 MG/ML ribavirin oral capsule 200 ribavirin oral tablet 200 SOVALDI ORAL TABLET 400 MG ZEPATIER ORAL TABLET MG Antiviral, Hiv abacavir oral tablet 300 abacavir lamivudine zidovudine oral tablet APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 125, 200, 250, 400 EDURANT ORAL TABLET 25 MG EMTRIVA ORAL CAPSULE 200 MG 9

13 EMTRIVA ORAL SOLUTION 10 MG/ML EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG, MG lamivudine oral solution 10 /ml lamivudine oral tablet 150, 300 lamivudine zidovudine oral tablet LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine oral suspension 50 /5 ml nevirapine oral tablet 200 nevirapine oral tablet extended release 24 hr 100, 400 NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG 10

14 stavudine oral capsule 15, 20, 30, 40 stavudine oral recon soln 1 /ml STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG TYBOST ORAL TABLET 150 MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 250 MG, 625 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 zidovudine oral syrup 10 /ml zidovudine oral tablet 300 Antiviral, Other acyclovir oral capsule 200 acyclovir oral suspension 200 /5 ml acyclovir oral tablet 400, 800 amantadine hcl oral capsule 100 amantadine hcl oral solution 50 /5 ml famciclovir oral tablet 125, 250, 500 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML 11

15 valacyclovir oral tablet 1 gram, 500 valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 450 Tuberculosis cycloserine oral capsule 250 PA ethambutol oral tablet 100, 400 isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, 300 PRIFTIN ORAL TABLET 150 MG PA pyrazinamide oral tablet 500 rifampin oral capsule 150, 300 SIRTURO ORAL TABLET 100 MG PA TRECATOR ORAL TABLET 250 MG PA Urinary Anti Infectives MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule 100, 50 nitrofurantoin monohyd/m cryst oral capsule 100 ; AE ; AE nitrofurantoin oral suspension 25 /5 ml ; AE Arthritis Arthritis, Other DEPEN TITRATABS ORAL TABLET 250 MG Disease Modifying Agents ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10, 20 12

16 methotrexate sodium (pf) injection solution 25 /ml methotrexate sodium injection solution 25 /ml methotrexate sodium oral tablet 2.5 RASUVO (PF) SUBCUTANEOUS 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, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML PA RIDAURA ORAL CAPSULE 3 MG Asthma & Copd Asthma & Copd, Other ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION cromolyn inhalation solution for nebulization 20 /2 ml DALIRESP ORAL TABLET 500 MCG PA ipratropium bromide inhalation solution 0.02 % montelukast oral granules in packet 4 montelukast oral tablet 10 montelukast oral tablet,chewable 4, 5 SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG Bronchodilators, Inhaled albuterol sulfate inhalation solution for nebulization 0.63 /3 ml, 1.25 /3 ml, 2.5 /3 ml (0.083 %), 5 /ml FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE 12 MCG SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Bronchodilators, Oral albuterol sulfate oral syrup 2 /5 ml 13

17 albuterol sulfate oral tablet 2, 4 albuterol sulfate oral tablet extended release 12 hr 4, 8 LUFYLLIN ORAL TABLET 200 MG, 400 MG terbutaline oral tablet 2.5, 5 theophylline oral tablet extended release 12 hr 100, 200, 300, 450 theophylline oral tablet extended release 400, 600 Combination Agents, Inhaled ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION ipratropium albuterol inhalation solution for nebulization (2.5 base)/3 ml Corticosteroids, Inhaled ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) budesonide inhalation suspension for nebulization 0.25 /2 ml, 0.5 /2 ml, 1 /2 ml 14 PA PA AE

18 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION Behavioral Health Antipsychotic aripiprazole oral solution 1 /ml AE aripiprazole oral tablet 10, 15, 2, 20, 30, 5 aripiprazole oral tablet,disintegrating 10, 15 chlorpromazine oral tablet 10, 100, 200, 25, 50 clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet,disintegrating 100, 12.5, 150, 200, 25 AE PA; AE AE AE PA; AE fluphenazine hcl oral concentrate 5 /ml AE fluphenazine hcl oral elixir 2.5 /5 ml AE fluphenazine hcl oral tablet 1, 10, 2.5, 5 AE haloperidol lactate oral concentrate 2 /ml AE haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 loxapine succinate oral capsule 10, 25, 5, 50 AE AE NUPLAZID ORAL TABLET 17 MG olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet,disintegrating 10, 15, 20, 5 AE PA; AE 15

19 perphenazine oral tablet 16, 2, 4, 8 quetiapine oral tablet 100, 200, 25, 300, 400, 50 AE AE risperidone oral solution 1 /ml AE risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet,disintegrating 0.25, 0.5, 1, 2, 3, 4 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG thioridazine oral tablet 10, 100, 25, 50 AE PA; AE PA; AE AE thiothixene oral capsule 1, 10, 2, 5 AE trifluoperazine oral tablet 1, 10, 2, 5 AE VERSACLOZ ORAL SUSPENSION 50 MG/ML PA; AE ziprasidone hcl oral capsule 20, 40, 60, 80 Anxiety alprazolam oral tablet 0.25, 0.5, 1, 2 alprazolam oral tablet extended release 24 hr 0.5, 1, 2, 3 buspirone oral tablet 10, 15, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 25, 5 AE clonazepam oral tablet 0.5, 1, 2 diazepam intensol oral concentrate 5 /ml diazepam oral solution 5 /5 ml (1 /ml) diazepam oral tablet 10, 2, 5 diazepam rectal kit , 2.5, lorazepam oral concentrate 2 /ml lorazepam oral tablet 0.5, 1, 2 16

20 Attention Deficit/Hyperactivity Disorder (Adhd) adderall xr oral capsule,extended release 24hr 10, 15, 20, 25, 30, 5 dexmethylphenidate oral tablet 10, 2.5, 5 dextroamphetamine oral capsule, extended release 10, 15, 5 dextroamphetamine oral tablet 10, 5 dextroamphetamine amphetamine oral tablet 10, 12.5, 15, 20, 30, 5, 7.5 guanfacine oral tablet extended release 24 hr 1, 2, 3, 4 methylphenidate oral capsule, er biphasic , 20, 30, 40, 50, 60 methylphenidate oral capsule,er biphasic , 30, 40 methylphenidate oral tablet 10, 20, 5 methylphenidate oral tablet extended release 10, 20 methylphenidate oral tablet extended release 24hr 18, 27, 36, 54 QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG Bipolar Disorder divalproex oral capsule, sprinkle 125 divalproex oral tablet extended release 24 hr 250, 500 divalproex oral tablet,delayed release (dr/ec) 125, 250, 500 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium carbonate oral tablet extended release 300,

21 lithium citrate oral solution 8 meq/5 ml Depression, Atypical Antidepressants budeprion sr oral tablet extended release 150 bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release 100, 150, 200 bupropion hcl oral tablet extended release 24 hr 150, 300 mirtazapine oral tablet 15, 30, 45, 7.5 Depression, Maois phenelzine oral tablet 15 tranylcypromine oral tablet 10 Depression, Serotonin Modulators nefazodone oral tablet 100, 150, 200, 250, 50 trazodone oral tablet 100, 150, 300, 50 Depression, Snris duloxetine oral capsule,delayed release(dr/ec) 20, 30, 60 venlafaxine oral capsule,extended release 24hr 150, 37.5, 75 venlafaxine oral tablet 100, 25, 37.5, 50, 75 Depression, Ssris citalopram oral solution 10 /5 ml citalopram oral tablet 10, 20, 40 escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 20, 5 fluoxetine oral capsule 10, 20, 40 fluoxetine oral solution 20 /5 ml (4 /ml) fluvoxamine oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 PAXIL ORAL SUSPENSION 10 MG/5 ML 18

22 sertraline oral concentrate 20 /ml sertraline oral tablet 100, 25, 50 Depression, Tricyclic & Tetracyclic Antidepressants amitriptyline oral tablet 10, 100, 25, 50, 75 AE amitriptyline oral tablet 150 AE clomipramine oral capsule 25, 50, 75 AE desipramine oral tablet 10, 100, 150, 25, 50, 75 doxepin oral capsule 10, 100, 150, 25, 50, 75 AE doxepin oral concentrate 10 /ml AE imipramine hcl oral tablet 10, 25, 50 AE nortriptyline oral capsule 10, 25, 50, 75 nortriptyline oral solution 10 /5 ml Birth Control Contraceptives, Other NUVARING VAGINAL RING MG/24 HR xulane transdermal patch weekly mcg/24 hr Emergency Contraception ELLA ORAL TABLET 30 MG levonorgestrel oral tablet 0.75, 1.5 my way oral tablet 1.5 next choice one dose oral tablet 1.5 Oral Contraceptives altavera (28) oral tablet alyacen 1/35 (28) oral tablet 1 35 mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 35 mcg apri oral tablet aranelle (28) oral tablet 0.5/1/ mcg aubra oral tablet mcg aviane oral tablet mcg 19

23 azurette (28) oral tablet x21 /0.01 x 5 balziva (28) oral tablet mcg blisovi fe 1.5/30 (28) oral tablet mcg (21)/75 (7) blisovi fe 1/20 (28) oral tablet 1 20 mcg (21)/75 (7) brevicon (28) oral tablet mcg briellyn oral tablet mcg camila oral tablet 0.35 caziant (28) oral tablet 0.1/.125/ mcg cesia (28) oral tablet 0.1/.125/ mcg chateal oral tablet cryselle (28) oral tablet mcg cyclafem 1/35 (28) oral tablet 1 35 mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 35 mcg dasetta 1/35 (28) oral tablet 1 35 mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 35 mcg desogestrel ethinyl estradiol oral tablet drospirenone ethinyl estradiol oral tablet elinest oral tablet mcg emoquette oral tablet enpresse oral tablet (6)/75 40 (5)/125 30(10) enskyce oral tablet errin oral tablet 0.35 estarylla oral tablet mcg falmina (28) oral tablet mcg gianvi (28) oral tablet gildagia oral tablet mcg gildess 1.5/30 (21) oral tablet mcg gildess 1/20 (21) oral tablet 1 20 mcg gildess fe 1.5/30 (28) oral tablet mcg (21)/75 (7) 20

24 gildess fe 1/20 (28) oral tablet 1 20 mcg (21)/75 (7) heather oral tablet 0.35 introvale oral tablets,dose pack,3 month mcg jencycla oral tablet 0.35 jolessa oral tablets,dose pack,3 month mcg jolivette oral tablet 0.35 junel 1.5/30 (21) oral tablet mcg junel 1/20 (21) oral tablet 1 20 mcg junel fe 1.5/30 (28) oral tablet mcg (21)/75 (7) junel fe 1/20 (28) oral tablet 1 20 mcg (21)/75 (7) kariva (28) oral tablet x21 /0.01 x 5 kelnor 1/35 (28) oral tablet 1 35 mcg kurvelo oral tablet larin 1/20 (21) oral tablet 1 20 mcg larin fe 1.5/30 (28) oral tablet mcg (21)/75 (7) larin fe 1/20 (28) oral tablet 1 20 mcg (21)/75 (7) leena 28 oral tablet 0.5/1/ mcg lessina oral tablet mcg levlen (28) oral tablet levonest (28) oral tablet (6)/75 40 (5)/125 30(10) levonorgestrel ethinyl estrad oral tablet mcg, levonorgestrel ethinyl estrad oral tablets,dose pack,3 month mcg levora 28 oral tablet loryna (28) oral tablet low ogestrel (28) oral tablet mcg lutera (28) oral tablet mcg lyza oral tablet

25 marlissa oral tablet microgestin 1.5/30 (21) oral tablet mcg microgestin 1/20 (21) oral tablet 1 20 mcg microgestin fe 1.5/30 (28) oral tablet mcg (21)/75 (7) microgestin fe 1/20 (28) oral tablet 1 20 mcg (21)/75 (7) mono linyah oral tablet mcg mononessa (28) oral tablet mcg myzilra oral tablet (6)/75 40 (5)/125 30(10) necon 0.5/35 (28) oral tablet mcg necon 1/35 (28) oral tablet 1 35 mcg necon 1/50 (28) oral tablet 1 50 mcg necon 10/11 (28) oral tablet /1 35 mcg/ mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1 35 mcg nora be oral tablet 0.35 norethindrone (contraceptive) oral tablet 0.35 norgestimate ethinyl estradiol oral tablet 0.18/0.215/ mcg, 0.18/0.215/ mcg (28), mcg norinyl 1+35 (28) oral tablet 1 35 mcg nortrel 0.5/35 (28) oral tablet mcg nortrel 1/35 (21) oral tablet 1 35 mcg nortrel 1/35 (28) oral tablet 1 35 mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 35 mcg ocella oral tablet ogestrel (28) oral tablet mcg orsythia oral tablet mcg philith oral tablet mcg pimtrea (28) oral tablet x21 /0.01 x 5 pirmella oral tablet 0.5/0.75/1 35 mcg, 1 35 mcg 22

26 portia oral tablet previfem oral tablet mcg quasense oral tablets,dose pack,3 month mcg reclipsen (28) oral tablet sprintec (28) oral tablet mcg sronyx oral tablet mcg syeda oral tablet tilia fe oral tablet 1 20(5)/1 30(7) /1 35mcg (9) tri estarylla oral tablet 0.18/0.215/ mcg (28) tri legest fe oral tablet 1 20(5)/1 30(7) /1 35mcg (9) tri linyah oral tablet 0.18/0.215/ mcg (28) tri lo estarylla oral tablet 0.18/0.215/ mcg tri lo sprintec oral tablet 0.18/0.215/ mcg trinessa (28) oral tablet 0.18/0.215/ mcg (28) trinessa lo oral tablet 0.18/0.215/ mcg tri previfem (28) oral tablet 0.18/0.215/ mcg (28) tri sprintec (28) oral tablet 0.18/0.215/ mcg (28) trivora (28) oral tablet (6)/75 40 (5)/125 30(10) velivet triphasic regimen (28) oral tablet 0.1/.125/ mcg vestura (28) oral tablet viorele (28) oral tablet x21 /0.01 x 5 vyfemla (28) oral tablet mcg wera (28) oral tablet mcg zarah oral tablet zenchent (28) oral tablet mcg 23

27 zovia 1/35e (28) oral tablet 1 35 mcg zovia 1/50e (28) oral tablet 1 50 mcg Bleeding Disorders Bleeding Disorders, Hemophilia STIMATE NASAL SPRAY,NON AEROSOL 150 MCG/SPRAY (0.1 ML) Bleeding Disorders, Other PA AMICAR ORAL TABLET 500 MG aminocaproic acid oral solution 250 /ml (25 %) aminocaproic acid oral tablet 500 Blood Modifier Blood Modifiers ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML ; ONC LEUKINE INJECTION RECON SOLN 250 MCG NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML 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, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 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 24

28 Clotting Disorders ADVATE INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT, 1,500 (+/ ) UNIT, 2,000 (+/ ) UNIT, 250 (+/ ) UNIT, 3,000 (+/ ) UNIT, 4,000 (+/ ) UNIT, 500 (+/ ) UNIT ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/ ) UNIT, 2,000 (+/ ) UNIT, 250 (+/ ) UNIT, 500 (+/ ) UNIT AFSTYLA INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT RANGE, 2,000 (+/ ) UNIT RANGE, 250 (+/ ) UNIT RANGE, 3,000 (+/ ) UNIT RANGE, 500 (+/ ) UNIT RANGE ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML ALPHANINE SD INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT, 1,500 (+/ ) UNIT, 500 (+/ ) UNIT ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT BEBULIN INTRAVENOUS RECON SOLN 700 (+/ ) UNIT BENEFIX INTRAVENOUS KIT 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT COAGADEX INTRAVENOUS RECON SOLN 250 (+/ ) UNIT RANGE, 500 (+/ ) UNIT RANGE CORIFACT INTRAVENOUS KIT 1,000 1,600 UNIT ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT, 750 UNIT FEIBA NF INTRAVENOUS RECON SOLN 1,750 3,250 UNIT, UNIT, 651 1,200 UNIT HELIXATE FS INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT, 2,000 (+/ ) UNIT, 250 (+/ ) UNIT, 3,000 (+/ ) UNIT, 500 (+/ ) UNIT HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801 1,500 UNIT 25

29 HEMOFIL M LOW INTRAVENOUS RECON SOLN UNIT HEMOFIL M MID INTRAVENOUS RECON SOLN UNIT HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1,501 2,000 UNIT HUMATE P INTRAVENOUS KIT 1,000 2,400 UNIT, UNIT, 500 1,200 UNIT IDELVION INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT, 2,000 (+/ ) UNIT, 250 (+/ ) UNIT, 500 (+/ ) UNIT IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 500 UNIT KOATE DVI INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT, 250 (+/ ) UNIT, 500 (+/ ) UNIT KOGENATE FS INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT, 2,000 (+/ ) UNIT, 250 (+/ ) UNIT, 3,000 (+/ ) UNIT, 500 (+/ ) UNIT MONOCLATE P INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT, 1,500 (+/ ) UNIT MONONINE INTRAVENOUS KIT 1,000 (+/ ) UNIT NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT, 1,500 (+/ ) UNIT, 2,000 (+/ ) UNIT, 250 (+/ ) UNIT, 3,000 (+/ ) UNIT, 500 (+/ ) UNIT NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG) NUWIQ INTRAVENOUS RECON SOLN 1000 (+/ ) UNIT, 2,000 (+/ ) UNIT, 250 (+/ ) UNIT, 500 (+/ ) UNIT OBIZUR INTRAVENOUS RECON SOLN 500 (+/ ) UNIT RANGE PLASMANATE INTRAVENOUS PARENTERAL SOLUTION 5 % PROFILNINE INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT, 1,500 (+/ ) UNIT, 500 (+/ ) UNIT RECOMBINATE INTRAVENOUS RECON SOLN 1,000 (+/ ) UNIT, 1,500 (+/ ) UNIT, 2,000 (+/ ) UNIT, 250 (+/ ) UNIT, 500 (+/ ) UNIT 26

30 RIXUBIS INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT THROMBATE III INTRAVENOUS RECON SOLN 500 (+/ ) UNIT TRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT VONVENDI INTRAVENOUS RECON SOLN 1,300 (+/ ) UNIT RANGE, 650 (+/ ) UNIT RANGE WILATE INTRAVENOUS KIT 1,000 1,000 UNIT, UNIT, UNIT, UNIT WILATE INTRAVENOUS RECON SOLN 1,000 1,000 UNIT, UNIT XYNTHA INTRAVENOUS SOLUTION 1,000 (+/ ) UNIT, 2,000 (+/ ) UNIT, 250 (+/ ) UNIT, 500 (+/ ) UNIT XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1,000 (+/ ) UNIT, 2,000 (+/ ) UNIT, 250 (+/ ) UNIT, 3,000 (+/ ) UNIT, 500 (+/ ) UNIT Blood Thinner Anticoagulants ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous solution 300 /3 ml enoxaparin subcutaneous syringe 100 /ml, 120 /0.8 ml, 150 /ml, 30 /0.3 ml, 40 /0.4 ml, 60 /0.6 ml, 80 /0.8 ml fondaparinux subcutaneous syringe 10 /0.8 ml, 2.5 /0.5 ml, 5 /0.4 ml, 7.5 /0.6 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 (pf) injection syringe 5,000 unit/0.5 ml jantoven oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 PA 27

31 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42) 20 MG (9) Platelet Inhibitors anagrelide oral capsule 0.5, 1 aspirin dipyridamole oral capsule, er multiphase 12 hr BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100, 50 clopidogrel oral tablet 75 dipyridamole oral tablet 25, 50, 75 EFFIENT ORAL TABLET 10 MG, 5 MG pentoxifylline oral tablet extended release 400 ZONTIVITY ORAL TABLET 2.08 MG PA Bone Health Bone Health, Other etidronate disodium oral tablet 200, 400 Osteoporosis alendronate oral solution 70 /75 ml alendronate oral tablet 10, 35, 40, 5, 70 calcitonin (salmon) nasal spray,non aerosol 200 unit/actuation FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE 600 MCG/2.4 ML FORTICAL NASAL SPRAY,NON AEROSOL 200 UNIT/ACTUATION ibandronate oral tablet 150 raloxifene oral tablet 60 Cancer Cancer, Alkylating Agents ALKERAN ORAL TABLET 2 MG EMCYT ORAL CAPSULE 140 MG GLEOSTINE ORAL CAPSULE 10 MG, 40 MG HEXALEN ORAL CAPSULE 50 MG ; ONC LEUKERAN ORAL TABLET 2 MG 28

32 lomustine oral capsule 10, 100, 40 MATULANE ORAL CAPSULE 50 MG ; ONC MYLERAN ORAL TABLET 2 MG temozolomide oral capsule 100, 140, 180, 20, 250, 5 ; ONC VALCHLOR TOPICAL GEL % ; ONC; Cancer, Antiandrogens bicalutamide oral tablet 50 flutamide oral capsule 125 XTANDI ORAL CAPSULE 40 MG ; TD; ONC ZYTIGA ORAL TABLET 250 MG ; TD; ONC Cancer, Antimetabolites capecitabine oral tablet 150, 500 ; ONC hydroxyurea oral capsule 500 LONSURF ORAL TABLET MG, MG ; ONC mercaptopurine oral tablet 50 TABLOID ORAL TABLET 40 MG Cancer, Aromatase Inhibitors anastrozole oral tablet 1 exemestane oral tablet 25 letrozole oral tablet 2.5 Cancer, Hdac Inhibitors ZOLINZA ORAL CAPSULE 100 MG ; TD; ONC Cancer, Immunosuppressives AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG cyclophosphamide oral tablet 25, 50 POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG ; TD; ONC ; TD; ONC ; ONC ; ONC ; ONC 29

33 Cancer, Interferons SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Cancer, Natural And Semi Synthetic ; ONC etoposide oral capsule 50 HYCAMTIN INTRAVENOUS RECON SOLN 4 MG ; ONC HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG ; ONC Cancer, Other Agents megestrol oral tablet 20, 40 ODOMZO ORAL CAPSULE 200 MG ; ONC Cancer, Retinoids tretinoin (chemotherapy) oral capsule 10 ; ONC Cancer, Serms SOLTAMOX ORAL SOLUTION 10 MG/5 ML tamoxifen oral tablet 10, 20 Cancer, Signal Transduction Inhibitors BOSULIF ORAL TABLET 100 MG, 500 MG ; TD; ONC CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG ; ONC CAPRELSA ORAL TABLET 100 MG, 300 MG ; ONC 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) ; ONC COTELLIC ORAL TABLET 20 MG ; ONC ERIVEDGE ORAL CAPSULE 150 MG ; TD; ONC GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG ; ONC ICLUSIG ORAL TABLET 15 MG, 45 MG ; ONC imatinib oral tablet 100, 400 ; TD; ONC IMBRUVICA ORAL CAPSULE 140 MG ; ONC INLYTA ORAL TABLET 1 MG, 5 MG ; TD; ONC IRESSA ORAL TABLET 250 MG ; ONC JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG ; TD; ONC MEKINIST ORAL TABLET 0.5 MG, 2 MG ; ONC NEXAVAR ORAL TABLET 200 MG ; TD; ONC NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ; ONC 30

34 SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG ; TD; ONC STIVARGA ORAL TABLET 40 MG ; ONC SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG ; TD; ONC TAFINLAR ORAL CAPSULE 50 MG, 75 MG ; ONC TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG ; TD; ONC TASIGNA ORAL CAPSULE 150 MG, 200 MG ; TD; ONC TYKERB ORAL TABLET 250 MG ; ONC VOTRIENT ORAL TABLET 200 MG ; TD; ONC XALKORI ORAL CAPSULE 200 MG, 250 MG ; TD; ONC ZELBORAF ORAL TABLET 240 MG ; ONC Corticosteroids Corticosteroids, Oral DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML dexamethasone oral elixir 0.5 /5 ml dexamethasone oral solution 0.5 /5 ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 2, 4, 6 fludrocortisone oral tablet 0.1 hydrocortisone oral tablet 10, 20, 5 MEDROL ORAL TABLET 2 MG methylprednisolone oral tablet 16, 32, 4, 8 methylprednisolone oral tablets,dose pack 4 MILLIPRED ORAL TABLET 5 MG prednisolone oral solution 15 /5 ml prednisolone sodium phosphate oral solution 15 /5 ml (3 /ml), 25 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 /5 ml prednisone oral tablet 1, 10, 2.5, 20, 5, 50 prednisone oral tablets,dose pack 10, 5 31

35 Cough & Cold Cough & Cold benzonatate oral capsule 100, 200 codeine guaifenesin oral liquid /5 ml ; AE guaiatussin ac oral liquid /5 ml ; AE promethazine vc oral syrup /5 ml promethazine dm oral syrup /5 ml Cystic Fibrosis Cystic Fibrosis acetylcysteine solution 100 /ml (10 %), 200 /ml (20 %) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG ORKAMBI ORAL TABLET MG PULMOZYME INHALATION SOLUTION 1 MG/ML ; tobramycin in % nacl inhalation solution for nebulization 300 /5 ml Dementia Dementia donepezil oral tablet 10, 5 donepezil oral tablet,disintegrating 10, 5 galantamine oral capsule,ext rel. pellets 24 hr 16, 24, 8 galantamine oral solution 4 /ml galantamine oral tablet 12, 4, 8 memantine oral solution 2 /ml memantine oral tablet 10, 5 memantine oral tablets,dose pack 5 10 rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 Diabetes Diabetes, Alpha Glucosidase Inhibitors acarbose oral tablet 100, 25, 50 32

36 miglitol oral tablet 100, 25, 50 Diabetes, Biguanides metformin oral tablet 1,000, 500, 850 metformin oral tablet extended release 24 hr 500, 750 Diabetes, Dpp 4 Inhibitor / Biguanide Combinations 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 Diabetes, Dpp 4 Inhibitors TRADJENTA ORAL TABLET 5 MG Diabetes, Glp 1 Agonists BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA 2 PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) VICTOZA 3 PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) Diabetes, Intermediate Acting Insulins HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N PEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML Diabetes, Long Acting Insulins LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) PA; 33

37 LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) Diabetes, Meglitinides ST ST nateglinide oral tablet 120, 60 repaglinide oral tablet 0.5, 1, 2 Diabetes, Other Oral Agents CYCLOSET ORAL TABLET 0.8 MG PA Diabetes, Pre Mixed Insulins HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50 50) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50 50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75 25) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75 25) HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70 30) HUMULIN 70/30 PEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70 30) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70 30) Diabetes, Rapid Acting Insulins HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML) HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML 34

38 Diabetes, Rescue Agents GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGEN INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG Diabetes, Sglt2 Inhibitor / Biguanide Combinations INVOKAMET ORAL TABLET 150 1,000 MG, MG, 50 1,000 MG, MG SYNJARDY ORAL TABLET ,000 MG, MG, 5 1,000 MG, MG Diabetes, Sglt2 Inhibitors ST ST INVOKANA ORAL TABLET 100 MG, 300 MG ST JARDIANCE ORAL TABLET 10 MG, 25 MG ST Diabetes, Short Acting Insulins HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U 500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) HUMULIN R U 500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML Diabetes, Sulfonylurea / Biguanide Combination glipizide metformin oral tablet , , Diabetes, Sulfonylureas glimepiride oral tablet 1, 2, 4 glipizide oral tablet 10, 5 glipizide oral tablet extended release 24hr 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 GE Female; AE glyburide oral tablet 1.25, 2.5, 5 GE Female; AE Diabetes, Thiazolidinedione / Biguanide Combinations pioglitazone metformin oral tablet ,

39 Diabetes, Thiazolidinedione / Sulfonylurea Combinations pioglitazone glimepiride oral tablet 30 2, 30 4 Diabetes, Thiazolidinediones pioglitazone oral tablet 15, 30, 45 Ear Conditions Anti Infectives, Ear acetic acid otic solution 2 % CIPRO HC OTIC DROPS,SUSPENSION % CIPRODEX OTIC DROPS,SUSPENSION % neomycin polymyxin hc otic drops,suspension ,000 1 /ml unit/ml % neomycin polymyxin hc otic solution ,000 1 /ml unit/ml % ofloxacin otic drops 0.3 % Ear Conditions, Other antipyrine benzocaine otic drops % fluocinolone acetonide oil otic drops 0.01 % Enzyme Replacement Enzyme Replacement CERDELGA ORAL CAPSULE 84 MG CREON ORAL 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 STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML SUCRAID ORAL SOLUTION 8,500 UNIT/ML ZAVESCA ORAL CAPSULE 100 MG Eye Conditions Anti Infectives, Eye bacitracin ophthalmic ointment 500 unit/gram bacitracin polymyxin b ophthalmic ointment ,000 unit/gram 36

40 BESIVANCE OPHTHALMIC DROPS,SUSPENSION 0.6 % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % CILOXAN OPHTHALMIC OINTMENT 0.3 % ciprofloxacin hcl ophthalmic drops 0.3 % erythromycin ophthalmic ointment 5 /gram (0.5 %) gentamicin ophthalmic ointment 0.3 % (3 /gram) neomycin bacitracin polymyxin ophthalmic ointment ,000 unit unit/g neomycin polymyxin gramicidin ophthalmic drops ,000 unit 0.025/ml ofloxacin ophthalmic drops 0.3 % polymyxin b sulf trimethoprim ophthalmic drops 10,000 unit 1 /ml sulfacetamide sodium ophthalmic drops 10 % sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide prednisolone ophthalmic drops 10 % 0.23 % (0.25 %) TOBRADEX OPHTHALMIC OINTMENT % tobramycin ophthalmic drops 0.3 % tobramycin dexamethasone ophthalmic drops,suspension % TOBREX OPHTHALMIC OINTMENT 0.3 % trifluridine ophthalmic drops 1 % ZIRGAN OPHTHALMIC GEL 0.15 % Anti Inflammatories, Eye bromfenac ophthalmic drops 0.09 % dexamethasone sodium phosphate ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % fluorometholone ophthalmic drops,suspension 0.1 % flurbiprofen sodium ophthalmic drops 0.03 % FML S.O.P. OPHTHALMIC OINTMENT 0.1 % ketorolac ophthalmic drops 0.4 %, 0.5 % PA 37

41 PRED FORTE OPHTHALMIC DROPS,SUSPENSION 1 % PRED MILD OPHTHALMIC DROPS,SUSPENSION 0.12 % prednisolone acetate ophthalmic drops,suspension 1 % prednisolone sodium phosphate ophthalmic drops 1 % Eye Conditions, Other atropine ophthalmic drops 1 % atropine ophthalmic ointment 1 % cyclopentolate ophthalmic drops 1 % CYSTARAN OPHTHALMIC DROPS 0.44 % homatropaire ophthalmic drops 5 % phenylephrine hcl ophthalmic drops 10 %, 2.5 % RESTASIS OPHTHALMIC DROPPERETTE 0.05 % Glaucoma betaxolol ophthalmic drops 0.5 % bimatoprost ophthalmic drops 0.03 % brimonidine ophthalmic drops 0.15 %, 0.2 % carteolol ophthalmic drops 1 % COSOPT (PF) OPHTHALMIC DROPPERETTE % PA dorzolamide ophthalmic drops 2 % dorzolamide timolol ophthalmic drops /ml latanoprost ophthalmic drops % levobunolol ophthalmic drops 0.5 % LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral tablet 25, 50 pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % timolol maleate ophthalmic drops 0.25 %, 0.5 % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS % travoprost (benzalkonium) ophthalmic drops % 38

42 ZIOPTAN (PF) OPHTHALMIC DROPPERETTE % Gout Gout PA allopurinol oral tablet 100, 300 colchicine oral capsule 0.6 colchicine oral tablet 0.6 colchicine probenecid oral tablet probenecid oral tablet 500 ULORIC ORAL TABLET 40 MG, 80 MG ST Heart Health Angina isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide dinitrate oral tablet extended release 40 isosorbide mononitrate oral tablet 10, 20 isosorbide mononitrate oral tablet extended release 24 hr 120, 30, 60 NITRO BID TRANSDERMAL OINTMENT 2 % nitroglycerin sublingual tablet 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr Antiarrhythmics amiodarone oral tablet 100, 200, 400 disopyramide phosphate oral capsule 100, 150 dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg flecainide oral tablet 100, 150, 50 mexiletine oral capsule 150, 200, 250 MULTAQ ORAL TABLET 400 MG PA NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 100 MG, 150 MG propafenone oral tablet 150, 225,

43 quinidine gluconate oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 quinidine sulfate oral tablet extended release 300 sotalol af oral tablet 120, 160, 80 sotalol oral tablet 120, 160, 240, 80 Blood Pressure, Acei & Arb amlodipine benazepril oral capsule 10 20, , 5 10, 5 20, 5 40 amlodipine valsartan oral tablet ST amlodipine valsartan hcthiazid oral tablet ST benazepril oral tablet 10, 20, 40, 5 benazepril hydrochlorothiazide oral tablet , , 20 25, captopril oral tablet 100, 12.5, 25, 50 captopril hydrochlorothiazide oral tablet 25 15, 25 25, 50 15, enalapril maleate oral tablet 10, 2.5, 20, 5 enalapril hydrochlorothiazide oral tablet 10 25, fosinopril oral tablet 10, 20, 40 fosinopril hydrochlorothiazide oral tablet , irbesartan oral tablet 150, 300, 75 irbesartan hydrochlorothiazide oral tablet , lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 lisinopril hydrochlorothiazide oral tablet , , losartan oral tablet 100, 25, 50 losartan hydrochlorothiazide oral tablet , , moexipril oral tablet 15,

44 moexipril hydrochlorothiazide oral tablet , 15 25, perindopril erbumine oral tablet 2, 4, 8 quinapril oral tablet 10, 20, 40, 5 quinapril hydrochlorothiazide oral tablet , , ramipril oral capsule 1.25, 10, 2.5, 5 trandolapril oral tablet 1, 2, 4 valsartan oral tablet 160, 320, 40, 80 valsartan hydrochlorothiazide oral tablet , , , , Blood Pressure, Beta Blockers atenolol oral tablet 100, 25, 50 atenolol chlorthalidone oral tablet , bisoprolol fumarate oral tablet 10, 5 bisoprolol hydrochlorothiazide oral tablet , , carvedilol oral tablet 12.5, 25, 3.125, 6.25 COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG, 80 MG ST labetalol oral tablet 100, 200, 300 metoprolol succinate oral tablet extended release 24 hr 100, 200, 25, 50 metoprolol ta hydrochlorothiaz oral tablet , , metoprolol tartrate oral tablet 100, 25, 50 nadolol oral tablet 20, 40, 80 propranolol oral capsule,extended release 24 hr 120, 160, 60, 80 propranolol oral solution 20 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 10, 20, 40, 60, 80 41