2019 Abridged Formulary. (Partial List of Covered Drugs)

Transcription

1 FirstMedicare Direct HMO preferred Plus 209 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN This abridged formulary was updated on 2/28/209. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact FirstMedicare Direct Member Services at or, for TTY users, 7, 24 hours a day/ 7 days a week, or visit This Formulary may change at any time. You will receive notice when necessary. FirstCarolinaCare Insurance Company is a HMO and PPO health plan with a Medicare contract. Enrollment in a FirstMedicare Direct plan depends on contract renewal. FirstCarolinaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means FirstCarolinaCare Insurance Company. When it refers to plan or our plan, it means FirstMedicare Direct. This document includes a partial list of the drugs (formulary) for our plan which is current as of 03/0/209. For a complete, 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, 209, and from time to time during the year. Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

3 What is the FirstMedicare Direct Abridged Formulary? A formulary is a list of covered drugs selected by FirstMedicare Direct 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. FirstMedicare Direct will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a FirstMedicare Direct network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a partial formulary and includes only some of the drugs covered by FirstMedicare Direct. For a complete listing of all prescription drugs covered by FirstMedicare Direct, please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 209 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 209 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 costsharing 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: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the FirstMedicare Direct s Formulary? ] 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 make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, 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. Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

4 The enclosed formulary is current as of 03/0/209. To get updated information about the drugs covered by FirstMedicare Direct, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 3. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page number. 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-. 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? FirstMedicare Direct 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: FirstMedicare Direct requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from FirstMedicare Direct before you fill your prescriptions. If you don t get approval, FirstMedicare Direct may not cover the drug. Quantity Limits: For certain drugs, FirstMedicare Direct limits the amount of the drug that FirstMedicare Direct will cover. For example, FirstMedicare Direct provides 30 tablets per prescription for pioglitazone. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, FirstMedicare Direct 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, FirstMedicare Direct may not cover Drug B unless you try Drug A first. If Drug A does not work for you, FirstMedicare Direct 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 documents that explain our prior authorization restrictions and Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

5 step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask FirstMedicare Direct 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 FirstMedicare Direct s formulary? on page 5 for information about how to request an exception. 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. This document includes only a partial list of covered drugs, so FirstMedicare Direct may cover your drug. For more information, 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 learn that FirstMedicare Direct does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by FirstMedicare Direct. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by FirstMedicare Direct. You can ask FirstMedicare Direct to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the FirstMedicare Direct s Formulary? You can ask FirstMedicare Direct 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 waive coverage restrictions or limits on your drug. For example, for certain drugs, FirstMedicare Direct 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, FirstMedicare Direct 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. Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

6 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 30-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30 day supply of medication. After your first 30-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 3-day emergency supply of that drug while you pursue a formulary exception. Transition medications will be provided to members who change treatment settings due to changes in level of care (e.g. individuals who enter long term care facilities from hospitals or enter an ambulatory setting from a hospital). For more information For more detailed information about your FirstMedicare Direct prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about FirstMedicare Direct, 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 FirstMedicare Direct s Formulary The abridged formulary that begins on the next page provides coverage information about some of the drugs covered by FirstMedicare Direct. If you have trouble finding your drug in the list, turn to the Index that begins on page I-. Remember: This is only a partial list of drugs covered by FirstMedicare Direct. If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., simvastatin). Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

7 The information in the Requirements/Limits column tells you if FirstMedicare Direct has any special requirements for coverage of your drug. The following abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION GENERAL generic(brand) UTILIZATION MANAGEMENT RESTRICTIONS AGE NDS PA PA B v D PA HRM PA NSO QL ST Restriction for members over 64 years of age Non-Extended Days Supply Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medication Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction The reference brand name in parentheses is provided for information only, to assist in identifying the generic medication and does NOT indicate formulary status or coverage A clinical review may be required for members 65 years of age and older. Without prior approval, FirstMedicare Direct may not cover this drug. This drug is not available for an extended day supply (example: 90 days supply) You (or your physician) are required to get prior authorization from FirstMedicare Direct before you fill your prescription for this drug. Without prior approval, FirstMedicare Direct 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 FirstMedicare Direct to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, FirstMedicare Direct 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 and older. Members age 65 years and older are required to get prior authorization from FirstMedicare Direct before you fill your prescription for this drug. Without prior approval, FirstMedicare Direct may not cover this drug. If you are a new member, you (or your physician) are required to get prior authorization from FirstMedicare Direct before you fill your prescription for this drug. Without prior approval, FirstMedicare Direct may not cover this drug. FirstMedicare Direct limits the amount of this drug that is covered per prescription, or within a specific time frame. Before FirstMedicare Direct will provide coverage for this drug, you must first try another drug(s) to treat your Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

8 ABBREVIATION DESCRIPTION EXPLANATION medical condition. This drug may only be covered if the other drug(s) does not work for you. OTHER SPECIAL REQUIREMENTS FOR COVERAGE GC LA Gap Coverage Limited Access Drug We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , 24 hours a day/7 days a week. TTY/TDD users should call 7. STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 2h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 2h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt DESCRIPTION adhesive patch aerosol, breath activated aerosol, powder aerosol powder, breath activated aerosol refill aerosol with adapter ampule bulk bag injection capsule, delayed release multiphasic capsule, dose pack capsule, 2 hour extended release capsule, 24 hour extended release capsule, extended release degradable capsule, extended release pellets capsule, multiphasic capsule, 24 hour sustained action capsule, 2 hour sustained release capsule, 24 hour sustained release capsule, 24 hour controlled-onset pellets capsule, 24 hour sustained release pellets capsule, sprinkle capsule sustained release pellets capsule with device capsule, delayed release capsule, extended release capsule, sustained action combination: capsule, pad combination: ointment, foam combination: ointment, lotion Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

9 ABBREVIATION DESCRIPTION cmb tabpad combination: tablet, pad combo. pkg combination package cpmp 2hr capsule, 2 hour multiphasic cpmp 24hr capsule, 24 hour multiphasic cpmp capsule, multiphasic, 30%-70% cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package dehp fr bg di(2-ethylhexyl)phthalate free bag dis needle disposable needle disk w/dev disk with inhalation device disp syrin disposable syringe drops susp drops, suspension drps hpvis drops, hyperviscous emul adhes emulsion adhesive emul packt emulsion packet emulsn(g) emulsion (grams) foam/appl. foam with applicator froz.piggy frozen piggyback G gram gel/pf app gel with prefilled applicator gel (gm) gel (grams) gel (ml) gel (milliliters) gel md pmp gel in metered dose pump gel w/appl gel with applicator gel w/pump gel with pump gran pack granule pack hfa aer ad hfa aerosol adapter infus. btl infusion bottle insuln pen insulin pen ip soln intraperitoneal solution irrig soln irrigating solution iv soln. intravenous solution Jel jelly jelly/app jelly with applicator jel/pf app jelly with pre-filled applicator kit cl&crm kit: cleanser and cream kt crm le kit: cream, lotion emollient kt lotn ce kit: lotion, cream emollient kt oint le kit: ointment, lotion emollient lotion, er lotion, extended release lozenge hd lozenge handle m.ht patch medicated heated patch Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

10 ABBREVIATION ma buc tab Mcg med. pad med. swab med. tape Mg Ml muc er 2h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 2h DESCRIPTION mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, 2 hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 24 hour transdermal patch, 72 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal suppository suspension, 24 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, 2 hour extended release Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

11 ABBREVIATION tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 2h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 2hr tbmp 24hr U vag ring DESCRIPTION tablet, 24 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 24 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 2 hour sustained release tablet, 24 hour sustained release tablet, 24 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack tablet, 3-month dose pack tablet, 2 hour multiphasic tablet, 24 hour multiphasic unit vaginal ring Formulary ID: 90, Version Number: Effective: 03/0/209 H6306_9850_C

12 Discrimination is Against the Law FirstCarolinaCare Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. FirstCarolinaCare Insurance Company does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. FirstCarolinaCare Insurance Company provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters 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: Qualified interpreters Information written in other languages. If you need these services, contact the Civil Rights Coordinator for FirstCarolinaCare Insurance Company. If you believe that FirstCarolinaCare Insurance Company has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: FCC Civil Rights Coordinator FirstCarolinaCare Insurance Company 42 Memorial Drive Pinehurst, NC Telephone: Fax number: fccfmd@firstcarolinacare.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the FCC 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, HHS Building, Washington, DC 2020, , (TDD). Complaint forms are available at Y0094_9027_C

13 MULTI-LANGUAGE INTERPRETER SERVICES Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY 7). 繁體中文 (Chinese) 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 7) Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY 7). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY 7) 번으로전화해주십시오. Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS 7). (Arabic) العر ية ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم -<< (رقم ھاتف الصم والبكم: 7 -TTY Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY 7). Y0094_9027_C

14 Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 7). Tagalog (Tagalog Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY 7). જર ત (Gujarati) ચન : જ તમ જર ત બ લત હ, ત ન: લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY 7). ខ រ (Cambodian) របយ ត ប ស នជ អ កន យ យ ភ ស ខ រ, សវ ជ ន យ ផ កភ ស ដ យម នគ តឈ ល គ ឣ ចម នស រ ប ប រ អ ក ច រ ទ រស ព (TTY 7) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY 7). ह द (Hindi) ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY 7) पर क ल कर ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບລການຊ ວຍເຫ ອ ດ ານພາສາ, ໂດຍບ ເ ສ ຽ ຄ າ, ແ ມ ນ ມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY 7). 日本語 (Japanese) 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:7) まで お電話にてご連絡ください Y0094_9027_C

15 Table of Contents Analgesics...3 Anesthetics... 4 Anti-Addiction/Substance Abuse Treatment Agents...5 Antianxiety Agents...5 Antibacterials... 5 Anticancer Agents... 8 Anticholinergic Agents... 0 Anticonvulsants...0 Antidementia Agents... Antidepressants... Antidiabetic Agents... 2 Antifungals...4 Antigout Agents... 4 Antihistamines...4 Anti-Infectives (Skin And Mucous Membrane)...5 Antimigraine Agents...5 Antimycobacterials...5 Antinausea Agents...5 Antiparasite Agents...6 Antiparkinsonian Agents...6 Antipsychotic Agents...6 Antivirals (Systemic)...7 Blood Products/Modifiers/Volume Expanders Caloric Agents...2 Cardiovascular Agents... 2 Central Nervous System Agents Contraceptives...26 Dental And Oral Agents...29 Dermatological Agents...29 Devices... 3 Enzyme Replacement/Modifiers...3 Eye, Ear, Nose, Throat Agents...32 Gastrointestinal Agents Genitourinary Agents...34 Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying... 34

16 Immunological Agents...38 Inflammatory Bowel Disease Agents...4 Irrigating Solutions...4 Metabolic Bone Disease Agents... 4 Miscellaneous Therapeutic Agents... 4 Ophthalmic Agents...42 Replacement Preparations...42 Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents...45 Vitamins And Minerals

17 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 20- QL (2700 per 30 2 /5 ml acetaminophen-codeine oral tablet QL (360 per 30 acetaminophen-codeine oral tablet (Tylenol-Codeine #3) QL (360 per 30 acetaminophen-codeine oral tablet (Tylenol-Codeine #4) QL (80 per 30 endocet oral tablet QL (80 per 30 endocet oral tablet QL (360 per 30 endocet oral tablet QL (240 per 30 hydrocodone-acetaminophen oral solution /5 ml QL (2700 per 30 hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (80 per hydrocodone-acetaminophen oral tablet (Verdrocet) QL (240 per hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) QL (240 per hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (80 per lorcet (hydrocodone) oral tablet QL (240 per 30 lorcet hd oral tablet QL (80 per 30 lorcet plus oral tablet QL (80 per 30 oxycodone oral solution 5 /5 ml QL (300 per 30 oxycodone oral tablet 0 QL (80 per 30 oxycodone oral tablet 5, 30 (Roxicodone) QL (20 per 30 oxycodone oral tablet 20 QL (20 per 30 oxycodone oral tablet 5 (Roxicodone) QL (80 per 30 oxycodone oral tablet,oral only,ext.rel.2 (OxyContin) QL (60 per 30 hr 0, 5, 20, 30, 40, 60, 80 oxycodone-acetaminophen oral tablet 0- (Endocet) QL (80 per oxycodone-acetaminophen oral tablet , (Endocet) QL (360 per 30 3

18 oxycodone-acetaminophen oral tablet (Endocet) QL (240 per OXYCONTIN ORAL QL (60 per 30 TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG tramadol oral tablet 50 (Ultram) QL (240 per 30 Nonsteroidal Anti-Inflammatory Agents diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 diclofenac sodium topical drops.5 % QL (300 per 30 diclofenac sodium topical gel 3 % (Solaraze) PA; QL (00 per 28 ibu oral tablet 600, 800 ibuprofen oral suspension 00 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, (IBU) 800 meloxicam oral tablet 5, 7.5 (Mobic) naproxen oral tablet 250, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 500 PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 PA; QL (224 per 28 MG/GRAM /ACTUATION(2 %) VOLTAREN TOPICAL GEL % Anesthetics Local Anesthetics lidocaine hcl mucous membrane jelly 2 % QL (30 per 30 lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 30 lidocaine topical ointment 5 % PA; QL (90 per 30 lidocaine viscous mucous membrane solution 2 % 4

19 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents buprenorphine hcl sublingual tablet 2, QL (90 per 30 8 buprenorphine-naloxone sublingual tablet QL (90 per , 8-2 CHANTIX CONTINUING MONTH QL (336 per 365 BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, QL (336 per 365 MG CHANTIX STARTING MONTH QL (06 per 365 BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) SUBOXONE SUBLINGUAL FILM QL (60 per MG, 8-2 MG SUBOXONE SUBLINGUAL FILM 2- QL (30 per MG, 4- MG ZUBSOLV SUBLINGUAL TABLET QL (30 per MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET QL (60 per MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5, (Xanax) QL (20 per 30 alprazolam oral tablet 2 (Xanax) QL (50 per 30 clonazepam oral tablet 0.5, (Klonopin) QL (90 per 30 clonazepam oral tablet 2 (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating QL (90 per , 0.25, 0.5, clonazepam oral tablet,disintegrating 2 QL (300 per 30 lorazepam oral tablet 0.5, (Ativan) QL (90 per 30 lorazepam oral tablet 2 (Ativan) QL (50 per 30 Antibacterials Aminoglycosides neomycin oral tablet 500 5

20 tobramycin in % nacl inhalation (Tobi) PA BvD solution for nebulization 300 /5 ml Antibacterials, Miscellaneous clindamycin hcl oral capsule 50, 300, 75 (Cleocin HCl) metronidazole oral tablet 250, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin) QL (20 per 30 00, 25, 50 nitrofurantoin monohyd/m-cryst oral (Macrobid) QL (60 per 30 capsule 00 Cephalosporins cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefprozil oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 cefuroxime axetil oral tablet 250, 500 cephalexin oral capsule 250, 500 (Keflex) cephalexin oral suspension for reconstitution 25 /5 ml, 250 /5 ml Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250 (6 pack), 500 (3 pack), 600 azithromycin oral tablet 250, 500 (Zithromax) clarithromycin oral suspension for reconstitution 25 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION LA SOLUTION FOR NEBULIZATION 75 MG/ML ertapenem injection recon soln gram (Invanz) 6

21 INVANZ INJECTION RECON SOLN GRAM Penicillins amoxicillin oral capsule 250, 500 amoxicillin oral suspension for reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 25, 250 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet,chewable , dicloxacillin oral capsule 250, 500 penicillin v potassium oral recon soln 25 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 Quinolones ciprofloxacin hcl oral tablet 250, 500 (Cipro) ciprofloxacin hcl oral tablet 750 levofloxacin intravenous solution 25 /ml levofloxacin oral solution 250 /0 ml levofloxacin oral tablet 250 levofloxacin oral tablet 500, 750 (Levaquin) ofloxacin oral tablet 300, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) 7

22 sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 20 minocycline oral capsule 00, 75 minocycline oral capsule 50 (Minocin) Anticancer Agents Anticancer Agents AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 PA NSO; QL (2 per 28 MG, 5 MG AFINITOR ORAL TABLET 0 MG PA NSO; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG PA NSO; QL (28 per 28 anastrozole oral tablet (Arimidex) bicalutamide oral tablet 50 (Casodex) DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) exemestane oral tablet 25 (Aromasin) hydroxyurea oral capsule 500 (Hydrea) JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG PA NSO; QL (60 per 30 letrozole oral tablet 2.5 (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit /0.2 ml 8

23 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.25 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 megestrol oral tablet 20, 40 mercaptopurine oral tablet 50 methotrexate sodium injection solution 25 PA BvD /ml methotrexate sodium oral tablet 2.5 PA BvD; ST NEXAVAR ORAL TABLET 200 MG PA NSO; QL (20 per 30 POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG PA NSO; QL (2 per 28 PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG SOLTAMOX ORAL SOLUTION 0 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 50 MG, 70 MG, 80 MG PA NSO; LA; QL (28 per 28 PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG PA NSO; QL (90 per 30 SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG PA NSO; QL (30 per 30 tamoxifen oral tablet 0, 20 TARCEVA ORAL TABLET 00 MG, 25 MG PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 50 MG PA NSO; QL (90 per 30 TASIGNA ORAL CAPSULE 50 MG, 200 MG PA NSO; QL (2 per 28 9

24 TASIGNA ORAL CAPSULE 50 MG PA NSO; QL (20 per 30 VOTRIENT ORAL TABLET 200 MG PA NSO; QL (20 per 30 XTANDI ORAL CAPSULE 40 MG PA NSO; QL (20 per 30 ZYTIGA ORAL TABLET 250 MG, 500 MG Anticholinergic Agents Antimuscarinics/Antispasmodics propantheline oral tablet 5 Anticonvulsants Anticonvulsants carbamazepine oral capsule, er (Carbatrol) multiphase 2 hr 00, 200, 300 carbamazepine oral suspension 00 /5 (Tegretol) ml carbamazepine oral tablet 200 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 2 hr 00, 200, 400 carbamazepine oral tablet,chewable 00 divalproex oral capsule, delayed rel sprinkle 25 (Depakote Sprinkles) divalproex oral tablet extended release 24 (Depakote ER) hr 250, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 25, 250, 500 epitol oral tablet 200 gabapentin oral capsule 00, 300, (Neurontin) 400 gabapentin oral solution 250 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) lamotrigine oral tablet 00, 50, (Lamictal) 200, 25 lamotrigine oral tablet, chewable (Lamictal) dispersible 25, 5 levetiracetam oral solution 00 /ml (Keppra) levetiracetam oral tablet,000, 250, 500, 750 (Keppra) PA NSO; QL (20 per 30 0

25 levetiracetam oral tablet extended release 24 hr 500, 750 LYRICA ORAL CAPSULE 00 MG, 50 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML ROWEEPRA ORAL TABLET,000 MG, 500 MG, 750 MG SPRITAM ORAL TABLET FOR SUSPENSION,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG topiramate oral capsule, sprinkle 5, 25 topiramate oral capsule,sprinkle,er 24hr 00, 50, 200, 25, 50 topiramate oral tablet 00, 200, 25, 50 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG Antidementia Agents Antidementia Agents (Keppra XR) (Topamax) (Qudexy XR) (Topamax) QL (90 per 30 QL (900 per 30 ST; QL (60 per 30 ST; QL (20 per 30 ST; QL (60 per 30 donepezil oral tablet 0, 5 (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating 0 QL (30 per 30, 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (30 per hr 6, 24, 8 galantamine oral solution 4 /ml QL (200 per 30 galantamine oral tablet 2, 4, 8 (Razadyne) QL (60 per 30 Antidepressants Antidepressants bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release (Wellbutrin XL) 24 hr 50, 300 bupropion hcl oral tablet sustainedrelease 2 hr 00, 50, 200 (Wellbutrin SR) citalopram oral solution 0 /5 ml QL (600 per 30

26 citalopram oral tablet 0, 20, 40 (Celexa) QL (30 per 30 escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 0, (Lexapro) 20, 5 fluoxetine oral capsule 0, 20, 40 (Prozac) fluoxetine oral solution 20 /5 ml (4 /ml) paroxetine hcl oral tablet 0, 20, (Paxil) 30, 40 PAXIL ORAL SUSPENSION 0 MG/5 ML sertraline oral concentrate 20 /ml (Zoloft) sertraline oral tablet 00, 25, 50 (Zoloft) trazodone oral tablet 00, 50, 300, 50 venlafaxine oral capsule,extended release (Effexor XR) QL (30 per 30 24hr 50 venlafaxine oral capsule,extended release (Effexor XR) QL (90 per 30 24hr 37.5, 75 venlafaxine oral tablet 00, 25, 37.5, 50, 75 Antidiabetic Agents Antidiabetic Agents, Miscellaneous JANUMET ORAL TABLET 50-,000 QL (60 per 30 MG, MG JANUMET XR ORAL TABLET, ER QL (30 per 30 MULTIPHASE 24 HR 00-,000 MG JANUMET XR ORAL TABLET, ER QL (60 per 30 MULTIPHASE 24 HR 50-,000 MG, MG JANUVIA ORAL TABLET 00 MG, QL (30 per MG, 50 MG metformin oral tablet,000 (Glucophage) QL (75 per 30 metformin oral tablet 500 (Glucophage) QL (50 per 30 metformin oral tablet 850 (Glucophage) QL (90 per 30 metformin oral tablet extended release 24 hr 500 (Glucophage XR) QL (20 per 30 2

27 metformin oral tablet extended release 24 (Glucophage XR) QL (60 per 30 hr 750 pioglitazone oral tablet 5, 30, 45 (Actos) QL (30 per 30 VICTOZA SUBCUTANEOUS PEN QL (9 per 30 INJECTOR 0.6 MG/0. ML (8 MG/3 ML) Insulins LANTUS SOLOSTAR U-00 QL (30 per 28 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS U-00 INSULIN QL (40 per 28 SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN U-00 QL (30 per 28 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML NOVOLOG MIX U-00 QL (40 per 28 INSULN SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U- QL (30 per SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG PENFILL U-00 QL (30 per 28 INSULIN SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG U-00 INSULIN QL (40 per 28 ASPART SUBCUTANEOUS SOLUTION 00 UNIT/ML TOUJEO MAX U-300 SOLOSTAR QL (8 per 28 SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U-300 QL (3.5 per 28 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (.5 ML) Sulfonylureas glimepiride oral tablet, 2 (Amaryl) QL (30 per 30 glimepiride oral tablet 4 (Amaryl) QL (60 per 30 glipizide oral tablet 0 (Glucotrol) QL (20 per 30 glipizide oral tablet 5 (Glucotrol) QL (60 per 30 3

28 glipizide oral tablet extended release 24hr (Glucotrol XL) QL (60 per 30 0 glipizide oral tablet extended release 24hr (Glucotrol XL) QL (30 per , 5 Antifungals Antifungals clotrimazole-betamethasone topical (Lotrisone) cream % fluconazole oral suspension for (Diflucan) reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 50, (Diflucan) 200, 50 ketoconazole oral tablet 200 ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % (Nizoral) nyamyc topical powder 00,000 unit/gram nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 (Nyamyc) unit/gram nystop topical powder 00,000 unit/gram terbinafine hcl oral tablet 250 Antigout Agents Antigout Agents, Other allopurinol oral tablet 00, 300 (Zyloprim) ULORIC ORAL TABLET 40 MG, 80 QL (30 per 30 MG Antihistamines Antihistamines hydroxyzine hcl oral solution 0 /5 ml hydroxyzine hcl oral tablet 0, 25, 50 levocetirizine oral solution 2.5 /5 ml (Xyzal) levocetirizine oral tablet 5 (24HR Allergy Relief) 4

29 Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 Antimigraine Agents Antimigraine Agents rizatriptan oral tablet 0 (Maxalt) QL (8 per 28 rizatriptan oral tablet 5 QL (8 per 28 rizatriptan oral tablet,disintegrating 0 (Maxalt-MLT) QL (8 per 28, 5 sumatriptan succinate oral tablet 00, (Imitrex) QL (8 per 28 25, 50 sumatriptan succinate subcutaneous (Imitrex STATdose QL (4 per 28 cartridge 4 /0.5 ml, 6 /0.5 ml Refill) sumatriptan succinate subcutaneous pen (Imitrex STATdose QL (4 per 28 injector 4 /0.5 ml, 6 /0.5 ml Pen) sumatriptan succinate subcutaneous (Imitrex) QL (4 per 28 solution 6 /0.5 ml sumatriptan succinate subcutaneous QL (4 per 28 syringe 6 /0.5 ml Antimycobacterials Antimycobacterials dapsone oral tablet 00, 25 isoniazid oral solution 50 /5 ml isoniazid oral tablet 00, 300 rifampin intravenous recon soln 600 (Rifadin) rifampin oral capsule 50, 300 (Rifadin) Antinausea Agents Antinausea Agents meclizine oral tablet 2.5 meclizine oral tablet 25 (Dramamine Less Drowsy) ondansetron oral tablet,disintegrating 4 PA BvD, 8 phenadoz rectal suppository 2.5 promethazine oral tablet 2.5, 25, 50 5

30 promethazine rectal suppository 2.5, (Phenadoz) 25 promethazine rectal suppository 50 (Phenergan) promethegan rectal suppository 25, 50 Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG atovaquone-proguanil oral tablet (Malarone) atovaquone-proguanil oral tablet (Malarone Pediatric) hydroxychloroquine oral tablet 200 (Plaquenil) mefloquine oral tablet 250 Antiparkinsonian Agents Antiparkinsonian Agents benztropine oral tablet 0.5,, 2 carbidopa-levodopa oral tablet 0-00 (Sinemet), 25-00, carbidopa-levodopa oral tablet extended (Sinemet CR) release 25-00, pramipexole oral tablet 0.25, 0.25 (Mirapex), 0.5, 0.75,,.5 ropinirole oral tablet 0.25, 0.5, (Requip), 3, 4, 5 ropinirole oral tablet 2 Antipsychotic Agents Antipsychotic Agents clozapine oral tablet 00 (Clozaril) QL (270 per 30 clozapine oral tablet 200 QL (35 per 30 clozapine oral tablet 25 (Clozaril) QL (90 per 30 clozapine oral tablet 50 QL (90 per 30 clozapine oral tablet,disintegrating 00 (FazaClo) ST; QL (90 per 30, 2.5, 25 clozapine oral tablet,disintegrating 50 (FazaClo) ST; QL (80 per 30 clozapine oral tablet,disintegrating 200 (FazaClo) ST; QL (20 per 30 6

31 haloperidol oral tablet 0.5,, 0, 2, 20, 5 LATUDA ORAL TABLET 20 MG, QL (30 per MG, 40 MG, 60 MG, 80 MG olanzapine intramuscular recon soln 0 (Zyprexa) QL (30 per 30 olanzapine oral tablet 0, 5, 2.5 (Zyprexa) QL (30 per 30, 20, 5, 7.5 olanzapine oral tablet,disintegrating 0 (Zyprexa Zydis) QL (30 per 30, 5, 20, 5 perphenazine oral tablet 6, 2, 4, 8 quetiapine oral tablet 00, 200, 25 (Seroquel) QL (90 per 30, 300, 400, 50 risperidone oral solution /ml (Risperdal) QL (480 per 30 risperidone oral tablet 0.25, 0.5, (Risperdal) QL (60 per 30, 2, 3, 4 risperidone oral tablet,disintegrating 0.25 QL (60 per 30, 0.5,, 2 risperidone oral tablet,disintegrating 3 QL (20 per 30, 4 ziprasidone hcl oral capsule 20, 40 (Geodon) QL (60 per 30, 60, 80 Antivirals (Systemic) Antiretrovirals abacavir oral solution 20 /ml (Ziagen) abacavir oral tablet 300 (Ziagen) ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) INTELENCE ORAL TABLET 00 MG, 200 MG, 25 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG 7

32 ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 25 MG KALETRA ORAL TABLET MG, MG lamivudine oral solution 0 /ml (Epivir) lamivudine oral tablet 00 (Epivir HBV) lamivudine oral tablet 50, 300 (Epivir) lamivudine-zidovudine oral tablet 50- (Combivir) 300 lopinavir-ritonavir oral solution (Kaletra) /5 ml nevirapine oral tablet 200 (Viramune) nevirapine oral tablet extended release 24 (Viramune XR) hr 00, 400 NORVIR ORAL POWDER IN PACKET 00 MG NORVIR ORAL SOLUTION 80 MG/ML PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG ritonavir oral tablet 00 (Norvir) STRIBILD ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIRAMUNE ORAL SUSPENSION 50 MG/5 ML Antivirals, Miscellaneous RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 00 (Flumadine) Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG PA; QL (28 per 28 EPCLUSA ORAL TABLET MG PA; QL (28 per 28 8

33 HARVONI ORAL TABLET MG PA; QL (30 per 30 ledipasvir-sofosbuvir oral tablet (Harvoni) PA; QL (30 per 30 MAVYRET ORAL TABLET MG PA; QL (84 per 28 sofosbuvir-velpatasvir oral tablet (Epclusa) PA; QL (28 per 28 SOVALDI ORAL TABLET 400 MG PA; QL (28 per 28 TECHNIVIE ORAL TABLET MG PA; QL (56 per 28 VIEKIRA PAK ORAL TABLETS,DOSE PACK 2.5 MG-75 MG -50 MG/250 MG PA; QL (2 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 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML Nucleosides And Nucleotides acyclovir oral capsule 200 (Zovirax) acyclovir oral suspension 200 /5 ml (Zovirax) acyclovir oral tablet 400, 800 (Zovirax) PA; QL (84 per 28 PA; QL (28 per 28 PA; QL (30 per 30 PA NSO PA NSO 9

34 valacyclovir oral tablet gram, 500 (Valtrex) Blood Products/Modifiers/Volume Expanders Anticoagulants jantoven oral tablet, 0, 2, 2.5, 3, 4, 5, 6, 7.5 warfarin oral tablet, 0, 2, (Coumadin) 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 0 MG, 5 MG, 2.5 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (42)- 20 MG (9) Blood Formation Modifiers EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 2.5 MG PA; QL (2 per 28 PA PA PA; QL (2 per 28 PA; QL (6 per 28 PA; QL (30 per 30 PROMACTA ORAL TABLET 25 MG PA; QL (20 per 30 PROMACTA ORAL TABLET 50 MG PA; QL (90 per 30 PROMACTA ORAL TABLET 75 MG PA; QL (60 per 30 Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 (Agrylin) anagrelide oral capsule 20

35 tranexamic acid oral tablet 650 (Lysteda) QL (30 per 30 Platelet-Aggregation Inhibitors cilostazol oral tablet 00, 50 clopidogrel oral tablet 75 (Plavix) Caloric Agents Caloric Agents CLINIMIX 5%-D20W(SULFITE- PA BvD FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 4.25%/D25W SUL PA BvD FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D5W SULFIT PA BvD FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT PA BvD FREE INTRAVENOUS PARENTERAL SOLUTION 5 % dextrose 5 % in water (d5w) intravenous parenteral solution INTRALIPID INTRAVENOUS PA BvD EMULSION 20 %, 30 % NUTRILIPID INTRAVENOUS PA BvD EMULSION 20 % PROSOL 20 % INTRAVENOUS PA BvD PARENTERAL SOLUTION TRAVASOL 0 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 0 % TROPHAMINE 0 % PA BvD INTRAVENOUS PARENTERAL SOLUTION 0 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0., 0.2, (Catapres) 0.3 doxazosin oral tablet, 2, 4, 8 (Cardura) Angiotensin Ii Receptor Antagonists losartan oral tablet 00, 25, 50 (Cozaar) 2