2019 Formulary/Formulario (List of Covered Drugs)/(Lista de medicamentos cubiertos)

Transcription

1 019 Formulary/Formulario (List of Covered Drugs)/(Lista de medicamentos cubiertos) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN LEA: ESTE DOCUMENTO TIENE INFORMACIÓN SOBRELOS MEDICAMENTOS CUBIERTOS EN ESTE PLAN LiveWe (HMO) PlanWe ll (HMO) Imagine your life with AgeWell New York The Way to Age Well in New York HPMS Approved Formulary File Submission ID: 19518, Version Number: 6 This formulary was updated on 0/019. For more recent information or other questions, please contact our Pharmacy Benefit Manager, EnvisionRx for AgeWell New York Member Services at or, for TTY users, , 7 days a week hours a day, or visit H9_HMOFormulary1085_C NM ll

2 019 Part D Formulary (Comprehensive) 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 AgeWell New York. When it refers to plan or our plan, it means LiveWell (HMO) or PlanWell (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 0/019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 00, and from time to time during the year. What is the LiveWell (HMO) or PlanWell (HMO) Formulary? A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at our plan s network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: 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. i

3 019 Part D Formulary (Comprehensive) 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 plan 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 add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier.). Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. The enclosed formulary is current as of 0/019. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. In the event that the plan makes a mid-year non-maintenance formulary change, we will mail you updated information at least 60 days prior to the date the change becomes effective. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, cardiovascular agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. 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 88. 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. ii

4 019 Part D Formulary (Comprehensive) What are generic drugs? Our plan 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: Our plan requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, the plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that the plan will cover. For example, our plan provides 9 tablets per prescription for Sumatriptan Succinate 100 mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan 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, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan 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 1. 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 and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan 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 plan s formulary? on page iv 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. iii

5 019 Part D Formulary (Comprehensive) If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan. You can ask the plan 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 LiveWell (HMO) or PlanWell (HMO) Formulary? You can ask the plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the plan 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, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, [the lower cost-sharing drug] or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tier exception or utilization restriction exception. When you request a formulary tier exception or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. iv

6 019 Part D Formulary (Comprehensive) 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 31-day emergency supply of that drug while you pursue a formulary exception. Existing Member with Level of Care Changes If you are outside your transition period and experience a level of care change in which you are changing from one treatment setting to another (example: Long Term Care to hospital, hospital to home, home to Long Term Care), upon admission or discharge from a treatment setting or Long Term Care, we will allow you access to a 30/31 day refill (30 days in the retail setting and 31 days in the Long Term Care setting) for formulary medications and an emergency 30/31 day refill (30 days in the retail setting and 31 days in the Long Term Care setting) for non-formulary medications (including Part D drugs that are on our formulary but require prior authorization or step therapy). This policy does not apply for short-term leaves of absences (i.e. holidays or vacations) from Long Term Care or hospital facilities. To the extent that you are outside your 90-day transition period and are in an outpatient setting, we will still provide an emergency 30 day supply of non-formulary medications (including Part D drugs that are on our formulary that would otherwise require prior authorization or step therapy under our utilization management rules), on a case by case basis, while an exception request is being processed. To the extent that you are outside your 90-day transition period and are in a Long Term Care setting, we will still provide an emergency 31 day supply of Part D covered non-formulary medications (including Part D covered drugs that are on our formulary that would otherwise require prior authorization or step therapy under our utilization management rules), while an exception request is being processed. For more information For more detailed information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. v

7 019 Part D Formulary (Comprehensive) If you have questions about our plan, 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 ( ) hours a day/7 days a week. TTY users should call Or, visit LiveWell (HMO) or PlanWell (HMO) Formulary The formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 88. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., NAMENDA XR) and generic drugs are listed in lower-case italics (e.g., memantine). The information in the Requirements/Limits column tells you if the plan has any special requirements for coverage of your drug. vi

8 019 Part D Formulary (Comprehensive) LEGEND Symbol Name QL PA ST Quantity Limit Prior Authorization Step Therapy Description There is a limit on the amount of this drug that is covered per prescription or within a specific time frame. You (or your physician) are required to obtain a prior authorization before you fill your prescription for this drug. Without a prior authorization, we may not cover this drug. In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. GC Gap Coverage We provide additional coverage of this prescription drug in the coverage gap MO Mail Order This prescription may also be available via mail. LA Limited Access This prescription drug is limited to certain pharmacies. HRM High Risk Medications The Centers for Medicare and Medicaid Services (CMS) has identified the drug listed as posing a higher risk to patients, especially to seniors (PA required for ages 65 or over) BD Part B vs. Part D This prescription drug may be covered under Medicare Part B or Part D depending on the circumstances. Tier Name 1 Preferred Generic drugs This is the lowest cost-sharing tier. Generic drugs 3 Preferred Brand name drugs Non-preferred drugs 5 Specialty Drugs This is the highest cost-sharing tier. vii

9 Formulario de la Parte D 018 (Integral) Nota para los miembros actuales: Este formulario ha cambiado con respecto al año pasado. Revise este documento para asegurarse de que aún contiene los medicamentos que toma. Cuando esta lista de medicamentos (formulario) dice nosotros, nos o nuestro/a, hace referencia a AgeWell New York. Cuando dice plan o nuestro plan, hace referencia a LiveWell (HMO) o PlanWell (HMO). Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la cual estará en vigencia a partir del 0/019. Para obtener un formulario actualizado, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario aparece en las páginas de la portada y la portada posterior. Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de medicamentos con receta. Los beneficios, el Formulario, la red de farmacias o los copagos/el coseguro pueden cambiar el 1 de enero de 00 y periódicamente durante el año. Qué es el formulario LiveWell (HMO) o PlanWell (HMO)? Un Formulario es una lista de medicamentos cubiertos seleccionados por nuestro plan con la colaboración de un equipo de proveedores de atención médica, que representa los tratamientos con receta que se considera que son parte necesaria de un programa de tratamiento de calidad. Normalmente, nuestro plan cubrirá los medicamentos incluidos en el Formulario siempre que el medicamento sea médicamente necesario, el medicamento con receta se obtenga en una farmacia de la red del plan y se cumpla con otras normas del plan. Para obtener más información sobre cómo obtener sus medicamentos con receta, consulte la Evidencia de cobertura. Puede cambiar el Formulario (lista de medicamentos)? En general, si usted toma un medicamento de nuestro Formulario para 019 que estaba cubierto al comienzo del año, nosotros no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 019, excepto cuando esté disponible un nuevo medicamento genérico de menor costo, cuando se dé a conocer nueva información acerca de la seguridad o eficacia del medicamento o se retire el medicamento del mercado. (Para obtener más información sobre los cambios que afectan a los miembros que actualmente toman el medicamento, consulte las viñetas a continuación). Otros tipos de cambios en el Formulario, por ejemplo, la eliminación de un medicamento, no afectarán a los miembros que estén actualmente tomando el medicamento. Por el resto del año de cobertura, continuará disponible al mismo costo compartido para aquellos miembros que estén tomándolo. A continuación, verá los cambios a la lista de medicamentos que también afectarán a los miembros que actualmente toman un medicamento: Medicamentos genéricos nuevos. Eliminaremos el medicamento de marca de la Lista de medicamentos de inmediato si lo reemplazaremos con un medicamento genérico nuevo que aparecerá en el mismo nivel de costo compartido o en uno inferior y con las mismas restricciones o menos restricciones. Además, cuando agreguemos un medicamento genérico nuevo, podemos decidir conservar el medicamento de marca en la Lista de medicamentos, pero lo pasaremos de inmediato a un nivel de costo compartido diferente o agregaremos restricciones nuevas. Si actualmente toma un medicamento de marca, podríamos no informarle antes de realizar el cambio, pero posteriormente le proporcionaremos información sobre los cambios específicos que realizamos. viii

10 Formulario de la Parte D 018 (Integral) o Si introducimos un cambio, usted o la persona autorizada a dar recetas pueden solicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de marca. El aviso que le enviemos también incluirá información sobre los pasos que puede dar para solicitar una excepción y usted puede encontrar información en la siguiente sección titulada Cómo puedo solicitar una excepción al formulario del plan?. Medicamentos retirados del mercado. Si la Administración de Drogas y Alimentos (Food and Drug Administration, FDA) considera que un medicamento de nuestro Formulario es inseguro o el fabricante del medicamento lo retira del mercado, eliminaremos de inmediato dicho medicamento de nuestro Formulario y notificaremos a los miembros que toman el medicamento en cuestión. Otros cambios. Podríamos introducir otros cambios que afecten a los miembros que actualmente toman un medicamento. Por ejemplo, podemos agregar un medicamento genérico que no sea nuevo en el mercado para reemplazar un medicamento de marca que actualmente esté en el Formulario o agregar restricciones nuevas al medicamento de marca o pasarlo a un nivel de costo compartido diferente. O bien, podríamos introducir cambios a partir de pautas clínicas nuevas. Si retiramos medicamentos de nuestro Formulario, [o] agregamos autorizaciones previas, límites de cantidad o restricciones en tratamientos escalonados en relación con un medicamento, o si pasamos un medicamento a un nivel superior de costo compartido, debemos notificar sobre el cambio a los miembros afectados del cambio al menos 30 días antes de que entre en vigencia dicho cambio, o cuando el miembro solicite una reposición del medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 30 días. El Formulario adjunto está vigente a partir del 0/019. Para recibir información actualizada sobre los medicamentos cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de la portada y la portada posterior. En el caso de que el plan realice a mitad de año un cambio en el formulario no relacionado con su mantenimiento, le enviaremos por correo su información actualizada al menos 60 días antes de que entre en vigencia dicho cambio. Cómo utilizo el Formulario? Hay dos formas para encontrar su medicamento dentro del Formulario: Afección médica El Formulario empieza en la página 1. Los medicamentos de este Formulario están agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para tratar una enfermedad cardíaca se enumeran dentro de la categoría agentes cardiovasculares. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que empieza en la página 1. Luego busque su medicamento debajo del nombre de la categoría. ix

11 Formulario de la Parte D 018 (Integral) Listado alfabético Si no está seguro de qué categoría consultar, debe buscar su medicamento en el Índice que comienza en la página 88. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. En el Índice, están tanto los medicamentos de marca como los genéricos. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información acerca de la cobertura. Vaya a la página que figura en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Nuestro plan cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la FDA dado que se considera que tiene el mismo ingrediente activo que el medicamento de marca. Normalmente, los medicamentos genéricos cuestan menos que los de marca. Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y límites pueden incluir: Autorización previa: Nuestro plan exige que usted [o su médico] obtengan una autorización previa para determinados medicamentos. Esto significa que necesitará contar con la aprobación de nuestro plan antes de obtener sus medicamentos con receta. Si no consigue la autorización, es posible que el plan no cubra el medicamento. Límites de cantidad: Para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubrirá. Por ejemplo: nuestro plan provee 9 comprimidos de Sumatriptan Succinate 100 mg por receta. Esto puede ser complementario a un suministro estándar para uno o tres meses. Tratamiento escalonado: en algunos casos, nuestro plan requiere que usted primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa enfermedad. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que el plan no cubra el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona para usted, entonces el plan cubrirá el medicamento B. Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el Formulario que empieza en la página 1. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado documentos en Internet que explican nuestra autorización previa y las restricciones de tratamientos escalonados. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del formulario aparece en las páginas de la portada y la portada posterior. x

12 Formulario de la Parte D 018 (Integral) Puede pedirle a nuestro plan que haga una excepción a estas restricciones o límites o puede solicitarle una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección Cómo solicito una excepción al formulario del plan? en la página IV para obtener información acerca de cómo solicitar una excepción. Qué pasa si mi medicamento no está en el Formulario? Si el medicamento que toma no está incluido en este Formulario (lista de medicamentos cubiertos), primero debe ponerse en contacto con el Departamento de Servicios para los miembros y preguntar si su medicamento está cubierto. Si resulta que nuestro plan no cubre el medicamento que toma, tiene dos alternativas: Puede pedir al Departamento de Servicios para los miembros una lista de medicamentos similares que estén cubiertos por nuestro plan. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por el plan. Puede solicitarle al plan que haga una excepción y cubra el medicamento. Consulte más abajo para obtener información sobre cómo solicitar una excepción. Cómo solicito una excepción al formulario de LiveWell (HMO) o PlanWell (HMO)? Puede solicitarle al plan que haga una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos. Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro Formulario. Si se aprueba, este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido menor. Puede pedirnos que cubramos un medicamento del formulario a un nivel de costo compartido menor si este medicamento no está incluido en el nivel de medicamentos especializados. Si se aprueba, esto reduciría el monto que usted debe pagar por su medicamento. Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Por ejemplo, para ciertos medicamentos, el plan limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción al límite y cubramos una cantidad mayor. xi

13 Formulario de la Parte D 018 (Integral) Por lo general, nuestro plan solo aprobará su pedido de excepción si los demás medicamentos incluidos en el Formulario del plan, [el medicamento de menor costo compartido] o las restricciones de uso adicionales no fueran tan efectivos para tratar su enfermedad o pudieran causarle efectos médicos adversos. Debe ponerse en contacto con nosotros para solicitarnos una decisión inicial de cobertura respecto de una excepción al Formulario, al nivel o a la restricción de uso. Cuando solicita una excepción al nivel del Formulario o a la restricción de uso, debe presentar una declaración de su médico o de la persona autorizada a dar recetas que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 7 horas a partir de la fecha de haber recibido la declaración que respalda su solicitud por parte de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que esperar 7 horas para la toma de la decisión podría perjudicar gravemente su salud. Si se le concede el trámite acelerado de la excepción, debemos comunicarle nuestra decisión a más tardar dentro de las horas después de haber recibido la declaración de respaldo de su médico o de otra persona autorizada a dar recetas. Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos que tomo o la solicitud de una excepción? Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no están incluidos en el Formulario. También es posible que esté tomando un medicamento incluido en el Formulario, pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización previa antes de poder obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al formulario para que le cubramos el medicamento que toma. Mientras evalúa con su médico el procedimiento adecuado para seguir en su caso, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en que usted sea miembro de nuestro plan. Para cada uno de los medicamentos que no está incluido en el Formulario, o si su capacidad para conseguir los medicamentos es limitada, cubriremos un suministro temporal para 30 días. Si su receta está indicada para menos días, permitiremos obtener resurtidos de los medicamentos hasta llegar a un suministro máximo del medicamento para 30 días. Después del primer suministro para 30 días, no seguiremos pagando estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días. Si reside en un centro de atención a largo plazo y necesita un medicamento que no está en el Formulario o si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia del medicamento para 31 días mientras solicita la excepción al formulario. Miembro actual de un plan con cambios en el nivel de atención Si se encuentra fuera de su período de transición y experimenta cambios en el nivel de atención en el que pasaron de un entorno de tratamiento a otro (por ejemplo: de un centro de atención a largo plazo (Long Term Care, LTC) a un hospital, de un hospital a su casa, de su casa a un centro de LTC, al momento en que se lo admita o se le dé el alta en el entorno de tratamiento o centro de LTC, les xii

14 Formulario de la Parte D 018 (Integral) permitiremos acceder a un resurtido para 30/31 días (30 días en el entorno minorista, y 31 días en el entorno de LTC) de medicamentos del formulario y a un resurtido de emergencia para 30/31 días (30 días en el entorno minorista, y 31 días en el entorno de LTC) de medicamentos que no se encuentran en el formulario (como medicamentos de la Parte D que se encuentren en el formulario del patrocinador del plan pero que requieren autorización previa o tratamiento escalonado). Esta política no se aplica a licencias a corto plazo (como feriados y vacaciones) del centro de atención a largo plazo (LTC) o centro hospitalario. En la medida en que usted se encuentre fuera del período de transición de 90 días, y que se encuentre en un entorno para pacientes externos, le ofreceremos un suministro de emergencia para 30 días de medicamentos que no están en el formulario (como medicamentos de la Parte D que se encuentren en nuestro formulario y que de otro modo requerirían autorización previa o tratamiento escalonado en virtud de nuestras normas de manejo de la utilización de medicamentos), revisando caso por caso mientras se aguarda que se procese la solicitud de excepción. En la medida en que usted se encuentre fuera del período de transición de 90 días, y que se encuentre en un entorno de LTC, le ofreceremos un suministro de emergencia para 31 días de medicamentos cubiertos por la Parte D que no están en el formulario (como medicamentos cubiertos por la Parte D que se encuentren en nuestro formulario y que de otro modo requerirían autorización previa o tratamiento escalonado en virtud de nuestras normas de manejo de la utilización de medicamentos) mientras se aguarda que se procese la solicitud de excepción. Para obtener más información Para obtener información más detallada sobre la cobertura para medicamentos con receta del plan, consulte la Evidencia de cobertura y otra documentación del plan. Si tiene alguna pregunta sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario aparece en las páginas de la portada y la portada posterior. Si tiene preguntas generales sobre su cobertura para medicamentos con receta de Medicare, llame a Medicare al MEDICARE ( ), durante las horas, los 7 días de la semana. Los usuarios de TTY deben llamar al O bien, visite Formulario LiveWell (HMO) o PlanWell (HMO) El formulario que se incluye más abajo brinda información sobre la cobertura de los medicamentos que cubre nuestro plan. Si tiene alguna dificultad para encontrar el medicamento que toma en la lista, consulte el Índice que comienza en la página 88. La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están en letra mayúscula (p. ej., NAMENDA XR), y los medicamentos genéricos están en letra minúscula y cursiva (p. ej., memantine). La información incluida en la columna de Requisitos/límites indica si el plan tiene algún requisito especial para la cobertura del medicamento. xiii

15 Formulario de la Parte D 018 (Integral) LEYENDA Símbolo Nombre QL PA ST Límite de cantidad Autorización previa Tratamiento escalonado Descripción Existe un límite con respecto a la cantidad de este medicamento que se cubre mediante receta o en un plazo específico. Usted (o su médico) debe obtener una autorización previa antes de surtir la receta de este medicamento. Sin autorización previa, es posible que no cubramos este medicamento. En algunos casos, es posible que deba probar otros medicamentos para tratar su afección médica, antes de que podamos cubrir otro medicamento para dicha afección. GC Período sin cobertura Proporcionamos cobertura adicional para este medicamento con receta durante el período sin cobertura. MO Pedidos por correo Esta receta también podría estar disponible por correo. LA Acceso limitado Este medicamento con receta está limitado a ciertas farmacias. HRM BD Medicamento de alto riesgo Parte B vs. Parte D Los Centros de Servicios de Medicare y Medicaid (Centers for Medicare and Medicaid Services, CMS) han identificado el medicamento detallado como un medicamento con riesgo elevado para los pacientes, especialmente para personas mayores (se requiere autorización previa para pacientes de 65 años o más) Este medicamento con receta puede estar cubierto por la Parte B o la Parte D de Medicare, según las circunstancias. Nivel Nombre 1 Medicamentos genéricos preferidos Este es el nivel de distribución de costos más bajo. Medicamentos genéricos 3 Medicamentos de marca preferidos Medicamentos no preferidos 5 Medicamentos especializados Este es el nivel de distribución de costos más alto. xiv

16 LEGEND 1: Tier 1 - Preferred Generics Drugs (This is the lowest cost-sharing tier.) : Tier - Generic Drugs 3: Tier 3 - Preferred Brand Name Drugs : Tier - Non-Preferred Drugs 5: Tier 5 - Specialty Drugs (This is the highest cost-sharing tier.) BD: Part B vs Part D - This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. HR: High Risk Medication - (PA required for ages 65 or over). LA: Limited Access - This prescription drug is limited to certain pharmacies. MO: Mail Order - This prescription may also be available via mail. PA: Prior Authorization - You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL: Quantity Limit - There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. ST: Step Therapy - In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. 1

17 Agewell 5-Tier (List of Covered Drugs) ANALGESICS OPIOID ANALGESICS, LONG- ACTING fentanyl citrate buccal lozenge on a handle 100 mcg, 1600 mcg, 00 mcg, 00 mcg, 600 mcg, PA; QL (10 EA per 30 days) mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, QL (10 EA per 30 days) 6.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr hydromorphone hcl oral liquid 1 mg/ml methadone hcl oral solution 10 mg/5ml, 5 mg/5ml methadone hcl oral tablet 10 mg, 5 mg morphine sulfate er beads oral capsule extended release hour 10 mg, 30 mg, 5 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release hour 10 mg, 100 mg, 0 mg, 30 mg, 0 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral tablet extended release 100 mg, 15 mg, 00 mg, 30 mg, 60 mg 3 oxycodone hcl er oral tablet er 1 hour abusedeterrent 10 mg, 15 mg, 0 mg, 30 mg, 0 mg, 60 mg, 80 mg OPIOID ANALGESICS, SHORT- ACTING acetaminophen-codeine #3 oral tablet mg QL (00 EA per 30 days) acetaminophen-codeine oral solution 10-1 mg/5ml QL (5000 ML per 30 days) acetaminophen-codeine oral tablet mg, mg QL (00 EA per 30 days) ASCOMP-CODEINE ORAL CAPSULE MG PA; HR; QL (180 EA per 30 days) butalbital-apap-caff-cod oral capsule mg PA; HR; QL (370 EA per 30 days) butalbital-asa-caff-codeine oral capsule mg PA; HR; QL (180 EA per 30 days) duramorph injection solution 0.5 mg/ml, 1 mg/ml BD

18 hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg hydrocodone-ibuprofen oral tablet 5-00 mg, mg hydromorphone hcl oral tablet mg, mg, 8 mg morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate oral solution 10 mg/5ml, 0 mg/5ml morphine sulfate oral tablet 15 mg, 30 mg oxycodone hcl oral capsule 5 mg oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution 5 mg/5ml oxycodone hcl oral tablet 10 mg, 15 mg, 0 mg, 30 mg, 5 mg oxycodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg QL (5500 ML per 30 days) QL (370 EA per 30 days) QL (150 EA per 30 days) QL (370 EA per 30 days) oxycodone-aspirin oral tablet mg 3 QL (360 EA per 30 days) oxycodone-ibuprofen oral tablet 5-00 mg 3 QL (360 EA per 30 days) oxymorphone hcl oral tablet 10 mg, 5 mg 3 pentazocine-naloxone hcl oral tablet mg PA; HR tramadol hcl oral tablet 50 mg 1 GC; QL (0 EA per 30 days) tramadol-acetaminophen oral tablet mg QL (370 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine external patch 5 % PA; QL (90 EA per 30 days) lidocaine-prilocaine external cream.5-.5 % ZTLIDO EXTERNAL PATCH 1.8 % PA; QL (90 EA per 30 days) ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI- CRAVING acamprosate calcium oral tablet delayed release 333 mg MO disulfiram oral tablet 50 mg, 500 mg MO 3

19 naltrexone hcl oral tablet 50 mg VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG OPIOID ANTAGONISTS buprenorphine hcl sublingual tablet sublingual mg, 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual -0.5 mg, 8- mg naloxone hcl injection solution 0. mg/ml 1 GC naloxone hcl injection solution cartridge 0. mg/ml naloxone hcl injection solution prefilled syringe mg/ml NARCAN NASAL LIQUID MG/0.1ML 3 SUBOXONE SUBLINGUAL FILM 1-3 MG, MG, -1 MG, 8- MG SMOKING CESSATION AGENTS bupropion hcl er (sr) oral tablet extended release 1 hour 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG 5 1 GC 1 GC MO 3 QL (56 EA per 8 days) CHANTIX ORAL TABLET 0.5 MG 3 QL (60 EA per 30 days) CHANTIX ORAL TABLET 1 MG 3 QL (180 EA per 90 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X NICOTROL INHALATION INHALER 10 MG ANTIBACTERIALS AMINOGLYCOSIDES amikacin sulfate injection solution 500 mg/ml ARIKAYCE INHALATION SUSPENSION 590 MG/8.ML gentamicin in saline intravenous solution mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-% gentamicin sulfate injection solution 0 mg/ml 3 QL (53 EA per 30 days) PA neomycin sulfate oral tablet 500 mg 1 GC paromomycin sulfate oral capsule 50 mg

20 streptomycin sulfate intramuscular solution reconstituted 1 gm tobramycin inhalation nebulization solution 300 mg/5ml tobramycin sulfate injection solution 10 mg/ml, 80 mg/ml ANTIBACTERIALS, OTHER clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml clindamycin phosphate injection solution 300 mg/ml, 600 mg/ml, 900 mg/6ml colistimethate sodium (cba) injection solution reconstituted 150 mg daptomycin intravenous solution reconstituted 350 mg daptomycin intravenous solution reconstituted 500 mg linezolid intravenous solution 600 mg/300ml 5 linezolid oral suspension reconstituted 100 mg/5ml linezolid oral tablet 600 mg 5 metronidazole in nacl intravenous solution mg/100ml-% metronidazole oral capsule 375 mg metronidazole oral tablet 50 mg, 500 mg nitrofurantoin macrocrystal oral capsule 100 mg, 5 mg, 50 mg nitrofurantoin monohyd macro oral capsule 100 mg nitrofurantoin oral suspension 5 mg/5ml tigecycline intravenous solution reconstituted 50 mg BD BD 5 5 BD trimethoprim oral tablet 100 mg 1 GC vancomycin hcl intravenous solution reconstituted 1 gm, 10 gm, 1000 mg, 50 mg, 500 mg, 750 mg 5

21 vancomycin hcl oral capsule 15 mg vancomycin hcl oral capsule 50 mg 5 XIFAXAN ORAL TABLET 00 MG XIFAXAN ORAL TABLET 550 MG MO BETA-LACTAM, CEPHALOSPORINS cefaclor er oral tablet extended release 1 hour 500 mg cefaclor oral capsule 50 mg, 500 mg cefaclor oral suspension reconstituted 15 mg/5ml, 50 mg/5ml, 375 mg/5ml cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 50 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cefepime hcl injection solution reconstituted 1 gm, gm cefixime oral suspension reconstituted 100 mg/5ml, 00 mg/5ml cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous solution reconstituted 1 gm, gm cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 00 mg cefprozil oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cefprozil oral tablet 50 mg, 500 mg ceftazidime injection solution reconstituted 1 gm, gm, 6 gm ceftriaxone sodium injection solution reconstituted 1 gm, gm, 50 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted 10 gm 6 BD

22 cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg cefuroxime sodium intravenous solution reconstituted 1.5 gm cephalexin oral capsule 50 mg, 500 mg 1 GC cephalexin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cephalexin oral tablet 50 mg, 500 mg 1 GC SUPRAX ORAL CAPSULE 00 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML TAZICEF INJECTION SOLUTION RECONSTITUTED 1 GM, GM, 6 GM TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 600 MG BETA-LACTAM, OTHER AZACTAM INJECTION SOLUTION RECONSTITUTED GM aztreonam injection solution reconstituted 1 gm CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG doripenem intravenous solution reconstituted 500 mg ertapenem sodium injection solution reconstituted 1 gm imipenem-cilastatin intravenous solution reconstituted 50 mg, 500 mg meropenem intravenous solution reconstituted 1 gm, 500 mg BETA-LACTAM, PENICILLINS 7 5 PA amoxicillin oral capsule 50 mg, 500 mg 1 GC amoxicillin oral suspension reconstituted 15 mg/5ml, 00 mg/5ml, 50 mg/5ml, 00 mg/5ml 1 GC amoxicillin oral tablet 500 mg, 875 mg 1 GC amoxicillin oral tablet chewable 15 mg, 50 mg 1 GC amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml

23 amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 500 mg 1 GC ampicillin sodium injection solution reconstituted 1 gm, 15 mg ampicillin sodium intravenous solution reconstituted 10 gm ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (-1) gm BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/ML, UNIT/ML, UNIT/ML dicloxacillin sodium oral capsule 50 mg, 500 mg nafcillin sodium injection solution reconstituted 1 gm, gm nafcillin sodium intravenous solution reconstituted 10 gm oxacillin sodium injection solution reconstituted 1 gm, 10 gm, gm penicillin g pot in dextrose intravenous solution 0000 unit/ml, unit/ml penicillin g potassium injection solution reconstituted unit penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 15 mg/5ml, 50 mg/5ml 8 BD penicillin v potassium oral tablet 50 mg, 500 mg 1 GC piperacillin sod-tazobactam so intravenous solution reconstituted.5 (-0.5) gm, ( ) gm,.5 (-0.5) gm, 0.5 (36-.5) gm MACROLIDES azithromycin intravenous solution reconstituted 500 mg azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 mg/5ml, 00 mg/5ml BD

24 azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 500 mg (3 pack) azithromycin oral tablet 600 mg clarithromycin er oral tablet extended release hour 500 mg clarithromycin oral tablet 50 mg, 500 mg DIFICID ORAL TABLET 00 MG 5 ERY-TAB ORAL TABLET DELAYED RELEASE 50 MG, 333 MG, 500 MG ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ERYTHROCIN STEARATE ORAL TABLET 50 MG erythromycin base oral capsule delayed release particles 50 mg erythromycin base oral tablet 50 mg, 500 mg erythromycin ethylsuccinate oral tablet 00 mg QUINOLONES ciprofloxacin hcl oral tablet 100 mg, 50 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous solution 00 mg/100ml ciprofloxacin oral suspension reconstituted 50 mg/5ml (5%), 500 mg/5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release hour 1000 mg, 500 mg levofloxacin in d5w intravenous solution 500 mg/100ml, 750 mg/150ml levofloxacin intravenous solution 5 mg/ml levofloxacin oral solution 5 mg/ml 1 GC 9 1 GC levofloxacin oral tablet 50 mg, 500 mg, 750 mg 1 GC SULFONAMIDES sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim oral suspension 00-0 mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg 1 GC sulfasalazine oral tablet 500 mg

25 sulfasalazine oral tablet delayed release 500 mg TETRACYCLINES DOXY 100 INTRAVENOUS SOLUTION RECONSTITUTED 100 MG doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 00 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral suspension reconstituted 5 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg minocycline hcl oral tablet 100 mg, 50 mg, 75 mg 3 SOLOXIDE ORAL TABLET DELAYED RELEASE 150 MG tetracycline hcl oral capsule 50 mg, 500 mg ANTICONVULSANTS ANTICONVULSANTS, OTHER EPIDIOLEX ORAL SOLUTION 100 MG/ML PA; MO levetiracetam er oral tablet extended release hour 500 mg, 750 mg 10 3 levetiracetam oral solution 100 mg/ml MO levetiracetam oral tablet 1000 mg, 50 mg, 500 mg, 750 mg MO oxcarbazepine oral tablet 150 mg MO ROWEEPRA ORAL TABLET 1000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE HOUR 500 MG, 750 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 50 MG, 500 MG, 750 MG BARBITURATES MO MO; QL (90 EA per 30 days) MO; QL (10 EA per 30 days)

26 phenobarbital oral elixir 0 mg/5ml 1 PA; MO; GC; HR phenobarbital oral tablet 100 mg, 15 mg, 16. mg, 30 mg, 3. mg, 60 mg, 6.8 mg, 97. mg 1 PA; MO; GC; HR primidone oral tablet 50 mg, 50 mg MO BENZODIAZEPINES clobazam oral suspension.5 mg/ml MO clobazam oral tablet 10 mg, 0 mg MO clonazepam oral tablet 0.5 mg, 1 mg, mg clonazepam oral tablet dispersible 0.15 mg, 0.5 mg, 0.5 mg, 1 mg, mg DIASTAT ACUDIAL RECTAL GEL 10 MG, 0 MG DIASTAT PEDIATRIC RECTAL GEL.5 MG diazepam rectal gel 10 mg,.5 mg CALCIUM CHANNEL MODIFYING AGENTS MO CELONTIN ORAL CAPSULE 300 MG MO ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5ml LYRICA ORAL CAPSULE 00 MG, 5 MG, 5 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML zonisamide oral capsule 100 mg, 5 mg, 50 mg MO GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS divalproex sodium er oral tablet extended release hour 50 mg, 500 mg divalproex sodium oral tablet delayed release 50 mg, 500 mg MO MO FYCOMPA ORAL SUSPENSION 0.5 MG/ML MO FYCOMPA ORAL TABLET 10 MG, 1 MG, MG, MG, 6 MG, 8 MG MO gabapentin oral capsule 100 mg, 300 mg, 00 mg MO gabapentin oral solution 50 mg/5ml MO gabapentin oral tablet 600 mg, 800 mg MO SABRIL ORAL TABLET 500 MG 5 MO 11

27 tiagabine hcl oral tablet 1 mg, 16 mg, mg, mg MO valproate sodium oral solution 50 mg/5ml MO valproic acid oral capsule 50 mg MO vigabatrin oral packet 500 mg 5 LA; MO GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 mg/5ml 5 MO felbamate oral tablet 00 mg, 600 mg MO LAMICTAL XR ORAL KIT 5 & 50 & 100 MG, 5 (1)-50 (7) MG, 50 & 100 & 00 MG lamotrigine er oral tablet extended release hour 100 mg, 00 mg, 5 mg, 50 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 00 mg, 5 mg 1 MO lamotrigine oral tablet chewable 5 mg, 5 mg lamotrigine oral tablet dispersible 100 mg, 00 mg, 5 mg, 50 mg lamotrigine starter kit-blue oral kit 5 (35) mg lamotrigine starter kit-green oral kit 5 (8)- 100(1) mg lamotrigine starter kit-orange oral kit 5 ()-100 (7) mg topiramate er oral capsule er hour sprinkle 100 mg, 150 mg, 00 mg, 5 mg, 50 mg MO topiramate oral capsule sprinkle 15 mg, 5 mg MO topiramate oral tablet 00 mg, 5 mg, 50 mg TROKENDI XR ORAL CAPSULE EXTENDED RELEASE HOUR 100 MG, 5 MG, 50 MG TROKENDI XR ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG SODIUM CHANNEL AGENTS MO 5 MO APTIOM ORAL TABLET 00 MG MO APTIOM ORAL TABLET 00 MG, 600 MG, 800 MG 5 MO BANZEL ORAL SUSPENSION 0 MG/ML 5 MO BANZEL ORAL TABLET 00 MG, 00 MG 5 MO BRIVIACT ORAL SOLUTION 10 MG/ML 5 MO

28 BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG carbamazepine er oral capsule extended release 1 hour 00 mg, 300 mg carbamazepine er oral tablet extended release 1 hour 100 mg, 00 mg, 00 mg 5 MO MO MO carbamazepine oral suspension 100 mg/5ml MO carbamazepine oral tablet 00 mg MO DILANTIN ORAL CAPSULE 30 MG MO EPITOL ORAL TABLET 00 MG MO EQUETRO ORAL CAPSULE EXTENDED RELEASE 1 HOUR 100 MG, 00 MG, 300 MG MO oxcarbazepine oral suspension 300 mg/5ml MO oxcarbazepine oral tablet 300 mg, 600 mg MO OXTELLAR XR ORAL TABLET EXTENDED RELEASE HOUR 150 MG, 300 MG, 600 MG MO PEGANONE ORAL TABLET 50 MG MO phenytoin oral suspension 15 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 100 mg phenytoin sodium extended oral capsule 00 mg, 300 mg MO VIMPAT ORAL SOLUTION 10 MG/ML MO VIMPAT ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER MO ergoloid mesylates oral tablet 1 mg PA; MO; HR CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 10 mg, 3 mg, 5 mg MO donepezil hcl oral tablet dispersible 10 mg, 5 mg MO galantamine hydrobromide er oral capsule extended release hour 16 mg, mg, 8 mg MO galantamine hydrobromide oral solution mg/ml MO galantamine hydrobromide oral tablet 1 mg, mg, 8 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg,.5 mg, 6 mg MO MO 13

29 rivastigmine transdermal patch hour 13.3 mg/hr,.6 mg/hr, 9.5 mg/hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl er oral capsule extended release hour 1 mg, 1 mg, 8 mg, 7 mg MO memantine hcl oral solution mg/ml MO memantine hcl oral tablet 10 mg, 5 mg MO memantine hcl oral tablet 5 (8)-10 (1) mg NAMZARIC ORAL CAPSULE ER HOUR THERAPY PACK 7 & 1 & 1 &8-10 MG NAMZARIC ORAL CAPSULE EXTENDED RELEASE HOUR 1-10 MG, 1-10 MG, 8-10 MG, 7-10 MG ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER bupropion hcl er (smoking det) oral tablet extended release 1 hour 150 mg bupropion hcl er (sr) oral tablet extended release 1 hour 100 mg, 00 mg bupropion hcl er (xl) oral tablet extended release hour 150 mg, 300 mg bupropion hcl er (xl) oral tablet extended release hour 50 mg 1 3 MO MO bupropion hcl oral tablet 100 mg, 75 mg MO maprotiline hcl oral tablet 5 mg, 50 mg, 75 mg MO mirtazapine oral tablet 15 mg, 30 mg, 5 mg, 7.5 mg mirtazapine oral tablet dispersible 15 mg, 30 mg, 5 mg nefazodone hcl oral tablet 100 mg, 150 mg, 00 mg, 50 mg, 50 mg MO MO MO trazodone hcl oral tablet 100 mg 1 GC trazodone hcl oral tablet 150 mg, 50 mg trazodone hcl oral tablet 300 mg MO TRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG VIIBRYD ORAL TABLET 10 MG, 0 MG, 0 MG ST; MO

30 VIIBRYD STARTER PACK ORAL KIT 10 & 0 MG MONOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH HOUR 1 MG/HR, 6 MG/HR, 9 MG/HR 3 5 MO MARPLAN ORAL TABLET 10 MG MO phenelzine sulfate oral tablet 15 mg tranylcypromine sulfate oral tablet 10 mg MO SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg, 0 mg, 0 mg desvenlafaxine er oral tablet extended release hour 100 mg, 50 mg desvenlafaxine succinate er oral tablet extended release hour 100 mg, 5 mg, 50 mg duloxetine hcl oral capsule delayed release particles 0 mg, 30 mg, 0 mg, 60 mg MO MO MO MO escitalopram oxalate oral solution 5 mg/5ml MO escitalopram oxalate oral tablet 10 mg, 0 mg, 5 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 0 MG, 0 MG, 80 MG fluoxetine hcl oral capsule 10 mg, 0 mg, 0 mg fluoxetine hcl oral capsule delayed release 90 mg MO fluoxetine hcl oral solution 0 mg/5ml MO fluoxetine hcl oral tablet 10 mg, 0 mg MO fluoxetine hcl oral tablet 60 mg MO fluvoxamine maleate er oral capsule extended release hour 100 mg, 150 mg fluvoxamine maleate oral tablet 100 mg, 5 mg, 50 mg olanzapine-fluoxetine hcl oral capsule 1-5 mg, 1-50 mg, 3-5 mg, 6-5 mg, 6-50 mg MO 15

31 paroxetine hcl er oral tablet extended release hour 1.5 mg, 5 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 0 mg, 30 mg, 0 mg MO paroxetine mesylate oral capsule 7.5 mg MO PAXIL ORAL SUSPENSION 10 MG/5ML MO sertraline hcl oral concentrate 0 mg/ml MO sertraline hcl oral tablet 100 mg, 5 mg, 50 mg venlafaxine hcl er oral capsule extended release hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release hour 150 mg, 5 mg, 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 5 mg, 37.5 mg, 50 mg, 75 mg TRICYCLICS amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 5 mg, 50 mg clomipramine hcl oral capsule 5 mg, 50 mg, 75 mg desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg MO 1 PA; MO; GC; HR MO PA; MO; HR MO PA; MO; HR doxepin hcl oral concentrate 10 mg/ml PA; MO; HR imipramine hcl oral tablet 10 mg, 5 mg, 50 mg PA; MO; HR imipramine pamoate oral capsule 100 mg, 15 mg, 150 mg, 75 mg nortriptyline hcl oral capsule 10 mg, 5 mg, 50 mg, 75 mg PA; MO; HR nortriptyline hcl oral solution 10 mg/5ml protriptyline hcl oral tablet 10 mg, 5 mg MO trimipramine maleate oral capsule 100 mg, 5 mg, 50 mg ANTIEMETICS ANTIEMETICS, OTHER PA; MO; HR meclizine hcl oral tablet 1.5 mg, 5 mg 1 GC 16

32 metoclopramide hcl oral tablet 5 mg scopolamine transdermal patch 7 hour 1 mg/3days EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 15 mg, 0 mg, 80 & 15 mg, 80 mg BD dronabinol oral capsule 10 mg 5 BD; QL (60 EA per 30 days) dronabinol oral capsule.5 mg, 5 mg BD; QL (60 EA per 30 days) granisetron hcl oral tablet 1 mg BD; QL (60 EA per 30 days) ondansetron hcl oral solution mg/5ml BD ondansetron hcl oral tablet mg BD; QL (30 EA per 30 days) ondansetron hcl oral tablet mg, 8 mg BD; QL (90 EA per 30 days) ondansetron oral tablet dispersible mg, 8 mg BD; QL (90 EA per 30 days) SYNDROS ORAL SOLUTION 5 MG/ML BD; QL (10 ML per 30 days) VARUBI ORAL TABLET 90 MG 3 BD ANTIFUNGALS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg 5 BD 5 BD BD 5 BD clotrimazole mouth/throat lozenge 10 mg 1 GC ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG fluconazole in sodium chloride intravenous solution mg/100ml-%, mg/00ml- % fluconazole oral suspension reconstituted 10 mg/ml, 0 mg/ml fluconazole oral tablet 100 mg, 150 mg, 00 mg, 50 mg flucytosine oral capsule 50 mg, 500 mg 5 BD 17

33 griseofulvin microsize oral suspension 15 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 15 mg, 50 mg itraconazole oral capsule 100 mg 3 itraconazole oral solution 10 mg/ml 3 ketoconazole oral tablet 00 mg MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG NOXAFIL ORAL SUSPENSION 0 MG/ML 5 MO NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin oral tablet unit MO terbinafine hcl oral tablet 50 mg QL (90 EA per 365 days) voriconazole intravenous solution reconstituted 00 mg voriconazole oral suspension reconstituted 0 mg/ml voriconazole oral tablet 00 mg, 50 mg 5 ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 100 mg colchicine oral capsule 0.6 mg 3 colchicine oral tablet 0.6 mg 3 colchicine-probenecid oral tablet mg MO probenecid oral tablet 500 mg MO ULORIC ORAL TABLET 0 MG, 80 MG 3 ST; MO ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI- INFLAMMATORY DRUGS butalbital-apap-caffeine oral tablet mg QL (180 EA per 30 days) celecoxib oral capsule 100 mg, 00 mg, 00 mg, 50 mg 5 5 diclofenac potassium oral tablet 50 mg MO diclofenac sodium er oral tablet extended release hour 100 mg

34 diclofenac sodium oral tablet delayed release 5 mg, 50 mg, 75 mg diflunisal oral tablet 500 mg MO etodolac er oral tablet extended release hour 00 mg, 500 mg, 600 mg MO etodolac oral capsule 00 mg, 300 mg MO etodolac oral tablet 00 mg, 500 mg MO flurbiprofen oral tablet 100 mg, 50 mg IBU ORAL TABLET 600 MG, 800 MG ibuprofen oral suspension 100 mg/5ml 1 GC ibuprofen oral tablet 00 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg PA; MO; HR indomethacin oral capsule 5 mg, 50 mg 1 PA; MO; GC; HR ketoprofen er oral capsule extended release hour 00 mg MO ketoprofen oral capsule 5 mg MO ketorolac tromethamine oral tablet 10 mg PA; HR meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 15 mg/5ml naproxen oral tablet 50 mg, 375 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 mg MO oxaprozin oral tablet 600 mg MO piroxicam oral capsule 10 mg, 0 mg MO sulindac oral tablet 150 mg, 00 mg ANTIMIGRAINE AGENTS ANTIMIGRAINE AGENTS, PROPHYLACTIC divalproex sodium oral capsule delayed release sprinkle 15 mg divalproex sodium oral tablet delayed release 15 mg MO MO topiramate oral tablet 100 mg ERGOT ALKALOIDS 19

35 dihydroergotamine mesylate nasal solution mg/ml ergotamine-caffeine oral tablet mg QL (0 EA per 8 days) SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS eletriptan hydrobromide oral tablet 0 mg, 0 mg sumatriptan nasal solution 0 mg/act, 5 mg/act sumatriptan succinate oral tablet 100 mg, 5 mg, 50 mg sumatriptan succinate refill subcutaneous solution cartridge mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution auto-injector mg/0.5ml, 6 mg/0.5ml ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine hcl oral tablet 15 mg 3 MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide oral tablet 60 mg ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 100 mg, 5 mg MO pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg 3 ANTITUBERCULARS ethambutol hcl oral tablet 100 mg, 00 mg 3 isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg PASER ORAL PACKET GM PRIFTIN ORAL TABLET 150 MG rifampin intravenous solution reconstituted 600 mg rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG 5 3 0

36 TRECATOR ORAL TABLET 50 MG ANTINEOPLASTICS ALKYLATING AGENTS cyclophosphamide oral capsule 5 mg, 50 mg 3 BD GLEOSTINE ORAL CAPSULE 10 MG, 0 MG GLEOSTINE ORAL CAPSULE 100 MG 5 LEUKERAN ORAL TABLET MG 3 ANTIANGIOGENIC AGENTS DEPEN TITRATABS ORAL TABLET 50 MG 5 REVLIMID ORAL CAPSULE 10 MG, 15 MG, 5 MG, 5 MG 5 PA; LA REVLIMID ORAL CAPSULE.5 MG, 0 MG 5 PA THALOMID ORAL CAPSULE 100 MG, 150 MG, 00 MG, 50 MG trientine hcl oral capsule 50 mg 5 ANTIMETABOLITES DROXIA ORAL CAPSULE 00 MG, 300 MG, 00 MG mercaptopurine oral tablet 50 mg 5 PA; MO MO methotrexate oral tablet.5 mg BD methotrexate sodium (pf) injection solution 50 mg/ml methotrexate sodium injection solution 50 mg/10ml primaquine phosphate oral tablet 6.3 mg PURIXAN ORAL SUSPENSION 000 MG/100ML TABLOID ORAL TABLET 0 MG BD BD XATMEP ORAL SOLUTION.5 MG/ML 5 BD ANTINEOPLASTICS abiraterone acetate oral tablet 50 mg 5 PA ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML AFINITOR DISPERZ ORAL TABLET SOLUBLE MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 MG, 5 MG, 7.5 MG PA; LA; MO 5 PA 5 PA

37 ALECENSA ORAL CAPSULE 150 MG 5 PA ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG 5 PA 5 PA AZASAN ORAL TABLET 100 MG, 75 MG BD; MO bexarotene oral capsule 75 mg 5 bicalutamide oral tablet 50 mg BOSULIF ORAL TABLET 100 MG, 00 MG, 500 MG 5 PA BRAFTOVI ORAL CAPSULE 50 MG, 75 MG 5 PA; LA CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG 5 PA CALQUENCE ORAL CAPSULE 100 MG 5 PA; LA CAPRELSA ORAL TABLET 100 MG, 300 MG 5 PA COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 0 MG COMETRIQ (10 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 0 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 0 MG 5 PA 5 PA 5 PA COPIKTRA ORAL CAPSULE 15 MG, 5 MG 5 PA COTELLIC ORAL TABLET 0 MG 5 PA; LA DEPO-PROVERA INTRAMUSCULAR SUSPENSION 00 MG/ML ELIGARD SUBCUTANEOUS KIT.5 MG, 30 MG, 5 MG, 7.5 MG EMCYT ORAL CAPSULE 10 MG BD BD ERIVEDGE ORAL CAPSULE 150 MG 5 PA ERLEADA ORAL TABLET 60 MG 5 PA; LA FARESTON ORAL TABLET 60 MG 5 MO FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG fluorouracil external solution %, 5 % 3 5 PA 5 BD BD flutamide oral capsule 15 mg 1 GC

38 GILOTRIF ORAL TABLET 0 MG, 30 MG, 0 MG 5 PA hydroxyurea oral capsule 500 mg 1 GC IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG 5 PA ICLUSIG ORAL TABLET 15 MG, 5 MG 5 PA IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA imatinib mesylate oral tablet 100 mg, 00 mg 5 PA IMBRUVICA ORAL CAPSULE 10 MG, 70 MG IMBRUVICA ORAL TABLET 10 MG, 80 MG, 0 MG, 560 MG 5 PA 5 PA INLYTA ORAL TABLET 1 MG, 5 MG 5 PA INTRON A INJECTION SOLUTION UNIT/ML INTRON A INJECTION SOLUTION UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT 5 MO 5 BD; MO 5 BD; MO IRESSA ORAL TABLET 50 MG 5 PA JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG 5 PA KISQALI 00 DOSE ORAL TABLET 00 MG 5 PA KISQALI 00 DOSE ORAL TABLET 00 MG 5 PA KISQALI 600 DOSE ORAL TABLET 00 MG 5 PA KISQALI FEMARA 00 DOSE ORAL TABLET THERAPY PACK 00 &.5 MG KISQALI FEMARA 00 DOSE ORAL TABLET THERAPY PACK 00 &.5 MG KISQALI FEMARA 600 DOSE ORAL TABLET THERAPY PACK 00 &.5 MG LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 MG LENVIMA 1 MG DAILY DOSE ORAL CAPSULE THERAPY PACK (3) MG LENVIMA 1 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & MG LENVIMA 18 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & () MG 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 5 PA 3

39 LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 () MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 () & MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK () MG leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg, 5 mg 5 PA 5 PA 5 PA 5 PA leuprolide acetate injection kit 1 mg/0.ml 3 PA LONSURF ORAL TABLET MG, MG 5 PA LORBRENA ORAL TABLET 100 MG, 5 MG 5 PA LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT.5 MG LUPRON DEPOT (-MONTH) INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 5 MG 5 PA 5 PA 5 PA 5 PA LYNPARZA ORAL CAPSULE 50 MG 5 PA LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA; LA LYSODREN ORAL TABLET 500 MG 3 MATULANE ORAL CAPSULE 50 MG 5 megestrol acetate oral suspension 0 mg/ml 1 PA; GC; HR megestrol acetate oral suspension 65 mg/5ml PA; MO; HR megestrol acetate oral tablet 0 mg, 0 mg 1 PA; GC; HR MEKINIST ORAL TABLET 0.5 MG, MG 5 PA; LA MEKTOVI ORAL TABLET 15 MG 5 PA; LA NERLYNX ORAL TABLET 0 MG 5 PA; LA NEXAVAR ORAL TABLET 00 MG 5 PA; LA nilutamide oral tablet 150 mg 5 NINLARO ORAL CAPSULE.3 MG, 3 MG, MG 5 PA ODOMZO ORAL CAPSULE 00 MG 5 PA; LA POMALYST ORAL CAPSULE 1 MG, MG, 3 MG, MG 5 PA; LA

40 RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG 5 PA RYDAPT ORAL CAPSULE 5 MG 5 PA SPRYCEL ORAL TABLET 100 MG, 10 MG, 0 MG, 50 MG, 70 MG, 80 MG 5 PA STIVARGA ORAL TABLET 0 MG 5 PA SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 37.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG 5 PA 5 PA; MO TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA; LA TAGRISSO ORAL TABLET 0 MG, 80 MG 5 PA; LA TALZENNA ORAL CAPSULE 0.5 MG, 1 MG 5 PA tamoxifen citrate oral tablet 10 mg, 0 mg TARCEVA ORAL TABLET 100 MG, 150 MG, 5 MG TASIGNA ORAL CAPSULE 150 MG, 00 MG, 50 MG PA 5 PA TIBSOVO ORAL TABLET 50 MG 5 PA; LA TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.5 MG,.5 MG, 3.75 MG tretinoin oral capsule 10 mg 5 TYKERB ORAL TABLET 50 MG 5 5 BD VENCLEXTA ORAL TABLET 10 MG, 50 MG PA; LA VENCLEXTA ORAL TABLET 100 MG 5 PA; LA VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG VIZIMPRO ORAL TABLET 15 MG, 30 MG, 5 MG 5 PA; LA 5 PA; LA VOTRIENT ORAL TABLET 00 MG 5 PA XALKORI ORAL CAPSULE 00 MG, 50 MG 5 PA XTANDI ORAL CAPSULE 0 MG 5 PA YONSA ORAL TABLET 15 MG 5 PA ZEJULA ORAL CAPSULE 100 MG 5 PA 5 PA; QL (30 EA per 30 days)

41 ZELBORAF ORAL TABLET 0 MG 5 ZOLINZA ORAL CAPSULE 100 MG 5 PA ZYDELIG ORAL TABLET 100 MG, 150 MG 5 ZYKADIA ORAL CAPSULE 150 MG 5 PA ZYTIGA ORAL TABLET 500 MG 5 PA AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet 1 mg exemestane oral tablet 5 mg MO letrozole oral tablet.5 mg TREATMENT ADJUNCTS allopurinol oral tablet 300 mg MESNEX ORAL TABLET 00 MG 5 ANTIPARASITICS ANTHELMINTICS ALBENZA ORAL TABLET 00 MG benznidazole oral tablet 100 mg, 1.5 mg EMVERM ORAL TABLET CHEWABLE 100 MG ivermectin oral tablet 3 mg 3 ANTIPROTOZOALS ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5ml 5 atovaquone-proguanil hcl oral tablet mg, mg chloroquine phosphate oral tablet 50 mg, 500 mg COARTEM ORAL TABLET 0-10 MG DARAPRIM ORAL TABLET 5 MG MO hydroxychloroquine sulfate oral tablet 00 mg MO mefloquine hcl oral tablet 50 mg MO NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG BD

42 quinine sulfate oral capsule 3 mg ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate oral tablet 0.5 mg, 1 mg, mg 1 PA; MO; GC; HR trihexyphenidyl hcl oral elixir 0. mg/ml 1 PA; MO; GC; HR trihexyphenidyl hcl oral tablet mg, 5 mg 1 PA; MO; GC; HR ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 100 mg MO amantadine hcl oral syrup 50 mg/5ml MO amantadine hcl oral tablet 100 mg MO entacapone oral tablet 00 mg MO GOCOVRI ORAL CAPSULE EXTENDED RELEASE HOUR 137 MG, 68.5 MG DOPAMINE AGONISTS APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML 5 PA; MO 5 LA bromocriptine mesylate oral capsule 5 mg MO bromocriptine mesylate oral tablet.5 mg MO NEUPRO TRANSDERMAL PATCH HOUR 1 MG/HR, MG/HR, 3 MG/HR, MG/HR, 6 MG/HR, 8 MG/HR pramipexole dihydrochloride er oral tablet extended release hour mg, 0.75 mg, 1.5 mg,.5 mg, 3 mg, 3.75 mg,.5 mg pramipexole dihydrochloride oral tablet 0.15 mg, 0.5 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl oral tablet 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg, mg, 5 mg RYTARY ORAL CAPSULE EXTENDED RELEASE MG, MG, MG, MG DOPAMINE PRECURSORS/ L- AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa er oral tablet extended release mg, mg MO MO MO MO ST; MO MO 7

43 carbidopa-levodopa oral tablet mg, mg, 5-50 mg carbidopa-levodopa oral tablet dispersible mg, mg, 5-50 mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg MONOAMINE OXIDASE B (MAO-B) INHIBITORS MO MO rasagiline mesylate oral tablet 0.5 mg, 1 mg MO selegiline hcl oral capsule 5 mg MO selegiline hcl oral tablet 5 mg MO ANTIPSYCHOTICS 1ST GENERATION/TYPICAL chlorpromazine hcl oral tablet 10 mg, 5 mg BD; MO chlorpromazine hcl oral tablet 100 mg, 00 mg, 50 mg COMPRO RECTAL SUPPOSITORY 5 MG fluphenazine decanoate injection solution 5 mg/ml fluphenazine hcl injection solution.5 mg/ml MO fluphenazine hcl oral concentrate 5 mg/ml MO fluphenazine hcl oral elixir.5 mg/5ml MO fluphenazine hcl oral tablet 1 mg, 10 mg,.5 mg, 5 mg haloperidol decanoate intramuscular solution 100 mg/ml, 100 mg/ml 1 ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml, 5 mg/ml(1 ml prefilled syringe) 8 MO haloperidol lactate oral concentrate mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, mg, 0 mg, 5 mg loxapine succinate oral capsule 10 mg, 5 mg, 5 mg, 50 mg 3 MO molindone hcl oral tablet 10 mg, 5 mg, 5 mg MO perphenazine oral tablet 16 mg, mg, mg, 8 mg MO perphenazine-amitriptyline oral tablet -10 mg, -5 mg, -10 mg, -5 mg, -50 mg PA; MO; HR

44 pimozide oral tablet 1 mg, mg MO prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 5 mg thioridazine hcl oral tablet 10 mg, 100 mg, 5 mg, 50 mg 1 PA; MO; GC; HR thiothixene oral capsule 1 mg, 10 mg, mg, 5 mg MO trifluoperazine hcl oral tablet 1 mg, 10 mg, mg, 5 mg ND GENERATION/ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 00 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 00 MG MO 5 MO 5 MO MO aripiprazole oral solution 1 mg/ml MO; QL (750 ML per 30 days) aripiprazole oral tablet 10 mg, 15 mg, mg, 0 mg, 30 mg, 5 mg MO aripiprazole oral tablet dispersible 10 mg, 15 mg 5 MO FANAPT ORAL TABLET 1 MG, MG, MG ST FANAPT ORAL TABLET 10 MG, 1 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET 1 & & & 6 MG GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 0 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 3 MG/1.5ML, 78 MG/0.5ML INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 73 MG/0.875ML, 10 MG/1.315ML, 56 MG/1.75ML, 819 MG/.65ML LATUDA ORAL TABLET 10 MG, 0 MG, 0 MG, 60 MG, 80 MG 5 ST ST ST 5 5 MO NUPLAZID ORAL CAPSULE 3 MG 5 PA; LA; MO NUPLAZID ORAL TABLET 10 MG 5 PA; LA; MO 9

45 NUPLAZID ORAL TABLET 17 MG 5 PA; MO olanzapine intramuscular solution reconstituted 10 mg olanzapine oral tablet 10 mg, 15 mg,.5 mg, 0 mg, 5 mg, 7.5 mg olanzapine oral tablet dispersible 10 mg, 15 mg, 0 mg, 5 mg paliperidone er oral tablet extended release hour 1.5 mg, 3 mg, 6 mg paliperidone er oral tablet extended release hour 9 mg quetiapine fumarate er oral tablet extended release hour 150 mg, 00 mg, 300 mg, 00 mg, 50 mg quetiapine fumarate oral tablet 100 mg, 00 mg, 5 mg, 300 mg, 00 mg, 50 mg REXULTI ORAL TABLET 0.5 MG, 0.5 MG, 1 MG, MG, 3 MG, MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 1.5 MG, 5 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG MO MO 5 MO 5 MO risperidone oral solution 1 mg/ml MO risperidone oral tablet 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg, mg risperidone oral tablet dispersible 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg, mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG,.5 MG, 5 MG VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG,.5 MG, 6 MG VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG ziprasidone hcl oral capsule 0 mg, 0 mg, 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 10 MG TREATMENT-RESISTANT 5 MO ST; MO 5 ST; MO ST MO ST 30

46 clozapine oral tablet 100 mg, 00 mg, 5 mg, 50 mg clozapine oral tablet dispersible 100 mg, 1.5 mg, 150 mg, 5 mg clozapine oral tablet dispersible 00 mg 5 ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS valganciclovir hcl oral solution reconstituted 50 mg/ml MO valganciclovir hcl oral tablet 50 mg 5 MO VEMLIDY ORAL TABLET 5 MG 5 MO ZIRGAN OPHTHALMIC GEL 0.15 % ANTIHEPATITIS AGENTS adefovir dipivoxil oral tablet 10 mg 5 MO BARACLUDE ORAL SOLUTION 0.05 MG/ML 5 MO entecavir oral tablet 0.5 mg, 1 mg 5 MO RIBASPHERE ORAL CAPSULE 00 MG RIBASPHERE ORAL TABLET 00 MG, 00 MG RIBASPHERE ORAL TABLET 600 MG 5 ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING MAVYRET ORAL TABLET MG 5 PA VOSEVI ORAL TABLET MG 5 PA ANTI-HEPATITIS C (HCV) AGENTS, OTHER MODERIBA 100 DOSE PACK ORAL TABLET 600 MG MODERIBA 800 DOSE PACK ORAL TABLET 00 MG MODERIBA ORAL TABLET 00 MG PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML ribavirin oral capsule 00 mg PA 5 PA 31

47 ribavirin oral tablet 00 mg ANTIHERPETIC AGENTS acyclovir oral capsule 00 mg 1 GC acyclovir oral suspension 00 mg/5ml acyclovir oral tablet 00 mg, 800 mg 1 GC acyclovir sodium intravenous solution 50 mg/ml BD famciclovir oral tablet 15 mg, 50 mg, 500 mg valacyclovir hcl oral tablet 1 gm, 500 mg ANTI-HIV AGENTS, NON- NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ATRIPLA ORAL TABLET MG 5 MO COMPLERA ORAL TABLET MG 5 MO DELSTRIGO ORAL TABLET MG 5 MO EDURANT ORAL TABLET 5 MG 5 MO efavirenz oral capsule 00 mg, 50 mg MO efavirenz oral tablet 600 mg 5 MO GENVOYA ORAL TABLET MG 5 MO INTELENCE ORAL TABLET 100 MG, 00 MG 5 MO INTELENCE ORAL TABLET 5 MG MO nevirapine er oral tablet extended release hour 100 mg, 00 mg nevirapine oral tablet 00 mg MO ODEFSEY ORAL TABLET MG 5 MO PIFELTRO ORAL TABLET 100 MG 5 MO RESCRIPTOR ORAL TABLET 100 MG, 00 MG MO SYMFI LO ORAL TABLET MG 5 MO; QL (30 EA per 30 days) SYMFI ORAL TABLET MG 5 MO; QL (30 EA per 30 days) SYMTUZA ORAL TABLET MG 5 MO VIRAMUNE ORAL SUSPENSION 50 MG/5ML ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate oral solution 0 mg/ml MO 3

48 abacavir sulfate oral tablet 300 mg MO abacavir sulfate-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg 5 MO 5 MO BIKTARVY ORAL TABLET MG 5 MO; QL (30 EA per 30 days) CIMDUO ORAL TABLET MG 5 MO DESCOVY ORAL TABLET 00-5 MG 5 MO desloratadine oral tablet dispersible 5 mg didanosine oral capsule delayed release 00 mg, 50 mg, 00 mg EMTRIVA ORAL CAPSULE 00 MG MO EMTRIVA ORAL SOLUTION 10 MG/ML MO EPIVIR HBV ORAL SOLUTION 5 MG/ML EVOTAZ ORAL TABLET MG 5 MO JULUCA ORAL TABLET 50-5 MG 5 MO lamivudine oral solution 10 mg/ml MO lamivudine oral tablet 100 mg, 150 mg, 300 mg lamivudine-zidovudine oral tablet mg MO PREZCOBIX ORAL TABLET MG 5 MO stavudine oral capsule 15 mg, 0 mg, 30 mg, 0 mg tenofovir disoproxil fumarate oral tablet 300 mg 5 MO TRIUMEQ ORAL TABLET MG 5 MO TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX EC ORAL CAPSULE DELAYED RELEASE 15 MG VIDEX ORAL SOLUTION RECONSTITUTED GM 5 MO MO VIREAD ORAL POWDER 0 MG/GM 5 MO VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG ZERIT ORAL SOLUTION RECONSTITUTED 1 MG/ML 5 MO zidovudine oral capsule 100 mg MO zidovudine oral syrup 50 mg/5ml MO zidovudine oral tablet 300 mg MO 33

49 ANTI-HIV AGENTS, OTHER FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG 5 MO ISENTRESS HD ORAL TABLET 600 MG 5 MO ISENTRESS ORAL PACKET 100 MG MO ISENTRESS ORAL TABLET 00 MG 5 MO ISENTRESS ORAL TABLET CHEWABLE 100 MG ISENTRESS ORAL TABLET CHEWABLE 5 MG 5 MO MO SELZENTRY ORAL SOLUTION 0 MG/ML MO SELZENTRY ORAL TABLET 150 MG, 300 MG, 75 MG 5 MO SELZENTRY ORAL TABLET 5 MG MO STRIBILD ORAL TABLET MG 5 MO TIVICAY ORAL TABLET 10 MG MO TIVICAY ORAL TABLET 5 MG, 50 MG 5 MO TYBOST ORAL TABLET 150 MG MO ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS ORAL CAPSULE 50 MG 5 MO APTIVUS ORAL SOLUTION 100 MG/ML 5 MO atazanavir sulfate oral capsule 150 mg, 00 mg MO atazanavir sulfate oral capsule 300 mg 5 MO CRIXIVAN ORAL CAPSULE 00 MG, 00 MG fosamprenavir calcium oral tablet 700 mg 5 MO INVIRASE ORAL CAPSULE 00 MG 5 MO INVIRASE ORAL TABLET 500 MG 5 MO KALETRA ORAL TABLET MG MO KALETRA ORAL TABLET MG 5 MO LEXIVA ORAL SUSPENSION 50 MG/ML MO lopinavir-ritonavir oral solution mg/5ml MO NORVIR ORAL PACKET 100 MG MO NORVIR ORAL SOLUTION 80 MG/ML MO PREZISTA ORAL SUSPENSION 100 MG/ML 5 MO PREZISTA ORAL TABLET 150 MG, 75 MG MO 3

50 PREZISTA ORAL TABLET 600 MG, 800 MG 5 MO REYATAZ ORAL PACKET 50 MG 5 MO ritonavir oral tablet 100 mg MO VIRACEPT ORAL TABLET 50 MG, 65 MG 5 MO ANTI-INFLUENZA AGENTS oseltamivir phosphate oral capsule 30 mg, 5 mg, 75 mg oseltamivir phosphate oral suspension reconstituted 6 mg/ml RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 100 mg 3 XOFLUZA ORAL TABLET THERAPY PACK 0 () MG, 0 () MG ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 3 1 GC hydroxyzine hcl oral syrup 10 mg/5ml PA; HR hydroxyzine hcl oral tablet 10 mg, 5 mg, 50 mg 1 PA; GC; HR hydroxyzine pamoate oral capsule 100 mg, 5 mg, 50 mg BENZODIAZEPINES alprazolam er oral tablet extended release hour 0.5 mg, 1 mg, mg, 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML 1 PA; GC; HR QL (10 EA per 30 days) QL (300 ML per 30 days) alprazolam oral tablet 0.5 mg, 0.5 mg 1 GC; QL (10 EA per 30 days) alprazolam oral tablet 1 mg 1 GC; QL (180 EA per 30 days) alprazolam oral tablet mg 1 GC; QL (150 EA per 30 days) alprazolam oral tablet dispersible 0.5 mg QL (70 EA per 30 days) alprazolam oral tablet dispersible 0.5 mg QL (180 EA per 30 days) alprazolam oral tablet dispersible 1 mg QL (360 EA per 30 days) alprazolam oral tablet dispersible mg QL (150 EA per 30 days) chlordiazepoxide hcl oral capsule 10 mg, 5 mg, 5 mg 1 GC; QL (10 EA per 30 days) 35

51 clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML QL (180 EA per 30 days) 3 QL (0 ML per 30 days) diazepam oral solution 5 mg/5ml 3 QL (100 ML per 30 days) diazepam oral tablet 10 mg 1 GC; QL (10 EA per 30 days) diazepam oral tablet mg 1 GC; QL (600 EA per 30 days) diazepam oral tablet 5 mg 1 GC; QL (0 EA per 30 days) lorazepam oral concentrate mg/ml QL (0 ML per 30 days) lorazepam oral tablet 0.5 mg, 1 mg, mg 1 GC; QL (150 EA per 30 days) oxazepam oral capsule 10 mg, 15 mg, 30 mg 1 GC; QL (10 EA per 30 days) BIPOLAR AGENTS MOOD STABILIZERS carbamazepine er oral capsule extended release 1 hour 100 mg MO carbamazepine oral tablet chewable 100 mg MO lithium carbonate er oral tablet extended release 300 mg, 50 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium oral solution 8 meq/5ml MO BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose oral tablet 100 mg, 5 mg, 50 mg MO ASSURE ID INSULIN SAFETY SYR 9G X 1/" 1 ML COMFORT ASSIST INSULIN SYRINGE 9G X 1/" 1 ML cvs gauze sterile pad "x" CYCLOSET ORAL TABLET 0.8 MG MO EXEL COMFORT POINT PEN NEEDLE 9G X 1MM glimepiride oral tablet 1 mg, mg, mg glipizide er oral tablet extended release hour 10 mg,.5 mg, 5 mg glipizide oral tablet 10 mg, 5 mg 36

52 glipizide-metformin hcl oral tablet.5-50 mg, mg, mg global alcohol prep ease pad 70 % INVOKAMET ORAL TABLET MG, MG, MG, MG INVOKAMET XR ORAL TABLET EXTENDED RELEASE HOUR MG, MG, MG, MG INVOKANA ORAL TABLET 100 MG, 300 MG JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE HOUR MG, MG, MG JANUVIA ORAL TABLET 100 MG, 5 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 5 MG metformin hcl er oral tablet extended release hour 500 mg, 750 mg metformin hcl oral tablet 1000 mg, 500 mg, 850 mg miglitol oral tablet 100 mg, 5 mg, 50 mg MO nateglinide oral tablet 10 mg, 60 mg MO OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.5 OR 0.5 MG/DOSE, 1 MG/DOSE pioglitazone hcl oral tablet 15 mg, 30 mg, 5 mg MO pioglitazone hcl-glimepiride oral tablet 30- mg MO pioglitazone hcl-metformin hcl oral tablet mg, mg preferred plus insulin syringe 8g x 1/" 0.5 ml RELI-ON INSULIN SYRINGE 9G 0.3 ML MO repaglinide oral tablet 0.5 mg, 1 mg, mg MO repaglinide-metformin hcl oral tablet mg, -500 mg RIOMET ORAL SOLUTION 500 MG/5ML MO SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR UNT-MCG/ML SYMLINPEN 10 SUBCUTANEOUS SOLUTION PEN-INJECTOR 700 MCG/.7ML 3 ST; MO 5 MO 37

53 SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML SYNJARDY ORAL TABLET MG, MG, MG, MG SYNJARDY XR ORAL TABLET EXTENDED RELEASE HOUR MG, MG, MG, MG MO tolazamide oral tablet 50 mg, 500 mg MO tolbutamide oral tablet 500 mg MO TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML valsartan-hydrochlorothiazide oral tablet mg VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR UNIT-MG/ML GLYCEMIC AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML INSULINS FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML FIASP SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML MO 3 ST; MO 3 3 MO 5 MO 5 MO 38

54 LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 00 UNIT/ML BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS ANTICOAGULANTS ELIQUIS ORAL TABLET.5 MG, 5 MG ELIQUIS STARTER PACK ORAL TABLET 5 MG enoxaparin sodium subcutaneous solution 100 mg/ml, 10 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 0 mg/0.ml, 60 mg/0.6ml, 80 mg/0.8ml fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 5 mg/0.ml, 7.5 mg/0.6ml 5 39

55 fondaparinux sodium subcutaneous solution.5 mg/0.5ml FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, 1500 UNIT/0.5ML, UNIT/0.6ML, UNT/0.7ML, 7500 UNIT/0.3ML, UNIT/3.8ML FRAGMIN SUBCUTANEOUS SOLUTION 500 UNIT/0.ML, 5000 UNIT/0.ML heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, 0000 unit/ml, 5000 unit/ml JANTOVEN ORAL TABLET 1 MG, 10 MG, MG,.5 MG, 3 MG, MG, 5 MG, 6 MG, 7.5 MG PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin sodium oral tablet 1 mg, 10 mg, mg,.5 mg, 3 mg, mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG,.5 MG, 0 MG XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 0 MG BLOOD FORMATION MODIFIERS EPOGEN INJECTION SOLUTION UNIT/ML, 000 UNIT/ML, 0000 UNIT/ML, 3000 UNIT/ML, 000 UNIT/ML LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 50 MCG MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.3ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 80 MCG/1.6ML NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 80 MCG/0.8ML PROCRIT INJECTION SOLUTION UNIT/ML, 000 UNIT/ML, 3000 UNIT/ML, 000 UNIT/ML PROCRIT INJECTION SOLUTION 0000 UNIT/ML, 0000 UNIT/ML 5 1 GC MO 3 PA 5 PA BD 5 PA 5 PA PA 5 PA 0

56 PROMACTA ORAL TABLET 1.5 MG, 5 MG, 50 MG, 75 MG tranexamic acid oral tablet 650 mg ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 80 MCG/0.8ML PLATELET MODIFYING AGENTS 5 PA; MO 5 PA anagrelide hcl oral capsule 0.5 mg, 1 mg MO aspirin-dipyridamole er oral capsule extended release 1 hour 5-00 mg MO BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg clopidogrel bisulfate oral tablet 75 mg dipyridamole oral tablet 5 mg, 50 mg, 75 mg 1 PA; MO; GC; HR CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl oral tablet 0.1 mg, 0. mg, 0.3 mg clonidine hcl transdermal patch weekly 0.1 mg/hr, 0. mg/hr, 0.3 mg/hr clonidine transdermal patch weekly 0.1 mg/hr, 0. mg/hr, 0.3 mg/hr MO MO methyldopa oral tablet 50 mg, 500 mg 1 PA; MO; GC; HR midodrine hcl oral tablet 10 mg,.5 mg, 5 mg ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate oral tablet 1 mg, mg, mg, 8 mg prazosin hcl oral capsule 1 mg, mg, 5 mg terazosin hcl oral capsule 1 mg, 10 mg, mg, 5 mg terazosin hcl oral capsule 10 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil oral tablet 16 mg, 3 mg, mg, 8 mg MO eprosartan mesylate oral tablet 600 mg irbesartan oral tablet 150 mg, 300 mg, 75 mg 1

57 losartan potassium oral tablet 100 mg, 5 mg, 50 mg olmesartan medoxomil oral tablet 0 mg, 0 mg, 5 mg MO telmisartan oral tablet 0 mg, 0 mg, 80 mg MO valsartan oral tablet 160 mg, 30 mg, 0 mg, 80 mg ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS benazepril hcl oral tablet 10 mg, 0 mg, 0 mg, 5 mg captopril oral tablet 100 mg, 1.5 mg, 5 mg, 50 mg enalapril maleate oral tablet 10 mg,.5 mg, 0 mg, 5 mg MO MO fosinopril sodium oral tablet 10 mg, 0 mg, 0 mg lisinopril oral tablet 10 mg,.5 mg, 0 mg, 30 mg, 0 mg, 5 mg moexipril hcl oral tablet 15 mg, 7.5 mg MO perindopril erbumine oral tablet mg, mg, 8 mg quinapril hcl oral tablet 10 mg, 0 mg, 0 mg, 5 mg ramipril oral capsule 1.5 mg, 10 mg,.5 mg, 5 mg trandolapril oral tablet 1 mg, mg, mg ANTIARRHYTHMICS amiodarone hcl oral tablet 100 mg, 00 mg, 00 mg disopyramide phosphate oral capsule 100 mg, 150 mg dofetilide oral capsule 15 mcg, 50 mcg, 500 mcg flecainide acetate oral tablet 100 mg, 150 mg, 50 mg mexiletine hcl oral capsule 150 mg, 00 mg, 50 mg MO PA; MO; HR MO MO MO MULTAQ ORAL TABLET 00 MG MO

58 PACERONE ORAL TABLET 100 MG, 00 MG, 00 MG propafenone hcl er oral capsule extended release 1 hour 5 mg, 35 mg, 5 mg propafenone hcl oral tablet 150 mg, 5 mg, 300 mg quinidine gluconate er oral tablet extended release 3 mg MO MO MO MO quinidine sulfate oral tablet 00 mg, 300 mg ANTIHYPERTENSIVE COMBINATIONS amiloride-hydrochlorothiazide oral tablet 5-50 mg amlodipine besy-benazepril hcl oral capsule 10-0 mg, 10-0 mg,.5-10 mg, 5-10 mg, 5-0 mg, 5-0 mg amlodipine besylate-valsartan oral tablet mg, mg, mg, 5-30 mg amlodipine-olmesartan oral tablet 10-0 mg, 10-0 mg, 5-0 mg, 5-0 mg amlodipine-valsartan-hctz oral tablet mg, mg, mg, mg, mg atenolol-chlorthalidone oral tablet mg, 50-5 mg benazepril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg, mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg candesartan cilexetil-hctz oral tablet mg, mg, 3-5 mg captopril-hydrochlorothiazide oral tablet 5-15 mg, 5-5 mg, mg, 50-5 mg enalapril-hydrochlorothiazide oral tablet 10-5 mg, mg ENTRESTO ORAL TABLET -6 MG, 9-51 MG, MG fosinopril sodium-hctz oral tablet mg, mg irbesartan-hydrochlorothiazide oral tablet mg, mg MO MO MO MO MO MO 3 PA; MO MO 3

59 lisinopril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg losartan potassium-hctz oral tablet mg, mg, mg methyldopa-hydrochlorothiazide oral tablet mg, 50-5 mg metoprolol-hydrochlorothiazide oral tablet mg, mg, 50-5 mg moexipril-hydrochlorothiazide oral tablet mg, 15-5 mg, mg nadolol-bendroflumethiazide oral tablet 0-5 mg, 80-5 mg olmesartan medoxomil-hctz oral tablet mg, mg, 0-5 mg olmesartan-amlodipine-hctz oral tablet mg, mg, mg, mg, mg 1 PA; MO; GC; HR MO MO MO pioglitazone hcl-glimepiride oral tablet 30- mg MO propranolol-hctz oral tablet 0-5 mg, 80-5 mg quinapril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg spironolactone-hctz oral tablet 5-5 mg MO telmisartan-amlodipine oral tablet 0-10 mg, 0-5 mg, mg, 80-5 mg telmisartan-hctz oral tablet mg, mg, 80-5 mg trandolapril-verapamil hcl er oral tablet extended release 1-0 mg, -180 mg, -0 mg, -0 mg MO MO MO triamterene-hctz oral capsule mg triamterene-hctz oral tablet mg, mg valsartan-hydrochlorothiazide oral tablet mg, mg, 30-5 mg, mg BETA-ADRENERGIC BLOCKING AGENTS MO acebutolol hcl oral capsule 00 mg, 00 mg atenolol oral tablet 100 mg, 5 mg, 50 mg bisoprolol fumarate oral tablet 10 mg, 5 mg BYSTOLIC ORAL TABLET 10 MG,.5 MG, 0 MG, 5 MG MO

60 carvedilol oral tablet 1.5 mg, 5 mg, 3.15 mg, 6.5 mg carvedilol phosphate er oral capsule extended release hour 10 mg, 0 mg, 0 mg, 80 mg MO labetalol hcl oral tablet 100 mg, 00 mg, 300 mg metoprolol succinate er oral tablet extended release hour 100 mg, 00 mg, 5 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 5 mg, 50 mg nadolol oral tablet 0 mg, 0 mg, 80 mg MO pindolol oral tablet 10 mg, 5 mg MO propranolol hcl er oral capsule extended release hour 10 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 0 mg/5ml, 0 mg/5ml propranolol hcl oral tablet 10 mg, 0 mg, 0 mg, 60 mg, 80 mg SORINE ORAL TABLET 10 MG, 160 MG, 0 MG, 80 MG MO sotalol hcl (af) oral tablet 10 mg, 160 mg, 80 mg sotalol hcl oral tablet 10 mg, 160 mg, 0 mg, 80 mg timolol maleate oral tablet 10 mg, 0 mg, 5 mg CALCIUM CHANNEL BLOCKING AGENTS AFEDITAB CR ORAL TABLET EXTENDED RELEASE HOUR 30 MG amlodipine besylate oral tablet 10 mg,.5 mg, 5 mg CARTIA XT ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 180 MG, 0 MG, 300 MG diltiazem hcl er beads oral capsule extended release hour 360 mg, 0 mg diltiazem hcl er coated beads oral capsule extended release hour 10 mg, 180 mg, 0 mg, 300 mg diltiazem hcl er oral capsule extended release 1 hour 10 mg, 60 mg, 90 mg MO MO MO MO MO 5

61 diltiazem hcl oral tablet 10 mg, 30 mg, 60 mg, 90 mg dilt-xr oral capsule extended release hour 10 mg, 180 mg, 0 mg felodipine er oral tablet extended release hour 10 mg,.5 mg, 5 mg isradipine oral capsule.5 mg, 5 mg nicardipine hcl oral capsule 0 mg, 30 mg nifedipine er oral tablet extended release hour 30 mg, 60 mg, 90 mg nifedipine er osmotic release oral tablet extended release hour 30 mg, 60 mg, 90 mg MO MO nimodipine oral capsule 30 mg MO nisoldipine er oral tablet extended release hour 17 mg, 0 mg, 5.5 mg, 30 mg, 3 mg, 0 mg, 8.5 mg TAZTIA XT ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 180 MG, 0 MG, 300 MG TAZTIA XT ORAL CAPSULE EXTENDED RELEASE HOUR 360 MG verapamil hcl er oral capsule extended release hour 100 mg, 10 mg, 180 mg, 00 mg, 0 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 10 mg, 180 mg, 0 mg MO MO MO verapamil hcl oral tablet 10 mg, 0 mg, 80 mg CARDIOVASCULAR AGENTS, OTHER amlodipine-atorvastatin oral tablet mg, 10-0 mg, 10-0 mg, mg,.5-10 mg,.5-0 mg,.5-0 mg, 5-10 mg, 5-0 mg, 5-0 mg, 5-80 mg MO BIDIL ORAL TABLET MG MO CORLANOR ORAL TABLET 5 MG, 7.5 MG PA; MO DIGITEK ORAL TABLET 15 MCG, 50 MCG 1 DIGITEK ORAL TABLET 15 MCG, 50 MCG DIGOX ORAL TABLET 15 MCG, 50 MCG digoxin oral solution 0.05 mg/ml digoxin oral tablet 15 mcg, 50 mcg 6

62 NORTHERA ORAL CAPSULE 100 MG, 00 MG, 300 MG pentoxifylline er oral tablet extended release 00 mg RANEXA ORAL TABLET EXTENDED RELEASE 1 HOUR 1000 MG, 500 MG TEKTURNA HCT ORAL TABLET MG, MG, MG, MG 5 PA TEKTURNA ORAL TABLET 150 MG, 300 MG DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide oral tablet 15 mg, 50 mg MO bumetanide oral tablet 0.5 mg, 1 mg, mg MO methazolamide oral tablet 5 mg, 50 mg MO DIURETICS, LOOP bumetanide injection solution 0.5 mg/ml furosemide injection solution 10 mg/ml, 10 mg/ml (ml syringe) furosemide oral solution 10 mg/ml, 8 mg/ml MO furosemide oral tablet 0 mg, 0 mg, 80 mg torsemide oral tablet 10 mg, 100 mg, 0 mg, 5 mg DIURETICS, POTASSIUM-SPARING amiloride hcl oral tablet 5 mg DEMSER ORAL CAPSULE 50 MG 5 eplerenone oral tablet 5 mg, 50 mg MO spironolactone oral tablet 100 mg, 5 mg, 50 mg DIURETICS, THIAZIDE chlorothiazide oral tablet 50 mg, 500 mg MO chlorthalidone oral tablet 5 mg, 50 mg hydrochlorothiazide oral capsule 1.5 mg hydrochlorothiazide oral tablet 1.5 mg, 5 mg, 50 mg 7 indapamide oral tablet 1.5 mg,.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg,.5 mg, 5 mg MO DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES

63 fenofibrate micronized oral capsule 130 mg, 13 mg, 00 mg, 3 mg, 67 mg MO fenofibrate oral capsule 150 mg, 50 mg fenofibrate oral tablet 15 mg, 160 mg, 8 mg, 5 mg MO gemfibrozil oral tablet 600 mg DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 10 mg, 0 mg, 0 mg, 80 mg fluvastatin sodium er oral tablet extended release hour 80 mg MO fluvastatin sodium oral capsule 0 mg, 0 mg MO LIVALO ORAL TABLET 1 MG, MG, MG lovastatin oral tablet 10 mg, 0 mg, 0 mg pravastatin sodium oral tablet 10 mg, 0 mg, 0 mg, 80 mg rosuvastatin calcium oral tablet 10 mg, 0 mg, 0 mg, 5 mg simvastatin oral tablet 10 mg, 0 mg, 0 mg, 5 mg, 80 mg DYSLIPIDEMICS, OTHER cholestyramine light oral powder gm/dose MO cholestyramine oral packet gm MO colesevelam hcl oral packet 3.75 gm colestipol hcl oral packet 5 gm MO colestipol hcl oral tablet 1 gm MO ezetimibe oral tablet 10 mg JUXTAPID ORAL CAPSULE 10 MG, 0 MG, 30 MG, 0 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/ML niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg 5 PA; MO 5 PA; MO MO NIACOR ORAL TABLET 500 MG 1 GC omega-3-acid ethyl esters oral capsule 1 gm MO PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 150 MG/ML, 75 MG/ML 5 PA; MO 8

64 REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 0 MG/3.5ML REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10 MG/ML REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/ML 5 PA; MO 5 PA; MO 5 PA; MO VASCEPA ORAL CAPSULE 0.5 GM, 1 GM MO WELCHOL ORAL TABLET 65 MG VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS isosorbide dinitrate er oral tablet extended release 0 mg isosorbide dinitrate oral tablet 10 mg, 0 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release hour 10 mg, 30 mg, 60 mg MO MO isosorbide mononitrate oral tablet 10 mg, 0 mg NITRO-BID TRANSDERMAL OINTMENT % NITRO-DUR TRANSDERMAL PATCH HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet sublingual 0.3 mg, 0. mg, 0.6 mg nitroglycerin transdermal patch hour 0.1 mg/hr, 0. mg/hr, 0. mg/hr, 0.6 mg/hr MO nitroglycerin translingual solution 0. mg/spray MO VASODILATORS, DIRECT-ACTING ARTERIAL hydralazine hcl oral tablet 10 mg, 100 mg, 5 mg, 50 mg minoxidil oral tablet 10 mg,.5 mg CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES amphetamine-dextroamphetamine oral tablet 10 mg, 1.5 mg, 15 mg, 0 mg, 30 mg, 5 mg, 7.5 mg MO 9

65 dextroamphetamine sulfate er oral capsule extended release hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral tablet 10 mg, 5 mg ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 5 mg, 0 mg, 60 mg, 80 mg guanfacine hcl er oral tablet extended release hour 1 mg, mg, 3 mg, mg METADATE ER ORAL TABLET EXTENDED RELEASE 0 MG methylphenidate hcl er (cd) oral capsule extended release 10 mg, 0 mg, 30 mg, 0 mg, 50 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg, 0 mg, 7 mg methylphenidate hcl er oral tablet extended release hour 18 mg, 7 mg, 36 mg, 5 mg methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 10 mg, 0 mg, 5 mg CENTRAL NERVOUS SYSTEM, OTHER AUSTEDO ORAL TABLET 1 MG, 6 MG, 9 MG MO MO MO PA; MO; HR MO MO MO MO MO MO 5 PA; MO NUEDEXTA ORAL CAPSULE 0-10 MG 3 PA; MO riluzole oral tablet 50 mg MO tetrabenazine oral tablet 1.5 mg, 5 mg 5 PA; MO TIGLUTIK ORAL SUSPENSION 50 MG/10ML MO FIBROMYALGIA AGENTS LYRICA ORAL CAPSULE 100 MG, 150 MG SAVELLA ORAL TABLET 100 MG, 1.5 MG, 5 MG, 50 MG SAVELLA TITRATION PACK ORAL 1.5 & 5 & 50 MG MULTIPLE SCLEROSIS AGENTS 50 3

66 AUBAGIO ORAL TABLET 1 MG, 7 MG 5 PA; LA; MO AVONEX INTRAMUSCULAR KIT 30 MCG 5 PA; MO AVONEX PEN INTRAMUSCULAR AUTO- INJECTOR KIT 30 MCG/0.5ML AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML 5 PA; MO 5 PA; MO BETASERON SUBCUTANEOUS KIT 0.3 MG 5 PA; MO dalfampridine er oral tablet extended release 1 hour 10 mg 5 PA; MO GILENYA ORAL CAPSULE 0.5 MG 5 PA; MO glatiramer acetate subcutaneous solution prefilled syringe 0 mg/ml, 0 mg/ml PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN- INJECTOR 63 & 9 MCG/0.5ML PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 9 MCG/0.5ML PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR 15 MCG/0.5ML PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 15 MCG/0.5ML 5 PA; MO 5 PA 5 PA 5 PA; MO 5 PA; MO SOLTAMOX ORAL SOLUTION 10 MG/5ML MO TECFIDERA ORAL 10 & 0 MG 5 PA TECFIDERA ORAL CAPSULE DELAYED RELEASE 10 MG, 0 MG DENTAL AND ORAL AGENTS DENTAL AND ORAL AGENTS chlorhexidine gluconate mouth/throat solution 0.1 % lidocaine viscous mouth/throat solution % nystatin mouth/throat suspension unit/ml ORAVIG BUCCAL TABLET 50 MG 5 PA; MO 1 GC pilocarpine hcl oral tablet 5 mg, 7.5 mg MO triamcinolone acetonide mouth/throat paste 0.1 % DERMATOLOGICAL AGENTS DERMATOLOGICAL AGENTS acitretin oral capsule 10 mg, 17.5 mg, 5 mg 5 51

67 acyclovir external ointment 5 % alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % amcinonide external cream 0.1 % amcinonide external lotion 0.1 % amcinonide external ointment 0.1 % 3 ammonium lactate external cream 1 % 1 GC ammonium lactate external lotion 1 % 1 GC AMNESTEEM ORAL CAPSULE 10 MG, 0 MG, 0 MG benzoyl peroxide-erythromycin external gel 5-3 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0.1 % 1 GC betamethasone valerate external lotion 0.1 % 1 GC betamethasone valerate external ointment 0.1 % 1 GC calcipotriene external cream % calcipotriene external ointment % calcipotriene external solution % calcitriol external ointment 3 mcg/gm ciclopirox external gel 0.77 % ciclopirox external shampoo 1 % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % 5

68 CLARAVIS ORAL CAPSULE 10 MG, 0 MG, 30 MG, 0 MG clindamycin phosphate external gel 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % clobetasol prop emollient base external cream 0.05 % clobetasol propionate external cream 0.05 % clobetasol propionate external gel 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external solution 0.05 % clotrimazole external cream 1 % 1 GC clotrimazole external solution 1 % 1 GC clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % CONDYLOX EXTERNAL GEL 0.5 % COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 150 MG/ML desonide external cream 0.05 % desonide external lotion 0.05 % 3 desonide external ointment 0.05 % 3 desoximetasone external cream 0.05 %, 0.5 % desoximetasone external gel 0.05 % desoximetasone external ointment 0.05 %, 0.5 % diclofenac sodium transdermal gel 1 % 53 5 PA; MO 5 PA; MO diclofenac sodium transdermal gel 3 % 5 PA diclofenac sodium transdermal solution 1.5 % diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % econazole nitrate external cream 1 % ELIDEL EXTERNAL CREAM 1 %

69 ery external pad % erythromycin external gel % erythromycin external solution % EUCRISA EXTERNAL OINTMENT % fluocinolone acetonide external cream 0.01 %, 0.05 % fluocinolone acetonide external ointment 0.05 % fluocinolone acetonide external solution 0.01 % fluocinolone acetonide scalp external oil 0.01 % fluocinonide emulsified base external cream 0.05 % fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluorouracil external cream 5 % fluticasone propionate external cream 0.05 % fluticasone propionate external ointment % gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % HALOG EXTERNAL CREAM 0.1 % HALOG EXTERNAL OINTMENT 0.1 % hydrocortisone ace-pramoxine rectal cream 1-1 % hydrocortisone butyrate external cream 0.1 % 3 hydrocortisone butyrate external lotion 0.1 % 3 hydrocortisone butyrate external ointment 0.1 % 3 hydrocortisone butyrate external solution 0.1 % 3 hydrocortisone external cream 1 %,.5 % 1 GC hydrocortisone external lotion.5 % 1 GC hydrocortisone external ointment 1 %,.5 % 1 GC hydrocortisone valerate external cream 0. % hydrocortisone valerate external ointment 0. % imiquimod external cream 5 % 3 isotretinoin oral capsule 10 mg, 0 mg, 30 mg, 0 mg 5

70 JUBLIA EXTERNAL SOLUTION 10 % ketoconazole external cream % ketoconazole external shampoo % 1 GC lidocaine hcl external gel % lidocaine hcl external solution % 1 GC lindane external shampoo 1 % 3 malathion external lotion 0.5 % 3 methoxsalen rapid oral capsule 10 mg 5 metronidazole external cream 0.75 % metronidazole external gel 0.75 %, 1 % metronidazole external lotion 0.75 % mometasone furoate external cream 0.1 % 1 GC mometasone furoate external ointment 0.1 % 1 GC mometasone furoate external solution 0.1 % 1 GC mupirocin calcium external cream % mupirocin external ointment % NYAMYC EXTERNAL POWDER UNIT/GM nystatin external cream unit/gm 1 GC nystatin external ointment unit/gm 1 GC nystatin external powder unit/gm nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% NYSTOP EXTERNAL POWDER UNIT/GM PANRETIN EXTERNAL GEL 0.1 % 5 permethrin external cream 5 % PICATO EXTERNAL GEL %, 0.05 % podofilox external solution 0.5 % prednicarbate external cream 0.1 % prednicarbate external ointment 0.1 % PROCTO-MED HC RECTAL CREAM.5 % PROCTO-PAK RECTAL CREAM 1 % PROCTOSOL HC RECTAL CREAM.5 % PROCTOZONE-HC RECTAL CREAM.5 % 55

71 REGRANEX EXTERNAL GEL 0.01 % 5 PA SANTYL EXTERNAL OINTMENT 50 UNIT/GM selenium sulfide external lotion.5 % 1 GC silver sulfadiazine external cream 1 % 1 GC SSD EXTERNAL CREAM 1 % 1 GC STELARA SUBCUTANEOUS SOLUTION 5 MG/0.5ML STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 5 MG/0.5ML, 90 MG/ML sulfacetamide sodium (acne) external lotion 10 % tacrolimus external ointment 0.03 %, 0.1 % TARGRETIN EXTERNAL GEL 1 % 5 tazarotene external cream 0.1 % TAZORAC EXTERNAL CREAM 0.05 % TAZORAC EXTERNAL GEL 0.05 %, 0.1 % TOLAK EXTERNAL CREAM % tretinoin external gel 0.01 %, 0.05 %, 0.05 % triamcinolone acetonide external cream 0.05 %, 0.1 %, 0.5 % triamcinolone acetonide external lotion 0.05 %, 0.1 % triamcinolone acetonide external ointment 0.05 %, 0.1 %, 0.5 % UCERIS RECTAL FOAM MG/ACT VALCHLOR EXTERNAL GEL % 5 ELECTROLYTES/MINERALS/META LS/VITAMINS ELECTROLYTE/MINERAL REPLACEMENT 5 PA; MO 5 PA; MO 1 GC 1 GC 1 GC CARBAGLU ORAL TABLET 00 MG 5 MO dextrose-nacl intravenous solution %, %, %, 5-0. %, %, %, %, % IONOSOL-MB IN D5W INTRAVENOUS SOLUTION 3 56

72 ISOLYTE-P IN D5W INTRAVENOUS SOLUTION ISOLYTE-S INTRAVENOUS SOLUTION kcl in dextrose-nacl intravenous solution meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-% kcl-lactated ringers-d5w intravenous solution 0 meq/l KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ KLOR-CON M10 ORAL TABLET EXTENDED RELEASE 10 MEQ KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ KLOR-CON M0 ORAL TABLET EXTENDED RELEASE 0 MEQ KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 10 MEQ, 8 MEQ magnesium sulfate injection solution 50 %, 50 % (10ml syringe) NORMOSOL-M IN D5W INTRAVENOUS SOLUTION NORMOSOL-R IN D5W INTRAVENOUS SOLUTION NORMOSOL-R PH 7. INTRAVENOUS SOLUTION PLASMA-LYTE 18 INTRAVENOUS SOLUTION PLASMA-LYTE A INTRAVENOUS SOLUTION potassium chloride crys er oral tablet extended release 10 meq, 0 meq potassium chloride er oral capsule extended release 10 meq, 8 meq potassium chloride er oral tablet extended release 10 meq, 0 meq, 8 meq 3 MO 1 GC MO 57

73 potassium chloride in dextrose intravenous solution 0-5 meq/l-%, 0-5 meq/l-% potassium chloride in nacl intravenous solution meq/l-%, meq/l-%, meq/l-% potassium chloride intravenous solution 10 meq/100ml, meq/ml, meq/ml (0 ml), 0 meq/100ml, 0 meq/100ml potassium chloride oral solution 0 meq/15ml (10%), 0 meq/15ml (0%) potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (160 mg), 5 meq (50 mg) sodium chloride intravenous solution 0.5 %, 0.9 %, 3 %, 5 % 58 MO sodium lactate intravenous solution 5 meq/ml 1 GC TPN ELECTROLYTES INTRAVENOUS SOLUTION ELECTROLYTE/MINERAL/METAL MODIFIERS CHEMET ORAL CAPSULE 100 MG 3 EXJADE ORAL TABLET SOLUBLE 15 MG, 50 MG, 500 MG 5 MO FERRIPROX ORAL SOLUTION 100 MG/ML 5 MO FERRIPROX ORAL TABLET 500 MG 5 MO KIONEX ORAL SUSPENSION 15 GM/60ML SAMSCA ORAL TABLET 15 MG, 30 MG 5 PA sodium polystyrene sulfonate oral powder SPS ORAL SUSPENSION 15 GM/60ML VELTASSA ORAL PACKET 16.8 GM, 5. GM, 8. GM NUTRIENTS AMINOSYN II INTRAVENOUS SOLUTION 10 %, 8.5 % AMINOSYN II/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 % AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 %, 8.5 % AMINOSYN-HBC INTRAVENOUS SOLUTION 7 % MO BD BD BD BD

74 AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 % AMINOSYN-RF INTRAVENOUS SOLUTION 5. % CLINIMIX E/DEXTROSE (.75/10) INTRAVENOUS SOLUTION.75 % CLINIMIX E/DEXTROSE (.75/5) INTRAVENOUS SOLUTION.75 % CLINIMIX E/DEXTROSE (.5/10) INTRAVENOUS SOLUTION.5 % CLINIMIX E/DEXTROSE (.5/5) INTRAVENOUS SOLUTION.5 % CLINIMIX E/DEXTROSE (.5/5) INTRAVENOUS SOLUTION.5 % CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/0) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (.5/10) INTRAVENOUS SOLUTION.5 % CLINIMIX/DEXTROSE (.5/5) INTRAVENOUS SOLUTION.5 % CLINIMIX/DEXTROSE (.5/5) INTRAVENOUS SOLUTION.5 % CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/0) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/5) INTRAVENOUS SOLUTION 5 % CLINISOL SF INTRAVENOUS SOLUTION 15 % BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD BD dextrose intravenous solution 10 %, 5 % BD FREAMINE HBC INTRAVENOUS SOLUTION 6.9 % HEPATAMINE INTRAVENOUS SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 0 %, 30 % BD BD BD 59

75 NEPHRAMINE INTRAVENOUS SOLUTION 5. % BD nutrilipid intravenous emulsion 0 % BD PLENAMINE INTRAVENOUS SOLUTION 15 % PREMASOL INTRAVENOUS SOLUTION 10 %, 6 % PROCALAMINE INTRAVENOUS SOLUTION 3 % BD BD BD PROSOL INTRAVENOUS SOLUTION 0 % BD TRAVASOL INTRAVENOUS SOLUTION 10 % TROPHAMINE INTRAVENOUS SOLUTION 10 % VITAMINS BD BD prenatal oral tablet 7-1 mg 1 GC sodium fluoride oral tablet. (1 f) mg 1 GC GASTROINTESTINAL AGENTS ANTISPASMODICS, GASTROINTESTINAL dicyclomine hcl oral capsule 10 mg 1 GC dicyclomine hcl oral solution 10 mg/5ml dicyclomine hcl oral tablet 0 mg 1 GC glycopyrrolate oral tablet 1 mg, mg methscopolamine bromide oral tablet.5 mg, 5 mg GASTROINTESTINAL AGENTS, OTHER cromolyn sodium oral concentrate 100 mg/5ml MO diphenoxylate-atropine oral liquid mg/5ml 1 GC diphenoxylate-atropine oral tablet mg 1 GC GATTEX SUBCUTANEOUS KIT 5 MG 5 MO loperamide hcl oral capsule mg 1 GC metoclopramide hcl oral solution 5 mg/5ml 1 GC metoclopramide hcl oral tablet 10 mg MOVANTIK ORAL TABLET 1.5 MG, 5 MG 3 60

76 ursodiol oral capsule 300 mg MO ursodiol oral tablet 50 mg, 500 mg MO HISTAMINE (H) RECEPTOR ANTAGONISTS famotidine oral suspension reconstituted 0 mg/5ml MO famotidine oral tablet 0 mg, 0 mg ranitidine hcl oral capsule 150 mg, 300 mg ranitidine hcl oral syrup 75 mg/5ml MO ranitidine hcl oral tablet 150 mg, 300 mg IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl oral tablet 0.5 mg, 1 mg 5 MO AMITIZA ORAL CAPSULE MCG, 8 MCG LINZESS ORAL CAPSULE 15 MCG, 90 MCG, 7 MCG LAXATIVES CLENPIQ ORAL SOLUTION MG- GM -GM/160ML enulose oral solution 10 gm/15ml GAVILYTE-C ORAL SOLUTION RECONSTITUTED 0 GM GAVILYTE-G ORAL SOLUTION RECONSTITUTED 36 GM GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 0 GM generlac oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml peg 3350/electrolytes oral solution reconstituted 0 gm peg 3350-kcl-na bicarb-nacl oral solution reconstituted 0 gm peg-3350/electrolytes oral solution reconstituted 36 gm polyethylene glycol 3350 oral powder PREPOPIK ORAL PACKET MG-GM- GM 61

77 SUPREP BOWEL PREP KIT ORAL SOLUTION GM/177ML TRILYTE ORAL SOLUTION RECONSTITUTED 0 GM PROTECTANTS CARAFATE ORAL SUSPENSION 1 GM/10ML MO misoprostol oral tablet 100 mcg, 00 mcg MO sucralfate oral tablet 1 gm PROTON PUMP INHIBITORS DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG esomeprazole magnesium oral capsule delayed release 0 mg, 0 mg lansoprazole oral capsule delayed release 15 mg, 30 mg omeprazole oral capsule delayed release 10 mg, 0 mg, 0 mg pantoprazole sodium oral tablet delayed release 0 mg, 0 mg GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT ENZYME REPLACEMENT/ MODIFIERS CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 1000 UNIT, UNIT, UNIT, UNIT, 6000 UNIT 3 ST; MO 3 ST; MO MO CYSTADANE ORAL POWDER 5 MO GALAFOLD ORAL CAPSULE 13 MG 5 KUVAN ORAL PACKET 100 MG, 500 MG 5 PA; MO KUVAN ORAL TABLET SOLUBLE 100 MG 5 PA; LA; MO levocarnitine oral solution 1 gm/10ml 1 BD; MO; GC levocarnitine oral tablet 330 mg 1 BD; MO; GC miglustat oral capsule 100 mg 5 PA; MO ORFADIN ORAL CAPSULE 10 MG, MG, 0 MG, 5 MG 5 MO PA; LA; MO; QL (15 EA per 30 days) 6

78 ORFADIN ORAL SUSPENSION MG/ML 5 LA; MO RAVICTI ORAL LIQUID 1.1 GM/ML 5 MO XURIDEN ORAL PACKET GM 5 PA; MO ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, UNIT GENITOURINARY AGENTS ANTISPASMODICS, URINARY bethanechol chloride oral tablet 10 mg, 5 mg, 5 mg, 50 mg darifenacin hydrobromide er oral tablet extended release hour 15 mg, 7.5 mg MYRBETRIQ ORAL TABLET EXTENDED RELEASE HOUR 5 MG, 50 MG oxybutynin chloride er oral tablet extended release hour 10 mg, 15 mg, 5 mg 63 MO MO oxybutynin chloride oral syrup 5 mg/5ml MO oxybutynin chloride oral tablet 5 mg tolterodine tartrate er oral capsule extended release hour mg, mg tolterodine tartrate oral tablet 1 mg, mg MO BENIGN PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl er oral tablet extended release hour 10 mg dutasteride oral capsule 0.5 mg MO dutasteride-tamsulosin hcl oral capsule mg MO; QL (30 EA per 30 days) MO; QL (30 EA per 30 days) MO finasteride oral tablet 5 mg RAPAFLO ORAL CAPSULE MG, 8 MG MO tamsulosin hcl oral capsule 0. mg MO GENITOURINARY AGENTS, OTHER CYSTAGON ORAL CAPSULE 150 MG, 50 MG MO ELMIRON ORAL CAPSULE 100 MG sodium chloride irrigation solution 0.9 % PHOSPHATE BINDERS

79 AURYXIA ORAL TABLET 1 GM 10 MG(FE) PA; MO calcium acetate (phos binder) oral capsule 667 mg MO calcium acetate (phos binder) oral tablet 667 mg MO sevelamer carbonate oral packet 0.8 gm,. gm 5 MO sevelamer carbonate oral tablet 800 mg VELPHORO ORAL TABLET CHEWABLE 500 MG VAGINAL PRODUCTS clindamycin phosphate vaginal cream % MO estradiol vaginal cream 0.1 mg/gm estradiol vaginal tablet 10 mcg MO INTRAROSA VAGINAL INSERT 6.5 MG PA; MO metronidazole vaginal gel 0.75 % miconazole 3 vaginal suppository 00 mg 1 GC PREMARIN VAGINAL CREAM 0.65 MG/GM terconazole vaginal cream 0. %, 0.8 % terconazole vaginal suppository 80 mg YUVAFEM VAGINAL TABLET 10 MCG MO HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) GLUCOCORTICOIDS/MINERALOC ORTICOIDS budesonide er oral tablet extended release hour 9 mg budesonide oral capsule delayed release particles 3 mg DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, mg, mg, 6 mg 5 1 GC fludrocortisone acetate oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 0 mg, 5 mg methylprednisolone oral tablet 16 mg, 3 mg, mg, 8 mg 1 GC 6

80 methylprednisolone oral tablet therapy pack mg prednisolone oral solution 15 mg/5ml prednisolone sodium phosphate oral solution 10 mg/5ml, 0 mg/5ml, 5 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg prednisone oral solution 5 mg/5ml 1 GC prednisone oral tablet 1 mg, 10 mg,.5 mg, 0 mg, 5 mg, 50 mg prednisone oral tablet therapy pack 10 mg (1), 10 mg (8), 5 mg (1), 5 mg (8) HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) ANABOLIC STEROIDS ANADROL-50 ORAL TABLET 50 MG 5 oxandrolone oral tablet 10 mg 5 oxandrolone oral tablet.5 mg ANDROGENS danazol oral capsule 100 mg, 00 mg, 50 mg 1 GC 1 GC methyltestosterone oral capsule 10 mg 5 MO testosterone cypionate intramuscular solution 100 mg/ml, 00 mg/ml testosterone enanthate intramuscular solution 00 mg/ml testosterone transdermal gel 10 mg/act (%), 1.5 mg/act (1%), 5 mg/.5gm (1%), 50 mg/5gm (1%) testosterone transdermal gel 0.5 mg/1.5gm (1.6%), 0.5 mg/act (1.6%), 0.5 mg/.5gm (1.6%) MO testosterone transdermal solution 30 mg/act MO CONTRACEPTIVES ALTAVERA ORAL TABLET MG- MCG MO alyacen 1/35 oral tablet 1-35 mg-mcg MO 65

81 AMETHIA ORAL TABLET &0.01 MG MO APRI ORAL TABLET MG-MCG MO ARANELLE ORAL TABLET 0.5/1/ MG- MCG ASHLYNA ORAL TABLET &0.01 MG MO MO AUBRA ORAL TABLET MG-MCG MO AVIANE ORAL TABLET MG-MCG MO BALZIVA ORAL TABLET MG-MCG MO BLISOVI FE ORAL TABLET 1-0 MG- MCG() BLISOVI FE 1.5/30 ORAL TABLET MG-MCG BLISOVI FE 1/0 ORAL TABLET 1-0 MG- MCG MO MO MO briellyn oral tablet mg-mcg MO CAMILA ORAL TABLET 0.35 MG CAZIANT ORAL TABLET 0.1/0.15/ MG CRYSELLE-8 ORAL TABLET MG- MCG CYCLAFEM 1/35 ORAL TABLET 1-35 MG- MCG CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG MO 66 MO MO CYRED EQ ORAL TABLET MG-MCG MO DEBLITANE ORAL TABLET 0.35 MG DELYLA ORAL TABLET MG-MCG MO DEPO-SUBQ PROVERA 10 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 10 MG/0.65ML desogestrel-ethinyl estradiol oral tablet /0.01 mg (1/5), mg-mcg drospirenone-ethinyl estradiol oral tablet mg, mg EMOQUETTE ORAL TABLET MG- MCG MO MO MO ENPRESSE-8 ORAL TABLET MO

82 ENSKYCE ORAL TABLET MG-MCG MO ERRIN ORAL TABLET 0.35 MG ESTARYLLA ORAL TABLET MG- MCG ethynodiol diac-eth estradiol oral tablet 1-35 mgmcg, 1-50 mg-mcg MO MO FALMINA ORAL TABLET MG-MCG MO FEMYNOR ORAL TABLET MG-MCG MO GIANVI ORAL TABLET MG MO INCASSIA ORAL TABLET 0.35 MG INTROVALE ORAL TABLET MG MO ISIBLOOM ORAL TABLET MG-MCG MO JOLIVETTE ORAL TABLET 0.35 MG JULEBER ORAL TABLET MG-MCG MO JUNEL 1.5/30 ORAL TABLET MG- MCG MO JUNEL 1/0 ORAL TABLET 1-0 MG-MCG MO JUNEL FE 1.5/30 ORAL TABLET MG- MCG MO JUNEL FE 1/0 ORAL TABLET 1-0 MG-MCG MO JUNEL FE ORAL TABLET 1-0 MG- MCG() KARIVA ORAL TABLET /0.01 MG (1/5) MO KELNOR 1/35 ORAL TABLET 1-35 MG-MCG MO KELNOR 1/50 ORAL TABLET 1-50 MG-MCG MO KURVELO ORAL TABLET MG-MCG MO LARIN 1.5/30 ORAL TABLET MG- MCG MO LARIN 1/0 ORAL TABLET 1-0 MG-MCG MO LARIN FE 1.5/30 ORAL TABLET MG- MCG MO LARIN FE 1/0 ORAL TABLET 1-0 MG-MCG MO LARISSIA ORAL TABLET MG-MCG MO LEENA ORAL TABLET 0.5/1/ MG-MCG MO LESSINA ORAL TABLET MG-MCG MO LEVONEST ORAL TABLET MO 67

83 levonorgest-eth estrad 91-day oral tablet &0.01 mg, mg levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg-mcg MO MO levonorg-eth estrad triphasic oral tablet MO LEVORA 0.15/30 (8) ORAL TABLET MG-MCG MO LORYNA ORAL TABLET MG MO LOW-OGESTREL ORAL TABLET MG- MCG MO LUTERA ORAL TABLET MG-MCG MO LYZA ORAL TABLET 0.35 MG marlissa oral tablet mg-mcg MO medroxyprogesterone acetate intramuscular suspension 150 mg/ml medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml MICROGESTIN 1.5/30 ORAL TABLET MG-MCG MICROGESTIN 1/0 ORAL TABLET 1-0 MG-MCG MICROGESTIN FE 1.5/30 ORAL TABLET MG-MCG MICROGESTIN FE 1/0 ORAL TABLET 1-0 MG-MCG 68 MO MO MO MO MILI ORAL TABLET MG-MCG MO MONONESSA ORAL TABLET MG- MCG NECON 0.5/35 (8) ORAL TABLET MG-MCG MO MO NIKKI ORAL TABLET MG MO NORA-BE ORAL TABLET 0.35 MG norethin ace-eth estrad-fe oral tablet 1-0 mgmcg() norethindrone acet-ethinyl est oral tablet 1-0 mg-mcg MO MO norethindrone oral tablet 0.35 mg norethin-eth estradiol-fe oral tablet chewable mg-mcg MO

84 norgestimate-eth estradiol oral tablet mgmcg norgestim-eth estrad triphasic oral tablet 0.18/0.15/0.5 mg-5 mcg, 0.18/0.15/0.5 mg- 35 mcg MO MO NORLYROC ORAL TABLET 0.35 MG NORTREL 0.5/35 (8) ORAL TABLET MG-MCG NORTREL 1/35 (1) ORAL TABLET 1-35 MG- MCG NORTREL 1/35 (8) ORAL TABLET 1-35 MG- MCG NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG NUVARING VAGINAL RING MG/HR MO MO MO MO MO OCELLA ORAL TABLET MG MO OGESTREL ORAL TABLET MG-MCG MO ORSYTHIA ORAL TABLET MG-MCG MO PIMTREA ORAL TABLET /0.01 MG (1/5) PIRMELLA 1/35 ORAL TABLET 1-35 MG- MCG MO MO PORTIA-8 ORAL TABLET MG-MCG MO PREVIFEM ORAL TABLET MG-MCG MO QUASENSE ORAL TABLET MG MO RECLIPSEN ORAL TABLET MG- MCG MO SETLAKIN ORAL TABLET MG MO SHAROBEL ORAL TABLET 0.35 MG SPRINTEC 8 ORAL TABLET MG- MCG MO SRONYX ORAL TABLET MG-MCG MO SYEDA ORAL TABLET MG MO TARINA FE 1/0 ORAL TABLET 1-0 MG- MCG TRI-LEGEST FE ORAL TABLET 1-0/1-30/1-35 MG-MCG MO MO 69

85 TRI-LO-ESTARYLLA ORAL TABLET 0.18/0.15/0.5 MG-5 MCG TRI-LO-SPRINTEC ORAL TABLET 0.18/0.15/0.5 MG-5 MCG TRI-MILI ORAL TABLET 0.18/0.15/0.5 MG- 35 MCG TRINESSA (8) ORAL TABLET 0.18/0.15/0.5 MG-35 MCG TRI-PREVIFEM ORAL TABLET 0.18/0.15/0.5 MG-35 MCG TRI-SPRINTEC ORAL TABLET 0.18/0.15/0.5 MG-35 MCG MO MO MO MO MO MO TRIVORA (8) ORAL TABLET MO TRI-VYLIBRA ORAL TABLET 0.18/0.15/0.5 MG-35 MCG VELIVET ORAL TABLET 0.1/0.15/ MG MO MO VIENVA ORAL TABLET MG-MCG MO VYFEMLA ORAL TABLET MG-MCG MO VYLIBRA ORAL TABLET MG-MCG MO WYMZYA FE ORAL TABLET CHEWABLE MG-MCG MO ZARAH ORAL TABLET MG MO ZENCHENT ORAL TABLET MG-MCG MO ZOVIA 1/35E (8) ORAL TABLET 1-35 MG- MCG ESTROGENS MO estradiol oral tablet 0.5 mg, 1 mg, mg 1 PA; MO; GC; HR estradiol-norethindrone acet oral tablet mg, mg PA; MO; HR FYAVOLV ORAL TABLET 1-5 MG-MCG PA; MO; HR JINTELI ORAL TABLET 1-5 MG-MCG PA; MO; HR MENEST ORAL TABLET 0.3 MG, 0.65 MG, 1.5 MG norethindrone-eth estradiol oral tablet mg-mcg norethindrone-eth estradiol oral tablet 1-5 mgmcg PA; MO; HR 1 PA; MO; GC; HR PA; MO; HR 70

86 PREMARIN ORAL TABLET 0.3 MG, 0.5 MG, 0.65 MG, 0.9 MG, 1.5 MG 3 PA; MO; HR PREMPHASE ORAL TABLET MG 3 PA; MO; HR PREMPRO ORAL TABLET MG, MG, MG, MG PROGESTINS medroxyprogesterone acetate oral tablet 10 mg,.5 mg, 5 mg 3 PA; MO; HR norethindrone acetate oral tablet 5 mg progesterone micronized oral capsule 100 mg, 00 mg SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS MO OSPHENA ORAL TABLET 60 MG PA; MO raloxifene hcl oral tablet 60 mg MO HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY) HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (PITUITARY) cabergoline oral tablet 0.5 mg desmopressin ace spray refrig nasal solution 0.01 % MO desmopressin acetate oral tablet 0.1 mg, 0. mg MO INCRELEX SUBCUTANEOUS SOLUTION 0 MG/ML NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) 5 PA; LA; MO 5 PA; MO 71

87 LEVO-T ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 137 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine sodium oral tablet 100 mcg, 11 mcg, 15 mcg, 137 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 137 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine sodium oral tablet 5 mcg, 5 mcg, 50 mcg SYNTHROID ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 137 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG UNITHROID ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG HORMONAL AGENTS, SUPPRESSANT (PITUITARY) HORMONAL AGENTS, SUPPRESSANT (PITUITARY) MO KORLYM ORAL TABLET 300 MG 5 PA; LA; MO LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.5 MG octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml 5 PA 5 MO ORILISSA ORAL TABLET 150 MG, 00 MG PA SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 10 MG/0.5ML, 60 MG/0.ML, 90 MG/0.3ML SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 0 MG, 5 MG, 30 MG 5 MO 5 PA 5 PA; LA; MO 7

88 SYNAREL NASAL SOLUTION MG/ML 5 HORMONAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg propylthiouracil oral tablet 50 mg IMMUNOLOGICAL AGENTS IMMUNE SUPPRESSANTS ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE HOUR 0.5 MG, 1 MG ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE HOUR 5 MG BD; MO 5 BD; MO azathioprine oral tablet 50 mg BD; MO BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 00 MG/ML BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/ML cyclosporine modified oral capsule 100 mg, 5 mg, 50 mg 5 MO 5 MO BD; MO cyclosporine modified oral solution 100 mg/ml BD; MO cyclosporine oral capsule 100 mg, 5 mg BD; MO ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 5 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 5 MG ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 5 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML ENVARSUS XR ORAL TABLET EXTENDED RELEASE HOUR 0.75 MG, 1 MG, MG 5 PA; MO 5 PA 5 PA; MO 5 PA; MO BD; MO GENGRAF ORAL CAPSULE 100 MG, 5 MG BD; MO GENGRAF ORAL SOLUTION 100 MG/ML BD; MO HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 0 MG/0.8ML, 0 MG/0.8ML (6 PACK), 80 MG/0.8ML, 80 MG/0.8ML & 0MG/0.ML 5 PA; MO 73

89 HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 0 MG/0.ML, 0 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 0 MG/0.8ML, 80 MG/0.8ML HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 0 MG/0.8ML, 80 MG/0.8ML & 0MG/0.ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.ML, 0 MG/0.ML, 0 MG/0.ML, 0 MG/0.ML, 0 MG/0.8ML 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO mycophenolate mofetil oral capsule 50 mg BD; MO mycophenolate mofetil oral suspension reconstituted 00 mg/ml 5 BD; MO mycophenolate mofetil oral tablet 500 mg BD; MO mycophenolate sodium oral tablet delayed release 180 mg, 360 mg BD; MO RAPAMUNE ORAL SOLUTION 1 MG/ML 5 BD; MO SANDIMMUNE ORAL SOLUTION 100 MG/ML SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR 100 MG/ML, 50 MG/0.5ML SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML BD; MO 5 PA; MO 5 PA; MO sirolimus oral tablet 0.5 mg, 1 mg BD; MO sirolimus oral tablet mg 5 BD; MO tacrolimus oral capsule 0.5 mg, 1 mg BD; MO tacrolimus oral capsule 5 mg BD; MO TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG ZORTRESS ORAL TABLET 0.5 MG, 0.5 MG, 0.75 MG, 1 MG IMMUNIZING AGENTS, PASSIVE BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 6 GM BD 5 BD; MO 5 BD 5 BD 7

90 FLEBOGAMMA DIF INTRAVENOUS SOLUTION 5 GM/50ML GAMMAGARD INJECTION SOLUTION.5 GM/5ML GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM GAMMAKED INJECTION SOLUTION 1 GM/10ML GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/00ML, 0 GM/00ML, 5 GM/50ML GAMUNEX-C INJECTION SOLUTION 1 GM/10ML OCTAGAM INTRAVENOUS SOLUTION 1 GM/0ML, GM/0ML PRIVIGEN INTRAVENOUS SOLUTION 0 GM/00ML VARIZIG INTRAMUSCULAR SOLUTION 15 UNIT/1.ML IMMUNOMODULATORS ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 0 MG 5 BD 5 BD 5 BD 5 BD 5 BD 5 BD 5 BD 5 BD 5 5 BD; MO leflunomide oral tablet 10 mg, 0 mg MO XELJANZ ORAL TABLET 10 MG, 5 MG 5 PA; MO XELJANZ XR ORAL TABLET EXTENDED RELEASE HOUR 11 MG VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED ADACEL INTRAMUSCULAR SUSPENSION (PREFILLED SYRINGE), LF- MCG/0.5 bcg vaccine injection injectable 3 BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE BOOSTRIX INTRAMUSCULAR SUSPENSION , (0.5ML SYRINGE) 5 PA; MO

91 DAPTACEL INTRAMUSCULAR SUSPENSION LF-MCG/0.5 diphtheria-tetanus toxoids dt intramuscular suspension 5-5 lfu/0.5ml ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 0 MCG/ML GARDASIL 9 INTRAMUSCULAR SUSPENSION GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE HAVRIX INTRAMUSCULAR SUSPENSION 10 EL U/ML, 10 EL U/ML 1 ML, 70 EL U/0.5ML, 70 EL U/0.5ML 0.5 ML HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG IMOVAX RABIES INTRAMUSCULAR INJECTABLE.5 UNIT/ML INFANRIX INTRAMUSCULAR SUSPENSION IPOL INJECTION INJECTABLE 3 IXIARO INTRAMUSCULAR SUSPENSION 3 KINRIX INTRAMUSCULAR SUSPENSION, INJECTION 0.5 ML MENACTRA INTRAMUSCULAR INJECTABLE MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED M-M-R II SUBCUTANEOUS INJECTABLE 3 PEDIARIX INTRAMUSCULAR SUSPENSION 3 PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML PROQUAD SUBCUTANEOUS INJECTABLE 3 PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED QUADRACEL INTRAMUSCULAR SUSPENSION RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED BD BD BD 76

92 RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 10 MCG/ML (1ML SYRINGE), 0 MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION RECONSTITUTED ROTATEQ ORAL SOLUTION 3 SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG, 50 MCG/0.5ML TENIVAC INTRAMUSCULAR INJECTABLE 5- LFU tetanus-diphtheria toxoids td intramuscular suspension - lf/0.5ml TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE TWINRIX INTRAMUSCULAR SUSPENSION 70-0 TYPHIM VI INTRAMUSCULAR SOLUTION 5 MCG/0.5ML, 5 MCG/0.5ML (0.5ML SYRINGE) VAQTA INTRAMUSCULAR SUSPENSION 5 UNIT/0.5ML, 5 UNIT/0.5ML 0.5 ML, 50 UNIT/ML, 50 UNIT/ML 1 ML VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML YF-VAX SUBCUTANEOUS INJECTABLE 3 ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED 1900 UNT/0.65ML INFLAMMATORY BOWEL DISEASE AGENTS AMINOSALICYLATES APRISO ORAL CAPSULE EXTENDED RELEASE HOUR GM balsalazide disodium oral capsule 750 mg LIALDA ORAL TABLET DELAYED RELEASE 1. GM mesalamine oral tablet delayed release 800 mg 3 mesalamine rectal enema gm METABOLIC BONE DISEASE AGENTS 3 BD

93 HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) paricalcitol oral capsule mcg BD; MO SENSIPAR ORAL TABLET 30 MG 3 BD; MO SENSIPAR ORAL TABLET 60 MG, 90 MG 5 BD; MO METABOLIC BONE DISEASE AGENTS alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg alendronate sodium oral tablet 0 mg 1 GC calcitonin (salmon) nasal solution 00 unit/act 3 BD; MO calcitriol oral capsule 0.5 mcg, 0.5 mcg MO calcitriol oral solution 1 mcg/ml MO ibandronate sodium oral tablet 150 mg MO NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 5 MCG, 50 MCG, 75 MCG 5 PA; MO paricalcitol oral capsule 1 mcg, mcg BD; MO PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML risedronate sodium oral tablet 150 mg, 35 mg, 35 mg (1 pack), 35 mg ( pack), 5 mg risedronate sodium oral tablet 30 mg risedronate sodium oral tablet delayed release 35 mg TYMLOS SUBCUTANEOUS SOLUTION PEN- INJECTOR 310 MCG/1.56ML XGEVA SUBCUTANEOUS SOLUTION 10 MG/1.7ML MISCELLANEOUS MISCELLANEOUS CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT MO MO 5 PA; MO 5 PA ENDARI ORAL PACKET 5 GM PA; LA; QL (180 EA per 30 days) FETZIMA TITRATION ORAL CAPSULE ER HOUR THERAPY PACK 0 & 0 MG FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML

94 TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/ML OPHTHALMIC AGENTS OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS 5 PA; LA; MO bimatoprost ophthalmic solution 0.03 % MO latanoprost ophthalmic solution % LUMIGAN OPHTHALMIC SOLUTION 0.01 % TRAVATAN Z OPHTHALMIC SOLUTION 0.00 % OPHTHALMIC AGENTS, OTHER atropine sulfate ophthalmic solution 1 % MO pilocarpine hcl ophthalmic solution 1 %, %, % proparacaine hcl ophthalmic solution 0.5 % MO RESTASIS OPHTHALMIC EMULSION 0.05 % OPHTHALMIC ANTI INFECTIVES bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm BESIVANCE OPHTHALMIC SUSPENSION 0.6 % ciprofloxacin hcl ophthalmic solution 0.3 % 1 GC erythromycin ophthalmic ointment 5 mg/gm 1 GC GENTAK OPHTHALMIC OINTMENT 0.3 % gentamicin sulfate ophthalmic solution 0.3 % 1 GC MOXEZA OPHTHALMIC SOLUTION 0.5 % 3 moxifloxacin hcl ophthalmic solution 0.5 % 3 NATACYN OPHTHALMIC SUSPENSION 5 % neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution 0.3 % polymyxin b-trimethoprim ophthalmic solution unit/ml-% 79 1 GC sulfacetamide sodium ophthalmic solution 10 % 1 GC

95 tobramycin ophthalmic solution 0.3 % 1 GC trifluridine ophthalmic solution 1 % OPHTHALMIC ANTI-ALLERGY AGENTS azelastine hcl ophthalmic solution 0.05 % BEPREVE OPHTHALMIC SOLUTION 1.5 % BROMSITE OPHTHALMIC SOLUTION % cromolyn sodium ophthalmic solution % 1 GC epinastine hcl ophthalmic solution 0.05 % olopatadine hcl ophthalmic solution 0.1 %, 0. % 3 PAZEO OPHTHALMIC SOLUTION 0.7 % PROLENSA OPHTHALMIC SOLUTION 0.07 % OPHTHALMIC ANTIGLAUCOMA AGENTS ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % apraclonidine hcl ophthalmic solution 0.5 % AZOPT OPHTHALMIC SUSPENSION 1 % betaxolol hcl ophthalmic solution 0.5 % MO brimonidine tartrate ophthalmic solution 0.15 %, 0. % MO carteolol hcl ophthalmic solution 1 % MO COMBIGAN OPHTHALMIC SOLUTION % MO dorzolamide hcl ophthalmic solution % MO dorzolamide hcl-timolol mal ophthalmic solution mg/ml dorzolamide hcl-timolol mal pf ophthalmic solution mg/ml MO MO levobunolol hcl ophthalmic solution 0.5 % MO metipranolol ophthalmic solution 0.3 % MO PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.15 % SIMBRINZA OPHTHALMIC SUSPENSION 1-0. % MO MO 80

96 timolol maleate ophthalmic gel forming solution 0.5 %, 0.5 % timolol maleate ophthalmic solution 0.5 %, 0.5 %, 0.5 % (daily) OPHTHALMIC ANTI- INFLAMMATORIES bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % BLEPHAMIDE OPHTHALMIC SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % CYSTARAN OPHTHALMIC SOLUTION 0. % dexamethasone sodium phosphate ophthalmic solution 0.1 % MO 81 5 PA; MO diclofenac sodium ophthalmic solution 0.1 % 1 GC DUREZOL OPHTHALMIC EMULSION 0.05 % 3 flurbiprofen sodium ophthalmic solution 0.03 % 1 GC ILEVRO OPHTHALMIC SUSPENSION 0.3 % 3 ketorolac tromethamine ophthalmic solution 0. %, 0.5 % LOTEMAX OPHTHALMIC GEL 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % LOTEMAX OPHTHALMIC SUSPENSION 0.5 % neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-hc ophthalmic suspension prednisolone acetate ophthalmic suspension 1 % prednisolone sodium phosphate ophthalmic solution 1 % sulfacetamide-prednisolone ophthalmic solution % tobramycin-dexamethasone ophthalmic suspension % 1 GC 1 GC

97 ZYLET OPHTHALMIC SUSPENSION % OTIC AGENTS OTIC AGENTS acetic acid otic solution % CIPRODEX OTIC SUSPENSION % ciprofloxacin hcl otic solution 0. % fluocinolone acetonide otic oil 0.01 % hydrocortisone-acetic acid otic solution 1- % neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension ofloxacin otic solution 0.3 % RESPIRATORY TRACT AGENTS ANTIHISTAMINES cetirizine hcl oral solution 1 mg/ml 1 GC desloratadine oral tablet 5 mg desloratadine oral tablet dispersible.5 mg levocetirizine dihydrochloride oral solution.5 mg/5ml levocetirizine dihydrochloride oral tablet 5 mg promethazine hcl oral tablet 1.5 mg, 5 mg, 50 mg ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 00 MCG/ACT, 50 MCG/ACT ASMANEX 10 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 0 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 0 MCG/INH 1 GC 8

98 ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 00 MCG/ACT budesonide inhalation suspension 0.5 mg/ml, 0.5 mg/ml, 1 mg/ml FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 0 MCG/ACT, MCG/ACT ANTILEUKOTRIENES BD; MO montelukast sodium oral packet mg MO montelukast sodium oral tablet 10 mg montelukast sodium oral tablet chewable mg, 5 mg zafirlukast oral tablet 10 mg, 0 mg MO zileuton er oral tablet extended release 1 hour 600 mg 5 MO ZYFLO ORAL TABLET 600 MG 5 MO BRONCHODILATORS, ANTICHOLINERGIC ipratropium bromide inhalation solution 0.0 % 1 BD; MO; GC SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.5 MCG/ACT,.5 MCG/ACT BRONCHODILATORS, SYMPATHOMIMETIC ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, 30-1 MCG/ACT, 5-1 MCG/ACT albuterol sulfate er oral tablet extended release 1 hour mg, 8 mg albuterol sulfate inhalation nebulization solution (.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.5 mg/3ml MO BD; MO 83

99 albuterol sulfate oral syrup mg/5ml albuterol sulfate oral tablet mg, mg MO ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, 00-5 MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act, 3-1 mcg/act, 55-1 mcg/act ipratropium-albuterol inhalation solution (3) mg/3ml levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.5 mg/0.5ml, 1.5 mg/3ml PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION.5-.5 MCG/ACT MO BD; MO BD; MO terbutaline sulfate oral tablet.5 mg, 5 mg MO TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH MAST CELL STABILIZERS cromolyn sodium inhalation nebulization solution 0 mg/ml NASAL AGENTS azelastine hcl nasal solution 0.1 %, 0.15 % flunisolide nasal solution 5 mcg/act (0.05%) fluticasone propionate nasal suspension 50 mcg/act 3 ST; MO 3 BD; MO 8

100 ipratropium bromide nasal solution 0.03 %, 0.06 % mometasone furoate nasal suspension 50 mcg/act PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE DALIRESP ORAL TABLET 50 MCG, 500 MCG theophylline er oral tablet extended release 1 hour 100 mg, 00 mg, 300 mg theophylline er oral tablet extended release hour 00 mg, 600 mg PULMONARY ANTIHYPERTENSIVES ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, MG,.5 MG MO ; QL (30 EA per 30 days) MO MO 5 PA; MO LETAIRIS ORAL TABLET 10 MG, 5 MG 5 PA; MO OPSUMIT ORAL TABLET 10 MG 5 PA; MO sildenafil citrate oral tablet 0 mg PA; MO TRACLEER ORAL TABLET 15 MG, 6.5 MG 5 PA; LA; MO TRACLEER ORAL TABLET SOLUBLE 3 MG 5 PA; LA; MO UPTRAVI ORAL TABLET 1000 MCG, 100 MCG, 100 MCG, 1600 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET THERAPY PACK 00 & 800 MCG PULMONARY FIBROSIS AGENTS 5 PA; LA; MO 5 PA; LA ESBRIET ORAL CAPSULE 67 MG 5 PA; MO ESBRIET ORAL TABLET 67 MG, 801 MG 5 PA; MO OFEV ORAL CAPSULE 100 MG, 150 MG 5 MO RESPIRATORY TRACT AGENTS, OTHER acetylcysteine inhalation solution 10 %, 0 % BD epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml KALYDECO ORAL PACKET 50 MG, 75 MG 5 PA; MO KALYDECO ORAL TABLET 150 MG 5 PA; MO NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 100 MG 85 5 PA; MO

101 ORKAMBI ORAL PACKET MG, MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG PULMOZYME INHALATION SOLUTION 1 MG/ML SYMDEKO ORAL TABLET THERAPY PACK & 150 MG XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML, 75 MG/0.5ML XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS 5 PA; LA; MO 5 PA; MO 5 BD 5 BD; MO 5 PA; LA; MO 5 PA; LA 5 PA; LA baclofen oral tablet 10 mg, 0 mg, 5 mg MO cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg PA; HR methocarbamol oral tablet 500 mg, 750 mg PA; HR orphenadrine citrate er oral tablet extended release 1 hour 100 mg PA; HR tizanidine hcl oral capsule mg, mg, 6 mg MO tizanidine hcl oral tablet mg, mg MO SLEEP DISORDER AGENTS BENZODIAZEPINES estazolam oral tablet 1 mg 1 GC; QL (60 EA per 30 days) estazolam oral tablet mg 1 GC; QL (30 EA per 30 days) flurazepam hcl oral capsule 15 mg QL (60 EA per 30 days) flurazepam hcl oral capsule 30 mg QL (30 EA per 30 days) temazepam oral capsule 15 mg,.5 mg, 30 mg 3 QL (30 EA per 30 days) temazepam oral capsule 7.5 mg 3 QL (10 EA per 30 days) triazolam oral tablet 0.15 mg QL (30 EA per 30 days) triazolam oral tablet 0.5 mg QL (60 EA per 30 days) GABA RECEPTOR MODULATORS zaleplon oral capsule 10 mg PA; HR; QL (60 EA per 30 days) 86

102 zaleplon oral capsule 5 mg PA; HR; QL (30 EA per 30 days) zolpidem tartrate oral tablet 10 mg, 5 mg PA; HR; QL (30 EA per 30 days) SLEEP DISORDERS, OTHER BELSOMRA ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG HETLIOZ ORAL CAPSULE 0 MG 5 PA; MO modafinil oral tablet 100 mg, 00 mg 3 PA; MO; QL (30 EA per 30 days) SILENOR ORAL TABLET 3 MG, 6 MG MO XYREM ORAL SOLUTION 500 MG/ML 5 LA 87

103 Alphabetical Listing A abacavir sulfate... 3, 33 abacavir sulfate-lamivudine abacavir-lamivudine-zidovudine ABELCET ABILIFY MAINTENA... 9 abiraterone acetate... 1 acamprosate calcium... 3 acarbose acebutolol hcl... acetaminophen-codeine... acetaminophen-codeine #3... acetazolamide... 7 acetic acid... 8 acetylcysteine acitretin ACTHIB ACTIMMUNE... 1 acyclovir... 3, 5 acyclovir sodium... 3 ADACEL adefovir dipivoxil ADEMPAS ADVAIR DISKUS ADVAIR HFA AFEDITAB CR... 5 AFINITOR... 1 AFINITOR DISPERZ... 1 ALBENZA... 6 albuterol sulfate... 83, 8 albuterol sulfate er alclometasone dipropionate... 5 ALECENSA... alendronate sodium alfuzosin hcl er ALINIA... 6 allopurinol... 18, 6 alosetron hcl ALPHAGAN P alprazolam alprazolam er ALPRAZOLAM INTENSOL 35 ALTAVERA ALUNBRIG... alyacen 1/ amantadine hcl... 7 AMBISOME amcinonide... 5 AMETHIA amikacin sulfate... amiloride hcl... 7 amiloride-hydrochlorothiazide3 AMINOSYN II AMINOSYN II/ELECTROLYTES AMINOSYN/ELECTROLYTE S AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl... AMITIZA amitriptyline hcl amlodipine besy-benazepril hcl... 3 amlodipine besylate... 5 amlodipine besylate-valsartan 3 amlodipine-atorvastatin... 6 amlodipine-olmesartan... 3 amlodipine-valsartan-hctz... 3 ammonium lactate... 5 AMNESTEEM... 5 amoxapine amoxicillin... 7 amoxicillin-pot clavulanate.. 7, 8 amphetaminedextroamphetamine... 9 amphotericin b ampicillin... 8 ampicillin sodium... 8 ampicillin-sulbactam sodium... 8 ANADROL anagrelide hcl... 1 anastrozole... 6 ANORO ELLIPTA... 8 APOKYN... 7 apraclonidine hcl aprepitant APRI APRISO APTIOM... 1 APTIVUS... 3 ARANELLE ARCALYST ARIKAYCE... aripiprazole... 9 ARNUITY ELLIPTA... 8 ASCOMP-CODEINE... ASHLYNA ASMANEX 10 METERED DOSES... 8 ASMANEX 30 METERED DOSES... 8 ASMANEX 60 METERED DOSES... 8 ASMANEX HFA aspirin-dipyridamole er... 1 ASSURE ID INSULIN SAFETY SYR ASTAGRAF XL atazanavir sulfate... 3 atenolol... atenolol-chlorthalidone... 3 atomoxetine hcl atorvastatin calcium... 8 atovaquone... 6 atovaquone-proguanil hcl... 6 ATRIPLA... 3 atropine sulfate AUBAGIO AUBRA AURYXIA... 6 AUSTEDO AVIANE AVONEX AVONEX PEN AVONEX PREFILLED AZACTAM... 7 AZASAN... azathioprine azelastine hcl... 80, 8 azithromycin... 8, 9 AZOPT aztreonam... 7 B bacitracin bacitracin-polymyxin b bacitra-neomycin-polymyxin-hc baclofen balsalazide disodium BALZIVA BANZEL

104 BARACLUDE bcg vaccine BELSOMRA benazepril hcl... benazepril-hydrochlorothiazide... 3 BENLYSTA benznidazole... 6 benzoyl peroxide-erythromycin... 5 benztropine mesylate... 7 BEPREVE BESIVANCE betamethasone dipropionate... 5 betamethasone dipropionate aug... 5 betamethasone valerate... 5 BETASERON betaxolol hcl bethanechol chloride bexarotene... BEXSERO bicalutamide... BICILLIN L-A... 8 BIDIL... 6 BIKTARVY bimatoprost bisoprolol fumarate... bisoprolol-hydrochlorothiazide... 3 BIVIGAM... 7 BLEPHAMIDE BLEPHAMIDE S.O.P BLISOVI FE BLISOVI FE 1.5/ BLISOVI FE 1/ BOOSTRIX BOSULIF... BRAFTOVI... BREO ELLIPTA... 8 briellyn BRILINTA... 1 brimonidine tartrate BRIVIACT... 1, 13 bromocriptine mesylate... 7 BROMSITE budesonide... 6, 83 budesonide er... 6 bumetanide... 7 buprenorphine hcl... buprenorphine hcl-naloxone hcl... bupropion hcl... 1 bupropion hcl er (smoking det)... 1 bupropion hcl er (sr)..., 1 bupropion hcl er (xl)... 1 buspirone hcl butalbital-apap-caff-cod... butalbital-apap-caffeine butalbital-asa-caff-codeine... BYSTOLIC... C cabergoline CABOMETYX... calcipotriene... 5 calcitonin (salmon) calcitriol... 5, 78 calcium acetate (phos binder). 6 CALQUENCE... CAMILA candesartan cilexetil... 1 candesartan cilexetil-hctz... 3 CAPRELSA... captopril... captopril-hydrochlorothiazide 3 CARAFATE... 6 CARBAGLU carbamazepine... 13, 36 carbamazepine er... 13, 36 carbidopa-levodopa... 8 carbidopa-levodopa er... 7 carbidopa-levodopa-entacapone... 8 CARIMUNE NF... 7 carteolol hcl CARTIA XT... 5 carvedilol... 5 carvedilol phosphate er... 5 caspofungin acetate CAYSTON... 7 CAZIANT cefaclor... 6 cefaclor er... 6 cefadroxil... 6 cefazolin sodium... 6 cefdinir... 6 cefepime hcl... 6 cefixime... 6 cefoxitin sodium... 6 cefpodoxime proxetil... 6 cefprozil... 6 ceftazidime... 6 ceftriaxone sodium... 6 cefuroxime axetil... 7 cefuroxime sodium... 7 celecoxib CELONTIN cephalexin... 7 cetirizine hcl... 8 CHANTIX... CHANTIX CONTINUING MONTH PAK... CHANTIX STARTING MONTH PAK... CHEMET chlordiazepoxide hcl chlorhexidine gluconate chloroquine phosphate... 6 chlorothiazide... 7 chlorpromazine hcl... 8 chlorthalidone... 7 cholestyramine... 8 cholestyramine light... 8 ciclopirox... 5 ciclopirox olamine... 5 cilostazol... 1 CIMDUO CINRYZE CIPRODEX... 8 ciprofloxacin... 9 ciprofloxacin hcl... 9, 79, 8 ciprofloxacin in d5w... 9 ciprofloxacin-ciproflox hcl er... 9 citalopram hydrobromide CLARAVIS clarithromycin... 9 clarithromycin er... 9 CLENPIQ clindamycin hcl... 5 clindamycin palmitate hcl... 5 clindamycin phosphate. 5, 53, 6 clindamycin phosphate in d5w. 5 CLINIMIX E/DEXTROSE (.75/10) CLINIMIX E/DEXTROSE (.75/5) CLINIMIX E/DEXTROSE (.5/10)

105 CLINIMIX E/DEXTROSE (.5/5) CLINIMIX E/DEXTROSE (.5/5) CLINIMIX E/DEXTROSE (5/15) CLINIMIX E/DEXTROSE (5/0) CLINIMIX E/DEXTROSE (5/5) CLINIMIX/DEXTROSE (.5/10) CLINIMIX/DEXTROSE (.5/5) CLINIMIX/DEXTROSE (.5/5) CLINIMIX/DEXTROSE (5/15) CLINIMIX/DEXTROSE (5/0) CLINIMIX/DEXTROSE (5/5) CLINISOL SF clobazam clobetasol prop emollient base53 clobetasol propionate clomipramine hcl clonazepam clonidine... 1 clonidine hcl... 1 clopidogrel bisulfate... 1 clorazepate dipotassium clotrimazole... 17, 53 clotrimazole-betamethasone clozapine COARTEM... 6 colchicine colchicine-probenecid colesevelam hcl... 8 colestipol hcl... 8 colistimethate sodium (cba)... 5 COMBIGAN COMBIVENT RESPIMAT... 8 COMETRIQ (100 MG DAILY DOSE)... COMETRIQ (10 MG DAILY DOSE)... COMETRIQ (60 MG DAILY DOSE)... COMFORT ASSIST INSULIN SYRINGE COMPLERA... 3 COMPRO... 8 CONDYLOX COPIKTRA... CORLANOR... 6 COSENTYX 300 DOSE COSENTYX SENSOREADY 300 DOSE COTELLIC... CREON... 6 CRIXIVAN... 3 cromolyn sodium... 60, 80, 8 CRYSELLE cvs gauze sterile CYCLAFEM 1/ CYCLAFEM 7/7/ cyclobenzaprine hcl cyclophosphamide... 1 CYCLOSET cyclosporine cyclosporine modified CYRED EQ CYSTADANE... 6 CYSTAGON CYSTARAN D dalfampridine er DALIRESP danazol dapsone... 0 DAPTACEL daptomycin... 5 DARAPRIM... 6 darifenacin hydrobromide er.. 63 DEBLITANE DELSTRIGO... 3 DELYLA DEMSER... 7 DEPEN TITRATABS... 1 DEPO-PROVERA... DEPO-SUBQ PROVERA DESCOVY desipramine hcl desloratadine... 33, 8 desmopressin ace spray refrig 71 desmopressin acetate desogestrel-ethinyl estradiol desonide desoximetasone desvenlafaxine er desvenlafaxine succinate er dexamethasone... 6 DEXAMETHASONE INTENSOL... 6 dexamethasone sodium phosphate DEXILANT... 6 dextroamphetamine sulfate dextroamphetamine sulfate er. 50 dextrose dextrose-nacl DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam... 11, 36 DIAZEPAM INTENSOL diclofenac potassium diclofenac sodium... 19, 53, 81 diclofenac sodium er dicloxacillin sodium... 8 dicyclomine hcl didanosine DIFICID... 9 diflorasone diacetate diflunisal DIGITEK... 6 DIGOX... 6 digoxin... 6 dihydroergotamine mesylate.. 0 DILANTIN diltiazem hcl... 6 diltiazem hcl er... 5 diltiazem hcl er beads... 5 diltiazem hcl er coated beads.. 5 dilt-xr... 6 diphenoxylate-atropine diphtheria-tetanus toxoids dt.. 76 dipyridamole... 1 disopyramide phosphate... disulfiram... 3 divalproex sodium... 11, 19 divalproex sodium er dofetilide... donepezil hcl doripenem... 7 dorzolamide hcl dorzolamide hcl-timolol mal

106 dorzolamide hcl-timolol mal pf doxazosin mesylate... 1 doxepin hcl DOXY doxycycline hyclate doxycycline monohydrate dronabinol drospirenone-ethinyl estradiol 66 DROXIA... 1 duloxetine hcl duramorph... DUREZOL dutasteride dutasteride-tamsulosin hcl E econazole nitrate EDURANT... 3 efavirenz... 3 eletriptan hydrobromide... 0 ELIDEL ELIGARD... ELIQUIS ELIQUIS STARTER PACK.. 39 ELMIRON EMCYT... EMOQUETTE EMSAM EMTRIVA EMVERM... 6 enalapril maleate... enalapril-hydrochlorothiazide 3 ENBREL ENBREL SURECLICK ENDARI ENGERIX-B enoxaparin sodium ENPRESSE ENSKYCE entacapone... 7 entecavir ENTRESTO... 3 enulose ENVARSUS XR EPIDIOLEX epinastine hcl epinephrine EPITOL EPIVIR HBV eplerenone... 7 EPOGEN... 0 eprosartan mesylate... 1 EQUETRO ERAXIS ergoloid mesylates ergotamine-caffeine... 0 ERIVEDGE... ERLEADA... ERRIN ertapenem sodium... 7 ery... 5 ERY-TAB... 9 ERYTHROCIN LACTOBIONATE... 9 ERYTHROCIN STEARATE... 9 erythromycin... 5, 79 erythromycin base... 9 erythromycin ethylsuccinate... 9 ESBRIET escitalopram oxalate esomeprazole magnesium... 6 ESTARYLLA estazolam estradiol... 6, 70 estradiol-norethindrone acet ethambutol hcl... 0 ethosuximide ethynodiol diac-eth estradiol.. 67 etodolac etodolac er EUCRISA... 5 EVOTAZ EXEL COMFORT POINT PEN NEEDLE exemestane... 6 EXJADE ezetimibe... 8 F FALMINA famciclovir... 3 famotidine FANAPT... 9 FANAPT TITRATION PACK... 9 FARESTON... FARYDAK... felbamate... 1 felodipine er... 6 FEMYNOR fenofibrate... 8 fenofibrate micronized... 8 fentanyl... fentanyl citrate... FERRIPROX FETZIMA FETZIMA TITRATION FIASP FIASP FLEXTOUCH finasteride FIRAZYR FIRMAGON... FLEBOGAMMA DIF flecainide acetate... FLOVENT DISKUS FLOVENT HFA fluconazole fluconazole in sodium chloride flucytosine fludrocortisone acetate... 6 flunisolide... 8 fluocinolone acetonide... 5, 8 fluocinolone acetonide scalp.. 5 fluocinonide... 5 fluocinonide emulsified base.. 5 fluorouracil..., 5 fluoxetine hcl fluphenazine decanoate... 8 fluphenazine hcl... 8 flurazepam hcl flurbiprofen flurbiprofen sodium flutamide... fluticasone propionate... 5, 8 fluticasone-salmeterol... 8 fluvastatin sodium... 8 fluvastatin sodium er... 8 fluvoxamine maleate fluvoxamine maleate er fondaparinux sodium... 39, 0 fosamprenavir calcium... 3 fosinopril sodium... fosinopril sodium-hctz... 3 FRAGMIN... 0 FREAMINE HBC furosemide... 7 FUZEON... 3 FYAVOLV FYCOMPA

107 G gabapentin GALAFOLD... 6 galantamine hydrobromide galantamine hydrobromide er. 13 GAMMAGARD GAMMAGARD S/D LESS IGA GAMMAKED GAMMAPLEX GAMUNEX-C GARDASIL GATTEX GAVILYTE-C GAVILYTE-G GAVILYTE-N WITH FLAVOR PACK gemfibrozil... 8 generlac GENGRAF GENTAK gentamicin in saline... gentamicin sulfate..., 5, 79 GENVOYA... 3 GEODON... 9 GIANVI GILENYA GILOTRIF... 3 glatiramer acetate GLEOSTINE... 1 glimepiride glipizide glipizide er glipizide-metformin hcl global alcohol prep ease GLUCAGEN HYPOKIT GLUCAGON EMERGENCY 38 glycopyrrolate GOCOVRI... 7 granisetron hcl griseofulvin microsize griseofulvin ultramicrosize guanfacine hcl er guanidine hcl... 0 H halobetasol propionate... 5 HALOG... 5 haloperidol... 8 haloperidol decanoate... 8 haloperidol lactate... 8 HAVRIX heparin sodium (porcine)... 0 HEPATAMINE HETLIOZ HIBERIX HUMIRA... 7 HUMIRA PEDIATRIC CROHNS START HUMIRA PEN... 7 HUMIRA PEN-CD/UC/HS STARTER... 7 HUMIRA PEN-PS/UV/ADOL HS START... 7 HUMULIN R U-500 (CONCENTRATED) HUMULIN R U-500 KWIKPEN hydralazine hcl... 9 hydrochlorothiazide... 7 hydrocodone-acetaminophen... 3 hydrocodone-ibuprofen... 3 hydrocortisone... 5, 6 hydrocortisone ace-pramoxine5 hydrocortisone butyrate... 5 hydrocortisone valerate... 5 hydrocortisone-acetic acid... 8 hydromorphone hcl..., 3 hydroxychloroquine sulfate... 6 hydroxyurea... 3 hydroxyzine hcl hydroxyzine pamoate I ibandronate sodium IBRANCE... 3 IBU ibuprofen ICLUSIG... 3 IDHIFA... 3 ILEVRO imatinib mesylate... 3 IMBRUVICA... 3 imipenem-cilastatin... 7 imipramine hcl imipramine pamoate imiquimod... 5 IMOVAX RABIES INCASSIA INCRELEX indapamide... 7 indomethacin indomethacin er INFANRIX INLYTA... 3 INTELENCE... 3 INTRALIPID INTRAROSA... 6 INTRON A... 3 INTROVALE INVEGA SUSTENNA... 9 INVEGA TRINZA... 9 INVIRASE... 3 INVOKAMET INVOKAMET XR INVOKANA IONOSOL-MB IN D5W IPOL ipratropium bromide... 83, 85 ipratropium-albuterol... 8 irbesartan... 1 irbesartan-hydrochlorothiazide... 3 IRESSA... 3 ISENTRESS... 3 ISENTRESS HD... 3 ISIBLOOM ISOLYTE-P IN D5W ISOLYTE-S isoniazid... 0 isosorbide dinitrate... 9 isosorbide dinitrate er... 9 isosorbide mononitrate... 9 isosorbide mononitrate er... 9 isotretinoin... 5 isradipine... 6 itraconazole ivermectin... 6 IXIARO J JAKAFI... 3 JANTOVEN... 0 JANUMET JANUMET XR JANUVIA JARDIANCE JINTELI JOLIVETTE JUBLIA JULEBER JULUCA JUNEL 1.5/

108 JUNEL 1/ JUNEL FE 1.5/ JUNEL FE 1/ JUNEL FE JUXTAPID... 8 K KALETRA... 3 KALYDECO KARIVA kcl in dextrose-nacl kcl-lactated ringers-d5w KELNOR 1/ KELNOR 1/ ketoconazole... 18, 55 ketoprofen ketoprofen er ketorolac tromethamine... 19, 81 KINRIX KIONEX KISQALI 00 DOSE... 3 KISQALI 00 DOSE... 3 KISQALI 600 DOSE... 3 KISQALI FEMARA 00 DOSE... 3 KISQALI FEMARA 00 DOSE... 3 KISQALI FEMARA 600 DOSE... 3 KLOR-CON KLOR-CON KLOR-CON M KLOR-CON M KLOR-CON M KLOR-CON SPRINKLE KORLYM... 7 KURVELO KUVAN... 6 KYNAMRO... 8 L labetalol hcl... 5 lactulose LAMICTAL XR... 1 lamivudine lamivudine-zidovudine lamotrigine... 1 lamotrigine er... 1 lamotrigine starter kit-blue... 1 lamotrigine starter kit-green... 1 lamotrigine starter kit-orange. 1 lansoprazole... 6 LANTUS LANTUS SOLOSTAR LARIN 1.5/ LARIN 1/ LARIN FE 1.5/ LARIN FE 1/ LARISSIA latanoprost LATUDA... 9 LEENA leflunomide LENVIMA 10 MG DAILY DOSE... 3 LENVIMA 1 MG DAILY DOSE... 3 LENVIMA 1 MG DAILY DOSE... 3 LENVIMA 18 MG DAILY DOSE... 3 LENVIMA 0 MG DAILY DOSE... LENVIMA MG DAILY DOSE... LENVIMA MG DAILY DOSE... LENVIMA 8 MG DAILY DOSE... LESSINA LETAIRIS letrozole... 6 leucovorin calcium... LEUKERAN... 1 LEUKINE... 0 leuprolide acetate... levalbuterol hcl... 8 LEVEMIR LEVEMIR FLEXTOUCH levetiracetam levetiracetam er levobunolol hcl levocarnitine... 6 levocetirizine dihydrochloride 8 levofloxacin... 9 levofloxacin in d5w... 9 LEVONEST levonorgest-eth estrad 91-day 68 levonorgestrel-ethinyl estrad.. 68 levonorg-eth estrad triphasic.. 68 LEVORA 0.15/30 (8) LEVO-T... 7 levothyroxine sodium... 7 LEVOXYL... 7 LEXIVA... 3 LIALDA lidocaine... 3 lidocaine hcl lidocaine viscous lidocaine-prilocaine... 3 lindane linezolid... 5 LINZESS liothyronine sodium... 7 lisinopril... lisinopril-hydrochlorothiazide lithium lithium carbonate lithium carbonate er LIVALO... 8 LONSURF... loperamide hcl lopinavir-ritonavir... 3 lorazepam LORBRENA... LORYNA losartan potassium... losartan potassium-hctz... LOTEMAX lovastatin... 8 LOW-OGESTREL loxapine succinate... 8 LUMIGAN LUPRON DEPOT (1-MONTH)... LUPRON DEPOT (3-MONTH)..., 7 LUPRON DEPOT (-MONTH)... LUPRON DEPOT (6-MONTH)... LUTERA LYNPARZA... LYRICA... 11, 50 LYSODREN... LYZA M magnesium sulfate malathion maprotiline hcl... 1 marlissa MARPLAN

109 MATULANE... MAVYRET meclizine hcl medroxyprogesterone acetate 68, 71 mefloquine hcl... 6 megestrol acetate... MEKINIST... MEKTOVI... meloxicam memantine hcl... 1 memantine hcl er... 1 MENACTRA MENEST MENVEO mercaptopurine... 1 meropenem... 7 mesalamine MESNEX... 6 MESTINON... 0 METADATE ER metformin hcl metformin hcl er methadone hcl... methazolamide... 7 methimazole methocarbamol methotrexate... 1 methotrexate sodium... 1 methotrexate sodium (pf)... 1 methoxsalen rapid methscopolamine bromide methyclothiazide... 7 methyldopa... 1 methyldopa-hydrochlorothiazide... methylphenidate hcl methylphenidate hcl er methylphenidate hcl er (cd) methylprednisolone... 6, 65 methyltestosterone metipranolol metoclopramide hcl... 17, 60 metolazone... 7 metoprolol succinate er... 5 metoprolol tartrate... 5 metoprolol-hydrochlorothiazide... metronidazole... 5, 55, 6 metronidazole in nacl... 5 mexiletine hcl... miconazole MICROGESTIN 1.5/ MICROGESTIN 1/ MICROGESTIN FE 1.5/ MICROGESTIN FE 1/ midodrine hcl... 1 miglitol miglustat... 6 MILI minocycline hcl minoxidil... 9 MIRCERA... 0 mirtazapine... 1 misoprostol... 6 M-M-R II modafinil MODERIBA MODERIBA 100 DOSE PACK MODERIBA 800 DOSE PACK moexipril hcl... moexipril-hydrochlorothiazide... molindone hcl... 8 mometasone furoate... 55, 85 MONONESSA montelukast sodium morphine sulfate... 3 morphine sulfate (concentrate). 3 morphine sulfate er... morphine sulfate er beads... MOVANTIK MOXEZA moxifloxacin hcl MULTAQ... mupirocin mupirocin calcium MYCAMINE mycophenolate mofetil... 7 mycophenolate sodium... 7 MYRBETRIQ N nabumetone nadolol... 5 nadolol-bendroflumethiazide.. nafcillin sodium... 8 naloxone hcl... naltrexone hcl... NAMZARIC... 1 naproxen naproxen dr naproxen sodium NARCAN... NATACYN nateglinide NATPARA NEBUPENT... 6 NECON 0.5/35 (8) nefazodone hcl... 1 neomycin sulfate... neomycin-bacitracin znpolymyx neomycin-polymyxin-dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc... 81, 8 NEPHRAMINE NERLYNX... NEUPOGEN... 0 NEUPRO... 7 nevirapine... 3 nevirapine er... 3 NEXAVAR... niacin er (antihyperlipidemic) 8 NIACOR... 8 nicardipine hcl... 6 NICOTROL... nifedipine er... 6 nifedipine er osmotic release.. 6 NIKKI nilutamide... nimodipine... 6 NINLARO... nisoldipine er... 6 NITRO-BID... 9 NITRO-DUR... 9 nitrofurantoin... 5 nitrofurantoin macrocrystal... 5 nitrofurantoin monohyd macro. 5 nitroglycerin... 9 NORA-BE NORDITROPIN FLEXPRO.. 71 norethin ace-eth estrad-fe norethindrone norethindrone acetate norethindrone acet-ethinyl est 68 norethindrone-eth estradiol

110 norethin-eth estradiol-fe norgestimate-eth estradiol norgestim-eth estrad triphasic 69 NORLYROC NORMOSOL-M IN D5W NORMOSOL-R IN D5W NORMOSOL-R PH NORTHERA... 7 NORTREL 0.5/35 (8) NORTREL 1/35 (1) NORTREL 1/35 (8) NORTREL 7/7/ nortriptyline hcl NORVIR... 3 NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA NUEDEXTA NUPLAZID... 9, 30 nutrilipid NUVARING NYAMYC nystatin... 18, 51, 55 nystatin-triamcinolone NYSTOP O OCELLA OCTAGAM octreotide acetate... 7 ODEFSEY... 3 ODOMZO... OFEV ofloxacin... 79, 8 OGESTREL olanzapine olanzapine-fluoxetine hcl olmesartan medoxomil... olmesartan medoxomil-hctz... olmesartan-amlodipine-hctz... olopatadine hcl omega-3-acid ethyl esters... 8 omeprazole... 6 ondansetron ondansetron hcl OPSUMIT ORAVIG ORFADIN... 6, 63 ORILISSA... 7 ORKAMBI orphenadrine citrate er ORSYTHIA oseltamivir phosphate OSPHENA oxacillin sodium... 8 oxandrolone oxaprozin oxazepam oxcarbazepine... 10, 13 OXTELLAR XR oxybutynin chloride oxybutynin chloride er oxycodone hcl... 3 oxycodone hcl er... oxycodone-acetaminophen... 3 oxycodone-aspirin... 3 oxycodone-ibuprofen... 3 oxymorphone hcl... 3 OZEMPIC P PACERONE... 3 paliperidone er PANRETIN pantoprazole sodium... 6 paricalcitol paromomycin sulfate... paroxetine hcl paroxetine hcl er paroxetine mesylate PASER... 0 PAXIL PAZEO PEDIARIX PEDVAX HIB peg 3350/electrolytes peg 3350-kcl-na bicarb-nacl peg-3350/electrolytes PEGANONE PEGASYS PEGASYS PROCLICK penicillin g pot in dextrose... 8 penicillin g potassium... 8 penicillin g sodium... 8 penicillin v potassium... 8 PENTAM... 6 pentazocine-naloxone hcl... 3 pentoxifylline er... 7 perindopril erbumine... permethrin perphenazine... 8 perphenazine-amitriptyline... 8 phenelzine sulfate phenobarbital phenytoin phenytoin sodium extended PHOSPHOLINE IODIDE PICATO PIFELTRO... 3 pilocarpine hcl... 51, 79 pimozide... 9 PIMTREA pindolol... 5 pioglitazone hcl pioglitazone hcl-glimepiride.. 37, pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so. 8 PIRMELLA 1/ piroxicam PLASMA-LYTE PLASMA-LYTE A PLEGRIDY PLEGRIDY STARTER PACK PLENAMINE podofilox polyethylene glycol polymyxin b-trimethoprim POMALYST... PORTIA potassium chloride potassium chloride crys er potassium chloride er potassium chloride in dextrose potassium chloride in nacl potassium citrate er PRADAXA... 0 PRALUENT... 8 pramipexole dihydrochloride.. 7 pramipexole dihydrochloride er

111 pravastatin sodium... 8 prazosin hcl... 1 prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 65, 81 prednisone preferred plus insulin syringe. 37 PREMARIN... 6, 71 PREMASOL PREMPHASE PREMPRO prenatal PREPOPIK PREVIFEM PREZCOBIX PREZISTA... 3, 35 PRIFTIN... 0 primaquine phosphate... 1 primidone PRIVIGEN PROAIR HFA... 8 PROAIR RESPICLICK... 8 probenecid PROCALAMINE prochlorperazine... 9 prochlorperazine maleate... 9 PROCRIT... 0 PROCTO-MED HC PROCTO-PAK PROCTOSOL HC PROCTOZONE-HC progesterone micronized PROGLYCEM PROLASTIN-C PROLENSA PROLIA PROMACTA... 1 promethazine hcl... 8 propafenone hcl... 3 propafenone hcl er... 3 proparacaine hcl propranolol hcl... 5 propranolol hcl er... 5 propranolol-hctz... propylthiouracil PROQUAD PROSOL protriptyline hcl PULMOZYME PURIXAN... 1 pyrazinamide... 0 pyridostigmine bromide... 0 Q QUADRACEL QUASENSE quetiapine fumarate quetiapine fumarate er quinapril hcl... quinapril-hydrochlorothiazide quinidine gluconate er... 3 quinidine sulfate... 3 quinine sulfate... 7 R RABAVERT raloxifene hcl ramipril... RANEXA... 7 ranitidine hcl RAPAFLO RAPAMUNE... 7 rasagiline mesylate... 8 RAVICTI RECLIPSEN RECOMBIVAX HB REGRANEX RELENZA DISKHALER RELI-ON INSULIN SYRINGE repaglinide repaglinide-metformin hcl REPATHA... 9 REPATHA PUSHTRONEX SYSTEM... 9 REPATHA SURECLICK... 9 RESCRIPTOR... 3 RESTASIS REVLIMID... 1 REXULTI REYATAZ RIBASPHERE ribavirin... 31, 3 rifabutin... 0 rifampin... 0 RIFATER... 0 riluzole rimantadine hcl RIOMET risedronate sodium RISPERDAL CONSTA risperidone ritonavir rivastigmine... 1 rivastigmine tartrate ropinirole hcl... 7 rosuvastatin calcium... 8 ROTARIX ROTATEQ ROWEEPRA ROWEEPRA XR RUBRACA... 5 RYDAPT... 5 RYTARY... 7 S SABRIL SAMSCA SANDIMMUNE... 7 SANTYL SAPHRIS SAVELLA SAVELLA TITRATION PACK scopolamine selegiline hcl... 8 selenium sulfide SELZENTRY... 3 SENSIPAR SEREVENT DISKUS... 8 sertraline hcl SETLAKIN sevelamer carbonate... 6 SHAROBEL SHINGRIX SIGNIFOR... 7 sildenafil citrate SILENOR silver sulfadiazine SIMBRINZA SIMPONI... 7 simvastatin... 8 sirolimus... 7 SIRTURO... 0 sodium chloride... 58, 63 sodium fluoride sodium lactate sodium polystyrene sulfonate. 58 SOLIQUA SOLOXIDE SOLTAMOX

112 SOMATULINE DEPOT... 7 SOMAVERT... 7 SORINE... 5 sotalol hcl... 5 sotalol hcl (af)... 5 SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone... 7 spironolactone-hctz... SPRINTEC SPRITAM SPRYCEL... 5 SPS SRONYX SSD stavudine STELARA STIOLTO RESPIMAT... 8 STIVARGA... 5 streptomycin sulfate... 5 STRIBILD... 3 SUBOXONE... sucralfate... 6 sulfacetamide sodium sulfacetamide sodium (acne).. 56 sulfacetamide-prednisolone sulfadiazine... 9 sulfamethoxazole-trimethoprim 9 sulfasalazine... 9, 10 sulindac sumatriptan... 0 sumatriptan succinate... 0 sumatriptan succinate refill... 0 SUPRAX... 7 SUPREP BOWEL PREP KIT 6 SUTENT... 5 SYEDA SYLATRON... 5 SYMDEKO SYMFI... 3 SYMFI LO... 3 SYMLINPEN SYMLINPEN SYMTUZA... 3 SYNAREL SYNDROS SYNJARDY SYNJARDY XR SYNRIBO... 5 SYNTHROID... 7 T TABLOID... 1 tacrolimus... 56, 7 TAFINLAR... 5 TAGRISSO... 5 TAKHZYRO TALZENNA... 5 tamoxifen citrate... 5 tamsulosin hcl TARCEVA... 5 TARGRETIN TARINA FE 1/ TASIGNA... 5 tazarotene TAZICEF... 7 TAZORAC TAZTIA XT... 6 TECFIDERA TEFLARO... 7 TEKTURNA... 7 TEKTURNA HCT... 7 telmisartan... telmisartan-amlodipine... telmisartan-hctz... temazepam TENIVAC tenofovir disoproxil fumarate. 33 terazosin hcl... 1 terbinafine hcl terbutaline sulfate... 8 terconazole... 6 testosterone testosterone cypionate testosterone enanthate tetanus-diphtheria toxoids td.. 77 tetrabenazine tetracycline hcl THALOMID... 1 theophylline er thioridazine hcl... 9 thiothixene... 9 tiagabine hcl... 1 TIBSOVO... 5 tigecycline... 5 TIGLUTIK timolol maleate... 5, 81 TIVICAY... 3 tizanidine hcl tobramycin... 5, 80 tobramycin sulfate... 5 tobramycin-dexamethasone TOLAK tolazamide tolbutamide tolterodine tartrate tolterodine tartrate er topiramate... 1, 19 topiramate er... 1 torsemide... 7 TOUJEO MAX SOLOSTAR. 39 TOUJEO SOLOSTAR TPN ELECTROLYTES TRACLEER tramadol hcl... 3 tramadol-acetaminophen... 3 trandolapril... trandolapril-verapamil hcl er.. tranexamic acid... 1 tranylcypromine sulfate TRAVASOL TRAVATAN Z trazodone hcl... 1 TRECATOR... 1 TRELEGY ELLIPTA... 8 TRELSTAR MIXJECT... 5 TRESIBA FLEXTOUCH tretinoin... 5, 56 TREXALL... 7 triamcinolone acetonide... 51, 56 triamterene-hctz... triazolam trientine hcl... 1 trifluoperazine hcl... 9 trifluridine trihexyphenidyl hcl... 7 TRI-LEGEST FE TRI-LO-ESTARYLLA TRI-LO-SPRINTEC TRILYTE... 6 trimethoprim... 5 TRI-MILI trimipramine maleate TRINESSA (8) TRINTELLIX... 1 TRI-PREVIFEM TRI-SPRINTEC TRIUMEQ TRIVORA (8) TRI-VYLIBRA TROKENDI XR

113 TROPHAMINE TRULICITY TRUMENBA TRUVADA TWINRIX TYBOST... 3 TYKERB... 5 TYMLOS TYPHIM VI U UCERIS ULORIC UNITHROID... 7 UPTRAVI ursodiol V valacyclovir hcl... 3 VALCHLOR valganciclovir hcl valproate sodium... 1 valproic acid... 1 valsartan... valsartan-hydrochlorothiazide... 38, vancomycin hcl... 5, 6 VAQTA VARIVAX VARIZIG VARUBI VASCEPA... 9 VELIVET VELPHORO... 6 VELTASSA VEMLIDY VENCLEXTA... 5 VENCLEXTA STARTING PACK... 5 venlafaxine hcl venlafaxine hcl er verapamil hcl... 6 verapamil hcl er... 6 VERZENIO... 5 VICTOZA VIDEX VIDEX EC VIENVA vigabatrin... 1 VIIBRYD... 1 VIIBRYD STARTER PACK. 15 VIMPAT VIRACEPT VIRAMUNE... 3 VIREAD VIVITROL... VIZIMPRO... 5 voriconazole VOSEVI VOTRIENT... 5 VRAYLAR VYFEMLA VYLIBRA W warfarin sodium... 0 WELCHOL... 9 WYMZYA FE X XALKORI... 5 XARELTO... 0 XARELTO STARTER PACK... 0 XATMEP... 1 XELJANZ XELJANZ XR XGEVA XIFAXAN... 6 XOFLUZA XOLAIR XTANDI... 5 XULTOPHY XURIDEN XYREM Y YF-VAX YONSA... 5 YUVAFEM... 6 Z zafirlukast zaleplon... 86, 87 ZARAH ZARXIO... 1 ZEJULA... 5 ZELBORAF... 6 ZENCHENT ZENPEP ZERIT zidovudine zileuton er ziprasidone hcl ZIRGAN ZOLINZA... 6 zolpidem tartrate zonisamide ZORTRESS... 7 ZOSTAVAX ZOVIA 1/35E (8) ZTLIDO... 3 ZYDELIG... 6 ZYFLO ZYKADIA... 6 ZYLET... 8 ZYPREXA RELPREVV ZYTIGA

114 AgeWell New York, LLC is a Health Maintenance Organization (HMO) plan with a Medicare contract and a Coordination of Benefits Agreement with New York State Department of Health. Enrollment in AgeWell New York, LLC depends on contract renewal. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Assistance services for other languages are also available free of charge at the number above. Notice of Non-Discrimination AgeWell New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. AgeWell New York does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AgeWell New York 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) Free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages If you need these services, contact AgeWell New York Member Services at If you believe that AgeWell New York 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: AgeWell New York Civil Rights Coordination Unit 1991 Marcus Avenue Suite M01 Lake Success, New York TTY/TDD: Fax: civilrightsunit@agewellnewyork.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Civil Rights Coordination Unit 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, 00 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 001, , TDD: Complaint forms are available at 16

115 AgeWell New York, LLC es un plan deorganización para el mantenimiento de la salud (Health Maintenance Organization, HMO) que tiene un contrato con Medicare y un convenio de coordinación de beneficios con el Departamento de Salud del estado de Nueva York. La inscripción en AgeWell New York, LLC depende de la renovación del contrato. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). También hay disponibles servicios de asistencia gratuitos para otros idiomas llamando al número que se menciona arriba. Aviso sobre no discriminación AgeWell New York cumple con todas las leyes federales sobre derechos civiles que corresponden y no discrimina por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo. AgeWell New York no excluye a las personas ni las trata diferente por su raza, color, nacionalidad, edad, discapacidad o sexo. AgeWell New York proporciona ayuda y servicios gratuitos a personas con discapacidades a fin de que puedan comunicarse con nosotros eficazmente, como los siguientes: Intérpretes calificados de lenguaje de señas Información escrita en otros formatos (tamaño de letra grande, audio, formatos de acceso electrónico, otros formatos) Servicios lingüísticos gratuitos para personas cuyo idioma nativo no sea inglés, como intérpretes calificados e información escrita en otros idiomas Si necesita estos servicios, comuníquese con Servicios para miembros de AgeWell New York al Si considera que AgeWell New York no proporcionó estos servicios o hizo algún tipo de discriminación por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo ante: AgeWell New York Civil Rights Coordination Unit 1991 Marcus Avenue Suite M01 Lake Success, New York TTY/TDD: Fax: Correo electrónico: civilrightsunit@agewellnewyork.com Puede interponer un reclamo personalmente o por correo postal, fax o correo electrónico. Si necesita ayuda para presentar un reclamo, la Unidad de Coordinación de Derechos Civiles está disponible para usted. También puede presentar una queja relacionada con los derechos civiles ante el Departamento de Salud y Servicios Sociales, Oficina de Derechos Civiles, en forma electrónica a través del Portal de Quejas ante la Oficina de Derechos Civiles, disponible en o bien por teléfono o correo a: U.S. Department of Health and Human Services, 00 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 001, , TDD: Los formularios de quejas se encuentran disponibles en 17

116 Multi-Language Insert / Encarte multilingüe English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call (TTY: ). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Chínese: 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: ) Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). 18

117 Yiddish: Bengali: אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופ ) (TTY: লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন ১ (TTY: ১ ) Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). Arabic: French: ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم: (. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). Urdu : Tagolog: خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کريں (TTY: ) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Greek: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: ). 19

118 We re here for your c all. This formulary was updated on 0/019. For more recent information or other questions, please contact our Pharmacy Benefit Manager, EnvisionRx for AgeWell New York Member Services at or, for TTY users, , 7 days a week hours a day, or visit agewellnewyork.com TTY/TDD