Senior Preferred (HMO) 2019 Formulary (List of Covered Drugs)

Transcription

1 Senior Preferred (HMO) 09 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary ID: 96, Version 3 This formulary was updated on 3/0/09. For more recent information or other questions, please contact Customer Service at (800) Monday Friday 8 a.m.-8 p.m. October - March 3, daily 8 a.m. to 8 p.m. TTY / TDD users, 7 or toll-free (800) or visit SeniorPreferred.org. 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 Gundersen Health Plan. When it refers to plan or our plan, it means Senior Preferred. This document includes a list of the drugs (formulary) for our plan which is current as of 3/0/09. 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, 00, and from time-to-time during the year. Y009_8 7_C CMS ACCEPTED

2 What is the Senior Preferred 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Senior Preferred 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 09 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 09 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, 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 3/0/09. To get updated information about the drugs covered by Senior Preferred, please contact us. Our contact information appears on the front and back cover pages. In the event of non-maintenance changes to the formulary throughout the plan year, we may make changes via errata sheets mailed to you. Additionally, you may visit our website for a link to the errata sheet. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. 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 below. Then look under the category name for your drug. i

3 Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Senior Preferred 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 us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 60 tablets per month for enalapril. 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we 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. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization restrictions 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 us 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 Senior Preferred formulary? on page iii 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 Customer Service and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by us. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. ii

4 You can ask us 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 Senior Preferred Formulary? You can ask us 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, our 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, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and / or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 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. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug while you pursue a formulary exception. iii

5 What if I experience a change in the level of care that I have been receiving, such as transition from one facility or treatment center to another? We will make every effort to expedite these transitions in collaboration with the pharmacy benefit manager. There will be automated claims processing logic to override refill too soon, non-formulary, prior authorization requirements, step therapy requirements, or non-safety related drug utilization review (DUR) reason to facilitate smooth transition between level of care issues. For more information For more detailed information about your Senior Preferred prescription drug coverage, please review your Evidence of Coverage and other plan materials. 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 Senior Preferred 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 I-. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CHANTIX) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Initial Coverage Stage- Copayment / Coinsurance Amount Retail (30-day supply) and Mail-Order (90-day supply) member cost-sharing (in-network copay/coinsurance) Plan Name Gundersen Senior Preferred (HMO) ProHealth Senior Preferred (HMO) SwedishAmerican Senior Preferred (HMO) UW Health Senior Preferred (HMO) Pharmacy Type Tier Tier Tier 3 Tier Tier 5 Retail $3 $5 $5 0% 33% Mail $7 $38 $3 0% - Retail $ $ $7 0% 8% Mail $ $ $8 0% - Retail $3 $ $7 0% 8% Mail $7 $30 $8 0% - Retail $6 $5 $7 0% 5% Mail $5 $38 $8 0% - iv

6 LEGEND TIER LABEL DESCRIPTION Preferred Generic Generic drugs covered at the lowest cost-sharing level Generic Generic drugs 3 Preferred Brand Brand drugs covered at the lowest cost-sharing level available to Brand drugs Non-Preferred Drug Brand and generic drugs covered at the highest costsharing level 5 Specialty High cost and some injectable drugs SYMBOL DESCRIPTION EXPLANATION AGE Age Restriction This drug is covered for certain age groups only. Prior authorization is required if you are outside of the listed age range. LA Limited Access Drugs This prescription may be available only at certain pharmacies. NDS Non-Extended Days Supply This drug is limited to 30-day supply per fill. NM No Mail Order This drug is not available through mail order. PA PA BvD PA NSO Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for New Starts Only You (or your provider) are required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your provider) are required to get authorization from us to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, we may not cover this drug. If you are a new member or you have not taken this drug previously, you (or your provider) are required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL Quantity Limit Restriction We limit the amount of this drug that is covered per prescription, or within a specific time frame. ST Step Therapy Restriction Before we will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) do not work for you. v

7 Table of Contents Analgesics... 3 Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents... 7 Antianxiety Agents... 8 Antibacterials... 0 Anticancer Agents... 7 Anticholinergic Agents... Anticonvulsants... 5 Antidementia Agents... 8 Antidepressants... 8 Antidiabetic Agents... 3 Antifungals... 3 Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents... 0 Antipsychotic Agents... Antivirals (Systemic)... Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents... 66

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

9 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 0- /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet BELBUCA BUCCAL FILM 50 MCG, 300 MCG, 50 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine transdermal patch weekly 0 mcg/hour, 5 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital-acetaminophen-caff oral tablet butorphanol tartrate nasal spray,nonaerosol 0 /ml codeine sulfate oral tablet 5, 30, 60 DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, MG/ML EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 00- MG, MG, 30-. MG, 50- MG, 60-. MG, MG endocet oral tablet 0-35,.5-35, 5-35, fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 600 mcg, 800 mcg fentanyl citrate buccal lozenge on a handle 00 mcg, 00 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour mcg/hr, 5 mcg/hr, 50 mcg/hr hydrocodone-acetaminophen oral solution /5 ml hydrocodone-acetaminophen oral tablet 0-35 QL (500 per 30 QL (390 per 30 (Tylenol-Codeine #3) QL (360 per 30 (Tylenol-Codeine #) QL (80 per 30 QL (60 per 30 (Butrans) QL ( per 8 (Esgic) QL (0 per 30 QL (80 per 30 PA BvD; QL (50 per 30 3 QL (60 per 30 QL (360 per 30 (Actiq) 5 PA; NM; NDS; QL (0 per 30 (Actiq) PA; QL (0 per 30 (Duragesic) QL (0 per 30 (Duragesic) QL (5 per 30 QL (5550 per 30 (Lorcet HD) QL (360 per 30 3

10 hydrocodone-acetaminophen oral tablet (Verdrocet) QL (360 per hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) QL (360 per hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (360 per hydrocodone-ibuprofen oral tablet 0-00 (Ibudone) QL (50 per 30, 5-00 hydrocodone-ibuprofen oral tablet 7.5- QL (50 per hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone injection solution /ml, /ml, /ml hydromorphone injection syringe 0.5 /0.5 ml, /ml, /ml, /ml hydromorphone oral tablet (Dilaudid) QL (360 per 30 hydromorphone oral tablet (Dilaudid) QL (0 per 30 hydromorphone oral tablet 8 (Dilaudid) QL (0 per 30 ibuprofen-oxycodone oral tablet 00-5 QL (0 per 30 lorcet (hydrocodone) oral tablet 5-35 QL (360 per 30 lorcet hd oral tablet 0-35 QL (360 per 30 lorcet plus oral tablet QL (360 per 30 methadone oral solution 0 /5 ml, 5 QL (800 per 30 /5 ml methadone oral tablet 0 (Dolophine) QL (0 per 30 methadone oral tablet 5 (Dolophine) QL (0 per 30 morphine concentrate oral solution 00 QL (50 per 30 /5 ml (0 /ml) morphine injection solution 0 /ml, 5 /ml MORPHINE INJECTION SOLUTION MG/ML morphine injection syringe 0 /ml QL (50 per 30 morphine injection syringe /ml QL (750 per 30 morphine injection syringe /ml QL (375 per 30 morphine injection syringe 8 /ml QL (88 per 30 morphine intravenous solution 0 /ml, /ml, 8 /ml morphine intravenous syringe 0 /ml, /ml, /ml, 8 /ml morphine oral capsule, er multiphase hr 0 QL (30 per 30

11 morphine oral capsule, er multiphase QL (0 per 30 hr 30, 5 morphine oral capsule, er multiphase QL (60 per 30 hr 60, 75, 90 morphine oral capsule,extend.release (Kadian) QL (0 per 30 pellets 0, 0, 30, 0, 50 morphine oral capsule,extend.release (Kadian) QL (30 per 30 pellets 00 morphine oral capsule,extend.release (Kadian) QL (60 per 30 pellets 60, 80 morphine oral solution 0 /5 ml QL (3600 per 30 morphine oral solution 0 /5 ml ( QL (700 per 30 /ml) MORPHINE ORAL TABLET 5 MG QL (0 per 30 MORPHINE ORAL TABLET 30 MG QL (0 per 30 morphine oral tablet extended release 00 (MS Contin) QL (60 per 30, 00, 60 morphine oral tablet extended release 5 (MS Contin) QL (80 per 30 morphine oral tablet extended release 30 (MS Contin) QL (0 per 30 oxycodone oral capsule 5 QL (80 per 30 oxycodone oral concentrate 0 /ml QL (360 per 30 oxycodone oral solution 5 /5 ml QL (00 per 30 oxycodone oral tablet 0 QL (0 per 30 oxycodone oral tablet 5 (Roxicodone) QL (80 per 30 oxycodone oral tablet 0 QL (0 per 30 oxycodone oral tablet 30 (Roxicodone) QL (90 per 30 oxycodone oral tablet 5 (Roxicodone) QL (80 per 30 oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (0 per 30 hr 0, 5, 0, 30, 0 oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (90 per 30 hr 60 oxycodone oral tablet,oral only,ext.rel. (OxyContin) QL (60 per 30 hr 80 oxycodone-acetaminophen oral tablet 0- (Endocet) QL (360 per 30 35,.5-35, 5-35, oxycodone-aspirin oral tablet QL (360 per 30 5

12 OXYCONTIN ORAL TABLET,ORAL 3 QL (0 per 30 ONLY,EXT.REL. HR 0 MG, 5 MG, 0 MG, 30 MG, 0 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (90 per 30 ONLY,EXT.REL. HR 60 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (60 per 30 ONLY,EXT.REL. HR 80 MG tramadol oral tablet 50 (Ultram) QL (0 per 30 tramadol oral tablet extended release QL (30 per 30 hr 00, 00, 300 tramadol oral tablet, er multiphase hr QL (30 per 30 00, 00, 300 tramadol-acetaminophen oral tablet (Ultracet) QL (0 per xylon 0 oral tablet 0-00 QL (50 per 30 Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 00 (Celebrex) QL (90 per 30 celecoxib oral capsule 00, 00, 50 (Celebrex) QL (60 per 30 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops.5 % PA diclofenac sodium topical gel % (Voltaren) diclofenac sodium topical gel 3 % (Solaraze) 5 PA; NM; NDS diflunisal oral tablet 500 etodolac oral capsule 00, 300 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release hr 00, 500, 600 FLECTOR TRANSDERMAL PATCH HOUR PA; QL (60 per 30.3 % flurbiprofen oral tablet 00, 50 ibu oral tablet 00, 600, 800 ibuprofen oral suspension 00 /5 ml (Children's Advil) ibuprofen oral tablet 00, 600, 800 (IBU) indomethacin oral capsule 5 QL (0 per 30 indomethacin oral capsule 50 QL (0 per 30 6

13 indomethacin oral capsule, extended QL (60 per 30 release 75 ketoprofen oral capsule 5, 50, 75 ketorolac oral tablet 0 QL (0 per 5 meclofenamate oral capsule 00, 50 mefenamic acid oral capsule 50 meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral suspension 5 /5 ml (Naprosyn) naproxen oral tablet 50 naproxen oral tablet 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 500 oxaprozin oral tablet 600 (Daypro) piroxicam oral capsule 0, 0 (Feldene) sulindac oral tablet 50, 00 tolmetin oral capsule 00 tolmetin oral tablet 00, 600 Anesthetics Local Anesthetics lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution PA BvD % (0 /ml) lidocaine topical adhesive (Lidoderm) PA; QL (90 per 30 patch,medicated 5 % lidocaine topical ointment 5 % PA lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % PA; QL (30 per 30 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 buprenorphine hcl sublingual tablet, 8 QL (90 per 30 7

14 buprenorphine-naloxone sublingual film -3, -0.5, -, 8- (Suboxone) buprenorphine-naloxone sublingual tablet QL (90 per , 8- bupropion hcl (smoking deter) oral tablet (Zyban) QL (60 per 30 extended release hr 50 CHANTIX CONTINUING MONTH BOX ORAL 3 QL (60 per 30 TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG 3 QL (60 per 30 CHANTIX STARTING MONTH BOX ORAL 3 QL (53 per 8 TABLETS,DOSE PACK 0.5 MG ()- MG () disulfiram oral tablet 50, 500 (Antabuse) LUCEMYRA ORAL TABLET 0.8 MG PA; QL ( per naloxone injection solution 0. /ml naloxone injection syringe 0. /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON-AEROSOL 3 QL ( per day) MG/ACTUATION NICOTROL INHALATION CARTRIDGE 0 QL (30 per 80 MG NICOTROL NS NASAL SPRAY,NON- QL (70 per 80 AEROSOL 0 MG/ML SUBOXONE SUBLINGUAL FILM -3 MG, 3 QL (60 per 30 - MG SUBOXONE SUBLINGUAL FILM -0.5 MG, 3 QL (90 per MG VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG 5 NM; NDS; QL ( per 8 Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL QL (300 per 30 CONCENTRATE MG/ML alprazolam oral tablet 0.5, 0.5, (Xanax) QL (0 per 30 alprazolam oral tablet (Xanax) QL (50 per 30 alprazolam oral tablet extended release (Xanax XR) QL (30 per 30 hr 0.5, alprazolam oral tablet extended release hr (Xanax XR) QL (50 per 30 8

15 alprazolam oral tablet extended release (Xanax XR) QL (90 per 30 hr 3 alprazolam oral tablet,disintegrating 0.5 QL (0 per 30, 0.5, alprazolam oral tablet,disintegrating QL (50 per 30 buspirone oral tablet 0, 5, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 0 QL (0 per 30 chlordiazepoxide hcl oral capsule 5 QL (360 per 30 chlordiazepoxide hcl oral capsule 5 QL (0 per 30 clobazam oral suspension.5 /ml (Onfi) QL (80 per 30 clobazam oral tablet 0, 0 (Onfi) QL (60 per 30 clonazepam oral tablet 0.5, (Klonopin) QL (90 per 30 clonazepam oral tablet (Klonopin) QL (300 per 30 clonazepam oral tablet,disintegrating QL (90 per , 0.5, 0.5, clonazepam oral tablet,disintegrating QL (300 per 30 clorazepate dipotassium oral tablet 5 QL (80 per 30, 3.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (80 per 30 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam intensol oral concentrate 5 QL (0 per 30 /ml diazepam oral solution 5 /5 ml ( QL (00 per 30 /ml) diazepam oral tablet 0 (Valium) QL (0 per 30 diazepam oral tablet (Valium) QL (300 per 30 diazepam oral tablet 5 (Valium) QL (0 per 30 diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit.5 (Diastat) estazolam oral tablet, QL (30 per 30 lorazepam oral concentrate /ml (Lorazepam Intensol) QL (50 per 30 lorazepam oral tablet 0.5,, (Ativan) QL (50 per 30 meprobamate oral tablet 00 meprobamate oral tablet 00 PA; AGE (Max 6 Years) ONFI ORAL SUSPENSION.5 MG/ML 5 NM; NDS; QL (80 per 30 ONFI ORAL TABLET 0 MG, 0 MG QL (60 per 30 9

16 oxazepam oral capsule 0, 5, 30 QL (0 per 30 SYMPAZAN ORAL FILM 0 MG 5 PA NSO; NM; NDS; QL (0 per 30 SYMPAZAN ORAL FILM 0 MG 5 PA NSO; NM; NDS; QL (60 per 30 SYMPAZAN ORAL FILM 5 MG PA NSO; QL (0 per 30 temazepam oral capsule 5, 30 (Restoril) QL (30 per 30 Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR 5 PA BvD; NM; NDS NEBULIZATION 300 MG/ ML gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 00 /50 ml, 0 /00 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 0 / ml, 0 /ml gentamicin sulfate (pf) intravenous solution 00 /0 ml, 60 /6 ml, 80 /8 ml neomycin oral tablet 500 streptomycin intramuscular recon soln PA BvD gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG 5 NM; NDS; QL (0 per 30 tobramycin in 0.5 % nacl inhalation solution for nebulization 300 /5 ml (Tobi) 5 PA BvD; NM; NDS; QL (80 per 56 tobramycin sulfate injection solution 0 PA BvD /ml, 0 /ml Antibacterials, Miscellaneous clindamycin hcl oral capsule 50, 300 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln (Cleocin Pediatric) 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) 0

17 clindamycin phosphate injection solution (Cleocin) 50 /ml clindamycin phosphate intravenous (Cleocin) solution 600 / ml colistin (colistimethate na) injection recon (Coly-Mycin M PA BvD soln 50 Parenteral) CUBICIN INTRAVENOUS RECON SOLN PA BvD; NM; NDS MG DALVANCE INTRAVENOUS SOLUTION NM; NDS MG daptomycin intravenous recon soln 500 (Cubicin) 5 PA BvD; NM; NDS FIRVANQ ORAL RECON SOLN 5 MG/ML, 3 50 MG/ML linezolid 600 /300 ml-0.9% nacl NM; NDS /300 ml linezolid in dextrose 5% intravenous (Zyvox) 5 NM; NDS piggyback 600 /300 ml linezolid oral suspension for reconstitution 00 /5 ml (Zyvox) 5 NM; NDS; QL (800 per 30 linezolid oral tablet 600 (Zyvox) QL (60 per 30 methenamine hippurate oral tablet (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml (Metro I.V.) metronidazole oral tablet 50, 500 (Flagyl) MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule (Macrodantin) 00, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 (Macrobid) nitrofurantoin oral suspension 5 /5 ml (Furadantin) SIVEXTRO INTRAVENOUS RECON SOLN 00 MG 5 NM; NDS; QL (6 per 30 SIVEXTRO ORAL TABLET 00 MG 5 NM; NDS; QL (6 per 30 trimethoprim oral tablet 00 vancomycin intravenous recon soln,000, 0 gram, 50, 5 gram, 500, 750 VANCOMYCIN INTRAVENOUS RECON SOLN.5 GRAM vancomycin oral capsule 5, 50 (Vancocin)

18 XIFAXAN ORAL TABLET 00 MG, 550 MG 5 PA; NM; NDS Cephalosporins AVYCAZ INTRAVENOUS RECON SOLN.5 5 NM; NDS GRAM cefaclor oral capsule 50, 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin injection recon soln gram, 0 PA BvD gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefepime injection recon soln gram, (Maxipime) PA BvD gram cefixime oral suspension for reconstitution (Suprax) 00 /5 ml, 00 /5 ml cefotaxime injection recon soln gram, 500 cefotaxime injection recon soln 0 gram, (Claforan) gram cefoxitin intravenous recon soln gram, PA BvD 0 gram, gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftriaxone injection recon soln gram, 0 gram, gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln PA BvD 750 cefuroxime sodium intravenous recon soln PA BvD.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex)

19 cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml SUPRAX ORAL CAPSULE 00 MG 3 SUPRAX ORAL SUSPENSION FOR 3 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 00 3 MG, 00 MG tazicef injection recon soln gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 00 5 NM; NDS MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) PA BvD azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 (3 pack) azithromycin oral tablet 50, 500 (Zithromax) azithromycin oral tablet 600 clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release hr 500 DIFICID ORAL TABLET 00 MG 5 NM; NDS ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN,000 MG ERYTHROCIN INTRAVENOUS RECON SOLN PA BvD 500 MG erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet 00 (E.E.S. 00) 3

20 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics AZACTAM INJECTION RECON SOLN GRAM, GRAM AZACTAM-ISO-OSMOT GM/50 ML 'S,SINGLE USE GRAM/50 ML aztreonam injection recon soln gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 PA; NM; LA; NDS; QL (8 per 8 doripenem intravenous recon soln 50 doripenem intravenous recon soln 500 PA BvD ertapenem injection recon soln gram (Invanz) imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet 50-5 amoxicillin-pot clavulanate oral tablet 500-5, (Augmentin)

21 amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release hr, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, 500 ampicillin sodium injection recon soln PA BvD gram, 0 gram, 5 ampicillin sodium injection recon soln gram, 50, 500 ampicillin-sulbactam injection recon soln (Unasyn) PA BvD.5 gram, 5 gram, 3 gram BICILLIN C-R INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML(600K/600K),,00,000 UNIT/ ML(900K/300K) BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm/ 50 ml inj gram/50 ml PA BvD nafcillin injection recon soln gram, 0 PA BvD gram, gram oxacillin gm add-vantage vl addvantage, inner gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, gram/50 ml oxacillin injection recon soln gram, 0 gram, gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) PA BvD 0 million unit penicillin g sodium injection recon soln 5 PA BvD million unit penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous recon soln.5 gram, gram,.5 gram, 0.5 gram (Zosyn) 5

22 ZOSYN IN DEXTROSE (ISO-OSM) PA BvD INTRAVENOUS PIGGYBACK GRAM/50 ML ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK.5 GRAM/00 ML Quinolones BAXDELA INTRAVENOUS RECON SOLN NM; NDS MG BAXDELA ORAL TABLET 50 MG 5 NM; NDS ciprofloxacin hcl oral tablet 00 ciprofloxacin hcl oral tablet 50, 500 (Cipro) ciprofloxacin hcl oral tablet 750 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /00 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 00 /00 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50 levofloxacin oral tablet 500, 750 (Levaquin) moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 300, 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet sulfatrim oral suspension 00-0 /5 ml 3 Tetracyclines demeclocycline oral tablet 50, 300 6

23 doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon soln (Doxy-00) 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 0 doxycycline hyclate oral tablet 50 (Targadox) doxycycline monohydrate oral capsule 00 (Mondoxyne NL), 50 doxycycline monohydrate oral tablet 00 (Avidoxy) doxycycline monohydrate oral tablet 50 doxycycline monohydrate oral tablet 50, 75 minocycline oral capsule 00, 75 minocycline oral capsule 50 (Minocin) NUZYRA (7 DAY WITH LOAD DOSE) ORAL TABLET 50 MG 5 PA; NM; NDS; QL (90 per 30 NUZYRA (7 DAY) ORAL TABLET 50 MG 5 PA; NM; NDS; QL (90 per 30 NUZYRA INTRAVENOUS RECON SOLN 00 MG 5 PA; NM; NDS NUZYRA ORAL TABLET 50 MG 5 PA; NM; NDS; QL (90 per 30 okebo oral capsule 00 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) 5 NM; NDS Anticancer Agents Anticancer Agents abiraterone oral tablet 50 (Zytiga) 5 PA NSO; NM; NDS; QL (0 per 30 AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 3 MG, 5 MG 5 PA NSO; NM; NDS; QL (60 per 30 AFINITOR ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (60 per 30 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; NM; NDS; QL (30 per 30 ALECENSA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (0 per 30 ALUNBRIG ORAL TABLET 80 MG 5 PA NSO; NM; NDS; QL (30 per 30 7

24 ALUNBRIG ORAL TABLET 30 MG 5 PA NSO; NM; NDS; QL (80 per 30 ALUNBRIG ORAL TABLET 90 MG 5 PA NSO; NM; NDS; QL (60 per 30 ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (3) 5 PA NSO; NM; NDS; QL (30 per 30 anastrozole oral tablet (Arimidex) arsenic trioxide intravenous solution 5 NM; NDS /ml BENDEKA INTRAVENOUS SOLUTION 5 5 PA BvD; NM; NDS MG/ML bexarotene oral capsule 75 (Targretin) 5 PA NSO; NM; NDS bicalutamide oral tablet 50 (Casodex) BOSULIF ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (0 per 30 BOSULIF ORAL TABLET 00 MG, 500 MG 5 PA NSO; NM; NDS; QL (30 per 30 BRAFTOVI ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (0 per 30 BRAFTOVI ORAL CAPSULE 75 MG 5 PA NSO; NM; NDS; QL (80 per 30 CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG 5 PA NSO; NM; NDS; QL (30 per 30 CALQUENCE ORAL CAPSULE 00 MG 5 PA NSO; NM; NDS; QL (60 per 30 CAPRELSA ORAL TABLET 00 MG 5 PA NSO; NM; LA; NDS; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X) 5 PA NSO; NM; NDS; QL (56 per 8 COMETRIQ ORAL CAPSULE 0 MG/DAY(80 MG X-0 MG X3) 5 PA NSO; NM; NDS; QL ( per 8 COMETRIQ ORAL CAPSULE 60 MG/DAY (0 MG X 3/DAY) 5 PA NSO; NM; NDS; QL (8 per 8 COPIKTRA ORAL CAPSULE 5 MG, 5 MG 5 PA NSO; NM; NDS; QL (60 per 30 COTELLIC ORAL TABLET 0 MG 5 PA NSO; NM; LA; NDS; QL (90 per 30 CYCLOPHOSPHAMIDE ORAL CAPSULE 5 PA BvD MG, 50 MG daunorubicin intravenous solution 5 /ml PA BvD 8

25 DAURISMO ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (30 per 30 DAURISMO ORAL TABLET 5 MG 5 PA NSO; NM; NDS; QL (0 per 30 docetaxel intravenous solution 60 /8 ml (0 /ml), 0 / ml (0 /ml), 0 /ml, 80 /8 ml (0 /ml) docetaxel intravenous solution 0 /ml (Taxotere) ( ml), 80 / ml (0 /ml) doxorubicin intravenous recon soln 0, (Adriamycin) PA BvD 50 doxorubicin intravenous solution 0 /5 (Adriamycin) PA BvD ml, /ml, 0 /0 ml, 50 /5 ml DROXIA ORAL CAPSULE 00 MG, 300 MG, 3 00 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE.5 MG PA NSO; QL ( per 8 ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 30 MG PA NSO; QL ( per 8 ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 5 MG PA NSO; QL ( per 8 ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) PA NSO; QL ( per 8 EMCYT ORAL CAPSULE 0 MG 5 NM; NDS ERIVEDGE ORAL CAPSULE 50 MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 ERLEADA ORAL TABLET 60 MG 5 PA NSO; NM; NDS; QL (0 per 30 exemestane oral tablet 5 (Aromasin) QL (60 per 30 FARESTON ORAL TABLET 60 MG 5 NM; NDS FARYDAK ORAL CAPSULE 0 MG, 5 MG, 5 PA NSO; NM; NDS 0 MG FIRMAGON KIT W DILUENT SYRINGE PA NSO SUBCUTANEOUS RECON SOLN 0 MG, 80 MG flutamide oral capsule 5 GILOTRIF ORAL TABLET 0 MG, 30 MG, 0 MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 GLEOSTINE ORAL CAPSULE 0 MG, 00 3 MG, 0 MG, 5 MG HERCEPTIN INTRAVENOUS RECON SOLN 5 PA BvD; NM; NDS 50 MG HEXALEN ORAL CAPSULE 50 MG 5 NM; NDS 9

26 hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG 5 PA NSO; NM; NDS; QL ( per 8 ICLUSIG ORAL TABLET 5 MG 5 PA NSO; NM; LA; NDS; QL (60 per 30 ICLUSIG ORAL TABLET 5 MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 IDHIFA ORAL TABLET 00 MG, 50 MG 5 PA NSO; NM; NDS; QL (30 per 30 imatinib oral tablet 00 (Gleevec) 5 PA NSO; NM; NDS; QL (90 per 30 imatinib oral tablet 00 (Gleevec) 5 PA NSO; NM; NDS; QL (60 per 30 IMBRUVICA ORAL CAPSULE 0 MG 5 PA NSO; NM; NDS; QL (0 per 30 IMBRUVICA ORAL CAPSULE 70 MG 5 PA NSO; NM; NDS; QL (30 per 30 IMBRUVICA ORAL TABLET 0 MG, 80 MG, 0 MG, 560 MG 5 PA NSO; NM; NDS; QL (30 per 30 INLYTA ORAL TABLET MG 5 PA NSO; NM; LA; NDS; QL (0 per 30 INLYTA ORAL TABLET 5 MG 5 PA NSO; NM; LA; NDS; QL (0 per 30 IRESSA ORAL TABLET 50 MG 5 PA NSO; NM; NDS; QL (60 per 30 JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NM; LA; NDS; QL (60 per 30 KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG 5 PA NSO; NM; NDS; QL (9 per 8 KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG 5 PA NSO; NM; NDS; QL (70 per 8 KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X 3)-.5 MG 5 PA NSO; NM; NDS; QL (9 per 8 KISQALI ORAL TABLET 00 MG/DAY (00 MG X ), 00 MG/DAY (00 MG X ), PA NSO; NM; NDS; QL (63 per MG/DAY (00 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 30 MG, 60 MG 5 PA NSO; NM; NDS 0

27 LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), MG/DAY ( MG X 3), MG/DAY(0 MG X - MG X ), 8 MG/DAY (0 MG X - MG X), 0 MG/DAY (0 MG X ), MG/DAY(0 MG X - MG X ), MG, 8 MG/DAY ( MG X ) 5 PA NSO; NM; NDS letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit /0. ml PA NSO LIBTAYO INTRAVENOUS SOLUTION 350 MG/7 ML (50 MG/ML) 5 PA NSO; NM; NDS; QL (7 per LONSURF ORAL TABLET 5-6. MG 5 PA NSO; NM; NDS; QL (00 per 8 LONSURF ORAL TABLET MG 5 PA NSO; NM; NDS; QL (80 per 8 LORBRENA ORAL TABLET 00 MG, 5 MG 5 PA NSO; NM; NDS LUMOXITI INTRAVENOUS RECON SOLN 5 PA NSO; NM; NDS MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG 5 PA NSO; NM; NDS; QL ( per 8 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG 5 PA NSO; NM; NDS; QL ( per 8 LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG 5 PA NSO; NM; NDS; QL ( per 8 LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG 5 PA NSO; NM; NDS; QL ( per 8 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG 5 PA NSO; NM; NDS; QL ( per 8 LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (80 per 30 LYNPARZA ORAL TABLET 00 MG, 50 MG 5 PA NSO; NM; NDS; QL (0 per 30 LYSODREN ORAL TABLET 500 MG 3 MATULANE ORAL CAPSULE 50 MG 5 NM; LA; NDS megestrol oral tablet 0, 0 MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NM; LA; NDS; QL (0 per 30 MEKINIST ORAL TABLET MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 MEKTOVI ORAL TABLET 5 MG 5 PA NSO; NM; NDS; QL (80 per 30 mercaptopurine oral tablet 50

28 methotrexate sodium (pf) injection solution 5 /ml methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 PA BvD NERLYNX ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (80 per 30 NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NM; LA; NDS; QL (0 per 30 nilutamide oral tablet 50 (Nilandron) 5 NM; NDS NINLARO ORAL CAPSULE.3 MG, 3 MG, MG 5 PA NSO; NM; NDS; QL (3 per 8 ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 POMALYST ORAL CAPSULE MG, MG, 3 MG, MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 POTELIGEO INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS MG/ML PURIXAN ORAL SUSPENSION 0 MG/ML 5 NM; NDS REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 romidepsin intravenous recon soln 0 (Istodax) 5 PA NSO; NM; NDS / ml RUBRACA ORAL TABLET 00 MG, 300 MG 5 PA NSO; NM; NDS; QL (0 per 30 RUBRACA ORAL TABLET 50 MG 5 NM; NDS; QL (0 per 30 RYDAPT ORAL CAPSULE 5 MG 5 PA NSO; NM; NDS; QL (0 per 30 SOLTAMOX ORAL SOLUTION 0 MG/5 ML SPRYCEL ORAL TABLET 00 MG, 0 MG, 50 MG, 70 MG 5 PA NSO; NM; NDS; QL (30 per 30 SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (90 per 30 SPRYCEL ORAL TABLET 80 MG 5 PA NSO; NM; NDS; QL (60 per 30 STIVARGA ORAL TABLET 0 MG 5 PA NSO; NM; LA; NDS; QL (8 per 8 SUTENT ORAL CAPSULE.5 MG, 5 MG, 37.5 MG, 50 MG 5 PA NSO; NM; NDS; QL (30 per 30 SYNRIBO SUBCUTANEOUS RECON SOLN 5 PA NSO; NM; NDS 3.5 MG TABLOID ORAL TABLET 0 MG

29 TAFINLAR ORAL CAPSULE 50 MG 5 PA NSO; NM; LA; NDS; QL (80 per 30 TAFINLAR ORAL CAPSULE 75 MG 5 PA NSO; NM; LA; NDS; QL (0 per 30 TAGRISSO ORAL TABLET 0 MG, 80 MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 TALZENNA ORAL CAPSULE 0.5 MG 5 PA NSO; NM; NDS; QL (0 per 30 TALZENNA ORAL CAPSULE MG 5 PA NSO; NM; NDS; QL (30 per 30 tamoxifen oral tablet 0, 0 TARCEVA ORAL TABLET 00 MG, 50 MG 5 PA NSO; NM; LA; NDS; QL (30 per 30 TARCEVA ORAL TABLET 5 MG 5 PA NSO; NM; LA; NDS; QL (0 per 30 TARGRETIN TOPICAL GEL % 5 PA NSO; NM; NDS TASIGNA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (50 per 30 TASIGNA ORAL CAPSULE 00 MG 5 PA NSO; NM; NDS; QL (0 per 30 TASIGNA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (0 per 30 temsirolimus intravenous recon soln 30 (Torisel) 5 PA BvD; NM; NDS /3 ml (0 /ml) (first) TIBSOVO ORAL TABLET 50 MG 5 PA NSO; NM; NDS; QL (60 per 30 toremifene oral tablet 60 (Fareston) 5 NM; NDS TREANDA INTRAVENOUS RECON SOLN 00 MG, 5 MG 5 PA BvD; NM; NDS TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 MG,.5 MG TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 3.75 MG tretinoin (chemotherapy) oral capsule 0 5 PA NSO; NM; NDS; QL ( per 8 5 PA NSO; NM; NDS; QL ( per 8 5 NM; NDS TYKERB ORAL TABLET 50 MG 5 PA NSO; NM; LA; NDS; QL (50 per 30 VENCLEXTA ORAL TABLET 0 MG PA NSO; QL (60 per 30 VENCLEXTA ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (0 per 30 3

30 VENCLEXTA ORAL TABLET 50 MG PA NSO; QL (30 per 30 VENCLEXTA STARTING PACK ORAL 5 PA NSO; NM; NDS TABLETS,DOSE PACK 0 MG-50 MG- 00 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG 5 PA NSO; NM; NDS; QL (60 per 30 VITRAKVI ORAL CAPSULE 00 MG 5 PA NSO; NM; NDS; QL (60 per 30 VITRAKVI ORAL CAPSULE 5 MG 5 PA NSO; NM; NDS; QL (0 per 30 VITRAKVI ORAL SOLUTION 0 MG/ML 5 PA NSO; NM; NDS; QL (300 per 30 VIZIMPRO ORAL TABLET 5 MG, 30 MG, 5 MG 5 PA NSO; NM; NDS; QL (30 per 30 VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NM; LA; NDS; QL (0 per 30 XALKORI ORAL CAPSULE 00 MG, 50 MG 5 PA NSO; NM; LA; NDS; QL (60 per 30 XATMEP ORAL SOLUTION.5 MG/ML XOSPATA ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (0 per 30 XTANDI ORAL CAPSULE 0 MG 5 PA NSO; NM; LA; NDS; QL (0 per 30 YONSA ORAL TABLET 5 MG 5 PA NSO; NM; NDS; QL (0 per 30 ZEJULA ORAL CAPSULE 00 MG 5 PA NSO; NM; NDS; QL (90 per 30 ZELBORAF ORAL TABLET 0 MG 5 PA NSO; NM; LA; NDS; QL (0 per 30 ZOLINZA ORAL CAPSULE 00 MG 5 PA NSO; NM; NDS ZYDELIG ORAL TABLET 00 MG, 50 MG 5 PA NSO; NM; NDS; QL (60 per 30 ZYKADIA ORAL CAPSULE 50 MG 5 PA NSO; NM; LA; NDS; QL (50 per 30 ZYTIGA ORAL TABLET 50 MG 5 PA NSO; NM; LA; NDS; QL (0 per 30 ZYTIGA ORAL TABLET 500 MG 5 NM; NDS; QL (60 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0. /ml

31 propantheline oral tablet 5 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 600 MG, 800 MG 5 NM; NDS; QL (60 per 30 APTIOM ORAL TABLET 00 MG 5 NM; NDS; QL (30 per 30 BANZEL ORAL SUSPENSION 0 MG/ML 5 NM; NDS; QL (00 per 30 BANZEL ORAL TABLET 00 MG, 00 MG 5 NM; NDS; QL (0 per 30 BRIVIACT ORAL SOLUTION 0 MG/ML 5 NM; NDS BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG 5 NM; NDS carbamazepine oral capsule, er (Carbatrol) multiphase hr 00, 00, 300 carbamazepine oral suspension 00 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release hr 00, 00, 00 carbamazepine oral tablet,chewable 00 CELONTIN ORAL CAPSULE 300 MG DILANTIN EXTENDED ORAL CAPSULE 00 MG DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG DILANTIN ORAL CAPSULE 30 MG 3 DILANTIN-5 ORAL SUSPENSION 5 MG/5 ML divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 5 divalproex oral tablet extended release (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 5, 50, 500 (Depakote) EPIDIOLEX ORAL SOLUTION 00 MG/ML 5 PA NSO; NM; NDS epitol oral tablet 00 EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG, 00 MG, 300 MG 3 ethosuximide oral capsule 50 (Zarontin) 5

32 ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 00, 600 (Felbatol) FYCOMPA ORAL SUSPENSION 0.5 MG/ML QL (70 per 30 FYCOMPA ORAL TABLET 0 MG, MG, MG, MG, 6 MG, 8 MG QL (30 per 30 gabapentin oral capsule 00, 300, (Neurontin) 00 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) GABITRIL ORAL TABLET MG, 6 MG, MG, MG lamotrigine oral tablet 00, 50, (Lamictal) 00, 5 lamotrigine oral tablet disintegrating, (Lamictal ODT Starter dose pk 5 () -50 (7) (Blue)) lamotrigine oral tablet disintegrating, (Lamictal ODT Starter dose pk 5 ()-50 ()-00 (7) (Orange)) lamotrigine oral tablet disintegrating, (Lamictal ODT Starter dose pk 50 () -00 () (Green)) lamotrigine oral tablet extended release (Lamictal XR) hr 00, 00, 5, 50, 300, 50 lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 lamotrigine oral tablet,disintegrating 00 (Lamictal ODT), 00, 5, 50 levetiracetam oral solution 00 /ml (Keppra) levetiracetam oral tablet,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release (Keppra XR) QL (80 per 30 hr 500 levetiracetam oral tablet extended release (Keppra XR) QL (0 per 30 hr 750 LYRICA ORAL CAPSULE 00 MG, 50 MG, 3 QL (90 per MG, 5 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 5 MG, 300 MG 3 QL (60 per 30 LYRICA ORAL SOLUTION 0 MG/ML 3 QL (900 per 30 oxcarbazepine oral suspension 300 /5 (Trileptal) ml (60 /ml) oxcarbazepine oral tablet 50, 300 (Trileptal), 600 PEGANONE ORAL TABLET 50 MG 6

33 phenobarbital oral elixir 0 /5 ml ( QL (500 per 30 /ml) phenobarbital oral tablet 00 QL (0 per 30 phenobarbital oral tablet 5, 6., QL (90 per 30 30, 3., 60, 6.8 phenobarbital oral tablet 97. QL (60 per 30 PHENYTEK ORAL CAPSULE 00 MG, 300 MG phenytoin oral suspension 5 /5 ml (Dilantin-5) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 00 phenytoin sodium extended oral capsule (Phenytek) 00, 300 primidone oral tablet 50, 50 (Mysoline) ROWEEPRA ORAL TABLET,000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED QL (80 per 30 RELEASE HR 500 MG ROWEEPRA XR ORAL TABLET EXTENDED QL (0 per 30 RELEASE HR 750 MG SABRIL ORAL TABLET 500 MG 5 PA NSO; NM; LA; NDS; QL (80 per 30 SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 50 MG, 500 MG, 750 MG subvenite oral tablet 00, 50, 00, 5 tiagabine oral tablet, 6,, (Gabitril) topiramate oral capsule, sprinkle 5, (Topamax) 5 topiramate oral capsule,sprinkle,er hr (Qudexy XR) 00, 50, 00, 5, 50 topiramate oral tablet 00, 00, (Topamax) 5, 50 valproic acid (as sodium salt) oral solution (Depakene) 50 /5 ml valproic acid oral capsule 50 (Depakene) vigabatrin oral powder in packet 500 (Sabril) 5 PA NSO; NM; LA; NDS; QL (80 per 30 vigabatrin oral tablet 500 (Sabril) 5 PA NSO; NM; LA; NDS; QL (80 per 30 7