EnvisionRxPlus Formulary. (List of Covered Drugs)

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1 EnvisionRxPlus 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission 18365, Version Number 8 This formulary was updated on 11/17/017. For more recent information or other questions, please contact EnvisionRxPlus Member Services at or, for TTY users, 711, hours a day, 7 days a week, or visit 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 Envision Insurance Company. When it refers to plan or our plan, it means EnvisionRxPlus. This document includes a list of the drugs (formulary) for our plan which is current as of January 1, 018. 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, 019, and from time to time during the year. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). EnvisionRxPlus is a PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. S769_018 CF H Accepted 9/3/17 i

2 What is the EnvisionRxPlus Formulary? A formulary is a list of covered drugs selected by EnvisionRxPlus 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. EnvisionRxPlus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an EnvisionRxPlus 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 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. 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. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. 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 60 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 60-day supply of the drug. 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. The enclosed formulary is current as of January 1, 018. To get updated information about the drugs covered by EnvisionRxPlus, please contact us. Our contact information appears on the front and back cover pages. If we make certain non-routine changes to coverage for drugs, we will send members an errata sheet to update the formulary they received. 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 89. 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. EnvisionRxPlus is a PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. S769_018 CF H Accepted 9/3/17 ii

3 What are generic drugs? EnvisionRxPlus 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: EnvisionRxPlus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from EnvisionRxPlus before you fill your prescriptions. If you don t get approval, EnvisionRxPlus may not cover the drug. Quantity Limits: For certain drugs, EnvisionRxPlus limits the amount of the drug that EnvisionRxPlus will cover. For example, EnvisionRxPlus provides 0 tablets per 30-day per prescription for Tramadol. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, EnvisionRxPlus 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, EnvisionRxPlus may not cover Drug B unless you try Drug A first. If Drug A does not work for you, EnvisionRxPlus 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 EnvisionRxPlus 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 EnvisionRxPlus 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. If you learn that EnvisionRxPlus does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by EnvisionRxPlus. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by EnvisionRxPlus. You can ask EnvisionRxPlus to make an exception and cover your drug. See below for information about how to request an exception. EnvisionRxPlus is a PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. S769_018 CF H Accepted 9/3/17 iii

4 How do I request an exception to the EnvisionRxPlus Formulary? You can ask EnvisionRxPlus 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, EnvisionRxPlus 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, EnvisionRxPlus 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 (unless you have a prescription written for fewer days) when you go to a network pharmacy. 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, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If 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 31-day EnvisionRxPlus is a PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. S769_018 CF H Accepted 9/3/17 iv

5 emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. For more information For more detailed information about your EnvisionRxPlus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about EnvisionRxPlus, 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 EnvisionRxPlus Formulary The formulary that begins on the next page provides coverage information about the drugs covered by EnvisionRxPlus. If you have trouble finding your drug in the list, turn to the Index that begins on page 89. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine). The information in the Requirements/Limits column tells you if EnvisionRxPlus has any special requirements for coverage of your drug. Abbreviation /Symbol BD HR LA PA QL Short Definition Part B vs Part D High Risk Medication Limited Access Prior Authorization Quantity Limit Explanation This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. According to medical experts, these drugs may cause more side effects if you are 65 years of age or older. If you are taking one of these drugs, ask your doctor if there are safer options available. These medications require prior authorization if you are 65 years of age or older. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at , hours a day, 7 days a week. TTY/TDD users should call 711. This medication requires that you or your provider get approval from the plan before we will agree to cover the drug for you. Most limits per 30-day supply. If the limit is for a day supply other than 30 the entry will read quantity/day supply (i.e. REVLIMID 8/8 means you can only fill 8 capsules for 8 day supply). EnvisionRxPlus is a PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. S769_018 CF H Accepted 9/3/17 v

6 ST Step Therapy This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. The Tier column of the drug list that begins on page 1 tells you which tier your drug is in. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during the initial coverage period) for up to a one month supply of drugs in each tier. Standard retail-costsharing (innetwork) (up to 30-day supply) Preferred retail costsharing (innetwork) (up to a 30- day supply) Standard Mail-order cost-sharing (up to a 30- day supply) Preferred Mail-order cost-sharing (up to a 30- day supply Long-term care (LTC) cost-sharing (up to 31-day supply) Tier Cost-Sharing Tier 1 (Preferred Generic Drugs) $15.00 $1.00 $15.00 $1.00 $15.00 Cost-Sharing Tier (Generic Drugs) $0.00 $6.00 $0.00 $6.00 $0.00 Cost-Sharing Tier 3* (Preferred Brand Drugs) $7.00 $9.00 * $3.00: OR, WA $7.00 $9.00 * $3.00: OR, WA $7.00 Cost-Sharing Tier (Non-Preferred Drugs) 1%-50% Please refer to Exhibit 1 for the exact Coinsurance amount in your state 35%-3% Please refer to Exhibit 1 for the exact Coinsurance amount in your state 1%-50% Please refer to Exhibit 1 for the exact Coinsurance amount in your state 35%-3% Please refer to Exhibit 1 for the exact Coinsurance amount in your state 1%-50% Please refer to Exhibit 1 for the exact Coinsurance amount in your state Cost-Sharing Tier 5 (Specialty Drugs) 7% 7% 7% 7% 7% EnvisionRxPlus is a PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. S769_018 CF H Accepted 9/3/17 vi

7 Exhibit 1: Your share of the cost when you get a one-month supply of a covered Part D prescription drug for Tier drugs: State/ Territory Standard retail-costsharing (innetwork) (up to 30- day supply) Preferred retail costsharing (innetwork (up to a 30- day supply) Standard Mail-order cost-sharing (up to a 30-day supply) Preferred Mail-order cost-sharing (up to a 30-day supply) Long-term care (LTC) cost-sharing (up to 31-day supply) OH 1% 35% 1% 35% 1% PA, WV 3% 36% 3% 36% 3% GA, OR, WA 3% 0% 3% 0% 3% CT, MA, NY, RI, VT 5% 38% 5% 38% 5% ME, NH 7% 0% 7% 0% 7% SC 7% % 7% % 7% NC 7% 3% 7% 3% 7% DC, DE, MD 8% 39% 8% 39% 8% MS 50% % 50% % 50% MI 50% 3% 50% 3% 50% If you qualified for extra help with your drug costs, your costs may be different from those described above. You can find complete cost-sharing information in your Evidence of Coverage. EnvisionRxPlus is a PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. S769_018 CF H Accepted 9/3/17 vii

8 ANALGESICS Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 100 mg, 00 mg, 00 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release hour 100 mg diclofenac sodium oral tablet delayed release 5 mg diclofenac sodium oral tablet delayed release 50 mg, 75 mg diflunisal oral tablet 500 mg etodolac oral capsule 00 mg, 300 mg etodolac oral tablet 00 mg, 500 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 00 mg, 600 mg, 800 mg 1 indomethacin oral capsule 5 mg ST ketoprofen oral capsule 50 mg, 75 mg meloxicam oral tablet 15 mg, 7.5 mg 1 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 1 naproxen sodium er oral tablet extended release hour 500 mg naproxen sodium oral tablet 75 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 0 mg sulindac oral tablet 150 mg, 00 mg VIVLODEX ORAL CAPSULE 5 MG ZORVOLEX ORAL CAPSULE 18 MG, 35 MG Opioid Analgesics, Long-Acting 1

9 fentanyl citrate buccal lozenge on a handle 100 mcg, 1600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr ; QL (180 EA per 30 days) ST; QL (10 EA per 30 days) methadone hcl oral tablet 10 mg, 5 mg QL (0 EA per 30 days) morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er oral tablet extended release 100 mg, 00 mg, 30 mg, 60 mg morphine sulfate er oral tablet extended release 15 mg morphine sulfate oral solution 10 mg/5ml, 0 mg/5ml Opioid Analgesics, Short-Acting PA; QL (300 ML per 30 days) QL (90 EA per 30 days) QL (90 EA per 30 days) PA; QL (900 ML per 30 days) acetaminophen-codeine # oral tablet mg 3 QL (00 EA per 30 days) acetaminophen-codeine #3 oral tablet mg 3 QL (00 EA per 30 days) acetaminophen-codeine # oral tablet mg 3 QL (00 EA per 30 days) acetaminophen-codeine oral solution 10-1 mg/5ml 3 QL (5000 ML per 30 days) butalbital-acetaminophen oral tablet mg PA; HR; QL (360 EA per 30 days) butalbital-apap-caffeine oral tablet mg PA; HR; QL (180 EA per 30 days) butalbital-asa-caff-codeine oral capsule mg butalbital-aspirin-caffeine oral capsule mg PA; HR; QL (180 EA per 30 days) PA; HR; QL (180 EA per 30 days) codeine sulfate oral tablet 15 mg, 30 mg, 60 mg QL (360 EA per 30 days) ENDOCET ORAL TABLET MG, MG QL (370 EA per 30 days) ENDOCET ORAL TABLET 5-35 MG 3 QL (370 EA per 30 days) hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg, 5-35 mg, mg QL (5500 ML per 30 days) 3 QL (370 EA per 30 days) hydrocodone-ibuprofen oral tablet mg 3 QL (180 EA per 30 days) hydromorphone hcl injection solution mg/ml QL (10 ML per 30 days)

10 hydromorphone hcl oral liquid 1 mg/ml QL (198 ML per 30 days) hydromorphone hcl oral tablet mg, mg 3 QL (360 EA per 30 days) hydromorphone hcl oral tablet 8 mg QL (0 EA per 30 days) hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml QL (0 ML per 30 days) LORCET ORAL TABLET 5-35 MG 3 QL (370 EA per 30 days) LORTAB ORAL TABLET 5-35 MG 3 QL (370 EA per 30 days) morphine sulfate oral tablet 15 mg, 30 mg 3 QL (180 EA per 30 days) nalbuphine hcl injection solution 10 mg/ml QL (800 ML per 10 days) nalbuphine hcl injection solution 0 mg/ml QL (00 ML per 10 days) oxycodone hcl oral capsule 5 mg QL (180 EA per 30 days) oxycodone hcl oral concentrate 100 mg/5ml PA; QL (180 ML per 30 days) oxycodone hcl oral solution 5 mg/5ml QL (1080 ML per 30 days) oxycodone hcl oral tablet 10 mg, 15 mg, 0 mg, 30 mg QL (180 EA per 30 days) oxycodone hcl oral tablet 5 mg QL (180 EA per 30 days) oxycodone-acetaminophen oral solution 5-35 mg/5ml oxycodone-acetaminophen oral tablet mg, mg QL (1800 ML per 30 days) QL (370 EA per 30 days) oxycodone-acetaminophen oral tablet 5-35 mg 3 QL (370 EA per 30 days) tramadol hcl oral tablet 50 mg QL (0 EA per 30 days) tramadol-acetaminophen oral tablet mg 3 QL (370 EA per 30 days) ANESTHETICS Local Anesthetics lidocaine hcl (pf) injection solution 0.5 %, 1 % lidocaine hcl injection solution % ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-Craving acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 50 mg, 500 mg Opioid Antagonists 3

11 buprenorphine hcl injection solution 0.3 mg/ml 3 PA; QL (180 ML per 30 days) buprenorphine hcl sublingual tablet sublingual mg buprenorphine hcl sublingual tablet sublingual 8 mg naloxone hcl injection solution 0. mg/ml 3 naloxone hcl injection solution prefilled syringe mg/ml naltrexone hcl oral tablet 50 mg 3 3 PA; QL (0 EA per 30 days) 3 PA; QL (80 EA per 30 days) SUBOXONE SUBLINGUAL FILM 1-3 MG 3 PA; QL (60 EA per 30 days) SUBOXONE SUBLINGUAL FILM -0.5 MG 3 PA; QL (360 EA per 30 days) SUBOXONE SUBLINGUAL FILM -1 MG 3 PA; QL (180 EA per 30 days) SUBOXONE SUBLINGUAL FILM 8- MG 3 PA; QL (90 EA per 30 days) Smoking Cessation Agents bupropion hcl er (smoking det) oral tablet extended release 1 hour 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG 3 3 QL (60 EA per 30 days) PA CHANTIX ORAL TABLET 0.5 MG, 1 MG PA 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 gentamicin in saline intravenous solution mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-% gentamicin sulfate injection solution 0 mg/ml gentamicin sulfate intravenous solution 10 mg/ml neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 50 mg tobramycin sulfate injection solution 10 mg/ml, 80 mg/ml Antibacterials, Other PA

12 clindamycin hcl oral capsule 150 mg, 300 mg clindamycin hcl oral capsule 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 injection solution reconstituted 150 mg CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 MG daptomycin intravenous solution reconstituted 500 mg linezolid intravenous solution 600 mg/300ml linezolid oral suspension reconstituted 100 mg/5ml 5 5 linezolid oral tablet 600 mg methenamine hippurate oral tablet 1 gm metronidazole in nacl intravenous solution mg/100ml-% metronidazole oral tablet 50 mg, 500 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd macro oral capsule 100 mg PA; B/D QL (90 EA per 365 days) QL (90 EA per 365 days) nitrofurantoin oral suspension 5 mg/5ml QL (7590 ML per 10 days) PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 00 MG SIVEXTRO ORAL TABLET 00 MG 5 SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG 5 5

13 tigecycline intravenous solution reconstituted 50 mg trimethoprim oral tablet 100 mg vancomycin hcl intravenous solution reconstituted 10 gm, 1000 mg, 500 mg vancomycin hcl oral capsule 15 mg, 50 mg 5 XIFAXAN ORAL TABLET 00 MG, 550 MG 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 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 cefotaxime sodium injection solution reconstituted 1 gm, gm, 500 mg 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 3 ceftazidime injection solution reconstituted 1 gm, gm, 6 gm 6

14 ceftriaxone sodium injection solution reconstituted 50 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted 1 gm, 10 gm, gm cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg cephalexin oral capsule 50 mg, 500 mg cephalexin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cephalexin oral tablet 50 mg, 500 mg SUPRAX ORAL CAPSULE 00 MG TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 600 MG Beta-Lactam, Other AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION GM aztreonam injection solution reconstituted 1 gm 3 CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG imipenem-cilastatin intravenous solution reconstituted 50 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM meropenem intravenous solution reconstituted 1 gm, 500 mg Beta-Lactam, Penicillins amoxicillin oral capsule 50 mg, 500 mg amoxicillin oral suspension reconstituted 15 mg/5ml, 00 mg/5ml, 50 mg/5ml, 00 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 15 mg, 50 mg amoxicillin-pot clavulanate er oral tablet extended release 1 hour mg 5 ; QL (8 ML per 8 days) 7

15 amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 50 mg, 500 mg ampicillin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml 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, 3 (-1) gm ampicillin-sulbactam sodium intravenous solution reconstituted 15 (10-5) 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, 10 gm oxacillin sodium injection solution reconstituted 10 gm, gm penicillin g pot in dextrose intravenous solution 0000 unit/ml, unit/ml penicillin g potassium injection solution reconstituted unit penicillin g procaine intramuscular suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 15 mg/5ml, 50 mg/5ml penicillin v potassium oral tablet 50 mg, 500 mg 8

16 piperacillin sod-tazobactam so intravenous solution reconstituted ( ) 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 azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 600 mg clarithromycin er oral tablet extended release hour 500 mg clarithromycin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml clarithromycin oral tablet 50 mg, 500 mg 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 ciprofloxacin hcl oral tablet 50 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous solution 00 mg/100ml ciprofloxacin intravenous solution 00 mg/0ml ciprofloxacin oral suspension reconstituted 50 mg/5ml (5%), 500 mg/5ml (10%) 3 9

17 levofloxacin in d5w intravenous solution 500 mg/100ml, 750 mg/150ml levofloxacin intravenous solution 5 mg/ml levofloxacin oral solution 5 mg/ml levofloxacin oral tablet 50 mg, 500 mg, 750 mg Sulfonamides sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5ml sulfamethoxazole-trimethoprim oral suspension 00-0 mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg Tetracyclines DOXY 100 INTRAVENOUS SOLUTION RECONSTITUTED 100 MG doxycycline hyclate oral capsule 100 mg, 50 mg 3 doxycycline hyclate oral tablet 100 mg, 0 mg 3 doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg minocycline hcl oral tablet 100 mg, 50 mg, 75 mg ANTICONVULSANTS Anticonvulsants, Other BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML PA BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG PA BRIVIACT ORAL TABLET 100 MG, 5 MG, 50 MG, 75 MG levetiracetam er oral tablet extended release hour 500 mg, 750 mg 10

18 levetiracetam in nacl intravenous solution 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml levetiracetam intravenous solution 500 mg/5ml PA; B/D levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 750 mg 3 levetiracetam oral tablet 50 mg, 500 mg SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 50 MG, 500 MG, 750 MG Barbiturates phenobarbital oral elixir 0 mg/5ml ST phenobarbital oral tablet 100 mg, 16. mg, 3. mg, 6.8 mg, 97. mg 11 QL (90 EA per 30 days) QL (10 EA per 30 days) ST phenobarbital oral tablet 15 mg, 30 mg, 60 mg ST primidone oral tablet 50 mg, 50 mg Benzodiazepines clonazepam oral tablet 0.5 mg, 1 mg QL (90 EA per 30 days) clonazepam oral tablet mg QL (300 EA per 30 days) clonazepam oral tablet dispersible 0.15 mg, 0.5 mg, 0.5 mg, 1 mg QL (90 EA per 30 days) clonazepam oral tablet dispersible mg QL (300 EA per 30 days) DIASTAT ACUDIAL RECTAL GEL 0 MG diazepam rectal gel 10 mg,.5 mg ONFI ORAL SUSPENSION.5 MG/ML 5 ST; QL (80 ML per 30 days) ONFI ORAL TABLET 10 MG ST; QL (60 EA per 30 days) ONFI ORAL TABLET 0 MG 5 ST; QL (60 EA per 30 days) Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5ml zonisamide oral capsule 100 mg, 5 mg, 50 mg Gamma-Aminobutyric Acid (Gaba) Augmenting Agents

19 divalproex sodium er oral tablet extended release hour 50 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 15 mg divalproex sodium oral tablet delayed release 15 mg, 50 mg, 500 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML ST FYCOMPA ORAL TABLET 10 MG, MG, MG, 6 MG, 8 MG 1 3 ST; QL (30 EA per 30 days) FYCOMPA ORAL TABLET 1 MG 5 ST; QL (30 EA per 30 days) gabapentin oral capsule 100 mg, 300 mg, 00 mg gabapentin oral solution 50 mg/5ml gabapentin oral tablet 600 mg, 800 mg 3 QL (180 EA per 30 days) SABRIL ORAL PACKET 500 MG ; QL (180 EA per 30 days) SABRIL ORAL TABLET 500 MG ; QL (180 EA per 30 days) tiagabine hcl oral tablet mg, mg valproate sodium intravenous solution 100 mg/ml valproate sodium oral solution 50 mg/5ml valproic acid oral capsule 50 mg vigabatrin oral packet 500 mg ; QL (180 EA per 30 days) Glutamate Reducing Agents felbamate oral suspension 600 mg/5ml 5 felbamate oral tablet 00 mg, 600 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 lamotrigine oral tablet chewable 5 mg, 5 mg 3 topiramate oral capsule sprinkle 15 mg, 5 mg topiramate oral tablet 100 mg, 00 mg, 5 mg, 50 mg Sodium Channel Agents APTIOM ORAL TABLET 00 MG, 00 MG, 800 MG 5 ST; QL (30 EA per 30 days)

20 APTIOM ORAL TABLET 600 MG 5 ST; QL (60 EA per 30 days) BANZEL ORAL SUSPENSION 0 MG/ML 5 ST; QL (760 ML per 30 days) BANZEL ORAL TABLET 00 MG 5 ST; QL (80 EA per 30 days) BANZEL ORAL TABLET 00 MG 5 ST; QL (0 EA per 30 days) carbamazepine er oral capsule extended release 1 hour 100 mg, 300 mg carbamazepine er oral tablet extended release 1 hour 100 mg, 00 mg, 00 mg carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 00 mg carbamazepine oral tablet chewable 100 mg DILANTIN ORAL CAPSULE 30 MG EPITOL ORAL TABLET 00 MG oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 150 mg oxcarbazepine oral tablet 300 mg, 600 mg PEGANONE ORAL TABLET 50 MG 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 phenytoin sodium injection solution 50 mg/ml TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 1 HOUR 100 MG VIMPAT INTRAVENOUS SOLUTION 00 MG/0ML VIMPAT ORAL SOLUTION 10 MG/ML 5 ST; QL (1395 ML per 30 days) VIMPAT ORAL TABLET 100 MG QL (10 EA per 30 days) VIMPAT ORAL TABLET 150 MG, 00 MG 5 ST; QL (60 EA per 30 days) VIMPAT ORAL TABLET 50 MG QL (90 EA per 30 days) ANTIDEMENTIA AGENTS Cholinesterase Inhibitors donepezil hcl oral tablet 10 mg, 5 mg 13 3

21 donepezil hcl oral tablet 3 mg QL (30 EA per 30 days) donepezil hcl oral tablet dispersible 10 mg QL (60 EA per 30 days) donepezil hcl oral tablet dispersible 5 mg QL (30 EA per 30 days) galantamine hydrobromide er oral capsule extended release hour 16 mg, mg, 8 mg QL (30 EA per 30 days) galantamine hydrobromide oral solution mg/ml QL (180 ML per 30 days) galantamine hydrobromide oral tablet 1 mg, mg, 8 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg,.5 mg, 6 mg rivastigmine transdermal patch hour 13.3 mg/hr,.6 mg/hr, 9.5 mg/hr N-Methyl-D-Aspartate (Nmda) Receptor Antagonist QL (60 EA per 30 days) QL (60 EA per 30 days) memantine hcl oral solution mg/ml QL (360 ML per 30 days) memantine hcl oral tablet 10 mg, 5 (8)-10 (1) mg, 5 mg ANTIDEPRESSANTS Antidepressants, Other bupropion hcl er (sr) oral tablet extended release 1 hour 100 mg bupropion hcl er (sr) oral tablet extended release 1 hour 150 mg bupropion hcl er (sr) oral tablet extended release 1 hour 00 mg bupropion hcl er (xl) oral tablet extended release hour 150 mg, 300 mg 1 3 QL (10 EA per 30 days) 3 QL (90 EA per 30 days) 3 QL (60 EA per 30 days) 3 QL (90 EA per 30 days) bupropion hcl oral tablet 100 mg 3 QL (180 EA per 30 days) bupropion hcl oral tablet 75 mg 3 QL (10 EA per 30 days) maprotiline hcl oral tablet 5 mg, 50 mg, 75 mg mirtazapine oral tablet 15 mg, 30 mg, 5 mg mirtazapine oral tablet 7.5 mg QL (5 EA per 30 days) mirtazapine oral tablet dispersible 15 mg, 30 mg, 5 mg nefazodone hcl oral tablet 100 mg, 150 mg, 00 mg, 50 mg, 50 mg QL (30 EA per 30 days)

22 trazodone hcl oral tablet 100 mg, 150 mg, 50 mg trazodone hcl oral tablet 300 mg TRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG VIIBRYD ORAL TABLET 10 MG, 0 MG, 0 MG VIIBRYD STARTER PACK ORAL KIT 10 & 0 MG Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL PATCH HOUR 1 MG/HR, 6 MG/HR, 9 MG/HR ST; QL (30 EA per 30 days) 3 QL (30 EA per 30 days) 3 QL (30 EA per 30 days) 5 ST; QL (30 EA per 30 days) MARPLAN ORAL TABLET 10 MG ST; QL (180 EA per 30 days) phenelzine sulfate oral tablet 15 mg 3 tranylcypromine sulfate oral tablet 10 mg Selective Serotonin Reuptake Inhibitors (Ssris) citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg, 0 mg, 0 mg escitalopram oxalate oral solution 5 mg/5ml QL (600 ML per 30 days) escitalopram oxalate oral tablet 10 mg, 0 mg, 5 mg fluoxetine hcl oral capsule 10 mg, 0 mg, 0 mg fluoxetine hcl oral solution 0 mg/5ml QL (600 ML per 30 days) fluoxetine hcl oral tablet 10 mg, 0 mg 3 fluvoxamine maleate oral tablet 100 mg, 5 mg, 50 mg paroxetine hcl oral tablet 10 mg, 0 mg, 30 mg, 0 mg QL (90 EA per 30 days) PA; HR PAXIL ORAL SUSPENSION 10 MG/5ML QL (900 ML per 30 days) sertraline hcl oral concentrate 0 mg/ml sertraline hcl oral tablet 100 mg, 5 mg, 50 mg 1 Serotonin/Norepinephrine Reuptake Inhibitors (Snris)

23 desvenlafaxine er oral tablet extended release hour 100 mg desvenlafaxine er oral tablet extended release hour 50 mg desvenlafaxine succinate er oral tablet extended release hour 100 mg desvenlafaxine succinate er oral tablet extended release hour 5 mg, 50 mg duloxetine hcl oral capsule delayed release particles 0 mg, 30 mg, 60 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 0 MG, 0 MG, 80 MG FETZIMA TITRATION ORAL CAPSULE ER HOUR THERAPY PACK 0 & 0 MG venlafaxine hcl er oral capsule extended release hour 150 mg venlafaxine hcl er oral capsule extended release hour 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 QL (10 EA per 30 days) QL (30 EA per 30 days) QL (10 EA per 30 days) QL (30 EA per 30 days) QL (60 EA per 30 days) 3 PA; HR; QL (30 EA per 30 days) 3 PA; HR; QL (8 EA per 8 days) QL (60 EA per 30 days) 16 3 PA; HR ST ST PA; HR doxepin hcl oral concentrate 10 mg/ml PA; HR imipramine hcl oral tablet 10 mg, 5 mg, 50 mg PA; HR nortriptyline hcl oral capsule 10 mg, 5 mg, 50 mg, 75 mg nortriptyline hcl oral solution 10 mg/5ml PA; HR

24 protriptyline hcl oral tablet 10 mg, 5 mg trimipramine maleate oral capsule 100 mg, 5 mg, 50 mg ANTIEMETICS Antiemetics, Other chlorpromazine hcl oral tablet 10 mg, 5 mg PA; B/D COMPRO RECTAL SUPPOSITORY 5 MG diphenhydramine hcl injection solution 50 mg/ml meclizine hcl oral tablet 1.5 mg, 5 mg prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 5 mg promethazine hcl oral tablet 1.5 mg, 5 mg, 50 mg TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 7 HOUR 1 MG/3DAYS Emetogenic Therapy Adjuncts PA; B/D PA; HR aprepitant oral capsule 15 mg, 0 mg, 80 mg PA; B/D; QL (30 EA per 30 days) aprepitant oral capsule 80 & 15 mg PA; B/D; QL (1 EA per 30 days) dronabinol oral capsule 10 mg,.5 mg, 5 mg PA; B/D; QL (60 EA per 30 days) EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG EMEND ORAL SUSPENSION RECONSTITUTED 15 MG granisetron hcl intravenous solution 0.1 mg/ml, 1 mg/ml, mg/ml PA; B/D PA; B/D granisetron hcl oral tablet 1 mg PA; B/D; QL (60 EA per 30 days) ondansetron hcl injection solution mg/ml, mg/ml (ml syringe) PA; B/D ondansetron hcl oral solution mg/5ml PA; B/D ondansetron hcl oral tablet mg, mg, 8 mg PA; B/D ondansetron oral tablet dispersible mg, 8 mg PA; B/D 17

25 SYNDROS ORAL SOLUTION 5 MG/ML 5 ANTIFUNGALS Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG caspofungin acetate intravenous solution reconstituted 50 mg, 70 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, 00 mg, 50 mg 3 fluconazole oral tablet 150 mg 1 flucytosine oral capsule 50 mg, 500 mg 5 ; B/D ; B/D PA; B/D ; B/D ; B/D itraconazole oral capsule 100 mg PA ketoconazole oral tablet 00 mg NATACYN OPHTHALMIC SUSPENSION 5 % PA; B/D; QL (10 ML per 30 days) NOXAFIL ORAL SUSPENSION 0 MG/ML ; QL (80 ML per 8 days) NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin oral tablet unit 18 ; QL (93 EA per 30 days) 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 ; QL (10 EA per 30 days) voriconazole oral tablet 50 mg PA; QL (10 EA per 30 days)

26 ANTIGOUT AGENTS Antigout Agents colchicine oral tablet 0.6 mg colchicine-probenecid oral tablet mg 3 probenecid oral tablet 500 mg 3 ANTI-INFLAMMATORY AGENTS Nonsteroidal Anti-Inflammatory Drugs TIVORBEX ORAL CAPSULE 0 MG, 0 MG ST VIVLODEX ORAL CAPSULE 10 MG ANTIMIGRAINE AGENTS Ergot Alkaloids dihydroergotamine mesylate injection solution 1 mg/ml ergotamine-caffeine oral tablet mg QL (0 EA per 8 days) MIGERGOT RECTAL SUPPOSITORY -100 MG Serotonin (5-Ht) 1B-1D Receptor Agonists 19 QL (0 EA per 8 days) naratriptan hcl oral tablet 1 mg,.5 mg QL (9 EA per 30 days) rizatriptan benzoate oral tablet 10 mg 3 QL (1 EA per 30 days) rizatriptan benzoate oral tablet 5 mg 3 QL ( EA per 30 days) rizatriptan benzoate oral tablet dispersible 10 mg 3 QL (1 EA per 30 days) rizatriptan benzoate oral tablet dispersible 5 mg 3 QL ( EA per 30 days) sumatriptan nasal solution 0 mg/act, 5 mg/act QL (18 EA per 30 days) sumatriptan succinate oral tablet 100 mg, 5 mg, 50 mg sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml QL (9 EA per 30 days) QL (8 ML per 30 days) QL (8 ML per 30 days) zolmitriptan oral tablet.5 mg QL (1 EA per 30 days) zolmitriptan oral tablet 5 mg QL (6 EA per 30 days) zolmitriptan oral tablet dispersible.5 mg QL (1 EA per 30 days) zolmitriptan oral tablet dispersible 5 mg QL (6 EA per 30 days)

27 ANTIMYASTHENIC AGENTS Parasympathomimetics guanidine hcl oral tablet 15 mg 3 pyridostigmine bromide oral tablet 60 mg ANTIMYCOBACTERIALS Antimycobacterials, Other dapsone oral tablet 100 mg, 5 mg 3 rifabutin oral capsule 150 mg Antituberculars CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM ethambutol hcl oral tablet 100 mg, 00 mg isoniazid injection solution 100 mg/ml isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg PASER ORAL PACKET GM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifampin intravenous solution reconstituted 600 mg rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG ; QL (188 EA per 168 days) TRECATOR ORAL TABLET 50 MG ANTINEOPLASTICS Alkylating Agents busulfan intravenous solution 6 mg/ml PA; B/D cyclophosphamide oral capsule 5 mg, 50 mg PA; B/D GLEOSTINE ORAL CAPSULE 5 MG HEXALEN ORAL CAPSULE 50 MG LEUKERAN ORAL TABLET MG MATULANE ORAL CAPSULE 50 MG 0

28 melphalan hcl intravenous solution reconstituted 50 mg thiotepa injection solution reconstituted 15 mg Antiandrogens bicalutamide oral tablet 50 mg flutamide oral capsule 15 mg ; B/D nilutamide oral tablet 150 mg 5 QL (60 EA per 30 days) XTANDI ORAL CAPSULE 0 MG ; QL (10 EA per 30 days) Antiangiogenic Agents REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 00 MG, 50 MG ; QL (8 EA per 8 days) ; QL (30 EA per 30 days) THALOMID ORAL CAPSULE 150 MG ; QL (60 EA per 30 days) Antiestrogens/Modifiers FARESTON ORAL TABLET 60 MG ; QL (30 EA per 30 days) SOLTAMOX ORAL SOLUTION 10 MG/5ML PA tamoxifen citrate oral tablet 10 mg, 0 mg Anti-Hepatitis C (Hcv) Agents, Other SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG Antimetabolites ADRUCIL INTRAVENOUS SOLUTION 500 MG/10ML azacitidine injection suspension reconstituted 100 mg hydroxyurea oral capsule 500 mg PURIXAN ORAL SUSPENSION 000 MG/100ML ; QL ( EA per 8 days) PA; B/D ; B/D TABLOID ORAL TABLET 0 MG PA Antineoplastics ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG ADRIAMYCIN INTRAVENOUS SOLUTION MG/ML 1 5 ; B/D PA; B/D

29 AFINITOR DISPERZ ORAL TABLET SOLUBLE MG, 3 MG AFINITOR DISPERZ ORAL TABLET SOLUBLE 5 MG AFINITOR ORAL TABLET 10 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG AVASTIN INTRAVENOUS SOLUTION 00 MG/16ML BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ; QL (30 EA per 30 days) ; QL (60 EA per 30 days) ; QL (30 EA per 30 days) ; B/D bexarotene oral capsule 75 mg BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG bleomycin sulfate injection solution reconstituted 30 unit PA; B/D PA; B/D BOSULIF ORAL TABLET 100 MG ; QL (10 EA per 30 days) BOSULIF ORAL TABLET 500 MG ; QL (30 EA per 30 days) CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG CAPRELSA ORAL TABLET 100 MG ; QL (60 EA per 30 days) CAPRELSA ORAL TABLET 300 MG ; QL (30 EA per 30 days) carboplatin intravenous solution 150 mg/15ml PA; B/D cisplatin intravenous solution 100 mg/100ml PA; B/D cladribine intravenous solution 10 mg/10ml ; B/D clofarabine intravenous solution 1 mg/ml ; B/D 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 ; QL (56 EA per 8 days) ; QL (11 EA per 8 days) ; QL (8 EA per 8 days) COTELLIC ORAL TABLET 0 MG ; QL (63 EA per 8 days)

30 CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML cytarabine injection solution 0 mg/ml PA; B/D dacarbazine intravenous solution reconstituted 00 mg DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML 3 5 daunorubicin hcl intravenous injectable 5 mg/ml PA; B/D DEPO-PROVERA INTRAMUSCULAR SUSPENSION 00 MG/ML dexrazoxane intravenous solution reconstituted 50 mg PA; B/D ; B/D docetaxel intravenous concentrate 80 mg/ml ; B/D doxorubicin hcl intravenous solution mg/ml PA; B/D doxorubicin hcl liposomal intravenous injectable mg/ml ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG EMCYT ORAL CAPSULE 10 MG ; B/D epirubicin hcl intravenous solution 00 mg/100ml PA; B/D ERIVEDGE ORAL CAPSULE 150 MG ; QL (8 EA per 8 days) FARYDAK ORAL CAPSULE 10 MG ; QL (60 EA per 30 days) FARYDAK ORAL CAPSULE 15 MG, 0 MG ; QL (30 EA per 30 days) FASLODEX INTRAMUSCULAR SOLUTION 50 MG/5ML fludarabine phosphate intravenous solution reconstituted 50 mg FUSILEV INTRAVENOUS SOLUTION RECONSTITUTED 50 MG gemcitabine hcl intravenous solution reconstituted 1 gm GILOTRIF ORAL TABLET 0 MG, 30 MG, 0 MG HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 0 MG hydroxyprogesterone caproate intramuscular solution 1.5 gm/5ml ; B/D; QL (30 ML per 30 days) ; B/D ; B/D ; QL (30 EA per 30 days)

31 IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG ; QL (30 EA per 30 days) ICLUSIG ORAL TABLET 15 MG ; QL (60 EA per 30 days) ICLUSIG ORAL TABLET 5 MG ; QL (30 EA per 30 days) idarubicin hcl intravenous solution 10 mg/10ml ; B/D IDHIFA ORAL TABLET 100 MG ; QL (30 EA per 30 days) IDHIFA ORAL TABLET 50 MG ; QL (60 EA per 30 days) ifosfamide intravenous solution reconstituted 1 gm PA; B/D imatinib mesylate oral tablet 100 mg, 00 mg ; QL (90 EA per 30 days) IMBRUVICA ORAL CAPSULE 10 MG ; QL (10 EA per 30 days) IMFINZI INTRAVENOUS SOLUTION 10 MG/.ML, 500 MG/10ML INLYTA ORAL TABLET 1 MG ; QL (180 EA per 30 days) INLYTA ORAL TABLET 5 MG ; QL (60 EA per 30 days) INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT IRESSA ORAL TABLET 50 MG irinotecan hcl intravenous solution 100 mg/5ml PA; B/D ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 10 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 MG LENVIMA 1 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & MG LENVIMA 18 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & () MG LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 () MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 () & MG ; B/D ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) ; QL (60 EA per 30 days)

32 LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK () MG leucovorin calcium injection solution reconstituted 100 mg, 350 mg leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg, 5 mg levoleucovorin calcium intravenous solution 175 mg/17.5ml LONSURF ORAL TABLET MG, MG ; QL (60 EA per 30 days) PA; B/D ; B/D LYNPARZA ORAL CAPSULE 50 MG ; QL (8 EA per 8 days) LYNPARZA ORAL TABLET 100 MG ; LA; QL (180 EA per 30 days) LYNPARZA ORAL TABLET 150 MG ; LA; QL (10 EA per 30 days) LYSODREN ORAL TABLET 500 MG MEKINIST ORAL TABLET 0.5 MG ; QL (10 EA per 30 days) MEKINIST ORAL TABLET MG ; QL (30 EA per 30 days) mesna intravenous solution 100 mg/ml PA; B/D MESNEX ORAL TABLET 00 MG 5 mitomycin intravenous solution reconstituted 0 mg, 0 mg, 5 mg mitoxantrone hcl intravenous concentrate 5 mg/1.5ml MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG PA; B/D PA; B/D NERLYNX ORAL TABLET 0 MG ; LA; QL (180 EA per 30 days) NEXAVAR ORAL TABLET 00 MG ; QL (10 EA per 30 days) NINLARO ORAL CAPSULE.3 MG, 3 MG, MG NIPENT INTRAVENOUS SOLUTION RECONSTITUTED 10 MG ; B/D ODOMZO ORAL CAPSULE 00 MG oxaliplatin intravenous solution 100 mg/0ml PA; B/D paclitaxel intravenous concentrate 300 mg/50ml PA; B/D POMALYST ORAL CAPSULE 1 MG, MG, 3 MG, MG ; QL (1 EA per 8 days) 5

33 PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT RITUXAN INTRAVENOUS SOLUTION 500 MG/50ML SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 MG, 80 MG ; QL (60 EA per 30 days) SPRYCEL ORAL TABLET 10 MG ; QL (30 EA per 30 days) SPRYCEL ORAL TABLET 0 MG ; QL (90 EA per 30 days) STIVARGA ORAL TABLET 0 MG ; QL (8 EA per 8 days) SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 37.5 MG, 50 MG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG ; QL (8 EA per 8 days) TAFINLAR ORAL CAPSULE 50 MG ; QL (180 EA per 30 days) TAFINLAR ORAL CAPSULE 75 MG ; QL (10 EA per 30 days) TAGRISSO ORAL TABLET 0 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG ; QL (30 EA per 30 days) TARCEVA ORAL TABLET 5 MG ; QL (90 EA per 30 days) TASIGNA ORAL CAPSULE 150 MG, 00 MG ; QL (10 EA per 30 days) TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG tretinoin oral capsule 10 mg 5 TRISENOX INTRAVENOUS SOLUTION 10 MG/10ML ; B/D ; B/D TYKERB ORAL TABLET 50 MG ; QL (180 EA per 30 days) VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML VENCLEXTA ORAL TABLET 10 MG, 50 MG PA VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG vinblastine sulfate intravenous solution 1 mg/ml PA; B/D VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML PA; B/D vincristine sulfate intravenous solution 1 mg/ml PA; B/D 6

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