Formulario 2018 Lista de Medicamentos Cubiertos

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1 Génesis Constellation Health (HMO SNP) Génesis Prime Constellation Health (HMO SNP) Home Constellation Health (HMO SNP) Orión Constellation Health (HMO) Formulario 208 Lista de Medicamentos Cubiertos FAVOR DE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN [HPMS Approved Formulary File Submission ID 8463, Version Number 8] Este formulario se actualizó el 02/0/208. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con nosotros, Constellation Health, llamando al o, para usuarios de TTY, , lunes a domingo de 8:00 a.m. a 8:00 p.m., o visite Nota a los miembros existentes: Este formulario ha cambiado desde el año pasado. Examine este documento para asegurarse de que aún contiene lo medicamentos que usted toma. Cuando esta lista de medicamentos (formulario) se refiere a nosotros, nos, o nuestro, quiere decir Constellation Health. Cuando se refiere a plan o nuestro plan, quiere decir Génesis Constellation Health (HMO SNP) / Génesis Prime (HMO SNP) / Home Constellation Health (HMO SNP)/ Orión Constellation Health (HMO). Este documento incluye una lista de medicamentos (formulario) para nuestro plan que está al día el 02/0/208. Para el formulario actualizado, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en las cubiertas delantera y trasera. Generalmente, debe utilizar farmacias de red para utilizar su beneficio de medicamentos de receta. Los beneficios, el formulario, la red de farmacias, y/o los copagos/el coseguro pueden cambiar el de enero de 209 y de vez en cuando durante el año. Page of 3 Y0099_208_S3 CMS Accepted

2 Qué es el Formulario de Génesis Constellation Health (HMO SNP) / Génesis Prime (HMO SNP) / Home Constellation Health (HMO SNP)/ Orión Constellation Health (HMO)? Un formulario es una lista de medicamentos cubiertos seleccionados por Constellation Health consultando con un equipo de proveedores de atención médica, que representa las terapias de receta que se cree son parte necesaria de un programa de tratamiento de calidad. Generalmente, Constellation Health cubrirá los medicamentos enumerados en nuestro formulario siempre que el medicamento sea necesario por motivos médicos, la receta se surta en una farmacia de la red de Constellation Health y se sigan otras reglas del plan. Para mayor información acerca de cómo surtir sus recetas, examine su Evidencia de Cobertura. Puede cambiar el Formulario (lista de medicamentos)? Generalmente, si está tomando un medicamento de nuestro formulario de 208 que estaba cubierto al principio del año, no eliminaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 208 excepto cuando un medicamento genérico nuevo y menos caro esté disponible o cuando se divulgue nueva información adversa acerca de la seguridad o eficacia de un medicamento. Otros tipos de cambios al formulario, tales como quitar un medicamento del mismo, no afectarán a los miembros que estén tomando el medicamento actualmente. Seguirá estando disponible al mismo costo compartido para los miembros que lo tomen durante el resto del año de cobertura. Creemos que es importante que tenga acceso continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto en los casos en que pueda ahorrar más dinero o podamos garantizar su seguridad. Si quitamos medicamentos de nuestro formulario [o] añadimos, después de obtener autorización, límites de cantidades y/o restricciones de terapia en pasos que afecten a un medicamento o trasladamos un medicamento a un nivel más alto de costo compartido, debemos notificar a los miembros afectados del cambio al menos 60 días antes de que entre en vigor, o en el momento en que el miembro solicite que se le repita la receta del medicamento, cuando el miembro recibirá un suministro de 60 días del medicamento. Si la Administración de Alimentos y Medicamentos considera que uno de los medicamentos de nuestro formulario no es seguro o el fabricante del medicamento lo retira del mercado, retiraremos inmediatamente el medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario adjunto está al día el de febrero del 208. Para obtener información actualizada acerca de los medicamentos cubiertos por Constellation Health póngase en contacto con nosotros. Nuestra información de contacto aparece en las cubiertas delantera y trasera. Las actualizaciones al formulario aparecerán en o también puede comunicarse con Servicio al Cliente. Cómo se utiliza el Formulario? Hay dos maneras de encontrar su medicamento en el formulario: Condición Médica El formulario empieza en la página 7. Los medicamentos de este formulario están agrupados en categorías según el tipo de condición médica para el tratamiento de la cual se utilizan. Por ejemplo, los medicamentos que se utilizan para tratar una condición cardiaca se enumeran bajo la categoría, Cardiovasculares. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que empieza en la página 2. Después, busque su medicamento bajo el nombre de la categoría. Page 2 of 3

3 Lista Alfabética Si no está seguro de la categoría bajo la cual buscar, debe buscar su medicamento en el Índice que empieza en la página 20. El Índice es una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los genéricos se enumeran en el Índice. Mire en el Índice para encontrar su medicamento. Al lado de su medicamento verá el número de la página donde puede encontrar información de cobertura. Vaya a la página indicada en el Índice y busque el nombre de su medicamento en la primera columna de la lista. Qué son medicamentos genéricos? Constellation Health cubre tanto medicamentos de marca como los medicamentos genéricos. Un medicamento genérico está aprobado por la Administración de Alimentos y Medicamentos (FDA) indicando que tiene el mismo ingrediente activo que el medicamento de marca. Generalmente, los medicamentos genéricos cuestan menos que los medicamentos de marca. Hay restricciones en mi cobertura? Es posible que algunos medicamentos cubiertos tengan requisitos adicionales o límites de cobertura. Estos requisitos y límites pueden incluir: Autorización Previa: Constellation Health requiere que usted [o su médico] obtenga autorización previa para ciertos medicamentos. Esto quiere decir que necesitará obtener la aprobación de Constellation Health antes de surtir sus recetas. Si no obtiene aprobación, es posible que Constellation Health no cubra el medicamento. Límites de Cantidad: Para ciertos medicamentos, Constellation Health limita la cantidad de medicamento que cubrirá Constellation Health. Por ejemplo, Constellation Health proporciona 60 capsulas para 30 días por receta para celecoxib capsula. Esto puede ser además de un suministro estándar de un mes o tres meses. Puede averiguar si su medicamento tiene requisitos o límites adicionales mirando en el formulario que empieza en la página 7. También puede obtener más información acerca de las restricciones aplicadas a medicamentos específicos cubiertos visitando nuestro sitio Web. Hemos colocado en nuestro sitio web el documento que explica nuestros criterios de autorización. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum, aparece en las cubiertas delantera y trasera. Puede pedirle a Constellation Health que haga una excepción a estas restricciones a límites, o pedirle una lista de otros medicamentos parecidos que puedan tratar su condición médica. Vea la sección, Qué tengo que hacer para solicitar una excepción al formulario de Constellation Health? en la página 4 para ver información acerca de la manera de solicitar una excepción. Qué pasa si mi medicamento no está en el Formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), lo primero que debe hacer es ponerse en contacto con Servicios de Miembros y preguntar si está cubierto su medicamento. Page 3 of 3

4 Si averigua que Constellation Health no cubre su medicamento, tiene dos opciones: Puede pedirle a Servicios de Miembros una lista de medicamentos parecidos que estén cubiertos por Constellation Health. Cuando reciba la lista, enséñesela a su médico y pídale que le recete un medicamento parecido que esté cubierto por Constellation Health. Le puede pedir a Constellation Health que haga una excepción y cubra su medicamento. Vea la información que aparece a continuación para ver cómo solicitar una excepción. Cómo se solicita una excepción al Formulario de Génesis Constellation Health (HMO SNP) / Génesis Prime (HMO SNP) / Home Constellation Health (HMO SNP)/ Orión Constellation Health (HMO)? Le puede pedir a Constellation Health que haga una excepción a nuestras reglas de cobertura. Hay varios tipos de excepciones que puede pedirnos que hagamos. Puede pedirnos que cubramos un medicamento aún si no está en nuestro formulario. Si se aprueba, este medicamento se cubrirá a un nivel predeterminado de costo compartido, y usted no podría pedirnos que proporcionemos el medicamento a un nivel más bajo de costo compartido. Puede pedirnos que cubramos un medicamento del formulario a un nivel más bajo de costo compartido [si este medicamento no está en el nivel de especialidad]. Si se aprueba, esto reduciría la cantidad que debe pagar usted por su medicamento. Puede pedirnos que demos una exepción para las restricciones o límites de cobertura de su medicamento. Por ejemplo, para ciertos medicamentos, Constellation Health limita la cantidad de medicamento que cubrimos. Si su medicamento tiene un límite de cantidad, puede pedirnos que otorguemos una exención para el límite y que cubramos una cantidad mayor. Generalmente, Constellation Health solamente aprobará su solicitud de excepción si los medicamentos de alternativa incluidos en el formulario del plan, [el medicamento de costo compartido más bajo] o las restricciones de utilización adicionales no serían tan efectivas en el tratamiento de su condición y/o harían que usted tuviera efectos médicos adversos. Debe ponerse en contacto con nosotros para pedirnos una decisión de cobertura inicial para una excepción al formulario, o de las restricciones de utilización. Cuando solicite una excepción al formulario, o de restricciones de utilización, debe presentar una declaración de su recetador o médico apoyando su solicitud. Generalmente, tenemos que tomar una decisión dentro de las 72 horas siguientes a recibir la declaración de apoyo de su recetador. Puede solicitar una excepción acelerada (rápida) si usted o su médico creen que su salud podría verse severamente dañada si espera 72 horas para recibir una decisión. Si su solicitud de acelerar se concede, debemos darle una decisión no más de 24 horas después de recibir una declaración de apoyo de su médico u otro recetador. Page 4 of 3

5 Qué hago antes de poder hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo de o si continua en nuestro plan, puede que esté tomando medicamentos que no estén en nuestro formulario. O puede que esté tomando un medicamento que esté en el formulario pero su habilidad de obtenerlo sea limitada. Por ejemplo, puede que necesite autorización previa nuestra antes de poder surtir su receta. Debe hablar con su médico para decidir si debería cambiar a un medicamento apropiado que cubramos o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras habla con su médico para determinar el rumbo correcto que seguir, puede que cubramos su medicamento en ciertos casos durante los primeros 90 días que sea miembro de nuestro plan. Para cada uno de sus medicamentos que no esté en nuestro formulario o si su habilidad de obtener sus medicamentos es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una receta que indique un número de días menor) cuando vaya a una farmacia de la red. Después de su primer suministro de 30 días, no pagaremos por estos medicamentos, aún si ha sido miembro del plan en menos de 90 días. Si es residente de una clínica de cuidado de largo plazo, permitiremos que repita su receta hasta que le hayamos provisto un suministro de transición de al menos 9 y hasta 98 días, consistente con el incremento de suministro (a menos que tenga una receta que indique un número menor de días). Cubriremos más de una repetición de estos medicamentos durante los primeros 90 días que sea miembro de nuestro plan. Si necesita un medicamento que no esté en nuestro formulario o si su habilidad de obtener sus medicamentos es limitada, pero ya han pasado los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 30 días de ese medicamento (a menos que tenga una receta que indique un número menor de días) mientras tramita una excepción al formulario. Constellation Health tiene una política del proceso de transición para los afiliados nuevos y existentes del plan. El proceso de transición se aplica a los afiliados recientemente elegibles a un plan de Medicare Parte D de otra cubierta, la transición de los afiliados de un plan a otro después del inicio de un año del plan (es decir, después del de enero), el movimiento de los afiliados dentro o fuera de las instalaciones de cuidado prolongado, o los afiliados actualmente inscritos en un plan de Constellation Health afectados por cambios en el formulario de un año del plan a otro. El copago y la participación en los costos para las reclamaciones de transición se procesan de acuerdo con el diseño de beneficio completo de la persona inscrita. Constellation Health extiende su proceso de transición de un año contrato a otro si un afiliado se inscribe en un plan con una fecha de inscripción efectiva ya sea el de noviembre o de diciembre y necesite acceso a un suplido de transición. Una notificación por escrito es enviada a la persona afiliada posterior a un despacho temporero recibido durante el período de transición. El aviso está en conformidad con las guías de Medicare y contiene la siguiente información: una explicación del suplido temporero de transición que el afiliado recibió durante el período de transición, las instrucciones para trabajar con Constellation Health y el médico del afiliado para identificar alternativas terapéuticas apropiadas que se encuentran en los formularios de Constellation Health o los formularios de solicitud de excepción (disponibles para el afiliado a través de correo electrónico, página Web o fax) para los medicamentos del formulario que necesitan una autorización, una explicación del derecho del afiliado para solicitar una excepción, y una descripción del procedimiento para solicitar una excepción. Para obtener más información sobre nuestra política de transición, por favor visite nuestro sitio web Page 5 of 3

6 Para más información Para obtener información más detallada acerca de su cobertura de medicamentos de receta de Constellation Health, examine su Evidencia de Cobertura y otros materiales del plan. Si tiene preguntas acerca de Constellation Health, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del vademécum, aparece en las cubiertas delantera y trasera. Si tiene preguntas generales acerca de la cobertura de medicamentos de receta de Medicare, llame a Medicare al -800-MEDICARE ( ) 24 horas al día / 7 días a la semana. Los usuarios de TTY deben llamar al O visite Formulario de Constellation Health El formulario provee información sobre los medicamentos cubiertos por Constellation Health. Si tienes algún problema buscando el medicamento en la lista, ve al Índice que comienza en la página 20. La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca están en letras mayúsculas (por ejemplo, LYRICA CAPSULA ORAL y los medicamentos genéricos aparecen en cursiva minúscula (por ejemplo, gabapentin capsula oral). La información de la columna de Requisitos/Límites le dice si Constellation Health tiene algún requisito especial para la cobertura de su medicamento. Page 6 of 3

7 Génesis Constellation Health (HMO SNP) Génesis Prime Constellation Health (HMO SNP) Home Constellation Health (HMO SNP) Orión Constellation Health (HMO) Formulario 208 Drug (Medicamento) Level (Nivel) Instruction (Instrucción) Analgesics (Analgésicos) Analgesics (Analgésicos) acetaminophen-codeine #2 oral tablet mg QL (360 EA per 30 days); CO acetaminophen-codeine #3 oral tablet mg QL (360 EA per 30 days); CO acetaminophen-codeine #4 oral tablet mg QL (80 EA per 30 days); CO acetaminophen-codeine oral solution 20-2 mg/5ml hydrocodone-acetaminophen oral solution mg/5ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg CO CO hydrocodone-acetaminophen oral tablet mg CO oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (80 EA per 30 days); CO QL (20 EA per 30 days); CO tramadol-acetaminophen oral tablet mg QL (240 EA per 30 days); CO Nonsteroidal Anti-Inflammatory Drugs (Anti-inflamatorios No Esteroidales) celecoxib oral capsule 00 mg, 200 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 00 mg QL (60 EA per 30 days) Page 7 of 3

8 diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg diclofenac sodium transdermal gel 3 % etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg flurbiprofen oral tablet 00 mg, 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg QL (60 EA per 30 days) indomethacin oral capsule 25 mg, 50 mg QL (20 EA per 30 days) ketorolac tromethamine injection solution 5 mg/ml, 30 mg/ml ketorolac tromethamine intramuscular solution 60 mg/2ml meloxicam oral tablet 5 mg, 7.5 mg QL (30 EA per 30 days) nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 25 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg piroxicam oral capsule 0 mg, 20 mg sulindac oral tablet 50 mg, 200 mg Opioid Analgesics, Long-Acting (Analgésicos Opiodes, Larga Duración) duramorph injection solution 0.5 mg/ml, mg/ml fentanyl citrate buccal lozenge on a handle 200 mcg, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg PA; QL (20 EA per 30 days); CO Page 8 of 3

9 fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr morphine sulfate (concentrate) oral solution 00 mg/5ml morphine sulfate er oral tablet extended release 00 mg, 5 mg, 30 mg, 60 mg morphine sulfate er oral tablet extended release 200 mg morphine sulfate oral solution 0 mg/5ml, 20 mg/5ml QL (5 EA per 30 days); CO CO QL (90 EA per 30 days); CO QL (60 EA per 30 days); CO CO morphine sulfate oral tablet 5 mg, 30 mg QL (20 EA per 30 days); CO oxycodone hcl er oral tablet er 2 hour abusedeterrent 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 60 mg oxycodone hcl er oral tablet er 2 hour abusedeterrent 80 mg QL (90 EA per 30 days); CO QL (60 EA per 30 days); CO Opioid Analgesics, Short-acting (Analgésicos Opiodes, Corta Duración) butorphanol tartrate injection solution mg/ml, 2 mg/ml butorphanol tartrate nasal solution 0 mg/ml 3 CO fentanyl citrate buccal lozenge on a handle 200 mcg, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr LAZANDA NASAL SOLUTION 00 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT meperidine hcl injection solution 00 mg/ml, 25 mg/ml, 50 mg/ml morphine sulfate (concentrate) oral solution 00 mg/5ml morphine sulfate oral solution 0 mg/5ml, 20 mg/5ml PA; QL (20 EA per 30 days); CO QL (5 EA per 30 days); CO 3 PA; CO PA^ CO CO morphine sulfate oral tablet 5 mg, 30 mg QL (20 EA per 30 days); CO Page 9 of 3

10 oxycodone hcl oral capsule 5 mg QL (80 EA per 30 days); CO oxycodone hcl oral tablet 5 mg, 30 mg, 5 mg QL (80 EA per 30 days); CO tramadol hcl oral tablet 50 mg QL (240 EA per 30 days); CO Anesthetics (Anestésico) Local Anesthetics (Anestésico Local) lidocaine external ointment 5 % lidocaine external patch 5 % PA; QL (90 EA per 30 days) lidocaine hcl (pf) injection solution 0.5 %, % PA^ lidocaine hcl external gel 2 % lidocaine viscous mouth/throat solution 2 % lidocaine-prilocaine external cream % Anti-Addiction / Substance Abuse Treatment Agents (Agentes Contra la Adicción / Tratamiento de Abuso de Sustancias) Alcohol Deterrents/ Anti-Craving (Disuasivos de Alcohol/Anti-ansiedad) acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 250 mg, 500 mg naltrexone hcl oral tablet 50 mg VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG Opioid Dependence Treatments (Tratamiento Contra la Dependencia a Opioides) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual mg, 8-2 mg naltrexone hcl oral tablet 50 mg SUBOXONE SUBLINGUAL FILM 2-3 MG, MG, 4- MG, 8-2 MG VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG 3 PA PA 3 PA 3 Page 0 of 3

11 ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG, MG, MG 3 PA Opioid Reversal Agents (Agentes para la Reversión del Efecto Opioide) naloxone hcl injection solution 0.4 mg/ml naloxone hcl injection solution prefilled syringe 2 mg/2ml Smoking Cessation Agents (Agentes para Cesación de Fumar) bupropion hcl er (smoking det) oral tablet extended release 2 hour 50 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET MG 2 MO/90 CHANTIX ORAL TABLET 0.5 MG, MG 2 MO/90 CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X & MG X 42 2 EX-BFF; MO/90 NICOTROL INHALATION INHALER 0 MG 3 MO/90 NICOTROL NS NASAL SOLUTION 0 MG/ML 3 MO/90 Antibacterials (Antibacterianos) Aminoglycosides (Aminoglicósidos) gentak ophthalmic ointment 0.3 % gentamicin sulfate external cream 0. % gentamicin sulfate external ointment 0. % gentamicin sulfate injection solution 40 mg/ml PA^ gentamicin sulfate intravenous solution 0 mg/ml PA^ gentamicin sulfate ophthalmic solution 0.3 % neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg streptomycin sulfate intramuscular solution reconstituted gm TOBI PODHALER INHALATION CAPSULE 28 MG 3 PA^ 4 PA Page of 3

12 tobramycin inhalation nebulization solution 300 mg/5ml tobramycin ophthalmic solution 0.3 % tobramycin sulfate injection solution 0 mg/ml, 80 mg/2ml Antibacterials (Antibacterianos) colistimethate sodium injection solution reconstituted 50 mg SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG Antibacterials, Other (Antibacterianos, Otros) 4 PA^ PA^ PA^ 3 PA^ acetic acid otic solution 2 % bacitracin ophthalmic ointment 500 unit/gm 3 MO/90 chloramphenicol sod succinate intravenous solution reconstituted gm CLEOCIN VAGINAL SUPPOSITORY 00 MG 3 clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg 3 PA^ M clindamycin phosphate external solution % clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml clindamycin phosphate vaginal cream 2 % daptomycin intravenous solution reconstituted 500 mg PA^; MO/90 PA^ global alcohol prep ease pad 70 % 3 MO/90 linezolid intravenous solution 600 mg/300ml 4 PA# linezolid oral suspension reconstituted 00 mg/5ml 4 PA# linezolid oral tablet 600 mg 4 PA# MACRODANTIN ORAL CAPSULE 50 MG 3 methenamine hippurate oral tablet gm metronidazole external cream 0.75 % Page 2 of 3

13 metronidazole external gel 0.75 % metronidazole external lotion 0.75 % metronidazole in nacl intravenous solution mg/00ml-% metronidazole oral tablet 250 mg, 500 mg PA^ metronidazole vaginal gel 0.75 % mupirocin external ointment 2 % nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg nitrofurantoin monohyd macro oral capsule 00 mg SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG 3 PA# SIVEXTRO ORAL TABLET 200 MG 3 PA# trimethoprim oral tablet 00 mg TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG vancomycin hcl intravenous solution reconstituted 000 mg, 500 mg vancomycin hcl oral capsule 25 mg, 250 mg XIFAXAN ORAL TABLET 200 MG, 550 MG 3 3 PA^ PA^ Beta-Lactam, Cephalosporins (Cefalosporinas, Beta-lactámicas) cefaclor er oral tablet extended release 2 hour 500 mg cefaclor oral capsule 250 mg, 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet gm cefazolin sodium injection solution reconstituted gm, 500 mg 3 PA^ Page 3 of 3

14 cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefepime hcl injection solution reconstituted gm, 2 gm cefixime oral suspension reconstituted 00 mg/5ml, 200 mg/5ml cefoxitin sodium injection solution reconstituted 0 gm cefoxitin sodium intravenous solution reconstituted gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 00 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 00 mg, 200 mg cefprozil oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection solution reconstituted gm, 2 gm CEFTIN ORAL SUSPENSION RECONSTITUTED 250 MG/5ML ceftriaxone sodium injection solution reconstituted 250 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted gm ceftriaxone sodium intravenous solution reconstituted 2 gm cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection solution reconstituted.5 gm, 750 mg cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml PA^ PA^ PA^ 3 PA^ PA^ PA^ Page 4 of 3

15 SUPRAX ORAL CAPSULE 400 MG 3 MO/90 SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG Beta-Lactam, Other (Beta-lactámicos, Otros) aztreonam injection solution reconstituted gm CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED GM meropenem intravenous solution reconstituted 500 mg, gm Beta-Lactam, Penicillins (Penicilinas, Beta-lactámicas) amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension reconstituted 25 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 25 mg, 250 mg amoxicillin-pot clavulanate er oral tablet extended release 2 hour mg 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 500 mg ampicillin sodium injection solution reconstituted gm, 25 mg 3 MO/90 3 PA^ 4 LA 3 PA^ PA^ PA^ Page 5 of 3

16 ampicillin-sulbactam sodium injection solution reconstituted.5 (-0.5) gm, 3 (2-) gm ampicillin-sulbactam sodium intravenous solution reconstituted 5 (0-5) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML dicloxacillin sodium oral capsule 250 mg, 500 mg nafcillin sodium injection solution reconstituted gm penicillin g procaine intramuscular suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 25 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 ( gm)3.375 ( ) gm, 4.5 (4-0.5) gm Macrolides (Macrólidos) PA^ PA^ PA^ 3 PA^ PA^ AZASITE OPHTHALMIC SOLUTION % 3 MO/90 azithromycin intravenous solution reconstituted 500 mg azithromycin oral suspension reconstituted 00 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg PA^ Page 6 of 3

17 clarithromycin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg e.e.s. 400 oral tablet 400 mg ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG erythrocin stearate oral tablet 250 mg erythromycin base oral tablet 250 mg, 500 mg 3 erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg 3 3 PA^ erythromycin external gel 2 % erythromycin external solution 2 % erythromycin ophthalmic ointment 5 mg/gm Quinolones (Quinolonas) ciprofloxacin hcl ophthalmic solution 0.3 % ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg ciprofloxacin intravenous solution 400 mg/40ml PA^ ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (0%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 000 mg, 500 mg levofloxacin intravenous solution 25 mg/ml PA^ levofloxacin oral tablet 250 mg, 500 mg, 750 mg MOXEZA OPHTHALMIC SOLUTION 0.5 % 3 MO/90 moxifloxacin hcl oral tablet 400 mg ofloxacin ophthalmic solution 0.3 % Page 7 of 3

18 ofloxacin otic solution 0.3 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % 3 MO/90 Sulfonamides (Sulfonamidas) silver sulfadiazine external cream % sulfacetamide sodium ophthalmic solution 0 % sulfadiazine oral tablet 500 mg 3 sulfamethoxazole-trimethoprim intravenous solution mg/5ml sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg Tetracyclines (Tetraciclinas) demeclocycline hcl oral tablet 50 mg, 300 mg doxy 00 intravenous solution reconstituted 00 mg doxycycline hyclate oral capsule 00 mg, 50 mg doxycycline hyclate oral tablet 00 mg, 20 mg minocycline hcl oral capsule 00 mg, 50 mg, 75 mg Anticonvulsants (Anticonvulsivantes) Anticonvulsants, Other (Anticonvulsivantes, Otros) BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML 3 PA^ PA^ 3 PA^ BRIVIACT ORAL SOLUTION 0 MG/ML 3 MO/90 BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG DIASTAT ACUDIAL RECTAL GEL 0 MG, 20 MG 3 MO/90 3 MO/90 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG 3 MO/90 diazepam intensol oral concentrate 5 mg/ml Page 8 of 3

19 diazepam oral solution mg/ml diazepam oral tablet 0 mg, 2 mg, 5 mg QL (20 EA per 30 days) levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg levetiracetam intravenous solution 500 mg/5ml PA^ levetiracetam oral solution 00 mg/ml levetiracetam oral tablet 000 mg, 250 mg, 500 mg, 750 mg SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 000 MG, 250 MG, 500 MG, 750 MG 3 MO/90 Calcium Channel Modifying Agents (Agentes Modificadores de Canales de Calcio) CELONTIN ORAL CAPSULE 300 MG 3 MO/90 ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml LYRICA ORAL CAPSULE 00 MG, 50 MG, 200 MG, 25 MG, 50 MG, 75 MG 2 QL (90 EA per 30 days); MO/90 LYRICA ORAL CAPSULE 225 MG, 300 MG 2 QL (60 EA per 30 days); MO/90 LYRICA ORAL SOLUTION 20 MG/ML 2 MO/90 zonisamide oral capsule 00 mg, 25 mg, 50 mg Gamma-Aminobutyric Acid (GABA) Augmenting Agents (Agentes Aumentadores del Ácido Gamma-Aminobutírico) clonazepam oral tablet 0.5 mg, mg, 2 mg clonazepam oral tablet dispersible 0.25 mg, 0.25 mg, 0.5 mg, mg, 2 mg clorazepate dipotassium oral tablet 5 mg, 3.75 mg, 7.5 mg DIASTAT ACUDIAL RECTAL GEL 0 MG, 20 MG 3 MO/90 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG 3 MO/90 diazepam intensol oral concentrate 5 mg/ml diazepam oral solution mg/ml Page 9 of 3

20 diazepam oral tablet 0 mg, 2 mg, 5 mg QL (20 EA per 30 days); MO/90 divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 25 mg divalproex sodium oral tablet delayed release 25 mg, 250 mg, 500 mg gabapentin oral capsule 00 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg, 800 mg QL (20 EA per 30 days); MO/90 GABITRIL ORAL TABLET 2 MG, 6 MG 3 MO/90 lorazepam oral tablet 0.5 mg, mg, 2 mg ONFI ORAL SUSPENSION 2.5 MG/ML 3 MO/90 ONFI ORAL TABLET 0 MG 3 QL (60 EA per 30 days); MO/90 ONFI ORAL TABLET 20 MG 3 QL (20 EA per 30 days); MO/90 phenobarbital oral elixir 20 mg/5ml phenobarbital oral tablet 00 mg, 5 mg, 6.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg primidone oral tablet 250 mg, 50 mg QL (90 EA per 30 days); MO/90 SABRIL ORAL PACKET 500 MG 3 LA; MO/90 SABRIL ORAL TABLET 500 MG 3 LA; MO/90 tiagabine hcl oral tablet 2 mg, 4 mg valproate sodium intravenous solution 00 mg/ml PA^ valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg Glutamate Reducing Agents (Agentes Reductores de Glutamato) felbamate oral suspension 600 mg/5ml felbamate oral tablet 400 mg, 600 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML 3 MO/90 Page 20 of 3

21 FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG lamotrigine er oral tablet extended release 24 hour 00 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 00 mg, 50 mg, 200 mg, 25 mg 3 QL (30 EA per 30 days); MO/90 lamotrigine oral tablet chewable 25 mg, 5 mg topiramate oral capsule sprinkle 5 mg, 25 mg topiramate oral tablet 00 mg, 200 mg, 25 mg, 50 mg TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 00 MG, 200 MG, 25 MG, 50 MG Sodium Channel Agents (Agentes Canales de Sodio) APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG 3 MO/90 3 QL (30 EA per 30 days); MO/90 APTIOM ORAL TABLET 600 MG 3 QL (60 EA per 30 days); MO/90 BANZEL ORAL SUSPENSION 40 MG/ML 3 MO/90 BANZEL ORAL TABLET 200 MG, 400 MG 3 MO/90 carbamazepine er oral tablet extended release 2 hour 00 mg, 200 mg, 400 mg carbamazepine oral suspension 00 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 00 mg DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG 2 MO/90 DILANTIN ORAL CAPSULE 00 MG, 30 MG 2 MO/90 DILANTIN ORAL SUSPENSION 25 MG/5ML 2 MO/90 fosphenytoin sodium injection solution 00 mg pe/2ml PA^ oxcarbazepine oral suspension 300 mg/5ml Page 2 of 3

22 oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG, 300 MG, 600 MG 3 MO/90 PEGANONE ORAL TABLET 250 MG 3 MO/90 phenytoin oral suspension 25 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 00 mg phenytoin sodium injection solution 50 mg/ml PA^ VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML 3 PA^ VIMPAT ORAL SOLUTION 0 MG/ML 3 MO/90 VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG Antidementia Agents (Agentes Antidemencia) Antidementia Agents, Other (Agentes Antidemencia, Otros) 3 MO/90 ergoloid mesylates oral tablet mg Cholinesterase Inhibitors (Inhibidores de Colinesterasa) donepezil hcl oral tablet 0 mg, 23 mg, 5 mg QL (30 EA per 30 days); MO/90 donepezil hcl oral tablet dispersible 0 mg, 5 mg QL (30 EA per 30 days); MO/90 galantamine hydrobromide er oral capsule extended release 24 hour 6 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml galantamine hydrobromide oral tablet 2 mg, 4 mg, 8 mg rivastigmine tartrate oral capsule.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 3.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr QL (30 EA per 30 days); MO/90 QL (60 EA per 30 days); MO/90 QL (60 EA per 30 days); MO/90 QL (30 EA per 30 days); EX-BFF; MO/90 N-Methyl-D-Aspartate (NMDA) Receptor Antagonist (Antagonista del Receptor N-metil- D-aspartato (NMDA)) memantine hcl oral solution 2 mg/ml Page 22 of 3

23 memantine hcl oral tablet 0 mg, 5 mg memantine hcl oral tablet 5 (28)-0 (2) mg NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 MG, 2 MG, 28 MG, 7 MG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 4 & 2 &28 MG Antidepressants (Antidepresivos) Antidepressants, Other (Antidepresivos, Otros) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 300 MG (.5ML SYRINGE), 400 MG aripiprazole oral tablet 0 mg, 5 mg, 2 mg, 20 mg, 30 mg, 5 mg 2 QL (30 EA per 30 days); MO/ PA^; MO/90 QL (30 EA per 30 days); MO/90 aripiprazole oral tablet dispersible 0 mg QL (90 EA per 30 days); MO/90 aripiprazole oral tablet dispersible 5 mg QL (60 EA per 30 days); MO/90 aripiprazole oral solution mg/ml bupropion hcl er (sr) oral tablet extended release 2 hour 00 mg, 50 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 50 mg, 300 mg bupropion hcl oral tablet 00 mg, 75 mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 3 MO/90 mirtazapine oral tablet 5 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 5 mg, 30 mg, 45 mg QL (60 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 nefazodone hcl oral tablet 00 mg, 250 mg, 50 mg 3 QL (60 EA per 30 days); MO/90 nefazodone hcl oral tablet 50 mg 3 QL (20 EA per 30 days); MO/90 nefazodone hcl oral tablet 200 mg 3 QL (90 EA per 30 days); MO/90 Page 23 of 3

24 quetiapine fumarate er oral tablet extended release 24 hour 50 mg, 200 mg, 50 mg quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg quetiapine fumarate oral tablet 00 mg, 200 mg, 25 mg, 50 mg QL (30 EA per 30 days); MO/90 QL (60 EA per 30 days); MO/90 QL (90 EA per 30 days); MO/90 quetiapine fumarate oral tablet 300 mg, 400 mg QL (60 EA per 30 days); MO/90 trazodone hcl oral tablet 00 mg, 50 mg, 300 mg, 50 mg Monoamine Oxidase Inhibitors (Inhibidores de Monoamina Oxidasa) EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 0 MG 3 MO/90 phenelzine sulfate oral tablet 5 mg tranylcypromine sulfate oral tablet 0 mg 3 QL (30 EA per 30 days); MO/90 SSRIs/ SNRIs (Selective Serotonin Reuptake Inhibitors / Serotonin and Norepinephrine Reuptake Inhibitors) (SSRIs/SNRIs (Inhibidores de la Recaptación Selectiva de Serotonina / Inhibidores de la Recaptación de Serotonina y Norepinefrina)) citalopram hydrobromide oral solution 0 mg/5ml citalopram hydrobromide oral tablet 0 mg, 20 mg, 40 mg desvenlafaxine succinate er oral tablet extended release 24 hour 00 mg, 25 mg, 50 mg duloxetine hcl oral capsule delayed release particles 20 mg duloxetine hcl oral capsule delayed release particles 30 mg, 60 mg escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 0 mg, 20 mg, 5 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 20 MG, 40 MG, 80 MG QL (30 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 QL (90 EA per 30 days); MO/90 QL (60 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 3 QL (30 EA per 30 days); MO/90 Page 24 of 3

25 FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG 3 MO/90 fluoxetine hcl oral capsule 0 mg, 20 mg, 40 mg QL (60 EA per 30 days); MO/90 fluoxetine hcl oral solution 20 mg/5ml fluvoxamine maleate oral tablet 00 mg, 25 mg, 50 mg paroxetine hcl er oral tablet extended release 24 hour 2.5 mg, 25 mg paroxetine hcl er oral tablet extended release 24 hour 37.5 mg QL (90 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 QL (60 EA per 30 days); MO/90 paroxetine hcl oral tablet 0 mg, 20 mg, 40 mg QL (30 EA per 30 days); MO/90 paroxetine hcl oral tablet 30 mg QL (60 EA per 30 days); MO/90 PAXIL ORAL SUSPENSION 0 MG/5ML 3 MO/90 sertraline hcl oral concentrate 20 mg/ml sertraline hcl oral tablet 00 mg QL (60 EA per 30 days); MO/90 sertraline hcl oral tablet 25 mg, 50 mg QL (30 EA per 30 days); MO/90 TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG venlafaxine hcl er oral capsule extended release 24 hour 50 mg, 37.5 mg venlafaxine hcl er oral capsule extended release 24 hour 75 mg venlafaxine hcl oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG Tricyclics (Tricíclicos) amitriptyline hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg 3 QL (30 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 QL (90 EA per 30 days); MO/90 3 QL (30 EA per 30 days); MO/90 3 MO/90 Page 25 of 3

26 clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral concentrate 0 mg/ml imipramine hcl oral tablet 0 mg, 25 mg, 50 mg nortriptyline hcl oral capsule 0 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl oral solution 0 mg/5ml protriptyline hcl oral tablet 0 mg, 5 mg trimipramine maleate oral capsule 00 mg, 25 mg, 50 mg Antiemetics (Antieméticos) Antiemetics, Other (Antieméticos, Otros) chlorpromazine hcl injection solution 50 mg/2ml 3 MO/90 chlorpromazine hcl oral tablet 0 mg, 00 mg, 200 mg, 25 mg, 50 mg diphenhydramine hcl injection solution 50 mg/ml hydroxyzine hcl oral syrup 0 mg/5ml hydroxyzine hcl oral tablet 0 mg, 25 mg, 50 mg meclizine hcl oral tablet 2.5 mg, 25 mg metoclopramide hcl injection solution 5 mg/ml 3 MO/90 metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 0 mg, 5 mg perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 25 mg Page 26 of 3

27 promethazine hcl injection solution 25 mg/ml, 50 mg/ml promethazine hcl oral syrup 6.25 mg/5ml EX-BFF; MO/90 promethazine hcl oral tablet 2.5 mg, 25 mg, 50 mg promethazine hcl rectal suppository 2.5 mg, 25 mg, 50 mg promethegan rectal suppository 50 mg TRANSDERM-SCOP (.5 MG) TRANSDERMAL PATCH 72 HOUR MG/3DAYS EX-BFF; MO/90 Emetogenic Therapy Adjuncts (Adjuvantes para Terapia Emetogénica) aprepitant oral capsule 25 mg, 40 mg, 80 & 25 mg, 80 mg 3 PA^ dronabinol oral capsule 0 mg, 2.5 mg, 5 mg PA^ ondansetron hcl injection solution 4 mg/2ml PA^ ondansetron hcl oral tablet 4 mg, 8 mg PA^ ondansetron oral tablet dispersible 4 mg, 8 mg PA^ VARUBI ORAL TABLET 90 MG 3 PA^ Antifungals (Antifungales) Antifungals (Antifungales) 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 3 PA^ 3 PA^ PA^ 4 PA^ ciclopirox external solution 8 % clotrimazole external cream % clotrimazole external solution % Page 27 of 3

28 clotrimazole mouth/throat lozenge 0 mg CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 372 MG CRESEMBA ORAL CAPSULE 86 MG 4 4 PA^ econazole nitrate external cream % ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG fluconazole in sodium chloride intravenous solution mg/00ml-%, mg/200ml- % fluconazole oral suspension reconstituted 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 25 mg, 250 mg itraconazole oral capsule 00 mg 3 PA^ PA^ ketoconazole external cream 2 % ketoconazole external shampoo 2 % ketoconazole oral tablet 200 mg MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 00 MG MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 50 MG 4 PA^ 3 PA^ NATACYN OPHTHALMIC SUSPENSION 5 % 3 MO/90 NOXAFIL ORAL SUSPENSION 40 MG/ML 3 NOXAFIL ORAL TABLET DELAYED RELEASE 00 MG nystatin external cream unit/gm nystatin external ointment unit/gm 3 Page 28 of 3

29 nystatin external powder unit/gm nystatin mouth/throat suspension unit/ml nystatin oral tablet unit terbinafine hcl oral tablet 250 mg terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg voriconazole intravenous solution reconstituted 200 mg voriconazole oral suspension reconstituted 40 mg/ml voriconazole oral tablet 200 mg, 50 mg Antigout Agents (Agentes Antigota) Antigout Agents (Agentes Antigota) PA^ allopurinol oral tablet 00 mg, 300 mg colchicine oral tablet 0.6 mg colchicine-probenecid oral tablet mg probenecid oral tablet 500 mg Anti-Inflammatory Agents (Agentes Anti-Inflamatorios) Glucocorticoids (Glucocorticoides) betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % Page 29 of 3

30 betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0. % betamethasone valerate external lotion 0. % betamethasone valerate external ointment 0. % cortisone acetate oral tablet 25 mg DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML dexamethasone intensol oral concentrate mg/ml dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg,.5 mg, 4 mg, 6 mg dexamethasone oral tablet mg, 2 mg 3 dexamethasone sodium phosphate injection solution 0 mg/ml, 20 mg/30ml hydrocortisone oral tablet 20 mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 6 mg, 32 mg, 4 mg, 8 mg methylprednisolone sodium succ injection solution reconstituted 25 mg, 40 mg millipred oral tablet 5 mg 3 PA^ PA^ PA^ prednisolone acetate ophthalmic suspension % prednisolone sodium phosphate oral solution 5 mg/5ml, 6.7 (5 base) mg/5ml prednisone oral tablet mg, 0 mg, 2.5 mg, 20 mg, 5 mg prednisone oral tablet 50 mg 3 SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 00 MG, 250 MG 3 Page 30 of 3

31 SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 500 MG sulfacetamide-prednisolone ophthalmic solution % 3 PA^ Nonsteroidal Anti-Inflammatory Drugs (Anti-inflamatorios No Esteroidales) celecoxib oral capsule 00 mg, 200 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 00 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg etodolac oral tablet 400 mg, 500 mg flurbiprofen oral tablet 00 mg, 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg QL (60 EA per 30 days) QL (60 EA per 30 days) indomethacin oral capsule 25 mg, 50 mg QL (20 EA per 30 days) ketorolac tromethamine injection solution 5 mg/ml, 30 mg/ml ketorolac tromethamine intramuscular solution 60 mg/2ml meloxicam oral tablet 5 mg, 7.5 mg QL (30 EA per 30 days) nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 25 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg Page 3 of 3

32 piroxicam oral capsule 0 mg, 20 mg sulindac oral tablet 50 mg, 200 mg Antimigraine Agents (Antimigraña) Ergot Alkaloids (Alcaloides de Ergotamina) dihydroergotamine mesylate injection solution mg/ml dihydroergotamine mesylate nasal solution 4 mg/ml ergotamine-caffeine oral tablet -00 mg Prophylactic (Profilaxis) divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 25 mg divalproex sodium oral tablet delayed release 25 mg, 250 mg, 500 mg PA^ timolol maleate oral tablet 0 mg, 20 mg, 5 mg topiramate oral capsule sprinkle 5 mg, 25 mg topiramate oral tablet 00 mg, 200 mg, 25 mg, 50 mg valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg Serotonin (5-HT) B/D Receptor Agonists (Agonistas del Receptor de Serotonina) naratriptan hcl oral tablet mg, 2.5 mg QL (9 EA per 30 days) rizatriptan benzoate oral tablet 0 mg, 5 mg rizatriptan benzoate oral tablet dispersible 0 mg, 5 mg sumatriptan succinate oral tablet 00 mg QL (9 EA per 30 days) sumatriptan succinate oral tablet 25 mg, 50 mg QL (8 EA per 30 days) sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml Page 32 of 3

33 sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution autoinjector 4 mg/0.5ml, 6 mg/0.5ml Antimyasthenic Agents (Antimiasténicos) Parasympathomimetics (Parasimpatomiméticos) guanidine hcl oral tablet 25 mg 3 MESTINON ORAL SYRUP 60 MG/5ML 3 pyridostigmine bromide er oral tablet extended release 80 mg pyridostigmine bromide oral tablet 60 mg Antimycobacterials (Antimicobacterianos) Antimycobacterials, Other (Antimicobacterianos, Otros) dapsone oral tablet 00 mg, 25 mg 2 PRIFTIN ORAL TABLET 50 MG 3 rifabutin oral capsule 50 mg Antituberculars (Antituberculosos) CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED GM ethambutol hcl oral tablet 00 mg, 400 mg isoniazid oral syrup 50 mg/5ml 3 isoniazid oral tablet 00 mg, 300 mg PASER ORAL PACKET 4 GM 3 pyrazinamide oral tablet 500 mg rifampin intravenous solution reconstituted 600 mg rifampin oral capsule 50 mg, 300 mg RIFATER ORAL TABLET MG 3 3 PA^ PA^ SIRTURO ORAL TABLET 00 MG 4 PA TRECATOR ORAL TABLET 250 MG 3 Page 33 of 3

34 Antineoplastics (Antineoplásicos) Alkylating Agents (Agentes Alquilantes) cyclophosphamide oral capsule 25 mg, 50 mg 3 PA^; MO/90 HEXALEN ORAL CAPSULE 50 MG 3 MO/90 LEUKERAN ORAL TABLET 2 MG 2 MO/90 MATULANE ORAL CAPSULE 50 MG 4 MO/90 VALCHLOR EXTERNAL GEL 0.06 % 4 MO/90 Antiandrogens (Antiandrógenos) bicalutamide oral tablet 50 mg QL (30 EA per 30 days); MO/90 flutamide oral capsule 25 mg nilutamide oral tablet 50 mg QL (60 EA per 30 days); MO/90 XTANDI ORAL CAPSULE 40 MG 4 PA; QL (20 EA per 30 days); MO/90 ZYTIGA ORAL TABLET 250 MG 4 PA; MO/90 Antiangiogenic Agents (Agentes Antiangiogénicos) POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG Antiestrogens/Modifiers (Antiestrógenos/Modificadores) 4 PA; LA; MO/90 4 PA; LA; MO/90 4 PA; MO/90 EMCYT ORAL CAPSULE 40 MG 3 MO/90 FARESTON ORAL TABLET 60 MG 3 QL (30 EA per 30 days); MO/90 SOLTAMOX ORAL SOLUTION 0 MG/5ML 3 MO/90 tamoxifen citrate oral tablet 0 mg, 20 mg Antimetabolites (Antimetabolitos) hydroxyurea oral capsule 500 mg LONSURF ORAL TABLET MG, MG 4 PA; MO/90 Page 34 of 3

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