2018 FORMULARY (List of Covered Drugs)

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1 InterCommunity Health Network CCO 2018 FORMULARY (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/01/2017. For more recent information or other questions, please contact us, InterCommunity Health Network CCO at or, for TTY users, , daily 8 a.m. to 8 p.m., or visit

2 InterCommunity Health Network CCO 2018 Formulary 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 InterCommunity Health Network CCO. When it refers to plan or our plan, it means InterCommunity Health Network CCO. This document includes a list of the drugs (formulary) for our plan, which is current as of 11/01/2017. The formulary may change at any time. You will receive notice when necessary. 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, 2019, and from time to time during the year. What is the InterCommunity Health Network CCO Formulary? A formulary is a list of covered drugs selected by InterCommunity Health Network CCO 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. InterCommunity Health Network CCO will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an InterCommunity Health Network CCO network pharmacy, and other plan rules are followed. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 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 11/01/2017. To get updated information about the drugs covered by InterCommunity Health Network CCO please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition ii

3 InterCommunity Health Network CCO 2018 Formulary The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page. 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. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? InterCommunity Health Network CCO 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: Samaritan Advantage Special Needs Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, Samaritan Advantage Special Needs Plan limits the amount of the drug that our plan will cover. For example, Samaritan Advantage Special Needs Plan provides 30 tabs per 30 days per prescription of Brintellix. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Samaritan Advantage Special Needs Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. Morphine Equivalent Dose (MED): Morphine is considered the Gold Standard of opioids. MED allows prescribers, pharmacists, and patients to compare different opioid medications to each other. IHN may use the MED calculation to limit the amount of opioid medication that is covered. You can find out if your drug has any additional requirements or limits by looking in the formulary. 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. iii

4 InterCommunity Health Network CCO 2018 Formulary You can ask InterCommunity Health Network CCO 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 InterCommunity Health Network CCO formulary? on page iv for information about how to request an exception. Mental Health Drugs The following drugs are financed separately by the State of Oregon (OMAP) and not subject to the IHN Formulary. This list contains the vast majority of products covered by the state, but may not be all-inclusive. Brand names listed are for reference only. To check for changes to the list, search for 7-11 Drug Carveout List at What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that InterCommunity Health Network CCO does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by InterCommunity Health Network CCO. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask InterCommunity Health Network CCO to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the InterCommunity Health Network CCO Formulary? You can ask InterCommunity Health Network CCO to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, InterCommunity Health Network CCO 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, InterCommunity Health Network CCO will only approve your request for an exception if the alternative drugs included on the plan s formulary 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 iv

5 InterCommunity Health Network CCO 2018 Formulary decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. 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 more information For more detailed information about your InterCommunity Health Network CCO prescription drug coverage, please review the InterCommunity Health Network websitehttps:// If you have questions about InterCommunity Health Network CCO please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. The IHN-CCO formulary is developed to reflect the State of Oregon Prioritized List of Health Services. The list uses ICD-10-CM diagnosis codes to rank health services. The prioritized health services list emphasizes prevention services and chronic diseases management. For more information about the prioritized health services list see InterCommunity Health Network CCO Formulary The formulary that begins on the next page provides coverage information about the drugs covered by InterCommunity Health Network CCO. If you have trouble finding your drug in the list, turn to the Index at the back of the book. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AMOXIL) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if InterCommunity Health Network CCO has any special requirements for coverage of your drug. v

6 InterCommunity Health Network CCO 2018 Formulary

7 Formulary Table of Contents *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*...9 *Aminoglycosides*...10 *Analgesics - Anti-Inflammatory*...10 *Analgesics - Nonnarcotic* *Analgesics - Opioid* *Androgens-Anabolic* *Anorectal Agents*...13 *Anthelmintics* *Antianginal Agents*...14 *Antianxiety Agents*...15 *Antiarrhythmics* *Antiasthmatic And Bronchodilator Agents*...15 *Anticoagulants* *Anticonvulsants* *Antidiabetics* *Antidiarrheals* *Antidotes*...21 *Antiemetics* *Antifungals*...22 *Antihistamines*...23 *Antihyperlipidemics*...23 *Antihypertensives* *Anti-Infective Agents - Misc.*...25 *Antimalarials* *Antimyasthenic Agents*...26 *Antimyasthenic/Cholinergic Agents* *Antimycobacterial Agents* *Antineoplastics And Adjunctive Therapies* *Antiparkinson Agents*...29 *Antipsychotics/Antimanic Agents* *Antivirals* *Assorted Classes*...32 *Beta Blockers*...33 *Biologicals Misc*...34 *Calcium Channel Blockers*...34 *Cardiotonics*...35 *Cardiovascular Agents - Misc.*...35 *Cephalosporins*...36 *Contraceptives*...36 *Corticosteroids*...43 *Cough/Cold/Allergy* *Dermatologicals* *Digestive Aids* *Diuretics* *Endocrine And Metabolic Agents - Misc.*...47 *Estrogens* *Fluoroquinolones* *Gastrointestinal Agents - Misc.*

8 *Genitourinary Agents - Miscellaneous* *Gout Agents* *Hematological Agents - Misc.* *Hematopoietic Agents* *Hepatitis C Agent - Combinations*** *Hypnotics*...51 *Laxatives* *Macrolides* *Medical Devices* *Migraine Products* *Minerals & Electrolytes*...55 *Mouth/Throat/Dental Agents* *Multivitamins*...57 *Musculoskeletal Therapy Agents* *Nasal Agents - Systemic And Topical* *Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag Comb***...60 *Ophthalmic Agents*...60 *Otic Agents*...62 *Oxytocics*...63 *Pcsk9 Inhibitors*** *Penicillins*...63 *Progestins* *Psychotherapeutic And Neurological Agents - Misc.* *Tetracyclines*...65 *Thyroid Agents*...65 *Ulcer Drugs*...66 *Urinary Anti-Infectives*...67 *Urinary Antispasmodics* *Vaccines*...67 *Vaginal Products*...68 *Vasopressors* *Vitamins*

9 Status ALT = Alt BE = Benefit Exclusion NC = Not Covered NF = Non Formulary SCO = State Carveout = Tier 1 lowercase italics = Generic drugs UPPERCASE = Brand name drugs Drug Status Notes *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg dextroamphetamine sulfate oral tablet 10 mg, 5 mg VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG ZENZEDI ORAL TABLET 5 MG *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg methylphenidate hcl er oral tablet extended release 10 mg, 20 mg methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 36 mg, 54 mg Notes = Prior Authorization Required QL = Quantity Limit ST = Step Therapy Required QL (30 EA per 30 days) 9

10 methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG *Aminoglycosides* *Aminoglycosides*** neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML 10

11 HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg *Interleukin-1 Receptor Antagonist (Il-1Ra)*** KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg, 50 mg meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 125 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg sulindac oral tablet 150 mg, 200 mg *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* *Analgesics-Sedatives*** butalbital-apap-caffeine oral capsule mg, mg butalbital-apap-caffeine oral tablet mg QL (20 EA per 30 days) QL (20 EA per 30 days) 11

12 butalbital-aspirin-caffeine oral capsule mg *Salicylates*** salsalate oral tablet 500 mg, 750 mg *Analgesics - Opioid* *Codeine Combinations*** QL (20 EA per 30 days) acetaminophen-codeine #2 oral tablet mg QL (180 EA per 30 days) acetaminophen-codeine #3 oral tablet mg QL (180 EA per 30 days) acetaminophen-codeine #4 oral tablet mg QL (180 EA per 30 days) acetaminophen-codeine oral solution mg/5ml acetaminophen-codeine oral tablet mg, mg *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution mg/5ml, mg/10ml, mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg *Opioid Agonists*** fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydromorphone hcl oral liquid 1 mg/ml QL (180 EA per 30 days) QL (180 EA per 30 days) ; QL (10 EA per 30 days) hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg QL (180 EA per 30 days) METHADONE HCL INTENSOL ORAL CONCENTRATE 10 MG/ML methadone hcl oral concentrate 10 mg/ml methadone hcl oral solution 10 mg/5ml, 5 mg/5ml methadone hcl oral tablet 10 mg, 5 mg QL (180 EA per 30 days) methadone hcl oral tablet soluble 40 mg QL (180 EA per 30 days) METHADOSE ORAL CONCENTRATE 10 MG/ML METHADOSE ORAL TABLET SOLUBLE 40 MG METHADOSE SUGAR-FREE ORAL CONCENTRATE 10 MG/ML morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg 12 QL (180 EA per 30 days) ; QL (180 EA per 30 days)

13 morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml morphine sulfate oral tablet 15 mg, 30 mg QL (180 EA per 30 days) morphine sulfate rectal suppository 10 mg, 20 mg, 30 mg, 5 mg oxycodone hcl er oral tablet er 12 hour abusedeterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg ; QL (180 EA per 30 days) oxycodone hcl oral capsule 5 mg QL (180 EA per 30 days) oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution 5 mg/5ml oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg QL (180 EA per 30 days) tramadol hcl oral tablet 50 mg QL (180 EA per 30 days) *Opioid Combinations*** ENDOCET ORAL TABLET MG, MG, MG, MG oxycodone-acetaminophen oral tablet mg, mg, mg, mg *Opioid Partial Agonists*** SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG, MG, MG, MG *Androgens-Anabolic* *Androgens*** testosterone cypionate intramuscular solution 200 mg/ml *Anorectal Agents* *Intrarectal Steroids*** CORTIFOAM RECTAL FOAM 10 % hydrocortisone rectal enema 100 mg/60ml *Rectal Anesthetic/Steroids*** hydrocortisone ace-pramoxine rectal cream % *Rectal Steroids*** anucort-hc rectal suppository 25 mg QL (180 EA per 30 days) QL (180 EA per 30 days) QL (90 EA per 30 days) 13

14 ANUSOL-HC RECTAL SUPPOSITORY 25 MG HEMMOREX-HC RECTAL SUPPOSITORY 25 MG, 30 MG hemorrhoidal-hc rectal suppository 25 mg hydrocortisone acetate rectal suppository 25 mg, 30 mg hydrocortisone rectal cream 1 %, 2.5 % PROCTOCARE-HC RECTAL CREAM 2.5 % PROCTOCORT RECTAL CREAM 1 % PROCTOCORT RECTAL SUPPOSITORY 30 MG PROCTO-MED HC RECTAL CREAM 2.5 % PROCTO-K RECTAL CREAM 1 % PROCTOSOL HC RECTAL CREAM 2.5 % PROCTOZONE-HC RECTAL CREAM 2.5 % *Anthelmintics* *Anthelmintics*** ivermectin oral tablet 3 mg *Antianginal Agents* *Nitrates*** ISORDIL TITRADOSE ORAL TABLET 40 MG isosorbide dinitrate er oral tablet extended release 40 mg isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 20 mg MINITRAN TRANSDERMAL TCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NITRO-DUR TRANSDERMAL TCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg 14

15 nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG *Antianxiety Agents* *Antianxiety Agents - Misc.*** hydroxyzine hcl oral syrup 10 mg/5ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg *Antiarrhythmics* *Antiarrhythmics Type I-A*** quinidine gluconate er oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100 mg, 150 mg, 50 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200 mg, 400 mg *Antiasthmatic And Bronchodilator Agents* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT QL (60 doses per 30 days) QL (12 GM per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (4 GM per 30 days) QL (13 GM per 30 days) 15

16 fluticasone-salmeterol inhalation aerosol powder breath activated mcg/act, mcg/act, mcg/act ipratropium-albuterol inhalation solution (3) mg/3ml SYMBICORT INHALATION AEROSOL MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT *Beta Adrenergics*** albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml albuterol sulfate oral syrup 2 mg/5ml albuterol sulfate oral tablet 2 mg, 4 mg PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT PROVENTIL HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate oral tablet 2.5 mg, 5 mg VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG *Leukotriene Receptor Antagonists*** montelukast sodium oral tablet 10 mg montelukast sodium oral tablet chewable 4 mg, 5 mg 16 ST; QL (1 EA per 30 days) QL (180 VIAL per 30 days) QL (6 GM per 30 days) QL (6.9 GM per 30 days) QL (180 VIAL per 30 days) QL (2 INH per 30 days) QL (2 INH per 30 days) QL (60 EA per 30 days) QL (2 INH per 30 days) QL (2 INH per 30 days) QL (1 EA per 30 days) QL (30 EA per 30 days)

17 zafirlukast oral tablet 10 mg, 20 mg *Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH QL (2 EA per 30 days) QL (2 EA per 30 days) QL (2 EA per 30 days) QL (2 EA per 30 days) QL (2 EA per 30 days) budesonide inhalation suspension 0.25 mg/2ml QL (120 VIAL per 30 days) budesonide inhalation suspension 0.5 mg/2ml QL (60 VIAL per 30 days) budesonide inhalation suspension 1 mg/2ml QL (30 VIAL per 30 days) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthines*** ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg, 450 mg QL (60 doses per 30 days) QL (24 GM per 30 days) QL (22 GM per 30 days) QL (15 GM per 30 days) 17

18 *Anticoagulants* *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 mg/3ml enoxaparin sodium subcutaneous solution 100 mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml *Anticonvulsants* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5 mg, 1 mg, 2 mg DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 100 mg EPITOL ORAL TABLET 200 MG gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5ml levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg 18

19 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG primidone oral tablet 250 mg, 50 mg ROWEEPRA ORAL TABLET 500 MG TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG topiramate oral capsule sprinkle 15 mg, 25 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg zonisamide oral capsule 100 mg, 25 mg, 50 mg *Carbamates*** felbamate oral tablet 400 mg, 600 mg *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2 mg, 4 mg *Hydantoins*** DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG DILANTIN ORAL CAPSULE 30 MG PHENYTEK ORAL CAPSULE 200 MG, 300 MG PHENYTOIN INFATABS ORAL TABLET CHEWABLE 50 MG phenytoin oral suspension 125 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg *Succinimides*** ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml *Antidiabetics* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100 mg, 25 mg, 50 mg *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg metformin hcl oral tablet 1000 mg, 500 mg, 850 mg 19

20 *Diabetic Other*** GLUCAGON EMERGENCY INJECTION KIT 1 MG *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG ONGLYZA ORAL TABLET 2.5 MG, 5 MG ST TRADJENTA ORAL TABLET 5 MG ST *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG *Human Insulin*** BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML 20 ST ST ST ST

21 NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TANZEUM SUBCUTANEOUS PEN- INJECTOR 30 MG, 50 MG *Meglitinide Analogues*** nateglinide oral tablet 120 mg, 60 mg repaglinide oral tablet 0.5 mg, 1 mg, 2 mg *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** FARXIGA ORAL TABLET 10 MG, 5 MG ST INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG *Sulfonylureas*** glimepiride oral tablet 1 mg, 2 mg, 4 mg glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg glipizide oral tablet 10 mg, 5 mg glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg *Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg *Antidiarrheals* *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg loperamide hcl oral capsule 2 mg *Antidotes* *Antidotes - Chelating Agents*** EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG ST ST ST 21

22 *Opioid Antagonists*** naloxone hcl injection solution prefilled syringe 2 mg/2ml naltrexone hcl oral tablet 50 mg NARCAN NASAL LIQUID 4 MG/0.1ML QL (1 EA per 365 days) *Antiemetics* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 mg ondansetron hcl oral solution 4 mg/5ml QL (600 ML per 30 days) ondansetron hcl oral tablet 24 mg QL (30 EA per 30 days) ondansetron hcl oral tablet 4 mg QL (180 EA per 30 days) ondansetron hcl oral tablet 8 mg QL (90 EA per 30 days) ondansetron oral tablet dispersible 4 mg QL (180 EA per 30 days) ondansetron oral tablet dispersible 8 mg QL (90 EA per 30 days) *Antiemetics - Anticholinergic*** dimenhydrinate oral tablet 50 mg meclizine hcl oral tablet 12.5 mg, 25 mg *Antiemetics - Miscellaneous*** dronabinol oral capsule 2.5 mg, 5 mg *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE 125 MG, 40 MG, 80 MG *Antifungals* *Antifungals*** terbinafine hcl oral tablet 250 mg *Imidazoles*** ketoconazole oral tablet 200 mg *Triazoles*** fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg itraconazole oral capsule 100 mg SPORANOX ORAL SOLUTION 10 MG/ML voriconazole oral suspension reconstituted 40 mg/ml voriconazole oral tablet 200 mg, 50 mg 22

23 *Antihistamines* *Antihistamines - Ethanolamines*** diphenhydramine hcl oral capsule 25 mg, 50 mg pharbedryl oral capsule 50 mg *Antihistamines - Phenothiazines*** PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG promethazine hcl injection solution 50 mg/ml promethazine hcl oral solution 6.25 mg/5ml promethazine hcl oral syrup 6.25 mg/5ml promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 mg/5ml cyproheptadine hcl oral tablet 4 mg *Antihyperlipidemics* *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral powder 4 gm/dose PREVALITE ORAL CKET 4 GM *Fibric Acid Derivatives*** fenofibrate oral tablet 145 mg, 48 mg, 54 mg gemfibrozil oral tablet 600 mg *Hmg Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg lovastatin oral tablet 10 mg, 20 mg, 40 mg pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg 23

24 *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** VYTORIN ORAL TABLET MG, MG, MG, MG *Intestinal Cholesterol Absorption Inhibitors*** ZETIA ORAL TABLET 10 MG *Nicotinic Acid Derivatives*** niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg *Antihypertensives* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg *Ace Inhibitors & Thiazide/Thiazide-Like*** fosinopril sodium-hctz oral tablet mg, mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg *Ace Inhibitors*** benazepril hcl oral tablet 5 mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg moexipril hcl oral tablet 15 mg, 7.5 mg quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet mg, mg, mg *Angiotensin Ii Receptor Antagonists*** irbesartan oral tablet 150 mg, 300 mg, 75 mg 24

25 losartan potassium oral tablet 100 mg, 25 mg, 50 mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr guanfacine hcl oral tablet 1 mg, 2 mg methyldopa oral tablet 250 mg, 500 mg *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg prazosin hcl oral capsule 1 mg, 2 mg, 5 mg terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg *Vasodilators*** hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.*** FIRST-METRONIDAZOLE 100 ORAL SUSPENSION RECONSTITUTED 100 MG/ML FIRST-METRONIDAZOLE 50 ORAL SUSPENSION RECONSTITUTED 50 MG/ML FIRST-VANCOMYCIN 25 ORAL SOLUTION 25 MG/ML FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML metronidazole oral tablet 250 mg, 500 mg trimethoprim oral tablet 100 mg *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg SULFATRIM PEDIATRIC ORAL SUSPENSION MG/5ML 25

26 *Antiprotozoal Agents*** ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG *Leprostatics*** dapsone oral tablet 100 mg, 25 mg *Lincosamides*** clindamycin hcl oral capsule 150 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml *Antimalarials* *Antimalarials*** chloroquine phosphate oral tablet 250 mg, 500 mg hydroxychloroquine sulfate oral tablet 200 mg mefloquine hcl oral tablet 250 mg primaquine phosphate oral tablet 26.3 mg *Antimyasthenic Agents* *Antimyasthenic Agents*** MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 mg pyridostigmine bromide oral tablet 60 mg *Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 mg pyridostigmine bromide oral tablet 60 mg *Antimyasthenic/Cholinergic Agents* MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 mg pyridostigmine bromide oral tablet 60 mg *Antimycobacterial Agents* *Antimycobacterial Agents*** ethambutol hcl oral tablet 100 mg, 400 mg isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg 26

27 pyrazinamide oral tablet 500 mg rifampin oral capsule 150 mg, 300 mg *Antineoplastics And Adjunctive Therapies* *Alkylating Agents*** MYLERAN ORAL TABLET 2 MG *Antiadrenals*** LYSODREN ORAL TABLET 500 MG *Antiandrogens*** bicalutamide oral tablet 50 mg flutamide oral capsule 125 mg NILANDRON ORAL TABLET 150 MG *Antiestrogens*** FARESTON ORAL TABLET 60 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML tamoxifen citrate oral tablet 10 mg, 20 mg *Antimetabolites*** capecitabine oral tablet 150 mg, 500 mg mercaptopurine oral tablet 50 mg methotrexate oral tablet 2.5 mg methotrexate sodium injection solution 50 mg/2ml TABLOID ORAL TABLET 40 MG TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CAPSULE 100 MG *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG *Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 200 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG *Antineoplastic - Tyrosine Kinase Inhibitors*** imatinib mesylate oral tablet 100 mg, 400 mg SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG 27

28 TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CAPSULE 150 MG, 200 MG VOTRIENT ORAL TABLET 200 MG *Antineoplastics Misc.*** hydroxyurea oral capsule 500 mg *Aromatase Inhibitors*** anastrozole oral tablet 1 mg exemestane oral tablet 25 mg letrozole oral tablet 2.5 mg *Estrogens-Antineoplastic*** EMCYT ORAL CAPSULE 140 MG *Folic Acid Antagonists Rescue Agents*** leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg *Imidazotetrazines*** temozolomide oral capsule 100 mg, 20 mg, 5 mg *Mitotic Inhibitors*** etoposide oral capsule 50 mg *Nitrogen Mustards*** ALKERAN ORAL TABLET 2 MG cyclophosphamide oral capsule 25 mg, 50 mg LEUKERAN ORAL TABLET 2 MG *Nitrosoureas*** GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG *Progestins-Antineoplastic*** megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml megestrol acetate oral tablet 20 mg, 40 mg *Retinoids*** tretinoin oral capsule 10 mg *Selective Retinoid X Receptor Agonists*** bexarotene oral capsule 75 mg TARGRETIN ORAL CAPSULE 75 MG 28

29 *Topoisomerase I Inhibitors*** HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG *Urinary Tract Protective Agents*** MESNEX ORAL TABLET 400 MG *Antiparkinson Agents* *Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg trihexyphenidyl hcl oral elixir 0.4 mg/ml trihexyphenidyl hcl oral tablet 2 mg, 5 mg *Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 mg amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 100 mg bromocriptine mesylate oral capsule 5 mg bromocriptine mesylate oral tablet 2.5 mg *Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg *Levodopa Combinations*** carbidopa-levodopa er oral tablet extended release mg, mg carbidopa-levodopa oral tablet mg, mg, mg *Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg *Antipsychotics/Antimanic Agents* *Phenothiazines*** prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg *Antivirals* *Antiretroviral Combinations*** ATRIPLA ORAL TABLET MG 29

30 COMBIVIR ORAL TABLET MG COMPLERA ORAL TABLET MG EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG GENVOYA ORAL TABLET MG KALETRA ORAL SOLUTION MG/5ML KALETRA ORAL TABLET MG, MG lamivudine-zidovudine oral tablet mg STRIBILD ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG *Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL TABLET 150 MG, 300 MG *Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG *Antiretrovirals - Protease Inhibitors*** APTIVUS ORAL CAPSULE 250 MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 30

31 REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG VIRACEPT ORAL TABLET 250 MG, 625 MG *Antiretrovirals - Rti-Non-Nucleoside Analogues*** EDURANT ORAL TABLET 25 MG INTELENCE ORAL TABLET 100 MG, 200 MG nevirapine oral suspension 50 mg/5ml nevirapine oral tablet 200 mg SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG *Antiretrovirals - Rti-Nucleoside Analogues- Purines*** didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM ZIAGEN ORAL SOLUTION 20 MG/ML *Antiretrovirals - Rti-Nucleoside Analogues- Pyrimidines*** EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML LAMIVUDINE ORAL SOLUTION 10 MG/ML lamivudine oral tablet 150 mg, 300 mg *Antiretrovirals - Rti-Nucleoside Analogues- Thymidines*** stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg zidovudine oral capsule 100 mg zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 300 mg *Antiretrovirals - Rti-Nucleotide Analogues*** VIREAD ORAL TABLET 300 MG *Hepatitis B Agents*** EPIVIR HBV ORAL SOLUTION 5 MG/ML lamivudine oral tablet 100 mg 31

32 *Hepatitis C Agents*** MODERIBA 1200 DOSE CK ORAL TABLET 600 MG MODERIBA 800 DOSE CK ORAL TABLET 400 MG MODERIBA ORAL TABLET 200 MG PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML REBETOL ORAL SOLUTION 40 MG/ML RIBASPHERE ORAL CAPSULE 200 MG RIBASPHERE ORAL TABLET 200 MG, 400 MG, 600 MG RIBASPHERE RIBAK ORAL TABLET 400 & 600 MG, 400 MG, 600 MG ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg *Herpes Agents - Purine Analogues*** acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5ml acyclovir oral tablet 400 mg, 800 mg *Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML *Assorted Classes* *Antileprotics*** THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG *Chelating Agents*** DEPEN TITRATABS ORAL TABLET 250 MG 32

33 *Cyclosporine Analogs*** cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg cyclosporine modified oral solution 100 mg/ml cyclosporine oral capsule 100 mg, 25 mg GENGRAF ORAL CAPSULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML *Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG *Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension reconstituted 200 mg/ml mycophenolate mofetil oral tablet 500 mg *Macrolide Immunosuppressants*** RAMUNE ORAL SOLUTION 1 MG/ML sirolimus oral tablet 0.5 mg, 1 mg, 2 mg tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG *Purine Analogs*** AZASAN ORAL TABLET 100 MG, 75 MG azathioprine oral tablet 50 mg *Beta Blockers* *Alpha-Beta Blockers*** carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg labetalol hcl oral tablet 100 mg, 200 mg, 300 mg *Beta Blockers Cardio-Selective*** atenolol oral tablet 100 mg, 25 mg, 50 mg metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 33

34 *Beta Blockers Non-Selective*** nadolol oral tablet 20 mg, 80 mg pindolol oral tablet 10 mg propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg propranolol hcl oral solution 20 mg/5ml propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg *Biologicals Misc* *Allergenic Extracts*** GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800 BAU *Calcium Channel Blockers* *Calcium Channel Blockers*** AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG diltiazem cd oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl er coated beads oral tablet extended release 24 hour 180 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release 24 hour 180 mg, 240 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg 34

35 dilt-xr oral capsule extended release 24 hour 180 mg, 240 mg felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HOUR 60 MG nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg nifedipine oral capsule 10 mg TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg *Cardiotonics* *Cardiac Glycosides*** DIGITEK ORAL TABLET 125 MCG, 250 MCG DIGOX ORAL TABLET 125 MCG, 250 MCG digoxin oral tablet 125 mcg, 250 mcg *Cardiovascular Agents - Misc.* *Pulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG TRACLEER ORAL TABLET 125 MG, 62.5 MG *Pulmonary Hypertension - Phosphodiesterase Inhibitors*** sildenafil citrate oral tablet 20 mg 35

36 *Cephalosporins* *Cephalosporins - 1St Generation*** cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg *Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml cefuroxime axetil oral tablet 250 mg, 500 mg *Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg *Contraceptives* *Biphasic Contraceptives - Oral*** AZURETTE ORAL TABLET /0.01 MG (21/5) BEKYREE ORAL TABLET /0.01 MG (21/5) desogestrel-ethinyl estradiol oral tablet /0.01 mg (21/5) KARIVA ORAL TABLET /0.01 MG (21/5) KIMIDESS ORAL TABLET /0.01 MG (21/5) LO LOESTRIN FE ORAL TABLET 1 MG- 10 MCG / 10 MCG MIRCETTE ORAL TABLET /0.01 MG (21/5) NECON 10/11 (28) ORAL TABLET 35 MCG PIMTREA ORAL TABLET /0.01 MG (21/5) viorele oral tablet /0.01 mg (21/5) *Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET MG- MCG alyacen 1/35 oral tablet 1-35 mg-mcg 36

37 APRI ORAL TABLET MG-MCG AUBRA ORAL TABLET MG-MCG AVIANE ORAL TABLET MG-MCG BALZIVA ORAL TABLET MG-MCG BEYAZ ORAL TABLET MG BLISOVI 24 FE ORAL TABLET 1-20 MG- MCG(24) BLISOVI FE 1.5/30 ORAL TABLET MG-MCG BREVICON (28) ORAL TABLET MG-MCG briellyn oral tablet mg-mcg CHATEAL ORAL TABLET MG- MCG CRYSELLE-28 ORAL TABLET MG- MCG CYCLAFEM 1/35 ORAL TABLET 1-35 MG- MCG CYRED ORAL TABLET MG-MCG DASETTA 1/35 ORAL TABLET 1-35 MG- MCG DELYLA ORAL TABLET MG-MCG desogestrel-ethinyl estradiol oral tablet mg-mcg drospirenone-ethinyl estradiol oral tablet mg, mg ELINEST ORAL TABLET MG-MCG EMOQUETTE ORAL TABLET MG- MCG ENSKYCE ORAL TABLET MG- MCG ESTARYLLA ORAL TABLET MG- MCG FALESSA ORAL KIT MCG-MG FALMINA ORAL TABLET MG- MCG GENERESS FE ORAL TABLET CHEWABLE MG-MCG GIANVI ORAL TABLET MG 37

38 GILDAGIA ORAL TABLET MG- MCG GILDESS FE 1.5/30 ORAL TABLET MG-MCG GILDESS FE 1/20 ORAL TABLET 1-20 MG- MCG JULEBER ORAL TABLET MG- MCG JUNEL 1.5/30 ORAL TABLET MG- MCG JUNEL 1/20 ORAL TABLET 1-20 MG-MCG JUNEL FE 1.5/30 ORAL TABLET MG-MCG JUNEL FE 1/20 ORAL TABLET 1-20 MG- MCG JUNEL FE 24 ORAL TABLET 1-20 MG- MCG(24) KELNOR 1/35 ORAL TABLET 1-35 MG- MCG KURVELO ORAL TABLET MG- MCG LARIN 1.5/30 ORAL TABLET MG- MCG LARIN 1/20 ORAL TABLET 1-20 MG-MCG LARIN 24 FE ORAL TABLET 1-20 MG- MCG(24) LARIN FE 1.5/30 ORAL TABLET MG-MCG LARIN FE 1/20 ORAL TABLET 1-20 MG- MCG LAYOLIS FE ORAL TABLET CHEWABLE MG-MCG LESSINA ORAL TABLET MG-MCG levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg-mcg LEVORA 0.15/30 (28) ORAL TABLET MG-MCG LOMEDIA 24 FE ORAL TABLET 1-20 MG- MCG(24) LORYNA ORAL TABLET MG 38

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