BlueCross BlueShield of Western New York Formulary. List of Covered Drugs

Transcription

1 BlueCross BlueShield of Western New York 018 Formulary List of Covered s PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID , Version Number 9 This formulary was updated on 4/4/018. For more recent information or other questions, please contact BlueCross BlueShield of Western New York at or, for TTY users, 711, October 1 February 14 8 a.m. to 8 p.m., 7 days a week and February 15 September 30 8 a.m. to 8 p.m. Monday Friday, or visit I EG189

2 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 BlueCross BlueShield of Western New York. When it refers to plan or our plan, BlueCross BlueShield Retiree Pharmacy PDP. This document includes a list of the drugs (formulary) for our plan which is current as of 4/4/018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 019, and from time to time during the year. What is the BlueCross BlueShield of Western New York Formulary? A formulary is a list of covered drugs selected by BlueCross BlueShield of Western New York 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. BlueCross BlueShield of Western New York will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BlueCross BlueShield of Western New York network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and 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 4/4/018. To get updated information about the drugs covered by BlueCross BlueShield of Western New York please contact us. Our contact information appears on the front and back cover pages. In the event that our plan has made an error in the printed formulary during the year, we will notify you directly by mail. We will send you a written notification explaining the error and a new formulary page reflecting the correct text and benefit. II EG189

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Antihypertensive Therapy. If you know what your drug is used for, look for the category name in the list that begins on page number. 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 index page number 146. 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? BlueCross BlueShield of Western New York 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: BlueCross BlueShield of Western New York requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BlueCross BlueShield of Western New York before you fill your prescriptions. If you don t get approval, \BlueCross BlueShield of Western New York may not cover the drug. Quantity Limits: For certain drugs, BlueCross BlueShield of Western New York limits the amount of the drug that BlueCross BlueShield of Western New York will cover. For example, BlueCross BlueShield of Western New York provides 30 tablets per prescription for atorvastatin. This may be in addition to a standard one-month or three-month supply. III EG189

4 Step Therapy: In some cases, BlueCross BlueShield of Western New York requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, BlueCross BlueShield of Western New York may not cover B unless you try A first. If A does not work for you, BlueCross BlueShield of Western New York will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask BlueCross BlueShield of Western New York 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 BlueCross BlueShield of Western New York formulary? on IV for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Plan. \BlueCross BlueShield of Western New York pays for certain OTC drugs. The cost to BlueCross BlueShield of Western New York will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap). What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that BlueCross BlueShield of Western New York does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by BlueCross BlueShield of Western New York. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BlueCross BlueShield of Western New York. You can ask BlueCross BlueShield of Western New York to make an exception and cover your drug. See below for information about how to request an exception. IV EG189

5 How do I request an exception to the BlueCross BlueShield of Western New York Formulary? You can ask BlueCross BlueShield of Western New York to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, BlueCross BlueShield of Western New York 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, BlueCross BlueShield of Western New York will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30- day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. V EG189

6 If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you submit a prescription for a transition eligible drug and it is rejected at Point of Sale, a message will be relayed to the pharmacists to call for additional instructions if you underwent a recent level of care change. After confirming that you had a level of care change, the pharmacist will be instructed to enter a series of override codes to allow you to receive a one-time transition supply of your prescription. At that time, all transition supply procedures will apply including member notifications for transition supply fills. For more information For more detailed information about your BlueCross BlueShield of Western New York prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BlueCross BlueShield of Western New York please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit BlueCross BlueShield of Western New York Formulary The formulary that begins on the next page provides coverage information about the drugs covered by BlueCross BlueShield of Western New York. If you have trouble finding your drug in the list, turn to the Index that begins on page 146. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., WELCHOL) and generic drugs are listed in lower-case italics (e.g., simvasatin). The information in the column tells you if BlueCross BlueShield of Western New York has any special requirements for coverage of your drug. VI EG189

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9 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. : We offer additional coverage of some prescription drugs not normally covered under a Medicare prescription drug plan (enhanced drug coverage). The amount you pay when you fill a prescription for these excluded drugs will not count towards any True out-of-pocket (TROOP) cost calculation. In addition, if you are receiving Extra Help from Medicare to pay for your prescriptions, the Extra Help program will not pay for these drugs. Please see your evidence of coverage (EOC) for further details. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the 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 A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. 1

10 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 5 B/D PA; AMBISOME 5 B/D PA; amphotericin b 4 B/D PA; ANCOBON 5 MO CANCIDAS 5 B/D PA; caspofungin intravenous recon soln 50 mg CASPOFUNGIN INTRAVENOUS RECON SOLN 70 MG clotrimazole mucous membrane CRESEMBA INTRAVENOUS 5 B/D PA; 5 B/D PA; CRESEMBA ORAL 5 MO DIFLUCAN ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 50 MG 5 5 MO fluconazole fluconazole in dextrose(iso-o) Name fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/00 ml flucytosine 5 MO griseofulvin microsize griseofulvin ultramicrosize GRIS-PEG (ULTRAMICROSIZ E) itraconazole ketoconazole oral LAMISIL ORAL TABLET MYCAMINE 5 MO NOXAFIL ORAL 5 MO nystatin oral suspension nystatin oral tablet ONMEL 5 MO; QL (30 ORAVIG SPORANOX ORAL CAPSULE SPORANOX ORAL SOLUTION terbinafine hcl oral VFEND 5 MO VFEND IV

11 Name voriconazole intravenous voriconazole oral 5 MO ANTIVIRALS abacavir abacavir-lamivudine 5 MO abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 00 mg/5 ml 5 MO acyclovir oral tablet acyclovir sodium intravenous recon soln 500 mg acyclovir sodium intravenous solution B/D PA; 4 B/D PA; adefovir 5 MO amantadine hcl APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 150 mg, 00 mg atazanavir oral capsule 300 mg 5 MO 5 5 MO ATRIPLA 5 MO BARACLUDE ORAL SOLUTION BARACLUDE ORAL TABLET 5 MO Name BIKTARVY 5 MO cidofovir 5 B/D PA; COMBIVIR 5 MO COMPLERA 5 MO CRIXIVAN ORAL CAPSULE 00 MG, 400 MG CYTOVENE 4 B/D PA; DAKLINZA (8 per 8 DESCOVY 5 MO didanosine oral capsule,delayed release(dr/ec) 15 mg didanosine oral capsule,delayed release(dr/ec) 00 mg, 50 mg, 400 mg EDURANT 5 MO efavirenz oral capsule 00 mg efavirenz oral capsule 50 mg 5 MO efavirenz oral tablet 5 MO EMTRIVA entecavir 5 MO EPCLUSA (8 per 8 EPIVIR EPIVIR HBV ORAL SOLUTION 3

12 Name EPIVIR HBV ORAL TABLET EPZICOM 5 MO EVOTAZ 5 MO famciclovir FLUMADINE ORAL TABLET fosamprenavir 5 MO foscarnet B/D PA; FUZEON SUBCUTANEOUS RECON SOLN 5 MO ganciclovir sodium B/D PA; GENVOYA 5 MO HARVONI (8 per 8 HEPSERA 5 MO INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG 5 MO INVIRASE 5 MO ISENTRESS HD 5 MO ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 100 MG 5 MO 5 MO 5 MO Name ISENTRESS ORAL TABLET,CHEWAB LE 5 MG JULUCA 5 MO KALETRA ORAL SOLUTION KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG 5 MO 5 MO lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET 5 MO lopinavir-ritonavir MAVYRET (84 per 8 moderiba moderiba dose pack oral tablets,dose pack 00 mg (8)- 400 mg (8), mg (8)-mg (8) moderiba dose pack oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8) 5 MO nevirapine NORVIR ORAL CAPSULE 3 4

13 Name NORVIR ORAL SOLUTION NORVIR ORAL TABLET ODEFSEY 5 MO OLYSIO (8 per 8 oseltamivir PREVYMIS INTRAVENOUS PREVYMIS ORAL 5 MO PREZCOBIX 5 MO PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG REBETOL ORAL SOLUTION RELENZA DISKHALER 5 5 MO 5 MO RESCRIPTOR RETROVIR INTRAVENOUS RETROVIR ORAL CAPSULE RETROVIR ORAL SYRUP REYATAZ ORAL CAPSULE 150 MG, 00 MG, 300 MG 5 MO Name REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 00 mg (8)- 400 mg (8) ribasphere ribapak oral tablets,dose pack 00 mg (7)- 400 mg (7) ribasphere ribapak oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) ribasphere ribapak oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8), mg (8)-mg (8) ribavirin oral capsule ribavirin oral tablet 00 mg 5 MO 5 MO 5 5 MO rimantadine ritonavir SELZENTRY 5

14 Name SOVALDI (8 per 8 stavudine oral capsule STRIBILD 5 MO SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET 5 MO 5 MO SYMFI LO 5 MO SYNAGIS 5 MO; LA TAMIFLU TECHNIVIE (56 per 8 tenofovir disoproxil fumarate TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 5 MG, 50 MG 5 MO 5 MO TRIUMEQ 5 MO TRIZIVIR 5 MO TROGARZO 5 MO TRUVADA 5 MO TYBOST valacyclovir oral tablet 1 gram valacyclovir oral tablet 500 mg ; QL (10 ; QL (60 VALCYTE 5 MO valganciclovir 5 MO Name VALTREX ORAL TABLET 1 GRAM VALTREX ORAL TABLET 500 MG 6 ; QL (10 ; QL (60 VEMLIDY 5 MO VIDEX GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC VIEKIRA PAK (11 per 8 VIEKIRA XR (84 per 8 VIRACEPT ORAL TABLET 5 MO VIRAMUNE VIRAMUNE XR VIREAD 5 MO VOSEVI (8 per 8 ZEPATIER (8 per 8 ZERIT ZIAGEN ORAL SOLUTION ZIAGEN ORAL TABLET zidovudine ZOVIRAX ORAL CAPSULE ZOVIRAX ORAL SUSPENSION

15 Name ZOVIRAX ORAL TABLET 800 MG CEPHALOSPORINS AVYCAZ 5 MO cefaclor oral capsule cefaclor oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml cefaclor oral suspension for reconstitution 375 mg/5 ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, gram/50 ml cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram, 100 gram, 0 gram, 300 g cefazolin intravenous cefdinir Name 7 cefepime cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback gram/100 ml cefixime cefotaxime injection recon soln 1 gram, gram, 500 mg cefotaxime injection recon soln 10 gram cefotetan cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram, gram cefoxitin intravenous recon soln 10 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln 6 gram CEFTIN ORAL SUSPENSION FOR RECONSTITUTIO N ceftriaxone in dextrose,iso-os

16 Name ceftriaxone injection recon soln 1 gram, gram, 50 mg, 500 mg ceftriaxone injection recon soln 10 gram ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cephalexin MAXIPIME INJECTION SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 100 MG/5 ML, 00 MG/5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 4 Name TAZICEF INJECTION RECON SOLN 1 GRAM TAZICEF INJECTION RECON SOLN GRAM, 6 GRAM 8 4 TEFLARO 5 MO ZERBAXA 5 ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin DIFICID 5 MO e.e.s. 400 oral tablet E.E.S. GRANULES ERYPED 00 ERYPED 400 ery-tab oral tablet,delayed release (dr/ec) 50 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution

17 Name erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet PCE ZITHROMAX ZITHROMAX TRI- PAK ZITHROMAX Z- PAK ZMAX MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 1,000 mg/4 ml, 500 mg/ ml 5 MO atovaquone 5 MO atovaquoneproguanil AZACTAM aztreonam baciim bacitracin intramuscular BENZNIDAZOLE 3 Name BETHKIS 5 B/D PA; ; QL (4 per 8 BILTRICIDE CAPASTAT 4 CAYSTON 5 MO; LA; QL (84 per 8 chloramphenicol sod succinate chloroquine phosphate CLEOCIN HCL CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 300 MG/50 ML, 600 MG/50 ML CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 900 MG/50 ML CLEOCIN INJECTION CLEOCIN PEDIATRIC 4 clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection 9

18 Name clindamycin phosphate intravenous COARTEM colistin (colistimethate na) CUBICIN 5 MO DALVANCE dapsone oral daptomycin 5 MO DARAPRIM 5 PA; MO DORIPENEM INTRAVENOUS RECON SOLN 500 MG EMVERM 5 MO ethambutol FLAGYL gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/100 ml, 90 mg/100 ml 4 gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml Name GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML hydroxychloroquine imipenem-cilastatin IMPAVIDO 5 MO INVANZ INJECTION INVANZ INTRAVENOUS isoniazid injection isoniazid oral ivermectin KITABIS PAK 5 MO LINCOCIN lincomycin linezolid intravenous 5 linezolid oral 5 MO linezolid-0.9% sodium chloride MALARONE MALARONE PEDIATRIC 4 5 mefloquine MEPRON 5 MO meropenem MERREM INTRAVENOUS RECON SOLN 500 MG metro i.v. metronidazole in nacl (iso-os) 10

19 Name metronidazole oral MYAMBUTOL ORAL TABLET 400 MG MYCOBUTIN NEBUPENT 3 B/D PA; ; QL (1 per 8 neomycin ORBACTIV 5 MO paromomycin PASER PENTAM PLAQUENIL polymyxin b sulfate PRIFTIN PRIMAQUINE PRIMAXIN IV INTRAVENOUS RECON SOLN 500 MG pyrazinamide QUALAQUIN quinine sulfate rifabutin RIFADIN ORAL CAPSULE 150 MG RIFAMATE rifampin RIFATER SIRTURO 5 MO; LA SIVEXTRO INTRAVENOUS 5 Name SIVEXTRO ORAL 5 MO STREPTOMYCIN STROMECTOL SYNERCID 5 TIGECYCLINE 5 TINDAMAX ORAL TABLET 500 MG tinidazole TOBI 5 B/D PA; ; QL (80 per 8 TOBI PODHALER INHALATION CAPSULE TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in 0.5 % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution 5 QL (4 per 8 5 MO; QL (4 per 8 5 B/D PA; ; QL (80 per 8 TRECATOR TYGACIL 5 MO VABOMERE 5 XIFAXAN ORAL TABLET 00 MG XIFAXAN ORAL TABLET 550 MG 5 MO; QL (9 per 30 5 MO; QL (60 11

20 Name ZYVOX INTRAVENOUS PARENTERAL SOLUTION 00 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML 5 5 MO ZYVOX ORAL 5 MO PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15 mg, 50 mg amoxicillin-pot clavulanate ampicillin oral capsule ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln 1.5 gram Name ampicillin-sulbactam intravenous recon soln 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML 1 BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml nafcillin in dextrose iso-osm intravenous piggyback gram/100 ml nafcillin injection recon soln 1 gram, gram nafcillin injection recon soln 10 gram 5 MO nafcillin intravenous oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml oxacillin injection recon soln 1 gram 5 MO

21 Name oxacillin injection recon soln 10 gram oxacillin injection recon soln gram oxacillin intravenous PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 1 MILLION UNIT/50 ML, MILLION UNIT/50 ML PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 3 MILLION UNIT/50 ML penicillin g potassium penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml 5 3 penicillin g sodium penicillin v potassium pfizerpen-g piperacillintazobactam intravenous recon soln.5 gram, gram, 4.5 gram, 40.5 gram Name UNASYN INJECTION RECON SOLN 15 GRAM UNASYN INJECTION RECON SOLN 3 GRAM ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK.5 GRAM/50 ML ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML ZOSYN INTRAVENOUS RECON SOLN 40.5 GRAM QUINOLONES 4 4 AVELOX AVELOX IN NACL (ISO-OSMOTIC) BAXDELA INTRAVENOUS BAXDELA ORAL 5 MO CIPRO IN D5W INTRAVENOUS PIGGYBACK 400 MG/00 ML CIPRO ORAL SUSPENSION,MIC ROCAPSULE RECON

22 Name CIPRO ORAL TABLET 50 MG, 500 MG ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose ciprofloxacin lactate intravenous solution 400 mg/40 ml LEVAQUIN ORAL TABLET levofloxacin in d5w intravenous piggyback 50 mg/50 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous levofloxacin oral moxifloxacin in nacl (iso-osm) moxifloxacin oral MOXIFLOXACIN- SOD.ACE,SUL- WATER ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg 4 SULFA'S / RELATED AGENTS Name BACTRIM BACTRIM DS sulfadiazine sulfamethoxazoletrimethoprim sulfatrim TETRACYCLINES coremino demeclocycline DORYX MPC 4 ST; MO DORYX ORAL TABLET,DELAYE D RELEASE (DR/EC) 00 MG, 50 MG 4 ST; MO doxy-100 doxycycline hyclate oral capsule doxycycline hyclate oral tablet doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet MINOCIN ORAL CAPSULE 100 MG, 50 MG 4 ST; MO 14

23 Name minocycline oral capsule minocycline oral tablet minocycline oral tablet extended release 4 hr 115 mg, 65 mg minocycline oral tablet extended release 4 hr 135 mg, 45 mg, 90 mg 5 MO mondoxyne nl morgidox okebo oral capsule 75 mg ORACEA 4 ST; MO SOLODYN ORAL TABLET EXTENDED RELEASE 4 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG 5 ST; MO TARGADOX 4 ST; MO tetracycline VIBRAMYCIN ORAL CAPSULE 100 MG VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTIO N VIBRAMYCIN ORAL SYRUP 4 ST; MO XIMINO 4 ST; MO URINARY TRACT AGENTS Name 15 FURADANTIN 4 HIPREX MACROBID MACRODANTIN methenamine hippurate methenamine mandelate MONUROL nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst PRIMSOL trimethoprim VANCOMYCIN VANCOCIN 5 MO VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK VANCOMYCIN INJECTION vancomycin intravenous vancomycin oral capsule VIBATIV INTRAVENOUS RECON SOLN 750 MG MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS 5

24 Name ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 50 mg dexrazoxane hcl intravenous recon soln 500 mg 5 MO 5 5 MO ELITEK 5 MO FUSILEV 5 MO KEPIVANCE 5 MO leucovorin calcium injection recon soln 100 mg, 00 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral LEVOLEUCOVORI N INTRAVENOUS RECON SOLN 175 MG levoleucovorin intravenous recon soln 50 mg levoleucovorin intravenous solution mesna MESNEX INTRAVENOUS MESNEX ORAL 5 MO VISTOGARD 5 MO XGEVA 5 B/D PA; Name ZINECARD (AS HCL) INTRAVENOUS RECON SOLN 50 MG 5 MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 5 B/D PA; adriamycin intravenous solution adrucil intravenous solution.5 gram/50 ml adrucil intravenous solution 5 gram/100 ml, 500 mg/10 ml AFINITOR DISPERZ AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG B/D PA; B/D PA; B/D PA; 5 PA; MO (60 per 30 5 PA; MO ALECENSA (40 per 30 ALIMTA 5 B/D PA; ALIQOPA 5 B/D PA; ; LA ALKERAN INTRAVENOUS 5 B/D PA; ALKERAN ORAL 3 B/D PA; 16

25 Name ALUNBRIG ORAL TABLET 180 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLET 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK (30 per 30 (180 per 30 (60 per 30 (30 per 30 anastrozole ARIMIDEX AROMASIN ARRANON 5 B/D PA; ARZERRA 5 B/D PA; ASTAGRAF XL 4 B/D PA; AVASTIN 5 B/D PA; azacitidine 5 B/D PA; AZASAN 4 B/D PA; azathioprine B/D PA; azathioprine sodium B/D PA; BAVENCIO 5 B/D PA; ; LA BELEODAQ 5 B/D PA; BENDEKA 5 B/D PA; Name 17 BESPONSA 5 B/D PA; bexarotene 5 MO bicalutamide BICNU 5 B/D PA; bleomycin B/D PA; BLINCYTO INTRAVENOUS KIT 5 B/D PA; BORTEZOMIB 5 B/D PA; BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 400 MG, 500 MG 5 PA; MO (30 per 30 busulfan 5 B/D PA; BUSULFEX 5 B/D PA; CABOMETYX 5 PA; MO; LA CALQUENCE 5 PA; MO; LA; QL (60 per 30 CAMPTOSAR INTRAVENOUS SOLUTION 100 MG/5 ML 4 B/D PA; capecitabine CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG 5 PA; MO; LA; QL (90 per 30 5 PA; MO; LA; QL (30 per 30

26 Name carboplatin intravenous solution B/D PA; CASODEX CELLCEPT INTRAVENOUS CELLCEPT ORAL CAPSULE CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N CELLCEPT ORAL TABLET 3 B/D PA; 4 B/D PA; 5 B/D PA; 5 B/D PA; cisplatin B/D PA; cladribine 5 B/D PA; clofarabine 5 B/D PA; CLOLAR 5 B/D PA; COMETRIQ 5 PA; MO COSMEGEN 5 B/D PA; COTELLIC 5 PA; MO; LA; QL (63 per 8 cyclophosphamide intravenous CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule B/D PA; 3 B/D PA; B/D PA; B/D PA; B/D PA; Name 18 CYRAMZA 5 B/D PA; cytarabine B/D PA; cytarabine (pf) injection solution 100 mg/5 ml (0 mg/ml), gram/0 ml (100 mg/ml) cytarabine (pf) injection solution 0 mg/ml B/D PA; B/D PA; dacarbazine B/D PA; DACOGEN 5 B/D PA; dactinomycin B/D PA; DARZALEX 5 B/D PA; ; LA daunorubicin intravenous solution B/D PA; decitabine 5 B/D PA; docetaxel intravenous solution 160 mg/16 ml (10 mg/ml), 0 mg/ ml (10 mg/ml) docetaxel intravenous solution 160 mg/8 ml (0 mg/ml), 0 mg/ml (1 ml), 80 mg/4 ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) 5 B/D PA; 5 B/D PA;

27 Name DOCETAXEL INTRAVENOUS SOLUTION 0 MG/ML 5 B/D PA; DOXIL 5 B/D PA; doxorubicin intravenous recon soln 10 mg doxorubicin intravenous recon soln 50 mg doxorubicin intravenous solution doxorubicin, pegliposomal B/D PA; B/D PA; B/D PA; 5 B/D PA; DROXIA ELIGARD 4 PA; MO ELIGARD (3 MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) ELLENCE INTRAVENOUS SOLUTION 00 MG/100 ML 4 PA; MO 4 PA; MO 4 PA; MO 4 B/D PA; EMCYT EMPLICITI 5 B/D PA; ENVARSUS XR 4 B/D PA; epirubicin intravenous solution B/D PA; ERBITUX 5 B/D PA; Name 19 ERIVEDGE (30 per 30 ERLEADA 5 PA; MO ERWINAZE 5 B/D PA; ETOPOPHOS 4 B/D PA; etoposide intravenous B/D PA; etoposide oral exemestane FARESTON 5 MO FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 0 MG (1 per 1 (6 per 1 FASLODEX 5 B/D PA; FEMARA FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG 5 B/D PA; 3 B/D PA; floxuridine B/D PA; fludarabine intravenous recon soln B/D PA;

28 Name fludarabine intravenous solution fluorouracil intravenous B/D PA; B/D PA; flutamide FOLOTYN 5 B/D PA; GAZYVA 5 B/D PA; gemcitabine intravenous recon soln 1 gram, 00 mg gemcitabine intravenous recon soln gram gemcitabine intravenous solution 1 gram/6.3 ml (38 mg/ml), 00 mg/5.6 ml (38 mg/ml) gemcitabine intravenous solution gram/5.6 ml (38 mg/ml) GEMZAR INTRAVENOUS RECON SOLN 1 GRAM B/D PA; B/D PA; B/D PA; B/D PA; 4 B/D PA; gengraf B/D PA; GILOTRIF ORAL TABLET 0 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG (60 per 30 (40 per 30 (30 per 30 Name GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG 0 5 PA; MO (60 per 30 GLEOSTINE HALAVEN 5 B/D PA; HERCEPTIN 5 B/D PA; HEXALEN 5 MO HYCAMTIN INTRAVENOUS 5 B/D PA; HYCAMTIN ORAL ; HYDREA hydroxyurea IBRANCE (1 per 8 ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG 5 PA; QL (90 (30 per 30 IDAMYCIN PFS 4 B/D PA; idarubicin B/D PA; IDHIFA ORAL TABLET 100 MG IDHIFA ORAL TABLET 50 MG IFEX INTRAVENOUS RECON SOLN 1 GRAM 5 PA; MO; LA; QL (30 per 30 5 PA; MO; LA; QL (60 per 30 4 B/D PA;

29 Name ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE 140 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET 140 MG IMBRUVICA ORAL TABLET 80 MG, 40 MG, 560 MG B/D PA; B/D PA; 5 PA; MO (60 per 30 (10 per 30 5 PA; MO (10 per 30 5 PA; MO IMFINZI 5 B/D PA; ; LA IMURAN 4 B/D PA; INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG 5 PA; MO (10 per 30 IRESSA (30 per 30 irinotecan intravenous solution 100 mg/5 ml B/D PA; Name irinotecan intravenous solution 40 mg/ ml irinotecan intravenous solution 500 mg/5 ml 1 5 B/D PA; 5 B/D PA; ISTODAX 5 B/D PA; IXEMPRA 5 B/D PA; JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG JAKAFI ORAL TABLET 5 MG 5 PA; MO (60 per 30 JEVTANA 5 B/D PA; KADCYLA 5 PA; MO KEYTRUDA 5 PA; MO KISQALI 5 PA; MO KISQALI FEMARA CO-PACK 5 PA; MO KYPROLIS 5 B/D PA; LARTRUVO 5 B/D PA; ; LA LENVIMA 5 PA; MO letrozole LEUKERAN leuprolide subcutaneous kit LONSURF 5 PA; MO LUPRON DEPOT 5 PA; MO LUPRON DEPOT (NTH) 5 PA; MO

30 Name LUPRON DEPOT (NTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED LUPRON DEPOT- PED (NTH) 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO LYNPARZA 5 PA; MO LYSODREN MARQIBO 3 B/D PA; MATULANE 5 MO MEGACE ES 5 PA; MO megestrol oral suspension 400 mg/10 ml (10 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml), 65 mg/5 ml PA PA; MO megestrol oral tablet PA; MO MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET MG (10 per 30 (30 per 30 melphalan B/D PA; melphalan hcl 5 B/D PA; mercaptopurine methotrexate sodium B/D PA; Name methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin intravenous recon soln 0 mg, 5 mg mitomycin intravenous recon soln 40 mg B/D PA; B/D PA; B/D PA; 5 B/D PA; mitoxantrone B/D PA; MUSTARGEN 4 B/D PA; mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium B/D PA; B/D PA; 5 B/D PA; B/D PA; B/D PA; MYFORTIC 4 B/D PA; MYLERAN ; MYLOTARG 5 B/D PA; ; LA NEORAL 4 B/D PA; NERLYNX 5 MO; LA

31 Name NEXAVAR 5 PA; MO; LA; QL (10 per 30 NILANDRON 5 MO nilutamide 5 MO NINLARO ORAL CAPSULE.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG (6 per 8 (4 per 8 (3 per 8 NIPENT 5 B/D PA; NULOJIX 5 B/D PA; octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml) octreotide acetate injection syringe 500 mcg/ml (1 ml) 5 MO 5 MO ODOMZO 5 PA; MO; LA; QL (30 per 30 ONCASPAR 5 B/D PA; ONIVYDE 5 B/D PA; OPDIVO 5 PA; MO Name oxaliplatin intravenous recon soln 100 mg oxaliplatin intravenous recon soln 50 mg oxaliplatin intravenous solution B/D PA; B/D PA; B/D PA; paclitaxel B/D PA; PERJETA 5 B/D PA; POMALYST 5 MO; LA PORTRAZZA 5 B/D PA; PROGRAF INTRAVENOUS PROGRAF ORAL CAPSULE 0.5 MG, 1 MG PROGRAF ORAL CAPSULE 5 MG 3 B/D PA; 4 B/D PA; 5 B/D PA; PURIXAN 5 MO RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET 0.5 MG RAPAMUNE ORAL TABLET 1 MG, MG 5 B/D PA; 4 B/D PA; 5 B/D PA; REVLIMID 5 PA; MO; LA RITUXAN 5 PA; MO RITUXAN HYCELA 5 PA; MO ROMIDEPSIN 5 B/D PA; 3

32 Name RUBRACA ORAL TABLET 00 MG RUBRACA ORAL TABLET 50 MG RUBRACA ORAL TABLET 300 MG 5 PA; MO; LA; QL (180 per 30 5 PA; MO; LA; QL (150 per 30 5 PA; MO; LA; QL (10 per 30 RYDAPT 5 PA; MO SANDIMMUNE INTRAVENOUS SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION SANDOSTATIN INJECTION SOLUTION 100 MCG/ML SANDOSTATIN INJECTION SOLUTION 50 MCG/ML, 500 MCG/ML SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 4 B/D PA; 4 B/D PA; 3 B/D PA; 5 MO 5 MO SIGNIFOR 5 MO SIGNIFOR LAR 5 MO SIMULECT INTRAVENOUS RECON SOLN 10 MG 3 B/D PA; Name SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet mg 4 3 B/D PA; B/D PA; 5 B/D PA; SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100 MG, 0 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 140 MG SPRYCEL ORAL TABLET 70 MG 5 MO 5 PA; MO (30 per 30 (60 per 30 STIVARGA (84 per 8 SUTENT ORAL CAPSULE 1.5 MG SUTENT ORAL CAPSULE 5 MG, 37.5 MG SUTENT ORAL CAPSULE 50 MG 5 PA; MO (60 per 30 (30 per 30 SYLVANT 5 B/D PA; SYNRIBO 5 B/D PA; TABLOID tacrolimus oral B/D PA;

33 Name TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG (180 per 30 (10 per 30 5 PA; MO; LA; QL (60 per 30 5 PA; MO; LA; QL (30 per 30 tamoxifen TARCEVA ORAL TABLET 100 MG, 5 MG TARCEVA ORAL TABLET 150 MG 5 PA; MO (30 per 30 TARGRETIN 5 MO TASIGNA ORAL CAPSULE 150 MG TASIGNA ORAL CAPSULE 00 MG TASIGNA ORAL CAPSULE 50 MG TAXOTERE INTRAVENOUS SOLUTION 80 MG/4 ML (0 MG/ML) 5 PA; MO (11 per B/D PA; TECENTRIQ 5 B/D PA; ; LA TEMODAR INTRAVENOUS 5 B/D PA; TEMODAR ORAL ; temozolomide Name 5 THALOMID 5 PA; MO thiotepa 5 B/D PA; toposar B/D PA; topotecan intravenous recon soln topotecan intravenous solution 5 B/D PA; 5 B/D PA; TORISEL 5 B/D PA; TREANDA INTRAVENOUS RECON SOLN 5 B/D PA; TRELSTAR 5 B/D PA; tretinoin (chemotherapy) 5 MO TREXALL 4 B/D PA; TRISENOX INTRAVENOUS SOLUTION MG/ML 5 B/D PA; TYKERB 5 PA; MO; LA; QL (180 per 30 UNITUXIN 5 B/D PA; VALSTAR 5 B/D PA; VANTAS 4 B/D PA; VECTIBIX 5 B/D PA; VELCADE 5 B/D PA;

34 Name VENCLEXTA ORAL TABLET 10 MG, 50 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK VERZENIO ORAL TABLET 100 MG VERZENIO ORAL TABLET 150 MG VERZENIO ORAL TABLET 00 MG VERZENIO ORAL TABLET 50 MG 3 PA; MO; LA 5 PA; MO; LA 5 PA; MO; LA; QL (4 per PA; MO; LA; QL (10 per 30 5 PA; MO; LA; QL (80 per 30 5 PA; MO; LA; QL (60 per 30 5 PA; MO; LA; QL (40 per 30 VIDAZA 5 B/D PA; vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml vincasar pfs intravenous solution mg/ ml B/D PA; B/D PA; B/D PA; vincristine B/D PA; vinorelbine B/D PA; VOTRIENT (10 per 30 Name VYXEOS 5 B/D PA; XALKORI ORAL CAPSULE 00 MG XALKORI ORAL CAPSULE 50 MG 5 PA; MO (60 per 30 XATMEP 5 B/D PA; XELODA ; XERMELO 5 PA; MO; LA; QL (90 per 30 XTANDI (10 per 30 YERVOY 5 B/D PA; YONDELIS 5 B/D PA; ZALTRAP 5 B/D PA; ZANOSAR 4 B/D PA; ZEJULA 5 PA; MO; LA; QL (90 per 30 ZELBORAF (40 per 30 ZOLADEX 4 B/D PA; ZOLINZA 5 MO ZORTRESS 5 B/D PA; ZYDELIG (90 per 30 6

35 Name ZYKADIA (150 per 30 ZYTIGA ORAL TABLET 50 MG ZYTIGA ORAL TABLET 500 MG (10 per 30 (60 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 00 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS 5 MO 5 MO BRIVIACT ORAL 5 MO carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr 4 1 MO Name carbamazepine oral tablet,chewable 7 1 MO CARBATROL CELONTIN ORAL CAPSULE 300 MG CEREBYX INJECTION SOLUTION 500 MG PE/10 ML 4 clonazepam PA; MO DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES DIASTAT DIASTAT ACUDIAL diazepam rectal DILANTIN 30 MG DILANTIN EXTENDED 100 MG DILANTIN INFATABS 50 MG DILANTIN MG/5 ML divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 4 hr divalproex oral tablet,delayed release (dr/ec) 1 MO

36 Name epitol EQUETRO ethosuximide felbamate oral suspension 5 MO felbamate oral tablet FELBATOL 5 MO fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 50 mg/5 ml gabapentin oral solution 50 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 1 MG, 16 MG GABITRIL ORAL TABLET MG, 4 MG GRALISE 30-DAY STARTER PACK 5 MO 1 MO; QL ( MO; QL (360 1 MO; QL (70 ; QL (160 QL (160 per 30 1 MO; QL (180 1 MO; QL (135 3 PA; MO; QL (78 per 180 Name GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 300 MG GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 600 MG 3 PA; MO; QL (30 per 30 3 PA; MO; QL (90 per 30 KEPPRA ORAL KEPPRA XR KLONOPIN 4 PA; MO LAMICTAL ODT LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 5 MG, 5 MG LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT LAMICTAL XR LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) 8

37 Name Name lamotrigine oral tablet lamotrigine oral tablet disintegrating, dose pk lamotrigine oral tablet extended release 4hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml 1 MO LYRICA CR ORAL TABLET EXTENDED RELEASE 4 HR 165 MG LYRICA CR ORAL TABLET EXTENDED RELEASE 4 HR 330 MG LYRICA CR ORAL TABLET EXTENDED RELEASE 4 HR 8.5 MG LYRICA ORAL CAPSULE 100 MG LYRICA ORAL CAPSULE 150 MG 4 PA; MO; QL (10 per 30 4 PA; MO; QL (60 per 30 4 PA; MO; QL (40 per 30 3 PA; MO; QL (180 per 30 3 PA; MO; QL (10 per 30 levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml levetiracetam intravenous LYRICA ORAL CAPSULE 00 MG LYRICA ORAL CAPSULE 5 MG 3 PA; MO; QL (90 per 30 3 PA; MO; QL (81 per 30 levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 4 hr LYRICA ORAL CAPSULE 5 MG LYRICA ORAL CAPSULE 300 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG 3 PA; MO; QL (70 per 30 3 PA; MO; QL (60 per 30 3 PA; MO; QL (360 per 30 3 PA; MO; QL (40 per 30 9

38 Name LYRICA ORAL SOLUTION 3 PA; MO; QL (900 per 30 MYSOLINE 5 MO NEURONTIN ORAL CAPSULE 100 MG NEURONTIN ORAL CAPSULE 300 MG NEURONTIN ORAL CAPSULE 400 MG NEURONTIN ORAL SOLUTION NEURONTIN ORAL TABLET 600 MG NEURONTIN ORAL TABLET 800 MG ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 0 MG 4 PA; MO; QL (1080 per 30 4 PA; MO; QL (360 per 30 4 PA; MO; QL (70 per 30 4 PA; MO; QL (160 per 30 4 PA; MO; QL (180 per 30 4 PA; MO; QL (135 per 30 3 PA; MO 3 PA; MO oxcarbazepine OXTELLAR XR PEGANONE phenobarbital PA; MO phenobarbital sodium injection solution 130 mg/ml phenobarbital sodium injection solution 65 mg/ml PHENYTEK Name phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution phenytoin sodium intravenous syringe primidone QUDEXY XR 4 PA; MO roweepra roweepra xr SABRIL 5 MO; LA SPRITAM TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL XR tiagabine TOPAMAX 4 PA; MO topiramate oral capsule, sprinkle TOPIRAMATE ORAL CAPSULE,SPRINK LE,ER 4HR topiramate oral tablet PA; MO 4 PA; MO 1 PA; MO TRILEPTAL 30

39 Name TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE 4HR 100 MG, 5 MG, 50 MG TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE 4HR 00 MG 4 PA; MO 5 PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 50 mg/5 ml valproic acid (as sodium salt) oral solution 50 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) vigabatrin 5 MO; LA VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 3 ZARONTIN ZONEGRAN ORAL CAPSULE 100 MG, 5 MG 4 PA; MO zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN 5 MO; LA AZILECT benztropine injection benztropine oral PA; MO Name 31 bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone COGENTIN COMTAN DUOPA 4 B/D PA; ELDEPRYL 4 entacapone GOCOVRI ORAL CAPSULE,EXTEN DED RELEASE 4HR 137 MG GOCOVRI ORAL CAPSULE,EXTEN DED RELEASE 4HR 68.5 MG (60 per 30 (30 per 30 LODOSYN MIRAPEX MIRAPEX ER NEUPRO PARLODEL pramipexole rasagiline REQUIP REQUIP XL ropinirole RYTARY selegiline hcl SINEMET SINEMET CR STALEVO 100

40 Name STALEVO 15 STALEVO 150 STALEVO 00 STALEVO 50 STALEVO 75 TASMAR ORAL TABLET 100 MG 5 MO tolcapone 5 MO ZELAPAR MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate oral tablet 1.5 mg almotriptan malate oral tablet 6.5 mg ; QL (4 per 8 ; QL (18 per 8 AMERGE ; QL (18 per 8 AXERT ORAL TABLET 1.5 MG AXERT ORAL TABLET 6.5 MG ; QL (4 per 8 ; QL (18 per 8 CAFERGOT dihydroergotamine injection dihydroergotamine nasal ; QL (8 per 8 eletriptan hbr ; QL (18 per 8 ergotamine-caffeine FROVA ; QL (7 per 8 frovatriptan ; QL (7 per 8 Name IMITREX NASAL SPRAY,NON- AEROSOL 0 MG/ACTUATION IMITREX NASAL SPRAY,NON- AEROSOL 5 MG/ACTUATION ; QL (18 per 8 ; QL (36 per 8 IMITREX ORAL ; QL (18 per 8 IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML IMITREX SUBCUTANEOUS MAXALT ORAL TABLET 10 MG MAXALT ORAL TABLET 5 MG ; QL (8 per 8 ; QL (8 per 8 ; QL (8 per 8 ; QL (36 per 8 4 QL (36 per 8 MAXALT-MLT ; QL (36 per 8 migergot MIGRANAL ; QL (8 per 8 naratriptan ; QL (18 per 8 ONZETRA XSAIL ; QL (3 per 8 RELPAX ; QL (18 per 8 3

41 Name rizatriptan ; QL (36 per 8 sumatriptan nasal spray,non-aerosol 0 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution sumatriptannaproxen SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML TREXIMET ORAL TABLET MG TREXIMET ORAL TABLET MG ZEMBRACE SYMTOUCH ; QL (18 per 8 ; QL (36 per 8 ; QL (18 per 8 ; QL (8 per 8 ; QL (8 per 8 ; QL (8 per 8 ; QL (18 per 8 ; QL (9 per 8 ; QL (9 per 8 ; QL (18 per 8 5 MO; QL (8 per 8 zolmitriptan ; QL (18 per 8 Name ZOMIG ; QL (18 per 8 ZOMIG ZMT ; QL (18 per 8 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA ARICEPT AUBAGIO 5 PA; MO AUSTEDO ORAL TABLET 1 MG, 9 MG AUSTEDO ORAL TABLET 6 MG COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 3 mg donepezil oral tablet,disintegrating EXELON TRANSDERMAL 5 PA; MO; LA; QL (10 per 30 5 PA; MO; LA; QL (60 per 30 (30 per 30 (1 per 8 1 MO 1 MO EXONDYS 51 5 PA; MO galantamine GILENYA 5 PA; MO glatiramer subcutaneous syringe 0 mg/ml (30 per 30 33

42 Name glatiramer subcutaneous syringe 40 mg/ml glatopa subcutaneous syringe 0 mg/ml glatopa subcutaneous syringe 40 mg/ml HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG HORIZANT ORAL TABLET EXTENDED RELEASE 600 MG INGREZZA ORAL CAPSULE 40 MG INGREZZA ORAL CAPSULE 80 MG (1 per 8 (30 per 30 (1 per 8 4 PA; MO; QL (30 per 30 4 PA; MO; QL (60 per 30 5 PA; MO; LA; QL (60 per 30 5 PA; MO; LA; QL (30 per 30 KEVEYIS 5 PA; MO LEMTRADA 5 PA; MO memantine oral capsule,sprinkle,er 4hr memantine oral solution memantine oral tablet MEMANTINE ORAL TABLETS,DOSE PACK NAMENDA ORAL TABLET PA; MO PA; MO PA; MO 4 PA; MO 4 PA; MO Name NAMENDA TITRATION PAK 4 PA; MO NAMENDA XR 3 PA; MO NAMZARIC 3 PA; MO NUEDEXTA OCREVUS 5 PA; MO RADICAVA 5 MO RAZADYNE ER RAZADYNE ORAL TABLET rivastigmine rivastigmine tartrate TECFIDERA 5 PA; MO; LA tetrabenazine oral tablet 1.5 mg tetrabenazine oral tablet 5 mg (40 per 30 (10 per 30 TYSABRI 5 PA; MO; LA XENAZINE ORAL TABLET 1.5 MG XENAZINE ORAL TABLET 5 MG 5 PA; MO; LA; QL (40 per 30 5 PA; MO; LA; QL (10 per 30 ZINBRYTA 5 PA; MO; LA; QL (1 per 8 MUSCLE RELAXANTS / ANTISPASMODIC THERAPY anectine baclofen cyclobenzaprine oral tablet 4 PA; MO 34