Stanford Health Care Advantage 2018 Formulary List of Covered Drugs

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1 Stanford Health Care Advantage 018 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN , 1 This formulary was updated on 04/01/018. For more recent information or other questions, please contact Stanford Health Care Advantage Member Care Services, at or, for TTY users, 711, 8 am to 8 pm, seven days a week (except Thanksgiving and Christmas) from October 1 through February 14 and Monday through Friday (except holidays) from February 15 through September 0, or visit StanfordHealthCareAdvantage.org.

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12 Table of Contents Analgesics... Anesthetics... 9 Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents...11 Antibacterials... 1 Anticancer Agents... 1 Anticholinergic Agents... Anticonvulsants... Antidementia Agents...6 Antidepressants... 7 Antidiabetic Agents Antifungals...45 Antigout Agents Antihistamines...47 Anti-Infectives (Skin And Mucous Membrane)...48 Antimigraine Agents...48 Antimycobacterials...49 Antinausea Agents...50 Antiparasite Agents...51 Antiparkinsonian Agents...5 Antipsychotic Agents...54 Antivirals (Systemic)...58 Blood Products/Modifiers/Volume Expanders Caloric Agents...67 Cardiovascular Agents Central Nervous System Agents... 8 Contraceptives...86 Dental And Oral Agents...9 Dermatological Agents...9 Devices Enzyme Replacement/Modifiers...99 Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying

13 Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions...17 Metabolic Bone Disease Agents...17 Miscellaneous Therapeutic Agents...19 Ophthalmic Agents...11 Replacement Preparations... 1 Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals...14

14 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet 00-0 acetaminophen-codeine oral tablet ascomp with codeine oral capsule BELBUCA BUCCAL FILM 150 MCG, 00 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0. /ml buprenorphine hcl injection syringe 0. /ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule , butalbital-acetaminophen oral tablet 50-5 butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet butorphanol tartrate nasal spray,nonaerosol 10 /ml BUTRANS TRANSDERMAL PATCH WEEKLY 7.5 MCG/HOUR QL (700 per 0 days) QL (60 per 0 days) (Tylenol-Codeine #) QL (60 per 0 days) (Tylenol-Codeine #4) QL (180 per 0 days) (Buprenex) QL (180 per 0 days) QL (60 per 0 days) (Butrans) QL (4 per 8 days) QL (180 per 0 days) QL (180 per 0 days) (Marten-Tab) QL (180 per 0 days) (Capacet) QL (180 per 0 days) (Esgic) QL (180 per 0 days) (Fiorinal) QL (180 per 0 days) QL (180 per 0 days) QL (5 per 8 days) QL (4 per 8 days)

15 capacet oral capsule QL (180 per 0 days) codeine sulfate oral tablet 15, 0, QL (180 per 0 days) 60 EMBEDA ORAL CAPSULE,ORAL 4 QL (60 per 0 days) ONLY,EXT.REL PELL MG, MG, 0-1. MG, 50- MG, MG, 80-. MG endocet oral tablet 10-5 QL (40 per 0 days) endocet oral tablet.5-5, 5-5 QL (60 per 0 days) endocet oral tablet QL (00 per 0 days) fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, (Actiq) 5 PA; NM; NDS; QL (10 per 0 days) 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 (Duragesic) QL (10 per 0 days) mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution QL (700 per 0 days) /5 ml, 5-16 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (700 per 0 days) /15 ml hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (90 per 0 days) hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (60 per 0 days) 10-5 hydrocodone-acetaminophen oral tablet (Verdrocet) QL (60 per 0 days).5-5 hydrocodone-acetaminophen oral tablet (Vicodin) QL (90 per 0 days) 5-00 hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) QL (60 per 0 days) 5-5 hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (90 per 0 days) hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (60 per 0 days) hydrocodone-ibuprofen oral tablet (Ibudone) QL (150 per 0 days), 5-00 hydrocodone-ibuprofen oral tablet 7.5- QL (150 per 0 days) 00 hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml 4

16 hydromorphone injection solution /ml, 4 /ml hydromorphone injection syringe (Dilaudid) /ml, 4 /ml hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 0 days) hydromorphone oral tablet, 4, 8 (Dilaudid) QL (180 per 0 days) HYSINGLA ER ORAL QL (0 per 0 days) TABLET,ORAL ONLY,EXT.REL.4 HR 100 MG, 10 MG, 0 MG, 0 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 5 PA; NM; NDS; QL (0 per 0 days) MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-5 QL (60 per 0 days) lorcet hd oral tablet 10-5 QL (60 per 0 days) lorcet plus oral tablet QL (60 per 0 days) methadone injection solution 10 /ml methadone oral solution 10 /5 ml, 5 QL (1800 per 0 days) /5 ml methadone oral tablet 10 (Dolophine) QL (60 per 0 days) methadone oral tablet 5 (Dolophine) QL (180 per 0 days) methadose oral tablet,soluble 40 QL (90 per 0 days) morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml carpuject outer,l/f,p/f, sdv 4 /ml morphine 8 /ml carpuject sdv, l/f, outer 8 /ml morphine concentrate oral solution 100 QL (180 per 0 days) /5 ml (0 /ml) morphine intravenous syringe 10 /ml, /ml, 4 /ml, 8 /ml morphine oral solution 10 /5 ml QL (700 per 0 days) morphine oral solution 0 /5 ml (4 QL (00 per 0 days) /ml) MORPHINE ORAL TABLET 15 MG 4 QL (180 per 0 days) MORPHINE ORAL TABLET 0 MG 4 QL (10 per 0 days) morphine oral tablet extended release 100 (MS Contin) QL (60 per 0 days), 00, 60 5

17 morphine oral tablet extended release 15 (MS Contin) QL (90 per 0 days), 0 morphine sulfate 10 /ml vial 10 /ml NUCYNTA ER ORAL TABLET QL (60 per 0 days) EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, QL (181 per 0 days) 50 MG, 75 MG oxycodone oral capsule 5 QL (180 per 0 days) oxycodone oral concentrate 0 /ml QL (10 per 0 days) oxycodone oral solution 5 /5 ml QL (100 per 0 days) oxycodone oral tablet 10 QL (180 per 0 days) oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 days) oxycodone oral tablet 0 QL (10 per 0 days) oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 days) oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 0 days) hr 10, 15, 0, 0, 40, 60 oxycodone oral tablet,oral only,ext.rel.1 hr 80 (OxyContin) ; QL (10 per 0 days) oxycodone-acetaminophen oral solution QL (1800 per 0 days) 5-5 /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (40 per 0 days) 5 oxycodone-acetaminophen oral tablet (Endocet) QL (60 per 0 days).5-5, 5-5 oxycodone-acetaminophen oral tablet (Endocet) QL (00 per 0 days) oxycodone-aspirin oral tablet QL (60 per 0 days) OXYCONTIN ORAL QL (60 per 0 days) TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (10 per 0 days) TABLET,ORAL ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 (Opana) QL (10 per 0 days) oxymorphone oral tablet 5 (Opana) QL (180 per 0 days) 6

18 oxymorphone oral tablet extended release QL (60 per 0 days) 1 hr 10, 15, 0, 0, 40, 5, 7.5 reprexain oral tablet 10-00,.5-00 QL (150 per 0 days), 5-00 SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 00 MG/1.5 ML tencon oral tablet 50-5 QL (180 per 0 days) tramadol oral tablet 50 (Ultram) 1 GC; QL (40 per 0 days) tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (40 per 0 days) 5 vicodin es oral tablet QL (90 per 0 days) vicodin hp oral tablet QL (90 per 0 days) vicodin oral tablet 5-00 QL (90 per 0 days) XARTEMIS XR ORAL TAB,ORAL QL (00 per 0 days) ONLY,IR - ER, BIPHASE MG XTAMPZA ER ORAL QL (60 per 0 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 1.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (10 per 0 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG XTAMPZA ER ORAL QL (40 per 0 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 6 MG xylon 10 oral tablet QL (150 per 0 days) zebutal oral capsule QL (180 per 0 days) ZOHYDRO ER ORAL CAPSULE, 4 QL (60 per 0 days) ORAL ONLY, ER 1HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 50 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS 4 RECON SOLN 800 MG/8 ML (100 MG/ML) celecoxib oral capsule 100, 00, (Celebrex) QL (60 per 0 days) 400, 50 diclofenac potassium oral tablet 50 7

19 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 DUEXIS ORAL TABLET MG 5 PA; NM; NDS; QL (90 per 0 days) etodolac oral capsule 00, 00 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 (ProFeno) flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, 1 GC 800 indomethacin oral capsule 5 1 GC; QL (40 per 0 days) indomethacin oral capsule 50 1 GC; QL (10 per 0 days) indomethacin oral capsule, extended QL (60 per 0 days) release 75 indomethacin sodium intravenous recon soln 1 ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac injection cartridge 15 /ml QL (40 per 0 days) ketorolac injection cartridge 0 /ml QL (0 per 0 days) ketorolac injection solution 15 /ml QL (40 per 0 days) ketorolac injection solution 0 /ml (1 QL (0 per 0 days) ml) ketorolac intramuscular cartridge 60 / ml QL (0 per 0 days) 8

20 ketorolac intramuscular solution 60 / QL (0 per 0 days) ml ketorolac intramuscular syringe 60 / QL (0 per 0 days) ml ketorolac oral tablet 10 QL (0 per 0 days) mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) 1 GC nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 1 GC naproxen oral tablet 500 (Naprosyn) 1 GC naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75, 500 piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet 150, 00 tolmetin oral capsule 400 tolmetin oral tablet 00, 600 VIMOVO ORAL TABLET,IR,DELAYED 5 PA; NM; NDS; QL (60 per 0 days) REL,BIPHASIC 75-0 MG, MG Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %), 15 /ml (1.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 10 /ml (Xylocaine) (1 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 0 days) lidocaine topical ointment 5 % PA; QL (90 per 0 days) 9

21 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) BUNAVAIL BUCCAL FILM.1-0. QL (0 per 0 days) MG BUNAVAIL BUCCAL FILM QL (60 per 0 days) MG, 6.-1 MG buprenorphine hcl sublingual tablet, QL (90 per 0 days) 8 buprenorphine-naloxone sublingual tablet QL (90 per 0 days) -0.5, 8- bupropion hcl (smoking deter) oral tablet (Zyban) extended release 1 hr 150 CHANTIX CONTINUING MONTH QL (168 per 84 days) BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (168 per 84 days) MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) QL (5 per 8 days) disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, 1 /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL (4 per 0 days) AEROSOL MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION 4 QL (1008 per 90 days) CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM QL (60 per 0 days) 1- MG, 8- MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG QL (0 per 0 days) 10

22 ZUBSOLV SUBLINGUAL TABLET QL (0 per 0 days) MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET QL (60 per 0 days) MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 GC; QL (10 per 0 days) alprazolam oral tablet (Xanax) 1 GC; QL (150 per 0 days) alprazolam oral tablet extended release (Xanax XR) QL (10 per 0 days) 4 hr 0.5, 1, alprazolam oral tablet extended release (Xanax XR) QL (90 per 0 days) 4 hr buspirone oral tablet 10, 15, 0, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 5, 5 1 GC; QL (10 per 0 days) clonazepam oral tablet 0.5, 1 (Klonopin) 1 GC; QL (90 per 0 days) clonazepam oral tablet (Klonopin) 1 GC; QL (00 per 0 days) clonazepam oral tablet,disintegrating QL (90 per 0 days) 0.15, 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 days) clorazepate dipotassium oral tablet 15 QL (180 per 0 days),.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (180 per 0 days) DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG 4 diazepam injection solution 5 /ml QL (10 per 8 days) diazepam intensol oral concentrate 5 QL (100 per 0 days) /ml diazepam oral solution 5 /5 ml (1 QL (100 per 0 days) /ml) diazepam oral tablet 10,, 5 (Valium) 1 GC; QL (10 per 0 days) 11

23 diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit.5 (Diastat) estazolam oral tablet 1 QL (60 per 0 days) estazolam oral tablet QL (0 per 0 days) flurazepam oral capsule 15 QL (60 per 0 days) flurazepam oral capsule 0 QL (0 per 0 days) lorazepam injection solution /ml, 4 (Ativan) QL ( per 0 days) /ml lorazepam injection syringe /ml QL ( per 0 days) lorazepam oral concentrate /ml (Lorazepam Intensol) QL (150 per 0 days) lorazepam oral tablet 0.5, 1 (Ativan) 1 GC; QL (90 per 0 days) lorazepam oral tablet (Ativan) 1 GC; QL (150 per 0 days) midazolam oral syrup /ml QL (10 per 0 days) ONFI ORAL SUSPENSION.5 MG/ML 5 PA NSO; NM; NDS; QL (480 per 0 days) ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) oxazepam oral capsule 10, 15, 0 QL (10 per 0 days) temazepam oral capsule 15, 0 (Restoril) QL (0 per 0 days) triazolam oral tablet 0.15 QL (10 per 0 days) triazolam oral tablet 0.5 (Halcion) QL (60 per 0 days) Antibacterials Aminoglycosides BETHKIS INHALATION 5 PA BvD; NM; NDS SOLUTION FOR NEBULIZATION 00 MG/4 ML gentamicin 10 /ml vial sdv 60 /6 ml gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 10 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 0 / ml, 40 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml 1

24 gentamicin sulfate (pf) intravenous solution 100 /10 ml neomycin oral tablet GC streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION ; QL (4 per 8 days) DEVICE 8 MG tobramycin in 0.5 % nacl inhalation (Tobi) 5 PA BvD; NM; NDS solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 40 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150, 00, 75 (Cleocin HCl) clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution 150 /ml clindamycin phosphate intravenous solution 600 /4 ml colistin (colistimethate na) injection recon soln 150 daptomycin intravenous recon soln 500 linezolid intravenous parenteral solution 600 /00 ml (Cleocin in 5 % dextrose) (Cleocin Pediatric) (Cleocin) (Cleocin) (Coly-Mycin M Parenteral) (Cubicin) (Zyvox) 1

25 linezolid oral suspension for (Zyvox) reconstitution 100 /5 ml linezolid oral tablet 600 (Zyvox) linezolid-0.9% nacl 600 / /00 ml methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 /100 ml (Metro I.V.) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin) QL (10 per 0 days) 100, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) QL (60 per 0 days) nitrofurantoin oral suspension 5 /5 ml (Furadantin) QL (400 per 0 days) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet GC vancomycin in dextrose 5 % intravenous piggyback 1 gram/00 ml, 500 /100 ml, 750 /150 ml vancomycin intravenous recon soln 1,000, 10 gram, 5 gram, 500, 750 vancomycin oral capsule 15, 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG 5 PA; NM; NDS; QL (9 per 0 days) XIFAXAN ORAL TABLET 550 MG 5 PA; NM; NDS Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefaclor oral tablet extended release 1 hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin in 0.9% sod chloride intravenous solution gram/100 ml 14

26 cefazolin in dextrose (iso-os) intravenous piggyback gram/100 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 (Spectracef) CEFEPIME 1 GM INJECTION 1 4 GRAM/50 ML CEFEPIME INJECTION RECON (Maxipime) 4 SOLN 1 GRAM, GRAM CEFEPIME-DEXTROSE GM/50 4 ML GRAM/50 ML cefixime oral suspension for (Suprax) reconstitution 100 /5 ml, 00 /5 ml cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln 10 gram, (Claforan) gram cefoxitin gm piggyback bag gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftibuten oral capsule 400 ceftibuten oral suspension for reconstitution 180 /5 ml ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml ceftriaxone gm piggyback l/f, single use gram/50 ml 15

27 ceftriaxone injection recon soln 1 gram, gram ceftriaxone injection recon soln 10 gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cefuroxime-dextrose (iso-osm) intravenous piggyback 1.5 gram/50 ml, 750 /50 ml cephalexin oral capsule 50, 500 (Keflex) 1 GC cephalexin oral capsule 750 (Keflex) cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 MEFOXIN IN DEXTROSE (ISO- 4 OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 4 SUPRAX ORAL SUSPENSION FOR 4 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL 4 TABLET,CHEWABLE 100 MG, 00 MG tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON 4 SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 ( pack) 16

28 azithromycin oral tablet 50, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 DIFICID ORAL TABLET 00 MG 5 ST; NM; NDS; QL (0 per 10 days) e.e.s. 400 oral tablet E.E.S. GRANULES ORAL 4 SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION 4 FOR RECONSTITUTION 00 MG/5 ML ERYPED 400 ORAL SUSPENSION 4 FOR RECONSTITUTION 400 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL 4 TABLET,DELAYED RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG 4 erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram (Azactam) 17

29 CAYSTON INHALATION 5 NM; LA; NDS SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN 4 1 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, GC amoxicillin oral suspension for 1 GC reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, GC amoxicillin oral tablet,chewable 15, 1 GC 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, GC ampicillin oral suspension for reconstitution 15 /5 ml, 50 /5 ml 1 GC 18

30 ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram BICILLIN C-R INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) BICILLIN L-A INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram nafcillin intravenous recon soln gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 10 gram, gram oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit 19

31 piperacillin-tazobactam intravenous (Zosyn) recon soln.5 gram,.75 gram, 4.5 gram, 40.5 gram Quinolones BAXDELA ORAL TABLET 450 MG 5 PA; NM; NDS; QL (8 per 14 days) ciprofloxacin (mixture) oral tablet, er multiphase 4 hr 1,000, 500 (Cipro XR) ciprofloxacin hcl oral tablet 100, GC ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 GC ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50, 500, (Levaquin) 750 moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 00, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) 1 GC 0

32 sulfatrim oral suspension /5 ml Tetracyclines demeclocycline oral tablet 150, 00 doxy-100 intravenous recon soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline hyclate oral tablet,delayed release (dr/ec) 100, 150, 75 doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 00, 50 doxycycline monohydrate oral capsule (Mondoxyne NL) 100, 50, 75 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 150, 50, 75 MINOCIN INTRAVENOUS RECON SOLN 100 MG minocycline oral capsule 100, 50, (Minocin) 75 minocycline oral tablet 100, 50, 75 minocycline oral tablet extended release (CoreMino) 4 hr 15, 45, 90 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 /5 ml, 0 /10 ml PA BvD 1

33 adrucil intravenous solution.5 gram/50 PA BvD ml, 500 /10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 5 PA NSO; NM; NDS; QL (11 per 8 days) MG, 5 MG AFINITOR ORAL TABLET 10 MG 5 PA NSO; NM; NDS; QL (56 per 8 days) AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; NM; NDS; QL (8 per 8 days) ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS; QL (40 per 0 days) ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG 5 PA NSO; NM; NDS; QL ( per 8 days) ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) ALUNBRIG ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG () 5 PA NSO; NM; NDS; QL (0 per 0 days) anastrozole oral tablet 1 (Arimidex) 1 GC AVASTIN INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 5 MG/ML, 5 MG/ML (16 ML) azacitidine injection recon soln 100 (Vidaza) BAVENCIO INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 500 MG BENDEKA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 5 PA NSO; NM; NDS; QL (40 per 0 days) bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 15 unit, 0 unit PA BvD

34 BLINCYTO INTRAVENOUS KIT 5 MCG 5 PA NSO; NM; NDS; QL (5 per 65 days) BORTEZOMIB INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN.5 MG BOSULIF ORAL TABLET 100 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) BOSULIF ORAL TABLET 400 MG, 500 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) CABOMETYX ORAL TABLET 0 MG, 60 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) CABOMETYX ORAL TABLET 40 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) CAPRELSA ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) carboplatin intravenous solution 10 /ml cladribine intravenous solution 10 /10 PA BvD ml clofarabine intravenous solution 0 /0 (Clolar) ml COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), PA NSO; NM; NDS; QL (11 per 8 days) MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COTELLIC ORAL TABLET 0 MG 5 PA NSO; NM; LA; NDS; QL (6 per 8 days) cyclophosphamide intravenous recon soln 5 PA BvD; NM; NDS 1 gram, gram, 500 CYCLOPHOSPHAMIDE ORAL 4 PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 0 MG/ML 5 PA NSO; NM; LA; NDS decitabine intravenous recon soln 50 (Dacogen)

35 docetaxel intravenous solution 140 /7 ml (0 /ml), 160 /16 ml (10 /ml), 0 /ml docetaxel intravenous solution 80 /4 (Taxotere) ml (0 /ml) doxorubicin intravenous solution 10 /5 (Adriamycin) PA BvD ml, /ml, 0 /10 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 5 PA BvD; NM; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 400 MG ELIGARD ( MONTH) 4 SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) 4 SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) 4 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS 4 SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 00 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) ERLEADA ORAL TABLET 60 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) ETOPOPHOS INTRAVENOUS 4 RECON SOLN 100 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 5 PA NSO; NM; NDS MG, 15 MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution 5 gram/100 ml, 500 /10 ml (Adrucil) PA BvD 4

36 flutamide oral capsule 15 GAZYVA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 1,000 MG/40 ML gemcitabine intravenous recon soln 1 (Gemzar) gram, 00 gemcitabine intravenous recon soln gram gemcitabine intravenous solution 1 gram/6. ml (8 /ml), 100 /ml, gram/5.6 ml (8 /ml), 00 /5.6 ml (8 /ml) GILOTRIF ORAL TABLET 0 MG, 0 MG, 40 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) GLEOSTINE ORAL CAPSULE 10 4 MG, 100 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 150 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG 5 PA NSO; NM; NDS; QL (1 per 8 days) ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) ICLUSIG ORAL TABLET 45 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) ifosfamide intravenous recon soln 1 gram, (Ifex) PA BvD gram ifosfamide intravenous solution 1 gram/0 PA BvD ml, gram/60 ml ifosfamide-mesna intravenous kit 1-1 gram,,000-1,000 5 PA BvD; NM; NDS imatinib oral tablet 100 (Gleevec) 5 PA NSO; NM; NDS; QL (90 per 0 days) imatinib oral tablet 400 (Gleevec) 5 PA NSO; NM; NDS; QL (60 per 0 days) IMBRUVICA ORAL CAPSULE 140 MG 5 PA NSO; NM; NDS 5

37 IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (4 per 65 days) 5 PA NSO; NM; NDS; QL (8 per 8 days) INLYTA ORAL TABLET 1 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) INLYTA ORAL TABLET 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) IRESSA ORAL TABLET 50 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) irinotecan intravenous solution 100 /5 (Camptosar) ml, 40 / ml irinotecan intravenous solution 500 /5 ml IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) KEYTRUDA INTRAVENOUS RECON SOLN 50 MG 5 PA NSO; NM; NDS; QL (4 per 1 days) KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML 5 PA NSO; NM; NDS; QL (8 per 1 days) KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X ) 5 PA NSO; NM; NDS; QL (49 per 8 days) 5 PA NSO; NM; NDS; QL (70 per 8 days) 5 PA NSO; NM; NDS; QL (91 per 8 days) 5 PA NSO; NM; NDS; QL (6 per 8 days) 6

38 KYPROLIS INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 0 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML 5 PA NSO; NM; LA; NDS (19 ML) LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X), 0 MG/DAY (10 MG X ), 4 MG/DAY(10 MG X -4 MG X 1), 8 MG/DAY (4 MG X ) 5 PA NSO; NM; NDS letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG 4 leuprolide subcutaneous kit 1 /0. ml LONSURF ORAL TABLET MG 5 PA NSO; NM; NDS; QL (100 per 8 days) LONSURF ORAL TABLET MG 5 PA NSO; NM; NDS; QL (80 per 8 days) LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (448 per 8 days) LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 MG/1 ML(0.16 MG/ML) FINAL 5 PA NSO; NM; NDS; QL (4 per 8 days) MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 40 7

39 MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) MEKINIST ORAL TABLET MG 5 PA NSO; NM; NDS; QL (0 per 0 days) melphalan hcl intravenous recon soln 50 (Alkeran) mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon PA BvD soln 1 gram methotrexate sodium (pf) injection PA BvD solution 5 /ml, 5 /ml (10 ml) methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST mitoxantrone intravenous concentrate /ml MYLOTARG INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 4.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) nilutamide oral tablet 150 (Nilandron) NINLARO ORAL CAPSULE. MG, MG, 4 MG 5 PA NSO; NM; NDS; QL ( per 8 days) ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; NM; LA; NDS ONCASPAR INJECTION 5 PA NSO; NM; NDS SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS 5 PA BvD; NM; NDS DISPERSION 4. MG/ML OPDIVO INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 100 MG/10 ML, 40 MG/4 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 100, 50 oxaliplatin intravenous solution 100 /0 ml, 50 /10 ml (5 /ml) paclitaxel intravenous concentrate 6 /ml 8

40 PERJETA INTRAVENOUS SOLUTION 40 MG/14 ML (0 MG/ML) POMALYST ORAL CAPSULE 1 MG, MG, MG, 4 MG PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (10 MG/ML), 1600 MG/1.4 ML (10 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML, 10 MG/ML (10 ML) RUBRACA ORAL TABLET 00 MG, 50 MG, 00 MG 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (1 per 8 days) 5 PA NSO; NM; NDS; QL (100 per 1 days) 5 PA NSO; NM; LA; NDS 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (10 per 0 days) RYDAPT ORAL CAPSULE 5 MG 5 PA NSO; NM; NDS; QL (4 per 8 days) SOLTAMOX ORAL SOLUTION 10 4 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) STIVARGA ORAL TABLET 40 MG 5 PA NSO; NM; NDS; QL (84 per 8 days) SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 7.5 MG, 50 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) SYLVANT INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG 5 PA NSO; NM; NDS; QL (8 per 8 days) TABLOID ORAL TABLET 40 MG 4 9

41 TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) TAGRISSO ORAL TABLET 40 MG, 80 MG 5 PA NSO; NM; LA; NDS; QL (0 per 0 days) tamoxifen oral tablet 10, 0 TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) TARCEVA ORAL TABLET 150 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) TARGRETIN TOPICAL GEL 1 % 5 PA NSO; NM; NDS; QL (60 per 8 days) TASIGNA ORAL CAPSULE 150 MG, 00 MG 5 PA NSO; NM; NDS; QL (11 per 8 days) TECENTRIQ INTRAVENOUS SOLUTION 1,00 MG/0 ML (60 5 PA NSO; NM; NDS; QL (0 per 1 days) MG/ML) TEMODAR INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 100 MG thiotepa injection recon soln 15 (Tepadina) toposar intravenous solution 0 /ml topotecan intravenous recon soln 4 (Hycamtin) topotecan intravenous solution 4 /4 ml (1 /ml) TORISEL INTRAVENOUS RECON SOLN 0 MG/ ML (10 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON SOLN 100 MG, 5 MG TRELSTAR 11.5 MG VIAL INNER, SDV 11.5 MG TRELSTAR.5 MG VIAL INNER,SDV.5 MG TRELSTAR.75 MG VIAL INNER, SDV.75 MG TRELSTAR INTRAMUSCULAR SYRINGE 11.5 MG/ ML TRELSTAR INTRAMUSCULAR SYRINGE.5 MG/ ML TRELSTAR INTRAMUSCULAR SYRINGE.75 MG/ ML 5 PA BvD; NM; NDS; QL (4 per 8 days) ; QL (1 per 84 days) ; QL (1 per 168 days) ; QL (1 per 84 days) ; QL (1 per 168 days) 0

42 tretinoin (chemotherapy) oral capsule 10 TREXALL ORAL TABLET 10 MG, 4 PA BvD; ST 15 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 50 MG UNITUXIN INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VECTIBIX INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 100 MG/5 ML (0 MG/ML), 400 MG/0 ML (0 MG/ML) VELCADE INJECTION RECON 5 PA NSO; NM; NDS SOLN.5 MG VENCLEXTA ORAL TABLET 10 MG PA NSO; LA; QL (60 per 0 days) VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; NM; LA; NDS; QL (10 per 0 days) VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (0 per 0 days) VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG 5 PA NSO; NM; LA; NDS; QL (4 per 8 days) 5 PA NSO; NM; NDS; QL (56 per 8 days) vinblastine intravenous recon soln 10 PA BvD vinblastine intravenous solution 1 /ml PA BvD vincasar pfs intravenous solution 1 PA BvD /ml, / ml vincristine intravenous solution 1 /ml, (Vincasar PFS) PA BvD / ml vinorelbine intravenous solution 10 (Navelbine) /ml, 50 /5 ml VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) VYXEOS INTRAVENOUS RECON 5 PA BvD; NM; NDS SOLN MG XALKORI ORAL CAPSULE 00 MG, 50 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) 1

43 XATMEP ORAL SOLUTION.5 4 PA BvD; ST MG/ML XTANDI ORAL CAPSULE 40 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) YERVOY INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 00 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 1 MG ZALTRAP INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 100 MG/4 ML (5 MG/ML), 00 MG/8 ML (5 MG/ML) ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) ZELBORAF ORAL TABLET 40 MG 5 PA NSO; NM; NDS; QL (40 per 0 days) ZOLADEX SUBCUTANEOUS 4 QL (1 per 84 days) IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS 4 QL (1 per 8 days) IMPLANT.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS; QL (140 per 8 days) ZYTIGA ORAL TABLET 50 MG, 500 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0.1 /ml propantheline oral tablet 15 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 00 MG, 400 MG

44 BRIVIACT INTRAVENOUS 4 QL (80 per 0 days) SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 4 QL (600 per 0 days) MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG ; QL (60 per 0 days) carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr 100, 00, 400 carbamazepine oral tablet,chewable 100 CELONTIN ORAL CAPSULE 00 MG DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, delayed rel sprinkle 15 (Depakote Sprinkles) divalproex oral tablet extended release 4 (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 15, 50, 500 epitol oral tablet 00 ethosuximide oral capsule 50 (Zarontin) ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 400, 600 (Felbatol) fosphenytoin injection solution 100 (Cerebyx) pe/ ml, 500 pe/10 ml FYCOMPA ORAL SUSPENSION MG/ML FYCOMPA ORAL TABLET 10 MG, 4 1 MG, MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100, 00, (Neurontin) 400 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) GABITRIL ORAL TABLET 1 MG, 16 MG

45 GRALISE 0-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 4 HR 00 MG (9)- 600 MG (69) GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 00 MG, 600 MG lamotrigine oral tablet 100, 150, 00, 5 lamotrigine oral tablet disintegrating, dose pk 5 (1) -50 (7) lamotrigine oral tablet disintegrating, dose pk 5 (14)-50 (14)-100 (7) lamotrigine oral tablet disintegrating, dose pk 50 (4) -100 (14) lamotrigine oral tablet extended release 4hr 100, 00, 5, 50, 00, 50 lamotrigine oral tablet, chewable dispersible 5, 5 lamotrigine oral tablet,disintegrating 100, 00, 5, 50 levetiracetam in nacl (iso-os) intravenous piggyback 1,000 /100 ml, 1,500 /100 ml, 500 /100 ml levetiracetam intravenous solution 500 /5 ml (Lamictal) (Lamictal ODT Starter (Blue)) (Lamictal ODT Starter (Orange)) (Lamictal ODT Starter (Green)) (Lamictal XR) (Lamictal) (Lamictal ODT) (Keppra) 4 ST; QL (78 per 0 days) 4 ST; QL (90 per 0 days) levetiracetam oral solution 100 /ml (Keppra) levetiracetam oral tablet 1,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 (Keppra XR) LYRICA ORAL CAPSULE 100 MG, QL (90 per 0 days) 150 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML QL (900 per 0 days) oxcarbazepine oral suspension 00 /5 ml (60 /ml) (Trileptal) 4

46 oxcarbazepine oral tablet 150, 00 (Trileptal), 600 OXTELLAR XR ORAL TABLET 4 EXTENDED RELEASE 4 HR 150 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml (4 /ml) phenobarbital oral tablet GC phenobarbital oral tablet 15, 16., 0,.4, 60, 64.8, 97. phenytoin oral suspension 15 /5 ml (Dilantin-15) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 100 phenytoin sodium extended oral capsule (Phenytek) 00, 00 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml POTIGA ORAL TABLET 00 MG, 00 MG, 400 MG ; QL (90 per 0 days) POTIGA ORAL TABLET 50 MG ; QL (70 per 0 days) primidone oral tablet 50, 50 (Mysoline) ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR 4 ST; QL (60 per 0 days) SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 50 MG, 500 MG, 750 MG 4 ST; QL (10 per 0 days) tiagabine oral tablet, 4 (Gabitril) topiramate oral capsule, sprinkle 15, 5 (Topamax) 5

47 topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) 100, 150, 00, 5, 50 topiramate oral tablet 100, 00, (Topamax) 50 topiramate oral tablet 5 (Topamax) 1 GC TROKENDI XR ORAL 4 QL (0 per 0 days) CAPSULE,EXTENDED RELEASE 4HR 100 MG, 5 MG, 50 MG TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE ; QL (60 per 0 days) 4HR 00 MG valproate sodium intravenous solution (Depacon) 500 /5 ml (100 /ml) valproic acid (as sodium salt) oral (Depakene) solution 50 /5 ml valproic acid oral capsule 50 (Depakene) vigabatrin oral powder in packet 500 (Sabril) VIMPAT INTRAVENOUS QL (00 per 5 days) SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 10 QL (100 per 0 days) MG/ML VIMPAT ORAL TABLET 100 MG, QL (60 per 0 days) 150 MG, 00 MG, 50 MG zonisamide oral capsule 100, 5 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 10,, 5 (Aricept) QL (0 per 0 days) donepezil oral tablet,disintegrating 10 QL (0 per 0 days), 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (0 per 0 days) 4 hr 16, 4, 8 galantamine oral solution 4 /ml QL (00 per 0 days) galantamine oral tablet 1, 4, 8 (Razadyne) QL (60 per 0 days) memantine oral capsule,sprinkle,er 4hr (Namenda XR) QL (0 per 0 days) 14, 1, 8, 7 memantine oral solution /ml QL (60 per 0 days) memantine oral tablet 10, 5 (Namenda) QL (60 per 0 days) 6

48 memantine oral tablets,dose pack 5-10 NAMENDA XR ORAL CAP,SPRINKLE,ER 4HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 4HR 14 MG, 1 MG, 8 MG, 7 MG NAMZARIC ORAL CAP,SPRINKLE,ER 4HR DOSE PACK 7/14/1/8 MG-10 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 4HR MG, 1-10 MG, 8-10 MG, 7-10 MG rivastigmine tartrate oral capsule 1.5,, 4.5, 6 rivastigmine transdermal patch 4 hour 1. /4 hour, 4.6 /4 hr, 9.5 /4 hr Antidepressants Antidepressants amitriptyline oral tablet 10, 100, 150, 5, 50, 75 amitriptyline-chlordiazepoxide oral tablet 1.5-5, 5-10 amoxapine oral tablet 100, 150, 5, 50 (Namenda Titration Pak) QL (49 per 8 days) QL (8 per 8 days) QL (0 per 0 days) QL (56 per 65 days) QL (0 per 0 days) QL (60 per 0 days) (Exelon) QL (0 per 0 days) bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release (Wellbutrin SR) 1 hr 100, 150, 00 bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr 150, 00 citalopram oral solution 10 /5 ml QL (600 per 0 days) citalopram oral tablet 10, 0, 40 (Celexa) 1 GC; QL (0 per 0 days) clomipramine oral capsule 5, 50, (Anafranil) 75 desipramine oral tablet 10, 5 (Norpramin) desipramine oral tablet 100, 150, 50, 75 7

49 desvenlafaxine succinate oral tablet (Pristiq) QL (0 per 0 days) extended release 4 hr 100, 5, 50 doxepin oral capsule 10, 100, 150, 5, 50, 75 doxepin oral concentrate 10 /ml duloxetine oral capsule,delayed (Cymbalta) QL (60 per 0 days) release(dr/ec) 0, 60 duloxetine oral capsule,delayed (Cymbalta) QL (0 per 0 days) release(dr/ec) 0 duloxetine oral capsule,delayed release(dr/ec) 40 QL (0 per 0 days) EMSAM TRANSDERMAL PATCH 4 HOUR 1 MG/4 HR, 6 MG/4 HR, 9 MG/4 HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 0, 5 FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK 0 MG ()- 40 MG (6) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 10 MG, 0 MG, 40 MG, 80 MG fluoxetine oral capsule 10, 0, 40 fluoxetine oral capsule,delayed release(dr/ec) 90 fluoxetine oral solution 0 /5 ml (4 /ml) (Lexapro) 1 GC (Prozac) 1 GC fluoxetine oral tablet 10, 0 (Sarafem) FLUOXETINE ORAL TABLET 60 4 MG fluvoxamine oral capsule,extended release 4hr 100, 150 fluvoxamine oral tablet 100, 5, 50 imipramine hcl oral tablet 10, 5, 50 (Tofranil) ; QL (0 per 0 days) 4 ST; QL (56 per 65 days) 4 ST; QL (0 per 0 days) QL (4 per 8 days) 8

50 imipramine pamoate oral capsule 100, 15, 150, 75 maprotiline oral tablet 5, 50, 75 MARPLAN ORAL TABLET 10 MG 4 mirtazapine oral tablet 15 (Remeron) 1 GC mirtazapine oral tablet 0, 45 (Remeron) mirtazapine oral tablet 7.5 mirtazapine oral tablet,disintegrating 15 (Remeron SolTab), 0, 45 nefazodone oral tablet 100, 150, 00, 50, 50 nortriptyline oral capsule 10, 5, (Pamelor) 1 GC 50, 75 nortriptyline oral solution 10 /5 ml paroxetine hcl oral tablet 10, 0, (Paxil) 1 GC 0, 40 paroxetine hcl oral tablet extended (Paxil CR) release 4 hr 1.5, 5, 7.5 PAXIL ORAL SUSPENSION 10 4 MG/5 ML perphenazine-amitriptyline oral tablet - 10, -5, 4-10, 4-5, 4-50 phenelzine oral tablet 15 (Nardil) protriptyline oral tablet 10, 5 sertraline oral concentrate 0 /ml (Zoloft) sertraline oral tablet 100, 5, 50 (Zoloft) 1 GC SURMONTIL ORAL CAPSULE MG, 5 MG, 50 MG tranylcypromine oral tablet 10 (Parnate) trazodone oral tablet 100, 50 1 GC trazodone oral tablet 150, 00 trimipramine oral capsule 100, 5, (Surmontil) 50 TRINTELLIX ORAL TABLET 10 ST; QL (0 per 0 days) MG, 0 MG, 5 MG venlafaxine oral capsule,extended release 4hr 150 (Effexor XR) QL (0 per 0 days) 9

51 venlafaxine oral capsule,extended release 4hr 7.5, 75 venlafaxine oral tablet 100, 5, 7.5, 50, 75 venlafaxine oral tablet extended release 4hr 150, 7.5, 75 venlafaxine oral tablet extended release 4hr 5 VIIBRYD ORAL TABLET 10 MG, 0 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG () Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100, 5, 50 (Effexor XR) QL (90 per 0 days) 4 ST; QL (0 per 0 days) ST; QL (0 per 180 days) (Precose) QL (90 per 0 days) CYCLOSET ORAL TABLET 0.8 MG 4 QL (180 per 0 days) GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT 4 (HUMAN) INJECTION KIT 1 MG GLYXAMBI ORAL TABLET 10-5 ST; QL (0 per 0 days) MG, 5-5 MG INVOKAMET ORAL TABLET 150- ST; QL (60 per 0 days) 1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG ST; QL (10 per 0 days) INVOKAMET XR ORAL TABLET, ST; QL (60 per 0 days) IR - ER, BIPHASIC 4HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 ST; QL (60 per 0 days) MG INVOKANA ORAL TABLET 00 ST; QL (0 per 0 days) MG JANUMET ORAL TABLET 50-1,000 QL (60 per 0 days) MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 100-1,000 MG QL (0 per 0 days) 40

52 JANUMET XR ORAL TABLET, ER QL (60 per 0 days) MULTIPHASE 4 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, QL (0 per 0 days) 5 MG, 50 MG JARDIANCE ORAL TABLET 10 ST; QL (0 per 0 days) MG, 5 MG JENTADUETO ORAL TABLET.5- QL (60 per 0 days) 1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, QL (60 per 0 days) IR - ER, BIPHASIC 4HR.5-1,000 MG JENTADUETO XR ORAL TABLET, QL (0 per 0 days) IR - ER, BIPHASIC 4HR 5-1,000 MG KAZANO ORAL TABLET 1.5-1,000 4 QL (60 per 0 days) MG, MG KORLYM ORAL TABLET 00 MG 5 PA; NM; NDS; QL (11 per 8 days) metformin oral tablet 1,000 (Glucophage) 6 GC; QL (75 per 0 days) metformin oral tablet 500 (Glucophage) 6 GC; QL (150 per 0 days) metformin oral tablet 850 (Glucophage) 6 GC; QL (90 per 0 days) metformin oral tablet extended release 4 hr 500 (Glucophage XR) 6 GC; QL (10 per 0 days) metformin oral tablet extended release 4 hr 750 (Glucophage XR) 6 GC; QL (90 per 0 days) miglitol oral tablet 100, 5, 50 (Glyset) QL (90 per 0 days) nateglinide oral tablet 10, 60 (Starlix) QL (90 per 0 days) NESINA ORAL TABLET 1.5 MG, 5 4 QL (0 per 0 days) MG, 6.5 MG OSENI ORAL TABLET MG, 4 QL (0 per 0 days) MG, MG, 5-15 MG, 5-0 MG, 5-45 MG pioglitazone oral tablet 15, 0, 45 (Actos) QL (0 per 0 days) pioglitazone-glimepiride oral tablet 0- (DUETACT) QL (0 per 0 days), 0-4 pioglitazone-metformin oral tablet , (Actoplus MET) QL (90 per 0 days) 41

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