Superior Select Health Plans Formulary. (List of Covered Drugs)

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1 Superior Select Health Plans 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 18379, Version Number 14 This formulary was updated on 09/01/2018. For more recent information or other questions, please contact Member Services, at or, for TTY users, 711, 7 days a week, 8:00 a.m. to 8:00 p.m., or visit H1587_D_003_COMFORM18_0917 ACCEPTED I

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 Arkansas Superior Select, Inc. When it refers to plan or our plan, it means. This document includes a list of the drugs (formulary) for our plan which is current as of 09/01/2018. 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, 2018, and from time to time during the year. H1587_D_003_COMFORM18_0917 ACCEPTED II

3 What is the Superior Select Health Plans Formulary? A formulary is a list of covered drugs selected by Select 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. Select will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Select 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 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 09/01/2018. To get updated information about the drugs covered by Select, please contact us. Our contact information appears on the front and back cover pages. Select will send you a notice in the event of a mid-year non-maintenance formulary change. The notice will generally be sent 60 days prior to the change. Any formulary updates are listed at along with the most current formulary. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 2. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, cardiovascular agents. If you know what your drug is used for, look for the category name in the list that begins 2. 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 108. 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 H1587_D_003_COMFORM18_0917 ACCEPTED III

4 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? Select 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: Select requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Select before you fill your prescriptions. If you don t get approval, Select may not cover the drug. Quantity Limits: For certain drugs, Select limits the amount of the drug that Select will cover. For example, Select provides 30 tablets per prescription for ROZEREM. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Select requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Select may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Select will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 2. 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 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 Select 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 Select formulary? on page V for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Select does not cover your drug, you have two options: H1587_D_003_COMFORM18_0917 ACCEPTED IV

5 You can ask Member Services for a list of similar drugs that are covered by Select. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Select. You can ask Select to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Superior Select Health Plan s Formulary? You can ask Select to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Select 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, Select will only approve your request for an exception if the alternative drugs included on the plan s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30 day supply (unless you have a prescription written for fewer days) when you go to a H1587_D_003_COMFORM18_0917 ACCEPTED V

6 network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. For members who are outside their transition period, and experience a change in the level of care when changing from one treatment setting to another (example: long-term care facility to hospital, hospital to longterm care facility, hospital to home, home to long-term care facility, hospice to long-term care facility, hospice to home): We will allow an early refill for a 30-day supply of medication in the retail setting and up to a 31-day supply in the long-term care setting for formulary medications and an emergency transition fill for non-formulary medications (including those medications that are on formulary but require prior authorization, step therapy, or are subject to quantity limit restrictions). For more information For more detailed information about your Select prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Select, 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 ( ) 24 hours a day/7 days a week. TTY users should call Or, visit H1587_D_003_COMFORM18_0917 ACCEPTED VI

7 Select s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Select. If you have trouble finding your drug in the list, turn to the Index that begins on page 108. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ROZEREM) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Requirements/Limits column tells you if Select has any special requirements for coverage of your drug. Your share of the cost when you get a one-month supply of a covered Part D prescription drug: Standard retail cost-sharing (in-network) (up to a 30-day supply) Mail-order costsharing (up to a 30-day supply) Long-term care (LTC) costsharing (up to a 31-day supply) Out-of-network costsharing (Coverage is limited to certain situations; see Chapter 5 for details.) (up to a 30-day supply) Cost-Sharing (Preferred Generic) Cost-Sharing (Generic) Cost-Sharing (Preferred Brand) Cost-Sharing (Non-Preferred Drug) Cost-Sharing (Specialty Tier) $2.00 $2.00 $2.00 $2.00 $8.00 $8.00 $8.00 $8.00 $47.00 $47.00 $47.00 $47.00 $ $ $ $ % 33% 33% 33% If you qualified for extra help with your drug costs, your costs may be different from those described above. You can find complete cost-sharing information in your Evidence of Coverage H1587_D_003_COMFORM18_0917 ACCEPTED VII

8 LEGEND : Preferred Generic : Generic : Preferred Brand : Non-Preferred Drug : Specialty BvD: Part B vs. Part D-This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. HRM: High Risk Medication (PA required for ages 65 or over) LA: Limited Access-This prescription drug is limited to certain pharmacies. : Mail Order Eligible-This prescription may also be available via mail. NEDS: This medication is not eligible to be filled for more than a 30 day supply. PA1: Prior Authorization-You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. PA2: Prior Authorization (New Starts Only)-You (or your physician) are required to get prior authorization before you fill your prescription for this drug unless you are a previous user of the drug. If you have a history of using this medication, you will not need prior authorization. QL: Quantity Limit-There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. ST1: Step Therapy-In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. ST2: Step Therapy (New Starts Only)-In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition unless you are a previous user of the drug. If you have a history of using this medication, you will not need to try other medications first. 1

9 Superior Select Health Plan: Select: 5 Tier (List of Covered Drugs) DRUG NAME DRUG TIER REQUIREMENTS/LIMITS ANALGESICS OPIOID ANALGESICS, LONG-ACTING fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 12, 8 hydromorphone hcl er oral tablet er 24 hour abuse-deterrent 16, 32 HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG morphine sulfate er beads oral capsule extended release 24 hour 120, 30, 45, 60, 75, 90 morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, 50, 60, 80 morphine sulfate er oral tablet extended release 100 morphine sulfate er oral tablet extended release 15, 30 morphine sulfate er oral tablet extended release 60 OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG OPIOID ANALGESICS, SHORT-ACTING ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG 2 acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet acetaminophen-codeine #4 oral tablet PA1;

10 acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet , buprenorphine hcl injection solution 0.3 /ml, 0.3 /ml (cartridge) buprenorphine hcl sublingual tablet sublingual 2 buprenorphine hcl sublingual tablet sublingual 8 butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR 3 PA1; ; QL (240 EA per 30 days) PA1; ; QL (90 EA per 30 days) ; QL (180 EA per 30 days) ; QL (180 EA per 30 days) codeine sulfate oral tablet 15, 30, 60 duramorph injection solution 0.5 /ml, 1 /ml ENDOCET ORAL TABLET MG, MG, MG hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral tablet , , , 5-300, hydrocodone-acetaminophen oral tablet 5-325, hydrocodone-ibuprofen oral tablet 5-200, hydromorphone hcl injection solution 2 /ml hydromorphone hcl oral liquid 1 /ml hydromorphone hcl oral tablet 2, 4, 8 hydromorphone hcl pf injection solution 2 /ml LORCET HD ORAL TABLET MG LORCET ORAL TABLET MG LORCET PLUS ORAL TABLET MG

11 meperidine hcl injection solution 100 /ml, 25 /ml methadone hcl injection solution 10 /ml methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10, 5 morphine sulfate (concentrate) oral solution 100 /5ml PA1; ; HRM morphine sulfate injection solution 5 /ml morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 nalbuphine hcl injection solution 10 /ml nalbuphine hcl injection solution 20 /ml oxycodone hcl oral capsule 5 oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 15, 20, 5 oxycodone hcl oral tablet 30 oxycodone-acetaminophen oral tablet , , 5-325, oxycodone-aspirin oral tablet oxycodone-ibuprofen oral tablet oxymorphone hcl oral tablet 10, 5 pentazocine-naloxone hcl oral tablet PA1; ; HRM tramadol hcl oral tablet 50 ; QL (240 EA per 30 days) tramadol-acetaminophen oral tablet ; QL (240 EA per 30 days) VICODIN ES ORAL TABLET MG VICODIN HP ORAL TABLET MG VICODIN ORAL TABLET MG ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (pf) injection solution 0.5 %, 1 %, 2 % 4

12 lidocaine hcl external gel 2 % PA2; lidocaine hcl injection solution 1 %, 2 % lidocaine-prilocaine external cream % PA2; ; QL (30 GM per 30 days) ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI-CRAVING acamprosate calcium oral tablet delayed release disulfiram oral tablet 250, 500 OPIOID ANTAGONISTS butorphanol tartrate injection solution 1 /ml, 2 /ml butorphanol tartrate nasal solution 10 /ml ; QL (10 ML per 30 days) naloxone hcl injection solution 0.4 /ml naloxone hcl injection solution cartridge 0.4 /ml naloxone hcl injection solution prefilled syringe 2 /2ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML ; QL (2 EA per 30 days) SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG ; QL (90 EA per 30 days) SUBOXONE SUBLINGUAL FILM 8-2 MG ; QL (120 EA per 30 days) VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG SKING CESSATION AGENTS bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 CHANTIX CONTINUING NTH PAK ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING NTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 NICOTROL INHALATION INHALER 10 MG ANTIBACTERIALS

13 AMINOGLYCOSIDES amikacin sulfate injection solution 500 /2ml BvD; gentamicin in saline intravenous solution /ml-%, /ml-%, /ml-%, /ml-% 6 gentamicin sulfate injection solution 40 /ml neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 streptomycin sulfate intramuscular solution reconstituted 1 gm TOBI PODHALER INHALATION CAPSULE 28 MG tobramycin inhalation nebulization solution 300 /5ml tobramycin sulfate injection solution 10 /ml tobramycin sulfate injection solution 80 /2ml ANTIBACTERIALS, OTHER chloramphenicol sod succinate intravenous solution reconstituted 1 gm clindamycin hcl oral capsule 150, 300 clindamycin hcl oral capsule 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate in d5w intravenous solution 300 /50ml, 600 /50ml, 900 /50ml clindamycin phosphate injection solution 300 /2ml, 900 /6ml clindamycin phosphate injection solution 600 /4ml colistimethate sodium (cba) injection solution reconstituted 150 colistimethate sodium injection solution reconstituted 150 PA1; ; QL (224 EA per 56 days) PA1; BvD; BvD; dapsone oral tablet 100, 25 daptomycin intravenous solution reconstituted 500 BvD;

14 lincomycin hcl injection solution 300 /ml linezolid intravenous solution 600 /300ml PA1; linezolid oral tablet 600 PA1; methenamine hippurate oral tablet 1 gm metronidazole in nacl intravenous solution /100ml-% metronidazole oral capsule 375 metronidazole oral tablet 250, 500 BvD; NUROL ORAL PACKET 3 GM ; QL (2 EA per 30 days) NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG nitrofurantoin macrocrystal oral capsule 100, 25, 50 nitrofurantoin monohyd macro oral capsule 100 PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG tigecycline intravenous solution reconstituted 50 BvD; 7 tinidazole oral tablet 250, 500 trimethoprim oral tablet 100 vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, /150ml-% vancomycin hcl in nacl intravenous solution gm/200ml-%, /100ml-%, /150ml-%, /250ml-% vancomycin hcl intravenous solution reconstituted 10 gm, 1000, 500, 5000, 750 vancomycin hcl oral capsule 125 vancomycin hcl oral capsule 250 XIFAXAN ORAL TABLET 200 MG, 550 MG BETA-LACTAM, CEPHALOSPORINS cefaclor oral capsule 250, 500 BvD; BvD; BvD; BvD; BvD;

15 cefadroxil oral capsule 500 cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefepime hcl injection solution reconstituted 1 gm, 2 gm cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml BvD; cefpodoxime proxetil oral tablet 100, 200 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250, 500 ceftriaxone sodium intravenous solution reconstituted 1 gm, 10 gm, 2 gm cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 cefuroxime sodium intravenous solution reconstituted 1.5 gm BvD; BvD; cephalexin oral capsule 250, 500 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml cephalexin oral tablet 250 SUPRAX ORAL CAPSULE 400 MG 8

16 TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM BETA-LACTAM, OTHER AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION 1 GM, 2 GM AZACTAM INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM aztreonam injection solution reconstituted 1 gm CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG doripenem intravenous solution reconstituted 500 imipenem-cilastatin intravenous solution reconstituted 250, 500 INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM meropenem intravenous solution reconstituted 1 gm, 500 BETA-LACTAM, PENICILLINS BvD; BvD; BvD; BvD; PA1; BvD; BvD; 9 amoxicillin oral capsule 250, 500 amoxicillin oral suspension reconstituted 125 /5ml, 200 /5ml, 250 /5ml, 400 /5ml BvD; amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 125, 250 amoxicillin-pot clavulanate oral suspension reconstituted /5ml, /5ml, /5ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet chewable , ampicillin oral capsule 500 ampicillin sodium injection solution reconstituted 1 gm

17 ampicillin sodium injection solution reconstituted 125 ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 3 (2-1) gm ampicillin-sulbactam sodium injection solution reconstituted 15 (10-5) gm ampicillin-sulbactam sodium intravenous solution reconstituted 15 (10-5) gm BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML BvD; BvD; dicloxacillin sodium oral capsule 250, 500 nafcillin sodium injection solution reconstituted 1 gm, 10 gm nafcillin sodium intravenous solution reconstituted 10 gm oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm penicillin g potassium injection solution reconstituted unit, unit penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 125 /5ml, 250 /5ml penicillin v potassium oral tablet 250, 500 piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, ( ) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm MACROLIDES azithromycin intravenous solution reconstituted 500 azithromycin oral packet 1 gm BvD; BvD; 10

18 azithromycin oral suspension reconstituted 100 /5ml azithromycin oral suspension reconstituted 200 /5ml azithromycin oral tablet 250, 250 (6 pack), 500, 500 (3 pack) 11 azithromycin oral tablet 600 clarithromycin er oral tablet extended release 24 hour 500 clarithromycin oral tablet 250, 500 DIFICID ORAL TABLET 200 MG ST1; ERY-TAB ORAL TABLET DELAYED RELEASE 500 MG ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG erythromycin base oral capsule delayed release particles 250 BvD; erythromycin base oral tablet 250 QUINOLONES ciprofloxacin hcl oral tablet 100 ciprofloxacin hcl oral tablet 250, 500, 750 ciprofloxacin in d5w intravenous solution 200 /100ml ciprofloxacin oral suspension reconstituted 250 /5ml (5%), 500 /5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000, 500 levofloxacin in d5w intravenous solution 500 /100ml, 750 /150ml BvD; BvD; levofloxacin intravenous solution 25 /ml BvD; levofloxacin oral solution 25 /ml levofloxacin oral tablet 250, 500, 750

19 moxifloxacin hcl in nacl intravenous solution 400 /250ml moxifloxacin hcl intravenous solution 400 /250ml moxifloxacin hcl oral tablet 400 ofloxacin oral tablet 300, 400 SULFONAMIDES sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5ml sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet , SULFATRIM PEDIATRIC ORAL SUSPENSION MG/5ML TETRACYCLINES DOXY 100 INTRAVENOUS SOLUTION RECONSTITUTED 100 MG BvD; BvD; BvD; 12 doxycycline hyclate oral capsule 100 doxycycline hyclate oral capsule 50 doxycycline hyclate oral tablet 100 doxycycline hyclate oral tablet 20 doxycycline monohydrate oral capsule 100 doxycycline monohydrate oral capsule 50 doxycycline monohydrate oral tablet 100, 50 BvD; minocycline hcl oral capsule 100 minocycline hcl oral capsule 50, 75 minocycline hcl oral tablet 100, 50, 75 ANTICONVULSANTS ANTICONVULSANTS, OTHER BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML PA2;

20 BRIVIACT ORAL SOLUTION 10 MG/ML PA2; BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG levetiracetam er oral tablet extended release 24 hour 500, 750 levetiracetam in nacl intravenous solution 1000 /100ml, 1500 /100ml, 500 /100ml PA2; 13 BvD; levetiracetam intravenous solution 500 /5ml BvD; levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000 levetiracetam oral tablet 250, 500, 750 ROWEEPRA ORAL TABLET 1000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 250 MG, 500 MG, 750 MG BARBITURATES phenobarbital oral tablet 100, 15, 16.2, 30, 32.4, 60, 64.8, 97.2 ; QL (90 EA per 30 days) ; QL (120 EA per 30 days) primidone oral tablet 250, 50 BENZODIAZEPINES clonazepam oral tablet 0.5, 1, 2 clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG diazepam rectal gel 10, 2.5 ONFI ORAL SUSPENSION 2.5 MG/ML ONFI ORAL TABLET 10 MG ONFI ORAL TABLET 20 MG CALCIUM CHANNEL DIFYING AGENTS

21 CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml LYRICA ORAL CAPSULE 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML zonisamide oral capsule 100, 25, 50 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250, 500 FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 2 MG, 4 MG, 6 MG, 8 MG FYCOMPA ORAL TABLET 12 MG gabapentin oral capsule 100 gabapentin oral capsule 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 SABRIL ORAL TABLET 500 MG PA2; tiagabine hcl oral tablet 12, 16, 2, 4 valproate sodium intravenous solution 100 /ml BvD; valproate sodium oral solution 250 /5ml valproic acid oral capsule 250 vigabatrin oral packet 500 PA2; VIGADRONE ORAL PACKET 500 MG PA2; GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 /5ml felbamate oral tablet 400,

22 LAMICTAL XR ORAL KIT 25 & 50 & 100 MG, 25 (21)-50 (7) MG, 50 & 100 & 200 MG lamotrigine er oral tablet extended release 24 hour 100, 200, 250, 300, 50 lamotrigine er oral tablet extended release 24 hour 25 lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25 lamotrigine oral tablet chewable 5 lamotrigine oral tablet dispersible 100, 200 lamotrigine oral tablet dispersible 25, 50 lamotrigine starter kit-blue oral kit 25 (35) lamotrigine starter kit-green oral kit 25 (84)- 100(14) lamotrigine starter kit-orange oral kit 25 (42)-100 (7) QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 100 MG, 25 MG, 50 MG QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE 150 MG, 200 MG SUBVENITE ORAL TABLET 100 MG, 150 MG, 200 MG, 25 MG SUBVENITE STARTER KIT-BLUE ORAL KIT 25 (35) MG SUBVENITE STARTER KIT-GREEN ORAL KIT 25 (84)-100(14) MG SUBVENITE STARTER KIT-ORANGE ORAL KIT 25 (42)-100 (7) MG topiramate er oral capsule er 24 hour sprinkle 100, 150, 200, 25, 50 topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG 15

23 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG 16 BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 100, 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 DILANTIN ORAL CAPSULE 30 MG EPITOL ORAL TABLET 200 MG fosphenytoin sodium injection solution 100 pe/2ml, 500 pe/10ml oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 125 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 50 MG VIMPAT ORAL TABLET 150 MG, 200 MG ANTIDEMENTIA AGENTS BvD;

24 CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 10, 5 donepezil hcl oral tablet 23 donepezil hcl oral tablet dispersible 10, 5 galantamine hydrobromide er oral capsule extended release 24 hour 16, 24, 8 17 galantamine hydrobromide oral solution 4 /ml galantamine hydrobromide oral tablet 12, 4, 8 rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 rivastigmine transdermal patch 24 hour 13.3 /24hr, 4.6 /24hr, 9.5 /24hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl er oral capsule extended release 24 hour 14, 21, 28, 7 memantine hcl oral solution 2 /ml memantine hcl oral tablet 10, 5 (28)-10 (21), 5 ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150 bupropion hcl er (sr) oral tablet extended release 12 hour 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 bupropion hcl oral tablet 100, 75 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG maprotiline hcl oral tablet 25, 50, 75 mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 ST2;

25 nefazodone hcl oral tablet 100, 150, 200, 250, trazodone hcl oral tablet 100, 150, 50 trazodone hcl oral tablet 300 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG NOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 10 MG phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 ST2; ST2; ST2; PA2; SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20, 40 desvenlafaxine er oral tablet extended release 24 hour 100, 50 desvenlafaxine succinate er oral tablet extended release 24 hour 100, 25, 50 duloxetine hcl oral capsule delayed release particles 20, 30, 40, 60 escitalopram oxalate oral solution 5 /5ml escitalopram oxalate oral tablet 10, 20, 5 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG fluoxetine hcl oral capsule 10 fluoxetine hcl oral capsule 20, 40 ST2; ST2;

26 fluoxetine hcl oral capsule delayed release 90 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10, 20 fluoxetine hcl oral tablet 60 fluvoxamine maleate er oral capsule extended release 24 hour 100, 150 fluvoxamine maleate oral tablet 100, 25 fluvoxamine maleate oral tablet 50 olanzapine-fluoxetine hcl oral capsule 12-25, 12-50, 3-25, 6-25, 6-50 paroxetine hcl er oral tablet extended release 24 hour 12.5, 25, 37.5 paroxetine hcl oral tablet 10, 20, 40 paroxetine hcl oral tablet 30 PAXIL ORAL SUSPENSION 10 MG/5ML PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100 sertraline hcl oral tablet 25, 50 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl er oral tablet extended release 24 hour 150, 37.5, 75 venlafaxine hcl er oral tablet extended release 24 hour 225 ST2; venlafaxine hcl oral tablet 100, 37.5, 75 venlafaxine hcl oral tablet 25, 50 TRICYCLICS amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 25, 50 amoxapine oral tablet

27 chlordiazepoxide-amitriptyline oral tablet 10-25, clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 25 desipramine hcl oral tablet 100, 150, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 imipramine pamoate oral capsule 100, 125, 150, 75 nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml protriptyline hcl oral tablet 10, 5 trimipramine maleate oral capsule 100, 25, 50 ANTIEMETICS ANTIEMETICS, OTHER meclizine hcl oral tablet 12.5, 25 scopolamine transdermal patch 72 hour 1 /3days EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 125, 40, 80 BvD; ; QL (8 EA per 30 days) aprepitant oral capsule 80 & 125 BvD; ; QL (12 EA per 30 days) dronabinol oral capsule 10 BvD; ; QL (60 EA per 30 days) dronabinol oral capsule 2.5 BvD; ; QL (60 EA per 30 days) dronabinol oral capsule 5 BvD; ; QL (60 EA per 30 days) EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG EMEND ORAL SUSPENSION RECONSTITUTED 125 MG BvD; BvD; 20

28 granisetron hcl intravenous solution 0.1 /ml, 1 /ml, 4 /4ml BvD; granisetron hcl oral tablet 1 BvD; ; QL (60 EA per 30 days) ondansetron hcl injection solution 4 /2ml, 4 /2ml (2ml syringe) BvD; ondansetron hcl oral solution 4 /5ml BvD; ondansetron hcl oral tablet 24 BvD; ; QL (30 EA per 30 days) ondansetron hcl oral tablet 4 BvD; ; QL (120 EA per 30 days) ondansetron hcl oral tablet 8 BvD; ; QL (60 EA per 30 days) ondansetron oral tablet dispersible 4 BvD; ; QL (120 EA per 30 days) ondansetron oral tablet dispersible 8 BvD; ; QL (60 EA per 30 days) VARUBI ORAL TABLET 90 MG BvD; ; QL (8 EA per 30 days) ANTIFUNGALS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 caspofungin acetate intravenous solution reconstituted 50, 70 clotrimazole mouth/throat lozenge 10 ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG fluconazole in sodium chloride intravenous solution /100ml-%, /200ml- % fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 BvD; BvD; BvD; BvD; BvD; BvD; 21 flucytosine oral capsule 250, 500 griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500

29 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 PA1; 22 ketoconazole oral tablet 200 MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG BvD; NOXAFIL ORAL SUSPENSION 40 MG/ML PA1; NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin mouth/throat suspension unit/ml nystatin oral tablet unit ORAVIG BUCCAL TABLET 50 MG terbinafine hcl oral tablet 250 voriconazole intravenous solution reconstituted 200 voriconazole oral suspension reconstituted 40 /ml PA1; BvD; voriconazole oral tablet 200, 50 ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 100 colchicine oral capsule 0.6 colchicine oral tablet 0.6 colchicine-probenecid oral tablet COLCRYS ORAL TABLET 0.6 MG MITIGARE ORAL CAPSULE 0.6 MG probenecid oral tablet 500 ULORIC ORAL TABLET 40 MG, 80 MG ST1; ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS BUPAP ORAL TABLET MG ; QL (180 EA per 30 days) butalbital-acetaminophen oral tablet ; QL (180 EA per 30 days) butalbital-apap-caffeine oral tablet ; QL (180 EA per 30 days)

30 celecoxib oral capsule 100, 200, 400 ST1; ; QL (60 EA per 30 days) celecoxib oral capsule 50 ST1; ; QL (60 EA per 30 days) diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25 diclofenac sodium oral tablet delayed release 50, 75 diclofenac-misoprostol oral tablet delayed release , diflunisal oral tablet 500 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 IBU ORAL TABLET 600 MG, 800 MG ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 indomethacin oral capsule 25 PA1; ; HRM indomethacin oral capsule 50 PA1; ; HRM ketoprofen er oral capsule extended release 24 hour 200 ketoprofen oral capsule 75 ketorolac tromethamine injection solution 15 /ml, 30 /ml ketorolac tromethamine intramuscular solution 60 /2ml PA1; ; HRM PA1; ; HRM ketorolac tromethamine oral tablet 10 PA1; ; HRM meclofenamate sodium oral capsule 100, 50 meloxicam oral tablet 15, 7.5

31 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 275, 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 600 ANTIMIGRAINE AGENTS SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS dihydroergotamine mesylate injection solution 1 /ml dihydroergotamine mesylate nasal solution 4 /ml ; QL (24 ML per 28 days) eletriptan hydrobromide oral tablet 20, 40 ; QL (9 EA per 30 days) ergotamine-caffeine oral tablet ; QL (40 EA per 28 days) naratriptan hcl oral tablet 1, 2.5 ; QL (12 EA per 30 days) sumatriptan succinate oral tablet 100, 25, 50 sumatriptan succinate refill subcutaneous solution cartridge 4 /0.5ml, 6 /0.5ml sumatriptan succinate subcutaneous solution 6 /0.5ml sumatriptan succinate subcutaneous solution autoinjector 4 /0.5ml, 6 /0.5ml ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS ; QL (9 EA per 30 days) guanidine hcl oral tablet 125 pyridostigmine bromide oral tablet 60 ANTIMYCOBACTERIALS ANTITUBERCULARS

32 CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM 25 ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 PASER ORAL PACKET 4 GM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin intravenous solution reconstituted 600 rifampin oral capsule 150, 300 RIFATER ORAL TABLET MG TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS ALKYLATING AGENTS BvD; cyclophosphamide oral capsule 25, 50 BvD; GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG PA2; HEXALEN ORAL CAPSULE 50 MG PA2; LEUKERAN ORAL TABLET 2 MG thiotepa injection solution reconstituted 15 BvD; ANTIANGIOGENIC AGENTS DEPEN TITRATABS ORAL TABLET 250 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG PA2; LA REVLIMID ORAL CAPSULE 2.5 MG, 20 MG PA2; THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG ANTIMETABOLITES ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 500 MG PA2; BvD;

33 azacitidine injection suspension reconstituted 100 decitabine intravenous solution reconstituted 50 fludarabine phosphate intravenous solution reconstituted 50 BvD; BvD; BvD; gemcitabine hcl intravenous solution 1 gm/26.3ml BvD; gemcitabine hcl intravenous solution reconstituted 1 gm mercaptopurine oral tablet 50 methotrexate sodium (pf) injection solution 250 /10ml, 50 /2ml methotrexate sodium injection solution 250 /10ml methotrexate sodium injection solution reconstituted 1 gm PURIXAN ORAL SUSPENSION 2000 MG/100ML BvD; BvD; BvD; BvD; 26 TABLOID ORAL TABLET 40 MG ANTINEOPLASTICS ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML ADRUCIL INTRAVENOUS SOLUTION 500 MG/10ML AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG BvD; LA BvD; PA2; PA2; ALECENSA ORAL CAPSULE 150 MG PA2; ALIQOPA INTRAVENOUS SOLUTION RECONSTITUTED 60 MG ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG PA2; LA PA2; PA2;

34 ARRANON INTRAVENOUS SOLUTION 5 MG/ML AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML, 400 MG/16ML BAVENCIO INTRAVENOUS SOLUTION 200 MG/10ML BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG BvD; PA2; PA2; PA2; bexarotene oral capsule 75 PA2; bicalutamide oral tablet 50 BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG bleomycin sulfate injection solution reconstituted 30 unit bortezomib intravenous solution reconstituted 3.5 BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG BvD; BvD; PA2; PA2; busulfan intravenous solution 6 /ml BvD; CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA2; CALQUENCE ORAL CAPSULE 100 MG PA2; LA CAPRELSA ORAL TABLET 100 MG, 300 MG PA2; carboplatin intravenous solution 150 /15ml, 450 /45ml, 50 /5ml, 600 /60ml cisplatin intravenous solution 100 /100ml, 50 /50ml BvD; BvD; cladribine intravenous solution 10 /10ml BvD; clofarabine intravenous solution 1 /ml BvD; COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG PA2; PA2; PA2; COTELLIC ORAL TABLET 20 MG PA2; LA 27

35 CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML BvD; cytarabine (pf) injection solution 100 /ml BvD; cytarabine injection solution 20 /ml BvD; dacarbazine intravenous solution reconstituted 200 dactinomycin intravenous solution reconstituted 0.5 DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML BvD; BvD; PA2; LA daunorubicin hcl intravenous injectable 5 /ml BvD; dexrazoxane intravenous solution reconstituted 250 docetaxel intravenous concentrate 20 /ml, 80 /4ml docetaxel intravenous solution 160 /16ml, 20 /2ml, 80 /8ml BvD; BvD; BvD; doxorubicin hcl intravenous solution 2 /ml BvD; doxorubicin hcl liposomal intravenous injectable 2 /ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG BvD; 28 EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG, 400 MG PA2; BvD; PA2; epirubicin hcl intravenous solution 200 /100ml BvD; ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML PA2; ERIVEDGE ORAL CAPSULE 150 MG PA2; ERLEADA ORAL TABLET 60 MG PA2; LA ERWINAZE INJECTION SOLUTION RECONSTITUTED UNIT PA2;

36 ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG etoposide intravenous solution 1 gm/50ml, 100 /5ml, 500 /25ml BvD; BvD; FARESTON ORAL TABLET 60 MG PA2; FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG fluorouracil external solution 2 %, 5 % fluorouracil intravenous solution 2.5 gm/50ml, 5 gm/100ml flutamide oral capsule 125 FOLOTYN INTRAVENOUS SOLUTION 40 MG/2ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG, 440 MG hydroxyprogesterone caproate intramuscular solution 1.25 gm/5ml hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PA2; BvD; PA2; PA2; BvD; BvD; PA2; PA2; PA2; PA2; PA2; ICLUSIG ORAL TABLET 15 MG, 45 MG PA2; idarubicin hcl intravenous solution 10 /10ml, 20 /20ml, 5 /5ml BvD; IDHIFA ORAL TABLET 100 MG, 50 MG PA2; LA ifosfamide intravenous solution reconstituted 1 gm BvD; imatinib mesylate oral tablet 100, 400 PA2; 29

37 IMBRUVICA ORAL CAPSULE 140 MG, 70 MG PA2; IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG IMFINZI INTRAVENOUS SOLUTION 120 MG/2.4ML, 500 MG/10ML PA2; PA2; LA INLYTA ORAL TABLET 1 MG, 5 MG PA2; INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT PA2; PA2; IRESSA ORAL TABLET 250 MG PA2; irinotecan hcl intravenous solution 100 /5ml BvD; ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 10 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG JEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 160 MG KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML PA2; PA2; BvD; PA2; PA2; LA BvD; PA2; KISQALI 200 DOSE ORAL TABLET 200 MG PA2; KISQALI 400 DOSE ORAL TABLET 200 MG PA2; KISQALI 600 DOSE ORAL TABLET 200 MG PA2; KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 400 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 600 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG PA2; PA2; PA2; 30

38 KYPROLIS INTRAVENOUS SOLUTION RECONSTITUTED 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 190 MG/19ML, 500 MG/50ML LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 MG LENVIMA 14 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 MG LENVIMA 18 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 (2) MG LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) MG LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) & 4 MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) MG leucovorin calcium injection solution reconstituted 100, 350 leucovorin calcium oral tablet 10, 15, 5 leucovorin calcium oral tablet 25 BvD; PA2; LA PA2; PA2; PA2; PA2; PA2; PA2; BvD; leuprolide acetate injection kit 1 /0.2ml PA2; levoleucovorin calcium intravenous solution 175 /17.5ml levoleucovorin calcium intravenous solution reconstituted 50 LONSURF ORAL TABLET MG, MG LUPRON DEPOT (1-NTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-NTH) INTRAMUSCULAR KIT MG, 22.5 MG LUPRON DEPOT (4-NTH) INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-NTH) INTRAMUSCULAR KIT 45 MG BvD; BvD; PA2; PA2; PA2; PA2; PA2; LYNPARZA ORAL CAPSULE 50 MG PA2; LYNPARZA ORAL TABLET 100 MG, 150 MG PA2; LA 31

39 LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol acetate oral suspension 40 /ml PA2; ; HRM megestrol acetate oral tablet 20, 40 PA2; ; HRM MEKINIST ORAL TABLET 0.5 MG, 2 MG PA2; LA melphalan hcl intravenous solution reconstituted 50 MESNEX ORAL TABLET 400 MG mitomycin intravenous solution reconstituted 20, 5 mitomycin intravenous solution reconstituted 40 mitoxantrone hcl intravenous concentrate 25 /12.5ml MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG BvD; BvD; BvD; BvD; BvD; PA2; LA NERLYNX ORAL TABLET 40 MG PA2; LA NEXAVAR ORAL TABLET 200 MG PA2; LA NILANDRON ORAL TABLET 150 MG NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PA2; ODOMZO ORAL CAPSULE 200 MG PA2; LA OPDIVO INTRAVENOUS SOLUTION 100 MG/10ML, 40 MG/4ML PA2; oxaliplatin intravenous solution 100 /20ml BvD; oxaliplatin intravenous solution reconstituted 100 paclitaxel intravenous concentrate 100 /16.7ml, 30 /5ml, 300 /50ml PERJETA INTRAVENOUS SOLUTION 420 MG/14ML POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG BvD; BvD; PA2; PA2; LA 32

40 PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT RITUXAN INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PA2; BvD; PA2; LA RYDAPT ORAL CAPSULE 25 MG PA2; SOLTAX ORAL SOLUTION 10 MG/5ML PA2; SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG PA2; STIVARGA ORAL TABLET 40 MG PA2; SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG PA2; PA2; PA2; TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA2; LA TAGRISSO ORAL TABLET 40 MG, 80 MG PA2; LA tamoxifen citrate oral tablet 10 tamoxifen citrate oral tablet 20 TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML TICE BCG INTRAVESICAL SUSPENSION RECONSTITUTED 50 MG TOPOSAR INTRAVENOUS SOLUTION 1 GM/50ML topotecan hcl intravenous solution reconstituted 4 TORISEL INTRAVENOUS SOLUTION 25 MG/ML PA2; PA2; PA2; BvD; BvD; BvD; 33

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