List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Transcription

1 Génesis Constellation Health (HMO SNP) Génesis Prime Constellation Health (HMO SNP) Home Constellation Health (HMO SNP) Orion Constellation Health (HMO) 208 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 8463, Version Number 9. This formulary was updated on 03/0/208. For more recent information or other questions, please contact us Constellation Health at (Metro Area), (Toll Free) or, for TTY users, , Monday through Sunday, from 8:00 a.m. to 8:00 p.m., or visit 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 Constellation Health. When it refers to plan or our plan, it means Génesis Constellation Health (HMO SNP) / Génesis Prime (HMO SNP) / Home Constellation Health (HMO SNP)/ Orion Constellation Health (HMO). This document includes list of the drugs (formulary) for our plan which is current as of March, 208. 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, 209 and from time to time during the year. Y0099_208_E33 CMS Accepted Page of 30

2 What is the Génesis Constellation Health (HMO SNP) / Génesis Prime (HMO SNP) / Home Constellation Health (HMO SNP)/ Orion Constellation Health (HMO) Formulary? A formulary is a list of covered drugs selected by Constellation Health 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. Constellation Health will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Constellation Health 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 208 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 208 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 03/0/208. To get updated information about the drugs covered by Constellation Health please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 6. 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, Analgesics. If you know what your drug is used for, look for the category name in the list that begins on page number. Then look under the category name for your drug. Page 2 of 30

3 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 9. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Constellation Health 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: Constellation Health requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Constellation Health before you fill your prescriptions. If you don t get approval, Constellation Health may not cover the drug. Quantity Limits: For certain drugs, Constellation Health limits the amount of the drug that Constellation Health will cover. For example, Constellation Health provides 60 capsules per 30 days for celecoxib oral capsule. This may be in addition to a standard one-month or three-month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 6. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explain our prior authorization restriction. 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 Constellation Health 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 Constellation Health formulary? on page 4 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. For more information, 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 learn that Constellation Health does not cover your drug, you have two options: Page 3 of 30

4 You can ask Member Services for a list of similar drugs that are covered by Constellation Health. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Constellation Health. You can ask Constellation Health 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 Génesis Constellation Health (HMO SNP) / Génesis Prime (HMO SNP) / Home Constellation Health (HMO SNP)/ Orion Constellation Health (HMO)? You can ask Constellation Health to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Constellation Health 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, Constellation Health will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, 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 must be at least 90 days you are a member of our plan. Page 4 of 30

5 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 network pharmacy. After your first the temporary 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 9 and may be up to a 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 3 day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. For more information For more detailed information about your Constellation Health prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Constellation Health 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 Constellation Health Formulary The formulary provides coverage information about some of the drugs covered by Constellation Health. If you have trouble finding your drug in the list, turn to the Index that begins on page 9. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LYRICA ORAL CAPSULE) and generic drugs are listed in lower-case italics (e.g., gabapentin oral capsule). The information in the Requirements/Limits column tells you if Constellation Health has any special requirements for coverage of your drug. Page 5 of 30

6 Génesis Constellation Health (HMO SNP) Génesis Prime Constellation Health (HMO SNP) Home Constellation Health (HMO SNP) Orión Constellation Health (HMO) 208 Formulary List of Covered Drugs Drug (Medicamento) Level (Nivel) Instruction (Instrucción) Analgesics (Analgésicos) Analgesics (Analgésicos) acetaminophen-codeine #2 oral tablet mg QL (360 EA per 30 days); CO acetaminophen-codeine #3 oral tablet mg QL (360 EA per 30 days); CO acetaminophen-codeine #4 oral tablet mg QL (80 EA per 30 days); CO acetaminophen-codeine oral solution 20-2 mg/5ml hydrocodone-acetaminophen oral solution mg/5ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg CO CO QL (80 EA per 30 days); CO hydrocodone-acetaminophen oral tablet mg CO oxycodone-acetaminophen oral tablet mg, mg, mg, mg QL (20 EA per 30 days); CO tramadol-acetaminophen oral tablet mg QL (240 EA per 30 days); CO Nonsteroidal Anti-Inflammatory Drugs (Anti-inflamatorios No Esteroidales) celecoxib oral capsule 00 mg, 200 mg, 400 mg, 50 mg QL (60 EA per 30 days) diclofenac potassium oral tablet 50 mg Page 6 of 30

7 diclofenac sodium er oral tablet extended release 24 hour 00 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg diclofenac sodium transdermal gel 3 % etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg flurbiprofen oral tablet 00 mg, 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg QL (60 EA per 30 days) indomethacin oral capsule 25 mg, 50 mg QL (20 EA per 30 days) ketorolac tromethamine injection solution 5 mg/ml, 30 mg/ml ketorolac tromethamine intramuscular solution 60 mg/2ml meloxicam oral tablet 5 mg, 7.5 mg QL (30 EA per 30 days) nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 25 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg piroxicam oral capsule 0 mg, 20 mg sulindac oral tablet 50 mg, 200 mg Opioid Analgesics, Long-Acting (Analgésicos Opiodes, Larga Duración) duramorph injection solution 0.5 mg/ml, mg/ml Page 7 of 30

8 fentanyl citrate buccal lozenge on a handle 200 mcg, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr morphine sulfate (concentrate) oral solution 00 mg/5ml morphine sulfate er oral tablet extended release 00 mg, 5 mg, 30 mg, 60 mg morphine sulfate er oral tablet extended release 200 mg morphine sulfate oral solution 0 mg/5ml, 20 mg/5ml PA; QL (20 EA per 30 days); CO QL (5 EA per 30 days); CO CO QL (90 EA per 30 days); CO QL (60 EA per 30 days); CO CO morphine sulfate oral tablet 5 mg, 30 mg QL (20 EA per 30 days); CO oxycodone hcl er oral tablet er 2 hour abusedeterrent 0 mg, 5 mg, 20 mg, 30 mg, 40 mg, 60 mg oxycodone hcl er oral tablet er 2 hour abusedeterrent 80 mg QL (90 EA per 30 days); CO QL (60 EA per 30 days); CO Opioid Analgesics, Short-acting (Analgésicos Opiodes, Corta Duración) butorphanol tartrate injection solution mg/ml, 2 mg/ml butorphanol tartrate nasal solution 0 mg/ml 3 CO fentanyl citrate buccal lozenge on a handle 200 mcg, 600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr LAZANDA NASAL SOLUTION 00 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT meperidine hcl injection solution 00 mg/ml, 25 mg/ml, 50 mg/ml morphine sulfate (concentrate) oral solution 00 mg/5ml PA; QL (20 EA per 30 days); CO QL (5 EA per 30 days); CO 3 PA; CO PA^ CO Page 8 of 30

9 morphine sulfate oral solution 0 mg/5ml, 20 mg/5ml CO morphine sulfate oral tablet 5 mg, 30 mg QL (20 EA per 30 days); CO oxycodone hcl oral capsule 5 mg QL (80 EA per 30 days); CO oxycodone hcl oral tablet 5 mg, 30 mg, 5 mg QL (80 EA per 30 days); CO tramadol hcl oral tablet 50 mg QL (240 EA per 30 days); CO Anesthetics (Anestésico) Local Anesthetics (Anestésico Local) lidocaine external ointment 5 % lidocaine external patch 5 % PA; QL (90 EA per 30 days) lidocaine hcl (pf) injection solution 0.5 %, % PA^ lidocaine hcl external gel 2 % lidocaine viscous mouth/throat solution 2 % lidocaine-prilocaine external cream % Anti-Addiction / Substance Abuse Treatment Agents (Agentes Contra la Adicción / Tratamiento de Abuso de Sustancias) Alcohol Deterrents/ Anti-Craving (Disuasivos de Alcohol/Anti-ansiedad) acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 250 mg, 500 mg naltrexone hcl oral tablet 50 mg VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG Opioid Dependence Treatments (Tratamiento Contra la Dependencia a Opioides) buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual mg, 8-2 mg naltrexone hcl oral tablet 50 mg 3 PA PA Page 9 of 30

10 SUBOXONE SUBLINGUAL FILM 2-3 MG, MG, 4- MG, 8-2 MG VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG, MG, MG 3 PA 3 3 PA Opioid Reversal Agents (Agentes para la Reversión del Efecto Opioide) naloxone hcl injection solution 0.4 mg/ml naloxone hcl injection solution prefilled syringe 2 mg/2ml Smoking Cessation Agents (Agentes para Cesación de Fumar) bupropion hcl er (smoking det) oral tablet extended release 2 hour 50 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET MG 2 MO/90 CHANTIX ORAL TABLET 0.5 MG, MG 2 MO/90 CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X & MG X 42 2 EX-BFF; MO/90 NICOTROL INHALATION INHALER 0 MG 3 MO/90 NICOTROL NS NASAL SOLUTION 0 MG/ML 3 MO/90 Antibacterials (Antibacterianos) Aminoglycosides (Aminoglicósidos) gentak ophthalmic ointment 0.3 % gentamicin sulfate external cream 0. % gentamicin sulfate external ointment 0. % gentamicin sulfate injection solution 40 mg/ml PA^ gentamicin sulfate intravenous solution 0 mg/ml PA^ gentamicin sulfate ophthalmic solution 0.3 % neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg Page 0 of 30

11 streptomycin sulfate intramuscular solution reconstituted gm TOBI PODHALER INHALATION CAPSULE 28 MG tobramycin inhalation nebulization solution 300 mg/5ml tobramycin ophthalmic solution 0.3 % tobramycin sulfate injection solution 0 mg/ml, 80 mg/2ml Antibacterials (Antibacterianos) colistimethate sodium injection solution reconstituted 50 mg SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG Antibacterials, Other (Antibacterianos, Otros) 3 PA^ 4 PA 4 PA^ PA^ PA^ 3 PA^ acetic acid otic solution 2 % bacitracin ophthalmic ointment 500 unit/gm 3 MO/90 chloramphenicol sod succinate intravenous solution reconstituted gm CLEOCIN VAGINAL SUPPOSITORY 00 MG 3 clindamycin hcl oral capsule 50 mg, 300 mg, 75 mg 3 PA^ M clindamycin phosphate external solution % clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml clindamycin phosphate vaginal cream 2 % daptomycin intravenous solution reconstituted 500 mg PA^; MO/90 PA^ global alcohol prep ease pad 70 % 3 MO/90 linezolid intravenous solution 600 mg/300ml 4 PA# linezolid oral suspension reconstituted 00 mg/5ml 4 PA# linezolid oral tablet 600 mg 4 PA# Page of 30

12 MACRODANTIN ORAL CAPSULE 50 MG 3 methenamine hippurate oral tablet gm metronidazole external cream 0.75 % metronidazole external gel 0.75 % metronidazole external lotion 0.75 % metronidazole in nacl intravenous solution mg/00ml-% metronidazole oral tablet 250 mg, 500 mg PA^ metronidazole vaginal gel 0.75 % mupirocin external ointment 2 % nitrofurantoin macrocrystal oral capsule 00 mg, 25 mg, 50 mg nitrofurantoin monohyd macro oral capsule 00 mg SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG 3 PA# SIVEXTRO ORAL TABLET 200 MG 3 PA# trimethoprim oral tablet 00 mg TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG vancomycin hcl intravenous solution reconstituted 000 mg, 500 mg vancomycin hcl oral capsule 25 mg, 250 mg XIFAXAN ORAL TABLET 200 MG, 550 MG 3 3 PA^ PA^ Beta-Lactam, Cephalosporins (Cefalosporinas, Beta-lactámicas) cefaclor er oral tablet extended release 2 hour 500 mg cefaclor oral capsule 250 mg, 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml 3 Page 2 of 30

13 cefadroxil oral tablet gm cefazolin sodium injection solution reconstituted gm, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefepime hcl injection solution reconstituted gm, 2 gm cefixime oral suspension reconstituted 00 mg/5ml, 200 mg/5ml cefoxitin sodium injection solution reconstituted 0 gm cefoxitin sodium intravenous solution reconstituted gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 00 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 00 mg, 200 mg cefprozil oral suspension reconstituted 25 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection solution reconstituted gm, 2 gm CEFTIN ORAL SUSPENSION RECONSTITUTED 250 MG/5ML ceftriaxone sodium injection solution reconstituted 250 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted gm ceftriaxone sodium intravenous solution reconstituted 2 gm cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection solution reconstituted.5 gm, 750 mg PA^ PA^ PA^ PA^ 3 PA^ PA^ PA^ Page 3 of 30

14 cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml SUPRAX ORAL CAPSULE 400 MG 3 MO/90 SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG Beta-Lactam, Other (Beta-lactámicos, Otros) aztreonam injection solution reconstituted gm CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED GM meropenem intravenous solution reconstituted 500 mg, gm Beta-Lactam, Penicillins (Penicilinas, Beta-lactámicas) amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension reconstituted 25 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 25 mg, 250 mg amoxicillin-pot clavulanate er oral tablet extended release 2 hour mg amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg 3 MO/90 3 PA^ 4 LA 3 PA^ PA^ Page 4 of 30

15 ampicillin oral capsule 500 mg ampicillin sodium injection solution reconstituted gm, 25 mg ampicillin-sulbactam sodium injection solution reconstituted.5 (-0.5) gm, 3 (2-) gm ampicillin-sulbactam sodium intravenous solution reconstituted 5 (0-5) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML dicloxacillin sodium oral capsule 250 mg, 500 mg nafcillin sodium injection solution reconstituted gm penicillin g procaine intramuscular suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 25 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 ( gm)3.375 ( ) gm, 4.5 (4-0.5) gm Macrolides (Macrólidos) PA^ PA^ PA^ PA^ 3 PA^ PA^ AZASITE OPHTHALMIC SOLUTION % 3 MO/90 azithromycin intravenous solution reconstituted 500 mg PA^ Page 5 of 30

16 azithromycin oral suspension reconstituted 00 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin oral suspension reconstituted 25 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg e.e.s. 400 oral tablet 400 mg ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG erythrocin stearate oral tablet 250 mg erythromycin base oral tablet 250 mg, 500 mg 3 erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg 3 3 PA^ erythromycin external gel 2 % erythromycin external solution 2 % erythromycin ophthalmic ointment 5 mg/gm Quinolones (Quinolonas) ciprofloxacin hcl ophthalmic solution 0.3 % ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg ciprofloxacin intravenous solution 400 mg/40ml PA^ ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (0%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 000 mg, 500 mg levofloxacin intravenous solution 25 mg/ml PA^ levofloxacin oral tablet 250 mg, 500 mg, 750 mg Page 6 of 30

17 MOXEZA OPHTHALMIC SOLUTION 0.5 % 3 MO/90 moxifloxacin hcl oral tablet 400 mg ofloxacin ophthalmic solution 0.3 % ofloxacin otic solution 0.3 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % 3 MO/90 Sulfonamides (Sulfonamidas) silver sulfadiazine external cream % sulfacetamide sodium ophthalmic solution 0 % sulfadiazine oral tablet 500 mg 3 sulfamethoxazole-trimethoprim intravenous solution mg/5ml sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg Tetracyclines (Tetraciclinas) demeclocycline hcl oral tablet 50 mg, 300 mg doxy 00 intravenous solution reconstituted 00 mg doxycycline hyclate oral capsule 00 mg, 50 mg doxycycline hyclate oral tablet 00 mg, 20 mg minocycline hcl oral capsule 00 mg, 50 mg, 75 mg Anticonvulsants (Anticonvulsivantes) Anticonvulsants, Other (Anticonvulsivantes, Otros) BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML 3 PA^ PA^ 3 PA^ BRIVIACT ORAL SOLUTION 0 MG/ML 3 MO/90 BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG 3 MO/90 Page 7 of 30

18 DIASTAT ACUDIAL RECTAL GEL 0 MG, 20 MG 3 MO/90 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG 3 MO/90 diazepam intensol oral concentrate 5 mg/ml diazepam oral solution mg/ml diazepam oral tablet 0 mg, 2 mg, 5 mg QL (20 EA per 30 days) levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg levetiracetam intravenous solution 500 mg/5ml PA^ levetiracetam oral solution 00 mg/ml levetiracetam oral tablet 000 mg, 250 mg, 500 mg, 750 mg SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 000 MG, 250 MG, 500 MG, 750 MG 3 MO/90 Calcium Channel Modifying Agents (Agentes Modificadores de Canales de Calcio) CELONTIN ORAL CAPSULE 300 MG 3 MO/90 ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml LYRICA ORAL CAPSULE 00 MG, 50 MG, 200 MG, 25 MG, 50 MG, 75 MG 2 QL (90 EA per 30 days); MO/90 LYRICA ORAL CAPSULE 225 MG, 300 MG 2 QL (60 EA per 30 days); MO/90 LYRICA ORAL SOLUTION 20 MG/ML 2 MO/90 zonisamide oral capsule 00 mg, 25 mg, 50 mg Gamma-Aminobutyric Acid (GABA) Augmenting Agents (Agentes Aumentadores del Ácido Gamma-Aminobutírico) clonazepam oral tablet 0.5 mg, mg, 2 mg clonazepam oral tablet dispersible 0.25 mg, 0.25 mg, 0.5 mg, mg, 2 mg clorazepate dipotassium oral tablet 5 mg, 3.75 mg, 7.5 mg Page 8 of 30

19 DIASTAT ACUDIAL RECTAL GEL 0 MG, 20 MG 3 MO/90 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG 3 MO/90 diazepam intensol oral concentrate 5 mg/ml diazepam oral solution mg/ml diazepam oral tablet 0 mg, 2 mg, 5 mg QL (20 EA per 30 days); MO/90 divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 25 mg divalproex sodium oral tablet delayed release 25 mg, 250 mg, 500 mg gabapentin oral capsule 00 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg, 800 mg QL (20 EA per 30 days); MO/90 GABITRIL ORAL TABLET 2 MG, 6 MG 3 MO/90 lorazepam oral tablet 0.5 mg, mg, 2 mg ONFI ORAL SUSPENSION 2.5 MG/ML 3 MO/90 ONFI ORAL TABLET 0 MG 3 QL (60 EA per 30 days); MO/90 ONFI ORAL TABLET 20 MG 3 QL (20 EA per 30 days); MO/90 phenobarbital oral elixir 20 mg/5ml phenobarbital oral tablet 00 mg, 5 mg, 6.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg primidone oral tablet 250 mg, 50 mg QL (90 EA per 30 days); MO/90 SABRIL ORAL PACKET 500 MG 3 LA; MO/90 SABRIL ORAL TABLET 500 MG 3 LA; MO/90 tiagabine hcl oral tablet 2 mg, 4 mg valproate sodium intravenous solution 00 mg/ml PA^ valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg Page 9 of 30

20 Glutamate Reducing Agents (Agentes Reductores de Glutamato) felbamate oral suspension 600 mg/5ml felbamate oral tablet 400 mg, 600 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML 3 MO/90 FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG lamotrigine er oral tablet extended release 24 hour 00 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 00 mg, 50 mg, 200 mg, 25 mg 3 QL (30 EA per 30 days); MO/90 lamotrigine oral tablet chewable 25 mg, 5 mg topiramate oral capsule sprinkle 5 mg, 25 mg topiramate oral tablet 00 mg, 200 mg, 25 mg, 50 mg TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 00 MG, 200 MG, 25 MG, 50 MG Sodium Channel Agents (Agentes Canales de Sodio) APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG 3 MO/90 3 QL (30 EA per 30 days); MO/90 APTIOM ORAL TABLET 600 MG 3 QL (60 EA per 30 days); MO/90 BANZEL ORAL SUSPENSION 40 MG/ML 3 MO/90 BANZEL ORAL TABLET 200 MG, 400 MG 3 MO/90 carbamazepine er oral tablet extended release 2 hour 00 mg, 200 mg, 400 mg carbamazepine oral suspension 00 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 00 mg DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG 2 MO/90 DILANTIN ORAL CAPSULE 00 MG, 30 MG 2 MO/90 Page 20 of 30

21 DILANTIN ORAL SUSPENSION 25 MG/5ML 2 MO/90 fosphenytoin sodium injection solution 00 mg pe/2ml PA^ oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG, 300 MG, 600 MG 3 MO/90 PEGANONE ORAL TABLET 250 MG 3 MO/90 phenytoin oral suspension 25 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 00 mg phenytoin sodium injection solution 50 mg/ml PA^ VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML 3 PA^ VIMPAT ORAL SOLUTION 0 MG/ML 3 MO/90 VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG Antidementia Agents (Agentes Antidemencia) Antidementia Agents, Other (Agentes Antidemencia, Otros) 3 MO/90 ergoloid mesylates oral tablet mg Cholinesterase Inhibitors (Inhibidores de Colinesterasa) donepezil hcl oral tablet 0 mg, 23 mg, 5 mg QL (30 EA per 30 days); MO/90 donepezil hcl oral tablet dispersible 0 mg, 5 mg QL (30 EA per 30 days); MO/90 galantamine hydrobromide er oral capsule extended release 24 hour 6 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml galantamine hydrobromide oral tablet 2 mg, 4 mg, 8 mg rivastigmine tartrate oral capsule.5 mg, 3 mg, 4.5 mg, 6 mg QL (30 EA per 30 days); MO/90 QL (60 EA per 30 days); MO/90 QL (60 EA per 30 days); MO/90 Page 2 of 30

22 rivastigmine transdermal patch 24 hour 3.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr QL (30 EA per 30 days); EX-BFF; MO/90 N-Methyl-D-Aspartate (NMDA) Receptor Antagonist (Antagonista del Receptor N-metil- D-aspartato (NMDA)) memantine hcl oral solution 2 mg/ml memantine hcl oral tablet 0 mg, 5 mg memantine hcl oral tablet 5 (28)-0 (2) mg NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 4 MG, 2 MG, 28 MG, 7 MG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 4 & 2 &28 MG Antidepressants (Antidepresivos) Antidepressants, Other (Antidepresivos, Otros) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 300 MG (.5ML SYRINGE), 400 MG aripiprazole oral tablet 0 mg, 5 mg, 2 mg, 20 mg, 30 mg, 5 mg 2 QL (30 EA per 30 days); MO/ PA^; MO/90 QL (30 EA per 30 days); MO/90 aripiprazole oral tablet dispersible 0 mg QL (90 EA per 30 days); MO/90 aripiprazole oral tablet dispersible 5 mg QL (60 EA per 30 days); MO/90 aripiprazole oral solution mg/ml bupropion hcl er (sr) oral tablet extended release 2 hour 00 mg, 50 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 50 mg, 300 mg bupropion hcl oral tablet 00 mg, 75 mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 3 MO/90 mirtazapine oral tablet 5 mg, 30 mg, 45 mg, 7.5 mg QL (60 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 Page 22 of 30

23 mirtazapine oral tablet dispersible 5 mg, 30 mg, 45 mg QL (30 EA per 30 days); MO/90 nefazodone hcl oral tablet 00 mg, 250 mg, 50 mg 3 QL (60 EA per 30 days); MO/90 nefazodone hcl oral tablet 50 mg 3 QL (20 EA per 30 days); MO/90 nefazodone hcl oral tablet 200 mg 3 QL (90 EA per 30 days); MO/90 quetiapine fumarate er oral tablet extended release 24 hour 50 mg, 200 mg, 50 mg quetiapine fumarate er oral tablet extended release 24 hour 300 mg, 400 mg quetiapine fumarate oral tablet 00 mg, 200 mg, 25 mg, 50 mg QL (30 EA per 30 days); MO/90 QL (60 EA per 30 days); MO/90 QL (90 EA per 30 days); MO/90 quetiapine fumarate oral tablet 300 mg, 400 mg QL (60 EA per 30 days); MO/90 trazodone hcl oral tablet 00 mg, 50 mg, 300 mg, 50 mg Monoamine Oxidase Inhibitors (Inhibidores de Monoamina Oxidasa) EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 0 MG 3 MO/90 phenelzine sulfate oral tablet 5 mg tranylcypromine sulfate oral tablet 0 mg 3 QL (30 EA per 30 days); MO/90 SSRIs/ SNRIs (Selective Serotonin Reuptake Inhibitors / Serotonin and Norepinephrine Reuptake Inhibitors) (SSRIs/SNRIs (Inhibidores de la Recaptación Selectiva de Serotonina / Inhibidores de la Recaptación de Serotonina y Norepinefrina)) citalopram hydrobromide oral solution 0 mg/5ml citalopram hydrobromide oral tablet 0 mg, 20 mg, 40 mg desvenlafaxine succinate er oral tablet extended release 24 hour 00 mg, 25 mg, 50 mg duloxetine hcl oral capsule delayed release particles 20 mg duloxetine hcl oral capsule delayed release particles 30 mg, 60 mg QL (30 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 QL (90 EA per 30 days); MO/90 QL (60 EA per 30 days); MO/90 Page 23 of 30

24 escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 0 mg, 20 mg, 5 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG QL (30 EA per 30 days); MO/90 3 QL (30 EA per 30 days); MO/90 3 MO/90 fluoxetine hcl oral capsule 0 mg, 20 mg, 40 mg QL (60 EA per 30 days); MO/90 fluoxetine hcl oral solution 20 mg/5ml fluvoxamine maleate oral tablet 00 mg, 25 mg, 50 mg paroxetine hcl er oral tablet extended release 24 hour 2.5 mg, 25 mg paroxetine hcl er oral tablet extended release 24 hour 37.5 mg QL (90 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 QL (60 EA per 30 days); MO/90 paroxetine hcl oral tablet 0 mg, 20 mg, 40 mg QL (30 EA per 30 days); MO/90 paroxetine hcl oral tablet 30 mg QL (60 EA per 30 days); MO/90 PAXIL ORAL SUSPENSION 0 MG/5ML 3 MO/90 sertraline hcl oral concentrate 20 mg/ml sertraline hcl oral tablet 00 mg QL (60 EA per 30 days); MO/90 sertraline hcl oral tablet 25 mg, 50 mg QL (30 EA per 30 days); MO/90 TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG venlafaxine hcl er oral capsule extended release 24 hour 50 mg, 37.5 mg venlafaxine hcl er oral capsule extended release 24 hour 75 mg venlafaxine hcl oral tablet 00 mg, 25 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG 3 QL (30 EA per 30 days); MO/90 QL (30 EA per 30 days); MO/90 QL (90 EA per 30 days); MO/90 3 QL (30 EA per 30 days); MO/90 Page 24 of 30

25 Tricyclics (Tricíclicos) amitriptyline hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg desipramine hcl oral tablet 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 0 mg, 00 mg, 50 mg, 25 mg, 50 mg, 75 mg 3 MO/90 doxepin hcl oral concentrate 0 mg/ml imipramine hcl oral tablet 0 mg, 25 mg, 50 mg nortriptyline hcl oral capsule 0 mg, 25 mg, 50 mg, 75 mg nortriptyline hcl oral solution 0 mg/5ml protriptyline hcl oral tablet 0 mg, 5 mg trimipramine maleate oral capsule 00 mg, 25 mg, 50 mg Antiemetics (Antieméticos) Antiemetics, Other (Antieméticos, Otros) chlorpromazine hcl injection solution 50 mg/2ml 3 MO/90 chlorpromazine hcl oral tablet 0 mg, 00 mg, 200 mg, 25 mg, 50 mg diphenhydramine hcl injection solution 50 mg/ml hydroxyzine hcl oral syrup 0 mg/5ml hydroxyzine hcl oral tablet 0 mg, 25 mg, 50 mg meclizine hcl oral tablet 2.5 mg, 25 mg metoclopramide hcl injection solution 5 mg/ml 3 MO/90 metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 0 mg, 5 mg Page 25 of 30

26 perphenazine oral tablet 6 mg, 2 mg, 4 mg, 8 mg prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine hcl injection solution 25 mg/ml, 50 mg/ml promethazine hcl oral syrup 6.25 mg/5ml EX-BFF; MO/90 promethazine hcl oral tablet 2.5 mg, 25 mg, 50 mg promethazine hcl rectal suppository 2.5 mg, 25 mg, 50 mg promethegan rectal suppository 50 mg TRANSDERM-SCOP (.5 MG) TRANSDERMAL PATCH 72 HOUR MG/3DAYS EX-BFF; MO/90 Emetogenic Therapy Adjuncts (Adjuvantes para Terapia Emetogénica) aprepitant oral capsule 25 mg, 40 mg, 80 & 25 mg, 80 mg 3 PA^ dronabinol oral capsule 0 mg, 2.5 mg, 5 mg PA^ ondansetron hcl injection solution 4 mg/2ml PA^ ondansetron hcl oral tablet 4 mg, 8 mg PA^ ondansetron oral tablet dispersible 4 mg, 8 mg PA^ VARUBI ORAL TABLET 90 MG 3 PA^ Antifungals (Antifungales) Antifungals (Antifungales) ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg 3 PA^ 3 PA^ PA^ Page 26 of 30

27 CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG 4 PA^ ciclopirox external solution 8 % clotrimazole external cream % clotrimazole external solution % clotrimazole mouth/throat lozenge 0 mg CRESEMBA INTRAVENOUS SOLUTION RECONSTITUTED 372 MG CRESEMBA ORAL CAPSULE 86 MG 4 4 PA^ econazole nitrate external cream % ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 00 MG, 50 MG fluconazole in sodium chloride intravenous solution mg/00ml-%, mg/200ml- % fluconazole oral suspension reconstituted 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 50 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 25 mg, 250 mg itraconazole oral capsule 00 mg 3 PA^ PA^ ketoconazole external cream 2 % ketoconazole external shampoo 2 % ketoconazole oral tablet 200 mg MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 00 MG MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 50 MG 4 PA^ 3 PA^ NATACYN OPHTHALMIC SUSPENSION 5 % 3 MO/90 Page 27 of 30

28 NOXAFIL ORAL SUSPENSION 40 MG/ML 3 NOXAFIL ORAL TABLET DELAYED RELEASE 00 MG nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystatin mouth/throat suspension unit/ml nystatin oral tablet unit terbinafine hcl oral tablet 250 mg terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg voriconazole intravenous solution reconstituted 200 mg voriconazole oral suspension reconstituted 40 mg/ml voriconazole oral tablet 200 mg, 50 mg Antigout Agents (Agentes Antigota) Antigout Agents (Agentes Antigota) 3 PA^ allopurinol oral tablet 00 mg, 300 mg colchicine oral tablet 0.6 mg colchicine-probenecid oral tablet mg probenecid oral tablet 500 mg Anti-Inflammatory Agents (Agentes Anti-Inflamatorios) Glucocorticoids (Glucocorticoides) betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % Page 28 of 30

29 betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0. % betamethasone valerate external lotion 0. % betamethasone valerate external ointment 0. % cortisone acetate oral tablet 25 mg DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML dexamethasone intensol oral concentrate mg/ml dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg,.5 mg, 4 mg, 6 mg dexamethasone oral tablet mg, 2 mg 3 dexamethasone sodium phosphate injection solution 0 mg/ml, 20 mg/30ml hydrocortisone oral tablet 20 mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 6 mg, 32 mg, 4 mg, 8 mg methylprednisolone sodium succ injection solution reconstituted 25 mg, 40 mg millipred oral tablet 5 mg 3 PA^ PA^ PA^ prednisolone acetate ophthalmic suspension % prednisolone sodium phosphate oral solution 5 mg/5ml, 6.7 (5 base) mg/5ml Page 29 of 30

30 prednisone oral tablet mg, 0 mg, 2.5 mg, 20 mg, 5 mg prednisone oral tablet 50 mg 3 SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 00 MG, 250 MG SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 500 MG sulfacetamide-prednisolone ophthalmic solution % 3 3 PA^ Nonsteroidal Anti-Inflammatory Drugs (Anti-inflamatorios No Esteroidales) celecoxib oral capsule 00 mg, 200 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 00 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg etodolac oral tablet 400 mg, 500 mg flurbiprofen oral tablet 00 mg, 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg QL (60 EA per 30 days) QL (60 EA per 30 days) indomethacin oral capsule 25 mg, 50 mg QL (20 EA per 30 days) ketorolac tromethamine injection solution 5 mg/ml, 30 mg/ml ketorolac tromethamine intramuscular solution 60 mg/2ml meloxicam oral tablet 5 mg, 7.5 mg QL (30 EA per 30 days) nabumetone oral tablet 500 mg, 750 mg Page 30 of 30

31 naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 25 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg piroxicam oral capsule 0 mg, 20 mg sulindac oral tablet 50 mg, 200 mg Antimigraine Agents (Antimigraña) Ergot Alkaloids (Alcaloides de Ergotamina) dihydroergotamine mesylate injection solution mg/ml dihydroergotamine mesylate nasal solution 4 mg/ml ergotamine-caffeine oral tablet -00 mg Prophylactic (Profilaxis) divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 25 mg divalproex sodium oral tablet delayed release 25 mg, 250 mg, 500 mg PA^ timolol maleate oral tablet 0 mg, 20 mg, 5 mg topiramate oral capsule sprinkle 5 mg, 25 mg topiramate oral tablet 00 mg, 200 mg, 25 mg, 50 mg valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg Serotonin (5-HT) B/D Receptor Agonists (Agonistas del Receptor de Serotonina) naratriptan hcl oral tablet mg, 2.5 mg QL (9 EA per 30 days) rizatriptan benzoate oral tablet 0 mg, 5 mg Page 3 of 30

32 rizatriptan benzoate oral tablet dispersible 0 mg, 5 mg sumatriptan succinate oral tablet 00 mg QL (9 EA per 30 days) sumatriptan succinate oral tablet 25 mg, 50 mg QL (8 EA per 30 days) sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution autoinjector 4 mg/0.5ml, 6 mg/0.5ml Antimyasthenic Agents (Antimiasténicos) Parasympathomimetics (Parasimpatomiméticos) guanidine hcl oral tablet 25 mg 3 MESTINON ORAL SYRUP 60 MG/5ML 3 pyridostigmine bromide er oral tablet extended release 80 mg pyridostigmine bromide oral tablet 60 mg Antimycobacterials (Antimicobacterianos) Antimycobacterials, Other (Antimicobacterianos, Otros) dapsone oral tablet 00 mg, 25 mg 2 PRIFTIN ORAL TABLET 50 MG 3 rifabutin oral capsule 50 mg Antituberculars (Antituberculosos) CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED GM ethambutol hcl oral tablet 00 mg, 400 mg isoniazid oral syrup 50 mg/5ml 3 isoniazid oral tablet 00 mg, 300 mg PASER ORAL PACKET 4 GM 3 pyrazinamide oral tablet 500 mg 3 PA^ Page 32 of 30

33 rifampin intravenous solution reconstituted 600 mg rifampin oral capsule 50 mg, 300 mg RIFATER ORAL TABLET MG 3 PA^ SIRTURO ORAL TABLET 00 MG 4 PA TRECATOR ORAL TABLET 250 MG 3 Antineoplastics (Antineoplásicos) Alkylating Agents (Agentes Alquilantes) cyclophosphamide oral capsule 25 mg, 50 mg 3 PA^; MO/90 HEXALEN ORAL CAPSULE 50 MG 3 MO/90 LEUKERAN ORAL TABLET 2 MG 2 MO/90 MATULANE ORAL CAPSULE 50 MG 4 MO/90 VALCHLOR EXTERNAL GEL 0.06 % 4 MO/90 Antiandrogens (Antiandrógenos) bicalutamide oral tablet 50 mg QL (30 EA per 30 days); MO/90 flutamide oral capsule 25 mg nilutamide oral tablet 50 mg QL (60 EA per 30 days); MO/90 XTANDI ORAL CAPSULE 40 MG 4 PA; QL (20 EA per 30 days); MO/90 ZYTIGA ORAL TABLET 250 MG 4 PA; MO/90 Antiangiogenic Agents (Agentes Antiangiogénicos) POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG Antiestrogens/Modifiers (Antiestrógenos/Modificadores) 4 PA; LA; MO/90 4 PA; LA; MO/90 4 PA; MO/90 EMCYT ORAL CAPSULE 40 MG 3 MO/90 FARESTON ORAL TABLET 60 MG 3 QL (30 EA per 30 days); MO/90 Page 33 of 30

34 SOLTAMOX ORAL SOLUTION 0 MG/5ML 3 MO/90 tamoxifen citrate oral tablet 0 mg, 20 mg Antimetabolites (Antimetabolitos) hydroxyurea oral capsule 500 mg LONSURF ORAL TABLET MG, MG PURIXAN ORAL SUSPENSION 2000 MG/00ML 4 PA; MO/90 4 MO/90 TABLOID ORAL TABLET 40 MG 3 MO/90 Antineoplastics (Antineoplásicos) ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG AVASTIN INTRAVENOUS SOLUTION 00 MG/4ML, 400 MG/6ML azacitidine injection suspension reconstituted 00 mg BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG bleomycin sulfate injection solution reconstituted 30 unit 4 PA^; MO/90 4 PA#; MO/90 PA^; MO/90 4 PA^; MO/90 PA^; MO/90 bortezomib intravenous injection 3.5 mg 4 PA^; MO/90 ELITEK INTRAVENOUS SOLUTION RECONSTITUTED.5 MG, 7.5 MG ERWINAZE INJECTION SOLUTION RECONSTITUTED 0000 UNIT FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 440 MG 4 PA^; MO/90 4 PA^; MO/90 3 PA^; MO/90 3 MO/90 4 PA^; MO/90 irinotecan hcl intravenous solution 00 mg/5ml PA^; MO/90 Page 34 of 30

35 ISTODAX (OVERFILL) INTRAVENOUS SOLUTION RECONSTITUTED 0 MG levoleucovorin calcium intravenous solution 75 mg/7.5ml 4 PA^; MO/90 3 PA^; MO/90 LYNPARZA ORAL CAPSULE 50 MG 4 PA; MO/90 LYNPARZA ORAL TABLET 00 MG, 50 MG 4 PA; MO/90 mesna intravenous solution 00 mg/ml PA^; MO/90 MESNEX ORAL TABLET 400 MG 3 MO/90 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG 4 PA; MO/90 paclitaxel intravenous concentrate 300 mg/50ml PA^; MO/90 PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT 4 PA^; MO/90 RUBRACA ORAL TABLET 200 MG, 300 MG 4 PA; MO/90 TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 25 MG, 00 MG TRISENOX INTRAVENOUS SOLUTION 0 MG/0ML, 2 MG/6ML VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG 4 PA^; MO/90 3 PA^; MO/90 4 PA^; MO/90 VENCLEXTA ORAL TABLET 0 MG, 50 MG 3 PA; LA; MO/90 VENCLEXTA ORAL TABLET 00 MG 4 PA; LA; MO/90 VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 0 & 50 & 00 MG YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED MG 4 PA; LA; MO/90 4 PA#; MO/90 ZEJULA ORAL CAPSULE 00 MG 4 PA; MO/90 Antineoplastics, Other (Antineoplásicos, Otros) leucovorin calcium injection solution reconstituted 00 mg, 350 mg PA^; MO/90 leucovorin calcium oral tablet 5 mg Page 35 of 30

36 mitoxantrone hcl intravenous concentrate 25 mg/2.5ml REVLIMID ORAL CAPSULE 0 MG, 5 MG, 25 MG, 5 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG YERVOY INTRAVENOUS SOLUTION 50 MG/0ML ZALTRAP INTRAVENOUS SOLUTION 00 MG/4ML PA^; MO/90 4 PA; LA; MO/90 4 PA; MO/90 4 PA#; MO/90 4 PA#; MO/90 4 PA^; MO/90 Aromatase Inhibitors, 3rd Generation (Inhibidores de Aromatasa, 3ra generación) anastrozole oral tablet mg QL (30 EA per 30 days); MO/90 exemestane oral tablet 25 mg letrozole oral tablet 2.5 mg Enzyme Inhibitors (Inhibidores de Enzimas) ALIQOPA INTRAVENOUS SOLUTION 60 MG 4 PA # ; MO/90 etopophos intravenous solution reconstituted 00 mg PA^; MO/90 etoposide intravenous solution 500 mg/25ml PA^; MO/90 FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG 4 PA; MO/90 4 PA; MO/90 IDHIFA ORAL TABLET 50 MG, 00 MG 4 PA; MO/90 KISQALI 200 DOSE ORAL TABLET 200 MG 4 PA; MO/90 KISQALI 400 DOSE ORAL TABLET 200 MG 4 PA; MO/90 KISQALI 600 DOSE ORAL TABLET 200 MG 4 PA; MO/90 toposar intravenous solution mg/50ml PA^; MO/90 topotecan hcl intravenous solution reconstituted 4 mg PA^; MO/90 Page 36 of 30

37 VERZENIO ORAL TABLET 50 MG, 00 MG, 50 MG, 200 MG 4 PA; MO/90 ZOLINZA ORAL CAPSULE 00 MG 4 PA; MO/90 ZYDELIG ORAL TABLET 00 MG, 50 MG 4 PA; MO/90 Molecular Target Inhibitors (Inhibidores del Blanco Molecular) AFINITOR ORAL TABLET 0 MG, 2.5 MG, 5 MG, 7.5 MG 4 PA; MO/90 ALECENSA ORAL CAPSULE 50 MG 4 PA; MO/90 ALUNBRIG ORAL TABLET 30 MG, 90 MG, 80 MG ALUNBRIG ORAL THERAPY PACK 90 MG & 80 MG BOSULIF ORAL TABLET 00 MG, 400 MG, 500 MG CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG 4 PA; MO/90 4 PA; MO/90 4 PA; MO/90 4 PA; MO/90 CALQUENCE ORAL CAPSULE 00 MG 4 PA; MO/90 CAPRELSA ORAL TABLET 00 MG, 300 MG 4 PA; LA; MO/90 COMETRIQ (00 MG DAILY DOSE) ORAL KIT X 80 & X 20 MG COMETRIQ (40 MG DAILY DOSE) ORAL KIT X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG 4 PA; MO/90 4 PA; MO/90 4 PA; MO/90 COTELLIC ORAL TABLET 20 MG 4 PA; MO/90 ERIVEDGE ORAL CAPSULE 50 MG 4 PA; LA; MO/90 GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG 4 PA; MO/90 ICLUSIG ORAL TABLET 5 MG, 45 MG 4 PA; MO/90 imatinib mesylate oral tablet 00 mg, 400 mg 4 PA; MO/90 IMBRUVICA ORAL CAPSULE 40 MG 4 PA; MO/90 INLYTA ORAL TABLET MG, 5 MG 4 PA; LA; MO/90 Page 37 of 30