FORMULARY List of Covered Drugs

Blue Cross Blue Shield of Arizona Advantage (HMO) (BCBSAZ Advantage) 017 FORMULARY List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary 17091, Version This formulary was updated on October 0, 017. For more recent information or other questions, please contact BCBSAZ Advantage at 1-800-6-81 or, for TTY users, 711, 8:00 a.m. to 8:00 p.m., Monday - Friday from February 15 to September 0; and 7 days a week from October 1 to February 1, or visit www.azbluemedicare.com. Blue Cross Blue Shield of Arizona Advantage is an HMO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Arizona Advantage depends on contract renewal. The Formulary may change at any time. You will receive notice when necessary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Member Services can be contacted toll-free at 1-800-6-81. TTY/TDD users should call 711. We are available from 8:00 a.m. to 8:00 p.m., Monday - Friday from February 15 to September 0; and 7 days a week from October 1 to February 1. This information is available for free in other languages. If you have special needs, this document may be available in other formats. El departamento de servicio al cliente puede ser contactado al número gratuito 1-800-6-81. Los usuarios de TTY/TDD deben llamar al 711. Estamos disponibles de 8:00 a.m. a 8:00 p.m., lunes a viernes desde el 15 de febrero hasta el 0 de septiembre; y los 7 días de la semana desde el 1 de octubre hasta el 1 de febrero. Esta información está disponible sin ningún costo en otros idiomas. Si usted tiene necesidades especiales, este documento puede estar disponible en otros formatos. H00_789_017 Accepted 07/06/016

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 BCBSAZ Advantage. When it refers to plan or our plan, it means BCBSAZ Advantage. This document includes a list of the drugs (formulary) for our plan which is current as of November 1, 017. 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, 018, and from time to time during the year. What is the BCBSAZ Advantage Formulary? A formulary is a list of covered drugs selected by BCBSAZ Advantage 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. BCBSAZ Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BCBSAZ Advantage 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 017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 017 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 costsharing 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 November 1, 017. To get updated information about the drugs covered by BCBSAZ Advantage, please contact us. Our i

contact information appears on the front and back cover pages. If non-maintenance changes are made to the formulary during the plan year, BCBSAZ Advantage will communicate those changes in the member newsletter and in your monthly Part D Explanation of Benefits (EOB). Changes to the BCBSAZ Advantage formulary are also posted on our Web site at www.azbluemedicare.com. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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, Cardiac Drugs. If you know what your drug is used for, look for the category name in the list that begins on page number I-1. 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 I-1. 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? BCBSAZ Advantage 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 (PA): BCBSAZ Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BCBSAZ Advantage before you fill your prescriptions. If you don t get approval, BCBSAZ Advantage may not cover the drug. Quantity Limits (QL): For certain drugs, BCBSAZ Advantage limits the amount of the drug that BCBSAZ Advantage will cover. For example, BCBSAZ Advantage provides 0 capsules per prescription for temazepam. This may be in addition to a standard one-month or three-month supply. Step Therapy (ST): In some cases, BCBSAZ Advantage 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, BCBSAZ Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, BCBSAZ Advantage will then cover Drug B. ii

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask BCBSAZ Advantage 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 BCBSAZ Advantage formulary?, on this page 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 BCBSAZ Advantage does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by BCBSAZ Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BCBSAZ Advantage. You can ask BCBSAZ Advantage to make an exception and cover your drug. See above for information about how to request an exception. How do I request an exception to the BCBSAZ Advantage Formulary? You can ask BCBSAZ Advantage 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, BCBSAZ Advantage 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, BCBSAZ Advantage will only approve your request for an exception if the alternative drug is 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. iii

Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 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 0-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0-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 91-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 1-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If you have a change in the level of care (e.g. are discharged from a hospital to your home or are admitted or discharged to a long-term care facility), you may obtain an override for an early refill of a drug you were already using. An early refill will not be used to limit appropriate and necessary access to your Part D benefits if you are admitted or discharged from a longterm care facility. For more information For more detailed information about your BCBSAZ Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BCBSAZ Advantage, 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 1-800-MEDICARE (1-800-6-7) hours a day/7 days a week. TTY users should call 1-877-86-08. Or, visit http://www.medicare.gov. iv

BCBSAZ Advantage s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by BCBSAZ Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., rosuvastatin). The information in the Requirements/Limits column tells you if BCBSAZ Advantage has any special requirements for coverage of your drug. The abbreviations you may see in the drug listing include: BvD: Medical Benefit. This prescription drug may be covered under our medical benefit. For more information, call Member Services at 1-800-6-81, October 1 - February 1, 8 a.m. to 8 p.m., 7 days a week (February 15 - September 0, 8 a.m. to 8 p.m. Monday - Friday). TTY/TDD users should call 711. GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. LA: Limited Access. This prescription drug may be available only at certain pharmacies. For more information consult your Provider/Pharmacy Directory or call Member Services at 1-800-6-81, October 1 February 1, 8 a.m. to 8 p.m., 7 days a week (February 15 - September 0, 8 a.m. to 8 p.m. Monday - Friday). TTY/TDD users should call 711. NM: Not Available through Mail Order. PA: Prior Authorization. QL: Drug has a quantity limit. ST: Step therapy required. Stages of the Part D Prescription Drug Benefit Under the BCBSAZ Advantage prescription drug coverage, there are four different stages. Your drug costs will depend on which stage you are in, as well as which BCBSAZ Advantage plan you are enrolled in. The following is a description of each drug stage. STAGE 1: Yearly Deductible Stage BCBSAZ Advantage has no yearly deductible for any of our plans. STAGE : Initial Coverage Stage You begin this stage when you fill your first prescription of the year. Each time you get a prescription filled, the cost of the drug (this is the amount both you and BCBSAZ Advantage pay) is tracked by your plan. Your share of the cost for your drugs is called a copayment or coinsurance. As your copayments and/or coinsurance add up, along with whatever your plan is paying for your drugs, you will continue to stay in the Initial Coverage Stage - until your year-to-date total drug costs reach the dollar limit for your plan. This limit may differ, depending on which plan you are enrolled in (please refer to the next section BCBSAZ Advantage Prescription Benefit Charts on pages vii-viii to determine what the specific dollar limit is for your plan), but once you have reached this limit, you are automatically placed in Stage. v

STAGE : Coverage Gap Stage Once you are in the Coverage Gap Stage, you will pay 0% of the price (plus the dispensing fee) for brand name drugs and 51% of the price for generic drugs. You stay in this stage until your year-to-date out-of-pocket costs (your payments plus any payments made on your behalf) towards your Part D covered drugs, reach a total of $,950. Once you have reached this limit, you are out of the Coverage Gap Stage and are now in Stage. STAGE : Catastrophic Coverage Stage During this stage, the plan will pay most of the cost of your drugs for the rest of the calendar year (through December 1, 017), and your share of cost will be the greater of: J$.0 for generic drugs OR J5% of the cost of the drug J$8.5 for all other drugs OR J5% of the cost of the drug BCBSAZ Advantage pays the rest of the cost. BCBSAZ Advantage Prescription Benefit Charts Each drug that is covered by your Plan is grouped into one of five (5) tiers. In general, the lower the tier number, the lower your cost for the drug. The following shows how the drugs are grouped: Tier 1 Preferred Generic Drugs Tier Generic Drugs Tier Preferred Brand Drugs Tier Non-Preferred Brand Drugs Tier 5 Specialty Drugs The cost for drugs on each tier depends on which BCBSAZ Advantage plan you are in. On the following page, there are charts designed to help you understand what you will pay for your drugs. Find the chart for your plan, and in the last row of each table, you will see what your copayment (a dollar amount) or coinsurance (a percentage amount) will be for the different tiers in your plan. Each plan chart page includes a smaller chart which indicates what your costs will be for a 90-day supply of drugs when ordered from our Mail Order Pharmacy. The following charts show what your costs will be for each BCBSAZ Advantage plan and what stage you are in. vi

Blue Medicare Advantage Classic (HMO) ($0 Monthly Premium) Maricopa County, Pima County and parts of Pinal County* *Only the following zip codes in Pinal County are included: 85117, 85118, 85119, 8510, 8510, 851, 851, 85178, 8517, 8518, 8519, 850, 850, 85. What YOU PAY as a Member of This Plan Stage 1 Yearly Deductible Stage Stage Initial Coverage Stage (Up to $,700 spent towards covered drugs based on the total shared cost between you and the Plan) 0-Day 60-Day 90-Day Stage Coverage Gap Stage (This stage begins when the total shared drug costs reach $,700) Stage Catastrophic Coverage Stage (This stage begins when your total out-of-pocket drug costs reach $,950) $0 Tier 1 $ Tier $10 Tier $5 Tier $95 Tier 5 % Tier 1 $ Tier $0 Tier $90 Tier $190 Tier 5 Not Offered Tier 1 $6 Tier $0 Tier $15 Tier $85 Tier 5 Not Offered Generics 51% Brands 0% Generics 5% or $.0 Brands 5% or $8.5 The following is a chart which indicates what you will pay for a 90-day supply of drugs through our Mail Order Pharmacy. Mail Order Pharmacy 90-Day Supply Tier 1 Tier Tier Tier $6 $0 $15 $85 vii

Blue Medicare Advantage Plus (HMO) ($ Monthly Premium) Maricopa County and parts of Pinal County* *Only the following zip codes in Pinal County are included: 85117, 85118, 85119, 8510, 8510, 851, 851, 85178, 8517, 8518, 8519, 850, 850, 85. What YOU PAY as a Member of This Plan Stage 1 Yearly Deductible Stage Stage Initial Coverage Stage (Up to $,700 spent towards covered drugs based on the total shared cost between you and the Plan) 0-Day 60-Day 90-Day Stage Coverage Gap Stage (This stage begins when the total shared drug costs reach $,700) Stage Catastrophic Coverage Stage (This stage begins when your total out-of-pocket drug costs reach $,950) $0 Tier 1 $ Tier $10 Tier $0 Tier $90 Tier 5 % Tier 1 $ Tier $0 Tier $80 Tier $180 Tier 5 Not Offered Tier 1 $6 Tier $0 Tier $10 Tier $70 Tier 5 Not Offered Generics 51% Brands 0% Generics 5% or $.0 Brands 5% or $8.5 The following is a chart which indicates what you will pay for a 90-day supply of drugs through our Mail Order Pharmacy. Mail Order Pharmacy 90-Day Supply Tier 1 Tier Tier Tier $6 $0 $10 $70 viii

Table of Contents Analgesics... Anesthetics... 8 Anti-Addiction/Substance Abuse Treatment Agents...9 Antianxiety Agents...10 Antibacterials... 11 Anticancer Agents... Anticholinergic Agents... Anticonvulsants... Antidementia Agents...6 Antidepressants... 7 Antidiabetic Agents... 0 Antifungals...5 Antigout Agents... 7 Antihistamines...7 Anti-Infectives (Skin And Mucous Membrane)...8 Antimigraine Agents...8 Antimycobacterials...9 Antinausea Agents...50 Antiparasite Agents...51 Antiparkinsonian Agents...5 Antipsychotic Agents...5 Antivirals (Systemic)...58 Blood Products/Modifiers/Volume Expanders... 6 Caloric Agents...68 Cardiovascular Agents... 71 Central Nervous System Agents... 8 Contraceptives...86 Dental And Oral Agents...91 Dermatological Agents...91 Devices... 98 Enzyme Replacement/Modifiers...98 Eye, Ear, Nose, Throat Agents... 100 Gastrointestinal Agents... 105 Genitourinary Agents... 109 Heavy Metal Antagonists... 110 Hormonal Agents, Stimulant/Replacement/Modifying...110 1

Immunological Agents...116 Inflammatory Bowel Disease Agents... 15 Irrigating Solutions...16 Metabolic Bone Disease Agents...16 Miscellaneous Therapeutic Agents...18 Ophthalmic Agents...11 Replacement Preparations... 1 Respiratory Tract Agents... 16 Skeletal Muscle Relaxants... 11 Sleep Disorder Agents... 11 Vasodilating Agents...11 Vitamins And Minerals...1

Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml, 60-6 /15 ml (15 ml) acetaminophen-codeine oral tablet 00-15 acetaminophen-codeine oral tablet 00-0 (Tylenol-Codeine #) acetaminophen-codeine oral tablet 00-60 (Tylenol-Codeine #) ascomp with codeine oral capsule 0-50- 5-0 aspirin-caffeine-dihydrocodein oral (Synalgos-DC) capsule 56.-0-16 buprenorphine hcl injection solution 0. (Buprenex) /ml buprenorphine hcl injection syringe 0. /ml butalbital compound w/codeine oral capsule 0-50-5-0 butalbital-acetaminop-caf-cod oral capsule 50-00-0-0, 50-5-0-0 butalbital-acetaminophen-caff oral (Fioricet) capsule 50-00-0 butalbital-acetaminophen-caff oral (Capacet) capsule 50-5-0 butalbital-acetaminophen-caff oral tablet (Esgic) 50-5-0 butorphanol tartrate injection solution 1 /ml, /ml butorphanol tartrate nasal spray,nonaerosol QL (5 per days) 10 /ml capacet oral capsule 50-5-0 CAPITAL WITH CODEINE ORAL SUSPENSION 10-1 MG/5 ML codeine sulfate oral tablet 15, 0, 60 DILAUDID ORAL LIQUID 1 MG/ML

DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML endocet oral tablet 10-5,.5-5, 5-5, 7.5-5 endodan oral tablet.855-5 fentanyl transdermal patch 7 hour 100 (Duragesic) mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution.5-167 /5 ml, 5-16 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) 7.5-5 /15 ml hydrocodone-acetaminophen oral tablet (Xodol 10/00) 10-00 hydrocodone-acetaminophen oral tablet (Norco) 10-5 hydrocodone-acetaminophen oral tablet (Verdrocet).5-5 hydrocodone-acetaminophen oral tablet (Xodol 5/00) 5-00 hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) 5-5 hydrocodone-acetaminophen oral tablet (Xodol 7.5/00) 7.5-00 hydrocodone-acetaminophen oral tablet (Lorcet Plus) 7.5-5 hydrocodone-ibuprofen oral tablet 10-00 (Ibudone), 5-00 hydrocodone-ibuprofen oral tablet 7.5-00 hydromorphone (pf) injection solution 10 (/ml) (5 ml) hydromorphone (pf) injection solution 10 /ml hydromorphone 10 /ml vial p/f,sdv,latex-f 10 /ml hydromorphone oral liquid 1 /ml (Dilaudid) hydromorphone oral tablet,, 8 (Dilaudid) ibuprofen-oxycodone oral tablet 00-5

LAZANDA NASAL SPRAY,NON- PA AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY levorphanol tartrate oral tablet lorcet (hydrocodone) oral tablet 5-5 lorcet hd oral tablet 10-5 margesic oral capsule 50-5-0 meperidine (pf) injection solution 100 (Demerol (PF)) PA /ml, 50 /ml meperidine (pf) injection solution 5 PA /ml meperidine injection cartridge 10 /ml meperidine oral solution 50 /5 ml meperidine oral tablet 100 (Demerol) meperidine oral tablet 50 methadone injection solution 10 /ml methadone intensol oral concentrate 10 /ml methadone oral solution 10 /5 ml, 5 /5 ml methadone oral tablet 10, 5 (Dolophine) morphine (pf) injection solution 0.5 (Duramorph (PF)) /ml morphine (pf) injection solution 1 /ml (Astramorph-PF) morphine (pf) intravenous patient control.analgesia soln 150 /0 ml, 0 /0 ml morphine 10 /ml carpuject outer, p/f, l/f, suv 10 /ml morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine /ml syringe p/f, latexfree,suv /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 100 /5 ml (0 /ml) morphine intramuscular pen injector 10 /0.7 ml morphine intravenous cartridge 15 /ml 5

morphine intravenous syringe 10 /ml, /ml, /ml, 8 /ml morphine oral capsule,extend.release (Kadian) QL (90 per 0 days) pellets 10, 100, 0, 0, 50, 60, 80 morphine oral solution 10 /5 ml, 0 /5 ml ( /ml) MORPHINE ORAL TABLET 15 MG, 0 MG morphine oral tablet extended release 100 (MS Contin) QL (10 per 0 days), 15, 00, 0, 60 nalbuphine injection solution 10 /ml, 0 /ml oxycodone oral capsule 5 oxycodone oral concentrate 0 /ml oxycodone oral solution 5 /5 ml oxycodone oral tablet 10, 0 oxycodone oral tablet 15, 0, 5 (Roxicodone) oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (90 per 0 days) hr 10, 15, 0, 0, 0, 60, 80 oxycodone-acetaminophen oral tablet 10- (Primlev) 00, 5-00, 7.5-00 oxycodone-acetaminophen oral tablet 10- (Endocet) 5,.5-5, 7.5-5 oxycodone-acetaminophen oral tablet 5- (Percocet) 5 oxycodone-aspirin oral tablet.855-5 OXYCONTIN ORAL QL (90 per 0 days) TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG oxymorphone oral tablet 10, 5 (Opana) reprexain oral tablet 10-00,.5-00, 5-00 6

SUBSYS SUBLINGUAL 5 PA; NM; NDS SPRAY,NON-AEROSOL 1,00 MCG (600 MCG/SPRAY X ), 1,600 MCG (800 MCG/SPRAY X ), 100 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY tramadol oral tablet 50 (Ultram) QL (0 per 0 days) tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (0 per 0 days) 5 ZAMICET ORAL SOLUTION 10-5 MG/15 ML zebutal oral capsule 50-5-0 Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 100, 00, (Celebrex) 00, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops 1.5 % diclofenac sodium topical gel 1 % (Voltaren) diflunisal oral tablet 500 etodolac oral capsule 00, 00 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release hr 00, 500, 600 fenoprofen oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 00, 600, 800 indomethacin oral capsule 5, 50 indomethacin oral capsule, extended release 75 ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets hr 00 7

ketorolac injection cartridge 0 /ml ketorolac injection solution 15 /ml, 0 /ml (1 ml) ketorolac injection syringe 0 /ml ketorolac intramuscular solution 60 / ml ketorolac oral tablet 10 QL (0 per 5 days) meclofenamate oral capsule 100, 50 mefenamic acid oral capsule 50 (Ponstel) meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75, 500 naproxen sodium oral tablet 75 naproxen sodium oral tablet 550 (Anaprox DS) oxaprozin oral tablet 600 (Daypro) piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet 150, 00 tolmetin oral capsule 00 tolmetin oral tablet 00, 600 VOLTAREN TOPICAL GEL 1 % ZORVOLEX ORAL CAPSULE 18 MG, 5 MG Anesthetics Local Anesthetics lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %) lidocaine (pf) injection solution 5 /ml (Xylocaine-MPF) (0.5 %) lidocaine hcl injection solution 10 /ml (Xylocaine) (1 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl injection syringe 10 /ml (1 %) lidocaine hcl mucous membrane jelly % 8

lidocaine hcl mucous membrane solution % (0 /ml) lidocaine hcl(pf) in 0.9% nacl injection syringe 100 /10 ml (1 %) lidocaine topical adhesive (Lidoderm) PA patch,medicated 5 % lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % LIDODERM TOPICAL ADHESIVE PA; ST PATCH,MEDICATED 5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual tablet QL (90 per 0 days) -0.5, 8- buproban oral tablet extended release 1 hr 150 bupropion hcl (smoking deter) oral tablet (Zyban) QL (60 per 0 days) extended release 1 hr 150 CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG () disulfiram oral tablet 50, 500 (Antabuse) naloxone injection syringe 1 /ml naltrexone oral tablet 50 (Revia) NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML 9

SUBOXONE SUBLINGUAL FILM QL (60 per 0 days) 1- MG SUBOXONE SUBLINGUAL FILM - QL (90 per 0 days) 0.5 MG, -1 MG, 8- MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax), clonazepam oral tablet 0.5, 1, (Klonopin) clonazepam oral tablet,disintegrating 0.15, 0.5, 0.5, 1, clorazepate dipotassium oral tablet 15,.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) DIASTAT ACUDIAL RECTAL KIT 1.5-15-17.5-0 MG, 5-7.5-10 MG DIASTAT RECTAL KIT.5 MG diazepam intensol oral concentrate 5 /ml diazepam oral solution 5 /5 ml (1 /ml) diazepam oral tablet 10,, 5 (Valium) diazepam rectal kit 1.5-15-17.5-0, (Diastat AcuDial) 5-7.5-10 diazepam rectal kit.5 (Diastat) estazolam oral tablet 1, lorazepam /ml oral concent /ml (Lorazepam Intensol) lorazepam injection solution /ml (Ativan) lorazepam injection syringe /ml, /ml lorazepam intensol oral concentrate /ml lorazepam oral tablet 0.5, 1, (Ativan) ONFI ORAL SUSPENSION.5 MG/ML ONFI ORAL TABLET 10 MG, 0 MG oxazepam oral capsule 10, 15, 0 10

temazepam oral capsule 15, 0, (Restoril) QL (0 per 0 days) 7.5 Antibacterials Aminoglycosides amikacin injection solution 1,000 / ml, 500 / ml BETHKIS INHALATION 5 PA BvD; NM; NDS SOLUTION FOR NEBULIZATION 00 MG/ ML gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 0 /ml gentamicin ped 0 / ml vial latexfree, sdv 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml neomycin oral tablet 500 streptomycin intramuscular recon soln 1 gram TOBI INHALATION SOLUTION 5 PA BvD; NM; NDS FOR NEBULIZATION 00 MG/5 ML TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation (Tobi) 5 PA BvD; NM; NDS solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 0 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln (BACiiM) 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram 11

CLEOCIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 00 MG/50 ML, 600 MG/50 ML, 900 MG/50 ML clindamycin 75 /5 ml soln 75 /5 ml (Cleocin Pediatric) clindamycin hcl oral capsule 150, 00, 75 (Cleocin HCl) clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution 150 /ml clindamycin phosphate intravenous solution 600 / ml colistin (colistimethate na) injection recon soln 150 CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 LINCOCIN INJECTION SOLUTION 00 MG/ML (Cleocin in 5 % dextrose) (Cleocin) (Cleocin) (Coly-Mycin M Parenteral) 5 PA BvD; NM; NDS (Cubicin) lincomycin injection solution 00 /ml (Lincocin) linezolid intravenous parenteral solution (Zyvox) 600 /00 ml linezolid oral suspension for (Zyvox) reconstitution 100 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 /100 ml (Metro I.V.) metronidazole oral tablet 50, 500 (Flagyl) 1 MONUROL ORAL PACKET GRAM nitrofurantoin macrocrystal oral capsule 100, 5, 50 (Macrodantin) 1

nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) nitrofurantoin oral suspension 5 /5 ml (Furadantin) polymyxin b sulfate injection recon soln 500,000 unit PRIMSOL ORAL SOLUTION 50 MG/5 ML SIVEXTRO INTRAVENOUS RECON SOLN 00 MG SIVEXTRO ORAL TABLET 00 MG 5 PA; NM; NDS SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 VANCOCIN ORAL CAPSULE 15 MG, 50 MG vancomycin hcl 1g/00 ml bag 1 PA BvD gram/00 ml vancomycin in 0.9% sodium cl intravenous solution 1.5 gram/500 ml vancomycin intravenous recon soln 1,000, 10 gram, 750 vancomycin intravenous recon soln 500 PA BvD vancomycin oral capsule 15, 50 (Vancocin) VIBATIV INTRAVENOUS RECON SOLN 750 MG XIFAXAN ORAL TABLET 00 MG XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PARENTERAL SOLUTION 00 MG/100 ML, 600 MG/00 ML ZYVOX ORAL SUSPENSION FOR 5 ST; NM; NDS RECONSTITUTION 100 MG/5 ML ZYVOX ORAL TABLET 600 MG 5 ST; NM; NDS Cephalosporins CEDAX ORAL CAPSULE 00 MG cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefaclor oral tablet extended release 1 hr 500 1

cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 00 (Spectracef) CEFEPIME 1 GM INJECTION 1 GRAM/50 ML cefepime hcl 1 gm vial 10's, sdv 1 gram (Maxipime) cefepime hcl gram vial latex/f, sdv, (Maxipime) outer gram CEFEPIME INJECTION RECON (Maxipime) SOLN 1 GRAM, GRAM CEFEPIME-DEXTROSE GM/50 ML GRAM/50 ML cefixime oral suspension for (Suprax) reconstitution 100 /5 ml, 00 /5 ml CEFOTAN INJECTION RECON SOLN 1 GRAM, GRAM cefotaxime injection recon soln 1 gram, (Claforan) 10 gram, gram cefotaxime injection recon soln 500 cefotetan injection recon soln 1 gram, (Cefotan) gram cefotetan intravenous recon soln 10 gram cefotetan-dextr 1 g duplex bag 1 gram/50 ml cefotetan-dextr g duplex bag gram/50 ml cefoxitin gm piggyback bag gram/50 ml cefoxitin gm vial l/f, outer, sdv gram cefoxitin intravenous recon soln 1 gram, 10 gram 1

cefoxitin intravenous recon soln gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML ceftazidime injection recon soln 1 gram (TAZICEF) ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 00 (Cedax) ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml ceftriaxone gm piggyback l/f, single use gram/50 ml ceftriaxone injection recon soln 10 gram, 50, 500 ceftriaxone intravenous recon soln 1 gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln (Zinacef) 750 cefuroxime sodium intravenous recon soln (Zinacef) 1.5 gram, 7.5 gram cefuroxime-dextrose (iso-osm) intravenous piggyback 750 /50 ml cephalexin oral capsule 50, 500, (Keflex) 1 750 cephalexin oral suspension for 1 reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 FORTAZ INJECTION RECON SOLN 1 GRAM, GRAM FORTAZ INTRAVENOUS RECON SOLN GRAM SUPRAX ORAL CAPSULE 00 MG 15

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 00 MG/5 ML, 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 00 MG tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG ZINACEF INJECTION RECON SOLN 750 MG ZINACEF INTRAVENOUS RECON SOLN 1.5 GRAM Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (Zithromax Z-Pak) azithromycin oral tablet 50 (6 pack), 500 ( pack) azithromycin oral tablet 500, 600 (Zithromax) clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50 1 clarithromycin oral tablet 500 clarithromycin oral tablet extended release hr 500 DIFICID ORAL TABLET 00 MG e.e.s. granules oral suspension for reconstitution 00 /5 ml ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 16

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 50 1 ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral (EryPed 00) suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 00) 1 00 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 1 KETEK ORAL TABLET 00 MG, 00 MG ZMAX ORAL SUSPENSION,EXTENDED REL RECON GRAM/60 ML Miscellaneous B-Lactam Antibiotics AZACTAM GM VIAL 15ML, SDV GRAM AZACTAM IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML aztreonam injection recon soln 1 gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML DORIBAX INTRAVENOUS RECON SOLN 50 MG, 500 MG imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon soln 500 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 (Primaxin IV) (Merrem) 5 NM; LA; NDS; QL (8 per 8 days) 17

Penicillins amoxicillin oral capsule 50, 500 1 amoxicillin oral suspension for 1 reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, 875 1 amoxicillin oral tablet,chewable 15, 1 50 amoxicillin-pot clavulanate oral suspension for reconstitution 00-8.5 /5 ml, 00-57 /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution 50-6.5 /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution 600-.9 /5 ml amoxicillin-pot clavulanate oral tablet 50-15 amoxicillin-pot clavulanate oral tablet (Augmentin) 500-15, 875-15 amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1,000-6.5 amoxicillin-pot clavulanate oral tablet,chewable 00-8.5, 00-57 ampicillin oral capsule 50, 500 1 ampicillin oral suspension for 1 reconstitution 15 /5 ml, 50 /5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 15-1.5 MG/5 ML BICILLIN C-R INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) 18

BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial 10's, latex-free gram nafcillin in dextrose iso-osm intravenous piggyback gram/100 ml nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram nafcillin intravenous recon soln gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml oxacillin injection recon soln 10 gram oxacillin injection recon soln gram oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin g sodium injection recon soln 5 million unit penicillin gk 0 million unit 0 million (Pfizerpen-G) unit penicillin v potassium oral recon soln 15 1 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 1 500 piperacillin-tazobactam intravenous (Zosyn) recon soln.5 gram,.75 gram,.5 gram, 0.5 gram Quinolones ciprofloxacin (mixture) oral tablet, er multiphase hr 1,000, 500 (Cipro XR) 19

ciprofloxacin hcl oral tablet 100, 750 ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 00 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 00 /0 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50, 500, (Levaquin) 750 moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 00, 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution 00-80 /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) 1 suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) 1 tablet 00-80 sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 tablet 800-160 sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 500 sulfatrim oral suspension 00-0 /5 ml Tetracyclines demeclocycline oral tablet 150, 00 doxy-100 intravenous recon soln 100 0

doxycycline hyclate intravenous recon (Doxy-100) soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline hyclate oral tablet 150, (Acticlate) 75 doxycycline hyclate oral tablet,delayed release (dr/ec) 100, 150, 75 doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 00, 50 doxycycline monohydrate oral capsule (Monodox) 100, 50 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral capsule 75 (Mondoxyne NL) doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 150, 50, 75 minocycline oral capsule 100, 50, (Minocin) 75 minocycline oral tablet 100, 50, 75 minocycline oral tablet extended release hr 15, 5, 90 SOLODYN ORAL TABLET 5 ST; NM; NDS EXTENDED RELEASE HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) TYGACIL INTRAVENOUS RECON SOLN 50 MG VIBRAMYCIN ORAL SYRUP 50 MG/5 ML ST 1

Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG adriamycin intravenous solution /ml, 0 /10 ml adrucil,500 /50 ml vial outer, latexfree PA BvD.5 gram/50 ml adrucil 500 /10 ml vial sdv,latexfree,inner 500 /10 ml adrucil intravenous solution 500 /10 ml PA BvD AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 5 PA NSO; NM; NDS MG ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG ALUNBRIG ORAL TABLET 0 MG anastrozole oral tablet 1 (Arimidex) AVASTIN INTRAVENOUS SOLUTION 5 MG/ML, 5 MG/ML (16 ML) azacitidine injection recon soln 100 (Vidaza) BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG BENDEKA INTRAVENOUS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin)

bicalutamide oral tablet 50 (Casodex) BICNU INTRAVENOUS RECON SOLN 100 MG bleomycin injection recon soln 15 unit (Bleo 15K) bleomycin injection recon soln 0 unit PA BvD BLINCYTO INTRAVENOUS KIT 5 MCG BOSULIF ORAL TABLET 100 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) BOSULIF ORAL TABLET 500 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) busulfan intravenous solution 60 /10 (Busulfex) ml BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG CAPRELSA ORAL TABLET 100 MG, 5 NM; LA; NDS 00 MG carboplatin intravenous solution 10 /ml clofarabine intravenous solution 0 /0 (Clolar) ml COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), 10 MG/DAY(80 MG X1-0 MG X) COMETRIQ ORAL CAPSULE 60 MG/DAY (0 MG X /DAY) COTELLIC ORAL TABLET 0 MG 5 PA NSO; NM; LA; NDS cyclophosphamide intravenous recon soln PA BvD 1 gram, gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML (50 ML) cytarabine (pf) injection recon soln 1 gram, 100 PA BvD

cytarabine (pf) injection solution PA BvD gram/0 ml (100 /ml) cytarabine 100 /5 ml vial p/f,sdv,latexfree PA BvD 100 /5 ml (0 /ml) cytarabine injection solution 0 /ml PA BvD dacarbazine intravenous recon soln 100, 00 DACOGEN INTRAVENOUS RECON SOLN 50 MG DARZALEX INTRAVENOUS 5 NM; LA; NDS SOLUTION 0 MG/ML daunorubicin intravenous recon soln 0 daunorubicin intravenous solution 5 /ml DAUNOXOME INTRAVENOUS SOLUTION MG/ML decitabine intravenous recon soln 50 (Dacogen) DEPOCYT (PF) INTRATHECAL SUSPENSION 50 MG/5 ML (10 MG/ML) docetaxel 160 /16 ml vial mdv, sterile,l/f 160 /16 ml (10 /ml) docetaxel intravenous solution 10 /7 ml (0 /ml), 0 /ml, 80 /8 ml (10 /ml) docetaxel intravenous solution 80 / (Taxotere) ml (0 /ml) DOXIL INTRAVENOUS SUSPENSION MG/ML doxorubicin 00 /100 ml vial latexfree (Adriamycin) /ml doxorubicin intravenous recon soln 10, 50 doxorubicin intravenous solution 50 (Adriamycin) /5 ml doxorubicin, peg-liposomal intravenous (Doxil) suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG

ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE.5 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 5 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS RECON SOLN 00 MG, 00 MG epirubicin intravenous recon soln 50 epirubicin intravenous solution 00 (Ellence) /100 ml, 50 /5 ml ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML, 00 MG/100 ML ERIVEDGE ORAL CAPSULE 150 MG ERWINAZE INJECTION RECON SOLN 10,000 UNIT etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG, 80 MG floxuridine injection recon soln 0.5 gram fludarabine 50 / ml vial suv 50 / ml fludarabine intravenous recon soln 50 fluorouracil 5,000 /100 ml latex-free 5 (Adrucil) PA BvD gram/100 ml fluorouracil intravenous solution 1 gram/0 ml 5

fluorouracil intravenous solution.5 (Adrucil) PA BvD gram/50 ml fluorouracil intravenous solution 500 (Adrucil) /10 ml flutamide oral capsule 15 FOLOTYN 0 MG/ML VIAL 0 MG/ML (1 ML) FOLOTYN INTRAVENOUS SOLUTION 0 MG/ ML (0 MG/ML) GAZYVA INTRAVENOUS SOLUTION 1,000 MG/0 ML GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG 5 NM; LA; NDS; QL (0 per 0 days) GLEEVEC ORAL TABLET 100 MG, 00 MG GLEOSTINE ORAL CAPSULE 5 MG HALAVEN INTRAVENOUS SOLUTION 1 MG/ ML (0.5 MG/ML) HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 0 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG 5 PA NSO; NM; NDS; QL (1 per 8 days) ICLUSIG ORAL TABLET 15 MG, 5 MG IDHIFA ORAL TABLET 100 MG, 50 MG ifosfamide-mesna intravenous kit 1-1 gram,,000-1,000 imatinib oral tablet 100, 00 (Gleevec) IMBRUVICA ORAL CAPSULE 10 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML, 10EXP8 (100 MILLION) PFU/ML 6

INLYTA ORAL TABLET 1 MG, 5 MG IRESSA ORAL TABLET 50 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION) KADCYLA INTRAVENOUS 5 NM; LA; NDS RECON SOLN 100 MG, 160 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML KISQALI FEMARA CO-PACK 5 PA NSO; NM; NDS ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG, 00 MG/DAY(00 MG X )-.5 MG, 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 5 PA NSO; NM; NDS MG/DAY (00 MG X 1), 00 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 1 MG/DAY(10 MG X 1- MG X 1), 18 MG/DAY (10 MG X 1- MG X), 0 MG/DAY (10 MG X ), MG/DAY(10 MG X - MG X 1), 8 MG/DAY ( MG X ) 5 PA NSO; NM; NDS letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit 1 /0. ml LONSURF ORAL TABLET 15-6.1 MG, 0-8.19 MG 5 PA NSO; NM; NDS 7

LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 100 MG, 150 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 0 MEKINIST ORAL TABLET 0.5 MG, 5 NM; LA; NDS MG mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln 1 gram methotrexate sodium (pf) injection solution 5 /ml methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 mitomycin intravenous recon soln 0, 0, 5 mitoxantrone intravenous concentrate PA BvD /ml NERLYNX ORAL TABLET 0 MG NEXAVAR ORAL TABLET 00 MG 5 NM; LA; NDS NILANDRON ORAL TABLET 150 MG 8

nilutamide oral tablet 150 (Nilandron) NINLARO ORAL CAPSULE. MG, 5 PA NSO; NM; NDS MG, MG ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; NM; LA; NDS ONCASPAR INJECTION SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS DISPERSION. MG/ML OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 0 MG/ ML paclitaxel intravenous concentrate 6 /ml PERJETA INTRAVENOUS SOLUTION 0 MG/1 ML (0 MG/ML) PHOTOFRIN INTRAVENOUS RECON SOLN 75 MG POMALYST ORAL CAPSULE 1 MG, MG, MG, MG PORTRAZZA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 10 5 NM; LA; NDS MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS SOLUTION 100 MG/11.7 ML (10 MG/ML), 1600 MG/1. ML (10 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML RUBRACA ORAL TABLET 00 MG, 50 MG, 00 MG RYDAPT ORAL CAPSULE 5 MG 9