<Add Logo> BlueShield of Northeastern New York Formulary. (List of Covered Drugs)

<Add Logo> BlueShield of Northeastern New York 017 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 00017493, Version Number 6 This formulary was updated on 08/3/016. For more recent information or other questions, please contact BlueShield of Northeastern New York at 1-800-39-79 or, for TTY users, 711, October 1 February 14 8 a.m. to 8 p.m., 7 days a week and February 15 September 30 8 a.m. to 8 p.m. Monday Friday, or visit www.bsneny.com/medicare. Y0086_PTD51 Accepted

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 BlueShield of Northeastern New York. When it refers to plan or our plan, it means Senior Blue HMO-POS 650 (HMO-POS), Senior Blue HMO 65 (HMO), Forever Blue Medicare PPO Value (PPO) and Forever Blue Medicare PPO 770 (PPO). This document includes list of the drugs (formulary) for our plan which is current as of 8/3/016. 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 BlueShield of Northeastern New York Formulary? A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan 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 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 8/3/016. To get updated information about the drugs covered by our plan please contact us. Our contact information appears on the front and back cover pages. In the event that our plan has made an error in the printed formulary during the year, we will notify you directly by mail. We will send you written notification explaining the error and a new formulary page reflecting the correct text and benefit. II

How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Antihypertensive Therapy. If you know what your drug is used for, look for the category name in the list that begins on page number. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 80. 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? Our plan 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 These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 30 tablets per prescription for atorvastatin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and III

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 our plan 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 plan formulary? on page IV 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 our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan 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 BlueShield of Northeastern New York s Formulary? You can ask our plan 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, our plan 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, our plan will only approve your request for an exception if the alternative drugs included on our plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. IV

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30 day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30 day supply, we will not pay for these drugs, even if you have been a member of our 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 93 day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31 day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you submit a prescription for a transition eligible drug and it is rejected at Point of Sale, a message will be relayed to the pharmacists to call for additional instructions if you underwent a recent level of care change. After confirming you had a level of care change, the pharmacist will be instructed to enter a series of override codes to allow you to receive a one-time transition supply of your prescription. At that time, all transition supply procedures will apply including member notifications for transition supply fills. For more information For more detailed information about your plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, 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 (1-800-633-47) 4 hours a day/7 days a week. TTY users should call 1-877-486-048. Or, visit http://www.medicare.gov. V

Our Plan Formulary The formulary that begins on the next page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 80. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., WELCHOL) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements column tells you if our plan has any special requirements for coverage of your drug. VI

Below is a list of abbreviations that may appear on the following pages in the Requirements column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations +: We provide additional coverage of this prescription drug in the coverage gap for Senior Blue HMO 65 and Forever Blue Medicare PPO 770. Please refer to our Evidence of Coverage for more information about this *: Diabetic test strips are not covered under Medicare Part D. The test strips listed in this document are those that may be covered under Medicare Part B if your Plan includes Part B B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. If it is determined that coverage for this drug falls under Medicare Part B, your cost will not be the tier copay in this drug list. Please refer to Chapter 4 of your evidence of coverage for the cost of Part B drugs or contact customer service. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for shortterm prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 1

ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 5 B/D PA; MO AMBISOME 5 B/D PA; MO amphotericin b 4 B/D PA; MO CANCIDAS 5 B/D PA; MO clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL fluconazole fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/00 ml 5 flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole oral LAMISIL ORAL GRANULES IN PACKET MYCAMINE NOXAFIL ORAL nystatin oral suspension nystatin oral tablet ORAVIG SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole intravenous voriconazole oral ANTIVIRALS abacavir abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 00 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution B/D PA; MO adefovir amantadine hcl APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION 5

ATRIPLA BARACLUDE ORAL SOLUTION cidofovir 5 B/D PA; MO COMPLERA CRIXIVAN ORAL CAPSULE 00 MG, 400 MG DAKLINZA ORAL TABLET 30 MG, 60 MG DAKLINZA ORAL TABLET 90 MG DESCOVY 5 5 PA; MO; QL (84 per 8 didanosine EDURANT EMTRIVA entecavir EPIVIR HBV ORAL SOLUTION 5 PA; QL (84 per 84 EPZICOM EVOTAZ famciclovir FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium B/D PA; MO GENVOYA HARVONI 5 PA; MO; QL (168 per 168 INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE 5 MG KALETRA ORAL SOLUTION KALETRA ORAL TABLET 100-5 MG KALETRA ORAL TABLET 00-50 MG lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET moderiba moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7) 3

moderiba dose pack oral tablets,dose pack 600 mg (7)- 600 mg (7) nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 4 hr 100 mg nevirapine oral tablet extended release 4 hr 400 mg NORVIR ODEFSEY 5 OLYSIO 5 PA; MO; QL (168 per 168 PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG REBETOL ORAL SOLUTION RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 00 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg ribasphere oral tablet 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 400-400 mg (8)-mg (8), 600-400 mg (8)-mg (8), 600-600 mg (8)-mg (8) ribavirin oral capsule ribavirin oral tablet 00 mg rimantadine SELZENTRY SOVALDI 5 PA; MO; QL (168 per 168 stavudine STRIBILD 4

SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML ; LA TAMIFLU TECHNIVIE 5 PA; MO; QL (56 per 8 TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 5 MG TIVICAY ORAL TABLET 50 MG 3 5 TRIUMEQ TRUVADA ORAL TABLET 100-150 MG, 133-00 MG, 167-50 MG TRUVADA ORAL TABLET 00-300 MG 5 TYZEKA valacyclovir ; QL (30 VALCYTE ORAL RECON SOLN valganciclovir VIDEX GRAM PEDIATRIC VIEKIRA PAK 5 PA; MO; QL (11 per 8 VIRACEPT ORAL TABLET VIRAZOLE VIREAD VITEKTA ZEPATIER 5 PA; MO; QL (11 per 11 ZIAGEN ORAL SOLUTION zidovudine CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 15 mg/5 ml cefaclor oral suspension for reconstitution 50 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule 5

cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram cefdinir cefepime cefixime cefotaxime injection recon soln 1 gram, gram, 500 mg cefotetan injection cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram cefoxitin intravenous recon soln gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram ceftazidime injection recon soln gram ceftazidime injection recon soln 6 gram 4 ceftriaxone injection recon soln 10 gram ceftriaxone injection recon soln 50 mg, 500 mg ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous cephalexin SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 4 TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin e.e.s. 400 oral tablet E.E.S. GRANULES 6

ery-tab oral tablet,delayed release (dr/ec) 50 mg ery-tab oral tablet,delayed release (dr/ec) 333 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet 50 mg erythromycin oral tablet 500 mg 3 MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 500 mg/ ml atovaquone atovaquoneproguanil AZACTAM IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML aztreonam injection recon soln 1 gram baciim bacitracin intramuscular 3 BETHKIS 5 B/D PA; MO; QL (4 per 8 BILTRICIDE CAPASTAT 4 CAYSTON ; LA; QL (84 per 8 chloramphenicol sod succinate chloroquine phosphate oral clindamycin hcl clindamycin in 5 % dextrose clindamycin pediatric 7

clindamycin phosphate injection solution 150 (mg/ml) (6 ml) clindamycin phosphate injection solution 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) CUBICIN DAPSONE DARAPRIM 3 PA; MO EMVERM 5 ethambutol gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 80 mg/100 ml, 80 mg/50 ml gentamicin injection solution 40 mg/ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid injection isoniazid oral ivermectin oral lincomycin injection linezolid intravenous 5 linezolid oral mefloquine meropenem intravenous recon soln 500 mg metronidazole in nacl (iso-os) metronidazole oral NEBUPENT 3 B/D PA; MO; QL (1 per 8 neomycin paromomycin PASER PENTAM polymyxin b sulfate PRIFTIN PRIMAQUINE 8

pyrazinamide quinine sulfate rifabutin rifampin SIRTURO ; LA SIVEXTRO INTRAVENOUS STREPTOMYCIN INTRAMUSCULAR SYNERCID 5 5 tinidazole TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in 0.5 % nacl tobramycin sulfate injection solution ; QL (4 per 8 5 B/D PA; MO; QL (80 per 8 TRECATOR TYGACIL XIFAXAN ORAL TABLET 00 MG XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule ; QL (9 per 30 ; QL (60 amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15 mg, 50 mg amoxicillin-pot clavulanate ampicillin ampicillin sodium injection recon soln 1 gram, 10 gram, 15 mg ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam injection recon soln 3 gram ampicillin-sulbactam intravenous recon soln 1.5 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 15-31.5 MG/5 ML BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin injection recon soln 1 gram 9

nafcillin injection recon soln 10 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 intravenous recon soln gram PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml 3 penicillin g sodium penicillin v potassium piperacillintazobactam intravenous recon soln 3.375 gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 00 mg/100 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous levofloxacin oral moxifloxacin ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine oral sulfamethoxazoletrimethoprim 10

TETRACYCLINES demeclocycline oral tablet 150 mg demeclocycline oral tablet 300 mg doxy-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 00 mg doxycycline hyclate oral tablet,delayed release (dr/ec) 50 mg doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg doxycycline monohydrate oral capsule 75 mg 5 doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet minocycline oral tablet extended release 4 hr 135 mg, 45 mg minocycline oral tablet extended release 4 hr 90 mg tetracycline oral capsule 50 mg tetracycline oral capsule 500 mg VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS methenamine hippurate nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitrofurantoin oral trimethoprim 11

VANCOMYCIN vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg vancomycin oral ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 50 mg ELITEK FUSILEV KEPIVANCE 5 leucovorin calcium injection recon soln 100 mg, 350 mg leucovorin calcium oral levoleucovorin calcium intravenous solution 5 mesna MESNEX ORAL XGEVA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 5 adrucil intravenous solution 500 mg/10 ml B/D PA; MO AFINITOR DISPERZ 5 PA; MO AFINITOR ORAL TABLET 10 MG AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA; MO; QL (60 per 30 5 PA; MO ALECENSA 5 PA; MO; QL (40 per 30 ALIMTA INTRAVENOUS RECON SOLN 500 MG anastrozole ARRANON 5 AVASTIN azacitidine azathioprine B/D PA; MO azathioprine sodium B/D PA BELEODAQ bexarotene bicalutamide BICNU bleomycin injection recon soln 30 unit BOSULIF ORAL TABLET 100 MG B/D PA; MO 5 PA; MO 1

BOSULIF ORAL TABLET 500 MG BUSULFEX 5 5 PA; MO; QL (30 per 30 CABOMETYX 5 PA; LA CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS 5 PA; MO; LA; QL (90 per 30 5 PA; MO; LA; QL (30 per 30 3 B/D PA; MO cisplatin cladribine 5 B/D PA; MO CLOLAR COMETRIQ 5 PA; MO COSMEGEN COTELLIC 5 PA; MO; LA; QL (63 per 8 CYCLOPHOSPHAMID E ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule 3 B/D PA; MO B/D PA B/D PA; MO B/D PA; MO CYRAMZA 5 B/D PA; MO cytarabine B/D PA; MO cytarabine (pf) injection solution gram/0 ml (100 mg/ml) dacarbazine intravenous recon soln 00 mg B/D PA; MO DARZALEX ; LA daunorubicin intravenous solution decitabine DOCEFREZ INTRAVENOUS RECON SOLN 0 MG docetaxel intravenous solution 80 mg/4 ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin intravenous solution 50 mg/5 ml doxorubicin, pegliposomal 5 DROXIA EMCYT EMPLICITI 5 B/D PA; MO ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML 13

ERIVEDGE 5 PA; MO; QL (30 per 30 ERWINAZE ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 0 MG 5 PA; MO; QL (1 per 1 5 PA; MO; QL (6 per 1 FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fluorouracil intravenous solution.5 gram/50 ml B/D PA; MO flutamide FOLOTYN INTRAVENOUS SOLUTION 40 MG/ ML (0 MG/ML) gemcitabine intravenous recon soln 1 gram gengraf oral capsule 100 mg gengraf oral capsule 5 mg 4 B/D PA; MO B/D PA; MO gengraf oral solution 4 B/D PA; MO GILOTRIF ORAL TABLET 0 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG 5 PA; MO; QL (60 per 30 5 PA; MO; QL (40 per 30 5 PA; MO; QL (30 per 30 GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE 5 PA; MO; QL (1 per 8 ICLUSIG ORAL TABLET 15 MG 5 PA; MO; QL (90 per 30 14

ICLUSIG ORAL TABLET 45 MG idarubicin ifosfamide intravenous recon soln 1 gram imatinib oral tablet 100 mg imatinib oral tablet 400 mg 5 PA; MO; QL (30 per 30 5 PA; MO 5 PA; MO; QL (60 per 30 IMBRUVICA 5 PA; MO; QL (10 per 30 INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG 5 PA; MO 5 PA; MO; QL (10 per 30 IRESSA 5 PA; MO; QL (30 per 30 irinotecan intravenous solution 100 mg/5 ml ISTODAX JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG JAKAFI ORAL TABLET 5 MG 5 PA; MO 5 PA; MO; QL (60 per 30 JEVTANA KADCYLA INTRAVENOUS RECON SOLN 100 MG 5 PA; MO KEYTRUDA LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 0 MG/DAY (10 MG X ), 4 MG/DAY(10 MG X -4 MG X 1) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X), 8 MG/DAY (4 MG X ) 5 PA; MO 5 PA letrozole LEUKERAN leuprolide subcutaneous kit LONSURF 5 PA; MO LUPRON DEPOT 5 PA; MO LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) 5 PA; MO 5 PA; MO 5 PA; MO 15

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.5 MG, 15 MG 5 PA; MO LYNPARZA 5 PA; MO LYSODREN MATULANE megestrol oral suspension 400 mg/10 ml (40 mg/ml), 65 mg/5 ml megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET MG melphalan hcl 5 PA; MO PA; MO 5 PA; QL (10 mercaptopurine methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium oral mitomycin intravenous recon soln 0 mg, 5 mg 5 PA; QL (30 per 30 B/D PA B/D PA; MO B/D PA; MO mitomycin intravenous recon soln 40 mg mitoxantrone MUSTARGEN mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium B/D PA; MO 5 B/D PA; MO B/D PA; MO B/D PA; MO NEXAVAR 5 PA; MO; LA; QL (10 per 30 NILANDRON NINLARO ORAL CAPSULE.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG 5 PA; MO; QL (6 per 8 5 PA; MO; QL (4 per 8 5 PA; MO; QL (3 per 8 NULOJIX 5 B/D PA; MO octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml 16

octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml ODOMZO 5 PA; MO; LA; QL (30 per 30 OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 mg/0 ml paclitaxel PERJETA POMALYST PROGRAF INTRAVENOUS 3 B/D PA; MO PURIXAN RAPAMUNE ORAL SOLUTION 5 B/D PA; MO REVLIMID 5 PA; MO; LA RHEUMATREX 4 B/D PA; MO RITUXAN 5 PA; MO SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTEN DED REL RECON 3 B/D PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet mg 3 B/D PA; MO B/D PA; MO 5 B/D PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100 MG, 0 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 140 MG SPRYCEL ORAL TABLET 70 MG 5 PA; MO 5 PA; MO; QL (30 per 30 5 PA; MO; QL (60 per 30 STIVARGA 5 PA; MO; QL (84 per 8 SUTENT ORAL CAPSULE 1.5 MG SUTENT ORAL CAPSULE 5 MG, 37.5 MG SUTENT ORAL CAPSULE 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG 5 PA; MO 5 PA; MO; QL (60 per 30 5 PA; MO; QL (30 per 30 SYNRIBO 17

TABLOID tacrolimus oral B/D PA; MO TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG 5 PA; QL (180 5 PA; QL (10 5 PA; MO; LA; QL (60 per 30 5 PA; MO; LA; QL (30 per 30 tamoxifen TARCEVA ORAL TABLET 100 MG, 5 MG TARCEVA ORAL TABLET 150 MG 5 PA; MO 5 PA; MO; QL (30 per 30 TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG TASIGNA ORAL CAPSULE 00 MG 5 PA; MO TECENTRIQ 5 LA 5 PA; MO; QL (11 per 8 THALOMID 5 PA; MO thiotepa toposar topotecan intravenous recon soln 5 TORISEL TREANDA INTRAVENOUS RECON SOLN 100 MG TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE 11.5 MG/ ML, 3.75 MG/ ML tretinoin (chemotherapy) TRISENOX TYKERB 5 PA; MO; LA; QL (180 per 30 VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (0 MG/ML) 5 B/D PA; MO VELCADE VENCLEXTA ORAL TABLET 10 MG, 50 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK 3 PA; LA 5 PA; LA 5 PA; LA; QL (4 per 180 18

vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml vincristine intravenous solution 1 mg/ml vinorelbine intravenous solution 50 mg/5 ml B/D PA; MO B/D PA B/D PA; MO VOTRIENT 5 PA; MO; QL (10 per 30 XALKORI ORAL CAPSULE 00 MG XALKORI ORAL CAPSULE 50 MG 5 PA; MO 5 PA; MO; QL (60 per 30 XTANDI 5 PA; MO; QL (10 per 30 YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (5 MG/ML) ZANOSAR ZELBORAF 5 PA; MO; QL (40 per 30 ZOLINZA ZORTRESS 5 B/D PA; MO ZYDELIG 5 PA; MO; QL (90 per 30 ZYKADIA 5 PA; MO; QL (150 per 30 ZYTIGA 5 PA; MO; QL (10 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 00 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS BRIVIACT ORAL 5 4 19

carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr 100 mg carbamazepine oral tablet extended release 1 hr 00 mg, 400 mg carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG 1 MO; + 1 MO; + clonazepam PA; MO diazepam rectal PA; MO DILANTIN 30 MG divalproex oral capsule, sprinkle divalproex oral tablet extended release 4 hr divalproex oral tablet,delayed release (dr/ec) 1 MO; + epitol ethosuximide felbamate oral suspension felbamate oral tablet 400 mg felbamate oral tablet 600 mg fosphenytoin injection solution 100 mg pe/ ml FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule gabapentin oral solution 50 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 1 MG, 16 MG lamotrigine oral tablet lamotrigine oral tablet extended release 4hr 100 mg, 00 mg, 5 mg, 50 mg 5 1 MO; + 1 MO; + 1 MO; + 0

lamotrigine oral tablet extended release 4hr 50 mg, 300 mg lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK 1,000 MG/100 ML, 1,500 MG/100 ML LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK 500 MG/100 ML levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 4 hr 3 LYRICA 3 PA; MO ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 0 MG 3 PA; MO 3 PA; MO oxcarbazepine PEGANONE phenobarbital phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution POTIGA primidone roweepra SABRIL ; LA SPRITAM 4 tiagabine topiramate oral capsule, sprinkle topiramate oral tablet PA; MO 1 PA; MO; + valproate sodium valproic acid valproic acid (as sodium salt) oral solution 50 mg/5 ml VIMPAT INTRAVENOUS 3 1

VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine bromocriptine oral capsule bromocriptine oral tablet carbidopa carbidopa-levodopa carbidopa-levodopaentacapone entacapone NEUPRO pramipexole oral tablet pramipexole oral tablet extended release 4 hr 0.375 mg, 0.75 mg,.5 mg, 3 mg, 4.5 mg pramipexole oral tablet extended release 4 hr 1.5 mg ropinirole oral tablet ropinirole oral tablet extended release 4 hr 1 mg ropinirole oral tablet extended release 4 hr mg, 4 mg, 6 mg, 8 mg selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate oral tablet 1.5 mg almotriptan malate oral tablet 6.5 mg dihydroergotamine injection dihydroergotamine nasal ; QL (4 per 8 ; QL (18 per 8 ; QL (8 per 8 frovatriptan QL (7 per 8 migergot naratriptan ; QL (18 per 8 rizatriptan ; QL (36 per 8 sumatriptan nasal spray,non-aerosol 0 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation ; QL (18 per 8 ; QL (36 per 8

sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml ; QL (18 per 8 ; QL (8 per 8 ; QL (8 per 8 ; QL (8 per 8 QL (8 per 8 zolmitriptan ; QL (18 per 8 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA AUBAGIO 5 PA; MO COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 3 mg donepezil oral tablet,disintegrating 5 PA; MO; QL (1 per 8 1 MO; + 1 MO; + galantamine GILENYA 5 PA; MO glatopa 5 PA; MO; QL (30 per 30 memantine oral solution memantine oral tablet PA; MO PA; MO NAMENDA XR 3 PA; MO NAMZARIC 3 PA; MO NUEDEXTA rivastigmine rivastigmine tartrate TECFIDERA 5 PA; MO tetrabenazine 5 PA; MO TYSABRI 5 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen cyclobenzaprine oral tablet PA; MO dantrolene LIORESAL INTRATHECAL SOLUTION,000 MCG/ML, 500 MCG/ML 3 B/D PA; MO 3

LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP pyridostigmine bromide tizanidine oral capsule mg, 4 mg tizanidine oral capsule 6 mg 3 B/D PA tizanidine oral tablet NARCOTIC ANALGESICS acetaminophencodeine oral solution 300 mg-30 mg /1.5 ml acetaminophencodeine oral tablet 300-15 mg, 300-30 mg acetaminophencodeine oral tablet 300-60 mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet mg QL (4500 per 30 ; QL (360 ; QL (180 ; QL (67 QL (67 per 30 ; QL (300 buprenorphine hcl sublingual tablet 8 mg ; QL (75 BUTRANS ; QL (4 per 8 codeine sulfate oral tablet duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet 10-35 mg, 5-35 mg, 7.5-35 mg fentanyl citrate buccal lozenge on a handle 1,00 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg fentanyl citrate buccal lozenge on a handle 00 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg ; QL (180 ; QL (4000 QL (000 per 30 ; QL (360 5 PA; MO; QL (39 per 30 5 PA; MO; QL (9 per 30 5 PA; MO; QL (10 per 30 5 PA; MO; QL (116 per 30 5 PA; MO; QL (77 per 30 5 PA; MO; QL (58 per 30 4

fentanyl transdermal patch 7 hour 100 mcg/hr fentanyl transdermal patch 7 hour 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodoneacetaminophen oral solution 7.5-35 mg/15 ml hydrocodoneacetaminophen oral tablet 10-300 mg, 10-35 mg,.5-35 mg, 5-300 mg, 5-35 mg, 7.5-300 mg, 7.5-35 mg hydrocodoneibuprofen oral tablet 10-00 mg, 5-00 mg, 7.5-00 mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml hydromorphone injection syringe mg/ml hydromorphone oral liquid hydromorphone oral tablet ; QL (9 per 30 ; QL (10 ; QL (5550 ; QL (360 ; QL (50 ; QL (40 QL (100 per 30 ; QL (1500 ; QL (180 hydromorphone oral tablet extended release 4 hr 1 mg, 8 mg hydromorphone oral tablet extended release 4 hr 16 mg hydromorphone oral tablet extended release 4 hr 3 mg ibuprofenoxycodone ; QL (60 ; QL (60 ; QL (47 ; QL (8 levorphanol tartrate ; QL (10 lorcet (hydrocodone) ; QL (360 lorcet plus oral tablet 7.5-35 mg ; QL (360 lortab 10-35 ; QL (360 lortab 5-35 ; QL (360 lortab 7.5-35 ; QL (360 methadone injection QL (160 per 30 methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg ; QL (600 ; QL (100 ; QL (10 5

methadone oral tablet 5 mg morphine concentrate oral solution morphine intravenous syringe mg/ml morphine intravenous syringe 4 mg/ml morphine oral capsule, er multiphase 4 hr 10 mg morphine oral capsule, er multiphase 4 hr 30 mg, 90 mg morphine oral capsule, er multiphase 4 hr 45 mg, 60 mg, 75 mg morphine oral capsule,extend.relea se pellets 10 mg, 0 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.relea se pellets 100 mg morphine oral capsule,extend.relea se pellets 80 mg ; QL (40 ; QL (300 QL (1000 per 30 QL (500 per 30 ; QL (50 ; QL (60 ; QL (60 ; QL (90 ; QL (60 ; QL (75 morphine oral solution ; QL (900 morphine oral tablet ; QL (180 morphine oral tablet extended release 100 mg morphine oral tablet extended release 15 mg, 30 mg morphine oral tablet extended release 00 mg morphine oral tablet extended release 60 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 0 mg oxycodone oral tablet 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral solution ; QL (60 ; QL (10 ; QL (30 ; QL (100 ; QL (360 ; QL (180 ; QL (100 ; QL (180 ; QL (134 ; QL (360 QL (800 per 30 6

oxycodoneacetaminophen oral tablet 10-35 mg,.5-35 mg, 5-35 mg, 7.5-35 mg ; QL (360 oxycodone-aspirin ; QL (360 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 30 MG, 40 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 1 hr 10 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 1 hr 15 mg, 0 mg oxymorphone oral tablet extended release 1 hr 30 mg ; QL (90 ; QL (67 ; QL (60 ; QL (00 ; QL (180 ; QL (90 ; QL (90 ; QL (67 oxymorphone oral tablet extended release 1 hr 40 mg reprexain oral tablet 10-00 mg, 5-00 mg ; QL (50 ; QL (50 vicodin ; QL (360 vicodin es ; QL (360 vicodin hp ; QL (360 zamicet QL (5550 per 30 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet -0.5 mg buprenorphinenaloxone sublingual tablet 8- mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution mg/ml butorphanol tartrate nasal ; QL (360 ; QL (90 ; QL (70 ; QL (360 ; QL (5 per 8 celecoxib diclofenac potassium 7

diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel 1 % diclofenacmisoprostol diflunisal etodolac fenoprofen oral tablet FLECTOR 4 PA; MO; QL (60 per 30 flurbiprofen ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg meclofenamate oral capsule 100 mg meclofenamate oral capsule 50 mg 1 MO; + mefenamic acid meloxicam oral suspension meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg 1 MO; + nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 0 mg/ml naloxone injection solution naloxone injection syringe 1 mg/ml 1 MO; QL (30 ; + ; QL (00 ; QL (100 naltrexone naproxen oral suspension naproxen oral tablet 1 MO; + naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 75 mg, 550 mg naproxen sodium oral tablet, er multiphase 4 hr NARCAN ; QL ( per 8 oxaprozin piroxicam 8

SUBOXONE SUBLINGUAL FILM 1-3 MG SUBOXONE SUBLINGUAL FILM - 0.5 MG SUBOXONE SUBLINGUAL FILM 4-1 MG, 8- MG ; QL (60 ; QL (360 ; QL (90 sulindac oral 1 MO; + tolmetin oral capsule tolmetin oral tablet 600 mg tramadol oral tablet ; QL (40 tramadol oral tablet extended release 4 hr 100 mg, 00 mg tramadol oral tablet, er multiphase 4 hr 300 mg tramadolacetaminophen VOLTAREN GEL TOPICAL GEL 1 % ; QL (30 ; QL (30 ; QL (40 PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTEN DED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTEN DED REL SYRING alprazolam oral tablet amitriptyline PA; MO amoxapine aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg aripiprazole oral tablet mg aripiprazole oral tablet 0 mg aripiprazole oral tablet 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet,disintegrating 10 mg aripiprazole oral tablet,disintegrating 15 mg ; QL (90 ; QL (60 ; QL (450 ; QL (60 ; QL (30 ; QL (180 ; QL (90 ; QL (60 ARISTADA armodafinil PA bupropion hcl oral tablet bupropion hcl oral tablet extended release 100 mg ; QL (10 9

bupropion hcl oral tablet extended release 150 mg bupropion hcl oral tablet extended release 00 mg bupropion hcl oral tablet extended release 4 hr 150 mg bupropion hcl oral tablet extended release 4 hr 300 mg ; QL (90 ; QL (60 ; QL (90 ; QL (60 buspirone chlorpromazine injection chlorpromazine oral tablet 10 mg, 00 mg, 5 mg, 50 mg chlorpromazine oral tablet 100 mg citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 0 mg citalopram oral tablet 40 mg clomipramine oral capsule 5 mg, 50 mg 1 MO; QL (10 ; + 1 MO; QL (60 ; + 1 MO; QL (30 ; + PA; MO clomipramine oral capsule 75 mg clonidine hcl oral tablet extended release 1 hr clorazepate dipotassium 4 PA; MO PA; MO clozapine oral tablet clozapine oral tablet,disintegrating 100 mg, 1.5 mg, 5 mg desipramine oral dexedrine dexmethylphenidate oral capsule,er biphasic 50-50 10 mg, 0 mg, 5 mg dexmethylphenidate oral capsule,er biphasic 50-50 15 mg, 30 mg, 40 mg dexmethylphenidate oral tablet dextroamphetamine oral capsule, extended release 10 mg, 15 mg dextroamphetamine oral capsule, extended release 5 mg dextroamphetamine oral tablet 30

dextroamphetamine -amphetamine diazepam intensol PA; MO diazepam oral solution 5 mg/5 ml (1 mg/ml) PA; MO diazepam oral tablet PA; MO doxepin oral PA; MO duloxetine oral capsule,delayed release(dr/ec) 0 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg ; QL (180 ; QL (10 ; QL (90 ; QL (60 EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 5 mg 1 MO; QL (60 ; + 1 MO; QL (30 ; + 1 MO; QL (10 ; + eszopiclone ST; MO; QL (30 FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET 10 MG FANAPT ORAL TABLET 1 MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTEGRA TING 150 MG, 00 MG FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 10 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 0 MG ; QL (70 5 QL (90 per 30 ; QL (60 ; QL (360 ; QL (180 ; QL (10 ; QL (90 ; QL (8 per 8 4 ; QL (8 per 8 ; QL (30 ; QL (180 31

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 40 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 80 MG fluoxetine oral capsule 10 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 0 mg fluphenazine decanoate ; QL (90 ; QL (45 1 MO; QL (40 ; + 1 MO; + 1 MO; QL (60 ; + ; QL (4 per 8 ; QL (40 fluphenazine hcl fluvoxamine oral capsule,extended release 4hr 100 mg fluvoxamine oral capsule,extended release 4hr 150 mg fluvoxamine oral tablet 100 mg ; QL (90 ; QL (60 ; QL (90 fluvoxamine oral tablet 5 mg fluvoxamine oral tablet 50 mg ; QL (360 ; QL (180 FORFIVO XL ; QL (30 GEODON INTRAMUSCULAR guanidine haloperidol 1 MO; + haloperidol decanoate haloperidol lactate HETLIOZ 5 PA; MO; QL (30 per 30 imipramine hcl PA; MO imipramine pamoate INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 34 MG/1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.5 ML 4 PA; MO INVEGA TRINZA LATUDA ORAL TABLET 10 MG ; QL (30 3

LATUDA ORAL TABLET 0 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG, 80 MG ; QL (40 ; QL (10 ; QL (60 lithium carbonate 1 MO; + lithium citrate oral solution 8 meq/5 ml lorazepam intensol PA; MO lorazepam oral tablet PA; MO loxapine succinate maprotiline MARPLAN metadate er methamphetamine PA; MO methylphenidate oral capsule, er biphasic 30-70 10 mg, 30 mg, 50 mg, 60 mg methylphenidate oral capsule,er biphasic 50-50 0 mg, 40 mg methylphenidate oral solution 10 mg/5 ml methylphenidate oral solution 5 mg/5 ml methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 4hr methylphenidate oral tablet,chewable mirtazapine oral tablet mirtazapine oral tablet,disintegrating 1 MO; + modafinil PA; MO molindone nefazodone nortriptyline NUPLAZID 5 olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg, 0 mg olanzapine oral tablet.5 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg ; QL (60 ; QL (30 ; QL (40 ; QL (10 ; QL (81 33

olanzapine oral tablet,disintegrating 10 mg olanzapine oral tablet,disintegrating 15 mg, 0 mg olanzapine oral tablet,disintegrating 5 mg olanzapinefluoxetine oral capsule 1-5 mg, 3-5 mg olanzapinefluoxetine oral capsule 1-50 mg, 6-5 mg, 6-50 mg ; QL (60 ; QL (30 ; QL (10 oxazepam PA; MO paliperidone oral tablet extended release 4hr 1.5 mg paliperidone oral tablet extended release 4hr 3 mg paliperidone oral tablet extended release 4hr 6 mg paliperidone oral tablet extended release 4hr 9 mg paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 0 mg ; QL (40 ; QL (10 ; QL (60 ; QL (41 1 MO; QL (180 ; + 1 MO; QL (90 ; + paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 4 hr 1.5 mg paroxetine hcl oral tablet extended release 4 hr 5 mg paroxetine hcl oral tablet extended release 4 hr 37.5 mg PAXIL ORAL SUSPENSION 1 MO; QL (60 ; + 1 MO; QL (45 ; + ; QL (180 ; QL (90 ; QL (60 perphenazine phenelzine pimozide PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 100 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 5 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 4 HR 50 MG ; QL (10 ; QL (480 ; QL (40 procentra protriptyline 34

quetiapine oral tablet 100 mg quetiapine oral tablet 00 mg quetiapine oral tablet 5 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET 1 MG REXULTI ORAL TABLET MG REXULTI ORAL TABLET 3 MG REXULTI ORAL TABLET 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 1.5 MG/ ML, 5 MG/ ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 MG/ ML, 50 MG/ ML ; QL (40 ; QL (10 ; QL (90 ; QL (81 ; QL (60 ; QL (480 ; QL (480 ; QL (40 ; QL (10 ; QL (60 ; QL (40 ; QL (30 risperidone oral solution risperidone oral tablet 0.5 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 1 mg risperidone oral tablet,disintegrating mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ; QL (480 1 MO; QL (190 ; + 1 MO; QL (960 ; + 1 MO; QL (480 ; + 1 MO; QL (40 ; + 1 MO; QL (161 ; + 1 MO; QL (10 ; + ; QL (190 ; QL (960 ; QL (480 ; QL (40 ; QL (161 ; QL (10 ROZEREM ; QL (30 35

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 4 HR 150 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 4 HR 00 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 4 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 4 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 4 HR 50 MG sertraline oral concentrate ; QL (60 ; QL (40 ; QL (10 ; QL (161 ; QL (10 ; QL (81 ; QL (60 ; QL (480 sertraline oral tablet 100 mg sertraline oral tablet 5 mg sertraline oral tablet 50 mg STRATTERA 1 MO; QL (60 ; + 1 MO; QL (40 ; + 1 MO; QL (10 ; + temazepam PA; MO thioridazine thiothixene 1 MO; + tranylcypromine trazodone 1 MO; + trifluoperazine trimipramine PA; MO TRINTELLIX ORAL TABLET 10 MG TRINTELLIX ORAL TABLET 0 MG TRINTELLIX ORAL TABLET 5 MG venlafaxine oral capsule,extended release 4hr 150 mg venlafaxine oral capsule,extended release 4hr 37.5 mg venlafaxine oral capsule,extended release 4hr 75 mg 3 QL (60 per 30 3 QL (30 per 30 3 QL (10 per 30 ; QL (60 ; QL (180 ; QL (90 36