Formulary List of Covered Drugs Health Partners Medicare

Transcription

1 04 Formulary List of Covered Drugs Health Partners Medicare

2 Health Partners Medicare Prime/PrimePlus (HMO) & Special (HMO SNP) Plans 04 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID , Version This formulary was updated on /4/03. For more recent information or other questions, please call Member Relations anytime at (TTY ), or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Health Partners Plans. When it refers to plan or our plan, it means Health Partners Medicare. This document includes a list of the drugs (formulary) for our plan which is current as of /4/03. 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, premium and/or copayments/coinsurance may change on January, 05. A-

3 What is the Health Partners Medicare Formulary? A formulary is a list of covered drugs selected by Health Partners Medicare 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. Health Partners Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Health Partners Medicare 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 04 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 04 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 09/3/03. To get updated information about the drugs covered by Health Partners Medicare, please call Member Relations anytime at (TTY ). Our contact information also appears on the front and back cover pages. Our print formulary will be updated, either by reprinting or through the use of correction sheets, in the event of mid-year non-maintenance formulary changes. 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, Cardiovascular Drugs. If you know what your drug is used for, look for the category name in the list that begins on page 3. 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 90. The Index provides an alphabetical list of all of the drugs included in A-

4 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? Health Partners Medicare 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: Health Partners Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Health Partners Plans before you fill your prescriptions. If you don t get approval, Health Partners Plans may not cover the drug. Quantity Limits: For certain drugs, Health Partners Medicare limits the amount of the drug that Health Partners Plans will cover. For example, Health Partners Medicare provides tablets per day per prescription for Endocet tablets, This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Health Partners Medicare 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, Health Partners Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Health Partners Medicare 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 3. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Health Partners Medicare 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 Health Partners Medicare formulary? on page A-4 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Relations at (TTY ) and ask if your drug is covered. A-3

5 If you learn that Health Partners Medicare does not cover your drug, you have two options: You can ask Member Relations for a list of similar drugs that are covered by Health Partners Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Health Partners Medicare. You can ask Health Partners Medicare 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 Health Partners Medicare Formulary? You can ask Health Partners Medicare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Health Partners Medicare 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, Health Partners Medicare 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. 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. 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. A-4

6 For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 9-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Medicare Part D Transition Policy for Current and New Enrollees We want to make sure that all new and current enrollees have a smooth and safe transition to the new contract year and their Medicare Part D prescription benefit. Upon enrollment, new and current enrollees receive benefit information including: A list of covered medications (this formulary). Plan requirements and coverage limits. Information on the process for requesting a prior authorization or formulary exception. Participating pharmacy network directory. This information provides details on formulary medication and coverage requirements. Prior authorization or a formulary exception may be needed for medications that: Have other available options that are similarly effective, safe, and are less expensive. Have limited uses or dosing based upon scientific studies or FDA approval. May be prescribed for conditions that are not a covered Part D benefit. Drugs that are not on our formulary. Require special handling or monitoring of labs. Quantity limits that exceed FDA dosing parameters. If you are currently taking a medication that requires a formulary exception or prior authorization, we realize that you may need time to work with your healthcare provider to consider formulary alternatives or request authorization for coverage. Working with your healthcare provider is your best way of getting the most value from your Medicare Part D prescription benefit. You ll avoid expensive prescription costs by considering available formulary options that have been proven to be equally effective and safe. During your first 90 days of eligibility: For new members, you can receive a temporary supply (up to 30-day supply) for the non-formulary prescribed Part D medications during the first 90 days of eligibility (unless the prescription is written by the prescriber for less than 30 days). After your first 30-day A-5

7 supply, we will not pay for these drugs even if you have been a member of our plan for less than 90 days. For enrollees in long-term care facilities, you can fill a temporary supply (up to a 3-day supply) for the non-formulary prescribed Part D medication during the first 90 days of eligibility (unless the prescription is written by the prescriber for less than 3 days). Also, additional refills during your 90-day transition may be provided, so you can work with your healthcare provider to find formulary medication options or request a coverage exception. If you are an enrollee in a long-term care facility and you are past the first 90 days of eligibility with our plan and you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover a 3-day emergency supply of that drug (unless your prescription is for fewer days) while you pursue a formulary exception. If you are a current member, you may receive up to a temporary 30-day supply of a drug that is not on the formulary or has new prior authorization restrictions in the new contract year within the first 90 days of renewal. After your first 30-day supply, we will not cover these drugs unless approved through the non-formulary exception process or through prior authorization. If you are a current member and have a change in treatment setting due to a change in the level of care you require you can ask us to make a formulary exception. Examples of level of care changes might include: Discharge from a hospital to home; Ending your skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and you now need to use your Part D plan; Changing from Hospice Status and reverting back to standard Medicare Part A and B coverage; Ending a long-term care stay and returning to the community; Discharges from chronic psychiatric hospitals with highly individualized drug regimens. For these unplanned transitions, you can ask us to make a formulary exception or appeal for continued coverage of your drug. In addition we will review requests for continuation of therapy on a case-by-case basis for members that have had a change in their level of care and are stabilized on drug regimens that if altered, are known to have risks. If you are a new or current member and receive coverage for a temporary medication fill, we will notify you if a formulary exception determination or prior authorization is needed for continued coverage of your medication. A-6

8 For more information For more detailed information about your Health Partners Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Health Partners Medicare, 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 -800-MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit A-7

9 Health Partners Medicare Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Health Partners Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page 90. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., DIOVAN) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if Health Partners Medicare has any special requirements for coverage of your drug. Drugs marked SP or LA: This prescription may be available only at certain pharmacies. For more information call Member Relations anytime at TTY users should call A-8

10 Health Partners Medicare 04 Formulary Table of Contents Analgesics...3 Anesthetics...6 Anti-Addiction/ Substance Abuse Treatment Agents...6 Antibacterials...7 Anticonvulsants...4 Antidementia Agents...7 Antidepressants...8 Antiemetics... Antifungals... Antigout Agents...3 Anti-Inflammatory Agents...3 Antimigraine Agents...4 Antimyasthenic Agents...5 Antimycobacterials...5 Antineoplastics...6 Antiparasitics...3 Antiparkinson Agents...3 Antipsychotics...34 Antispasticity Agents...36 Antivirals...37 Anxiolytics...4 Bipolar Agents...43 Blood Glucose Regulators...45 Blood Products/ Modifiers/ Volume Expanders...48 Cardiovascular Agents...50 Central Nervous System Agents...57 Dental And Oral Agents...59 Dermatological Agents...59 Enzyme Replacement/ Modifiers...60 Gastrointestinal Agents...6 Genitourinary Agents...63 Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)...64 Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)...67 Hormonal Agents, Stimulant/ Replacement/ Modifying (Prostaglandins)...68 Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)...68 Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)...7 Hormonal Agents, Suppressant (Adrenal)...7 Hormonal Agents, Suppressant (Parathyroid)...7 Hormonal Agents, Suppressant (Pituitary)...7 Hormonal Agents, Suppressant (Sex Hormones/ Modifiers)...73 Hormonal Agents, Suppressant (Thyroid)...73 Immunological Agents...73 Inflammatory Bowel Disease Agents...78 Metabolic Bone Disease Agents...79 Non-Frf...80 Ophthalmic Agents...83 Otic Agents...86 Respiratory Tract Agents...86

11 Skeletal Muscle Relaxants...90 Sleep Disorder Agents...9 Therapeutic Nutrients/ Minerals/ Electrolytes...9

12 Health Partners Medicare 04 Formulary Analgesics Analgesics acetaminophen-codeine oral solution /.5 ml acetaminophen-codeine tablet QL (3 per Day(s)) acetaminophen-codeine tablet QL ( per Day(s)) acetaminophen-codeine tablet QL (6 per Day(s)) butalbital-acetaminophen-caffeine-codeine capsule butalbital-acetaminophen tablet butalbital-acetaminophen-caffeine capsule butalbital-acetaminophen-caffeine tablet , butalbital-aspirin-caffeine capsule butalbital-aspirin-caffeine tablet ENDOCET TABLET 5-35 MG QL ( per Day(s)) hydrocodone-acetaminophen oral solution.5-08 /5 ml hydrocodone-acetaminophen oral solution /5 ml hydrocodone-acetaminophen tablet 0-35, 0-500, 0-650, 0-660, , hydrocodone-acetaminophen tablet 0-750, hydrocodone-acetaminophen tablet.5-500, 5-500, QL (0 per Day(s)) QL (6 per Day(s)) QL (5 per Day(s)) QL (8 per Day(s)) hydrocodone-acetaminophen tablet 5-35 QL ( per Day(s)) hydrocodone-ibuprofen tablet QL (5 per Day(s))

13 ORPHENADRINE COMPOUND TABLET MG oxycodone-acetaminophen capsule QL (8 per Day(s)) oxycodone-acetaminophen tablet.5-35, 5-35 oxycodone-aspirin tablet QL ( per Day(s)) pentazocine-acetaminophen tablet QL (6 per Day(s)) pentazocine-naloxone tablet QL ( per Day(s)) tramadol-acetaminophen tablet QL (8 per Day(s)) Nonsteroidal Anti-Inflammatory Drugs CELEBREX CAPSULE 00 MG, 00 MG, 400 MG, 50 MG diclofenac potassium tablet 50 diclofenac er tablet,extended release 4 hr 00 diclofenac sodium tablet,delayed release 5, 50, 75 diflunisal tablet 500 etodolac capsule 00, 300 etodolac tablet 400, 500 fenoprofen tablet 600 flurbiprofen tablet 00, 50 ibuprofen tablet 400, 600, 800 ibuprofen-oxycodone tablet ketoprofen capsule 50, 75 ketoprofen er 4 hr capsule,extended release 00 meclofenamate capsule 00, 50 meloxicam oral suspension 7.5 /5 ml PA QL ( per Day(s)) meloxicam tablet 5, 7.5 QL ( per Day(s)) nabumetone tablet 500, 750 naproxen oral suspension 5 /5 ml naproxen tablet 50, 375, 500 naproxen sodium tablet 75, 550 oxaprozin tablet 600 piroxicam capsule 0, 0 sulindac tablet 50, 00

14 tolmetin capsule 400 tolmetin tablet 00, 600 Opioid Analgesics, Long-Acting DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, MG/ML fentanyl transdermal patch 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg methadone oral solution 0 /5 ml, 5 /5 ml methadone tablet 0, 5 morphine er tablet,extended release 00, 5, 00, 30 morphine er tablet,extended release 60 morphine oral solution 0 /5 ml, 0 /5 ml morphine tablet 5, 30 morphine concentrate oral solution 00 /5 ml (0 /ml) OXYCONTIN TABLET,EXTENDED RELEASE 0 MG, 5 MG, 0 MG, 30 MG, 40 MG, 60 MG, 80 MG oxymorphone er tablet,extended release, hr 0, 5, 0, 30, 40, 5, 7.5 Opioid Analgesics, Short-Acting butorphanol tartrate nasal spray 0 /ml fentanyl transdermal patch 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg hydromorphone tablet, 4, 8 LAZANDA NASAL SPRAY 00 MCG/SPRAY, 400 MCG/SPRAY oxycodone capsule 5 oxycodone oral concentrate 0 /ml oxycodone tablet 0, 5, 0, 30, 5 oxymorphone tablet 0, 5 tramadol tablet 50 QL (0 per 6 Day(s)) QL (3 per Day(s)) PA; QL ( per Day(s)) QL (0 per 6 Day(s)) 3

15 Anesthetics Local Anesthetics lidocaine topical ointment 5 % lidocaine (pf) injection solution 0 /ml ( %), 5 /ml (0.5 %) lidocaine mucosal gel % lidocaine mucosal solution %, 4 % lidocaine mucous membrane jelly in applicator % lidocaine-prilocaine topical cream.5-.5 % LIDODERM ADHESIVE PATCH 5 %(700 MG/PATCH) Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/ Anti-Craving CAMPRAL TABLET,DELAYED RELEASE 333 MG disulfiram tablet 50, 500 naltrexone tablet 50 Vivitrol intramuscular suspension,extended release 380 Anti-Addiction/ Substance Abuse Treatment Agents SUBOXONE SUBLINGUAL FILM -0.5 MG, 8- MG Opioid Antagonists buprenorphine injection syringe 0.3 /ml 3 PA buprenorphine sublingual tablet, 8 PA naloxone injection syringe /ml naltrexone tablet 50 SUBOXONE SUBLINGUAL FILM -3 MG, 4- MG Vivitrol intramuscular suspension,extended release 380 Smoking Cessation Agents CHANTIX TABLET 0.5 MG, MG PA 3 4

16 CHANTIX STARTING MONTH BOX TABLETS IN DOSE PACK 0.5 ()- (4) MG NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY 0 MG/ML ZYBAN TABLET,SUSTAINED-RELEASE 50 MG Antibacterials Aminoglycosides amikacin injection solution,000 /4 ml, 00 / ml gentamicin eye drops 0.3 % gentamicin injection solution 40 /ml gentamicin topical cream 0. % gentamicin topical ointment 0. % gentamicin in sodium chloride(iso-osm) intravenous piggyback 00 /00 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin sulfate (pf) intravenous solution 80 /8 ml neomycin tablet 500 paromomycin capsule 50 streptomycin intramuscular solution gram Tobi solution for nebulization 300 /5 ml 3 Tobi Podhaler capsule with inhalation device 8 TOBRADEX EYE OINTMENT % tobramycin eye drops 0.3 % tobramycin in 0.9 % sodium chloride intravenous piggyback 60 /50 ml, 80 /00 ml tobramycin injection solution 0 /ml, 40 /ml Antibacterials colistin (colistimethate sodium) solution for injection 50 neomycin-polymyxin b gu irrigation solution 40-00,000 -unit/ml 3 5

17 Synercid intravenous solution Antibacterials, Other acetic acid ear solution % alcohol swabs bacitracin eye ointment 500 unit/gram bacitracin intramuscular solution 50,000 unit BACTROBAN NASAL OINTMENT % chloramphenicol sod succinate intravenous solution gram clindamycin capsule 50, 300, 75 clindamycin in dextrose 5% intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin intravenous solution 600 /4 ml clindamycin lotion % clindamycin phosphate topical swab % clindamycin topical gel % clindamycin topical solution % clindamycin vaginal cream % CUBICIN INTRAVENOUS SOLUTION 500 MG methenamine hippurate tablet gram metronidazole lotion 0.75 % metronidazole tablet 50, 500 metronidazole topical cream 0.75 % metronidazole topical gel 0.75 % metronidazole vaginal gel 0.75 % metronidazole in sodium chloride(iso) intravenous piggyback 500 /00 ml mupirocin topical ointment % mupirocin topical cream % ST nitrofurantoin oral suspension 5 /5 ml QL (0 per 365 Day(s)) nitrofurantoin macrocrystal capsule 50 QL ( per 30 Day(s)) nitrofurantoin monohydrate/macrocrystals capsule 00 polymyxin b sulfate solution for injection 500,000 unit 6

18 trimethoprim tablet 00 TYGACIL INTRAVENOUS SOLUTION 50 MG vancomycin capsule 5 QL (4 per Day(s)) vancomycin capsule 50 QL (8 per Day(s)) vancomycin intravenous solution,000, 0 gram, 500 ZYVOX INTRAVENOUS SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION 00 MG/5 ML PA; ST PA; ST ZYVOX TABLET 600 MG PA; ST Beta-Lactam, Cephalosporins cefaclor capsule 50, 500 cefaclor er tablet,extended release, hr 500 cefadroxil capsule 500 cefadroxil oral suspension 50 /5 ml, 500 /5 ml cefadroxil tablet gram cefazolin solution for injection gram, 0 gram, 500 cefazolin in dextrose (iso-osmotic) intravenous piggyback gram/50 ml cefdinir capsule 300 cefdinir oral suspension 5 /5 ml, 50 /5 ml cefepime solution for injection gram, gram cefotaxime solution for injection 0 gram cefotetan intravenous solution 0 gram cefotetan solution for injection gram, gram cefoxitin intravenous solution gram, 0 gram, gram cefoxitin in dextrose, iso-osmotic intravenous piggyback gram/50 ml, gram/50 ml cefpodoxime oral suspension 00 /5 ml, 50 /5 ml cefpodoxime tablet 00, 00 7

19 cefprozil oral suspension 5 /5 ml, 50 /5 ml cefprozil tablet 50, 500 ceftazidime solution for injection gram, gram, 6 gram ceftazidime in dextrose 5 % intravenous piggyback gram/50 ml, gram/50 ml ceftriaxone intravenous solution gram, gram ceftriaxone solution for injection 0 gram, 50 ceftriaxone solution for injection 500 cefuroxime axetil tablet 50, 500 cefuroxime sodium intravenous solution 7.5 gram cefuroxime sodium solution for injection.5 gram, 750 cephalexin capsule 50, 500 cephalexin oral suspension 5 /5 ml, 50 /5 ml SUPRAX CAPSULE 400 MG SUPRAX TABLET 400 MG Beta-Lactam, Other aztreonam solution for injection gram imipenem-cilastatin intravenous solution 50, 500 INVANZ SOLUTION FOR INJECTION GRAM meropenem intravenous solution 500 Beta-Lactam, Penicillins amoxicillin capsule 50, 500 amoxicillin chewable tablet 5, 50 amoxicillin oral suspension 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin tablet 500, 875 amoxicillin-potassium clavulanate chewable tablet , amoxicillin-potassium clavulanate oral suspension /5 ml, /5 ml, /5 ml, /5 ml 8

20 amoxicillin-potassium clavulanate tablet 50-5, 500-5, amoxicillin-potassium clavulanate tablet ext.release hr, ampicillin capsule 50, 500 ampicillin oral suspension 5 /5 ml, 50 /5 ml ampicillin solution for injection gram, 0 gram, 5 BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin capsule 50, 500 nafcillin solution for injection gram, 0 gram nafcillin in dextrose (iso-osmotic) intravenous piggyback gram/50 ml oxacillin solution for injection gram, 0 gram oxacillin in dextrose (iso-osmotic) intravenous piggyback gram/50 ml, gram/50 ml penicillin g pot in dextrose intravenous piggyback million unit/50 ml, 3 million unit/50 ml penicillin g potassium solution for injection 5 million unit penicillin g procaine intramuscular syringe. million unit/ ml penicillin g sodium solution for injection 5 million unit penicillin v potassium oral solution 5 /5 ml, 50 /5 ml penicillin v potassium tablet 50, 500 piperacillin-tazobactam intravenous solution gram, 4.5 gram Macrolides azithromycin intravenous solution 500 azithromycin oral suspension 00 /5 ml, 00 /5 ml azithromycin tablet 50 QL (5 per Day(s)) azithromycin tablet 500 QL (0 per 3 Day(s)) 9

21 azithromycin tablet 600 QL ( per Day(s)) clarithromycin er tablet,extended release 4 hr 500 clarithromycin oral suspension 5 /5 ml, 50 /5 ml clarithromycin tablet 50, 500 QL ( per Day(s)) ERY-TAB TABLET,DELAYED RELEASE 50 MG, 333 MG, 500 MG ERYTHROCIN INTRAVENOUS SOLUTION 500 MG erythromycin eye ointment 5 /gram (0.5 %) erythromycin tablet 50, 500 erythromycin ethylsuccinate tablet 400 erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % ZMAX ORAL SUSPENSION,EXTENDED RELEASE GRAM/60 ML Quinolones ciprofloxacin eye drops 0.3 % ciprofloxacin intravenous solution 400 /40 ml ciprofloxacin tablet 00, 50, 500, 750 ciprofloxacin er tablet,extended release 4hr mphase,000, 500 ciprofloxacin in dextrose 5 % intravenous piggyback 00 /00 ml levofloxacin eye drops 0.5 % levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /0 ml levofloxacin tablet 50, 500, 750 QL ( per Day(s)) levofloxacin in 5 % dextrose intravenous piggyback 500 /00 ml ofloxacin ear drops 0.3 % ofloxacin eye drops 0.3 % ofloxacin tablet 00, 300, 400 Sulfonamides BLEPH-0 EYE DROPS 0 % silver sulfadiazine topical cream % 0

22 sulfacetamide sodium eye drops 0 % sulfacetamide sodium (acne) topical suspension 0 % sulfadiazine tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim tablet , Tetracyclines demeclocycline tablet 50, 300 doxycycline hyclate capsule 00, 50 doxycycline hyclate intravenous solution 00 doxycycline hyclate tablet 00 doxycycline monohydrate oral suspension 5 /5 ml doxycycline monohydrate tablet 50, 50, 75 minocycline capsule 00, 50, 75 Anticonvulsants Anticonvulsants, Other levetiracetam er tablet,extended release 4 hr 500, 750 levetiracetam intravenous solution 500 /5 ml levetiracetam oral solution 00 /ml levetiracetam tablet,000, 750 QL (4 EA per Day(s)) levetiracetam tablet 50, 500 QL (3 EA per Day(s)) ONFI TABLET 0 MG, 0 MG, 5 MG ST-N phenobarbital oral elixir 0 /5 ml phenobarbital tablet 00, 5, 6., 30, 3.4, 60, 64.8, 97. POTIGA TABLET 00 MG, 300 MG, 400 MG, 50 MG Calcium Channel Modifying Agents ST-N CELONTIN CAPSULE 300 MG ST-N ethosuximide capsule 50 ethosuximide oral solution 50 /5 ml

23 LYRICA CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 5 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML zonisamide capsule 00, 5, 50 Gamma-Aminobutyric Acid (Gaba) Augmenting Agents divalproex er tablet,extended release 4 hr 50, 500 divalproex sprinkle capsule 5 divalproex tablet,delayed release 5, 50, 500 gabapentin capsule 00, 300, 400 gabapentin oral solution 50 /5 ml QL (6 ML per Day(s)) gabapentin tablet 600 QL (6 EA per Day(s)) gabapentin tablet 800 QL (4 EA per Day(s)) GABITRIL TABLET MG ST-N; QL (4 EA per Day(s)) GABITRIL TABLET 6 MG ST-N; QL (3 per Day(s)) GRALISE TABLET,EXTENDED RELEASE 300 MG, 600 MG GRALISE 30-DAY STARTER PACK TABLET,EXTENDED RELEASE 300 MG (9)- 600 MG (69) HORIZANT ER TABLET,EXTENDED RELEASE 600 MG primidone tablet 50, 50 ST-N ST-N Sabril oral powder packet ST-N; SP; LA Sabril tablet ST-N; SP; LA STAVZOR CAPSULE,DELAYED RELEASE 5 MG, 50 MG, 500 MG ST-N tiagabine tablet, 4 QL (4 per Day(s)) valproate sodium intravenous solution 500 /5 ml (00 /ml) valproic acid capsule 50 valproic acid (as sodium salt) oral solution 50 /5 ml Glutamate Reducing Agents felbamate oral suspension 600 /5 ml

24 felbamate tablet 400, 600 LAMICTAL ODT DISINTEGRATING TABLET 00 MG, 00 MG, 5 MG, 50 MG LAMICTAL STARTER (BLUE) KIT TABLETS IN A DOSE PACK 5 MG (35) LAMICTAL STARTER (GREEN) KIT TABLETS, DOSE PACK 5 MG (84) -00 MG (4) LAMICTAL STARTER (ORANGE) KIT TABLETS, DOSE PACK 5 MG (4) -00 MG (7) LAMICTAL XR STARTER (BLUE) TABLET,EXTEND RELEASE 5 MG () -50 MG (7) LAMICTAL XR STARTER (GREEN) TABLET,EXTENDED RELEASE PACK 50 MG(4)-00MG (4)-00 MG (7) LAMICTAL XR STARTER (ORANGE) TABLET,EXTENDED RELEASE PACK 5MG (4)-50 MG (4)-00MG (7) lamotrigine chewable dispersible tablet 5, 5 lamotrigine er tablet,extended release 4 hr 00, 00, 5, 50, 300, 50 lamotrigine tablet 00, 50, 00, 5 topiramate sprinkle capsule 5, 5 ST-N topiramate tablet 00, 00, 5, 50 QL (4 per Day(s)) Sodium Channel Agents BANZEL ORAL SUSPENSION 40 MG/ML ST-N BANZEL TABLET 00 MG, 400 MG ST-N carbamazepine chewable tablet 00 carbamazepine er tablet,extended release, hr 00, 400 carbamazepine oral suspension 00 /5 ml carbamazepine tablet 00 CARBATROL CAPSULE, EXTENDED RELEASE 00 MG, 00 MG, 300 MG ST-N DILANTIN CAPSULE 30 MG ST-N EPITOL TABLET 00 MG ST-N 3

25 EQUETRO CAPSULE, EXTENDED RELEASE 00 MG, 00 MG, 300 MG fosphenytoin injection solution 00 pe/ ml oxcarbazepine oral suspension 300 /5 ml oxcarbazepine tablet 50, 300, 600 ST-N PEGANONE TABLET 50 MG ST-N phenytoin chewable tablet 50 phenytoin oral suspension 5 /5 ml phenytoin sodium intravenous solution 50 /ml phenytoin sodium extended capsule 00, 00, 300 TEGRETOL XR TABLET,EXTENDED RELEASE 00 MG VIMPAT INTRAVENOUS SOLUTION 00 MG/0 ML ST-N ST-N VIMPAT ORAL SOLUTION 0 MG/ML ST-N VIMPAT TABLET 00 MG, 50 MG, 00 MG, 50 MG Antidementia Agents Antidementia Agents, Other ergoloid tablet Cholinesterase Inhibitors ST-N ARICEPT TABLET 3 MG QL ( per Day(s)) donepezil disintegrating tablet 0, 5 QL ( per Day(s)) donepezil tablet 0, 5 QL ( per Day(s)) EXELON ORAL SOLUTION MG/ML QL (6 per Day(s)) EXELON TRANSDERMAL 4 HOUR PATCH 3.3 MG/4 HOUR, 4.6 MG/4 HOUR, 9.5 MG/4 HOUR galantamine er 4 hr capsule,extended release 6, 4, 8 galantamine oral solution 4 /ml galantamine tablet, 4, 8 QL ( per Day(s)) rivastigmine capsule.5, 3, 4.5, 6 QL ( per Day(s)) N-Methyl-D-Aspartate (Nmda) Receptor Antagonist NAMENDA ORAL SOLUTION 0 MG/5 ML QL (0 per Day(s)) 4

26 NAMENDA TABLET 0 MG, 5 MG QL ( per Day(s)) NAMENDA TITRATION PAK TABLETS IN A DOSE PACK 5-0 MG NAMENDA XR CAPSULE SPRINKLE,ER 4HR 4 MG, MG, 8 MG, 7 MG NAMENDA XR CAPSULE,SPRINKLE,ER 4HR,DOSE PACK MG Antidepressants Antidepressants amitriptyline-chlordiazepoxide tablet.5-5, 5-0 fluoxetine tablet 60 olanzapine-fluoxetine capsule -5, -50, 3-5, 6-5, 6-50 perphenazine-amitriptyline tablet -0, -5, 4-0, 4-5, 4-50 Antidepressants, Other APLENZIN TABLET,EXTENDED RELEASE 74 MG, 348 MG, 5 MG BUDEPRION SR TABLET,EXTENDED RELEASE 00 MG, 50 MG BUPROBAN TABLET,EXTENDED RELEASE 50 MG bupropion hcl sr tablet,sustained-release 00, 50, 00 QL ( per Day(s)) ST ST QL ( EA per Day(s)) QL ( EA per Day(s)) QL ( EA per Day(s)) bupropion hcl tablet 00, 75 QL (4 EA per Day(s)) bupropion hcl xl 4 hr tablet, extended release 50, 300 FORFIVO XL TABLET,EXTENDED RELEASE 450 MG maprotiline tablet 5, 50, 75 mirtazapine disintegrating tablet 5, 30, 45 QL ( per Day(s)) QL ( per Day(s)) mirtazapine tablet 5, 30, 45, 7.5 QL ( per Day(s)) nefazodone tablet 00, 50, 50 QL ( per Day(s)) nefazodone tablet 50 QL (4 per Day(s)) nefazodone tablet 00 QL (3 per Day(s)) OLEPTRO ER TABLET,EXTENDED RELEASE 50 MG, 300 MG 5

27 SEROQUEL XR TABLET,EXTENDED RELEASE 50 MG, 00 MG SEROQUEL XR TABLET,EXTENDED RELEASE 300 MG, 400 MG, 50 MG trazodone tablet 00, 50, 300, 50 VIIBRYD TABLET 0 MG, 0 MG, 40 MG VIIBRYD TABLETS IN A DOSE PACK 0 MG (7)-0 MG (7)-40 MG (6) Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL 4 HOUR PATCH MG/4 HR, 6 MG/4 HR, 9 MG/4 HR MARPLAN TABLET 0 MG phenelzine tablet 5 tranylcypromine tablet 0 Serotonin/ Norepinephrine Reuptake Inhibitors citalopram oral solution 0 /5 ml QL ( per Day(s)) QL ( per Day(s)) citalopram tablet 0 QL ( per Day(s)) citalopram tablet 0, 40 QL (.5 per Day(s)) CYMBALTA CAPSULE,DELAYED RELEASE 0 MG, 30 MG, 60 MG desvenlafaxine er tablet,extended release 4 hr 00, 50 escitalopram oral solution 5 /5 ml QL (0 per Day(s)) escitalopram tablet 0, 0, 5 QL ( per Day(s)) fluoxetine capsule 0 QL (3 per Day(s)) fluoxetine capsule 0 QL (4 per Day(s)) fluoxetine capsule 40 QL ( per Day(s)) fluoxetine capsule,delayed release 90 fluoxetine oral solution 0 /5 ml fluoxetine tablet 0 QL (3 per Day(s)) fluoxetine tablet 0 QL (4 per Day(s)) fluvoxamine er capsule,extended release 4 hr 00, 50 fluvoxamine tablet 00 QL (3 per Day(s)) fluvoxamine tablet 5 QL ( per Day(s)) fluvoxamine tablet 50 QL (.5 per Day(s)) 6

28 paroxetine er tablet,extended release 4 hr.5, 5, 37.5 paroxetine tablet 0, 0, 30, 40 PAXIL ORAL SUSPENSION 0 MG/5 ML PEXEVA TABLET 0 MG, 0 MG, 30 MG, 40 MG PRISTIQ TABLET,EXTENDED RELEASE 00 MG, 50 MG sertraline oral concentrate 0 /ml QL (0 per Day(s)) sertraline tablet 00 QL ( per Day(s)) sertraline tablet 5 QL ( per Day(s)) sertraline tablet 50 QL (.5 per Day(s)) venlafaxine er capsule,extended release 4 hr 50 venlafaxine er capsule,extended release 4 hr 37.5, 75 venlafaxine er tablet,extended release 4 hr 50 venlafaxine er tablet,extended release 4 hr 5, 37.5, 75 venlafaxine tablet 00, 5, 37.5, 50, 75 Tricyclics amitriptyline tablet 0, 00, 50, 5, 50, 75 amoxapine tablet 00, 50, 5, 50 QL ( EA per Day(s)) QL ( EA per Day(s)) QL ( per Day(s)) QL ( per Day(s)) chlordiazepoxide capsule 0 QL (0 per Day(s)) chlordiazepoxide capsule 5 QL ( per Day(s)) chlordiazepoxide capsule 5 QL (8 per Day(s)) clomipramine capsule 5, 50, 75 desipramine tablet 0, 00, 50, 5, 50, 75 doxepin capsule 0, 00, 50, 5, 50, 75 doxepin oral concentrate 0 /ml imipramine tablet 0, 5, 50 imipramine pamoate capsule 00, 5, 50, 75 7

29 nortriptyline capsule 0, 5, 50, 75 protriptyline tablet 0, 5 PRUDOXIN TOPICAL CREAM 5 % SILENOR TABLET 3 MG, 6 MG trimipramine capsule 00, 5, 50 Antiemetics Antiemetics, Other chlorpromazine injection solution 5 /ml chlorpromazine tablet 0, 00, 00, 5, 50 diphenhydramine capsule 50 diphenhydramine injection solution 50 /ml hydroxyzine hcl intramuscular solution 5 /ml, 50 /ml hydroxyzine hcl syrup 0 /5 ml hydroxyzine hcl tablet 0, 5, 50 hydroxyzine pamoate capsule 00, 5, 50 meclizine tablet.5, 5 metoclopramide injection solution 5 /ml metoclopramide oral solution 5 /5 ml metoclopramide tablet 0, 5 perphenazine tablet 6,, 4, 8 prochlorperazine rectal suppository 5 prochlorperazine edisylate injection solution 0 / ml (5 /ml) prochlorperazine maleate tablet 0, 5 promethazine injection syringe 5 /ml promethazine rectal suppository.5, 5 promethazine syrup 6.5 /5 ml promethazine tablet.5, 5, 50 trimethobenzamide capsule 300 Emetogenic Therapy Adjuncts dronabinol capsule 0,.5, 5 EMEND CAPSULE 5 MG, 40 MG, 80 MG 8

30 EMEND CAPSULES IN A DOSE PACK MG granisetron intravenous solution /ml ( ml) granisetron tablet granisetron (pf) intravenous solution 00 mcg/ml ondansetron disintegrating tablet 4, 8 ondansetron hcl intravenous solution /ml ondansetron hcl oral solution 4 /5 ml ondansetron hcl tablet 4 QL (3 per 4 Day(s)) ondansetron hcl tablet 4, 8 QL (3 per Day(s)) Antifungals Antifungals AmBisome intravenous suspension 50 3 amphotericin b solution for injection 50 CANCIDAS INTRAVENOUS SOLUTION 50 MG, 70 MG ciclopirox shampoo % ciclopirox topical cream 0.77 % ciclopirox topical gel 0.77 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % clotrimazole topical cream % clotrimazole topical solution % clotrimazole troche 0 fluconazole oral suspension 0 /ml, 40 /ml fluconazole tablet 00, 00, 50 fluconazole tablet 50 QL ( per Day(s)) fluconazole in dextrose (iso-osmotic) intravenous piggyback 400 /00 ml flucytosine capsule 50, 500 griseofulvin microsize oral suspension 5 /5 ml griseofulvin microsize tablet 500 griseofulvin ultramicrosize tablet 5, 50 GYNAZOLE- VAGINAL CREAM % 9

31 itraconazole capsule 00 ketoconazole shampoo % ketoconazole tablet 00 ketoconazole topical cream % NOXAFIL ORAL SUSPENSION 00 MG/5 ML (40 MG/ML) nystatin oral suspension 00,000 unit/ml nystatin tablet 500,000 unit nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 unit/gram ONMEL TABLET 00 MG SPORANOX ORAL SOLUTION 0 MG/ML terbinafine tablet 50 QL ( per Day(s)) terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 VFEND ORAL SUSPENSION 00 MG/5 ML (40 MG/ML) voriconazole intravenous solution 00 voriconazole tablet 00, 50 Zolinza capsule 00 3 SP Antigout Agents Antigout Agents allopurinol tablet 00, 300 allopurinol intravenous solution 500 COLCRYS TABLET 0.6 MG QL (4 per Day(s)) probenecid tablet 500 Anti-Inflammatory Agents Nonsteroidal Anti-Inflammatory Drugs CELEBREX CAPSULE 00 MG, 00 MG, 400 MG, 50 MG diclofenac potassium tablet 50 diclofenac er tablet,extended release 4 hr 00 diclofenac sodium tablet,delayed release 5, 50, 75 PA 0

32 diflunisal tablet 500 etodolac capsule 00 etodolac tablet 400, 500 fenoprofen tablet 600 flurbiprofen tablet 00, 50 ibuprofen oral suspension 00 /5 ml ibuprofen tablet 400, 600, 800 ibuprofen-oxycodone tablet ketoprofen capsule 50, 75 ketoprofen er 4 hr capsule,extended release 00 meclofenamate capsule 00, 50 meloxicam oral suspension 7.5 /5 ml QL ( per Day(s)) meloxicam tablet 5, 7.5 QL ( per Day(s)) nabumetone tablet 500, 750 naproxen oral suspension 5 /5 ml naproxen tablet 50, 375, 500 naproxen sodium tablet 75, 550 oxaprozin tablet 600 piroxicam capsule 0, 0 sulindac tablet 50, 00 tolmetin capsule 400 tolmetin tablet 00, 600 Antimigraine Agents Antimigraine Agents methylergonovine tablet 0. TREXIMET TABLET MG ST Ergot Alkaloids dihydroergotamine injection solution /ml ERGOMAR SUBLINGUAL TABLET MG MIGRANAL NASAL SPRAY 0.5 MG/PUMP ACT. (4 MG/ML) Prophylactic BOTOX INJECTION 00 UNIT PA; SP divalproex er tablet,extended release 4 hr 50, 500

33 divalproex sprinkle capsule 5 divalproex tablet,delayed release 5, 50, 500 STAVZOR CAPSULE,DELAYED RELEASE 5 MG, 50 MG, 500 MG timolol tablet 0, 0, 5 topiramate sprinkle capsule 5, 5 ST-N topiramate tablet 00, 00, 5, 50 QL (4 per Day(s)) valproic acid capsule 50 valproic acid (as sodium salt) oral solution 50 /5 ml Serotonin (5-Ht) B/D Receptor Agonists naratriptan tablet,.5 QL (9 per 6 Day(s)) rizatriptan disintegrating tablet 0, 5 rizatriptan tablet 0, 5 QL (9 per 6 Day(s)) sumatriptan subcutaneous pen injector 6 /0.5 ml sumatriptan subcutaneous solution 6 /0.5 ml QL ( per 6 Day(s)) sumatriptan tablet 00, 5, 50 QL (9 per 6 Day(s)) Antimyasthenic Agents Parasympathomimetics guanidine tablet 5 MESTINON SYRUP 60 MG/5 ML MESTINON TIMESPAN TABLET,EXTENDED RELEASE 80 MG pyridostigmine bromide tablet 60 Antimycobacterials Antimycobacterials, Other dapsone tablet 00, 5 MYCOBUTIN CAPSULE 50 MG Antituberculars CAPASTAT SOLUTION FOR INJECTION GRAM ethambutol tablet 00, 400 isoniazid injection solution 00 /ml isoniazid oral solution 50 /5 ml isoniazid tablet 00, 300

34 pyrazinamide tablet 500 rifampin capsule 50, 300 rifampin intravenous solution 600 RIFATER TABLET MG SEROMYCIN CAPSULE 50 MG Antineoplastics Alkylating Agents ALKERAN INTRAVENOUS SOLUTION 50 MG SP Busulfex intravenous solution 60 /0 ml 3 SP CEENU CAPSULE 0 MG, 40 MG SP cyclophosphamide tablet 5, 50 SP Hexalen capsule 50 3 PA-N; SP LEUKERAN TABLET MG SP Matulane capsule 50 3 PA-N; SP melphalan intravenous solution 50 3 SEROMYCIN CAPSULE 50 MG Antiangiogenic Agents REVLIMID capsule 0, 5, 5, 5 Thalomid capsule 00, 50, 00, 50 Antiestrogens/Modifiers 3 PA-N; SP 3 PA-N; SP EMCYT CAPSULE 40 MG PA-N; SP FARESTON TABLET 60 MG PA-N; QL (4 per Day(s)) SOLTAMOX ORAL SOLUTION 0 MG/5 ML tamoxifen tablet 0, 0 Antimetabolites DROXIA CAPSULE 00 MG, 300 MG, 400 MG gemcitabine intravenous powder for solution gram hydroxyurea capsule 500 PURINETHOL TABLET 50 MG 3 SP TABLOID TABLET 40 MG PA-N Antineoplastics 3

35 ADRIAMYCIN PFS INTRAVENOUS SOLUTION MG/ML SP Alimta intravenous solution PA-N; SP Arranon intravenous solution 50 /50 ml 3 SP AVASTIN intravenous solution 5 /ml 3 PA-N; SP BICNU INTRAVENOUS SOLUTION 00 MG SP bleomycin solution for injection 30 unit SP carboplatin intravenous solution 0 /ml SP CERUBIDINE INTRAVENOUS SOLUTION 0 MG SP cisplatin intravenous solution /ml SP cladribine intravenous solution 0 /0 ml 3 SP CLOLAR intravenous solution 0 /0 ml 3 SP Cosmegen intravenous solution SP cytarabine injection solution 0 /ml SP cytarabine (pf) injection solution gram/0 ml (00 /ml) SP cytarabine (pf) solution for injection 500 SP dacarbazine intravenous solution 00 SP Dacogen intravenous solution 50 3 SP daunorubicin intravenous solution 5 /ml SP dexrazoxane intravenous solution SP Docefrez intravenous solution 0, 80 3 SP docetaxel intravenous solution 80 /4 ml (0 /ml), 80 /8 ml (0 /ml) DOXIL INTRAVENOUS SOLUTION MG/ML 3 SP SP doxorubicin intravenous solution 50 /5 ml SP Elitek intravenous solution.5 3 SP epirubicin intravenous solution 50 /5 ml SP Erbitux intravenous solution 00 /50 ml 3 SP Erivedge capsule 50 3 PA-N; SP Faslodex intramuscular syringe 50 /5 ml 3 SP Folotyn intravenous solution 40 / ml (0 /ml) 3 SP Gemzar intravenous solution gram 3 SP 4

36 Halaven intravenous solution / ml (0.5 /ml) 3 SP Herceptin intravenous solution SP idarubicin intravenous solution /ml 3 SP ifosfamide intravenous powder for solution gram 3 SP Inlyta tablet, 5 3 PA-N; SP irinotecan intravenous solution 00 /5 ml 3 SP Istodax intravenous solution 0 / ml 3 SP Ixempra intravenous solution 45 3 SP Jevtana intravenous solution 0 /ml (Final) 3 SP Kadcyla intravenous solution 00 3 Mekinist tablet 0.5, 3 SP mesna intravenous solution 00 /ml SP MESNEX INTRAVENOUS SOLUTION 00 MG/ML SP Mesnex tablet SP mitomycin intravenous solution 0 SP MUSTARGEN SOLUTION FOR INJECTION 0 MG SP Ontak intravenous solution 50 mcg/ml 3 PA-N; SP oxaliplatin intravenous solution 00 /0 ml 3 SP paclitaxel concentrate,intravenous 6 /ml SP pentostatin intravenous solution 0 3 PA-N; SP Perjeta intravenous solution 40 /4 ml (30 /ml) 3 SP Pomalyst capsule,, 3, 4 3 SP Proleukin intravenous solution million unit 3 SP Stivarga tablet 40 3 SP Tafinlar capsule 50, 75 3 SP thiotepa Solution for Injection 5 3 SP Treanda intravenous solution 00 3 SP Trisenox intravenous solution 0 /0 ml 3 SP Vectibix intravenous solution 00 /5 ml (0 /ml) 3 PA-N; SP Velcade Solution for Injection PA-N; SP Vidaza Solution for Injection 00 3 SP 5

37 vinblastine intravenous powder for solution 0 SP vincristine intravenous solution /ml SP vinorelbine intravenous solution 50 /5 ml SP Xtandi capsule 40 3 SP Zinecard intravenous solution 50 3 SP Antineoplastics, Other Abraxane intravenous solution 00 3 SP amifostine crystalline intravenous solution 500 Cometriq capsule 00 /day(80 []-0 []), 40 /day(80 []-0 [3]), 60 /day (0 [3]/day) fludarabine intravenous powder for solution 50 3 SP 3 PA-N; SP SP Fusilev intravenous solution 50 3 SP Iclusig tablet 5, 45 3 PA-N; SP leucovorin calcium solution for injection 00 SP leucovorin calcium solution for injection 350 SP leucovorin calcium tablet 0, 5, 5, 5 mitoxantrone concentrate,intravenous /ml SP Synribo subcutaneous solution PA-N; SP Yervoy intravenous solution 50 /0 ml (5 /ml) Zaltrap intravenous solution 00 /4 ml (5 /ml) 3 SP 3 SP Zelboraf tablet 40 3 PA-N; SP Aromatase Inhibitors, 3Rd Generation anastrozole tablet QL ( per Day(s)) exemestane tablet 5 letrozole tablet.5 Enzyme Inhibitors ETOPOPHOS INTRAVENOUS SOLUTION 00 MG SP etoposide intravenous solution 0 /ml SP Jakafi tablet 0, 5, 0, 5, 5 3 PA-N; SP 6

38 topotecan intravenous powder for solution 4 Molecular Target Inhibitors 3 SP Afinitor tablet 0, 5, PA-N; SP Bosulif tablet 00, SP Caprelsa tablet 00, PA-N; SP Gleevec tablet 00, PA-N; SP Nexavar tablet 00 3 PA-N; SP; QL (4 per Day(s)) Sprycel tablet 00, 40, 0, 50, 70, 80 3 PA-N; SP Sutent capsule.5 3 PA-N; SP; QL (3 per Day(s)) Sutent capsule 5, 50 3 PA-N; SP; QL ( per Day(s)) Tarceva tablet 00, 50, 5 3 PA-N; SP Tasigna capsule 50, 00 3 PA-N; SP Tykerb tablet 50 3 PA-N; SP Votrient tablet 00 3 PA-N; SP Xalkori capsule 00, 50 3 PA-N; SP Monoclonal Antibodies Arzerra intravenous solution 00 /5 ml 3 SP Rituxan concentrate,intravenous 0 /ml 3 SP Retinoids ATRALIN TOPICAL GEL 0.05 % AVITA TOPICAL CREAM 0.05 % AVITA TOPICAL GEL 0.05 % PANRETIN TOPICAL GEL 0. % RETIN-A MICRO TOPICAL GEL 0.04 %, 0. % Targretin capsule 75 3 PA-N; SP TARGRETIN TOPICAL GEL % PA-N; SP TRETIN-X TOPICAL COMBO PACK 0.05 %, 0.05 %, 0. % tretinoin topical cream 0.05 %, 0.05 %, 0. % tretinoin topical gel 0.0 %, 0.05 % tretinoin (chemotherapy) capsule 0 3 PA-N; SP Antiparasitics Anthelmintics 7

39 ALBENZA TABLET 00 MG BILTRICIDE TABLET 600 MG STROMECTOL TABLET 3 MG Antiprotozoals ALINIA ORAL SUSPENSION 00 MG/5 ML ALINIA TABLET 500 MG atovaquone-proguanil tablet chloroquine tablet 50, 500 COARTEM TABLET 0-0 MG DARAPRIM TABLET 5 MG hydroxychloroquine tablet 00 MALARONE PEDIATRIC TABLET MG mefloquine tablet 50 MEPRON ORAL SUSPENSION 750 MG/5 ML NEBUPENT SOLUTION FOR INHALATION 300 MG PENTAM SOLUTION FOR INJECTION 300 MG primaquine tablet 6.3 QL ( per Day(s)) quinine capsule 34 Pediculicides/ Scabicides lindane lotion % lindane shampoo % permethrin topical cream 5 % ULESFIA LOTION 5 % Antiparkinson Agents Anticholinergics benztropine injection solution / ml benztropine tablet 0.5,, diphenhydramine capsule 50 diphenhydramine injection solution 50 /ml trihexyphenidyl oral elixir 0.4 /ml trihexyphenidyl tablet, 5 8

40 Antiparkinson Agents NEUPRO TRANSDERMAL 4 HOUR PATCH MG/4 HOUR, MG/4 HOUR, 3 MG/4 HOUR, 4 MG/4 HOUR, 6 MG/4 HOUR, 8 MG/4 HOUR ST STALEVO 00 TABLET MG ST STALEVO 5 TABLET MG ST STALEVO 50 TABLET MG ST STALEVO 00 TABLET MG ST STALEVO 50 TABLET MG ST STALEVO 75 TABLET MG ST Antiparkinson Agents, Other amantadine hcl capsule 00 amantadine hcl syrup 50 /5 ml amantadine hcl tablet 00 entacapone tablet 00 TASMAR TABLET 00 MG Dopamine Agonists APOKYN subcutaneous cartridge 0 /ml 3 ST bromocriptine capsule 5 bromocriptine tablet.5 MIRAPEX ER TABLET,EXTENDED RELEASE MG, 0.75 MG,.5 MG,.5 MG, 3 MG, 3.75 MG, 4.5 MG pramipexole tablet 0.5, 0.5, 0.5, 0.75,,.5 ropinirole er tablet,extended release 4 hr,, 4, 6, 8 ropinirole tablet 0.5, 0.5,,, 3, 4, 5 Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa-levodopa disintegrating tablet 0-00, 5-00, 5-50 carbidopa-levodopa er tablet,extended release 5-00, carbidopa-levodopa tablet 0-00, 5-00, 5-50 QL (3 per Day(s)) 9