THE FORMULARY HOW TO USE THE FORMULARY

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2 THE FORMULARY Capital BlueCross (Capital) has created the Formulary to give members access to quality, affordable medications and to provide physicians with a reference list of preferred medications for cost-effective prescribing. The Formulary represents the cornerstone of drug therapy quality assurance and cost containment efforts. The Capital Formulary was developed and is maintained by the Capital BlueCross Pharmacy and Therapeutics (P&T) Committee. This committee, composed of practicing physicians from various medical specialties, practicing pharmacists, and other health care providers, reviews medications in all therapeutic categories based on safety and effectiveness and designates the most effective agent(s) in each class. Formulary development and maintenance is a dynamic process. The P&T Committee will regularly review new and existing medications to ensure the Formulary remains responsive to the needs of our members and providers. A provider may request a reconsideration of tier status for a medication on the Capital Formulary by completing a Formulary Status Reconsiderations Form or by writing a letter indicating the significant advantages of the specific drug product and mailing it to the address below: Pharmacy Services Capital BlueCross P&T Committee P.O. Box Harrisburg, PA The P&T Committee will review drug-specific requests and communicate the results of the review to the requesting provider. Patient-specific requests need to follow the Professional Provider dispute and appeal process. HOW TO USE THE FORMULARY The Formulary lists the most commonly prescribed medications by therapeutic class. Medications listed in bold lower case print are generic medications, and medications listed in all UPPER CASE PRINT are brand-name medications. For each drug listed, it is indicated whether that drug falls in the Generic category, Brand Preferred category or Brand Non-Preferred category. These categories are defined as follows: Generic Preferred () and Generic Non-Preferred ()*: Drugs that contain the same active ingredient(s) as their corresponding brand-name drug and have been approved by the U.S. Food and Drug Administration (FDA) for therapeutic equivalency to their brand-name product. (Not all strengths and formulations of generic drugs have the same tier status.) Brand Preferred (): Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found to have therapeutic advantage or overall value over non-preferred brands, factoring safety, efficacy, and cost. Brand Non-Preferred (): Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative generics, preferred brands or over-the-counter medications. *Please note that all plans do not include separate cost shares for generic preferred and generic non-preferred drugs. For plans that do not include separate cost shares, the generic cost share will be applied to both generic preferred and generic non-preferred drugs. Please also note that for specialty medications, the specialty generic cost share will apply to both generic preferred and generic nonpreferred specialty medications when applicable. To help maximize the pharmacy benefit, preferred formulary alternatives, where applicable, are provided. Please note that the information provided is not intended to substitute for the physician's independent 2

3 medical judgment based on the member's specific needs. The information contained in this document is current at the time of printing, is not all encompassing and is subject to change. The following Selectively Closed Formulary provides access to generic preferred, generic non-preferred, brand preferred and select brand non-preferred drugs. Under a selectively closed formulary, only select brand non-preferred drugs (non-formulary drugs) are covered unless approved via a Non-Formulary Consideration Process. The provider may request that coverage be granted when medically necessary. The Non-Formulary Consideration Process may require the trial and failure of two (2) formulary alternatives (if two are available) prior to approval of the non-formulary medication. Approvals will be member- and drugspecific. Each unique non-formulary drug exception must be reviewed and approved separately. As determined by the member s benefit plan, the member may share more of the cost for brand-name drugs, especially those designated as non-preferred brands. Despite being listed in the formulary, please note that some drugs are excluded by benefit design and therefore are not covered (see Benefit Exclusions/Limitations below). Newly-released brand-name drugs are not covered until the P&T Committee reviews the medication s safety and efficacy profile. Brand-name drugs that have an available generic equivalent, deemed suitable for substitution by the P&T Committee, are placed in the non-preferred brand category. The Formulary applies only to prescription medications dispensed in outpatient pharmacies. The Formulary does not apply to inpatient medications or to medications obtained from and/or administered by a physician or a home health agency. While Capital BlueCross strives to provide prompt notice of changes and updates, the Formulary, as well as the pharmacy clinical programs (such as prior authorization, quantity level limits, etc.), are subject to change. Please visit our website at for current information. If preferred, contact our pharmacy benefit manager via phone at the number listed below. CVS/caremark (for provider and member inquires) On behalf of Capital BlueCross, CVS/caremark assists in the administration of our prescription drug program. CVS/caremark is an independent pharmacy benefit manager. GENERIC DRUG SUBSTITUTION Generic drug substitution is encouraged if the FDA has determined the generic drug is bioequivalent to the brand-name product. The member's financial responsibility for a brand-name medication when a generic equivalent is available will vary as indicated below. For members with mandatory generic substitution, if the physician indicates "Dispense As Written" (DAW) or a member requests a brand-name product when a generic is available, the member is responsible for the cost difference between the brand-name medication and its generic cost (ancillary charge) in addition to the member's applicable brand copayment/coinsurance, up to the original cost of the brand-name medication. For members with restricted generic substitution, if a member requests a brand-name product when a generic is available, the member is responsible for the cost difference between the brand-name medication and its generic cost in addition to the member's applicable brand copayment/coinsurance, up to the original cost of the brand-name medication. If the physician indicates DAW, then the member pays the applicable copayment/coinsurance for the brand product and is not required to pay the ancillary charge. Capital encourages generic substitution, when possible and appropriate, to help reduce the member's out-ofpocket expense, plus help contain the overall cost of the prescription drug benefit. NON-PRESCRIPTION MEDICATION (OTC) POLICY* Select Over-The-Counter (OTC) products may be covered as determined by Capital BlueCross or if mandated by the Patient Protection and Affordable Care Act (PPACA). 3

4 If a prescription drug has an available OTC equivalent, the prescription drug will not be covered. Physicians and pharmacists should guide and refer members to the OTC equivalent product, when appropriate. *As mandated by PPACA, select Over-The-Counter medications may be covered at $0 cost share for members with individual coverage or members of a non-grandfathered group health plan. Please consult your employer for questions relating to grandfathered status. COMPOUND DRUG POLICY Prescribed compound drug products are considered Brand Non-Preferred () and require prior authorization. BENEFIT EXCLUSIONS / LIMITATIONS* Depending on the member's pharmacy benefit plan, some medications listed may not be covered for individual members based on benefit design purchased by the member or employer group. Examples of contractual exclusions include, but are not limited to: Appetite suppressants (weight loss) Infertility medications Drugs used for cosmetic purposes (wrinkles, hair loss, etc.) Erectile dysfunction medications Smoking cessation products Contraceptives Non self-administered injectable drugs Allergy serums Experimental and investigational (including off-label use) use Some types of vitamins (non-prenatal) Products with OTC equivalents *As mandated by PPACA, select medications in these drug classes may be covered at $0 cost share for members with individual coverage or members of a non-grandfathered group health plan. Please consult your employer for questions relating to grandfathered status. PRIOR AUTHORIZATION PROGRAM Pharmacy benefit plans include the prior authorization program. Prior authorization helps encourage appropriate and cost-effective use of certain drugs by allowing coverage only after clinical criteria are met. All clinical criteria are regularly reviewed and approved by the P&T Committee. Drugs requiring prior authorization are subject to change. Please always visit our website ( for the most up-to-date information on drugs requiring prior authorization. Drugs requiring prior authorization are designated in the Formulary by PAR (Prior Authorization Required) after the drug name. These drugs require prior authorization before members can obtain them as a covered benefit. For some drugs, part of the criteria may be automated (Enhanced Prior Authorization or EPA) to encourage first-line agents before second-line agents are utilized. If automated criteria are not met, then prior authorization is required by the physician (or representative) or pharmacist by calling / faxing the request with supporting clinical information to the pharmacy benefit manager at: QUANTITY LIMITATIONS CVS/caremark Prior Authorization Department Telephone: Fax: Some drug products may be subject to quantity limitations based on FDA-recommended doses or adopted clinical guidelines. These drugs are designated in the Formulary by QLL (Quantity Level Limits) after the 4

5 drug name. The purpose of these maximum quantity limits is to ensure the proper billing of products and encourage the use of therapeutically indicated drug regimens. Quantity limitations are subject to change. Please check your provider manual or the on-line formulary at our website ( for the most up-to-date information on drugs that are part of this program. If a quantity of medication exceeding the limit is required, the physician (or representative) or pharmacist should call / fax the request with supporting clinical information to the pharmacy benefit manager at: MAINTENANCE DRUGS CVS/caremark Prior Authorization Department Telephone: Fax: Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or longterm. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease and diabetes. INJECTABLE MEDICATION POLICY Self-administered pharmacy injectable medications are usually covered under the Capital BlueCross prescription drug benefit. Injectable medications that are not routinely self-administered are not covered under the prescription drug benefit, but may be covered under the member s medical benefit. Procurement of select medical injectable medications may be available from ACRO Pharmaceuticals (by calling or faxing ), Capital BlueCross specialty medical injectable provider, which will assist with distribution and billing of these medications. On behalf of Capital BlueCross, ACRO Pharmaceutical Services LLC assists in the administration of physician-administered specialty medications. ACRO Pharmaceutical Services is an independent company. SPECIALTY MEDICATION PROVIDER: OUTPATIENT PRESCRIPTION DRUG BENEFIT Specialty oral medications and self-administered injectable medications are available through Accredo under the Capital BlueCross outpatient prescription drug benefit. Members or providers can call or fax to receive more information on starting service. The following medications are available through Accredo. (This list is current as of the printing of this formulary but is subject to change.) On behalf of Capital BlueCross, Accredo Health Group, Inc. assists in the delivery of specialty medications directly to our Members. Accredo Health Group, Inc. is an independent company. Specialty Drugs ACTIMMUNE ACTEMRA PAR ADCIRCA PAR ADEMPAS PAR ADVATE AFINITOR ALPHANATE ALPHANINE SD AMPYRA PAR, QLL APOKYN ARANESP PAR ARCALYST AUBAGIO PAR AVONEX BEBULIN BEBULIN VH BENEFIX BERINERT CAPECITABINE CAPRELSA CARBAGLU CERDELGA PAR CHOLBAM PAR CHORIONIC GONADOTROPIN CIMZIA PAR, QLL COMETRIQ PAR COPAXONE CYSTADANE CYSTAGON PAR CYSTARAN EGRIFTA PAR ELIGARD ENBREL PAR, QLL ERIVEDGE PAR ESBRIET PAR EXJADE PAR EXTAVIA EPA FEIBA NF FEIBA VH FERRIPROX PAR FIRAZYR FIRMAGON FORTEO PAR FUZEON GILENYA PAR GILOTRIF PAR GLATOPA GLEEVEC 5

6 HARVONI PAR HELIXATE FS HEMOFIL M HIZENTRA HUMATE-P HUMIRA PAR, QLL HYCAMTIN IBRANCE PAR ICLUSIG PAR IMBRUVICA PAR INCRELEX PAR INLYTA PAR INTRON A JAKAFI PAR JUXTAPID PAR KALYDECO PAR KINERET PAR, QLL KOATE-DVI KOGENATE FS KORLYM PAR KUVAN LENVIMA PAR LETAIRIS PAR LEUKINE LEUPROLIDE ACETATE LUPRON DEPOT LYNPARZA PAR MATULANE MEKINIST PAR MONOCLATE-P MONONINE MOZOBIL PAR MYALEPT PAR NEULASTA NEUMEGA NEUPOGEN NEXAVAR NORDITROPIN PAR NOVAREL NOVOSEVEN RT OCTREOTIDE OFEV PAR ORENCIA 125 /ml PAR, QLL ORFADIN ORKAMBI PAR PEGASYS PEGINTRON EPA PEGINTRON REDIPEN EPA PREGNYL PROCRIT PAR PROFILNINE SD PROMACTA PULMOZYME REBETOL solution RECOMBINATE REVATIO SUSP PAR REVLIMID RIBASPHERE RIBAVIRIN SABRIL SAMSCA SANDOSTATIN LAR SENSIPAR SEROSTIM PAR SIGNIFOR PAR SILDENAFIL PAR SIMPONI PAR, QLL SOMATULINE PAR SOMAVERT SOVALDI PAR SPRYCEL STIVARGA PAR SUTENT SYNAREL TAFINLAR PAR TARCEVA PAR TARGRETIN TASIGNA TEMOZOLOMIDE THALOMID TIKOSYN TOBRAMYCIN INHALATION SOLN TRACLEER PAR TYKERB VALCHLOR VENTAVIS PAR VICTRELIS PAR VOTRIENT WILATE XALKORI XELJANZ PAR, QLL XENAZINE PAR XTANDI PAR ZELBORAF ZOLINZA ZYDELIG PAR ZYKADIA PAR ZYTIGA PAR LEGEND AL EPA and M OTC Age Limitations apply. Brand Non-Preferred: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative generics, preferred brands or over-thecounter medications. Brand Preferred: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found to have therapeutic advantage or overall value over non-preferred brands, factoring safety, efficacy, and cost. Enhanced Prior Authorization applies. Generic Preferred and Generic Non-Preferred: Drugs that contain the same active ingredient(s) as their corresponding brand-name drug and have been approved by the Food and Drug Administration (FDA) for therapeutic equivalency to their brand-name product. Maintenance Drugs: An M located after the drug class name indicates the drugs in the class are generally considered maintenance drugs. Over-The-Counter medication. 6

7 PAR PHC QLL SRx Lower case italicized letters UPPER CASE letters Prior Authorization Required. Preventive Health Care: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and are mandated by the Patient Protection and Affordable Care Act (PPACA) to have $0 cost share for members with individual coverage or members of a group health plan that is not "grandfathered" under PPACA. Please consult your employer for questions relating to grandfathered status. Quantity Level Limits apply. Specialty Drug available from Accredo. Generic; every strength or dosage form under the listed generic name may not apply. Indicates brand medication; every strength or dosage form under the listed name may not apply. NOTICE The information provided is intended to establish a guideline to help promote Formulary compliance, but it is in no way to be considered all encompassing. The Formulary is also in no way meant to interfere with the physician's independent medical judgment based on specific needs of the patient. The information contained herein is current at the time of printing and may be subject to change. Members should refer to their Certificate of Coverage for specific terms, conditions, exclusions and limitations relating to coverage. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission All rights reserved. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Capital BlueCross and CVS/caremark do not operate the websites/organizations listed below, nor are they responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by Capital BlueCross or CVS/caremark. 7

8 Effective 01/01/2016 Drug Name NATURAL PENICILLINS penicillin v potassium tab 250 penicillin v potassium tab 500 penicillin v potassium for soln 125 /5ml penicillin v potassium for soln 250 /5ml AMINOPENICILLINS amoxicillin (trihydrate) cap 250 amoxicillin (trihydrate) cap 500 amoxicillin (trihydrate) tab 500 amoxicillin (trihydrate) tab 875 amoxicillin (trihydrate) chew tab 125 amoxicillin (trihydrate) chew tab 250 amoxicillin (trihydrate) for susp 125 /5ml amoxicillin (trihydrate) for susp 200 /5ml amoxicillin (trihydrate) for susp 250 /5ml amoxicillin (trihydrate) for susp 400 /5ml ampicillin cap 250 ampicillin cap 500 ampicillin for susp 125 /5ml ampicillin for susp 250 /5ml PENICILLINASE-RESISTANT PENICILLINS dicloxacillin sodium cap 250 dicloxacillin sodium cap 500 PENICILLIN COMBINATIONS amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate chew tab amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml 8

9 amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate for susp /5ml amoxicillin & k clavulanate tab sr 12hr CEPHALOSPORINS - 1ST GENERATION cefadroxil cap 500 cefadroxil tab 1 gm cefadroxil for susp 250 /5ml cefadroxil for susp 500 /5ml cephalexin cap 250 cephalexin cap 500 cephalexin cap 750 cephalexin tab 250 cephalexin tab 500 cephalexin for susp 125 /5ml cephalexin for susp 250 /5ml CEPHALOSPORINS - 2ND GENERATION cefaclor cap 250 cefaclor cap 500 cefaclor for susp 125 /5ml cefaclor for susp 250 /5ml cefaclor for susp 375 /5ml CEFACLOR ER TAB 500MG cefprozil tab 250 cefprozil tab 500 cefprozil for susp 125 /5ml cefprozil for susp 250 /5ml cefuroxime axetil tab 250 cefuroxime axetil tab 500 CEFTIN SUS 125/5ML CEPHALOSPORINS - 3RD GENERATION cefdinir cap 300 cefdinir for susp 125 /5ml cefdinir for susp 250 /5ml cefditoren pivoxil tab 200 (base equivalent) cefditoren pivoxil tab 400 (base equivalent) SUPRAX CAP 400MG SUPRAX CHW 100MG SUPRAX CHW 200MG cefixime for susp 100 /5ml cefixime for susp 200 /5ml SUPRAX SUS 500/5ML 9

10 cefpodoxime proxetil tab 100 cefpodoxime proxetil tab 200 cefpodoxime proxetil for susp 50 /5ml cefpodoxime proxetil for susp 100 /5ml ceftibuten cap 400 CEDAX SUS 90MG/5ML ceftibuten for susp 180 /5ml ERYTHROMYCINS erythromycin tab 250 erythromycin tab 500 erythromycin w/ delayed release particles cap 250 erythrocin tab 250 e.e.s. 400 tab 400 AZITHROMYCIN azithromycin tab 250 azithromycin tab 500 azithromycin tab 600 azithromycin for susp 100 /5ml azithromycin for susp 200 /5ml azithromycin powd pack for susp 1 gm CLARITHROMYCIN clarithromycin tab 250 clarithromycin tab 500 clarithromycin for susp 125 /5ml clarithromycin for susp 250 /5ml clarithromycin tab sr 24hr 500 FIDAXOMICIN DIFICID TAB 200MG TETRACYCLINES demeclocycline hcl tab 150 demeclocycline hcl tab 300 doxycycline monohydrate cap 50 doxycycline monohydrate cap 75 doxycycline monohydrate cap 100 doxycycline monohydrate cap 150 doxycycline monohydrate tab 50 doxycycline monohydrate tab 75 doxycycline monohydrate tab 100 doxycycline monohydrate tab 150 doxycycline monohydrate for susp 25 /5ml doxycycline hyclate cap 50 doxycycline hyclate cap 100 doxycycline hyclate tab 20 10

11 doxycycline hyclate tab 100 doxycycline hyclate tab delayed release 75 doxycycline hyclate tab delayed release 100 doxycycline hyclate tab delayed release 150 minocycline hcl cap 50 minocycline hcl cap 75 minocycline hcl cap 100 minocycline hcl tab 50 minocycline hcl tab 75 minocycline hcl tab 100 minocycline hcl tab sr 24hr 45 minocycline hcl tab sr 24hr 90 minocycline hcl tab sr 24hr 135 tetracycline hcl cap 250 tetracycline hcl cap 500 FLUOROQUINOLONES ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 (base eq) ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 (base eq) ciprofloxacin hcl tab 100 (base equiv) ciprofloxacin hcl tab 250 (base equiv) ciprofloxacin hcl tab 500 (base equiv) ciprofloxacin hcl tab 750 (base equiv) levofloxacin tab 250 levofloxacin tab 500 levofloxacin tab 750 levofloxacin oral soln 25 /ml moxifloxacin hcl tab 400 (base equiv) ofloxacin tab 400 FACTIVE TAB 320MG AMINOGLYCOSIDES neomycin sulfate tab 500 paromomycin sulfate cap 250 tobramycin nebu soln 300 /5ml SRx SULFONAMIDES SULFADIAZINE TAB 500MG ANTIMYCOBACTERIAL AGENTS PASER GRA 4GM cycloserine cap 250 ethambutol hcl tab 100 ethambutol hcl tab

12 TRECATOR TAB 250MG isoniazid tab 100 isoniazid tab 300 isoniazid syrup 50 /5ml pyrazinamide tab 500 rifabutin cap 150 rifampin cap 150 rifampin cap 300 PRIFTIN TAB 150MG ANTI TB COMBINATIONS RIFAMATE CAP RIFATER TAB ANTIFUNGALS flucytosine cap 250 flucytosine cap 500 griseofulvin microsize tab 500 griseofulvin microsize susp 125 /5ml griseofulvin ultramicrosize tab 125 griseofulvin ultramicrosize tab 250 nystatin tab unit bio-statin pow terbinafine hcl tab 250 LAMISIL GRA 125MG LAMISIL GRA 187.5MG IMIDAZOLE-RELATED ANTIFUNGALS ketoconazole tab 200 fluconazole tab 50 fluconazole tab 100 fluconazole tab 150 fluconazole tab 200 fluconazole for susp 10 /ml fluconazole for susp 40 /ml itraconazole cap 100 NOXAFIL TAB 100MG NOXAFIL SUS 40MG/ML voriconazole tab 50 voriconazole tab 200 ANTIRETROVIRALS SELZENTRY TAB 150MG SELZENTRY TAB 300MG FUZEON INJ 90MG SRx ISENTRESS TAB 400MG ISENTRESS CHW 25MG ISENTRESS CHW 100MG ISENTRESS POW 100MG 12

13 REYATAZ CAP 150MG REYATAZ CAP 200MG REYATAZ CAP 300MG REYATAZ POW 50MG PREZISTA TAB 75MG PREZISTA TAB 150MG PREZISTA TAB 600MG PREZISTA TAB 800MG PREZISTA SUS 100MG/ML LEXIVA TAB 700MG LEXIVA SUS 50MG/ML CRIXIVAN CAP 200MG CRIXIVAN CAP 400MG VIRACEPT TAB 250MG VIRACEPT TAB 625MG NORVIR CAP 100MG NORVIR TAB 100MG NORVIR SOL 80MG/ML INVIRASE CAP 200MG INVIRASE TAB 500MG APTIVUS CAP 250MG APTIVUS SOL abacavir sulfate tab 300 (base equiv) ZIAGEN SOL 20MG/ML VIDEX SOL 2GM VIDEX SOL 4GM didanosine delayed release capsule 125 didanosine delayed release capsule 200 didanosine delayed release capsule 250 didanosine delayed release capsule 400 EMTRIVA CAP 200MG EMTRIVA SOL 10MG/ML lamivudine tab 150 lamivudine tab 300 lamivudine oral soln 10 /ml stavudine cap 15 stavudine cap 20 stavudine cap 30 stavudine cap 40 stavudine for oral soln 1 /ml zidovudine cap 100 zidovudine tab 300 zidovudine syrup 10 /ml VIREAD TAB 150MG VIREAD TAB 200MG VIREAD TAB 250MG 13

14 VIREAD TAB 300MG VIREAD POW 40MG/GM RESCRIPTOR TAB 100 MG RESCRIPTOR TAB 200MG SUSTIVA CAP 50MG SUSTIVA CAP 200MG SUSTIVA TAB 600MG INTELENCE TAB 25MG INTELENCE TAB 100MG INTELENCE TAB 200MG nevirapine tab 200 nevirapine susp 50 /5ml VIRAMUNE XR TAB 100MG nevirapine tab sr 24hr 400 EDURANT TAB 25MG EPZICOM TAB TRUVADA TAB lamivudine-zidovudine tab KALETRA TAB MG KALETRA TAB MG KALETRA SOL TRIUMEQ TAB abacavir sulfate-lamivudine-zidovudine tab ATRIPLA TAB COMPLERA TAB STRIBILD TAB CMV AGENTS valganciclovir hcl tab 450 (base equivalent) VALCYTE SOL 50MG/ML HEPATITIS AGENTS adefovir dipivoxil tab 10 entecavir tab 0.5 entecavir tab 1 BARACLUDE SOL.05MG/ML lamivudine tab 100 (hbv) TYZEKA TAB 600MG VICTRELIS CAP 200MG PAR; SRx PEGASYS INJ 180MCG/M SRx PEGASYS INJ PROCLICK SRx PEGASYS INJ SRx PEG-INTRON KIT 50MCG RP SRx, EPA PEG-INTRON KIT 80MCG SRx, EPA PEG-INTRON KIT 120MCG SRx, EPA 14

15 PEG-INTRON KIT 150 RP SRx, EPA ribavirin cap 200 SRx ribavirin tab 200 SRx ribasphere tab 400 SRx ribasphere tab 600 SRx REBETOL SOL 40MG/ML SRx SOVALDI TAB 400MG PAR; SRx HARVONI TAB MG PAR; SRx HERPES AGENTS acyclovir cap 200 acyclovir tab 400 acyclovir tab 800 acyclovir susp 200 /5ml valacyclovir hcl tab 500 valacyclovir hcl tab 1 gm famciclovir tab 125 famciclovir tab 250 famciclovir tab 500 INFLUENZA AGENTS rimantadine hydrochloride tab 100 TAMIFLU CAP 30MG QLL (20 caps per Rx; max of 2 prescriptions per year) TAMIFLU CAP 45MG QLL (10 caps per Rx; max of 2 prescriptions per year) TAMIFLU CAP 75MG QLL (10 caps per Rx; max of 2 prescriptions per year) TAMIFLU SUS 6MG/ML QLL (240 ml's per Rx; max of 2 prescriptions per year) RELENZA MIS DISKHALE QLL (1 kit per prescription); Limit of 2 prescriptions per year ANTIMALARIALS chloroquine phosphate tab 250 chloroquine phosphate tab 500 hydroxychloroquine sulfate tab 200 mefloquine hcl tab 250 PRIMAQUINE TAB 26.3MG DARAPRIM TAB 25MG quinine sulfate cap 324 ANTIMALARIAL COMBINATIONS COARTEM TAB MG atovaquone-proguanil hcl tab

16 atovaquone-proguanil hcl tab ANTHELMINTICS ALBENZA TAB 200MG ivermectin tab 3 BILTRICIDE TAB 600MG ANTI-INFECTIVE AGENTS - MISC. CAYSTON INH 75MG metronidazole cap 375 metronidazole tab 250 metronidazole tab 500 NEBUPENT INH 300MG XIFAXAN TAB 200MG XIFAXAN TAB 550MG tinidazole tab 250 tinidazole tab 500 trimethoprim tab 100 vancomycin hcl cap 125 vancomycin hcl cap 250 KETOLIDES KETEK TAB 300MG KETEK TAB 400MG LINCOSAMIDES clindamycin hcl cap 75 clindamycin hcl cap 150 clindamycin hcl cap 300 clindamycin palmitate hcl for soln 75 /5ml (base equiv) OXAZOLIDINONES linezolid tab 600 ZYVOX SUS 100MG/5M SIVEXTRO TAB 200MG LEPROSTATICS dapsone tab 25 dapsone tab 100 ANTIPROTOZOAL AGENTS atovaquone susp 750 /5ml ALINIA TAB 500MG ALINIA SUS 100/5ML ANTI-INFECTIVE MISC. - COMBINATIONS sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim susp /5ml 16

17 IMMUNE SERUMS HIZENTRA INJ 1GM/5ML SRx HIZENTRA INJ 2GM/10ML SRx HIZENTRA INJ 4GM/20ML SRx HIZENTRA INJ 10/50ML SRx ALKYLATING AGENTS HEXALEN CAP 50MG MYLERAN TAB 2MG LEUKERAN TAB 2MG CYCLOPHOSPH CAP 25MG CYCLOPHOSPH CAP 50MG ALKERAN TAB 2MG lomustine cap 10 lomustine cap 40 lomustine cap 100 temozolomide cap 5 SRx temozolomide cap 20 SRx temozolomide cap 100 SRx temozolomide cap 140 SRx temozolomide cap 180 SRx temozolomide cap 250 SRx ANTIMETABOLITES capecitabine tab 150 SRx capecitabine tab 500 SRx mercaptopurine tab 50 methotrexate sodium tab 2.5 (base equiv) TREXALL TAB 5MG TREXALL TAB 7.5MG TREXALL TAB 10MG TREXALL TAB 15MG methotrexate sodium inj 25 /ml methotrexate sodium inj pf 25 /ml TABLOID TAB 40MG ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS ERIVEDGE CAP 150MG PAR; SRx ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS LYSODREN TAB 500MG bicalutamide tab 50 XTANDI CAP 40MG PAR; SRx flutamide cap 125 NILANDRON TAB 150MG 17

18 tamoxifen citrate tab 10 (base equivalent) tamoxifen citrate tab 20 (base equivalent) PAR; PHC, PAR is needed for coverage under PHC. Limited to women age 35 years and older with no previous history of breast cancer, ductal carcinoma in situ (CIS) or lobular carcinoma in situ. PAR; PHC, PAR is needed for coverage under PHC. Limited to women age 35 years and older with no previous history of breast cancer, ductal carcinoma in situ (CIS) or lobular carcinoma in situ. SOLTAMOX SOL 10MG/5ML FARESTON TAB 60MG anastrozole tab 1 exemestane tab 25 letrozole tab 2.5 EMCYT CAP 140MG megestrol acetate tab 20 megestrol acetate tab 40 megestrol acetate susp 40 /ml LUPRON DEPOT INJ 3.75MG SRx leuprolide acetate inj kit 5 /ml SRx LUPRON DEPOT INJ 7.5MG SRx ELIGARD INJ 7.5MG SRx LUPRON DEPOT INJ 11.25MG SRx LUPRON DEPOT INJ 22.5MG SRx ELIGARD INJ 22.5MG SRx LUPRON DEPOT INJ 30MG SRx ELIGARD INJ 30MG SRx ELIGARD INJ 45MG SRx LUPRON DEPOT INJ 45MG SRx FIRMAGON INJ 80MG SRx FIRMAGON INJ 120MG SRx ZYTIGA TAB 250MG PAR; SRx MITOTIC INHIBITORS etoposide cap 50 ANTINEOPLASTIC ENZYME INHIBITORS IBRANCE CAP 75MG PAR; SRx 18

19 IBRANCE CAP 100MG PAR; SRx IBRANCE CAP 125MG PAR; SRx ZOLINZA CAP 100MG SRx TAFINLAR CAP 50MG PAR; SRx TAFINLAR CAP 75MG PAR; SRx ZELBORAF TAB 240MG SRx AFINITOR TAB 2.5MG SRx AFINITOR TAB 5MG SRx AFINITOR TAB 7.5MG SRx AFINITOR TAB 10MG SRx AFINITOR DIS TAB 2MG SRx AFINITOR DIS TAB 3MG SRx AFINITOR DIS TAB 5MG SRx STIVARGA TAB 40MG PAR; SRx NEXAVAR TAB 200MG SRx SUTENT CAP 12.5MG SRx SUTENT CAP 25MG SRx SUTENT CAP 37.5MG SRx SUTENT CAP 50MG SRx MEKINIST TAB 0.5MG PAR; SRx MEKINIST TAB 2MG PAR; SRx GILOTRIF TAB 20MG PAR; SRx GILOTRIF TAB 30MG PAR; SRx GILOTRIF TAB 40MG PAR; SRx INLYTA TAB 1MG PAR; SRx INLYTA TAB 5MG PAR; SRx COMETRIQ KIT 60MG PAR; SRx COMETRIQ KIT 100MG PAR; SRx COMETRIQ KIT 140MG PAR; SRx ZYKADIA CAP 150MG PAR; SRx XALKORI CAP 200MG SRx XALKORI CAP 250MG SRx SPRYCEL TAB 20MG SRx SPRYCEL TAB 50MG SRx SPRYCEL TAB 70MG SRx SPRYCEL TAB 80MG SRx SPRYCEL TAB 100MG SRx SPRYCEL TAB 140MG SRx TARCEVA TAB 25MG PAR; SRx TARCEVA TAB 100MG PAR; SRx TARCEVA TAB 150MG PAR; SRx IMBRUVICA CAP 140MG PAR; SRx GLEEVEC TAB 100MG SRx GLEEVEC TAB 400MG SRx TYKERB TAB 250MG SRx LENVIMA CAP 10MG PAR; SRx 19

20 LENVIMA CAP 20MG PAR; SRx LENVIMA CAP 14MG PAR; SRx LENVIMA CAP 24MG PAR; SRx TASIGNA CAP 150MG SRx TASIGNA CAP 200MG SRx VOTRIENT TAB 200MG SRx ICLUSIG TAB 15MG PAR; SRx ICLUSIG TAB 45MG PAR; SRx CAPRELSA TAB 100MG SRx CAPRELSA TAB 300MG SRx LYNPARZA CAP 50MG PAR; SRx JAKAFI TAB 5MG PAR; SRx JAKAFI TAB 10MG PAR; SRx JAKAFI TAB 15MG PAR; SRx JAKAFI TAB 20MG PAR; SRx JAKAFI TAB 25MG PAR; SRx ZYDELIG TAB 100MG PAR; SRx ZYDELIG TAB 150MG PAR; SRx TOPOISOMERASE I INHIBITORS HYCAMTIN CAP 0.25MG SRx HYCAMTIN CAP 1MG SRx ANTINEOPLASTICS MISC. hydroxyurea cap 500 MATULANE CAP 50MG SRx INTRON A INJ 18MU SRx INTRON A INJ 25MU SRx INTRON A INJ 10MU SRx INTRON A INJ 18MU SRx INTRON A INJ 50MU SRx ACTIMMUNE INJ 2MU/0.5 SRx tretinoin cap 10 bexarotene cap 75 CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS leucovorin calcium tab 5 leucovorin calcium tab 10 leucovorin calcium tab 15 leucovorin calcium tab 25 MESNEX TAB 400MG GLUCOCORTICOSTEROIDS budesonide cap sr 24hr 3 cortisone acetate tab 25 dexamethasone tab 0.5 dexamethasone tab 0.75 dexamethasone tab 1 dexamethasone tab

21 dexamethasone tab 2 dexamethasone tab 4 dexamethasone tab 6 dexamethasone elixir 0.5 /5ml DEXAMETHASON CON 1MG/ML dexamethasone soln 0.5 /5ml hydrocortisone tab 5 hydrocortisone tab 10 hydrocortisone tab 20 methylprednisolone tab 4 methylprednisolone tab 8 methylprednisolone tab 16 methylprednisolone tab 32 methylprednisolone tab 4 dose pack prednisolone syrup 15 /5ml (usp solution equivalent) prednisolone sod phosphate oral soln 15 /5ml (base equiv) prednisolone sodium phosphate oral soln 25 /5ml (base eq) prednisolone sod phosph oral soln 6.7 /5ml (5 /5ml base) prednisone tab 1 prednisone tab 2.5 prednisone tab 5 prednisone tab 10 prednisone tab 20 prednisone tab 50 PREDNISONE CON 5MG/ML prednisone oral soln 5 /5ml prednisone tab 5 dose pack prednisone tab 10 dose pack MINERALOCORTICOIDS fludrocortisone acetate tab 0.1 ANDROGENS danazol cap 50 danazol cap 100 danazol cap 200 ANDROXY TAB 10MG android cap 10 METHITEST TAB 10MG AXIRON SOL 30MG/ACT testosterone td gel 25 /2.5gm (1%) ANDROGEL GEL 1%(50MG) testosterone td gel 50 /5gm (1%) testosterone td gel 12.5 /act (1%) 21

22 ANDROGEL GEL 1.62% ANDROGEL GEL 1.62% ANDROGEL GEL 1.62% ANDRODERM DIS 2MG/24HR ANDRODERM DIS 4MG/24HR testosterone cypionate im inj in oil 100 /ml testosterone cypionate im inj in oil 200 /ml testosterone enanthate im inj in oil 200 /ml ANABOLIC STEROIDS oxandrolone tab 2.5 oxandrolone tab 10 ANADROL-50 TAB 50MG ESTROGENS PREMARIN TAB 0.3MG PREMARIN TAB 0.45MG PREMARIN TAB 0.625MG PREMARIN TAB 0.9MG PREMARIN TAB 1.25MG ENJUVIA TAB 0.3MG ENJUVIA TAB 0.45MG ENJUVIA TAB 0.625MG ENJUVIA TAB 0.9MG ENJUVIA TAB 1.25MG MENEST TAB 0.3MG MENEST TAB 0.625MG MENEST TAB 1.25MG MENEST TAB 2.5MG estradiol tab 0.5 estradiol tab 1 estradiol tab 2 estradiol td patch weekly /24hr estradiol td patch weekly /24hr (37.5 mcg/24hr) estradiol td patch weekly 0.05 /24hr estradiol td patch weekly 0.06 /24hr estradiol td patch weekly /24hr estradiol td patch weekly 0.1 /24hr DEPO-ESTRADI INJ 5MG/ML estradiol valerate im in oil 20 /ml estradiol valerate im in oil 40 /ml estropipate tab 0.75 estropipate tab 1.5 estropipate tab 3 22

23 ESTROGEN COMBINATIONS est estrogen tab mtest hs esterified estrogens & methyltestosterone tab PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPRO TAB PREMPHASE TAB mimvey lo tab estradiol & norethindrone acetate tab COMBIPATCH DIS.05/.14 COMBIPATCH DIS.05/.25 norethindrone acetate-ethinyl estradiol tab mcg jinteli tab 1-5mcg CLIMARA PRO DIS WEEKLY PROGESTIN CONTRACEPTIVES - ORAL norlyroc tab 0.35 PHC PROGESTIN CONTRACEPTIVES - INJECTABLE medroxyprogesterone acetate im susp 150 PHC /ml DEPO-SQ PROV INJ 104 EMERGENCY CONTRACEPTIVES levonorgestrel tab 1.5 PHC ELLA TAB 30MG PHC COMBINATION CONTRACEPTIVES - TRANSDERMAL xulane dis PHC COMBINATION CONTRACEPTIVES - VAGINAL NUVARING MIS PHC COMBINATION CONTRACEPTIVES - ORAL reclipsen tab PHC gianvi tab PHC ocella tab PHC zovia 1/35e tab PHC zovia 1/50e tab PHC levonorgestrel & ethinyl estradiol tab 0.1 PHC -20 mcg marlissa tab 0.15/30 PHC zenchent tab PHC wera tab 0.5/35 PHC pirmella tab 1/35 PHC larin tab 1/20 PHC gildess tab 1.5/30 PHC 23

24 necon tab 1/50-28 PHC low-ogestrel tab PHC ogestrel tab PHC norgestimate & ethinyl estradiol tab 0.25 PHC -35 mcg BEYAZ TAB PHC SAFYRAL TAB PHC FALESSA KIT PHC wymzya fe chw PHC norethindrone & ethinyl estradiol-fe chew PHC tab mcg larin fe tab 1/20 PHC norethindrone ace-ethinyl estradiol-fe tab PHC 1-20 mcg (24) microgestin tab fe1.5/30 PHC MINASTRIN 24 CHW FE PHC desogest-eth estrad & eth estrad tab PHC 0.02/0.01 (21/5) NECON TAB 10/11-28 PHC LO LOESTRIN TAB PHC velivet pak PHC myzilra tab PHC pirmella tab 7/7/7 PHC leena tab PHC ORTHO TRI- TAB CYCLN LO PHC tri-estaryll tab PHC tilia fe tab PHC NATAZIA TAB PHC amethia lo tab PHC levonorgestrel & ethinyl estradiol (91-day) PHC tab ashlyna tab PHC QUARTETTE TAB PHC amethyst tab 90-20mcg PHC PROGESTINS medroxyprogesterone acetate tab 2.5 medroxyprogesterone acetate tab 5 medroxyprogesterone acetate tab 10 norethindrone acetate tab 5 progesterone im in oil 50 /ml progesterone micronized cap 100 progesterone micronized cap 200 INSULIN NOVOLOG INJ PENFILL NOVOLOG INJ FLEXPEN NOVOLOG INJ PENFILL 24

25 LANTUS INJ 100/ML LANTUS INJ SOLOSTAR TOUJEO SOLO INJ 300IU/ML APIDRA INJ U-100 PAR APIDRA INJ SOLOSTAR PAR HUMALOG INJ 100/ML PAR HUMALOG KWIK INJ 100/ML PAR HUMALOG KWIK INJ 200/ML PAR HUMALOG INJ 100/ML PAR LEVEMIR INJ LEVEMIR INJ FLEXTOUC HUMULIN R INJ U-100 PAR NOVOLIN R INJ U-100 HUMULIN R INJ U-500 HUMULIN N INJ U-100 PAR NOVOLIN N INJ U-100 HUMULIN N INJ U-100KWP PAR NOVOLOG MIX INJ 70/30 NOVOLOG MIX INJ FLEXPEN HUMALOG MIX SUS 75/25 PAR HUMALOG MIX INJ 50/50 PAR HUMALOG MIX INJ 75/25KWP PAR HUMALOG MIX INJ 50/50KWP PAR HUMULIN INJ 70/30 PAR NOVOLIN70/30 INJ RELION HUMULIN INJ 70/30KWP PAR ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 60 INJ 1000MCG EPA SYMLNPEN 120 INJ 1000MCG EPA INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) TRULICITY INJ 0.75/0.5 TRULICITY INJ 1.5/0.5 BYETTA INJ 5MCG PAR BYETTA INJ 10MCG PAR VICTOZA INJ 18MG/3ML SULFONYLUREAS chlorpropamide tab 100 chlorpropamide tab 250 glimepiride tab 1 glimepiride tab 2 glimepiride tab 4 glipizide tab 5 glipizide tab 10 glipizide xl tab 2.5 glipizide xl tab 5 25

26 glipizide xl tab 10 glyburide tab 1.25 glyburide tab 2.5 glyburide tab 5 glyburide micronized tab 1.5 glyburide micronized tab 3 glyburide micronized tab 6 tolazamide tab 250 tolazamide tab 500 tolbutamide tab 500 BIGUANIDES metformin hcl tab 500 metformin hcl tab 850 metformin hcl tab 1000 metformin hcl tab sr 24hr 500 metformin hcl tab sr 24hr 750 metformin hcl tab sr 24hr osmotic 500 metformin hcl tab sr 24hr osmotic 1000 MEGLITINIDE ANALOGUES nateglinide tab 60 nateglinide tab 120 repaglinide tab 0.5 repaglinide tab 1 repaglinide tab 2 DIABETIC OTHER GLUCAGON KIT 1MG GLUCAGEN INJ HYPOKIT PROGLYCEM SUS 50MG/ML GLUCOSE CHEW TAB 1 GM OTC GLUCOSE CHEW TAB 4 GM OTC GLUCOSE CHEW TAB 5 GM OTC glutose 15 gel 40% OTC KORLYM TAB 300MG PAR; SRx GLUCOSE-VITAMIN C CHEW TAB OTC ALPHA-GLUCOSIDASE INHIBITORS acarbose tab 25 acarbose tab 50 acarbose tab 100 GLYSET TAB 25MG GLYSET TAB 50MG GLYSET TAB 100MG DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS NESINA TAB 6.25MG PAR NESINA TAB 12.5MG PAR 26

27 NESINA TAB 25MG PAR TRADJENTA TAB 5MG ONGLYZA TAB 2.5MG PAR ONGLYZA TAB 5MG PAR JANUVIA TAB 25MG JANUVIA TAB 50MG JANUVIA TAB 100MG DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC CYCLOSET TAB 0.8MG INSULIN SENSITIZING AGENTS pioglitazone hcl tab 15 (base equiv) pioglitazone hcl tab 30 (base equiv) pioglitazone hcl tab 45 (base equiv) AVANDIA TAB 2MG AVANDIA TAB 4MG AVANDIA TAB 8MG SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA TAB 5MG FARXIGA TAB 10MG JARDIANCE TAB 10MG JARDIANCE TAB 25MG ANTIDIABETIC COMBINATIONS KAZANO TAB 500MG PAR KAZANO TAB 1000MG PAR JENTADUETO TAB JENTADUETO TAB JENTADUETO TAB KOMBIGLYZE TAB PAR KOMBIGLYZE TAB 5-500MG PAR KOMBIGLYZE TAB MG PAR JANUMET TAB MG JANUMET TAB JANUMET XR TAB MG JANUMET XR TAB JANUMET XR TAB OSENI TAB PAR OSENI TAB PAR OSENI TAB PAR OSENI TAB 25-15MG PAR OSENI TAB 25-30MG PAR OSENI TAB 25-45MG PAR XIGDUO XR TAB 5-500MG XIGDUO XR TAB MG XIGDUO XR TAB MG XIGDUO XR TAB

28 glipizide-metformin hcl tab glipizide-metformin hcl tab glipizide-metformin hcl tab glyburide-metformin tab glyburide-metformin tab glyburide-metformin tab pioglitazone hcl-glimepiride tab 30-2 pioglitazone hcl-glimepiride tab 30-4 pioglitazone hcl-metformin hcl tab pioglitazone hcl-metformin hcl tab ACTOPLUS MET TAB XR ACTOPLUS MET TAB XR AVANDAMET TAB MG THYROID HORMONES levoxyl tab 25mcg levoxyl tab 50mcg levoxyl tab 75mcg levoxyl tab 88mcg levoxyl tab 100mcg levothyroxine sodium tab 112 mcg levothyroxine sodium tab 125 mcg levoxyl tab 137mcg levothyroxine sodium tab 150 mcg unithroid tab 175mcg unithroid tab 200mcg unithroid tab 300mcg liothyronine sodium tab 5 mcg liothyronine sodium tab 25 mcg liothyronine sodium tab 50 mcg THYROLAR-1/4 TAB 15MG THYROLAR-1/2 TAB 30MG THYROLAR-1 TAB 60MG THYROLAR-2 TAB 120MG THYROLAR-3 TAB 180MG ARMOUR THYRO TAB 15MG NATURE-THROI TAB 16.25MG np thyroid tab 30 NATURE-THROI TAB 32.5MG NATURE-THROI TAB 48.75MG np thyroid tab 60 WP THYROID TAB 65MG NATURE-THROI TAB 81.25MG WESTHROID TAB 97.5MG NATURE-THROI TAB MG 28

29 ARMOUR THYRO TAB 120MG WP THYROID TAB 130MG NATURE THROI TAB 162.5MG ARMOUR THYRO TAB 180MG WESTHROID TAB 195MG ARMOUR THYRO TAB 240MG NATURE-THROI TAB 260MG ARMOUR THYRO TAB 300MG NATURE-THROI TAB 325MG NATURE-THROI TAB MG THYROID POW ANTITHYROID AGENTS methimazole tab 5 methimazole tab 10 propylthiouracil tab 50 OXYTOCICS methylergonovine maleate tab 0.2 BONE DENSITY REGULATORS alendronate sodium tab 5 alendronate sodium tab 10 alendronate sodium tab 35 QLL (4 tabs / 30 days) alendronate sodium tab 40 alendronate sodium tab 70 QLL (4 tabs / 28 days) alendronate sodium oral soln 70 /75ml FOSAMAX + D TAB QLL (4 tabs / 28 days); EPA FOSAMAX + D TAB QLL (4 tabs / 28 days); EPA etidronate disodium tab 200 etidronate disodium tab 400 ibandronate sodium tab 150 (base QLL (1 tabs / 28 days) equivalent) risedronate sodium tab 5 risedronate sodium tab 30 risedronate sodium tab 35 QLL (4 tabs / 30 days) risedronate sodium tab 150 QLL (1 tabs / 30 days) calcitonin (salmon) nasal soln 200 unit/act FORTEO SOL 600/2.4 PAR; SRx HORMONE RECEPTOR MODULATORS 29

30 raloxifene hcl tab 60 PAR; PHC, PAR is needed for coverage under PHC. Limited to women age 35 years and older with no previous history of breast cancer, ductal carcinoma in situ (CIS) or lobular carcinoma in situ. FERTILITY REGULATORS pregnyl inj 10000unt SRx clomiphene citrate tab 50 LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS LUPR DEP-PED INJ 7.5MG SRx LUPR DEP-PED INJ 11.25MG SRx LUPR DEP-PED INJ 15MG SRx LUPR DEP-PED INJ 11.25MG SRx LUPR DEP-PED INJ 30MG SRx SYNAREL SOL 2MG/ML SRx GROWTH HORMONES NORDITROPIN INJ 5/1.5ML PAR; SRx NORDITROPIN INJ 10/1.5ML PAR; SRx NORDITROPIN INJ 15/1.5ML PAR; SRx NORDITROPIN INJ 30/3ML PAR; SRx SEROSTIM INJ 4MG PAR; SRx SEROSTIM INJ 5MG PAR; SRx SEROSTIM INJ 6MG PAR; SRx GROWTH HORMONE RELEASING HORMONES (GHRH) EGRIFTA SOL 1MG PAR; SRx EGRIFTA SOL 2MG PAR; SRx INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX INJ 40MG/4ML PAR; SRx SOMATOSTATIC AGENTS SOMATULINE INJ 60/0.2ML PAR; SRx SOMATULINE INJ 90/0.3ML PAR; SRx SOMATULINE INJ 120/.5ML PAR; SRx octreotide acetate inj 50 mcg/ml (0.05 SRx /ml) octreotide acetate inj 100 mcg/ml (0.1 SRx /ml) octreotide acetate inj 200 mcg/ml (0.2 SRx /ml) octreotide acetate inj 500 mcg/ml (0.5 /ml) SRx 30

31 octreotide acetate inj 1000 mcg/ml (1 SRx /ml) SANDOSTATIN KIT LAR 10MG SRx SANDOSTATIN KIT LAR 20MG SRx SANDOSTATIN KIT LAR 30MG SRx SIGNIFOR INJ 0.3MG/ML PAR; SRx SIGNIFOR INJ 0.6MG/ML PAR; SRx SIGNIFOR INJ 0.9MG/ML PAR; SRx GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT INJ 10MG SRx SOMAVERT INJ 15MG SRx SOMAVERT INJ 20MG SRx SOMAVERT INJ 25MG SRx SOMAVERT INJ 30MG SRx POSTERIOR PITUITARY HORMONES desmopressin acetate tab 0.1 desmopressin acetate tab 0.2 STIMATE SOL 1.5MG/ML desmopressin acetate inj 4 mcg/ml desmopressin acetate nasal soln 0.01% (refrigerated) desmopressin acetate nasal spray soln 0.01% (refrigerated) PROLACTIN INHIBITORS cabergoline tab 0.5 VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA TAB 15MG SRx SAMSCA TAB 30MG SRx METABOLIC MODIFIERS levocarnitine tab 330 levocarnitine oral soln 1 gm/10ml (10%) ORFADIN CAP 2MG SRx ORFADIN CAP 5MG SRx ORFADIN CAP 10MG SRx CYSTADANE POW SRx calcitriol cap 0.25 mcg calcitriol cap 0.5 mcg calcitriol oral soln 1 mcg/ml doxercalciferol cap 0.5 mcg doxercalciferol cap 1 mcg doxercalciferol cap 2.5 mcg paricalcitol cap 1 mcg paricalcitol cap 2 mcg paricalcitol cap 4 mcg SENSIPAR TAB 30MG SRx 31

32 SENSIPAR TAB 60MG SRx SENSIPAR TAB 90MG SRx MYALEPT INJ 11.3MG PAR; SRx BUPHENYL TAB 500MG sodium phenylbutyrate oral powder 3 gm/teaspoonful CARBAGLU TAB 200MG SRx KUVAN POW 100MG SRx KUVAN POW 500MG SRx KUVAN TAB 100MG SRx CARDIAC GLYCOSIDES digoxin tab 125 mcg (0.125 ) digoxin tab 250 mcg (0.25 ) digoxin oral soln 0.05 /ml NITRATES DILATRATE SR CAP 40MG isosorbide dinitrate tab 5 isosorbide dinitrate tab 10 isosorbide dinitrate tab 20 isosorbide dinitrate tab 30 ISORDIL TAB 40MG isoditrate tab 40 er isosorbide mononitrate tab 10 isosorbide mononitrate tab 20 isosorbide mononitrate tab sr 24hr 30 isosorbide mononitrate tab sr 24hr 60 isosorbide mononitrate tab sr 24hr 120 nitroglycerin cap cr 2.5 nitroglycerin cap cr 6.5 nitroglycerin cap cr 9 NITROSTAT SUB 0.3MG NITROSTAT SUB 0.4MG NITROSTAT SUB 0.6MG nitroglycerin tl soln 0.4 /spray (400 mcg/spray) nitroglycerin lingual aerosol 400 mcg/spray NITRO-BID OIN 2% nitroglycerin td patch 24hr 0.1 /hr nitroglycerin td patch 24hr 0.2 /hr NITRO-DUR DIS 0.3MG/HR nitroglycerin td patch 24hr 0.4 /hr nitroglycerin td patch 24hr 0.6 /hr NITRO-DUR DIS 0.8MG/HR ANTIANGINALS-OTHER RANEXA TAB 500MG PAR 32

33 RANEXA TAB 1000MG PAR BETA BLOCKERS NON-SELECTIVE nadolol tab 20 nadolol tab 40 nadolol tab 80 LEVATOL TAB 20MG pindolol tab 5 pindolol tab 10 propranolol hcl tab 10 propranolol hcl tab 20 propranolol hcl tab 40 propranolol hcl tab 60 propranolol hcl tab 80 propranolol hcl oral soln 20 /5ml propranolol hcl oral soln 40 /5ml propranolol hcl cap sr 24hr 60 propranolol hcl cap sr 24hr 80 propranolol hcl cap sr 24hr 120 propranolol hcl cap sr 24hr 160 sorine tab 80 sorine tab 120 sorine tab 160 sorine tab 240 sotalol hcl (afib/afl) tab 80 sotalol hcl (afib/afl) tab 120 sotalol hcl (afib/afl) tab 160 timolol maleate tab 5 timolol maleate tab 10 timolol maleate tab 20 BETA BLOCKERS CARDIO-SELECTIVE acebutolol hcl cap 200 acebutolol hcl cap 400 atenolol tab 25 atenolol tab 50 atenolol tab 100 betaxolol hcl tab 10 betaxolol hcl tab 20 bisoprolol fumarate tab 5 bisoprolol fumarate tab 10 metoprolol succinate tab sr 24hr 25 metoprolol succinate tab sr 24hr 50 metoprolol succinate tab sr 24hr 100 metoprolol succinate tab sr 24hr 200 metoprolol tartrate tab 25 metoprolol tartrate tab 50 33

34 metoprolol tartrate tab 100 BYSTOLIC TAB 2.5MG BYSTOLIC TAB 5MG BYSTOLIC TAB 10MG BYSTOLIC TAB 20MG ALPHA-BETA BLOCKERS carvedilol tab carvedilol tab 6.25 carvedilol tab 12.5 carvedilol tab 25 labetalol hcl tab 100 labetalol hcl tab 200 labetalol hcl tab 300 CALCIUM CHANNEL BLOCKERS amlodipine besylate tab 2.5 amlodipine besylate tab 5 amlodipine besylate tab 10 diltiazem hcl tab 30 diltiazem hcl tab 60 diltiazem hcl tab 90 diltiazem hcl tab 120 diltiazem hcl cap sr 12hr 60 diltiazem hcl cap sr 12hr 90 diltiazem hcl cap sr 12hr 120 diltiazem hcl cap sr 24hr 120 diltiazem hcl cap sr 24hr 180 diltiazem hcl cap sr 24hr 240 diltiazem hcl extended release beads cap sr 24hr 120 diltiazem hcl extended release beads cap sr 24hr 180 diltiazem hcl extended release beads cap sr 24hr 240 diltiazem hcl extended release beads cap sr 24hr 300 taztia xt cap 360/24 diltiazem hcl extended release beads cap sr 24hr 420 diltiazem hcl coated beads cap sr 24hr 120 diltiazem hcl coated beads cap sr 24hr 180 diltiazem hcl coated beads cap sr 24hr 240 diltiazem hcl coated beads cap sr 24hr

35 diltiazem hcl coated beads cap sr 24hr 360 diltiazem hcl coated beads tab sr 24hr 180 diltiazem hcl coated beads tab sr 24hr 240 diltiazem hcl coated beads tab sr 24hr 300 diltiazem hcl coated beads tab sr 24hr 360 diltiazem hcl coated beads tab sr 24hr 420 felodipine tab sr 24hr 2.5 felodipine tab sr 24hr 5 felodipine tab sr 24hr 10 isradipine cap 2.5 isradipine cap 5 nicardipine hcl cap 20 nicardipine hcl cap 30 nifedipine cap 10 nifedipine cap 20 afeditab tab 30 cr nifedipine tab sr 24hr 60 nifedipine tab sr 24hr 90 nifedipine tab sr 24hr osmotic 30 nifedipine tab sr 24hr osmotic 60 nifedipine tab sr 24hr osmotic 90 nimodipine cap 30 nisoldipine tab sr 24hr 8.5 nisoldipine tab sr 24hr 17 nisoldipine tab sr 24hr 20 nisoldipine tab sr 24hr 25.5 nisoldipine tab sr 24hr 30 nisoldipine tab sr 24hr 34 nisoldipine tab sr 24hr 40 verapamil hcl tab 40 verapamil hcl tab 80 verapamil hcl tab 120 verapamil hcl tab cr 120 verapamil hcl tab cr 180 verapamil hcl tab cr 240 verapamil hcl cap sr 24hr 100 verapamil hcl cap sr 24hr 120 verapamil hcl cap sr 24hr 180 verapamil hcl cap sr 24hr 200 verapamil hcl cap sr 24hr

36 verapamil hcl cap sr 24hr 300 verapamil hcl cap sr 24hr 360 ANTIARRHYTHMICS TYPE I-A disopyramide phosphate cap 150 NORPACE CAP 100MG CR NORPACE CAP 150MG CR quinidine gluconate tab cr 324 quinidine sulfate tab 200 quinidine sulfate tab 300 quinidine sulfate tab cr 300 ANTIARRHYTHMICS TYPE I-B mexiletine hcl cap 150 mexiletine hcl cap 200 mexiletine hcl cap 250 ANTIARRHYTHMICS TYPE I-C flecainide acetate tab 50 flecainide acetate tab 100 flecainide acetate tab 150 propafenone hcl tab 150 propafenone hcl tab 225 propafenone hcl tab 300 propafenone hcl cap sr 12hr 225 propafenone hcl cap sr 12hr 325 propafenone hcl cap sr 12hr 425 ANTIARRHYTHMICS TYPE III amiodarone hcl tab 100 amiodarone hcl tab 200 amiodarone hcl tab 400 TIKOSYN CAP 125MCG SRx TIKOSYN CAP 250MCG SRx TIKOSYN CAP 500MCG SRx MULTAQ TAB 400MG ACE INHIBITORS benazepril hcl tab 5 benazepril hcl tab 10 benazepril hcl tab 20 benazepril hcl tab 40 captopril tab 12.5 captopril tab 25 captopril tab 50 captopril tab 100 enalapril maleate tab 2.5 enalapril maleate tab 5 enalapril maleate tab 10 enalapril maleate tab 20 36

37 fosinopril sodium tab 10 fosinopril sodium tab 20 fosinopril sodium tab 40 lisinopril tab 2.5 lisinopril tab 5 lisinopril tab 10 lisinopril tab 20 lisinopril tab 30 lisinopril tab 40 moexipril hcl tab 7.5 moexipril hcl tab 15 perindopril erbumine tab 2 perindopril erbumine tab 4 perindopril erbumine tab 8 quinapril hcl tab 5 quinapril hcl tab 10 quinapril hcl tab 20 quinapril hcl tab 40 ramipril cap 1.25 ramipril cap 2.5 ramipril cap 5 ramipril cap 10 trandolapril tab 1 trandolapril tab 2 trandolapril tab 4 ANGIOTENSIN II RECEPTOR ANTAGONISTS EDARBI TAB 40MG PAR EDARBI TAB 80MG PAR candesartan cilexetil tab 4 candesartan cilexetil tab 8 candesartan cilexetil tab 16 candesartan cilexetil tab 32 eprosartan mesylate tab 600 irbesartan tab 75 irbesartan tab 150 irbesartan tab 300 losartan potassium tab 25 losartan potassium tab 50 losartan potassium tab 100 BENICAR TAB 5MG BENICAR TAB 20MG BENICAR TAB 40MG telmisartan tab 20 telmisartan tab 40 telmisartan tab 80 37

38 valsartan tab 40 valsartan tab 80 valsartan tab 160 valsartan tab 320 DIRECT RENIN INHIBITORS TEKTURNA TAB 150MG TEKTURNA TAB 300MG ANTIADRENERGIC ANTIHYPERTENSIVES clonidine hcl tab 0.1 clonidine hcl tab 0.2 clonidine hcl tab 0.3 clonidine hcl td patch weekly 0.1 /24hr clonidine hcl td patch weekly 0.2 /24hr clonidine hcl td patch weekly 0.3 /24hr guanfacine hcl tab 1 guanfacine hcl tab 2 methyldopa tab 250 methyldopa tab 500 doxazosin mesylate tab 1 doxazosin mesylate tab 2 doxazosin mesylate tab 4 doxazosin mesylate tab 8 prazosin hcl cap 1 prazosin hcl cap 2 prazosin hcl cap 5 terazosin hcl cap 1 terazosin hcl cap 2 terazosin hcl cap 5 terazosin hcl cap 10 reserpine tab 0.1 reserpine tab 0.25 SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone tab 25 eplerenone tab 50 AGENTS FOR PHEOCHROMOCYTOMA phenoxybenzamine hcl cap 10 DEMSER CAP 250MG VASODILATORS hydralazine hcl tab 10 hydralazine hcl tab 25 hydralazine hcl tab 50 hydralazine hcl tab 100 minoxidil tab 2.5 minoxidil tab 10 ANTIHYPERTENSIVE COMBINATIONS 38