formulary COMPREHENSIVE list of covered drugs 2017

Transcription

1 COMPREHENSIVE formulary list of covered drugs 07 This formulary was updated on /0/07. For more recent information or other questions, please contact SelectHealth Member Services toll-free, at or, for TTY users, 7, during the following dates and times: October to February : Weekdays 7:00 a.m. to 8:00 p.m., Saturday and Sunday 8:00 a.m. to 8:00 p.m. February 5 to September 0: Weekdays 7:00 a.m. to 8:00 p.m., Saturday 9:00 a.m. to :00 p.m., closed Sunday. Outside these hours of operation, please leave a message. Your call will be returned within one business day, or visit selecthealthadvantage.org.

2 SelectHealth Advantage (HMO) 07 Comprehensive Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN SelectHealth is an HMO plan sponsor with a Medicare contract. Enrollment in SelectHealth Advantage depends on contract renewal. This information is available for free in other languages. Please call our customer service number at (toll-free), during the dates and times indicated on the front and back covers of this book. TTY users may call 7. Esta información está disponible de forma gratuita en otros idiomas. Por favor llame a nuestra línea de Servicio para clientes al (cobro revertido), durante las fechas y horarios indicados en la portada y contraportada de este libro. Los usuarios de TTY pueden llamar al 7. H99_59R_FINAL_C_v5 Accepted HPMS Approved Formulary File Submission ID 7000 Version 5

3 Non-Discrimination Notice SelectHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We provide free aid and services to people with disabilities to help them communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). We also provide free language services to people whose primary language is not English, such as qualified interpreters and member materials written in other languages. If you need these services, please call SelectHealth Advantage Member Services at Any member or other person who believes he/she may have been subject to discrimination may file a complaint or grievance by calling the SelectHealth 50/Civil Rights Coordinator at or the Compliance Hotline at (TTY Users: 7). You may also call the Office for Civil Rights at (TTY Users: ). 06 SelectHealth. All rights reserved /6

4 Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 7). Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:7) Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 7). Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 7) 번으로전화해주십시오. Navajo Díí baa akó nínízin: Díí saad bee yáníłti go Diné Bizaad, saad bee áká ánída áwo dęʹęʹ, t áá jiik eh, éí ná hólǫʹ, kojį hódíílnih (TTY: 7). Nepali ध य न द न ह स : तप र इ ल न प ल ब ल न ह न छ भन तप र इ क न म त भ ष सह यत स व हर न श ल क र पम उपलब ध छ फ न गर न ह स (ट ट व इ: 7) Tongan FAKATOKANGA I: Kapau oku ke Lea-Fakatonga, ko e kau tokoni fakatonu lea oku nau fai atu ha tokoni ta etotongi, pea teke lava o ma u ia. Telefoni mai (TTY: 7). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 7). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 7). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 7). Arabic ةدعاسملا تامدخ نإف ةغللا ركذا ثدحتت تنك اذإ :ةظوحلم مقرب لصتا.ناجملاب كل رفاوتت ةيوغللا.( 7 :مكبلاو مصلا فتاه مقر) Mon-khmer, Cambodian ប រយ ត ន ប ស នជ អ នកន យ យ ភ ស ខ ម រ, ស វ ជ ន យផ ន កភ ស ដ យម នគ តឈ ន ល គ អ ចម នស រ ប ប រ អ នក ច រ ទ រស ព ទ (TTY: 7) French ATTENTION: Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 7). Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 7) まで お電話にてご連絡ください Serb-Croatian OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 7).

5 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 SelectHealth. When it refers to plan or our plan, it means SelectHealth Advantage. This document includes a list of the drugs (formulary) for our plan which is current as of November 0, 07. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 08, and from time to time during the year. What is the SelectHealth Advantage Formulary? A formulary is a list of covered drugs selected by SelectHealth Advantage in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. SelectHealth Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SelectHealth Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 07 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 07 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, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November 0, 07. To get updated information about the drugs covered by SelectHealth Advantage, please contact us. Our contact information appears on the front and back cover pages. In the event of non-maintenance changes to the formulary throughout the plan year, SelectHealth may make changes via errata sheets mailed to you. Additionally, you may visit our Website for a link to the errata sheet.

6 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 0. 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/hypotensive agents. If you know what your drug is used for, look for the category name in the list that begins on page 0. 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. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? SelectHealth Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: SelectHealth Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from SelectHealth Advantage before you fill your prescriptions. If you don t get approval, SelectHealth Advantage may not cover the drug. Quantity Limits: For certain drugs, SelectHealth Advantage limits the amount of the drug that SelectHealth Advantage will cover. For example, SelectHealth Advantage provides 60 tablets per prescription for Valsartan. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, SelectHealth Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, SelectHealth Advantage may not cover B unless you try A first. If A does not work for you, SelectHealth Advantage will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 0. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. 5

7 You can ask SelectHealth Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the SelectHealth Advantage formulary? on page 6 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that SelectHealth Advantage does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by SelectHealth Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by SelectHealth Advantage. You can ask SelectHealth Advantage 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 SelectHealth Advantage Formulary? You can ask SelectHealth Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, SelectHealth Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, SelectHealth Advantage will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. 6

8 What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the 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 -day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If you experience a change in your level of care, such as a move from a hospital to a home setting, 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 one-time temporary supply for up to 0 days (or days if you are a long-term care resident) when you use a network pharmacy. During this period, you should use the plan's exception process if you wish to have continued coverage of the drug after the temporary supply is finished. For more information For more detailed information about your SelectHealth Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about SelectHealth Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ) hours a day/7 days a week. TTY users should call Or, visit 7

9 SelectHealth Advantage Formulary The formulary that begins on the next page provides coverage information about some of the drugs covered by SelectHealth Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ADVAIR) and generic drugs are listed in lower-case italics (e.g., simvastatin). The second column of the chart lists the Tier. The Tier column lets you know the type of copayment or coinsurance you will be responsible for at the pharmacy. Please refer to your Evidence of Coverage for more information regarding how much you will pay for your prescription drugs. The table below tells you the copayment/coinsurance amount for drugs in each tier: Annual Prescription Deductible This is the amount you will be required to pay for your prescriptions this year before your copay or coinsurance applies. The amounts shown in the table below apply to Tier, Tier, and Tier 5 and both retail and mail order prescription drugs. They do not apply to the Wasatch Enhanced and Treasure Valley Enhanced benefit plans for which there is no annual prescription drug deductible. Service Area / Plan Name Annual Prescription Tier,,5 Deductible Wasatch Essential, Southwest and Central Utah, Cache Valley, Eastern and Central Idaho $00.00 Treasure Valley Essential and Magic Valley $50.00 Wasatch Enhanced and Treasure Valley Enhanced $0 Initial Coverage Period Copayment/Coinsurance Levels Service Areas: Wasatch Essential, Southwest and Central Utah, Treasure Valley Essential, Magic Valley, Cache Valley, and Eastern and Central Idaho Tier Retail Network Pharmacy (Up to a 0-day supply) Mail Order 0 Day 60 Day 90 Day Tier : Preferred Generic $.00 $.00 $6.00 $6.00 Tier : Generic $5.00 $5.00 $0.00 $0.00 Tier : Preferred Brand $5.00 after deductible $5.00 after deductible $90.00 after deductible $5.00 after deductible Tier : Non-Preferred Brand $95.00 after deductible $95.00 after deductible $90.00 after deductible $85.00 after deductible 8

10 Service Areas: Wasatch Enhanced and Treasure Valley Enhanced Tier Retail Network Pharmacy (Up to a 0-day supply) Mail Order 0 Day 60 Day 90 Day Tier : Preferred Generic $0.00 $0.00 $0.00 $0.00 Tier : Generic $0.00 $0.00 $0.00 $0.00 Tier : Preferred Brand $5.00 $5.00 $90.00 $5.00 Tier : Non-Preferred Brand $95.00 $95.00 $90.00 $85.00 Service Areas: Wasatch Essential, Southwest and Central Utah, Cache Valley, and Eastern and Central Idaho Tier 5: Specialty 9% coinsurance after deductible 9% coinsurance after deductible Service Areas: Treasure Valley Essential and Magic Valley Tier 5: Specialty 0% coinsurance after deductible 0% coinsurance after deductible Service Areas: Wasatch Enhanced and Treasure Valley Enhanced Tier 5: Specialty % coinsurance % coinsurance Not Available Not Available Not Available Not Available Not Available Not Available The information in the Requirements column tells you if SelectHealth Advantage has any special requirements for coverage of your drug. PA We require you or your physician to get prior authorization for certain drugs before you fill your prescriptions. QL We limit the amount of the drug covered in a specific time period. ST We require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. LA This drug requires special handling or has special dispensing requirements. This prescription may be available only at certain pharmacies. For more information, consult your Provider and Pharmacy Directory or call Member Services toll-free at TTY users should call 7. NM This drug is not available through our mail order pharmacy. BvsD This drug may be covered under the Part B or Part D Medicare benefit. 9

11 ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA TABLET 00MG NM BILTRICIDE TABLET 600MG NM ivermectin tablet mg NM ANTIBACTERIALS amikacin sulfate solution 500 mg/ ml BvsD; HI; NM amoxicillin capsule 50mg NM amoxicillin capsule 500mg NM amoxicillin for suspension 5 mg/5 ml NM amoxicillin for suspension 00 mg/5 ml NM amoxicillin for suspension 50 mg/5 ml NM amoxicillin for suspension 00 mg/5 ml NM amoxicillin tablet 500mg NM amoxicillin tablet 875mg NM amoxicillin tablet chewable 5mg NM amoxicillin tablet chewable 50mg NM amoxicillin-clavulanate pot er tablet er hr, mg NM amoxicillin-clavulanate potass for suspension 00 mg-8.5 NM mg/5 ml amoxicillin-clavulanate potass for suspension 50 mg-6.5 mg/5 ml NM amoxicillin-clavulanate potass for suspension 00 mg-57 mg/5 ml amoxicillin-clavulanate potass for suspension 600 mg-.9 mg/5 ml amoxicillin-clavulanate potass tablet 50-5mg amoxicillin-clavulanate potass tablet 500-5mg amoxicillin-clavulanate potass tablet 875-5mg amoxicillin-clavulanate potass tablet chewable mg amoxicillin-clavulanate potass tablet chewable 00-57mg ampicillin sodium for solution gram ampicillin sodium for solution 0 gram ampicillin sodium for solution 5mg ampicillin trihydrate capsule 50mg ampicillin trihydrate capsule 500mg ampicillin-sulbactam for solution.5 gram ampicillin-sulbactam for solution 5 gram ampicillin-sulbactam for solution gram azithromycin for solution 500mg azithromycin for suspension 00 mg/5 ml NM NM NM NM NM NM NM BvsD; HI; NM BvsD; HI; NM BvsD; HI; NM NM NM BvsD; HI; NM BvsD; HI; NM BvsD; HI; NM BvsD; HI; NM NM 0

12 azithromycin for suspension 00 mg/5 ml NM azithromycin packet gram NM azithromycin tablet 50mg QL; NM azithromycin tablet 500mg NM azithromycin tablet 500mg QL each per 0 QL; NM azithromycin tablet 600mg NM aztreonam for solution gram BvsD; HI; NM BETHKIS 00 MG/ ML AMPULE QL 80 milliliter(s) per 0 ; NM BICILLIN C-R SUSPENSION,00,000 UNIT/ ML NM (600,000/600,000) BICILLIN C-R SUSPENSION,00,000 UNIT/ ML NM (900,000/00,000) BICILLIN L-A SUSPENSION. MILLION UNIT/ ML NM BICILLIN L-A SUSPENSION. MILLION UNIT/ ML NM BICILLIN L-A SUSPENSION 600,000 UNIT/ML NM CAYSTON FOR SOLUTION 75 MG/ML QL 80 milliliter(s) per 0 ; NM CEDAX CAPSULE 00MG NM cefaclor capsule 50mg NM cefaclor capsule 500mg NM cefaclor er tablet er hr 500mg NM cefadroxil capsule 500mg NM cefadroxil for suspension 50 mg/5 ml NM cefadroxil for suspension 500 mg/5 ml NM cefadroxil tablet gram NM cefazolin sodium for solution gram BvsD; HI; NM cefazolin sodium for solution 0 gram BvsD; HI; NM cefazolin sodium for solution 500mg BvsD; HI; NM cefdinir capsule 00mg NM cefdinir for suspension 5 mg/5 ml NM cefdinir for suspension 50 mg/5 ml NM cefepime hcl for solution gram BvsD; HI; NM cefepime hcl for solution gram BvsD; HI; NM cefixime for suspension 00 mg/5 ml NM cefixime for suspension 00 mg/5 ml NM cefotaxime sodium for solution gram BvsD; HI; NM cefotaxime sodium for solution gram BvsD; HI; NM cefotaxime sodium for solution 500mg BvsD; HI; NM

13 cefoxitin for solution gram BvsD; HI; NM cefoxitin for solution 0 gram BvsD; HI; NM cefoxitin for solution gram BvsD; HI; NM cefpodoxime proxetil for suspension 00 mg/5 ml NM cefpodoxime proxetil for suspension 50 mg/5 ml NM cefpodoxime proxetil tablet 00mg NM cefpodoxime proxetil tablet 00mg NM cefprozil for suspension 5 mg/5 ml NM cefprozil for suspension 50 mg/5 ml NM cefprozil tablet 50mg NM cefprozil tablet 500mg NM CEFTIN FOR SUSPENSION 5 MG/5 ML NM CEFTIN FOR SUSPENSION 50 MG/5 ML NM ceftriaxone for solution gram BvsD; HI; NM ceftriaxone for solution 0 gram BvsD; HI; NM ceftriaxone for solution gram BvsD; HI; NM ceftriaxone for solution 50mg BvsD; HI; NM ceftriaxone for solution 500mg BvsD; HI; NM cefuroxime sodium for solution.5 gram BvsD; HI; NM cefuroxime sodium for solution 7.5 gram BvsD; HI; NM cefuroxime sodium for solution 750mg BvsD; HI; NM cefuroxime tablet 50mg NM cefuroxime tablet 500mg NM cephalexin capsule 50mg NM cephalexin capsule 500mg NM cephalexin for suspension 5 mg/5 ml NM cephalexin for suspension 50 NM mg/5 ml cephalexin tablet 50mg NM cephalexin tablet 500mg NM chloramphenicol sod succinate for solution gram ciprofloxacin er tablet er hr,000mg NM ciprofloxacin er tablet er hr 500mg NM ciprofloxacin for suspension 50 mg/5 ml NM ciprofloxacin for suspension 500 mg/5 ml NM ciprofloxacin hcl tablet 00mg NM ciprofloxacin hcl tablet 50mg NM ciprofloxacin hcl tablet 500mg NM ciprofloxacin hcl tablet 750mg NM ciprofloxacin solution 00 mg/0 ml ciprofloxacin-d5w solution 00 mg/00 ml clarithromycin er tablet er hr 500mg clarithromycin for suspension 5 mg/5 ml clarithromycin for suspension 50 mg/5 ml BvsD; HI; NM BvsD; HI; NM BvsD; HI; NM NM NM NM

14 clarithromycin tablet 50mg NM clarithromycin tablet 500mg NM clindamycin hcl capsule 50mg NM clindamycin hcl capsule 00mg NM clindamycin hcl capsule 75mg NM clindamycin pediatric for solution 75 mg/5 ml NM clindamycin phosphate solution 50 mg/ml BvsD; HI; NM clindamycin phosphate solution 600 mg/ ml BvsD; HI; NM clindamycin phosphate-d5w solution 00 mg/50 ml BvsD; HI; NM clindamycin phosphate-d5w solution 600 mg/50 ml BvsD; HI; NM clindamycin phosphate-d5w solution 900 mg/50 ml BvsD; HI; NM colistimethate for solution 50mg BvsD; HI; NM DALVANCE FOR SOLUTION 500MG PA; HI; NM daptomycin for solution 500mg QL 50 each per 0 QL; PA; HI; NM DARAPRIM TABLET 5MG NM dicloxacillin sodium capsule 50mg NM dicloxacillin sodium capsule 500mg NM DIFICID TABLET 00MG QL 0 each per 0 ; PA; NM doxycycline hyclate capsule NM 00mg doxycycline hyclate capsule 50mg NM doxycycline hyclate tablet 00mg doxycycline hyclate tablet 0mg doxycycline hyclate tablet dr 00mg doxycycline hyclate tablet dr 50mg doxycycline hyclate tablet dr 75mg doxycycline monohydrate capsule 00mg doxycycline monohydrate capsule 50mg doxycycline monohydrate capsule 75mg doxycycline monohydrate for suspension 5 mg/5 ml doxycycline monohydrate tablet 00mg doxycycline monohydrate tablet 50mg doxycycline monohydrate tablet 50mg doxycycline monohydrate tablet 75mg ERY-TAB TABLET DR 50MG ERY-TAB TABLET DR MG NM QL; NM QL; NM NM QL; NM NM NM NM NM NM QL NM NM NM NM

15 ERY-TAB TABLET DR 500MG NM ERYPED 00 FOR SUSPENSION 00 MG/5 ML NM ERYPED 00 FOR SUSPENSION 00 MG/5 ML NM ERYTHROCIN LACTOBIONATE FOR BvsD; HI; NM SOLUTION 500MG ERYTHROCIN STEARATE TABLET 50MG NM erythromycin capsule dr part 50mg NM erythromycin ethylsuccinate for suspension 00 mg/5 ml NM erythromycin tablet 50mg NM erythromycin tablet 500mg NM gentamicin sulfate in ns solution 00 mg/00 ml BvsD; HI; NM gentamicin sulfate in ns solution 60 mg/50 ml BvsD; HI; NM gentamicin sulfate in ns solution 80 mg/00 ml BvsD; HI; NM gentamicin sulfate in ns solution 80 mg/50 ml BvsD; HI; NM gentamicin sulfate solution 00 mg/0 ml BvsD; HI; NM gentamicin sulfate solution 0 mg/ml BvsD; HI; NM imipenem-cilastatin sodium for solution 50mg PA; HI; NM imipenem-cilastatin sodium for solution 500mg PA; HI; NM INVANZ FOR SOLUTION GRAM BvsD; HI; NM lansoprazol-amoxicil-clarithro QL each per QL; NM levofloxacin solution 5 mg/ml BvsD; HI; NM levofloxacin tablet 50mg NM levofloxacin tablet 500mg NM levofloxacin tablet 750mg NM levofloxacin-d5w solution 500 mg/00 ml BvsD; HI; NM levofloxacin-d5w solution 750 mg/50 ml BvsD; HI; NM linezolid for suspension 00 mg/5 ml NM linezolid solution 600 mg/00 ml BvsD; HI; NM linezolid tablet 600mg QL; NM meropenem for solution gram HI; NM meropenem for solution 500mg BvsD; HI; NM metronidazole solution 500 mg/00 ml BvsD; HI; NM minocycline hcl capsule 00mg NM minocycline hcl capsule 50mg NM minocycline hcl capsule 75mg NM minocycline hcl er tablet er hr 5mg QL; NM minocycline hcl er tablet er hr 5mg QL; NM minocycline hcl er tablet er hr 90mg QL; NM moxifloxacin hcl tablet 00mg NM

16 nafcillin sodium for solution gram PA; HI; NM nafcillin sodium for solution 0 gram PA; HI; NM neomycin sulfate tablet 500mg NM ofloxacin tablet 00mg NM ofloxacin tablet 00mg NM ORACEA CAPSULE DR 0MG ; NM ORBACTIV FOR SOLUTION 00MG ; PA; HI; NM QL 50 each per 0 paromomycin sulfate capsule NM 50mg PCE TABLET DR MG NM PCE TABLET DR 500MG NM penicillin g potassium for solution 5 million unit penicillin g procaine suspension. million unit/ ml penicillin g sodium for solution 5 million unit penicillin gk-iso-osm dextrose solution million unit/50 ml penicillin gk-iso-osm dextrose solution million unit/50 ml penicillin v potassium for solution 5 mg/5 ml penicillin v potassium for solution 50 mg/5 ml penicillin v potassium tablet 50mg penicillin v potassium tablet 500mg BvsD; HI; NM BvsD; NM BvsD; HI; NM BvsD; HI; NM BvsD; HI; NM NM NM NM NM PENTAM 00 FOR SOLUTION 00MG piperacillin-tazobactam for solution.75 gram piperacillin-tazobactam for solution.5 gram piperacillin-tazobactam for solution 0.5 gram PYLERA CAPSULE MG NM rifabutin capsule 50mg NM rifampin capsule 50mg NM rifampin capsule 00mg NM rifampin for solution 600mg HI; NM RIFATER TABLET MG SIVEXTRO FOR SOLUTION 00MG QL 6 each per 0 BvsD; HI; NM BvsD; HI; NM BvsD; HI; NM BvsD; HI; NM NM ; PA; HI; NM SIVEXTRO TABLET 00MG QL 6 each per 0 ; PA; NM streptomycin sulfate for solution gram BvsD; NM sulfadiazine tablet 500mg NM sulfamethoxazoletrimethoprim solution 80 mg- 6 mg/ml BvsD; HI; NM sulfamethoxazoletrimethoprim suspension 00 mg-0 mg/5 ml sulfamethoxazoletrimethoprim tablet 00-80mg sulfamethoxazoletrimethoprim tablet mg NM NM NM 5

17 SUPRAX CAPSULE 00MG SUPRAX FOR SUSPENSION 00 MG/5 ML SUPRAX FOR SUSPENSION 00 MG/5 ML SUPRAX FOR SUSPENSION 500 MG/5 ML SUPRAX TABLET CHEWABLE 00MG SUPRAX TABLET CHEWABLE 00MG SYNAGIS SOLUTION 50 MG/0.5 ML SYNERCID FOR SOLUTION 500MG QL 50 each per 0 TEFLARO FOR SOLUTION 00MG TEFLARO FOR SOLUTION 600MG tigecycline for solution 50mg QL 8 each per TOBI PODHALER CAPSULE 8MG QL each per tobramycin 00 mg/5 ml ampule tobramycin sulfate solution 0 mg/ml tobramycin sulfate solution 0 mg/ml vancomycin hcl capsule 5mg QL 0 each per 0 ; NM vancomycin hcl capsule 50mg QL 0 each per 0 NM vancomycin hcl for solution gram NM vancomycin hcl for solution 0 gram NM vancomycin hcl for solution 500mg XIFAXAN TABLET 00MG ; NM QL 0 each per 0 XIFAXAN TABLET 550MG ; NM ZMAX FOR SUSPENSION GRAM/60 ML PA ZOSYN SOLUTION.5 GRAM/50 ML ANTIFUNGAL (SYSTEMIC) ; PA; HI; NM AMBISOME FOR SUSPENSION 50MG PA; HI; NM amphotericin b for solution 50mg PA; HI; NM CANCIDAS FOR SOLUTION 50MG QL; PA; HI; NM CANCIDAS FOR SOLUTION 70MG caspofungin acetate for ; NM solution 50mg caspofungin acetate for 5 PA; NM solution 70mg CRESEMBA CAPSULE BvsD; HI; NM 86MG BvsD; HI; NM CRESEMBA FOR SOLUTION 7MG QL; NM QL 50 each per 0 QL; NM BvsD; HI; NM BvsD; HI; NM BvsD; HI; NM ; PA; NM ; PA; NM NM BvsD; HI; NM PA; HI; NM PA; HI; NM 5 PA; HI; NM 5 PA; HI; NM 5 PA; HI; NM 5 PA; HI; NM ; PA; NM ; PA; HI; NM 6

18 fluconazole for suspension 0 mg/ml NM fluconazole for suspension 0 mg/ml NM fluconazole tablet 00mg NM fluconazole tablet 50mg NM fluconazole tablet 00mg NM fluconazole tablet 50mg NM fluconazole-nacl solution 00 mg/00 ml BvsD; HI; NM fluconazole-nacl solution 00 mg/00 ml BvsD; HI; NM flucytosine capsule 50mg NM flucytosine capsule 500mg NM griseofulvin suspension 5 mg/5 ml NM griseofulvin tablet 500mg NM griseofulvin ultramicrosize tablet 5mg NM griseofulvin ultramicrosize tablet 50mg NM itraconazole capsule 00mg QL 6 each per 0 QL; NM ketoconazole tablet 00mg NM NOXAFIL SUSPENSION 00 MG/5 ML (0 MG/ML) PA; NM NOXAFIL TABLET DR 00MG ; PA; NM QL 0 each per 0 nystatin suspension 00,000 unit/ml NM nystatin tablet 500,000 unit NM SPORANOX SOLUTION 0 MG/ML NM terbinafine hcl tablet 50mg QL 90 each per 0 ; NM voriconazole for solution 00mg PA; HI; NM voriconazole for suspension 00 mg/5 ml (0 mg/ml) QL 50 milliliter(s) per 0 QL; PA; NM voriconazole tablet 00mg QL 90 each per 0 QL; PA; NM voriconazole tablet 50mg QL 60 each per 0 QL; PA; NM ANTIMYCOBACTERIALS CAPASTAT SULFATE FOR SOLUTION GRAM PA; HI; NM dapsone tablet 00mg NM dapsone tablet 5mg NM ethambutol hcl tablet 00mg NM ethambutol hcl tablet 00mg NM isoniazid solution 00 mg/ml NM isoniazid tablet 00mg NM isoniazid tablet 00mg NM PASER PACKET GRAM NM PRIFTIN TABLET 50MG QL each per 8 ; NM pyrazinamide tablet 500mg NM SIRTURO TABLET 00MG QL 88 each per 0 ; PA; NM TRECATOR TABLET 50MG NM ANTIPROTOZOALS ALINIA FOR SUSPENSION 00 MG/5 ML QL 0 milliliter(s) per 0 ; NM 7

19 ALINIA TABLET 500MG QL 0 each per 0 ; NM atovaquone suspension 750 mg/5 ml NM atovaquone-proguanil hcl tablet 50-00mg NM atovaquone-proguanil hcl tablet 6.5 mg-5 mg NM (pediatric) chloroquine phosphate tablet 50mg NM chloroquine phosphate tablet 500mg NM COARTEM TABLET 0-0MG ; NM QL each per 0 hydroxychloroquine sulfate tablet 00mg NM mefloquine hcl tablet 50mg QL 5 each per 0 QL; NM metronidazole capsule 75mg NM metronidazole tablet 50mg NM metronidazole tablet 500mg NM NEBUPENT FOR SOLUTION 00MG BvsD; NM primaquine tablet 6.mg NM quinidine sulfate tablet 00mg NM quinidine sulfate tablet 00mg NM quinine sulfate capsule mg NM tinidazole tablet 50mg NM tinidazole tablet 500mg NM ANTIVIRALS (SYSTEMIC) abacavir tablet 00mg QL 80 each per 0 QL; NM abacavir-lamivudine tablet mg QL; NM abacavir-lamivudinezidovudine tablet mg QL; NM acyclovir capsule 00mg NM acyclovir sodium solution 50 mg/ml BvsD; HI; NM acyclovir suspension 00 mg/5 ml NM acyclovir tablet 00mg NM acyclovir tablet 800mg NM adefovir dipivoxil tablet 0mg NM amantadine capsule 00mg QL 0 each per 0 QL; NM amantadine syrup 50 mg/5 ml QL 00 milliliter(s) per 0 QL; NM amantadine tablet 00mg QL 0 each per 0 QL; NM APTIVUS CAPSULE 50MG QL 0 each per 0 ; NM APTIVUS SOLUTION 00 MG/ML QL 00 milliliter(s) per 0 ; NM ATRIPLA TABLET MG ; NM BARACLUDE SOLUTION 0.05 MG/ML NM cidofovir solution 75 mg/ml BvsD; HI; NM COMPLERA TABLET MG NM 8

20 CRIXIVAN CAPSULE 00MG QL 0 each per 0 CRIXIVAN CAPSULE 00MG QL 0 each per 0 DAKLINZA TABLET 0MG QL 8 each per 8 DAKLINZA TABLET 60MG QL 8 each per 8 DAKLINZA TABLET 90MG QL 8 each per 8 DESCOVY TABLET 00-5MG didanosine capsule dr 5mg didanosine capsule dr 00mg didanosine capsule dr 50mg didanosine capsule dr 00mg EDURANT TABLET 5MG EMTRIVA CAPSULE 00MG EMTRIVA SOLUTION 0 MG/ML QL 70 milliliter(s) per 0 entecavir tablet 0.5mg ; NM ; NM ; NM ; NM ; NM ; NM QL; NM QL; NM QL; NM QL; NM ; NM ; NM ; NM QL; NM entecavir tablet mg QL; NM EPCLUSA TABLET 00-00MG EPIVIR HBV SOLUTION 5 MG/5 ML (5 MG/ML) QL 800 milliliter(s) per 0 ; NM EVOTAZ TABLET 00-50MG ; NM famciclovir tablet 5mg NM famciclovir tablet 50mg NM famciclovir tablet 500mg NM FUZEON FOR SOLUTION 90MG 5 QL; NM ganciclovir sodium for solution 500mg BvsD; HI; NM GENVOYA TABLET MG ; NM HARVONI TABLET 90-00MG INTELENCE TABLET 00MG NM INTELENCE TABLET 00MG NM INTELENCE TABLET 5MG NM INTRON A FOR SOLUTION 0 MILLION UNIT ( ML) QL 0 each per 5 QL; NM 9

21 INTRON A FOR SOLUTION 8 MILLION UNIT ( ML) QL 7 each per INTRON A FOR SOLUTION 50 MILLION UNIT ( ML) QL each per INTRON A SOLUTION 0 MILLION UNIT/ML INTRON A SOLUTION 6 MILLION UNIT/ML QL 7 milliliter(s) per INVIRASE CAPSULE 00MG QL 00 each per 0 INVIRASE TABLET 500MG QL 0 each per 0 ISENTRESS HD TABLET 600MG ISENTRESS PACKET 00MG ISENTRESS TABLET 00MG ISENTRESS TABLET CHEWABLE 00MG QL 80 each per 0 ISENTRESS TABLET CHEWABLE 5MG QL 80 each per 0 5 QL 5 QL 5 NM 5 QL; NM ; NM ; NM ; NM ; NM ; NM ; NM ; NM KALETRA TABLET 00-5MG ; NM QL 00 each per 0 KALETRA TABLET 00-50MG ; NM QL 0 each per 0 lamivudine hbv tablet 00mg QL; NM lamivudine solution 0 mg/ml NM lamivudine tablet 50mg QL; NM lamivudine tablet 00mg QL; NM lamivudine-zidovudine tablet 50-00mg NM LEXIVA SUSPENSION 50 NM MG/ML LEXIVA TABLET 700MG NM lopinavir-ritonavir solution 00 mg-00 mg/5 ml QL 90 milliliter(s) per 0 nevirapine er tablet er hr 00mg nevirapine er tablet er hr 00mg nevirapine suspension 50 mg/5 ml QL 00 milliliter(s) per 0 nevirapine tablet 00mg QL; NM NM QL; NM QL; NM QL; NM 0

22 NORVIR CAPSULE 00MG QL 50 each per 0 NORVIR SOLUTION 80 MG/ML QL 50 milliliter(s) per 0 NORVIR TABLET 00MG QL 60 each per 0 ODEFSEY TABLET MG OLYSIO CAPSULE 50MG oseltamivir phosphate capsule 0mg QL 8 each per 80 oseltamivir phosphate capsule 5mg QL each per 80 oseltamivir phosphate capsule 75mg QL 8 each per 80 PEGASYS PROCLICK SOLUTION 5 MCG/0.5 ML QL milliliter(s) per 0 PEGASYS PROCLICK SOLUTION 80 MCG/0.5 ML QL milliliter(s) per 0 PEGASYS SOLUTION 80 MCG/0.5 ML QL milliliter(s) per 0 ; NM ; NM ; NM ; NM ; NM QL; NM QL; NM QL; NM ; NM PEGASYS SOLUTION 80 MCG/ML QL milliliter(s) per 8 PEGINTRON KIT 50 MCG/0.5 ML QL each per 0 PEGINTRON REDIPEN KIT 0 MCG/0.5 ML QL each per 0 PREZCOBIX TABLET MG PREZISTA SUSPENSION 00 MG/ML QL 60 milliliter(s) per 0 PREZISTA TABLET 50MG QL 90 each per 0 PREZISTA TABLET 600MG PREZISTA TABLET 75MG PREZISTA TABLET 800MG PURIXAN SUSPENSION 0 MG/ML QL 00 milliliter(s) per 0 REBETOL SOLUTION 0 MG/ML ; NM ; NM ; NM ; NM ; NM ; NM ; NM ; NM ; NM NM

23 RELENZA AERO POW BR ACT 5MG RESCRIPTOR TABLET 00MG QL 80 each per 0 RESCRIPTOR TABLET 00MG QL 80 each per 0 RETROVIR SOLUTION 0 MG/ML REYATAZ CAPSULE 50MG REYATAZ CAPSULE 00MG REYATAZ CAPSULE 00MG REYATAZ PACKET 50MG QL 0 each per 0 ribasphere capsule 00mg QL 0 each per 0 ribasphere tablet 00mg QL 0 each per 0 ribavirin capsule 00mg QL 0 each per 0 ribavirin tablet 00mg QL 0 each per 0 SELZENTRY TABLET 50MG QL 0 each per 0 ; NM ; NM ; NM NM ; NM ; NM ; NM ; NM QL; NM QL; NM QL; NM QL; NM ; NM SELZENTRY TABLET 5MG QL 0 each per 0 SELZENTRY TABLET 00MG QL 0 each per 0 SELZENTRY TABLET 75MG QL 0 each per 0 SOVALDI TABLET 00MG stavudine capsule 5mg stavudine capsule 0mg stavudine capsule 0mg stavudine capsule 0mg STRIBILD TABLET MG SUSTIVA CAPSULE 00MG SUSTIVA CAPSULE 50MG QL 90 each per 0 SUSTIVA TABLET 600MG TAMIFLU FOR SUSPENSION 6 MG/ML QL 55 milliliter(s) per 80 TECHNIVIE TABLET MG QL 68 each per 8 ; NM ; NM ; NM ; NM QL; NM QL; NM QL; NM QL; NM 5 QL; NM ; NM ; NM ; NM ; NM ; NM

24 TIVICAY TABLET 0MG TIVICAY TABLET 5MG TIVICAY TABLET 50MG TRIUMEQ TABLET MG TRUVADA TABLET 00-50MG TRUVADA TABLET - 00MG TRUVADA TABLET 67-50MG TRUVADA TABLET 00-00MG TYBOST TABLET 50MG valacyclovir tablet,000mg valacyclovir tablet 500mg VALCHLOR GEL 0.06 % QL 0 gram(s) per 0 valganciclovir hcl for solution 50 mg/ml valganciclovir hcl tablet 50mg QL 90 each per 0 ; NM ; NM ; NM ; NM ; NM ; NM ; NM ; NM QL; NM QL; NM NM QL; NM VIDEX FOR SOLUTION 0 MG/ML (FINAL NM CONCENTRATION) VIRACEPT TABLET 50MG NM VIRACEPT TABLET 65MG NM VIREAD POWDER 0 MG/SCOOP (0 MG/GRAM) NM VIREAD TABLET 50MG ; NM VIREAD TABLET 00MG ; NM VIREAD TABLET 50MG ; NM VIREAD TABLET 00MG ; NM ZEPATIER TABLET 50-00MG QL each per 65 ZERIT FOR SOLUTION MG/ML QL 00 milliliter(s) per 0 ; NM ZIAGEN SOLUTION 0 MG/ML NM zidovudine capsule 00mg NM zidovudine syrup 0 mg/ml NM zidovudine tablet 00mg NM URINARY ANTI-INFECTIVES methenamine hippurate tablet gram NM MONUROL PACKET GRAM NM

25 nitrofurantoin capsule 00mg NM nitrofurantoin capsule 5mg NM nitrofurantoin capsule 50mg NM nitrofurantoin mono-macro capsule 00mg NM nitrofurantoin suspension 5 mg/5 ml NM PRIMSOL SOLUTION 50 NM MG/5 ML trimethoprim tablet 00mg NM ANTIHISTAMINE DRUGS FIRST GENERATION ANTIHISTAMINES cyproheptadine hcl syrup mg/5 ml QL 500 milliliter(s) per 0 cyproheptadine hcl tablet mg QL 50 each per 0 meclizine hcl tablet.5mg meclizine hcl tablet 5mg prochlorperazine edisylate solution 0 mg/ ml (5 mg/ml) prochlorperazine maleate tablet 0mg prochlorperazine maleate tablet 5mg prochlorperazine suppository 5mg promethazine hcl solution 5 mg/ml promethazine hcl solution 50 mg/ml promethazine hcl tablet.5mg promethazine hcl tablet 5mg promethazine hcl tablet 50mg QL QL BvsD BvsD SECOND GENERATION ANTIHISTAMINES cetirizine hcl syrup mg/ml QL 00 milliliter(s) per 0 QL CLARINEX SYRUP.5 MG/5 ML (0.5 MG/ML) CLARINEX-D HOUR TABLET ER HR.5-0MG desloratadine tablet 5mg desloratadine tablet disperse.5mg desloratadine tablet disperse 5mg levocetirizine dihydrochloride solution.5 mg/5 ml levocetirizine dihydrochloride tablet 5mg SEMPREX-D CAPSULE 60-8MG ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE FOR SUSPENSION 00MG 5 PA AFINITOR DISPERZ TABLET SOLUBLE MG AFINITOR DISPERZ TABLET SOLUBLE MG AFINITOR DISPERZ TABLET SOLUBLE 5MG

26 AFINITOR TABLET 0MG AFINITOR TABLET.5MG AFINITOR TABLET 5MG AFINITOR TABLET 7.5MG ALECENSA CAPSULE 50MG QL 0 each per 0 ALIMTA FOR SOLUTION 500MG 5 PA ALUNBRIG TABLET 0MG anastrozole tablet mg QL ARRANON SOLUTION 50 MG/50 ML 5 BvsD AVASTIN SOLUTION 5 MG/ML 5 PA azacitidine for suspension 00mg 5 BvsD BAVENCIO SOLUTION 00 MG/0 ML (0 MG/ML) 5 PA BELEODAQ FOR SOLUTION 500MG QL 00 each per 0 bexarotene capsule 75mg 5 PA bicalutamide tablet 50mg QL BICNU FOR SOLUTION 00MG BvsD bleomycin sulfate for solution 0 unit BvsD BOSULIF TABLET 00MG BOSULIF TABLET 500MG busulfan solution 60 mg/0 ml 5 BvsD CABOMETYX TABLET 0MG CABOMETYX TABLET 0MG CABOMETYX TABLET 60MG CAPRELSA TABLET 00MG ; PA CAPRELSA TABLET 00MG ; PA carboplatin solution 0 mg/ml BvsD cisplatin solution mg/ml BvsD cladribine solution 0 mg/0 ml 5 BvsD clofarabine solution 0 mg/0 ml 5 BvsD COMETRIQ KIT 00 MG/DAY (80 MG X -0 MG 5 PA X /DAY) COMETRIQ KIT 0 MG/DAY (80 MG X -0 MG X /DAY) 5 PA 5

27 COMETRIQ KIT 60 MG/DAY (0 MG X /DAY) 5 PA COTELLIC TABLET 0MG QL 6 each per 8 ; LA cyclophosphamide capsule 5mg BvsD cyclophosphamide capsule 50mg BvsD CYRAMZA SOLUTION 00 MG/0 ML (0 MG/ML) 5 PA CYRAMZA SOLUTION 500 MG/50 ML (0 MG/ML) 5 PA cytarabine solution gram/0 ml (00 mg/ml) BvsD cytarabine solution 0 mg/ml BvsD DARZALEX SOLUTION 00 MG/5 ML (0 MG/ML) 5 PA; LA daunorubicin hcl injectable 5 mg/ml BvsD decitabine for solution 50mg 5 BvsD docetaxel concentrate 80 mg/ ml (0 mg/ml) 5 BvsD docetaxel solution 80 mg/8 ml (0 mg/ml) 5 BvsD doxorubicin hcl liposome injectable mg/ml BvsD doxorubicin hcl solution 50 mg/5 ml BvsD DROXIA CAPSULE 00MG DROXIA CAPSULE 00MG DROXIA CAPSULE 00MG ELIGARD KIT.5 MG ( MONTH) BvsD ELIGARD KIT 0 MG ( MONTH) BvsD ELIGARD KIT 7.5 MG ( MONTH) BvsD EMCYT CAPSULE 0MG QL 60 each per 0 EMPLICITI FOR SOLUTION 00MG 5 PA EMPLICITI FOR SOLUTION 00MG 5 PA epirubicin hcl solution 00 mg/00 ml BvsD ERBITUX SOLUTION 00 MG/50 ML 5 PA ERIVEDGE CAPSULE 50MG ERWINAZE FOR SOLUTION 0,000 UNIT 5 PA etoposide solution 0 mg/ml BvsD exemestane tablet 5mg QL FARESTON TABLET 60MG FARYDAK CAPSULE 0MG QL 96 each per 6 FARYDAK CAPSULE 5MG QL 96 each per 6 FARYDAK CAPSULE 0MG QL 96 each per 6 FASLODEX SOLUTION 50 MG/5 ML 5 BvsD FIRMAGON FOR SOLUTION 0MG 5 BvsD FIRMAGON FOR SOLUTION 80MG BvsD fludarabine phosphate for solution 50mg BvsD 6

28 fluorouracil solution % fluorouracil solution.5 gram/50 ml BvsD fluorouracil solution 5 % flutamide capsule 5mg FOLOTYN SOLUTION 0 MG/ ML (0 MG/ML) 5 PA GILOTRIF TABLET 0MG GILOTRIF TABLET 0MG GILOTRIF TABLET 0MG GLEEVEC TABLET 00MG QL 90 each per 0 GLEEVEC TABLET 00MG GLEOSTINE CAPSULE 00MG GLEOSTINE CAPSULE 0MG GLEOSTINE CAPSULE 0MG GLEOSTINE CAPSULE 5MG HALAVEN SOLUTION MG/ ML (0.5 MG/ML) 5 PA HERCEPTIN FOR SOLUTION 0MG 5 BvsD HEXALEN CAPSULE 50MG hydroxyurea capsule 500mg IBRANCE CAPSULE 00MG QL each per 8 IBRANCE CAPSULE 5MG QL each per 8 IBRANCE CAPSULE 75MG QL each per 8 ICLUSIG TABLET 5MG ICLUSIG TABLET 5MG idarubicin hcl solution mg/ml 5 BvsD IDHIFA TABLET 00MG IDHIFA TABLET 50MG ifosfamide for solution gram BvsD IMBRUVICA CAPSULE 0MG QL 0 each per 0 IMFINZI SOLUTION 0 MG/. ML (50 MG/ML) 5 PA IMFINZI SOLUTION 500 MG/0 ML (50 MG/ML) 5 PA INLYTA TABLET MG QL 600 each per 0 INLYTA TABLET 5MG QL 0 each per 0 IRESSA TABLET 50MG irinotecan hcl solution 00 mg/5 ml BvsD ISTODAX FOR SOLUTION 0 MG/ ML 5 PA JAKAFI TABLET 0MG ; PA 7

29 JAKAFI TABLET 5MG JAKAFI TABLET 0MG JAKAFI TABLET 5MG JAKAFI TABLET 5MG JEVTANA SOLUTION 0 MG/ML (FIRST DILUTION) KADCYLA FOR SOLUTION 00MG KEYTRUDA FOR SOLUTION 50MG QL 6 each per 8 KEYTRUDA SOLUTION 00 MG/ ML (5 MG/ML) QL 6 milliliter(s) per 8 KISQALI FEMARA CO- PACK TAB THER PACK 00 MG/DAY (00 MG X )-.5 MG QL 70 each per 8 KISQALI FEMARA CO- PACK TAB THER PACK 00 MG/DAY (00 MG X )-.5 MG QL 70 each per 8 KISQALI FEMARA CO- PACK TAB THER PACK 600 MG/DAY (00 MG X )-.5 MG QL 70 each per 8 ; PA ; PA ; PA ; PA 5 PA 5 PA KISQALI TABLET 00 MG/DAY (00 MG X ) QL 6 each per 8 KISQALI TABLET 00 MG/DAY (00 MG X ) QL 6 each per 8 KISQALI TABLET 600 MG/DAY (00 MG X ) QL 6 each per 8 KYPROLIS FOR SOLUTION 0MG QL each per 8 KYPROLIS FOR SOLUTION 60MG QL each per 8 LARTRUVO SOLUTION 500 MG/50 ML (0 MG/ML) QL 00 milliliter(s) per LENVIMA CAP THER PACK 0 MG/DAY (0 MG X /DAY) QL 90 each per 0 LENVIMA CAP THER PACK MG/DAY (0 MG X AND MG X ) QL 90 each per 0 LENVIMA CAP THER PACK 8 MG/DAY (0 MG X AND MG X ) QL 90 each per 0 LENVIMA CAP THER PACK 0 MG/DAY (0 MG X ) QL 90 each per 0 8

30 LENVIMA CAP THER PACK MG PER DAY (0 MG X AND MG X ) QL 90 each per 0 LENVIMA CAP THER PACK 8 MG/DAY ( MG X ) QL 90 each per 0 letrozole tablet.5mg QL LEUKERAN TABLET MG leuprolide acetate kit mg/0. ml levoleucovorin calcium for solution 50mg 5 PA levoleucovorin calcium solution 0 mg/ml 5 PA LONSURF TABLET 5-6.MG QL 80 each per 8 LONSURF TABLET 0-8.9MG QL 80 each per 8 LUPRON DEPOT KIT.5MG 5 BvsD LUPRON DEPOT KIT.5 MG ( MONTH) 5 BvsD LUPRON DEPOT KIT.75MG 5 BvsD LUPRON DEPOT KIT 0 MG ( MONTH) 5 BvsD LUPRON DEPOT KIT 5 MG (6 MONTH) 5 BvsD LUPRON DEPOT KIT 7.5 MG ( MONTH) 5 BvsD LUPRON DEPOT-PED KIT.5MG 5 BvsD LUPRON DEPOT-PED KIT 5MG 5 BvsD LYNPARZA CAPSULE 50MG QL 80 each per 0 LYNPARZA TABLET 00MG QL 0 each per 0 LYNPARZA TABLET 50MG QL 0 each per 0 LYSODREN TABLET 500MG MATULANE CAPSULE 50MG megestrol acetate suspension 00 mg/0 ml (0 mg/ml) megestrol acetate suspension 65 mg/5 ml megestrol acetate tablet 0mg megestrol acetate tablet 0mg MEKINIST TABLET 0.5MG QL 90 each per 0 MEKINIST TABLET MG melphalan hcl for solution 50mg 5 BvsD mercaptopurine tablet 50mg methotrexate sodium solution 5 mg/ml BvsD methotrexate solution 5 mg/ml BvsD 9

31 methotrexate tablet.5mg mitoxantrone hcl concentrate mg/ml BvsD MUSTARGEN FOR SOLUTION 0MG BvsD NERLYNX TABLET 0MG QL 80 each per 0 NEXAVAR TABLET 00MG QL 0 each per 0 nilutamide tablet 50mg NINLARO CAPSULE.MG QL each per 8 NINLARO CAPSULE MG QL each per 8 NINLARO CAPSULE MG QL each per 8 ODOMZO CAPSULE 00MG ; LA OPDIVO SOLUTION 0 MG/ ML QL 5 milliliter(s) per 8 oxaliplatin solution 00 mg/0 ml (5 mg/ml) BvsD paclitaxel concentrate 6 mg/ml BvsD POMALYST CAPSULE MG QL each per 8 POMALYST CAPSULE MG QL each per 8 POMALYST CAPSULE MG QL each per 8 POMALYST CAPSULE MG QL each per 8 PROLEUKIN FOR SOLUTION MILLION UNIT RASUVO SOLN AUTO-INJ 0 MG/0. ML QL 0.8 milliliter(s) per 8 RASUVO SOLN AUTO-INJ.5 MG/0.5 ML QL milliliter(s) per 8 RASUVO SOLN AUTO-INJ 5 MG/0. ML QL. milliliter(s) per 8 RASUVO SOLN AUTO-INJ 7.5 MG/0.5 ML QL. milliliter(s) per 8 RASUVO SOLN AUTO-INJ 0 MG/0. ML QL.6 milliliter(s) per 8 RASUVO SOLN AUTO-INJ.5 MG/0.5 ML QL.8 milliliter(s) per 8 RASUVO SOLN AUTO-INJ 5 MG/0.5 ML QL milliliter(s) per 8 RASUVO SOLN AUTO-INJ 0 MG/0.6 ML QL. milliliter(s) per 8 5 PA ; ST ; ST ; ST ; ST ; ST ; ST ; ST ; ST 0

32 RASUVO SOLN AUTO-INJ 7.5 MG/0.5 ML QL 0.6 milliliter(s) per 8 REVLIMID CAPSULE 0MG QL 8 each per 8 REVLIMID CAPSULE 5MG QL 8 each per 8 REVLIMID CAPSULE.5MG QL 8 each per 8 REVLIMID CAPSULE 0MG QL 8 each per 8 REVLIMID CAPSULE 5MG QL 8 each per 8 REVLIMID CAPSULE 5MG QL 8 each per 8 RITUXAN SOLUTION 0 MG/ML RUBRACA TABLET 00MG QL 0 each per 0 RUBRACA TABLET 00MG QL 0 each per 0 RYDAPT CAPSULE 5MG QL 0 each per 0 SOLTAMOX SOLUTION 0 MG/5 ML SPRYCEL TABLET 00MG SPRYCEL TABLET 0MG ; ST ; LA ; LA ; LA ; LA ; LA ; LA 5 BvsD SPRYCEL TABLET 0MG SPRYCEL TABLET 50MG SPRYCEL TABLET 70MG SPRYCEL TABLET 80MG STIVARGA TABLET 0MG QL 8 each per SUTENT CAPSULE.5MG QL 90 each per 0 SUTENT CAPSULE 5MG SUTENT CAPSULE 7.5MG SUTENT CAPSULE 50MG SYLATRON KIT 00 MCG 5 PA SYLATRON KIT 00 MCG 5 PA SYLATRON KIT 600 MCG 5 PA SYNRIBO FOR SOLUTION.5MG 5 PA TABLOID TABLET 0MG TAFINLAR CAPSULE 50MG QL 0 each per 0 TAFINLAR CAPSULE 75MG QL 0 each per 0 TAGRISSO TABLET 0MG ; LA

33 TAGRISSO TABLET 80MG ; LA tamoxifen citrate tablet 0mg tamoxifen citrate tablet 0mg TARCEVA TABLET 00MG TARCEVA TABLET 50MG TARCEVA TABLET 5MG TASIGNA CAPSULE 50MG QL 0 each per 0 TASIGNA CAPSULE 00MG QL 0 each per 0 TECENTRIQ SOLUTION,00 MG/0 ML (60 MG/ML) QL 0 milliliter(s) per thiotepa for solution 5mg 5 PA toposar solution 0 mg/ml BvsD topotecan hcl for solution mg 5 BvsD TORISEL SOLUTION 0 MG/ ML (0 MG/ML) 5 PA (FIRST DILUTION) TREANDA FOR SOLUTION 00MG 5 PA TRELSTAR FOR SUSPENSION.5 MG/ 5 BvsD ML TRELSTAR FOR SUSPENSION.5 MG/ ML 5 BvsD TRELSTAR FOR SUSPENSION.75 MG/ ML 5 BvsD tretinoin capsule 0mg QL 60 each per 0 QL TREXALL TABLET 0MG TREXALL TABLET 5MG TREXALL TABLET 5MG TREXALL TABLET 7.5MG TRISENOX SOLUTION 0 MG/0 ML 5 BvsD TYKERB TABLET 50MG QL 50 each per 0 ; LA VECTIBIX SOLUTION 00 MG/5 ML (0 MG/ML) 5 PA VELCADE FOR SOLUTION.5MG 5 PA VENCLEXTA STARTING PACK TAB THER PACK 0 MG ()-50 MG (7)-00 MG () QL 0 each per 0 VENCLEXTA TABLET 00MG QL 0 each per 0 VENCLEXTA TABLET 0MG ; PA QL 0 each per 0 VENCLEXTA TABLET 50MG ; PA QL 0 each per 0 vinblastine sulfate solution mg/ml BvsD vincasar pfs solution mg/ml BvsD vincristine sulfate solution mg/ml BvsD

34 vinorelbine tartrate solution 50 mg/5 ml BvsD VOTRIENT TABLET 00MG 5 PA VYXEOS FOR SUSPENSION -00MG QL each per 8 XALKORI CAPSULE 00MG XALKORI CAPSULE 50MG XTANDI CAPSULE 0MG QL 0 each per 0 YERVOY SOLUTION 50 MG/0 ML (5 MG/ML) 5 PA YONDELIS FOR SOLUTION MG QL each per ZANOSAR FOR SOLUTION GRAM BvsD ZEJULA CAPSULE 00MG QL 90 each per 0 ZELBORAF TABLET 0MG QL 0 each per 0 ZOLINZA CAPSULE 00MG QL 0 each per 0 ; PA ZYDELIG TABLET 00MG ZYDELIG TABLET 50MG ZYKADIA CAPSULE 50MG QL 50 each per 0 ZYTIGA TABLET 50MG QL 0 each per 0 ZYTIGA TABLET 500MG QL 0 each per 0 AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ATROVENT HFA AEROSOL SOLN 7 MCG/ACTUATION BEVESPI AEROSPHERE AEROSOL 9 MCG-.8 MCG ; ST QL 0.7 gram(s) per 0 COMBIVENT RESPIMAT AEROSOL SOLN 0 MCG- 00 MCG/ACTUATION dicyclomine hcl capsule 0mg QL 0 each per 0 dicyclomine hcl solution 0 mg/5 ml QL 00 milliliter(s) per 0 QL dicyclomine hcl tablet 0mg QL 0 each per 0 glycopyrrolate tablet mg glycopyrrolate tablet mg ipratropium bromide solution 0. mg/ml (0.0 %) BvsD ipratropium-albuterol solution 0.5 mg- mg (.5 mg base)/ BvsD ml methscopolamine bromide tablet.5mg