Precise RxCare (PDP) 2015 Formulary for 4 Tier Plan (List of Covered Drugs)

Transcription

1 Precise RxCare (PDP) 2015 Formulary for 4 Plan (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on December For more recent information or other questions, please contact Precise RxCare (PDP) Customer Care at or, for TTY users, , Monday through Friday, 8:00 AM to 8:00 PM (EST), or visit preciserxcare.amwins.com. When this drug list (formulary) refers to we, us, or our, it means Heartland Fidelity Insurance Company. When it refers to plan or our plan, it means Precise RxCare (PDP). This document includes list of the drugs (formulary) for our plan which is current as of September For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/co-insurance may change on January 1 of each year. ations, copayments and restrictions may apply. Underwritten by Heartland Fidelity Insurance Company Formulary ID# Last updated 09/2014

2 What is the Precise RxCare (PDP) Formulary? A formulary is a list of covered drugs selected by Precise RxCare (PDP) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Precise RxCare (PDP) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Precise RxCare (PDP) 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 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 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 a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60 day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of September To get updated information about the drugs covered by Precise RxCare (PDP), please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 6. 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. If you know what your drug is used for, look for the category name in the list that begins page 6. Then look under the category name for your drug. 1

3 Alphabetical Listing 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? Precise RxCare (PDP) 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: : Precise RxCare (PDP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Precise RxCare (PDP) before you fill your prescriptions. If you don t get approval, Precise RxCare (PDP) may not cover the drug. s: For certain drugs, Precise RxCare (PDP) limits the amount of the drug that Precise RxCare (PDP) will cover. For example, Precise RxCare (PDP) provides 30 tablets for 30 days for BENICAR 20mg. This may be in addition to a standard one-month or three-month supply. : In some cases, Precise RxCare (PDP) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Precise RxCare (PDP) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Precise RxCare (PDP) will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 6. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explains our prior authorization restriction, and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Precise RxCare (PDP) 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 Precise RxCare (PDP) s formulary? on page 3 for information about how to request an exception. 2

4 What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. 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 Customer Care and ask if your drug is covered. If you learn that Precise RxCare (PDP) does not cover your drug, you have two options: You can ask Customer Care for a list of similar drugs that are covered by Precise RxCare (PDP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Precise RxCare (PDP). You can ask Precise RxCare (PDP) 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 Precise RxCare (PDP) s Formulary? You can ask Precise RxCare (PDP) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs Precise RxCare (PDP) 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, Precise RxCare (PDP) 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 3

5 must make our decision within 72 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 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31 day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31 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 98 day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. A transition supply will also be provided if you experience a level of care change. If you enter a Long Term Care (LTC) facility from a hospital, you will receive up to a 98 day transitional supply (with multiple refills as necessary) of the non-formulary medication. If you are discharged from a hospital or a skilled nursing facility to home, and need to revert back to the Precise RxCare (PDP) plan formulary you will need to adhere to the plan s Exceptions and Appeals processes. Transitional supplies will be granted while you wait for the exception process or a. For more information For more detailed information about your Precise RxCare Rx (PDP) prescription drug coverage, please review your Evidence of Coverage and other plan materials. 4

6 If you have questions about Precise RxCare (PDP), 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 MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Precise RxCare (PDP s) Formulary The formulary that begins on page 6 provides coverage information about the drugs covered by Precise RxCare (PDP). If you have trouble finding your drug in the list, turn to the Index that begins on page 58. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/s column tells you if Precise RxCare (PDP) has any special requirements for coverage of your drug. The symbol B/D in the Requirements/s column indicates that a drug may be covered under Part B or Part D coverage. The symbol LA in the Requirement/s column indicates that a drug may only be available at one or limited number of pharmacies The symbol QL in the Requirement/s column indicates that quantities dispensed may be limited. The symbol PA in the Requirement/s column indicates that prior authorization is needed. The symbol ST in the Requirement/s column indicates that step therapy may apply. The symbol ODT in the Requirement/s column indicates the drug is an Orally Disintegrating Tablet The symbol LPOP in the Requirement/s column indicates this drug is a Lollipop. The symbol PTCH in the Requirement/s column indicates this drug is a Patch. 5

7 ABACAV/LAMIV TAB /ZIDOVUD 1 ABACAVIR TAB 300MG 4 ABELCET INJ 5MG/ML 3 May Be Billable to Part B* ABILIFY INJ 9.75MG 4 ABILIFY SOL 1MG/ML 3 750ML per 30 days ABILIFY TAB 10MG 4 30 per 30 days ABILIFY TAB 15MG 4 30 per 30 days ABILIFY TAB 20MG 4 30 per 30 days ABILIFY TAB 2MG 4 30 per 30 days ABILIFY TAB 30MG 4 30 per 30 days ABILIFY TAB 5MG 4 30 per 30 days ABILIFY DISC TAB 10MG 4 30 per 30 days ABILIFY DISC TAB 15MG 4 30 per 30 days ABILIFY MAIN INJ 300MG 4 ABRAXANE INJ 100MG 4 PA for New Treatments ABSTRAL SUB 100MCG per 30 days ABSTRAL SUB 200MCG per 30 days ABSTRAL SUB 300MCG per 30 days ABSTRAL SUB 400MCG per 30 days 6

8 ABSTRAL SUB 600MCG per 30 days ABSTRAL SUB 800MCG per 30 days ACAMPRO CAL TAB 333MG 4 ACARBOSE TAB 100MG 3 90 per 30 days ACARBOSE TAB 25MG per 30 days ACARBOSE TAB 50MG per 30 days ACEBUTOLOL CAP 200MG 1 ACEBUTOLOL CAP 400MG 1 ACETAZOLAMID CAP 500MG ER 1 ACETAZOLAMID INJ 500MG 1 ACETAZOLAMID TAB 125MG 1 ACETAZOLAMID TAB 250MG 1 ACETIC ACID SOL 2% OTIC 1 ACETYLCYST SOL 10% 1 May Be Billable to Part B* ACETYLCYST SOL 20% 1 May Be Billable to Part B* ACITRETIN CAP 10MG 1 ACITRETIN CAP 17.5MG 4 7

9 ACITRETIN CAP 25MG 4 ACTEMRA INJ 162/0.9 4 ACTEMRA INJ 200/10ML 4 ACTHIB INJ 4 ACTIMMUNE INJ 2MU/0.5 2 ACUVAIL SOL 0.45% 4 ACYCLOVIR CAP 200MG 3 ACYCLOVIR OIN 5% 1 ACYCLOVIR SUS 200/5ML 1 ACYCLOVIR TAB 400MG 1 ACYCLOVIR TAB 800MG 1 ACYCLOVIR NA INJ 50MG/ML 1 May Be Billable to Part B* ADACEL INJ 1 ADAGEN INJ 250/ML 2 ADAPALENE CRE 0.1% 4 ADAPALENE GEL 0.1% 1 ADAPALENE GEL 0.3% 1 ADCIRCA TAB 20MG 1 60 per 30 days ADEFOV DIPIV TAB 10MG 4 ADEMPAS TAB 0.5MG 4 90 per 30 days 8

10 ADEMPAS TAB 1.5MG 4 90 per 30 days ADEMPAS TAB 1MG 4 90 per 30 days ADEMPAS TAB 2.5MG 4 90 per 30 days ADEMPAS TAB 2MG 4 90 per 30 days ADRENALIN INJ 1MG/ML 4 ADVAIR DISKU AER 100/ per 30 days ADVAIR DISKU AER 250/ per 30 days ADVAIR DISKU AER 500/ per 30 days ADVAIR HFA AER 115/ per 30 days ADVAIR HFA AER 230/ per 30 days ADVAIR HFA AER 45/ per 30 days ADVICOR TAB per 30 days ADVICOR TAB per 30 days ADVICOR TAB MG 3 60 per 30 days ADVICOR TAB MG 3 60 per 30 days AEROSPAN AER 80MCG GM per 30 days AFEDITAB TAB 30MG CR 3 90 per 30 days 9

11 AFEDITAB TAB 60MG CR 1 30 per 30 days AFINITOR TAB 10MG 1 PA for New Treatments AFINITOR TAB 2.5MG 4 PA for New Treatments AFINITOR TAB 5MG 4 PA for New Treatments AFINITOR TAB 7.5MG 4 PA for New Treatments AFINITOR DIS TAB 2MG 4 PA for New Treatments AFINITOR DIS TAB 3MG 4 PA for New Treatments AFINITOR DIS TAB 5MG 4 PA for New Treatments AGGRENOX CAP MG 4 60 per 30 days A-HYDROCORT INJ 100MG 2 AKNE-MYCIN OIN 2% 3 ALA CORT CRE 1% 1 ALBENZA TAB 200MG 2 ALBUTEROL NEB 0.083% 1 May Be Billable to Part B* ALBUTEROL NEB 0.5% 1 May Be Billable to Part B* ALBUTEROL NEB 0.63MG/3 1 May Be Billable to Part B* ALBUTEROL NEB 1.25MG/3 1 May Be Billable to Part B* ALBUTEROL SYP 2MG/5ML 1 ALBUTEROL TAB 2MG 1 ALBUTEROL TAB 4MG 1 ALCLOMETASON CRE 1 10

12 0.05% ALCLOMETASON OIN 0.05% 1 ALCOHOL PREP PAD 2 ALDACTAZIDE TAB 50/50 3 ALDURAZYME INJ 2.9MG/5M 4 ALENDRONATE SOL 70/75ML 1 ALENDRONATE TAB 10MG 1 ALENDRONATE TAB 35MG 1 ALENDRONATE TAB 40MG 1 ALENDRONATE TAB 5MG 1 ALENDRONATE TAB 70MG 1 ALFUZOSIN TAB 10MG 1 30 per 30 days ALIMTA INJ 500MG 4 PA for New Treatments ALINIA SUS 100/5ML 3 ALINIA TAB 500MG 3 ALLOPURINOL TAB 100MG 1 ALLOPURINOL TAB 300MG 1 ALOCRIL SOL 2% 3 ALOMIDE SOL 0.1% 3 11

13 OP ALOXI INJ 0.25MG/5 3 ALPHAGAN P SOL 0.1% 2 ALPRAZOLAM CON 1 MG/ML 1 300ML per 30 days ALPRAZOLAM TAB 0.25 ODT per 30 days ALPRAZOLAM TAB 0.25MG per 30 days ALPRAZOLAM TAB 0.5MG per 30 days ALPRAZOLAM TAB 0.5MG ER 1 30 per 30 days ALPRAZOLAM TAB 0.5MG OD per 30 days ALPRAZOLAM TAB 1MG per 30 days ALPRAZOLAM TAB 1MG ER 1 30 per 30 days ALPRAZOLAM TAB 1MG ODT per 30 days ALPRAZOLAM TAB 2MG per 30 days ALPRAZOLAM TAB 2MG ER per 30 days ALPRAZOLAM TAB 2MG ODT per 30 days ALPRAZOLAM TAB 3MG ER 1 90 per 30 days ALREX SUS 0.2% 2 12

14 ALTOPREV TAB 20MG ER 3 30 per 30 days ALTOPREV TAB 40MG ER 3 30 per 30 days ALTOPREV TAB 60MG ER 3 30 per 30 days ALVESCO AER 160MCG GM per 30 days ALVESCO AER 80MCG GM per 30 days AMANTADINE CAP 100MG 1 AMANTADINE SYP 50MG/5ML 1 AMANTADINE TAB 100MG 1 AMBISOME INJ 50MG 4 May Be Billable to Part B* AMCINONIDE CRE 0.1% 1 AMCINONIDE LOT 0.1% 1 AMCINONIDE OIN 0.1% 1 AMETHIA TAB 1 AMETHYST TAB 90-20MCG 1 AMIFOSTINE INJ 500MG 4 Required Required Required Required Required 13

15 AMIKACIN INJ 500/2ML 1 AMILOR/HCTZ TAB AMILORIDE TAB 5MG 1 AMINOPHYLLIN INJ 25MG/ML 1 AMINOSYN INJ 8.5/LYTE 1 May Be Billable to Part B* AMINOSYN II INJ 10% 3 May Be Billable to Part B* AMINOSYN II INJ 7% 3 May Be Billable to Part B* AMINOSYN II INJ 8.5/LYTE 1 May Be Billable to Part B* AMINOSYN M INJ 3.5% 3 May Be Billable to Part B* AMINOSYN-HBC INJ 7% 3 May Be Billable to Part B* AMINOSYN-PF INJ 10% 3 May Be Billable to Part B* AMINOSYN-PF INJ 7% 3 May Be Billable to Part B* AMIODARONE INJ 50MG/ML 1 AMIODARONE TAB 200MG 1 AMIODARONE TAB 400MG 1 AMITIZA CAP 24MCG 2 60 per 30 days AMITIZA CAP 8MCG 2 60 per 30 days AMITRIPTYLIN TAB 100MG 1 PA for New Treatments AMITRIPTYLIN TAB 10MG 1 PA for New Treatments AMITRIPTYLIN TAB 1 PA for New Treatments 14

16 150MG AMITRIPTYLIN TAB 25MG 1 PA for New Treatments AMITRIPTYLIN TAB 50MG 1 PA for New Treatments AMITRIPTYLIN TAB 75MG 1 PA for New Treatments AMLOD/ATORVA TAB 10-10MG 1 30 per 30 days AMLOD/ATORVA TAB 10-20MG 1 30 per 30 days AMLOD/ATORVA TAB 10-40MG 1 30 per 30 days AMLOD/ATORVA TAB 10-80MG 1 30 per 30 days AMLOD/ATORVA TAB MG 1 30 per 30 days AMLOD/ATORVA TAB MG 1 30 per 30 days AMLOD/ATORVA TAB MG 1 30 per 30 days AMLOD/ATORVA TAB 5-10MG 1 30 per 30 days AMLOD/ATORVA TAB 5-20MG 1 30 per 30 days AMLOD/ATORVA TAB 5-40MG 1 30 per 30 days AMLOD/ATORVA TAB 5-80MG 1 30 per 30 days AMLOD/BENAZP CAP 10-20MG 1 15

17 AMLOD/BENAZP CAP 10-40MG 1 AMLOD/BENAZP CAP MG 1 AMLOD/BENAZP CAP 5-10MG 1 AMLOD/BENAZP CAP 5-20MG 1 AMLOD/BENAZP CAP 5-40MG 1 AMLODIPINE TAB 10MG 1 30 per 30 days AMLODIPINE TAB 2.5MG per 30 days AMLODIPINE TAB 5MG 1 60 per 30 days AMMONIUM LAC CRE 12% 1 AMMONIUM LAC LOT 12% 1 AMNESTEEM CAP 10MG 3 AMNESTEEM CAP 20MG 3 AMNESTEEM CAP 40MG 3 AMOX/K CLAV CHW 200MG 1 AMOX/K CLAV CHW 400MG 1 AMOX/K CLAV SUS 200/5ML 1 16

18 AMOX/K CLAV SUS 250/5ML 1 AMOX/K CLAV SUS 400/5ML 1 AMOX/K CLAV SUS 600/5ML 1 AMOX/K CLAV TAB 250MG 1 AMOX/K CLAV TAB 500MG 1 AMOX/K CLAV TAB 875MG 1 AMOXAPINE TAB 100MG 1 AMOXAPINE TAB 150MG 1 AMOXAPINE TAB 25MG 1 AMOXAPINE TAB 50MG 1 AMOXICILLIN CAP 250MG 1 AMOXICILLIN CAP 500MG 1 AMOXICILLIN CHW 125MG 1 AMOXICILLIN CHW 250MG 1 AMOXICILLIN SUS 125/5ML 1 AMOXICILLIN SUS 200/5ML 1 17

19 AMOXICILLIN SUS 250/5ML 1 AMOXICILLIN SUS 400/5ML 1 AMOXICILLIN TAB 500MG 1 AMOXICILLIN TAB 875MG 1 AMOX-POT CLA TAB ER 1 AMPHETAMINE CAP 10MG ER 3 60 per 30 days AMPHETAMINE CAP 15MG ER 3 60 per 30 days AMPHETAMINE CAP 20MG ER 1 60 per 30 days AMPHETAMINE CAP 25MG ER 1 60 per 30 days AMPHETAMINE CAP 30MG ER 1 60 per 30 days AMPHETAMINE CAP 5MG ER 1 60 per 30 days AMPHETAMINE TAB 10MG 1 60 per 30 days AMPHETAMINE TAB 12.5MG 1 60 per 30 days AMPHETAMINE TAB 15MG 1 60 per 30 days AMPHETAMINE TAB 20MG 1 60 per 30 days AMPHETAMINE TAB 30MG 1 60 per 30 days AMPHETAMINE TAB 1 60 per 30 days 18

20 5MG AMPHETAMINE TAB 7.5MG 1 60 per 30 days AMPHOTERICIN INJ 50MG 1 May Be Billable to Part B* AMPICILLIN CAP 250MG 1 AMPICILLIN CAP 500MG 3 AMPICILLIN INJ 10GM 1 AMPICILLIN INJ 125MG 1 AMPICILLIN INJ 1GM 3 AMPICILLIN SUS 125/5ML 3 AMPICILLIN SUS 250/5ML 3 AMP-SULBACTA INJ 15GM 1 AMP-SULBACTA INJ 3GM 1 AMPYRA TAB 10MG 4 60 per 30 days ANADROL-50 TAB 50MG 4 ANAGRELIDE CAP 0.5MG 1 ANAGRELIDE CAP 1MG 1 ANASTROZOLE TAB 1MG 1 ANDRODERM DIS 2MG/24HR 2 30 per 30 days 19

21 ANDRODERM DIS 4MG/24HR 2 30 per 30 days ANDROGEL GEL 1%(50MG) 2 300GM per 30 days ANDROGEL GEL 1.62% 2 150GM per 30 days ANDROXY TAB 10MG 3 ANGELIQ TAB ANGELIQ TAB 0.5-1MG 3 ANZEMET INJ 20MG/ML 3 ANZEMET TAB 100MG 4 3 per 3 days May Be Billable to Part B* ANZEMET TAB 50MG 4 6 per 3 days May Be Billable to Part B* APAP/CODEINE SOL / ML per 30 days APAP/CODEINE TAB MG per 30 days APAP/CODEINE TAB MG per 30 days APAP/CODEINE TAB MG per 30 days APEXICON E CRE 0.05% 3 APIDRA INJ SOLOSTAR 2 APIDRA INJ U APOKYN INJ 10MG/ML 4 60ML per 30 days 20

22 APRACLONIDIN SOL 0.5% OP 1 APRI TAB 1 APRISO CAP 0.375GM 2 APTIOM TAB 200MG 3 60 per 30 days APTIOM TAB 400MG 4 30 per 30 days APTIOM TAB 600MG 4 60 per 30 days APTIOM TAB 800MG 4 60 per 30 days APTIVUS CAP 250MG 4 APTIVUS SOL 4 ARALAST NP INJ 400MG 4 ARANELLE TAB 1 ARANESP INJ 100MCG 4 4ML per 28 days ARANESP INJ 100MCG 4 2ML per 28 days ARANESP INJ 150MCG 4 1.2ML per 28 days ARANESP INJ 200MCG 4 4ML per 28 days ARANESP INJ 200MCG 4 1.6ML per 28 days ARANESP INJ 25MCG 3 4ML per 28 days ARANESP INJ 25MCG 3 1.7ML per 28 days ARANESP INJ 300MCG 4 4ML per 28 days ARANESP INJ 300MCG 4 2.4ML per 28 days 21

23 ARANESP INJ 40MCG 3 4ML per 28 days ARANESP INJ 40MCG 3 1.6ML per 28 days ARANESP INJ 500MCG 4 1ML per 21 days ARANESP INJ 60MCG 3 4ML per 28 days ARANESP INJ 60MCG 3 1.2ML per 28 days ARCALYST INJ 220MG 4 ARCAPTA CAP 75MCG 3 30 per 30 days ARGATROBAN INJ 100MG/ML 4 May Be Billable to Part B* ARGATROBAN INJ 125/125 4 May Be Billable to Part B* ARRANON INJ 5MG/ML 4 ARZERRA CON 100/5ML 4 PA for New Treatments ASCOMP/COD CAP 30MG per 30 days ASMANEX 120 AER 220MCG per 30 days ASMANEX 30 AER 110MCG per 30 days ASMANEX 30 AER 220MCG per 30 days ASMANEX 60 AER 220MCG per 30 days ASTEPRO SPR 0.15% 2 60ML per 30 days ATELVIA TAB 2 4 per 28 days 22

24 ATENOL/CHLOR TAB MG 1 ATENOL/CHLOR TAB 50-25MG 1 ATENOLOL TAB 100MG 1 ATENOLOL TAB 25MG 1 ATENOLOL TAB 50MG 1 ATGAM INJ 250MG 4 ATORVASTATIN TAB 10MG 1 30 per 30 days ATORVASTATIN TAB 20MG 1 30 per 30 days ATORVASTATIN TAB 40MG 1 30 per 30 days ATORVASTATIN TAB 80MG 1 30 per 30 days ATOVAQ/PROGU TAB ATOVAQ/PROGU TAB ATOVAQUONE SUS 750/5ML 1 ATRALIN GEL 0.05% 3 ATRIPLA TAB 4 ATROVENT HFA AER 17MCG GM per 30 days AUBAGIO TAB 14MG 4 30 per 30 days AUBAGIO TAB 7MG 4 30 per 30 days 23

25 AUG BETAMET CRE 0.05% 1 AUG BETAMET GEL 0.05% 1 AUG BETAMET LOT 0.05% 1 AUG BETAMET OIN 0.05% 1 AUGMENTIN SUS 125/5ML 3 AUVI-Q INJ 0.15MG 3 AUVI-Q INJ 0.3MG 3 AVANDAMET TAB MG 3 60 per 30 days AVANDAMET TAB 2-500MG per 30 days AVANDAMET TAB MG 3 60 per 30 days AVANDAMET TAB 4-500MG 3 60 per 30 days AVANDARYL TAB 4-1MG 3 30 per 30 days AVANDARYL TAB 4-2MG 3 30 per 30 days AVANDARYL TAB 4-4MG 3 30 per 30 days AVANDARYL TAB 8-2MG 3 30 per 30 days AVANDARYL TAB 8-4MG 3 30 per 30 days AVANDIA TAB 2MG per 30 days 24

26 AVANDIA TAB 4MG 3 60 per 30 days AVANDIA TAB 8MG 3 30 per 30 days AVASTIN INJ 4 PA for New Treatments AVIANE TAB 1 AVITA CRE 0.025% 1 AVITA GEL 0.025% 3 AVODART CAP 0.5MG 2 30 per 30 days AVONEX KIT 30MCG 4 AVONEX PREFL KIT 30MCG 4 AXERT TAB 12.5MG 3 12 per 30 days AXERT TAB 6.25MG 3 12 per 30 days AZACITIDINE INJ 100MG 4 PA for New Treatments AZACTAM/DEX INJ 1GM 3 AZACTAM/DEX INJ 2GM 3 AZASAN TAB 100MG 2 May Be Billable to Part B* AZASAN TAB 75 MG 2 May Be Billable to Part B* AZASITE SOL 1% 2 AZATHIOPRINE TAB 50MG 1 May Be Billable to Part B* AZELASTINE DRO 0.05% 1 Required Required 25

27 AZELASTINE SPR 0.1% 1 60ML per 30 days AZELASTINE SPR 0.15% 1 60ML per 30 days AZELEX CRE 20% 3 AZILECT TAB 0.5MG 2 AZILECT TAB 1MG 2 AZITHROMYCIN INJ 500MG 1 AZITHROMYCIN POW 1GM PAK 1 AZITHROMYCIN SUS 100/5ML 1 AZITHROMYCIN SUS 200/5ML 1 AZITHROMYCIN TAB 250MG 1 AZITHROMYCIN TAB 500MG 1 AZITHROMYCIN TAB 600MG 1 AZOPT SUS 1% OP 2 AZOR TAB 10-20MG 2 30 per 30 days AZOR TAB 10-40MG 2 30 per 30 days AZOR TAB 5-20MG 2 30 per 30 days AZOR TAB 5-40MG 2 30 per 30 days AZTREONAM INJ 1GM 3 BACIIM INJ 50000UNT 3 BACIT/POLYMY OIN OP 1 BACITRACIN INJ 1 26

28 50000UNT BACITRACIN OIN OP 1 BACLOFEN TAB 10MG 1 BACLOFEN TAB 20MG 1 BACTOCILL INJ DEX 1GM 3 BACTOCILL INJ DEX 2GM 4 BACTROBAN OIN NASAL 2% 2 BALSALAZIDE CAP 750MG 1 BALZIVA TAB 1 BANZEL SUS 40MG/ML 4 BANZEL TAB 200MG 3 BANZEL TAB 400MG 4 BARACLUDE SOL.05MG/ML 4 BARACLUDE TAB 0.5MG 4 BARACLUDE TAB 1MG 4 BD PEN NEEDL MIS 29GX1/2" 2 BECONASE AQ SUS 0.042% 3 50GM per 30 days BENAZEP/HCTZ TAB

29 BENAZEP/HCTZ TAB BENAZEP/HCTZ TAB 20-25MG 1 BENAZEP/HCTZ TAB BENAZEPRIL TAB 10MG 1 BENAZEPRIL TAB 20MG 1 BENAZEPRIL TAB 40MG 1 BENAZEPRIL TAB 5MG 1 BENICAR TAB 20MG 2 30 per 30 days BENICAR TAB 40MG 2 30 per 30 days BENICAR TAB 5MG 2 30 per 30 days BENICAR HCT TAB per 30 days BENICAR HCT TAB per 30 days BENICAR HCT TAB 40-25MG 2 30 per 30 days BENLYSTA INJ 120MG 4 BENZTROPINE INJ 1MG/ML 3 BENZTROPINE TAB 0.5MG 1 BENZTROPINE TAB 1MG 1 BENZTROPINE TAB 2MG 1 28

30 BEPREVE DRO 1.5% 3 BESIVANCE SUS 0.6% 2 BETAMETH DIP CRE 0.05% 1 BETAMETH DIP LOT 0.05% 1 BETAMETH DIP OIN 0.05% 1 BETAMETH VAL AER 0.12% 1 BETAMETH VAL CRE 0.1% 1 BETAMETH VAL LOT 0.1% 1 BETAMETH VAL OIN 0.1% 1 BETASERON INJ 0.3MG 4 BETAXOLOL SOL 0.5% OP 1 BETAXOLOL TAB 10MG 1 BETAXOLOL TAB 20MG 1 BETHANECHOL TAB 10MG 1 BETHANECHOL TAB 25MG 1 BETHANECHOL TAB 50MG 1 BETHANECHOL TAB 5MG 1 29

31 BETHKIS NEB 300/4ML 4 May Be Billable to Part B* BETIMOL SOL 0.5% 3 BICALUTAMIDE TAB 50MG 1 BICILLIN C-R INJ BICILLIN C-R INJ 900/300 3 BICILLIN L-A INJ BICILLIN L-A INJ BICILLIN L-A INJ BICNU INJ 100MG 3 BIDIL TAB 2 BILTRICIDE TAB 600MG 2 BINOSTO TAB 70MG 3 BISOPRL/HCTZ TAB 10/ BISOPRL/HCTZ TAB 2.5/ BISOPRL/HCTZ TAB MG 1 BISOPROL FUM TAB 10MG 1 BISOPROL FUM TAB 5MG 1 BIVIGAM INJ 10% 4 30

32 BLEOMYCIN INJ 30UNIT 3 May Be Billable to Part B* BLEPHAMIDE OIN S.O.P. 2 BLEPHAMIDE SUS OP 2 BOOSTRIX INJ 2 BOOSTRIX INJ 2 BOSULIF TAB 100MG 4 PA for New Treatments BOSULIF TAB 500MG 4 PA for New Treatments BOTOX INJ 100UNIT 3 BREO ELLIPTA INH BRIELLYN TAB 1 BRILINTA TAB 90MG 2 60 per 30 days BRIMONIDINE SOL 0.15% 1 BRIMONIDINE SOL 0.2% OP 1 BRINTELLIX TAB 10MG 3 30 per 30 days BRINTELLIX TAB 20MG 3 30 per 30 days BRINTELLIX TAB 5MG 3 30 per 30 days BROMFENAC SOL 0.09% OP 1 BROMOCRIPTIN CAP 5MG 3 Required Required Required 31

33 BROMOCRIPTIN TAB 2.5MG 3 BROVANA NEB 15MCG 3 120ML per 30 days May Be Billable to Part B* BUDESONIDE CAP 3MG/24HR 4 BUDESONIDE SUS 0.25MG/2 3 May Be Billable to Part B* BUDESONIDE SUS 0.5MG/2 3 May Be Billable to Part B* BUDESONIDE SUS 32MCG GM per 30 days BUMETANIDE INJ 0.25/ML 1 BUMETANIDE TAB 0.5MG 1 BUMETANIDE TAB 1MG 1 BUMETANIDE TAB 2MG 1 BUPREN/NALOX SUB 2-0.5MG 1 90 per 30 days BUPREN/NALOX SUB 8-2MG 1 90 per 30 days BUPRENORPHIN INJ 0.3MG/ML 3 BUPRENORPHIN SUB 2MG 3 90 per 30 days BUPRENORPHIN SUB 8MG 3 90 per 30 days BUPROBAN TAB 150MG 1 60 per 30 days 32

34 BUPROPION TAB 100MG per 30 days BUPROPION TAB 100MG SR per 30 days BUPROPION TAB 150MG SR 1 60 per 30 days BUPROPION TAB 200MG SR 1 60 per 30 days BUPROPION TAB 75MG 1 90 per 30 days BUPROPN HCL TAB 150MG XL 1 90 per 30 days BUPROPN HCL TAB 300MG XL 1 30 per 30 days BUSPIRONE TAB 10MG 1 BUSPIRONE TAB 15MG 1 BUSPIRONE TAB 30MG 1 BUSPIRONE TAB 5MG 1 BUSPIRONE TAB 7.5MG 1 BUSULFEX INJ 6MG/ML 4 BUT/APAP/CAF CAP per 30 days BUT/APAP/CAF CAP per 30 days BUT/APAP/CAF CAP CODEINE per 30 days BUT/APAP/CAF CAP CODEINE per 30 days 33

35 BUT/ASA/CAFF CAP per 30 days BUTAL/APAP TAB MG per 30 days BUTISOL SOD ELX 30MG/5ML ML per 30 days BUTISOL SOD TAB 30MG per 30 days BUTISOL SOD TAB 50MG 3 60 per 30 days BUTORPHANOL INJ 1MG/ML 1 BUTORPHANOL INJ 2MG/ML 1 BUTORPHANOL SOL 10MG/ML 1 5ML per 1 day BUTRANS DIS 10MCG/HR 2 4 per 28 days BUTRANS DIS 15MCG/HR 2 4 per 28 days BUTRANS DIS 20MCG/HR 2 4 per 28 days BUTRANS DIS 5MCG/HR 2 4 per 28 days BYETTA INJ 10MCG 2 2.4ML per 30 days BYETTA INJ 5MCG 2 1.2ML per 30 days BYSTOLIC TAB 10MG 2 90 per 30 days BYSTOLIC TAB 2.5MG 2 30 per 30 days BYSTOLIC TAB 20MG 2 60 per 30 days Required Required 34

36 BYSTOLIC TAB 5MG 2 90 per 30 days CABERGOLINE TAB 0.5MG 2 CAFERGOT TAB 1-100MG 3 CALC ACETATE CAP 667MG 1 CALCIPOTRIEN CRE 0.005% 1 CALCIPOTRIEN OIN 0.005% 1 CALCIPOTRIEN OIN BETAMETH 1 CALCIPOTRIEN SOL 0.005% 1 CALCITONIN SPR 200/ACT 1 3.7ML per 30 days May Be Billable to Part B* CALCITRIOL CAP 0.25MCG 1 May Be Billable to Part B* CALCITRIOL CAP 0.5MCG 1 May Be Billable to Part B* CALCITRIOL INJ 1MCG/ML 1 May Be Billable to Part B* CALCITRIOL SOL 1MCG/ML 1 May Be Billable to Part B* CAMILA TAB 0.35MG 1 CAMPRAL TAB 333MG 3 CANASA SUP 1000MG 4 CANCIDAS INJ 50MG 4 35

37 CANCIDAS INJ 70MG 4 CANDESA/HCTZ TAB per 30 days CANDESA/HCTZ TAB per 30 days CANDESA/HCTZ TAB 32-25MG 1 30 per 30 days CANDESARTAN TAB 16MG 1 60 per 30 days CANDESARTAN TAB 32MG 1 30 per 30 days CANDESARTAN TAB 4MG 1 30 per 30 days CANDESARTAN TAB 8MG 1 90 per 30 days CAPASTAT SUL INJ 1GM 3 CAPEX SHA 0.01% 3 CAPRELSA TAB 100MG 4 PA for New Treatments CAPRELSA TAB 300MG 4 PA for New Treatments CAPTOPR/HCTZ TAB 25-15MG 1 CAPTOPR/HCTZ TAB 25-25MG 1 CAPTOPR/HCTZ TAB 50-15MG 1 CAPTOPR/HCTZ TAB 50-25MG 1 CAPTOPRIL TAB 100MG 1 36

38 CAPTOPRIL TAB 12.5MG 1 CAPTOPRIL TAB 25MG 1 CAPTOPRIL TAB 50MG 1 CARAC CRE 0.5% 2 CARAFATE SUS 1GM/10ML 2 CARB/LEVO TAB MG 1 CARB/LEVO TAB MG 1 CARB/LEVO TAB MG 1 CARB/LEVO TAB MG 1 CARB/LEVO TAB MG 1 CARB/LEVO TAB MG 1 CARB/LEVO 50 TAB /ENTACAP 1 CARB/LEVO 75 TAB /ENTACAP 1 CARB/LEVO ER TAB MG 1 CARB/LEVO ER TAB MG 1 CARB/LEVO100 TAB /ENTACAP 1 CARB/LEVO125 TAB /ENTACAP 1 37

39 CARB/LEVO150 TAB /ENTACAP 1 CARB/LEVO200 TAB /ENTACAP 1 CARBAGLU TAB 200MG 4 CARBAMAZEPIN CAP 100MG ER 1 CARBAMAZEPIN CAP 200MG ER 1 CARBAMAZEPIN CAP 300MG ER 1 CARBAMAZEPIN CHW 100MG 1 CARBAMAZEPIN SUS 100/5ML 1 CARBAMAZEPIN TAB 200MG 1 CARBAMAZEPIN TAB 200MG ER 1 CARBAMAZEPIN TAB 400MG ER 1 CARBIDOPA TAB 25MG 3 CARBOPLATIN INJ 150/15ML 1 CARDENE SR CAP 30MG 3 CARDENE SR CAP 60MG 3 CARDURA XL TAB 4MG 3 30 per 30 days 38

40 CARDURA XL TAB 8MG 3 30 per 30 days CARIMUNE NF INJ 6GM 4 CARISOPRODOL TAB 350MG per 30 days CARTEOLOL SOL 1% OP 1 CARTIA XT CAP 120/24HR 1 CARTIA XT CAP 180/24HR 1 CARTIA XT CAP 240/24HR 1 CARTIA XT CAP 300/24HR 1 CARVEDILOL TAB 12.5MG per 30 days CARVEDILOL TAB 25MG per 30 days CARVEDILOL TAB 3.125MG per 30 days CARVEDILOL TAB 6.25MG per 30 days CAYSTON INH 75MG 4 CDP/AMITRIP TAB 10-25MG 1 PA for New Treatments CDP/AMITRIP TAB MG 1 PA for New Treatments CEDAX SUS 90MG/5ML 3 CEFACLOR CAP 250MG 1 39

41 CEFACLOR CAP 500MG 1 CEFACLOR ER TAB 500MG 1 CEFADROXIL CAP 500MG 1 CEFADROXIL SUS 250/5ML 1 CEFADROXIL SUS 500/5ML 1 CEFADROXIL TAB 1GM 1 CEFAZOLIN INJ 10GM 1 CEFAZOLIN INJ 1GM 1 CEFAZOLIN INJ 1GM/50ML 1 CEFAZOLIN INJ 500MG 1 CEFDINIR CAP 300MG 1 CEFDINIR SUS 125/5ML 1 CEFDINIR SUS 250/5ML 1 CEFEPIME INJ 1GM 3 CEFEPIME INJ 2GM 3 CEFOTAXIME INJ 10GM 1 CEFOTAXIME INJ 1GM 1 CEFOTAXIME INJ 2GM 1 CEFOTAXIME INJ 1 40

42 500MG CEFOXITIN INJ 10GM 3 CEFOXITIN INJ 1GM 3 CEFOXITIN INJ 2GM 3 CEFPODO PROX SUS 100/5ML 3 CEFPODO PROX SUS 50MG/5ML 3 CEFPODOXIME TAB 100MG 1 CEFPODOXIME TAB 200MG 1 CEFPROZIL SUS 125/5ML 1 CEFPROZIL SUS 250/5ML 1 CEFPROZIL TAB 250MG 1 CEFPROZIL TAB 500MG 1 CEFTAZIDIME INJ 1GM 1 CEFTAZIDIME INJ 2GM 1 CEFTAZIDIME INJ 6GM 1 CEFTAZIDIME/ SOL D5W 1GM 1 CEFTAZIDIME/ SOL D5W 2GM 1 CEFTRIAXONE INJ 10GM 1 CEFTRIAXONE INJ 1GM 1 41

43 CEFTRIAXONE INJ 250MG 1 CEFTRIAXONE INJ 2GM 1 CEFTRIAXONE INJ 500MG 1 CEFUROXIME INJ 1.5GM 1 CEFUROXIME INJ 7.5GM 1 CEFUROXIME INJ 750MG 1 CEFUROXIME TAB 250MG 1 CEFUROXIME TAB 500MG 1 CELEBREX CAP 100MG 2 90 per 30 days CELEBREX CAP 200MG 2 60 per 30 days CELEBREX CAP 400MG 2 60 per 30 days CELEBREX CAP 50MG 2 60 per 30 days CELLCEPT SUS 200MG/ML 4 PA for New Treatments CELLCEPT IV INJ 500MG 3 PA for New Treatments CELONTIN CAP 300MG 3 CENESTIN TAB 0.3MG 2 CENESTIN TAB 0.45MG 2 42

44 CENESTIN TAB 0.625MG 2 CENESTIN TAB 0.9MG 2 CEPHALEXIN CAP 250MG 1 CEPHALEXIN CAP 500MG 1 CEPHALEXIN CAP 750MG 1 CEPHALEXIN SUS 125/5ML 1 CEPHALEXIN SUS 250/5ML 1 CEPHALEXIN TAB 250MG 1 CEPHALEXIN TAB 500MG 1 CEREZYME INJ 400UNIT 4 CERVARIX INJ 2 CETIRIZINE SYP 1MG/ML 1 CEVIMELINE CAP 30MG 1 CHANTIX PAK 0.5& 1MG 2 53 per 30 days CHANTIX TAB 0.5MG 2 60 per 30 days CHANTIX TAB 1MG 2 60 per 30 days CHENODAL TAB 250MG 4 Required 43

45 CHLORAMPHEN INJ 1GM 3 CHLORDIAZEP CAP 10MG per 30 days CHLORDIAZEP CAP 25MG per 30 days CHLORDIAZEP CAP 5MG per 30 days CHLORHEX GLU SOL 0.12% 1 CHLOROQUINE TAB 250MG 1 CHLOROQUINE TAB 500MG 1 CHLOROTHIAZ INJ 500MG 1 May Be Billable to Part B* CHLOROTHIAZ TAB 250MG 1 CHLOROTHIAZ TAB 500MG 1 CHLORPROMAZ INJ 25MG/ML 1 CHLORPROMAZ TAB 100MG 1 CHLORPROMAZ TAB 10MG 1 CHLORPROMAZ TAB 200MG 1 CHLORPROMAZ TAB 25MG 1 CHLORPROMAZ TAB 50MG 1 44

46 CHLORTHALID TAB 25MG 1 CHLORTHALID TAB 50MG 1 CHLORZOXAZON TAB 500MG per 30 days CHOLESTYRAM POW 4GM LITE 1 CHOR GONADOT INJ 10000UNT 3 CIALIS TAB 2.5MG 2 30 per 30 days CIALIS TAB 5MG 2 30 per 30 days CICLOPIROX CRE 0.77% 1 CICLOPIROX GEL 0.77% 1 CICLOPIROX SHA 1% 1 CICLOPIROX SOL 8% 1 CICLOPIROX SUS 0.77% 1 CIDOFOVIR INJ 75MG/ML 4 CILOSTAZOL TAB 100MG 1 CILOSTAZOL TAB 50MG 1 CILOXAN OIN 0.3% OP 2 CIMETIDINE SOL 300/5ML 1 CIMETIDINE TAB 1 45

47 200MG CIMETIDINE TAB 300MG 1 CIMETIDINE TAB 400MG 1 CIMETIDINE TAB 800MG 1 CIMZIA KIT 4 CIMZIA PREFL KIT 200MG/ML 4 CINRYZE SOL 500 UNIT 4 CIPRO (10%) SUS 500MG/5 3 CIPRO (5%) SUS 250MG/5 3 CIPRO HC SUS OTIC 2 CIPRODEX SUS % 2 CIPROFLOXACN INJ 200MG 1 CIPROFLOXACN INJ 400MG 1 CIPROFLOXACN SOL 0.3% OP 1 CIPROFLOXACN SUS 250MG/5 1 CIPROFLOXACN SUS 500MG/5 1 CIPROFLOXACN TAB 1000MG 1 46

48 CIPROFLOXACN TAB 100MG 1 CIPROFLOXACN TAB 250MG 1 CIPROFLOXACN TAB 500MG 1 CIPROFLOXACN TAB 500MG ER 1 CIPROFLOXACN TAB 750MG 1 CISPLATIN INJ 100MG 1 CITALOPRAM SOL 10MG/5ML 1 600ML per 30 days CITALOPRAM TAB 10MG 1 30 per 30 days CITALOPRAM TAB 20MG 1 30 per 30 days CITALOPRAM TAB 40MG 1 30 per 30 days CLADRIBINE INJ 1MG/ML 3 May Be Billable to Part B* CLARAVIS CAP 10MG 3 CLARAVIS CAP 20MG 3 CLARAVIS CAP 30MG 3 CLARAVIS CAP 40MG 3 CLARITHROMYC SUS 125/5ML 1 CLARITHROMYC SUS 250/5ML 1 CLARITHROMYC TAB 250MG 1 47

49 CLARITHROMYC TAB 500MG 1 CLARITHROMYC TAB 500MG ER 1 CLEMASTINE SYP 0.5/5ML 1 CLEMASTINE TAB 2.68MG 1 CLEOCIN SUP 100MG 3 CLIMARA PRO DIS WEEKLY 3 CLINDAMY/BEN GEL 1-5% 3 CLINDAMYCIN AER 1% 1 CLINDAMYCIN CAP 150MG 1 CLINDAMYCIN CAP 300MG 1 CLINDAMYCIN CAP 75MG 1 CLINDAMYCIN CRE 2% VAG 1 CLINDAMYCIN GEL 1% 1 CLINDAMYCIN INJ 150MG/ML 1 CLINDAMYCIN INJ 300MG 1 CLINDAMYCIN INJ 600MG 1 CLINDAMYCIN INJ 900MG 1 48

50 CLINDAMYCIN LOT 1% 1 CLINDAMYCIN PAD 1% 1 CLINDAMYCIN SOL 1% 1 CLINDAMYCIN SOL 75MG/5ML 1 CLINIMIX INJ 2.75/D5W 3 May Be Billable to Part B* CLINIMIX INJ 4.25/D10 3 May Be Billable to Part B* CLINIMIX INJ 4.25/D20 3 May Be Billable to Part B* CLINIMIX INJ 4.25/D25 3 May Be Billable to Part B* CLINIMIX INJ 4.25/D5W 3 May Be Billable to Part B* CLINIMIX INJ 5%/D15W 3 May Be Billable to Part B* CLINIMIX INJ 5%/D20W 3 May Be Billable to Part B* CLINIMIX INJ 5%/D25W 3 May Be Billable to Part B* CLINIMIX E INJ 2.75/D10 3 May Be Billable to Part B* CLINIMIX E INJ 2.75/D5W 3 May Be Billable to Part B* CLINIMIX E INJ 4.25/D25 3 May Be Billable to Part B* CLINIMIX E INJ 4.25/D5W 3 May Be Billable to Part B* CLINIMIX E INJ 5%/D15W 3 May Be Billable to Part B* CLINIMIX E INJ 5%/D20W 3 May Be Billable to Part B* 49

51 CLINIMIX E INJ 5%/D25W 3 May Be Billable to Part B* CLOBETASOL AER 0.05% 1 CLOBETASOL GEL 0.05% 1 CLOBETASOL LOT 0.05% 1 CLOBETASOL OIN 0.05% 1 CLOBETASOL SHA 0.05% 1 CLOBETASOL SOL 0.05% 1 CLOBETASOL E CRE 0.05% 1 CLOBEX SPR 0.05% 2 CLOLAR INJ 1MG/ML 4 CLOMIPRAMINE CAP 25MG 1 PA for New Treatments CLOMIPRAMINE CAP 50MG 1 PA for New Treatments CLOMIPRAMINE CAP 75MG 1 PA for New Treatments CLONAZEP ODT TAB 0.125MG 1 90 per 30 days CLONAZEP ODT TAB 0.25MG 1 90 per 30 days CLONAZEP ODT TAB 0.5MG 1 90 per 30 days CLONAZEP ODT TAB 1 90 per 30 days 50

52 1MG CLONAZEP ODT TAB 2MG per 30 days CLONAZEPAM TAB 0.5MG 1 90 per 30 days CLONAZEPAM TAB 1MG 1 90 per 30 days CLONAZEPAM TAB 2MG per 30 days CLONIDINE DIS 0.1/24HR 1 4 per 28 days CLONIDINE DIS 0.2/24HR 1 8 per 28 days CLONIDINE DIS 0.3/24HR 1 8 per 28 days CLONIDINE TAB 0.1MG 1 CLONIDINE TAB 0.1MG ER per 30 days CLONIDINE TAB 0.2MG 1 CLONIDINE TAB 0.3MG 1 CLOPIDOGREL TAB 300MG 1 3 per 30 days CLOPIDOGREL TAB 75MG 1 30 per 30 days CLORAZ DIPOT TAB 15MG per 30 days CLORAZ DIPOT TAB 3.75MG per 30 days CLORAZ DIPOT TAB per 30 days 51

53 7.5MG CLORPRES TAB MG 3 60 per 30 days CLORPRES TAB MG 3 60 per 30 days CLORPRES TAB MG 3 60 per 30 days CLOTRIM/BETA CRE DIPROP 1 CLOTRIM/BETA LOT DIPROP 3 CLOTRIMAZOLE CRE 1% 1 CLOTRIMAZOLE SOL 1% 1 CLOTRIMAZOLE TRO 10MG 1 CLOZAPINE TAB 100MG 1 CLOZAPINE TAB 200MG 1 CLOZAPINE TAB 25MG 1 CLOZAPINE TAB 50MG 1 COARTEM TAB MG 3 CODEINE SULF TAB 15MG 1 CODEINE SULF TAB 30MG 1 CODEINE SULF TAB 1 52

54 60MG COLCRYS TAB 0.6MG per 30 days COLESTIPOL GRA 5GM 1 COLESTIPOL TAB 1GM 1 COLISTIMETH INJ 150MG 4 COLOCORT ENE 100MG 1 COLY-MYCIN S SUS OTIC 3 COMBIGAN SOL 0.2/0.5% 2 COMBIPATCH DIS.05/.14 3 COMBIPATCH DIS.05/.25 3 COMBIVENT AER RESPIMAT 2 8GM per 30 days COMETRIQ KIT 100MG 4 PA for New Treatments COMETRIQ KIT 140MG 4 PA for New Treatments COMETRIQ KIT 60MG 4 PA for New Treatments COMPLERA TAB 4 COMPRO SUP 25MG 1 COMVAX INJ 2 CONDYLOX GEL 0.5% 2 CONSTULOSE SOL 10GM/15 1 COPAXONE INJ 4 53

55 40MG/ML COPAXONE KIT 20MG/ML 4 30 per 30 days CORDRAN 80X3 TAP 4MCG/CM 2 CORTIFOAM AER 90MG 3 CORTISONE AC TAB 25MG 1 CORTISPORIN CRE 0.5% 2 CORTISPORIN OIN 1% 3 CORTISPORIN SUS -TC OTIC 3 COUMADIN INJ 5 MG 3 COUMADIN TAB 10MG 2 COUMADIN TAB 1MG 2 COUMADIN TAB 2.5MG 2 COUMADIN TAB 2MG 2 COUMADIN TAB 3MG 2 COUMADIN TAB 4MG 2 COUMADIN TAB 5MG 2 COUMADIN TAB 6MG 2 COUMADIN TAB 7.5MG 2 CREON CAP 12000UNT 2 CREON CAP 2 54

56 24000UNT CREON CAP 3000UNIT 2 CREON CAP 36000UNT 2 CREON CAP 6000UNIT 2 CRESTOR TAB 10MG 2 30 per 30 days CRESTOR TAB 20MG 2 30 per 30 days CRESTOR TAB 40MG 2 30 per 30 days CRESTOR TAB 5MG 2 30 per 30 days CRINONE GEL 4% VAG 3 CRINONE GEL 8% VAG 3 CRIXIVAN CAP 200MG 2 CRIXIVAN CAP 400MG 2 CROMOLYN SOD CON 100/5ML 4 CROMOLYN SOD NEB 20MG/2ML 1 May Be Billable to Part B* CROMOLYN SOD SOL 4% OP 1 CRYSELLE-28 TAB 28 TABS 1 CUBICIN SOL 500MG 4 May Be Billable to Part B* CUPRIMINE CAP 250MG 4 CURITY GAUZE PAD 2 55

57 2"X2" CUVPOSA SOL 1MG/5ML 3 CYCLAFEM TAB 1/35 1 CYCLAFEM TAB 7/7/7 1 CYCLOBENZAPR TAB 10MG 1 90 per 30 days CYCLOBENZAPR TAB 5MG 1 90 per 30 days CYCLOBENZAPR TAB 7.5MG 1 90 per 30 days CYCLOPHOSPH CAP 25MG 1 May Be Billable to Part B* CYCLOPHOSPH CAP 50MG 1 May Be Billable to Part B* CYCLOPHOSPH TAB 25MG 1 May Be Billable to Part B* CYCLOPHOSPH TAB 50MG 1 May Be Billable to Part B* CYCLOSET TAB 0.8MG per 30 days CYCLOSPORINE CAP 100MG 1 May Be Billable to Part B* CYCLOSPORINE CAP 100MG MD 1 May Be Billable to Part B* CYCLOSPORINE CAP 25MG 1 May Be Billable to Part B* CYCLOSPORINE CAP 25MG MOD 1 May Be Billable to Part B* CYCLOSPORINE CAP 50MG MOD 1 May Be Billable to Part B* 56

58 CYCLOSPORINE INJ 50MG/ML 1 CYCLOSPORINE SOL MODIFIED 1 May Be Billable to Part B* CYPROHEPTAD SYP 2MG/5ML 1 CYPROHEPTAD TAB 4MG 1 CYSTADANE POW 4 CYSTAGON CAP 150MG 3 CYSTAGON CAP 50MG 3 CYSTARAN SOL 0.44% 4 CYTARABINE INJ 100MG/ML 3 May Be Billable to Part B* CYTARABINE INJ 20MG/ML 3 May Be Billable to Part B* D10W/NACL INJ 0.2% 1 D10W/NACL INJ 0.45% 1 D2.5W/NACL INJ 0.45% 1 D5W/LR INJ 1 D5W/NACL INJ 0.2% 1 D5W/NACL INJ 0.225% 1 D5W/NACL INJ 0.33% 1 D5W/NACL INJ 0.45% 1 D5W/NACL INJ 0.9% 1 DACARBAZINE INJ 200MG 3 57

59 DACOGEN INJ 50MG 4 DALIRESP TAB 500MCG 3 DANAZOL CAP 100MG 3 DANAZOL CAP 200MG 3 DANAZOL CAP 50MG 3 DANTROLENE CAP 100MG 1 DANTROLENE CAP 25MG 1 DANTROLENE CAP 50MG 1 DAPSONE TAB 100MG 2 DAPSONE TAB 25MG 2 DAPTACEL INJ 2 DARAPRIM TAB 25MG 2 DAUNORUBICIN INJ 5MG/ML 3 DAYTRANA DIS 10MG/9HR 3 30 per 30 days DAYTRANA DIS 15MG/9HR 3 30 per 30 days DAYTRANA DIS 20MG/9HR 3 30 per 30 days DAYTRANA DIS 30MG/9HR 3 30 per 30 days DECITABINE INJ 50MG 4 58

60 DEMECLOCYCL TAB 150MG 3 DEMECLOCYCL TAB 300MG 3 DEMSER CAP 250MG per 30 days DENAVIR CRE 1% 2 DEPEN TITRA TAB 250MG 2 DEPO-ESTRADI INJ 5MG/ML 3 DEPO-MEDROL INJ 20MG/ML 2 DEPO-PROVERA INJ 400/ML 3 DEPO-SQ PROV INJ DESIPRAMINE TAB 100MG 1 DESIPRAMINE TAB 10MG 1 DESIPRAMINE TAB 150MG 1 DESIPRAMINE TAB 25MG 1 DESIPRAMINE TAB 50MG 1 DESIPRAMINE TAB 75MG 1 DESLORATADIN TAB 5MG 1 30 per 30 days DESMOPRESSIN INJ 4MCG/ML 1 59

61 DESMOPRESSIN SPR 0.01% 1 DESMOPRESSIN TAB 0.1MG 1 DESMOPRESSIN TAB 0.2MG 1 DESONIDE CRE 0.05% 1 DESONIDE LOT 0.05% 1 DESONIDE OIN 0.05% 1 DESOXIMETAS CRE 0.05% 1 DESOXIMETAS CRE 0.25% 1 DESOXIMETAS GEL 0.05% 3 DESOXIMETAS OIN 0.05% 1 DESOXIMETAS OIN 0.25% 1 DESVENLAFAX TAB 100MG ER per 30 days DESVENLAFAX TAB 50MG ER 3 30 per 30 days DEXAMETH PHO INJ 10MG/ML 1 DEXAMETH PHO INJ 120MG/30 1 DEXAMETH PHO SOL 0.1% OP 1 DEXAMETHASON CON 1MG/ML 1 60

62 DEXAMETHASON ELX 0.5/5ML 1 DEXAMETHASON TAB 0.5MG 1 DEXAMETHASON TAB 0.75MG 1 DEXAMETHASON TAB 1.5MG 1 DEXAMETHASON TAB 1MG 1 DEXAMETHASON TAB 2MG 1 DEXAMETHASON TAB 4MG 1 DEXAMETHASON TAB 6MG 1 DEXILANT CAP 30MG DR 2 60 per 30 days DEXILANT CAP 60MG DR 2 60 per 30 days DEXMETHYLPH CAP 15MG ER 3 DEXMETHYLPH CAP 30MG ER 3 DEXMETHYLPH CAP 40MG ER 3 30 per 30 days DEXMETHYLPH TAB 10MG 1 60 per 30 days DEXMETHYLPH TAB 2.5MG 1 60 per 30 days DEXMETHYLPH TAB 5MG 1 60 per 30 days 61

63 DEXPAK PAK 13 DAY 3 DEXRAZOXANE INJ 250MG 4 PA for New Treatments DEXTROAMPHET CAP 10MG ER per 30 days DEXTROAMPHET CAP 15MG ER per 30 days DEXTROAMPHET CAP 5MG ER 3 60 per 30 days DEXTROAMPHET TAB 10MG per 30 days DEXTROAMPHET TAB 5MG 3 60 per 30 days DEXTROSE INJ 10% 1 DEXTROSE INJ 5% 1 DIASTAT ACDL GEL DIASTAT ACDL GEL 5-10MG 3 DIASTAT PED GEL 2.5M GEL 3 DIAZEPAM CON 5MG/ML 1 240ML per 30 days DIAZEPAM GEL 10MG 1 DIAZEPAM GEL 2.5MG 1 DIAZEPAM GEL 20MG 1 DIAZEPAM SOL 1MG/ML ML per 30 days DIAZEPAM TAB 10MG per 30 days 62

64 DIAZEPAM TAB 2MG per 30 days DIAZEPAM TAB 5MG per 30 days DIBENZYLINE CAP 10MG 3 DICLO/MISOPR TAB MG 1 DICLO/MISOPR TAB MG 1 DICLOFEN POT TAB 50MG 1 DICLOFENAC GEL 3% 1 DICLOFENAC SOL 0.1% OP 1 DICLOFENAC SOL 1.5% 1 DICLOFENAC TAB 100MG ER 1 DICLOFENAC TAB 25MG DR 1 DICLOFENAC TAB 50MG DR 1 DICLOFENAC TAB 75MG DR 1 DICLOXACILL CAP 250MG 1 DICLOXACILL CAP 500MG 1 DICYCLOMINE CAP 10MG 1 DICYCLOMINE SOL 10MG/5ML 1 DICYCLOMINE TAB 1 63

65 20MG DIDANOSINE CAP 125MG 3 DIDANOSINE CAP 200MG 3 DIDANOSINE CAP 250MG 3 DIDANOSINE CAP 400MG 3 DIFFERIN LOT 0.1% 3 DIFICID TAB 200MG 4 DIFLORASONE CRE 0.05% 3 DIFLORASONE OIN 0.05% 1 DIFLUNISAL TAB 500MG 1 DIGOXIN INJ 0.25MG/1 1 DIGOXIN SOL 50MCG/ML 1 75ML per 30 days DIGOXIN TAB 0.125MG 1 60 per 30 days DIGOXIN TAB 0.25MG 1 DIHYDROERGOT INJ 1MG/ML 3 DILANTIN CAP 30MG 2 DILTIAZEM CAP 120MG CD 1 DILTIAZEM CAP 1 64

66 120MG ER DILTIAZEM CAP 180MG/24 1 DILTIAZEM CAP 240MG CD 1 DILTIAZEM CAP 300MG ER 1 DILTIAZEM CAP 360MG/24 1 DILTIAZEM CAP 420MG/24 1 DILTIAZEM CAP 60MG ER 1 DILTIAZEM CAP 90MG ER 1 DILTIAZEM INJ 100MG 1 DILTIAZEM INJ 50/10ML 1 DILTIAZEM TAB 120MG 1 DILTIAZEM TAB 30MG 1 DILTIAZEM TAB 60MG 1 DILTIAZEM TAB 90MG 1 DILT-XR CAP 120MG 1 DILT-XR CAP 180MG 1 DILT-XR CAP 240MG 1 DIOVAN TAB 160MG 2 60 per 30 days DIOVAN TAB 320MG 2 30 per 30 days DIOVAN TAB 40MG 2 60 per 30 days DIOVAN TAB 80MG 2 60 per 30 days 65

67 DIP/TET PED INJ 25-5LFU 1 DIPENTUM CAP 250MG 4 DIPHENHYDRAM ELX 12.5/5ML ML per 30 days DIPHENHYDRAM INJ 50MG/ML 1 DISOPYRAMIDE CAP 100MG 1 DISOPYRAMIDE CAP 150MG 1 DISULFIRAM TAB 250MG 1 DISULFIRAM TAB 500MG 1 DIURIL SUS 250/5ML 2 DIVALPROEX CAP 125MG 1 DIVALPROEX TAB 125MG DR 1 DIVALPROEX TAB 250MG DR 1 DIVALPROEX TAB 250MG ER 1 DIVALPROEX TAB 500MG DR 1 DIVALPROEX TAB 500MG ER 1 DIVIGEL GEL 1MG/GM 3 30GM per 30 days DOCEFREZ INJ 20MG 4 66

68 DOCEFREZ INJ 80MG 4 DOCETAXEL INJ 80MG/4ML 4 DOCETAXEL INJ 80MG/8ML 4 DONEPEZIL TAB 10MG 1 DONEPEZIL TAB 10MG ODT 1 DONEPEZIL TAB 5MG 1 DONEPEZIL TAB 5MG ODT 1 DONEPEZIL TAB HCL 23MG 1 DORYX TAB 200MG 3 DORZOL/TIMOL SOL 2-0.5%OP 1 DORZOLAMIDE SOL 2% OP 1 DOXAZOSIN TAB 1MG 1 DOXAZOSIN TAB 2MG 1 DOXAZOSIN TAB 4MG 1 DOXAZOSIN TAB 8MG 1 DOXEPIN HCL CAP 100MG 1 PA for New Treatments DOXEPIN HCL CAP 10MG 1 PA for New Treatments DOXEPIN HCL CAP 150MG 1 PA for New Treatments DOXEPIN HCL CAP 1 PA for New Treatments 67

69 25MG DOXEPIN HCL CAP 50MG 1 PA for New Treatments DOXEPIN HCL CAP 75MG 1 PA for New Treatments DOXEPIN HCL CON 10MG/ML 1 PA for New Treatments DOXERCALCIF CAP 0.5MCG 3 May Be Billable to Part B* DOXERCALCIF CAP 1MCG 3 May Be Billable to Part B* DOXERCALCIF CAP 2.5MCG 3 May Be Billable to Part B* DOXERCALCIF INJ 4MCG/2ML 1 May Be Billable to Part B* DOXIL INJ 2MG/ML 4 DOXORUBICIN INJ 50MG 1 May Be Billable to Part B* DOXYCYC MONO TAB 150MG 1 DOXYCYC MONO TAB 50MG 1 DOXYCYC MONO TAB 75MG 1 DOXYCYCL HYC CAP 100MG 1 DOXYCYCL HYC CAP 50MG 1 DOXYCYCL HYC INJ 100MG 1 DOXYCYCL HYC TAB 100MG 1 68

70 DOXYCYCL HYC TAB 100MG DR 1 DOXYCYCL HYC TAB 150MG DR 1 DOXYCYCL HYC TAB 75MG DR 1 DOXYCYCLINE CAP 150MG 1 DOXYCYCLINE CAP 75MG 1 DOXYCYCLINE SUS 25MG/5ML 1 DOXYCYCLINE TAB 20MG 1 DRONABINOL CAP 10MG 1 DRONABINOL CAP 2.5MG per 30 days DRONABINOL CAP 5MG per 30 days DROSPIR/ETHI TAB MG 1 DROXIA CAP 200MG 2 DROXIA CAP 300MG 2 DROXIA CAP 400MG 2 DULERA AER 100-5MCG 2 13GM per 30 days DULERA AER 200-5MCG 2 13GM per 30 days DULOXETINE CAP 20MG 3 60 per 30 days 69

71 DULOXETINE CAP 30MG 3 60 per 30 days DULOXETINE CAP 60MG 3 60 per 30 days DURAMORPH INJ 0.5MG/ML 1 DURAMORPH INJ 1MG/ML 1 DUREZOL EMU 0.05% 2 DYMISTA SPR GM per 30 days DYRENIUM CAP 100MG 2 DYRENIUM CAP 50MG 2 E.E.S. GRAN SUS 200/5ML 1 E.S.P. SUS ECONAZOLE CRE 1% 1 EDARBI TAB 40MG 3 30 per 30 days EDARBI TAB 80MG 3 30 per 30 days EDARBYCLOR TAB per 30 days EDARBYCLOR TAB 40-25MG 3 30 per 30 days EDECRIN TAB 25MG 2 EDURANT TAB 25MG 4 EFFIENT TAB 10MG 2 30 per 30 days EFFIENT TAB 5MG 2 30 per 30 days EGRIFTA SOL 2MG 4 ELAPRASE INJ 4 70

72 6MG/3ML ELIDEL CRE 1% 2 ELIGARD INJ 22.5MG 3 1 per 84 days ELIGARD INJ 30MG 3 1 per ELIGARD INJ 45MG 4 1 per 112 days 168 days ELIGARD INJ 7.5MG 3 1 per 28 days ELIPHOS TAB 667MG 1 ELIQUIS TAB 2.5MG 2 60 per 30 days ELIQUIS TAB 5MG 2 60 per 30 days ELITEK INJ 1.5MG 4 ELLA TAB 30MG 2 ELMIRON CAP 100MG 2 EMADINE SOL 0.05% OP 3 EMCYT CAP 140MG 2 PA for New Treatments EMEND CAP 125MG 2 EMEND CAP 40MG 2 EMEND CAP 80MG 2 EMEND PAK 80 & EMOQUETTE TAB 1 EMSAM DIS 12MG/24H days Required Required Required 71

73 EMSAM DIS 6MG/24HR days EMSAM DIS 9MG/24HR days EMTRIVA CAP 200MG 3 EMTRIVA SOL 10MG/ML 3 ENALAPR/HCTZ TAB 10-25MG 1 ENALAPR/HCTZ TAB MG 1 ENALAPRIL TAB 10MG 1 ENALAPRIL TAB 2.5MG 1 ENALAPRIL TAB 20MG 1 ENALAPRIL TAB 5MG 1 ENBREL INJ 25/0.5ML ML per 28 days ENBREL INJ 25MG 4 8 per 28 days ENBREL INJ 50MG/ML ML per 28 days ENDOCET TAB MG per 30 days ENDOCET TAB 5-325MG per 30 days ENDOCET TAB per 30 days Required Required 72

74 ENDODAN TAB per 30 days ENGERIX-B INJ 10/0.5ML 2 May Be Billable to Part B* ENGERIX-B INJ 10/0.5ML 2 May Be Billable to Part B* ENGERIX-B INJ 20MCG/ML 2 May Be Billable to Part B* ENOXAPARIN INJ 100MG/ML 1 60ML per 30 days ENOXAPARIN INJ 120/ ML per 30 days ENOXAPARIN INJ 150MG/ML 1 48ML per 30 days ENOXAPARIN INJ 30/0.3ML 1 18ML per 30 days ENOXAPARIN INJ 300/3ML 1 90ML per 30 days ENOXAPARIN INJ 40/0.4ML 1 24ML per 30 days ENOXAPARIN INJ 60/0.6ML 1 36ML per 30 days ENOXAPARIN INJ 80/0.8ML 1 48ML per 30 days ENPRESSE-28 TAB 1 ENTACAPONE TAB 200MG 1 ENULOSE SOL 10GM/15 1 EPANED SOL 1MG/ML 4 EPIDUO GEL % 3 73

75 EPINASTINE DRO 0.05% 1 EPIPEN 2-PAK INJ 0.3MG 2 EPIPEN-JR INJ 2-PAK 2 EPIRUBICIN INJ 50/25ML 3 EPITOL TAB 200MG 1 EPIVIR SOL 10MG/ML 2 EPIVIR TAB 150MG 2 EPIVIR TAB 300MG 2 EPIVIR HBV SOL 5MG/ML 2 EPIVIR HBV TAB 100MG 2 EPLERENONE TAB 25MG per 30 days EPLERENONE TAB 50MG 1 60 per 30 days EPOGEN INJ 10000/ML 3 12ML per 28 days EPROSART MES TAB 600MG 1 30 per 30 days EPZICOM TAB EQUETRO CAP 100MG 2 EQUETRO CAP 200MG 2 EQUETRO CAP 300MG 2 74

76 ERAXIS INJ 100MG 4 ERBITUX INJ 100MG 4 PA for New Treatments ERGOLOID MES TAB 1MG ORAL 1 ERGOMAR SUB 2MG 2 ERIVEDGE CAP 150MG 4 30 per 30 days PA for New Treatments ERRIN TAB 0.35MG 1 ERTACZO CRE 2% 2 ERWINAZE INJ 10000UNT 4 ERY PAD 2% 1 ERYPED SUS 200/5ML 2 ERYPED SUS 400/5ML 2 ERY-TAB TAB 250MG EC 2 ERY-TAB TAB 333MG EC 2 ERY-TAB TAB 500MG EC 2 ERYTHROCIN INJ 500MG 1 ERYTHROCIN TAB 250MG 1 ERYTHROM ETH TAB 400MG 1 ERYTHROMYCIN GEL /BENZOYL 1 75