SecureRx PDP Generic Standard Formulary (List of Covered Drugs)

Transcription

1 SecureRx PDP Generic Standard SecureRx PDP Option Employer Group Retiree Plan Standard Options 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID v.17 This formulary was updated on 10//018. For more recent information or other questions, please contact SecureRx PDP Customer Service at or, for TTY users, 711, Monday through Friday, 8 a.m. to 8 p.m., or visit AV-8 (11/01/18) S8067_18_00_Accepted 09/0/017

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3 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 Avalon Insurance Company. When it refers to plan or our plan, it means SecureRx PDP. This document includes a list of the drugs (formulary) for our plan which is current as of November 1, 018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 019, and from time to time during the year. What is the SecureRx PDP Formulary? A formulary is a list of covered drugs selected by our Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SecureRx 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 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 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 November 1, 018. To get updated information about the drugs covered by SecureRx PDP, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid-year formulary change, unrelated to a generic becoming available, we will notify you with a written notification of the nonmaintenance formulary change. In addition, the printable formulary will be updated and posted on our website How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page one. 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 on page one. Then look under the category name for your drug. i

4 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 71. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our Plan before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, our Plan limits the amount of the drug that we will cover. For example, our Plan provides twelve tablets per prescription for sumatriptan tab 50mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we 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 one. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization 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 our Plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the SecureRx PDP formulary? on page iii 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 Customer Service and ask if your drug is covered. If you learn that our Plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by our Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our Plan. You can ask our Plan to make an exception and cover your drug. See below for information about how to request an exception. ii

5 How do I request an exception to the SecureRx PDP Formulary? You can ask our Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, our Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 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 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 9-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Our Plan also realizes that other situations may arise where you need access to non-formulary drugs. An example of this situation would include when you are discharged from a hospital. In these cases, members should use the exceptions processes described earlier. iii

6 For more information For more detailed information about your SecureRx PDP prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about SecureRx 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 ( ) hours a day/7 days a week. TTY users should call Or, visit SecureRx PDP Formulary The formulary that begins on page one provides coverage information about the drugs covered by our Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 71. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIVALO) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if our Plan has any special requirements for coverage of your drug. iv

7 018 SECURERX PDP MEDICARE FORMULARY Key Drug Tier Levels: Tier 1 Preferred Generic Tier Generic Tier Preferred Brand (includes preferred brand drugs and some generic drugs) Tier Non-Preferred Drug Tier 5 Specialty The symbol B/D next to a drug name indicates that prior authorization for determination of coverage under Part B vs. Part D may apply. The symbol LA next to a drug name indicates the drug has limited access or distribution. The symbol PA next to a drug name indicates that prior authorization may apply. The symbol QL next to a drug name indicates that quantities dispensed may be limited. The symbol ST next to a drug name indicates that Step Therapy may apply. The symbol NM next to a drug name indicates that the drug is not available through mail service. Note: Drugs that are non-formulary and are not listed in this document are not covered unless approval is provided through the Non-Formulary Exception Process. For employer-sponsored plans, please call Customer Service regarding the type of formulary that is offered. Tier Copayments/Coinsurance Up to a 0-Day Supply Up to a 0-Day Supply Up to a 90-Day Supply Up to a 90-Day Supply Preferred Pharmacy Standard Pharmacy Preferred Pharmacy Standard Pharmacy SecureRx PDP Option Tier 1 $5 copay $10 copay $15 copay $0 copay Tier $15 copay $0 copay $5 copay $60 copay Tier $8 copay $5 copay $11 copay $15 copay Tier 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance Tier 5 % coinsurance % coinsurance Not Covered Not Covered v

8 Tier Copayments/Coinsurance Up to a 0-Day Supply Up to a 0-Day Supply Up to a 90-Day Supply Up to a 90-Day Supply Preferred Pharmacy Standard Pharmacy Preferred Pharmacy Standard Pharmacy Employer Group Retiree Plan Standard Option Tier 1 $6 copay $1 copay $18 copay $6 copay Tier $1 copay $0 copay $ copay $60 copay Tier $9 copay $7 copay $117 copay $11 copay Tier $90 copay $99 copay $70 copay $97 copay Tier 5 % coinsurance % coinsurance Not Covered Not Covered vi

9 018 Generic Standard Formulary ANALGESICS GOUT allopurinol tab (generic of ZYLOPRIM) colchicine w/ probenecid COLCRYS QL (10 tabs / 0 days) MITIGARE QL (60 caps / 0 days) probenecid ULORIC ST NSAIDS celecoxib (generic of CELEBREX) CAPS QL (0 caps / 0 days) 50mg celecoxib (generic of CELEBREX) CAPS QL (10 caps / 0 days) 100mg celecoxib (generic of CELEBREX) CAPS QL (60 caps / 0 days) 00mg celecoxib (generic of CELEBREX) CAPS QL (0 caps / 0 days) 00mg diclofenac potassium QL (10 tabs / 0 days) diclofenac sodium TB; TBEC diflunisal etodolac CAPS etodolac (generic of LODINE) TABS 00mg etodolac TABS 500mg etodolac TB flurbiprofen TABS ibu tabs 600mg 1 ibu tabs 800mg 1 ibuprofen SUSP ibuprofen TABS 00mg, 600mg, 800mg 1 ketoprofen CAPS 50mg, 75mg meloxicam (generic of MOBIC) TABS 1 nabumetone TABS naproxen (generic of NAPROSYN) SUSP naproxen (generic of NAPROSYN) TABS 1 50mg, 500mg naproxen TABS 75mg 1 naproxen dr (generic of EC-NAPROSYN) naproxen sodium TABS 75mg naproxen sodium (generic of ANAPROX DS) TABS 550mg piroxicam (generic of FELDENE) CAPS sulindac TABS OPIOID ANALGESICS 1

10 acetaminophen w/ codeine SOLN QL (5000 ml / 0 days) acetaminophen w/ codeine TABS QL (00 tabs / 0 days) acetaminophen w/ codeine (generic of QL (00 tabs / 0 days) TYLENOL/CODEINE #) TABS acetaminophen w/ codeine (generic of QL (00 tabs / 0 days) TYLENOL/CODEINE #) TABS butorphanol tartrate SOLN 1mg/ml, mg/ml nalbuphine hcl SOLN tramadol hcl (generic of ULTRAM) TABS QL (0 tabs / 0 days) tramadol-acetaminophen (generic of QL (0 tabs / 0 days) ULTRACET) OPIOID ANALGESICS, CII endocet (generic of PERCOCET) QL (60 tabs / 0 days) fentanyl citrate (generic of ACTIQ) LPOP 5 QL (10 lozenges / 0 days), PA fentanyl patch 1 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 days) fentanyl patch 5 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 days) fentanyl patch 50 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 days), PA fentanyl patch 75 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 days), PA fentanyl patch 100 mcg/hr (generic of DURAGESIC) QL (10 patches / 0 days), PA FENTORA 5 QL (10 tabs / 0 days), PA hydroco/apap tab 5-5mg (generic of QL (60 tabs / 0 days) NORCO) hydroco/apap tab (generic of QL (60 tabs / 0 days) NORCO) hydroco/apap tab 10-5mg (generic of QL (60 tabs / 0 days) NORCO) hydrocodone-acetaminophen QL (500 ml / 0 days) mg/15ml hydrocodone-ibuprofen tab mg QL (150 tabs / 0 days) hydromorphone hcl (generic of DILAUDID) LIQD hydromorphone hcl (generic of HYDROMORPHONE HYDROCHLORI) SOLN 10mg/ml, 50mg/5ml, 500mg/50ml B/D hydromorphone hcl (generic of DILAUDID) QL (70 tabs / 0 days) TABS HYSINGLA ER 0mg, 0mg, 0mg, 60mg QL (60 tabs / 0 days) HYSINGLA ER 80mg, 100mg, 10mg QL (0 tabs / 0 days) lorcet hd tab 10-5mg (generic of NORCO) QL (60 tabs / 0 days)

11 lorcet plus tab (generic of NORCO) QL (60 tabs / 0 days) methadone hcl SOLN 5mg/5ml, QL (50 ml / 0 days) 10mg/5ml methadone hcl 5mg (generic of QL (180 tabs / 0 days) DOLOPHINE) methadone hcl 10mg (generic of QL (180 tabs / 0 days) DOLOPHINE) methadone hcl intensol (generic of QL (10 ml / 0 days) METHADOSE) morphine ext-rel tab (generic of MS QL (90 tabs / 0 days) CONTIN) 15mg, 0mg, 60mg, 100mg morphine ext-rel tab (generic of MS QL (60 tabs / 0 days) CONTIN) 00mg morphine sul inj 1mg/ml B/D MORPHINE SUL INJ MG/ML B/D morphine sul inj 10mg/ml (generic of B/D MORPHINE SULFATE) MORPHINE SULFATE SOLN mg/ml, B/D mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/0ml morphine sulfate (generic of MORPHINE SULFATE) SOLN mg/ml, 8mg/ml B/D morphine sulfate SOLN 8mg/ml, 10mg/ml B/D morphine sulfate TABS QL (180 tabs / 0 days) morphine sulfate oral sol NUCYNTA ER 50mg, 100mg QL (10 tabs / 0 days) NUCYNTA ER 150mg, 00mg, 50mg QL (60 tabs / 0 days) oxycodone hcl CAPS QL (180 caps / 0 days) oxycodone hcl CONC oxycodone hcl SOLN oxycodone hcl (generic of ROXICODONE) QL (180 tabs / 0 days) TABS 5mg, 15mg, 0mg oxycodone hcl TABS 10mg, 0mg QL (180 tabs / 0 days) oxycodone w/ acetaminophen.5-5mg QL (60 tabs / 0 days) (generic of PERCOCET) oxycodone w/ acetaminophen 5-5mg QL (60 tabs / 0 days) (generic of PERCOCET) oxycodone w/ acetaminophen 7.5-5mg QL (60 tabs / 0 days) (generic of PERCOCET) oxycodone w/ acetaminophen 10-5mg (generic of PERCOCET) QL (60 tabs / 0 days) ANESTHETICS LOCAL ANESTHETICS lidocaine inj 0.5% (generic of XYLOCAINE) B/D lidocaine inj 0.5% preservative free (pf) B/D (generic of XYLOCAINE-MPF) lidocaine inj 1% (generic of XYLOCAINE) B/D

12 lidocaine inj 1% preservative free (pf) B/D (generic of XYLOCAINE-MPF) lidocaine inj 1.5% preservative free (pf) B/D (generic of XYLOCAINE-MPF) lidocaine inj % (generic of XYLOCAINE) B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN gentamicin in saline gentamicin sulfate SOLN neomycin sulfate TABS paromomycin sulfate CAPS streptomycin sulfate SOLR SULFADIAZINE TABS tobramycin (generic of KITABIS PAK) 5 NM, PA NEBU tobramycin inj 1. gm/0ml tobramycin inj 1.gm 5 tobramycin inj 10mg/ml tobramycin inj 0mg/ml tobramycin inj 80mg/ml ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 5 ALINIA 5 atovaquone (generic of MEPRON) SUSP 5 AZACTAM IN ISO-OSMOTIC DE AZACTAM/DEX INJ aztreonam (generic of AZACTAM) BILTRICIDE CAYSTON 5 NM, LA, PA clindamycin cap 75mg (generic of 1 CLEOCIN) clindamycin cap 00 mg (generic of 1 CLEOCIN) clindamycin hcl cap 150 mg (generic of 1 CLEOCIN) clindamycin phosphate in d5w (generic of CLEOCIN IN D5W) clindamycin phosphate in d5w (generic of CLEOCIN PHOSPHATE) CLINDAMYCIN PHOSPHATE IN NACL clindamycin phosphate inj (generic of CLEOCIN PHOSPHATE) clindamycin soln 75mg/5ml (generic of CLEOCIN PEDIATRIC GRANULE)

13 colistimethate sodium (generic of COLY- MYCIN M) SOLR dapsone TABS daptomycin (generic of CUBICIN) 500mg 5 EMVERM 5 ertapenem sodium imipenem-cilastatin imipenem-cilastatin (generic of PRIMAXIN IV) INVANZ ivermectin (generic of STROMECTOL) TABS linezolid (generic of ZYVOX) 5 linezolid in sodium chloride 5 meropenem (generic of MERREM) methenamine hippurate (generic of HIPREX) metronidazole (generic of FLAGYL) TABS metronidazole in nacl NEBUPENT B/D nitrofurantoin macrocrystal (generic of MACRODANTIN) 50mg, 100mg PA; PA applies if 65 years and older after a 90 day supply in a calendar year nitrofurantoin monohyd macro (generic of MACROBID) PENTAM 00 praziquantel (generic of BILTRICIDE) TABS SIVEXTRO 5 sulfamethoxazole-trimethop ds (generic of 1 BACTRIM DS) sulfamethoxazole-trimethoprim SUSP sulfamethoxazole-trimethoprim (generic of 1 BACTRIM) TABS sulfamethoxazole-trimethoprim inj SYNERCID 5 TIGECYCLINE 50mg 5 tigecycline (generic of TYGACIL) 50mg 5 trimethoprim TABS vancomycin hcl (generic of VANCOCIN HCL) CAPS vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg VANCOMYCIN IN NACL PA; PA applies if 65 years and older after a 90 day supply in a calendar year 5 5

14 ANTIFUNGALS ABELCET 5 B/D AMBISOME 5 B/D amphotericin b SOLR B/D CANCIDAS 5 CASPOFUNGIN ACETATE 50mg, 70mg 5 caspofungin acetate (generic of CANCIDAS) 50mg, 70mg 5 fluconazole (generic of DIFLUCAN) SUSR fluconazole (generic of DIFLUCAN) TABS fluconazole in dextrose FLUCONAZOLE INJ NACL 100 fluconazole inj nacl 00 fluconazole inj nacl 00 flucytosine (generic of ANCOBON) CAPS 5 griseofulvin microsize SUSP griseofulvin microsize TABS griseofulvin ultramicrosize itraconazole (generic of SPORANOX) PA CAPS ketoconazole TABS PA MYCAMINE 5 NOXAFIL SUSP 5 QL (60 ml / 0 days) NOXAFIL TBEC 5 QL (9 tabs / 0 days) nystatin TABS terbinafine hcl (generic of LAMISIL) TABS QL (90 tabs / 65 days) voriconazole (generic of VFEND IV) SOLR voriconazole (generic of VFEND) SUSR; 5 TABS ANTIMALARIALS atovaquone-proguanil hcl (generic of MALARONE) chloroquine phosphate TABS COARTEM mefloquine hcl PRIMAQUINE PHOSPHATE quinine sulfate (generic of QUALAQUIN) PA CAPS ANTIRETROVIRAL AGENTS abacavir sulfate (generic of ZIAGEN) NM APTIVUS 5 NM atazanavir sulfate (generic of REYATAZ) 5 NM CRIXIVAN NM didanosine (generic of VIDEX EC) NM EDURANT 5 NM 6

15 efavirenz (generic of SUSTIVA) CAPS NM 50mg efavirenz (generic of SUSTIVA) CAPS 5 NM 00mg efavirenz (generic of SUSTIVA) TABS 5 NM EMTRIVA NM fosamprenavir tab 700 mg (generic of 5 NM LEXIVA) FUZEON 5 NM INTELENCE 5mg NM INTELENCE 100mg, 00mg 5 NM INVIRASE 5 NM ISENTRESS CHEW 5mg NM ISENTRESS CHEW 100mg 5 NM ISENTRESS PACK 5 NM ISENTRESS TABS 5 NM ISENTRESS HD 5 NM lamivudine (generic of EPIVIR) NM LEXIVA SUSP NM LEXIVA TABS 5 NM nevirapine susp 50 mg/5ml (generic of NM VIRAMUNE) nevirapine tab 100mg (generic of NM VIRAMUNE XR) nevirapine tab 00mg (generic of NM VIRAMUNE) nevirapine tab 00mg er (generic of NM VIRAMUNE XR) NORVIR NM PREZISTA SUSP 5 QL (00 ml / 0 days), NM PREZISTA TABS 75mg QL (80 tabs / 0 days), NM PREZISTA TABS 150mg 5 QL (0 tabs / 0 days), NM PREZISTA TABS 600mg 5 QL (60 tabs / 0 days), NM PREZISTA TABS 800mg 5 QL (0 tabs / 0 days), NM RESCRIPTOR NM RETROVIR IV INFUSION NM REYATAZ PACK 5 NM ritonavir (generic of NORVIR) NM SELZENTRY SOLN 5 NM SELZENTRY TABS 5mg NM SELZENTRY TABS 75mg, 150mg, 00mg 5 NM stavudine (generic of ZERIT) NM 7

16 SUSTIVA TABS 5 NM tenofovir disoproxil fumarate (generic of 5 NM VIREAD) TIVICAY 10mg NM TIVICAY 5mg, 50mg 5 NM TROGARZO 5 NM, LA TYBOST NM VIDEX EC 15mg NM VIDEX PEDIATRIC NM VIRACEPT 5 NM VIRAMUNE SUSP NM VIREAD 5 NM ZERIT SOLR 5 NM zidovudine cap 100mg (generic of NM RETROVIR) zidovudine syp 50mg/5ml (generic of NM RETROVIR) zidovudine tab 00mg NM ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine (generic of 5 NM EPZICOM) abacavir sulfate-lamivudine-zidovudine 5 NM (generic of TRIZIVIR) ATRIPLA 5 NM BIKTARVY 5 NM CIMDUO 5 NM COMPLERA 5 NM DESCOVY 5 NM EVOTAZ 5 NM GENVOYA 5 NM JULUCA 5 NM KALETRA TAB 100-5MG NM KALETRA TAB 00-50MG 5 NM lamivudine-zidovudine (generic of NM COMBIVIR) lopinavir-ritonavir (generic of KALETRA) 5 NM ODEFSEY 5 NM PREZCOBIX 5 NM STRIBILD 5 NM SYMFI 5 NM SYMFI LO 5 NM SYMTUZA 5 NM TRIUMEQ 5 NM TRUVADA TAB QL (60 tabs / 0 days), NM 8

17 TRUVADA TAB QL (0 tabs / 0 days), NM TRUVADA TAB QL (0 tabs / 0 days), NM TRUVADA TAB QL (0 tabs / 0 days), NM ANTITUBERCULAR AGENTS CAPASTAT SULFATE cycloserine CAPS 5 ethambutol hcl (generic of MYAMBUTOL) TABS isoniazid TABS 1 isoniazid inj 100 mg/ml isoniazid syp 50mg/5ml PASER D/R PRIFTIN pyrazinamide TABS rifabutin (generic of MYCOBUTIN) rifampin (generic of RIFADIN) CAPS rifampin (generic of RIFADIN) SOLR RIFATER SIRTURO 5 LA, PA TRECATOR ANTIVIRALS acyclovir (generic of ZOVIRAX) CAPS; TABS acyclovir (generic of ZOVIRAX) SUSP acyclovir sodium B/D adefovir dipivoxil (generic of HEPSERA) 5 NM BARACLUDE SOLN 5 NM DAKLINZA 5 NM, PA entecavir (generic of BARACLUDE) 5 NM EPCLUSA 5 NM, PA EPIVIR HBV SOLN NM famciclovir TABS ganciclovir inj 500mg (generic of B/D CYTOVENE) GANCICLOVIR INJ 500MG/10ML B/D HARVONI 5 NM, PA lamivudine (hbv) (generic of EPIVIR HBV) NM MAVYRET 5 NM, PA moderiba tab 00mg NM oseltamivir phosphate (generic of QL (168 caps / year) TAMIFLU) CAPS 0mg oseltamivir phosphate (generic of TAMIFLU) CAPS 5mg, 75mg QL (8 caps / year) 9

18 oseltamivir phosphate (generic of QL (1080 ml / year) TAMIFLU) SUSR PEGASYS 5 NM, PA PEGASYS PROCLICK 5 NM, PA REBETOL SOLN 5 NM RELENZA DISKHALER QL (6 inhalers / year) ribasphere (generic of REBETOL) CAPS NM ribasphere TABS 00mg NM ribasphere TABS 00mg, 600mg 5 NM ribavirin cap 00mg (generic of REBETOL) NM ribavirin tab 00mg NM rimantadine hydrochloride (generic of FLUMADINE) SOVALDI 5 NM, PA valacyclovir hcl (generic of VALTREX) TABS valganciclovir hcl (generic of VALCYTE) 5 VEMLIDY 5 NM VOSEVI 5 NM, PA ZEPATIER 5 NM, PA CEPHALOSPORINS cefaclor CAPS cefaclor SUSR CEFACLOR ER TAB 500MG cefadroxil CAPS cefadroxil SUSR; TABS CEFAZOLIN IN DEXTROSE GM/100ML-% cefazolin inj cefazolin sodium SOLR 1gm, 0gm CEFAZOLIN SODIUM 1 GM/50ML cefdinir CAPS cefdinir SUSR cefepime for inj (generic of MAXIPIME) cefixime (generic of SUPRAX) cefotaxime sodium cefoxitin for inj cefpodoxime proxetil cefprozil ceftazidime SOLR CEFTAZIDIME/DEXTROSE ceftriaxone sodium SOLR 1gm, gm, 10gm, 50mg, 500mg cefuroxime axetil cefuroxime sodium cephalexin (generic of KEFLEX) CAPS 1 50mg, 500mg 10

19 cephalexin SUSR SUPRAX CAPS SUPRAX CHEW SUPRAX SUSR 500mg/5ml tazicef SOLR TEFLARO 5 ERYTHROMYCINS/MACROLIDES azithromycin PACK azithromycin (generic of ZITHROMAX) SOLR; SUSR azithromycin (generic of ZITHROMAX) 1 TABS clarithromycin TABS 50mg clarithromycin (generic of BIAXIN) TABS 500mg clarithromycin er (generic of BIAXIN XL) clarithromycin for susp DIFICID 5 e.e.s. 00 ery-tab ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin base erythromycin cap 50mg ec erythromycin ethylsuccinate TABS FLUOROQUINOLONES ciprofloxacin SUSR 50mg/5ml ciprofloxacin (generic of CIPRO) SUSR 500mg/5ml ciprofloxacin hcl tab 100mg ciprofloxacin hcl tab (generic of CIPRO) 1 50mg, 500mg ciprofloxacin hcl tab 750mg 1 ciprofloxacin in d5w ciprofloxacin in d5w (generic of CIPRO I.V.- IN D5W) levofloxacin (generic of LEVAQUIN) TABS 1 levofloxacin in d5w levofloxacin inj 5mg/ml levofloxacin oral soln 5 mg/ml PENICILLINS amoxicillin CAPS; SUSR; TABS 1 amoxicillin CHEW amoxicillin & pot clavulanate CHEW amoxicillin & pot clavulanate SUSR 11

20 amoxicillin & pot clavulanate (generic of AUGMENTIN) SUSR amoxicillin & pot clavulanate (generic of AUGMENTIN ES-600) SUSR amoxicillin & pot clavulanate TABS amoxicillin & pot clavulanate (generic of AUGMENTIN) TABS amoxicillin & pot clavulanate (generic of AUGMENTIN XR) TB1 ampicillin & sulbactam sodium ampicillin & sulbactam sodium (generic of UNASYN) ampicillin & sulbactam sodium (generic of UNASYN BULK PACK) ampicillin cap 50mg ampicillin cap 500mg ampicillin inj ampicillin sodium ampicillin susp BICILLIN L-A dicloxacillin sodium nafcillin sodium for inj 1gm, gm nafcillin sodium for inj 10gm oxacillin sodium 1gm, gm oxacillin sodium 10gm PENICILLIN G POT IN DEXTROSE MU PENICILLIN G POT IN DEXTROSE MU PENICILLIN G PROCAINE penicillin g sodium penicillin v potassium SOLR penicillin v potassium TABS penicilln gk inj 5mu penicilln gk inj 0mu pfizerpen-g inj 5mu pfizerpen-g inj 0mu piper/tazoba inj -0.5gm (generic of ZOSYN) piper/tazoba inj -0.75gm (generic of ZOSYN) piper/tazoba inj -0.5gm (generic of ZOSYN) PIPER/TAZOBA INJ 1-1.5GM piper/tazoba inj 6-.5gm (generic of ZOSYN) TETRACYCLINES doxy

21 doxycycline (monohydrate) CAPS 50mg, 100mg doxycycline (monohydrate) TABS doxycycline hyclate CAPS 50mg doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg doxycycline hyclate SOLR doxycycline hyclate 0 mg doxycycline hyclate 100 mg minocycline hcl (generic of MINOCIN) CAPS 50mg, 100mg minocycline hcl CAPS 75mg morgidox cap 1x50mg ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA 5 B/D, NM busulfan (generic of BUSULFEX) 5 B/D CYCLOPHOSPHAMIDE CAPS 5mg, 50mg B/D cyclophosphamide (generic of B/D CYCLOPHOSPHAMIDE) CAPS 5mg, 50mg cyclophosphamide SOLR 5 B/D dacarbazine B/D EMCYT GLEOSTINE HEXALEN 5 IFEX INJ GM B/D ifosfamide inj 1gm (generic of IFEX) B/D ifosfamide inj 1gm/0ml B/D IFOSFAMIDE INJ GM B/D ifosfamide inj gm/60ml B/D LEUKERAN melphalan hcl (generic of ALKERAN) 5 B/D MUSTARGEN 5 B/D ANTHRACYCLINES adriamycin B/D doxorubicin hcl B/D doxorubicin hcl liposomal inj mg/ml 5 B/D (generic of DOXIL) doxorubicin hcl soln mg/ml B/D epirubicin hcl (generic of ELLENCE) B/D ANTIBIOTICS bleomycin sulfate B/D mitomycin SOLR 5 B/D ANTIMETABOLITES adrucil B/D 1

22 adrucil inj B/D ALIMTA 5 B/D azacitidine (generic of VIDAZA) 5 B/D, NM cladribine 5 B/D cytarabine 0mg/ml B/D fludarabine phosphate B/D fluorouracil SOLN B/D gemcitabine inj soln B/D gemcitabine inj solr (generic of GEMZAR) 5 B/D 1gm, 00mg gemcitabine inj solr gm 5 B/D mercaptopurine TABS methotrexate sodium inj B/D NIPENT 5 B/D PURIXAN 5 NM TABLOID ANTIMITOTIC, TAXOIDS ABRAXANE 5 B/D docetaxel (generic of TAXOTERE) CONC 5 B/D 0mg/ml, 80mg/ml DOCETAXEL CONC 80mg/ml, 160mg/8ml, 00mg/10ml 5 B/D DOCETAXEL SOLN 0mg/ml, 80mg/8ml, 5 B/D 160mg/16ml docetaxel (generic of DOCETAXEL) SOLN 5 B/D 0mg/ml, 80mg/8ml, 160mg/16ml paclitaxel B/D TAXOTERE 80mg/ml 5 B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate B/D vincasar pfs B/D vincristine sulfate B/D vinorelbine tartrate (generic of B/D NAVELBINE) BIOLOGIC RESPONSE MODIFIERS AVASTIN 5 NM, LA, PA BELEODAQ 5 NM, PA BORTEZOMIB 5 NM, PA ERIVEDGE 5 NM, LA, PA FARYDAK 5 NM, LA, PA HERCEPTIN 5 NM, PA IBRANCE 5 NM, LA, PA IDHIFA 5 NM, LA, PA KADCYLA 5 B/D, NM KEYTRUDA 5 NM, PA KISQALI 5 NM, PA 1

23 KISQALI FEMARA 00 DOSE 5 NM, PA KISQALI FEMARA 00 DOSE 5 NM, PA KISQALI FEMARA 600 DOSE 5 NM, PA LYNPARZA 5 NM, LA, PA MYLOTARG 5 NM, LA, PA NINLARO 5 NM, PA ODOMZO 5 NM, LA, PA RITUXAN 5 NM, LA, PA RITUXAN HYCELA 5 NM, LA, PA RUBRACA 5 NM, LA, PA TECENTRIQ 5 NM, LA, PA TIBSOVO 5 NM, LA, PA VELCADE 5 NM, PA VENCLEXTA 10mg, 50mg NM, LA, PA VENCLEXTA 100mg 5 NM, LA, PA VENCLEXTA STARTING PACK 5 NM, LA, PA VERZENIO 5 NM, LA, PA YERVOY 5 NM, PA ZEJULA 5 NM, LA, PA ZOLINZA 5 NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS bicalutamide (generic of CASODEX) DEPO-PROVERA INJ 00/ML B/D ERLEADA 5 NM, LA, PA exemestane (generic of AROMASIN) FARESTON 5 FASLODEX 5 B/D flutamide hydroxyprogesterone caproate 5 B/D (antineoplastic) letrozole (generic of FEMARA) TABS leuprolide inj 1mg/0. NM, PA LUPRON DEPOT (1-MONTH).75mg 5 NM, PA LUPRON DEPOT INJ 11.5MG (-MONTH) 5 NM, PA LYSODREN megestrol ac sus 0mg/ml PA; PA if 65 years and older megestrol ac tab 0mg PA; PA if 65 years and older megestrol ac tab 0mg PA; PA if 65 years and older megestrol sus 65mg/5ml (generic of PA MEGACE ES) nilutamide (generic of NILANDRON) 5 SOLTAMOX 15

24 tamoxifen citrate TABS 1 TRELSTAR DEP INJ.75MG 5 NM, PA TRELSTAR LA INJ 11.5MG 5 NM, PA XTANDI 5 NM, LA, PA ZYTIGA 5 NM, LA, PA IMMUNOMODULATORS POMALYST 5 NM, LA, PA REVLIMID 5 QL (8 caps / 8 days), NM, LA, PA THALOMID 50mg, 100mg 5 QL (0 caps / 0 days), NM, PA THALOMID 150mg, 00mg 5 QL (60 caps / 0 days), NM, PA KINASE INHIBITORS AFINITOR 5 QL (0 tabs / 0 days), NM, PA AFINITOR DISPERZ mg 5 QL (150 tabs / 0 days), NM, PA AFINITOR DISPERZ mg 5 QL (90 tabs / 0 days), NM, PA AFINITOR DISPERZ 5mg 5 QL (60 tabs / 0 days), NM, PA ALECENSA 5 NM, LA, PA ALUNBRIG 5 NM, LA, PA BOSULIF 5 NM, PA BRAFTOVI 5 NM, LA, PA CABOMETYX 5 QL (0 tabs / 0 days), NM, LA, PA CALQUENCE 5 NM, LA, PA CAPRELSA 5 NM, LA, PA COMETRIQ 5 NM, LA, PA COTELLIC 5 NM, LA, PA GILOTRIF TAB 0MG 5 NM, LA, PA GILOTRIF TAB 0MG 5 NM, LA, PA GILOTRIF TAB 0MG 5 NM, LA, PA ICLUSIG 5 NM, LA, PA imatinib mesylate (generic of GLEEVEC) 100mg 5 QL (90 tabs / 0 days), NM, PA imatinib mesylate (generic of GLEEVEC) 00mg 5 QL (60 tabs / 0 days), NM, PA IMBRUVICA 5 NM, LA, PA INLYTA 1mg 5 QL (180 tabs / 0 days), NM, LA, PA INLYTA 5mg 5 QL (10 tabs / 0 days), NM, LA, PA IRESSA 5 NM, LA, PA 16

25 JAKAFI 5 QL (60 tabs / 0 days), NM, LA, PA LENVIMA MG DAILY DOSE 5 NM, LA, PA LENVIMA 8 MG DAILY DOSE 5 NM, LA, PA LENVIMA 10 MG DAILY DOSE 5 NM, LA, PA LENVIMA 1MG DAILY DOSE 5 NM, LA, PA LENVIMA 1 MG DAILY DOSE 5 NM, LA, PA LENVIMA 18 MG DAILY DOSE 5 NM, LA, PA LENVIMA 0 MG DAILY DOSE 5 NM, LA, PA LENVIMA MG DAILY DOSE 5 NM, LA, PA MEKINIST 5 NM, LA, PA MEKTOVI 5 NM, LA, PA NERLYNX 5 NM, LA, PA NEXAVAR 5 NM, LA, PA RYDAPT 5 NM, PA SPRYCEL 5 NM, PA STIVARGA 5 NM, LA, PA SUTENT 5 NM, PA TAFINLAR 5 NM, LA, PA TAGRISSO 5 NM, LA, PA TARCEVA 5mg 5 QL (90 tabs / 0 days), NM, LA, PA TARCEVA 100mg, 150mg 5 QL (0 tabs / 0 days), NM, LA, PA TASIGNA 5 NM, PA TYKERB 5 NM, LA, PA VOTRIENT 5 NM, LA, PA XALKORI 5 NM, LA, PA ZELBORAF 5 NM, LA, PA ZYDELIG 5 NM, LA, PA ZYKADIA 5 NM, LA, PA MISCELLANEOUS bexarotene (generic of TARGRETIN) 5 NM, PA DROXIA hydroxyurea (generic of HYDREA) CAPS LONSURF 5 NM, PA MATULANE 5 LA mitoxantrone hcl B/D, NM SYLATRON KIT 00MCG 5 NM, PA SYLATRON KIT 00MCG 5 NM, PA SYLATRON KIT 600MCG 5 NM, PA SYNRIBO 5 NM, PA tretinoin (chemotherapy) 5 TRISENOX 5 B/D PLATINUM-BASED AGENTS carboplatin B/D 17

26 cisplatin B/D oxaliplatin inj 50mg 5 B/D oxaliplatin inj 50mg/10ml B/D oxaliplatin inj 100mg 5 B/D oxaliplatin inj 100mg/0ml B/D PROTECTIVE AGENTS dexrazoxane (generic of ZINECARD) 5 B/D ELITEK 5 B/D leucovorin calcium SOLR B/D leucovorin calcium TABS levoleucovorin calcium 175mg/17.5ml 5 B/D, NM LEVOLEUCOVORIN CALCIUM 50mg/5ml5 B/D, NM levoleucovorin calcium (generic of B/D, NM LEVOLEUCOVORIN) 50mg/5ml levoleucovorin calcium 50mg (generic of 5 B/D, NM FUSILEV) LEVOLEUCOVORIN CALCIUM 175MG 5 B/D, NM mesna (generic of MESNEX) B/D MESNEX TABS 5 TOPOISOMERASE INHIBITORS etoposide SOLN B/D irinotecan hcl (generic of CAMPTOSAR) B/D 0mg/ml, 100mg/5ml irinotecan hcl 500mg/5ml B/D toposar B/D topotecan inj mg (generic of TOPOTECAN 5 B/D HCL) SOLN topotecan inj mg (generic of HYCAMTIN) 5 B/D SOLR TOPOTECAN INJ MG/ML 5 B/D CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap mg amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) amlodipine besylate-benazepril hcl cap mg (generic of LOTREL) benazepril & hydrochlorothiazide 1 18

27 benazepril & hydrochlorothiazide (generic 1 of LOTENSIN HCT) captopril & hydrochlorothiazide 1 enalapril maleate & hydrochlorothiazide 1 enalapril maleate & hydrochlorothiazide 1 (generic of VASERETIC) fosinopril sodium & hydrochlorothiazide 1 lisinopril & hydrochlorothiazide (generic of 1 ZESTORETIC) moexipril-hydrochlorothiazide 1 quinapril-hydrochlorothiazide (generic of 1 ACCURETIC) ACE INHIBITORS benazepril hcl TABS 5mg 1 benazepril hcl (generic of LOTENSIN) 1 TABS 10mg, 0mg, 0mg captopril TABS 1 enalapril maleate (generic of VASOTEC) 1 TABS fosinopril sodium 1 lisinopril (generic of ZESTRIL) TABS 1.5mg, 0mg, 0mg lisinopril (generic of PRINIVIL) TABS 5mg, 1 10mg, 0mg moexipril hcl 1 perindopril erbumine 1 quinapril hcl (generic of ACCUPRIL) 1 ramipril (generic of ALTACE) 1 trandolapril 1mg, mg 1 trandolapril (generic of MAVIK) mg 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA) spironolactone (generic of ALDACTONE) 1 TABS ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA) QL (0 tabs / 0 days) TABS 1mg, mg, mg doxazosin mesylate (generic of CARDURA) TABS 8mg prazosin hcl (generic of MINIPRESS) terazosin hcl 1 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil 1 (generic of AZOR) amlodipine besylate-valsartan tab (generic 1 of EXFORGE) 19

28 amlodipine-valsartan-hydrochlorothiazide 1 tab (generic of EXFORGE HCT) ENTRESTO irbesartan-hydrochlorothiazide (generic of 1 AVALIDE) losartan-hydrochlorothiazide (generic of 1 HYZAAR) olmesartan medoxomil-amlodipinehydrochlorothiazide 1 (generic of TRIBENZOR) olmesartan medoxomil-hydrochlorothiazide 1 (generic of BENICAR HCT) valsartan-hydrochlorothiazide (generic of 1 DIOVAN HCT) ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan (generic of AVAPRO) 1 losartan potassium (generic of COZAAR) 1 olmesartan medoxomil (generic of 1 BENICAR) TABS valsartan (generic of DIOVAN) 1 ANTIARRHYTHMICS amiodarone hcl SOLN amiodarone hcl TABS 100mg, 00mg amiodarone hcl TABS 00mg 1 disopyramide phosphate (generic of NORPACE) PA; PA if 65 years and older dofetilide (generic of TIKOSYN) NM flecainide acetate mexiletine hcl MULTAQ NORPACE CR PA; PA if 65 years and older pacerone 100mg, 00mg pacerone 00mg 1 propafenone hcl propafenone hcl 1hr (generic of RYTHMOL SR) quinidine gluconate TBCR quinidine sulfate TABS sorine (generic of BETAPACE) 80mg, 10mg, 160mg sorine 0mg sotalol hcl (generic of BETAPACE) 80mg, 10mg, 160mg sotalol hcl 0mg sotalol hcl (afib/afl) (generic of BETAPACE AF) 0

29 ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium (generic of LIPITOR) 1 TABS lovastatin 10mg, 0mg 1 lovastatin (generic of MEVACOR) 0mg 1 pravastatin sodium 10mg 1 pravastatin sodium (generic of 1 PRAVACHOL) 0mg, 0mg, 80mg rosuvastatin calcium (generic of CRESTOR) 1 QL (0 tabs / 0 days) simvastatin (generic of ZOCOR) TABS 1 5mg, 10mg, 0mg, 0mg simvastatin (generic of ZOCOR) TABS 1 QL (0 tabs / 0 days) 80mg ANTILIPEMICS, MISCELLANEOUS cholestyramine (generic of QUESTRAN) cholestyramine light PACK cholestyramine light (generic of QUESTRAN LIGHT) POWD colesevelam hcl (generic of WELCHOL) colestipol hcl gran (generic of COLESTID) colestipol hcl pack (generic of COLESTID) colestipol hcl tabs (generic of COLESTID) ezetimibe (generic of ZETIA) fenofibrate (generic of TRICOR) TABS 8mg, 15mg fenofibrate TABS 5mg, 160mg fenofibrate micronized 67mg, 1mg, 00mg gemfibrozil (generic of LOPID) TABS JUXTAPID 5 NM, LA, PA KYNAMRO 5 NM, PA niacin er (antihyperlipidemic) (generic of QL (90 tabs / 0 days) NIASPAN) 500mg niacin er (antihyperlipidemic) (generic of NIASPAN) 750mg, 1000mg niacor omega--acid ethyl esters (generic of LOVAZA) PRALUENT 5 NM, PA prevalite PACK prevalite (generic of QUESTRAN LIGHT) POWD VASCEPA WELCHOL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 1

30 bisoprolol & hydrochlorothiazide (generic of 1 ZIAC) metoprolol & hydrochlorothiazide metoprolol & hydrochlorothiazide (generic of LOPRESSOR HCT) propranolol & hydrochlorothiazide BETA-BLOCKERS acebutolol hcl CAPS atenolol (generic of TENORMIN) TABS 1 5mg atenolol TABS 50mg, 100mg 1 bisoprolol fumarate BYSTOLIC.5mg, 5mg, 10mg QL (0 tabs / 0 days) BYSTOLIC 0mg QL (60 tabs / 0 days) carvedilol (generic of COREG) 1 labetalol hcl TABS metoprolol succinate (generic of TOPROL XL) metoprolol tartrate SOCT metoprolol tartrate SOLN metoprolol tartrate TABS 5mg 1 metoprolol tartrate (generic of 1 LOPRESSOR) TABS 50mg, 100mg nadolol (generic of CORGARD) TABS pindolol propranolol cap er (generic of INDERAL LA) propranolol hcl SOLN; TABS propranolol oral sol timolol maleate TABS CALCIUM CHANNEL BLOCKERS afeditab cr (generic of ADALAT CC) amlodipine besylate (generic of NORVASC) 1 TABS cartia xt (generic of CARDIZEM CD) dilt-xr cap diltiazem cap 10mg cd (generic of CARDIZEM CD) diltiazem cap 180mg cd (generic of CARDIZEM CD) diltiazem cap 0mg cd (generic of CARDIZEM CD) diltiazem cap 00mg cd (generic of CARDIZEM CD) diltiazem cap 60mg cd (generic of CARDIZEM CD) diltiazem cap er/1hr

31 diltiazem hcl (generic of CARDIZEM) TABS 0mg, 60mg, 10mg diltiazem hcl TABS 90mg diltiazem hcl cap sr hr diltiazem hcl coated beads cap sr hr (generic of CARDIZEM CD) diltiazem hcl extended release beads cap sr (generic of TIAZAC) 10mg, 180mg, 0mg, 00mg, 60mg, 0mg diltiazem hcl extended release beads cap sr (generic of CARDIZEM CD) 180mg diltiazem inj felodipine isradipine nicardipine hcl CAPS nifedical xl (generic of PROCARDIA XL) nifedipine (generic of PROCARDIA XL) TB nifedipine er (generic of ADALAT CC) nimodipine CAPS 5 NYMALIZE 5 taztia xt (generic of TIAZAC) verapamil cap er (generic of VERELAN PM) 100mg, 00mg, 00mg verapamil cap er (generic of VERELAN) 10mg, 180mg, 0mg verapamil cap er 60mg verapamil hcl SOLN verapamil hcl TABS 0mg 1 verapamil hcl (generic of CALAN) TABS 1 80mg, 10mg verapamil hcl (generic of CALAN SR) TBCR verapamil tab er (generic of CALAN SR) DIGITALIS GLYCOSIDES digitek (generic of LANOXIN).5mg PA; PA if 65 years and older digitek (generic of LANOXIN).15mg QL (0 tabs / 0 days) digox (generic of LANOXIN) 15mcg QL (0 tabs / 0 days) digox (generic of LANOXIN) 50mcg PA; PA if 65 years and older digoxin (generic of LANOXIN) TABS QL (0 tabs / 0 days) 15mcg digoxin (generic of LANOXIN) TABS 50mcg PA; PA if 65 years and older digoxin inj (generic of LANOXIN)

32 digoxin sol 50mcg/ml PA; PA if 65 years and older DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA TEKTURNA HCT DIURETICS acetazolamide CP1 acetazolamide TABS amiloride & hydrochlorothiazide amiloride hcl TABS bumetanide inj 0.5/ml bumetanide tab (generic of BUMEX) chlorothiazide tabs chlorthalidone furosemide SOLN furosemide (generic of LASIX) TABS 1 furosemide inj hydrochlorothiazide (generic of 1 MICROZIDE) CAPS hydrochlorothiazide TABS 1 indapamide methazolamide TABS methyclothiazide metolazone spironolactone & hydrochlorothiazide (generic of ALDACTAZIDE) torsemide tabs 5mg, 100mg torsemide tabs (generic of DEMADEX) 10mg, 0mg triamterene & hydrochlorothiazide cap mg (generic of DYAZIDE) triamterene & hydrochlorothiazide tabs 1 (generic of MAXZIDE) triamterene & hydrochlorothiazide tabs 1 (generic of MAXZIDE-5) MISCELLANEOUS clonidine hcl (generic of CATAPRES) TABS 1 clonidine hcl ptwk (generic of CATAPRES- TTS-1).1mg/hr clonidine hcl ptwk (generic of CATAPRES- TTS-).mg/hr clonidine hcl ptwk (generic of CATAPRES- TTS-).mg/hr CORLANOR DEMSER 5 hydralazine hcl SOLN

33 hydralazine hcl TABS midodrine hcl minoxidil TABS NORTHERA 5 NM, LA, PA RANEXA NITRATES isosorb mononitrate tab isosorbide dinitrate (generic of ISORDIL TITRADOSE) 5mg isosorbide dinitrate 10mg, 0mg, 0mg isosorbide dinitrate er isosorbide mononitrate er minitran (generic of NITRO-DUR) NITRO-BID NITRO-DUR DIS 0.MG/HR NITRO-DUR DIS 0.8MG/HR nitroglycerin (generic of NITROSTAT) SUBL nitroglycerin td patch.1mg/hr nitroglycerin td patch (generic of NITRO- DUR).mg/hr,.mg/hr,.6mg/hr PULMONARY ARTERIAL HYPERTENSION ADCIRCA 5 QL (60 tabs / 0 days), NM, PA ADEMPAS 5 QL (90 tabs / 0 days), NM, LA, PA LETAIRIS 5 QL (0 tabs / 0 days), NM, LA, PA OPSUMIT 5 QL (0 tabs / 0 days), NM, LA, PA REMODULIN 5 NM, LA, PA sildenafil citrate (pulmonary hypertension) QL (90 tabs / 0 days), (generic of REVATIO) TABS NM, PA tadalafil (pulmonary hypertension) (generic 5 QL (60 tabs / 0 days), of ADCIRCA) NM, PA TRACLEER TABS 6.5mg 5 QL (10 tabs / 0 days), NM, LA, PA TRACLEER TABS 15mg 5 QL (60 tabs / 0 days), NM, LA, PA VENTAVIS 5 NM, PA CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5mg (generic of XANAX) 1 QL (0 tabs / 0 days) alprazolam tab 0.5mg (generic of XANAX) 1 QL (80 tabs / 0 days) alprazolam tab 1mg (generic of XANAX) 1 QL (10 tabs / 0 days) alprazolam tab mg (generic of XANAX) 1 QL (150 tabs / 0 days) 5

34 buspirone hcl TABS 5mg, 7.5mg, 10mg, 15mg buspirone hcl TABS 0mg fluvoxamine maleate TABS 5mg, 50mg QL (5 tabs / 0 days) fluvoxamine maleate TABS 100mg lorazepam (generic of ATIVAN) SOLN lorazepam (generic of ATIVAN) TABS 1 QL (150 tabs / 0 days) lorazepam intensol QL (150 ml / 0 days) ANTICONVULSANTS APTIOM 00mg 5 QL (180 tabs / 0 days) APTIOM 00mg 5 QL (90 tabs / 0 days) APTIOM 600mg, 800mg 5 QL (60 tabs / 0 days) BANZEL SUS 0MG/ML 5 PA BANZEL TAB 00MG 5 PA BANZEL TAB 00MG 5 PA BRIVIACT SOLN 10mg/ml 5 PA BRIVIACT SOLN 50mg/5ml PA BRIVIACT TABS 5 PA carbamazepine CHEW carbamazepine (generic of CARBATROL) CP1 carbamazepine (generic of TEGRETOL) SUSP carbamazepine (generic of TEGRETOL) TABS carbamazepine (generic of TEGRETOL-XR) TB1 CELONTIN clonazepam (generic of KLONOPIN) TABS 1 QL (10 tabs / 0 days) 1mg clonazepam (generic of KLONOPIN) TABS 1 QL (00 tabs / 0 days) mg clonazepam (generic of KLONOPIN) TABS 1 QL (0 tabs / 0 days).5mg clonazepam TBDP 1mg QL (10 tabs / 0 days) clonazepam TBDP mg QL (00 tabs / 0 days) clonazepam TBDP.5mg QL (0 tabs / 0 days) clonazepam TBDP.5mg QL (80 tabs / 0 days) clonazepam TBDP.15mg QL (960 tabs / 0 days) clorazepate dipotassium.75mg QL (10 tabs / 0 days), PA; PA if 65 years and older clorazepate dipotassium (generic of TRANXENE T) 7.5mg QL (10 tabs / 0 days), PA; PA if 65 years and older 6

35 clorazepate dipotassium 15mg QL (180 tabs / 0 days), PA; PA if 65 years and older DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam SOLN 5mg/5ml QL (100 ml / 0 days), PA; PA if 65 years and older diazepam SOLN 5mg/ml diazepam (generic of VALIUM) TABS 1 QL (10 tabs / 0 days), PA; PA if 65 years and older diazepam gel diazepam intensol QL (0 ml / 0 days), PA; PA if 65 years and older DILANTIN DILANTIN-15 SUS 15/5ML divalproex sodium (generic of DEPAKOTE SPRINKLES) CSDR divalproex sodium (generic of DEPAKOTE ER) TB divalproex sodium (generic of DEPAKOTE) TBEC epitol (generic of TEGRETOL) ethosuximide (generic of ZARONTIN) CAPS; SOLN felbamate (generic of FELBATOL) SUSP 5 felbamate (generic of FELBATOL) TABS FYCOMPA SUSP 5 QL (70 ml / 0 days), PA FYCOMPA TABS mg QL (180 tabs / 0 days), PA FYCOMPA TABS mg 5 QL (90 tabs / 0 days), PA FYCOMPA TABS 6mg 5 QL (60 tabs / 0 days), PA FYCOMPA TABS 8mg, 10mg, 1mg 5 QL (0 tabs / 0 days), PA gabapentin (generic of NEURONTIN) CAPS 100mg QL (1080 caps / 0 days) gabapentin (generic of NEURONTIN) QL (60 caps / 0 days) CAPS 00mg gabapentin (generic of NEURONTIN) QL (70 caps / 0 days) CAPS 00mg gabapentin (generic of NEURONTIN) SOLN QL (160 ml / 0 days) 7

36 gabapentin (generic of NEURONTIN) QL (180 tabs / 0 days) TABS 600mg gabapentin (generic of NEURONTIN) QL (10 tabs / 0 days) TABS 800mg GABITRIL 1mg, 16mg lamotrigine (generic of LAMICTAL CHEWABLE DISPERS) CHEW lamotrigine (generic of LAMICTAL) TABS lamotrigine (generic of LAMICTAL XR) TB levetiracetam (generic of KEPPRA) TABS levetiracetam (generic of KEPPRA XR) TB levetiracetam in sodium chloride (generic of LEVETIRACETAM) levetiracetam inj (generic of KEPPRA) levetiracetam oral soln 100 mg/ml (generic of KEPPRA) LYRICA CAPS 5mg, 50mg, 75mg, QL (10 caps / 0 days) 100mg, 150mg LYRICA CAPS 00mg QL (90 caps / 0 days) LYRICA CAPS 5mg, 00mg QL (60 caps / 0 days) LYRICA SOLN QL (96 ml / 0 days) ONFI 5 PA oxcarbazepine (generic of TRILEPTAL) SUSP oxcarbazepine (generic of TRILEPTAL) TABS PEGANONE phenobarbital ELIX; TABS PA; PA if 65 years and older PHENOBARBITAL SODIUM SOLN 65mg/ml PA; PA if 65 years and older phenobarbital sodium SOLN 10mg/ml PA; PA if 65 years and older PHENYTEK phenytoin (generic of DILANTIN INFATABS) CHEW phenytoin (generic of DILANTIN-15) SUSP phenytoin sodium SOLN phenytoin sodium extended (generic of DILANTIN) 100mg phenytoin sodium extended (generic of PHENYTEK) 00mg, 00mg primidone (generic of MYSOLINE) TABS roweepra (generic of KEPPRA) 8

37 roweepra xr (generic of KEPPRA XR) SABRIL TABS 5 QL (180 tabs / 0 days), NM, LA, PA SPRITAM subvenite tab (generic of LAMICTAL) TEGRETOL TEGRETOL-XR tiagabine hcl (generic of GABITRIL) topiramate (generic of TOPAMAX SPRINKLE) CPSP topiramate (generic of TOPAMAX) TABS valproate sodium oral soln (generic of DEPAKENE) valproate sodium soln 100mg/ml (generic of DEPACON) valproic acid (generic of DEPAKENE) vigabatrin powd pack 500mg (generic of SABRIL) 5 QL (180 packets / 0 days), NM, LA, PA VIMPAT SOLN 10mg/ml 5 QL (100 ml / 0 days) VIMPAT SOLN 00mg/0ml 5 VIMPAT TABS 50mg QL (180 tabs / 0 days) VIMPAT TABS 100mg, 150mg, 00mg 5 QL (60 tabs / 0 days) zonisamide (generic of ZONEGRAN) CAPS 5mg, 100mg zonisamide CAPS 50mg ANTIDEMENTIA donepezil hydrochloride (generic of QL (60 tabs / 0 days) ARICEPT) TABS 5mg donepezil hydrochloride (generic of ARICEPT) TABS 10mg donepezil hydrochloride (generic of ARICEPT) TABS mg donepezil hydrochloride TBDP 5mg QL (60 tabs / 0 days) donepezil hydrochloride TBDP 10mg galantamine hydrobromide SOLN galantamine hydrobromide (generic of QL (180 tabs / 0 days) RAZADYNE) TABS mg galantamine hydrobromide (generic of QL (90 tabs / 0 days) RAZADYNE) TABS 8mg galantamine hydrobromide (generic of RAZADYNE) TABS 1mg galantamine hydrobromide er (generic of QL (0 caps / 0 days) RAZADYNE ER) 8mg, 16mg galantamine hydrobromide er (generic of RAZADYNE ER) mg memantine hcl SOLN PA; PA if < 0 yrs 9

38 memantine hcl (generic of NAMENDA) TABS PA; PA if < 0 yrs memantine hcl cp (generic of NAMENDA PA; PA if < 0 yrs XR) NAMENDA XR PA; PA if < 0 yrs NAMENDA XR TITRATION PACK PA; PA if < 0 yrs NAMZARIC rivastigmine tartrate rivastigmine td patch hr.6 mg/hr (generic of EXELON) QL (0 patches / 0 days) rivastigmine td patch hr 9.5 mg/hr (generic of EXELON) QL (0 patches / 0 days) rivastigmine td patch hr 1. mg/hr (generic of EXELON) QL (0 patches / 0 days) ANTIDEPRESSANTS amitriptyline hcl TABS PA; PA if 65 years and older amoxapine bupropion hcl TABS bupropion hcl (generic of WELLBUTRIN SR) TB1 bupropion hcl (generic of WELLBUTRIN XL) QL (90 tabs / 0 days) TB 150mg bupropion hcl (generic of WELLBUTRIN XL) QL (0 tabs / 0 days) TB 00mg citalopram hydrobromide SOLN citalopram hydrobromide (generic of 1 QL (5 tabs / 0 days) CELEXA) TABS 10mg, 0mg citalopram hydrobromide (generic of 1 QL (0 tabs / 0 days) CELEXA) TABS 0mg clomipramine hcl (generic of ANAFRANIL) CAPS PA; PA if 65 years and older desipramine hcl (generic of NORPRAMIN) TABS 10mg, 5mg desipramine hcl TABS 50mg, 75mg, 100mg, 150mg desvenlafaxine succinate (generic of QL (0 tabs / 0 days) PRISTIQ) doxepin hcl CAPS; CONC PA; PA if 65 years and older duloxetine hcl (generic of CYMBALTA) QL (180 caps / 0 days) CPEP 0mg duloxetine hcl (generic of CYMBALTA) QL (10 caps / 0 days) CPEP 0mg duloxetine hcl (generic of CYMBALTA) QL (60 caps / 0 days) CPEP 60mg EMSAM 5 QL (0 patches / 0 days), PA 0