2019 Comprehensive Formulary

Transcription

1 09 Comprehensive Formulary Aetna Medicare (List of Covered Drugs) GRP B Tier PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 0/0/09. For more recent information or other questions, please contact Aetna Medicare Member Services at or for TTY users: 7, 8 a.m. to 6 p.m. local time, Monday through Friday, or visit choose Manage your prescription drugs. Formulary ID Number: 9076 Version 0

2 Table of contents Mail-order Pharmacy What is the Aetna Medicare Comprehensive Formulary? Can the Formulary (drug list) change? How do I use the Formulary? What are generic drugs? Are there any restrictions on my coverage? What if my drug is not on the Formulary? How do I request an exception to the Aetna Medicare Formulary? What do I do before I can talk to my doctor about changing my drugs or requesting an exception? For more information Aetna Medicare Formulary Drug tier copay levels Formulary key Drug list Index of Drugs Enhanced drug list

3 Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Enrollment in our plans depends on contract renewal. You must continue to pay your Medicare Part B premium. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. Members who get Extra Help are not required to fill prescriptions at preferred network pharmacies in order to get Low Income Subsidy (LIS) copays. See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area. Mail-order Pharmacy For mail order, you can get prescription drugs shipped to your home through our preferred mail-order delivery program, which is called Aetna Rx Home Delivery. Typically, mail-order drugs arrive within 7 to 4 days. You can call (TTY: 7), 8 a.m. to 6 p.m. local time, Monday through Friday, if you do not receive your mail-order drugs within this timeframe. Members may have the option to sign up for automated mail-order delivery. ATTENTION: If you speak Spanish or Chinese, language assistance services, free of charge, are available to you. Call the number on your ID card. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que figura en su tarjeta de identificación. 注意 : 如果您使用中文, 您可以免費獲得語言援助服務 請撥打您的會員身分卡上的電話號碼 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 Aetna Medicare. When it refers to plan or our plan, it means Aetna. This document includes a list of the drugs (formulary) for our plan which is current as of 0/0/09. 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, 00, and from time to time during the year.

4 What is the Aetna Medicare Comprehensive 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Prescription Drug Schedule of Cost Sharing. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 09 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 09 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different costsharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Aetna Medicare Formulary? Drugs removed from the market. 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. 4

5 Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier.) Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or 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 0 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 0-day supply of the drug. The enclosed formulary is current as of 0/0/09. To get updated information about the drugs covered by our plan, 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 0. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 0. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 95. 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 us 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 0 tablets per 0 days per prescription for candesartan. This may be in addition to a standard one-month or three-month supply. 5

6 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, we 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 0. You can also get more information about the restrictions applied to specific covered drugs by visiting our Website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us 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 Aetna Medicare formulary? on page 6 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Member Services 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 us 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 Aetna Medicare Formulary? You can ask us 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, we 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 6

7 restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. 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. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 0-day supply of medication. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a -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 -day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. If you experience a change in your setting of care (such as being discharged or admitted to a long term care facility), your physician or pharmacy can request a one-time prescription override. This one-time override will provide you with temporary coverage (up to a 0-day supply) for the applicable drug(s). For more information For more detailed information abou our plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit 7

8 Aetna Medicare Formulary The comprehensive formulary that begins on page 0 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 95. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LEVEMIR) and generic drugs are listed in lower-case italics (e.g., candesartan). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. QL PA ST LA MO B/D Quantity Limits Prior Authorization Step Therapy Limited Access Mail-order Delivery Part B vs. D Prior Authorization QL: Quantity Limits. For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 0 tablets per 0 days per prescription for candesartan. PA: Prior Authorization. Our plan requires you or your provider to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. ST: 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, we 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. LA: Limited Access. These prescriptions may be available only at certain pharmacies. For more Information, consult your Pharmacy Directory or call Aetna Member Services at (TTY: 7), 8 a.m. to 6 p.m. local time, Monday through Friday. MO: Mail Order. For certain kinds of drugs, you can use Aetna Rx Home Delivery services. Generally, the drugs available through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan s mail-order service are marked as mail-order drugs in our Drug List or MO. For more information, consult your Pharmacy Directory or call Aetna Member Services at (TTY: 7), 8 a.m. to 6 p.m. local time, Monday through Friday. B/D: Part B versus Part D. This prescription drug has a Part B versus Part D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. 8

9 Drug tier copay levels This 09 comprehensive formulary is a listing of brand-name and generic drugs. Aetna Medicare s 09 formulary covers most drugs identified by Medicare as Part D drugs, and your copay may differ depending upon the tier at which the drug resides. The copay tiers for covered prescription medications are listed below. Copay amounts and coinsurance percentages for each tier vary by Aetna Medicare plan. Look in the 09 Prescription Drug Benefits Chart (The Prescription Drug Schedule of Cost Sharing) that was included in your Evidence of Coverage (EOC) packet. Copay tier Tier Tier Tier Type of drug Generic Drugs Preferred Brand Drugs Non-Preferred Drugs You may have drug coverage in the Coverage Gap Stage There are four drug payment stages of a Medicare Prescription Drug Plan. How much you pay for a Part D drug depends on which drug payment stage you are in. Your plan may include supplemental coverage for some drugs during the Coverage Gap stage of the plan. Look in the 09 Prescription Drug Benefits Chart (Prescription Drug Schedule of Cost Sharing) that was included in your EOC packet. The Prescription Drug Benefits Chart will tell you if your plan provides coverage in the gap, and how much you will pay for covered drugs. If you need assistance finding this information, call the number on the back of your ID card. Please Note: Our plan, in some instances, combines higher cost generic drugs on brand tiers. Refer to the drug list to determine the tier of coverage for each drug you take. 9

10 Key* UPPERCASE = Brand-name prescription drugs Lowercase italics = Generic medications,, = Copay tier level QL = Quantity Limit PA = Prior Authorization ST = Step Therapy LA = Limited Access MO = Mail-order Delivery B/D = Part B vs. Part D 0 ANALGESICS Analgesics ascomp/codeine QL (80 EA per 0 days) PA MO bupap tabs 00mg; 50mg QL (80 EA per 0 days) PA butalbital/acetaminophen/caffeine/ QL (80 EA per 0 days) PA MO codeine butalbital/acetaminophen/caffeine QL (80 EA per 0 days) PA MO caps butalbital/acetaminophen/caffeine QL (80 EA per 0 days) PA MO tabs 5mg; 50mg; 40mg butalbital/aspirin/caffeine QL (80 EA per 0 days) PA MO butalbital/aspirin/caffeine/codeine QL (80 EA per 0 days) PA MO esgic caps QL (80 EA per 0 days) PA MO phrenilin forte caps 00mg; 50mg; QL (80 EA per 0 days) PA 40mg zebutal caps 5mg; 50mg; 40mg QL (80 EA per 0 days) PA MO Nonsteroidal Anti-inflammatory Drugs CAMBIA PA MO celecoxib caps 400mg QL (0 EA per 0 days) MO celecoxib caps 00mg, 00mg, 50mg QL (60 EA per 0 days) MO diclofenac potassium MO diclofenac sodium dr MO diclofenac sodium er MO diclofenac sodium/misoprostol MO diclofenac sodium transdermal soln QL (450 ML per 0 days) PA MO.5% diflunisal tabs 500mg MO DUEXIS MO etodolac er MO etodolac caps, tabs MO fenoprofen calcium caps 400mg MO

11 fenoprofen calcium tabs 600mg MO FLECTOR QL (60 EA per 0 days) PA MO flurbiprofen tabs MO ibuprofen susp MO ibuprofen tabs 400mg, 600mg, MO 800mg ibu tabs 600mg, 800mg MO indomethacin er PA MO indomethacin immediate release PA MO caps ketoprofen er cp4 00mg MO ketoprofen caps 50mg, 75mg ketoprofen caps 5mg MO ketorolac tromethamine inj 5mg/ml, QL (0 ML per 0 days) PA MO 0mg/ml, 60mg/ml ketorolac tromethamine tabs 0mg QL (0 EA per 0 days) PA MO klofensaid ii QL (450 ML per 0 days) PA meclofenamate sodium caps MO meloxicam tabs MO nabumetone tabs MO naproxen dr tabs 75mg, 500mg MO naproxen sodium er tb4 75mg MO naproxen sodium er tb4 500mg MO naproxen sodium tabs 75mg, MO 550mg naproxen susp, tabs MO oxaprozin MO PENNSAID SOLN % QL (4 GM per 8 days) PA MO piroxicam caps MO profeno sulindac tabs MO VIMOVO MO Opioid Analgesics, Long-acting buprenorphine weekly patch QL (4 EA per 8 days) PA MO fentanyl transdermal patches QL (5 EA per 0 days) PA MO HYSINGLA ER QL (0 EA per 0 days) PA MO methadone hcl inj PA methadone hcl tabs QL (80 EA per 0 days) PA MO methadone hcl oral soln QL (000 ML per 0 days) PA MO

12 methadone hcl oral conc QL (60 ML per 0 days) PA MO morphine sulfate er cp4 (generic QL (0 EA per 0 days) PA MO Avinza) 0mg, 0mg, 45mg, 60mg, 75mg, 90mg morphine sulfate er cp4 (generic QL (60 EA per 0 days) PA MO Kadian) 00mg, 0mg, 0mg, 0mg, 50mg, 60mg, 80mg morphine sulfate er tbcr (generic MS QL (60 EA per 0 days) PA MO Contin) 00mg, 00mg, 0mg, 60mg morphine sulfate er tbcr (generic MS QL (90 EA per 0 days) PA MO Contin) 5mg NUCYNTA ER TB 00MG, 00MG, QL (60 EA per 0 days) PA MO 50MG, 50MG NUCYNTA ER TB 50MG QL (90 EA per 0 days) PA MO tramadol hcl er cp4 00mg, 00mg, QL (0 EA per 0 days) PA MO 00mg tramadol hcl er tb4 00mg, 00mg, QL (0 EA per 0 days) PA MO 00mg Opioid Analgesics, Short-acting acetaminophen/codeine tabs QL (80 EA per 0 days) MO acetaminophen/codeine oral soln QL (4500 ML per 0 days) MO butorphanol tartrate nasal soln QL (5 ML per 0 days) MO butorphanol tartrate inj mg/ml butorphanol tartrate inj mg/ml MO codeine sulfate tabs QL (80 EA per 0 days) MO endocet tabs 5mg; 0mg, 5mg; QL (80 EA per 0 days).5mg, 5mg; 5mg, 5mg; 7.5mg fentanyl citrate oral transmucosal QL (0 EA per 0 days) PA MO lozenge FENTORA TABS 00MCG, 00MCG, QL (0 EA per 0 days) PA MO 400MCG, 600MCG, 800MCG hydrocodone/acetaminophen oral QL (5550 ML per 0 days) MO soln 5mg/5ml; 7.5mg/5ml hydrocodone/acetaminophen QL (80 EA per 0 days) MO tabs 0mg/00mg, 5mg/00mg,7.5mg/00mg,.5/5mg hydrocodone/acetaminophen tabs 5mg; 0mg, 5mg; 5mg, 5mg; 7.5mg QL (80 EA per 0 days) MO

13 hydrocodone/ibuprofen tabs 0mg; 00mg, 5mg; 00mg, 7.5mg; 00mg hydromorphone hcl immediate release tabs QL (50 EA per 0 days) MO QL (80 EA per 0 days) MO hydromorphone hcl oral soln QL (400 ML per 0 days) MO hydromorphone hcl inj 0mg/ml, 50mg/5ml B/D hydromorphone hcl inj mg/ml, mg/ B/D MO ml, 4mg/ml hydromorphone hcl preservative free B/D inj mg/ml, mg/ml hydromorphone hcl preservative free B/D MO inj 4mg/ml ibudone tabs 5mg; 00mg QL (50 EA per 0 days) lorcet QL (80 EA per 0 days) lorcet hd QL (80 EA per 0 days) lorcet plus tabs 5mg; 7.5mg QL (80 EA per 0 days) meperidine hcl tabs QL (0 EA per 0 days) PA MO meperidine hcl oral soln QL (600 ML per 0 days) PA MO meperidine hcl inj 0mg/ml, 5mg/ml PA meperidine hcl inj 00mg/ml, 50mg/ ml PA MO morphine sulfate inj 0.5mg/ml, 0mg/ B/D ml, 50mg/0ml, mg/ml pf, 5mg/ ml, mg/ml, 4mg/ml, 50mg/ml, 5mg/ ml, 8mg/ml morphine sulfate inj mg/ml B/D MO morphine sulfate oral soln 0mg/5ml QL (800 ML per 0 days) MO morphine sulfate oral soln 0mg/5ml QL (900 ML per 0 days) MO morphine sulfate oral soln QL (80 ML per 0 days) MO 00mg/5ml morphine sulfate tabs 0mg QL (80 EA per 0 days) MO morphine sulfate tabs 5mg QL (60 EA per 0 days) MO nalbuphine hcl inj 0mg/ml, 0mg/ml MO oxycodone hcl caps QL (80 EA per 0 days) MO oxycodone hcl oral soln QL (5400 ML per 0 days) MO oxycodone hcl oral conc QL (80 ML per 0 days) MO oxycodone hcl tabs 0mg QL (0 EA per 0 days) MO oxycodone hcl tabs 0mg, 5mg, 0mg, 5mg QL (80 EA per 0 days) MO

14 4 oxycodone/acetaminophen tabs QL (80 EA per 0 days) MO 5mg; 0mg, 5mg;.5mg, 5mg; 5mg, 5mg; 7.5mg oxycodone/aspirin tabs 5mg; QL (80 EA per 0 days) MO 4.85mg oxycodone/ibuprofen QL (0 EA per 0 days) MO oxymorphone hcl immediate release QL (80 EA per 0 days) MO tabs pentazocine/naloxone hcl QL (60 EA per 0 days) PA MO reprexain tabs 0mg; 00mg QL (50 EA per 0 days) tramadol hcl immediate release tabs QL (40 EA per 0 days) MO tramadol hydrochloride/ QL (40 EA per 0 days) MO acetaminophen vicodin es tabs 00mg; 7.5mg QL (80 EA per 0 days) vicodin hp tabs 00mg; 0mg QL (80 EA per 0 days) vicodin tabs 00mg; 5mg QL (80 EA per 0 days) ANESTHETICS Local Anesthetics lidocaine hcl inj 0.5%, %,.5%, %, 4% lidocaine hcl topical soln 4% MO lidocaine viscous oral topical soln MO lidocaine/prilocaine crea QL (0 GM per 0 days) PA MO lidocaine ptch QL (90 EA per 0 days) PA MO lidocaine oint QL (5.44 GM per 0 days) PA MO ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving acamprosate calcium dr MO disulfiram tabs MO naltrexone hcl tabs MO VIVITROL INJ MO Opioid Dependence Treatments buprenorphine hcl/naloxone hcl subl QL (90 EA per 0 days) MO buprenorphine hcl subl QL (90 EA per 0 days) PA MO buprenorphine hydrochloride/ QL (90 EA per 0 days) naloxone hydrochloride film SUBOXONE FILM MG; MG QL (60 EA per 0 days) MO SUBOXONE FILM MG; 0.5MG, 4MG; MG, 8MG; MG QL (90 EA per 0 days) MO

15 Opioid Reversal Agents naloxone hcl inj 0.4mg/ml, mg/ml naloxone hcl inj 0.4mg/ml, 4mg/0ml MO NARCAN NASAL SPRAY MO Smoking Cessation Agents ANTIBACTERIALS bupropion hcl sr tb 50mg QL (60 EA per 0 days) MO CHANTIX CONTINUING MONTH PAK PA MO CHANTIX STARTING MONTH PAK PA MO CHANTIX TABS 0.5MG, MG PA MO NICOTROL INHALER MO NICOTROL NASAL SPRAY MO Aminoglycosides amikacin sulfate inj gm/4ml, MO 500mg/ml gentamicin sulfate inj 0mg/ml MO gentamicin sulfate/0.9% sodium chloride inj.mg/ml,.6mg/ml, mg/ml, mg/ml gentamicin sulfate inj 40mg/ml MO isotonic gentamicin inj 0.8mg/ml; MO 0.9% neomycin sulfate tabs MO paromomycin sulfate caps MO streptomycin sulfate inj gm MO tobramycin sulfate inj.gm, 0mg/ ml, 40mg/ml tobramycin sulfate inj.gm/0ml, MO 80mg/ml Antibacterials, Other baciim inj bacitracin inj 50000unit MO chloramphenicol sodium succinate inj clindamycin hcl caps MO clindamycin palmitate hcl oral soln MO 75mg/5ml clindamycin phosphate in d5w inj clindamycin phosphate inj 900mg/60ml 5

16 6 clindamycin phosphate vaginal crea MO % clindamycin phosphate inj 00mg/ml, 600mg/4ml, 9000mg/60ml clindamycin phosphate inj MO 600mg/4ml CLINDAMYCIN/SODIUM CHLORIDE IV SOLN colistimethate sodium inj PA MO DAPTOMYCIN INJ 50MG daptomycin inj 500mg ISOPROPYL ALCOHOL WIPES lansoprazole/amoxicillin/ QL (4 EA per 65 days) MO clarithromycin linezolid inj PA linezolid oral susp QL (800 ML per 8 days) PA MO linezolid tabs QL (56 EA per 8 days) PA MO MACROBID MO methenamine hippurate MO methenamine mandelate tabs 0.5gm, MO gm metronidazole in nacl 0.79% metronidazole vaginal gel MO metronidazole caps 75mg MO metronidazole inj 5mg/ml metronidazole tabs 50mg, 500mg MO MONUROL MO nitrofurantoin macrocrystals MO nitrofurantoin monohydrate MO nitrofurantoin susp MO SIVEXTRO INJ SIVEXTRO TABS MO SYNERCID INJ 500MG tigecycline inj tinidazole MO trimethoprim tabs MO VANCOMYCIN HCL INJ 0.9%; 500MG/00ML, 0.9%; 750MG/50ML

17 vancomycin hcl caps 50mg MO vancomycin hcl caps 5mg QL (0 EA per 0 days) MO VANCOMYCIN HCL IN SODIUM CHLORIDE INJ 0.9%; GM/00ML vancomycin hcl inj 00gm, 0gm, gm, 5gm, 750mg vancomycin hcl inj 500mg MO VANCOMYCIN HCL INJ.5GM,.5GM, 50MG VANDAZOLE VAGINAL GEL MO XIFAXAN TABS 550MG PA MO Beta-lactam, Cephalosporins cefaclor er tb 500mg MO cefaclor caps MO cefaclor oral susp 5mg/5ml, MO 50mg/5ml, 75mg/5ml cefadroxil MO CEFAZOLIN/ DEXTROSE INJ GM/50ML cefazolin sodium inj 00gm, gm, 0gm, 00gm cefazolin sodium inj 0gm, gm, MO 500mg CEFAZOLIN/DEXTROSE INJ GM/00ML cefdinir caps MO cefdinir oral susp MO cefepime inj gm, gm MO cefixime oral susp MO cefotaxime sodium inj 0gm, gm, 500mg cefotaxime sodium inj gm MO cefotetan inj cefoxitin sodium inj 0gm, gm, gm cefpodoxime proxetil MO cefprozil MO CEFTAZIDIME/DEXTROSE IV INJ ceftazidime inj 6gm ceftazidime inj gm, gm MO ceftriaxone sodium inj 00gm, gm 7

18 8 ceftriaxone sodium inj 0gm, gm, MO 50mg, gm, 500mg ceftriaxone/dextrose iv soln cefuroxime axetil tabs MO cefuroxime sodium inj.5gm, 7.5gm cefuroxime sodium inj 750mg MO cephalexin MO SUPRAX CAPS MO SUPRAX CHEW 00MG SUPRAX CHEW 00MG MO SUPRAX ORAL SUSP 500MG/5ML tazicef inj gm, gm, 6gm TEFLARO Beta-lactam, Other AZACTAM IN ISO-OSMOTIC DEXTROSE INJ GM/50ML, GM/50ML AZACTAM INJ GM, GM aztreonam inj gm MO aztreonam inj gm MO ertapenem MO imipenem/cilastatin MO INVANZ IV GM INVANZ INJ GM MO meropenem vial MO Beta-lactam, Penicillins amoxicillin/clavulanate potassium MO amoxicillin/clavulanate potassium er MO amoxicillin chew 5mg, 50mg MO amoxicillin caps, oral susp, tabs MO ampicillin sodium inj 0gm, 5mg, gm, 50mg, gm ampicillin sodium inj gm, gm, MO 500mg ampicillin-sulbactam inj ampicillin caps 500mg MO AUGMENTIN ES-600 ORAL SUSP MO AUGMENTIN XR AUGMENTIN SUSR 5MG/5ML, 50MG/5ML MO

19 AUGMENTIN TABS 500MG, 875MG MO BICILLIN L-A INJ 00000UNIT/ML, UNIT/4ML, UNIT/ML MO dicloxacillin sodium MO nafcillin sodium inj 0gm nafcillin sodium inj gm, gm nafcillin sodium inj gm MO oxacillin sodium inj 0gm, gm oxacillin sodium inj gm MO PENICILLIN G POTASSIUM IN ISO- OSMOTIC DEXTROSE INJ penicillin g potassium inj MO unit, unit penicillin g procaine inj MO penicillin g sodium inj penicillin v potassium MO piperacillin sodium/tazobactam sodium inj gm; 0.75gm piperacillin soduim/ tazobactam sodium 6gm; 4.5gm piperacillin/tazobactam inj gm;.5gm, gm; 0.5gm, 6gm; 4.5gm, 4gm; 0.5gm Macrolides AZITHROMYCIN GM PACK FOR MO ORAL SUSPENSION azithromycin susr, tabs MO azithromycin inj 500mg MO clarithromycin er MO clarithromycin oral susp, tabs MO DIFICID MO E.E.S. 400 TABS MO ERY-TAB MO ERYTHROCIN LACTOBIONATE INJ 500MG ERYTHROCIN STEARATE TABS MO 50MG erythromycin base tabs MO erythromycin ethylsuccinate tabs MO erythromycin stearate tabs 50mg MO 9

20 0 erythromycin caps dr 50mg MO Quinolones ciprofloxacin er MO ciprofloxacin hcl tabs 00mg, 50mg, MO 750mg ciprofloxacin hcl tabs 500mg MO ciprofloxacin iv in d5w 00mg/00ml iv soln ciprofloxacin iv in d5w 400mg/00ml MO iv soln CIPROFLOXACIN OTIC SOLN MO ciprofloxacin inj ciprofloxacin oral susp 50mg/5ml ciprofloxacin oral susp 500mg/5ml MO levofloxacin in d5w iv soln levofloxacin inj 5mg/ml levofloxacin oral soln 5mg/ml MO levofloxacin tabs 50mg, 500mg, MO 750mg moxifloxacin hcl/sodium chloride 400mg/50ml iv soln moxifloxacin hcl inj moxifloxacin hcl tabs MO moxifloxacin hcl ophthalmic soln MO ofloxacin tabs 00mg, 400mg MO Sulfonamides sulfadiazine tabs MO sulfamethoxazole/trimethoprim ds MO sulfamethoxazole/trimethoprim tabs MO sulfamethoxazole/trimethoprim inj, MO susp Tetracyclines doxy 00 inj MO doxycycline hyclate dr MO doxycycline hyclate caps MO doxycycline hyclate inj MO doxycycline hyclate tabs 00mg, MO 50mg, 0mg, 75mg doxycycline monohydrate tabs MO doxycycline monohydrate caps MO

21 doxycycline oral susp 5mg/5ml MO doxycycline tabs 00mg, 50mg MO minocycline hcl er ST MO minocycline hcl caps MO minocycline hcl tabs ST MO minocycline hydrochlorideer tb4 ST MO 55mg mondoxyne nl caps 00mg, 75mg morgidox x00mg caps morgidox x50mg caps morgidox x00mg caps okebo soloxide tetracycline hydrochloride MO ANTICONVULSANTS Anticonvulsants, Other APTIOM TABS 00MG QL (80 EA per 0 days) MO APTIOM TABS 600MG, 800MG QL (60 EA per 0 days) MO APTIOM TABS 400MG QL (90 EA per 0 days) MO BRIVIACT INJ PA BRIVIACT ORAL SOLN, TABS PA MO EPIDIOLEX PA FYCOMPA SUSP QL (70 ML per 0 days) PA MO FYCOMPA TABS 0MG, MG, 8MG QL (0 EA per 0 days) PA MO FYCOMPA TABS MG, 4MG, 6MG QL (60 EA per 0 days) PA MO levetiracetam er MO levetiracetam/sodium chloride inj 000mg/00ml; 750mg/00ml, 500mg/00ml; 80mg/00ml levetiracetam oral soln, tabs MO levetiracetam inj 5mg/ml, 0mg/ml, 5mg/ml levetiracetam inj 500mg/5ml MO roweepra roweepra xr SPRITAM MO Calcium Channel Modifying Agents CELONTIN CAPS 00MG MO ethosuximide MO

22 LYRICA ORAL SOLN QL (946 ML per 0 days) MO LYRICA CAPS 00MG, 50MG, QL (0 EA per 0 days) MO 5MG, 50MG, 75MG LYRICA CAPS 5MG, 00MG QL (60 EA per 0 days) MO LYRICA CAPS 00MG QL (90 EA per 0 days) MO zonisamide MO Gamma-aminobutyric Acid (GABA) Augmenting Agents clobazam susp PA MO clobazam tabs 0mg PA MO clobazam tabs 0mg PA MO clonazepam odt tbdp mg QL (0 EA per 0 days) MO clonazepam odt tbdp mg QL (00 EA per 0 days) MO clonazepam odt tbdp 0.5mg, QL (90 EA per 0 days) MO 0.5mg, 0.5mg clonazepam tabs mg QL (0 EA per 0 days) MO clonazepam tabs mg QL (00 EA per 0 days) MO clonazepam tabs 0.5mg QL (90 EA per 0 days) MO DIASTAT ACUDIAL MO DIASTAT PEDIATRIC GEL.5MG MO diazepam gel 0mg,.5mg, 0mg MO divalproex sodium dr MO divalproex sodium er MO divalproex sodium sprinkle caps MO gabapentin soln QL (60 ML per 0 days) MO gabapentin caps QL (90 EA per 0 days) MO gabapentin tabs 600mg QL (80 EA per 0 days) MO gabapentin tabs 800mg QL (90 EA per 0 days) MO GABITRIL TABS MG, 6MG, MG, MO 4MG ONFI SUSP PA MO ONFI TABS 0MG, 0MG PA MO phenobarbital elix QL (500 ML per 0 days) PA MO phenobarbital tabs 00mg, 5mg, QL (0 EA per 0 days) PA MO 6.mg, 0mg,.4mg, 60mg, 64.8mg, 97.mg primidone tabs MO SABRIL TABS QL (80 EA per 0 days) PA LA tiagabine hydrochloride MO valproate sodium inj 00mg/ml

23 valproic acid caps, soln MO vigabatrin 500mg oral susp pack QL (80 EA per 0 days) PA vigadrone QL (80 EA per 0 days) PA Glutamate Reducing Agents felbamate MO lamotrigine er MO lamotrigine odt MO lamotrigine starter kit/blue MO lamotrigine starter kit/green MO lamotrigine starter kit/orange MO lamotrigine chew, tabs MO subvenite subvenite starter kit/blue subvenite starter kit/green subvenite starter kit/orange topiramate er MO topiramate sprinkle caps, tabs MO Sodium Channel Agents BANZEL PA MO carbamazepine er MO carbamazepine chew, susp, tabs MO DILANTIN INFATABS CHEW TABS MO DILANTIN-5 ORAL SUSP MO DILANTIN CAPS MO epitol fosphenytoin sodium inj 00mg pe/ml fosphenytoin sodium inj 500mg MO pe/0ml oxcarbazepine tabs MO oxcarbazepine susp MO PEGANONE TABS 50MG MO PHENYTEK MO phenytoin sodium er caps MO phenytoin sodium inj phenytoin chew, susp MO VIMPAT INJ VIMPAT ORAL SOLN QL (00 ML per 0 days) MO VIMPAT TABS 50MG QL (0 EA per 0 days) MO

24 VIMPAT TABS 00MG, 50MG, QL (60 EA per 0 days) MO 00MG ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mesylates tabs PA MO NAMZARIC MO Cholinesterase Inhibitors donepezil hcl odt QL (0 EA per 0 days) MO donepezil hcl tabs mg, 5mg QL (0 EA per 0 days) MO donepezil hcl tabs 0mg QL (60 EA per 0 days) MO galantamine hydrobromide er caps QL (0 EA per 0 days) MO galantamine hydrobromide soln QL (00 ML per 0 days) MO galantamine hydrobromide tabs QL (60 EA per 0 days) MO rivastigmine patch QL (0 EA per 0 days) MO rivastigmine tartrate QL (60 EA per 0 days) MO N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl QL (60 EA per 0 days) PA MO memantine hcl titration pak QL (98 EA per 65 days) PA MO memantine hcl er PA MO memantine hcl soln QL (60 ML per 0 days) PA MO ANTIDEPRESSANTS Antidepressants, Other bupropion hcl er tb 50mg QL (60 EA per 0 days) MO bupropion hcl sr tb 00mg, 50mg, QL (60 EA per 0 days) MO 00mg bupropion hcl xl QL (0 EA per 0 days) MO bupropion hcl tabs 00mg QL (80 EA per 0 days) MO bupropion hcl er tb 00mg, 00mg QL (60 EA per 0 days) MO bupropion hydrochloride er tb4 QL (0 EA per 0 days) MO 50mg bupropion hcl tabs 75mg QL (80 EA per 0 days) MO mirtazapine odt QL (0 EA per 0 days) MO mirtazapine tabs QL (0 EA per 0 days) MO TRINTELLIX TABS 5MG QL (0 EA per 0 days) MO TRINTELLIX TABS 0MG QL (0 EA per 0 days) MO TRINTELLIX TABS 0MG QL (60 EA per 0 days) MO Monoamine Oxidase Inhibitors EMSAM PATCH QL (0 EA per 0 days) PA MO MARPLAN QL (80 EA per 0 days) MO 4

25 phenelzine sulfate MO tranylcypromine sulfate MO SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide soln QL (600 ML per 0 days) MO citalopram hydrobromide tabs 0mg QL (0 EA per 0 days) MO citalopram hydrobromide tabs 40mg QL (0 EA per 0 days) MO citalopram hydrobromide tabs 0mg QL (60 EA per 0 days) MO DESVENLAFAXINE ER TB4 QL (0 EA per 0 days) MO (BRANDED GENERIC KHEDEZLA) 00MG, 50MG desvenlafaxine er tb4 (generic QL (0 EA per 0 days) MO Pristiq) 00mg, 5mg, 50mg duloxetine hcl dr caps 0mg, 40mg QL (60 EA per 0 days) MO duloxetine hcl dr caps 60mg QL (60 EA per 0 days) MO duloxetine hcl dr caps 0mg QL (90 EA per 0 days) MO escitalopram oxalate soln QL (600 ML per 0 days) MO escitalopram oxalate tabs 0mg QL (0 EA per 0 days) MO escitalopram oxalate tabs 0mg, 5mg QL (45 EA per 0 days) MO FETZIMA TITRATION PACK PA MO FETZIMA ER CAP 0MG QL (80 EA per 0 days) PA MO FETZIMA ER CAP 0MG, 80MG QL (0 EA per 0 days) PA MO FETZIMA ER CAP 40MG QL (90 EA per 0 days) PA MO fluoxetine dr caps 90mg QL (4 EA per 8 days) MO fluoxetine hcl caps 0mg QL (0 EA per 0 days) MO fluoxetine hcl caps 0mg QL (0 EA per 0 days) MO fluoxetine hcl caps 40mg QL (60 EA per 0 days) MO fluoxetine hcl soln MO FLUOXETINE HCL TABS 60MG MO fluoxetine hcl tabs (generic Prozac) MO 0mg, 0mg fluvoxamine maleate MO fluvoxamine maleate er QL (60 EA per 0 days) MO maprotiline hcl MO nefazodone hcl tabs 00mg, 50mg MO nefazodone hcl tabs 00mg, 50mg, MO 50mg olanzapine/fluoxetine QL (0 EA per 0 days) MO paroxetine hcl er tb4 7.5mg QL (60 EA per 0 days) MO paroxetine hcl er tb4.5mg, 5mg QL (90 EA per 0 days) MO 5

26 paroxetine hcl tabs 0mg, 0mg QL (0 EA per 0 days) MO paroxetine hcl tabs 0mg, 40mg QL (60 EA per 0 days) MO PAXIL SUSP QL (900 ML per 0 days) MO sertraline hcl conc QL (00 ML per 0 days) MO sertraline hcl tabs 5mg QL (0 EA per 0 days) MO sertraline hcl tabs 00mg, 50mg QL (60 EA per 0 days) MO trazodone hydrochloride MO venlafaxine hcl MO venlafaxine hcl er cp4 7.5mg, 75mg QL (0 EA per 0 days) MO venlafaxine hcl er cp4 50mg QL (60 EA per 0 days) MO venlafaxine hcl er tb4 5mg, QL (0 EA per 0 days) MO 7.5mg, 75mg venlafaxine hcl er tb4 50mg QL (60 EA per 0 days) MO VIIBRYD STARTER PACK MO VIIBRYD TABS QL (0 EA per 0 days) MO Tricyclics amitriptyline hcl tabs PA MO amoxapine MO chlordiazepoxide/amitriptyline PA MO clomipramine hcl caps PA MO desipramine hcl tabs MO doxepin hcl caps, conc PA MO imipramine hcl tabs 5mg, 50mg PA MO imipramine hcl tabs 0mg PA MO imipramine pamoate caps PA MO nortriptyline hcl caps, soln MO perphenazine/amitriptyline PA MO protriptyline hcl MO trimipramine maleate caps PA MO ANTIEMETICS Antiemetics, Other dimenhydrinate inj meclizine hcl tabs MO phenadoz supp 5mg PA phenadoz supp.5mg PA MO phenergan supp PA promethazine hcl supp.5mg, PA MO 5mg, 50mg promethegan supp.5mg, 5mg PA 6

27 promethegan supp 50mg PA MO scopolamine transdermal patch QL (0 EA per 0 days) PA MO TRANSDERM-SCOP QL (0 EA per 0 days) PA MO trimethobenzamide hcl caps 00mg PA MO Emetogenic Therapy Adjuncts aprepitant B/D MO dronabinol QL (60 EA per 0 days) PA MO EMEND ORAL SUSP B/D granisetron hcl tabs QL (60 EA per 0 days) B/D MO ondansetron hcl oral soln QL (900 ML per 0 days) B/D MO ondansetron hcl inj 40mg/0ml, MO 4mg/ml ondansetron hcl tabs 4mg B/D ondansetron hcl tabs 4mg, 8mg B/D MO ondansetron odt B/D MO SANCUSO QL (4 EA per 8 days) MO ANTIFUNGALS Antifungals ABELCET INJ B/D AMBISOME INJ B/D amphotericin b inj B/D MO caspofungin acetate inj 50mg caspofungin acetate inj 70mg MO ciclodan topical soln ciclopirox nail lacquer MO ciclopirox olamine crea QL (90 GM per 0 days) MO ciclopirox susp MO ciclopirox gel QL (00 GM per 0 days) MO ciclopirox sham QL (0 ML per 0 days) MO clotrimazole/betamethasone QL (0 ML per 0 days) MO dipropionate lotn clotrimazole/betamethasone QL (45 GM per 0 days) MO dipropionate crea clotrimazole lozg MO clotrimazole topical soln QL (0 ML per 0 days) MO clotrimazole crea QL (45 GM per 0 days) MO econazole nitrate crea QL (85 GM per 0 days) MO ERTACZO CREA QL (60 GM per 0 days) MO 7

28 fluconazole in d5w iv inj 00mg/00ml, 400mg/00ml fluconazole in sodium chloride 0.9% iv soln 00mg/00ml, 400mg/00ml fluconazole tabs MO fluconazole oral susp MO flucytosine caps MO griseofulvin microsize oral susp, tabs MO griseofulvin ultramicrosize tabs MO 5mg, 50mg itraconazole caps PA MO ketoconazole tabs MO ketoconazole sham QL (0 ML per 0 days) MO ketoconazole crea QL (60 GM per 0 days) MO ketoconazole foam QL (00 GM per 0 days) MO miconazole supp MO MYCAMINE INJ 00MG MYCAMINE INJ 50MG MO naftifine hcl % cream QL (90 GM per 0 days) MO naftifine hcl % cream QL (60 GM per 0 days) MO NOXAFIL SUSP QL (60 ML per 0 days) MO NOXAFIL TBEC QL (9 EA per 0 days) MO nyamyc nystatin/triamcinolone QL (60 GM per 0 days) MO nystatin crea QL (0 GM per 0 days) MO nystatin powd MO nystatin susp, tabs MO nystatin oint QL (0 GM per 0 days) MO nystop MO oxiconazole nitrate QL (90 GM per 0 days) MO terbinafine hcl tabs MO terconazole crea MO terconazole supp MO voriconazole inj voriconazole oral susp, tabs MO ANTIGOUT AGENTS Antigout Agents allopurinol tabs MO colchicine caps QL (60 EA per 0 days) MO 8

29 colchicine tabs 0.6mg QL (0 EA per 0 days) MO COLCRYS QL (0 EA per 0 days) MO MITIGARE QL (60 EA per 0 days) MO probenecid/colchicine MO probenecid tabs MO ULORIC ST MO ANTIMIGRAINE AGENTS Ergot Alkaloids dihydroergotamine mesylate inj PA MO dihydroergotamine mesylate nasal QL (8 ML per 8 days) PA MO soln ergotamine tartrate/caffeine MO Serotonin (5-HT) b/d Receptor Agonists almotriptan malate QL (8 EA per 0 days) MO eletriptan hydrobromide QL ( EA per 0 days) MO frovatriptan succinate QL ( EA per 0 days) MO naratriptan hcl QL (9 EA per 0 days) MO rizatriptan benzoate odt QL ( EA per 0 days) MO rizatriptan benzoate tabs QL ( EA per 0 days) MO sumatriptan succinate refill inj QL (4 ML per 0 days) 6mg/0.5ml sumatriptan succinate refill inj QL (4 ML per 0 days) MO 4mg/0.5ml sumatriptan succinate tabs QL (9 EA per 0 days) MO sumatriptan succinate prefilled QL (4 ML per 0 days) syringe 6mg/0.5ml sumatriptan succinate inj 4mg/0.5ml, QL (4 ML per 0 days) MO 6mg/0.5ml sumatriptan/naproxen sodium QL (9 EA per 0 days) MO sumatriptan nasal spray QL ( EA per 0 days) MO zolmitriptan odt QL (6 EA per 0 days) MO zolmitriptan tabs QL (6 EA per 0 days) MO ANTIMYASTHENIC AGENTS Parasympathomimetics GUANIDINE HCL pyridostigmine bromide er MO pyridostigmine bromide tabs MO 9

30 ANTIMYCOBACTERIALS Antimycobacterials, Other dapsone tabs 00mg, 5mg MO rifabutin MO Antituberculars cycloserine MO ethambutol hcl tabs MO isoniazid syrp, tabs MO isoniazid inj PASER MO PRIFTIN MO pyrazinamide tabs MO rifampin caps MO rifampin inj RIFATER MO SIRTURO PA LA TRECATOR MO ANTINEOPLASTICS Alkylating Agents BENDEKA INJ busulfan inj cyclophosphamide inj cyclophosphamide caps B/D MO GLEOSTINE CAPS 0MG, 5MG GLEOSTINE CAPS 00MG, 40MG MO HEXALEN MO KISQALI FEMARA 00MG-.5MG PA CO-PACK KISQALI FEMARA 400MG-.5MG PA CO-PACK KISQALI FEMARA 600MG-.5MG PA CO-PACK LEUKERAN MO MATULANE LA melphalan hcl tablet melphalan inj B/D MO MUSTARGEN thiotepa inj 5mg VALCHLOR QL (60 GM per 0 days) PA MO 0

31 Antiandrogens abiraterone acetate PA bicalutamide MO ERLEADA PA LA flutamide MO nilutamide MO XTANDI PA LA ZYTIGA PA LA Antiangiogenic Agents POMALYST PA LA REVLIMID QL (8 EA per 8 days) PA LA THALOMID CAPS 00MG, 50MG QL (0 EA per 0 days) PA THALOMID CAPS 50MG, 00MG QL (60 EA per 0 days) PA Antiestrogens/Modifiers EMCYT MO FARESTON MO SOLTAMOX MO tamoxifen citrate tabs MO Antimetabolites clofarabine DROXIA MO fluorouracil inj gm/0ml B/D hydroxyurea caps MO mercaptopurine tabs MO PURIXAN TABLOID MO Antineoplastics, Other ABRAXANE adrucil B/D ALIMTA arsenic trioxide AVASTIN PA LA bleomycin sulfate B/D BORTEZOMIB PA BRAFTOVI PA MO carboplatin carmustine cisplatin cladribine B/D

32 COPIKTRA QL (56 EA per 8 days) PA MO cytarabine aqueous inj B/D dacarbazine dactinomycin daunorubicin hcl inj 5mg/ml DAUNORUBICIN HCL INJ 0MG/4ML, 50MG/0ML decitabine dexrazoxane DOCETAXEL INJ 60MG/6ML, 0MG/ML, 80MG/8ML docetaxel inj 60mg/8ml, 00mg/0ml, 80mg/4ml docetaxel inj 0mg/ml doxorubicin hcl liposome doxorubicin hcl inj 0mg, mg/ml, 50mg doxorubicin hcl liposomal epirubicin hcl inj 00mg/00ml, 50mg/5ml FASLODEX fludarabine phosphate fluorouracil inj.5gm/50ml, 5gm/00ml gemcitabine gemcitabine hcl B/D B/D HERCEPTIN INJ 440MG PA idarubicin hcl IFEX ifosfamide INTRON A INJ 0MU/ML, 0MU, 8MU irinotecan KADCYLA KHAPZORY PA KISQALI PA leucovorin calcium tabs MO leucovorin calcium inj 00mg/0ml, 00mg, 00mg, 50mg, 500mg/50ml, 500mg, 50mg

33 levoleucovorin calcium inj 75mg/7.5ml (0mg/ml) LEVOLEUCOVORIN INJ 75MG levoleucovorin inj 75mg/7.5ml, 50mg/5ml, 50mg LIBTAYO PA LONSURF PA LUMOXITI PA LYNPARZA TABS 00MG, 50MG PA LA MO MEKTOVI PA mitomycin inj 40mg mitomycin inj 0mg, 5mg mitoxantrone hcl inj mg/ml mutamycin inj 40mg mutamycin inj 0mg, 5mg NERLYNX PA LA NINLARO PA NIPENT INJ oxaliplatin paclitaxel inj 00mg/6.7ml, 50mg/5ml, 00mg/50ml, 0mg/5ml romidepsin RUBRACA PA LA RYDAPT PA SYNRIBO PA TALZENNA CAPS MG QL (0 EA per 0 days) PA TALZENNA CAPS 0.5MG QL (90 EA per 0 days) PA TAXOTERE INJ 80MG/4ML TRISENOX INJ MG/6ML VELCADE PA VERZENIO PA LA vinblastine sulfate inj mg/ml B/D vincasar pfs B/D vincristine sulfate B/D vinorelbine tartrate VIZIMPRO QL (0 EA per 0 days) PA YERVOY PA ZEJULA PA LA MO ZOLINZA PA

34 Aromatase Inhibitors, rd Generation anastrozole tabs MO exemestane MO letrozole MO Enzyme Inhibitors etoposide inj 00mg/5ml, gm/50ml, 500mg/5ml toposar inj 00mg/5ml, gm/50ml, 500mg/5ml TOPOTECAN HCL INJ 4MG/4ML topotecan hcl inj 4mg Molecular Target Inhibitors AFINITOR QL (0 EA per 0 days) PA AFINITOR DISPERZ TBSO MG QL (50 EA per 0 days) PA AFINITOR DISPERZ TBSO 5MG QL (60 EA per 0 days) PA AFINITOR DISPERZ TBSO MG QL (90 EA per 0 days) PA ALECENSA PA LA ALUNBRIG PA LA BELEODAQ PA BOSULIF PA CABOMETYX QL (0 EA per 0 days) PA LA CALQUENCE PA LA MO CAPRELSA PA LA MO COMETRIQ PA LA MO COTELLIC PA LA DAURISMO TABS 00MG QL (0 EA per 0 days) PA DAURISMO TABS 5MG QL (60 EA per 0 days) PA ERIVEDGE PA LA FARYDAK PA LA GILOTRIF PA LA MO IBRANCE PA LA ICLUSIG PA LA MO IDHIFA PA LA imatinib mesylate tabs 400mg QL (60 EA per 0 days) PA imatinib mesylate tabs 00mg QL (90 EA per 0 days) PA IMBRUVICA TABS PA LA IMBRUVICA CAPS 70MG PA LA IMBRUVICA CAPS 40MG PA LA MO INLYTA TABS 5MG QL (0 EA per 0 days) PA LA 4

35 INLYTA TABS MG QL (80 EA per 0 days) PA LA IRESSA PA LA MO JAKAFI QL (60 EA per 0 days) PA LA LENVIMA 0 MG DAILY DOSE PA LA MO LENVIMA MG DAILY DOSE PA MO LENVIMA 4 MG DAILY DOSE PA LA MO LENVIMA 8 MG DAILY DOSE PA LA MO LENVIMA 0 MG DAILY DOSE PA LA MO LENVIMA 4 MG DAILY DOSE PA LA MO LENVIMA 4 MG DAILY DOSE PA MO LENVIMA 8 MG DAILY DOSE PA LA MO LORBRENA TABS 00MG QL (0 EA per 0 days) PA LORBRENA TABS 5MG QL (90 EA per 0 days) PA LYNPARZA CAPS 50MG PA LA MO MEKINIST PA LA NEXAVAR PA LA ODOMZO PA LA SPRYCEL PA STIVARGA PA LA SUTENT PA TAFINLAR PA LA TAGRISSO PA LA TARCEVA TABS 00MG, 50MG QL (0 EA per 0 days) PA LA TARCEVA TABS 5MG QL (90 EA per 0 days) PA LA TASIGNA PA temsirolimus TIBSOVO PA TYKERB PA LA VENCLEXTA PA LA MO VENCLEXTA STARTING PACK PA LA MO VITRAKVI PA VOTRIENT PA LA XALKORI PA LA XOSPATA QL (90 EA per 0 days) PA MO ZELBORAF PA LA ZYDELIG PA LA MO ZYKADIA PA LA Monoclonal Antibody/Antibody-Drug Conjugate HERCEPTIN INJ 50MG PA 5

36 6 KEYTRUDA PA MYLOTARG PA LA POTELIGEO PA RITUXAN HYCELA PA LA RITUXAN INJ PA LA TECENTRIQ PA LA Retinoids bexarotene PA PANRETIN GEL QL (60 GM per 0 days) MO TARGRETIN GEL QL (60 GM per 0 days) PA tretinoin caps 0mg MO Treatment Adjuncts ANTIPARASITICS ELITEK mesna MESNEX TABS MO Anthelmintics albendazole tabs MO ALBENZA MO BILTRICIDE MO EMVERM MO ivermectin tabs MO praziquantel tabs MO Antiprotozoals ALINIA MO atovaquone PA MO atovaquone/proguanil hcl MO chloroquine phosphate tabs MO COARTEM MO hydroxychloroquine sulfate tabs MO mefloquine hcl MO NEBUPENT B/D MO PENTAM 00 MO primaquine phosphate tabs MO quinine sulfate caps 4mg PA MO Pediculicides/Scabicides lindane sham MO malathion lotion MO permethrin crea MO

37 ANTIPARKINSON AGENTS Anticholinergics benztropine mesylate inj, tabs PA MO trihexyphenidyl hcl elix PA MO trihexyphenidyl hydrochloride PA MO Antiparkinson Agents, Other amantadine hcl tabs MO amantadine hcl caps, syrp MO entacapone MO Dopamine Agonists APOKYN INJ 0MG/ML QL (60 ML per 0 days) PA LA bromocriptine mesylate caps, tabs MO NEUPRO MO pramipexole dihydrochloride MO pramipexole dihydrochloride er QL (0 EA per 0 days) MO ropinirole er tab 6mg QL (0 EA per 0 days) MO ropinirole er tab 4mg QL (50 EA per 0 days) MO ropinirole er tab mg QL (0 EA per 0 days) MO ropinirole er tab mg QL (60 EA per 0 days) MO ropinirole er tab 8mg QL (90 EA per 0 days) MO ropinirole hcl MO Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa er MO carbidopa/levodopa odt MO carbidopa/levodopa tabs MO carbidopa/levodopa/entacapone MO carbidopa tabs MO STALEVO 00 ST MO STALEVO 5 ST MO STALEVO 50 ST MO STALEVO 00 ST MO STALEVO 50 ST MO STALEVO 75 ST MO Monoamine Oxidase B (MAO-B) Inhibitors ANTIPSYCHOTICS rasagiline mesylate tabs MO selegiline hcl caps, tabs MO st Generation/Typical chlorpromazine hcl tabs MO 7

38 chlorpromazine hcl inj 50mg/ml chlorpromazine hcl inj 5mg/ml MO compro supp MO fluphenazine decanoate inj MO fluphenazine hcl conc, elix, tabs MO fluphenazine hcl inj MO haloperidol decanoate inj MO haloperidol lactate inj MO haloperidol conc, tabs MO loxapine succinate caps MO molindone hydrochloride perphenazine tabs MO pimozide MO prochlorperazine edisylate inj MO prochlorperazine maleate tabs MO prochlorperazine supp 5mg MO thioridazine hcl tabs 00mg, 0mg, PA MO 5mg, 50mg thiothixene caps 0mg, mg, mg, MO 5mg trifluoperazine hcl tabs MO nd Generation/Atypical ABILIFY MAINTENA INJ QL ( EA per 8 days) MO aripiprazole odt QL (60 EA per 0 days) MO aripiprazole tabs QL (0 EA per 0 days) MO aripiprazole soln QL (900 ML per 0 days) MO ARISTADA INITIO QL (.4 ML per 8 days) ARISTADA INJ 44MG/.6ML QL (.6 ML per 8 days) ARISTADA INJ 66MG/.4ML QL (.4 ML per 8 days) ARISTADA INJ 88MG/.ML QL (. ML per 8 days) ARISTADA INJ 064MG/.9ML QL (.9 ML per 56 days) FANAPT QL (60 EA per 0 days) MO FANAPT TITRATION PACK MO GEODON INJ QL (6 EA per days) MO INVEGA SUSTENNA INJ 9MG/0.5ML QL (0.5 ML per 8 days) MO INVEGA SUSTENNA INJ 78MG/0.5ML QL (0.5 ML per 8 days) MO INVEGA SUSTENNA INJ 7MG/0.75ML QL (0.75 ML per 8 days) MO 8