2015 Formulary (List of Covered Drugs)

Transcription

1 Blue Shield 65 Plus (HMO) 2015 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID , Version 7 This formulary was updated on 08/07/2014. For more recent information or other questions, please contact Blue Shield 65 Plus Member Services at (800) or, for TTY users, 711, 7 a.m. to 8 p.m., seven days a week, from October 1 through February 14. However, after February 14, your call will be handled by our automated phone system on weekends and holidays, or visit blueshieldca.com/med_formulary. 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 Blue Shield of California. When it refers to plan or our plan, it means Blue Shield 65 Plus (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 08/07/2014. 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, 2016, and from time to time during the year H0504_14_199C CMS Accepted

2 What is the Blue Shield 65 Plus (HMO) Formulary? A formulary is a list of covered drugs selected by Blue Shield 65 Plus 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. Blue Shield 65 Plus will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, 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 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 08/07/2014. To get updated information about the drugs covered by Blue Shield 65 Plus, please contact us. Our contact information appears on the front and back cover pages. If we make any other negative formulary changes during the year, you will receive 60 days notice via mail and the changes will be posted on our website.at blueshieldca.com/med_formulary How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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 number 1. 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 39. 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 i

3 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? Blue Shield 65 Plus 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: Blue Shield 65 Plus 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, our plan may not cover the drug. Quantity : For certain drugs, Blue Shield 65 Plus limits the amount of the drug that our plan will cover. For example, our plan provides 18 tablets per 30 days for sumatriptan (generic for IMITREX) This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Blue Shield 65 Plus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, our plan may not cover B unless you try A first. If A does not work for you, our plan will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. 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 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 Blue Shield 65 Plus 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 Blue Shield 65 Plus 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 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 Blue Shield 65 Plus. 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. ii

4 You can ask Blue Shield 65 Plus 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 Blue Shield 65 Plus Formulary? You can ask Blue Shield 65 Plus 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, Blue Shield 65 Plus 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, Blue Shield 65 Plus will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-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 up to a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days iii

5 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 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. Our transition policy applies to members who are stabilized on: Part D drugs not on the Blue Shield 65 Plus formulary Part D drugs on the Blue Shield 65 Plus formulary with a prior authorization, step therapy or a quantity limit requirement, or Part D drugs as listed above, where a distinction cannot be made at point of service whether it is a new or ongoing prescription drug And are members in any of the following scenarios: new members at the beginning of a plan year, newly eligible members transitioning from other coverage at the beginning of a plan year, transitioning individuals who switch from one Blue Shield plan to another after the beginning of a plan year, enrollees residing in long-term care (LTC) facilities, or in some cases, current enrollees affected by formulary changes from one plan year to the next. Members continuing coverage into a new plan year and experiencing negative formulary changes will have coverage continued for selected drugs in the new plan year, as determined by Blue Shield 65 Plus and in accordance with the Centers for Medicare and Medicaid Services (CMS) guidance for Part D drugs. Members on drugs that were not selected for automatic continued coverage; will be provided a transition process consistent with the transition process required for new members beginning in the new plan year. The transition policy will be extended across contract years if a member enrolls in a plan with an effective enrollment date of either November 1 or December 1 and needs access to a transition supply. During the transitional stage, members may talk to their prescribers to decide if they should switch to a different drug that we cover or request a formulary exception in order to get coverage for the drug, if it is not on our formulary or has restrictions such as step therapy or prior authorization. Members may contact Blue Shield 65 Plus Member Services for assistance in initiating a prior authorization or exception request. Prior authorization or exception request forms are available on our website at and are also provided upon request to members and prescribers, via mail, or fax. Per our transition policy in conjunction with network pharmacies, a temporary supply of non-formulary Part D drugs, or formulary drugs with coverage restrictions, is provided in order to prevent interruptions in continuing therapy. This temporary supply also provides sufficient time for members to work with their prescribers to switch to a therapeutically equivalent formulary medication, or to complete a formulary exception request based on medical necessity. Requests for prior authorization of formulary drugs are reviewed against the CMS-approved coverage criteria, and formulary exception requests are reviewed for medical necessity by Blue Shield pharmacy technicians, pharmacists and/or physicians. If a formulary iv

6 exception request is denied, we will provide the prescriber a list of appropriate therapeutic alternatives. A letter will also be sent to you providing instructions on how to appeal the decision. The transitional supply is a one-time, 30-day temporary supply (unless the prescription is written for fewer days in which case we will cover multiple fills to provide up to a total of 30 days of medication) of the nonformulary drug at a retail pharmacy during the first 90 days of new membership beginning on your effective date of coverage in Blue Shield 65 Plus. Refills may be provided for transition prescriptions dispensed for less than the written amount, due to a plan quantity limit edit for safety or drug utilization edits that are based on approved product labeling, and for up to a total of a 30-day supply. If a current member is affected by a negative formulary change from one year to the next, we will provide up to a 30-day temporary supply of the non-formulary drug, if you needs a refill for the drug during the first 90 days of the new plan year. Retail and LTC pharmacies have the ability to provide a point-of-sale override for coverage of a transition supply of a drug that is non-formulary, requires prior authorization or step therapy unless the drug is subject to review for Part B vs. Part D determination, limits to prevent coverage of non-part D drugs or limits that promote safe utilization of a Part D drug. We will cover a 30-day supply (unless the prescription is written for fewer days in which case we will cover multiple fills to provide up to a total of 30 days of medication). The cost-sharing for low-income subsidy (LIS) eligible members for a temporary supply of drugs provided under the transition process, will not exceed the statutory maximum cost-sharing amounts for LIS-eligible members. For all other members (non-lis members), we will apply the same cost-sharing for non-formulary Part D drugs provided during the transition that would apply for non-formulary drugs approved through a formulary exception and the same cost-sharing for formulary drugs subject to utilization management edits provided during the transition that would apply once the utilization management criteria are met. Members will not be required to pay additional cost-sharing associated with multiple fills of lesser quantities of Part D drugs based upon quantity limits for safety once the originally prescribed doses of Part D drugs have been determined to be medically necessary, after an exception process has been completed. After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will send you a written notice within 3 business days of the transitional fill after we cover the temporary supply. This notice will contain an explanation of the temporary nature of the transition supply received, instructions for working with us and the prescriber to identify appropriate therapeutic alternatives that are on our formulary, an explanation of your right to request a formulary exception and a description of the procedures for requesting a formulary exception. If a transition supply has been provided once and you is currently in the process of receiving a coverage determination, the transition supply may be extended by one additional 30 day prescription fill beyond the initial 30 days supply, unless you presents with a prescription written for less than 30 days. The extension of the transition period, is on a case-by-case basis, to the extent that themember s exception request or appeal has not been processed by the end of the minimum day transition period and until such time as a transition has been made (either through a switch to an appropriate formulary drug or a decision on an exception request). Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-part D drug or a drug out of network, unless you qualify for out-of-network access. For more information For more detailed information about your Blue Shield 65 Plus prescription drug coverage, please review your Evidence of Coverage and other plan materials. v

7 If you have questions about Blue Shield 65 Plus, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Blue Shield 65 Plus Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Blue Shield 65 Plus. If you have trouble finding your drug in the list, turn to the Index that begins on page 39. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AUGMENTIN) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the column tells you if our plan has any special requirements for coverage of your drug. Key to Formulary Abbreviations 1 Preferred Generic s Supply Preferred retail cost-sharing (in-network) (30-day supply) Preferred retail cost-sharing (innetwork) or the plan s mail service cost-sharing (90-day supply) Standard retail cost-sharing (innetwork) (30-day supply) Standard retail cost-sharing (innetwork) (90-day supply) Contra Costa, Santa Clara, Riverside, San Bernardino, and Fresno Counties Blue Shield 65 Plus Sacramento and Ventura Counties San Diego County $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $0 Copay $5 Copay $5 Copay $5 Copay $15 Copay $15 Copay $15 Copay vi

8 2 Non- Preferred Generic s Supply Preferred retail cost-sharing (in-network) (30-day supply) Preferred retail cost-sharing (innetwork) or the plan s mail service cost-sharing (90-day supply) Standard retail cost-sharing (innetwork) (30-day supply) Standard retail cost-sharing (innetwork) (90-day supply) Contra Costa, Santa Clara, Riverside, San Bernardino, and Fresno Counties Blue Shield 65 Plus Sacramento and Ventura Counties San Diego County $5 Copay $5 Copay $5 Copay $10 Copay $10 Copay $10 Copay $10 Copay $9 Copay $9 Copay $30 Copay $27 Copay $27 Copay 3 Preferred Brand s 4 Non- Preferred Brand s Preferred retail cost-sharing (in-network) (30-day supply) Preferred retail cost-sharing (innetwork) or the plan s mail service cost-sharing (90-day supply) Standard retail cost-sharing (innetwork) (30-day supply) Standard retail cost-sharing (innetwork) (90-day supply) Preferred retail cost-sharing (in-network) (30-day supply) Preferred retail cost-sharing (innetwork) or the plan s mail service cost-sharing (90-day supply) Standard retail cost-sharing (innetwork) (30-day supply) Standard retail cost-sharing (innetwork) (90-day supply) $40 Copay $40 Copay $40 Copay $80 Copay $80 Copay $80 Copay $45 Copay $45 Copay $45 Copay $135 Copay $135 Copay $135 Copay $90 Copay $85 Copay $80 Copay $180 Copay $170 Copay $160 Copay $95 Copay $90 Copay $85 Copay $285 Copay $270 Copay $255 Copay vii

9 5 Injectable s Supply Preferred retail cost-sharing (in-network) (30-day supply) Preferred retail cost-sharing (innetwork) or the plan s mail service cost-sharing (90-day supply) Standard retail cost-sharing (innetwork) (30-day supply) Standard retail cost-sharing (innetwork) (90-day supply) Contra Costa, Santa Clara, Riverside, San Bernardino, and Fresno Counties 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate Blue Shield 65 Plus Sacramento and Ventura Counties 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate San Diego County 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate 25% of Blue Shield's contracted rate 6 Specialty s Preferred retail cost-sharing (in-network) (30-day supply) Preferred retail cost-sharing (innetwork) or the plan s mail service cost-sharing (90-day supply) Standard retail cost-sharing (innetwork) (30-day supply) Standard retail cost-sharing (innetwork) (90-day supply) 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate 33% of Blue Shield's contracted rate Cost-sharing for out-of-network pharmacies (30-day supply) and network long-term care pharmacies (31-day supply) is the same as the in-network standard retail (30-day supply) cost-sharing. viii

10 Limit Codes Code Definition AG This prescription drug has coverage limits based on age groups. The limits may be based upon how the U.S. Food and Administration (FDA) approved the drug for use or special cautions for use by people in certain age groups. For new prescriptions, discuss alternatives with your physician. Your pharmacy or physician may call Blue Shield for assistance with coverage for ongoing use. B/D This prescription drug requires prior authorization review to determine whether coverage is under Part B or Part D of the Medicare benefit, based on Medicare coverage rules. Call Blue Shield to provide the necessary information to determine coverage. LA This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Member Services at (800) , 7 a.m. to 8 p.m. Pacific Standard Time from October 1 through February 14. However, after February 14, your call will be handled by our automated phone system on weekends and holidays. TTY users should call 711. QL This medication has a dosing or prescription quantity limit. Maximum daily dose limits are defined by the FDA and listed in the drug package insert. Other quantity limits encourage consolidated dosing when possible. PA Coverage for this prescription requires prior authorization from Blue Shield. Call Blue Shield to provide the necessary information to determine coverage. ST Coverage for this prescription is provided when other first-line or preferred drug therapies have been tried (step therapy). Medication is NOT available through Blue Shield s mail service pharmacy. Form Codes Abbreviation Definition Abbreviation Definition AERS Aerosol PACK Pack CAPS Capsule PTTW Patch - Biweekly CHEW Chewable PTWK Patch - Weekly CONC Concentrate SOLN Solution CP24 Capsule - Extended Release 24-hour SOLR Solution - Reconstituted CPDR Capsule - Delayed-Release SUSP Suspension CREA Cream SUSR Suspension - Reconstituted EA Each SYRP Syrup ELIX Elixir TABS Tablet FOAM Foam TB24 Tablet - Extended Release 24-hour GEL Gel TBDP Tablet - Dispersible LOTN Lotion TBEC Tablet - Enteric Coated OIL Oil TBEF Tablet - Effervescent OINT Ointment ix

11 Analgesics Analgesics butal/asa/caff 325mg; 50mg; 40mg butalbital/acetaminophe n 325mg; 50mg butalbital/acetaminophe n/caffeine tabs 325mg; 50mg; 40mg butalbital/acetaminophe n/caffeine/codeine caps 325mg; 50mg; 40mg; 30mg 2 QL(180 EA per 2 QL(180 EA per 2 QL(180 EA per 2 QL(180 EA per GRALISE STARTER 4 PA QL(78 EA per GRALISE TABS 300MG 4 PA QL(30 EA per GRALISE TABS 600MG 4 PA QL(90 EA per Nonsteroidal Anti-inflammatory s diclofenac 3 sodium/misoprostol ibuprofen tabs 800mg 1 meclofenamate sodium 3 mefenamic acid 2 naproxen sodium tabs 2 275mg, 550mg Opioid Analgesics, Long-acting fentanyl 3 QL(20 EA per KADIAN CP24 40MG 4 QL(60 EA per KADIAN CP24 130MG, 150MG, 200MG, 70MG 4 QL(90 EA per levorphanol tartrate 2 QL(270 EA per methadone hcl inj 5 B/D methadone hcl oral soln 10mg/5ml 2 QL(2700 ML per methadone hcl oral soln 5mg/5ml 2 QL(5400 ML per methadone hcl tabs 10mg 2 QL(540 EA per methadone hcl tabs 5mg 2 QL(1080 EA per methadose tabs 2 QL(540 EA per 1 morphine sulfate er cp24 30mg, 45mg, 60mg, 75mg morphine sulfate er cp24 10mg, 30mg, 50mg morphine sulfate er cp24 60mg, 80mg, 90mg morphine sulfate er cp24 20mg morphine sulfate er cp24 120mg morphine sulfate er tbcr 100mg, 200mg morphine sulfate er tbcr 60mg morphine sulfate er tbcr 15mg, 30mg morphine sulfate inj 0.5mg/ml, 8mg/ml morphine sulfate supp 30mg morphine sulfate supp 20mg morphine sulfate supp 10mg morphine sulfate supp 5mg morphine sulfate tabs 30mg morphine sulfate tabs 15mg OXYCONTIN T12A 60MG OXYCONTIN T12A 40MG, 80MG OXYCONTIN T12A 15MG, 20MG, 30MG OXYCONTIN T12A 10MG oxymorphone hydrochloride er tb12 10mg, 15mg, 20mg, 30mg, 5mg, 7.5mg oxymorphone hydrochloride er tb12 40mg tramadol hcl er tb24 100mg, 200mg, 300mg 4 QL(30 EA per 4 QL(60 EA per 4 QL(90 EA per 4 QL(120 EA per 4 QL(390 EA per 2 QL(90 EA per 2 QL(135 EA per 2 QL(180 EA per 5 B/D 2 QL(270 EA per 2 QL(405 EA per 2 QL(810 EA per 2 QL(1620 EA per 2 QL(270 EA per 2 QL(540 EA per 4 PA QL(60 EA per 4 PA QL(120 EA per 4 PA QL(180 EA per 4 PA QL(270 EA per 4 QL(60 EA per ST 4 QL(120 EA per ST 3 QL(30 EA per ST (RYZOLT)

12 tramadol hcl er tb24 200mg 3 QL(30 EA per ST (Ultram ER) tramadol hcl er tb24 100mg 3 QL(90 EA per ST (ULTRAM ER) Opioid Analgesics, Short-acting acetaminophen/codeine #3 2 QL(360 EA per acetaminophen/codeine oral soln 2 QL(2700 ML per acetaminophen/codeine tabs 300mg; 60mg 2 QL(180 EA per acetaminophen/codeine tabs 300mg; 15mg 2 QL(390 EA per ascomp/codeine 2 QL(270 EA per aspirin-caffeinedihydrocodeine 2 QL(510 EA per butorphanol tartrate inj 5 B/D butorphanol tartrate nasal soln 3 QL(10 ML per carbinoxamine maleate 2 codeine sulfate tabs 60mg 2 QL(270 EA per codeine sulfate tabs 30mg 2 QL(540 EA per codeine sulfate tabs 15mg 2 QL(1080 EA per DURAMORPH 5 B/D endocet tabs 325mg; 10mg, 325mg; 5mg, 2 QL(360 EA per 325mg; 7.5mg fentanyl citrate 5 B/D fentanyl citrate oral 6 PA QL(120 EA transmucosal hydrocodone bitartrate/acetaminophe n oral soln hydrocodone bitartrate/acetaminophe n tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg hydrocodone/acetamino phen tabs hydrocodone/ibuprofen tabs 2.5mg; 200mg, 7.5mg; 200mg per 2 QL(5400 ML per 2 QL(390 EA per 2 QL(360 EA per 2 QL(225 EA per 2 hydromorphone hcl inj 5 B/D 500mg/50ml hydromorphone hcl liqd 2 QL(3600 ML per hydromorphone hcl tabs 8mg 2 QL(450 EA per hydromorphone hcl tabs 4mg 2 QL(900 EA per hydromorphone hcl tabs 2mg 2 QL(1800 EA per LAZANDA 6 PA QL(30 EA per morphine sulfate inj 5 B/D 10mg/ml, 15mg/ml, 2mg/ml, 4mg/ml morphine sulfate oral soln 20mg/ml 3 QL(405 ML per morphine sulfate oral soln 20mg/5ml 3 QL(2025 ML per morphine sulfate oral soln 10mg/5ml 3 QL(4050 ML per NUCYNTA TABS 50MG 4 QL(180 EA per NUCYNTA TABS 100MG, 75MG 4 QL(210 EA per oxycodone hcl caps 2 QL(360 EA per oxycodone hcl conc 2 QL(180 ML per oxycodone hcl oral soln 2 QL(7200 ML per oxycodone hcl tabs 30mg, 5mg 2 QL(360 EA per oxycodone hcl tabs 20mg 2 QL(540 EA per oxycodone hcl tabs 15mg 2 QL(720 EA per oxycodone hcl tabs 10mg 2 QL(1080 EA per oxycodone/acetaminoph en 2 QL(360 EA per oxycodone/aspirin 2 QL(360 EA per oxymorphone hydrochloride 3 QL(360 EA per ROXICET ORAL SOLN 3 QL(1800 ML per roxicet tabs 2 QL(360 EA per

13 tramadol hcl 2 (ULTRAM) tramadol hydrochloride/acetamin 2 QL(240 EA per ophen Anesthetics Local Anesthetics lidocaine hcl external 2 soln lidocaine hcl inj 1%, 2% 5 lidocaine hcl jelly 2 lidocaine oint 2 lidocaine ptch 4 PA QL(90 EA per lidocaine viscous 2 lidocaine/prilocaine crea 2 Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr 3 disulfiram 2 naltrexone hcl 2 Opioid Dependence Treatments buprenorphine hcl subl 8mg 3 PA QL(120 EA per buprenorphine hcl subl 3 PA QL(480 EA 2mg buprenorphine hcl/naloxone hcl subl 8mg; 2mg buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg per 3 PA QL(120 EA per 3 PA QL(480 EA per SUBOXONE FILM 12MG; 3MG 4 PA QL(60 EA per SUBOXONE FILM 8MG; 2MG 4 PA QL(120 EA per SUBOXONE FILM 4MG; 1MG 4 PA QL(240 EA per SUBOXONE FILM 2MG; 0.5MG 4 PA QL(480 EA per ZUBSOLV 4 PA QL(90 EA per Opioid Reversal Agents naloxone hcl 5 Smoking Cessation Agents buproban 2 QL(60 EA per 30 3 CHANTIX STARTING MONTH PAK 3 QL(60 EA per 30 CHANTIX TABS 1MG 3 QL(60 EA per 30 CHANTIX TABS 0.5MG 3 QL(60 EA per 30 NICOTROL INHALER 3 NICOTROL NS 3 Anti-inflammatory Agents Nonsteroidal Anti-inflammatory s diclofenac potassium 2 diclofenac sodium dr 2 diclofenac sodium er 2 diclofenac sodium gel 4 diflunisal 2 etodolac 2 etodolac er 2 fenoprofen calcium 2 flurbiprofen 2 ibuprofen susp 2 ibuprofen tabs 400mg, 1 600mg INDOCIN SUSP 4 indomethacin caps 2 indomethacin er 3 ketoprofen 2 ketoprofen er 2 meloxicam 2 nabumetone 2 naproxen dr 2 naproxen susp 2 naproxen tabs 1 oxaprozin 2 piroxicam 2 sulindac 2 tolmetin sodium 2 Antibacterials Aminoglycosides BETHKIS 6 PA QL(224 ML per 28 gentamicin sulfate crea 2 gentamicin sulfate inj 5 B/D gentamicin sulfate oint 2 gentamicin sulfate 1 ophthalmic soln neomycin sulfate 2 paromomycin sulfate 2 streptomycin sulfate 5 B/D

14 TOBI PODHALER 6 PA QL(224 EA per 28 tobramycin 6 PA QL(280 ML per 28 tobramycin sulfate inj 5 10mg/ml, 80mg/2ml tobramycin sulfate 1 ophthalmic soln TOBREX OINT 3 Antibacterials, Other ak-poly-bac 2 alcohol preps pads 2 bacitracin ophthalmic 2 oint bacitracin/polymyxin b 2 BACTROBAN NASAL 4 chloramphenicol sodium 5 B/D succinate CLEOCIN SUPP 3 clindamycin hcl 2 clindamycin palmitate 2 hcl clindamycin phosphate 2 crea clindamycin phosphate 5 in d5w colistimethate sodium 5 B/D CORTISPORIN OINT 4 CUBICIN 6 LINCOCIN 5 MACRODANTIN 3 PA CAPS 25MG mafenide acetate 3 methenamine hippurate 3 metronidazole caps 2 metronidazole crea 2 metronidazole gel % metronidazole gel 1% 3 metronidazole in nacl % metronidazole lotn 3 metronidazole tabs 2 MONUROL 4 mupirocin crea 3 mupirocin oint 2 neomycin/bacitracin/pol ymyxin 2 4 neomycin/polymyxin/bac 1 itracin/hydrocortisone neomycin/polymyxin/gra 1 micidin neomycin/polymyxin/hyd 2 rocortisone ophthalmic susp nitrofurantoin 2 PA nitrofurantoin 2 PA macrocrystals nitrofurantoin 2 PA monohydrate nitrofurantoin 2 monohydrate/macrocrys tals polycin b 2 polymyxin b sulfate 5 polymyxin b 2 sulfate/trimethoprim sulfate PRIMSOL 4 silver sulfadiazine 2 SULFAMYLON CREA 4 SYNERCID 6 trimethoprim 2 TYGACIL 6 vancomycin hcl caps 6 vancomycin hcl inj mg, 10gm, 500mg vandazole 2 XIFAXAN TABS 200MG 6 PA QL(9 EA per XIFAXAN TABS 550MG 6 PA QL(90 EA per ZYVOX 6 PA Beta-lactam, Cephalosporins cefaclor 2 cefaclor er 2 cefadroxil 2 cefazolin sodium inj 5 500mg cefdinir 2 cefditoren pivoxil 2 cefepime inj 1gm, 2gm 5 cefotaxime sodium 5 cefoxitin sodium inj 5 10gm, 1gm, 2gm cefpodoxime proxetil 2 cefprozil 2

15 ceftazidime/dextrose 5 ceftriaxone sodium 5 cefuroxime axetil 2 cefuroxime sodium inj 5 1.5gm, 7.5gm, 750mg cephalexin caps 250mg, 1 500mg cephalexin susr 2 SUPRAX 4 tazicef inj 1gm, 2gm, 5 6gm TEFLARO INJ 400MG 5 TEFLARO INJ 600MG 6 Beta-lactam, Other aztreonam inj 1gm 5 CAYSTON 6 PA QL(84 ML per 28 IMIPENEM/CILASTA 5 TIN INJ 500MG; 500MG imipenem/cilastatin inj 5 250mg; 250mg INVANZ 5 meropenem inj 500mg 5 Beta-lactam, Penicillins amoxicillin 1 amoxicillin/clavulanate 2 potassium amoxicillin/clavulanate 2 potassium er ampicillin 2 ampicillin sodium inj 5 10gm, 125mg, 1gm ampicillin-sulbactam inj 5 10gm; 5gm, 2gm; 1gm AUGMENTIN SUSR 3 125MG/5ML; 31.25MG/5ML bactocill in dextrose inj 5 0; 1gm/50ml bactocill in dextrose inj 6 0; 2gm/50ml BICILLIN C-R 5 BICILLIN L-A 5 dicloxacillin sodium 2 nafcillin sodium inj 6 10gm nafcillin sodium inj 1gm 5 nallpen/dextrose 5 5 oxacillin sodium inj 2gm 5 oxacillin sodium inj 6 10gm, 1gm penicillin g potassium 5 inj 5mu penicillin g procaine 5 penicillin g sodium 5 penicillin v potassium 1 piperacillin 5 sodium/tazobactam sodium inj 3gm; 0.375gm, 4gm; 0.5gm Macrolides AKNE-MYCIN 4 azithromycin inj 500mg 5 azithromycin powder 2 pack azithromycin susr 2 azithromycin tabs 500mg 2 QL(3 EA per 3 azithromycin tabs 250mg 2 QL(6 EA per 5 azithromycin tabs 600mg 2 QL(8 EA per 30 clarithromycin er 2 QL(42 EA per 14 clarithromycin susr 2 clarithromycin tabs 2 QL(42 EA per 14 ery 2 ERY-TAB 3 ERYPED ERYPED ERYTHROCIN 5 LACTOBIONATE INJ 500MG ERYTHROCIN 3 STEARATE erythromycin base 2 erythromycin cpep 2 erythromycin 2 ethylsuccinate erythromycin external 2 soln erythromycin gel 2 erythromycin oint 2 KETEK TABS 400MG 3 QL(20 EA per 10

16 KETEK TABS 300MG 3 QL(20 EA per PCE 3 romycin 2 ZMAX 4 QL(60 EA per Quinolones CILOXAN OINT 3 CIPRO HC 4 CIPRODEX 4 ciprofloxacin er tb24 2 QL(3 EA per 3 500mg; 0 ciprofloxacin er tb24 2 QL(14 EA per 1000mg; 0 14 ciprofloxacin hcl 1 ciprofloxacin i.v.-in d5w 5 inj 200mg/100ml; 5% ciprofloxacin inj 5 400mg/40ml ciprofloxacin otic soln 3 ciprofloxacin susr 3 levofloxacin in d5w inj 5 5%; 500mg/100ml levofloxacin inj 5 levofloxacin ophthalmic 2 soln levofloxacin oral soln 2 levofloxacin tabs 1 QL(10 EA per 10 MOXEZA 3 moxifloxacin hcl 3 QL(10 EA per 10 ofloxacin 2 VIGAMOX 3 Sulfonamides sodium sulfacetamide ophthalmic soln 2 sulfacetamide sodium 2 oint sulfacetamide sodium 2 ophthalmic soln sulfadiazine 2 sulfamethoxazole/trimet 1 hoprim ds sulfamethoxazole/trimet 5 hoprim inj sulfamethoxazole/trimet hoprim susp 2 sulfamethoxazole/trimet 1 hoprim tabs Tetracyclines demeclocycline hcl 4 doxycycline caps 2 doxycycline hyclate caps 2 doxycycline hyclate dr 4 doxycycline hyclate tabs 2 doxycycline 2 monohydrate caps doxycycline 2 monohydrate tabs 100mg doxycycline 3 monohydrate tabs 150mg, 50mg, 75mg doxycycline susr 3 minocycline hcl caps 2 minocycline hcl tabs 3 ORACEA 3 tetracycline hcl 2 VIBRAMYCIN SYRP 4 Anticonvulsants Anticonvulsants, Other APTIOM TABS 200MG, 400MG, 800MG 4 PA QL(30 EA per APTIOM TABS 600MG 4 PA QL(60 EA per FYCOMPA TABS 10MG, 12MG, 4MG, 6MG, 8MG 4 PA QL(30 EA per FYCOMPA TABS 2MG 4 PA QL(90 EA per levetiracetam er tb24 750mg 2 QL(120 EA per levetiracetam er tb24 500mg 2 QL(180 EA per levetiracetam inj 5 500mg/5ml levetiracetam oral soln 2 levetiracetam tabs 2 phenobarbital 2 POTIGA TABS 200MG, 300MG, 400MG 4 QL(90 EA per 30 POTIGA TABS 50MG 4 QL(270 EA per 6

17 Calcium Channel Modifying Agents CELONTIN 3 ethosuximide 2 LYRICA CAPS 200MG, 225MG, 300MG LYRICA CAPS 100MG, 150MG, 25MG, 50MG, 75MG 4 PA QL(60 EA per 4 PA QL(90 EA per LYRICA ORAL SOLN 4 PA QL(900 ML per zonisamide 2 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tbdp 2mg clonazepam odt tbdp 1mg clonazepam odt tbdp 2 QL(300 EA per 2 QL(600 EA per 2 QL(1200 EA per 0.125mg, 0.25mg, 0.5mg clonazepam tabs 2mg 2 QL(300 EA per clonazepam tabs 1mg 2 QL(600 EA per clonazepam tabs 0.5mg 2 QL(1200 EA per clorazepate dipotassium tabs 15mg 2 QL(180 EA per clorazepate dipotassium tabs 7.5mg 2 QL(360 EA per clorazepate dipotassium tabs 3.75mg 2 QL(720 EA per diazepam gel 2.5mg 4 QL(5kits (40ml) per diazepam gel 10mg 4 QL(5kits (40ml) per diazepam gel 20mg 4 QL(5kits (40ml) per divalproex sodium 2 divalproex sodium dr 2 divalproex sodium er 2 gabapentin 2 GABITRIL TABS 4 PA 12MG, 16MG ONFI SUSP 4 PA QL(480 ML per ONFI TABS 4 PA QL(60 EA per primidone 2 7 SABRIL 6 PA QL(180 EA per tiagabine hydrochloride 3 PA valproate sodium 5 valproic acid 2 Glutamate Reducing Agents felbamate 2 LAMICTAL 3 STARTER/NOT TAKING CARBAMAZEPINE LAMICTAL 3 STARTER/TAKING CARBAMAZEPINE/N OT TAKING VALPROATE LAMICTAL 3 STARTER/TAKING VALPROATE lamotrigine 2 lamotrigine er tb24 3 ST 300mg lamotrigine er tb24 3 ST 250mg lamotrigine er tb24 100mg, 25mg, 50mg 3 QL(30 EA per 30 ST lamotrigine er tb24 200mg 3 QL(90 EA per 30 ST topiramate 2 PA TROKENDI XR CP24 100MG, 25MG 4 PA QL(90 EA per TROKENDI XR CP24 50MG 4 PA QL(210 EA per TROKENDI XR CP24 200MG 6 PA QL(60 EA per Sodium Channel Agents BANZEL SUSP 3 PA QL(2400 ML per BANZEL TABS 200MG 3 PA QL(60 EA per BANZEL TABS 400MG 3 PA QL(240 EA per carbamazepine chew 2 carbamazepine er 3 carbamazepine susp 3 carbamazepine tabs 2 DILANTIN CAPS 3 30MG epitol 2

18 EQUETRO 4 oxcarbazepine 2 PA OXTELLAR XR TB24 150MG, 300MG 4 PA QL(30 EA per OXTELLAR XR TB24 600MG 4 PA QL(120 EA per PEGANONE 3 phenytoin 2 phenytoin sodium 2 extended TEGRETOL-XR TB MG VIMPAT INJ 5 PA VIMPAT ORAL SOLN 4 PA QL(1200 ML per VIMPAT TABS 4 PA QL(60 EA per Antidementia Agents Antidementia Agents, Other ERGOLOID 3 PA MESYLATES Cholinesterase Inhibitors donepezil hcl tabs 10mg, 1 5mg donepezil hcl tabs 23mg 3 ST donepezil hcl tbdp 3 EXELON PT24 3 galantamine hydrobromide cp24 3 QL(30 EA per 30 galantamine 3 hydrobromide oral soln galantamine 3 hydrobromide tabs rivastigmine tartrate 3 N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA ORAL SOLN 3 QL(360 ML per NAMENDA TABS 3 QL(60 EA per 30 NAMENDA TITRATION PAK 3 QL(60 EA per 30 NAMENDA XR 3 QL(30 EA per 30 NAMENDA XR TITRATION PACK 3 QL(30 EA per 30 Antidepressants Antidepressants, Other BRINTELLIX 4 QL(30 EA per 30 ST bupropion hcl sr tb12 200mg 2 QL(60 EA per 30 bupropion hcl sr tb12 150mg 2 QL(90 EA per 30 bupropion hcl sr tb12 100mg 2 QL(120 EA per bupropion hcl tabs 100mg 2 QL(120 EA per bupropion hcl tabs 75mg 2 QL(180 EA per bupropion hcl xl tb24 300mg 2 QL(30 EA per 30 bupropion hcl xl tb24 150mg 2 QL(90 EA per 30 FORFIVO XL 4 QL(30 EA per 30 ST maprotiline hcl 2 mirtazapine odt tbdp 2 30mg, 45mg mirtazapine tabs 1 mirtazapine tbdp 2 nefazodone hcl 2 trazodone hcl tabs 2 100mg, 150mg, 50mg trazodone hcl tabs 3 300mg Monoamine Oxidase Inhibitors EMSAM 6 PA MARPLAN 3 phenelzine sulfate 2 tranylcypromine sulfate 3 SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitor citalopram hydrobromide oral soln citalopram hydrobromide tabs DESVENLAFAXINE ER duloxetine hcl cpep 60mg duloxetine hcl cpep 20mg, 30mg QL(30 EA per 30 ST 3 QL(60 EA per 30 3 QL(90 EA per 30 8

19 escitalopram oxalate oral soln 3 QL(720 ML per escitalopram oxalate tabs 20mg, 5mg 1 QL(30 EA per 30 escitalopram oxalate tabs 10mg 1 QL(45 EA per 30 FETZIMA 4 PA QL(30 EA per FETZIMA TITRATION PACK 4 PA QL(30 EA per fluoxetine dr 3 QL(4 EA per 28 fluoxetine hcl caps 2 fluoxetine hcl oral soln 2 fluoxetine hcl tabs 2 10mg, 20mg fluvoxamine maleate 2 fluvoxamine maleate er cp24 150mg 3 QL(60 EA per 30 ST fluvoxamine maleate er cp24 100mg 3 QL(90 EA per 30 ST KHEDEZLA 4 QL(30 EA per 30 ST olanzapine/fluoxetine 3 paroxetine hcl 1 paroxetine hcl er 3 PAXIL SUSP 4 QL(900 ML per PEXEVA TABS 40MG 4 QL(30 EA per 30 ST PEXEVA TABS 30MG 4 QL(60 EA per 30 ST PEXEVA TABS 20MG 4 QL(90 EA per 30 ST PEXEVA TABS 10MG 4 QL(180 EA per ST PRISTIQ TB24 50MG 4 QL(30 EA per 30 ST PRISTIQ TB24 100MG 4 QL(120 EA per ST sertraline hcl conc 3 sertraline hcl tabs 1 venlafaxine hcl 2 venlafaxine hcl er cp24 150mg, 37.5mg 2 QL(60 EA per 30 venlafaxine hcl er cp24 75mg 2 QL(90 EA per 30 venlafaxine hcl er tb24 150mg, 37.5mg, 75mg 3 QL(30 EA per QL(30 EA per 30 VENLAFAXINE HCL ER TB24 225MG VIIBRYD 4 QL(30 EA per 30 ST Tricyclics amitriptyline hcl 2 amoxapine 2 clomipramine hcl 2 desipramine hcl 3 doxepin hcl 2 imipramine hcl 2 imipramine pamoate 4 nortriptyline hcl 2 perphenazine/amitriptyli 2 ne protriptyline hcl 2 SURMONTIL 4 Antiemetics Antiemetics, Other meclizine hcl tabs 2 morphine sulfate er cp24 100mg 4 QL(60 EA per TRANSDERM-SCOP 4 Emetogenic Therapy Adjuncts ANZEMET INJ 5 PA ANZEMET TABS 3 PA QL(1 EA per 5 dronabinol caps 2.5mg, 5mg 4 PA QL(180 EA per dronabinol caps 10mg 6 PA QL(180 EA per EMEND CAPS 125MG, 4 PA 80MG EMEND CAPS 40MG 4 PA QL(1 EA per granisetron hcl inj 5 PA 0.1mg/ml, 1mg/ml granisetron hcl tabs 3 PA QL(60 EA per granisol 3 PA QL(300 ML per ondansetron hcl inj 4mg/2ml ondansetron hcl oral soln ondansetron hcl tabs 24mg 5 B/D 2 B/D QL(450 ML per 2 B/D QL(15 EA per

20 2 B/D QL(90 EA per ondansetron hcl tabs 4mg, 8mg ondansetron odt 2 B/D QL(90 EA per Antifungals Antifungals ABELCET 6 B/D AMBISOME 6 B/D amphotericin b 5 B/D BIO-STATIN CAPS 4 CANCIDAS 6 PA ciclopirox gel 3 ciclopirox nail lacquer 2 ciclopirox olamine 2 ciclopirox sham 3 ciclopirox susp 2 clotrimazole external 2 crea clotrimazole external 2 soln clotrimazole troc 2 econazole nitrate 2 EXELDERM 4 fluconazole 2 fluconazole in dextrose inj 56mg/ml; 400mg/200ml 5 flucytosine 6 griseofulvin microsize 2 susp griseofulvin microsize 3 tabs griseofulvin 3 ultramicrosize gynazole-1 2 itraconazole 4 PA ketoconazole 2 LAMISIL SPRAY 4 MENTAX 4 miconazole 3 2 MYCAMINE 6 NAFTIN CREA 1% 4 NAFTIN GEL 4 NATACYN 3 NOXAFIL SUSP 6 PA NOXAFIL TBEC 6 PA QL(90 EA per nyamyc 2 nystatin crea 2 10 nystatin oint 2 nystatin powd unit/gm nystatin susp 2 nystatin tabs 2 nystatin/triamcinolone 2 nystop 2 OXISTAT 4 pedi-dri 2 SPORANOX ORAL 6 PA SOLN terbinafine hcl tabs 2 QL(30 EA per terconazole 2 voriconazole inj 5 voriconazole susr 6 PA voriconazole tabs 6 PA Antigout Agents Antigout Agents allopurinol 1 COLCRYS 3 KRYSTEXXA 6 PA probenecid 2 probenecid/colchicine 2 ULORIC 3 QL(30 EA per 30 ST Antimigraine Agents Ergot Alkaloids dihydroergotamine 5 mesylate inj dihydroergotamine mesylate nasal soln 3 QL(8 ML per 30 migergot 3 Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl 2 QL(18 EA per RELPAX 4 QL(18 EA per rizatriptan benzoate 3 QL(24 EA per rizatriptan benzoate odt 3 QL(24 EA per sumatriptan nasal soln 2 QL(18 EA per sumatriptan succinate inj 5 QL(8 ML per 30 sumatriptan succinate refill inj 4mg/0.5ml 5 QL(8 ML per 30

21 2 QL(18 EA per sumatriptan succinate tabs SUMAVEL DOSEPRO 5 QL(8 ML per 30 zolmitriptan 4 QL(18 EA per zolmitriptan odt 4 QL(18 EA per Antimyasthenic Agents Parasympathomimetics guanidine hcl 2 MESTINON SYRP 4 MESTINON 4 TIMESPAN pyridostigmine bromide 2 Antimycobacterials Antimycobacterials, Other dapsone 2 rifabutin 4 Antituberculars CAPASTAT SULFATE 5 ethambutol hcl 2 isoniazid inj 5 isoniazid syrp 2 isoniazid tabs 1 PASER 4 PRIFTIN 3 pyrazinamide 2 rifampin caps 2 rifampin inj 5 RIFATER 4 TRECATOR 4 Antineoplastics Alkylating Agents BICNU 5 B/D BUSULFEX 5 B/D cyclophosphamide caps 4 PA cyclophosphamide inj 5 B/D cyclophosphamide tabs 3 PA dacarbazine 5 B/D HEXALEN 6 ifosfamide 5 B/D ifosfamide/mesna 5 B/D LEUKERAN 3 LOMUSTINE 3 MATULANE 6 melphalan hydrochloride 5 B/D 11 MUSTARGEN 6 B/D TREANDA 6 B/D ZANOSAR 5 Antiandrogens bicalutamide 2 flutamide 3 NILANDRON 6 XTANDI 6 PA QL(120 EA per Antiangiogenic Agents CAPRELSA TABS 300MG 6 PA QL(30 EA per CAPRELSA TABS 100MG 6 PA QL(60 EA per REVLIMID 6 PA QL(30 EA per THALOMID CAPS 100MG, 50MG 6 PA QL(30 EA per THALOMID CAPS 150MG, 200MG 6 PA QL(60 EA per Antiestrogens/Modifiers EMCYT 3 FARESTON 6 FASLODEX 6 SOLTAMOX 4 tamoxifen citrate 2 Antimetabolites ALIMTA 5 B/D cladribine 6 B/D CLOLAR 5 B/D cytarabine aqueous 5 B/D cytarabine inj 100mg, 5 B/D 1gm DROXIA 3 ELITEK 6 floxuridine 5 B/D fluorouracil inj 5 B/D 2.5gm/50ml gemcitabine hcl inj 1gm 5 B/D gemcitabine inj 5 B/D 200mg/5.26ml, 2gm/52.6ml hydroxyurea 2 mercaptopurine 2 NIPENT 5 B/D TABLOID 3 Antineoplastics KYPROLIS 6 B/D

22 ZYKADIA 6 PA QL(150 EA per Antineoplastics, Other ABRAXANE 5 B/D amifostine 5 B/D ARRANON 6 B/D azacitidine 6 B/D bleomycin sulfate 5 B/D carboplatin inj 5 B/D 150mg/15ml cisplatin inj 5 B/D 100mg/100ml COMETRIQ KIT 6 PA QL(56 EA per 28 COMETRIQ KIT 20MG 6 PA QL(84 EA per 28 COMETRIQ KIT 6 PA QL(112 EA per 28 COSMEGEN 6 B/D daunorubicin hcl 5 B/D decitabine 6 PA dexrazoxane inj 250mg 5 B/D docetaxel inj 5 B/D 160mg/8ml, 80mg/4ml, 80mg/8ml doxorubicin hcl inj 5 B/D 2mg/ml doxorubicin hcl 5 B/D liposome ELLENCE INJ 5 B/D 200MG/100ML epirubicin hcl inj 5 B/D 50mg/25ml ERIVEDGE 6 PA QL(30 EA per ERWINAZE 6 B/D fludarabine phosphate 5 B/D FUSILEV 5 B/D GILOTRIF 6 PA QL(30 EA per HALAVEN 6 B/D IDAMYCIN PFS INJ 5 B/D 20MG/20ML idarubicin hcl inj 5 B/D 10mg/10ml irinotecan inj 5 B/D 100mg/5ml ISTODAX 6 B/D IXEMPRA KIT 6 B/D 12 JAKAFI 6 PA QL(60 EA per JEVTANA 6 B/D leucovorin calcium inj 5 B/D 100mg, 350mg leucovorin calcium tabs 2 MEKINIST TABS 2MG 6 PA QL(30 EA per MEKINIST TABS 0.5MG MENEST 4 PA mesna 5 MESNEX TABS 3 mitomycin 5 B/D mitoxantrone hcl 3 B/D ONCASPAR 6 B/D 6 PA QL(90 EA per oxaliplatin inj 6 B/D 100mg/20ml paclitaxel inj 5 B/D 300mg/50ml PICATO GEL 0.05% 3 QL(2 EA per 30 PICATO GEL 0.015% 3 QL(3 EA per 30 POMALYST 6 PA QL(30 EA per PROLEUKIN 6 B/D SYLATRON 6 PA SYNRIBO 6 B/D TAFINLAR 6 PA QL(120 EA per TRISENOX 5 B/D VELCADE 6 B/D vinblastine sulfate inj 5 B/D 1mg/ml vincasar pfs 5 B/D vincristine sulfate 5 B/D vinorelbine tartrate inj 5 B/D 50mg/5ml ZALTRAP INJ 6 PA 100MG/4ML ZOLINZA 6 PA QL(120 EA per ZYTIGA 6 PA QL(120 EA per Aromatase Inhibitors, 3rd Generation anastrozole 2 exemestane 3 letrozole 2

23 Enzyme Inhibitors ETOPOPHOS 3 B/D etoposide inj 5 B/D 500mg/25ml topotecan hcl inj 4mg 5 B/D Molecular Target Inhibitors AFINITOR DISPERZ TBSO 5MG 6 PA QL(30 EA per AFINITOR DISPERZ TBSO 2MG 6 PA QL(60 EA per AFINITOR DISPERZ TBSO 3MG 6 PA QL(120 EA per AFINITOR TABS 2.5MG, 5MG 6 PA QL(30 EA per AFINITOR TABS 10MG, 7.5MG 6 PA QL(60 EA per BOSULIF TABS 500MG 6 PA QL(30 EA per BOSULIF TABS 100MG 6 PA QL(120 EA per GLEEVEC TABS 400MG 6 PA QL(60 EA per GLEEVEC TABS 100MG 6 PA QL(240 EA per IMBRUVICA 6 PA QL(120 EA per INLYTA TABS 5MG 6 PA QL(120 EA per INLYTA TABS 1MG 6 PA QL(180 EA per NEXAVAR 6 PA QL(120 EA per SPRYCEL TABS 100MG, 140MG 6 PA QL(30 EA per SPRYCEL TABS 70MG, 80MG 6 PA QL(60 EA per SPRYCEL TABS 50MG 6 PA QL(90 EA per SPRYCEL TABS 20MG 6 PA QL(180 EA per STIVARGA 6 PA QL(120 EA per SUTENT CAPS 50MG 6 PA QL(30 EA per SUTENT CAPS 25MG 6 PA QL(90 EA per SUTENT CAPS 12.5MG 6 PA QL(210 EA per 6 PA QL(90 EA per 6 PA QL(180 EA per TARCEVA TABS 100MG, 150MG TARCEVA TABS 25MG TASIGNA 6 PA QL(120 EA per TYKERB 6 PA QL(660 EA per VOTRIENT 6 PA QL(120 EA per XALKORI 6 PA QL(60 EA per ZELBORAF 6 PA QL(240 EA per Monoclonal Antibodies ARZERRA INJ 100MG/5ML 6 PA AVASTIN INJ 6 B/D 100MG/4ML ERBITUX INJ 6 B/D 100MG/50ML HERCEPTIN 6 B/D KADCYLA 6 PA RITUXAN 6 PA SYLVANT INJ 100MG 6 PA VECTIBIX INJ 6 B/D 100MG/5ML Retinoids PANRETIN 6 PA TARGRETIN 6 tretinoin caps 6 Antiparasitics Anthelmintics ALBENZA 4 BILTRICIDE 3 STROMECTOL 4 Antiprotozoals ALINIA SUSR 4 QL(180 ML per 3 ALINIA TABS 4 QL(6 EA per 3 atovaquone 6 PA atovaquone/proguanil 3 hcl tabs 62.5mg; 25mg atovaquone/proguanil 3 hcl tabs 250mg; 100mg chloroquine phosphate 2 13

24 COARTEM 3 QL(24 EA per 2 DARAPRIM 3 hydroxychloroquine 2 sulfate mefloquine hcl 2 NEBUPENT 3 B/D PENTAM B/D primaquine phosphate 2 quinine sulfate 3 PA tinidazole 3 Pediculicides/Scabicides acticin 2 EURAX 3 lindane 2 malathion 3 permethrin crea 2 spinosad 3 Antiparkinson Agents Anticholinergics benztropine mesylate 2 tabs trihexyphenidyl hcl 2 Antiparkinson Agents, Other entacapone 3 TASMAR 6 Dopamine Agonists APOKYN 6 PA bromocriptine mesylate 2 MIRAPEX ER 4 QL(30 EA per 30 NEUPRO 4 QL(30 EA per 30 pramipexole 2 dihydrochloride ropinirole er tb24 2mg, 4mg, 6mg 3 QL(30 EA per 30 ropinirole er tb24 12mg 3 QL(60 EA per 30 ropinirole er tb24 8mg 3 QL(90 EA per 30 ropinirole hcl 2 Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa 4 carbidopa/levodopa 2 carbidopa/levodopa er 2 carbidopa/levodopa odt carbidopa/levodopa/ent acapone Monoamine Oxidase B (MAO-B) Inhibitors AZILECT 3 QL(30 EA per 30 selegiline hcl caps 3 selegiline hcl tabs 2 Antipsychotics 1st Generation/Typical chlorpromazine hcl inj 5 chlorpromazine hcl tabs 2 compro 2 fluphenazine decanoate 5 fluphenazine hcl conc 2 fluphenazine hcl elix 2 fluphenazine hcl inj 5 fluphenazine hcl tabs 2 haloperidol 2 haloperidol decanoate 5 haloperidol lactate 5 loxapine succinate 2 ORAP 3 perphenazine 2 prochlorperazine 2 prochlorperazine 5 B/D edisylate prochlorperazine 2 maleate thioridazine hcl 2 PA thiothixene 2 trifluoperazine hcl 2 2nd Generation/Atypical ABILIFY DISCMELT 4 PA ABILIFY INJ 5 ABILIFY MAINTENA 6 PA ABILIFY ORAL SOLN 4 ABILIFY TABS 4 FANAPT TABS 1MG, 2MG, 4MG 4 QL(60 EA per 30 FANAPT TABS 10MG, 12MG, 6MG, 8MG 6 QL(60 EA per FANAPT TITRATION PACK 4 QL(8 EA per 30 GEODON INJ 5 INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/0.5ML 5 PA