The information contained in this document is current at the time of printing, is not all encompassing and is subject to change.

Transcription

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2 THE FORMULARY Capital BlueCross (Capital) has created the Formulary to give members access to quality, affordable medications and to provide physicians with a reference list of preferred medications for cost-effective prescribing. The Formulary represents the cornerstone of drug therapy quality assurance and cost containment efforts. The Capital Formulary was developed and is maintained by the Capital BlueCross Pharmacy and Therapeutics (P&T) Committee. This committee, composed of practicing physicians from various medical specialties, practicing pharmacists, and other health care providers, reviews medications in all therapeutic categories based on safety and effectiveness and designates the most effective agent(s) in each class. Formulary development and maintenance is a dynamic process. The P&T Committee will regularly review new and existing medications to ensure the Formulary remains responsive to the needs of our members and providers. A provider may request a reconsideration of tier status for a medication on the Capital Formulary by completing a Formulary Status Reconsiderations Form or by writing a letter indicating the significant advantages of the specific drug product and mailing it to the address below: Pharmacy Services Capital BlueCross P&T Committee P.O. Box Harrisburg, PA The P&T Committee will review drug-specific requests and communicate the results of the review to the requesting provider. Patient-specific requests need to follow the Professional Provider dispute and appeal process. HOW TO USE THE FORMULARY The Formulary lists the most commonly prescribed medications by therapeutic class. Medications listed in lower case print are generic medications, and medications listed in all UPPER CASE PRINT are brand-name medications. For each drug listed, it is indicated whether that drug falls in the eneric category, Brand Preferred category or Brand Non-Preferred category. These categories are defined as follows: eneric: Drugs that contain the same active ingredient(s) as their corresponding brand-name drug and have been approved by the U.S. Food and Drug Administration (FDA) for therapeutic equivalency to their brand-name product. Brand Preferred (): Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found to have therapeutic advantage or overall value over non-preferred brands, factoring safety, efficacy, and cost. Brand Non-Preferred (): Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative generics, preferred brands or over-the-counter medications. The information contained in this document is current at the time of printing, is not all encompassing and is subject to change. The following Selectively Closed Formulary provides access to select generic and select brand drugs. Under a selectively closed formulary, drugs that are not listed are not covered unless approved via the Non-Formulary Consideration Process. The provider or member may initiate a request that coverage be granted when medically necessary. The Non-Formulary Consideration Process may require the trial and failure of two (2) formulary alternatives (if two are available) prior to approval of the non-formulary medication. Approvals will be member- and drug-specific. Each unique non-formulary drug exception must be reviewed and approved separately. As determined by the member s benefit plan, the member may share more of the cost for brand-name drugs, especially those designated as non-preferred brands. Despite being listed in the formulary, please note that some drugs are excluded by benefit design and therefore are not covered (see Benefit Exclusions/Limitations below). Newly-released brand-name drugs are not covered until the P&T Committee reviews the medication s 2

3 safety and efficacy profile. Brand-name drugs that have an available generic equivalent, deemed suitable for substitution by the P&T Committee, are placed in the non-preferred brand category. The Formulary applies only to prescription medications dispensed in outpatient pharmacies. The Formulary does not apply to inpatient medications or to medications obtained from and/or administered by a physician or a home health agency. While Capital BlueCross strives to provide prompt notice of changes and updates, the Formulary, as well as the pharmacy clinical programs (such as prior authorization, quantity level limits, etc.), are subject to change. Please visit our website at for current information. If preferred, contact our pharmacy benefit manager via phone at the number listed below. CVS/caremark (for provider and member inquires) On behalf of Capital BlueCross, CVS/caremark assists in the administration of our prescription drug program. CVS/caremark is an independent pharmacy benefit manager. ENERIC DRU SUBSTITUTION eneric drug substitution is encouraged if the FDA has determined the generic drug is bioequivalent to the brand-name product. The member's financial responsibility for a brand-name medication when a generic equivalent is available will vary as indicated below. For members with mandatory generic substitution, if the physician indicates "Dispense As Written" (DAW) or a member requests a brand-name product when a generic is available, the member is responsible for the cost difference between the brand-name medication and its generic cost (ancillary charge) in addition to the member's applicable brand copayment/coinsurance, up to the original cost of the brand-name medication. For members with restricted generic substitution, if a member requests a brand-name product when a generic is available, the member is responsible for the cost difference between the brand-name medication and its generic cost (ancillary charge) in addition to the member's applicable brand copayment/coinsurance, up to the original cost of the brand-name medication. If the physician indicates DAW, then the member pays the applicable copayment/coinsurance for the brand product and is not required to pay the ancillary charge. Capital encourages generic substitution, when possible and appropriate, to help reduce the member's out-ofpocket expense, plus help contain the overall cost of the prescription drug benefit. NON-PRESCRIPTION MEDICATION (OTC) POLICY* Select Over-The-Counter (OTC) products may be covered as determined by Capital BlueCross or if mandated by the Patient Protection and Affordable Care Act (PPACA). If a prescription drug has an available OTC equivalent, the prescription drug will not be covered. Physicians and pharmacists should guide and refer members to the OTC equivalent product, when appropriate. *As mandated by PPACA, select Over-The-Counter medications may be covered at $0 cost share for members with individual coverage or members of a non-grandfathered group health plan. Please consult your employer for questions relating to grandfathered status. COMPOUND DRU POLICY Prescribed compound drug products are considered Brand Non-Preferred () and require prior authorization. 3

4 BENEFIT EXCLUSIONS / LIMITATIONS* Depending on the member's pharmacy benefit plan, some medications listed may not be covered for individual members based on benefit design purchased by the member or employer group. Examples of contractual exclusions include, but are not limited to: Appetite suppressants (weight loss) Infertility medications Drugs used for cosmetic purposes (wrinkles, hair loss, etc.) Erectile dysfunction medications Smoking cessation products Contraceptives Non self-administered injectable drugs Allergy serums Experimental and investigational (including off-label use) use Some types of vitamins (non-prenatal) Products with OTC equivalents *As mandated by PPACA, select medications in these drug classes may be covered at $0 cost share for members with individual coverage or members of a non-grandfathered group health plan. Please consult your employer for questions relating to grandfathered status. PRIOR AUTHORIZATION PRORAM Pharmacy benefit plans include the prior authorization program. Prior authorization helps encourage appropriate and cost-effective use of certain drugs by allowing coverage only after clinical criteria are met. All clinical criteria are regularly reviewed and approved by the P&T Committee. Drugs requiring prior authorization are subject to change. Please always visit our website ( for the most up-to-date information on drugs requiring prior authorization. Drugs requiring prior authorization are designated in the Formulary by (Prior Authorization Required) after the drug name. These drugs require prior authorization before members can obtain them as a covered benefit. For some drugs, part of the criteria may be automated (Enhanced Prior Authorization or EPA) to encourage first-line agents before second-line agents are utilized. If automated criteria are not met, then prior authorization is required by the physician (or representative) or pharmacist by calling / faxing the request with supporting clinical information to the pharmacy benefit manager at: QUANTITY LIMITATIONS CVS/caremark Prior Authorization Department Telephone: Fax: Some drug products may be subject to quantity limitations based on FDA-recommended doses or adopted clinical guidelines. These drugs are designated in the Formulary by QLL (Quantity Level Limits) after the drug name. The purpose of these maximum quantity limits is to ensure the proper billing of products and encourage the use of therapeutically indicated drug regimens. Quantity limitations are subject to change. Please check your provider manual or the on-line formulary at our website ( for the most up-to-date information on drugs that are part of this program. If a quantity of medication exceeding the limit is required, the physician (or representative) or pharmacist should call / fax the request with supporting clinical information to the pharmacy benefit manager at: CVS/caremark Prior Authorization Department Telephone: Fax:

5 MAINTENANCE DRUS Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or longterm. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease and diabetes. INJECTABLE MEDICATION POLICY Self-administered pharmacy injectable medications are usually covered under the Capital BlueCross prescription drug benefit. Injectable medications that are not routinely self-administered are not covered under the prescription drug benefit, but may be covered under the member s medical benefit. Procurement of select medical injectable medications may be available from AllianceRx Walgreens Prime (by calling (TTY ) or faxing ), Capital BlueCross specialty medical injectable provider, which will assist with distribution and billing of these medications. On behalf of Capital BlueCross, AllianceRx Walgreens Prime, an independent company by Walgreens Specialty Pharmacy Holdings, LLC, assists in dispensing specialty medications for our members. SPECIALTY MEDICATION PROVIDER: OUTPATIENT PRESCRIPTION DRU BENEFIT Specialty oral medications and self-administered injectable medications are available through AllianceRx Walgreens Prime under the Capital BlueCross outpatient prescription drug benefit. Members or providers can call (TTY ) or fax to receive more information on starting service. The following medications are available through AllianceRx Walgreens Prime. (This list is current as of the printing of this formulary but is subject to change.) SPECIALTY DRUS ACTEMRA ADCIRCA ADEMPAS ALECENZA AMPYRA, QLL ARANESP AUBAIO BERINERT BETASERON CAPECITABINE CARBALU CAYSTON CHORIONIC ONADOTROPIN CIMZIA CINRYZE COPAXONE COTELLIC CYCLOSPORINE CYSTADANE CYSTAON DOFETILIDE ELIARD ENBREL EPCLUSA ERIVEDE FERRIPROX FORTEO ENRAF ILENYA ILOTRIF LATOPA HARVONI HUMIRA HYQVIA IBRANCE IMATINIB IMBRUVICA INCRELEX INLYTA INTRON A JADENU KALYDECO KOENATE FS KOVALTRY KUVAN LENVIMA LETAIRIS LEUPROLIDE ACETATE LUPRON DEPOT MYCOPHENOLATE MOFETIL MYCOPHENOLATE SODIUM NEXAVAR NINLARO NORDITROPIN NOVOEIHT NUPLAZID NUWIQ OCTREOTIDE PEASYS POMALYST PRENYL PROCRIT RADIOARDASE REBIF RIBAVIRIN SILDENAFIL 5

6 SIMPONI SIROLIMUS SODIUM PHENYLBUTYRATE SOMATULINE SPRYCEL STELARA STIMATE SYNAREL TACROLIMUS TALTZ TARCEVA TASINA TECFIDERA TOBRAMYCIN INHALATION SOLN TRACLEER TYKERB VELTASSA VENCLEXTA VOSEVI XALKORI XELJANZ XELJANZ XR ZARXIO ZAVESCA ZYDELI ZYTIA LEEND AL EPA M OTC PHC QLL SRx Lower case italicized letters UPPER CASE letters Age Limitations apply. Brand Non-Preferred: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative generics, preferred brands or over-thecounter medications. Brand Preferred: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and found to have therapeutic advantage or overall value over non-preferred brands, factoring safety, efficacy, and cost. Enhanced Prior Authorization applies. eneric: Drugs that contain the same active ingredient(s) as their corresponding brandname drug and have been approved by the Food and Drug Administration (FDA) for therapeutic equivalency to their brand-name product. Maintenance Drugs: M located after the drug class name indicates the drugs in the class are generally considered maintenance drugs. Over-The-Counter medication. Prior Authorization Required. Preventive Health Care: Drugs that have been reviewed by the Capital BlueCross Pharmacy & Therapeutics Committee and are mandated by the Patient Protection and Affordable Care Act (PPACA) to have $0 cost share for members with individual coverage or members of a group health plan that is not "grandfathered" under PPACA. Please consult your employer for questions relating to grandfathered status. Quantity Level Limits apply. available from AllianceRx Walgreens Prime. eneric; every strength or dosage form under the listed generic name may not apply. Indicates brand medication; every strength or dosage form under the listed name may not apply. NOTICE The information provided is intended to establish a guideline to help promote Formulary compliance, but it is in no way to be considered all encompassing. The Formulary is also in no way meant to interfere with the physician's independent medical judgment based on specific needs of the patient. The information contained herein is current at the time of printing and may be subject to change. Members should refer to their Certificate of Coverage for specific terms, conditions, exclusions and limitations relating to coverage. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission All rights reserved. 6

7 This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Capital BlueCross and CVS/caremark do not operate the websites/organizations listed below, nor are they responsible for the availability or reliability of the websites' content. These listings do not imply or constitute an endorsement, sponsorship or recommendation by Capital BlueCross or CVS/caremark. 7

8 Effective 01/01/2018 Drug Name ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS amphetamine-dextroamphetamine cap er 24hr 5 amphetamine-dextroamphetamine cap er 24hr 10 amphetamine-dextroamphetamine cap er 24hr 15 amphetamine-dextroamphetamine cap er 24hr 20 amphetamine-dextroamphetamine cap er 24hr 25 amphetamine-dextroamphetamine cap er 24hr 30 amphetamine-dextroamphetamine tab 5 amphetamine-dextroamphetamine tab 7.5 amphetamine-dextroamphetamine tab 10 amphetamine-dextroamphetamine tab 12.5 amphetamine-dextroamphetamine tab 15 amphetamine-dextroamphetamine tab 20 amphetamine-dextroamphetamine tab 30 armodafinil tab 50 armodafinil tab 150 armodafinil tab 200 armodafinil tab 250 atomoxetine hcl cap 10 (base equiv) atomoxetine hcl cap 18 (base equiv) atomoxetine hcl cap 25 (base equiv) atomoxetine hcl cap 40 (base equiv) atomoxetine hcl cap 60 (base equiv) atomoxetine hcl cap 80 (base equiv) atomoxetine hcl cap 100 (base equiv) dexmethylphenidate hcl cap er 24 hr 5 dexmethylphenidate hcl cap er 24 hr 10 dexmethylphenidate hcl cap er 24 hr 15 8

9 dexmethylphenidate hcl cap er 24 hr 20 dexmethylphenidate hcl cap er 24 hr 25 dexmethylphenidate hcl cap er 24 hr 30 dexmethylphenidate hcl cap er 24 hr 35 dexmethylphenidate hcl cap er 24 hr 40 dexmethylphenidate hcl tab 2.5 dexmethylphenidate hcl tab 5 dexmethylphenidate hcl tab 10 dextroamphetamine sulfate cap er 24hr 5 dextroamphetamine sulfate cap er 24hr 10 dextroamphetamine sulfate cap er 24hr 15 dextroamphetamine sulfate oral solution 5 /5ml dextroamphetamine sulfate tab 2.5 dextroamphetamine sulfate tab 5 dextroamphetamine sulfate tab 7.5 dextroamphetamine sulfate tab 10 dextroamphetamine sulfate tab 15 dextroamphetamine sulfate tab 20 dextroamphetamine sulfate tab 30 guanfacine hcl tab er 24hr 1 (base equiv) guanfacine hcl tab er 24hr 2 (base equiv) guanfacine hcl tab er 24hr 3 (base equiv) guanfacine hcl tab er 24hr 4 (base equiv) methamphetamine hcl tab 5 methylphenidate hcl soln 5 /5ml methylphenidate hcl soln 10 /5ml methylphenidate hcl tab 5 methylphenidate hcl tab 10 methylphenidate hcl tab 20 methylphenidate hcl tab er osmotic release (osm) 18 methylphenidate hcl tab er osmotic release (osm) 27 9

10 methylphenidate hcl tab er osmotic release (osm) 36 methylphenidate hcl tab er osmotic release (osm) 54 modafinil tab 100 modafinil tab 200 VYVANSE CAP 10M VYVANSE CAP 20M VYVANSE CAP 30M VYVANSE CAP 40M VYVANSE CAP 50M VYVANSE CAP 60M VYVANSE CAP 70M AMINOLYCOSIDES neomycin sulfate tab 500 paromomycin sulfate cap 250 tobramycin nebu soln 300 /5ml SRx ANALESICS - ANTI-INFLAMMATORY ACTEMRA INJ 162/0.9 SRx celecoxib cap 50 celecoxib cap 100 celecoxib cap 200 celecoxib cap 400 diclofenac sodium tab delayed release 25 diclofenac sodium tab delayed release 50 diclofenac sodium tab delayed release 75 diclofenac sodium tab er 24hr 100 ENBREL INJ 25/0.5ML SRx ENBREL INJ 25M SRx ENBREL INJ 50M/ML SRx ENBREL MINI INJ 50M/ML SRx ENBREL SRCLK INJ 50M/ML SRx etodolac cap 200 etodolac cap 300 etodolac tab 400 etodolac tab 500 fenoprofen calcium cap 400 fenoprofen calcium tab 600 flurbiprofen tab 50 flurbiprofen tab 100 HUMIRA INJ 10M/0.2 SRx HUMIRA KIT 20M/0.4 SRx 10

11 HUMIRA KIT 40M/0.8 SRx HUMIRA PEDIA INJ CROHNS SRx HUMIRA PEN INJ 40M/0.8 SRx HUMIRA PEN INJ CROHNS SRx HUMIRA PEN INJ PSORIASI SRx ibuprofen tab 400 ibuprofen tab 600 ibuprofen tab 800 indomethacin cap 25 indomethacin cap 50 ketoprofen cap 50 ketoprofen cap 75 ketorolac tromethamine tab 10 leflunomide tab 10 leflunomide tab 20 meclofenamate sodium cap 50 meclofenamate sodium cap 100 meloxicam tab 7.5 meloxicam tab 15 nabumetone tab 500 nabumetone tab 750 naproxen susp 125 /5ml naproxen tab 250 naproxen tab 375 naproxen tab 500 naproxen tab ec 375 naproxen tab ec 500 oxaprozin tab 600 piroxicam cap 10 piroxicam cap 20 PONSTEL CAP 250M RIDAURA CAP 3M SIMPONI INJ 50/0.5ML SRx SIMPONI INJ 100M/ML SRx sulindac tab 150 sulindac tab 200 tolmetin sodium cap 400 tolmetin sodium tab 200 tolmetin sodium tab 600 XELJANZ TAB 5M SRx XELJANZ XR TAB 11M SRx ANALESICS - NONNARCOTIC 11

12 aspirin chew tab 81 PHC OTC, QLL (30 tabs / 30 days); AL, men and women age 50-59, women age required aspirin tab delayed release 81 PHC OTC, QLL (30 tabs / 30 days); AL, men and women age 50-59, women age required butalbital-acetaminophen-caffeine cap butalbital-acetaminophen-caffeine tab butalbital-aspirin-caffeine cap diflunisal tab 500 ANALESICS - OPIOID acetaminophen w/ codeine soln /5ml acetaminophen w/ codeine tab acetaminophen w/ codeine tab acetaminophen w/ codeine tab buprenorphine hcl-naloxone hcl sl tab (base equiv) buprenorphine hcl-naloxone hcl sl tab 8-2 (base equiv) butalbital-acetaminophen-caff w/ cod cap QLL (630 ml / 30 days) QLL (42 tabs / 30 days) QLL (42 tabs / 30 days) QLL (42 tabs / 30 days) QLL (90 tabs / 30 days), QLL (90 tabs / 30 days), butorphanol tartrate nasal soln 10 /ml QLL (5 (2 bottles) / 30 days) codeine sulfate tab 15 QLL (42 tabs / 30 days) codeine sulfate tab 30 QLL (42 tabs / 30 days) codeine sulfate tab 60 QLL (42 tabs / 30 days) fentanyl citrate lozenge on a handle 200 mcg QLL (120 lozenges / 30 days), fentanyl citrate lozenge on a handle 400 mcg QLL (120 lozenges / 30 days), fentanyl citrate lozenge on a handle 600 mcg QLL (120 lozenges / 30 days), fentanyl citrate lozenge on a handle 800 mcg QLL (120 lozenges / 30 days), fentanyl citrate lozenge on a handle 1200 mcg QLL (120 lozenges / 30 days), fentanyl citrate lozenge on a handle 1600 mcg QLL (120 lozenges / 30 days), 12

13 FENTANYL DIS 37.5MC QLL (10 patches per 30 days), FENTANYL DIS 62.5MC QLL (10 patches per 30 days), FENTANYL DIS 87.5MC QLL (10 patches per 30 days), fentanyl td patch 72hr 12 mcg/hr QLL (10 patches per 30 days), fentanyl td patch 72hr 25 mcg/hr QLL (10 patches per 30 days), fentanyl td patch 72hr 50 mcg/hr QLL (10 patches per 30 days), fentanyl td patch 72hr 75 mcg/hr QLL (10 patches per 30 days), fentanyl td patch 72hr 100 mcg/hr QLL (10 patches per 30 days), hydrocodone-acetaminophen soln QLL (630 ml / 30 days) /15ml hydrocodone-acetaminophen tab QLL (84 tabs / 30 days) hydrocodone-acetaminophen tab QLL (56 tabs / 30 days) hydrocodone-acetaminophen tab QLL (42 tabs / 30 days) hydrocodone-acetaminophen tab QLL (42 tabs / 30 days) hydrocodone-ibuprofen tab QLL (35 tabs / 30 days) hydrocodone-ibuprofen tab QLL (35 tabs / 30 days) hydrocodone-ibuprofen tab QLL (35 tabs / 30 days) hydrocodone-ibuprofen tab QLL (35 tabs / 30 days) hydromorphone hcl liqd 1 /ml QLL (140 ml / 30 days) hydromorphone hcl tab 2 QLL (42 tabs / 30 days) hydromorphone hcl tab 4 QLL (42 tabs / 30 days) hydromorphone hcl tab 8 QLL (42 tabs / 30 days) hydromorphone hcl tab er 24hr deter 8 QLL (30 tabs / 30 days), hydromorphone hcl tab er 24hr deter 12 QLL (30 tabs / 30 days), hydromorphone hcl tab er 24hr deter 16 QLL (30 tabs / 30 days), hydromorphone hcl tab er 24hr deter 32 QLL (30 tabs / 30 days), levorphanol tartrate tab 2 QLL (28 tabs / 30 days) meperidine hcl oral soln 50 /5ml QLL (90 ml / 30 days) meperidine hcl tab 50 QLL (18 tabs / 30 days) meperidine hcl tab 100 QLL (18 tabs / 30 days) methadone hcl soln 5 /5ml QLL (300 ml / 30 days), 13

14 methadone hcl soln 10 /5ml QLL (300 ml / 30 days), methadone hcl tab 5 QLL (60 tabs / 30 days), methadone hcl tab 10 QLL (60 tabs / 30 days), morphine sulfate oral soln 10 /5ml QLL (210 ml / 30 days) morphine sulfate oral soln 20 /5ml QLL (158 ml / 30 days) morphine sulfate oral soln 100 /5ml (20 QLL (32 ml / 30 days) /ml) morphine sulfate tab 15 QLL (42 tabs / 30 days) morphine sulfate tab 30 QLL (21 tabs / 30 days) morphine sulfate tab er 15 QLL (60 tabs / 30 days), morphine sulfate tab er 30 QLL (60 tabs / 30 days), morphine sulfate tab er 60 QLL (60 tabs / 30 days), morphine sulfate tab er 100 QLL (60 tabs / 30 days), morphine sulfate tab er 200 QLL (60 tabs / 30 days), NUCYNTA ER TAB 50M QLL (60 tabs / 30 days), NUCYNTA ER TAB 100M QLL (60 tabs / 30 days), NUCYNTA ER TAB 150M QLL (60 tabs / 30 days), NUCYNTA ER TAB 200M QLL (60 tabs / 30 days), NUCYNTA ER TAB 250M QLL (60 tabs / 30 days), NUCYNTA TAB 50M QLL (28 tabs / 30 days) NUCYNTA TAB 75M QLL (21 tabs / 30 days) NUCYNTA TAB 100M QLL (14 tabs / 30 days) oxycodone hcl conc 100 /5ml (20 QLL (30 ml / 30 days) /ml) oxycodone hcl soln 5 /5ml QLL (420 ml / 30 days) oxycodone hcl tab 5 QLL (42 tabs / 30 days) oxycodone hcl tab 10 QLL (42 tabs / 30 days) oxycodone hcl tab 15 QLL (28 tabs / 30 days) oxycodone hcl tab 20 QLL (21 tabs / 30 days) oxycodone hcl tab 30 QLL (14 tabs / 30 days) oxycodone hcl tab er 12hr deter 10 QLL (60 tabs / 30 days), oxycodone hcl tab er 12hr deter 15 QLL (60 tabs / 30 days), 14

15 oxycodone hcl tab er 12hr deter 20 QLL (60 tabs / 30 days), oxycodone hcl tab er 12hr deter 30 QLL (60 tabs / 30 days), oxycodone hcl tab er 12hr deter 40 QLL (60 tabs / 30 days), oxycodone hcl tab er 12hr deter 60 QLL (60 tabs / 30 days), oxycodone hcl tab er 12hr deter 80 QLL (60 tabs / 30 days), oxycodone w/ acetaminophen soln /5ml QLL (140 ml / 30 days) oxycodone w/ acetaminophen tab QLL (84 tabs / 30 days) oxycodone w/ acetaminophen tab QLL (84 tabs / 30 days) oxycodone w/ acetaminophen tab QLL (56 tabs / 30 days) oxycodone w/ acetaminophen tab QLL (42 tabs / 30 days) oxycodone-aspirin tab QLL (84 tabs / 30 days) oxycodone-ibuprofen tab QLL (28 tabs / 30 days) oxymorphone hcl tab er 12hr 5 QLL (60 tabs / 30 days), oxymorphone hcl tab er 12hr 7.5 QLL (60 tabs / 30 days), oxymorphone hcl tab er 12hr 10 QLL (60 tabs / 30 days), oxymorphone hcl tab er 12hr 15 QLL (60 tabs / 30 days), oxymorphone hcl tab er 12hr 20 QLL (60 tabs / 30 days), oxymorphone hcl tab er 12hr 30 QLL (60 tabs / 30 days), oxymorphone hcl tab er 12hr 40 QLL (60 tabs / 30 days), SUBOXONE MIS 2-0.5M QLL (90 films / 30 days), SUBOXONE MIS 4-1M QLL (90 films / 30 days), SUBOXONE MIS 8-2M QLL (90 films / 30 days), SUBOXONE MIS 12-3M QLL (60 films / 30 days), tramadol hcl tab 50 QLL (56 tabs / 30 days) tramadol hcl tab er 24hr 100 QLL (30 tabs / 30 days), 15

16 tramadol hcl tab er 24hr 200 QLL (30 tabs / 30 days), tramadol hcl tab er 24hr 300 QLL (30 tabs / 30 days), tramadol hcl tab er 24hr biphasic release 100 QLL (30 tabs / 30 days), tramadol hcl tab er 24hr biphasic release 200 QLL (30 tabs / 30 days), tramadol hcl tab er 24hr biphasic release 300 QLL (30 tabs / 30 days), XARTEMIS XR TAB QLL (28 tabs / 30 days), ANDROENS-ANABOLIC ANADROL-50 TAB 50M danazol cap 50 danazol cap 100 danazol cap 200 methyltestosterone cap 10 oxandrolone tab 2.5 oxandrolone tab 10 testosterone cypionate im inj in oil 100 /ml testosterone cypionate im inj in oil 200 /ml testosterone enanthate im inj in oil 200 /ml testosterone td gel 12.5 /act (1%) testosterone td gel 25 /2.5gm (1%) testosterone td gel 50 /5gm (1%) ANORECTAL AENTS hydrocortisone enema 100 /60ml hydrocortisone rectal cream 1% hydrocortisone rectal cream 2.5% RECTIV OIN 0.4% ANTHELMINTICS ALBENZA TAB 200M ivermectin tab 3 ANTI-INFECTIVE AENTS - MISC. ALINIA SUS 100/5ML ALINIA TAB 500M atovaquone susp 750 /5ml CAYSTON INH 75M SRx clindamycin hcl cap 75 clindamycin hcl cap 150 clindamycin hcl cap

17 clindamycin palmitate hcl for soln 75 /5ml (base equiv) dapsone tab 25 dapsone tab 100 linezolid for susp 100 /5ml linezolid tab 600 metronidazole tab 250 metronidazole tab 500 NEBUPENT INH 300M sulfamethoxazole-trimethoprim susp /5ml sulfamethoxazole-trimethoprim tab sulfamethoxazole-trimethoprim tab trimethoprim tab 100 vancomycin hcl cap 125 vancomycin hcl cap 250 XIFAXAN TAB 200M XIFAXAN TAB 550M ANTIANINAL AENTS isosorbide dinitrate tab 5 isosorbide dinitrate tab 10 isosorbide dinitrate tab 20 isosorbide dinitrate tab 30 isosorbide dinitrate tab er 40 isosorbide mononitrate tab 10 isosorbide mononitrate tab 20 isosorbide mononitrate tab er 24hr 30 isosorbide mononitrate tab er 24hr 60 isosorbide mononitrate tab er 24hr 120 NITRO-BID OIN 2% nitroglycerin cap er 2.5 nitroglycerin cap er 6.5 nitroglycerin cap er 9 nitroglycerin sl tab 0.3 nitroglycerin sl tab 0.4 nitroglycerin sl tab 0.6 nitroglycerin td patch 24hr 0.1 /hr nitroglycerin td patch 24hr 0.2 /hr nitroglycerin td patch 24hr 0.4 /hr nitroglycerin td patch 24hr 0.6 /hr ANTIANXIETY AENTS ALPRAZOLAM CON 1 M/ML alprazolam tab

18 alprazolam tab 0.25 alprazolam tab 1 alprazolam tab 2 buspirone hcl tab 5 buspirone hcl tab 7.5 buspirone hcl tab 10 buspirone hcl tab 15 buspirone hcl tab 30 hydroxyzine pamoate cap 25 hydroxyzine pamoate cap 50 lorazepam conc 2 /ml lorazepam tab 0.5 lorazepam tab 1 lorazepam tab 2 meprobamate tab 200 meprobamate tab 400 ANTIARRHYTHMICS amiodarone hcl tab 100 amiodarone hcl tab 200 amiodarone hcl tab 400 disopyramide phosphate cap 100 disopyramide phosphate cap 150 dofetilide cap 125 mcg (0.125 ) SRx dofetilide cap 250 mcg (0.25 ) SRx dofetilide cap 500 mcg (0.5 ) SRx flecainide acetate tab 50 flecainide acetate tab 100 flecainide acetate tab 150 mexiletine hcl cap 150 mexiletine hcl cap 200 mexiletine hcl cap 250 MULTAQ TAB 400M propafenone hcl cap er 12hr 225 propafenone hcl cap er 12hr 325 propafenone hcl cap er 12hr 425 propafenone hcl tab 150 propafenone hcl tab 225 propafenone hcl tab 300 quinidine gluconate tab er 324 quinidine sulfate tab 200 quinidine sulfate tab 300 quinidine sulfate tab er 300 ANTIASTHMATIC AND BRONCHODILATOR AENTS 18

19 ADVAIR DISKU AER 100/50 QLL (1 inhaler per 30 days) ADVAIR DISKU AER 250/50 QLL (1 inhaler per 30 days) ADVAIR DISKU AER 500/50 QLL (1 inhaler per 30 days) ADVAIR HFA AER 45/21 QLL (1 inhaler per 30 days) ADVAIR HFA AER 115/21 QLL (1 inhaler per 30 days) ADVAIR HFA AER 230/21 QLL (1 inhaler per 30 days) albuterol sulfate soln nebu 0.5% (5 /ml) albuterol sulfate soln nebu 0.63 /3ml (base equiv) albuterol sulfate soln nebu 0.083% (2.5 /3ml) albuterol sulfate soln nebu 1.25 /3ml (base equiv) albuterol sulfate syrup 2 /5ml albuterol sulfate tab 2 albuterol sulfate tab 4 albuterol sulfate tab er 12hr 4 albuterol sulfate tab er 12hr 8 ARCAPTA CAP 75MC ASMANEX 7 AER 110MC QLL (1 inhaler per 30 days) ASMANEX 120 AER 220MC QLL (1 inhaler per 30 days) ASMANEX HFA AER 100 MC QLL (1 inhaler per 30 days) ASMANEX HFA AER 200 MC QLL (1 inhaler per 30 days) BREO ELLIPTA INH QLL (1 inhaler per 30 days) BREO ELLIPTA INH QLL (1 inhaler per 30 days) BROVANA NEB 15MC budesonide inhalation susp 0.5 /2ml budesonide inhalation susp 0.25 /2ml budesonide inhalation susp 1 /2ml cromolyn sodium soln nebu 20 /2ml DALIRESP TAB 500MC FLOVENT DISK AER 50MC QLL (1 inhaler per 30 days) FLOVENT DISK AER 100MC QLL (1 inhaler per 30 days) 19

20 FLOVENT DISK AER 250MC QLL (1 inhaler per 30 days) FLOVENT HFA AER 44MC QLL (1 inhaler per 30 days) FLOVENT HFA AER 110MC QLL (1 inhaler per 30 days) FLOVENT HFA AER 220MC QLL (1 inhaler per 30 days) FORADIL CAP AEROLIZE ipratropium bromide inhal soln 0.02% ipratropium-albuterol nebu soln (3) /3ml levalbuterol hcl soln nebu 0.31 /3ml (base equiv) levalbuterol hcl soln nebu 0.63 /3ml (base equiv) levalbuterol hcl soln nebu 1.25 /3ml (base equiv) levalbuterol hcl soln nebu conc 1.25 /0.5ml (base equiv) levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) metaproterenol sulfate syrup 10 /5ml metaproterenol sulfate tab 10 metaproterenol sulfate tab 20 montelukast sodium chew tab 4 (base equiv) montelukast sodium chew tab 5 (base equiv) montelukast sodium tab 10 (base equiv) PROAIR HFA AER PROAIR RESPI AER QVAR AER 40MC QLL (1 inhaler per 30 days) QVAR AER 80MC QLL (1 inhaler per 30 days) SEREVENT DIS AER 50MC SPIRIVA AER 1.25MC SPIRIVA CAP HANDIHLR SPIRIVA SPR 2.5MC terbutaline sulfate tab 2.5 terbutaline sulfate tab 5 theophylline soln 80 /15ml theophylline tab er 12hr 100 theophylline tab er 12hr

21 theophylline tab er 12hr 300 theophylline tab er 12hr 450 theophylline tab er 24hr 400 theophylline tab er 24hr 600 TUDORZA PRES AER 400/ACT zafirlukast tab 10 zafirlukast tab 20 ZYFLO CR TAB 600M ANTICOAULANTS ELIQUIS TAB 2.5M ELIQUIS TAB 5M enoxaparin sodium inj 30 /0.3ml enoxaparin sodium inj 40 /0.4ml enoxaparin sodium inj 60 /0.6ml enoxaparin sodium inj 80 /0.8ml enoxaparin sodium inj 100 /ml enoxaparin sodium inj 120 /0.8ml enoxaparin sodium inj 150 /ml fondaparinux sodium subcutaneous inj 2.5 /0.5ml fondaparinux sodium subcutaneous inj 5 /0.4ml fondaparinux sodium subcutaneous inj 7.5 /0.6ml fondaparinux sodium subcutaneous inj 10 /0.8ml heparin sodium (porcine) lock flush iv soln 10 unit/ml heparin sodium (porcine) lock flush iv soln 100 unit/ml warfarin sodium tab 1 warfarin sodium tab 2 warfarin sodium tab 2.5 warfarin sodium tab 3 warfarin sodium tab 4 warfarin sodium tab 5 warfarin sodium tab 6 warfarin sodium tab 7.5 warfarin sodium tab 10 XARELTO STAR TAB 15/20M XARELTO TAB 10M XARELTO TAB 15M XARELTO TAB 20M ANTICONVULSANTS APTIOM TAB 200M 21

22 APTIOM TAB 400M APTIOM TAB 600M APTIOM TAB 800M BANZEL SUS 40M/ML BANZEL TAB 200M BANZEL TAB 400M carbamazepine chew tab 100 carbamazepine susp 100 /5ml carbamazepine tab 200 CELONTIN CAP 300M diazepam rectal gel delivery system 2.5 diazepam rectal gel delivery system 10 diazepam rectal gel delivery system 20 DILANTIN CAP 30M divalproex sodium cap delayed release sprinkle 125 divalproex sodium tab delayed release 125 divalproex sodium tab delayed release 250 divalproex sodium tab delayed release 500 ethosuximide cap 250 ethosuximide soln 250 /5ml felbamate susp 600 /5ml felbamate tab 400 felbamate tab 600 gabapentin cap 100 gabapentin cap 300 gabapentin cap 400 gabapentin oral soln 250 /5ml lamotrigine tab 25 lamotrigine tab 100 lamotrigine tab 150 lamotrigine tab 200 lamotrigine tab chewable dispersible 5 lamotrigine tab chewable dispersible 25 levetiracetam oral soln 100 /ml levetiracetam tab 250 levetiracetam tab 500 levetiracetam tab 750 levetiracetam tab 1000 levetiracetam tab er 24hr 500 levetiracetam tab er 24hr

23 LYRICA CAP 25M LYRICA CAP 50M LYRICA CAP 75M LYRICA CAP 100M LYRICA CAP 150M LYRICA CAP 200M LYRICA CAP 225M LYRICA CAP 300M LYRICA SOL 20M/ML oxcarbazepine susp 300 /5ml (60 /ml) oxcarbazepine tab 150 oxcarbazepine tab 300 oxcarbazepine tab 600 PEANONE TAB 250M phenytoin chew tab 50 phenytoin sodium extended cap 100 phenytoin susp 125 /5ml POTIA TAB 50M POTIA TAB 200M POTIA TAB 300M POTIA TAB 400M primidone tab 50 primidone tab 250 tiagabine hcl tab 2 tiagabine hcl tab 4 topiramate sprinkle cap 15 topiramate sprinkle cap 25 topiramate tab 25 topiramate tab 50 topiramate tab 100 topiramate tab 200 valproate sodium oral soln 250 /5ml (base equiv) VIMPAT SOL 10M/ML VIMPAT TAB 50M VIMPAT TAB 100M VIMPAT TAB 150M VIMPAT TAB 200M zonisamide cap 25 zonisamide cap 50 zonisamide cap 100 ANTIDEPRESSANTS amitriptyline hcl tab 10 amitriptyline hcl tab 25 23

24 amitriptyline hcl tab 50 amitriptyline hcl tab 75 amitriptyline hcl tab 100 amitriptyline hcl tab 150 amoxapine tab 25 amoxapine tab 50 amoxapine tab 100 amoxapine tab 150 bupropion hcl tab 75 bupropion hcl tab 100 bupropion hcl tab er 12hr 100 bupropion hcl tab er 12hr 150 bupropion hcl tab er 12hr 200 bupropion hcl tab er 24hr 150 bupropion hcl tab er 24hr 300 citalopram hydrobromide oral soln 10 /5ml citalopram hydrobromide tab 10 (base QLL (30 tabs / 30 days) equiv) citalopram hydrobromide tab 20 (base QLL (60 tabs / 30 days) equiv) citalopram hydrobromide tab 40 (base QLL (30 tabs / 30 days) equiv) clomipramine hcl cap 25 clomipramine hcl cap 50 clomipramine hcl cap 75 desipramine hcl tab 10 desipramine hcl tab 25 desipramine hcl tab 50 desipramine hcl tab 75 desipramine hcl tab 100 desipramine hcl tab 150 desvenlafaxine succinate tab er 24hr 25 QLL (30 tabs / 30 days) (base equiv) desvenlafaxine succinate tab er 24hr 50 QLL (30 tabs / 30 days) (base equiv) desvenlafaxine succinate tab er 24hr 100 QLL (30 tabs / 30 days) (base equiv) desvenlafaxine tab er 24hr 100 QLL (30 tabs / 30 days) doxepin hcl cap 10 doxepin hcl cap 25 doxepin hcl cap 50 doxepin hcl cap 75 doxepin hcl cap 100 doxepin hcl cap

25 doxepin hcl conc 10 /ml duloxetine hcl enteric coated pellets cap 20 (base eq) duloxetine hcl enteric coated pellets cap 30 (base eq) duloxetine hcl enteric coated pellets cap 60 (base eq) EMSAM DIS 6M/24HR EMSAM DIS 9M/24HR EMSAM DIS 12M/24H escitalopram oxalate soln 5 /5ml (base QLL (720 ml's / 30 days) equiv) escitalopram oxalate tab 5 (base QLL (30 tabs / 30 days) equiv) escitalopram oxalate tab 10 (base QLL (30 tabs / 30 days) equiv) escitalopram oxalate tab 20 (base QLL (30 tabs / 30 days) equiv) fluoxetine hcl cap 10 QLL (90 caps / 30 days) fluoxetine hcl cap 20 QLL (90 caps / 30 days) fluoxetine hcl cap 40 fluoxetine hcl solution 20 /5ml fluvoxamine maleate tab 25 fluvoxamine maleate tab 50 fluvoxamine maleate tab 100 imipramine hcl tab 10 imipramine hcl tab 25 imipramine hcl tab 50 maprotiline hcl tab 25 maprotiline hcl tab 50 maprotiline hcl tab 75 MARPLAN TAB 10M mirtazapine tab 7.5 mirtazapine tab 15 mirtazapine tab 30 mirtazapine tab 45 nefazodone hcl tab 50 nefazodone hcl tab 100 nefazodone hcl tab 150 nefazodone hcl tab 200 nefazodone hcl tab 250 nortriptyline hcl cap 10 nortriptyline hcl cap 25 nortriptyline hcl cap 50 nortriptyline hcl cap 75 25

26 nortriptyline hcl soln 10 /5ml paroxetine hcl tab 10 QLL (60 tabs / 30 days) paroxetine hcl tab 20 QLL (60 tabs / 30 days) paroxetine hcl tab 30 QLL (60 tabs / 30 days) paroxetine hcl tab 40 QLL (30 tabs / 30 days) phenelzine sulfate tab 15 protriptyline hcl tab 5 protriptyline hcl tab 10 sertraline hcl oral conc 20 /ml sertraline hcl tab 25 sertraline hcl tab 50 sertraline hcl tab 100 tranylcypromine sulfate tab 10 trazodone hcl tab 50 trazodone hcl tab 100 trazodone hcl tab 150 trazodone hcl tab 300 trimipramine maleate cap 25 trimipramine maleate cap 50 trimipramine maleate cap 100 venlafaxine hcl cap er 24hr 37.5 (base QLL (90 caps / 30 days) equivalent) venlafaxine hcl cap er 24hr 75 (base QLL (90 caps / 30 days) equivalent) venlafaxine hcl cap er 24hr 150 (base QLL (60 caps / 30 days) equivalent) venlafaxine hcl tab 25 venlafaxine hcl tab 37.5 venlafaxine hcl tab 50 venlafaxine hcl tab 75 venlafaxine hcl tab 100 VIIBRYD TAB 10M VIIBRYD TAB 20M VIIBRYD TAB 40M ANTIDIABETICS acarbose tab 25 acarbose tab 50 acarbose tab 100 alogliptin benzoate tab 6.25 (base equiv) alogliptin benzoate tab 12.5 (base equiv) alogliptin benzoate tab 25 (base equiv) alogliptin-metformin hcl tab alogliptin-metformin hcl tab

27 alogliptin-pioglitazone tab alogliptin-pioglitazone tab alogliptin-pioglitazone tab alogliptin-pioglitazone tab alogliptin-pioglitazone tab alogliptin-pioglitazone tab AVANDIA TAB 2M AVANDIA TAB 4M AVANDIA TAB 8M BD LUCOSE CHW 5M OTC chlorpropamide tab 100 chlorpropamide tab 250 CYCLOSET TAB 0.8M FARXIA TAB 5M FARXIA TAB 10M glimepiride tab 1 glimepiride tab 2 glimepiride tab 4 glipizide tab 5 glipizide tab 10 glipizide tab er 24hr 2.5 glipizide tab er 24hr 5 glipizide tab er 24hr 10 glipizide-metformin hcl tab glipizide-metformin hcl tab glipizide-metformin hcl tab LUCAON KIT 1M LUCOSE BITS CHW 1M OTC LUCOSE CHW 4M OTC glucose gel 40% OTC glucose oral liquid 15 gm/59ml OTC glyburide micronized tab 1.5 glyburide micronized tab 3 glyburide micronized tab 6 glyburide tab 1.25 glyburide tab 2.5 glyburide tab 5 glyburide-metformin tab glyburide-metformin tab glyburide-metformin tab HUMALO INJ 100/ML HUMALO KWIK INJ 100/ML HUMALO KWIK INJ 200/ML HUMALO MIX INJ 50/50 HUMALO MIX INJ 50/50KWP 27

28 HUMALO MIX INJ 75/25KWP HUMALO MIX SUS 75/25 HUMULIN R INJ U-500 JANUVIA TAB 25M JANUVIA TAB 50M JANUVIA TAB 100M JARDIANCE TAB 10M JARDIANCE TAB 25M LANTUS INJ 100/ML LANTUS INJ SOLOSTAR LEVEMIR INJ LEVEMIR INJ FLEXTOUC metformin hcl tab 500 metformin hcl tab 850 metformin hcl tab 1000 metformin hcl tab er 24hr 500 metformin hcl tab er 24hr 750 miglitol tab 25 miglitol tab 50 miglitol tab 100 nateglinide tab 60 nateglinide tab 120 NOVOLIN INJ 70/30 OTC NOVOLIN N INJ U-100 OTC NOVOLIN R INJ U-100 OTC NOVOLO INJ 100/ML NOVOLO INJ FLEXPEN NOVOLO INJ PENFILL NOVOLO MIX INJ 70/30 NOVOLO MIX INJ FLEXPEN pioglitazone hcl tab 15 (base equiv) pioglitazone hcl tab 30 (base equiv) pioglitazone hcl tab 45 (base equiv) pioglitazone hcl-glimepiride tab 30-2 pioglitazone hcl-glimepiride tab 30-4 pioglitazone hcl-metformin hcl tab pioglitazone hcl-metformin hcl tab repaglinide tab 0.5 repaglinide tab 1 repaglinide tab 2 tolazamide tab 250 tolazamide tab 500 tolbutamide tab

29 TOUJEO SOLO INJ 300IU/ML TRADJENTA TAB 5M TRESIBA FLEX INJ 100UNIT TRESIBA FLEX INJ 200UNIT TRULICITY INJ 0.75/0.5 TRULICITY INJ 1.5/0.5 VICTOZA INJ 18M/3ML ANTIDIARRHEALS diphenoxylate w/ atropine liq /5ml diphenoxylate w/ atropine tab ANTIDOTES AND SPECIFIC ANTAONISTS CHEMET CAP 100M FERRIPROX TAB 500M SRx JADENU TAB 90M SRx JADENU TAB 180M SRx JADENU TAB 360M SRx naloxone hcl soln prefilled syringe 2 /2ml naltrexone hcl tab 50 NARCAN SPR RADIOARDASE CAP 0.5M SRx ANTIEMETICS AKYNZEO CAP QLL (1 cap / 15 days), aprepitant capsule 40 QLL (8 caps per prescription) aprepitant capsule 80 QLL (8 caps per prescription) aprepitant capsule 125 QLL (4 caps per prescription) CESAMET CAP 1M QLL (6 caps per prescription), dronabinol cap 2.5 dronabinol cap 5 dronabinol cap 10 granisetron hcl tab 1 QLL (8 tabs per prescription) ondansetron hcl oral soln 4 /5ml QLL (250 ml's per prescription) ondansetron orally disintegrating tab 4 QLL (24 tabs per prescription) ondansetron orally disintegrating tab 8 QLL (24 tabs per prescription) SCOPOLAMINE DIS 1M/3DAY 29

30 TRANSDERM-SC DIS 1.5M trimethobenzamide hcl cap 300 ANTIFUNALS fluconazole for susp 10 /ml fluconazole for susp 40 /ml fluconazole tab 50 fluconazole tab 100 fluconazole tab 150 fluconazole tab 200 flucytosine cap 250 flucytosine cap 500 griseofulvin microsize susp 125 /5ml griseofulvin microsize tab 500 itraconazole cap 100 *nystatin oral powder* nystatin tab unit terbinafine hcl tab 250 voriconazole tab 50 voriconazole tab 200 ANTIHISTAMINES carbinoxamine maleate soln 4 /5ml carbinoxamine maleate tab 4 clemastine fumarate syrup 0.67 /5ml (0.5 /5ml base eq) clemastine fumarate tab 2.68 cyproheptadine hcl syrup 2 /5ml cyproheptadine hcl tab 4 promethazine hcl suppos 12.5 promethazine hcl suppos 25 promethazine hcl suppos 50 promethazine hcl syrup 6.25 /5ml promethazine hcl tab 12.5 promethazine hcl tab 25 promethazine hcl tab 50 ANTIHYPERLIPIDEMICS atorvastatin calcium tab 10 (base QLL (30 tabs / 30 days) equivalent) atorvastatin calcium tab 20 (base QLL (30 tabs / 30 days) equivalent) atorvastatin calcium tab 40 (base QLL (30 tabs / 30 days) equivalent) atorvastatin calcium tab 80 (base QLL (30 tabs / 30 days) equivalent) cholestyramine light powder 4 gm/dose cholestyramine light powder packets 4 gm 30

31 cholestyramine powder 4 gm/dose cholestyramine powder packets 4 gm colestipol hcl granule packets 5 gm colestipol hcl granules 5 gm colestipol hcl tab 1 gm ezetimibe tab 10 fenofibrate micronized cap 67 fenofibrate micronized cap 134 fenofibrate micronized cap 200 fenofibrate tab 54 fenofibrate tab 160 fluvastatin sodium cap 20 fluvastatin sodium cap 40 gemfibrozil tab 600 LIVALO TAB 1M QLL (30 tabs / 30 days), LIVALO TAB 2M QLL (30 tabs / 30 days), LIVALO TAB 4M QLL (30 tabs / 30 days), lovastatin tab 10 QLL (30 tabs / 30 days) lovastatin tab 20 QLL (30 tabs / 30 days) lovastatin tab 40 QLL (60 tabs / 30 days) niacin tab er 500 (antihyperlipidemic) niacin tab er 1000 (antihyperlipidemic) omega-3-acid ethyl esters cap 1 gm pravastatin sodium tab 10 QLL (30 tabs / 30 days) pravastatin sodium tab 20 QLL (30 tabs / 30 days) pravastatin sodium tab 40 QLL (30 tabs / 30 days) pravastatin sodium tab 80 QLL (30 tabs / 30 days) rosuvastatin calcium tab 5 QLL (30 tablets per 30 days) rosuvastatin calcium tab 10 QLL (30 tablets per 30 days) rosuvastatin calcium tab 20 QLL (30 tablets per 30 days) rosuvastatin calcium tab 40 QLL (30 tablets per 30 days) simvastatin tab 5 QLL (30 tabs / 30 days) simvastatin tab 10 QLL (30 tabs / 30 days) simvastatin tab 20 QLL (30 tabs / 30 days) simvastatin tab 40 QLL (30 tabs / 30 days) simvastatin tab 80 QLL (30 tabs / 30 days) WELCHOL PAK 3.75M WELCHOL TAB 625M 31

32 ANTIHYPERTENSIVES amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap 5-10 amlodipine besylate-benazepril hcl cap 5-20 amlodipine besylate-benazepril hcl cap 5-40 amlodipine besylate-benazepril hcl cap amlodipine besylate-benazepril hcl cap amlodipine besylate-olmesartan medoxomil tab 5-20 amlodipine besylate-olmesartan medoxomil tab 5-40 amlodipine besylate-olmesartan medoxomil tab amlodipine besylate-olmesartan medoxomil tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab amlodipine besylate-valsartan tab atenolol & chlorthalidone tab atenolol & chlorthalidone tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril & hydrochlorothiazide tab benazepril hcl tab 5 benazepril hcl tab 10 benazepril hcl tab 20 benazepril hcl tab 40 bisoprolol & hydrochlorothiazide tab bisoprolol & hydrochlorothiazide tab

33 bisoprolol & hydrochlorothiazide tab BYVALSON TAB 5-80M candesartan cilexetil tab 4 candesartan cilexetil tab 8 candesartan cilexetil tab 16 candesartan cilexetil tab 32 candesartan cilexetil-hydrochlorothiazide tab candesartan cilexetil-hydrochlorothiazide tab candesartan cilexetil-hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril & hydrochlorothiazide tab captopril tab 12.5 captopril tab 25 captopril tab 50 captopril tab 100 clonidine hcl tab 0.1 clonidine hcl tab 0.2 clonidine hcl tab 0.3 doxazosin mesylate tab 1 doxazosin mesylate tab 2 doxazosin mesylate tab 4 doxazosin mesylate tab 8 EDARBI TAB 40M EDARBI TAB 80M enalapril maleate & hydrochlorothiazide tab enalapril maleate & hydrochlorothiazide tab enalapril maleate tab 2.5 enalapril maleate tab 5 enalapril maleate tab 10 enalapril maleate tab 20 EPANED SOL 1M/ML eplerenone tab 25 eplerenone tab 50 eprosartan mesylate tab

34 fosinopril sodium & hydrochlorothiazide tab fosinopril sodium & hydrochlorothiazide tab fosinopril sodium tab 10 fosinopril sodium tab 20 fosinopril sodium tab 40 guanfacine hcl tab 1 guanfacine hcl tab 2 hydralazine hcl tab 10 hydralazine hcl tab 25 hydralazine hcl tab 50 hydralazine hcl tab 100 irbesartan tab 75 irbesartan tab 150 irbesartan tab 300 irbesartan-hydrochlorothiazide tab irbesartan-hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril & hydrochlorothiazide tab lisinopril tab 2.5 lisinopril tab 5 lisinopril tab 10 lisinopril tab 20 lisinopril tab 30 lisinopril tab 40 losartan potassium & hydrochlorothiazide tab losartan potassium & hydrochlorothiazide tab losartan potassium & hydrochlorothiazide tab losartan potassium tab 25 losartan potassium tab 50 losartan potassium tab 100 methyldopa tab 250 methyldopa tab 500 metoprolol & hydrochlorothiazide tab

35 metoprolol & hydrochlorothiazide tab metoprolol & hydrochlorothiazide tab minoxidil tab 2.5 minoxidil tab 10 moexipril hcl tab 7.5 moexipril hcl tab 15 moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab moexipril-hydrochlorothiazide tab olmesartan medoxomil tab 5 olmesartan medoxomil tab 20 olmesartan medoxomil tab 40 olmesartan medoxomil-hydrochlorothiazide tab olmesartan medoxomil-hydrochlorothiazide tab olmesartan medoxomil-hydrochlorothiazide tab perindopril erbumine tab 2 perindopril erbumine tab 4 perindopril erbumine tab 8 phenoxybenzamine hcl cap 10 prazosin hcl cap 1 prazosin hcl cap 2 prazosin hcl cap 5 propranolol & hydrochlorothiazide tab propranolol & hydrochlorothiazide tab quinapril hcl tab 5 quinapril hcl tab 10 quinapril hcl tab 20 quinapril hcl tab 40 quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab quinapril-hydrochlorothiazide tab ramipril cap 1.25 ramipril cap 2.5 ramipril cap 5 35

36 ramipril cap 10 reserpine tab 0.1 reserpine tab 0.25 TEKTURNA TAB 150M TEKTURNA TAB 300M telmisartan tab 20 telmisartan tab 40 telmisartan tab 80 telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab telmisartan-hydrochlorothiazide tab terazosin hcl cap 1 terazosin hcl cap 2 terazosin hcl cap 5 terazosin hcl cap 10 trandolapril tab 1 trandolapril tab 2 trandolapril tab 4 valsartan tab 40 valsartan tab 80 valsartan tab 160 valsartan tab 320 valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab valsartan-hydrochlorothiazide tab ANTIMALARIALS atovaquone-proguanil hcl tab atovaquone-proguanil hcl tab chloroquine phosphate tab 250 chloroquine phosphate tab 500 COARTEM TAB M DARAPRIM TAB 25M hydroxychloroquine sulfate tab 200 mefloquine hcl tab 250 PRIMAQUINE TAB 26.3M 36

37 quinine sulfate cap 324 ANTIMYASTHENIC/CHOLINERIC AENTS UANIDINE TAB 125M pyridostigmine bromide tab 60 ANTIMYCOBACTERIAL AENTS cycloserine cap 250 ethambutol hcl tab 100 ethambutol hcl tab 400 isoniazid syrup 50 /5ml isoniazid tab 100 isoniazid tab 300 PRIFTIN TAB 150M pyrazinamide tab 500 rifabutin cap 150 RIFAMATE CAP rifampin cap 150 rifampin cap 300 RIFATER TAB TRECATOR TAB 250M ANTINEOPLASTIC - HORMONAL AND RELATED AENTS ZYTIA TAB 500M SRx ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALECENSA CAP 150M SRx anastrozole tab 1 bicalutamide tab 50 capecitabine tab 150 SRx capecitabine tab 500 SRx COTELLIC TAB 20M SRx CYCLOPHOSPH CAP 25M CYCLOPHOSPH CAP 50M ELIARD INJ 7.5M SRx ELIARD INJ 22.5M SRx ELIARD INJ 30M SRx ELIARD INJ 45M SRx EMCYT CAP 140M ERIVEDE CAP 150M SRx exemestane tab 25 FARESTON TAB 60M flutamide cap 125 ILOTRIF TAB 20M SRx ILOTRIF TAB 30M SRx ILOTRIF TAB 40M SRx hydroxyurea cap 500 IBRANCE CAP 75M SRx 37

38 IBRANCE CAP 100M SRx IBRANCE CAP 125M SRx imatinib mesylate tab 100 (base SRx equivalent) imatinib mesylate tab 400 (base SRx equivalent) IMBRUVICA CAP 140M SRx INTRON A INJ 10MU SRx INTRON A INJ 18MU SRx INTRON A INJ 25MU SRx INTRON A INJ 50MU SRx LENVIMA CAP 8 M SRx LENVIMA CAP 10 M SRx LENVIMA CAP 14 M SRx LENVIMA CAP 18 M SRx LENVIMA CAP 20 M SRx LENVIMA CAP 24 M SRx letrozole tab 2.5 leucovorin calcium tab 5 leucovorin calcium tab 10 leucovorin calcium tab 15 leucovorin calcium tab 25 LEUKERAN TAB 2M leuprolide acetate inj kit 5 /ml SRx LUPRON DEPOT INJ 3.75M SRx LUPRON DEPOT INJ 7.5M SRx LUPRON DEPOT INJ 11.25M SRx LUPRON DEPOT INJ 22.5M SRx LUPRON DEPOT INJ 30M SRx LUPRON DEPOT INJ 45M SRx LYSODREN TAB 500M megestrol acetate susp 40 /ml megestrol acetate tab 20 megestrol acetate tab 40 mercaptopurine tab 50 methotrexate sodium inj 50 /2ml (25 /ml) methotrexate sodium inj pf 50 /2ml (25 /ml) methotrexate sodium tab 2.5 (base equiv) NEXAVAR TAB 200M SRx nilutamide tab 150 NINLARO CAP 2.3M SRx NINLARO CAP 3M SRx 38