comprehensive formulary (list of covered drugs) January 1st - December 31st leon cares medicare

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1 comprehensive formulary (list of covered drugs) leon cares 2019 medicare January 1st - December 31st PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Formulary ID , Version 8 This formulary was updated on February 1, For more recent information or other questions, please contact Leon Medical Centers Health Plans Member Services, at or toll-free or, for TTY users 711. Hours are 8:00 am - 8:00 pm, seven days a week, October 1st March 31st and 8:00 am - 8:00 pm, Monday Friday from April 1st September 30th. Messaging service used weekends, after hours, and on federal holidays. You can also visit Leon Medical Centers Health Plans is an HMO plan with a Medicare contract. Enrollment in Leon Medical Centers Health Plans depends on contract renewal. INT_19_66609_C Approved H5410_18_56769_Final_1 Accepted

2 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 Leon Medical Centers Health Plans. When it refers to plan or our plan, it means Leon Medical Centers Health Plans Leon Cares. This document includes a list of the drugs (formulary) for our plan which is current as of 03/01/2019. 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, 2020, and from time to time during the year. What is the Leon Medical Centers Health Plans Leon Cares Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Leon Medical Centers Health Plans Leon Cares 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 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Leon Medical Centers Health Plans Leon Cares Formulary? s removed from the market. 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify 1

3 affected members of the change at least 30 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 30 day supply of the drug. The enclosed formulary is current as of 03/01/2019. To get updated information about the drugs covered by our, please contact us. Our contact information appears on the front and back cover pages. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. Formularies located on our website are reviewed and updated on a monthly basis. If there are significant changes made to the printed formulary within the covered year, you may be notified by mail identifying the changes. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. 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 8. 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 148. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Leon Medical Centers Health Plans Leon Cares 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: Leon Medical Centers Health Plans Leon Cares requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, Leon Medical Centers Health Plans Leon Cares limits the amount of the drug that we will cover. For example, our plan provides 30 per prescription for Edarbi. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Leon Medical Centers Health Plans Leon Cares 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 2

4 and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we 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 8. 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 Leon Medical Centers Health Plans Leon Cares 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 Leon Medical Centers Health Plans Leon Cares formulary? on page 4 for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Plan. Leon Medical Centers Health Plans Leon Cares pays for certain OTC drugs. We will provide these OTC drugs at no cost to you. The cost to our plan of these OTC drugs will not count toward your total Part D drug costs (that is, the cost of the OTC drugs does not count for the coverage gap. OTC Covered s 3 DAY VAGINL CRE 2% GUAIFENESIN SOL DAC ALAWAY DRO 0.025%OP HYDROCORT CRE 0.5% ALLERGY RELF TAB LORATADINE TAB AMMONIUM LAC CRE 12% MECLIZINE TAB AMMONIUM LAC LOT 12% MI-ACID SUS ANTIFUNGAL CRE 2% MICONAZOLE CRE 2% ATHLETES FOOT SPRAY REMEDY POW ANTIFUNG CETIRIZINE TAB SLO-NIACIN TAB CR CHERATUSSIN SOL DAC SOD CHLORIDE OIN 5% OP CLOTRIMAZOLE CRE 1% SOD CHLORIDE SOL 5% OP CLOTRIMAZOLE CRE 1% VAG TRAVEL SICK CHW CLOTRIMAZOLE SOL 1% VINATE CARE CHW 40-1MG DIPHENHIST LIQ 12.5/5ML VIRTUSSIN AC SOL /5 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 Leon Medical Centers Health Plans Leon Cares does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Leon Medical Centers Health Plans Leon Cares. 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. 3

5 You can ask us to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Leon Medical Centers Health Plans Leon Cares Formulary? You can ask Leon Medical Centers Health Plans Leon Cares 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 predetermined 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, Leon Medical Centers Health Plans Leon Cares limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization 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. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30 day supply of medication. 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. 4

6 If you are a resident of a long-term care facility and 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 while you pursue a formulary exception. If a level of care change is received by the plan in accordance with Medicare s definition, an override will be allowed. The plan will identify those individuals who are impacted to ensure continuity of care by directing them through the appropriate steps. For more information For more detailed information about your Leon Medical Centers Health Plans Leon Cares prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Leon Medical Centers Health Plans Leon Cares, 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 Leon Medical Centers Health Plans Leon Cares Formulary The formulary below provides coverage information about the drugs covered by Leon Medical Centers Health Plans Leon Cares. If you have trouble finding your drug in the list, turn to the Index that begins on page 148. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., EDARBI) and generic drugs are listed in lower-case italics (e.g., atenolol). The information in the Requirements/Limits column tells you if Leon Medical Centers Health Plans Leon Cares has any special requirements for coverage of your drug. 5

7 List of Abbreviations #: This prescription drug is not normally covered in a Medicare Prescription Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. B: Brand B/D: This prescription has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. G: Generic GC: HI: LA: NDS: PA: QL: We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. This prescription drug may be covered under our medical benefit. For more information, call Member Services at , seven days a week from 8:00 am to 8:00 pm. TTY users should call 711. This prescription may be available only at certain pharmacies. For more information consult your Provider & Pharmacy Directory or call Member Services at , seven days a week from 8:00 am to 8 pm. TTY users should call 711. Non-Extended Day Supply. This prescription drug is not available for an extended days' supply. Prior Authorization. Leon Medical Centers Health Plans Leon Cares requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Leon Medical Centers Health Plans Leon Cares before you fill your prescriptions. If you don t get Approval, Leon Medical Centers Health Plans Leon Cares may not cover the drug. Quantity Limit. For certain drugs, Leon Medical Centers Health Plans Leon Cares limits the amount of the drug that Leon Medical Centers Health Plans Leon Cares will cover. For example, Leon Medical Centers Health Plans Leon Cares provides 30 tablets per prescription for EDARBI. This may be in addition to a standard one month or three month supply. S: Specialty Tier ST: Step Therapy. In some cases, Leon Medical Centers Health Plans Leon Cares 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, we may not cover B unless you try A first. If A does not work for you, we will then cover B. 6

8 Tier and Cost Share Table Preferred retail costsharing (in-network) (up to a 30-day supply) Standard retail costsharing (in-network) (up to a 30-day supply) Preferred retail cost-sharing (innetwork) (up to a 90-day supply) Standard retail cost-sharing (innetwork) (up to a 90-day supply) Cost-Sharing Tier 1 (generic and some brand drugs) $0 copay $5 copay $0 copay $15 copay Cost-Sharing Tier 2 (brand name drugs) $0 copay $10 copay $0 copay $30 copay Cost-Sharing Tier 3 (specialty drugs) 33% coinsurance 33% coinsurance A long-term supply is not available for drugs in tier 3 A long-term supply is not available for drugs in tier 3 Leon Medical Centers Health Plans' pharmacy network offers limited lower-cost, preferred pharmacies in urban and suburban Miami-Dade County, FL. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call , TTY users should call 711 or consult the online pharmacy directory at 7

9 Analgesics ABSTRAL SUBL 100MCG QL (120 EA per 30 days) PA NDS ABSTRAL SUBL 200MCG QL (120 EA per 30 days) PA NDS ABSTRAL SUBL 300MCG QL (120 EA per 30 days) PA NDS ABSTRAL SUBL 400MCG QL (120 EA per 30 days) PA NDS ABSTRAL SUBL 600MCG QL (120 EA per 30 days) PA NDS ABSTRAL SUBL 800MCG QL (120 EA per 30 days) PA NDS acetaminophen/caffeine/dihydrocodeine caps 320.5mg; 30mg; 1 G QL (300 EA per 30 days) NDS GC 16mg acetaminophen/codeine phosphate tabs 300mg; 30mg 1 G QL (360 EA per 30 days) NDS GC acetaminophen/codeine soln 120mg/5ml; 12mg/5ml 1 G QL (2700 ML per 30 days) NDS GC acetaminophen/codeine tabs 300mg; 15mg 1 G QL (360 EA per 30 days) NDS GC acetaminophen/codeine tabs 300mg; 30mg 1 G QL (360 EA per 30 days) NDS GC acetaminophen/codeine tabs 300mg; 60mg 1 G QL (180 EA per 30 days) NDS GC ascomp/codeine caps 325mg; 50mg; 40mg; 30mg 1 G QL (180 EA per 30 days) NDS GC aspirin-caffeine-dihydrocodeine caps 356.4mg; 30mg; 16mg 1 G QL (330 EA per 30 days) GC bupap tabs 300mg; 50mg 1 G GC buprenorphine hcl inj 0.3mg/ml 1 G QL (150 ML per 30 days) B/D GC buprenorphine hcl inj 0.3mg/ml 1 G QL (150 ML per 30 days) B/D GC buprenorphine ptwk 10mcg/hr 1 G QL (4 EA per 28 days) NDS GC buprenorphine ptwk 15mcg/hr 1 G QL (4 EA per 28 days) NDS GC buprenorphine ptwk 20mcg/hr 1 G QL (4 EA per 28 days) NDS GC buprenorphine ptwk 5mcg/hr 1 G QL (4 EA per 28 days) NDS GC buprenorphine ptwk 7.5mcg/hr 1 G QL (4 EA per 28 days) NDS GC butalbital/acetaminophen/caffeine/codeine caps 300mg; 1 G QL (180 EA per 30 days) NDS GC 50mg; 40mg; 30mg butalbital/acetaminophen/caffeine/codeine caps 325mg; 50mg; 40mg; 30mg 1 G QL (180 EA per 30 days) NDS GC butalbital/acetaminophen/caffeine caps 300mg; 50mg; 40mg 1 G GC butalbital/acetaminophen/caffeine caps 325mg; 50mg; 40mg 1 G GC butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg 1 G GC butalbital/acetaminophen tabs 300mg; 50mg 1 G GC butalbital/acetaminophen tabs 325mg; 50mg 1 G GC butalbital/aspirin/caffeine/codeine caps 325mg; 50mg; 40mg; 1 G QL (180 EA per 30 days) NDS GC 30mg butalbital/aspirin/caffeine caps 325mg; 50mg; 40mg 1 G GC butorphanol tartrate inj 1mg/ml 1 G QL (480 ML per 30 days) NDS GC butorphanol tartrate inj 2mg/ml 1 G QL (240 ML per 30 days) NDS GC butorphanol tartrate soln 10mg/ml 1 G QL (5 ML per 30 days) NDS GC CAMBIA PACK 50MG capacet caps 325mg; 50mg; 40mg 1 G GC CAPITAL/CODEINE SUSP 120MG/5ML; 12MG/5ML QL (2700 ML per 30 days) carisoprodol/aspirin/codeine tabs 325mg; 200mg; 16mg 1 G PA NDS GC celecoxib caps 100mg 1 G GC celecoxib caps 200mg 1 G GC celecoxib caps 400mg 1 G GC Page 8

10 celecoxib caps 50mg 1 G GC codeine sulfate tabs 15mg 1 G QL (720 EA per 30 days) NDS GC codeine sulfate tabs 30mg 1 G QL (360 EA per 30 days) NDS GC codeine sulfate tabs 60mg 1 G QL (180 EA per 30 days) NDS GC diclofenac potassium tabs 50mg 1 G GC diclofenac sodium dr tbec 25mg 1 G GC diclofenac sodium dr tbec 50mg 1 G GC diclofenac sodium dr tbec 75mg 1 G GC diclofenac sodium er tb24 100mg 1 G GC diclofenac sodium/misoprostol tbec 50mg; 200mcg 1 G GC diclofenac sodium/misoprostol tbec 75mg; 200mcg 1 G GC diclofenac sodium gel 1% 1 G QL (1000 GM per 30 days) GC diflunisal tabs 500mg 1 G GC DUEXIS TABS 26.6MG; 800MG DURAMORPH INJ 0.5MG/ML HI DURAMORPH INJ 1MG/ML HI EMBEDA CPCR 100MG; 4MG QL (60 EA per 30 days) NDS EMBEDA CPCR 20MG; 0.8MG QL (60 EA per 30 days) NDS EMBEDA CPCR 30MG; 1.2MG QL (60 EA per 30 days) NDS EMBEDA CPCR 50MG; 2MG QL (60 EA per 30 days) NDS EMBEDA CPCR 60MG; 2.4MG QL (60 EA per 30 days) NDS EMBEDA CPCR 80MG; 3.2MG QL (60 EA per 30 days) NDS endocet tabs 325mg; 10mg 1 G QL (180 EA per 30 days) NDS GC endocet tabs 325mg; 2.5mg 1 G QL (360 EA per 30 days) NDS GC endocet tabs 325mg; 5mg 1 G QL (360 EA per 30 days) NDS GC endocet tabs 325mg; 7.5mg 1 G QL (240 EA per 30 days) NDS GC endodan tabs 325mg; 4.835mg 1 G NDS GC esgic caps 325mg; 50mg; 40mg 1 G GC etodolac er tb24 400mg 1 G GC etodolac er tb24 500mg 1 G GC etodolac er tb24 600mg 1 G GC etodolac caps 200mg 1 G GC etodolac caps 300mg 1 G GC etodolac tabs 400mg 1 G GC etodolac tabs 500mg 1 G GC fenoprofen calcium caps 400mg 1 G GC fenoprofen calcium tabs 600mg 1 G GC fentanyl citrate oral transmucosal lpop 1200mcg 3 S QL (120 EA per 30 days) PA NDS fentanyl citrate oral transmucosal lpop 1600mcg 3 S QL (120 EA per 30 days) PA NDS fentanyl citrate oral transmucosal lpop 200mcg 1 G QL (120 EA per 30 days) PA NDS GC fentanyl citrate oral transmucosal lpop 400mcg 1 G QL (120 EA per 30 days) PA NDS GC fentanyl citrate oral transmucosal lpop 600mcg 1 G QL (120 EA per 30 days) PA NDS GC fentanyl citrate oral transmucosal lpop 800mcg 3 S QL (120 EA per 30 days) PA NDS Page 9

11 FENTANYL CITRATE INJ 1000MCG/20ML B/D NDS GC fentanyl citrate inj 100mcg/2ml 1 G B/D NDS GC FENTANYL CITRATE INJ 2500MCG/50ML B/D NDS GC FENTANYL CITRATE INJ 250MCG/5ML B/D NDS GC FENTANYL CITRATE INJ 500MCG/10ML B/D NDS GC fentanyl pt72 100mcg/hr 1 G QL (10 EA per 30 days) NDS GC fentanyl pt72 12mcg/hr 1 G QL (10 EA per 30 days) NDS GC fentanyl pt72 25mcg/hr 1 G QL (10 EA per 30 days) NDS GC fentanyl pt mcg/hr 1 G QL (10 EA per 30 days) NDS GC fentanyl pt72 50mcg/hr 1 G QL (10 EA per 30 days) NDS GC fentanyl pt mcg/hr 3 S QL (10 EA per 30 days) NDS fentanyl pt72 75mcg/hr 1 G QL (10 EA per 30 days) NDS GC fentanyl pt mcg/hr 3 S QL (10 EA per 30 days) NDS FENTORA TABS 100MCG 3 S QL (120 EA per 30 days) PA NDS FENTORA TABS 200MCG 3 S QL (120 EA per 30 days) PA NDS FENTORA TABS 400MCG 3 S QL (120 EA per 30 days) PA NDS FENTORA TABS 600MCG 3 S QL (120 EA per 30 days) PA NDS FENTORA TABS 800MCG 3 S QL (120 EA per 30 days) PA NDS FLECTOR PTCH 1.3% PA flurbiprofen tabs 100mg 1 G GC flurbiprofen tabs 50mg 1 G GC hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 1 G QL (2700 ML per 30 days) GC 10mg/15ml hydrocodone bitartrate/acetaminophen soln 325mg/15ml; 1 G QL (2700 ML per 30 days) NDS GC 7.5mg/15ml hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg 1 G QL (180 EA per 30 days) NDS GC hydrocodone bitartrate/acetaminophen tabs 300mg; 5mg 1 G QL (360 EA per 30 days) NDS GC hydrocodone bitartrate/acetaminophen tabs 300mg; 7.5mg 1 G QL (180 EA per 30 days) NDS GC hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg 1 G QL (360 EA per 30 days) NDS GC hydrocodone/acetaminophen soln 500mg/15ml; 7.5mg/15ml 1 G QL (3600 ML per 30 days) GC hydrocodone/acetaminophen tabs 325mg; 10mg 1 G QL (180 EA per 30 days) NDS GC hydrocodone/acetaminophen tabs 325mg; 5mg 1 G QL (360 EA per 30 days) NDS GC hydrocodone/acetaminophen tabs 325mg; 7.5mg 1 G QL (180 EA per 30 days) NDS GC hydrocodone/ibuprofen tabs 10mg; 200mg 1 G QL (150 EA per 30 days) NDS GC hydrocodone/ibuprofen tabs 2.5mg; 200mg 1 G QL (150 EA per 30 days) GC hydrocodone/ibuprofen tabs 5mg; 200mg 1 G QL (150 EA per 30 days) NDS GC hydrocodone/ibuprofen tabs 7.5mg; 200mg 1 G QL (150 EA per 30 days) NDS GC HYDROMORPHONE HCL DOSETTE INJ 2MG/ML QL (360 ML per 30 days) B/D NDS GC hydromorphone hcl er t24a 0; 8mg 1 G QL (30 EA per 30 days) NDS GC hydromorphone hcl er t24a 12mg 1 G QL (60 EA per 30 days) NDS GC hydromorphone hcl er t24a 16mg 1 G QL (30 EA per 30 days) NDS GC hydromorphone hcl inj 10mg/ml 1 G QL (120 ML per 30 days) B/D NDS GC HYDROMORPHONE HCL INJ 1MG/ML QL (360 ML per 30 days) B/D NDS GC Page 10

12 HYDROMORPHONE HCL INJ 2MG/ML QL (360 ML per 30 days) B/D NDS GC HYDROMORPHONE HCL INJ 4MG/ML QL (360 ML per 30 days) B/D NDS GC hydromorphone hcl inj 50mg/5ml 1 G QL (120 ML per 30 days) B/D NDS GC hydromorphone hcl liqd 1mg/ml 1 G QL (1200 ML per 30 days) NDS GC hydromorphone hcl tabs 2mg 1 G QL (180 EA per 30 days) NDS GC hydromorphone hcl tabs 4mg 1 G QL (180 EA per 30 days) NDS GC hydromorphone hcl tabs 8mg 1 G QL (120 EA per 30 days) NDS GC hydromorphone hydrochloride er t24a 32mg 1 G QL (30 EA per 30 days) NDS GC HYDROMORPHONE HYDROCHLORIDE INJ 1MG/ML QL (360 ML per 30 days) B/D NDS GC hydromorphone hydrochloride t24a 32mg 1 G QL (30 EA per 30 days) NDS GC ibudone tabs 5mg; 200mg 1 G QL (150 EA per 30 days) NDS GC ibuprofen susp 100mg/5ml 1 G GC ibuprofen tabs 400mg 1 G GC ibuprofen tabs 600mg 1 G GC ibuprofen tabs 800mg 1 G GC ibu tabs 600mg 1 G GC ibu tabs 800mg 1 G GC INDOCIN SUSP 25MG/5ML indomethacin er cpcr 75mg 1 G GC indomethacin caps 25mg 1 G GC indomethacin caps 50mg 1 G GC INFUMORPH 200 INJ 10MG/ML QL (200 ML per 30 days) B/D NDS INFUMORPH 500 INJ 25MG/ML QL (200 ML per 30 days) B/D NDS KADIAN CP24 200MG QL (90 EA per 30 days) NDS KADIAN CP24 40MG QL (30 EA per 30 days) NDS ketoprofen er cp24 200mg 1 G GC ketoprofen caps 50mg 1 G GC ketoprofen caps 75mg 1 G GC ketorolac tromethamine inj 15mg/ml 1 G B/D GC ketorolac tromethamine inj 300mg/10ml 1 G B/D GC ketorolac tromethamine inj 30mg/ml 1 G B/D GC ketorolac tromethamine inj 30mg/ml 1 G B/D GC ketorolac tromethamine inj 30mg/ml 1 G B/D GC ketorolac tromethamine tabs 10mg 1 G GC LAZANDA SOLN 100MCG/ACT 3 S QL (30 EA per 30 days) PA NDS LAZANDA SOLN 300MCG/ACT 3 S QL (30 EA per 30 days) PA NDS LAZANDA SOLN 400MCG/ACT 3 S QL (30 EA per 30 days) PA NDS lorcet hd tabs 325mg; 10mg 1 G QL (180 EA per 30 days) NDS GC lorcet plus tabs 325mg; 7.5mg 1 G QL (180 EA per 30 days) NDS GC lorcet tabs 325mg; 5mg 1 G QL (360 EA per 30 days) NDS GC lortab tabs 325mg; 10mg 1 G QL (180 EA per 30 days) NDS GC lortab tabs 325mg; 5mg 1 G QL (360 EA per 30 days) NDS GC Page 11

13 lortab tabs 325mg; 7.5mg 1 G QL (180 EA per 30 days) NDS GC marten-tab tabs 325mg; 50mg 1 G GC meclofenamate sodium caps 100mg 1 G GC meclofenamate sodium caps 50mg 1 G GC mefenamic acid caps 250mg 1 G GC meloxicam susp 7.5mg/5ml 1 G GC meloxicam tabs 15mg 1 G GC meloxicam tabs 7.5mg 1 G GC meperidine hcl inj 100mg/ml 1 G QL (360 ML per 30 days) B/D NDS GC meperidine hcl inj 10mg/ml 1 G QL (3600 ML per 30 days) B/D NDS GC meperidine hcl inj 25mg/ml 1 G QL (1440 ML per 30 days) B/D NDS GC meperidine hcl inj 50mg/ml 1 G QL (720 ML per 30 days) B/D NDS GC meperidine hcl soln 50mg/5ml 1 G QL (900 ML per 30 days) NDS GC meperidine hcl tabs 100mg 1 G QL (180 EA per 30 days) NDS GC meperidine hcl tabs 50mg 1 G QL (180 EA per 30 days) NDS GC methadone hcl intensol conc 10mg/ml 1 G QL (500 ML per 30 days) NDS GC methadone hcl conc 10mg/ml 1 G QL (500 ML per 30 days) NDS GC methadone hcl inj 10mg/ml 1 G QL (150 ML per 30 days) B/D NDS GC methadone hcl soln 10mg/5ml 1 G QL (450 ML per 30 days) NDS GC methadone hcl soln 5mg/5ml 1 G QL (600 ML per 30 days) NDS GC methadone hcl tabs 10mg 1 G QL (120 EA per 30 days) NDS GC methadone hcl tabs 5mg 1 G QL (180 EA per 30 days) NDS GC mitigo inj 10mg/ml 1 G QL (200 ML per 30 days) B/D GC mitigo inj 25mg/ml 1 G QL (200 ML per 30 days) B/D GC morphine sulfate add-vantage inj 25mg/ml 1 G HI morphine sulfate er cp24 100mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 10mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 120mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 20mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 30mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 30mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 40mg 1 G QL (30 EA per 30 days) NDS GC morphine sulfate er cp24 45mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 50mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 60mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 60mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 75mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 80mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er cp24 90mg 1 G QL (60 EA per 30 days) NDS GC morphine sulfate er tbcr 100mg 1 G QL (90 EA per 30 days) NDS GC morphine sulfate er tbcr 15mg 1 G QL (90 EA per 30 days) NDS GC Page 12

14 morphine sulfate er tbcr 200mg 1 G QL (90 EA per 30 days) NDS GC morphine sulfate er tbcr 30mg 1 G QL (90 EA per 30 days) NDS GC morphine sulfate er tbcr 60mg 1 G QL (90 EA per 30 days) NDS GC morphine sulfate inj 0.5mg/ml 1 G HI morphine sulfate inj 10mg/ml 1 G HI morphine sulfate inj 10mg/ml 1 G HI MORPHINE SULFATE INJ 10MG/ML NDS MORPHINE SULFATE INJ 150MG/30ML HI morphine sulfate inj 15mg/ml 1 G HI MORPHINE SULFATE INJ 15MG/ML HI morphine sulfate inj 1mg/ml 1 G HI morphine sulfate inj 1mg/ml 1 G HI morphine sulfate inj 25mg/ml 1 G HI MORPHINE SULFATE INJ 2MG/ML HI MORPHINE SULFATE INJ 2MG/ML HI morphine sulfate inj 4mg/ml 1 G HI morphine sulfate inj 4mg/ml 1 G HI MORPHINE SULFATE INJ 4MG/ML NDS morphine sulfate inj 50mg/ml 1 G HI MORPHINE SULFATE INJ 5MG/ML HI MORPHINE SULFATE INJ 5MG/ML NDS morphine sulfate inj 8mg/ml 1 G HI morphine sulfate inj 8mg/ml 1 G HI MORPHINE SULFATE INJ 8MG/ML NDS morphine sulfate soln 100mg/5ml 1 G QL (240 ML per 30 days) NDS GC morphine sulfate soln 10mg/5ml 1 G QL (700 ML per 30 days) NDS GC morphine sulfate soln 20mg/5ml 1 G QL (900 ML per 30 days) NDS GC MORPHINE SULFATE TABS 15MG QL (120 EA per 30 days) NDS GC MORPHINE SULFATE TABS 30MG QL (120 EA per 30 days) NDS GC nabumetone tabs 500mg 1 G GC nabumetone tabs 750mg 1 G GC nalbuphine hcl inj 10mg/ml 1 G QL (180 ML per 30 days) B/D NDS GC nalbuphine hcl inj 20mg/ml 1 G QL (90 ML per 30 days) B/D NDS GC NAPRELAN TB24 750MG naproxen dr tbec 375mg 1 G GC naproxen dr tbec 500mg 1 G GC naproxen sodium er tb24 375mg 1 G GC naproxen sodium er tb24 500mg 1 G GC naproxen sodium tabs 275mg 1 G GC naproxen sodium tabs 550mg 1 G GC naproxen sodium tb24 500mg 1 G GC naproxen susp 125mg/5ml 1 G GC naproxen tabs 250mg 1 G GC naproxen tabs 375mg 1 G GC Page 13

15 naproxen tabs 500mg 1 G GC NUCYNTA ER TB12 100MG QL (60 EA per 30 days) NDS NUCYNTA ER TB12 150MG QL (60 EA per 30 days) NDS NUCYNTA ER TB12 200MG QL (60 EA per 30 days) NDS NUCYNTA ER TB12 250MG QL (60 EA per 30 days) NDS NUCYNTA ER TB12 50MG QL (60 EA per 30 days) NDS NUCYNTA TABS 100MG QL (180 EA per 30 days) NDS NUCYNTA TABS 50MG QL (180 EA per 30 days) NDS NUCYNTA TABS 75MG QL (180 EA per 30 days) NDS OPANA ER (CRUSH RESISTANT) T12A 10MG QL (60 EA per 30 days) NDS OPANA ER (CRUSH RESISTANT) T12A 15MG QL (60 EA per 30 days) NDS OPANA ER (CRUSH RESISTANT) T12A 20MG QL (60 EA per 30 days) NDS OPANA ER (CRUSH RESISTANT) T12A 30MG QL (60 EA per 30 days) NDS OPANA ER (CRUSH RESISTANT) T12A 40MG QL (120 EA per 30 days) NDS OPANA ER (CRUSH RESISTANT) T12A 5MG QL (60 EA per 30 days) NDS OPANA ER (CRUSH RESISTANT) T12A 7.5MG QL (60 EA per 30 days) NDS oxaprozin tabs 600mg 1 G GC oxycodone hcl er t12a 10mg 1 G QL (60 EA per 30 days) NDS GC oxycodone hcl er t12a 15mg 1 G QL (60 EA per 30 days) NDS GC oxycodone hcl er t12a 20mg 1 G QL (60 EA per 30 days) NDS GC oxycodone hcl er t12a 30mg 1 G QL (60 EA per 30 days) NDS GC oxycodone hcl er t12a 40mg 1 G QL (60 EA per 30 days) NDS GC oxycodone hcl er t12a 60mg 1 G QL (60 EA per 30 days) NDS GC oxycodone hcl er t12a 80mg 1 G QL (60 EA per 30 days) NDS GC oxycodone hcl caps 5mg 1 G QL (120 EA per 30 days) NDS GC oxycodone hcl conc 100mg/5ml 1 G QL (120 ML per 30 days) NDS GC oxycodone hcl soln 5mg/5ml 1 G QL (1200 ML per 30 days) NDS GC oxycodone hcl tabs 10mg 1 G QL (120 EA per 30 days) NDS GC oxycodone hcl tabs 15mg 1 G QL (120 EA per 30 days) NDS GC oxycodone hcl tabs 20mg 1 G QL (120 EA per 30 days) NDS GC oxycodone hcl tabs 30mg 1 G QL (90 EA per 30 days) NDS GC oxycodone hcl tabs 5mg 1 G QL (120 EA per 30 days) NDS GC oxycodone/acetaminophen soln 325mg/5ml; 5mg/5ml 1 G QL (1800 ML per 30 days) NDS GC oxycodone/acetaminophen tabs 325mg; 10mg 1 G QL (180 EA per 30 days) NDS GC oxycodone/acetaminophen tabs 325mg; 2.5mg 1 G QL (360 EA per 30 days) NDS GC oxycodone/acetaminophen tabs 325mg; 5mg 1 G QL (360 EA per 30 days) NDS GC oxycodone/acetaminophen tabs 325mg; 7.5mg 1 G QL (240 EA per 30 days) NDS GC oxycodone/aspirin tabs 325mg; 4.835mg 1 G QL (180 EA per 30 days) NDS GC oxycodone/ibuprofen tabs 400mg; 5mg 1 G QL (28 EA per 30 days) NDS GC OXYCONTIN T12A 15MG QL (60 EA per 30 days) NDS OXYCONTIN T12A 30MG QL (60 EA per 30 days) NDS OXYCONTIN T12A 60MG QL (60 EA per 30 days) NDS oxymorphone hydrochloride er tb12 10mg 1 G QL (60 EA per 30 days) NDS GC oxymorphone hydrochloride er tb12 15mg 1 G QL (60 EA per 30 days) NDS GC oxymorphone hydrochloride er tb12 20mg 1 G QL (60 EA per 30 days) NDS GC oxymorphone hydrochloride er tb12 30mg 1 G QL (60 EA per 30 days) NDS GC Page 14

16 oxymorphone hydrochloride er tb12 40mg 1 G QL (120 EA per 30 days) NDS GC oxymorphone hydrochloride er tb12 5mg 1 G QL (60 EA per 30 days) NDS GC oxymorphone hydrochloride er tb12 7.5mg 1 G QL (60 EA per 30 days) NDS GC oxymorphone hydrochloride tabs 10mg 1 G QL (180 EA per 30 days) NDS GC oxymorphone hydrochloride tabs 5mg 1 G QL (180 EA per 30 days) NDS GC pentazocine/acetaminophen tabs 650mg; 25mg 1 G QL (180 EA per 30 days) GC pentazocine/naloxone hcl tabs 0.5mg; 50mg 1 G QL (360 EA per 30 days) NDS GC PHRENILIN FORTE CAPS 650MG; 50MG GC piroxicam caps 10mg 1 G GC piroxicam caps 20mg 1 G GC PRIMLEV TABS 300MG; 10MG QL (360 EA per 30 days) NDS PRIMLEV TABS 300MG; 5MG QL (360 EA per 30 days) NDS PRIMLEV TABS 300MG; 7.5MG QL (360 EA per 30 days) NDS profeno tabs 600mg 1 G GC reprexain tabs 10mg; 200mg 1 G QL (150 EA per 30 days) NDS GC salsalate tabs 500mg 1 G GC salsalate tabs 750mg 1 G GC SPRIX SOLN 15.75MG/SPRAY SUBSYS LIQD 100MCG 3 S QL (120 EA per 30 days) PA NDS SUBSYS LIQD 1200MCG 3 S QL (120 EA per 30 days) PA NDS SUBSYS LIQD 1600MCG 3 S QL (120 EA per 30 days) PA NDS SUBSYS LIQD 200MCG 3 S QL (120 EA per 30 days) PA NDS SUBSYS LIQD 400MCG 3 S QL (120 EA per 30 days) PA NDS SUBSYS LIQD 600MCG 3 S QL (120 EA per 30 days) PA NDS SUBSYS LIQD 800MCG 3 S QL (120 EA per 30 days) PA NDS sulindac tabs 150mg 1 G GC sulindac tabs 200mg 1 G GC SYNALGOS-DC CAPS 356.4MG; 30MG; 16MG QL (330 EA per 30 days) TALWIN INJ 30MG/ML QL (360 ML per 30 days) NDS tencon tabs 325mg; 50mg 1 G GC tencon tabs 650mg; 50mg 1 G GC TIVORBEX CAPS 20MG TIVORBEX CAPS 40MG tolmetin sodium caps 400mg 1 G GC tolmetin sodium tabs 200mg 1 G GC tolmetin sodium tabs 600mg 1 G GC tramadol hcl er cp24 100mg 1 G QL (30 EA per 30 days) NDS GC tramadol hcl er cp24 150mg 1 G QL (30 EA per 30 days) NDS GC tramadol hcl er cp24 200mg 1 G QL (30 EA per 30 days) NDS GC tramadol hcl er cp24 300mg 1 G QL (30 EA per 30 days) NDS GC tramadol hcl er tb24 100mg 1 G QL (30 EA per 30 days) NDS GC tramadol hcl er tb24 100mg 1 G QL (30 EA per 30 days) NDS GC tramadol hcl er tb24 200mg 1 G QL (30 EA per 30 days) NDS GC tramadol hcl er tb24 200mg 1 G QL (30 EA per 30 days) NDS GC tramadol hcl er tb24 300mg 1 G QL (30 EA per 30 days) NDS GC tramadol hcl tabs 50mg 1 G QL (240 EA per 30 days) NDS GC Page 15

17 tramadol hydrochloride/acetaminophen tabs 325mg; 37.5mg 1 G QL (240 EA per 30 days) NDS GC VANATOL LQ SOLN 325MG/15ML; 50MG/15ML; 40MG/15ML vicodin es tabs 300mg; 7.5mg 1 G QL (180 EA per 30 days) NDS GC vicodin hp tabs 300mg; 10mg 1 G QL (180 EA per 30 days) NDS GC vicodin tabs 300mg; 5mg 1 G QL (360 EA per 30 days) NDS GC XARTEMIS XR TBCR 325MG; 7.5MG QL (120 EA per 30 days) XTAMPZA ER C12A 13.5MG QL (60 EA per 30 days) NDS XTAMPZA ER C12A 18MG QL (60 EA per 30 days) NDS XTAMPZA ER C12A 27MG QL (60 EA per 30 days) NDS XTAMPZA ER C12A 36MG QL (60 EA per 30 days) NDS XTAMPZA ER C12A 9MG QL (60 EA per 30 days) NDS xylon tabs 10mg; 200mg 1 G QL (150 EA per 30 days) NDS GC xylon tabs 10mg; 200mg 1 G QL (150 EA per 30 days) NDS GC zebutal caps 325mg; 50mg; 40mg 1 G GC ZIPSOR CAPS 25MG ZOHYDRO ER C12A 10MG QL (60 EA per 30 days) PA NDS ZOHYDRO ER C12A 15MG QL (60 EA per 30 days) PA NDS ZOHYDRO ER C12A 20MG QL (60 EA per 30 days) PA NDS ZOHYDRO ER C12A 30MG QL (60 EA per 30 days) PA NDS ZOHYDRO ER C12A 40MG QL (60 EA per 30 days) PA NDS ZOHYDRO ER C12A 50MG QL (60 EA per 30 days) PA NDS ZORVOLEX CAPS 18MG ZORVOLEX CAPS 35MG ZYDONE TABS 400MG; 10MG QL (180 EA per 30 days) ZYDONE TABS 400MG; 5MG QL (300 EA per 30 days) ZYDONE TABS 400MG; 7.5MG QL (210 EA per 30 days) Anesthetics glydo gel 2% 1 G GC lidocaine hcl jelly gel 2% 1 G GC lidocaine hcl viscous soln 2% 1 G GC lidocaine hcl gel 2% 1 G GC lidocaine hcl inj 0.5% 1 G B/D GC lidocaine hcl inj 0.5% 1 G B/D GC lidocaine hcl inj 1% 1 G B/D GC lidocaine hcl inj 1% 1 G B/D GC lidocaine hcl inj 1.5% 1 G B/D GC lidocaine hcl inj 2% 1 G B/D GC lidocaine hcl inj 2% 1 G B/D GC lidocaine hcl inj 4% 1 G B/D GC lidocaine hcl soln 4% 1 G GC lidocaine hcl soln 4% 1 G GC lidocaine pak oint 5% 1 G QL (50 GM per 30 days) GC lidocaine viscous soln 2% 1 G GC lidocaine/prilocaine crea 2.5%; 2.5% 1 G GC lidocaine oint 5% 1 G QL (50 GM per 30 days) GC Page 16

18 lidocaine ptch 5% 1 G PA GC premium lidocaine oint 5% 1 G QL (50 GM per 30 days) GC SYNERA PTCH 70MG; 70MG Anti-Addiction/Substance Abuse Treatment Agents acamprosate calcium dr tbec 333mg 1 G GC buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg 1 G QL (90 EA per 30 days) GC buprenorphine hcl/naloxone hcl subl 8mg; 2mg 1 G QL (90 EA per 30 days) GC buprenorphine hcl subl 2mg 1 G GC buprenorphine hcl subl 8mg 1 G GC buproban tb12 150mg 1 G QL (60 EA per 30 days) GC bupropion hcl sr tb12 150mg 1 G QL (60 EA per 30 days) GC CHANTIX CONTINUING MONTH PAK TABS 1MG CHANTIX STARTING MONTH PAK TABS 0 CHANTIX TABS 0.5MG CHANTIX TABS 1MG disulfiram tabs 250mg 1 G GC disulfiram tabs 500mg 1 G GC naloxone hcl inj 0.4mg/ml 1 G GC naloxone hcl inj 2mg/2ml 1 G GC naloxone hcl inj 4mg/10ml 1 G GC naltrexone hcl tabs 50mg 1 G GC NARCAN LIQD 4MG/0.1ML QL (4 EA per 30 days) NICOTROL INHALER INHA 10MG NICOTROL NS SOLN 10MG/ML SUBOXONE FILM 12MG; 3MG QL (90 EA per 30 days) SUBOXONE FILM 2MG; 0.5MG QL (90 EA per 30 days) SUBOXONE FILM 4MG; 1MG QL (90 EA per 30 days) SUBOXONE FILM 8MG; 2MG QL (90 EA per 30 days) VIVITROL INJ 380MG 3 S B/D NDS ZUBSOLV SUBL 0.7MG; 0.18MG QL (30 EA per 30 days) ZUBSOLV SUBL 1.4MG; 0.36MG QL (90 EA per 30 days) ZUBSOLV SUBL 11.4MG; 2.9MG QL (30 EA per 30 days) ZUBSOLV SUBL 2.9MG; 0.71MG QL (90 EA per 30 days) ZUBSOLV SUBL 5.7MG; 1.4MG QL (90 EA per 30 days) ZUBSOLV SUBL 8.6MG; 2.1MG QL (90 EA per 30 days) Anti-inflammatory Agents hydrocortisone acetate/pramoxine crea 2.5%; 1% 1 G GC # pramosone lotn 1%; 1% 1 G GC pramosone lotn 2.5%; 1% 1 G GC Antibacterials ak-poly-bac oint 500unit/gm; 10000unit/gm 1 G GC ALCOHOL PREP PADS PADS 70% GC ALTABAX OINT 1% amikacin sulfate inj 1gm/4ml 1 G HI amikacin sulfate inj 500mg/2ml 1 G HI amoxicillin er tb24 775mg 1 G GC Page 17

19 amoxicillin/clavulanate potassium er tb mg; 62.5mg 1 G GC amoxicillin/clavulanate potassium chew 200mg; 28.5mg 1 G GC amoxicillin/clavulanate potassium chew 400mg; 57mg 1 G GC amoxicillin/clavulanate potassium susr 200mg/5ml; 1 G GC 28.5mg/5ml amoxicillin/clavulanate potassium susr 250mg/5ml; 62.5mg/5ml 1 G GC amoxicillin/clavulanate potassium susr 400mg/5ml; 57mg/5ml 1 G GC amoxicillin/clavulanate potassium susr 600mg/5ml; 1 G GC 42.9mg/5ml amoxicillin/clavulanate potassium tabs 250mg; 125mg 1 G GC amoxicillin/clavulanate potassium tabs 500mg; 125mg 1 G GC amoxicillin/clavulanate potassium tabs 875mg; 125mg 1 G GC amoxicillin caps 250mg 1 G GC amoxicillin caps 500mg 1 G GC amoxicillin chew 125mg 1 G GC amoxicillin chew 250mg 1 G GC amoxicillin susr 125mg/5ml 1 G GC amoxicillin susr 200mg/5ml 1 G GC amoxicillin susr 250mg/5ml 1 G GC amoxicillin susr 400mg/5ml 1 G GC amoxicillin tabs 500mg 1 G GC amoxicillin tabs 875mg 1 G GC ampicillin sodium inj 10gm 1 G HI ampicillin sodium inj 10gm 1 G HI ampicillin sodium inj 125mg 1 G HI ampicillin sodium inj 1gm 1 G HI ampicillin sodium inj 1gm 1 G HI ampicillin sodium inj 1gm 1 G HI ampicillin sodium inj 250mg 1 G HI ampicillin sodium inj 2gm 1 G HI ampicillin sodium inj 2gm 1 G HI ampicillin sodium inj 500mg 1 G HI ampicillin-sulbactam inj 10gm; 5gm 1 G HI ampicillin-sulbactam inj 10gm; 5gm 1 G HI ampicillin-sulbactam inj 1gm; 0.5gm 1 G HI ampicillin-sulbactam inj 1gm; 0.5gm 1 G HI ampicillin-sulbactam inj 2gm; 1gm 1 G HI ampicillin caps 250mg 1 G GC ampicillin caps 500mg 1 G GC ampicillin susr 125mg/5ml 1 G GC ampicillin susr 250mg/5ml 1 G GC AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML AVELOX INJ 400MG/250ML; 0.8% HI AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM/50ML; 0 HI Page 18

20 AZACTAM IN ISO-OSMOTIC DEXTROSE INJ HI 2GM/50ML; 0 AZACTAM INJ 1GM HI AZACTAM INJ 2GM HI AZASITE SOLN 1% azithromycin inj 500mg 1 G HI AZITHROMYCIN PACK 1GM GC azithromycin susr 100mg/5ml 1 G GC azithromycin susr 200mg/5ml 1 G GC azithromycin tabs 250mg 1 G GC azithromycin tabs 250mg 1 G GC azithromycin tabs 500mg 1 G GC azithromycin tabs 500mg 1 G GC azithromycin tabs 600mg 1 G GC aztreonam inj 1gm 1 G HI aztreonam inj 2gm 1 G HI baciim inj 50000unit 1 G GC bacitracin/polymyxin b oint 500unit/gm; 10000unit/gm 1 G GC bacitracin inj 50000unit 1 G GC bacitracin oint 500unit/gm 1 G GC BACTOCILL IN DEXTROSE INJ 5%; 1GM/50ML HI BACTOCILL IN DEXTROSE INJ 5%; 2GM/50ML HI BACTROBAN NASAL OINT 2% BESIVANCE SUSP 0.6% BICILLIN C-R INJ UNIT/ML; UNIT/ML BICILLIN C-R INJ UNIT/2ML; UNIT/2ML BICILLIN L-A INJ UNIT/2ML BICILLIN L-A INJ UNIT/4ML BICILLIN L-A INJ UNIT/ML BLEPHAMIDE S.O.P. OINT 0.2%; 10% BLEPHAMIDE SUSP 0.2%; 10% cefaclor er tb12 500mg 1 G GC cefaclor caps 250mg 1 G GC cefaclor caps 500mg 1 G GC cefaclor susr 125mg/5ml 1 G GC cefaclor susr 250mg/5ml 1 G GC cefaclor susr 375mg/5ml 1 G GC cefadroxil caps 500mg 1 G GC cefadroxil susr 250mg/5ml 1 G GC cefadroxil susr 500mg/5ml 1 G GC cefadroxil tabs 1gm 1 G GC cefazolin sodium/dextrose inj 1gm; 4% 1 G HI CEFAZOLIN SODIUM/DEXTROSE INJ 2GM; 3% HI cefazolin sodium inj 100gm 1 G HI cefazolin sodium inj 10gm 1 G HI cefazolin sodium inj 1gm/50ml; 4% 1 G HI Page 19

21 cefazolin sodium inj 1gm 1 G HI cefazolin sodium inj 1gm 1 G HI cefazolin sodium inj 300gm 1 G HI cefazolin sodium inj 500mg 1 G HI CEFAZOLIN INJ 2GM/100ML; 4% HI cefdinir caps 300mg 1 G GC cefdinir susr 125mg/5ml 1 G GC cefdinir susr 250mg/5ml 1 G GC cefditoren pivoxil tabs 200mg 1 G GC cefditoren pivoxil tabs 400mg 1 G GC cefepime/dextrose inj 1gm/50ml; 5% 1 G HI cefepime/dextrose inj 2gm/50ml; 5% 1 G HI cefepime inj 1gm/50ml 1 G HI cefepime inj 1gm 1 G HI cefepime inj 2gm/100ml 1 G HI cefepime inj 2gm 1 G HI cefixime susr 100mg/5ml 1 G GC cefixime susr 200mg/5ml 1 G GC cefotaxime sodium inj 10gm 1 G HI cefotaxime sodium inj 1gm 1 G HI cefotaxime sodium inj 2gm 1 G HI cefotaxime sodium inj 500mg 1 G HI cefotetan/dextrose inj 1gm; 3.58% 1 G HI cefotetan/dextrose inj 2gm; 2.08% 1 G HI cefotetan inj 10gm 1 G HI cefotetan inj 1gm 1 G HI cefotetan inj 2gm 1 G HI cefoxitin sodium inj 10gm 1 G HI cefoxitin sodium inj 1gm 1 G HI cefoxitin sodium inj 1gm; 4% 1 G HI cefoxitin sodium inj 2gm 1 G HI cefoxitin sodium inj 2gm; 2.2% 1 G HI cefpodoxime proxetil susr 100mg/5ml 1 G GC cefpodoxime proxetil susr 50mg/5ml 1 G GC cefpodoxime proxetil tabs 100mg 1 G GC cefpodoxime proxetil tabs 200mg 1 G GC cefprozil susr 125mg/5ml 1 G GC cefprozil susr 250mg/5ml 1 G GC cefprozil tabs 250mg 1 G GC cefprozil tabs 500mg 1 G GC ceftazidime/dextrose inj 1gm/50ml; 5% 1 G HI ceftazidime/dextrose inj 2gm/50ml; 5% 1 G HI ceftazidime inj 1gm 1 G HI ceftazidime inj 2gm 1 G HI ceftazidime inj 6gm 1 G HI ceftibuten caps 400mg 1 G GC Page 20

22 ceftibuten susr 180mg/5ml 1 G GC CEFTIN SUSR 125MG/5ML CEFTIN SUSR 250MG/5ML ceftriaxone in iso-osmotic dextrose inj 20mg/ml; 0 1 G HI ceftriaxone in iso-osmotic dextrose inj 40mg/ml; 0 1 G HI ceftriaxone sodium inj 100gm 1 G HI ceftriaxone sodium inj 10gm 1 G HI ceftriaxone sodium inj 1gm 1 G HI ceftriaxone sodium inj 1gm 1 G HI ceftriaxone sodium inj 250mg 1 G HI ceftriaxone sodium inj 2gm 1 G HI ceftriaxone sodium inj 2gm 1 G HI ceftriaxone sodium inj 500mg 1 G HI ceftriaxone/dextrose inj 1gm; 3.74% 1 G HI ceftriaxone/dextrose inj 2gm; 2.22% 1 G HI cefuroxime axetil tabs 250mg 1 G GC cefuroxime axetil tabs 500mg 1 G GC cefuroxime sodium inj 1.5gm 1 G HI cefuroxime sodium inj 7.5gm 1 G HI cefuroxime sodium inj 7.5gm 1 G HI cefuroxime sodium inj 750mg 1 G HI cefuroxime sodium inj 75gm 1 G HI cephalexin caps 250mg 1 G GC cephalexin caps 500mg 1 G GC cephalexin caps 750mg 1 G GC cephalexin susr 125mg/5ml 1 G GC cephalexin susr 250mg/5ml 1 G GC cephalexin tabs 250mg 1 G GC cephalexin tabs 500mg 1 G GC chloramphenicol sodium succinate inj 1gm 1 G HI CILOXAN OINT 0.3% CIPRO HC SUSP 0.2%; 1% CIPRODEX SUSP 0.3%; 0.1% ciprofloxacin er tb mg; 0 1 G GC ciprofloxacin er tb24 500mg; 0 1 G GC ciprofloxacin hcl soln 0.3% 1 G GC ciprofloxacin hcl tabs 100mg 1 G GC ciprofloxacin hcl tabs 250mg 1 G GC ciprofloxacin hcl tabs 750mg 1 G GC ciprofloxacin hydrochloride tabs 500mg 1 G GC ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% 1 G HI ciprofloxacin i.v.-in d5w inj 400mg/200ml; 5% 1 G HI ciprofloxacin inj 200mg/20ml 1 G HI ciprofloxacin inj 400mg/40ml 1 G HI ciprofloxacin susr 250mg/5ml 1 G GC ciprofloxacin susr 500mg/5ml 1 G GC Page 21

23 CLAFORAN/D5W INJ 1GM/50ML; 5% HI CLAFORAN/D5W INJ 2GM/50ML; 5% HI CLAFORAN INJ 1GM HI CLAFORAN INJ 2GM HI clarithromycin er tb24 500mg 1 G GC clarithromycin susr 125mg/5ml 1 G GC clarithromycin susr 250mg/5ml 1 G GC clarithromycin tabs 250mg 1 G GC clarithromycin tabs 500mg 1 G GC CLEOCIN SUPP 100MG clindacin etz pledgets swab 1% 1 G GC clindacin-p swab 1% 1 G GC clindamycin hcl caps 150mg 1 G GC clindamycin hcl caps 300mg 1 G GC clindamycin hcl caps 75mg 1 G GC clindamycin palmitate hcl solr 75mg/5ml 1 G GC clindamycin phosphate add-vantage inj 900mg/6ml 1 G HI clindamycin phosphate in d5w inj 300mg/50ml; 5% 1 G GC clindamycin phosphate in d5w inj 600mg/50ml; 5% 1 G GC clindamycin phosphate in d5w inj 900mg/50ml; 5% 1 G GC clindamycin phosphate crea 2% 1 G GC clindamycin phosphate foam 1% 1 G GC clindamycin phosphate gel 1% 1 G GC clindamycin phosphate inj 150mg/ml 1 G HI clindamycin phosphate inj 150mg/ml 1 G HI clindamycin phosphate inj 300mg/2ml 1 G HI clindamycin phosphate inj 600mg/4ml 1 G HI clindamycin phosphate inj 900mg/6ml 1 G HI clindamycin phosphate inj 900mg/6ml 1 G HI clindamycin phosphate lotn 1% 1 G GC clindamycin phosphate soln 1% 1 G GC clindamycin phosphate swab 1% 1 G GC CLINDAMYCIN/SODIUM CHLORIDE INJ 300MG/50ML; HI 0.9% CLINDAMYCIN/SODIUM CHLORIDE INJ 600MG/50ML; GC 0.9% CLINDAMYCIN/SODIUM CHLORIDE INJ 900MG/50ML; HI 0.9% clindamycin inj 900mg/6ml 1 G HI CLINDESSE CREA 2% colistimethate sodium inj 150mg 1 G HI CORTISPORIN CREA 0.5%; 3.5MG/GM; 10000UNIT/GM DALVANCE INJ 500MG 3 S HI DAPTOMYCIN INJ 350MG 3 S HI daptomycin inj 500mg 3 S HI demeclocycline hcl tabs 150mg 1 G GC Page 22

24 demeclocycline hcl tabs 300mg 1 G GC dicloxacillin sodium caps 250mg 1 G GC dicloxacillin sodium caps 500mg 1 G GC DIFICID TABS 200MG 3 S NDS DORIBAX INJ 250MG HI DORIBAX INJ 500MG HI doripenem inj 250mg 1 G HI doripenem inj 500mg 1 G HI doxy 100 inj 100mg 1 G HI doxycycline hyclate dr tbec 100mg 1 G GC doxycycline hyclate dr tbec 150mg 1 G GC doxycycline hyclate dr tbec 75mg 1 G GC doxycycline hyclate caps 100mg 1 G GC doxycycline hyclate caps 50mg 1 G GC doxycycline hyclate inj 100mg 1 G HI doxycycline hyclate tabs 100mg 1 G GC doxycycline hyclate tabs 150mg 1 G GC doxycycline hyclate tabs 20mg 1 G GC doxycycline hyclate tabs 75mg 1 G GC doxycycline monohydrate caps 100mg 1 G GC doxycycline monohydrate caps 150mg 1 G GC doxycycline monohydrate caps 50mg 1 G GC doxycycline monohydrate caps 75mg 1 G GC doxycycline monohydrate tabs 100mg 1 G GC doxycycline monohydrate tabs 150mg 1 G GC doxycycline monohydrate tabs 50mg 1 G GC doxycycline monohydrate tabs 75mg 1 G GC doxycycline susr 25mg/5ml 1 G GC e.e.s. 400 tabs 400mg 1 G GC ertapenem sodium inj 1gm 1 G HI ertapenem inj 1gm 1 G HI ERY-TAB TBEC 250MG ERY-TAB TBEC 333MG ERY-TAB TBEC 500MG ery pads 2% 1 G GC ERYPED 400 SUSR 400MG/5ML 3 S NDS ERYTHROCIN LACTOBIONATE INJ 500MG HI erythrocin stearate tabs 250mg 1 G GC erythromycin base tabs 250mg 1 G GC erythromycin base tabs 500mg 1 G GC erythromycin ethylsuccinate susr 200mg/5ml 1 G GC erythromycin ethylsuccinate tabs 400mg 1 G GC erythromycin gel 2% 1 G GC erythromycin oint 5mg/gm 1 G GC erythromycin pads 2% 1 G GC erythromycin soln 2% 1 G GC Page 23