2016 LIST OF COVERED DRUGS (FORMULARY)

Transcription

1 2016 LIST OF COVERED DRUGS (FORMULARY) WELLCARE ADVOCATE COMPLETE FIDA (MEDICARE-MEDICAID PLAN) This formulary was updated on 9/01/2015. If you have any questions, please contact WellCare Advocate Complete FIDA at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday or visit H2751_NY030536_MMP_FOR_ENG CMS Approved WellCare 2015 NY_06_15 NY6MMPFOR67979E_0615

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3 v v v v v v v v v This is a list of drugs that Participants can get in WellCare Advocate Complete FIDA. WellCare is a managed care plan that contracts with both the Medicare and New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check WellCare Advocate Complete FIDA s up-to-date List of Covered Drugs online at or by calling WellCare Advocate Complete FIDA Participant Services at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday. Limitations and restrictions may apply. For more information, call WellCare Participant Services or read the WellCare Advocate Complete FIDA Participant Handbook. There are no co-pays for any covered drugs. You can get this information for free in other formats, such as large print, Braille or audio. Call or TTY Our hours of operation are 8 a.m. to 8 p.m. Eastern, Monday Sunday. The call is free. You can get this information for free in other languages. Call and TTY/TDD 711 during 8 a.m. to 8 p.m. Eastern, Monday Sunday. The call is free. Puede obtener esta información gratis en otros idiomas. Llame al y TTY/TDD al 711 de 8 a.m. a 8 p.m., hora del este, de lunes a domingo. La llamada es gratis. v v v Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang yo. Rele nimewo ak TTY/TDD 711 depi 8 a.m. jiska 8 p.m. Lè Zòn Lès, Lendi Dimanch. Koutfil la gratis. Queste informazioni possono essere ottenute gratuitamente in altre lingue. Chiamare e TTY/TDD 711 dalle ore 8 alle 20, ora della costa orientale degli USA, dal lunedì alla domenica. La chiamata è gratuita. v v v The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by WellCare Advocate Complete FIDA. ICAN may be reached toll-free at or online at icannys.org.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 1

4 FREQUENTLY ASKED QUESTIONS (FAQ) Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page 9 are the drugs covered by WellCare Advocate Complete FIDA. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. u WellCare Advocate Complete FIDA will cover all drugs on the Drug List if: your doctor or other network prescriber says you need them to get better or stay healthy, the drug is medically necessary for your condition, and you fill the prescription at a WellCare Advocate Complete FIDA network pharmacy. u WellCare Advocate Complete FIDA may have additional steps to access certain drugs (see question #5 below). In some cases, you may have to do something before you can get a drug, like try other drugs first. You can also see an up-to-date list of drugs that we cover on our website at wellcareny.com/ or call Participant Services at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday. 2. Does the Drug List ever change? Yes. WellCare Advocate Complete FIDA may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a new drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page 3.)? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 2

5 We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug. Questions 3, 4 and 7 below have more information on what happens when the Drug List changes. u You can always check WellCare Advocate Complete FIDA s up-to-date Drug List online at You can also call Participant Services to check the current Drug List at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday. 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If a cheaper drug becomes available that works as well as a drug on the Drug List now: Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now. WellCare Advocate Complete FIDA may decide to take the more expensive drug off of the Drug List. If you are taking a drug that we remove from the Drug List because a cheaper drug that works just as well comes along, we will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. If there is a change to coverage for a drug you are taking, WellCare Advocate Complete FIDA will mail you a letter to tell you. 4. What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter and call you to tell you that the unsafe drug was taken off the Drug List. Your provider will also know about this change. After you receive this notice in the mail, you can work with your provider to find another drug for your condition. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) before you fill your prescription. If you don t get approval, WellCare Advocate Complete FIDA may not cover the drug. Quantity limits: Sometimes WellCare Advocate Complete FIDA limits the amount of a drug you can get. Step therapy: Sometimes WellCare Advocate Complete FIDA requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 3

6 You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 9. You can also get more information by visiting our Web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can also ask for an exception from these limits. Please see question 11 for more information on exceptions. u If you are in a nursing facility or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31- day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new WellCare Advocate Complete FIDA Participant. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 9 has a column labeled Necessary actions, restrictions, or limits on use. 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section on page 177. Then look for the name of your drug in the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 9. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 4

7 9. What if the drug you want to take is not on the Drug List? If you don t see your drug on the Drug List, call Participant Services at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday and ask about it. If you learn that WellCare Advocate Complete FIDA will not cover the drug, you can do one of these things: Ask Participant Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. What if you are a new WellCare Advocate Complete FIDA Participant and can t find your drug on the Drug List or have a problem getting your drug? We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of WellCare Advocate Complete FIDA. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. We will cover up to 90 days of temporary supplies of your drug if: you are taking a drug that is not on our Drug List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT), or you are taking a drug that is part of a step therapy restriction. If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 93 days. You may refill the drug multiple times during your first 93 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception. If you experience a level of care change (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can call our Provider Service Center and request a one-time override. This one-time override will be up to a 31-day supply (unless you have a prescription written for fewer days). 11. Can you ask for an exception to cover your drug? Yes. You can ask WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the Drug List. You can also ask WellCare Advocate Complete FIDA or your IDT to change the rules on your drug.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 5

8 For example, WellCare Advocate Complete FIDA may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more. Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, you will get a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, you will get a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand-name drugs. They usually cost less than the brand-name drug and usually don t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). WellCare Advocate Complete FIDA covers both brand-name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. WellCare Advocate Complete FIDA covers some OTC drugs when they are written as prescriptions by your provider. You can read the WellCare Advocate Complete FIDA Drug List to see what OTC drugs are covered. 16. Does WellCare Advocate Complete FIDA cover OTC non-drug products? WellCare Advocate Complete FIDA covers some OTC non-drug products when they are written as prescriptions by your provider, e.g., alcohol prep pads, gauze pads, and insulin syringes. You can read the WellCare Advocate Complete FIDA Drug List to see what OTC non-drug products are covered. 17. What is your co-pay? You will not be charged a co-pay for drugs on the Drug List.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 6

9 18. What are drug tiers? Tier 1 (Generic) includes generic drugs covered under Medicare Part D. Tier 2 (Brand) includes brand drugs and generic drugs covered under Medicare Part D. Tier 3 (Non-Medicare Rx/OTC Drugs) includes generic & brand drugs covered under the Medicaid benefit. All tiers have no co-pay. List of Covered Drugs The list of covered drugs below gives you information about the drugs covered by WellCare Advocate Complete FIDA. If you have trouble finding your drug in the list, turn to the Index that begins on page 177. The first column of the chart lists the name of the drug. Brand-name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lowercase italics (e.g., simvastatin). The information in the necessary actions, restrictions, or limits on use column tells you if WellCare Advocate Complete FIDA has any rules for covering your drug. NM means the drug is not available by mail-order. Other pharmacies are available in our network. PA stands for Prior Authorization: Please see page 3 for details. B/D stands for Prior Authorization Restriction for Part B vs. Part D Determination: This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from WellCare Advocate Complete FIDA to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, WellCare Advocate Complete FIDA may not cover this drug. QL stands for Quantity Limits: Please see page 3 for details. LA stands for Limited Access medication. This medication is available from the Specialty Pharmacy, and may be available from certain other pharmacies. For more information, please refer to the Pharmacy section of your Provider and Pharmacy Directory or contact Participant Services at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday. ST stands for Step Therapy: Please see page 3 for details.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 7

10 Note: The ^ symbol next to a drug means the drug is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking for a review of and change to a coverage decision if you think there was a mistake. For example, WellCare Advocate Complete FIDA or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday Sunday or the Independent Consumer Advocacy Network (ICAN) at You can also read the Participant Handbook to learn how to appeal a decision. You can also read the Participant Handbook to learn how to appeal a decision.? (TTY: ), 8 a.m. to 8 p.m. Eastern, Monday-Sunday. The call is free. For more information, visit 8

11 List of Drugs by Medical Condition The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. NAME OF DRUG ANALGESICS GOUT allopurinol oral tablet 100, 300 colchicine-probenecid oral tablet COLCRYS ORAL TABLET 0.6 MG QL (120 EA per 30 days) probenecid oral tablet 500 ULORIC ORAL TABLET 40 MG, 80 MG ST NSAIDS celecoxib oral capsule 100, 200, 400, 50 QL (60 EA per 30 days) diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hr* 100 diclofenac sodium oral tablet delayed release 25, 50, 75 diflunisal oral tablet 500 etodolac er oral tablet extended release 24 hr* 400, 500, 600 9

12 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 400, 600, 800 ketoprofen oral capsule 50, 75 meloxicam oral suspension 7.5 /5ml meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 naproxen oral suspension 125 /5ml naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 275, 550 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 OPIOID ANALGESICS, CII duramorph injection solution 0.5 /ml, 1 /ml B/D 10

13 endocet oral tablet , 5-325, QL (360 EA per 30 days) fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg, 200 mcg, 400 PA; QL (120 EA per 30 days) mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hr 100 mcg/hr, 50 mcg/hr, 75 mcg/hr PA; QL (10 EA per 30 days) fentanyl transdermal patch 72 hr 12 mcg/hr, 25 mcg/hr QL (10 EA per 30 days) FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 PA; QL (120 EA per 30 days) MCG, 800 MCG hydrocodone-acetaminophen oral solution /15ml QL (5400 ML per 30 days) hydrocodone-acetaminophen oral tablet , 5-325, QL (360 EA per 30 days) hydrocodone-ibuprofen oral tablet QL (150 EA per 30 days) hydromorphone hcl oral liquid 1 /ml hydromorphone hcl oral tablet 2, 4, 8 QL (270 EA per 30 days) hydromorphone hcl pf injection solution 500 /50ml B/D lorcet hd oral tablet QL (360 EA per 30 days) lorcet oral tablet QL (360 EA per 30 days) lorcet plus oral tablet QL (360 EA per 30 days) lortab oral tablet , 5-325, QL (360 EA per 30 days) methadone hcl intensol oral concentrate 10 /ml QL (120 ML per 30 days) 11

14 methadone hcl oral solution 10 /5ml, 5 /5ml QL (600 ML per 30 days) methadone hcl oral tablet 10, 5 QL (240 EA per 30 days) morphine sulfate (concentrate) oral solution 20 /ml morphine sulfate (pf) injection solution 0.5 /ml, 1 /ml B/D morphine sulfate (pf) intravenous* solution 10 /ml, 15 /ml, 2 B/D /ml, 4 /ml, 8 /ml morphine sulfate er beads oral capsule extended release 24 hour 120, 30, 45, 60, 75 QL (60 EA per 30 days), 90 morphine sulfate er oral capsule extended release 24 hour 10, 20 QL (60 EA per 30 days), 30, 50, 60 morphine sulfate er oral capsule extended release 24 hour 100, QL (60 EA per 30 days) 80 morphine sulfate er oral tablet extendedrelease* 100, 15, QL (90 EA per 30 days) 30, 60 morphine sulfate er oral tablet extendedrelease* 200 QL (60 EA per 30 days) morphine sulfate intravenous* solution 1 /ml B/D morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 QL (180 EA per 30 days) oxycodone hcl oral capsule 5 QL (180 EA per 30 days) 12

15 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 15, 20, 30, 5 QL (180 EA per 30 days) oxycodone-acetaminophen oral tablet , , QL (360 EA per 30 days) 5-325, roxicet oral solution /5ml QL (1800 ML per 30 days) OPIOID ANALGESICS acetaminophen-codeine #2 oral tablet QL (400 EA per 30 days) acetaminophen-codeine #3 oral tablet QL (400 EA per 30 days) acetaminophen-codeine #4 oral tablet QL (400 EA per 30 days) acetaminophen-codeine oral solution /5ml QL (5000 ML per 30 days) butorphanol tartrate injection solution 1 /ml, 2 /ml nalbuphine hcl injection solution 10 /ml, 20 /ml tramadol hcl oral tablet 50 QL (240 EA per 30 days) tramadol-acetaminophen oral tablet QL (240 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (pf) injection solution 0.5 %, 1 % B/D lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %, 2 % B/D 13

16 ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate injection solution 1 gm/4ml, 500 /2ml gentamicin in saline intravenous* solution /ml-%, /ml-%, /ml-%, /ml-%, /ml-%, /ml-%, /ml-% gentamicin sulfate injection solution 10 /ml, 40 /ml gentamicin sulfate intravenous* solution 10 /ml neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 streptomycin sulfate intramuscular* solution reconstituted 1 gm sulfadiazine oral tablet 500 tobramycin inhalation nebulization solution 300 /5ml B/D tobramycin sulfate in saline intravenous* solution /ml-% tobramycin sulfate injection solution 1.2 gm/30ml, 10 /ml, 2 gm/50ml, 80 /2ml tobramycin sulfate injection solution reconstituted 1.2 gm 14

17 ANTIFUNGALS ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML B/D AMBISOME INTRAVENOUS* SUSPENSION RECONSTITUTED 50 B/D MG amphotericin b injection solution reconstituted 50 B/D CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG, 70 MG fluconazole in dextrose intravenous* solution 200 /100ml, 400 /200ml fluconazole in sodium chloride intravenous* solution /100ml-%, /200ml-% fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 flucytosine oral capsule 250, 500 griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 PA ketoconazole oral tablet 200 PA 15

18 MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 50 MG NOXAFIL ORAL SUSPENSION 40 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin oral tablet unit terbinafine hcl oral tablet 250 QL (90 EA per 365 days) voriconazole intravenous* solution reconstituted 200 voriconazole oral suspension reconstituted 40 /ml voriconazole oral tablet 200, 50 ANTI-INFECTIVES - MISCELLANEOUS ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5ml AZACTAM IN DEXTROSE INTRAVENOUS* SOLUTION 1 GM, 2 GM aztreonam injection solution reconstituted 1 gm, 2 gm BILTRICIDE ORAL TABLET 600 MG CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG PA; LA 16

19 clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate in d5w intravenous* solution 300 /50ml, 600 /50ml, 900 /50ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml, 9000 /60ml clindamycin phosphate intravenous* solution 300 /2ml, 600 /4ml, 900 /6ml colistimethate sodium injection solution reconstituted 150 CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG dapsone oral tablet 100, 25 DARAPRIM ORAL TABLET 25 MG imipenem-cilastatin intravenous* solution reconstituted 250, 500 INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM INVANZ INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM ivermectin oral tablet 3 linezolid intravenous* solution 2 /ml LINEZOLID ORAL TABLET 600 MG 17

20 meropenem intravenous* solution reconstituted 1 gm, 500 methenamine hippurate oral tablet 1 gm metronidazole in nacl intravenous* solution /100ml-% metronidazole oral tablet 250, 500 NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG B/D nitrofurantoin macrocrystal oral capsule 100, 50 PA nitrofurantoin monohyd macro oral capsule 100 PA PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG SIVEXTRO INTRAVENOUS* SOLUTION RECONSTITUTED 200 MG SIVEXTRO ORAL TABLET 200 MG sulfamethoxazole-tmp ds oral tablet sulfamethoxazole-trimethoprim intravenous* solution /5ml sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet SYNERCID INTRAVENOUS* SOLUTION RECONSTITUTED MG trimethoprim oral tablet

21 TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG vancomycin hcl intravenous* solution reconstituted 10 gm, 1000, 500, 5000, 750 vancomycin hcl oral capsule 125, 250 ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ZYVOX ORAL TABLET 600 MG ANTIMALARIALS atovaquone-proguanil hcl oral tablet , chloroquine phosphate oral tablet 250, 500 COARTEM ORAL TABLET MG mefloquine hcl oral tablet 250 PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG quinine sulfate oral capsule 324 PA ANTIRETROVIRAL AGENTS abacavir sulfate oral tablet 300 APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine oral capsule delayed release 125, 200, 250, 400 EDURANT ORAL TABLET 25 MG 19

22 EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG lamivudine oral solution 10 /ml lamivudine oral tablet 150, 300 LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine er oral tablet extended release 24 hr* 400 nevirapine oral suspension 50 /5ml nevirapine oral tablet 200 NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 20

23 RESCRIPTOR ORAL TABLET 100 MG, 200 MG RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15, 20, 30, 40 stavudine oral solution reconstituted 1 /ml SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 50 MG TYBOST ORAL TABLET 150 MG VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule

24 zidovudine oral syrup 50 /5ml zidovudine oral tablet 300 ANTIRETROVIRAL COMBINATION AGENTS abacavir-lamivudine-zidovudine oral tablet ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG KALETRA ORAL SOLUTION MG/5ML KALETRA ORAL TABLET MG, MG lamivudine-zidovudine oral tablet PREZCOBIX ORAL TABLET MG STRIBILD ORAL TABLET MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG QL (30 EA per 30 days) ANTITUBERCULAR AGENTS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM cycloserine oral capsule

25 ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 paser oral packet 4 gm PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin intravenous* solution reconstituted 600 rifampin oral capsule 150, 300 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG PA; LA TRECATOR ORAL TABLET 250 MG ANTIVIRALS acyclovir oral capsule 200 acyclovir oral suspension 200 /5ml acyclovir oral tablet 400, 800 acyclovir sodium intravenous* solution 50 /ml B/D acyclovir sodium intravenous* solution reconstituted 500 B/D adefovir dipivoxil oral tablet 10 23

26 BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, 1 EPIVIR HBV ORAL SOLUTION 5 MG/ML famciclovir oral tablet 125, 250, 500 foscarnet sodium intravenous* solution 24 /ml ganciclovir sodium intravenous* solution reconstituted 500 B/D HARVONI ORAL TABLET MG PA lamivudine oral tablet 100 MODERIBA 1200 DOSE PACK ORAL TABLET 600 MG moderiba 800 dose pack oral tablet 400 moderiba oral 200 & 400, 400 & 600 moderiba oral tablet 200 PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 PA MCG/0.5ML, 80 MCG/0.5ML PEGINTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, PA 80 MCG/0.5ML PEG-INTRON SUBCUTANEOUS* KIT 50 MCG/0.5ML PA REBETOL ORAL SOLUTION 40 MG/ML 24

27 RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER ribasphere oral capsule 200 ribasphere oral tablet 200, 400 ribasphere oral tablet 600 ribasphere ribapak oral tablet 200 & 400, 400 & 600, 400, 600 ribavirin oral capsule 200 ribavirin oral tablet 200 rimantadine hcl oral tablet 100 SOVALDI ORAL TABLET 400 MG PA TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML TYZEKA ORAL TABLET 600 MG valacyclovir hcl oral tablet 1 gm, 500 VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML valganciclovir hcl oral tablet 450 CEPHALOSPORINS cefaclor er oral tablet extended release 12 hr* 500 cefaclor oral capsule 250, 500 cefaclor oral suspension reconstituted 125 /5ml, 250 /5ml, 375 /5ml 25

28 cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 20 gm, 500 cefazolin sodium intravenous* solution 1-5 gm-% cefazolin sodium intravenous* solution reconstituted 1 gm cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefepime hcl injection solution reconstituted 1 gm, 2 gm cefixime oral suspension reconstituted 100 /5ml, 200 /5ml cefotaxime sodium injection solution reconstituted 1 gm, 2 gm, 500 cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous* solution reconstituted 1 gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100,

29 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 CEFTAZIDIME AND DEXTROSE INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM/50ML, 2 GM/50ML ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250, 500 ceftriaxone sodium intravenous* solution reconstituted 1 gm, 10 gm, 2 gm cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 cefuroxime sodium intravenous* solution reconstituted 1.5 gm, 7.5 gm cephalexin oral capsule 250, 500 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML 27

30 suprax oral tablet chewable 100, 200 tazicef injection solution reconstituted 1 gm, 2 gm, 6 gm tazicef intravenous* solution reconstituted 1 gm, 2 gm TEFLARO INTRAVENOUS* SOLUTION RECONSTITUTED 400 MG, 600 MG ERYTHROMYCINS/MACROLIDES azithromycin intravenous* solution reconstituted 500 azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 /5ml, 200 /5ml azithromycin oral tablet 250, 500, 600 clarithromycin er oral tablet extended release 24 hr* 500 clarithromycin oral suspension reconstituted 125 /5ml, 250 /5ml clarithromycin oral tablet 250, 500 DIFICID ORAL TABLET 200 MG e.e.s. 400 oral tablet 400 ery-tab oral tablet delayed release 250, 333, 500 erythrocin lactobionate intravenous* solution reconstituted 500 erythrocin stearate oral tablet

31 erythromycin base oral capsule delayed release particles 250 erythromycin base oral tablet 250, 500 erythromycin ethylsuccinate oral tablet 400 FLUOROQUINOLONES ciprofloxacin hcl oral tablet 100, 250, 500, 750 ciprofloxacin in d5w intravenous* solution 200 /100ml, 400 /200ml ciprofloxacin intravenous* solution 200 /20ml, 400 /40ml ciprofloxacin oral suspension reconstituted 250 /5ml (5%), 500 /5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr* 1000, 500 levofloxacin in d5w intravenous* solution 250 /50ml, 500 /100ml, 750 /150ml levofloxacin intravenous* solution 25 /ml levofloxacin oral solution 25 /ml levofloxacin oral tablet 250, 500, 750 PENICILLINS amoxicillin oral capsule 250,

32 amoxicillin oral suspension reconstituted 125 /5ml, 200 /5ml, 250 /5ml, 400 /5ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 125, 250 amoxicillin-pot clavulanate er oral tablet extended release 12 hr* amoxicillin-pot clavulanate oral suspension reconstituted /5ml, /5ml, /5ml, /5ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet chewable , ampicillin oral capsule 250, 500 ampicillin oral suspension reconstituted 125 /5ml, 250 /5ml ampicillin sodium injection solution reconstituted 1 gm, 125, 2 gm, 250, 500 ampicillin sodium intravenous* solution reconstituted 1 gm, 10 gm, 2 gm 30

33 ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm ampicillin-sulbactam sodium intravenous* solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm BICILLIN L-A INTRAMUSCULAR* SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML dicloxacillin sodium oral capsule 250, 500 nafcillin sodium injection solution reconstituted 1 gm nafcillin sodium injection solution reconstituted 10 gm, 2 gm nafcillin sodium intravenous* solution reconstituted 1 gm nafcillin sodium intravenous* solution reconstituted 2 gm oxacillin sodium injection solution reconstituted 1 gm, 2 gm oxacillin sodium injection solution reconstituted 10 gm PENICILLIN G POT IN DEXTROSE INTRAVENOUS* SOLUTION UNIT/ML, UNIT/ML penicillin g potassium injection solution reconstituted unit, unit 31

34 penicillin g procaine intramuscular* suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 125 /5ml, 250 /5ml penicillin v potassium oral tablet 250, 500 piperacillin sod-tazobactam so intravenous* solution reconstituted gm, gm, gm, gm TETRACYCLINES doxy 100 intravenous* solution reconstituted 100 doxycycline hyclate intravenous* solution reconstituted 100 doxycycline hyclate oral capsule 100, 50 doxycycline hyclate oral tablet 100, 20 doxycycline monohydrate oral capsule 100, 50 doxycycline monohydrate oral tablet 100, 150, 50, 75 minocycline hcl oral capsule 100, 50, 75 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG B/D 32

35 BUSULFEX INTRAVENOUS* SOLUTION 6 MG/ML B/D cyclophosphamide injection solution reconstituted 1 gm, 500 B/D cyclophosphamide injection solution reconstituted 2 gm B/D CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG B/D dacarbazine intravenous* solution reconstituted 200 B/D EMCYT ORAL CAPSULE 140 MG HEXALEN ORAL CAPSULE 50 MG IFEX INTRAVENOUS* SOLUTION RECONSTITUTED 3 GM B/D ifosfamide intravenous* solution 1 gm/20ml, 3 gm/60ml B/D ifosfamide intravenous* solution reconstituted 1 gm B/D IFOSFAMIDE INTRAVENOUS* SOLUTION RECONSTITUTED 3 GM B/D LEUKERAN ORAL TABLET 2 MG lomustine oral capsule 10, 100, 40 melphalan hcl intravenous* solution reconstituted 50 B/D MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG B/D TREANDA INTRAVENOUS* SOLUTION 180 MG/2ML, 45 MG/0.5ML B/D TREANDA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 25 MG B/D 33

36 ANTHRACYCLINES adriamycin intravenous* solution reconstituted 50 daunorubicin hcl intravenous* injectable 5 /ml doxorubicin hcl intravenous* solution 2 /ml doxorubicin hcl intravenous* solution reconstituted 50 doxorubicin hcl liposomal intravenous* injectable 2 /ml epirubicin hcl intravenous* solution 200 /100ml, 50 /25ml idarubicin hcl intravenous* solution 10 /10ml, 20 /20ml, 5 /5ml ANTIBIOTICS bleomycin sulfate injection solution reconstituted 15 unit, 30 unit mitomycin intravenous* solution reconstituted 20, 40, 5 ANTIMETABOLITES adrucil intravenous* solution 2.5 gm/50ml, 5 gm/100ml, 500 /10ml ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 500 MG azacitidine injection suspension reconstituted 100 cladribine intravenous* solution 1 /ml B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D 34

37 cytarabine injection solution 20 /ml B/D fludarabine phosphate intravenous* solution 50 /2ml B/D fludarabine phosphate intravenous* solution reconstituted 50 B/D fluorouracil intravenous* solution 1 gm/20ml, 2.5 gm/50ml, 500 B/D /10ml GEMCITABINE HCL INTRAVENOUS* SOLUTION 1 GM/26.3ML, 2 B/D GM/52.6ML, 200 MG/5.26ML gemcitabine hcl intravenous* solution reconstituted 1 gm, 2 gm, B/D 200 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection solution 1 gm/40ml B/D methotrexate sodium injection solution 25 /ml B/D methotrexate sodium injection solution reconstituted 1 gm B/D NIPENT INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG B/D PURIXAN ORAL SUSPENSION 2000 MG/100ML TABLOID ORAL TABLET 40 MG ANTIMITOTIC, TAXOIDS ABRAXANE INTRAVENOUS* SUSPENSION RECONSTITUTED 100 MG B/D 35

38 docetaxel intravenous* concentrate 140 /7ml DOCETAXEL INTRAVENOUS* CONCENTRATE 20 MG/ML, 80 MG/4ML DOCETAXEL INTRAVENOUS* SOLUTION 200 MG/20ML, 80 MG/8ML paclitaxel intravenous* concentrate 100 /16.7ml, 150 /25ml, 30 /5ml, 300 /50ml ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate intravenous* solution 1 /ml vincasar pfs intravenous* solution 1 /ml vincristine sulfate intravenous* solution 1 /ml vinorelbine tartrate intravenous* solution 10 /ml, 50 /5ml BIOLOGIC RESPONSE MODIFIERS B/D B/D B/D B/D B/D B/D B/D B/D AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML B/D; LA BELEODAQ INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG PA ERIVEDGE ORAL CAPSULE 150 MG PA; LA FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG PA; LA HERCEPTIN INTRAVENOUS* SOLUTION RECONSTITUTED 440 MG B/D IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG PA; LA 36

39 ISTODAX INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG B/D KADCYLA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 160 MG B/D KEYTRUDA INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG PA LYNPARZA ORAL CAPSULE 50 MG PA; LA PROLEUKIN INTRAVENOUS* SOLUTION RECONSTITUTED B/D UNIT RITUXAN INTRAVENOUS* CONCENTRATE 10 MG/ML PA; LA VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG B/D YERVOY INTRAVENOUS* SOLUTION 50 MG/10ML PA ZOLINZA ORAL CAPSULE 100 MG PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole oral tablet 1 bicalutamide oral tablet 50 DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 400 MG/ML B/D exemestane oral tablet 25 FARESTON ORAL TABLET 60 MG FASLODEX INTRAMUSCULAR* SOLUTION 250 MG/5ML B/D flutamide oral capsule 125 letrozole oral tablet 2.5 leuprolide acetate injection kit 1 /0.2ml PA 37

40 LUPRON DEPOT INTRAMUSCULAR* KIT MG, 3.75 MG PA LUPRON DEPOT-PED INTRAMUSCULAR* KIT MG, MG (PED), 15 MG, 30 MG PA (PED), 7.5 MG LYSODREN ORAL TABLET 500 MG MEGACE ES ORAL SUSPENSION 625 MG/5ML PA megestrol acetate oral suspension 40 /ml PA megestrol acetate oral tablet 20, 40 PA NILANDRON ORAL TABLET 150 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML tamoxifen citrate oral tablet 10, 20 TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED MG, 3.75 PA MG XTANDI ORAL CAPSULE 40 MG PA; LA ZYTIGA ORAL TABLET 250 MG PA; LA KINASE INHIBITORS AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG BOSULIF ORAL TABLET 100 MG, 500 MG PA PA PA 38

41 CAPRELSA ORAL TABLET 100 MG, 300 MG PA; LA COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG PA; LA COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG PA; LA COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG PA; LA GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA; LA GLEEVEC ORAL TABLET 100 MG, 400 MG PA ICLUSIG ORAL TABLET 15 MG, 45 MG PA; LA IMBRUVICA ORAL CAPSULE 140 MG PA; LA INLYTA ORAL TABLET 1 MG, 5 MG PA; LA JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG PA; LA LENVIMA 10 MG DAILY DOSE ORAL 10 MG PA; LA LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG PA; LA LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG PA; LA LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG PA; LA MEKINIST ORAL TABLET 0.5 MG, 2 MG PA; LA NEXAVAR ORAL TABLET 200 MG PA; LA SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG PA 39

42 STIVARGA ORAL TABLET 40 MG PA; LA SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG PA TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA; LA TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG PA; LA TASIGNA ORAL CAPSULE 150 MG, 200 MG PA TYKERB ORAL TABLET 250 MG PA; LA VOTRIENT ORAL TABLET 200 MG PA; LA XALKORI ORAL CAPSULE 200 MG, 250 MG PA; LA ZELBORAF ORAL TABLET 240 MG PA; LA ZYDELIG ORAL TABLET 100 MG, 150 MG PA; LA ZYKADIA ORAL CAPSULE 150 MG PA; LA MISCELLANEOUS DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG hydroxyurea oral capsule 500 MATULANE ORAL CAPSULE 50 MG LA mitoxantrone hcl intravenous* concentrate 20 /10ml, 25 B/D /12.5ml, 30 /15ml POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PA; LA SYLATRON SUBCUTANEOUS* KIT 200 MCG, 300 MCG, 4 X 200 MCG, PA 4 X 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS* SOLUTION RECONSTITUTED 3.5 MG PA 40

43 TARGRETIN ORAL CAPSULE 75 MG PA tretinoin oral capsule 10 TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML B/D PLATINUM-BASED AGENTS carboplatin intravenous* solution 150 /15ml, 450 /45ml, 50 /5ml, 600 /60ml cisplatin intravenous* solution 100 /100ml, 200 /200ml, 50 /50ml oxaliplatin intravenous* solution 100 /20ml, 50 /10ml oxaliplatin intravenous* solution reconstituted 100, 50 PROTECTIVE AGENTS amifostine intravenous* solution reconstituted 500 dexrazoxane intravenous* solution reconstituted 250 ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG FUSILEV INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG leucovorin calcium injection solution reconstituted 100, 200, 350, 50, 500 leucovorin calcium oral tablet 10, 15, 25, 5 levoleucovorin calcium intravenous* solution 175 /17.5ml B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D 41

44 mesna intravenous* solution 100 /ml B/D MESNEX ORAL TABLET 400 MG TOPOISOMERASE INHIBITORS etoposide intravenous* solution 500 /25ml irinotecan hcl intravenous* solution 100 /5ml, 40 /2ml, 500 /25ml toposar intravenous* solution 1 gm/50ml topotecan hcl intravenous* solution reconstituted 4 CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besy-benazepril hcl oral capsule 10-20, , 5-10, 5-20, 5-40 amlodipine besy-benazepril hcl oral capsule benazepril-hydrochlorothiazide oral tablet , , 20-25, captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet 10-25, fosinopril sodium-hctz oral tablet , B/D B/D B/D B/D QL (30 EA per 30 days) 42

45 lisinopril-hydrochlorothiazide oral tablet , , moexipril-hydrochlorothiazide oral tablet , 15-25, quinapril-hydrochlorothiazide oral tablet , , ACE INHIBITORS benazepril hcl oral tablet 10, 20, 40, 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2, 4, 8 quinapril hcl oral tablet 10, 20, 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 trandolapril oral tablet 1, 2, 4 43

46 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone oral tablet 25, 50 spironolactone oral tablet 100, 25, 50 ALPHA BLOCKERS doxazosin mesylate oral tablet 1, 2, 4 QL (30 EA per 30 days) doxazosin mesylate oral tablet 8 prazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 1, 10, 2, 5 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan oral tablet , 5-160, QL (30 EA per 30 days) amlodipine besylate-valsartan oral tablet amlodipine-valsartan-hctz oral tablet , QL (30 EA per 30 days), amlodipine-valsartan-hctz oral tablet amlodipine-valsartan-hctz oral tablet QL (60 EA per 30 days) AZOR ORAL TABLET MG, 5-20 MG, 5-40 MG QL (30 EA per 30 days) AZOR ORAL TABLET MG 44

47 BENICAR HCT ORAL TABLET MG, MG, MG irbesartan-hydrochlorothiazide oral tablet , losartan potassium-hctz oral tablet , , TRIBENZOR ORAL TABLET MG, MG, MG, MG TRIBENZOR ORAL TABLET MG valsartan-hydrochlorothiazide oral tablet , , , , ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG irbesartan oral tablet 150, 300, 75 losartan potassium oral tablet 100, 25, 50 valsartan oral tablet 160, 320, 40, 80 ANTIARRHYTHMICS amiodarone hcl intravenous* solution 150 /3ml, 450 /9ml, 900 /18ml QL (30 EA per 30 days) 45

48 amiodarone hcl oral tablet 100, 200, 400 disopyramide phosphate oral capsule 100, 150 PA flecainide acetate oral tablet 100, 150, 50 mexiletine hcl oral capsule 150, 200, 250 MULTAQ ORAL TABLET 400 MG NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 PA MG, 150 MG pacerone oral tablet 100, 200, 400 propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 propafenone hcl oral tablet 150, 225, 300 quinidine gluconate er oral tablet extendedrelease* 324 quinidine sulfate oral tablet 200, 300 sorine oral tablet 120, 160, 240, 80 sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG 46

49 ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 10, 20, 40, 80 QL (30 EA per 30 days) CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG QL (30 EA per 30 days) lovastatin oral tablet 10 QL (30 EA per 30 days) lovastatin oral tablet 20 QL (120 EA per 30 days) lovastatin oral tablet 40 QL (60 EA per 30 days) pravastatin sodium oral tablet 10, 20, 40, 80 QL (30 EA per 30 days) simvastatin oral tablet 10, 20, 40, 5, 80 QL (30 EA per 30 days) ANTILIPEMICS, MISCELLANEOUS cholestyramine light oral packet 4 gm cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral packet 5 gm colestipol hcl oral tablet 1 gm fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 160, 48, 54 fenofibric acid oral capsule delayed release 135, 45 gemfibrozil oral tablet

50 JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 PA; LA MG KYNAMRO SUBCUTANEOUS* 200 MG/ML PA niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000, 750 niacin er (antihyperlipidemic) oral tablet extendedrelease* 500 QL (90 EA per 30 days) niacor oral tablet 500 omega-3-acid ethyl esters oral capsule 1 gm prevalite oral powder 4 gm/dose VASCEPA ORAL CAPSULE 1 GM WELCHOL ORAL PACKET 3.75 GM WELCHOL ORAL TABLET 625 MG ZETIA ORAL TABLET 10 MG BETA-BLOCKER/DIURETIC COMBINATIONS atenolol-chlorthalidone oral tablet , bisoprolol-hydrochlorothiazide oral tablet , , metoprolol-hydrochlorothiazide oral tablet , , propranolol-hctz oral tablet 40-25,