Rocky Mountain Health Plans 2016 Premier Medicare Formulary (List of Covered Drugs)

Transcription

1 Rocky Mountain Health Plans 016 Premier Medicare Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on July 1, 016. For more recent information or other questions, please contact Rocky Mountain Health Plans (RMHP) Customer Service at (TTY users should call 711 for Relay Colorado). Hours are 8:00 a.m. to 8:00 p.m., Mountain Time, October 1 - February 1, 7 days/week; February 1-September 0, Monday-Friday, or visit 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 RMHP. When it refers to plan or our plan, it means RMHP. This document includes a list of the drugs (formulary) for our plan which is current as of July 1, 016. 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, 017, and from time to time during the year. RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits may change on January 1 of each year. The formulary may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call our Customer Service at (TTY dial 711). Hours are 8am - 8pm, 7 days/week, Oct.1 Feb.1, and 8am - 8pm, M-F, Feb.1 Sept.0. Esta información está disponible gratuitamente en otros idiomas. Por favor llame a la línea de Atención a Clientes, al (TTY marque 711). Horario de 8am - 8pm, 7 días a la semana, del 1 de octubre al 1 de febrero; y 8am - 8pm, de lunes a viernes, del 1 de febrero al 0 de septiembre. H060_PH_PremierFormulary_ Populated Template Version 16 FORM-Premier

2 What is the Rocky Mountain Health Plans Formulary? A formulary is a list of covered drugs which represents the prescription therapies believed to be a necessary part of a quality treatment program. RMHP will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a RMHP 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 016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 016 coverage year. If a brand name drug becomes available as a cost saving generic, we may discontinue coverage of the brand name version or move it to a higher tier. We may remove a drug from the formulary for safety reasons if new information is released about the safety or effectiveness of a 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. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of July 1, 016. To get updated information about the drugs covered by RMHP, please contact us. Our contact information appears on the front and back cover pages. The only changes made to the formulary mid-year are maintenance drug changes. This means we may add new drugs to the formulary and we may move a brand name drug to a higher tier if a bioequivalent generic becomes available and is included in the formulary. RMHP does not make non-maintenance formulary changes mid-year. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition: The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page number. 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 I-1. 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. II

3 What are generic drugs? RMHP 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: RMHP 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, RMHP limits the amount of the drug that can be filled within a given amount of time. For example, RMHP provides 0 nitroglycerin patches for a 0 day supply. If you have a 90 day prescription benefit, you would multiply the quantity by to get the 90 day quantity limit. For example, RMHP covers 90 nitroglycerin patches for a 90 day supply (0 patches multiplied by ). Drugs that are subject to a quantity limit will have a QL symbol next to the drug. Refill Limitations: Prescriptions may be refilled when 7% or more of the day s supply has been used. Step Therapy: In some cases, RMHP requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Payment Determination: The Centers for Medicaid and Medicare Services (CMS) limits coverage of medications to medically-accepted uses. These uses are described in FDA approved drug labeling and in CMS approved drug research databases called Compendia. Some drugs are prescribed to treat conditions that are not FDA approved or Compendia supported. For this reason, CMS expects Part D sponsors like RMHP to have review procedures in place to make sure medications are being used for Part D covered conditions. These review procedures are called payment determinations. Medications commonly used for non-part D covered conditions will initially deny at the pharmacy until RMHP can determine if the drug is coverable under Part D. Examples of these drugs include, but are not limited to: Lidoderm patch (lidocaine), growth hormones, fentanyl products that dissolve in the mouth, botulinum toxins (Botox), wakepromoting drugs (Nuvigil, modafinil), drugs for the treatment of Pulmonary Arterial Hypertension (sildenafil, Adcirca), Flector patch and Cialis Daily (. and ). All of these medications can be used for conditions that are covered under Part D; however, if prescribed for a condition that is not covered by Part D the drug will deny and your pharmacy will provide you with the notice: Medicare Prescription Drug Coverage and Your Rights. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. 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. III

4 You can ask RMHP 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 RMHP formulary? below for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. CMS specifically excludes the following categories of medications from Part D coverage: Agents when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose (i.e., morbid obesity)). Agents when used to promote fertility. Agents when used for cosmetic purposes or hair growth. Agents when used for the symptomatic relief of cough and colds. Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations. Nonprescription drugs. Agents when used for the treatment of sexual or erectile dysfunction (ED). ED drugs will be covered under Part D when prescribed for conditions approved by the FDA other than sexual or erectile dysfunction (such as pulmonary hypertension). However, ED drugs will not be covered under Part D when used for conditions that are not FDA approved, even when the use is listed in one of the Compendia (e.g. American Hospital Formulary Service Drug Information, DRUGDEX Information System). If you learn that your drug is not excluded from Part D coverage, but RMHP does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by RMHP. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by RMHP. You can ask RMHP 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 RMHP Formulary? You can ask RMHP 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 your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level, if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, RMHP 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, RMHP 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. IV

5 You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting 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 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited; but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. When you have a level of care change (e.g. you are admitted to a Long Term Care facility), you may need additional supplies of your medications. When this occurs, the pharmacy can call the RMHP Pharmacy Help Desk to receive a transition supply of each affected drug. RMHP will not limit appropriate and necessary access to Part D benefits when you are being admitted to, or discharged from a Long Term Care facility. For more information For more detailed information about your RMHP prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about RMHP, 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 ( ) hours a day/7 days a week. TTY users should call Or, visit V

6 RMHP Formulary The formulary that begins on page provides coverage information about the drugs covered by RMHP. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ALLEGRA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if RMHP has any special requirements for coverage of your drug. The RMHP formulary key for the Requirements/Limits column is as follows: Drug Tier 1 Preferred Generic Drugs (lowest cost generic drugs) Drug Tier Generic Drugs Drug Tier Preferred Brand Drugs Drug Tier Non-Preferred Brand Drugs Drug Tier Specialty Drugs See the Summary of Benefits or Evidence of Coverage to determine how much you will pay for prescription drugs in each tier. The Evidence of Coverage will help you determine when drugs listed in the Part D Formulary may be covered under Part B. Drugs that appear with: italics = Generic drugs CAPITALIZATION = Brand name drugs VI

7 The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA BvD PA-HRM PA NSO QL ST Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction You (or your physician) are required to get prior authorization from RMHP before you fill your prescription for this drug. Without prior approval, RMHP may not cover this drug. 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 RMHP to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, RMHP may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 6 years or older. Members age 6 yrs or older are required to get prior authorization from RMHP before you fill your prescription for this drug. Without prior approval, RMHP may not cover this drug If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from RMHP before you fill your prescription for this drug. Without prior approval, RMHP may not cover this drug. RMHP limits the amount of this drug that is covered per prescription, or within a specific time frame. Before RMHP will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. The following additional coverage note abbreviations may be found within the body of this document OTHER SPECIAL REQUIREMENTS FOR COVERAGE ABBREVIATION DESCRIPTION EXPLANATION LA Limited Access Drug This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or call Customer Service at or (TTY users call 711.) We are available for phone calls 8:00 a.m. to 8:00 p.m., Mountain Time, (from October 1-February 1, 7 days/week and from February 1 - September 0, Monday - Friday). VII

8 Table of Contents Analgesics... Anesthetics... 9 Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials... 1 Anticancer Agents... 1 Anticholinergic Agents... 1 Anticonvulsants... 1 Antidementia Agents... Antidepressants... 6 Antidiabetic Agents... 9 Antifungals... Antihistamines... Anti-Infectives (Skin And Mucous Membrane)... 6 Antimigraine Agents... 6 Antimycobacterials... 7 Antinausea Agents... 7 Antiparasite Agents... 9 Antiparkinsonian Agents... 9 Antipsychotic Agents... 0 Antivirals (Systemic)... Blood Products/Modifiers/Volume Expanders... 9 Caloric Agents... 6 Cardiovascular Agents Central Nervous System Agents Contraceptives Dental And Oral Agents Dermatological Agents Devices... 9 Enzyme Replacement/Modifiers... 9 Eye, Ear, Nose, Throat Agents... 9 Gastrointestinal Agents Genitourinary Agents

9 Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents... 1 Replacement Preparations... 1 Respiratory Tract Agents Skeletal Muscle Relaxants... 1 Sleep Disorder Agents... 1 Vasodilating Agents... 1 Vitamins And Minerals... 1

10 Analgesics Analgesics, Miscellaneous acetaminophen-codeine 10-1 / ml solution 10-1 / ml acetaminophen-codeine oral solution 00-0 /1. ml acetaminophen-codeine oral tablet 00-1, 00-0 acetaminophen-codeine oral tablet (Acetaminophen with Codeine) QL (700 per 0 (Acetaminophen with QL (700 per 0 Codeine) (Tylenol-Codeine No.) QL (60 per 0 (Tylenol-Codeine No.) QL (180 per 0 ALLZITAL ORAL TABLET - MG ascomp with codeine oral capsule (Fiorinal with Codeine #) PA-HRM; QL (180 per 0 BELBUCA BUCCAL FILM 10 MCG, 00 MCG, 0 MCG, 600 MCG, 7 MCG, 70 MCG, 900 MCG ST; QL (60 per 0 buprenorphine hcl injection syringe 0. (Buprenorphine HCl) /ml butalbital compound w/codeine oral capsule (Fiorinal with Codeine #) PA-HRM; QL (180 per 0 butalbital-acetaminop-caf-cod oral capsule , (Fioricet with Codeine) PA-HRM; QL (180 per 0 butalbital-acetaminophen oral tablet 0- (Tencon) PA-HRM; QL (180 per 0 butalbital-acetaminophen-caff oral capsule 0--0 (Esgic) PA-HRM; QL (180 per 0 butalbital-acetaminophen-caff oral tablet 0--0 (Esgic) PA-HRM; QL (180 per 0 butalbital-aspirin-caffeine oral capsule 0--0 (Fiorinal) PA-HRM; QL (180 per 0 butorphanol tartrate nasal spray,nonaerosol (Butorphanol Tartrate) QL ( per 8 10 /ml BUTRANS TRANSDERMAL PATCH QL ( per 8 WEEKLY 10 MCG/HOUR, 1 MCG/HOUR, 0 MCG/HOUR, MCG/HOUR, 7. MCG/HOUR capacet oral capsule 0--0 (Esgic) PA-HRM; QL (180 per 0

11 codeine sulfate oral tablet 1, 0, (Codeine Sulfate) QL (180 per 0 60 EMBEDA ORAL CAPSULE,ORAL QL (60 per 0 ONLY,EXT.REL PELL 100- MG, MG, 0-1. MG, 0- MG, 60-. MG, 80-. MG endocet oral tablet 10-,.- (Xolox) QL (60 per 0, -, 7.- endodan oral tablet.8- (Percodan) QL (60 per 0 fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, (Actiq) PA; QL (10 per 0 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 (Duragesic) QL (10 per 0 mcg/hr, 1 mcg/hr, mcg/hr, 7. mcg/hour, 0 mcg/hr, 6. mcg/hour, 7 mcg/hr, 87. mcg/hour hydrocodone-acetaminophen oral solution 10- /1 ml(1 ml),.-167 / ml, 7.- /1 ml (Hycet) QL (700 per 0 hydrocodone-acetaminophen oral tablet 10-00, -00, (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 hydrocodone-acetaminophen oral tablet (Norco) QL (60 per 0 10-,.-, -, 7.- hydrocodone-ibuprofen oral tablet (Ibudone) QL (10 per 0,.-00, -00, hydromorphone (pf) injection solution 10 (Dilaudid-HP) /ml hydromorphone (pf) injection solution (Dilaudid) /ml hydromorphone injection solution /ml (Hydromorphone HCl) hydromorphone injection syringe /ml (Hydromorphone HCl) hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 0 hydromorphone oral tablet, (Dilaudid) QL (180 per 0 hydromorphone oral tablet 8 (Dilaudid) QL (0 per 0

12 HYSINGLA ER ORAL TABLET,ORAL QL (0 per 0 ONLY,EXT.REL. HR 100 MG, 10 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- PA; QL (0 per 0 AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY lorcet (hydrocodone) oral tablet - (Norco) QL (60 per 0 lorcet hd oral tablet 10- (Norco) QL (60 per 0 lorcet plus oral tablet 7.- (Norco) QL (60 per 0 margesic oral capsule 0--0 (Esgic) PA-HRM; QL (180 per 0 methadone injection solution 10 /ml (Methadone HCl) methadone oral solution 10 / ml, (Methadone HCl) QL (1800 per 0 / ml methadone oral tablet 10, (Diskets) QL (60 per 0 methadose oral tablet,soluble 0 (Diskets) QL (90 per 0 morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia syring 0 / ml ( /ml) (Morphine Sulfate/0.9% Nacl/PF) morphine 10 /ml carpuject 10 /ml (Morphine Sulfate) morphine /ml carpuject /ml (Morphine Sulfate) morphine /ml carpuject /ml (Morphine Sulfate) morphine 8 /ml syringe 8 /ml (Morphine Sulfate) morphine concentrate oral solution 100 (Morphine Sulfate) QL (00 per 0 / ml (0 /ml) morphine concentrate oral syringe 0 (Morphine Sulfate) /ml morphine in dextrose % injection pt (Morphine controlled analgesia syring 100 /0 ml ( /ml), 0 / ml ( /ml) Sulfate/DW) morphine injection solution 1 /ml, 8 (Morphine Sulfate) /ml morphine injection syringe 10 /ml (Morphine Sulfate) morphine intramuscular pen injector 10 (Morphine Sulfate) /0.7 ml morphine intravenous cartridge 1 /ml (Morphine Sulfate) morphine intravenous solution /ml, 0 /ml (Morphine Sulfate)

13 morphine intravenous syringe 10 /ml, (Morphine Sulfate) /ml, /ml, 8 /ml morphine oral solution 10 / ml (Morphine Sulfate) QL (700 per 0 morphine oral solution 0 / ml ( (Morphine Sulfate) QL (00 per 0 /ml) MORPHINE ORAL TABLET 1 MG, 0 QL (180 per 0 MG morphine oral tablet extended release 100 (MS Contin) QL (10 per 0, 0, 60 morphine oral tablet extended release 1 (MS Contin) QL (180 per 0, 00 morphine rectal suppository 10, 0 (Morphine Sulfate), 0, NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE 1 HR 100 MG, 10 MG, 00 MG, 0 MG, 0 MG NUCYNTA ORAL TABLET 100 MG, 0 QL (181 per 0 MG, 7 MG oxycodone oral capsule (Oxycodone HCl) QL (180 per 0 oxycodone oral concentrate 0 /ml (Oxycodone HCl) QL (180 per 0 oxycodone oral solution / ml (Oxycodone HCl) QL (100 per 0 oxycodone oral tablet 10, 1, 0 (Roxicodone) QL (180 per 0, 0, oxycodone oral tablet,oral only,ext.rel.1 (Oxycontin) QL (60 per 0 hr 10, 1, 0, 0, 0, 60 oxycodone oral tablet,oral only,ext.rel.1 (Oxycontin) QL (10 per 0 hr 80 oxycodone-acetaminophen oral tablet 10- (Xolox) QL (60 per 0,.-, -, 7.- oxycodone-acetaminophen oral tablet 10- (Xolox) QL (180 per 0 60 oxycodone-acetaminophen oral tablet 7.- (Xolox) QL (0 per 0 00 oxycodone-aspirin oral tablet.8- (Percodan) QL (60 per 0 6

14 OXYCONTIN ORAL TABLET,ORAL QL (60 per 0 ONLY,EXT.REL.1 HR 10 MG, 1 MG, 0 MG, 0 MG, 0 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (10 per 0 ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10, (Opana) QL (180 per 0 oxymorphone oral tablet extended release (Opana ER) QL (60 per 0 1 hr 10, 1, 0,, 7. oxymorphone oral tablet extended release (Opana ER) QL (10 per 0 1 hr 0, 0 reprexain oral tablet 10-00,.-00 (Ibudone) QL (10 per 0, -00 roxicet oral solution - / ml (Oxycodone QL (1800 per 0 HCl/Acetaminophen) tencon oral tablet 0- (Tencon) PA-HRM; QL (180 per 0 tramadol oral tablet 0 (Ultram) QL (0 per 0 tramadol-acetaminophen oral tablet 7.- (Ultracet) QL (0 per 0 vicodin es oral tablet (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 vicodin hp oral tablet (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 vicodin oral tablet -00 (Norco) (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 XARTEMIS XR ORAL TAB,ORAL QL (60 per 0 ONLY,IR - ER, BIPHASE 7.- MG xylon 10 oral tablet (Ibudone) QL (10 per 0 zebutal oral capsule 0--0 (Esgic) PA-HRM; QL (180 per 0 ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 1HR 10 MG, 1 MG, 0 MG, 0 MG, 0 MG, 0 MG QL (60 per 0 7

15 Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 00 MG/ ML (100 MG/ML) celecoxib oral capsule 100, 00, (Celebrex) QL (60 per 0 00, 0 choline,magnesium salicylate oral liquid (Choline Sal/Mag 00 / ml Salicylate) diclofenac potassium oral tablet 0 (Diclofenac Potassium) diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec), 0, 7 diclofenac sodium topical gel 1 % (Voltaren) diclofenac sodium topical gel % (Solaraze) diclofenac-misoprostol oral (Arthrotec 0) tablet,ir,delayed rel,biphasic 0-00 mcg, mcg diflunisal oral tablet 00 (Diflunisal) etodolac oral capsule 00, 00 (Etodolac) etodolac oral tablet 00, 00 (Etodolac) etodolac oral tablet extended release hr (Etodolac) 00, 00, 600 fenoprofen oral tablet 600 (Fenoprofen Calcium) FLECTOR TRANSDERMAL PATCH 1 HOUR 1. % PA flurbiprofen oral tablet 100, 0 (Flurbiprofen) ibuprofen oral suspension 100 / ml (Ibuprofen) ibuprofen oral tablet 00, 600, 800 (Ibuprofen) 1 indomethacin oral capsule (Indomethacin) PA-HRM; QL (0 per 0 indomethacin oral capsule 0 (Indomethacin) PA-HRM; QL (10 per 0 indomethacin oral capsule, extended release 7 (Indomethacin) PA-HRM; QL (60 per 0 indomethacin sodium intravenous recon (Indomethacin Sodium) PA-HRM soln 1 ketoprofen oral capsule 0, 7 (Ketoprofen) 8

16 ketoprofen oral capsule,ext rel. pellets (Ketoprofen) hr 00 ketorolac 0 /ml carpuject luer lock, (Ketorolac 10's,l/f 0 /ml Tromethamine) ketorolac injection cartridge 1 /ml (Ketorolac QL (0 per 0 Tromethamine) ketorolac injection cartridge 0 /ml (Ketorolac QL (0 per 0 Tromethamine) ketorolac injection solution 1 /ml (Ketorolac QL (0 per 0 Tromethamine) ketorolac injection solution 0 /ml (1 (Ketorolac QL (0 per 0 ml) Tromethamine) ketorolac intramuscular solution 60 / (Ketorolac QL (0 per 0 ml Tromethamine) ketorolac oral tablet 10 (Ketorolac QL (0 per 0 Tromethamine) mefenamic acid oral capsule 0 (Ponstel) meloxicam oral suspension 7. / ml (Mobic) meloxicam oral tablet 1, 7. (Mobic) 1 nabumetone oral tablet 00, 70 (Nabumetone) naproxen oral suspension 1 / ml (Naprosyn) naproxen oral tablet 0, 7, 00 (Naprosyn) 1 naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 7, 00 naproxen sodium oral tablet 7, 0 (Anaprox) 1 piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet 10, 00 (Sulindac) tolmetin oral capsule 00 (Tolmetin Sodium) tolmetin oral tablet 00, 600 (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 1 /ml (1. %), 0 /ml ( %), /ml (0. %) (Lidocaine HCl) (Xylocaine-MPF) 9

17 lidocaine (pf) intravenous syringe 100 (Lidocaine HCl/PF) / ml ( %) lidocaine % viscous soln % (Xylocaine) lidocaine hcl injection solution 10 /ml (1 %), 0 /ml ( %) (Xylocaine) lidocaine hcl laryngotracheal solution % (Xylocaine) lidocaine hcl mucous membrane gel % (Lidocaine HCl) lidocaine hcl mucous membrane jelly in applicator % (Lidocaine HCl) lidocaine hcl mucous membrane solution (Xylocaine) %, % (0 /ml) lidocaine hcl urethral gel % (Lidocaine HCl) lidocaine topical adhesive (Lidoderm) PA patch,medicated % lidocaine topical ointment % (Lidocaine) lidocaine-prilocaine topical cream.-. % (EMLA) Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (Acamprosate Calcium) (dr/ec) buprenorphine hcl sublingual tablet, (Buprenorphine HCl) PA; QL (90 per 0 8 buprenorphine-naloxone sublingual tablet (Buprenorphine PA; QL (90 per 0-0., 8- HCl/Naloxone HCl) bupropion hcl sr 10 tablet f/c 10 (Zyban) CHANTIX CONTINUING MONTH QL (168 per 8 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0. MG, 1 QL (168 per 8 MG CHANTIX STARTING MONTH BOX QL ( per 8 ORAL TABLETS,DOSE PACK 0. MG (11)- 1 MG () disulfiram oral tablet 0, 00 (Antabuse) naloxone injection solution 0. /ml (Naloxone HCl) naloxone injection syringe 0. /ml, 1 (Naloxone HCl) /ml naltrexone oral tablet 0 (Revia) 10

18 NARCAN NASAL SPRAY,NON- QL ( per 0 AEROSOL MG/ACTUATION NICOTROL INHALATION QL (1008 per 90 CARTRIDGE 10 MG ZUBSOLV SUBLINGUAL TABLET 1.- PA; QL (90 per MG, MG, MG,.7-1. MG, MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0., 0., 1, (Xanax) QL (10 per 0 alprazolam oral tablet extended release (Xanax XR) QL (10 per 0 hr 0., 1, alprazolam oral tablet extended release (Xanax XR) QL (90 per 0 hr chlordiazepoxide hcl oral capsule 10, (Chlordiazepoxide HCl) QL (10 per 0, clonazepam oral tablet 0., 1 (Klonopin) QL (90 per 0 clonazepam oral tablet (Klonopin) QL (00 per 0 clonazepam oral tablet,disintegrating (Clonazepam) QL (90 per 0 0.1, 0., 0., 1 clonazepam oral tablet,disintegrating (Clonazepam) QL (00 per 0 clorazepate dipotassium oral tablet 1 (Tranxene T-Tab) QL (10 per 0 clorazepate dipotassium oral tablet.7 (Tranxene T-Tab) QL (60 per 0, 7. diazepam injection syringe /ml (Diazepam) QL (10 per 8 diazepam intensol oral concentrate (Diazepam) QL (100 per 0 /ml diazepam oral solution / ml (1 (Diazepam) QL (100 per 0 /ml) diazepam oral tablet 10,, (Valium) QL (10 per 0 diazepam rectal kit , (Diastat)., estazolam oral tablet 1 (Estazolam) PA-HRM; QL (60 per 0 estazolam oral tablet (Estazolam) PA-HRM; QL (0 per 0 11

19 flurazepam oral capsule 1 (Flurazepam HCl) PA-HRM; QL (60 per 0 flurazepam oral capsule 0 (Flurazepam HCl) PA-HRM; QL (0 per 0 lorazepam intensol oral concentrate (Ativan) QL (10 per 0 /ml lorazepam oral tablet 0., 1, (Ativan) QL (90 per 0 midazolam oral syrup /ml (Midazolam HCl) QL (10 per 0 ONFI ORAL SUSPENSION. MG/ML PA NSO; QL (80 per 0 temazepam oral capsule 1,., 0 (Restoril) PA-HRM; QL (0 per 0 temazepam oral capsule 7. (Restoril) PA-HRM; QL (10 per 0 triazolam oral tablet 0.1 (Halcion) PA-HRM; QL (10 per 0 triazolam oral tablet 0. (Halcion) PA-HRM; QL (60 per 0 Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 00 MG/ ML gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /0 ml, 60 /0 ml, 70 /0 ml, 80 /100 ml, 80 /0 ml, 90 /100 ml (Gentamicin In Nacl, Iso-Osm) PA BvD gentamicin injection solution 0 /ml (Gentamicin Sulfate) gentamicin ped 0 / ml vial (Gentamicin Sulfate/PF) 's,pedi,latex-free 0 / ml gentamicin sulfate (pf) intravenous (Gentamicin Sulfate/PF) solution 80 /8 ml neomycin oral tablet 00 (Neomycin Sulfate) streptomycin intramuscular recon soln 1 gram (Streptomycin Sulfate) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG QL ( per 8 tobramycin in 0. % nacl inhalation solution for nebulization 00 / ml (Tobi) PA BvD 1

20 tobramycin in 0.9 % nacl intravenous piggyback 60 /0 ml, 80 /100 ml tobramycin sulfate injection solution 10 /ml, 0 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 0,000 unit (Tobramycin/Sodium Chloride) (Tobramycin Sulfate) (Bacitracin) bacitracin intramuscular recon soln (Bacitracin) 0,000 unit chloramphenicol sod succinate (Chloramphenicol Sod intravenous recon soln 1 gram Succ) clindamycin 7 / ml soln 7 / ml (Cleocin Palmitate) clindamycin hcl oral capsule 10, 00 (Cleocin HCl), 7 clindamycin in % dextrose intravenous piggyback 00 /0 ml, 600 /0 ml, 900 /0 ml (Cleocin Phosphate In Dw) clindamycin pediatric oral recon soln 7 (Cleocin Palmitate) / ml clindamycin phosphate injection solution (Cleocin Phosphate) 10 /ml clindamycin phosphate intravenous (Cleocin Phosphate) solution 600 / ml colistin (colistimethate na) injection recon (Coly-Mycin M soln 10 Parenteral) CUBICIN INTRAVENOUS RECON SOLN 00 MG linezolid intravenous parenteral solution 600 /00 ml (Zyvox) linezolid oral suspension for reconstitution (Zyvox) 100 / ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metronidazole/Sodium piggyback 00 /100 ml Chloride) metronidazole oral capsule 7 (Flagyl) metronidazole oral tablet 0, 00 (Flagyl) nitrofurantoin macrocrystal oral capsule 100,, 0 (Macrodantin) PA-HRM; QL (10 per 0 1

21 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) PA-HRM; QL (10 per 0 nitrofurantoin oral suspension / ml (Furadantin) PA-HRM; QL (00 per 0 polymyxin b sulfate injection recon soln (Polymyxin B Sulfate) 00,000 unit SYNERCID INTRAVENOUS RECON SOLN 00 MG trimethoprim oral tablet 100 (Trimethoprim) vancomycin hcl 1g/00 ml bag 1 gram/00 (Vancomycin ml HCl/DW) vancomycin intravenous recon soln 1,000 (Vancomycin HCl), 10 gram, 70 vancomycin intravenous recon soln 00 (Vancomycin HCl/DW) vancomycin oral capsule 1, 0 (Vancocin HCl) XIFAXAN ORAL TABLET 00 MG PA; QL (9 per 0 XIFAXAN ORAL TABLET 0 MG PA ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/ ML Cephalosporins cefaclor oral capsule 0, 00 (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 1 / ml, 0 / ml, 7 / ml cefaclor oral tablet extended release 1 hr (Cefaclor) 00 cefadroxil oral capsule 00 (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 0 / ml, 00 / ml cefadroxil oral tablet 1 gram (Cefadroxil) CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 1 GRAM/0 ML cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback gram/0 ml Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram, 10 (Cefazolin Sodium) gram, 00 cefdinir oral capsule 00 (Cefdinir) 1

22 cefdinir oral suspension for reconstitution (Cefdinir) 1 / ml, 0 / ml cefditoren pivoxil oral tablet 00, 00 (Spectracef) CEFEPIME GM INJECTION GRAM/100 ML CEFEPIME IN DEXTROSE % INTRAVENOUS PIGGYBACK 1 GRAM/0 ML, GRAM/0 ML cefepime injection recon soln 1 gram, (Maxipime) gram cefixime oral suspension for reconstitution (Suprax) 100 / ml, 00 / ml cefotaxime injection recon soln 1 gram, 10 (Claforan) gram, gram, 00 cefoxitin in dextrose, iso-osm intravenous (Cefoxitin piggyback gram/0 ml Sodium/Dextrose, Iso) cefoxitin intravenous recon soln 1 gram, (Cefoxitin Sodium) 10 gram, gram cefpodoxime oral suspension for (Cefpodoxime Proxetil) reconstitution 100 / ml, 0 / ml cefpodoxime oral tablet 100, 00 (Cefpodoxime Proxetil) cefprozil oral suspension for (Cefprozil) reconstitution 1 / ml, 0 / ml cefprozil oral tablet 0, 00 (Cefprozil) ceftazidime injection recon soln gram, 6 (Fortaz) gram ceftibuten oral capsule 00 (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 180 / ml ceftriaxone 1 gm piggyback 0ml (Ceftriaxone galaxycontainer 1 gram/0 ml Na/Dextrose, Iso) ceftriaxone 1 gm vial 10's, fliptop,l/f 1 (Rocephin) gram ceftriaxone gm piggyback 0ml (Ceftriaxone galaxycontainer gram/0 ml Na/Dextrose, Iso) ceftriaxone injection recon soln 10 gram, 0, 00 (Rocephin) 1

23 ceftriaxone intravenous recon soln 1 (Ceftriaxone gram, gram Na/Dextrose, Iso) cefuroxime axetil oral tablet 0, 00 (Ceftin) cefuroxime sodium injection recon soln (Zinacef) 1. gram, 70 cefuroxime sodium intravenous recon soln (Zinacef) 7. gram cephalexin oral capsule 0, 00, (Keflex) 1 70 cephalexin oral suspension for (Cephalexin) 1 reconstitution 1 / ml, 0 / ml cephalexin oral tablet 0, 00 (Cephalexin) 1 MEFOXIN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 1 GRAM/0 ML, GRAM/0 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/ ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 00 MG tazicef injection recon soln gram, 6 (Fortaz) gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG Macrolides azithromycin intravenous recon soln 00 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 / ml, 00 / ml azithromycin oral tablet 0, 0 (Zithromax) (6 pack), 600 azithromycin oral tablet 00 (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution 1 / ml, 0 / ml clarithromycin oral tablet 0, 00 (Biaxin) clarithromycin oral tablet extended release hr 00 (Clarithromycin) DIFICID ORAL TABLET 00 MG QL (0 per 10 16

24 e.e.s. 00 oral tablet 00 (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for (Eryped 00) reconstitution 00 / ml ery-tab oral tablet,delayed release (dr/ec) (Erythromycin Base) 0, 00 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 0 (Erythromycin Stearate) ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 00 MG erythromycin ethylsuccinate oral tablet (Erythromycin 00 Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin Base) release(dr/ec) 0 erythromycin oral tablet 0, 00 (Erythromycin Base) Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 7 MG/ML LA imipenem-cilastatin intravenous recon (Primaxin) soln 0, 00 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 00 (Merrem) meropenem iv 1 gm vial outer, latex-free 1 (Merrem) gram Penicillins amoxicillin oral capsule 0, 00 (Amoxicillin) 1 amoxicillin oral suspension for (Amoxicillin) 1 reconstitution 1 / ml, 00 / ml, 0 / ml, 00 / ml amoxicillin oral tablet 00, 87 (Amoxicillin) 1 amoxicillin oral tablet,chewable 1, 0 (Amoxicillin) 1 17

25 amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution / ml, 0-6. / ml, 00-7 / ml, / ml amoxicillin-pot clavulanate oral tablet (Augmentin) 0-1, 00-1, 87-1 amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1, amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable 00-8., 00-7 Clav) ampicillin gm vial 10's, latex-free (Ampicillin Sodium) gram ampicillin oral capsule 0, 00 (Ampicillin Trihydrate) 1 ampicillin oral suspension for (Ampicillin Trihydrate) 1 reconstitution 1 / ml, 0 / ml ampicillin sodium injection recon soln 1 (Ampicillin Sodium) gram, 10 gram, 1 ampicillin sodium intravenous recon soln (Ampicillin Sodium) gram ampicillin-sulbactam 1. gm vl p/f, latexfree (Unasyn) 1. gram ampicillin-sulbactam injection recon soln (Unasyn) 1 gram, gram ampicillin-sulbactam intravenous recon (Unasyn) soln 1. gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 0, 00 (Dicloxacillin Sodium) nafcillin gm vial sterile, latex-free (Nafcillin Sodium) gram nafcillin injection recon soln 1 gram, 10 (Nafcillin Sodium) gram nafcillin intravenous recon soln gram (Nafcillin Sodium) 18

26 oxacillin 1 gm add-vantage vl addvantage, (Oxacillin Sodium) inner 1 gram oxacillin in dextrose(iso-osm) intravenous (Oxacillin piggyback 1 gram/0 ml, gram/0 ml Sodium/Dextrose, Iso) oxacillin injection recon soln 10 gram (Oxacillin Sodium) oxacillin intravenous recon soln gram (Oxacillin Sodium) penicillin g pot in dextrose intravenous (Pen G Pot/Dextrose- piggyback 1 million unit/0 ml, million unit/0 ml, million unit/0 ml Water) penicillin g potassium injection recon soln (Penicillin G Potassium) million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml (Penicillin G Procaine) penicillin gk 0 million unit 0 million unit (Penicillin G Potassium) penicillin v potassium oral recon soln 1 (Penicillin V Potassium) / ml, 0 / ml penicillin v potassium oral tablet 0, (Penicillin V Potassium) 00 pfizerpen-g injection recon soln 0 million (Penicillin G Potassium) unit piperacillin-tazobactam intravenous recon (Zosyn) soln. gram,.7 gram,. gram piperacil-tazobact 0. gram p/f, (Zosyn) pharmacy bulk 0. gram Quinolones ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase hr 1,000, 00 ciprofloxacin 00 /0 ml vl sdv,latexfree (Ciprofloxacin Lactate) 00 /0 ml ciprofloxacin hcl oral tablet 100, 0 (Cipro) 1, 00, 70 ciprofloxacin in % dextrose intravenous (Cipro I.V.) piggyback 00 /100 ml ciprofloxacin lactate intravenous solution (Ciprofloxacin Lactate) 00 /0 ml ciprofloxacin oral suspension,microcapsule recon 0 / ml, 00 / ml (Cipro) 19

27 ciprofloxacn-dw 00 /00 ml (Cipro I.V.) p/f,latex/f, in dw 00 /00 ml levofloxacin in dw intravenous piggyback (Levaquin) 00 /100 ml, 70 /10 ml levofloxacin intravenous solution (Levofloxacin) /ml levofloxacin oral solution 0 /10 ml (Levaquin) levofloxacin oral tablet 0, 00, (Levaquin) 1 70 moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 00 (Ofloxacin) Sulfonamides sulfadiazine oral tablet 00 (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Trim intravenous solution / ml ethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Trim suspension 00-0 / ml ethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) , sulfasalazine oral tablet 00 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine) (dr/ec) 00 sulfatrim oral suspension 00-0 / ml (Sulfamethoxazole/Trim ethoprim) Tetracyclines demeclocycline oral tablet 10, 00 (Demeclocycline HCl) doxy 100 vial 10's, p/f 100 (Doxycycline Hyclate) doxycycline hyclate 100 cap 100 (Morgidox) doxycycline hyclate 100 tab f/c 100 (Doryx) doxycycline hyclate intravenous recon (Doxycycline Hyclate) soln 100 doxycycline hyclate oral capsule 100 (Adoxa) doxycycline hyclate oral capsule 0 (Morgidox) doxycycline hyclate oral tablet 100, 0 (Avidoxy) doxycycline hyclate oral tablet 0 (Doryx) 0

28 doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 100, 10, 7 doxycycline mono 100 cap 100 (Adoxa) doxycycline mono 100 tablet f/c 100 (Avidoxy) doxycycline mono 0 tablet 0 (Avidoxy) doxycycline monohydrate oral capsule 10 (Adoxa), 0, 7 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution / ml doxycycline monohydrate oral tablet 10 (Avidoxy), 7 MINOCIN INTRAVENOUS RECON SOLN 100 MG minocycline oral capsule 100, 0, (Minocin) 7 minocycline oral tablet 100, 0, 7 (Minocycline HCl) minocycline oral tablet extended release (Minocycline HCl) hr 1,, 90 tetracycline oral capsule 0, 00 (Tetracycline HCl) TYGACIL INTRAVENOUS RECON SOLN 0 MG Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 0 MG PA NSO; QL ( per 1 adriamycin intravenous recon soln 10, (Doxorubicin HCl) PA BvD 0, 0 adriamycin intravenous solution 10 / (Doxorubicin HCl) PA BvD ml adrucil,00 /0 ml vial outer, latexfree. gram/0 ml (Fluorouracil) PA BvD adrucil intravenous solution 00 /10 ml (Fluorouracil) PA BvD AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, MG PA NSO; QL (11 per 8 1

29 AFINITOR ORAL TABLET 10 MG PA NSO; QL (6 per 8 AFINITOR ORAL TABLET. MG, MG, 7. MG PA NSO; QL (8 per 8 ALECENSA ORAL CAPSULE 10 MG PA NSO; QL (0 per 0 ALIMTA INTRAVENOUS RECON SOLN 00 MG anastrozole oral tablet 1 (Arimidex) AVASTIN INTRAVENOUS SOLUTION MG/ML, MG/ML (16 ML) PA NSO azacitidine injection recon soln 100 (Vidaza) BELEODAQ INTRAVENOUS RECON PA NSO SOLN 00 MG BENDEKA INTRAVENOUS PA NSO SOLUTION MG/ML bexarotene oral capsule 7 (Targretin) PA NSO; QL (0 per 0 bicalutamide oral tablet 0 (Casodex) bleomycin injection recon soln 0 unit (Bleomycin Sulfate) PA BvD bleomycin sulfate 1 unit vial latex-free 1 (Bleomycin Sulfate) PA BvD unit BLINCYTO INTRAVENOUS KIT MCG PA NSO; QL (10 per 6 BOSULIF ORAL TABLET 100 MG PA NSO; QL (10 per 0 BOSULIF ORAL TABLET 00 MG PA NSO; QL (0 per 0 CABOMETYX ORAL TABLET 0 MG, 60 MG PA NSO; QL (0 per 0 CABOMETYX ORAL TABLET 0 MG PA NSO; QL (60 per 0 CAPRELSA ORAL TABLET 100 MG PA NSO; QL (60 per 0 CAPRELSA ORAL TABLET 00 MG PA NSO; QL (0 per 0 carboplatin intravenous solution 10 /ml (Carboplatin) cladribine intravenous solution 10 /10 ml (Cladribine) PA BvD

30 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]-0 MG[1]), 10 MG/DAY(80 MG[1]-0 MG[]), 60 MG/DAY (0 MG []/DAY) PA NSO; QL (11 per 8 COTELLIC ORAL TABLET 0 MG PA NSO; LA; QL (6 per 8 cyclophosphamide intravenous recon soln (Cyclophosphamide) PA BvD 1 gram, gram, 00 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE MG, 0 MG cyclophosphamide oral tablet, 0 (Cyclophosphamide) PA BvD; ST CYRAMZA INTRAVENOUS PA NSO SOLUTION 10 MG/ML, 10 MG/ML (0 ML) dactinomycin intravenous recon soln 0. (Dactinomycin) DARZALEX INTRAVENOUS PA NSO; LA SOLUTION 0 MG/ML DAUNOXOME INTRAVENOUS SOLUTION MG/ML decitabine intravenous recon soln 0 (Dacogen) docetaxel 160 /16 ml vial mdv 160 (Taxotere) /16 ml (10 /ml) docetaxel intravenous solution 0 / ml (Taxotere) (final), 80 / ml (0 /ml), 80 /8 ml (10 /ml) doxorubicin, peg-liposomal intravenous (Doxil) PA BvD suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG ELIGARD SUBCUTANEOUS SYRINGE QL (1 per 8. MG ( MONTH) ELIGARD SUBCUTANEOUS SYRINGE QL (1 per 11 0 MG ( MONTH) ELIGARD SUBCUTANEOUS SYRINGE QL (1 per 168 MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 7. MG (1 MONTH)

31 EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS RECON PA NSO SOLN 00 MG, 00 MG ERIVEDGE ORAL CAPSULE 10 MG PA NSO; QL (0 per 0 ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 0 /ml (Etoposide) exemestane oral tablet (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 1 PA NSO MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 0 MG/ ML floxuridine injection recon soln 0. gram (Floxuridine) PA BvD fluorouracil,000 /100 ml latex-free (Fluorouracil) PA BvD gram/100 ml fluorouracil intravenous solution. (Fluorouracil) PA BvD gram/0 ml flutamide oral capsule 1 (Flutamide) GAZYVA INTRAVENOUS SOLUTION PA NSO 1,000 MG/0 ML gemcitabine intravenous recon soln 1 (Gemzar) gram GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG PA NSO; QL (0 per 0 GLEEVEC ORAL TABLET 100 MG PA NSO; QL (90 per 0 GLEEVEC ORAL TABLET 00 MG PA NSO; QL (60 per 0 GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG HERCEPTIN INTRAVENOUS RECON PA NSO SOLN 0 MG HEXALEN ORAL CAPSULE 0 MG hydroxyurea oral capsule 00 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 1 MG, 7 MG PA NSO; QL (1 per 8

32 ICLUSIG ORAL TABLET 1 MG PA NSO; QL (60 per 0 ICLUSIG ORAL TABLET MG PA NSO; QL (0 per 0 ifosfamide 1 gm/0 ml vial sd polymer vial (Ifex) PA BvD 1 gram/0 ml ifosfamide intravenous recon soln 1 gram (Ifex) PA BvD ifosfamide-mesna intravenous kit 1-1 (Ifosfamide/Mesna) PA BvD gram,,000-1,000 imatinib oral tablet 100 (Gleevec) PA NSO; QL (90 per 0 imatinib oral tablet 00 (Gleevec) PA NSO; QL (60 per 0 IMBRUVICA ORAL CAPSULE 10 MG PA NSO IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML PA NSO; QL ( per 6 IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML PA NSO; QL (8 per 8 INLYTA ORAL TABLET 1 MG PA NSO; QL (180 per 0 INLYTA ORAL TABLET MG PA NSO; QL (60 per 0 IRESSA ORAL TABLET 0 MG PA NSO; QL (60 per 0 irinotecan intravenous solution 100 / (Camptosar) ml, 00 / ml IXEMPRA 1 MG KIT WITH DILUENT 1 MG IXEMPRA INTRAVENOUS RECON SOLN MG JAKAFI ORAL TABLET 10 MG, 1 MG, 0 MG, MG, MG PA NSO; QL (60 per 0 KEYTRUDA INTRAVENOUS RECON PA NSO SOLN 0 MG KEYTRUDA INTRAVENOUS PA NSO SOLUTION 100 MG/ ML ( MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 60 MG PA NSO; QL (6 per 8

33 LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 1 MG/DAY(10 MG X 1- MG X 1), 0 MG/DAY (10 MG X ), MG/DAY(10 MG X - MG X 1) PA NSO letrozole oral tablet. (Femara) LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit 1 /0. ml (Leuprolide Acetate) lipodox intravenous suspension /ml (Doxil) PA BvD lomustine oral capsule 10, 100, 0 (Lomustine) LONSURF ORAL TABLET MG PA NSO; QL (100 per 8 LONSURF ORAL TABLET MG PA NSO; QL (80 per 8 LUPRON DEPOT ( MONTH) QL (1 per 8 INTRAMUSCULAR SYRINGE KIT 11. MG,. MG LUPRON DEPOT ( MONTH) QL (1 per 8 INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) QL (1 per 168 INTRAMUSCULAR SYRINGE KIT MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.7 MG, 7. MG LYNPARZA ORAL CAPSULE 0 MG PA NSO; QL (80 per 0 LYSODREN ORAL TABLET 00 MG MARQIBO INTRAVENOUS KIT MG/1 ML(0.16 MG/ML) FINAL PA NSO; QL ( per 8 MATULANE ORAL CAPSULE 0 MG megestrol oral tablet 0, 0 (Megestrol Acetate) MEKINIST ORAL TABLET 0. MG PA NSO; QL (90 per 0 MEKINIST ORAL TABLET MG PA NSO; QL (0 per 0 melphalan hcl intravenous recon soln 0 (Alkeran) 6