Express Scripts Medicare (PDP) 2013 Formulary (List of Covered Drugs)

Transcription

1 Value plan Express Scripts Medicare (PDP) 2013 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 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. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium, and/or copayments/coinsurance may change on January 1, A Medicare-approved Part D sponsor This information is available for free in other languages. Please contact our Customer Service numbers at ; New York State residents: (TTY users only: ) for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Por favor comuníquese a los números de Servicio al cliente al ; residentes de New York: (sólo los usuarios de TTY: ) para obtener información adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana. This document is available in braille. Please call the Customer Service numbers listed above if you need plan information in another format. Y0046_F00SNS3A CMS Accepted Last Updated: October 15, 2013 Formulary ID: 13012, V19

2 What is the Express Scripts Medicare formulary? A formulary is a list of covered drugs selected by Express Scripts Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Express Scripts Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 coverage year, except when a new, less expensive generic drug becomes available, or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits, and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Administration deems a drug on our formulary to be unsafe, or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November 1, To get updated information about the drugs covered by Express Scripts Medicare, please visit our website at or call Customer Service at ; New York State residents: , 24 hours a day, 7 days a week. Customer Service is available in English and other languages. TTY users should call If there are additional changes made to the formulary that affect you and are not mentioned above, you will also be notified in writing of these changes within a reasonable period of time from when the changes are made. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular, Hypertension/Lipids. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 41. 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 i

3 information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Express Scripts Medicare 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: Express Scripts Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Express Scripts Medicare before you fill your prescriptions. If you don t get approval, Express Scripts Medicare may not cover the drug. Quantity : For certain drugs, Express Scripts Medicare limits the amount of the drug that Express Scripts Medicare will cover. For example, Express Scripts Medicare provides two inhalers (17 grams) for a one-month supply per prescription for PROAIR HFA. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Express Scripts Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, Express Scripts Medicare may not cover B unless you try A first. If A does not work for you, Express Scripts Medicare will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at You can ask Express Scripts Medicare to make an exception to these restrictions or limits. See the section below How do I request an exception to the Express Scripts Medicare formulary? 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, you should first contact Customer Service and confirm that your drug is not covered. If you learn that Express Scripts Medicare does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Express Scripts Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Express Scripts Medicare. You can ask Express Scripts Medicare to make an exception and cover your drug. See below for information about how to request an exception. ii

4 How do I request an exception to the Express Scripts Medicare formulary? You can ask Express Scripts Medicare 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. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Express Scripts Medicare 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 more. You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our Non-Preferred Brand tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Brand tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier. Generally, Express Scripts Medicare will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower-tiered drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you are requesting a formulary, tiering, or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s or prescribing physician s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber s or prescribing physician s supporting statement. 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 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-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 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first iii

5 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 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Other times when we will cover a temporary 31-day transition supply (or less, if you have a prescription written for fewer days) include: When you enter a long-term care facility When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized The plan will send you a letter within 3 business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options. For more information For more detailed information about your Express Scripts Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Express Scripts Medicare, please call Customer Service at ; New York State residents: , 24 hours a day, 7 days a week. Customer Service is available in English and other languages. TTY users should call Or visit If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), 24 hours a day/7 days a week. TTY users should call Or visit Express Scripts Medicare s formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by Express Scripts Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page 41. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NEXIUM ) and generic drugs are listed in lowercase italics (e.g., omeprazole). The information in the requirements/ column tells you if Express Scripts Medicare has any special requirements for coverage of your drug. iv

6 Your Costs The amount you pay for a covered drug will depend on: Your coverage stage. Express Scripts Medicare has different stages of coverage. In each stage, the amount you pay for a drug may change. The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different copayment or coinsurance amount. The s chart below explains what types of drugs are included in each tier and shows how costs may change with each tier. The Evidence of Coverage (EOC) has more information about the plan s coverage stages and lists the copayment and coinsurance amounts for each tier. If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may be lower. Members who qualify for Extra Help will receive the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription s (LIS Rider). Please read it to find out what your costs are. You can also contact Customer Service for more information. s Includes Helpful Tips 1: Preferred Generic s This tier includes many commonly prescribed low-cost drugs. This tier includes commonly prescribed generic drugs and may include other low-cost drugs. Use 1 drugs for the lowest copayments. 2: Non-Preferred Generic s 3: Preferred Brand s 4: Non-Preferred Brand s 5: Specialty s This tier includes additional low-cost drugs. This tier includes preferred brand-name drugs as well as some generic drugs. This tier includes non-preferred brand-name drugs as well as some generic drugs. This tier includes very high-cost drugs. This tier includes generic drugs and may include other low-cost drugs. Use 2 drugs to keep your copayments low. s in this tier will generally have lower copayments than non-preferred drugs. Many non-preferred drugs have lower-cost alternatives in s 1, 2, and 3. Ask your doctor if switching to a lower-cost generic or preferred brand drug may be right for you. To learn more about medications in this tier, you may contact a pharmacist at the numbers listed on the cover of this document. v

7 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover the drug. HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Customer Service. GC: Gap Coverage. We provide coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about this coverage. LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, call Customer Service at ; New York State residents: , 24 hours a day, 7 days a week. (TTY users should call ) FF: Free First Fill. This prescription drug may be provided at a reduced cost-sharing amount the first time you fill it. ED: Enhanced. This prescription drug is not normally covered in a Medicare prescription drug plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for Catastrophic Coverage). In addition, if you are receiving Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for this drug. CB: Capped Benefit. This prescription drug has a capped benefit limit. : Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). vi

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9 Commonly Prescribed Therapeutic Categories ANTI - INFECTIVES ANTIFUNGAL AGENTS amphotericin b 2 PA ANCOBON 3 clotrimazole troc 2 ERAXIS INJ 100MG 3 fluconazole 1 fluconazole in dextrose inj 2 56mg/ml; 400mg/200ml flucytosine 2 GRIS-PEG 4 griseofulvin microsize 2 griseofulvin ultramicrosize 2 itraconazole 2 ketoconazole 2 NOXAFIL 3 nystatin susp 1 nystatin tabs 1 SPORANOX ORAL SOLN 3 terbinafine hcl tabs 1 VFEND IV 3 VFEND SUSR 3 voriconazole 2 ANTIVIRALS abacavir 2 QL(180 per acyclovir caps 1 acyclovir sodium inj 500mg 1 acyclovir susp 1 acyclovir tabs 1 amantadine hcl 2 APTIVUS CAPS 5 QL(360 per APTIVUS ORAL SOLN 5 QL(950 per ATRIPLA 5 QL(90 per BARACLUDE ORAL SOLN 3 QL(1890 per BARACLUDE TABS 3 QL(90 per CIDOFOVIR 5 COMPLERA 5 QL(90 per CRIXIVAN 3 didanosine 2 QL(90 per EDURANT 5 QL(90 per EMTRIVA CAPS 3 QL(90 per EMTRIVA ORAL SOLN 3 QL(2210 per EPIVIR HBV 3 EPIVIR ORAL SOLN 3 QL(2880 per EPZICOM 5 QL(90 per famciclovir 2 foscarnet sodium 2 PA FUZEON 5 QL(180 per ganciclovir 2 HEPSERA 5 QL(90 per INCIVEK 5 PA QL(504 per 84 days) 1

10 INTELENCE TABS 200MG 5 QL(180 per INTELENCE TABS 100MG 5 QL(360 per INTELENCE TABS 25MG 3 QL(360 per INVIRASE CAPS 4 QL(900 per INVIRASE TABS 5 QL(360 per ISENTRESS CHEW 100MG 5 QL(540 per ISENTRESS CHEW 25MG 3 QL(540 per ISENTRESS TABS 5 QL(360 per KALETRA ORAL SOLN 5 QL(1280 per KALETRA TABS 200MG; 50MG KALETRA TABS 100MG; 25MG 5 QL(360 per 3 QL(900 per lamivudine tabs 300mg 2 QL(90 per lamivudine tabs 150mg 2 QL(180 per lamivudine/zidovudine 2 QL(180 per LEXIVA SUSP 3 QL(5175 per LEXIVA TABS 5 QL(360 per nevirapine tabs 2 QL(180 per NORVIR CAPS 3 QL(1080 per NORVIR ORAL SOLN 3 QL(1440 per NORVIR TABS 3 QL(1080 per PREZISTA SUSP 5 PREZISTA TABS 800MG 5 PREZISTA TABS 400MG, 600MG 5 QL(180 per PREZISTA TABS 150MG 3 QL(540 per PREZISTA TABS 75MG 3 QL(900 per REBETOL ORAL SOLN 3 PA RELENZA DISKHALER 3 QL(300 per 365 days) RESCRIPTOR TABS 200MG 4 QL(540 per RESCRIPTOR TABS 100MG 4 QL(1080 per RETROVIR IV INFUSION 3 REYATAZ CAPS 300MG 3 QL(90 per REYATAZ CAPS 150MG, 200MG 3 QL(180 per REYATAZ CAPS 100MG 3 QL(360 per ribapak tabs 5 PA ribasphere caps 2 PA 2

11 ribasphere tabs 400mg 2 PA ribasphere tabs 200mg 2 PA ribasphere tabs 600mg 5 PA ribavirin 2 PA rimantadine hcl 2 SELZENTRY TABS 150MG 5 QL(180 per SELZENTRY TABS 300MG 5 QL(360 per stavudine caps 2 QL(180 per stavudine oral soln 2 QL(7200 per STRIBILD 5 QL(90 per SUSTIVA CAPS 200MG 3 QL(360 per SUSTIVA CAPS 50MG 3 QL(630 per SUSTIVA TABS 3 QL(90 per TAMIFLU CAPS 45MG, 75MG 3 QL(60 per 365 days) TAMIFLU CAPS 30MG 3 QL(120 per 365 days) TAMIFLU SUSR 3 QL(720 per 365 days) TIVICAY 5 TRIZIVIR 5 QL(180 per TRUVADA 5 QL(90 per TYZEKA 5 valacyclovir hcl tabs 1000mg 2 QL(100 per valacyclovir hcl tabs 500mg 2 QL(200 per VALCYTE 5 VICTRELIS 5 PA QL(1008 per 84 days) VIDEX PEDIATRIC ORAL SOLN 2GM 3 QL(3600 per VIRACEPT TABS 625MG 5 QL(360 per VIRACEPT TABS 250MG 5 QL(900 per VIRAMUNE SUSP 3 QL(3600 per VIRAMUNE XR 3 VIRAZOLE 5 VIREAD POWD 3 QL(720 per VIREAD TABS 3 QL(90 per ZERIT ORAL SOLN 4 QL(7200 per ZIAGEN ORAL SOLN 3 QL(2880 per ZIAGEN TABS 3 QL(180 per zidovudine caps 2 QL(540 per 3

12 zidovudine syrp 2 QL(5520 per zidovudine tabs 2 QL(180 per CEPHALOSPORINS cefaclor caps 2 cefadroxil 2 cefazolin sodium inj 10gm, 1gm; 2 5%, 500mg cefazolin sodium inj 1gm 2 cefdinir 2 cefepime inj 2gm 2 cefepime inj 1gm 2 cefotaxime sodium inj 1gm, 2gm 2 cefotaxime sodium inj 10gm 2 cefoxitin sodium inj 10gm, 2gm 2 cefoxitin sodium inj 1gm 2 cefpodoxime proxetil 2 ceftazidime inj 1gm, 6gm 2 ceftazidime inj 2gm 2 ceftriaxone sodium inj 10gm 2 ceftriaxone sodium inj 1gm, 2 250mg, 2gm, 500mg cefuroxime axetil tabs 2 cefuroxime sodium inj 7.5gm 2 cefuroxime sodium inj 1.5gm, 2 750mg cephalexin caps 250mg, 500mg 1 cephalexin susr 1 cephalexin tabs 1 FORTAZ INJ 1GM/50ML; 5%, 3 2GM/50ML; 5%, 6GM SUPRAX CAPS 4 SUPRAX SUSR 500MG/5ML 4 SUPRAX SUSR 100MG/5ML, 4 200MG/5ML SUPRAX TABS 4 TEFLARO 3 ZINACEF IN ISO-OSTIC DEXTROSE 3 ZINACEF IN ISO-OSTIC DILUENT 3 ERYTHROMYCINS / OTHER MACROLIDES azithromycin inj 500mg 2 azithromycin susr 2 azithromycin tabs 2 clarithromycin 2 clarithromycin er 2 DIFICID 3 QL(60 per e.e.s E.E.S. GRANULES 3 ERY-TAB TBEC 500MG 3 ery-tab tbec 250mg, 333mg 2 ERYTHROCIN 3 LACTOBIONATE INJ 500MG erythrocin stearate 1 erythromycin base 2 erythromycin ethylsuccinate 2 ZMAX 3 MISCELLANEOUS ANTIINFECTIVES ALBENZA 3 ALINIA 3 amikacin sulfate inj 1gm/4ml, 2 50mg/ml atovaquone/proguanil hcl tabs 2 250mg; 100mg AZACTAM IN ISO-OSTIC 3 DEXTROSE AZACTAM INJ 2GM 3 aztreonam inj 1gm 2 BILTRICIDE 3 CAPASTAT SULFATE 4 CAYSTON 5 LA chloroquine phosphate 2 CLEOCIN IN D5W 3 CLEOCIN PEDIATRIC 3 GRANULES clindamycin hcl 2 clindamycin palmitate hcl 2 4

13 clindamycin phosphate 2 addvantage clindamycin phosphate in d5w inj 2 300mg/50ml; 5%, 600mg/50ml; 5% clindamycin phosphate in d5w inj 2 900mg/50ml; 5% COARTEM 3 colistimethate sodium 2 CUBICIN 3 PA DAPSONE 3 DARAPRIM 3 ethambutol hcl 2 gentamicin sulfate inj 2 gentamicin sulfate/0.9% sodium 2 chloride inj 0.9mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9% hydroxychloroquine sulfate 2 imipenem/cilastatin 2 isoniazid syrp 2 isoniazid tabs 1 isotonic gentamicin inj 0.8mg/ml; 2 0.9%, 1.2mg/ml; 0.9% KETEK 3 QL(20 per 30 days) MALARONE 3 mefloquine hcl 2 MEPRON 5 meropenem inj 500mg 2 metronidazole 1 metronidazole in nacl 0.79% 2 MYCOBUTIN 3 NEBUPENT 3 PA neomycin sulfate tabs 2 paromomycin sulfate 2 PASER 3 PRIMAQUINE PHOSPHATE 3 pyrazinamide 2 QUALAQUIN 3 quinine sulfate 2 rifampin 2 SEROMYCIN 3 SIRTURO 5 LA STREPTOMYCIN SULFATE 3 STROMECTOL 3 tinidazole 2 QL(60 per TOBI 5 PA tobramycin sulfate inj 10mg/ml, 1 80mg/2ml tobramycin sulfate/sodium 2 chloride inj 0.9%; 1.2mg/ml tobramycin sulfate/sodium 2 chloride inj 0.9%; 0.8mg/ml TRECATOR 3 TYGACIL 3 XIFAXAN TABS 200MG 3 QL(9 per 30 days) XIFAXAN TABS 550MG 3 QL(180 per ZYVOX INJ 3 ZYVOX SUSR 3 QL(1800 per 30 days) ZYVOX TABS 3 QL(56 per 30 days) PENICILLINS amoxicillin 1 amoxicillin/clavulanate potassium 2 chew amoxicillin/clavulanate potassium 2 er amoxicillin/clavulanate potassium 2 susr 250mg/5ml; 62.5mg/5ml, 400mg/5ml; 57mg/5ml, 600mg/5ml; 42.9mg/5ml amoxicillin/clavulanate potassium 2 tabs 250mg; 125mg amoxicillin/potassium clavulanate 2 susr 200mg/5ml; 28.5mg/5ml amoxicillin/potassium clavulanate tabs 2 5

14 ampicillin 2 ampicillin sodium inj 1gm 2 ampicillin sodium inj 10gm, 2 125mg ampicillin-sulbactam inj 10gm; 2 5gm ampicillin-sulbactam inj 2gm; 2 1gm BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium 2 nafcillin sodium inj 10gm, 1gm 2 nallpen/dextrose 2 PENICILLIN G POTASSIUM IN 3 ISO-OSTIC DEXTROSE INJ 0; 40000UNIT/ML, 0; 60000UNIT/ML penicillin g potassium inj 5mu 2 penicillin g procaine 2 penicillin g sodium 2 penicillin v potassium 1 pfizerpen-g inj 20mu 2 piperacillin sodium/tazobactam 2 sodium inj 3gm; 0.375gm, 4gm; 0.5gm ZOSYN INJ 5%; 2GM/50ML; GM/50ML ZOSYN INJ 5%; 3GM/50ML; GM/50ML QUINOLONES AVELOX 3 AVELOX ABC PACK 3 CIPRO I.V.-IN D5W INJ 3 200MG/100ML; 5% ciprofloxacin hcl 1 ciprofloxacin i.v.-in d5w inj 2 200mg/100ml; 5% ciprofloxacin inj 400mg/40ml 1 levofloxacin 2 levofloxacin in d5w inj 5%; 2 500mg/100ml NOROXIN 4 ofloxacin 2 SULFA'S / RELATED AGENTS sulfadiazine 2 sulfamethoxazole/trimethoprim 1 sulfamethoxazole/trimethoprim ds 1 TETRACYCLINES demeclocycline hcl 3 doxycycline hyclate caps 1 doxycycline hyclate dr 1 doxycycline hyclate inj 1 doxycycline hyclate tabs 1 doxycycline monohydrate caps 2 75mg doxycycline monohydrate susr 2 doxycycline monohydrate tabs 2 150mg, 50mg, 75mg minocycline hcl 2 minocycline hcl er 2 tetracycline hcl 1 VIBRAMYCIN SUSR 3 VIBRAMYCIN SYRP 3 URINARY TRACT AGENTS MACRODANTIN CAPS 25MG 3 methenamine hippurate 2 nitrofurantoin macrocrystalline 2 caps 50mg nitrofurantoin monohydrate 2 nitrofurantoin susp 2 PRIMSOL 4 trimethoprim 2 VANCOMYCIN vancomycin hcl caps 2 vancomycin hcl inj 500mg 2 PA vancomycin hcl inj 1000mg, 10gm 2 PA VIBATIV INJ 250MG 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine 5 dexrazoxane inj 500mg 2 ELITEK INJ 1.5MG 5 6

15 FUSILEV 5 leucovorin calcium inj 100mg, 2 350mg leucovorin calcium tabs 2 mesna 2 MESNEX TABS 3 XGEVA 5 PA QL(8.5 per ZINECARD INJ 250MG 3 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 adriamycin inj 2mg/ml 2 AFINITOR DISPERZ 5 PA QL(360 per AFINITOR TABS 10MG, 7.5MG 5 PA QL(180 per AFINITOR TABS 2.5MG, 5MG 5 PA QL(270 per ALIMTA INJ 500MG 4 ALKERAN INJ 4 anastrozole 2 ARRANON 4 ARZERRA INJ 100MG/5ML 3 AVASTIN INJ 100MG/4ML 4 azathioprine 2 PA azathioprine sodium 2 bicalutamide 2 BICNU 4 bleomycin sulfate inj 30unit 2 BOSULIF TABS 500MG 5 PA QL(90 per BOSULIF TABS 100MG 5 PA QL(360 per BUSULFEX 3 CAMPATH 4 CAPRELSA TABS 300MG 5 QL(90 per CAPRELSA TABS 100MG 5 QL(180 per carboplatin inj 150mg/15ml 2 CEENU 3 CELLCEPT INTRAVENOUS 3 CELLCEPT SUSR 3 PA cisplatin inj 100mg/100ml 2 cladribine 2 CLOLAR 4 COMETRIQ 5 PA COSMEGEN 4 cyclophosphamide tabs 2 PA cyclosporine caps 2 PA cyclosporine inj 2 cyclosporine modified 2 PA cytarabine aqueous 2 cytarabine inj 500mg 2 dacarbazine inj 200mg 2 DACOGEN 3 daunorubicin hcl inj 5mg/ml 2 decitabine 5 DOCEFREZ 5 docetaxel inj 80mg/8ml 2 docetaxel inj 80mg/4ml 2 DOXIL 3 doxorubicin hcl inj 2mg/ml 2 DROXIA 3 ELLENCE INJ 200MG/100ML 4 ELOXATIN INJ 100MG/20ML 4 ELSPAR 4 EMCYT 3 epirubicin hcl inj 50mg/25ml 2 ERBITUX INJ 100MG/50ML 4 ERIVEDGE 5 PA ETOPOPHOS 4 etoposide inj 500mg/25ml 2 exemestane 2 7

16 FARESTON 4 FASLODEX 5 FIRMAGON INJ 120MG 5 QL(240 per 84 days) FIRMAGON INJ 80MG 3 QL(240 per 84 days) fludarabine phosphate inj 50mg 2 fluorouracil inj 2.5gm/50ml 2 flutamide 2 gemcitabine hcl inj 1gm 5 gengraf 2 PA GILOTRIF TABS 40MG 5 PA QL(31 per 31 days) GILOTRIF TABS 30MG 5 PA QL(42 per 31 days) GILOTRIF TABS 20MG 5 PA QL(62 per 31 days) GLEEVEC 5 HALAVEN 5 HERCEPTIN 4 HEXALEN 5 hydroxyurea 2 ICLUSIG 5 PA idarubicin hcl inj 10mg/10ml 2 IFEX INJ 3GM 4 ifosfamide inj 1gm 2 INLYTA 5 PA irinotecan inj 100mg/5ml 5 ISTODAX 3 IXEMPRA KIT INJ 45MG 5 JAKAFI 5 PA QL(180 per JEVTANA 5 KADCYLA INJ 100MG 5 letrozole 2 LEUKERAN 3 leuprolide acetate 2 LUPRON DEPOT INJ 3.75MG 3 LUPRON DEPOT INJ 22.5MG, 5 30MG, 45MG, 7.5MG LUPRON DEPOT-PED INJ MG, 15MG LYSODREN 3 MATULANE 5 MEGACE ES 3 QL(150 per 30 days) megestrol acetate 1 MEKINIST TABS 2MG 5 PA QL(30 per 30 days) MEKINIST TABS 0.5MG 5 PA QL(120 per 30 days) melphalan hydrochloride 2 mercaptopurine 2 methotrexate 2 PA methotrexate sodium inj 25mg/ml 2 METHOTREXATE SODIUM 4 INJ 1GM mitomycin inj 20mg 2 mitoxantrone hcl 2 MUSTARGEN 4 mycophenolate mofetil 2 PA MYFORTIC 3 PA NEORAL 3 PA NEXAVAR 5 LA PA QL(360 per NILANDRON 4 QL(120 per NIPENT 4 NULOJIX 5 octreotide acetate inj mcg/ml, 500mcg/ml octreotide acetate inj 100mcg/ml, 2 200mcg/ml, 50mcg/ml ONTAK 4 oxaliplatin inj 100mg/20ml 5 8

17 paclitaxel inj 300mg/50ml 2 pentostatin 2 PERJETA 5 PA POMALYST 5 PROGRAF INJ 3 RAPAMUNE 3 PA REVLIMID CAPS 2.5MG 5 LA REVLIMID CAPS 25MG 5 LA QL(21 per 28 days) REVLIMID CAPS 10MG, 15MG, 5MG 5 LA QL(30 per 30 days) RHEUMATREX 4 RITUXAN 3 PA SANDIMMUNE CAPS 3 PA SANDIMMUNE INJ 3 SANDIMMUNE ORAL SOLN 3 PA SANDOSTATIN LAR DEPOT 4 SIGNIFOR 5 PA SIMULECT INJ 20MG 3 SOLTAX 3 SOMATULINE DEPOT 5 SPRYCEL TABS 140MG, 50MG, 70MG, 80MG 5 QL(90 per SPRYCEL TABS 100MG, 20MG 5 QL(180 per STIVARGA 5 PA QL(252 per SUTENT CAPS 25MG, 50MG 5 PA QL(90 per SUTENT CAPS 12.5MG 5 PA QL(270 per SYNRIBO 5 PA TABLOID 3 tacrolimus 2 PA TAFINLAR CAPS 75MG 5 PA QL(124 per 31 days) TAFINLAR CAPS 50MG 5 PA QL(186 per 31 days) tamoxifen citrate 2 TARCEVA TABS 100MG, 150MG 5 PA QL(90 per TARCEVA TABS 25MG 5 PA QL(180 per TARGRETIN 3 TASIGNA 5 QL(336 per 84 days) TAXOTERE INJ 80MG/4ML 5 THALOMID 5 PA thiotepa 2 toposar inj 1gm/50ml 2 topotecan hcl inj 4mg 2 TORISEL 5 PA TREANDA INJ 100MG 5 TRELSTAR DEPOT MIXJECT 4 TRELSTAR LA MIXJECT 4 TRELSTAR MIXJECT 4 tretinoin 2 TRISENOX 3 TYKERB 5 LA QL(540 per VECTIBIX INJ 100MG/5ML 5 VELCADE 4 VIDAZA 5 QL(4200 per vinblastine sulfate inj 10mg 2 vincasar pfs 2 vincristine sulfate 2 vinorelbine tartrate inj 50mg/5ml 2 9

18 VOTRIENT 5 QL(360 per XALKORI 5 PA QL(180 per XTANDI 5 PA QL(360 per YERVOY INJ 50MG/10ML 5 PA ZALTRAP INJ 100MG/4ML 5 PA ZANOSAR 4 ZELBORAF 5 PA QL(720 per ZOLINZA 5 QL(360 per ZORTRESS TABS 0.5MG, 5 PA 0.75MG ZORTRESS TABS 0.25MG 3 PA ZYTIGA 5 PA QL(360 per AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS BANZEL 3 carbamazepine 1 carbamazepine er 1 CARBATROL 3 CELONTIN 3 clonazepam 2 clonazepam odt 2 diazepam gel 2 DILANTIN CAPS 30MG 3 DILANTIN INFATABS 3 divalproex sodium 2 divalproex sodium dr 2 divalproex sodium er 2 epitol 1 ethosuximide 2 felbamate 2 FELBATOL 3 fosphenytoin sodium inj 100mg 2 pe/2ml gabapentin 2 GABITRIL 3 LAMICTAL ODT TBDP 3 LAMICTAL STARTER/NOT 3 TAKING CARBAMAZEPINE LAMICTAL 3 STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE LAMICTAL 3 STARTER/TAKING VALPROATE LAMICTAL XR 3 lamotrigine 2 lamotrigine er 2 levetiracetam er 2 levetiracetam inj 500mg/5ml 2 levetiracetam oral soln 2 levetiracetam tabs 2 LYRICA CAPS 225MG, 300MG 3 QL(180 per LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG 3 QL(270 per LYRICA ORAL SOLN 3 QL(2880 per ONFI 3 oxcarbazepine 2 PEGANONE 3 phenobarbital 2 PA phenytoin 2 phenytoin sodium 2 phenytoin sodium extended 2 POTIGA 4 primidone 2 SABRIL 3 TEGRETOL-XR TB12 100MG 3 tiagabine hydrochloride 2 10

19 topiramate 2 TRILEPTAL SUSP 4 valproate sodium 2 valproic acid 2 VIMPAT INJ 3 VIMPAT ORAL SOLN 3 VIMPAT TABS 3 zonisamide 2 ANTIPARKINSONISM AGENTS APOKYN 3 LA AZILECT 3 benztropine mesylate inj 1 benztropine mesylate tabs 1 bromocriptine mesylate 2 carbidopa/levodopa 2 carbidopa/levodopa er 2 carbidopa/levodopa odt 2 COMTAN 3 entacapone 2 LODOSYN 3 MIRAPEX ER 3 pramipexole dihydrochloride 2 ropinirole er 2 ropinirole hcl 2 selegiline hcl 2 STALEVO STALEVO STALEVO STALEVO STALEVO 50 3 STALEVO 75 3 trihexyphenidyl hcl 1 ZELAPAR 3 MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine mesylate inj 2 migergot 2 MIGRANAL 4 QL(24 per naratriptan hcl tabs 2.5mg 2 QL(24 per naratriptan hcl tabs 1mg 2 QL(36 per RELPAX 3 QL(36 per rizatriptan benzoate 2 QL(54 per rizatriptan benzoate odt 2 QL(54 per sumatriptan succinate inj 6mg/0.5ml 2 QL(12 per sumatriptan succinate tabs 100mg 2 QL(27 per sumatriptan succinate tabs 25mg, 50mg 2 QL(54 per MISCELLANEOUS NEUROLOGICAL THERAPY ARICEPT TABS 23MG 3 QL(90 per COPAXONE 5 PA QL(90 per donepezil hcl 2 QL(90 per EXELON ORAL SOLN 3 EXELON PT24 3 QL(90 per galantamine hydrobromide cp24 2 QL(90 per galantamine hydrobromide oral soln 2 11

20 galantamine hydrobromide tabs 2 QL(180 per GILENYA 5 PA QL(28 per 28 days) MYTELASE 3 NAMENDA ORAL SOLN 3 NAMENDA TABS 10MG 3 QL(180 per NAMENDA TABS 5MG 3 QL(270 per NAMENDA TITRATION PAK 3 NAMENDA XR 3 NAMENDA XR TITRATION 3 PACK NUEDEXTA 3 QL(180 per rivastigmine tartrate 2 QL(180 per TECFIDERA 5 PA TECFIDERA STARTER PACK 5 PA XENAZINE 5 LA MUSCLE RELAXANTS / ANTISPASDIC THERAPY baclofen 1 cyclobenzaprine hcl tabs 10mg, 1 5mg dantrolene sodium caps 2 LIORESAL INTRATHECAL INJ 3 PA 0.05MG/ML LIORESAL INTRATHECAL INJ 3 PA 10MG/20ML, 10MG/5ML MESTINON SYRP 3 MESTINON TIMESPAN 3 pyridostigmine bromide 2 regonol 2 tizanidine hcl 2 NARCOTIC ANALGESICS acetaminophen/codeine #3 2 acetaminophen/codeine oral soln 2 acetaminophen/codeine tabs 2 ascomp/codeine 2 BUPRENEX 3 buprenorphine hcl inj 2 buprenorphine hcl subl 2 BUTRANS PTWK 10MCG/HR, 3 20MCG/HR, 5MCG/HR codeine sulfate tabs 2 DILAUDID INJ 3 DILAUDID-5 3 DILAUDID-HP INJ 10MG/ML 3 duramorph inj 1mg/ml 2 duramorph inj 0.5mg/ml 2 endocet tabs 650mg; 10mg 2 QL(540 per endocet tabs 500mg; 7.5mg 2 QL(720 per endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg EXALGO T24A 12MG, 16MG, 8MG fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 400mcg, 600mcg, 800mcg fentanyl citrate oral transmucosal lpop 200mcg 2 QL(1080 per 3 5 PA QL(360 per 2 PA QL(360 per fentanyl patches 2 QL(30 per hydrocodone bitartrate/acetaminophen oral soln hydrocodone bitartrate/acetaminophen tabs 750mg; 10mg hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg 2 QL(5550 per 30 days) 2 QL(450 per 2 QL(1080 per 12

21 hydrocodone/acetaminophen oral soln hydrocodone/acetaminophen tabs 750mg; 7.5mg hydrocodone/acetaminophen tabs 650mg; 10mg, 650mg; 7.5mg, 660mg; 10mg hydrocodone/acetaminophen tabs 500mg; 10mg, 500mg; 2.5mg, 500mg; 5mg, 500mg; 7.5mg hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg hydrocodone/ibuprofen tabs 7.5mg; 200mg hydromorphone hcl inj 2 QL(3600 per 30 days) 2 QL(450 per 2 QL(540 per 2 QL(720 per 2 QL(1080 per 2 500mg/50ml hydromorphone hcl tabs 2 LAZANDA 5 LA PA QL(31 per levorphanol tartrate 2 methadone hcl conc 2 methadone hcl inj 2 methadone hcl oral soln 2 methadone hcl tabs 2 methadose tabs 2 morphine sulfate er cp24 10mg 2 morphine sulfate er cp24 100mg, 2 20mg, 30mg, 50mg, 60mg, 80mg morphine sulfate er tbcr 2 morphine sulfate oral soln 2 morphine sulfate tabs 2 ONSOLIS FILM 1200MCG, 400MCG, 600MCG, 800MCG 3 3 PA QL(360 per ONSOLIS FILM 200MCG 3 PA QL(720 per OPANA ER (CRUSH RESISTANT) 3 QL(540 per oxycodone hcl caps 2 QL(1080 per oxycodone hcl conc 2 QL(1800 per oxycodone hcl oral soln 2 QL(3600 per oxycodone hcl tabs 10mg, 15mg, 20mg, 30mg 2 QL(540 per oxycodone hcl tabs 5mg 2 QL(1080 per oxycodone/acetaminophen caps 2 QL(720 per oxycodone/acetaminophen tabs 650mg; 10mg oxycodone/acetaminophen tabs 500mg; 7.5mg oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg 2 QL(540 per 2 QL(720 per 2 QL(1080 per oxycodone/aspirin 2 OXYCONTIN 3 QL(540 per oxymorphone hydrochloride 2 oxymorphone hydrochloride er 2 tb12 15mg, 7.5mg reprexain tabs 10mg; 200mg 2 ROXICET ORAL SOLN 3 QL(5580 per stagesic 2 QL(720 per vicodin 2 QL(1080 per 13

22 vicodin es 2 QL(1080 per vicodin hp 2 QL(1080 per NON-NARCOTIC ANALGESICS ARTHROTEC 50 4 ARTHROTEC 75 4 buprenorphine hcl/naloxone hcl 2 butorphanol tartrate nasal soln 2 PA QL(30 per CELEBREX 4 QL(180 per diclofenac potassium 2 diclofenac sodium dr 1 diclofenac sodium er 1 diclofenac sodium/misoprostol 2 diflunisal 2 etodolac 2 etodolac er 2 fenoprofen calcium 2 FLECTOR 4 flurbiprofen 2 ibuprofen susp 1 ibuprofen tabs 400mg, 600mg, 1 800mg indomethacin caps 1 indomethacin er 1 ketoprofen 2 ketoprofen er 2 meclofenamate sodium 2 mefenamic acid 2 meloxicam 1 nabumetone 2 naloxone hcl inj 1mg/ml 2 naltrexone hcl 2 naproxen 1 naproxen dr 1 naproxen sodium tabs 275mg, 2 550mg NUCYNTA 3 QL(541 per NUCYNTA ER 3 QL(180 per oxaprozin 2 PENNSAID 3 piroxicam 1 SUBOXONE 3 sulindac 2 tolmetin sodium 2 tramadol hcl 2 QL(720 per tramadol hcl er tb24 3 QL(90 per VIVO 3 QL(180 per VOLTAREN GEL GEL 3 PSYCHOTHERAPEUTIC DRUGS ABILIFY DISCMELT TBDP 15MG ABILIFY DISCMELT TBDP 10MG 4 QL(180 per 4 QL(270 per ABILIFY INJ 4 ABILIFY MAINTENA INJ 5 300MG ABILIFY ORAL SOLN 4 ABILIFY TABS 20MG, 2MG, 30MG, 5MG 4 QL(90 per ABILIFY TABS 15MG 4 QL(180 per ABILIFY TABS 10MG 4 QL(270 per amitriptyline hcl 1 14

23 amoxapine 2 budeprion sr 2 QL(180 per bupropion hcl 2 bupropion hcl sr 2 QL(180 per bupropion hcl xl tb24 300mg 2 QL(90 per bupropion hcl xl tb24 150mg 2 QL(270 per buspirone hcl 2 chlordiazepoxide/amitriptyline 2 chlorpromazine hcl inj 2 chlorpromazine hcl tabs 2 citalopram hydrobromide oral 1 soln citalopram hydrobromide tabs 40mg citalopram hydrobromide tabs 10mg citalopram hydrobromide tabs 20mg 1 QL(90 per 1 QL(180 per 1 QL(270 per clomipramine hcl 2 clorazepate dipotassium 2 clozapine 2 CYMBALTA CPEP 60MG 3 QL(180 per CYMBALTA CPEP 30MG 3 QL(360 per CYMBALTA CPEP 20MG 3 QL(540 per desipramine hcl 2 dextroamphetamine sulfate er 2 PA dextroamphetamine sulfate tabs 2 PA diazepam intensol 2 diazepam oral soln 2 diazepam tabs 2 doxepin hcl 1 EMSAM 4 QL(90 per escitalopram oxalate oral soln 2 QL(1920 per escitalopram oxalate tabs 2 QL(90 per FANAPT TABS 1MG, 2MG, 4MG FANAPT TABS 10MG, 12MG, 6MG, 8MG 4 QL(90 per 4 QL(180 per FANAPT TITRATION PACK 4 FAZACLO 4 fluoxetine dr 1 QL(12 per fluoxetine hcl caps 40mg 1 QL(180 per fluoxetine hcl caps 20mg 1 QL(360 per fluoxetine hcl caps 10mg 1 QL(720 per fluoxetine hcl oral soln 1 fluoxetine hcl tabs 20mg 1 QL(360 per fluoxetine hcl tabs 10mg 1 QL(720 per fluphenazine decanoate 1 fluphenazine hcl conc 1 fluphenazine hcl elix 1 fluphenazine hcl inj 1 fluphenazine hcl tabs 1 15

24 fluvoxamine maleate 2 QL(270 per fluvoxamine maleate er cp24 150mg fluvoxamine maleate er cp24 100mg 2 QL(180 per 2 QL(270 per FOCALIN XR 3 PA FORFIVO XL 4 QL(90 per GEODON INJ 4 HALDOL 3 HALDOL DECANOATE HALDOL DECANOATE 50 3 haloperidol conc 2 haloperidol decanoate 2 haloperidol lactate 2 haloperidol tabs 1 imipramine hcl 2 imipramine pamoate 3 INTUNIV 4 INVEGA SUSTENNA INJ 39MG/0.25ML INVEGA SUSTENNA INJ 78MG/0.5ML INVEGA SUSTENNA INJ 117MG/0.75ML INVEGA SUSTENNA INJ 156MG/ML INVEGA SUSTENNA INJ 234MG/1.5ML INVEGA TB24 1.5MG, 3MG, 9MG 3 QL(0.75 per 3 QL(1.5 per 3 QL(2.25 per 3 QL(3 per 90 days) 3 QL(4.5 per 4 QL(90 per INVEGA TB24 6MG 4 QL(180 per LATUDA TABS 120MG 3 QL(90 per LATUDA TABS 80MG 3 QL(180 per LATUDA TABS 40MG 3 QL(360 per LATUDA TABS 20MG 3 QL(720 per lithium carbonate 1 lithium carbonate er 1 lithium citrate 2 lorazepam intensol 2 lorazepam tabs 2 loxapine succinate 2 LUNESTA 4 QL(90 per maprotiline hcl 2 MARPLAN 3 METADATE CD CPCR 20MG, 4 PA 30MG, 40MG, 50MG, 60MG methylphenidate hcl 2 PA methylphenidate hcl cd cpcr 2 PA 50mg, 60mg methylphenidate hcl er cp24 2 PA methylphenidate hydrochloride 2 PA mirtazapine 2 QL(90 per mirtazapine odt tbdp 30mg, 45mg 2 QL(90 per modafinil 2 PA QL(90 per nefazodone hcl 2 QL(180 per nortriptyline hcl 1 olanzapine inj 2 16

25 olanzapine odt 2 QL(90 per olanzapine tabs 2 QL(90 per olanzapine/fluoxetine 2 QL(90 per ORAP 3 paroxetine hcl er tb mg, 37.5mg 1 QL(180 per paroxetine hcl er tb24 25mg 1 QL(270 per paroxetine hcl tabs 20mg, 40mg 1 QL(90 per paroxetine hcl tabs 10mg, 30mg 1 QL(180 per PAXIL SUSP 3 perphenazine 2 phenelzine sulfate 2 PRISTIQ 3 QL(90 per procentra 2 PA protriptyline hcl 2 PROVIGIL 3 PA QL(90 per quetiapine fumarate tabs 25mg, 300mg, 400mg quetiapine fumarate tabs 100mg, 200mg, 50mg 2 QL(180 per 2 QL(270 per RISPERDAL CONSTA 3 QL(12 per 84 days) risperidone odt 2 QL(180 per risperidone oral soln 2 risperidone tabs 2 QL(180 per RITALIN LA 4 PA SAPHRIS 3 QL(180 per SEROQUEL XR TB24 150MG, 300MG, 400MG SEROQUEL XR TB24 200MG, 50MG 3 QL(180 per 3 QL(270 per sertraline hcl conc 2 sertraline hcl tabs 100mg, 25mg 2 QL(180 per sertraline hcl tabs 50mg 2 QL(270 per SILENOR 4 QL(90 per STRATTERA 3 SYMBYAX 4 QL(90 per temazepam 2 thioridazine hcl 2 thiothixene 1 tranylcypromine sulfate 2 trazodone hcl 1 trifluoperazine hcl 2 trimipramine maleate 2 venlafaxine hcl er cp24 150mg, 37.5mg 2 QL(90 per venlafaxine hcl er cp24 75mg 2 QL(270 per venlafaxine hcl tabs 100mg, 25mg, 37.5mg 2 QL(270 per 17

26 venlafaxine hcl tabs 75mg 2 QL(450 per venlafaxine hcl tabs 50mg 2 QL(675 per VIIBRYD KIT 3 QL(30 per 365 days) VIIBRYD TABS 3 QL(90 per XYREM 5 PA zaleplon caps 5mg 2 QL(90 per zaleplon caps 10mg 2 QL(180 per zenzedi 2 PA ziprasidone hcl 2 QL(180 per zolpidem tartrate 2 QL(90 per zolpidem tartrate er 2 QL(90 per CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone hcl inj 50mg/ml 2 amiodarone hcl tabs 200mg, 2 400mg disopyramide phosphate 2 flecainide acetate 2 mexiletine hcl 2 MULTAQ 3 NORPACE CR 3 pacerone tabs 100mg, 200mg 2 procainamide hcl inj 500mg/ml 2 procainamide hcl inj 100mg/ml 2 propafenone hcl 2 propafenone hcl er 2 quinidine gluconate cr 2 quinidine sulfate 2 quinidine sulfate er 2 sorine 1 sotalol hcl (af) tabs 120mg 1 sotalol hcl tabs 160mg, 240mg, 1 80mg TIKOSYN 4 ANTIHYPERTENSIVE THERAPY acebutolol hcl 2 afeditab cr 2 amiloride hcl 2 amiloride/hydrochlorothiazide 1 amlodipine besylate 2 amlodipine besylate/benazepril hcl amlodipine besylate/benazepril hydrochloride 2 QL(90 per 2 QL(90 per AMTURNIDE 3 QL(90 per atenolol 1 atenolol/chlorthalidone 1 AZOR 3 QL(90 per benazepril hcl 1 benazepril hcl/hydrochlorothiazide tabs 20mg; 12.5mg, 20mg; 25mg benazepril hcl/hydrochlorothiazide tabs 10mg; 12.5mg benazepril hcl/hydrochlorothiazide tabs 5mg; 6.25mg 2 QL(360 per 2 QL(720 per 2 QL(1440 per BENICAR HCT 3 QL(90 per 18

27 BENICAR TABS 20MG, 40MG 3 QL(90 per BENICAR TABS 5MG 3 QL(180 per betaxolol hcl 2 BIDIL 3 QL(540 per bisoprolol fumarate 2 bisoprolol 1 fumarate/hydrochlorothiazide bumetanide 1 BYSTOLIC 3 candesartan cilexetil 2 candesartan cilexetil/hydrochlorothiazide 2 captopril 1 captopril/hydrochlorothiazide tabs 25mg; 15mg, 25mg; 25mg, 50mg; 15mg 2 QL(90 per captopril/hydrochlorothiazide tabs 50mg; 25mg 2 QL(270 per cartia xt 2 carvedilol 2 chlorothiazide 1 chlorothiazide sodium 2 chlorthalidone tabs 25mg, 50mg 1 clonidine hcl ptwk 2 clonidine hcl tabs 1 COREG CR 3 DEMSER 3 DIBENZYLINE 4 dilt-cd cp24 120mg, 300mg 2 dilt-xr cp24 180mg, 240mg 2 diltiazem cd cp24 120mg, 240mg, 2 300mg diltiazem hcl er cp12 2 diltiazem hcl er cp24 180mg, 2 360mg, 420mg diltiazem hcl inj 100mg, 50mg/10ml 2 diltiazem hcl tabs 2 DIOVAN 3 doxazosin mesylate 1 QL(180 per EDECRIN 3 enalapril maleate 1 enalapril maleate/hydrochlorothiazide tabs 5mg; 12.5mg enalapril maleate/hydrochlorothiazide tabs 10mg; 25mg 1 QL(90 per 1 QL(180 per eplerenone 2 eprosartan mesylate 2 QL(90 per EXFORGE 3 QL(90 per EXFORGE HCT 3 QL(90 per felodipine er 2 fosinopril sodium 2 fosinopril sodium/hydrochlorothiazide tabs 10mg; 12.5mg fosinopril sodium/hydrochlorothiazide tabs 20mg; 12.5mg 2 QL(90 per 2 QL(360 per furosemide 1 guanfacine hcl 1 hydralazine hcl 1 hydrochlorothiazide 1 indapamide 1 irbesartan 2 QL(90 per irbesartan/hydrochlorothiazide 2 QL(90 per isradipine 2 labetalol hcl 2 19

28 lisinopril 1 lisinopril/hydrochlorothiazide 1 QL(90 per tabs 12.5mg; 10mg, 12.5mg; 20mg lisinopril/hydrochlorothiazide tabs 25mg; 20mg 1 QL(360 per losartan potassium tabs 100mg 2 QL(90 per losartan potassium tabs 25mg, 50mg losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg losartan potassium/hydrochlorothiazide 2 QL(180 per 2 QL(90 per 2 QL(180 per tabs 12.5mg; 50mg matzim la 2 methyclothiazide 2 metolazone 2 metoprolol succinate er 2 metoprolol tartrate inj 1 metoprolol tartrate tabs 1 metoprolol/hydrochlorothiazide 2 MICARDIS HCT 3 QL(90 per MICARDIS TABS 20MG, 40MG 3 QL(90 per MICARDIS TABS 80MG 3 QL(180 per minoxidil tabs 2 moexipril hcl 2 moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 12.5mg; 7.5mg moexipril/hydrochlorothiazide tabs 25mg; 15mg 2 QL(90 per 2 QL(180 per nadolol 1 nadolol/bendroflumethiazide 2 nicardipine hcl caps 2 nifediac cc tb24 90mg 2 nifedical xl 2 nifedipine 2 nifedipine er 2 nimodipine 2 nisoldipine 2 nisoldipine er 2 perindopril erbumine 2 pindolol 1 prazosin hcl 1 QL(360 per propranolol hcl er 1 propranolol hcl inj 1 propranolol hcl oral soln 1 propranolol hcl tabs 1 propranolol/hydrochlorothiazide 2 quinapril hcl 2 quinapril/hydrochlorothiazide 2 QL(90 per ramipril 2 REDULIN 5 PA reserpine 2 spironolactone 1 spironolactone/hydrochlorothiazi 2 de taztia xt 2 TEKAMLO 3 QL(90 per TEKTURNA 3 QL(90 per TEKTURNA HCT 3 QL(90 per terazosin hcl 1 QL(180 per timolol maleate 1 20

29 torsemide tabs 2 trandolapril 2 triamterene/hydrochlorothiazide 1 TRIBENZOR 3 QL(90 per TWYNSTA 3 QL(90 per valsartan/hydrochlorothiazide 2 QL(90 per verapamil hcl er 1 verapamil hcl inj 1 verapamil hcl sr cp24 360mg 1 verapamil hcl tabs 1 CARDIAC GLYCOSIDES digoxin 1 LANOXIN 3 LANOXIN PEDIATRIC 3 COAGULATION THERAPY AGGRENOX 3 BRILINTA 3 cilostazol 2 clopidogrel 2 CYKLOKAPRON 3 EFFIENT 3 ELIQUIS 3 enoxaparin sodium inj 2 300mg/3ml, 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml enoxaparin sodium inj 100mg/ml, 5 120mg/0.8ml, 150mg/ml fondaparinux sodium 2 FRAGMIN 3 heparin sodium inj 10000unit/ml, unit/ml, 20000unit/ml, 5000unit/ml heparin sodium/d5w inj 5%; 2 40unit/ml heparin sodium/nacl 0.45% 2 heparin sodium/sodium chloride 2 0.9% premix jantoven 1 LOVENOX INJ 300MG/3ML 3 pentoxifylline er 2 PRADAXA 3 PROMACTA 5 LA PA QL(90 per ticlopidine hcl 2 warfarin sodium 1 XARELTO 3 LIPID/CHOLESTEROL LOWERING AGENTS atorvastatin calcium 1 QL(90 per cholestyramine light pack 2 colestipol hcl 2 CRESTOR 3 QL(90 per fenofibrate 2 fenofibrate micronized 2 fenofibric acid dr 2 fluvastatin 2 QL(90 per gemfibrozil 2 JUXTAPID 5 LIPOFEN 3 lovastatin tabs 10mg 1 QL(90 per lovastatin tabs 20mg, 40mg 1 QL(180 per LOVAZA 3 NIASPAN 3 pravastatin sodium tabs 10mg, 20mg, 80mg 2 QL(90 per 21

30 pravastatin sodium tabs 40mg 2 QL(180 per prevalite powd 2 simvastatin 2 QL(90 per TRILIPIX 3 VASCEPA 3 WELCHOL 3 ZETIA 3 QL(90 per MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 3 NITRATES isosorbide dinitrate 1 isosorbide dinitrate er 1 isosorbide mononitrate 2 isosorbide mononitrate er 1 nitro-bid 2 NITRO-DUR PT24 0.3MG/HR, 3 0.8MG/HR nitroglycerin inj 2 PA nitroglycerin pt24 2 nitroglycerin transdermal pt mg/hr NITROLINGUAL PUMPSPRAY 3 NITROSTAT 3 DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin 2 calcipotriene 2 selenium sulfide lotn 1 SORIATANE 3 BURN THERAPY silver sulfadiazine 2 ssd 2 MISCELLANEOUS DERMATOLOGICALS 8-P 3 ammonium lactate 2 CARAC 3 CARL-HC 3 CONDYLOX GEL 3 ELIDEL 4 FLUOROPLEX 3 fluorouracil crea 2 fluorouracil external soln 2 imiquimod 2 laclotion 2 OXSORALEN ULTRA 5 PANRETIN 3 podofilox 2 PROTOPIC 4 prudoxin 2 REGRANEX 3 PA SOLARAZE 4 UVADEX 4 VEREGEN 4 THERAPY FOR ACNE adapalene 2 amnesteem 2 avita crea 2 AZELEX 3 claravis caps 10mg, 20mg, 40mg 3 claravis caps 30mg 5 clindamycin phosphate external 2 soln clindamycin phosphate foam 2 clindamycin phosphate gel 2 clindamycin phosphate lotn 2 clindamycin phosphate swab 2 clindamycin/benzoyl peroxide gel 2 5%; 1% DIFFERIN GEL 0.3% 3 DIFFERIN LOTN 3 ery 1 erythromycin external soln 1 erythromycin gel 1 erythromycin/benzoyl peroxide 2 22

31 FINACEA 3 METROGEL 3 metronidazole 1 myorisan 2 TAZORAC 3 tretinoin 2 TOPICAL ANESTHETICS lidocaine hcl external soln 2 lidocaine hcl inj 0.5%, 1% 2 lidocaine hcl jelly 2 lidocaine oint 2 lidocaine viscous 2 lidocaine/prilocaine crea 2 LIDODERM 3 PA TOPICAL ANTIBACTERIALS ALTABAX 3 BACTROBAN CREA 3 gentamicin sulfate crea 1 gentamicin sulfate oint 0.1% 1 mafenide acetate 2 mupirocin 2 PHISOHEX 3 sulfacetamide sodium susp 2 SULFAMYLON 3 TOPICAL ANTIFUNGALS ciclopirox 2 ciclopirox nail lacquer 2 ciclopirox olamine 2 clotrimazole external crea 2 clotrimazole external soln 2 clotrimazole/betamethasone 2 dipropionate econazole nitrate 2 ketoconazole 2 ketodan kit 2 NAFTIN CREA 1% 3 NAFTIN GEL 2% 3 NAFTIN GEL 1% 3 nyamyc 1 nystatin crea 1 nystatin oint 1 nystatin powd unit/gm 1 nystatin/triamcinolone 1 nystop 1 pedi-dri 1 TOPICAL ANTIVIRALS acyclovir oint 2 DENAVIR 3 ZOVIRAX CREA 4 ZOVIRAX OINT 4 TOPICAL CORTICOSTEROIDS ala cort 1 alclometasone dipropionate 2 amcinonide 2 augmented betamethasone 1 dipropionate crea augmented betamethasone 2 dipropionate gel augmented betamethasone 2 dipropionate lotn augmented betamethasone 1 dipropionate oint betamethasone dipropionate 2 betamethasone valerate 1 CAPEX 3 clobetasol propionate e 2 clobetasol propionate external 2 soln clobetasol propionate foam 2 clobetasol propionate gel 2 clobetasol propionate lotn 2 clobetasol propionate oint 2 clobetasol propionate sham 2 CORDRAN TAPE 3 DERMA-SOTHE/FS BODY 3 OIL desonide 2 desoximetasone 2 diflorasone diacetate 2 fluocinolone acetonide body 1 fluocinolone acetonide crea 1 23

32 fluocinolone acetonide external 1 soln fluocinolone acetonide oint 1 fluocinonide external soln 2 fluocinonide gel 2 fluocinonide oint 2 fluocinonide-e 2 fluticasone propionate 2 halobetasol propionate 2 hydrocortisone butyrate 2 hydrocortisone crea 1%, 2.5% 1 hydrocortisone lotn 2.5% 1 hydrocortisone oint 1%, 2.5% 1 hydrocortisone valerate 2 LOCOID LOTN 3 LUXIQ 3 mometasone furoate crea 2 mometasone furoate external soln 2 mometasone furoate oint 2 PANDEL 3 prednicarbate 2 triamcinolone acetonide crea 1 triamcinolone acetonide lotn 1 triamcinolone acetonide oint 1 triderm 1 TOPICAL ENZYMES SANTYL 3 TOPICAL SCABICIDES / PEDICULICIDES EURAX 3 lindane 2 QL(1800 per 365 days) malathion 2 permethrin crea 2 SKLICE 3 spinosad 2 QL(720 per ULESFIA 4 DIAGNOSTICS / MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS acamprosate calcium dr 2 QL(540 per ACTONEL TABS 30MG 4 PA QL(60 per 120 days) ADAGEN 5 LA alendronate sodium tabs 40mg 2 QL(180 per 365 days) anagrelide hydrochloride 2 ANTABUSE TABS 250MG 3 ARALAST NP INJ 400MG 5 LA BUPHENYL 3 CAMPRAL 3 QL(540 per CARBAGLU 5 LA cevimeline hcl 2 CHEMET 3 CLINIMIX 4.25%/DEXTROSE 3 5% dextrose 10%/nacl 0.45% 2 dextrose 10% flex container 2 dextrose 10%/nacl 0.2% 2 dextrose 2.5%/sodium chloride % dextrose 5% 2 dextrose 5%/lactated ringers 2 dextrose 5%/nacl 0.2% 2 dextrose 5%/nacl 0.225% 2 dextrose 5%/nacl 0.33% 2 dextrose 5%/nacl 0.45% 2 dextrose 5%/nacl 0.9% 2 disulfiram 2 etidronate disodium 2 EVOXAC 3 EXJADE TBSO 125MG 3 LA EXJADE TBSO 250MG, 500MG 5 LA FOSRENOL 3 INCRELEX 5 LA PA 24