BeHealthy America, Inc Formulary. (List of Covered Drugs)

Transcription

1 BeHealthy America, Inc Formulary (List of Covered Drugs) HPMS Approved Formulary File Submission ID: Version Number: 12 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 5/27/2015. For more recent information or other questions, please contact the BeHealthy America, Inc. Customer Service Department at TTY users should call We are open: October 1 to February 14: Monday through Sunday, 8:00 am 8:00 pm February 15 to September 30: Monday through Friday, 8:00 am 8:00 pm or visit H2758_CompFormulary_2015 Accepted 10/06/2014

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means BeHealthy America. When it refers to plan or our plan, it means BeHealthy America. This document includes a list of the drugs (formulary) for our plan which is current as of 06/01/2015. 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, 2016, and from time to time during the year. What is the BeHealthy America, Inc. Formulary? A formulary is a list of covered drugs selected by BeHealthy America 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. BeHealthy America will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BeHealthy America 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 2014 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 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, 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 6/1/2015. To get updated information about the drugs covered by BeHealthy America, please contact us. Our contact information appears on the front and back cover pages. Every month, we update our printed formulary. I

3 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 Agents. If you know what your drug is used for, look for the category name in the list that begins on page number 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 63. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? BeHealthy America 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: BeHealthy America requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from BeHealthy America before you fill your prescriptions. If you don t get approval, BeHealthy America may not cover the drug. Quantity Limits: For certain drugs, BeHealthy America limits the amount of the drug that BeHealthy America will cover. For example, BeHealthy America provides 30 tablets per prescription for Cialis. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, BeHealthy America 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, BeHealthy America may not cover Drug B unless you try Drug A first. If Drug A does not work for you, BeHealthy America will then cover Drug B. II

4 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 Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask BeHealthy America 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 BeHealthy America formulary? on page III 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 Services and ask if your drug is covered. If you learn that BeHealthy America does not cover your drug, you have two options: You can ask Customer Services for a list of similar drugs that are covered by BeHealthy America. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BeHealthy America. You can ask BeHealthy America 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 BeHealthy America, Inc. Formulary? You can ask BeHealthy America to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a 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, BeHealthy America 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. III

5 Generally, BeHealthy America will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 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 day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). 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 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. For enrollees who are outside their transition period, and experience a level of care change in which an enrollee is changing from one treatment setting to another (example: LTC to hospital to LTC, hospitals to home, home to LTC), upon admission or discharge from a treatment setting or LTC, The Organization will allow the enrollee access to a 30/31 day refill (30 days in the retail setting and 31 days in the LTC setting) for formulary medications and an emergency 30/31 day refill (30 days in the retail setting and 31 days in the LTC setting) transition fill for non-formulary medications (including Part D drugs that are on Plan Sponsor s formulary but require prior authorization or step therapy). This policy does not apply for short-term leaves of absences (i.e. holidays or vacations) from LTC or hospital facilities. IV

6 For more information For more detailed information about your BeHealthy America s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about BeHealthy America, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit BeHealthy America s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by BeHealthy America. If you have trouble finding your drug in the list, turn to the Index that begins on page 63. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX CAP 100MG) and generic drugs are listed in lower-case italics (e.g., ibuprofen sus 100mg/5ml). The information in the Requirements/Limits column tells you if BeHealthy America has any special requirements for coverage of your drug. V

7 ANALGESICS Opioid Analgesics, Long-acting BUTRANS PATCH WK 15 MCG/HR 3 fentanyl 100 mcg/hr 2 ST QL 10 fentanyl 12 mcg/hr 2 ST QL 10 fentanyl 25 mcg/hr 2 ST QL 10 fentanyl 75 mcg/hr 2 ST QL 10 fentanyl patch 72hr 100 mcg/hr 2 ST QL 10 fentanyl patch 72hr 12 mcg/hr 2 ST QL 10 fentanyl patch 72hr 25 mcg/hr 2 ST QL 10 fentanyl patch 72hr 50 mcg/hr 2 ST QL 10 fentanyl patch 72hr 75 mcg/hr 2 ST QL 10 KADIAN CAP ER 24H 40 MG 2 methadone hcl sol 10 mg/5ml 1 GC METHADONE HCL SOL 10 MG/5ML 1 METHADONE HCL SOL 10 MG/ML 1 GC METHADONE HCL SOL 5 MG/5ML 2 methadone hcl sol 5 mg/5ml 2 methadone hcl tab 10 mg 2 methadone hcl tab 5 mg 2 methadose tab 10 mg 2 morphine sul er beads cap er 24h mg morphine sul er beads cap er 24h 30 2 mg morphine sul er beads cap er 24h 45 2 mg morphine sul er beads cap er 24h 60 2 mg morphine sul er beads cap er 24h 75 2 mg morphine sul er beads cap er 24h 90 2 mg morphine sul cap er 24h 10 mg 2 morphine sul cap er 24h 100 mg 2 morphine sul cap er 24h 20 mg 2 morphine sul cap er 24h 30 mg 2 morphine sul cap er 24h 50 mg 2 morphine sul cap er 24h 60 mg 2 morphine sul cap er 24h 80 mg 2 morphine sul tab er 100 mg 2 morphine sul tab er 15 mg 2 morphine sul tab er 30 mg 2 morphine sul tab er 60 mg 2 NUCYNTA TAB ER 12H 100 MG 3 NUCYNTA TAB ER 12H 150 MG 3 NUCYNTA TAB ER 12H 200 MG 3 NUCYNTA TAB ER 12H 250 MG 3 NUCYNTA TAB ER 12H 50 MG 3 OPANA TAB ER 12H 10 MG 3 OPANA TAB ER 12H 15 MG 3 OPANA TAB ER 12H 20 MG 3 OPANA TAB ER 12H 30 MG 3 OPANA TAB ER 12H 40 MG 3 OPANA TAB ER 12H 5 MG 3 OPANA TAB ER 12H 7.5 MG 3 OPANA ER TB12 DETER 10 MG 3 OPANA ER TB12 DETER 15 MG 3 OPANA ER TB12 DETER 20 MG 3 OPANA ER TB12 DETER 30 MG 3 OPANA ER TB12 DETER 40 MG 3 OPANA ER TB12 DETER 5 MG 3 OPANA ER TB12 DETER 7.5 MG 3 oxymorphone hcl tab er 12h 10 mg 2 oxymorphone hcl tab er 12h 15 mg 2 oxymorphone hcl tab er 12h 20 mg 2 oxymorphone hcl tab er 12h 30 mg 2 oxymorphone hcl tab er 12h 40 mg 2 oxymorphone hcl tab er 12h 5 mg 2 1

8 oxymorphone hcl tab er 12h 7.5 mg 2 ZOHYDRO CAP ER 12H 10 MG 4 PA QL 180 ZOHYDRO CAP ER 12H 15 MG 4 PA QL 180 ZOHYDRO CAP ER 12H 20 MG 4 PA QL 180 ZOHYDRO CAP ER 12H 30 MG 4 PA QL 180 ZOHYDRO CAP ER 12H 40 MG 4 PA QL 180 ZOHYDRO CAP ER 12H 50 MG 4 PA QL 180 ZOHYDRO ER CP12 DETER 10 MG 4 PA QL 180 ZOHYDRO ER CP12 DETER 15 MG 4 PA QL 180 ZOHYDRO ER CP12 DETER 20 MG 4 PA QL 180 ZOHYDRO ER CP12 DETER 30 MG 4 PA QL 180 ZOHYDRO ER CP12 DETER 40 MG 4 PA QL 180 ZOHYDRO ER CP12 DETER 50 MG 4 PA QL 180 Opioid Analgesics, Short-acting apap-codeine #2 tab mg 2 QL 400 apap-codeine # mg 2 QL 400 apap-codeine #3 tab mg 2 QL 400 apap-codeine #4 tab mg 2 QL 400 apap-codeine mg/5ml 2 QL 5000 apap-codeine sol mg/5ml 2 QL 5000 apap-codeine tab mg 2 QL 400 apap-codeine tab mg 2 QL 400 apap-codeine tab mg 2 QL 400 ascomp-codeine cap 2 PA butal-apap-caff-cod cap 2 PA QL 370 duramorph sol 0.5 mg/ml 1 GC duramorph sol 1 mg/ml 1 GC endocet tab mg 2 QL 370 endocet tab mg 2 QL 370 endocet tab mg 2 QL 370 FENTORA TAB 200 MCG 5 PA FENTORA TAB 400 MCG 5 PA FENTORA TAB 600 MCG 5 PA FENTORA TAB 800 MCG 5 PA hydrocodone-apap sol mg/5ml 1 QL 5500 GC hydrocodone-apap sol mg/10ml 1 QL 5500 GC hydrocodone-apap sol mg/15ml 1 QL 5500 GC hydrocodone-apap tab mg 2 QL 370 hydrocodone-apap tab mg 1 QL 370 hydrocodone-apap tab mg 2 QL 370 hydrocodone-apap tab mg 2 QL 370 hydrocodone-ibu tab mg 2 hydromorphone hcl er tb24 deter 12 mg 2 hydromorphone hcl er tb24 deter 16 mg 2 hydromorphone hcl er tb24 deter 8 mg 2 hydromorphone hcl 1 mg/ml 2 hydromorphone hcl pf sol 10 mg/ml 2 hydromorphone hcl pf sol 50 mg/5ml 2 hydromorphone hcl pf sol 500 mg/50ml 2 hydromorphone hcl sol 10 mg/ml 2 hydromorphone hcl sol 50 mg/5ml 2 hydromorphone hcl tab 2 mg 2 hydromorphone hcl tab 4 mg 2 2

9 hydromorphone hcl tab 8 mg 2 LAZANDA SOL 100 MCG/ACT 5 PA LAZANDA SOL 400 MCG/ACT 5 PA lorcet plus tab mg 2 QL 370 morphine sul (conc) 20 mg/ml 2 morphine sul (conc) sol 100 mg/5ml 2 morphine sul (conc) sol 20 mg/ml 2 morphine sul sol 10 mg/5ml 2 morphine sul sol 20 mg/5ml 1 GC RPHINE SUL TAB 15 MG 2 RPHINE SUL TAB 30 MG 2 nalbuphine hcl 10 mg/ml 2 nalbuphine hcl sol 10 mg/ml 2 nalbuphine hcl sol 20 mg/ml 2 NUCYNTA TAB 100 MG 3 NUCYNTA TAB 50 MG 3 NUCYNTA TAB 75 MG 3 OXYCODONE HCL CAP 5 MG 2 oxycodone hcl cap 5 mg 2 oxycodone hcl tab 10 mg 2 oxycodone hcl tab 15 mg 2 oxycodone hcl tab 20 mg 2 oxycodone hcl tab 30 mg 2 oxycodone hcl tab 5 mg 2 oxycodone-apap tab mg 2 QL 370 oxycodone-apap tab mg 2 QL 370 oxycodone-apap tab mg 2 QL 370 oxycodone-apap tab mg 2 QL 370 oxycodone-asa tab mg 2 oxycodone-ibu tab mg 2 oxymorphone hcl tab 10 mg 2 oxymorphone hcl tab 5 mg 2 pentazocine-naloxone hcl tab mg 2 PA tramadol hcl 50 mg 1 QL 240 GC tramadol hcl tab 50 mg 1 QL 240 GC tramadol-apap tab mg 2 QL 370 ANESTHETICS Local Anesthetics lidocaine hcl (pf) sol 0.5 % 1 GC lidocaine hcl (pf) sol 2 % 2 lidocaine hcl gel 2 % 2 lidocaine hcl sol 0.5 % 1 lidocaine hcl sol 2 % 2 lidocaine-prilocaine cr % 2 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-craving disulfiram tab 250 mg 2 disulfiram tab 500 mg 2 naltrexone hcl tab 50 mg 2 Opioid Antagonists buprenorphine hcl 0.3 mg/ml 1 GC buprenorphine hcl sl tab 2 mg 2 buprenorphine hcl sl tab 8 mg 2 buprenorphine hcl sol 0.3 mg/ml 1 GC buprenorphine hcl-naloxone hcl sl tab mg buprenorphine hcl-naloxone hcl sl tab mg EVZIO SOLN A-INJ 0.4 MG/0.4ML 4 BD naloxone hcl sol 1 mg/ml 1 GC SUBOXONE FILM 12-3 MG 4 SUBOXONE FILM 4-1 MG 4 ZUBSOLV SL TAB MG 3 ZUBSOLV SL TAB MG 3 ZUBSOLV SL TAB MG 4 3

10 Smoking Cessation Agents CHANTIX STARTING PAK 4 QL 53 CHANTIX TAB 0.5 MG 4 QL 11 CHANTIX TAB 1 MG 4 QL 180/90 NICOTROL INHALER 10 MG 3 ANTI-INFLAMMATORY AGENTS Nonsteroidal Anti-inflammatory Drugs CELEBREX CAP 100 MG 3 CELEBREX CAP 200 MG 3 CELEBREX CAP 400 MG 3 CELEBREX CAP 50 MG 3 diclofenac potassium tab 50 mg 2 diclofenac sod 50 mg 2 diclofenac sod 75 mg 1 GC diclofenac sod tab er 24h 100 mg 2 diclofenac sod tab dr 25 mg 2 diclofenac sod tab dr 50 mg 2 diclofenac sod tab dr 75 mg 1 GC diflunisal tab 500 mg 2 etodolac 500 mg 2 etodolac cap 200 mg 2 etodolac cap 300 mg 2 etodolac tab er 24h 400 mg 2 etodolac tab er 24h 500 mg 2 etodolac tab er 24h 600 mg 2 etodolac tab 400 mg 2 etodolac tab 500 mg 2 FENOPROFEN CA TAB 600 MG 1 flurbiprofen tab 100 mg 2 flurbiprofen tab 50 mg 1 GC ibu 800 mg 1 GC ibu susp 100 mg/5ml 1 GC ibu tab 400 mg 1 GC ibu tab 600 mg 1 GC ibu tab 800 mg 1 GC indomethacin cap 25 mg 1 PA GC indomethacin cap 50 mg 2 PA indomethacin cap er 75 mg 2 PA ketoprofen cap 50 mg 1 GC ketoprofen cap 75 mg 2 KETOPROFEN CAP ER 24H 200 MG 2 ketorolac 15 mg/ml 1 PA GC ketorolac 30 mg/ml 1 PA GC ketorolac 60 mg/2ml 1 PA ketorolac sol 15 mg/ml 1 PA GC ketorolac sol 30 mg/ml 1 PA GC ketorolac sol 60 mg/2ml 1 PA GC ketorolac tab 10 mg 2 PA MECLOFENAMATE SOD CAP 100 MG 1 MECLOFENAMATE SOD CAP 50 MG 1 MELOXICAM SUSP 7.5 MG/5ML 1 meloxicam tab 15 mg 2 meloxicam tab 7.5 mg 2 nabumetone 500 mg 2 nabumetone 750 mg 2 nabumetone tab 500 mg 2 nabumetone tab 750 mg 2 naproxen 250 mg 2 naproxen 375 mg 1 GC naproxen 500 mg 1 GC naproxen dr tab dr 375 mg 1 GC naproxen dr tab dr 500 mg 2 naproxen kit tab 500 mg 1 GC naproxen sod tab 275 mg 2 naproxen sod tab 550 mg 2 naproxen susp 125 mg/5ml 1 GC naproxen tab 250 mg 2 naproxen tab 375 mg 1 GC 4

11 naproxen tab 500 mg 1 GC oxaprozin tab 600 mg 2 piroxicam cap 10 mg 2 piroxicam cap 20 mg 1 GC sulindac tab 150 mg 2 sulindac tab 200 mg 2 tolmetin sod cap 400 mg 2 TOLMETIN SOD TAB 600 MG 1 ANTIBACTERIALS Aminoglycosides GENTAMICIN IN SALINE SOL MG/ML-% gentamicin in saline sol mg/ml-% 1 GC gentamicin in saline sol mg/ml- 1 GC % GENTAMICIN IN SALINE SOL MG/ML-% gentamicin in saline sol mg/ml- 1 GC % gentamicin sul sol 10 mg/ml 1 GC gentamicin sul sol 40 mg/ml 2 neomycin sul tab 500 mg 2 paromomycin sul cap 250 mg 2 STREPTOMYCIN SUL RECON SOLN 1 2 GM tobramycin nebu soln 300 mg/5ml 2 BD tobramycin sul recon soln 1.2 gm 2 tobramycin sul sol 1.2 gm/30ml 2 tobramycin sul sol 10 mg/ml 2 tobramycin sul sol 2 gm/50ml 2 tobramycin sul sol 80 mg/2ml 2 Antibacterials, Other baciim recon soln unit 1 GC CHLORAMPHENICOL SOD SUCC RECON 2 clindamycin hcl cap 150 mg 2 clindamycin hcl cap 300 mg 2 clindamycin hcl cap 75 mg 2 clindamycin palmitate hcl recon soln 75 2 mg/5ml clindamycin phos in d5w sol 300 mg/50ml 1 GC clindamycin phos in d5w sol 600 mg/50ml 1 GC clindamycin phos in d5w sol 900 mg/50ml 1 GC clindamycin phos sol 300 mg/2ml 1 clindamycin phos sol 600 mg/4ml 1 GC clindamycin phos sol 9 gm/60ml 1 clindamycin phos sol 900 mg/6ml 1 clindamycin phos sol 9000 mg/60ml 1 colistimethate sod recon soln 150 mg 2 CUBICIN RECON SOLN 500 MG 4 LINCOCIN SOL 300 MG/ML 4 metronidazole cap 375 mg 1 GC metronidazole in nacl mg/ml-% 2 BD metronidazole in nacl sol mg/ml-% 2 BD metronidazole in nacl sol BD mg/100ml-% metronidazole tab 250 mg 1 GC metronidazole tab 500 mg 1 GC nitrofurantoin macrocrystal cap 100 mg 2 PA nitrofurantoin macrocrystal cap 50 mg 2 PA nitrofurantoin monohyd macro cap 100 mg 2 PA SYNERCID RECON SOLN MG 4 tmp tab 100 mg 2 TYGACIL 50 MG 4 TYGACIL RECON SOLN 50 MG 4 vancomycin hcl cap 125 mg 2 vancomycin hcl cap 250 mg 2 vancomycin hcl recon soln 10 gm 2 5

12 vancomycin hcl recon soln 1000 mg 2 vancomycin hcl recon soln 500 mg 4 vancomycin hcl recon soln 500 mg 2 vancomycin hcl recon soln 5000 mg 2 XIFAXAN TAB 550 MG 4 ZYVOX RECON SUSP 100 MG/5ML 4 ZYVOX SOL 2 MG/ML 5 ZYVOX TAB 600 MG 5 Beta-lactam, Cephalosporins cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 CEFACLOR TAB ER 12H 500 MG 1 cefazolin sod 1 gm 2 cefazolin sod 10 gm 1 GC cefazolin sod 500 mg 1 GC CEFAZOLIN SOD RECON SOLN 1 GM 1 cefazolin sod recon soln 1 gm 2 cefazolin sod recon soln 10 gm 1 GC cefazolin sod recon soln 20 gm 1 cefazolin sod recon soln 500 mg 1 GC CEFAZOLIN SOD SOL 1-5 GM-% 1 CEFAZOLIN SOD-DEXT RECON SOLN GM-% cefdinir cap 300 mg 2 cefdinir recon susp 125 mg/5ml 1 GC cefdinir recon susp 250 mg/5ml 1 GC cefepime hcl 2 gm 2 cefepime hcl recon soln 1 gm 2 cefepime hcl recon soln 2 gm 2 cefoxitin sod recon soln 1 gm 2 cefoxitin sod recon soln 10 gm 2 cefoxitin sod recon soln 2 gm 2 cefpodoxime proxetil recon susp 100 mg/5ml 2 cefpodoxime proxetil recon susp 50 2 mg/5ml cefpodoxime proxetil tab 100 mg 2 cefpodoxime proxetil tab 200 mg 2 cefprozil 125 mg/5ml 2 cefprozil 250 mg/5ml 2 cefprozil recon susp 125 mg/5ml 2 cefprozil recon susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 ceftriaxone sod 1 gm 2 ceftriaxone sod 2 gm 2 ceftriaxone sod 250 mg 2 ceftriaxone sod 500 mg 2 ceftriaxone sod recon soln 1 gm 2 ceftriaxone sod recon soln 10 gm 2 ceftriaxone sod recon soln 2 gm 2 ceftriaxone sod recon soln 250 mg 2 ceftriaxone sod recon soln 500 mg 2 cefuroxime axetil tab 250 mg 2 cefuroxime sod 1.5 gm 1 GC cefuroxime sod 7.5 gm 1 GC cefuroxime sod 750 mg 1 GC cefuroxime sod recon soln 1.5 gm 1 GC cefuroxime sod recon soln 7.5 gm 1 GC cefuroxime sod recon soln 750 mg 1 GC cephalexin cap 250 mg 1 GC cephalexin cap 500 mg 1 GC cephalexin recon susp 125 mg/5ml 2 cephalexin recon susp 250 mg/5ml 1 GC CEPHALEXIN TAB 250 MG 1 CEPHALEXIN TAB 500 MG 1 SUPRAX CAP 400 MG 4 SUPRAX RECON SUSP 200 MG/5ML 4 TEFLARO RECON SOLN 400 MG 4 6

13 TEFLARO RECON SOLN 600 MG 4 Beta-lactam, Other AZACTAM IN DEXT SOL 1 GM 3 AZACTAM IN DEXT SOL 2 GM 5 aztreonam recon soln 1 gm 2 aztreonam recon soln 2 gm 2 CAYSTON RECON SOLN 75 MG 5 imipenem-cilastatin recon soln 250 mg 2 imipenem-cilastatin recon soln 500 mg 2 INVANZ RECON SOLN 1 GM 4 meropenem recon soln 1 gm 2 meropenem recon soln 500 mg 2 Beta-lactam, Penicillins amoxicillin cap 250 mg 1 GC amoxicillin cap 500 mg 1 GC AXICILLIN CHEW TAB 125 MG 1 AXICILLIN CHEW TAB 250 MG 1 amoxicillin recon susp 125 mg/5ml 1 GC amoxicillin recon susp 200 mg/5ml 1 GC amoxicillin recon susp 250 mg/5ml 1 GC amoxicillin recon susp 400 mg/5ml 1 GC amoxicillin tab 500 mg 1 GC amoxicillin tab 875 mg 2 amoxicillin-pot clav chew tab GC mg amoxicillin-pot clav chew tab mg 1 GC amoxicillin-pot clav recon susp GC mg/5ml amoxicillin-pot clav recon susp mg/5ml amoxicillin-pot clav recon susp mg/5ml amoxicillin-pot clav tab mg 2 amoxicillin-pot clav tab mg 2 amoxicillin-pot clav tab mg 2 ampicillin cap 250 mg 2 ampicillin cap 500 mg 2 AMPICILLIN RECON SUSP 125 MG/5ML 1 AMPICILLIN RECON SUSP 250 MG/5ML 1 ampicillin sod 1 gm 2 ampicillin sod 10 gm 2 ampicillin sod 2 gm 2 ampicillin sod 500 mg 2 ampicillin sod recon soln 1 gm 2 ampicillin sod recon soln 10 gm 2 AMPICILLIN SOD RECON SOLN 125 MG 2 ampicillin sod recon soln 2 gm 2 ampicillin sod recon soln 250 mg 2 ampicillin sod recon soln 500 mg 2 ampicillin-sulbactam sod recon soln 15 2 (10-5) gm BICILLIN L-A SUSP UNIT/ML 4 dicloxacillin sod cap 250 mg 2 dicloxacillin sod cap 500 mg 2 nafcillin sod recon soln 1 gm 2 nafcillin sod recon soln 10 gm 2 nafcillin sod recon soln 2 gm 2 penicillin g potassium recon soln unit penicillin g potassium recon soln GC unit PENICILLIN G SOD RECON SOLN UNIT penicillin v potassium 125 mg/5ml 1 GC penicillin v potassium recon soln GC mg/5ml penicillin v potassium recon soln GC mg/5ml penicillin v potassium tab 250 mg 1 GC 7

14 penicillin v potassium tab 500 mg 2 piperacillin sod-tazobactam so recon 2 soln gm piperacillin sod-tazobactam so recon 2 soln gm piperacillin sod-tazobactam so recon 2 soln gm piperacillin sod-tazobactam so recon 2 soln gm Macrolides AZITHROMYCIN PACKET 1 GM 2 azithromycin recon soln 500 mg 2 azithromycin recon susp 100 mg/5ml 1 GC azithromycin recon susp 200 mg/5ml 2 azithromycin tab 250 mg 2 azithromycin tab 500 mg 2 azithromycin tab 600 mg 2 clarithromycin 250 mg 2 clarithromycin tab 250 mg 2 clarithromycin tab 500 mg 2 DIFICID TAB 200 MG 5 ST ERYTHROCIN LACTOBIONATE 2 RECON SOLN 500 MG ERYTHROCIN STEARATE TAB 250 MG 2 ERYTHROMYCIN ETHYLSUCC TAB MG KETEK TAB 300 MG 4 KETEK TAB 400 MG 4 Quinolones ciprofloxacin 200 mg/20ml 1 ciprofloxacin 400 mg/40ml 1 GC ciprofloxacin hcl 250 mg 1 GC ciprofloxacin hcl 500 mg 1 GC ciprofloxacin hcl tab 100 mg 1 GC ciprofloxacin hcl tab 250 mg 1 GC ciprofloxacin hcl tab 500 mg 1 GC ciprofloxacin hcl tab 750 mg 2 ciprofloxacin in d5w 200 mg/100ml 1 GC ciprofloxacin in d5w 400 mg/200ml 1 ciprofloxacin in d5w sol 200 mg/100ml 1 GC ciprofloxacin in d5w sol 400 mg/200ml 1 ciprofloxacin recon susp 250 mg/5ml (5%) 1 GC ciprofloxacin recon susp 500 mg/5ml (10%) 1 GC ciprofloxacin sol 200 mg/20ml 1 ciprofloxacin sol 400 mg/40ml 1 GC ciprofloxacin-ciproflox hcl tab er 24h mg ciprofloxacin-ciproflox hcl tab er 24h mg levofloxacin in d5w sol 250 mg/50ml 2 levofloxacin in d5w sol 500 mg/100ml 2 levofloxacin in d5w sol 750 mg/150ml 2 levofloxacin sol 25 mg/ml 2 levofloxacin tab 250 mg 2 levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2 moxifloxacin hcl tab 400 mg 2 ofloxacin tab 300 mg 1 GC OFLOXACIN TAB 400 MG 2 Sulfonamides SULFADIAZINE TAB 500 MG 2 sulfamethoxazole-tmp ds tab mg 1 GC SULFAMETHOXAZOLE-TMP SOL MG/5ML sulfamethoxazole-tmp susp mg/5ml 1 GC sulfamethoxazole-tmp susp GC mg/20ml sulfamethoxazole-tmp tab mg 1 GC 8

15 Tetracyclines doxycycline hyclate cap 100 mg 1 GC doxycycline hyclate cap 50 mg 1 GC doxycycline hyclate recon soln 100 mg 1 GC doxycycline hyclate tab 100 mg 1 GC doxycycline hyclate tab 20 mg 2 doxycycline monohydrate 100 mg 1 doxycycline monohydrate 50 mg 1 GC doxycycline monohydrate 50 mg 1 doxycycline monohydrate 75 mg 2 doxycycline monohydrate cap 100 mg 1 GC doxycycline monohydrate cap 50 mg 1 GC doxycycline monohydrate recon susp 25 2 mg/5ml doxycycline monohydrate tab 100 mg 1 doxycycline monohydrate tab 50 mg 1 GC doxycycline monohydrate tab 75 mg 2 minocycline hcl cap 100 mg 2 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl tab 100 mg 2 minocycline hcl tab 50 mg 2 minocycline hcl tab 75 mg 2 ANTICONVULSANTS Anticonvulsants, Other FARYDAK CAP 20 MG 5 PA levetiracetam 1000 mg 2 levetiracetam 250 mg 2 levetiracetam 500 mg 2 levetiracetam 750 mg 2 levetiracetam tab er 24h 500 mg 2 levetiracetam tab er 24h 750 mg 2 LEVETIRACETAM IN NACL SOL 1000 MG/100ML 4 LEVETIRACETAM IN NACL SOL MG/100ML LEVETIRACETAM IN NACL SOL MG/100ML levetiracetam sol 100 mg/ml 2 levetiracetam sol 500 mg/5ml 2 levetiracetam tab 1000 mg 2 levetiracetam tab 250 mg 2 levetiracetam tab 500 mg 2 levetiracetam tab 750 mg 2 POTIGA TAB 200 MG 4 POTIGA TAB 300 MG 4 POTIGA TAB 400 MG 4 POTIGA TAB 50 MG 4 Barbiturates phenobarbital elixir 20 mg/5ml 1 GC phenobarbital sol 20 mg/5ml 1 GC PHENOBARBITAL TAB 100 MG 1 PHENOBARBITAL TAB 15 MG 1 phenobarbital tab 16.2 mg 1 GC PHENOBARBITAL TAB 30 MG 1 phenobarbital tab 32.4 mg 1 GC PHENOBARBITAL TAB 60 MG 1 phenobarbital tab 64.8 mg 1 phenobarbital tab 97.2 mg 1 Benzodiazepines clonazepam tab 0.5 mg 1 GC clonazepam tab 1 mg 1 GC clonazepam tab 2 mg 1 GC clonazepam tab disp mg 1 GC clonazepam tab disp 0.25 mg 1 GC clonazepam tab disp 0.5 mg 1 GC clonazepam tab disp 1 mg 1 GC clonazepam tab disp 2 mg 1 GC 9

16 DIAZEPAM GEL 10 MG 2 DIAZEPAM GEL 2.5 MG 2 DIAZEPAM GEL 20 MG 2 ONFI SUSP 2.5 MG/ML 4 ONFI TAB 10 MG 4 ONFI TAB 20 MG 4 Calcium Channel Modifying Agents CELONTIN CAP 300 MG 4 ethosuximide cap 250 mg 2 ethosuximide sol 250 mg/5ml 1 GC LYRICA CAP 200 MG 4 LYRICA CAP 225 MG 4 LYRICA CAP 25 MG 4 LYRICA CAP 300 MG 4 LYRICA CAP 50 MG 4 LYRICA CAP 75 MG 4 LYRICA SOL 20 MG/ML 3 zonisamide 100 mg 2 zonisamide 25 mg 2 zonisamide 50 mg 2 zonisamide cap 100 mg 2 zonisamide cap 25 mg 2 zonisamide cap 50 mg 2 Gamma-aminobutyric Acid (GABA) Augmenting Agents divalproex sod tab er 24h 250 mg 2 divalproex sod tab er 24h 500 mg 2 divalproex sod tab dr 250 mg 2 divalproex sod tab dr 500 mg 2 FYCOMPA TAB 10 MG 4 FYCOMPA TAB 12 MG 4 FYCOMPA TAB 2 MG 4 FYCOMPA TAB 4 MG 4 FYCOMPA TAB 6 MG 4 FYCOMPA TAB 8 MG 4 gabapentin 100 mg 2 gabapentin 300 mg 2 gabapentin 400 mg 2 gabapentin cap 100 mg 2 gabapentin cap 300 mg 2 gabapentin cap 400 mg 2 gabapentin sol 250 mg/5ml 2 gabapentin tab 600 mg 2 gabapentin tab 800 mg 2 GABITRIL TAB 12 MG 4 GABITRIL TAB 16 MG 4 primidone 250 mg 2 primidone tab 250 mg 2 primidone tab 50 mg 2 SABRIL PACKET 500 MG 5 SABRIL TAB 500 MG 5 tiagabine hcl tab 2 mg 2 tiagabine hcl tab 4 mg 2 valproate sod sol 100 mg/ml 1 GC valproate sod sol 500 mg/5ml 1 GC valproic acid cap 250 mg 2 valproic acid sol 250 mg/5ml 2 valproic acid syrup 250 mg/5ml 2 Glutamate Reducing Agents felbamate susp 600 mg/5ml 2 felbamate tab 400 mg 2 felbamate tab 600 mg 2 LAMICTAL ODT TAB DISP 100 MG 4 LAMICTAL ODT TAB DISP 200 MG 4 LAMICTAL ODT TAB DISP 25 MG 4 LAMICTAL ODT TAB DISP 50 MG 4 LAMICTAL STARTER KIT 25 (35) MG 4 10

17 LAMICTAL STARTER KIT 25 (42) LAMICTAL STARTER KIT 25 (84) (14) MG LAMICTAL XR KIT 25 & 50 & 100 MG 4 LAMICTAL XR KIT 25 (21)-50 (7) MG 4 LAMICTAL XR KIT 50 & 100 & 200 MG 4 lamotrigine chew tab 25 mg 2 lamotrigine chew tab 5 mg 2 lamotrigine tab er 24h 100 mg 2 lamotrigine tab er 24h 200 mg 2 lamotrigine tab er 24h 25 mg 2 lamotrigine tab er 24h 250 mg 2 lamotrigine tab er 24h 300 mg 2 lamotrigine tab er 24h 50 mg 2 lamotrigine tab 100 mg 2 lamotrigine tab 150 mg 2 lamotrigine tab 200 mg 2 lamotrigine tab 25 mg 2 lamotrigine tab disp 100 mg 2 lamotrigine tab disp 200 mg 2 lamotrigine tab disp 25 mg 2 lamotrigine tab disp 50 mg 2 QUDEXY XR CP24 SPRNK 100 MG 4 QUDEXY XR CP24 SPRNK 150 MG 4 QUDEXY XR CP24 SPRNK 200 MG 4 QUDEXY XR CP24 SPRNK 25 MG 4 QUDEXY XR CP24 SPRNK 50 MG 4 topiramate 25 mg 2 topiramate 50 mg 2 topiramate cap sprink 15 mg 2 topiramate cap sprink 25 mg 2 TOPIRAMATE ER CP24 SPRNK 100 MG 2 TOPIRAMATE ER CP24 SPRNK 150 MG 2 TOPIRAMATE ER CP24 SPRNK 200 MG 2 TOPIRAMATE ER CP24 SPRNK 25 MG 2 TOPIRAMATE ER CP24 SPRNK 50 MG 2 topiramate tab 100 mg 2 topiramate tab 200 mg 2 topiramate tab 25 mg 2 topiramate tab 50 mg 2 TROKENDI XR CAP ER 24H 100 MG 4 TROKENDI XR CAP ER 24H 200 MG 4 TROKENDI XR CAP ER 24H 25 MG 4 TROKENDI XR CAP ER 24H 50 MG 4 Sodium Channel Agents APTIOM TAB 200 MG 4 APTIOM TAB 400 MG 5 APTIOM TAB 600 MG 5 APTIOM TAB 800 MG 5 BANZEL SUSP 40 MG/ML 4 BANZEL TAB 200 MG 4 BANZEL TAB 400 MG 4 carbamazepine 100 mg/5ml 2 carbamazepine cap er 12h 200 mg 2 carbamazepine cap er 12h 300 mg 2 carbamazepine tab er 12h 200 mg 2 carbamazepine tab er 12h 400 mg 2 carbamazepine susp 100 mg/5ml 2 carbamazepine tab 200 mg 2 CEREBYX SOL 100 MG PE/2ML 4 CEREBYX SOL 500 MG PE/10ML 4 DILANTIN CAP 30 MG 4 epitol tab 200 mg 2 fosphenytoin sod 100 mg pe/2ml 2 fosphenytoin sod 500 mg pe/10ml 2 fosphenytoin sod sol 100 mg pe/2ml 2 fosphenytoin sod sol 500 mg pe/10ml 2 oxcarbazepine 150 mg 2 11

18 oxcarbazepine 300 mg 2 oxcarbazepine 600 mg 2 oxcarbazepine susp 300 mg/5ml 2 oxcarbazepine tab 150 mg 2 oxcarbazepine tab 300 mg 2 oxcarbazepine tab 600 mg 2 OXTELLAR XR TAB ER 24H 150 MG 4 OXTELLAR XR TAB ER 24H 300 MG 4 OXTELLAR XR TAB ER 24H 600 MG 4 PEGANONE TAB 250 MG 4 phenytoin 125 mg/5ml 2 phenytoin chew tab 50 mg 2 phenytoin infatabs chew tab 50 mg 2 phenytoin sod extended cap 100 mg 2 phenytoin sod extended cap 200 mg 2 phenytoin sod extended cap 300 mg 2 phenytoin sod sol 50 mg/ml 1 GC phenytoin susp 125 mg/5ml 2 TEGRETOL-XR TAB ER 12H 100 MG 4 VIMPAT SOL 10 MG/ML 4 VIMPAT SOL 200 MG/20ML 4 VIMPAT TAB 100 MG 4 VIMPAT TAB 150 MG 4 VIMPAT TAB 200 MG 4 VIMPAT TAB 50 MG 4 ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mesylates tab 1 mg 2 Cholinesterase Inhibitors donepezil hcl tab 10 mg 2 donepezil hcl tab 23 mg 2 donepezil hcl tab 5 mg 2 donepezil hcl tab disp 10 mg 2 donepezil hcl tab disp 5 mg 2 EXELON PATCH 24HR 13.3 MG/24HR 3 EXELON PATCH 24HR 4.6 MG/24HR 3 EXELON PATCH 24HR 9.5 MG/24HR 3 galantamine hbr cap er 24h 16 mg 2 galantamine hbr cap er 24h 24 mg 2 galantamine hbr cap er 24h 8 mg 2 galantamine hbr tab 12 mg 2 galantamine hbr tab 4 mg 2 galantamine hbr tab 8 mg 2 rivastigmine tartrate cap 1.5 mg 2 rivastigmine tartrate cap 3 mg 2 rivastigmine tartrate cap 4.5 mg 2 rivastigmine tartrate cap 6 mg 2 N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST NAMENDA XR CAP ER 24H 14 MG 4 NAMENDA XR CAP ER 24H 21 MG 4 NAMENDA XR CAP ER 24H 28 MG 4 NAMENDA XR CAP ER 24H 7 MG 3 ANTIDEPRESSANTS Antidepressants, Other APLENZIN TAB ER 24H 174 MG 4 APLENZIN TAB ER 24H 348 MG 4 APLENZIN TAB ER 24H 522 MG 5 BRINTELLIX TAB 10 MG 4 ST BRINTELLIX TAB 20 MG 4 ST BRINTELLIX TAB 5 MG 4 ST buproban tab er 12h 150 mg 2 bupropion hcl 100 mg 2 bupropion hcl er (sr) tab er 12h 100 mg 2 bupropion hcl er (sr) tab er 12h 150 mg 2 bupropion hcl er (sr) tab er 12h 200 mg 2 bupropion hcl er (xl) tab er 24h 150 mg 2 bupropion hcl er (xl) tab er 24h 300 mg 2 12

19 bupropion hcl tab 100 mg 2 bupropion hcl tab 75 mg 2 FORFIVO XL TAB ER 24H 450 MG 3 MAPROTILINE HCL TAB 25 MG 1 MAPROTILINE HCL TAB 50 MG 2 MAPROTILINE HCL TAB 75 MG 1 mirtazapine tab 15 mg 2 mirtazapine tab 30 mg 2 mirtazapine tab 45 mg 2 mirtazapine tab 7.5 mg 2 mirtazapine tab disp 15 mg 2 mirtazapine tab disp 30 mg 2 mirtazapine tab disp 45 mg 2 NEFAZODONE HCL TAB 100 MG 2 NEFAZODONE HCL TAB 150 MG 2 NEFAZODONE HCL TAB 200 MG 2 nefazodone hcl tab 250 mg 2 NEFAZODONE HCL TAB 50 MG 1 trazodone hcl 100 mg 1 GC trazodone hcl 150 mg 1 GC trazodone hcl 50 mg 1 GC trazodone hcl tab 100 mg 1 GC trazodone hcl tab 150 mg 1 GC trazodone hcl tab 300 mg 2 trazodone hcl tab 50 mg 1 GC VIIBRYD KIT 10 & 20 & 40 MG 3 VIIBRYD TAB 10 MG 3 VIIBRYD TAB 20 MG 3 VIIBRYD TAB 40 MG 3 Monoamine Oxidase Inhibitors EMSAM PATCH 24HR 12 MG/24HR 5 EMSAM PATCH 24HR 6 MG/24HR 5 EMSAM PATCH 24HR 9 MG/24HR 5 MARPLAN TAB 10 MG 4 phenelzine sul tab 15 mg 2 tranylcypromine sul tab 10 mg 2 Serotonin/Norepinephrine Reuptake Inhibitors BRISDELLE CAP 7.5 MG 4 citalopram hbr 10 mg 2 citalopram hbr 40 mg 1 GC citalopram hbr sol 10 mg/5ml 2 citalopram hbr tab 10 mg 2 citalopram hbr tab 20 mg 1 GC citalopram hbr tab 40 mg 1 GC DESVENLAFAXINE TAB ER 24H 100 MG 4 DESVENLAFAXINE TAB ER 24H 50 MG 4 DESVENLAFAXINE FUMARATE TAB ER 4 24H 100 MG DESVENLAFAXINE FUMARATE TAB ER 4 24H 50 MG duloxetine hcl cp dr part 20 mg 2 duloxetine hcl cp dr part 30 mg 2 duloxetine hcl cp dr part 60 mg 2 escitalopram oxalate sol 5 mg/5ml 2 escitalopram oxalate tab 10 mg 2 escitalopram oxalate tab 20 mg 2 escitalopram oxalate tab 5 mg 2 FETZIMA CAP ER 24H 120 MG 3 FETZIMA CAP ER 24H 20 MG 3 FETZIMA CAP ER 24H 40 MG 3 FETZIMA CAP ER 24H 80 MG 3 fluoxetine hcl cap 10 mg 1 GC fluoxetine hcl cap 20 mg 1 GC fluoxetine hcl cap 40 mg 1 GC fluoxetine hcl cap dr 90 mg 2 fluoxetine hcl sol 20 mg/5ml 2 fluoxetine hcl tab 10 mg 1 GC fluoxetine hcl tab 20 mg 2 13

20 FLUOXETINE HCL TAB 60 MG 4 fluvoxamine maleate 50 mg 2 fluvoxamine maleate cap er 24h 100 mg 2 fluvoxamine maleate cap er 24h 150 mg 2 fluvoxamine maleate tab 100 mg 2 fluvoxamine maleate tab 25 mg 2 fluvoxamine maleate tab 50 mg 2 KHEDEZLA TAB ER 24H 100 MG 3 KHEDEZLA TAB ER 24H 50 MG 3 olanzapine-fluoxetine hcl cap mg 2 olanzapine-fluoxetine hcl cap mg 2 olanzapine-fluoxetine hcl cap 3-25 mg 2 olanzapine-fluoxetine hcl cap 6-25 mg 2 olanzapine-fluoxetine hcl cap 6-50 mg 2 paroxetine hcl 10 mg 1 GC paroxetine hcl 20 mg 1 GC paroxetine hcl 30 mg 2 paroxetine hcl 40 mg 2 paroxetine hcl er 25 mg 2 paroxetine hcl tab er 24h 12.5 mg 2 paroxetine hcl tab er 24h 25 mg 2 paroxetine hcl tab er 24h 37.5 mg 2 paroxetine hcl tab 10 mg 1 GC paroxetine hcl tab 20 mg 1 GC paroxetine hcl tab 30 mg 2 paroxetine hcl tab 40 mg 2 PAXIL SUSP 10 MG/5ML 4 PEXEVA TAB 10 MG 4 PEXEVA TAB 20 MG 4 PEXEVA TAB 30 MG 4 PEXEVA TAB 40 MG 4 PRISTIQ TAB ER 24H 100 MG 4 PRISTIQ TAB ER 24H 50 MG 4 sertraline hcl 100 mg 2 sertraline hcl 25 mg 2 sertraline hcl 50 mg 2 sertraline hcl conc 20 mg/ml 2 sertraline hcl tab 100 mg 2 sertraline hcl tab 25 mg 2 sertraline hcl tab 50 mg 2 venlafaxine hcl cap er 24h 150 mg 2 venlafaxine hcl cap er 24h 37.5 mg 2 venlafaxine hcl cap er 24h 75 mg 2 VENLAFAXINE HCL TAB ER 24H 150 MG 2 venlafaxine hcl tab er 24h 150 mg 2 VENLAFAXINE HCL TAB ER 24H 225 MG 2 VENLAFAXINE HCL TAB ER 24H 37.5 MG 2 venlafaxine hcl tab er 24h 37.5 mg 2 VENLAFAXINE HCL TAB ER 24H 75 MG 2 venlafaxine hcl tab er 24h 75 mg 2 venlafaxine hcl tab 100 mg 2 venlafaxine hcl tab 25 mg 2 venlafaxine hcl tab 37.5 mg 2 venlafaxine hcl tab 50 mg 2 venlafaxine hcl tab 75 mg 2 Tricyclics amitriptyline hcl tab 10 mg 1 PA GC amitriptyline hcl tab 100 mg 1 PA GC amitriptyline hcl tab 150 mg 2 PA amitriptyline hcl tab 25 mg 1 PA BD GC amitriptyline hcl tab 50 mg 1 PA GC amitriptyline hcl tab 75 mg 1 PA GC AXAPINE TAB 100 MG 2 AXAPINE TAB 150 MG 1 AXAPINE TAB 25 MG 1 AXAPINE TAB 50 MG 1 CHLORDIAZEPOXIDE-AMITRIPTYLINE TAB MG 1 PA 14

21 CHLORDIAZEPOXIDE- 1 PA AMITRIPTYLINE TAB MG clomipramine hcl cap 25 mg 2 PA clomipramine hcl cap 50 mg 2 PA clomipramine hcl cap 75 mg 2 PA desipramine hcl tab 10 mg 2 desipramine hcl tab 100 mg 2 desipramine hcl tab 150 mg 2 desipramine hcl tab 25 mg 2 desipramine hcl tab 50 mg 2 desipramine hcl tab 75 mg 1 GC doxepin hcl cap 10 mg 1 PA GC doxepin hcl cap 100 mg 1 PA GC doxepin hcl cap 150 mg 2 PA doxepin hcl cap 25 mg 1 PA GC doxepin hcl cap 50 mg 1 PA GC DOXEPIN HCL CAP 75 MG 1 PA doxepin hcl conc 10 mg/ml 1 PA GC imipramine hcl tab 10 mg 2 PA imipramine hcl tab 25 mg 2 PA imipramine hcl tab 50 mg 2 PA imipramine pamoate cap 100 mg 2 PA imipramine pamoate cap 125 mg 2 PA imipramine pamoate cap 150 mg 2 PA imipramine pamoate cap 75 mg 2 PA mycophenolic acid tab dr 180 mg 2 BD mycophenolic acid tab dr 360 mg 2 BD nortriptyline hcl cap 10 mg 1 GC nortriptyline hcl cap 25 mg 1 GC nortriptyline hcl cap 50 mg 2 nortriptyline hcl cap 75 mg 2 NORTRIPTYLINE HCL SOL 10 MG/5ML 2 protriptyline hcl tab 10 mg 2 protriptyline hcl tab 5 mg 2 SURNTIL CAP 100 MG 4 SURNTIL CAP 25 MG 4 SURNTIL CAP 50 MG 4 ANTIEMETICS Antiemetics, Other meclizine hcl tab 12.5 mg 1 GC meclizine hcl tab 25 mg 1 GC metoclopramide hcl tab 10 mg 1 GC metoclopramide hcl tab 5 mg 2 TRANSDERM-SCOP PATCH 72HR 1 4 MG/3DAYS Emetogenic Therapy Adjuncts dronabinol cap 10 mg 5 QL 60 dronabinol cap 2.5 mg 2 QL 60 dronabinol cap 5 mg 2 QL 60 EMEND CAP 125 MG 4 BD QL 30 EMEND CAP 40 MG 4 BD QL 30 EMEND CAP 80 & 125 MG 4 BD QL 12 EMEND CAP 80 MG 3 BD QL 30 granisetron hcl 0.1 mg/ml 2 BD QL 60 granisetron hcl 1 mg 2 BD QL 60 granisetron hcl 1 mg/ml 2 BD QL 60 granisetron hcl 4 mg/4ml 2 BD QL 60 granisetron hcl sol 0.1 mg/ml 2 BD QL 60 granisetron hcl sol 1 mg/ml 2 BD QL 60 granisetron hcl sol 4 mg/4ml 2 BD QL 60 granisetron hcl tab 1 mg 2 BD QL 60 ondansetron hcl 4 mg 2 BD QL 60 ondansetron hcl 4 mg/2ml 2 BD QL 160 ondansetron hcl 40 mg/20ml 2 BD QL 160 ondansetron hcl 8 mg 2 BD QL 60 ondansetron hcl sol 4 mg/2ml 2 BD QL 160 ondansetron hcl sol 4 mg/5ml 2 BD 15

22 ondansetron hcl sol 40 mg/20ml 2 BD QL 160 ondansetron hcl tab 24 mg 2 BD QL 30 ondansetron hcl tab 4 mg 2 BD QL 60 ondansetron hcl tab 8 mg 2 BD QL 60 ondansetron tab disp 4 mg 2 BD QL 60 ondansetron tab disp 8 mg 2 BD QL 60 SANCUSO PATCH 3.1 MG/24HR 3 QL 4 ANTIFUNGALS Antifungals ABELCET SUSP 5 MG/ML 4 AMBISOME RECON SUSP 50 MG 4 AMPHOTERICIN B RECON SOLN 50 2 MG CANCIDAS RECON SOLN 50 MG 4 CANCIDAS RECON SOLN 70 MG 4 clotrimazole lozenge 10 mg 2 clotrimazole troche 10 mg 2 ERAXIS RECON SOLN 100 MG 4 ERAXIS RECON SOLN 50 MG 4 fluconazole 150 mg 2 fluconazole 200 mg 2 fluconazole 50 mg 2 fluconazole in dext sol 200 mg/100ml 2 fluconazole in dext sol 400 mg/200ml 2 fluconazole in sod chlor mg/100ml-% fluconazole in sod chlor mg/200ml-% 2 fluconazole in sod chlor sol mg/100ml-% fluconazole in sod chlor sol mg/200ml-% fluconazole recon susp 10 mg/ml 2 fluconazole recon susp 40 mg/ml 2 fluconazole tab 100 mg 2 fluconazole tab 150 mg 2 fluconazole tab 200 mg 2 fluconazole tab 50 mg 2 flucytosine cap 250 mg 5 flucytosine cap 500 mg 5 griseofulvin microsize susp 125 mg/5ml 1 GC itraconazole cap 100 mg 2 ketoconazole tab 200 mg 2 MYCAMINE RECON SOLN 100 MG 5 MYCAMINE RECON SOLN 50 MG 4 NOXAFIL SUSP 40 MG/ML 4 NOXAFIL TAB DR 100 MG 4 nystatin tab unit 2 voriconazole recon soln 200 mg 2 voriconazole recon susp 40 mg/ml 5 voriconazole tab 200 mg 5 ANTIGOUT AGENTS Antigout Agents allopurinol 100 mg 1 GC allopurinol tab 100 mg 1 GC allopurinol tab 300 mg 1 GC COLCRYS TAB 0.6 MG 4 probenecid tab 500 mg 2 ULORIC TAB 40 MG 3 ST ULORIC TAB 80 MG 3 ST ANTIMIGRAINE AGENTS Antimigraine Agents, Prophylactic 16

23 divalproex sod cap sprink 125 mg 2 divalproex sod tab dr 125 mg 2 divalproex sod tab dr 250 mg 2 divalproex sod tab dr 500 mg 2 topiramate 100 mg 2 topiramate tab 100 mg 2 Ergot Alkaloids dihydroergotamine mesylate sol 1 1 GC mg/ml ERGOMAR SL TAB 2 MG 4 Serotonin (5-HT) 1b/1d Receptor Agonists RELPAX TAB 20 MG 3 QL 9 RELPAX TAB 40 MG 3 QL 9 sumatriptan succ 100 mg 2 QL 9 sumatriptan succ 50 mg 2 QL 9 sumatriptan succ 6 mg/0.5ml 2 QL 10 sumatriptan succ refill soln cart 6 2 QL 4.5 mg/0.5ml sumatriptan succ soln a-inj 6 mg/0.5ml 2 QL 4.5 sumatriptan succ soln prsyr 6 mg/0.5ml 2 QL 4.5 sumatriptan succ sol 6 mg/0.5ml 2 QL 10 sumatriptan succ tab 100 mg 2 QL 9 sumatriptan succ tab 25 mg 2 QL 9 sumatriptan succ tab 50 mg 2 QL 9 ANTIMYASTHENIC AGENTS Parasympathomimetics GUANIDINE HCL TAB 125 MG 2 MESTINON SYRUP 60 MG/5ML 4 pyridostigmine bromide tab 60 mg 2 ANTIMYCOBACTERIALS Antimycobacterials, Other DAPSONE TAB 100 MG 2 DAPSONE TAB 25 MG 2 pyrazinamide tab 500 mg 2 rifabutin cap 150 mg 2 Antituberculars CAPASTAT SUL RECON SOLN 1 GM 4 ethambutol hcl tab 100 mg 2 ethambutol hcl tab 400 mg 2 ISONIAZID SOL 100 MG/ML 1 ISONIAZID SYRUP 50 MG/5ML 1 isoniazid tab 100 mg 1 GC isoniazid tab 300 mg 1 GC PASER PACKET 4 GM 4 rifampin cap 150 mg 1 GC rifampin cap 300 mg 2 rifampin recon soln 600 mg 1 GC RIFATER TAB MG 3 SIRTURO TAB 100 MG 5 TRECATOR TAB 250 MG 4 ANTINEOPLASTICS Alkylating Agents CYCLOPHOSPHAMIDE CAP 25 MG 2 BD CYCLOPHOSPHAMIDE CAP 50 MG 2 BD GLEOSTINE CAP 10 MG 4 GLEOSTINE CAP 100 MG 4 GLEOSTINE CAP 40 MG 4 HEXALEN 50 MG 4 HEXALEN CAP 50 MG 4 LEUKERAN TAB 2 MG 3 LOMUSTINE CAP 10 MG 2 LOMUSTINE CAP 100 MG 2 LOMUSTINE CAP 40 MG 2 ZANOSAR RECON SOLN 1 GM 4 Antiangiogenic Agents AVASTIN SOL 100 MG/4ML 5 17

24 AVASTIN SOL 400 MG/16ML 5 DEPEN TITRATABS TAB 250 MG 4 REVLIMID CAP 10 MG 5 LA REVLIMID CAP 15 MG 5 LA REVLIMID CAP 2.5 MG 5 REVLIMID CAP 20 MG 5 REVLIMID CAP 25 MG 5 LA REVLIMID CAP 5 MG 5 LA SYPRINE CAP 250 MG 4 THALOMID CAP 100 MG 5 THALOMID CAP 150 MG 5 THALOMID CAP 200 MG 5 THALOMID CAP 50 MG 5 Antimetabolites adrucil sol 2.5 gm/50ml 4 BD adrucil sol 5 gm/100ml 4 BD adrucil sol 500 mg/10ml 4 BD ALIMTA RECON SOLN 100 MG 5 ALIMTA RECON SOLN 500 MG 5 azacitidine recon susp 100 mg 5 DACOGEN RECON SOLN 50 MG 5 decitabine recon soln 50 mg 2 fludarabine phos recon soln 50 mg 2 fludarabine phos sol 50 mg/2ml 2 FLUDARABINE PHOS SOL 50 MG/2ML 2 gemcitabine hcl recon soln 1 gm 5 gemcitabine hcl recon soln 2 gm 5 gemcitabine hcl recon soln 200 mg 5 mercaptopurine tab 50 mg 2 methotrexate sod (pf) sol 1 gm/40ml 2 BD methotrexate sod (pf) sol 100 mg/4ml 2 BD methotrexate sod (pf) sol 200 mg/8ml 2 BD methotrexate sod (pf) sol 25 mg/ml 2 BD methotrexate sod (pf) sol 250 mg/10ml 2 BD methotrexate sod (pf) sol 50 mg/2ml 2 BD methotrexate sod recon soln 1 gm 1 BD GC methotrexate sod sol 25 mg/ml 2 BD methotrexate tab 2.5 mg 2 BD PRIMAQUINE PHOS TAB 26.3 MG 4 PURIXAN 20 MG/ML ORAL SUSP 4 TABLOID TAB 40 MG 4 Antineoplastics ABRAXANE RECON SUSP 100 MG 4 BD ACTIMMUNE SOL UNIT/0.5ML 5 LA AFINITOR DISPERZ TAB SOL 2 MG 5 AFINITOR DISPERZ TAB SOL 3 MG 5 AFINITOR DISPERZ TAB SOL 5 MG 5 AFINITOR TAB 10 MG 5 AFINITOR TAB 2.5 MG 5 AFINITOR TAB 5 MG 5 AFINITOR TAB 7.5 MG 5 amifostine recon soln 500 mg 5 ARRANON 5 MG/ML 4 BD ARRANON SOL 5 MG/ML 4 BD ARZERRA CONC 100 MG/5ML 5 BD ARZERRA CONC 1000 MG/50ML 5 BD AZASAN TAB 100 MG 4 BD AZASAN TAB 75 MG 4 BD BELEODAQ RECON SOLN 500 MG 5 bicalutamide tab 50 mg 2 BICNU RECON SOLN 100 MG 4 BD bleomycin sul recon soln 15 unit 2 bleomycin sul recon soln 30 unit 2 BOSULIF TAB 100 MG 5 PA BOSULIF TAB 500 MG 5 PA BUSULFEX SOL 6 MG/ML 4 BD CAPRELSA TAB 100 MG 5 CAPRELSA TAB 300 MG 5 18

25 CARAC CR 0.5 % 4 carboplatin recon soln 150 mg 2 BD carboplatin sol 150 mg/15ml 2 BD carboplatin sol 450 mg/45ml 2 BD carboplatin sol 50 mg/5ml 2 BD carboplatin sol 600 mg/60ml 2 BD cisplatin sol 100 mg/100ml 2 BD cisplatin sol 200 mg/200ml 2 BD cisplatin sol 50 mg/50ml 2 BD cladribine sol 1 mg/ml 2 BD CLOLAR 1 MG/ML 4 BD CLOLAR SOL 1 MG/ML 4 BD COMETRIQ (100 MG DAILY DOSE) KIT 5 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) KIT 5 1 X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) KIT 5 20 MG COSMEGEN RECON SOLN 0.5 MG 4 BD cytarabine (pf) sol 100 mg/ml 2 BD cytarabine (pf) sol 20 mg/ml 2 BD cytarabine recon soln 1 gm 2 BD cytarabine recon soln 2 gm 2 BD cytarabine sol 20 mg/ml 2 BD dacarbazine recon soln 200 mg 2 BD daunorubicin hcl injectable 5 mg/ml 2 BD daunorubicin hcl recon soln 20 mg 2 BD DAUNOXOME INJECTABLE 2 MG/ML 5 BD DEPO-PROVERA SUSP 400 MG/ML 4 BD dexrazoxane recon soln 250 mg 5 dexrazoxane recon soln 500 mg 5 DOCEFREZ RECON SOLN 20 MG 5 BD DOCETAXEL CONC 140 MG/7ML 5 docetaxel conc 20 mg/ml 5 DOCETAXEL CONC 80 MG/4ML 5 docetaxel conc 80 mg/4ml 5 DOCETAXEL SOL 160 MG/16ML 5 DOCETAXEL SOL 20 MG/2ML 5 DOCETAXEL SOL 200 MG/20ML 5 DOCETAXEL SOL 80 MG/8ML 5 DOXIL INJECTABLE 2 MG/ML 4 BD doxorubicin hcl recon soln 10 mg 2 BD doxorubicin hcl recon soln 50 mg 2 BD doxorubicin hcl sol 2 mg/ml 2 BD ELIGARD KIT 22.5 MG 4 BD ELIGARD KIT 30 MG 4 BD ELIGARD KIT 45 MG 4 BD ELIGARD KIT 7.5 MG 4 BD ELITEK RECON SOLN 1.5 MG 5 ELITEK RECON SOLN 7.5 MG 5 ELLENCE SOL 200 MG/100ML 4 BD ELLENCE SOL 50 MG/25ML 4 BD EMCYT CAP 140 MG 4 epirubicin hcl sol 200 mg/100ml 2 BD epirubicin hcl sol 50 mg/25ml 2 BD ERBITUX SOL 100 MG/50ML 5 BD ERBITUX SOL 200 MG/100ML 5 BD ERIVEDGE CAP 150 MG 5 ERWINAZE RECON SOLN UNIT 4 PA ETOPOPHOS RECON SOLN 100 MG 4 BD etoposide sol 1 gm/50ml 2 BD etoposide sol 100 mg/5ml 2 BD etoposide sol 500 mg/25ml 2 BD FARESTON TAB 60 MG 4 FARYDAK CAP 10 MG 5 PA FARYDAK CAP 15 MG 5 PA FASLODEX SOL 250 MG/5ML 5 FIRMAGON RECON SOLN 120 MG 5 FIRMAGON RECON SOLN 80 MG 4 fluorouracil 5 % 2 19

26 fluorouracil sol 1 gm/20ml 2 BD fluorouracil sol 2 % 2 fluorouracil sol 2.5 gm/50ml 2 BD fluorouracil sol 5 % 2 fluorouracil sol 5 gm/100ml 2 BD fluorouracil sol 500 mg/10ml 2 BD flutamide cap 125 mg 2 FOLOTYN SOL 20 MG/ML 4 BD FOLOTYN SOL 40 MG/2ML 4 BD FUSILEV RECON SOLN 50 MG 5 GILOTRIF TAB 20 MG 5 PA GILOTRIF TAB 30 MG 5 PA GILOTRIF TAB 40 MG 5 PA GLEEVEC TAB 100 MG 5 GLEEVEC TAB 400 MG 5 HALAVEN SOL 1 MG/2ML 5 HERCEPTIN RECON SOLN 440 MG 5 BD hydroxyurea cap 500 mg 2 IBRANCE CAP 100 MG 5 PA IBRANCE CAP 125 MG 5 PA IBRANCE CAP 75 MG 5 PA ICLUSIG TAB 15 MG 5 PA ICLUSIG TAB 45 MG 5 PA IDAMYCIN PFS SOL 10 MG/10ML 4 BD IDAMYCIN PFS SOL 20 MG/20ML 4 BD IDAMYCIN PFS SOL 5 MG/5ML 4 BD idarubicin hcl sol 10 mg/10ml 2 BD idarubicin hcl sol 20 mg/20ml 2 BD idarubicin hcl sol 5 mg/5ml 2 BD IFEX RECON SOLN 1 GM 4 BD IFEX RECON SOLN 3 GM 4 BD ifosfamide recon soln 1 gm 2 BD IFOSFAMIDE RECON SOLN 3 GM 2 BD ifosfamide sol 1 gm/20ml 2 BD ifosfamide sol 3 gm/60ml 2 BD IMBRUVICA CAP 140 MG 5 PA INLYTA TAB 1 MG 5 INLYTA TAB 5 MG 5 INTRON A RECON SOLN UNIT 5 INTRON A RECON SOLN UNIT 4 INTRON A RECON SOLN UNIT 4 INTRON-A RECON SOLN UNIT 5 INTRON-A RECON SOLN UNIT 4 INTRON-A RECON SOLN UNIT 4 INTRON-A SOL UNIT/ML 5 INTRON-A SOL UNIT/ML 4 irinotecan hcl 100 mg/5ml 5 BD irinotecan hcl 40 mg/2ml 5 BD irinotecan hcl sol 100 mg/5ml 5 BD irinotecan hcl sol 40 mg/2ml 5 BD irinotecan hcl sol 500 mg/25ml 5 BD ISTODAX RECON SOLN 10 MG 5 IXEMPRA KIT RECON SOLN 15 MG 4 BD IXEMPRA KIT RECON SOLN 45 MG 4 BD JAKAFI TAB 10 MG 5 JAKAFI TAB 15 MG 5 JAKAFI TAB 20 MG 5 JAKAFI TAB 25 MG 5 JAKAFI TAB 5 MG 5 JEVTANA SOL 60 MG/1.5ML 5 BD KADCYLA RECON SOLN 100 MG 5 KADCYLA RECON SOLN 160 MG 5 KEPIVANCE 6.25 MG 4 BD KEPIVANCE RECON SOLN 6.25 MG 4 BD KEYTRUDA RECON SOLN 50 MG 5 PA KEYTRUDA SOL 100 MG/4ML 5 PA LENVIMA 10 MG DAILY DOSE CAP THPK 3 10 MG LENVIMA 14 MG DAILY DOSE CAP THPK 10 & 4 MG 5 20