AvMed Medicare Choice Formulary (List of Covered Drugs)

Transcription

1 AvMed Medicare Choice 2011 Formulary (List of Covered Drugs) 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, To get this material in other formats or ask for language translation services, call AvMed Member services at TTY users call HPMS Approved Formulary File 11206, Version 22 Page 1 of 128

2 What is the AvMed Medicare Choice Formulary? A formulary is a list of covered drugs selected by AvMed Medicare Choice 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. AvMed Medicare Choice will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a AvMed Medicare Choice 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 2011 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2011 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 August 1, To get updated information about the drugs covered by AvMed Medicare Choice, please visit our Web site at or call Member Services at , 24 hours a day/7 days a week. TTY/TDD users should call The AvMed Medicare Choice monthly formulary updates include all changes approved by CMS and is posted monthly at You may request a printed formulary by calling , 24 hours a day/7 days a week. TTY/TDD users should call How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used Page 2 of 128

3 to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 113. 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? AvMed Medicare Choice 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: AvMed Medicare Choice requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from AvMed Medicare Choice before you fill your prescriptions. If you don t get approval, AvMed Medicare Choice may not cover the drug. Quantity Limits: For certain drugs, AvMed Medicare Choice limits the amount of the drug that AvMed Medicare Choice will cover. For example, AvMed Medicare Choice provides 30 tablets per prescription for Zetia. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, AvMed Medicare Choice 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, AvMed Medicare Choice may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AvMed Medicare Choice will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at Page 3 of 128

4 You can ask AvMed Medicare Choice to make an exception to these restrictions or limits. See the section, How do I request an exception to the AvMed Medicare Choice s formulary? on page 4 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 Member Services and confirm that your drug is not covered. If you learn that AvMed Medicare Choice does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by AvMed Medicare Choice. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by AvMed Medicare Choice. You can ask AvMed Medicare Choice 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 AvMed Medicare Choice s Formulary? You can ask AvMed Medicare Choice 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, AvMed Medicare Choice limit 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 Name Drug tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Brand Name Drug 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 Drug tier. Generally, AvMed Medicare Choice will only approve your request for an exception if the alternative drugs included on the plan s formulary, Preferred Brand Name Drug tier 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 Page 4 of 128

5 prescribing physician 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 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 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (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. You will be allowed to refill any appropriate and necessary drugs upon admission to or discharge from a long-term care facility. For more information For more detailed information about your AvMed Medicare Choice prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about AvMed Medicare Choice, please call Member Services at , 24 hours a day/7 days a week. TTY/TDD 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/TDD users should call Or, visit Page 5 of 128

6 AvMed Medicare Choice Formulary The formulary that begins on the next page provides coverage information about some of the drugs covered by AvMed Medicare Choice. If you have trouble finding your drug in the list, turn to the Index that begins on page 113. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The second column specifies the cost sharing tiers for your prescribed drugs. There are 4 tiers of cost sharing described as follows: Cost Sharing Tier 1 - Generic drugs Cost Sharing Tier 2 - Preferred brand drugs Cost Sharing Tier 3 Non-preferred brand drugs Cost Sharing Tier 4 Specialty drugs Please refer to your Evidence of Coverage for more information regarding how much you will pay for your prescription drugs. The information in the Notes column tells you if AvMed Medicare Choice has any special requirements for coverage of your drug. QL indicates that there is a quantity limit for the medication. PA indicates that a prior authorization is required before the medication will be covered. B/D indicates this drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. ST indicates that the medication has a step therapy and a preferred medication must first be tried. LA indicates limited availability. This prescription may be available only at certain pharmacies. E indicates 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 towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. MO indicates this is a medication that can be obtained through mail order. GAP indicates we provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. Page 6 of 128

7 Analgesics Opioid Analgesics, Long-Acting AVINZA 24 HR CAP 120 mg, 30 mg, 60 mg, 90 mg AVINZA 24 HR CAP 45 mg, 75 mg 2 QL (30 EA per 30 DURAGESIC TRANSDERM PATCH 3 QL (10 EA per 30 EMBEDA CAP 3 QL (60 EA per 30 EXALGO ER 24 HR TAB 12 mg, 16 mg 3 QL (120 EA per 30 EXALGO ER 24 HR TAB 8 mg 3 QL (30 EA per 30 fentanyl transderm patch 1 GAP; QL (10 EA per 30 KADIAN CAP 2 morphine er tab 1 GAP MS CONTIN TAB 3 OPANA ER 12 HR TAB 3 OXYCONTIN 12 HR TAB 80 mg 2 QL (120 EA per 30 OXYCONTIN 12 HR TAB 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg 2 2 QL (60 EA per 30 tramadol er 24 hr tab 200 mg 1 GAP; QL (60 EA per 30 tramadol er 24 hr tab 100 mg 1 GAP; QL (90 EA per 30 ULTRAM ER 24 HR TAB 200 mg 3 QL (60 EA per 30 ULTRAM ER 24 HR TAB 100 mg 3 QL (90 EA per 30 Opioid Analgesics, Short-Acting ABSTRAL SUBLINGUAL TAB 3 QL (240 EA per 30 acetaminophen-codeine elixir 1 GAP acetaminophen-codeine tab 1 GAP; QL (360 EA per 30 ACTIQ LOZENGE ON A HANDLE 3 QL (120 EA per 30 ASCOMP W/CODEINE CAP 1 GAP; QL (240 EA per 30 buprenorphine sublingual tab 1 GAP codeine-butalbital-acetaminophen-caffeine cap 1 GAP; QL (240 EA per 30 codeine tab 1 GAP CO-GESIC TAB 1 GAP; QL (240 EA per 30 Page 7 of 128

8 COMBUNOX TAB 3 QL (150 EA per 30 DEMEROL TAB 3 DILAUDID TAB 3 DILAUDID-5 ORAL LIQUID 3 DILAUDID-HP INJECTION 3 B/D DOLOPHINE TAB 3 DURAMORPH INJECTION 1 B/D; GAP ENDOCET TAB mg 1 GAP; QL (180 EA per 30 ENDOCET TAB mg 1 GAP; QL (240 EA per 30 ENDOCET TAB mg, mg, mg 1 GAP; QL (360 EA per 30 ENDODAN TAB 1 GAP; QL (360 EA per 30 fentanyl lozenge on a handle 3 QL (120 EA per 30 FENTORA BUCCAL TAB, EFFERVESCENT 3 QL (120 EA per 30 FIORICET-CODEINE CAP 3 QL (240 EA per 30 FIORINAL-CODEINE #3 CAP 3 QL (240 EA per 30 hydrocodone-acetaminophen oral soln mg/15 ml hydrocodone-acetaminophen tab mg, mg hydrocodone-acetaminophen tab mg, mg, mg hydrocodone-acetaminophen tab mg, mg, mg, mg hydrocodone-acetaminophen tab mg, mg, mg 1 GAP 1 GAP; QL (150 EA per 30 1 GAP; QL (180 EA per 30 1 GAP; QL (240 EA per 30 1 GAP; QL (360 EA per 30 hydrocodone-ibuprofen tab 1 GAP; QL (240 EA per 30 hydromorphone tab 1 GAP hydromorphone (pf) injection 1 B/D; GAP ibuprofen-oxycodone tab 1 GAP; QL (150 EA per 30 LORCET 10/650 TAB 3 QL (180 EA per 30 LORCET PLUS TAB 3 QL (180 EA per 30 Page 8 of 128

9 LORTAB TAB 3 QL (240 EA per 30 LORTAB ELIXIR ORAL SOLN 3 MARGESIC-H CAP 1 GAP; QL (240 EA per 30 MAXIDONE TAB 3 QL (150 EA per 30 meperidine oral soln 1 GAP meperidine tab 1 GAP meperidine (pf) pca syringe 1 B/D; GAP methadone injection 1 B/D; GAP methadone oral concentrate 1 GAP methadone oral soln 1 GAP methadone tab 1 GAP METHADOSE TAB 1 GAP morphine injection 1 B/D; GAP morphine tab 1 GAP morphine (pf) injection 1 B/D; GAP morphine concentrate oral 1 GAP NORCO TAB 3 QL (360 EA per 30 ONSOLIS BUCCAL FILM 3 QL (120 EA per 30 OPANA TAB 3 oxycodone cap 1 oxycodone oral concentrate 1 oxycodone tab 1 GAP oxycodone hcl-oxycodone ter-aspirin tab 1 GAP; QL (360 EA per 30 oxycodone-acetaminophen cap 1 GAP; QL (240 EA per 30 oxycodone-acetaminophen tab mg 1 GAP; QL (180 EA per 30 oxycodone-acetaminophen tab mg 1 GAP; QL (240 EA per 30 oxycodone-acetaminophen tab mg, mg, mg, mg oxycodone-aspirin tab 1 oxymorphone tab 1 GAP 1 GAP; QL (360 EA per 30 Page 9 of 128

10 pentazocine-acetaminophen tab 1 GAP; QL (180 EA per 30 pentazocine-naloxone tab 1 GAP; QL (360 EA per 30 PERCOCET TAB mg 3 QL (240 EA per 30 PERCOCET TAB mg, mg, mg 3 QL (360 EA per 30 PERCODAN TAB 3 QL (360 EA per 30 ROXICET ORAL SOLN 3 QL (960 ML per 30 ROXICET TAB mg 1 GAP; QL (360 EA per 30 ROXICET TAB mg 3 QL (240 EA per 30 ROXICODONE TAB 3 SUBOXONE SUBLINGUAL FILM 3 SUBOXONE SUBLINGUAL TAB 3 SUBUTEX SUBLINGUAL TAB 3 TALACEN TAB 3 QL (180 EA per 30 TALWIN NX TAB 3 QL (360 EA per 30 tramadol tab 1 GAP; QL (240 EA per 30 tramadol-acetaminophen tab 1 GAP; QL (240 EA per 30 TYLENOL-CODEINE #3 TAB 3 QL (360 EA per 30 TYLENOL-CODEINE #4 TAB 3 QL (360 EA per 30 TYLOX CAP 3 QL (240 EA per 30 ULTRACET TAB 3 QL (240 EA per 30 ULTRAM TAB 3 QL (240 EA per 30 VICODIN TAB 3 QL (240 EA per 30 VICODIN ES TAB 3 QL (150 EA per 30 VICOPROFEN TAB 3 QL (240 EA per 30 Anesthetics Local Anesthetics EMLA TOPICAL CREAM 3 lidocaine mucosal gel 1 GAP lidocaine mucosal soln 1 GAP Page 10 of 128

11 lidocaine mucous membrane jelly in applicator 1 GAP lidocaine ointment 1 GAP lidocaine-prilocaine topical cream 1 GAP LIDODERM ADHESIVE PATCH 3 QL (90 EA per 30 SYNERA PATCH 2 XYLOCAINE JELLY MUCOSAL GEL 3 Antibacterials Amino Derivative Penicillins amoxicillin cap 1 GAP amoxicillin chewable tab 1 GAP amoxicillin oral susp 1 GAP amoxicillin tab 1 GAP amoxicillin-potassium clavulanate chewable tab 1 GAP amoxicillin-potassium clavulanate er 12 hr tab 1 GAP amoxicillin-potassium clavulanate oral susp 1 GAP amoxicillin-potassium clavulanate tab 1 GAP ampicillin cap 1 GAP ampicillin oral susp 1 GAP ampicillin solution for injection 1 B/D; GAP ampicillin-sulbactam solution for injection 1 B/D; GAP AUGMENTIN ES-600 ORAL SUSP 3 UNASYN SOLUTION FOR INJECTION 3 B/D Aminoglycosides amikacin injection 1 GAP gentamicin eye drops 1 GAP gentamicin injection 1 B/D; GAP gentamicin ointment 1 GAP gentamicin topical cream 1 GAP gentamicin in sodium chloride(iso-osmotic) iv piggy back 70 mg/50 ml 1 B/D Page 11 of 128

12 gentamicin in sodium chloride(iso-osmotic) iv piggy back 100 mg/100 ml, 60 mg/100 ml, 60 mg/50 ml, 80 mg/100 ml gentamicin in sodium chloride(iso-osmotic) iv piggy back 80 mg/50 ml gentamicin in sodium chloride(iso-osmotic) iv piggy back 90 mg/100 ml gentamicin sulfate (pf) iv 3 1 B/D; GAP 1 GAP kanamycin injection 1 B/D; GAP neomycin tab 1 GAP paromomycin cap 1 GAP streptomycin im 3 B/D tobramycin in ns iv piggy back 3 B/D tobramycin eye drops 1 GAP tobramycin injection 1 B/D; GAP Antifolate Antibacterials PRIMSOL ORAL SOLN 2 trimethoprim tab 1 GAP Beta-Lactam, Other AZACTAM SOLUTION FOR INJECTION 3 AZACTAM IN ISO-OSMOTIC DEXTROSE IV PIGGY BACK aztreonam solution for injection 1 GAP INVANZ SOLUTION FOR INJECTION 3 PRIMAXIN IM SUSP 3 PRIMAXIN IV IV SOLUTION 3 Cephalosporin Antibacterials, 1St Generation cefadroxil cap 1 GAP cefadroxil oral susp 1 GAP cefadroxil tab 1 GAP cefazolin solution for injection 1 B/D; GAP cefazolin in dextrose (iso-osmotic) iv piggy back 1 B/D; GAP 3 3 Page 12 of 128

13 cephalexin cap 1 GAP cephalexin oral susp 1 GAP cephalexin tab 1 GAP KEFLEX CAP 250 mg, 500 mg 3 Cephalosporin Antibacterials, 2Nd Generation cefaclor cap 1 GAP cefaclor er 12 hr tab 1 GAP cefaclor oral susp 1 GAP cefoxitin iv solution 1 B/D; GAP cefoxitin in dextrose, iso-osmotic iv piggy back 1 gram/50 ml cefoxitin in dextrose, iso-osmotic iv piggy back 2 gram/50 ml 1 B/D; GAP 1 GAP cefprozil oral susp 1 GAP cefprozil tab 1 GAP CEFTIN ORAL SUSP 125 mg/5 ml 3 CEFTIN TAB 3 cefuroxime axetil oral susp 1 GAP cefuroxime axetil tab 1 GAP cefuroxime sodium iv solution 1 B/D; GAP cefuroxime sodium solution for injection 1 B/D; GAP cefuroxime-dextrose (iso-osmotic) iv piggy back 1 GAP Cephalosporin Antibacterials, 3Rd Generation CEDAX CAP 3 cefdinir cap 1 GAP cefdinir oral susp 1 GAP cefepime solution for injection 1 B/D; GAP cefotaxime solution for injection 500 mg 1 B/D; GAP cefotaxime solution for injection 1 gram, 10 gram, 2 gram 1 GAP cefpodoxime oral susp 1 GAP Page 13 of 128

14 cefpodoxime tab 1 GAP ceftazidime solution for injection 6 gram 1 B/D; GAP ceftazidime solution for injection 1 gram, 2 gram 1 GAP ceftriaxone iv solution 1 B/D; GAP CLAFORAN SOLUTION FOR INJECTION 10 gram, 2 gram CLAFORAN SOLUTION FOR INJECTION 500 mg FORTAZ SOLUTION FOR INJECTION 3 FORTAZ IN D5W IV PIGGY BACK 3 OMNICEF CAP 3 OMNICEF ORAL SUSP 3 SPECTRACEF TAB 3 SUPRAX ORAL SUSP 3 SUPRAX TAB B/D TAZICEF IV SOLUTION 1 GAP TAZICEF SOLUTION FOR INJECTION 1 GAP VANTIN TAB 3 Cephalosporin Antibacterials, 4Th Generation MAXIPIME SOLUTION FOR INJECTION 3 B/D Extended Spectrum Penicillins piperacillin iv solution 1 B/D; GAP piperacillin solution for injection 1 B/D; GAP piperacillin-tazobactam iv solution 4.5 gram 1 B/D piperacillin-tazobactam iv solution gram 1 B/D; GAP TIMENTIN IV SOLUTION 3 B/D ZOSYN IV SOLUTION 3 B/D ZOSYN IN DEXTROSE (ISO-OSMOTIC) IV PIGGY BACK Glycopeptide Antibacterials VANCOCIN CAP 2 3 B/D Page 14 of 128

15 vancomycin iv solution 10 gram 1 B/D; GAP vancomycin iv solution 1,000 mg, 500 mg 3 B/D VIBATIV IV SOLUTION 3 B/D Lincomycin Antibacterials CLEOCIN CAP 150 mg, 300 mg 3 CLEOCIN ORAL SOLUTION 3 CLEOCIN VAGINAL CREAM 3 CLEOCIN VAGINAL SUPPOSITORY 2 CLEOCIN IN D5W IV PIGGY BACK 3 B/D clindamycin cap 1 GAP clindamycin iv 1 B/D; GAP clindamycin vaginal cream 1 GAP CLINDESSE VAGINAL CREAM 3 LINCOCIN INJECTION 3 B/D Macrolides azithromycin iv solution 1 GAP azithromycin oral susp 1 GAP azithromycin tab 250 mg, 500 mg 1 GAP; QL (12 EA per 30 azithromycin tab 600 mg 1 GAP; QL (30 EA per 30 BIAXIN ORAL SUSP 3 BIAXIN TAB 3 BIAXIN XL 24 HR TAB 3 clarithromycin er 24 hr tab 1 GAP clarithromycin oral susp 1 GAP clarithromycin tab 1 GAP DIFICID TAB 3 PA; QL (20 EA per 30 ERY-TAB TAB 2 ERYTHROCIN IV SOLUTION 3 B/D ERYTHROCIN STEARATE TAB 1 GAP erythromycin eye ointment 1 GAP Page 15 of 128

16 erythromycin tab 2 erythromycin ethylsuccinate tab 1 erythromycin-sulfisoxazole oral susp 1 GAP KETEK TAB 3 ZITHROMAX IV SOLUTION 3 ZITHROMAX ORAL SUSP 3 ZITHROMAX TAB 250 mg, 500 mg 3 QL (12 EA per 30 ZITHROMAX TAB 600 mg 3 QL (30 EA per 30 ZITHROMAX TRI-PAK TAB 3 QL (12 EA per 30 ZITHROMAX Z-PAK TAB 3 QL (12 EA per 30 ZMAX ADULT-PEDIATRIC ORAL SUSP 2 Miscellaneous Antibacterials alcohol swabs 2 MO ALTABAX OINTMENT 3 QL (15 GM per 30 BACI-IM IM 1 B/D; GAP bacitracin im 1 B/D; GAP BACTROBAN OINTMENT 3 BACTROBAN TOPICAL CREAM 2 BACTROBAN NASAL OINTMENT 3 colistimethate sodium solution for injection 1 B/D; GAP COLY-MYCIN M PARENTERAL SOLUTION FOR INJECTION 3 B/D CUBICIN IV SOLUTION 3 B/D FLAGYL CAP 3 FLAGYL TAB 3 HIPREX TAB 3 meropenem iv solution 1 GAP MERREM IV SOLUTION 3 methenamine hippurate tab 1 GAP METROCREAM TOPICAL 3 Page 16 of 128

17 METROGEL VAGINAL 3 METROLOTION 3 metronidazole cap 1 GAP metronidazole lotion 1 GAP metronidazole tab 1 GAP metronidazole topical cream 1 GAP metronidazole topical gel 1 GAP metronidazole vaginal gel 1 GAP metronidazole in sodium chloride (iso-osm) iv piggy back MONUROL ORAL PACKET 2 1 GAP mupirocin ointment 1 GAP NEO-FRADIN ORAL SOLN 3 neomycin-polymyxin-hc ear drops, susp 1 GAP neomycin-polymyxin-hc ear soln 1 GAP polymyxin b sulfate solution for injection 1 GAP PREVPAC ORAL PACK 3 SILVADENE TOPICAL CREAM 3 silver sulfadiazine topical cream 1 GAP SSD TOPICAL CREAM 1 GAP SULFATRIM ORAL SUSP 1 GAP TEFLARO IV SOLUTION 4 B/D THERMAZENE TOPICAL CREAM 1 GAP TYGACIL IV SOLUTION 3 B/D VANDAZOLE VAGINAL GEL 1 GAP XIFAXAN TAB 550 mg 3 QL (60 EA per 30 XIFAXAN TAB 200 mg 3 QL (9 EA per 30 Natural Penicillins BICILLIN C-R IM SYRINGE 3 penicillin g pot in dextrose iv piggy back 1 B/D; GAP Page 17 of 128

18 penicillin g potassium solution for injection 1 B/D; GAP penicillin g procaine im syringe 1 B/D; GAP penicillin g sodium solution for injection 1 B/D; GAP penicillin v potassium oral susp 1 GAP penicillin v potassium tab 1 GAP PFIZERPEN-G SOLUTION FOR INJECTION 3 B/D Nitrofuran Antibacterials FURADANTIN ORAL SUSP 3 MACROBID CAP 3 MACRODANTIN CAP 100 mg, 50 mg 3 nitrofurantoin oral susp 1 nitrofurantoin macrocrystal cap 1 GAP nitrofurantoin monohydrate/macrocrystals cap 1 GAP Oxazolidinone Antibacterials ZYVOX IV 2 B/D ZYVOX ORAL SUSP 2 QL (180 ML per 3 ZYVOX TAB 2 QL (6 EA per 3 Penicillinase-Resistant Penicillins dicloxacillin cap 1 GAP nafcillin solution for injection 1 B/D; GAP oxacillin solution for injection 1 GAP oxacillin in dextrose, iso-osmotic iv piggy back 3 B/D Quinolones AVELOX TAB 2 AVELOX ABC PACK TAB 2 AVELOX IN SODIUM CHLORIDE (ISO- OSMOTIC) IV PIGGY BACK CIPRO ORAL SUSP 2 CIPRO TAB 3 CIPRO HC EAR DROPS, SUSP 3 2 B/D Page 18 of 128

19 CIPRODEX EAR DROPS, SUSP 3 QL (7.5 ML per 30 ciprofloxacin eye drops 1 GAP ciprofloxacin iv 1 B/D; GAP ciprofloxacin tab 1 GAP ciprofloxacin er multiphase 24 hr tab 1 GAP FACTIVE TAB 2 LEVAQUIN IV 3 B/D LEVAQUIN ORAL SOLN 3 LEVAQUIN TAB 3 LEVAQUIN IN D5W IV PIGGY BACK 3 B/D levofloxacin oral soln 1 levofloxacin tab 1 levofloxacin in d5w iv piggy back 1 B/D OCUFLOX EYE DROPS 3 ofloxacin ear drops 1 GAP ofloxacin eye drops 1 GAP ofloxacin tab 1 GAP Sulfonamides BACTRIM TAB 3 BACTRIM DS TAB 3 sulfacetamide-prednisolone eye drops 1 GAP sulfadiazine tab 2 sulfamethoxazole-trimethoprim iv 1 B/D; GAP sulfamethoxazole-trimethoprim oral susp 1 GAP sulfamethoxazole-trimethoprim tab 1 GAP Tetracyclines ADOXA TAB 50 mg 3 ADOXA PAK TAB 75 mg 3 demeclocycline tab 1 GAP doxycycline hyclate cap 1 GAP Page 19 of 128

20 doxycycline hyclate cap, delayed release 1 GAP doxycycline hyclate iv solution 100 mg 1 B/D; GAP doxycycline hyclate tab 1 GAP doxycycline hyclate tab, delayed release 1 doxycycline cap 1 doxycycline tab 1 GAP DYNACIN TAB 3 MINOCIN CAP 3 minocycline cap 1 GAP minocycline tab 1 GAP PERIOSTAT TAB 3 tetracycline cap 1 GAP VIBRAMYCIN CAP 3 VIBRA-TABS TAB 3 Anticonvulsants Anticonvulsants, Other BANZEL ORAL SUSP 3 QL (2400 ML per 30 BANZEL TAB 400 mg 3 MO; QL (240 EA per 30 BANZEL TAB 200 mg 3 MO; QL (480 EA per 30 clonazepam tab 2 mg 1 E; QL (120 EA per 30 clonazepam tab 0.5 mg, 1 mg 1 E; QL (90 EA per 30 DIASTAT ACUDIAL RECTAL KIT 3 E; QL (5 EA per 30 KEPPRA IV 3 KEPPRA ORAL SOLN 3 MO KEPPRA TAB 250 mg, 750 mg 3 MO; QL (120 EA per 30 KEPPRA TAB 500 mg 3 MO; QL (180 EA per 30 KEPPRA TAB 1,000 mg 3 MO; QL (90 EA per 30 KEPPRA XR 24 HR TAB 750 mg 2 MO; QL (120 EA per 30 KEPPRA XR 24 HR TAB 500 mg 2 MO; QL (180 EA per 30 levetiracetam iv 1 GAP Page 20 of 128

21 levetiracetam oral soln 1 MO; GAP levetiracetam tab 250 mg, 750 mg 1 MO; GAP; QL (120 EA per 30 levetiracetam tab 500 mg 1 MO; GAP; QL (180 EA per 30 levetiracetam tab 1,000 mg 1 MO; GAP; QL (90 EA per 30 Calcium Channel Modifying Agents CELONTIN CAP 2 MO ethosuximide cap 1 MO; GAP ethosuximide syrup 1 MO; GAP LYRICA CAP 150 mg 3 MO; QL (120 EA per 30 LYRICA CAP 100 mg, 25 mg, 50 mg, 75 mg 3 MO; QL (150 EA per 30 LYRICA CAP 225 mg, 300 mg 3 MO; QL (60 EA per 30 LYRICA CAP 200 mg 3 MO; QL (90 EA per 30 ZARONTIN CAP 3 MO ZARONTIN SYRUP 3 MO ZONEGRAN CAP 3 MO zonisamide cap 1 MO; GAP Gamma-Aminobutyric Acid (Gaba) Augmenting Agents DEPACON IV 3 DEPAKENE CAP 3 MO DEPAKENE SYRUP 3 MO DEPAKOTE TAB 3 MO DEPAKOTE ER 24 HR TAB 3 MO DEPAKOTE SPRINKLES SPRINKLE CAP 3 MO divalproex er 24 hr tab 1 MO; GAP divalproex sprinkle cap 1 MO; GAP divalproex tab, delayed release 1 MO; GAP gabapentin cap 1 MO; GAP gabapentin oral soln 1 QL (2160 ML per 30 Page 21 of 128

22 gabapentin tab 1 MO; GAP GABITRIL TAB 2 MO MYSOLINE TAB 50 mg 3 MYSOLINE TAB 250 mg 3 MO NEURONTIN CAP 3 MO NEURONTIN ORAL SOLN 3 MO; QL (2160 ML per 30 NEURONTIN TAB 3 MO primidone tab 1 MO; GAP SABRIL ORAL POWDER IN PACKET 4 LA; QL (180 EA per 30 SABRIL TAB 4 LA; QL (180 EA per 30 valproate sodium iv 1 GAP valproic acid cap 1 MO; GAP valproic acid (as sodium salt) syrup 1 MO; GAP Glutamate Reducing Agents FELBATOL ORAL SUSP 2 MO FELBATOL TAB 2 MO LAMICTAL TAB 3 MO lamotrigine dispersible tab 1 MO; GAP lamotrigine tab 1 MO; GAP TOPAMAX SPRINKLE CAP 3 MO TOPAMAX TAB 3 MO topiramate sprinkle cap 1 MO; GAP topiramate tab 1 MO; GAP Sodium Channel Inhibitors carbamazepine chewable tab 1 MO; GAP carbamazepine er 12 hr tab 1 MO; GAP carbamazepine er multiphase 12 hr cap 1 carbamazepine oral susp 1 MO; GAP carbamazepine tab 1 MO; GAP CEREBYX INJECTION 3 B/D Page 22 of 128

23 DILANTIN CAP 2 MO DILANTIN EXTENDED CAP 3 MO DILANTIN INFATABS CHEWABLE 2 MO DILANTIN-125 ORAL SUSP 3 MO EPITOL TAB 1 MO; GAP fosphenytoin injection 1 B/D; GAP oxcarbazepine oral susp 1 MO; GAP oxcarbazepine tab 1 MO; GAP PEGANONE TAB 2 MO PHENYTEK CAP 3 MO phenytoin oral susp 1 MO; GAP phenytoin sodium iv 1 B/D; GAP phenytoin sodium extended cap 200 mg, 300 mg 1 GAP phenytoin sodium extended cap 100 mg 1 MO; GAP TEGRETOL CHEWABLE TAB 3 MO TEGRETOL ORAL SUSP 3 MO TEGRETOL TAB 3 MO TEGRETOL XR 12 HR TAB 100 mg 2 MO TEGRETOL XR 12 HR TAB 200 mg, 400 mg 3 MO TRILEPTAL ORAL SUSP 3 MO TRILEPTAL TAB 3 MO VIMPAT IV 3 VIMPAT ORAL SOLN 3 MO; QL (1800 ML per 30 VIMPAT TAB 3 MO; QL (60 EA per 30 Antidementia Agents Antidementia Agents, Other ergoloid tab 1 GAP Cholinesterase Inhibitors ARICEPT TAB 23 mg 2 MO; QL (30 EA per 30 ARICEPT TAB 10 mg, 5 mg 3 MO; QL (30 EA per 30 Page 23 of 128

24 ARICEPT ODT TAB, RAPID DISSOLVE 3 MO; QL (30 EA per 30 COGNEX CAP 3 donepezil tab 1 MO; GAP; QL (30 EA per 30 donepezil tab, rapid dissolve 1 MO; GAP; QL (30 EA per 30 EXELON CAP 3 MO; QL (60 EA per 30 EXELON ORAL SOLN 2 MO; QL (600 ML per 30 EXELON TRANSDERM 24 HR PATCH 2 MO; QL (30 EA per 30 galantamine er 24 hr cap 1 MO; GAP; QL (30 EA per 30 galantamine oral soln 1 MO; GAP; QL (600 ML per 30 galantamine tab 1 MO; GAP; QL (60 EA per 30 RAZADYNE ORAL SOLN 3 MO; QL (600 ML per 30 RAZADYNE TAB 3 MO; QL (60 EA per 30 RAZADYNE ER 24 HR CAP 3 MO; QL (30 EA per 30 rivastigmine cap 1 MO; GAP; QL (60 EA per 30 Glutamate Pathway Modifiers NAMENDA ORAL SOLN 2 MO; QL (300 ML per 30 NAMENDA TAB 2 MO; QL (60 EA per 30 NAMENDA TITRATION PAK TABS IN A DOSE PACK Antidepressants Antidepressants, Other 2 MO BUDEPRION SR TAB 1 MO; GAP; QL (60 EA per 30 BUDEPRION XL 24 HR TAB 300 mg 1 MO; GAP; QL (30 EA per 30 BUDEPRION XL 24 HR TAB 150 mg 1 MO; GAP; QL (90 EA per 30 Page 24 of 128

25 bupropion hcl sr tab 150 mg 1 GAP; QL (60 EA per 30 bupropion hcl sr tab 100 mg, 200 mg 1 MO; GAP; QL (60 EA per 30 bupropion hcl tab 1 MO; GAP maprotiline tab 1 MO; GAP mirtazapine tab 1 MO; GAP mirtazapine tab, rapid dissolve 1 MO; GAP nefazodone tab 100 mg, 150 mg, 250 mg, 50 mg 1 MO; GAP; QL (60 EA per 30 nefazodone tab 200 mg 1 MO; GAP; QL (90 EA per 30 OLEPTRO ER 24 HR TAB 300 mg 3 QL (30 EA per 30 OLEPTRO ER 24 HR TAB 150 mg 3 QL (75 EA per 30 REMERON TAB 3 MO REMERON SOLTAB 3 MO trazodone tab 1 MO; GAP VIIBRYD TAB 3 QL (30 EA per 30 WELLBUTRIN TAB 3 MO WELLBUTRIN SR TAB 3 MO; QL (60 EA per 30 WELLBUTRIN XL 24 HR TAB 300 mg 3 MO; QL (30 EA per 30 WELLBUTRIN XL 24 HR TAB 150 mg 3 MO; QL (90 EA per 30 Monoamine Oxidase Inhibitors EMSAM TRANSDERM 24 HR PATCH 3 MO; QL (30 EA per 30 MARPLAN TAB 3 MO PARNATE TAB 3 MO tranylcypromine tab 1 MO; GAP Serotonin/ Norepinephrine Reuptake Inhibitors CYMBALTA CAP 60 mg 2 MO; QL (30 EA per 30 CYMBALTA CAP 20 mg, 30 mg 2 MO; QL (60 EA per 30 EFFEXOR TAB 3 MO; QL (90 EA per 30 EFFEXOR XR 24 HR CAP 150 mg, 37.5 mg 3 MO; QL (30 EA per 30 Page 25 of 128

26 EFFEXOR XR 24 HR CAP 75 mg 3 MO; QL (90 EA per 30 PRISTIQ 24 HR TAB 3 MO; QL (30 EA per 30 SAVELLA TAB 2 QL (60 EA per 30 SAVELLA TABS IN A DOSE PACK 2 QL (55 EA per 28 venlafaxine er 24 hr cap 150 mg, 37.5 mg 1 MO; GAP; QL (30 EA per 30 venlafaxine er 24 hr cap 75 mg 1 MO; GAP; QL (90 EA per 30 venlafaxine er 24 hr tab 150 mg, 225 mg 2 MO; QL (30 EA per 30 venlafaxine er 24 hr tab 37.5 mg, 75 mg 2 MO; QL (90 EA per 30 venlafaxine tab 75 mg 1 MO; GAP; QL (150 EA per 30 venlafaxine tab 100 mg, 25 mg, 37.5 mg, 50 mg 1 MO; GAP; QL (90 EA per 30 Tricyclics amitriptyline tab 1 MO; GAP amoxapine tab 1 MO; GAP ANAFRANIL CAP 3 MO clomipramine cap 1 MO; GAP desipramine tab 1 MO; GAP doxepin cap 1 MO; GAP doxepin oral concentrate 1 MO; GAP imipramine tab 1 MO; GAP imipramine pamoate cap 1 MO; GAP NORPRAMIN TAB 3 MO nortriptyline cap 1 MO; GAP nortriptyline oral soln 1 MO; GAP PAMELOR CAP 3 MO perphenazine-amitriptyline tab 1 MO; GAP protriptyline tab 1 MO; GAP SURMONTIL CAP 3 Page 26 of 128

27 TOFRANIL TAB 3 MO VIVACTIL TAB 3 MO Antidotes, Deterrents, And Toxicologic Agents Alcohol Deterrents ANTABUSE TAB 2 CAMPRAL TAB 2 disulfiram tab 1 Antidotes acetylcysteine soln 1 GAP amifostine crystalline iv solution 1 GAP ANTIZOL IV 3 B/D ETHYOL IV SOLUTION 3 EXJADE TAB 2 LA fomepizole iv 1 B/D; GAP leucovorin calcium solution for injection 1 B/D; GAP leucovorin calcium tab 1 MO; GAP mesna iv 1 B/D; GAP MESNEX TAB 2 MO sodium polystyrene sulfonate oral powder 1 GAP SYPRINE CAP 2 Opioid Antagonists DEPADE TAB 1 GAP naloxone syringe 1 B/D; GAP naltrexone tab 1 GAP REVIA TAB 3 Smoking Cessation Agents CHANTIX TAB 3 CHANTIX STARTING MONTH PAK TABS IN A DOSE PACK NICOTROL INHALATION CARTRIDGE 2 3 Page 27 of 128

28 NICOTROL NS NASAL SPRAY 2 Antiemetics 5-Hydroxytryptamine 3 (5-Ht3) Antagonists ANZEMET TAB 100 mg 3 B/D; QL (4 EA per 30 ANZEMET TAB 50 mg 3 B/D; QL (8 EA per 30 granisetron tab 1 B/D; GAP; QL (30 EA per 30 GRANISOL ORAL SOLN 1 B/D; GAP KYTRIL TAB 3 B/D; QL (30 EA per 30 ondansetron tab, rapid dissolve 1 B/D; GAP; QL (45 EA per 30 ondansetron hcl oral soln 1 B/D; GAP; QL (450 ML per 30 ondansetron hcl tab 24 mg 1 B/D; GAP; QL (15 EA per 30 ondansetron hcl tab 4 mg, 8 mg 1 B/D; GAP; QL (45 EA per 30 ondansetron hcl (pf) injection 1 GAP ZOFRAN IV 3 ZOFRAN ORAL SOLN 3 B/D; QL (450 ML per 30 ZOFRAN TAB 3 B/D; QL (45 EA per 30 ZOFRAN ODT TAB, RAPID DISSOLVE 3 B/D; QL (45 EA per 30 Antiemetics, Other CESAMET CAP 3 QL (60 EA per 30 COMPRO RECTAL SUPPOSITORY 1 MO; GAP dronabinol cap 1 GAP; QL (120 EA per 30 MARINOL CAP 3 QL (120 EA per 30 metoclopramide oral soln 1 GAP metoclopramide tab 1 GAP PHENADOZ RECTAL SUPPOSITORY 1 GAP PHENERGAN INJECTION 3 B/D prochlorperazine rectal suppository 1 MO; GAP Page 28 of 128

29 prochlorperazine edisylate injection 1 GAP prochlorperazine maleate tab 1 MO; GAP promethazine injection 1 B/D; GAP promethazine rectal suppository 1 GAP promethazine syringe 1 B/D; GAP promethazine syrup 1 GAP promethazine tab 1 GAP PROMETHAZINE VC SYRUP 1 GAP PROMETHEGAN RECTAL SUPPOSITORY 1 GAP REGLAN TAB 3 SANCUSO TRANSDERM PATCH 3 QL (4 EA per 28 TIGAN CAP 3 TIGAN IM 3 B/D TRANSDERM-SCOP 72 HR TRANSDERM PATCH trimethobenzamide cap 1 GAP trimethobenzamide im syringe 1 B/D; GAP Neurokinin 1 (Nk1) Receptor Antagonists EMEND CAP 2 QL (6 EA per 30 EMEND CAPS IN DOSE PACK 2 QL (6 EA per 30 Antifungals Allylamine Antifungals LAMISIL TAB 3 QL (30 EA per 30 NAFTIN TOPICAL CREAM 2 NAFTIN TOPICAL GEL 2 terbinafine tab 1 GAP; QL (30 EA per 30 Antifungals (Other) ANCOBON CAP 3 ciclopirox shampoo 1 GAP ciclopirox topical cream 1 GAP 3 Page 29 of 128

30 ciclopirox topical gel 1 GAP ciclopirox topical soln 1 GAP ciclopirox topical susp 1 GAP GRIFULVIN V TAB 3 griseofulvin microsize oral susp 1 GAP LOPROX SHAMPOO 3 LOPROX TOPICAL GEL 3 PENLAC TOPICAL SOLN 3 Azole Antifungals clotrimazole topical cream 1 GAP clotrimazole troche 1 GAP clotrimazole-betamethasone lotion 1 GAP clotrimazole-betamethasone topical cream 1 GAP DIFLUCAN ORAL SUSP 3 DIFLUCAN TAB 100 mg, 200 mg, 50 mg 3 DIFLUCAN TAB 150 mg 3 QL (4 EA per 30 econazole topical cream 1 GAP EXELDERM TOPICAL CREAM 3 EXELDERM TOPICAL SOLN 3 fluconazole oral susp 1 GAP fluconazole tab 100 mg, 200 mg, 50 mg 1 GAP fluconazole tab 150 mg 1 GAP; QL (4 EA per 30 fluconazole in dextrose (iso-osmotic) iv piggy back 1 B/D; GAP itraconazole cap 1 PA; GAP ketoconazole shampoo 1 GAP ketoconazole tab 1 GAP ketoconazole topical cream 1 GAP KURIC TOPICAL CREAM 1 GAP LOTRISONE LOTION 3 Page 30 of 128

31 LOTRISONE TOPICAL CREAM 3 MICONAZOLE-3 VAGINAL SUPPOSITORY 1 GAP NIZORAL SHAMPOO 3 NOXAFIL ORAL SUSP 2 PA OXISTAT LOTION 3 OXISTAT TOPICAL CREAM 3 SPORANOX CAP 3 PA TERAZOL 3 VAGINAL CREAM 3 QL (40 GM per 30 TERAZOL 3 VAGINAL SUPPOSITORY 3 QL (12 EA per 30 TERAZOL 7 VAGINAL CREAM 3 QL (90 GM per 30 terconazole vaginal cream 0.8 % 1 GAP; QL (40 GM per 30 terconazole vaginal cream 0.4 % 1 GAP; QL (90 GM per 30 terconazole vaginal suppository 1 GAP; QL (12 EA per 30 VFEND ORAL SUSP 3 QL (300 ML per 30 VFEND TAB 50 mg 3 QL (120 EA per 30 VFEND TAB 200 mg 3 QL (60 EA per 30 VFEND IV SOLN 4 B/D voriconazole tab 50 mg 1 QL (120 EA per 30 voriconazole tab 200 mg 1 QL (60 EA per 30 ZAZOLE VAGINAL CREAM 0.8 % 1 GAP; QL (40 GM per 30 ZAZOLE VAGINAL CREAM 0.4 % 1 GAP; QL (90 GM per 30 ZAZOLE VAGINAL SUPPOSITORY 1 GAP Echinocandin Antifungals CANCIDAS IV SOLUTION 3 B/D ERAXIS(WATER DILUENT) IV SOLUTION 3 B/D Polyene Antifungals NATACYN EYE DROPS 3 nystatin ointment 1 GAP nystatin oral susp 1 GAP nystatin tab 1 GAP Page 31 of 128

32 nystatin topical cream 1 GAP nystatin topical powder 1 GAP nystatin-triamcinolone ointment 1 GAP nystatin-triamcinolone topical cream 1 GAP NYSTOP TOPICAL POWDER 1 GAP PEDI-DRI TOPICAL POWDER 1 GAP Antigout Agents Antigout Agents (Non-Renal Tubular Blocking Agents And Non-Xanthine Inhibitors) COLCRYS TAB 3 MO; QL (120 EA per 30 Renal Tubular Blocking Agents colchicine-probenecid tab 1 MO; GAP probenecid tab 1 MO; GAP Xanthine Oxidase Inhibitors allopurinol tab 1 MO; GAP allopurinol iv solution 1 B/D; GAP ALOPRIM IV SOLUTION 3 B/D; MO ULORIC TAB 2 MO; QL (30 EA per 30 ZYLOPRIM TAB 3 MO Anti-Inflammatory Agents Nonsteroidal Anti-Inflammatory Drugs ANAPROX TAB 3 ANAPROX DS TAB 3 ARTHROTEC 50 TAB 3 ARTHROTEC 75 TAB 3 CATAFLAM TAB 3 CELEBREX CAP 3 QL (60 EA per 30 CLINORIL TAB 3 DAYPRO TAB 3 diclofenac potassium tab 1 GAP diclofenac sodium er 24 hr tab 1 GAP Page 32 of 128

33 diclofenac sodium tab, delayed release 1 GAP diflunisal tab 1 GAP EC-NAPROSYN TAB 3 etodolac cap 1 GAP etodolac er 24 hr tab 1 GAP etodolac tab 1 GAP FELDENE CAP 3 fenoprofen tab 1 GAP FLECTOR ADHESIVE PATCH 3 QL (60 EA per 30 flurbiprofen tab 1 GAP ibuprofen tab 1 GAP indomethacin cap 1 GAP indomethacin er cap 1 GAP ketoprofen cap 1 GAP ketoprofen er 24 hr cap 1 GAP ketorolac injection 1 B/D; GAP ketorolac tab 1 GAP; QL (20 EA per 30 meclofenamate cap 3 meloxicam oral susp 1 GAP; QL (300 ML per 30 meloxicam tab 1 GAP; QL (30 EA per 30 MOBIC TAB 3 QL (30 EA per 30 nabumetone tab 1 GAP NALFON CAP 400 mg 3 NAPROSYN ORAL SUSP 3 NAPROSYN TAB 3 naproxen oral susp 1 GAP naproxen tab 500 mg 1 naproxen tab 250 mg, 375 mg 1 GAP naproxen tab, delayed release 1 GAP naproxen sodium tab 1 GAP Page 33 of 128

34 oxaprozin tab 1 GAP piroxicam cap 1 GAP sulindac tab 1 GAP tolmetin cap 1 GAP tolmetin tab 1 GAP VOLTAREN TAB 3 VOLTAREN TOPICAL GEL 3 VOLTAREN-XR 24 HR TAB 3 Antimigraine Agents Ergot Alkaloids CAFERGOT TAB 3 QL (40 EA per 30 D.H.E.45 INJECTION 3 B/D dihydroergotamine injection 1 B/D; GAP ergotamine-caffeine tab 1 GAP; QL (40 EA per 30 MIGERGOT RECTAL SUPPOSITORY 1 GAP; QL (20 EA per 28 MIGRANAL NASAL SPRAY 3 QL (16 ML per 30 Triptans AMERGE TAB 3 QL (9 EA per 30 FROVA TAB 3 QL (12 EA per 30 IMITREX SUB-Q 3 QL (6 ML per 30 IMITREX TAB 3 QL (9 EA per 30 MAXALT TAB 2 QL (12 EA per 30 MAXALT-MLT TAB, RAPID DISSOLVE 2 QL (12 EA per 30 naratriptan tab 1 GAP; QL (9 EA per 30 RELPAX TAB 2 QL (9 EA per 30 sumatriptan sub-q 6 mg/0.5 ml 1 GAP; QL (6 ML per 30 sumatriptan sub-q pen injector 1 QL (6 ML per 30 sumatriptan tab 1 GAP; QL (9 EA per 30 ZOMIG NASAL SPRAY 3 QL (6 EA per 30 ZOMIG TAB 3 QL (9 EA per 30 Page 34 of 128

35 ZOMIG ZMT TAB, RAPID DISSOLVE 3 QL (9 EA per 30 Antimyasthenic Agents Parasympathomimetics guanidine tab 1 GAP MESTINON SYRUP 3 MESTINON TAB 3 MYTELASE TAB 3 pyridostigmine bromide tab 1 GAP Antimycobacterials Antimycobacterials, Other ACZONE TOPICAL GEL 3 dapsone tab 2 MYCOBUTIN CAP 2 Antituberculars CAPASTAT SOLUTION FOR INJECTION 3 B/D ethambutol tab 1 GAP ISONARIF CAP 1 GAP isoniazid injection 1 GAP isoniazid syrup 1 GAP isoniazid tab 1 GAP MYAMBUTOL TAB 3 PASER ORAL PACKET 2 PRIFTIN TAB 2 pyrazinamide tab 1 GAP RIFADIN CAP 3 RIFADIN IV SOLUTION 3 B/D RIFAMATE CAP 3 rifampin cap 1 GAP rifampin iv solution 1 B/D; GAP RIFATER TAB 2 Page 35 of 128

36 SEROMYCIN CAP 2 TRECATOR TAB 2 Antineoplastics Alkylating Agents, Other BUSULFEX IV 3 B/D carboplatin iv 1 B/D; GAP cisplatin iv 1 B/D; GAP cyclophosphamide tab 1 MO; GAP dacarbazine iv solution 1 B/D; GAP ifosfamide iv solution 1 B/D; GAP ifosfamide-mesna iv kit 4 B/D MATULANE CAP 4 oxaliplatin soln 1 B/D; GAP thiotepa solution for injection 3 B/D TREANDA IV SOLUTION 4 B/D vinblastine iv powder for solution 2 B/D vincristine iv 1 B/D; GAP Antiangiogenic Agents REVLIMID CAP 4 LA; QL (30 EA per 30 THALOMID CAP 4 Anti-Cd20 Antibodies ARZERRA IV 4 B/D AVASTIN IV 3 B/D CAMPATH IV 2 B/D; LA ERBITUX IV 2 B/D RITUXAN CONCENTRATE, IV 4 B/D; LA SIMULECT IV SOLUTION 4 B/D VECTIBIX IV 3 B/D Antimetabolites, Other ALIMTA IV SOLUTION 4 B/D Page 36 of 128

37 DROXIA CAP 2 fluorouracil iv 1 B/D; GAP HYDREA CAP 3 MO hydroxyurea cap 1 MO; GAP idarubicin iv 1 B/D; GAP Antineoplastics, Other ABRAXANE IV SOLUTION 2 B/D ADRIAMYCIN PFS IV 1 B/D; GAP bleomycin solution for injection 2 B/D COSMEGEN IV SOLUTION 2 B/D daunorubicin iv solution 2 B/D DAUNOXOME IV 2 B/D DOCEFREZ IV SOLUTION 4 B/D docetaxel iv 4 B/D DOXIL IV 3 B/D doxorubicin iv 1 B/D; GAP ELSPAR SOLUTION FOR INJECTION 2 B/D epirubicin iv 1 B/D; GAP ETOPOPHOS IV SOLUTION 2 B/D etoposide iv 1 B/D; GAP HALAVEN IV 3 B/D HYCAMTIN IV SOLUTION 4 B/D irinotecan iv 1 B/D; GAP ISTODAX IV SOLUTION 4 B/D IXEMPRA IV SOLUTION 4 B/D JEVTANA IV 4 PA LYSODREN TAB 2 MO mitomycin iv solution 1 B/D; GAP mitoxantrone concentrate, iv 1 B/D; GAP NOVANTRONE CONCENTRATE, IV 3 B/D Page 37 of 128

38 ONCASPAR INJECTION 2 B/D ONTAK IV 2 B/D paclitaxel concentrate, iv 1 B/D; GAP PANRETIN TOPICAL GEL 2 PHOTOFRIN IV SOLUTION 4 B/D SYLATRON SUB-Q KIT 4 PA TAXOTERE IV 4 B/D topotecan iv solution 4 B/D TORISEL IV SOLUTION 4 B/D TRISENOX IV 2 B/D VELCADE IV SOLUTION 2 B/D vinorelbine iv 1 B/D; GAP ZANOSAR IV SOLUTION 2 B/D ZOLINZA CAP 4 QL (120 EA per 30 ZYTIGA TAB 4 PA Aromatase Inhibitors, 3Rd Generation anastrozole tab 1 MO; GAP ARIMIDEX TAB 3 MO AROMASIN TAB 3 MO exemestane tab 1 FEMARA TAB 3 MO letrozole tab 1 Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors IRESSA TAB 4 LA; QL (30 EA per 30 TARCEVA TAB 4 vandetanib tab 4 PA; LA Estrogen-Nitrosoureas EMCYT CAP 3 MO FASLODEX IM SYRINGE 4 B/D Ethylenimines/ Methylmelamines Page 38 of 128

39 HEXALEN CAP 4 Multitargeted Kinase Inhibitors, Bcr-Abl/C-Kit Receptor Tyrosine Kinase Inhibitors GLEEVEC TAB 4 SPRYCEL TAB 100 mg 4 MO; QL (30 EA per 30 SPRYCEL TAB 50 mg 4 QL (120 EA per 30 SPRYCEL TAB 140 mg, 80 mg 4 QL (30 EA per 30 SPRYCEL TAB 20 mg, 70 mg 4 QL (60 EA per 30 TASIGNA CAP 4 QL (112 EA per 28 Multitargeted Kinase Inhibitors, Her2 Receptor Tyrosine Kinase Inhibitors HERCEPTIN IV SOLUTION 4 B/D TYKERB TAB 4 QL (150 EA per 30 Multitargeted Kinase Inhibitors, Vascular Endothelial Growth Factor Receptor Tyrosine Kinase Inhib. AFINITOR TAB 4 QL (30 EA per 30 NEXAVAR TAB 4 LA; QL (120 EA per 30 SUTENT CAP 4 VOTRIENT TAB 4 MO; QL (120 EA per 30 ZORTRESS TAB 2 B/D; QL (60 EA per 30 Nitrogen Mustards LEUKERAN TAB 2 MO melphalan iv solution 1 B/D; GAP MUSTARGEN SOLUTION FOR INJECTION 2 B/D Nitrosoureas BICNU IV SOLUTION 3 B/D CEENU CAP 3 MO Purine Analogs And Related Inhibitors ARRANON IV 3 B/D cladribine iv 1 B/D; GAP CLOLAR IV 2 B/D cytarabine (pf) solution for injection 1 B/D; GAP DACOGEN IV SOLUTION 4 B/D Page 39 of 128

40 fludarabine iv powder for solution 1 B/D; GAP gemcitabine iv solution 1 B/D GEMZAR IV SOLUTION 3 B/D mercaptopurine tab 1 MO; GAP pentostatin iv solution 1 B/D; GAP PURINETHOL TAB 3 MO TABLOID TAB 3 MO VIDAZA SUB-Q SOLN 2 B/D Retinoids TARGRETIN CAP 4 TARGRETIN TOPICAL GEL 2 tretinoin (chemotherapy) cap 1 MO; GAP Selective Estrogen Receptor Modulators, 1St Generation FARESTON TAB 3 MO tamoxifen tab 1 MO; GAP Antiparasitics Anthelmintics ALBENZA TAB 3 BILTRICIDE TAB 3 mebendazole chewable tab 1 GAP Antimalarials ARALEN TAB 3 chloroquine tab 1 GAP COARTEM TAB 2 QL (24 EA per 31 DARAPRIM TAB 2 hydroxychloroquine tab 1 MO; GAP PLAQUENIL TAB 3 MO QUALAQUIN CAP 2 PA Antiprotozoals (Non-Antimalarials) ALINIA ORAL SUSP 3 QL (60 ML per 7 Page 40 of 128

41 ALINIA TAB 3 QL (60 EA per 30 MEPRON ORAL SUSP 2 NEBUPENT SOLUTION FOR INHALATION 3 PENTAM SOLUTION FOR INJECTION 3 B/D Pediculicides/ Scabicides EURAX LOTION 3 EURAX TOPICAL CREAM 3 OVIDE LOTION 3 permethrin topical cream 1 GAP Antiparkinson Agents Anticholinergics benztropine tab 1 MO; GAP trihexyphenidyl elixir 1 MO; GAP trihexyphenidyl tab 1 MO; GAP Antiparkinson Agents, Other amantadine cap 1 MO; GAP amantadine syrup 1 MO; GAP amantadine tab 1 MO; GAP APOKYN SUBQ CARTRIDGE 4 LA; QL (60 ML per 30 Catechol O-Methyltransferase (Comt) Inhibitors COMTAN TAB 2 MO TASMAR TAB 2 MO Dopamine Agonists, Ergot bromocriptine cap 1 MO; GAP bromocriptine tab 1 MO; GAP cabergoline tab 1 GAP PARLODEL CAP 3 MO PARLODEL TAB 3 MO Dopamine Agonists, Nonergot MIRAPEX TAB 3 MO Page 41 of 128

42 MIRAPEX ER 24 HR TAB mg, 0.75 mg, 1.5 mg, 3 mg 3 MO MIRAPEX ER 24 HR TAB 4.5 mg 3 MO; QL (30 EA per 30 pramipexole tab 1 MO; GAP REQUIP TAB 3 MO REQUIP XL 24 HR TAB 12 mg, 6 mg, 8 mg 2 MO; QL (60 EA per 30 REQUIP XL 24 HR TAB 2 mg, 4 mg 2 MO; QL (90 EA per 30 ropinirole tab 1 MO; GAP Dopamine Precursors carbidopa-levodopa er tab 1 MO; GAP carbidopa-levodopa tab 1 MO; GAP PARCOPA TAB, RAPID DISSOLVE mg, mg 3 MO SINEMET TAB 3 MO SINEMET CR TAB 3 MO STALEVO 100 TAB 2 MO STALEVO 125 TAB 2 MO STALEVO 150 TAB 2 MO STALEVO 200 TAB 2 MO STALEVO 50 TAB 2 MO STALEVO 75 TAB 2 MO Monoamine Oxidase B (Mao-B) Inhibitors AZILECT TAB 2 MO; QL (30 EA per 30 ELDEPRYL CAP 3 MO selegiline cap 1 MO; GAP selegiline tab 1 MO; GAP Antipsychotics Atypicals ABILIFY IM 2 ABILIFY ORAL SOLN 2 MO ABILIFY TAB 2 MO Page 42 of 128

43 ABILIFY DISCMELT 2 MO clozapine tab 1 MO; GAP CLOZARIL TAB 3 MO FANAPT TAB 3 MO FANAPT TABS IN A DOSE PACK 3 MO FAZACLO TAB, RAPID DISSOLVE 2 MO GEODON CAP 2 MO; QL (60 EA per 30 GEODON IM 2 INVEGA 24 HR TAB 3 mg, 9 mg 3 MO; QL (30 EA per 30 INVEGA 24 HR TAB 1.5 mg, 6 mg 3 MO; QL (60 EA per 30 INVEGA SUSTENNA IM SYRINGE 39 mg/0.25 ml INVEGA SUSTENNA IM SYRINGE 156 mg/ml (1 ml), 78 mg/0.5 ml INVEGA SUSTENNA IM SYRINGE 117 mg/0.75 ml, 234 mg/1.5 ml 3 MO; QL (0.5 ML per 30 3 MO; QL (1 ML per 30 3 MO; QL (1.5 ML per 30 LATUDA TAB 3 MO; QL (30 EA per 30 RISPERDAL ORAL SOLN 3 MO RISPERDAL TAB 3 MO RISPERDAL CONSTA IM SYRINGE 2 RISPERDAL M-TAB 3 MO risperidone oral soln 1 MO; GAP risperidone tab 1 MO; GAP risperidone tab, rapid dissolve 1 MO; GAP SAPHRIS SUBLINGUAL TAB 3 MO; QL (60 EA per 30 SEROQUEL TAB 50 mg 2 MO SEROQUEL TAB 100 mg, 200 mg, 25 mg, 300 mg, 400 mg 2 MO; QL (60 EA per 30 SEROQUEL XR 24 HR TAB 300 mg, 400 mg 2 MO; QL (60 EA per 30 SEROQUEL XR 24 HR TAB 150 mg, 200 mg, 50 mg ZYPREXA IM 2 2 MO; QL (90 EA per 30 Page 43 of 128

44 ZYPREXA TAB 2 MO; QL (30 EA per 30 ZYPREXA ZYDIS TAB, RAPID DISSOLVE 2 MO; QL (30 EA per 30 Conventional chlorpromazine injection 1 GAP chlorpromazine tab 1 MO; GAP fluphenazine decanoate injection 1 GAP fluphenazine elixir 1 MO; GAP fluphenazine injection 1 GAP fluphenazine oral concentrate 1 MO; GAP fluphenazine tab 1 MO; GAP HALDOL INJECTION 3 HALDOL DECANOATE IM 3 haloperidol tab 1 MO; GAP haloperidol decanoate im 1 GAP haloperidol injection 1 GAP haloperidol oral concentrate 1 MO; GAP loxapine cap 1 MO; GAP LOXITANE CAP 3 MO NAVANE CAP 10 mg, 2 mg, 5 mg 3 MO ORAP TAB 2 perphenazine tab 1 MO; GAP thioridazine tab 1 MO; GAP thiothixene cap 1 MO; GAP trifluoperazine tab 1 MO; GAP Antispasticity Agents Antispasticity Agents baclofen tab 1 GAP DANTRIUM CAP 3 dantrolene cap 1 GAP tizanidine tab 1 GAP Page 44 of 128

45 ZANAFLEX TAB 3 Antivirals Anti-Cytomegalovirus (Cmv) Agents foscarnet iv 1 B/D; GAP ganciclovir cap 1 MO; GAP VISTIDE IV 3 B/D Antihepatitis Agents BARACLUDE ORAL SOLN 2 QL (600 ML per 30 BARACLUDE TAB 2 QL (30 EA per 30 COPEGUS TAB 3 PA HEPSERA TAB 2 QL (30 EA per 30 INCIVEK TAB 4 PA REBETOL CAP 3 PA REBETOL ORAL SOLN 2 PA RIBASPHERE CAP 1 PA; GAP RIBASPHERE TAB 1 PA; GAP ribavirin cap 1 PA; GAP ribavirin tab 1 PA; GAP TYZEKA TAB 2 QL (30 EA per 30 VICTRELIS CAP 4 PA Antiherpetic Agents acyclovir cap 1 GAP acyclovir oral susp 1 GAP acyclovir tab 1 GAP acyclovir sodium iv powder for solution 1 B/D; GAP CYTOVENE IV SOLUTION 3 B/D DENAVIR TOPICAL CREAM 3 famciclovir tab 500 mg 1 GAP; QL (60 EA per 30 famciclovir tab 125 mg, 250 mg 1 GAP; QL (90 EA per 30 FAMVIR TAB 500 mg 3 QL (60 EA per 30 Page 45 of 128

46 FAMVIR TAB 125 mg, 250 mg 3 QL (90 EA per 30 ganciclovir iv solution 1 B/D; GAP valacyclovir tab 1 GAP; QL (60 EA per 30 VALCYTE ORAL SOLUTION 3 VALCYTE TAB 3 MO VALTREX TAB 3 QL (60 EA per 30 ZOVIRAX CAP 3 ZOVIRAX OINTMENT 2 QL (30 GM per 30 ZOVIRAX ORAL SUSP 3 ZOVIRAX TAB 3 ZOVIRAX TOPICAL CREAM 2 QL (15 GM per 30 Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors ATRIPLA TAB 4 QL (30 EA per 30 EDURANT TAB 3 QL (30 EA per 30 INTELENCE TAB 100 mg 4 QL (120 EA per 30 INTELENCE TAB 200 mg 4 QL (60 EA per 30 RESCRIPTOR DISPERSIBLE TAB 3 MO RESCRIPTOR TAB 3 MO SUSTIVA CAP 2 MO SUSTIVA TAB 2 MO VIRAMUNE ORAL SUSP 2 MO VIRAMUNE TAB 2 MO VIRAMUNE XR 24 HR TAB 2 Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors COMBIVIR TAB 2 MO didanosine cap, delayed release 1 MO; GAP EMTRIVA CAP 3 MO EMTRIVA ORAL SOLN 3 MO EPIVIR ORAL SOLN 2 MO EPIVIR TAB 2 MO Page 46 of 128