FORMULARY. List of Covered Drugs. Good health is where you live. Ultimate Premier Ultimate Premier Plus Ultimate Elite Ultimate Elite Plus

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1 2015 FORMULARY List of Covered Drugs Ultimate Premier Ultimate Premier Plus Ultimate Elite Ultimate Elite Plus PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 10/01/2015. For more recent information or other questions, please contact Ultimate Health Plans Member Services at or, for TTY users, 711, Monday through Sunday from 8 a.m. to 8 p.m., or visit Ultimate Health Plans is an HMO plan with a Medicare contract. Enrollment in Ultimate Health Plans depends on contract renewal. Good health is where you live. H2962_Formulary v115 Accepted , Version 16

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 Ultimate Health Plans. When it refers to plan or our plan, it means Ultimate Premier (HMO), Ultimate Premier Plus (HMO), Ultimate Elite (HMO) or Ultimate Elite Plus (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 10/01/2015. 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 Ultimate Premier, Ultimate Premier Plus, Ultimate Elite and Ultimate Elite Plus Formulary? A formulary is a list of covered drugs selected by our plan 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2015 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 10/01/2015. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. In the event of any mid-year, non-maintenance changes to the formulary, we will print and mail an errata sheet outlining the changes. If you are taking an affected drug at the time of the mid-year change, a letter will be mailed to you explaining that we will continue to cover the drug in question for the remainder of the plan year as long as the drug continues to be medically necessary and prescribed by your physician and was not removed for safety reasons. ii

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 below. 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 70. 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? Our plan 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: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 capsules per prescription for temazepam capsules. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 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 a document 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 us 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 plan s formulary? on page iv for information about how to request an exception. iii

4 What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. Our plan pays for certain OTC drugs. Minerals and vitamins In home testing and monitoring, such as equipment to monitor blood pressure, cholesterol, blood sugar, to test for pregnancy, HIV, fecal occult blood. Bathroom scales may be covered for enrollees with CHF or liver disease to monitor fluid retention Hormone replacement, such as Phytohormone, natural progesterone or DHEA Weight loss items, such as appetite suppressants and fat absorption inhibitors Fiber supplements, such as pills, powders and non-food liquids that supplement fiber in the diet First Aid supplies, such as adhesive bandages, gauze and other dressings, antibacterial ointment, peroxide, thermometers, non-sport tapes Incontinence supplies, such as diapers and pads Medicines, ointments and sprays with active medical ingredients that alleviate symptoms, such as Antacids, analgesics, antibacterials, anti-histamines, anti-inflammatories, antiseptics, decongestants, sleep aids Topical sunscreen Mouth care, such as Toothbrushes, toothpaste, floss, denture adhesives, denture cleaners and gum stimulators Our plan will provide these OTC drugs at no cost to you. The cost to our plan of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap. 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 Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask us 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 Ultimate Premier, Ultimate Premier Plus, Ultimate Elite and Ultimate Elite Plus Formulary? You can ask us 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, our plan 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. iv

5 Generally, we 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 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 allow you to refill your prescription until we have provided you with a 91-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. Ultimate Health Plans will cover a Transition Supply for enrollees who have a level of care change, which is defined as when enrollees: Enter a Long-Term-Care (LTC) facility from a hospital or other setting Leave a Long-Term-Care (LTC) facility and return to the community Are discharged from a hospital to a home End a skilled nursing facility (SNF) stay covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under their Part D plan Formulary Revert from hospice status to standard Medicare Part A and Part B benefits; or Are discharged from a psychiatric hospital with a medication regimen that is highly individualized We will provide you with a written notice after we cover the Transition Supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that Ultimate Health Plans covers. v

6 For more information For more detailed information about your our prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, 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 vi

7 Our Plan s Formulary The formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 70. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug, including utilization management restrictions; drugs that are available via mail-order, excluded drugs that are covered by the plan; limited access drugs; drugs covered in the coverage gap; and drugs covered under the medical benefit (home infusion drugs). BD: This prescription drug may be covered under our medical benefit. For more information, call Member Services at , Monday through Sunday from 8 a.m. to 8 p.m. TTY users should call 711. E: Excluded Drug. 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. GC: Gap Coverage. 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. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Member Services at , Monday through Sunday from 8 a.m. to 8 p.m. TTY users should call 711. MO: Mail Order Drug. This prescription drug is available through our mail order service, as well as through our retail network pharmacies. Generally, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. Our plan s mail-order service requires you to order a 90-day supply. Usually a mail-order pharmacy order will get to you in no more than 14 days. However, if your order is delayed, immediately contact EnvisionRx so they can make arrangements for you to pick up your prescription at your local pharmacy. You may contact them 24 hours a day, 7 days a week at (TTY users dial 711). You can also sign up for our optional automatic delivery program under which we will automatically fill all new prescriptions your health care provider sends to us, as well as refills for prescriptions that have already been filled but are running out. PA: Prior Authorization. We require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs we limit the amount of the drug that we will cover. ST: Step Therapy. In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. vii

8 The Formulary is Divided Into Four (4) Tiers Every drug on the plan s Drug List is in one of 4 cost-sharing tiers with a corresponding cost sharing amount depending on the plan as shown below. In general, the higher the cost-sharing tier, the higher your cost for the drug: Cost-Sharing Tier 1 includes preferred generic drugs. This is the lowest tier. Cost-Sharing Tier 2 includes non-preferred generic drugs and preferred brand drugs. Cost-Sharing Tier 3 includes non-preferred brand drugs. Cost-Sharing Tier 4 includes specialty drugs. This is the highest tier. For Ultimate Premier (001) and Ultimate Elite (003): Cost Sharing Tier Copay or coinsurance for a 30-day supply at a Retail Pharmacy Copay or coinsurance for a 90-day supply at a Retail Pharmacy Copay or coinsurance for a 90-day supply through the Mail Order Pharmacy Tier 1 $0 $0 $0 Tier 2 $20 $60 $40 Tier 3 $50 $150 $100 Tier 4 33 % coinsurance 33% coinsurance 33% coinsurance For Ultimate Premier Plus (002) and Ultimate Elite Plus (004): Cost Sharing Tier Copay or coinsurance for a 30-day supply at a Retail Pharmacy Copay or coinsurance for a 90-day supply at a Retail Pharmacy Copay or coinsurance for a 90-day supply through the Mail Order Pharmacy Tier 1 $0 $0 $0 Tier 2 $10 $30 $20 Tier 3 $45 $135 $90 Tier 4 33% coinsurance 33% coinsurance 33% coinsurance Please consult your Evidence of Coverage or Summary of Benefits for additional information on the applicable co-pays or co-insurance amounts in each formulary tier. viii

9 ANALGESICS (PAIN, INFLAMMATION, MUSCLE, JOINT CONDITION DRUGS) Opioid Analgesics, Long-acting (NARCOTIC PAIN RELIEVERS) EMBEDA CAP 100-4MG 4 QL 60 EMBEDA CAP MG 3 QL 60 MO EMBEDA CAP MG 3 QL 60 MO EMBEDA CAP 50-2MG 3 QL 60 MO EMBEDA CAP MG 3 QL 60 MO EMBEDA CAP MG 3 QL 60 MO fentanyl dis 100mcg/h 3 PA QL 10 ST MO fentanyl dis 12mcg/hr 3 PA QL 10 ST MO fentanyl dis 25mcg/hr 3 PA QL 10 ST MO FENTANYL DIS 37.5MCG 3 PA ST MO fentanyl dis 50mcg/hr 3 PA QL 10 ST MO FENTANYL DIS 62.5MCG 3 PA ST MO fentanyl dis 75mcg/hr 3 PA QL 10 ST MO FENTANYL DIS 87.5MCG 3 PA MO fentanyl ot loz 1200mcg 4 PA QL 180 ST fentanyl ot loz 1600mcg 4 PA QL 180 ST fentanyl ot loz 200mcg 4 PA QL 180 ST fentanyl ot loz 400mcg 4 PA QL 180 ST fentanyl ot loz 600mcg 4 PA QL 180 ST fentanyl ot loz 800mcg 4 PA QL 180 ST KADIAN CAP 40MG ER 2 MO METHADONE INJ 10MG/ML 1 MO methadone sol 10mg/5ml 1 GC MO methadone sol 5mg/5ml 2 GC MO methadone tab 10mg 2 GC MO methadone tab 5mg 1 GC MO morphine sul cap 100mg er 4 morphine sul cap 20mg er 2 GC MO morphine sul cap 30mg er 2 GC MO morphine sul cap 50mg er 2 GC MO morphine sul cap 60mg er 2 GC MO morphine sul cap 80mg er 4 morphine sul tab 100mg er 2 GC MO morphine sul tab 15mg er 2 GC MO morphine sul tab 30mg er 2 GC MO morphine sul tab 60mg er 2 GC MO NUCYNTA ER TAB 100MG 2 MO NUCYNTA ER TAB 150MG 2 MO NUCYNTA ER TAB 200MG 2 MO NUCYNTA ER TAB 250MG 2 MO NUCYNTA ER TAB 50MG 2 MO OPANA ER TAB 10MG 2 MO OPANA ER TAB 15MG 2 MO OPANA ER TAB 20MG 2 MO OPANA ER TAB 30MG 4 OPANA ER TAB 40MG 4 1

10 OPANA ER TAB 5MG 2 MO OPANA ER TAB 7.5MG 2 MO OXYCODONE TAB 10MG ER 2 MO OXYCODONE TAB 20MG ER 2 MO OXYCODONE TAB 40MG ER 2 MO OXYCODONE TAB 80MG ER 2 MO OXYCONTIN TAB 10MG CR 2 MO OXYCONTIN TAB 15MG CR 2 MO OXYCONTIN TAB 20MG CR 2 MO OXYCONTIN TAB 30MG CR 2 MO OXYCONTIN TAB 40MG CR 2 MO OXYCONTIN TAB 60MG CR 4 OXYCONTIN TAB 80MG CR 4 oxymorphone tab 10mg er 2 GC MO oxymorphone tab 15mg er 2 GC MO oxymorphone tab 20mg er 2 GC MO oxymorphone tab 30mg er 2 GC MO oxymorphone tab 40mg er 2 GC MO oxymorphone tab 5mg er 2 GC MO oxymorphone tab 7.5mg er 2 GC MO Opioid Analgesics, Short-acting (NARCOTIC PAIN RELIEVERS) apap/cod sol120-12mg/5ml 1 QL 5000 GC MO apap/codeine tab mg 2 QL 400 GC MO apap/codeine tab mg 2 QL 400 GC MO apap/codeine tab mg 2 QL 400 GC MO ascomp/cod cap 30mg 2 PA GC MO but/apap/caf cap codeine 2 PA QL 370 GC MO duramorph inj 0.5mg/ml 1 GC MO duramorph inj 1mg/ml 1 GC MO endocet tab mg 2 QL 370 GC MO endocet tab 5-325mg 2 QL 370 GC MO endocet tab m 2 QL 370 GC MO hydroco/apap sol mg 1 QL 5500 GC MO hydroco/apap tab mg 1 QL 370 GC MO hydroco/apap tab QL 370 MO hydroco/apap tab 5-325mg 1 QL 370 GC MO hydroco/apap tab mg 1 QL 370 GC MO hydrocod/ibu tab mg 1 GC MO hydromorphon liq 1mg/ml 2 GC MO hydromorphone inj 500/50ml 2 GC MO hydromorphone tab 2mg 2 GC MO hydromorphone tab 4mg 2 GC MO hydromorphone tab 8mg 2 GC MO LAZANDA SPR 100MCG 4 PA LAZANDA SPR 400MCG 4 PA lorcet plus tab QL 370 GC MO morphine sul cap 10mg er 2 GC MO morphine sul sol 10mg/5ml 2 GC MO morphine sul sol 20mg/5ml 1 GC MO 2

11 morphine sul sol 20mg/ml 2 GC MO morphine sul tab 15mg 2 GC MO morphine sul tab 30mg 2 GC MO nalbuphine inj 10mg/ml 2 GC MO nalbuphine inj 20mg/ml 2 GC MO NUCYNTA TAB 100MG 2 MO NUCYNTA TAB 50MG 2 MO NUCYNTA TAB 75MG 2 MO oxycod/apap tab mg 2 QL 370 GC MO oxycod/apap tab mg 2 QL 370 GC MO oxycod/apap tab 5-325mg 2 QL 370 GC MO oxycod/apap tab mg 2 QL 370 GC MO oxycod/asa tab mg 2 GC MO oxycod/ibu tab 5-400mg 2 GC MO oxycodone cap 5mg 2 GC MO oxycodone tab 10mg 2 GC MO oxycodone tab 15mg 2 GC MO oxycodone tab 20mg 2 GC MO oxycodone tab 30mg 2 GC MO oxycodone tab 5mg 2 GC MO oxymorphone tab hcl 10mg 2 GC MO oxymorphone tab hcl 5mg 2 GC MO tramad/apap tab mg 2 QL 370 GC MO tramadol hcl tab 50mg 1 QL 240 GC MO ANESTHETICS (NUMBING DRUGS) Local Anesthetics (LOCAL NUMBING DRUGS) lido/prilocn cre % 2 GC MO lidocaine inj 0.5% 1 GC MO lidocaine pad 5% 2 PA QL 90 GC MO ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (NERVE CONDITION DRUGS) Alcohol Deterrents/Anti-craving (MISCELLANEOUS MENTAL HEALTH DRUGS) disulfiram tab 250mg 2 GC MO disulfiram tab 500mg 2 GC MO naltrexone tab 50mg 2 GC MO Opioid Antagonists (MISCELLANEOUS MENTAL HEALTH DRUGS) bupren/nalox sub 2-0.5mg 2 GC MO bupren/nalox sub 8-2mg 2 GC MO buprenorphine inj 0.3mg/ml 1 GC MO buprenorphine sub 2mg 2 GC MO buprenorphine sub 8mg 2 GC MO BUTRANS DIS 15MCG/HR 2 MO naloxone inj 1mg/ml 1 GC MO SUBOXONE MIS 12-3MG 3 MO SUBOXONE MIS 2-0.5MG 2 MO SUBOXONE MIS 4-1MG 2 MO SUBOXONE MIS 8-2MG 2 MO ZUBSOLV SUB MO ZUBSOLV SUB MO 3

12 ZUBSOLV SUB MO Smoking Cessation Agents (MISCELLANEOUS MENTAL HEALTH DRUGS) buproban tab 150mg 2 GC MO bupropion hcl tab 150mg xl 1 GC MO CHANTIX PAK 0.5MG & 1MG 3 QL 53 MO CHANTIX PAK 1MG 3 MO CHANTIX TAB 0.5MG 3 QL 11 MO CHANTIX TAB 1MG 3 QL 180/90 MO NICOTROL INH 2 MO ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (NERVE CONDITIONS DRUGS) ALCOHOL DETERRENTS/ANTI-CRAVING (MISCELLANEOUS MENTAL HEALTH DRUGS) acampro cal tab 333mg 2 MO ANTI-INFLAMMATORY AGENTS (PAIN, INFLAMMATION, MUSCLE, JOINT CONDITION DRUGS) Nonsteroidal Anti-inflammatory Drugs (PAIN, ANTI-INFLAMMATORY DRUGS) CELEBREX CAP 400MG 3 ST MO celecoxib cap 100mg 2 GC MO celecoxib cap 200mg 2 GC MO celecoxib cap 400mg 2 GC MO celecoxib cap 50mg 2 GC MO diclofen pot tab 50mg 2 GC MO diclofenac tab 100mg er 2 GC MO diclofenac tab 25mg dr 2 GC MO diclofenac tab 50mg dr 2 GC MO diclofenac tab 75mg dr 1 GC MO diflunisal tab 500mg 2 GC MO etodolac cap 200mg 2 GC MO etodolac cap 300mg 2 GC MO etodolac er tab 400mg 2 GC MO etodolac er tab 500mg 2 GC MO etodolac er tab 600mg 2 GC MO etodolac tab 400mg 2 GC MO etodolac tab 500mg 2 GC MO fenoprofen tab 600mg 1 GC MO flurbiprofen tab 100mg 2 GC MO flurbiprofen tab 50mg 1 GC MO ibuprofen sus 100mg/5ml 1 GC MO ibuprofen tab 400mg 1 GC MO ibuprofen tab 600mg 1 GC MO ibuprofen tab 800mg 1 GC MO indomethacin cap 25mg 1 PA GC MO indomethacin cap 50mg 2 PA GC MO indomethacin cap 75mg er 2 PA GC MO ketoprofen cap 200mg er 2 GC MO ketoprofen cap 50mg 1 GC MO ketoprofen cap 75mg 2 GC MO ketorolac inj 15mg/ml 1 PA GC MO ketorolac inj 30mg/ml 1 PA GC MO 4

13 ketorolac tab 10mg 2 PA GC MO meclofen sod cap 100mg 1 GC MO meclofen sod cap 50mg 1 GC MO meloxicam sus 7.5/5ml 1 GC MO meloxicam tab 15mg 1 GC MO meloxicam tab 7.5mg 1 GC MO nabumetone tab 500mg 2 GC MO nabumetone tab 750mg 2 GC MO naproxen dr tab 375mg 1 GC MO naproxen dr tab 500mg 1 GC MO naproxen sod tab 275mg 1 GC MO naproxen sod tab 550mg 1 GC MO naproxen sus 125mg/5ml 1 GC MO naproxen tab 250mg 1 GC MO naproxen tab 375mg 1 GC MO naproxen tab 500mg 1 GC MO oxaprozin tab 600mg 2 GC MO piroxicam cap 10mg 2 GC MO piroxicam cap 20mg 1 GC MO sulindac tab 150mg 2 GC MO sulindac tab 200mg 2 GC MO tolmetin sod cap 400mg 2 GC MO tolmetin sod tab 600mg 1 GC MO VIMOVO TAB MG 2 MO VIMOVO TAB MG 2 MO ANTIBACTERIALS (INFECTION FIGHTING DRUGS) Aminoglycosides [BACTERIAL INFECTION DRUGS (ANTIBIOTICS)] gentamicin inj 10mg/ml 1 GC MO gentamicin inj 40mg/ml 2 GC MO gentamicin/nacl inj 0.9mg/ml 1 GC MO gentamicin/nacl inj 1.4mg/ml 1 GC MO gentamicin/nacl inj 1.6mg/ml 1 GC MO gentamicin/nacl inj 100mg 1 GC MO gentamicin/nacl inj 60mg 1 GC MO neomycin tab 500mg 2 GC MO paromomycin cap 250mg 2 GC MO streptomycin inj 1gm 1 GC MO TOBI NEB SOLN 300MG/5ML 4 BD TOBI PODHALR CAP 28MG 4 tobramycin inj 10mg/ml 2 GC MO tobramycin inj 80mg/2ml 2 GC MO tobramycin neb 300/5ml 2 GC MO BD Antibacterials, Other (MISCELLANEOUS INFECTION FIGHTING DRUGS) baciim inj 50000unit 1 GC MO chloramphenicol inj 1gm 1 GC MO clindamycin cap 150mg 2 GC MO clindamycin cap 300mg 2 GC MO clindamycin cap 75mg 2 GC MO clindamycin inj 150mg/ml 1 GC MO 5

14 clindamycin inj 300mg 2 GC MO clindamycin inj 600mg 2 GC MO clindamycin inj 900mg 2 GC MO clindamycin sol 75mg/5ml 2 GC MO colistimethate inj 150mg 2 GC MO CUBICIN SOL 500MG 4 BD linezolid inj 2mg/ml 4 linezolid tab 600mg 4 metronidazol cap 375mg 1 GC MO metronidazole tab 250mg 1 GC MO metronidazole tab 500mg 1 GC MO metronidazole/nacl inj 500mg 2 GC MO BD nitrofur mac cap 50mg 2 PA QL 90/365 GC MO nitrofurantn cap 100mg 2 PA QL 90/365 GC MO SYNERCID INJ 500MG 4 BD trimethoprim tab 100mg 2 GC MO TYGACIL INJ 50MG 3 MO BD vancomycin cap 125mg 4 vancomycin cap 250mg 4 vancomycin inj 1000mg 2 GC MO BD vancomycin inj 10gm 2 GC MO BD vancomycin inj 500mg 3 MO BD XIFAXAN TAB 550MG 4 ZYVOX SUS 100MG/5ML 4 ZYVOX TAB 600MG 4 Beta-lactam, Cephalosporins [BACTERIAL INFECTION DRUGS (ANTIBIOTICS)] cefaclor cap 250mg 2 GC MO cefaclor cap 500mg 2 GC MO cefaclor er tab 500mg 1 GC MO cefazolin inj 10gm 1 GC MO cefazolin inj 1gm 2 GC MO cefazolin inj 1gm/50ml 1 GC MO cefazolin inj 500mg 1 GC MO cefdinir cap 300mg 2 GC MO cefdinir sus 125mg/5ml 1 GC MO cefdinir sus 250mg/5ml 1 GC MO cefepime inj 1gm 2 GC MO cefepime inj 2gm 2 GC MO cefoxitin inj 10gm 2 GC MO cefoxitin inj 180 mg/ml 2 GC MO cefoxitin inj 95 mg/ml 2 GC MO cefpodo prox sus 100mg/5ml 2 GC MO cefpodo prox sus 50mg/5ml 2 GC MO cefpodoxime tab 100mg 2 GC MO cefpodoxime tab 200mg 2 GC MO ceftriaxone inj 10gm 2 GC MO ceftriaxone inj 1gm 2 GC MO ceftriaxone inj 250mg 2 GC MO ceftriaxone inj 2gm 1 GC MO 6

15 ceftriaxone inj 500mg 2 GC MO cefuroxime inj 1.5gm 1 GC MO cefuroxime inj 7.5gm 1 GC MO cefuroxime inj 750mg 1 GC MO cefuroxime tab 250mg 2 GC MO cefuroxime tab 500mg 2 GC MO cephalexin cap 250mg 1 GC MO cephalexin cap 500mg 1 GC MO cephalexin sus 125mg/5ml 2 GC MO cephalexin sus 250mg/5ml 1 GC MO cephalexin tab 250mg 1 GC MO cephalexin tab 500mg 1 GC MO SUPRAX CAP 400MG 3 MO TEFLARO INJ 400MG 3 MO BD TEFLARO INJ 600MG 3 MO BD Beta-lactam, Other [BACTERIAL INFECTION DRUGS (ANTIBIOTICS)] aztreonam inj 1gm 2 GC MO CAYSTON INH 75MG 4 INVANZ INJ 1GM 3 MO meropenem inj 500mg 2 GC MO Beta-lactam, Penicillins [BACTERIAL INFECTION DRUGS (ANTIBIOTICS)] amox/k clav chw 200mg 1 GC MO amox/k clav chw 400mg 1 GC MO amox/k clav sus 200/5ml 1 GC MO amox/k clav sus 400/5ml 2 GC MO amox/k clav sus 600/5ml 2 GC MO amox/k clav tab 250mg 2 GC MO amox/k clav tab 500mg 2 GC MO amox/k clav tab 875mg 2 GC MO amoxicillin cap 250mg 1 GC MO amoxicillin cap 500mg 1 GC MO amoxicillin chw tab 125mg 1 GC MO amoxicillin chw tab 250mg 1 GC MO amoxicillin sus 125/5ml 1 GC MO amoxicillin sus 200/5ml 1 GC MO amoxicillin sus 250/5ml 1 GC MO amoxicillin sus 400/5ml 1 GC MO amoxicillin tab 500mg 1 GC MO amoxicillin tab 875mg 1 GC MO amp-sulbacta inj 1.5gm 2 GC MO amp-sulbactam inj 15gm 2 GC MO ampicillin cap 250mg 1 GC MO ampicillin cap 500mg 1 GC MO ampicillin inj 10gm 2 GC MO ampicillin inj 125mg 2 GC MO ampicillin inj 1gm 2 GC MO ampicillin sus 125/5ml 1 GC MO ampicillin sus 250/5ml 1 GC MO BICILLIN L-A INJ MO 7

16 cefadroxil sus 500/5ml 1 GC MO dicloxacillin cap 250mg 2 GC MO dicloxacillin cap 500mg 2 GC MO imipenem/cilas inj 250mg 3 MO BD imipenem/cilas inj 500mg 3 MO BD nafcillin inj 10gm 2 GC MO nafcillin inj 1gm 2 GC MO pen g sod inj GC MO penicillin gk inj 5mu 1 GC MO penicillin gk/ inj dex 2mu 1 GC MO penicillin gk/ inj dex 3mu 1 GC MO penicillin vk sol 125/5ml 1 GC MO penicillin vk sol 250/5ml 1 GC MO penicillin vk tab 250mg 1 GC MO penicillin vk tab 500mg 1 GC MO PFIZERPEN-G INJ 20 MU 1 MO piper/tazoba inj g 2 GC MO piper/tazoba inj 4-0.5gm 2 GC MO Macrolides [BACTERIAL INFECTION DRUGS (ANTIBIOTICS)] azithromycin inj 500mg 1 GC MO azithromycin pow 1gm pak 1 MO azithromycin sus 100mg/5ml 1 GC MO azithromycin sus 200mg5ml 1 GC MO azithromycin tab 250mg 1 GC MO azithromycin tab 500mg 1 GC MO azithromycin tab 600mg 1 GC MO clarithromycin tab 250mg 2 GC MO clarithromycin tab 500mg 2 GC MO DIFICID TAB 200MG 4 ST e.e.s. 400 tab 400mg 1 GC MO erythrocin lac inj 500mg 2 MO BD erythrocin tab 250mg 2 GC MO erythromycin eth tab 400mg 1 GC MO Quinolones [BACTERIAL INFECTION DRUGS (ANTIBIOTICS)] ciprofloxacin inj 200mg 1 GC MO ciprofloxacin inj 400mg/40ml 1 GC MO ciprofloxacin tab 1000mg er 1 GC MO ciprofloxacin tab 100mg 1 GC MO ciprofloxacin tab 250mg 1 GC MO ciprofloxacin tab 500mg 1 GC MO ciprofloxacin tab 500mg er 1 GC MO ciprofloxacin tab 750mg 1 GC MO ciprofloxacn sus 250mg/5 1 MO ciprofloxacn sus 500mg/5 1 MO levoflox/d5w inj 500mg/100ml 2 GC MO levofloxacin inj 25mg/ml 2 GC MO levofloxacin sol 25mg/ml 2 GC MO levofloxacin tab 250mg 1 GC MO levofloxacin tab 500mg 1 GC MO 8

17 levofloxacin tab 750mg 2 GC MO MOXIFLOXACIN INJ 2 MO Sulfonamides [BACTERIAL INFECTION DRUGS (ANTIBIOTICS)] smz-tmp inj mg/5ml 2 GC MO smz-tmp sus mg/5ml 1 GC MO smz-tmp tab mg 1 GC MO smz/tmp ds tab mg 1 GC MO sulfadiazine tab 500mg 2 GC MO Tetracyclines [BACTERIAL INFECTION DRUGS (ANTIBIOTICS)] doxy 100 inj 100mg 1 MO doxycyc mono cap 100mg 1 GC MO doxycyc mono cap 50mg 1 GC MO doxycyc mono tab 100mg 1 GC MO doxycyc mono tab 50mg 1 MO doxycycl hyc inj 100mg 1 MO doxycycline hyc cap 100mg 1 GC MO doxycycline hyc cap 50mg 1 GC MO doxycycline hyc tab 100mg 1 GC MO doxycycline hyc tab 20mg 1 GC MO doxycycline mono tab 50mg 1 GC MO doxycycline mono tab 75mg 1 GC MO doxycycline sus 25mg/5ml 1 GC MO minocycline cap 100mg 2 GC MO minocycline cap 50mg 2 GC MO minocycline cap 75mg 2 GC MO minocycline tab 100mg 2 GC MO minocycline tab 50mg 2 GC MO minocycline tab 75mg 2 GC MO ANTICONVULSANTS (NERVE CONDITION DRUGS) Anticonvulsants, Other (SEIZURE CONTROL DRUGS) LEVETIRACETA INJ 10MG/ML 3 MO LEVETIRACETA INJ 15MG/ML 3 MO LEVETIRACETA INJ 5MG/ML 3 MO levetiraceta sol 100mg/ml 2 GC MO levetiraceta tab 1000mg 2 GC MO levetiraceta tab 250mg 2 GC MO levetiraceta tab 500mg 2 GC MO levetiraceta tab 500mg er 2 GC MO levetiraceta tab 750mg 2 GC MO levetiraceta tab 750mg er 2 GC MO levetiracetm inj 500mg/5ml 2 GC MO POTIGA TAB 200MG 4 POTIGA TAB 300MG 3 MO POTIGA TAB 400MG 4 POTIGA TAB 50MG 3 MO Barbiturates (SEIZURE CONTROL DRUGS) phenobarb elx 20mg/5ml 1 GC MO phenobarb tab 100mg 1 GC MO phenobarb tab 15mg 1 GC MO 9

18 phenobarb tab 16.2mg 1 GC MO phenobarb tab 30mg 1 GC MO phenobarb tab 32.4mg 1 GC MO phenobarb tab 60mg 1 GC MO phenobarb tab 64.8mg 1 GC MO phenobarb tab 97.2mg 1 GC MO Calcium Channel Modifying Agents (SEIZURE CONTROL DRUGS) CELONTIN CAP 300MG 3 MO ethosuximide cap 250mg 2 GC MO ethosuximide sol 250/5ml 1 GC MO zonisamide cap 100mg 2 GC MO zonisamide cap 25mg 2 GC MO zonisamide cap 50mg 2 GC MO Gamma-aminobutyric Acid (GABA) Augmenting Agents (SEIZURE CONTROL DRUGS) divalproex cap 125mg 2 GC MO divalproex tab 125mg dr 2 GC MO divalproex tab 250mg dr 2 GC MO divalproex tab 500mg dr 2 GC MO FYCOMPA TAB 10MG 3 MO FYCOMPA TAB 12MG 3 MO FYCOMPA TAB 2MG 3 MO FYCOMPA TAB 4MG 3 MO FYCOMPA TAB 6MG 3 MO FYCOMPA TAB 8MG 3 MO gabapentin cap 100mg 1 GC MO gabapentin cap 300mg 1 GC MO gabapentin cap 400mg 1 GC MO gabapentin sol 250/5ml 1 GC MO gabapentin tab 600mg 1 GC MO gabapentin tab 800mg 1 GC MO GABITRIL TAB 12MG 3 MO GABITRIL TAB 16MG 3 MO primidone tab 250mg 2 GC MO primidone tab 50mg 2 GC MO SABRIL POW 500MG 4 SABRIL TAB 500MG 4 tiagabine tab 2mg 2 GC MO tiagabine tab 4mg 2 GC MO valproate inj 100mg/ml 1 GC MO valproic acd cap 250mg 2 GC MO Glutamate Reducing Agents (SEIZURE CONTROL DRUGS) felbamate sus 600mg/5ml 4 felbamate tab 400mg 2 GC MO felbamate tab 600mg 4 lamotrigine chw 25mg 2 GC MO lamotrigine chw 5mg 2 GC MO lamotrigine tab 100mg 2 GC MO lamotrigine tab 100mg 3 MO lamotrigine tab 100mg er 2 GC MO 10

19 lamotrigine tab 150mg 2 GC MO lamotrigine tab 200mg 2 GC MO lamotrigine tab 200mg 3 MO lamotrigine tab 200mg er 2 GC MO lamotrigine tab 250mg er 2 GC MO lamotrigine tab 25mg 2 GC MO lamotrigine tab 25mg er 2 GC MO lamotrigine tab 25mg odt 3 MO lamotrigine tab 300mg er 2 GC MO lamotrigine tab 50mg er 2 GC MO lamotrigine tab 50mg odt 3 MO QUDEXY XR CAP 100/24HR 2 MO QUDEXY XR CAP 150/24HR 2 MO QUDEXY XR CAP 200/24HR 2 MO QUDEXY XR CAP 25/24HR 2 MO QUDEXY XR CAP 50/24HR 2 MO topiramate cap 15mg 1 GC MO topiramate cap 25mg 1 GC MO TOPIRAMATE CAP ER 100MG 2 MO TOPIRAMATE CAP ER 150MG 2 MO TOPIRAMATE CAP ER 200MG 2 MO TOPIRAMATE CAP ER 25MG 2 MO TOPIRAMATE CAP ER 50MG 2 MO topiramate tab 100mg 1 GC MO topiramate tab 200mg 1 GC MO topiramate tab 25mg 1 GC MO topiramate tab 50mg 1 GC MO TROKENDI XR CAP 100MG 2 MO TROKENDI XR CAP 200MG 2 MO TROKENDI XR CAP 25MG 2 MO TROKENDI XR CAP 50MG 2 MO Sodium Channel Agents (SEIZURE CONTROL DRUGS) APTIOM TAB 200MG 3 MO APTIOM TAB 400MG 4 APTIOM TAB 600MG 4 APTIOM TAB 800MG 4 BANZEL SUS 40MG/ML 4 BANZEL TAB 200MG 3 MO BANZEL TAB 400MG 4 carbamazepin cap 100mg er 1 GC MO carbamazepin chw 100mg 1 GC MO carbamazepin sus 100mg/5ml 1 GC MO carbamazepin tab 200mg 1 GC MO carbamazepin tab 200mg er 1 GC MO carbamazepin tab 400mg er 1 GC MO CEREBYX INJ 500/10ML 3 MO epitol tab 200mg 1 GC MO fosphenytoin inj 100mg/2ml 2 GC MO oxcarbazepin sus 300mg/5m 2 GC MO 11

20 oxcarbazepin tab 150mg 2 GC MO oxcarbazepin tab 300mg 2 GC MO oxcarbazepin tab 600mg 2 GC MO OXTELLAR XR TAB 150MG 2 MO OXTELLAR XR TAB 300MG 2 MO OXTELLAR XR TAB 600MG 2 MO PEGANONE TAB 250MG 3 MO phenytoin chw 50mg 2 GC MO phenytoin ex cap 100mg 2 GC MO phenytoin ex cap 200mg 2 GC MO phenytoin ex cap 300mg 2 GC MO phenytoin inj 50mg/ml 1 GC MO phenytoin sus 125mg/5ml 2 GC MO TEGRETOL XR TAB 100MG 3 MO VIMPAT INJ 200MG/20ML 3 MO VIMPAT SOL 10MG/ML 3 MO VIMPAT TAB 100MG 3 MO VIMPAT TAB 150MG 3 MO VIMPAT TAB 200MG 3 MO VIMPAT TAB 50MG 3 MO ANTIDEMENTIA AGENTS (NERVE CONDITION DRUGS) Antidementia Agents, Other (ALZEIMER'S AND DEMENTIA DRUGS) ergoloid mes tab 1mg oral 2 GC MO Cholinesterase Inhibitors (ALZEIMER'S AND DEMENTIA DRUGS) ARICEPT TAB 23MG 2 MO donepezil tab 10mg 2 GC MO donepezil tab 10mg odt 2 GC MO donepezil tab 5mg 2 GC MO donepezil tab 5mg odt 2 GC MO donepezil tab hcl 23mg 2 GC MO galantamine cap 16mg er 2 GC MO galantamine cap 24mg er 2 GC MO galantamine cap 8mg er 2 GC MO galantamine tab 12mg 2 GC MO galantamine tab 4mg 2 GC MO galantamine tab 8mg 2 GC MO memant titra pak 5-10mg 2 GC MO rivastigmine cap 1.5mg 2 GC MO rivastigmine cap 3mg 2 GC MO rivastigmine cap 4.5mg 2 GC MO rivastigmine cap 6mg 2 GC MO N-methyl-D-aspartate (NMDA) Receptor Antagonist (ALZEIMER'S AND DEMENTIA DRUGS) NAMENDA SOL 10MG/5ML 2 MO NAMENDA XR CAP 14MG 3 MO NAMENDA XR CAP 21MG 3 MO NAMENDA XR CAP 28MG 3 MO NAMENDA XR CAP 7MG 3 MO NAMENDA XR CAP TITRATION 3 MO ANTIDEPRESSANTS (NERVE CONDITION DRUGS) 12

21 Antidepressants, Other (DEPRESSION DRUGS) APLENZIN TAB 174MG 3 MO APLENZIN TAB 348MG 3 MO BRINTELLIX TAB 10MG 3 ST MO BRINTELLIX TAB 20MG 3 ST MO BRINTELLIX TAB 5MG 3 ST MO bupropion hcl tab 300mg xl 1 GC MO bupropion tab 100mg 1 GC MO bupropion tab 100mg sr 1 GC MO bupropion tab 150mg sr 1 GC MO bupropion tab 200mg sr 1 GC MO bupropion tab 75mg 1 GC MO maprotiline tab 25mg 1 GC MO maprotiline tab 50mg 2 GC MO maprotiline tab 75mg 1 GC MO mirtazapine tab 15mg 1 GC MO mirtazapine tab 15mg odt 2 GC MO mirtazapine tab 30mg 2 GC MO mirtazapine tab 30mg odt 2 GC MO mirtazapine tab 45mg 2 GC MO mirtazapine tab 45mg odt 2 GC MO mirtazapine tab 7.5mg 2 GC MO nefazodone tab 100mg 2 GC MO nefazodone tab 150mg 2 GC MO nefazodone tab 200mg 2 GC MO nefazodone tab 250mg 2 GC MO nefazodone tab 50mg 1 GC MO trazodone tab 100mg 1 GC MO trazodone tab 150mg 1 GC MO trazodone tab 300mg 2 GC MO trazodone tab 50mg 1 GC MO VIIBRYD KIT 2 MO VIIBRYD TAB 10MG 2 MO VIIBRYD TAB 20MG 2 MO VIIBRYD TAB 40MG 2 MO Monoamine Oxidase Inhibitors (DEPRESSION DRUGS) EMSAM DIS 12MG/24H 4 EMSAM DIS 6MG/24HR 4 EMSAM DIS 9MG/24HR 4 MARPLAN TAB 10MG 3 MO phenelzine tab 15mg 2 GC MO tranylcyprom tab 10mg 2 GC MO Serotonin/Norepinephrine Reuptake Inhibitors (DEPRESSION DRUGS) BRISDELLE CAP 7.5MG 3 MO citalopram sol 10mg/5ml 1 GC MO citalopram tab 10mg 1 GC MO citalopram tab 20mg 1 GC MO citalopram tab 40mg 1 GC MO desvenlafaxine tab 100mg er 2 GC MO 13

22 desvenlafaxine tab 50mg er 2 GC MO duloxetine cap 20mg 2 GC MO duloxetine cap 30mg 2 GC MO DULOXETINE CAP 40MG 3 MO duloxetine cap 60mg 2 GC MO escitalopram sol 5mg/5ml 2 GC MO escitalopram tab 10mg 2 GC MO escitalopram tab 20mg 2 GC MO escitalopram tab 5mg 2 GC MO FETZIMA CAP 120MG 2 MO FETZIMA CAP 20MG 2 MO FETZIMA CAP 40MG 2 MO FETZIMA CAP 80MG 2 MO FETZIMA CAP TITRATIO 3 MO fluoxetine cap 10mg 1 GC MO fluoxetine cap 20mg 1 GC MO fluoxetine cap 40mg 1 GC MO fluoxetine sol 20mg/5ml 1 GC MO fluoxetine tab 10mg 1 GC MO fluoxetine tab 20mg 1 GC MO FLUOXETINE TAB 60MG 1 MO fluvoxamine cap 100mg er 2 GC MO fluvoxamine cap 150mg er 2 GC MO fluvoxamine tab 100mg 2 GC MO fluvoxamine tab 25mg 2 GC MO fluvoxamine tab 50mg 2 GC MO FORFIVO XL TAB 450MG 2 MO IRENKA CAP 40MG 3 ST MO KHEDEZLA TAB 100MG ER 2 MO KHEDEZLA TAB 50MG ER 2 MO paroxetin er tab 12.5mg 2 GC MO paroxetine tab 10mg 1 GC MO paroxetine tab 20mg 1 GC MO paroxetine tab 25mg er 2 GC MO paroxetine tab 30mg 1 GC MO paroxetine tab 40mg 1 GC MO PAXIL SUS 10MG/5ML 3 MO PRISTIQ TAB 100MG 3 MO PRISTIQ TAB 25MG 3 MO PRISTIQ TAB 50MG 3 MO sertraline con 20mg/ml 1 GC MO sertraline tab 100mg 1 GC MO sertraline tab 25mg 1 GC MO sertraline tab 50mg 1 GC MO venlafaxine cap 150mg er 1 GC MO venlafaxine cap 37.5mg 1 GC MO venlafaxine cap 75mg er 1 GC MO venlafaxine tab 100mg 1 GC MO venlafaxine tab 150mg er 1 GC MO 14

23 venlafaxine tab 225mg er 1 GC MO venlafaxine tab 25mg 1 GC MO venlafaxine tab 37.5 er 1 GC MO venlafaxine tab 37.5mg 1 GC MO venlafaxine tab 50mg 1 GC MO venlafaxine tab 75mg 1 GC MO venlafaxine tab 75mg er 1 GC MO Serotonin/Norepinephrine Reuptake Inhibitors (MOOD DISORDER DRUGS) olanza/fluox cap 12-25mg 2 GC MO olanza/fluox cap 12-50mg 2 GC MO olanza/fluox cap 3-25mg 2 GC MO olanza/fluox cap 6-25mg 2 GC MO olanza/fluox cap 6-50mg 2 GC MO Tricyclics (DEPRESSION DRUGS) amitriptyline tab 100mg 1 PA GC MO amitriptyline tab 10mg 1 PA GC MO amitriptyline tab 150mg 1 PA GC MO amitriptyline tab 25mg 1 PA GC MO amitriptyline tab 50mg 1 PA GC MO amitriptyline tab 75mg 1 PA GC MO amoxapine tab 100mg 2 GC MO amoxapine tab 150mg 1 GC MO amoxapine tab 25mg 1 GC MO amoxapine tab 50mg 1 GC MO cdp/amitrip tab 10-25mg 1 PA GC MO cdp/amitrip tab mg 1 PA GC MO clomipramine cap 25mg 2 PA GC MO clomipramine cap 50mg 2 PA GC MO clomipramine cap 75mg 2 PA GC MO desipramine tab 100mg 2 GC MO desipramine tab 10mg 2 GC MO desipramine tab 150mg 2 GC MO desipramine tab 25mg 2 GC MO desipramine tab 50mg 2 GC MO desipramine tab 75mg 1 GC MO doxepin hcl cap 100mg 1 PA GC MO doxepin hcl cap 10mg 1 PA GC MO doxepin hcl cap 150mg 2 PA GC MO doxepin hcl cap 25mg 1 PA GC MO doxepin hcl cap 50mg 1 PA GC MO doxepin hcl cap 75mg 1 PA GC MO doxepin hcl con 10mg/ml 1 PA GC MO imipramine hcl tab 10mg 2 PA GC MO imipramine hcl tab 25mg 2 PA GC MO imipramine hcl tab 50mg 2 PA GC MO imipramine pam cap 100mg 2 PA GC MO imipramine pam cap 125mg 2 PA GC MO imipramine pam cap 150mg 2 PA GC MO imipramine pam cap 75mg 2 PA GC MO 15

24 NORTRIPTYLIN SOL 10MG/5ML 2 MO nortriptyline cap 10mg 1 GC MO nortriptyline cap 25mg 1 GC MO nortriptyline cap 50mg 2 GC MO nortriptyline cap 75mg 2 GC MO protriptyline tab 10mg 2 GC MO protriptyline tab 5mg 2 GC MO SURMONTIL CAP 100MG 3 PA MO SURMONTIL CAP 25MG 3 PA MO SURMONTIL CAP 50MG 3 PA MO ANTIEMETICS (BOWEL, INSTESTINE, AND STOMACH CONDITION DRUGS) Antiemetics, Other (NAUSEA AND VOMITING DRUGS) meclizine tab 12.5mg 1 GC MO meclizine tab 25mg 1 GC MO TRANSDERM-SC DIS 1.5MG 2 MO Emetogenic Therapy Adjuncts (NAUSEA AND VOMITING DRUGS) dronabinol cap 10mg 4 QL 60 BD dronabinol cap 2.5mg 2 QL 60 GC MO BD dronabinol cap 5mg 2 QL 60 GC MO BD EMEND CAP 125MG 2 QL 30 MO BD EMEND CAP 40MG 2 QL 30 MO BD EMEND CAP 80MG 3 QL 30 MO BD EMEND PAK 80 & 125MG 3 QL 12 MO BD granisetron inj 0.1mg/ml 2 QL 60 GC MO BD granisetron inj 1mg/ml 2 QL 60 GC MO BD granisetron tab 1mg 2 QL 60 GC MO BD ondansetron inj 4mg/2ml 2 GC MO BD ondansetron inj 4mg/2ml 2 QL 160 GC MO BD ondansetron sol 4mg/5ml 2 QL 900 GC MO BD ondansetron tab 24mg 2 QL 30 GC MO BD ondansetron tab 4mg 2 QL 60 GC MO BD ondansetron tab 4mg odt 2 QL 60 GC MO BD ondansetron tab 8mg 2 QL 60 GC MO BD ondansetron tab 8mg odt 2 QL 60 GC MO BD ANTIFUNGALS (DRUGS FOR THE MOUTH) Antifungals (MOUTH/THROAT/DENTAL DRUGS) clotrimazole troche 10mg 2 GC MO ANTIFUNGALS (INFECTION FIGHTING DRUGS) Antifungals (FUNGUS INFECTION DRUGS) ABELCET INJ 5MG/ML 4 ANTIFUNGALS (FUNGUS INFECTION DRUGS) AMBISOME INJ 50MG 3 MO Antifungals (FUNGUS INFECTION DRUGS) amphotericin b inj 50mg 2 GC MO CANCIDAS INJ 50MG 4 CANCIDAS INJ 70MG 4 ERAXIS INJ 100MG 3 MO fluconazole sus 10mg/ml 2 GC MO fluconazole sus 40mg/ml 2 GC MO 16

25 fluconazole tab 100mg 2 GC MO fluconazole tab 150mg 1 GC MO fluconazole tab 200mg 2 GC MO fluconazole tab 50mg 2 GC MO fluconazole/dex inj 400mg 2 GC MO flucytosine cap 250mg 4 flucytosine cap 500mg 4 griseofulvin sus 125mg/5ml 1 GC MO itraconazole cap 100mg 2 GC MO ketoconazole tab 200mg 2 GC MO MYCAMINE INJ 100MG 4 MYCAMINE INJ 50MG 3 MO NOXAFIL SUS 40MG/ML 4 NOXAFIL TAB 100MG 4 nystatin tab unit 2 GC MO voriconazole inj 200mg 3 MO voriconazole tab 200mg 4 voriconazole tab 50mg 4 ANTIGOUT AGENTS (PAIN, INFLAMMATION, MUSCLE, JOINT CONDITION DRUGS) Antigout Agents (GOUT DRUGS) allopurinol tab 100mg 1 GC MO allopurinol tab 300mg 1 GC MO COLCHICINE CAP 0.6MG 2 MO COLCHICINE TAB 0.6MG 2 MO probenecid tab 500mg 2 GC MO ULORIC TAB 40MG 2 ST MO ULORIC TAB 80MG 2 ST MO ANTIMIGRAINE AGENTS (NERVE CONDITION DRUGS) Ergot Alkaloids (MIGRAINE DRUGS) dihydroergot inj 1mg/ml 2 GC MO ERGOMAR SUB 2MG 2 MO Prophylactic (MIGRAINE PREVENTION) divalproex tab 250mg er 2 GC MO divalproex tab 500mg er 2 GC MO timolol mal tab 10mg 1 GC MO timolol mal tab 20mg 1 GC MO timolol mal tab 5mg 1 GC MO valproic acd syp 250mg/5ml 2 GC MO Serotonin (5-HT) 1b/1d Receptor Agonists (MIGRAINE DRUGS) naratriptan tab 1mg 2 QL 9 GC MO naratriptan tab 2.5mg 2 QL 9 GC MO sumatriptan inj 6mg/0.5ml 2 QL 10 GC MO sumatriptan pfs 6mg/0.5ml 2 QL 4.5 GC MO sumatriptan tab 100mg 2 QL 9 GC MO sumatriptan tab 25mg 2 QL 9 GC MO sumatriptan tab 50mg 2 QL 9 GC MO ANTIMYASTHENIC AGENTS (NERVE CONDITION DRUGS) Parasympathomimetics (MISCELLANEOUS NERVE CONDITION DRUGS) GUANIDINE TAB 125MG 2 MO 17

26 MESTINON SYP 60MG/5ML 3 MO pyridostigme tab 60mg 2 GC MO ANTIMYCOBACTERIALS (INFECTION FIGHTING DRUGS) Antimycobacterials, Other (MISCELLANEOUS INFECTION FIGHTING DRUGS) dapsone tab 100mg 2 GC MO dapsone tab 25mg 2 GC MO MYAMBUTOL TAB 400MG 2 MO Antituberculars (TUBERCULOSIS DRUGS) CAPASTAT SUL INJ 1GM 3 MO ethambutol tab 100mg 2 GC MO ethambutol tab 400mg 2 GC MO isoniazid inj 100mg/ml 1 GC MO isoniazid syp 50mg/5ml 1 GC MO isoniazid tab 100mg 1 GC MO isoniazid tab 300mg 1 GC MO PASER GRANULES 4GM 3 MO PRIFTIN TAB 150MG 3 MO pyrazinamide tab 500mg 2 MO rifabutin cap 150mg 2 GC MO rifampin cap 150mg 1 GC MO rifampin cap 300mg 2 GC MO rifampin inj 600 mg 1 GC MO RIFATER TAB 3 MO SIRTURO TAB 100MG 4 TRECATOR TAB 250MG 3 MO ANTINEOPLASTICS (CANCER DRUGS) Alkylating Agents (CHEMOTHERAPY DRUGS) BICNU INJ 100MG 3 MO BD BUSULFEX INJ 6MG/ML 4 BD carboplatin inj 150/15ml 2 GC MO BD cisplatin inj 100mg 2 GC MO BD GLEOSTINE CAP 100MG 3 MO GLEOSTINE CAP 10MG 3 MO GLEOSTINE CAP 40MG 3 MO HEXALEN CAP 50MG 4 IFEX INJ 3GM 3 MO BD ifosfamide inj 1gm 2 GC MO BD LEUKERAN TAB 2MG 2 MO lomustine cap 100mg 2 GC MO lomustine cap 10mg 2 GC MO lomustine cap 40mg 2 GC MO melphalan inj 50mg 4 BD MUSTARGEN INJ 10MG 4 BD oxaliplatin inj 100mg 4 BD TREANDA INJ 100MG 4 BD TREANDA INJ 45/0.5ML 4 ZANOSAR INJ 1GM 4 BD Antiangiogenic Agents (CHEMOTHERAPY DRUGS) AVASTIN INJ 100MG/4ML 4 18

27 AVASTIN INJ 400/16ML 3 MO CYRAMZA INJ 100/10ML 4 BD CYRAMZA INJ 500/50ML 4 BD DEPEN TITRA TAB 250MG 4 REVLIMID CAP 10MG 4 LA REVLIMID CAP 15MG 4 LA REVLIMID CAP 2.5MG 4 LA REVLIMID CAP 20MG 4 REVLIMID CAP 25MG 4 LA REVLIMID CAP 5MG 4 LA SYPRINE CAP 250MG 4 THALOMID CAP 100MG 4 THALOMID CAP 150MG 4 THALOMID CAP 200MG 4 THALOMID CAP 50MG 4 Antimetabolites (CHEMOTHERAPY DRUGS) adrucil inj 500/10ml 3 MO BD ALIMTA INJ 500MG 4 ARRANON INJ 5MG/ML 4 BD azacitidine inj 100mg 4 cladribine inj 1mg/ml 4 BD CLOLAR INJ 1MG/ML 4 BD cytarabine inj 100mg/ml 2 GC MO BD cytarabine inj 20mg/ml 2 GC MO BD DACOGEN INJ 50MG 4 decitabine inj 50mg 2 GC MO fludarabine inj 50mg 2 GC MO fluorouracil inj 2.5g/50ml 2 GC MO BD FOLOTYN INJ 40MG/2ML 4 BD gemcitabine inj 1gm 4 mercaptopurine tab 50mg 2 GC MO methotrexate inj 1gm 1 GC MO BD methotrexate inj 25mg/ml 1 GC MO BD methotrexate tab 2.5mg 1 GC MO BD PURIXAN SUS 20MG/ML 3 MO TABLOID TAB 40MG 3 MO Antineoplastics (Miscellaneous CHEMOTHERAPY DRUGS) ABRAXANE INJ 100MG 4 BD ACTIMMUNE INJ 2MU/0.5ML 4 LA AFINITOR DIS TAB 2MG 4 AFINITOR DIS TAB 3MG 4 AFINITOR DIS TAB 5MG 4 AFINITOR TAB 10MG 4 AFINITOR TAB 2.5MG 4 AFINITOR TAB 5MG 4 AFINITOR TAB 7.5MG 4 amifostine inj 500mg 4 BD ARZERRA CON 100/5ML 4 BD BELEODAQ INJ 500MG 4 19

28 bexarotene cap 75mg 4 PA bicalutamide tab 50mg 2 GC MO bleomycin inj 30unit 2 GC MO BOSULIF TAB 100MG 4 PA BOSULIF TAB 500MG 4 PA CAPRELSA TAB 100MG 4 CAPRELSA TAB 300MG 4 COMETRIQ KIT 100MG 4 COMETRIQ KIT 140MG 4 COMETRIQ KIT 60MG 4 COSMEGEN INJ 0.5MG 3 MO BD dacarbazine inj 200mg 2 GC MO BD daunorubicin inj 5mg/ml 2 GC MO BD DAUNOXOME INJ 2MG/ML 4 BD DEPO-PROVERA INJ 400/ML 3 MO BD dexrazoxane inj 500mg 4 BD DOCEFREZ INJ 20MG 4 BD DOCETAXEL INJ 80MG/4ML 4 DOCETAXEL INJ 80MG/8ML 4 DOXIL INJ 2MG/ML 4 BD doxorubicin inj 50mg 2 GC MO BD ELITEK INJ 1.5MG 4 BD ELLENCE INJ 2MG/ML 3 MO BD EMCYT CAP 140MG 3 MO epirubicin inj 50/25ml 2 GC MO BD ERIVEDGE CAP 150MG 4 ERWINAZE INJ 10000UNT 4 PA ETOPOPHOS INJ 100MG 3 MO BD etoposide inj 20mg/ml 2 GC MO BD FARESTON TAB 60MG 4 FARYDAK CAP 10MG 4 PA FARYDAK CAP 15MG 4 PA FARYDAK CAP 20MG 4 PA FASLODEX INJ 250MG/5ML 4 BD FIRMAGON INJ 120MG 4 BD FIRMAGON INJ 80MG 3 MO BD flutamide cap 125mg 2 GC MO GILOTRIF TAB 20MG 4 PA GILOTRIF TAB 30MG 4 PA GILOTRIF TAB 40MG 4 PA GLEEVEC TAB 100MG 4 GLEEVEC TAB 400MG 4 HALAVEN INJ 1MG/2ML 4 HERCEPTIN INJ 440MG 4 BD hydroxyurea cap 500mg 2 GC MO IBRANCE CAP 100MG 4 PA IBRANCE CAP 125MG 4 PA IBRANCE CAP 75MG 4 PA ICLUSIG TAB 15MG 4 PA 20

29 ICLUSIG TAB 45MG 4 PA IDAMYCIN PFS INJ 20/20ML 3 MO BD idarubicin inj 10/10ml 4 BD IMBRUVICA CAP 140MG 4 PA INLYTA TAB 1MG 4 INLYTA TAB 5MG 4 INTRON A INJ 18MU 3 MO INTRON A INJ 50MU 3 MO INTRON-A INJ 10MU 4 INTRON-A INJ 18MU 4 irinotecan inj 100/5ml 4 BD ISTODAX INJ 10MG 4 IXEMPRA KIT INJ 45MG 4 BD JAKAFI TAB 10MG 4 JAKAFI TAB 15MG 4 JAKAFI TAB 20MG 4 JAKAFI TAB 25MG 4 JAKAFI TAB 5MG 4 JEVTANA INJ 60/1.5ML 4 BD KEPIVANCE INJ 6.25MG 4 BD KEYTRUDA INJ 100MG/4M 4 PA KEYTRUDA SOL 50MG 4 PA LENVIMA CAP 10MG 4 LENVIMA CAP 14MG 4 LENVIMA CAP 20MG 4 LENVIMA CAP 24MG 4 leucovorin ca inj 100mg 2 GC MO BD leucovorin ca inj 350mg 2 GC MO BD leucovorin ca tab 10mg 2 GC MO leucovorin ca tab 15mg 2 GC MO leucovorin ca tab 25mg 2 GC MO leucovorin ca tab 5mg 2 GC MO leuprolide inj 1mg/0.2ml 2 GC MO LEVOLEUCOVOR INJ 50MG 3 MO BD LUPRON DEPOT INJ 22.5MG 4 LUPRON DEPOT INJ 3.75MG 4 LUPRON DEPOT INJ 30MG 4 LUPRON DEPOT INJ 45MG 4 LUPRON DEPOT INJ 7.5MG 4 LYNPARZA CAP 50MG 4 PA LYSODREN TAB 500MG 2 MO MATULANE CAP 50MG 4 megestrol ace sus 40mg/ml 1 PA GC MO megestrol acetate tab 20mg 1 PA GC MO megestrol acetate tab 40mg 1 PA GC MO MEKINIST TAB 0.5MG 4 LA MEKINIST TAB 2MG 4 LA mesna inj 1gm 2 GC MO BD MESNEX TAB 400MG 3 MO 21