CPL

2020 綜合處方一覽表 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) Centers Plan for Medicaid Advantage Plus (HMO SNP) 本處方一覽表更新於 03/2020 如需獲得更多最新資訊, 或者如果您有其他問題, 敬請致電以下電話, 聯絡 Centers Plan for Healthy Living:-877-940-9330, 聽力障礙電傳使用者請致電 :-800-42-220, 工作時間為 : 每週 7 天, 早 8 點至晚 8 點, 或者請瀏覽 :www.centersplan.com H6988_ENR085_C

Language Assistance Services Notification English Albanian Arabic Bengali ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call -877-940-9330 (TTY: -800-42-220). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në -877-940-9330 (TTY: -800-42-220). ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم 877-940- 9330 (رقم ھاتف الصم والبكم: 800-42-220- (. ল য কর ন য দ আপ ন ব ল, কথ বল ত প রন, ত হ ল ন খরচ য় ভ ষ সহ য়ত প র ষব উপল আ ছ ফ ন কর ন ১-877-940-9330 (TTY: ১-800-42-220) Chinese French Greek French Creole Italian 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 -877-940-9330 (TTY:-800-42-220) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le -877-940-9330 (ATS : -800-42-220). ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε -877-940-9330 (TTY: -800-42-220). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele -877-940-9330 (TTY: -800-42-220). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero -877-940-9330 (TTY: -800-42-220). Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. -877-940-9330 (TTY: -800-42-220) 번으로전화해주십시오. Polish Russian Spanish Tagalog Urdu Yiddish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer -877-940-9330 (TTY: -800-42-220). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните -877-940-9330 (телетайп: -800-42-220). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al -877-940-9330 (TTY: -800-42-220). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa -877-940-9330 (TTY: -800-42-220). خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کریں --877 940-9330 (TTY: -800-42-220). אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט -800-42-220) (TTY: -877-940-9330. H6988_MKT4036 Accepted 08208

Discrimination is Against the Law Notice of Nondiscrimination Centers Plan for Healthy Living, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Centers Plan for Healthy Living, LLC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Centers Plan for Healthy Living, LLC provides: Free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Member/Participant Services at -844-274-5227 (TTY users please call -800-42-220 or 7). If you believe that Centers Plan for Healthy Living, LLC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Grievances and Appeals Department: By Mail: Centers Plan for Healthy Living, LLC Attn: G&A Department 75 Vanderbilt Avenue Staten Island, NY 0304-2604 By Phone: -844-274-5227 (TTY users call -800-42-220) By Fax: -347-505-7089 By Email: GandA@centersplan.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Member/Participant Services is available to help you seven days a week from 8am to 8pm. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 2020-800-368-09, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. H6988_NMKT3035 Accepted 08206

Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) Centers Plan for Medicaid Advantage Plus (HMO SNP) 2020 處方一覽表 ( 承保藥品清單 ) CPHL 2020 處方一覽表 ID:20005, 版本 2 請閱讀 : 本文件含有關於本計劃承保藥品的相關資訊 本處方一覽表更新於 03/0/2020 如需獲得更多最新資訊, 或者您有其他問題, 敬請致電以下電話, 聯絡 Centers Plan for Healthy Living:-877-940-9330, 聽力障礙電傳使用者請致電 : -800-42-220, 工作時間為 : 週一至週日, 早上 8 點至晚上 8 點, 或者請瀏覽 www.centersplan.com 現有成員注意 : 此處方一覽表自去年以來發生了變更 請閱覽此文件, 確保處方一覽表仍然包含您服用的藥品 本藥品清單 ( 處方一覽表 ) 中的 我們 或 我們的 指代 Centers Plan for Healthy Living 其中的 計劃 或 我們的計劃 指代 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 及 Centers Plan for Medicaid Advantage Plus (HMO SNP) 本文件包含一份用於我們計劃的藥品清單 ( 處方一覽表 ), 最後更新日期為 03/0/2020 如需獲得最新處方一覽表, 請聯絡我們 我們的聯絡方式和處方一覽表最新更新日期會分別出現在封面和封底 一般情況下, 您必須使用網絡內藥店來使用您的處方藥福利 福利 處方一覽表 藥店網絡和 / 或自付費用 / 共同保險費可能會在 202 年 2 月 日發生變更, 並在年度內多次發生變更 H6988_ENR085_C I

什麼是 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 及 Centers Plan for Medicaid Advantage Plus (HMO SNP) 處方一覽表? 處方一覽表是 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 在諮詢醫療保健提供者團隊後選擇的承保藥品清單, 這個清單上列出了有效的治療計劃所必需的處方療法 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 一般會承保處方一覽表內列出的藥品, 只要這些藥品屬於醫療必需藥品, 且處方由 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 網絡內的藥房開出, 也符合其他的計劃規則 如想獲得關於如何開處方藥的更多資訊, 請查閱您的承保福利說明 處方一覽表 ( 藥品清單 ) 會發生變更嗎? 大部分藥物承保變更發生在 月 日, 但我們可能於年中新增或移除藥品清單中的藥品, 將它們移至不同的分攤費用等級, 或者新增限制 當年可影響您的變更 : 在以下案例中, 您將因年中的承保變更受到影響 : 新普通藥品 如果我們用一種新的 位於相同或較低費用分擔層級的 具有相同或更少限制的普通藥品替代某種品牌藥品, 我們可立即將該品牌藥品從我們的藥品清單上移除 此外, 在添加新普通藥品時, 我們可能會決定將品牌藥品保留在我們的藥品清單中, 但會立即將其移至另外一個費用分擔層級或添加新的限制 如果您目前正在服用該品牌藥品, 我們可能不會在進行變更之前提前告知您, 但我們之後會向您提供有關我們所做出的具體變更的資訊 o 如果我們做出這樣的變更, 您或您的處方醫生可以要求我們例外對待並繼續為您承保品牌藥品 我們為您提供的通知還包括如何申請特例對待, 您還可以在下面標題為 如何申請 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 及 Centers Plan for Medicaid Advantage Plus (HMO SNP) 處方一覽表特例? 部分中找到相關資訊 退市的藥品 如果食品與藥品管理局裁定我們處方一覽表上的一種藥品不安全或此藥品的製造商將藥品撤出市場, 我們會立即將此藥品從我們的處方一覽表上移除並通知服用此藥品的會員 其他變動 我們可能會進行影響目前服用藥品的會員的其他變動 例如, 我們可能會添加一種非新上市的普通藥品來替代目前處方一覽表中的品牌藥品, 或者對品牌藥品增加新的限制或將其轉移到另外一個費用分擔層級 或者我們可以根據新的臨床指導原則進行變更 如果我們將藥品從處方一覽表中移除, 增加了一種藥品的事前核准 數量限制以和 / 或者逐步治療限制, 或將一種藥品移至更高的分攤費用等級, 我們必須在變更生效前至少 30 天內通知受影響的會員這一變更情況, 或在會員要求續開藥品時進行通知, 在這種情況下, 此會員將獲得 30 天的藥品供應量 o 如果我們作出這樣的變更, 您或您的處方醫生可以要求我們特例對待並繼續為您承保品牌藥品 我們為您提供的通知還包括如何申請特例對待, 您還可以在下面標題為 如何申請 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing H6988_ENR085_C II

Home Care (HMO SNP) 及 Centers Plan for Medicaid Advantage Plus (HMO SNP) 處方一覽表特例? 部分中找到相關資訊 如果您正在服藥, 此變更不會影響到您 一般而言, 如果您正在服用 2020 處方一覽表中年初承保的藥品, 除上述情況之外, 我們在 2020 保險年內不會停止或減少藥品的承保 意思是正在服用這些藥品的會員能夠在該保險年的剩餘時間以相同的分攤費用獲得該藥品, 而沒有新的限制 隨信附上的處方一覽表最後更新日期為 03/0/2020 如需獲得 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 承保藥品的最新資訊, 請聯絡我們 我們的聯絡資料在封面和封底 如何使用處方一覽表? 有兩個方法可以在處方一覽表中尋找您的藥品 : 身體狀況 處方一覽表從第 3 頁開始 此處方一覽表中的藥品根據它們用於治療的醫療狀況類型劃分為不同種類 例如, 用於治療心臟狀況的藥品被列於 心血管藥物 種類之下 如果您知道自己藥品的作用, 則可從第 頁開始的清單中查詢種類名稱 然後在這一種類下方查詢您的藥品 字母排列 如果您不確定應該在哪個種類下方查詢, 您應該在從第 I- 頁開始的索引中尋找您的藥品 索引提供了一份清單, 將本文件包含的所有藥品按照字母順序進行排列 品牌藥品和普通藥品都列於此索引之中 查詢索引, 找到您的藥品 在您的藥品旁邊, 您將看到承保資訊所在頁面的頁碼 翻至索引中所列頁面, 並在清單第一欄找到您的藥品名稱 什麼是普通藥物? Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 承保品牌藥品和普通藥品 普通藥品是通過 FDA 審核的與品牌藥品具有相同活性成分的藥品 一般情況下, 普通藥品的費用比品牌藥品低 我的受保範圍是否有約束或限制? 部分承保藥品可能有額外承保要求或限制 這些要求和限制可能包括 : 事前核准 :Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 要求您或您的醫生為某些藥品獲得事前核准 意思是您領取處方藥之前需要獲得 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 的核准 如果您未獲得核准,Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 可能不承保此藥品 H6988_ENR085_C III

數量限制 : 對於一些藥品,Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 會限制 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 將承保的藥量 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 將 sumatriptan 的單次處方量限制為 2 片 這可能是對一個月或三個月標準供應藥量的補充 分步治療 : 在某些情況下,Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 會要求您在承保治療您所患病症的另一種藥品前, 先試用其他藥品 例如, 如果藥品 A 和藥品 B 都可治療您的疾病,Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 可能會要求您先試用藥品 A, 否則就不承保藥品 B 如果藥品 A 對您無效, 則 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 將承保藥品 B 如想了解您的藥品是否有其他額外要求或限制, 您可從第 3 頁開始檢視處方一覽表 您也可以瀏覽我們的網站, 瞭解有關特定承保藥品所受約束的詳細資訊 我們已在網上發佈文件, 解釋我們的核准和逐步治療限制 您也可以要求我們向您傳送一份副本 我們的聯絡方式和處方一覽表最新更新日期會分別出現在封面和封底 您可以要求 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 對這些約束和限制作出特例處理, 或對可能治療您的健康狀況的其他類似藥品清單作出特例處理 參見第 VI 頁的 如何申請 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 處方一覽表特例? 部分, 了解請求特例處理的方法 如果我的藥品未納入此處方一覽表該怎麼辦? 如果您的藥品未納入此處方一覽表 ( 承保藥品清單 ), 您首先應該聯絡會員服務部, 詢問您的藥品是否在承保範圍內 如果您了解到 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 不承保您的藥品, 則您有兩個選項 : 您可以向會員服務部索取一份 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 承保的類似藥品清單 當您收到這份清單之後, 將其交給您的醫生查看並要求醫生開一種 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 可以承保的同類藥品 您還可以向 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 請求特例處理並要求承保您的藥品 參見下方資訊, 了解如何請求特例處理 H6988_ENR085_C IV

如何申請 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 處方一覽表特例? 您可以向 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 請求求對我們的承保規則進行特例處理 您可以向我們請求進行幾類特例處理 即使一種藥品不在我們的處方一覽表之上, 您也可以向我們請求承保此藥品 如果請求被核准, 此藥品將以事先決定的費用分攤水準被承保, 而您無法要求我們提供更低的費用分攤水準 您能夠請求我們以更低的費用分攤水準承保一種處方藥品, 前提為這種藥物不屬於專業級藥品 如果請求被核准, 這將降低您必須支付的藥品費用 您可以向我們請求撤銷對您的藥品承保約束或限制 例如, 對於某些藥品,Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 限制我們承保的數量 如果您的藥品有藥量限制, 您可以向我們請求撤銷此限制並承保更大藥量 一般情況下, 只有當計劃處方一覽表上包含的替代藥品 分攤費用更低的藥品或額外使用約束限制對您的治療效果不佳以及 / 或者可能對您產生副作用,Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 才會核准您的特例請求 您應該聯絡我們, 要求獲得一份有關處方一覽表或使用限制特例的初始保險決定 當您請求一份處方一覽表或使用約束特例時, 您應該提交一份您的開藥醫生或醫師出具的支持您請求的聲明 一般情況下, 我們必須在收到您的開藥醫生出具的支持性聲明後的 72 小時內作出決定 如果您或您的醫生認為等待 72 小時才能裁定可能會對您的健康造成嚴重傷害, 您可以請求加急 ( 快速 ) 特例 如果您的加急請求得到許可, 我們必須在收到您的醫生或其他開藥醫生出具的支持性聲明的 24 小時之內告知您我們的決定 在我能夠和我的醫生討論變更我的藥品或請求特例之前我應該做什麼? 作為我們的計劃的新會員或持續會員, 您可能正在服用不在我們的處方一覽表上的藥品 或者, 您可能正在服用我們處方一覽表上的藥品, 但您獲得該藥品的能力受限 例如, 在開處方藥之前, 您可能需要得到我們的事前核准 您應該向您的醫生諮詢, 確認您是否應該更換為我們承保的合適藥品, 或請求處方一覽表特例處理, 要求我們承保您服用的藥品 在您向您的醫生諮詢並決定正確的處理措施之時, 我們可能會在特定情況下在您成為我們的計劃會員的最初 90 天內承保您的藥品 對於您所服用的不在我們處方一覽表上的每一種藥品或如果您獲得您的藥品的能力有限, 我們將暫時承保 30 天的供應藥量 如果您所開的處方藥用量天數較少, 我們將允許再次配藥, 以便提供最多 30 天的藥品供應 結束您最初 30 天的供應藥量之後, 我們不會為這些藥品支付費用, 即使您成為本計劃會員的時間不超過 90 天亦如此 H6988_ENR085_C V

如果您是一家長期護理機構的住院病患且您需要的藥品並不在我們的處方一覽表上或者如果您獲得藥品的能力有限, 而您加入我們計劃成為會員已經超過 90 天, 在您尋求處方一覽表例外處理期間, 我們將承保 3 天的緊急用藥用量 更多資訊 為獲得關於您的 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 處方藥品承保的詳細資訊, 請閱覽您的 承保福利說明 和其他計劃材料 如果您對 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 還有任何疑問, 請聯絡我們 我們的聯絡方式和處方一覽表最新更新日期會分別出現在封面和封底 如果您對 Medicare 處方藥品承保有一般性問題, 請致電 Medicare, 電話是 -800-MEDICARE (-800-633-4227), 每週 7 天 每天 24 小時開通 聽力障礙電傳使用者應致電 -877-486-2048 或者瀏覽 http://www.medicare.gov Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 及 Centers Plan for Medicaid Advantage Plus (HMO SNP) 處方一覽表 下方的處方一覽表中列出了 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 的承保藥品資訊 如果您在藥物清單上找藥物有困難, 請翻至 I- 頁, 開始閱讀索引部分 圖表第一列是藥品名稱 品牌藥品名稱大寫 ( 如 :LIPITOR), 普通藥品為斜體小寫 ( 如 : atorvastatin) 要求 / 限制欄中的資訊會告知您 Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) 和 Centers Plan for Medicaid Advantage Plus (HMO SNP) 是否對您的藥品承保有任何特殊要求 H6988_ENR085_C VI

Table of Contents Analgesics... 3 Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents... 8 Antianxiety Agents... 9 Antibacterials... 0 Anticancer Agents... 7 Anticholinergic Agents... 28 Anticonvulsants... 28 Antidementia Agents... 32 Antidepressants... 33 Antidiabetic Agents... 35 Antifungals... 39 Antigout Agents... 4 Antihistamines... 4 Anti-Infectives (Skin And Mucous Membrane)... 42 Antimigraine Agents... 42 Antimycobacterials... 43 Antinausea Agents... 44 Antiparasite Agents... 45 Antiparkinsonian Agents... 46 Antipsychotic Agents... 48 Antivirals (Systemic)... 53 Blood Products/Modifiers/Volume Expanders... 59 Caloric Agents... 62 Cardiovascular Agents... 65 Central Nervous System Agents... 75 Contraceptives... 78

Dental And Oral Agents... 85 Dermatological Agents... 85 Devices... 89 Enzyme Replacement/Modifiers... 90 Eye, Ear, Nose, Throat Agents... 9 Gastrointestinal Agents... 95 Genitourinary Agents... 99 Heavy Metal Antagonists... 00 Hormonal Agents, Stimulant/Replacement/Modifying... 00 Immunological Agents... 07 Inflammatory Bowel Disease Agents... 6 Irrigating Solutions... 7 Metabolic Bone Disease Agents... 7 Miscellaneous Therapeutic Agents... 8 Ophthalmic Agents... 20 Replacement Preparations... 2 Respiratory Tract Agents... 23 Skeletal Muscle Relaxants... 28 Sleep Disorder Agents... 28 Vasodilating Agents... 29 Vitamins And Minerals... 30 2

Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 20-2 /5 ml acetaminophen-codeine oral tablet 300-5 acetaminophen-codeine oral tablet 300-30 acetaminophen-codeine oral tablet 300-60 buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml butalbital-acetaminophen-caff oral tablet 50-325-40 butalbital-aspirin-caffeine oral capsule 50-325-40 butalbital-aspirin-caffeine oral tablet 50-325-40 NDS; NM; QL (4500 per NDS; NM; QL (360 per (Tylenol-Codeine #3) NDS; NM; QL (360 per (Tylenol-Codeine #4) NDS; NM; QL (80 per (Buprenex) 3 (Esgic) PA-HRM; QL (80 per ; AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (80 per ; AGE (Max 64 Years) PA-HRM; QL (80 per ; AGE (Max 64 Years) NDS; NM; QL (80 per codeine sulfate oral tablet 5, 30, 60 endocet oral tablet 0-325 NDS; NM; QL (80 per endocet oral tablet 2.5-325, 5- NDS; NM; QL (360 per 325 endocet oral tablet 7.5-325 NDS; NM; QL (240 per fentanyl citrate buccal lozenge on a (Actiq) PA; NDS; NM; QL (20 handle,200 mcg,,600 mcg, 200 per mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution 7.5-325 /5 ml hydrocodone-acetaminophen oral tablet 0-325 hydrocodone-acetaminophen oral tablet 2.5-325 (Duragesic) NDS; NM; QL (0 per NDS; NM; QL (2700 per (Lorcet HD) NDS; NM; QL (80 per NDS; NM; QL (240 per

hydrocodone-acetaminophen oral tablet 5-325 (Lorcet (hydrocodone)) NDS; NM; QL (240 per hydrocodone-acetaminophen oral tablet 7.5-325 (Lorcet Plus) NDS; NM; QL (80 per hydrocodone-ibuprofen oral tablet 7.5-200 NDS; NM; QL (50 per hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone oral liquid /ml (Dilaudid) NDS; NM; QL (200 per hydromorphone oral tablet 2, 4, 8 (Dilaudid) NDS; NM; QL (80 per LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 PA; NDS; NM; QL (30 per MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-325 NDS; NM; QL (240 per lorcet hd oral tablet 0-325 NDS; NM; QL (80 per lorcet plus oral tablet 7.5-325 NDS; NM; QL (80 per methadone injection solution 0 /ml methadone oral solution 0 /5 ml NDS; NM; QL (600 per methadone oral solution 5 /5 ml NDS; NM; QL (200 per methadone oral tablet 0 (Dolophine) NDS; NM; QL (20 per methadone oral tablet 5 (Dolophine) NDS; NM; QL (80 per methadose oral tablet,soluble 40 NDS; NM; QL (30 per morphine concentrate oral solution 00 /5 ml (20 /ml) NDS; NM; QL (80 per morphine intravenous solution 0 /ml, 4 /ml, 8 /ml morphine intravenous syringe 0 /ml morphine oral solution 0 /5 ml NDS; NM; QL (700 per morphine oral solution 20 /5 ml (4 /ml) NDS; NM; QL (300 per 4

MORPHINE ORAL TABLET 5 NDS; NM; QL (80 per MORPHINE ORAL TABLET 30 NDS; NM; QL (20 per morphine oral tablet extended release 00, 200, 60 (MS Contin) NDS; NM; QL (60 per morphine oral tablet extended release 5, 30 (MS Contin) NDS; NM; QL (90 per NUCYNTA ER ORAL TABLET EXTENDED RELEASE 2 HR 00 NDS; NM; QL (60 per, 50, 200, 250, 50 NUCYNTA ORAL TABLET 00, 50, 75 NDS; NM; QL (8 per oxycodone oral solution 5 /5 ml NDS; QL (300 per 30 oxycodone oral tablet 0 NDS; NM; QL (80 per oxycodone oral tablet 5, 30 (Roxicodone) NDS; NM; QL (20 per oxycodone oral tablet 20 NDS; NM; QL (20 per oxycodone oral tablet 5 (Roxicodone) NDS; NM; QL (80 per oxycodone oral tablet,oral only,ext.rel.2 hr 0, 5, 20, 30, 40, 60, 80 (OxyContin) NDS; NM; QL (60 per oxycodone-acetaminophen oral tablet (Endocet) NDS; NM; QL (80 per 0-325 oxycodone-acetaminophen oral tablet (Endocet) NDS; NM; QL (360 per 2.5-325, 5-325 oxycodone-acetaminophen oral tablet (Endocet) NDS; NM; QL (240 per 7.5-325 oxycodone-aspirin oral tablet 4.8355-325 NDS; NM; QL (360 per OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 0, 5, 20, 30, 40, 60, 80 NDS; NM; QL (60 per tramadol oral tablet 50 (Ultram) NDS; NM; QL (240 per 5

tramadol-acetaminophen oral tablet 37.5-325 (Ultracet) NDS; NM; QL (300 per XTAMPZA ER ORAL CAP,SPRINKL,ER2HR(DONT NDS; NM; QL (60 per CRUSH) 3.5, 8, 9 XTAMPZA ER ORAL CAP,SPRINKL,ER2HR(DONT NDS; NM; QL (20 per CRUSH) 27 XTAMPZA ER ORAL CAP,SPRINKL,ER2HR(DONT NDS; NM; QL (240 per CRUSH) 36 Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 800 /8 ML (00 /ML) celecoxib oral capsule 00, 200 (Celebrex) QL (60 per, 50 diclofenac epolamine transdermal (Flector) PA patch 2 hour.3 % diclofenac potassium oral tablet 50 diclofenac sodium oral tablet (Voltaren-XR) extended release 24 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 diclofenac sodium topical drops.5 QL (300 per % diclofenac sodium topical gel % (Voltaren) diclofenac sodium topical gel 3 % (Solaraze) PA; QL (00 per 28 etodolac oral capsule 200, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 flurbiprofen oral tablet 00, 50 ibu oral tablet 400, 600, 800 ibuprofen oral suspension 00 /5 (Children's Advil) ml ibuprofen oral tablet 400, 600, 800 (IBU) 6

indomethacin oral capsule 25 PA-HRM; QL (240 per ; AGE (Max 64 Years) indomethacin oral capsule 50 PA-HRM; QL (20 per ; AGE (Max 64 Years) ketorolac oral tablet 0 PA-HRM; QL (20 per 30 ; AGE (Max 64 Years) mefenamic acid oral capsule 250 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral tablet 250, 375 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (dr/ec) 375, 500 (EC-Naprosyn) PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 /GRAM /ACTUATION(2 %) sulindac oral tablet 50, 200 VOLTAREN TOPICAL GEL % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % lidocaine (pf) injection solution 0 /ml ( %), 5 /ml (.5 %), 20 /ml (2 %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine (pf) intravenous solution 20 /ml (2 %) lidocaine hcl injection solution 0 /ml ( %), 20 /ml (2 %), 5 /ml (0.5 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 /ml) (Xylocaine-MPF) (Xylocaine (Cardiac) (PF)) (Xylocaine) PA; NDS; QL (224 per 28 QL (30 per 7 QL (30 per

lidocaine topical adhesive (Lidoderm) PA; QL (90 per patch,medicated 5 % lidocaine topical ointment 5 % PA; QL (90 per lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream PA; QL (30 per 2.5-2.5 % ZTLIDO TOPICAL ADHESIVE PATCH,MEDICATED.8 % PA; QL (90 per Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 buprenorphine hcl sublingual tablet 2, 8 buprenorphine-naloxone sublingual film 2-3, 8-2 buprenorphine-naloxone sublingual film 2-0.5, 4- buprenorphine-naloxone sublingual tablet 2-0.5, 8-2 bupropion hcl (smoking deter) oral tablet extended release 2 hr 50 CHANTIX CONTINUING MONTH BOX ORAL TABLET CHANTIX ORAL TABLET 0.5, CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 ()- (42) 8 QL (90 per (Suboxone) QL (60 per (Suboxone) QL (30 per QL (90 per QL (336 per 365 QL (336 per 365 disulfiram oral tablet 250, 500 (Antabuse) LUCEMYRA ORAL TABLET 0.8 NDS; QL (228 per 4 naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- AEROSOL 4 /ACTUATION QL (4 per

NICOTROL INHALATION CARTRIDGE 0 SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 00 /0.5 ML, 300 /.5 ML ZUBSOLV SUBLINGUAL TABLET 0.7-0.8,.4-0.36,.4-2.9, 2.9-0.7, 5.7-.4 ZUBSOLV SUBLINGUAL TABLET 8.6-2. Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5 QL (008 per 90 NDS QL (30 per QL (60 per (Xanax) NDS; NM; QL (20 per, alprazolam oral tablet 2 (Xanax) NDS; NM; QL (50 per buspirone oral tablet 0, 5, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 0, 25, 5 NDS; NM; QL (20 per clonazepam oral tablet 0.5, (Klonopin) NDS; NM; QL (90 per clonazepam oral tablet 2 (Klonopin) NDS; NM; QL (300 per clonazepam oral tablet,disintegrating 0.25, 0.25, 0.5, NDS; NM; QL (90 per clonazepam oral tablet,disintegrating 2 NDS; NM; QL (300 per clorazepate dipotassium oral tablet 5, 3.75 NDS; NM; QL (80 per clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) NDS; NM; QL (80 per diazepam 5 /ml oral conc 5 /ml NDS; NM; QL (200 per diazepam injection solution 5 /ml QL (0 per 28 diazepam injection syringe 5 /ml QL (0 per 28 diazepam oral concentrate 5 /ml (Diazepam Intensol) NDS; NM; QL (200 per diazepam oral solution 5 /5 ml ( /ml) NDS; NM; QL (200 per 9

diazepam oral tablet 0, 2, 5 (Valium) NDS; NM; QL (20 per lorazepam injection solution 2 (Ativan) QL (2 per /ml, 4 /ml lorazepam injection syringe 2 /ml, QL (2 per 4 /ml lorazepam oral tablet 0.5, (Ativan) NDS; NM; QL (90 per lorazepam oral tablet 2 (Ativan) NDS; NM; QL (50 per temazepam oral capsule 5, 30 (Restoril) NDS; NM; QL (30 per Antibacterials Aminoglycosides BETHKIS INHALATION PA BvD; NDS SOLUTION FOR NEBULIZATION 300 /4 ML gentamicin injection solution 20 /2 ml, 40 /ml gentamicin sulfate (ped) (pf) injection solution 20 /2 ml gentamicin sulfate (pf) intravenous solution 00 /0 ml, 60 /6 ml, 80 /8 ml neomycin oral tablet 500 streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 tobramycin in 0.225 % nacl inhalation solution for nebulization 300 /5 ml tobramycin sulfate injection solution 40 /ml tobramycin with nebulizer inhalation solution for nebulization 300 /5 ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln gram NDS; QL (224 per 28 (Tobi) PA BvD; NDS (Kitabis Pak) PA BvD; NDS 0

clindamycin hcl oral capsule 50, (Cleocin HCl) 300, 75 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection (Cleocin) solution 50 /ml clindamycin phosphate intravenous (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection (Coly-Mycin M PA BvD; NDS recon soln 50 Parenteral) daptomycin intravenous recon soln (Cubicin) NDS 500 FIRVANQ ORAL RECON SOLN 25 /ML, 50 /ML linezolid 600 /300 ml-0.9% nacl NDS 600 /300 ml linezolid in dextrose 5% intravenous (Zyvox) NDS piggyback 600 /300 ml linezolid oral suspension for (Zyvox) NDS reconstitution 00 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet (Hiprex) gram metronidazole in nacl (iso-os) (Metro I.V.) intravenous piggyback 500 /00 ml metronidazole oral tablet 250, (Flagyl) 500 nitrofurantoin macrocrystal oral (Macrodantin) QL (20 per capsule 00, 25, 50 nitrofurantoin monohyd/m-cryst oral (Macrobid) QL (60 per capsule 00 polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS NDS RECON SOLN 500 trimethoprim oral tablet 00 vancomycin intravenous recon soln,000,.25 gram, 0 gram, 5 gram, 500, 750 PA BvD

vancomycin oral capsule 25, 250 (Vancocin) XIFAXAN ORAL TABLET 200 PA; NDS; QL (9 per 30 XIFAXAN ORAL TABLET 550 PA; NDS Cephalosporins cefaclor oral capsule 250, 500 cefaclor oral suspension for reconstitution 25 /5 ml, 250 /5 ml, 375 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml cefazolin injection recon soln gram, 0 gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefditoren pivoxil oral tablet 200 cefditoren pivoxil oral tablet 400 (Spectracef) cefepime injection recon soln gram, (Maxipime) 2 gram cefixime oral capsule 400 (Suprax) cefotaxime injection recon soln gram cefoxitin intravenous recon soln gram, 0 gram, 2 gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 200 cefprozil oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 ceftazidime injection recon soln gram, 2 gram, 6 gram (Tazicef) 2

ceftriaxone injection recon soln gram, 0 gram, 2 gram, 250, 500 cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 250, 500 (Keflex) cephalexin oral suspension for reconstitution 25 /5 ml, 250 /5 ml TEFLARO INTRAVENOUS NDS RECON SOLN 400, 600 Macrolides azithromycin intravenous recon soln (Zithromax) 500 azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250 (6 pack), 500 (3 pack), 600 azithromycin oral tablet 250, 500 (Zithromax) clarithromycin oral suspension for reconstitution 25 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 DIFICID ORAL TABLET 200 ST; NDS; QL (20 per 0 erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 200 /5 ml erythromycin ethylsuccinate oral (EryPed 400) suspension for reconstitution 400 /5 ml erythromycin oral tablet 250, 500 Miscellaneous B-Lactam Antibiotics 3

aztreonam injection recon soln gram, 2 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 /ML ertapenem injection recon soln gram imipenem-cilastatin intravenous recon soln 250 imipenem-cilastatin intravenous recon soln 500 meropenem intravenous recon soln gram, 500 Penicillins amoxicillin oral capsule 250, 500 amoxicillin oral suspension for reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 25, 250 amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 /5 ml, 400-57 /5 ml amoxicillin-pot clavulanate oral suspension for reconstitution 600-42.9 /5 ml amoxicillin-pot clavulanate oral tablet 500-25, 875-25 amoxicillin-pot clavulanate oral tablet,chewable 200-28.5, 400-57 ampicillin oral capsule 250, 500 ampicillin sodium injection recon soln gram, 0 gram, 25, 2 gram, 250, 500 ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram (Azactam) PA; LA; NDS (Invanz) (Primaxin IV) (Merrem) (Augmentin ES-600) (Augmentin) (Unasyn) 4

BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, 500 nafcillin gm/ 50 ml inj gram/50 ml nafcillin injection recon soln gram nafcillin injection recon soln 0 gram NDS nafcillin injection recon soln 2 gram penicillin g potassium injection recon (Pfizerpen-G) soln 20 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml, 600,000 unit/ml penicillin v potassium oral recon soln 25 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous (Zosyn) PA BvD recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram Quinolones BAXDELA ORAL TABLET 450 PA; NDS; QL (28 per 4 ciprofloxacin hcl oral tablet 250, (Cipro) 500 ciprofloxacin hcl oral tablet 750 ciprofloxacin in 5 % dextrose intravenous piggyback 200 /00 ml, 400 /200 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 250 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 25 /ml 5

levofloxacin oral solution 250 /0 ml levofloxacin oral tablet 250 levofloxacin oral tablet 500, 750 (Levaquin) moxifloxacin oral tablet 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution 400-80 /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 200-40 /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet 400-80 sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet 800-60 sulfatrim oral suspension 200-40 /5 ml Tetracyclines doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous (Doxy-00) recon soln 00 doxycycline hyclate oral capsule 00 (Morgidox), 50 doxycycline hyclate oral tablet 00, 20 doxycycline monohydrate oral (Mondoxyne NL) capsule 00 doxycycline monohydrate oral (Monodox) capsule 50 doxycycline monohydrate oral (Vibramycin) suspension for reconstitution 25 /5 ml doxycycline monohydrate oral tablet (Avidoxy) 00 doxycycline monohydrate oral tablet 50 minocycline oral capsule 00, 75 minocycline oral capsule 50 (Minocin) mondoxyne nl oral capsule 00, 50 6

tetracycline oral capsule 250, 500 tigecycline intravenous recon soln 50 Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 ADCETRIS INTRAVENOUS RECON SOLN 50 adriamycin intravenous solution 0 /5 ml, 2 /ml, 20 /0 ml, 50 /25 ml adrucil intravenous solution 2.5 gram/50 ml, 500 /0 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2, 3, 5 (Tygacil) NDS 7 NDS PA NSO; NDS PA BvD PA BvD PA NSO; NDS; QL (2 per 28 AFINITOR ORAL TABLET 0 PA NSO; NDS; QL (56 per 28 AFINITOR ORAL TABLET 2.5, 5, 7.5 PA NSO; NDS; QL (28 per 28 ALECENSA ORAL CAPSULE 50 PA NSO; NDS; QL (240 per ALIMTA INTRAVENOUS RECON NDS SOLN 00, 500 ALIQOPA INTRAVENOUS RECON SOLN 60 PA NSO; NDS; QL (3 per 28 ALUNBRIG ORAL TABLET 80, 90 PA NSO; NDS; QL (30 per ALUNBRIG ORAL TABLET 30 PA NSO; NDS; QL (20 per ALUNBRIG ORAL TABLETS,DOSE PACK 90 (7)- 80 (23) PA NSO; NDS anastrozole oral tablet (Arimidex) arsenic trioxide intravenous solution NDS /ml arsenic trioxide intravenous solution (Trisenox) NDS 2 /ml AVASTIN INTRAVENOUS SOLUTION 25 /ML PA NSO; NDS

AYVAKIT ORAL TABLET 00, 200, 300 PA NSO; NDS; QL (30 per azacitidine injection recon soln 00 (Vidaza) NDS BALVERSA ORAL TABLET 3 PA NSO; NDS; QL (84 per 28 BALVERSA ORAL TABLET 4 PA NSO; NDS; QL (56 per 28 BALVERSA ORAL TABLET 5 PA NSO; NDS; QL (28 per 28 BAVENCIO INTRAVENOUS PA NSO; NDS SOLUTION 20 /ML BELEODAQ INTRAVENOUS PA NSO; NDS RECON SOLN 500 BENDEKA INTRAVENOUS PA NSO; NDS SOLUTION 25 /ML BESPONSA INTRAVENOUS PA NSO; NDS RECON SOLN 0.9 (0.25 /ML INITIAL) bexarotene oral capsule 75 (Targretin) PA NSO; NDS; QL (420 per bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 5 unit, 30 unit BLINCYTO INTRAVENOUS KIT PA NSO; NDS 35 MCG BORTEZOMIB INTRAVENOUS PA NSO; NDS RECON SOLN 3.5 BOSULIF ORAL TABLET 00 PA NSO; NDS; QL (90 per BOSULIF ORAL TABLET 400, 500 PA NSO; NDS; QL (30 per BRAFTOVI ORAL CAPSULE 50 PA NSO; NDS; QL (20 per BRAFTOVI ORAL CAPSULE 75 PA NSO; NDS; QL (80 per BRUKINSA ORAL CAPSULE 80 PA NSO; NDS CABOMETYX ORAL TABLET 20, 60 PA NSO; NDS; QL (30 per CABOMETYX ORAL TABLET 40 PA NSO; NDS; QL (60 per 8

CALQUENCE ORAL CAPSULE 00 PA NSO; NDS; QL (60 per CAPRELSA ORAL TABLET 00 PA NSO; NDS; QL (60 per CAPRELSA ORAL TABLET 300 PA NSO; NDS; QL (30 per clofarabine intravenous solution 20 (Clolar) NDS /20 ml COMETRIQ ORAL CAPSULE 00 /DAY(80 X-20 X), PA NSO; NDS; QL (2 per 28 40 /DAY(80 X-20 X3), 60 /DAY (20 X 3/DAY) COPIKTRA ORAL CAPSULE 5, 25 PA NSO; NDS; QL (56 per 28 COTELLIC ORAL TABLET 20 PA NSO; LA; NDS; QL (63 per 28 cyclophosphamide intravenous recon PA BvD; NDS soln gram, 2 gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 25, 50 CYRAMZA INTRAVENOUS PA NSO; NDS SOLUTION 0 /ML DARZALEX INTRAVENOUS PA NSO; LA; NDS SOLUTION 20 /ML DAURISMO ORAL TABLET 00 PA NSO; NDS; QL (30 per DAURISMO ORAL TABLET 25 PA NSO; NDS; QL (60 per decitabine intravenous recon soln 50 (Dacogen) NDS doxorubicin intravenous solution 0 (Adriamycin) PA BvD /5 ml, 2 /ml, 20 /0 ml, 50 /25 ml doxorubicin, peg-liposomal (Doxil) PA BvD; NDS intravenous suspension 2 /ml DROXIA ORAL CAPSULE 200, 300, 400 ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 9

ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 ELIGARD SUBCUTANEOUS SYRINGE 7.5 ( MONTH) EMCYT ORAL CAPSULE 40 NDS EMPLICITI INTRAVENOUS PA NSO; NDS RECON SOLN 300, 400 ENHERTU INTRAVENOUS PA NSO; NDS RECON SOLN 00 ERIVEDGE ORAL CAPSULE 50 PA NSO; NDS; QL (30 per ERLEADA ORAL TABLET 60 PA NSO; NDS; QL (20 per erlotinib oral tablet 00, 25 (Tarceva) PA NSO; NDS; QL (60 per erlotinib oral tablet 50 (Tarceva) PA NSO; NDS; QL (90 per ETOPOPHOS INTRAVENOUS RECON SOLN 00 etoposide intravenous solution 20 (Toposar) /ml exemestane oral tablet 25 (Aromasin) FARYDAK ORAL CAPSULE 0 PA NSO; NDS, 5, 20 floxuridine injection recon soln 0.5 PA BvD gram fluorouracil intravenous solution PA BvD gram/20 ml, 5 gram/00 ml fluorouracil intravenous solution 500 (Adrucil) PA BvD /0 ml flutamide oral capsule 25 fulvestrant intramuscular syringe 250 (Faslodex) NDS /5 ml GAZYVA INTRAVENOUS PA NSO; NDS SOLUTION,000 /40 ML GILOTRIF ORAL TABLET 20, 30, 40 PA NSO; NDS; QL (30 per GLEOSTINE ORAL CAPSULE 0, 40, 5 20

GLEOSTINE ORAL CAPSULE 00 NDS HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 PA NSO; NDS; QL (5 per 2-0,000 UNIT/5 ML HERCEPTIN INTRAVENOUS RECON SOLN 50, 440 PA NSO; NDS hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00, 25, 75 PA NSO; NDS; QL (2 per 28 ICLUSIG ORAL TABLET 5 PA NSO; NDS; QL (60 per ICLUSIG ORAL TABLET 45 PA NSO; NDS; QL (30 per IDHIFA ORAL TABLET 00, 50 PA NSO; NDS; QL (30 per ifosfamide intravenous recon soln (Ifex) gram ifosfamide intravenous solution gram/20 ml, 3 gram/60 ml ifosfamide-mesna intravenous kit - gram, 3,000-,000 imatinib oral tablet 00 (Gleevec) PA NSO; QL (90 per 30 imatinib oral tablet 400 (Gleevec) PA NSO; QL (60 per 30 IMBRUVICA ORAL CAPSULE 40 PA NSO; NDS; QL (20 per IMBRUVICA ORAL CAPSULE 70 PA NSO; NDS; QL (28 per 28 IMBRUVICA ORAL TABLET 40, 280, 420, 560 PA NSO; NDS; QL (28 per 28 IMFINZI INTRAVENOUS PA NSO; NDS SOLUTION 50 /ML IMLYGIC INJECTION SUSPENSION 0EXP6 ( MILLION) PFU/ML PA NSO; NDS; QL (4 per 365 IMLYGIC INJECTION SUSPENSION 0EXP8 (00 MILLION) PFU/ML PA NSO; NDS; QL (8 per 28 INLYTA ORAL TABLET PA NSO; NDS; QL (80 per 2

INLYTA ORAL TABLET 5 PA NSO; NDS; QL (60 per INREBIC ORAL CAPSULE 00 PA NSO; NDS; QL (20 per IRESSA ORAL TABLET 250 PA NSO; NDS; QL (60 per IXEMPRA INTRAVENOUS NDS RECON SOLN 5, 45 JAKAFI ORAL TABLET 0, 5, 20, 25, 5 PA NSO; NDS; QL (60 per KANJINTI INTRAVENOUS PA NSO; NDS RECON SOLN 50, 420 KEYTRUDA INTRAVENOUS SOLUTION 25 /ML PA NSO; NDS; QL (8 per 2 KISQALI FEMARA CO-PACK ORAL TABLET 200 /DAY(200 X )-2.5 PA NSO; NDS; QL (49 per 28 KISQALI FEMARA CO-PACK ORAL TABLET 400 /DAY(200 X 2)-2.5 KISQALI FEMARA CO-PACK ORAL TABLET 600 /DAY(200 X 3)-2.5 KISQALI ORAL TABLET 200 /DAY (200 X ) KISQALI ORAL TABLET 400 /DAY (200 X 2) KISQALI ORAL TABLET 600 /DAY (200 X 3) KYPROLIS INTRAVENOUS RECON SOLN 0, 30, 60 LENVIMA ORAL CAPSULE 0 /DAY (0 X ), 2 /DAY (4 X 3), 4 /DAY(0 X -4 X ), 8 /DAY (0 X -4 X2), 20 /DAY (0 X 2), 24 /DAY(0 X 2-4 X ), 4, 8 /DAY (4 X 2) letrozole oral tablet 2.5 (Femara) LEUKERAN ORAL TABLET 2 PA NSO; NDS; QL (70 per 28 PA NSO; NDS; QL (9 per 28 PA NSO; NDS; QL (2 per 28 PA NSO; NDS; QL (42 per 28 PA NSO; NDS; QL (63 per 28 PA NSO; NDS PA NSO; NDS 22

leuprolide subcutaneous kit /0.2 ml LIBTAYO INTRAVENOUS SOLUTION 50 /ML PA NSO; NDS; QL (7 per 2 LONSURF ORAL TABLET 5-6.4 PA NSO; NDS; QL (00 per 28 LONSURF ORAL TABLET 20-8.9 PA NSO; NDS; QL (80 per 28 LORBRENA ORAL TABLET 00 PA NSO; NDS; QL (30 per LORBRENA ORAL TABLET 25 PA NSO; NDS; QL (90 per LUMOXITI INTRAVENOUS PA NSO; NDS RECON SOLN LUPRON DEPOT (3 MONTH) NDS INTRAMUSCULAR SYRINGE KIT 22.5 LUPRON DEPOT (4 MONTH) NDS INTRAMUSCULAR SYRINGE KIT 30 LUPRON DEPOT (6 MONTH) NDS INTRAMUSCULAR SYRINGE KIT 45 LUPRON DEPOT NDS INTRAMUSCULAR SYRINGE KIT 3.75 LYNPARZA ORAL TABLET 00, 50 PA NSO; NDS; QL (20 per LYSODREN ORAL TABLET 500 NDS MATULANE ORAL CAPSULE 50 NDS megestrol oral tablet 20, 40 PA NSO-HRM; AGE (Max 64 Years) MEKINIST ORAL TABLET 0.5 PA NSO; NDS; QL (90 per MEKINIST ORAL TABLET 2 PA NSO; NDS; QL (30 per MEKTOVI ORAL TABLET 5 PA NSO; NDS; QL (80 per mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln gram PA BvD 23

methotrexate sodium (pf) injection PA BvD solution 25 /ml methotrexate sodium injection PA BvD solution 25 /ml methotrexate sodium oral tablet 2.5 PA BvD; ST mitoxantrone intravenous concentrate 2 /ml MYLOTARG INTRAVENOUS PA NSO; NDS RECON SOLN 4.5 ( /ML INITIAL CONC) NERLYNX ORAL TABLET 40 PA NSO; NDS; QL (80 per NEXAVAR ORAL TABLET 200 PA NSO; NDS; QL (20 per nilutamide oral tablet 50 (Nilandron) NDS NINLARO ORAL CAPSULE 2.3, 3, 4 PA NSO; NDS; QL (3 per 28 NUBEQA ORAL TABLET 300 PA NSO; NDS; QL (20 per ODOMZO ORAL CAPSULE 200 PA NSO; LA; NDS OGIVRI INTRAVENOUS RECON PA NSO; NDS SOLN 50, 420 ONCASPAR INJECTION PA NSO; NDS SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS NDS DISPERSION 4.3 /ML OPDIVO INTRAVENOUS PA NSO; NDS SOLUTION 00 /0 ML, 240 /24 ML, 40 /4 ML PADCEV INTRAVENOUS RECON PA NSO; NDS SOLN 20, 30 PIQRAY ORAL TABLET 200 /DAY (200 X ) PA NSO; NDS; QL (28 per 28 PIQRAY ORAL TABLET 250 /DAY (200 X-50 X), PA NSO; NDS; QL (56 per 28 300 /DAY (50 X 2) POLIVY INTRAVENOUS RECON SOLN 40 PA NSO; NDS POMALYST ORAL CAPSULE, 2, 3, 4 PA NSO; NDS; QL (2 per 28 24

PORTRAZZA INTRAVENOUS SOLUTION 800 /50 ML (6 /ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 /ML REVLIMID ORAL CAPSULE 0, 5, 2.5, 20, 25, 5 RITUXAN HYCELA SUBCUTANEOUS SOLUTION 400 /.7 ML (20 /ML), 600 /3.4 ML (20 /ML) RITUXAN INTRAVENOUS CONCENTRATE 0 /ML ROZLYTREK ORAL CAPSULE 00 ROZLYTREK ORAL CAPSULE 200 RUBRACA ORAL TABLET 200, 250, 300 PA NSO; NDS; QL (00 per 2 NDS NDS PA NSO; LA; NDS; QL (28 per 28 PA NSO; NDS PA NSO; NDS PA NSO; NDS; QL (30 per PA NSO; NDS; QL (90 per PA NSO; NDS; QL (20 per RYDAPT ORAL CAPSULE 25 PA NSO; NDS; QL (224 per 28 SOLTAMOX ORAL SOLUTION 0 NDS /5 ML SPRYCEL ORAL TABLET 00 PA NSO; NDS; QL (30, 40, 50, 70, 80 per SPRYCEL ORAL TABLET 20 PA NSO; NDS; QL (90 per STIVARGA ORAL TABLET 40 PA NSO; NDS; QL (84 per 28 SUTENT ORAL CAPSULE 2.5, 25, 37.5, 50 PA NSO; NDS; QL (30 per SYLVANT INTRAVENOUS PA NSO; NDS RECON SOLN 00, 400 SYNRIBO SUBCUTANEOUS PA NSO; NDS RECON SOLN 3.5 TABLOID ORAL TABLET 40 TAFINLAR ORAL CAPSULE 50, 75 PA NSO; NDS; QL (20 per 25

TAGRISSO ORAL TABLET 40, 80 PA NSO; LA; NDS; QL (30 per TALZENNA ORAL CAPSULE 0.25 PA NSO; NDS; QL (90 per TALZENNA ORAL CAPSULE PA NSO; NDS; QL (30 per tamoxifen oral tablet 0, 20 TARGRETIN TOPICAL GEL % PA NSO; NDS; QL (60 per 28 TASIGNA ORAL CAPSULE 50, 200 PA NSO; NDS; QL (2 per 28 TASIGNA ORAL CAPSULE 50 PA NSO; NDS; QL (20 TECENTRIQ INTRAVENOUS SOLUTION,200 /20 ML (60 /ML), 840 /4 ML (60 /ML) per PA NSO; NDS TEMODAR INTRAVENOUS PA NSO; NDS RECON SOLN 00 thiotepa injection recon soln 5 (Tepadina) NDS TIBSOVO ORAL TABLET 250 PA NSO; NDS; QL (60 per toposar intravenous solution 20 /ml toremifene oral tablet 60 (Fareston) NDS TREANDA INTRAVENOUS PA NSO; NDS RECON SOLN 00, 25 TRELSTAR INTRAMUSCULAR NDS; QL ( per 84 SUSPENSION FOR RECONSTITUTION.25 TRELSTAR INTRAMUSCULAR SUSPENSION FOR NDS; QL ( per 68 RECONSTITUTION 22.5 TRELSTAR INTRAMUSCULAR NDS; QL ( per 28 SUSPENSION FOR RECONSTITUTION 3.75 tretinoin (chemotherapy) oral NDS capsule 0 TRUXIMA INTRAVENOUS PA NSO; NDS CONCENTRATE 0 /ML TURALIO ORAL CAPSULE 200 PA NSO; NDS; QL (20 per TYKERB ORAL TABLET 250 PA NSO; NDS 26

UNITUXIN INTRAVENOUS PA NSO; NDS SOLUTION 3.5 /ML valrubicin intravesical solution 40 (Valstar) NDS /ml VELCADE INJECTION RECON PA NSO; NDS SOLN 3.5 VENCLEXTA ORAL TABLET 0 PA NSO; LA; QL (60 per VENCLEXTA ORAL TABLET 00 PA NSO; LA; NDS; QL (80 per VENCLEXTA ORAL TABLET 50 PA NSO; LA; QL (30 per VENCLEXTA STARTING PACK PA NSO; LA; NDS ORAL TABLETS,DOSE PACK 0-50 - 00 VERZENIO ORAL TABLET 00, 50, 200, 50 PA NSO; NDS; QL (56 per 28 vinorelbine intravenous solution 0 (Navelbine) /ml, 50 /5 ml VITRAKVI ORAL CAPSULE 00 PA NSO; NDS; QL (60 per VITRAKVI ORAL CAPSULE 25 PA NSO; NDS; QL (80 per VITRAKVI ORAL SOLUTION 20 /ML PA NSO; NDS; QL (300 per VIZIMPRO ORAL TABLET 5, 30, 45 PA NSO; NDS; QL (30 per VOTRIENT ORAL TABLET 200 PA NSO; NDS; QL (20 per VYXEOS INTRAVENOUS RECON PA BvD; NDS SOLN 44-00 XALKORI ORAL CAPSULE 200, 250 PA NSO; NDS; QL (60 per XATMEP ORAL SOLUTION 2.5 PA BvD; ST /ML XOSPATA ORAL TABLET 40 PA NSO; NDS; QL (90 per XPOVIO ORAL TABLET 00 /WEEK (20 X 5) PA NSO; NDS; QL (20 per 28 XPOVIO ORAL TABLET 60 /WEEK (20 X 8) PA NSO; NDS; QL (32 per 28 XPOVIO ORAL TABLET 60 /WEEK (20 X 3) PA NSO; NDS; QL (2 per 28 27

XPOVIO ORAL TABLET 80 /WEEK (20 X 4) PA NSO; NDS; QL (6 per 28 XTANDI ORAL CAPSULE 40 PA NSO; NDS; QL (20 per YERVOY INTRAVENOUS PA NSO; NDS SOLUTION 200 /40 ML (5 /ML), 50 /0 ML (5 /ML) YONDELIS INTRAVENOUS PA NSO; NDS RECON SOLN YONSA ORAL TABLET 25 PA NSO; NDS; QL (20 per ZEJULA ORAL CAPSULE 00 PA NSO; NDS; QL (90 per ZELBORAF ORAL TABLET 240 PA NSO; NDS; QL (240 per ZIRABEV INTRAVENOUS PA NSO; NDS SOLUTION 25 /ML ZOLADEX SUBCUTANEOUS QL ( per 84 IMPLANT 0.8 ZOLADEX SUBCUTANEOUS QL ( per 28 IMPLANT 3.6 ZOLINZA ORAL CAPSULE 00 NDS ZYDELIG ORAL TABLET 00, 50 PA NSO; NDS; QL (60 per ZYKADIA ORAL CAPSULE 50 PA NSO; NDS; QL (90 per ZYKADIA ORAL TABLET 50 PA NSO; NDS; QL (84 per 28 ZYTIGA ORAL TABLET 250, 500 PA NSO; NDS; QL (20 per Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0. /ml Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200, 400 APTIOM ORAL TABLET 600, ST; NDS; QL (60 per 30 800 BANZEL ORAL SUSPENSION 40 ST; NDS /ML 28 ST; NDS; QL (30 per 30

BANZEL ORAL TABLET 200, ST; NDS 400 BRIVIACT INTRAVENOUS QL (80 per SOLUTION 50 /5 ML BRIVIACT ORAL SOLUTION 0 /ML NDS; QL (600 per 30 BRIVIACT ORAL TABLET 0, 00, 25, 50, 75 NDS; QL (60 per 30 carbamazepine oral capsule, er (Carbatrol) multiphase 2 hr 00, 200, 300 carbamazepine oral suspension 00 (Tegretol) /5 ml carbamazepine oral tablet 200 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 2 hr 00, 200, 400 carbamazepine oral tablet,chewable 00 CELONTIN ORAL CAPSULE 300 clobazam oral suspension 2.5 /ml (Onfi) PA NSO; QL (480 per 30 clobazam oral tablet 0, 20 (Onfi) PA NSO; QL (60 per 30 DIASTAT ACUDIAL RECTAL KIT 2.5-5-7.5-20, 5-7.5-0 DIASTAT RECTAL KIT 2.5 diazepam rectal kit 2.5-5-7.5-20 (Diastat AcuDial), 5-7.5-0 diazepam rectal kit 2.5 (Diastat) divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 25 divalproex oral tablet extended (Depakote ER) release 24 hr 250, 500 divalproex oral tablet,delayed (Depakote) release (dr/ec) 25, 250, 500 EPIDIOLEX ORAL SOLUTION PA NSO; NDS 00 /ML epitol oral tablet 200 ethosuximide oral capsule 250 (Zarontin) 29

ethosuximide oral solution 250 /5 (Zarontin) ml felbamate oral suspension 600 /5 (Felbatol) ml felbamate oral tablet 400, 600 (Felbatol) fosphenytoin injection solution 00 (Cerebyx) pe/2 ml, 500 pe/0 ml FYCOMPA ORAL SUSPENSION ST; QL (720 per 30 0.5 /ML FYCOMPA ORAL TABLET 0 ST; NDS; QL (30 per 30, 2, 8 FYCOMPA ORAL TABLET 2 ST; QL (30 per FYCOMPA ORAL TABLET 4, ST; NDS; QL (60 per 30 6 gabapentin oral capsule 00, 300 (Neurontin) QL (360 per gabapentin oral capsule 400 (Neurontin) QL (270 per gabapentin oral solution 250 /5 ml (Neurontin) QL (260 per gabapentin oral tablet 600 (Neurontin) QL (80 per gabapentin oral tablet 800 (Neurontin) QL (20 per lamotrigine oral tablet 00, 50 (Subvenite), 200, 25 lamotrigine oral tablet, chewable (Lamictal) dispersible 25, 5 levetiracetam intravenous solution (Keppra) 500 /5 ml levetiracetam oral solution 00 (Keppra) /ml levetiracetam oral tablet,000, (Keppra) 250, 500, 750 levetiracetam oral tablet extended (Keppra XR) release 24 hr 500, 750 NAYZILAM NASAL SPRAY,NON- QL (0 per AEROSOL 5 /SPRAY (0. ML) oxcarbazepine oral suspension 300 (Trileptal) /5 ml (60 /ml) oxcarbazepine oral tablet 50, (Trileptal) 300, 600 OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE 24 HR 50, 300, 600 PEGANONE ORAL TABLET 250 30

phenobarbital oral elixir 20 /5 ml (4 /ml) PA NSO-HRM; AGE (Max 64 Years) phenobarbital oral tablet 00, 5, 6.2, 30, 32.4, 60, 64.8, 97.2 PA NSO-HRM; AGE (Max 64 Years) phenytoin oral suspension 25 /5 ml (Dilantin-25) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral (Dilantin Extended) capsule 00 phenytoin sodium extended oral (Phenytek) capsule 200, 300 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml pregabalin oral capsule 00, 50 (Lyrica) QL (90 per, 200, 225, 25, 300, 50, 75 pregabalin oral solution 20 /ml (Lyrica) QL (900 per primidone oral tablet 250, 50 (Mysoline) SABRIL ORAL TABLET 500 PA NSO; NDS; QL (80 per SPRITAM ORAL TABLET FOR ST; QL (60 per SUSPENSION,000 SPRITAM ORAL TABLET FOR SUSPENSION 250, 500, ST; QL (20 per 30 750 subvenite oral tablet 00, 50, 200, 25 SYMPAZAN ORAL FILM 0, 20 PA NSO; NDS; QL (60 per SYMPAZAN ORAL FILM 5 PA NSO; QL (60 per 30 tiagabine oral tablet 2, 6, 2 (Gabitril), 4 topiramate oral capsule, sprinkle 5 (Topamax), 25 topiramate oral capsule,sprinkle,er (Qudexy XR) 24hr 00, 50, 200, 25, 50 topiramate oral tablet 00, 200, 25, 50 (Topamax) 3

valproate sodium intravenous solution 500 /5 ml (00 /ml) valproic acid (as sodium salt) oral solution 250 /5 ml valproic acid oral capsule 250 vigabatrin oral powder in packet 500 (Vigadrone) PA NSO; NDS; QL (80 per vigabatrin oral tablet 500 (Sabril) PA NSO; NDS; QL (80 per vigadrone oral powder in packet 500 PA NSO; NDS; QL (80 per VIMPAT INTRAVENOUS QL (200 per 5 SOLUTION 200 /20 ML VIMPAT ORAL SOLUTION 0 QL (200 per /ML VIMPAT ORAL TABLET 00, QL (60 per 50, 200, 50 zonisamide oral capsule 00, 25 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 0, 5 (Aricept) QL (30 per donepezil oral tablet,disintegrating QL (30 per 0, 5 galantamine oral capsule,ext rel. (Razadyne ER) QL (30 per pellets 24 hr 6, 24, 8 galantamine oral solution 4 /ml QL (200 per galantamine oral tablet 2, 4, (Razadyne) QL (60 per 8 memantine oral capsule,sprinkle,er (Namenda XR) QL (30 per 24hr 4, 2, 28, 7 memantine oral solution 2 /ml QL (360 per memantine oral tablet 0, 5 (Namenda) QL (60 per NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/4/2/28-0 NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 4-0, 2-0, 28-0, 7-0 QL (30 per rivastigmine tartrate oral capsule.5 QL (60 per, 3, 4.5, 6 32

rivastigmine transdermal patch 24 (Exelon) QL (30 per hour 3.3 /24 hour, 4.6 /24 hr, 9.5 /24 hr Antidepressants Antidepressants amitriptyline oral tablet 0, 00, 50, 25, 50, 75 amoxapine oral tablet 00, 50, 25, 50 bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended (Wellbutrin XL) release 24 hr 50, 300 bupropion hcl oral tablet sustainedrelease (Wellbutrin SR) 2 hr 00, 50, 200 citalopram oral solution 0 /5 ml QL (600 per citalopram oral tablet 0, 20, (Celexa) QL (30 per 40 clomipramine oral capsule 25, 50, 75 (Anafranil) desipramine oral tablet 0, 25 (Norpramin) desipramine oral tablet 00, 50, 50, 75 desvenlafaxine succinate oral tablet (Pristiq) QL (30 per extended release 24 hr 00, 25, 50 doxepin oral capsule 0, 00, 50, 25, 50, 75 doxepin oral concentrate 0 /ml DRIZALMA SPRINKLE ORAL ST; QL (60 per CAPSULE, DELAYED REL SPRINKLE 20, 30, 60 DRIZALMA SPRINKLE ORAL ST; QL (30 per CAPSULE, DELAYED REL SPRINKLE 40 duloxetine oral capsule,delayed (Cymbalta) QL (60 per release(dr/ec) 20, 30, 60 EMSAM TRANSDERMAL PATCH 24 HOUR 2 /24 HR, 6 /24 NDS; QL (30 per 30 HR, 9 /24 HR escitalopram oxalate oral solution 5 /5 ml 33