H8029_EPC15249_Accepted Elderplan FIDA Total Care (Medicare-Medicaid Plan 2016 年承保藥物清單 ( 處方藥一覽表 這是一份藥物清單, 參保者可從 Elderplan FIDA Total Care 獲取 Elderplan

2016 Elderplan FIDA Total Care (Medicare-Medicaid Plan 本綜合處方藥一覽表自 2016 年 4 月 01 日起未作任何變更 如有問題, 請致電 Elderplan FIDA Total Care 參保者服務部聯絡我們, 電話 :1-855-462-3167, 聽障和語障人士可致電 711, 服務時間為 : 早上 8 點至晚上 8 點, 每週七天, 或瀏覽 www.elderplanfida.org Elderplan FIDA Total Care (Medicare-Medicaid Plan 是一項與 Medicare 和紐約州衛生署 (Medicaid 均簽有合約, 以便經由全面整合雙重利惠 (FIDA 示範計劃向參保者提供兩項計劃之福利的管理式醫療保健計劃 承保藥物清單及藥房網絡在每年 1 月 1 日可能會有所調整, 在全年內也可能會不時變更 您可免費取得以其他語言撰寫的資訊 통화료는무료입니다.m 您可免費取得以其他語言撰寫的資訊 請於週一至週日上午 8 致電 1-855-462-3167,TTY/TDD 使用者 :711 此為免付費電話 時至下午 8 時 2016 年綜合處方藥一覽表 Elderplan FIDA Total Care (Medicare-Medicaid Plan 請閱讀 : 本文件包含有關本計劃承保藥物的資訊 本綜合處方藥一覽表自 2016 年 4 月 01 日起未作任何變更 如有問題, 請致電 Elderplan FIDA Total Care 參保者服務部聯絡我們, 電話 :1-855-462-3167, 聽障和語障人士可致電 711, 服務時間為 : 早上 8 點至晚上 8 點, 每週七天, 或瀏覽 www.elderplanf i da.org H8029_EPC15249_Accepted HPMS Approved Formulary File Submission ID 00016200, Version Number 10 H8029_EPC15249_Accepted

H8029_EPC15249_Accepted Elderplan FIDA Total Care (Medicare-Medicaid Plan 2016 年承保藥物清單 ( 處方藥一覽表 這是一份藥物清單, 參保者可從 Elderplan FIDA Total Care 獲取 Elderplan FIDA Total Care 是一項與 Medicare 和紐約州衛生署 (Medicaid 均簽有合約, 以便經由全面整合雙重利惠 (Fully Integrated Duals Advantage, 簡稱 FIDA 示範計劃向參保者提供兩項計劃之福利的管理式醫療保健計劃 承保藥物清單和 / 或藥房及提供者網絡在全年內可能會有所變更 在做出會影響您的變更之前, 我們將給您寄送通知 每年 1 月 1 日福利可能會發生變化 如需 Elderplan FIDA Total Care 的最新承保藥物清單, 您可以瀏覽網站 www.elderplanfida.org, 或致電 Elderplan FIDA Total Care 參保者服務部, 電話 :1-855- 462-3167 可能會有適用的約束及限制 如需更多資訊, 請致電 Elderplan FIDA Total Care 參保者服務部或細閱 Elderplan FIDA Total Care 參保者手冊 任何承保藥物均無需支付定額手續費 您可以免費取得此資訊的其他格式版本, 例如大號字體印刷版或音訊 請致電 1-855- 462-3167, 聽障 / 語障人士可致電 711, 服務時間為早上 8 點至晚上 8 點 此為免付費電話 You can get this information for free in other languages.call 1-855-462-3167 and TTY/TDD users should dial 711 during 8:00 A.M. to 8:00 P.M. The call is free. Puede obtener esta información de manera gratuita en otros idiomas. Llame al 1-855-462-3167 y TTY/TDD 711 de lunes a domingos de 8:00 A.M. a 8:00 P.M. La llamada es gratuita. Ou ka jwenn enfòmasyon sa a gratis nan lòt lang.rele nan 1-855-462-3167 ak nan TTY/TDD (pou moun ki gen pwoblèm tande oswa moun ki bèbè 711 de lendi a dimanch 8:00 A.M. - 8:00 P.M. Apèl la gratis. 이정보는다른언어로도제공됩니다무료. 월요일-일요일8:00 A.M. 8:00 P.M. 중 1-855-462-3167 나 TTY/TDD 71 로전화주십시오. 통화료는무료입니다. 您可免費取得以其他語言撰寫的資訊 請於週一至週日上午 8 時至下午 8 時致電 1-855-462-3167, TTY/TDD 使用者 :711 此為免付費電話 Данная информация доступна бесплатно на других языках. Звоните по номеру 1-855- 462-3167 или 711 (линия TTY/TDD с понедельника по воскресенье с 8:00 до 20:00. Звонок бесплатный. È possibile riceverequeste informazioni in altre lingue gratuitamente. Contatta il 855-462-3167 etty/tdd 711 dal lunedì alla domenica dalle ore 8:00 alle ore 20:00. Il servizio è gratuito. 紐約州設立了一個名為 Independent Consumer Advocacy Network (ICAN 的參保者監察官計劃, 就 Elderplan FIDA Total Care 提供的任何服務向參保者提供免費及保密的協助 您可致電免費電話 1-844-614-8800 或線上瀏覽網站 icannys.org 聯絡 ICAN 如有問題, 請致電 Elderplan FIDA Total Care, 電話 :1-855-462-3167, 服務時間為早上 8 點至晚上 8 點, 每週七天, 聽障 / 語障人士可致電 711 此為免付費電話 如需更多資訊, 請瀏覽 www.elderplanfida.org I

常見問題 (FAQ 在此處查找您對本承保藥物清單的問題解答 您可以閱讀全部的常見問題以瞭解更多資訊, 或是查找特定的問題和解答 1. 承保藥物清單上有哪些處方藥?( 我們將承保藥物清單簡稱為 藥物清單 從第 1 頁開始的承保藥物清單上的藥物是 Elderplan FIDA Total Care 承保的藥物 這些藥物可在我們網絡內的藥房購買 如果我們與一家藥房簽訂合作協議並向您提供服務, 這家藥房即屬於我們的網絡內藥房 我們將這些藥房稱為 網絡內藥房 g Elderplan FIDA Total Care 在以下情況中承保藥物清單上的所有藥物 : 您的醫生或其他處方醫師表示您需要這些藥物以恢復健康或保持健康, 藥物對您的病情具有醫療必要性, 及 您會在 Elderplan FIDA Total Care 網絡內藥房配取處方藥 g Elderplan FIDA Total Care 可能要求採取額外行動才能獲得某些藥物 ( 請參見下文第 5 題 在某些情況下, 您必須採取一些行動才能獲得藥物, 例如首先嘗試其他藥物 您也可以在我們的網站 www.elderplanfida.org 或致電參保者服務部 1-855-462-3167 查詢最新的承保藥物清單 2. 藥物清單會變更嗎? 是的 Elderplan FIDA Total Care 可能會在一年之中增加或刪減藥物清單上的藥物 一般而言, 藥物清單只會在以下情況下變更 : 出現一種新藥物, 其藥效與目前藥物清單上的藥物相同, 或 我們得知一種藥物不安全 我們也可能更改有關藥物的規則 例如, 我們 可能 : 決定要求或不要求某種藥物獲得事先批准 ( 事先批准是您在獲得藥物之前需要從 Elderplan FIDA Total Care 或您跨科團隊 (IDT 處獲得的許可 增加或改變您可以獲得的藥量 ( 稱為 數量限制 增加或改變藥物的階段療法限制 ( 階段療法指您必須先嘗試一種藥物, 我們才會承保另一種藥物 ( 有關這些藥物規則的更多資訊, 請參閱第 III 頁 如果您使用的藥物從藥物清單上刪除, 我們會告訴您 當我們改變承保藥物的規則時, 我們也會告訴您 下文中的問題 3 4 和 7 會提供藥物清單變更時的更多相關資訊 g 您可以隨時在網站 www.elderplanfida.org 查詢 Elderplan FIDA Total Care 的最新藥物清單 您也可以致電參保者服務部 1-855-462-3167, 查詢最新的藥物清單 如有問題, 請致電 Elderplan FIDA Total Care, 電話 :1-855-462-3167, 服務時間為早上 8 點至晚上 8 點, 每週七天, 聽障 / 語障人士可致電 711 此為免付費電話 如需更多資訊, 請瀏覽 www.elderplanfida.org II

Elderplan FIDA Total Care (Medicare-Medicaid Plan 2016 年處方藥一覽表 3. 如果市面上出現一種比較便宜的藥物, 而且藥效與目前藥物清單上的藥物相同時會如何處理? 如果出現一種比較便宜的藥物, 且藥效與目前藥物清單上的藥物相同 : 您的藥劑師可能在您下次配取處方藥時向您提供這種比較便宜的藥物 如果您和您的提供者認為這種較便宜的藥物不適合您, 您的提供者可以告知藥劑師, 繼續為您提供您目前使用 的藥物 Elderplan FIDA Total Care 可能會決定將價格較高的藥物從藥物清單中刪除 如果您使用的藥物因為市面上出現價格較低且藥效相同的藥物而被我們撤出藥物清單, 我們會在撤出藥物清單之前至少 60 天或是當您要求重新配藥時告訴您 然後, 您可以在藥物清單變更之前獲得 60 天份的供藥 如果您目前正在使用的藥物即將被刪除,Elderplan FIDA Total Care 會在我們更改藥物清單前至少 60 天為您來信說明 如果您決定使用將從藥物清單上刪除價格較高的藥物, 您的護理經理會與您和您的處方醫生合作獲得批准或換用藥物清單上價格較低的藥物 您的護理經理還會將您藥物治療方案的變化告知您的跨科團隊 (IDT 4. 當我們發現一種藥物不安全時會怎麼辦? 如果食品藥物管理局 (FDA 表示您正在使用的一種藥物不安全, 我們會立刻從藥物清單刪除 我們還會寄信並致電告知您, 不安全的藥物已從藥物清單中刪除 如果您收到我們參保者服務部寄出的此類信函, 請立刻致電您的護理經理 您可致電參保者服務部的免付費號碼 :1-855-462-3167 我們的護理經理將與您和您的處方醫生合作, 在藥物清單上尋找安全的替代藥物 您的護理經理還會告知您的跨科團隊 (IDT 此事宜, 確保及時更新您的護理計劃 5. 藥物承保有任何限制嗎? 還是需要採取任何行動才能獲得某些藥物? 是的, 某些藥物有承保規則或是對您可以獲得的藥量有限制 在某些情況下, 您或您的醫生或其他處方醫師必須採取一些行動才能獲得藥物 例如 : 事先批准 ( 或事先授權 : 就某些藥物而言, 您或您的醫生或其他處方醫師在您配取處方藥前必須取得 Elderplan FIDA Total Care 或您跨科團隊 (IDT 的批准 若您未獲得批准,Elderplan FIDA Total Care 可能不會承保該藥物 數量限制 : 有時,Elderplan FIDA Total Care 會限制您可以獲得的藥量 階段療法 : 有時,Elderplan FIDA Total Care 要求您接受階段療法 這是指您必須按某種順序使用藥物來治療您的疾病 您可能必須先嘗試一種藥物, 我們才會承保另一種藥物 如果您的醫生認為第一種藥物對您無效, 我們才會承保第二種藥物 如有問題, 請致電 Elderplan FIDA Total Care, 電話 :1-855-462-3167, 服務時間為早上 8 點至晚上 8 點, 每週七天, 聽障 / 語障人士可致電 711 此為免付費電話 如需更多資訊, 請瀏覽 www.elderplanfida.org III

您可以透過第 1 頁開始的表格查詢您的藥物是否有額外的要求或限制 您也可以瀏覽我們的網站 www.elderplanfida.org 瞭解更多資訊 我們已在線上刊載文件, 解釋我們事先授權和階段療法的限制 您也可以要求我們寄一份給您 您可以對這些限制提出 例外處理 要求 請參閱問題 11, 瞭解有關例外處理的更多資訊 g 如果您住在護理機構或其他長期護理機構, 而且需要一種不在藥物清單上的藥物, 或是您無法輕易取得需要的藥物, 我們可以為您提供幫助 無論您是否為 Elderplan FIDA Total Care 的新參保者, 我們都會為您需要的藥物承保 31 天份的緊急供藥 ( 除非處方開立更少天數, 以便您有時間與您的醫生或其他處方醫師討論 他們可以幫助您決定您是否可以使用藥物清單上的另一種類似藥物, 或是否要求例外處理 請參閱第 11 題有關例外處理的詳細資訊 6. 您如何知道您想要的藥物是否有限制或需要採取什麼行動來獲得藥物? 第 1 頁的承保藥物清單有 一欄 7. 如果我們更改承保某些藥物的規則會如何處理? 例如, 如果我們新增某種藥物的事先授權 ( 批准 數量限制及/ 或階段療法限制 我們會告訴您, 我們是否對某種藥物新增了事先批准 數量限制及 / 或階段療法限制 我們會在增加限制之前至少 60 天或是在您下次要求重新配取時告訴您 然後, 您可以在藥物清單變更之前獲得 60 天的藥量 這樣可以讓您有時間和醫生或其他處方醫師討論接下來該怎麼做 8. 如何查詢某種藥物是否列於藥物清單上? 有兩種方式可以查詢藥物 : 您可以按字母順序搜尋 ( 如果您知道如何拼寫藥物名稱, 或 您可以按照疾病搜尋 要按照字母順序搜尋, 請翻到第 59 頁的字母清單部分 然後在清單中查找藥物的名稱 要按疾病搜尋, 請翻到第 VIII 頁的 按疾病排列的藥物清單 一節 本節所列藥物按照所治療的病症類型分類 例如, 如果您患有心臟病, 您應該查看 心血管 類別 您可以在該類別找到治療心臟病的藥物 如有問題, 請致電 Elderplan FIDA Total Care, 電話 :1-855-462-3167, 服務時間為早上 8 點至晚上 8 點, 每週七天, 聽障 / 語障人士可致電 711 此為免付費電話 如需更多資訊, 請瀏覽 www.elderplanfida.org IV

Elderplan FIDA Total Care (Medicare-Medicaid Plan 2016 年處方藥一覽表 9. 如果您想要使用的藥物不在藥物清單上怎麼辦? 如果您在藥物清單上沒有查到您的藥物, 請致電參保者服務部諮詢, 電話 :1-855-462-3167 如果您得知 Elderplan FIDA Total Care 不會承保該藥物, 您可以採取以下一種行動 : 向參保者服務部索取一份與您想要使用的藥物類似的清單 然後將該清單出示給您的醫生或其他處方醫師 他們可以開立藥物清單上與您想要使用的藥物類似的藥物 或 您可要求計劃或您的跨科團隊 (IDT 破例承保您的藥物 請參閱第 11 題有關例外處理的詳細資訊 10. 如果您是 Elderplan FIDA Total Care 的新參保者, 而且在藥物清單上找不到您的藥物或是您在領取藥物時遇到困難該怎麼辦? 我們可以幫忙 我們會在您成為 Elderplan FIDA Total Care 參保者後的前 90 天按需要承保 90 天的臨時性供藥, 以便您有時間與您的醫生或其他處方醫師討論 他們可以幫助您決定您是否可以使用藥物清單上的另一種類似藥物, 或是否要求例外處理 如果您符合以下條件, 我們會承保 90 天的臨時性供藥 : 您正在使用未列於我們藥物清單上的藥物, 或 根據保健計劃的規則, 您無法取得處方醫師所開立的藥量, 或 藥物需要 Elderplan FIDA Total Care 或您跨科團隊 (IDT 的事先批准, 或 您正在使用的藥物屬於階段療法限制中的藥物 如果您住在護理機構或其他長期護理機構, 您可以重新配取 91 天 ( 最多 98 天 份量的處方藥 在您參保本計劃的前 90 天內, 您可多次重新配取藥物 這樣, 您的處方醫師有時間將您的藥物改成藥物清單上的藥物或是申請例外處理 Elderplan FIDA Total Care 現有參保者的護理等級變更 當參保者從一個治療機構轉到另一個治療機構時, 護理等級會發生變化 例如, 如果您從醫院或專業護理機構 (SNF 或門診機構轉入長期護理 (LTC 機構,Elderplan FIDA Total Care 將承保 31 天的過渡期臨時性供藥 ( 除非您的處方寫明更少的天數 在您入住長期護理機構的前 90 天內,Elderplan FIDA Total Care 將承保這些藥物的多次重新配取 如果您離開長期護理機構或出院返家,Elderplan FIDA Total Care 將承保 30 天的臨時性供藥 ( 除非您的處方寫明更少的天數 這適用於可能未列於 Elderplan FIDA Total Care 藥物清單上的藥物, 或受事先授權或數量限制等承保限制的藥物 您的護理經理將與您和您的處方醫師合作, 協助您申請例外處理, 以更好地適應護理等級變更 如有問題, 請致電 Elderplan FIDA Total Care, 電話 :1-855-462-3167, 服務時間為早上 8 點至晚上 8 點, 每週七天, 聽障 / 語障人士可致電 711 此為免付費電話 如需更多資訊, 請瀏覽 www.elderplanfida.org V

11. 我可以申請例外處理以獲得藥物承保嗎? 是的 您可以向 Elderplan FIDA Total Care 或您的跨科團隊 (IDT 申請例外處理, 以承保不在藥物清單中的藥物 您也可以要求 Elderplan FIDA Total Care 或您的 IDT 更改針對藥物的相關規則 例如,Elderplan FIDA Total Care 可能會限制某種藥物的承保藥量 如果您的藥物有上限規定, 您可要求我們或您的 IDT 更改這項限制, 承保更多藥量 其他例子 : 您可要求我們或您的 IDT 撤銷階段療法限制或是事先批准要求 12. 取得例外處理需要多長時間? 首先,Elderplan FIDA Total Care 或您的跨科團隊 (IDT 必須收到您的處方醫師支持您申請例外處理的聲明 我們收到聲明後, 會在 72 小時內對您的例外處理申請作出決定 如果您或您的處方醫師認為等候 72 小時作出決定 會對您的健康造成危害, 您可以申請加急例外處理 這是更快速的決定 如果您的處方醫師支持您的申請, 我們會在收到處方醫師的支持聲明後 24 小時內作出決定 13. 如何提出例外處理申請? 要提出例外處理申請, 請致電您的護理經理 您的護理經理將與您和您的提供者合作, 幫助您申請例外處理 14. 什麼是普通藥? 普通藥的成份與品牌藥相同 普通藥一般比品牌藥便宜, 而且普通藥的名稱通常較不為人所知 普通藥均已獲食品藥物管理局 (FDA 批准 Elderplan FIDA Total Care 承保品牌藥和普通藥 15. 什麼是 OTC 藥物? OTC 是指 非處方藥 Elderplan FIDA Total Care 承保部分 OTC 藥物 ( 若您的提供者開具該等藥物的 處方 您可以查閱 Elderplan FIDA Total Care 的藥物清單, 瞭解哪些 OTC 藥物可獲得承保 16. Elderplan FIDA Total Care 是否承保非藥物類 OTC 產品? Elderplan FIDA Total Care 承保部分非藥物類 OTC 產品 ( 若您的提供者開具該等產品的處方 非藥物類 OTC 產品的例子包括紗布墊與敷料以及注射胰島素所用的針頭和注射器 您可以查閱 Elderplan FIDA Total Care 的藥物清單, 瞭解哪些非藥物類 OTC 產品可獲得承保 17. 您需支付多少定額手續費? 您無需為藥物清單上的藥物支付定額手續費 如有問題, 請致電 Elderplan FIDA Total Care, 電話 :1-855-462-3167, 服務時間為早上 8 點至晚上 8 點, 每週七天, 聽障 / 語障人士可致電 711 此為免付費電話 如需更多資訊, 請瀏覽 www.elderplanfida.org VI

Elderplan FIDA Total Care (Medicare-Medicaid Plan 2016 年處方藥一覽表 18. 什麼是藥物等級? 藥物等級 承保藥物的類型 定額手續費 ( 分攤費用 1 普通藥 $0 2 品牌藥 $0 3 非 Medicare Rx( 處方 和 OTC ( 非處方 藥物 $0 註 : 如上文定額手續費一欄所述, 參保者無需為藥物清單上第 1 至第 3 級的藥物支付分攤費用 如有問題, 請致電 Elderplan FIDA Total Care, 電話 :1-855-462-3167, 服務時間為早上 8 點至晚上 8 點, 每週七天, 聽障 / 語障人士可致電 711 此為免付費電話 如需更多資訊, 請瀏覽 www.elderplanfida.org VII

承保藥物清單 下頁開始的承保藥物清單為您提供有關 Elderplan FIDA Total Care 承保藥物的資訊 若您在清單中尋找藥物時遇到困難, 請查閱第 59 頁開始的索引 表格的第一欄列出了藥物名稱 品牌藥用大寫字母表示 ( 如 LATUDA, 普通藥則用小寫斜體字母表示 ( 如 losartan 一欄的資訊會說明 Elderplan FIDA Total Care 在承保您的藥物時是否有任何規定 符號說明 * Medicaid 承保的非 D 部分藥物或 OTC 用品 B/D 由 Medicare B 部分或 D 部分承保 某些藥物可能由 Medicare B 部分或 D 部分承保 ( 視情況而定 可能需要提交資訊, 描述藥物的用途與規定, 以便作出裁決 PA 需要事先授權 某些藥物需要您或您的醫師獲得事先授權才能配取 這表示您將需要在配取處方藥前取得 Elderplan 或 IDT 的核准 ST 需要階段療法例外處理 您需要先嘗試藥物清單上的某些藥物, 我們才能承保此藥物 QL 數量限制 Elderplan 會限制某些藥物的承保數量 除非另有說明, 數量限制指 30 天的供藥量 例如,Elderplan 規定 Fentanyl 貼片 30 天的數量限制為 10 片 LA 取藥限制 此藥物可能僅在某些藥房提供 如需更多資訊, 請致電參保者服務部, 電話 : 1-855-462-3167 NM 不能在郵購藥房購買 註 : 藥物旁邊有 * 代表藥物不是 D 部分藥物 這些藥物有不同的上訴規則 上訴是指透過正式方式要求我們審查並更改您認為有誤的承保範圍決定 例如,Elderplan FIDA Total Care 或您的跨科團隊 (IDT 可能裁決某種您想要的藥物是 Medicare 或 Medicaid 不承保或不再承保的藥物 如果您或您的醫生或其他處方醫師不同意該裁決, 您可提出上訴 如需瞭解如何提出上訴, 請致電參保者服務部, 電話 :1-855-462-3167 或 Independent Consumer Advocacy Network (ICAN, 電話 :1-844-614-8800 您也可以參閱參保者手冊, 瞭解如何對裁決提出上訴 按疾病排列的藥物清單本節所列藥物按照所治療的病症類型分類 例如, 如果您患有心臟病, 您應該查看 心血管 類別 您可以在該類別找到治療心臟病的藥物 如有問題, 請致電 Elderplan FIDA Total Care, 電話 :1-855-462-3167, 服務時間為早上 8 點至晚上 8 點, 每週七天, 聽障 / 語障人士可致電 711 此為免付費電話 如需更多資訊, 請瀏覽 www.elderplanfida.org VIII

2Tier_Elderplan eff 04/01/2016 藥物名稱 Analgesics - DRUGS TO TREAT PAIN AND INFLAMMATION Opioid Analgesics, Long-acting - NARCOTIC PAIN RELIEVERS fentanyl 12mcg/hr, 25mcg/hr, 50mcg/hr, $0 (1 QL (10 patches / 30 75mcg/hr, 100mcg/hr days, PA FENTANYL 37.5mcg/hr, 62.5mcg/hr, 87.5mcg/hr $0 (1 QL (10 patches / 30 days, PA levorphanol tartrate TABS $0 (2 methadone hcl SOLN 5mg/5ml, 10mg/5ml $0 (1 METHADONE HCL SOLN 10mg/ml $0 (2 B/D methadone hcl TABS $0 (1 QL (240 tabs / 30 days morphine sulfate CP24 $0 (1 QL (90 caps / 30 days morphine sulfate TBCR 15mg, 30mg, $0 (1 QL (90 tabs / 30 days 60mg, 100mg morphine sulfate TBCR 200mg $0 (1 QL (60 tabs / 30 days morphine sulfate beads $0 (1 QL (90 caps / 30 days NUCYNTA ER $0 (2 QL (60 tabs / 30 days OXYCONTIN $0 (2 QL (120 tabs / 30 days, ST oxymorphone hcl TB12 5mg, 10mg, 20mg, $0 (1 QL (120 tabs / 30 days 30mg, 40mg oxymorphone hcl TB12 7.5mg $0 (1 QL (90 tabs / 30 days oxymorphone hcl TB12 15mg $0 (1 QL (60 tabs / 30 days tramadol hcl TB24 $0 (1 Opioid Analgesics, Short-acting - NARCOTIC PAIN RELIEVERS acetaminophen w/ codeine SOLN $0 (1 QL (5000ml / 30 days acetaminophen w/ codeine TABS $0 (1 QL (400 tabs / 30 days ascomp $0 (1 PA butalbital-acetaminophen-caffeine w/ codeine $0 (1 QL (370 caps / 30 days, PA codeine sulfate 15mg $0 (2 codeine sulfate 30mg, 60mg $0 (1 duramorph $0 (1 B/D endocet $0 (1 QL (370 tabs / 30 days fentanyl citrate LPOP $0 (1 QL (120 lpop / 30 days, PA hydroco/apap sol 7.5-325 $0 (1 QL (5500ml / 30 days hydroco/apap tab 2.5-325 $0 (1 QL (370 tabs / 30 days hydroco/apap tab 5-300mg $0 (1 QL (400 tabs / 30 days hydroco/apap tab 5-325mg $0 (1 QL (370 tabs / 30 days 1

hydroco/apap tab 7.5-300 $0 (1 QL (400 tabs / 30 days hydroco/apap tab 7.5-325 $0 (1 QL (370 tabs / 30 days hydroco/apap tab 10-300mg $0 (1 QL (400 tabs / 30 days hydroco/apap tab 10-325mg $0 (1 QL (370 tabs / 30 days hydrocodone-ibuprofen $0 (1 hydromorphone hcl LIQD $0 (1 hydromorphone hcl SOLN 500mg/50ml $0 (1 hydromorphone hcl TABS $0 (1 lorcet hd tab 10-325mg $0 (1 QL (370 tabs / 30 days lorcet plus tab 7.5-325 $0 (1 QL (370 tabs / 30 days lorcet tab 5-325mg $0 (1 QL (370 tabs / 30 days lortab TABS $0 (1 QL (370 tabs / 30 days morphine sulfate SOLN 10mg/5ml, $0 (1 20mg/5ml, 100mg/5ml morphine sulfate TABS $0 (2 nalbuphine hcl SOLN $0 (1 NUCYNTA $0 (2 QL (180 tabs / 30 days oxycodone hcl CAPS; CONC; SOLN; TABS $0 (1 oxycodone hcl T12A $0 (2 QL (120 tabs / 30 days oxycodone w/ acetaminophen $0 (1 QL (370 tabs / 30 days oxycodone-ibuprofen $0 (1 oxymorphone hcl TABS $0 (1 SYNALGOS-DC $0 (2 tramadol hcl TABS $0 (1 tramadol-acetaminophen $0 (1 QL (370 tabs / 30 days vicodin $0 (1 QL (400 tabs / 30 days Analgesics and Antipyretics, Misc - DRUGS TO TREAT PAIN AND FEVER Analgesics and Antipyretics, Misc - DRUGS TO TREAT PAIN AND FEVER acetaminophen CAPS $0 (3 QL (200 caps / 30 days; * acetaminophen CHEW $0 (3 * acetaminophen SOLN $0 (3 QL (200ml / 30 days; * acetaminophen SUPP $0 (3 QL (200 supp / 30 days; * acetaminophen SUSP $0 (3 * acetaminophen TABS 325mg $0 (3 * acetaminophen TABS 500mg $0 (3 QL (200 tabs / 30 days; * acetaminophen TBCR $0 (3 QL (200 tabs / 30 days; * 2

acetaminophen TBDP $0 (3 QL (200 tabs / 30 days; * Anesthetics - DRUGS FOR NUMBING Local Anesthetics - DRUGS FOR NUMBING lidocaine hcl (local anesth. $0 (1 lidocaine-prilocaine $0 (1 Anti-Addiction/Substance Abuse Treatment Agents - MISCELLANEOUS MENTAL HEALTH DRUGS Alcohol Deterrents/Anti-craving - MISCELLANEOUS MENTAL HEALTH DRUGS acamprosate calcium $0 (1 disulfiram TABS $0 (1 naltrexone hcl TABS $0 (1 Opioid Antagonists - MISCELLANEOUS MENTAL HEALTH DRUGS buprenorphine hcl SOLN; SUBL $0 (1 PA buprenorphine hcl-naloxone hcl dihydrate $0 (1 PA naloxone hcl SOLN 1mg/ml $0 (2 SUBOXONE $0 (2 PA Smoking Cessation Agents - MISCELLANEOUS MENTAL HEALTH DRUGS buproban $0 (1 CHANTIX 1mg $0 (2 QL (180 tabs / 90 days CHANTIX.5mg $0 (2 QL (11 tabs / 30 days CHANTIX CONTINUING MONTH $0 (1 QL (56 tabs / 28 days CHANTIX STARTING MONTH PA $0 (2 QL (53 tabs / 30 days NICOTROL INHALER $0 (2 NICOTROL NS $0 (2 Anti-inflammatory Agents - DRUGS TO TREAT PAIN AND INFLAMMATION Nonsteroidal Anti-inflammatory Drugs - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib CAPS $0 (1 diclofenac potassium $0 (1 diclofenac sodium TB24; TBEC $0 (1 diclofenac w/ misoprostol $0 (1 diflunisal $0 (1 etodolac $0 (1 fenoprofen calcium TABS $0 (1 flurbiprofen TABS $0 (1 ibuprofen SUSP $0 (1 3

ibuprofen TABS 400mg, 600mg, 800mg $0 (1 ketoprofen CAPS; CP24 $0 (1 meclofenamate sodium CAPS $0 (1 meloxicam SUSP; TABS $0 (1 nabumetone TABS $0 (1 naproxen SUSP; TABS; TBEC $0 (1 naproxen sodium TABS 275mg, 550mg $0 (1 oxaprozin $0 (1 piroxicam CAPS $0 (1 sulindac TABS $0 (1 tolmetin sodium CAPS $0 (1 tolmetin sodium TABS 600mg $0 (1 VOLTAREN GEL 1% $0 (2 Antianemia Drugs Iron Preparations FERROUS GLUCONATE TABS 324mg $0 (3 * ferrous sulfate TABS 325mg $0 (3 * ferrous sulfate TBEC 325mg $0 (3 * polysaccharide iron complex $0 (3 * Antibacterials - DRUGS TO TREAT INFECTIONS Aminoglycosides - DRUGS TO TREAT INFECTIONS amikacin sulfate SOLN 500mg/2ml $0 (1 GENTAM/NACL INJ 0.9MG/ML $0 (1 GENTAM/NACL INJ 1.4MG/ML $0 (1 gentam/nacl inj 60mg $0 (1 gentam/nacl inj 80mg $0 (1 gentam/nacl inj 100mg $0 (1 gentamicin in saline inj 1.6 mg/ml $0 (1 gentamicin sulfate SOLN $0 (1 gentamicin sulfate (ophth OINT $0 (1 neomycin sulfate TABS $0 (1 paromomycin sulfate CAPS $0 (1 streptomycin sulfate SOLR $0 (1 tobramycin NEBU $0 (1 B/D, NM tobramycin sulfate SOLN 10mg/ml, 80mg/2ml $0 (1 Antibacterials - DRUGS TO TREAT INFECTIONS bacitracin (topical $0 (3 * bacitracin zinc OINT $0 (3 * Antibacterials, Other - DRUGS TO TREAT INFECTIONS baci-im $0 (1 4

chloramphenicol sodium succinate $0 (1 clindamycin hcl CAPS $0 (1 clindamycin palmitate hydrochloride $0 (1 clindamycin phosphate SOLN 600mg/4ml $0 (1 clindamycin phosphate in d5w $0 (1 colistimethate sodium SOLR $0 (1 CUBICIN $0 (2 linezolid $0 (1 methenamine hippurate $0 (1 metronidazole CAPS; TABS $0 (1 metronidazole in nacl $0 (2 MONUROL $0 (2 nitrofurantoin macrocrystal $0 (1 PA nitrofurantoin monohyd macro $0 (1 PA polymyxin b sulfate SOLR $0 (1 PRIMSOL $0 (2 SYNERCID $0 (2 trimethoprim TABS $0 (1 TYGACIL $0 (2 vancomycin hcl CAPS $0 (1 vancomycin hcl SOLR 10gm, 1000mg $0 (1 vancomycin hcl SOLR 500mg $0 (2 XIFAXAN $0 (2 ZYVOX SUSR; TABS $0 (2 Beta-lactam, Cephalosporins - DRUGS TO TREAT INFECTIONS cefaclor CAPS $0 (1 CEFACLOR ER $0 (1 cefadroxil $0 (1 CEFAZOLIN SODIUM SOLN $0 (1 cefazolin sodium SOLR 1gm, 10gm, $0 (1 500mg cefdinir $0 (1 cefepime hcl $0 (1 cefotaxime sodium 1gm, 2gm, 500mg $0 (1 CEFOTETAN $0 (1 CEFOXITIN SODIUM $0 (1 cefoxitin sodium 1gm, 2gm, 10gm $0 (1 cefpodoxime proxetil $0 (1 cefprozil $0 (1 ceftazidime $0 (1 5

ceftriaxone sodium SOLR 1gm, 2gm, $0 (1 10gm, 250mg, 500mg cefuroxime axetil $0 (1 cefuroxime sodium 1.5gm, 7.5gm, 750mg $0 (1 cephalexin $0 (1 tazicef SOLR $0 (1 TEFLARO $0 (2 Beta-lactam, Other - DRUGS TO TREAT INFECTIONS aztreonam 1gm $0 (1 CAYSTON $0 (2 NM, PA imipenem-cilastatin $0 (1 INVANZ $0 (2 meropenem 500mg $0 (1 Beta-lactam, Penicillins - DRUGS TO TREAT INFECTIONS amoxicillin $0 (1 amoxicillin & pot clavulanate $0 (1 amp-sulbacta inj 1.5gm $0 (1 amp-sulbacta inj 3gm $0 (1 amp-sulbacta inj 15gm $0 (1 ampicillin $0 (1 ampicillin sodium 1gm, 10gm, 125mg $0 (1 BICILLIN C-R $0 (2 dicloxacillin sodium $0 (1 nafcillin sodium 1gm $0 (2 nafcillin sodium 10gm $0 (1 oxacillin sodium 2gm, 10gm $0 (1 penicillin g potassium $0 (1 PENICILLIN G POTASSIUM IN $0 (1 PENICILLIN G PROCAINE $0 (2 penicillin g sodium $0 (1 penicillin v potassium $0 (1 piperacillin sodium-tazobactam sodium $0 (1 Macrolides - DRUGS TO TREAT INFECTIONS azithromycin PACK $0 (1 azithromycin SOLR 500mg $0 (2 azithromycin SUSR $0 (1 QL (120ml / 30 days azithromycin TABS $0 (1 clarithromycin SUSR; TABS; TB24 $0 (1 E.E.S. GRANULES $0 (2 ERYPED 200 $0 (2 ERYPED 400 $0 (2 6

ERYTHROCIN LACTOBIONATE 500mg $0 (1 erythrocin stearate $0 (1 erythromycin base TABS $0 (1 ERYTHROMYCIN BASE TBEC $0 (1 erythromycin ethylsuccinate $0 (1 KETEK $0 (2 Quinolones - DRUGS TO TREAT INFECTIONS ciprofloxacin SOLN 400mg/40ml $0 (1 ciprofloxacin SUSR $0 (1 ciprofloxacin hcl TABS $0 (1 ciprofloxacin in d5w $0 (1 ciprofloxacn tab 500mg er $0 (1 ciprofloxacn tab 1000mg $0 (1 levofloxacin TABS $0 (1 levofloxacin in d5w $0 (1 levofloxacin inj 25mg/ml $0 (1 levofloxacin sol 25mg/ml $0 (1 MOXIFLOXACIN HCL SOLN $0 (1 moxifloxacin hcl TABS $0 (1 ofloxacin $0 (1 Sulfonamides - DRUGS TO TREAT INFECTIONS SULFADIAZINE TABS $0 (1 sulfamethoxazole-trimethoprim $0 (1 Tetracyclines - DRUGS TO TREAT INFECTIONS demeclocycline hcl $0 (1 doxy $0 (1 doxycycline (monohydrate $0 (1 doxycycline hyclate CAPS; TABS; TBEC $0 (1 minocycline hcl CAPS $0 (1 Anticonvulsants - DRUGS TO TREAT SEIZURES Anticonvulsants, Other - DRUGS TO TREAT SEIZURES LEVETIRACETAM SOLN $0 (2 levetiracetam SOLN 100mg/ml, $0 (1 500mg/5ml levetiracetam TABS $0 (1 levetiracetam TB24 $0 (1 POTIGA $0 (2 Barbiturates ONFI SUSP $0 (2 phenobarbital ELIX; TABS $0 (1 PA Benzodiazepines 7

clonazepam TABS; TBDP $0 (1 PA DIASTAT ACUDIAL 10mg $0 (2 PA DIASTAT PEDIATRIC $0 (2 PA diazepam (anticonvulsant $0 (1 PA ONFI TABS $0 (2 Calcium Channel Modifying Agents - DRUGS TO TREAT SEIZURES CELONTIN $0 (2 ethosuximide CAPS; SOLN $0 (1 LYRICA CAPS 25mg, 50mg, 75mg $0 (2 QL (120 caps / 30 days LYRICA CAPS 200mg $0 (2 QL (90 caps / 30 days LYRICA CAPS 225mg, 300mg $0 (2 QL (60 caps / 30 days LYRICA SOLN $0 (2 QL (946ml / 30 days zonisamide CAPS $0 (1 Gamma-aminobutyric Acid (GABA Augmenting Agents - DRUGS TO TREAT SEIZURES divalproex sodium $0 (1 FYCOMPA $0 (2 gabapentin CAPS 100mg $0 (1 QL (540 caps / 30 days gabapentin CAPS 300mg $0 (1 QL (360 caps / 30 days gabapentin CAPS 400mg $0 (1 QL (270 caps / 30 days gabapentin SOLN $0 (1 gabapentin TABS $0 (1 QL (120 tabs / 30 days GABITRIL 12mg, 16mg $0 (2 primidone TABS $0 (1 SABRIL $0 (2 NM tiagabine hcl $0 (1 valproate sodium SOLN; SYRP $0 (1 valproic acid $0 (1 Glutamate Reducing Agents - DRUGS TO TREAT SEIZURES felbamate $0 (1 LAMICTAL ODT TBDP $0 (2 LAMICTAL STARTER/NOT TAKI $0 (2 LAMICTAL STARTER/TAKING C $0 (2 LAMICTAL STARTER/TAKING V $0 (2 LAMICTAL XR KIT $0 (2 lamotrigine CHEW; TABS; TB24; TBDP $0 (1 QUDEXY XR $0 (2 topiramate CPSP; TABS $0 (1 topiramate CS24 $0 (2 TROKENDI XR $0 (2 Sodium Channel Agents - DRUGS TO TREAT SEIZURES 8

APTIOM $0 (2 BANZEL $0 (2 carbamazepine CHEW; CP12; SUSP; $0 (1 TABS; TB12 CEREBYX 500mgpe/10ml $0 (2 DILANTIN $0 (2 DILANTIN INFATABS $0 (2 DILANTIN-125 $0 (2 epitol $0 (1 fosphenytoin sodium 100mgpe/2ml $0 (1 oxcarbazepine $0 (1 OXTELLAR XR $0 (2 PEGANONE $0 (2 phenytoin CHEW; SUSP $0 (1 phenytoin sodium SOLN $0 (1 phenytoin sodium extended $0 (1 VIMPAT $0 (2 Antidementia Agents - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS Antidementia Agents, Other - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS ergoloid mesylates TABS $0 (1 PA Cholinesterase Inhibitors - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride $0 (1 EXELON PT24 $0 (2 galantamine hydrobromide CP24 8mg $0 (1 QL (90 caps / 30 days galantamine hydrobromide CP24 16mg, $0 (1 24mg galantamine hydrobromide TABS $0 (1 rivastigmine dis 4.6mg/24 $0 (1 rivastigmine dis 9.5mg/24 $0 (1 rivastigmine dis 13.3/24 $0 (1 rivastigmine tartrate 1.5mg, 3mg, 4.5mg $0 (1 N-methyl-D-aspartate (NMDA Receptor Antagonist - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS memant titra pak 5-10mg $0 (1 memantine hcl $0 (1 NAMENDA TITRATION PAK $0 (2 rivastigmine tartrate 6mg $0 (1 Antidepressants - DRUGS TO TREAT DEPRESSION 9

Antidepressants, Other - DRUGS TO TREAT DEPRESSION APLENZIN $0 (2 bupropion hcl TABS; TB12; TB24 $0 (1 FORFIVO XL $0 (2 maprotiline hcl $0 (1 mirtazapine $0 (1 nefazodone hcl $0 (1 trazodone hcl TABS $0 (1 VIIBRYD $0 (2 VIIBRYD STARTER PACK $0 (2 Monoamine Oxidase Inhibitors - DRUGS TO TREAT DEPRESSION EMSAM $0 (2 QL (30 patches / 30 days MARPLAN $0 (2 phenelzine sulfate TABS $0 (1 tranylcypromine sulfate $0 (1 Serotonin/Norepinephrine Reuptake Inhibitors - DRUGS TO TREAT DEPRESSION BRINTELLIX $0 (2 ST BRISDELLE $0 (2 citalopram hydrobromide SOLN $0 (1 citalopram hydrobromide TABS 10mg, $0 (1 QL (90 tabs / 30 days 20mg citalopram hydrobromide TABS 40mg $0 (1 QL (45 tabs / 30 days DESVENLAFAXINE ER $0 (1 duloxetine hcl CPEP 20mg, 30mg, 60mg $0 (1 QL (60 caps / 30 days DULOXETINE HCL CPEP 40mg $0 (1 escitalopram oxalate SOLN $0 (1 QL (600ml / 30 days escitalopram oxalate TABS $0 (1 QL (30 tabs / 30 days FETZIMA $0 (2 FETZIMA TITRATION PACK $0 (2 fluoxetine hcl CAPS $0 (1 fluoxetine hcl CPDR $0 (1 fluoxetine hcl SOLN $0 (1 fluoxetine hcl TABS 10mg, 20mg $0 (1 FLUOXETINE HCL TABS 60mg $0 (2 fluvoxamine maleate $0 (1 IRENKA $0 (1 KHEDEZLA $0 (2 paroxetine hcl TABS 10mg, 20mg $0 (1 QL (90 tabs / 30 days paroxetine hcl TABS 30mg $0 (1 QL (60 tabs / 30 days 10

paroxetine hcl TABS 40mg $0 (1 QL (45 tabs / 30 days paroxetine hcl TB24 $0 (1 PAXIL SUSP $0 (2 PRISTIQ 25mg $0 (2 PRISTIQ 50mg, 100mg $0 (2 QL (30 tabs / 30 days, ST SARAFEM $0 (2 sertraline hcl CONC $0 (1 sertraline hcl TABS 25mg, 50mg $0 (1 QL (90 tabs / 30 days sertraline hcl TABS 100mg $0 (1 QL (60 tabs / 30 days venlafaxine hcl CP24 37.5mg $0 (1 QL (180 caps / 90 days venlafaxine hcl CP24 75mg, 150mg $0 (1 QL (90 caps / 90 days venlafaxine hcl TABS $0 (1 venlafaxine hcl TB24 $0 (1 VENLAFAXINE HCL ER 225mg $0 (1 Tricyclics - DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS $0 (1 PA amoxapine $0 (1 clomipramine hcl CAPS $0 (1 PA desipramine hcl TABS $0 (1 doxepin hcl CAPS; CONC $0 (1 PA imipramine hcl TABS $0 (1 PA imipramine pamoate $0 (1 PA nortriptyline hcl CAPS $0 (1 nortriptyline hcl SOLN $0 (2 protriptyline hcl $0 (1 SURMONTIL $0 (2 PA trimipramine maleate CAPS $0 (1 PA Antiemetics - DRUGS FOR NAUSEA AND VOMITING Antiemetics, Other - DRUGS FOR NAUSEA AND VOMITING diphenhydramine hcl SOLN $0 (1 meclizine hcl TABS $0 (1 promethazine hcl TABS 12.5mg $0 (1 PA TRANSDERM-SCOP $0 (2 Emetogenic Therapy Adjuncts - DRUGS FOR NAUSEA AND VOMITING ALOXI $0 (2 QL (5ml / 7 days dronabinol $0 (1 B/D, QL (60 caps / 30 days EMEND CAPS $0 (2 B/D granisetron hcl SOLN.1mg/ml, 1mg/ml $0 (1 granisetron hcl TABS $0 (1 B/D 11

ondansetron hcl SOLN 4mg/2ml $0 (1 B/D, QL (160ml / 30 days ondansetron hcl SOLN 4mg/5ml $0 (1 B/D ondansetron hcl TABS 4mg, 8mg $0 (1 B/D, QL (15 tabs / 5 days ondansetron hcl TABS 24mg $0 (1 B/D, QL (30 tabs / 30 days ondansetron tab 4mg odt $0 (1 B/D, QL (15 tabs / 5 days ondansetron tab 8mg odt $0 (1 B/D, QL (15 tabs / 5 days Antifungals - DRUGS TO TREAT FUNGAL INFECTIONS Antifungals - DRUGS TO TREAT FUNGAL INFECTIONS AMBISOME $0 (2 B/D amphotericin b SOLR $0 (1 B/D CANCIDAS $0 (2 fluconazole SUSR; TABS $0 (1 fluconazole in dextrose $0 (1 flucytosine CAPS $0 (1 griseofulvin microsize SUSP $0 (1 itraconazole CAPS $0 (1 ketoconazole TABS $0 (1 MYCAMINE $0 (2 NOXAFIL SUSP $0 (2 nystatin TABS $0 (1 terbinafine hcl TABS $0 (1 voriconazole SOLR; SUSR; TABS $0 (1 Antigout Agents - DRUGS TO TREAT GOUT Antigout Agents - DRUGS TO TREAT GOUT allopurinol TABS $0 (1 colchicine CAPS; TABS $0 (2 colchicine w/ probenecid $0 (1 COLCRYS $0 (2 probenecid $0 (1 Antihistamine Drugs - DRUGS TO TREAT ALLERGIES Ethanolamine Derivatives diphenhydramine hcl CAPS 25mg $0 (3 * diphenhydramine hcl LIQD $0 (3 * diphenhydramine hcl TABS 25mg $0 (3 * Propylamine Derivatives - DRUGS TO TREAT ALLERGIES brompheniramine & phenyleph $0 (3 * 12

chlorpheniramine & phenylephrine $0 (3 * chlorpheniramine & pseudoeph $0 (3 * chlorpheniramine maleate SYRP; TABS $0 (3 * triprolidine & pseudoephedrine $0 (3 * Second Generation Antihistamines - DRUGS TO TREAT ALLERGIES cetirizine hcl SYRP 1mg/ml $0 (3 * cetirizine hcl TABS 10mg $0 (3 * cetirizine-pseudoephedrine $0 (3 * fexofenadine hcl TABS $0 (3 * loratadine SYRP; TABS $0 (3 * loratadine & pseudoephedrine $0 (3 * Antihistamines - DRUGS TO TREAT ALLERGIES Antihistamines - DRUGS TO TREAT ALLERGIES dimenhydrinate TABS $0 (3 * meclizine hcl CHEW $0 (3 * Antihypoglycemic Agents, Miscellaneous Antihypoglycemic Agents, Miscellaneous dextrose (diabetic use $0 (3 * Antimigraine Agents - DRUGS TO TREAT SEVERE HEADACHES Ergot Alkaloids - DRUGS TO TREAT SEVERE HEADACHES dihydroergotamine mesylate 1mg/ml $0 (1 ERGOMAR $0 (2 Serotonin (5-HT 1b/1d Receptor Agonists - DRUGS TO TREAT SEVERE HEADACHES naratriptan hcl $0 (1 QL (54 tabs / 84 days sumatriptan inj 4mg/0.5 $0 (1 QL (9 injections / 30 days sumatriptan inj 6mg/0.5 SOAJ; SOCT $0 (1 QL (9 injections / 30 days sumatriptan inj 6mg/0.5 SOLN $0 (1 QL (10ml / 30 days sumatriptan nasal spray 5 mg/act $0 (1 sumatriptan nasal spray 20 mg/act $0 (1 sumatriptan succinate TABS $0 (1 QL (9 tabs / 30 days zolmitriptan TABS; TBDP $0 (1 Antimyasthenic Agents - NERVE CONDITION DRUGS Parasympathomimetics - MISCELLANEOUS NERVE CONDITIONS GUANIDINE HCL $0 (2 MESTINON SYRP $0 (2 MESTINON TIMESPAN $0 (2 pyridostigmine bromide TABS; TBCR $0 (1 13

Antimycobacterials - DRUGS TO TREAT INFECTIONS Antimycobacterials, Other dapsone TABS $0 (1 rifabutin $0 (1 Antituberculars - DRUGS TO TREAT TUBERCULOSIS (TB CAPASTAT SULFATE $0 (2 ethambutol hcl TABS $0 (1 isoniazid SOLN; SYRP; TABS $0 (1 PASER $0 (2 PRIFTIN $0 (2 pyrazinamide TABS $0 (1 rifampin CAPS; SOLR $0 (1 RIFATER $0 (2 SIRTURO $0 (2 TRECATOR $0 (2 Antineoplastics - DRUGS TO TREAT CANCER Alkylating Agents - CHEMOTHERAPY DRUGS BICNU $0 (2 B/D BUSULFEX $0 (2 B/D carboplatin 150mg/15ml $0 (1 B/D cisplatin 100mg/100ml $0 (1 B/D CYCLOPHOSPHAMIDE CAPS $0 (2 B/D HEXALEN $0 (2 ifosfamide SOLR 1gm $0 (1 B/D LEUKERAN $0 (2 megestrol acetate (appetite $0 (1 PA melphalan hcl $0 (1 MUSTARGEN $0 (2 oxaliplatin SOLN 100mg/20ml $0 (1 B/D THIOTEPA SOLR $0 (1 B/D TREANDA SOLN $0 (2 NM TREANDA SOLR 100mg $0 (2 NM ZANOSAR $0 (2 B/D Antiangiogenic Agents - CHEMOTHERAPY DRUGS AVASTIN $0 (2 B/D, NM CUPRIMINE $0 (2 CYRAMZA $0 (2 B/D, NM DEPEN TITRATABS $0 (2 REVLIMID $0 (2 NM, LA, PA THALOMID $0 (2 NM ZALTRAP 100mg/4ml $0 (2 NM 14

Antimetabolites - CHEMOTHERAPY DRUGS adrucil 500mg/10ml $0 (2 B/D ALIMTA 500mg $0 (2 ARRANON $0 (2 B/D azacitidine $0 (1 NM cladribine $0 (1 B/D CLOLAR $0 (2 B/D cytarabine $0 (1 B/D decitabine $0 (1 B/D, NM DROXIA $0 (2 fludarabine phosphate SOLR $0 (1 B/D fluorouracil SOLN 2.5gm/50ml $0 (1 FOLOTYN 40mg/2ml $0 (2 NM gemcitabine hcl 1gm $0 (1 mercaptopurine TABS $0 (1 methotrexate sodium SOLN 1gm/40ml $0 (1 B/D methotrexate sodium SOLR $0 (1 B/D methotrexate sodium TABS $0 (1 B/D PURIXAN $0 (2 NM TABLOID $0 (2 TREXALL $0 (2 B/D Antineoplastics - DRUGS TO TREAT CANCER ABRAXANE $0 (2 B/D ACTIMMUNE $0 (2 NM, LA AFINITOR $0 (2 NM AFINITOR DISPERZ $0 (2 NM ALECENSA $0 (2 NM, PA amifostine crystalline $0 (1 ARZERRA 100mg/5ml $0 (2 B/D, NM BELEODAQ $0 (2 NM bexarotene $0 (1 NM, PA bicalutamide $0 (1 bleomycin sulfate 30unit $0 (1 B/D BOSULIF $0 (2 NM, PA CAPRELSA $0 (2 NM COMETRIQ $0 (2 NM COSMEGEN $0 (2 COTELLIC $0 (2 NM, LA, PA dacarbazine 200mg $0 (1 B/D DARZALEX 100mg/5ml $0 (2 B/D, NM daunorubicin hcl $0 (1 B/D 15

DAUNOXOME $0 (2 B/D DEPO-PROVERA $0 (2 dexrazoxane 250mg $0 (1 B/D DOCEFREZ 20mg $0 (2 docetaxel CONC 80mg/4ml $0 (2 DOCETAXEL SOLN 80mg/8ml $0 (2 doxorubicin hcl SOLN $0 (1 B/D ELIGARD $0 (2 NM ELITEK 1.5mg $0 (2 B/D EMCYT $0 (2 EMPLICITI $0 (2 B/D, NM epirubicin hcl 50mg/25ml $0 (1 ERBITUX 100mg/50ml $0 (2 B/D, NM ERIVEDGE $0 (2 NM ERWINAZE $0 (2 NM etoposide SOLN 500mg/25ml $0 (1 B/D FARESTON $0 (2 FARYDAK $0 (2 NM, PA FASLODEX $0 (2 FIRMAGON $0 (2 NM flutamide $0 (1 FUSILEV $0 (2 B/D, NM GILOTRIF $0 (2 NM, PA GLEEVEC 100mg $0 (2 QL (90 tabs / 30 days, NM GLEEVEC 400mg $0 (2 QL (60 tabs / 30 days, NM GLEOSTINE $0 (2 HALAVEN $0 (2 NM HERCEPTIN $0 (2 B/D, NM hydroxyurea CAPS $0 (1 IBRANCE $0 (2 NM ICLUSIG 15mg $0 (2 NM ICLUSIG 45mg $0 (2 NM, PA idarubicin hcl 10mg/10ml $0 (1 IMBRUVICA $0 (2 NM, PA INLYTA 1mg $0 (2 NM INTRON A SOLN 6000000unit/ml $0 (2 B/D, NM INTRON A SOLR $0 (2 NM INTRON A W/DILUENT $0 (2 B/D, NM IRESSA $0 (2 NM, PA irinotecan hcl $0 (1 16

ISTODAX $0 (2 NM IXEMPRA KIT 45mg $0 (2 NM JAKAFI $0 (2 NM JEVTANA $0 (2 NM KADCYLA 100mg $0 (2 NM KEPIVANCE $0 (2 KEYTRUDA $0 (2 NM, PA LENVIMA 10MG DAILY DOSE $0 (2 NM LENVIMA 14MG DAILY DOSE $0 (2 NM LENVIMA 20MG DAILY DOSE $0 (2 NM LENVIMA 24MG DAILY DOSE $0 (2 NM leucovorin calcium SOLR 100mg, 350mg $0 (1 B/D leucovorin calcium TABS $0 (1 leuprolide acetate KIT $0 (1 NM LEVOLEUCOVORIN CALCIUM $0 (1 B/D, NM LONSURF $0 (2 NM, PA LUPRON DEPOT 3.75mg, 7.5mg, 22.5mg, $0 (2 NM 30mg, 45mg LYNPARZA $0 (2 NM LYSODREN $0 (2 MATULANE $0 (2 megestrol acetate SUSP; TABS $0 (1 PA MEKINIST $0 (2 NM, LA mesna $0 (1 B/D MESNEX TABS $0 (2 mitomycin SOLR 20mg $0 (1 B/D mitoxantrone hcl $0 (1 B/D, NM NEXAVAR $0 (2 QL (120 tabs / 30 days, NM, LA NILANDRON $0 (2 NINLARO $0 (2 NM, PA ODOMZO $0 (2 NM, LA, PA ONCASPAR $0 (2 NM OPDIVO 40mg/4ml $0 (2 NM, PA paclitaxel 300mg/50ml $0 (1 B/D PERJETA $0 (2 NM POMALYST $0 (2 NM PROLEUKIN $0 (2 B/D, NM RITUXAN 500mg/50ml $0 (2 NM, PA SOLTAMOX $0 (2 SPRYCEL $0 (2 NM STIVARGA $0 (2 NM, PA 17

SUTENT $0 (2 NM SYLATRON $0 (2 NM SYNRIBO $0 (2 NM TAFINLAR $0 (2 NM, LA TAGRISSO $0 (2 NM, LA, PA tamoxifen citrate TABS $0 (1 TARCEVA $0 (2 NM TARGRETIN CAPS $0 (2 NM TASIGNA $0 (2 NM TAXOTERE 80mg/4ml $0 (2 toposar 1gm/50ml $0 (1 B/D topotecan hcl SOLR $0 (1 TORISEL $0 (2 NM TRELSTAR MIXJECT $0 (2 NM tretinoin (chemotherapy $0 (1 TRISENOX $0 (2 TYKERB $0 (2 NM UVADEX $0 (2 B/D VECTIBIX 100mg/5ml $0 (2 NM VELCADE $0 (2 B/D, NM vinblastine sulfate $0 (1 B/D vincasar $0 (1 B/D vincristine sulfate $0 (1 B/D vinorelbine tartrate 50mg/5ml $0 (1 B/D VOTRIENT $0 (2 NM XALKORI $0 (2 NM XTANDI $0 (2 NM, PA, ST YERVOY 50mg/10ml $0 (2 NM ZELBORAF $0 (2 NM ZOLINZA $0 (2 NM ZYDELIG $0 (2 NM ZYKADIA $0 (2 NM ZYTIGA $0 (2 NM, PA Aromatase Inhibitors, 3rd Generation - CHEMOTHERAPY DRUGS anastrozole TABS $0 (1 QL (30 tabs / 30 days exemestane $0 (1 letrozole TABS $0 (1 Antiparasitics - DRUGS TO TREAT INFECTIONS Anthelmintics - DRUGS TO TREAT INFECTIONS OF PARASITES ALBENZA $0 (2 ivermectin TABS $0 (1 18

Antiprotozoals - DRUGS TO TREAT INFECTIONS OF PARASITES ALINIA SUSR $0 (2 QL (180ml / 30 days ALINIA TABS $0 (2 QL (6 tabs / 3 days atovaquone SUSP $0 (1 atovaquone-proguanil hcl $0 (1 chloroquine phosphate TABS $0 (1 COARTEM $0 (2 DARAPRIM $0 (2 hydroxychloroquine sulfate $0 (1 mefloquine hcl $0 (1 NEBUPENT $0 (2 B/D PENTAM 300 $0 (2 PRIMAQUINE PHOSPHATE $0 (2 quinine sulfate CAPS $0 (1 Antiparkinson Agents - DRUGS TO TREAT PARKINSONS DISEASE Anticholinergics - DRUGS TO TREAT PARKINSONS DISEASE benztropine mesylate $0 (1 PA trihexyphenidyl hcl TABS $0 (1 PA Antiparkinson Agents, Other - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl CAPS; SYRP; TABS $0 (1 entacapone $0 (1 Dopamine Agonists - DRUGS TO TREAT PARKINSONS DISEASE APOKYN $0 (2 NM bromocriptine mesylate CAPS; TABS $0 (1 NEUPRO $0 (2 pramipexole dihydrochloride TABS $0 (1 ropinirole hydrochloride $0 (1 Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors - DRUGS TO TREAT PARKINSONS DISEASE carbidopa TABS $0 (1 carbidopa-levodopa $0 (1 carbidopa-levodopa-entacapone $0 (1 Monoamine Oxidase B (MAO-B Inhibitors - DRUGS TO TREAT PARKINSONS DISEASE AZILECT $0 (2 selegiline hcl CAPS; TABS $0 (1 Antipsychotics - DRUGS TO TREAT PSYCHOSES 1st Generation/Typical - DRUGS TO TREAT MOOD DISORDERS chlordiazepoxide-amitriptyline $0 (1 PA 19

CHLORPROMAZINE HCL SOLN 50mg/2ml $0 (1 chlorpromazine hcl TABS $0 (1 compro $0 (1 fluphenazine decanoate SOLN $0 (1 fluphenazine hcl $0 (1 haloperidol TABS $0 (1 haloperidol decanoate SOLN $0 (1 haloperidol lactate $0 (1 loxapine succinate $0 (1 molindone hcl $0 (1 ORAP $0 (2 perphenazine TABS $0 (1 perphenazine-amitriptyline $0 (1 PA pimozide $0 (1 prochlorperazine $0 (1 prochlorperazine edisylate $0 (1 prochlorperazine maleate TABS $0 (1 thioridazine hcl TABS 10mg $0 (1 PA thiothixene $0 (1 trifluoperazine hcl $0 (1 2nd Generation/Atypical - DRUGS TO TREAT MOOD DISORDERS ABILIFY $0 (2 ABILIFY MAINTENA $0 (2 aripiprazole TABS $0 (1 ARIPIPRAZOLE ODT $0 (1 FANAPT $0 (2 ST FANAPT TITRATION PACK $0 (2 ST GEODON SOLR $0 (2 INVEGA 1.5mg, 3mg $0 (2 QL (30 tabs / 30 days, ST INVEGA 6mg $0 (2 QL (60 tabs / 30 days, ST INVEGA 9mg $0 (2 QL (45 tabs / 30 days, ST INVEGA SUSTENNA $0 (2 ST INVEGA TRINZA $0 (2 ST LATUDA 20mg, 60mg $0 (2 QL (180 tabs / 30 days LATUDA 40mg $0 (2 QL (180 tabs / 90 days LATUDA 80mg, 120mg $0 (2 QL (90 tabs / 90 days olanzapine SOLR $0 (1 olanzapine TABS 2.5mg $0 (1 QL (53 tabs / 30 days olanzapine TABS 5mg $0 (1 QL (90 tabs / 90 days 20

olanzapine TABS 7.5mg $0 (1 QL (180 tabs / 30 days olanzapine TABS 10mg $0 (1 QL (60 tabs / 30 days olanzapine TABS 15mg $0 (1 QL (11 tabs / 30 days olanzapine TABS 20mg $0 (1 QL (30 tabs / 30 days olanzapine TBDP 5mg $0 (1 QL (120 tabs / 30 days olanzapine TBDP 10mg $0 (1 QL (60 tabs / 30 days olanzapine TBDP 15mg $0 (1 QL (180 tabs / 90 days olanzapine TBDP 20mg $0 (1 QL (30 tabs / 30 days olanzapine-fluoxetine hcl $0 (1 paliperidone 1.5mg, 3mg $0 (1 QL (30 tabs / 30 days, ST paliperidone 6mg $0 (1 QL (60 tabs / 30 days, ST paliperidone 9mg $0 (1 QL (45 tabs / 30 days, ST quetiapine fumarate 25mg, 300mg, $0 (1 QL (180 tabs / 90 days 400mg quetiapine fumarate 50mg, 100mg, $0 (1 QL (270 tabs / 90 days 200mg REXULTI $0 (2 PA RISPERDAL CONSTA $0 (2 risperidone SOLN $0 (1 QL (480ml / 30 days risperidone TABS 1mg, 2mg, 3mg $0 (1 QL (60 tabs / 30 days risperidone TABS 4mg $0 (1 QL (120 tabs / 30 days risperidone TABS.25mg,.5mg $0 (1 QL (90 tabs / 30 days risperidone TBDP 1mg, 2mg, 3mg $0 (1 QL (60 tabs / 30 days risperidone TBDP 4mg $0 (1 QL (120 tabs / 30 days risperidone TBDP.25mg,.5mg $0 (1 QL (90 tabs / 30 days SAPHRIS $0 (2 SEROQUEL XR 50mg, 200mg $0 (2 QL (270 tabs / 90 days SEROQUEL XR 150mg, 300mg, 400mg $0 (2 QL (180 tabs / 90 days ziprasidone hcl $0 (1 ZYPREXA RELPREVV 210mg $0 (2 Treatment-Resistant - DRUGS TO TREAT MOOD DISORDERS clozapine TABS $0 (1 clozapine TBDP 12.5mg, 25mg, 100mg $0 (2 clozapine TBDP 150mg, 200mg $0 (1 VERSACLOZ $0 (2 Antivirals - DRUGS TO TREAT VIRAL INFECTIONS Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors EDURANT $0 (2 INTELENCE $0 (2 21

nevirapine SUSP $0 (2 nevirapine TABS; TB24 $0 (1 RESCRIPTOR $0 (2 SUSTIVA $0 (2 TYBOST $0 (2 VIRAMUNE XR 100mg $0 (2 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir sulfate $0 (1 abacavir sulfate-lamivudine-zidovudine $0 (1 ATRIPLA $0 (2 COMPLERA $0 (2 didanosine $0 (1 EMTRIVA $0 (2 EPIVIR SOLN $0 (2 EPIVIR HBV SOLN $0 (2 EPZICOM $0 (2 GENVOYA $0 (2 lamivudine $0 (1 lamivudine (hbv $0 (1 lamivudine-zidovudine $0 (1 RETROVIR IV INFUSION $0 (2 stavudine $0 (1 STRIBILD $0 (2 TRIUMEQ $0 (2 TRUVADA $0 (2 VIDEX PEDIATRIC 2gm $0 (2 VIREAD $0 (2 ZIAGEN SOLN $0 (2 zidovudine $0 (1 Anti-HIV Agents, Other - DRUGS TO SUPPRESS HIV/AIDS INFECTION FUZEON $0 (2 NM ISENTRESS $0 (2 SELZENTRY $0 (2 TIVICAY $0 (2 VITEKTA $0 (2 Anti-HIV Agents, Protease Inhibitors - DRUGS TO SUPPRESS HIV/AIDS INFECTION APTIVUS $0 (2 CRIXIVAN $0 (2 EVOTAZ $0 (2 22

INVIRASE $0 (2 KALETRA SOL $0 (2 KALETRA TAB 100-25MG $0 (2 KALETRA TAB 200-50MG $0 (2 LEXIVA $0 (2 NORVIR $0 (2 PREZCOBIX $0 (2 PREZISTA $0 (2 REYATAZ $0 (2 VIRACEPT $0 (2 Anti-cytomegalovirus (CMV Agents - DRUGS TO TREAT VIRAL INFECTIONS cidofovir $0 (1 ganciclovir sodium $0 (1 valganciclovir hcl $0 (1 Anti-influenza Agents - DRUGS TO TREAT VIRAL INFECTIONS RELENZA DISKHALER $0 (2 rimantadine hydrochloride $0 (1 TAMIFLU CAPS 30mg $0 (2 TAMIFLU CAPS 45mg $0 (2 QL (35 caps / 30 days TAMIFLU CAPS 75mg $0 (2 QL (40 caps / 10 days TAMIFLU SUSR $0 (2 VIRAZOLE $0 (2 Antihepatitis Agents - DRUGS TO TREAT VIRAL INFECTIONS adefovir dipivoxil $0 (1 BARACLUDE SOLN $0 (2 entecavir $0 (1 HARVONI $0 (2 NM, PA moderiba TABS $0 (1 NM, PA MODERIBA 800 DOSE PACK $0 (1 NM, PA MODERIBA 1200 DOSE PACK $0 (2 NM, PA PEG-INTRON KIT 50MCG $0 (2 QL (4 boxes / 28 days, NM PEG-INTRON REDIPEN $0 (2 QL (4 boxes / 28 days, NM PEGASYS 180mcg/0.5ml $0 (2 QL (4 syringes / 30 days, NM, PA PEGASYS 180mcg/ml $0 (2 QL (4 vials / 30 days, NM, PA PEGASYS PROCLICK $0 (2 QL (4 syringes / 30 days, NM, PA 23

PEGINTRON 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml $0 (2 QL (4 boxes / 28 days, NM RIBAPAK PAK 800/DAY $0 (1 NM, PA RIBAPAK PAK 1000/DAY $0 (1 NM, PA RIBAPAK PAK 1200/DAY $0 (2 NM, PA ribasphere CAPS $0 (1 NM, PA ribasphere TABS 200mg $0 (1 NM, PA ribasphere TABS 400mg, 600mg $0 (2 NM, PA ribavirin (hepatitis c $0 (1 NM, PA SOVALDI $0 (2 NM, PA TYZEKA $0 (2 Antiherpetic Agents - DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS; SUSP; TABS $0 (1 acyclovir sodium SOLN $0 (1 B/D famciclovir TABS 125mg $0 (1 QL (21 tabs / 10 days famciclovir TABS 250mg $0 (1 QL (68 tabs / 34 days famciclovir TABS 500mg $0 (1 QL (21 tabs / 7 days valacyclovir hcl TABS $0 (1 QL (34 tabs / 34 days Antivirals - DRUGS TO TREAT VIRAL INFECTIONS ABREVA $0 (3 QL (2gm / 30 days; * Anxiolytics - DRUGS TO TREAT ANXIETY Anxiolytics, Other - DRUGS TO TREAT ANXIETY buspirone hcl TABS $0 (1 meprobamate $0 (1 PA Benzodiazepines alprazolam TABS; TB24; TBDP $0 (1 ALPRAZOLAM INTENSOL $0 (2 chlordiazepoxide hcl $0 (1 PA clorazepate dipotassium $0 (1 diazepam CONC $0 (1 PA diazepam SOLN 1mg/ml $0 (2 PA diazepam TABS 2mg, 5mg $0 (1 QL (240 tabs / 30 days, PA diazepam TABS 10mg $0 (1 QL (120 tabs / 30 days, PA lorazepam CONC $0 (1 lorazepam TABS 1mg $0 (1 QL (90 tabs / 30 days lorazepam TABS 2mg $0 (1 QL (60 tabs / 30 days lorazepam TABS.5mg $0 (1 QL (120 tabs / 30 days oxazepam $0 (1 Autonomic Drugs 24

Autonomic Drugs, Miscellaneous NICORETTE MINI $0 (3 * nicotine PT24 $0 (3 * nicotine polacrilex GUM $0 (3 * Bipolar Agents - DRUGS TO TREAT MOOD DISORDERS Mood Stabilizers - DRUGS TO TREAT MOOD DISORDERS EQUETRO $0 (2 LITHIUM $0 (1 lithium carbonate CAPS; TABS; TBCR $0 (1 Blood Glucose Regulators - DRUGS TO TREAT DIABETES Antidiabetic Agents - DRUGS TO TREAT BLOOD SUGAR acarbose $0 (1 ALCOHOL SWABS $0 (2 CYCLOSET $0 (2 GAUZE PADS 2" X 2" $0 (2 QL (120 pads / 30 days glimepiride $0 (1 glipizide TABS; TB24 $0 (1 glipizide-metformin hcl $0 (1 glyburide TABS $0 (1 PA glyburide micronized $0 (1 PA glyburide-metformin $0 (1 PA GLYSET $0 (2 INSULIN PEN NEEDLE $0 (2 INSULIN SAFETY NEEDLES $0 (2 QL (120 needles / 30 days INSULIN SYRINGE $0 (2 INVOKAMET $0 (2 INVOKANA $0 (2 JANUMET $0 (2 JANUMET XR $0 (2 JANUVIA $0 (2 JENTADUETO $0 (2 QL (60 tabs / 30 days KOMBIGLYZE XR $0 (2 KORLYM $0 (2 NM, PA metformin hcl TABS; TB24 $0 (1 nateglinide $0 (1 ONGLYZA $0 (2 pioglitazone hcl $0 (1 QL (30 tabs / 30 days pioglitazone hcl-glimepiride $0 (1 pioglitazone hcl-metformin hcl $0 (1 QL (90 tabs / 30 days repaglinide $0 (1 25

repaglinide-metformin hcl $0 (1 SYMLINPEN 60 $0 (2 SYMLINPEN 120 $0 (2 tolazamide $0 (1 tolbutamide $0 (1 TRADJENTA $0 (2 QL (30 tabs / 30 days VICTOZA $0 (2 Glycemic Agents - DRUGS TO TREAT BLOOD SUGAR GLUCAGEN HYPOKIT $0 (2 GLUCAGON EMERGENCY KIT $0 (2 PROGLYCEM $0 (2 Insulins - INJECTABLE DRUGS TO TREAT BLOOD SUGAR APIDRA $0 (2 APIDRA SOLOSTAR $0 (2 LANTUS $0 (2 LANTUS SOLOSTAR $0 (2 LEVEMIR $0 (2 LEVEMIR FLEXTOUCH $0 (2 NOVOLIN 70/30 $0 (2 NOVOLIN N $0 (2 NOVOLIN R $0 (2 NOVOLOG $0 (2 NOVOLOG FLEXPEN $0 (2 NOVOLOG MIX 70/30 $0 (2 NOVOLOG MIX 70/30 PREFILL $0 (2 NOVOLOG PENFILL $0 (2 TOUJEO SOLOSTAR $0 (2 Blood Products/Modifiers/ Volume Expanders - DRUGS TO TREAT BLOOD DISORDERS Anticoagulants - BLOOD THINNERS ELIQUIS $0 (2 enoxaparin sodium 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 100mg/ml, 120mg/0.8ml, 150mg/ml $0 (1 QL (20 syringes / 10 days enoxaparin sodium 300mg/3ml $0 (1 QL (20ml / 10 days fondaparinux sodium $0 (1 FRAGMIN 2500unit/0.2ml $0 (2 QL (2ml / 5 days FRAGMIN 5000unit/0.2ml, $0 (2 QL (3ml / 5 days 15000unit/0.6ml FRAGMIN 7500unit/0.3ml $0 (2 QL (1.5ml / 5 days FRAGMIN 10000unit/ml $0 (2 QL (9.5ml / 5 days 26

FRAGMIN 12500unit/0.5ml $0 (2 QL (2.5ml / 5 days FRAGMIN 18000unt/0.72ml $0 (2 QL (3.6ml / 5 days FRAGMIN 95000unit/3.8ml $0 (2 QL (19ml / 5 days heparin sod (porcine in d5w $0 (1 heparin sodium (porcine $0 (1 B/D jantoven $0 (1 PRADAXA 75mg, 150mg $0 (2 QL (180 caps / 90 days PRADAXA 110mg $0 (2 QL (60 caps / 30 days warfarin sodium $0 (1 XARELTO $0 (2 XARELTO STARTER PACK $0 (2 Blood Formation Modifiers - BLOOD FORMATION DRUGS ARANESP ALBUMIN FREE $0 (2 NM, PA, ST EPOGEN 2000unit/ml $0 (2 QL (22 vials / 30 days, NM, PA EPOGEN 3000unit/ml $0 (2 QL (15 vials / 30 days, NM, PA EPOGEN 4000unit/ml, 20000unit/ml $0 (2 QL (12 vials / 28 days, NM, PA EPOGEN 10000unit/ml $0 (2 QL (36 vials / 84 days, NM, PA LEUKINE $0 (2 NM, PA MOZOBIL $0 (2 QL (8 vials / 30 days, NM, PA NEULASTA $0 (2 QL (2 syringes / 28 days, NM, PA NEUPOGEN SOLN 300mcg/ml $0 (2 QL (4 vials / 28 days, NM, PA NEUPOGEN SOLN 480mcg/1.6ml $0 (2 NM, PA NEUPOGEN SOSY $0 (2 NM, PA PROCRIT 2000unit/ml $0 (2 QL (22 vials / 30 days, NM, PA PROCRIT 3000unit/ml $0 (2 QL (15 vials / 30 days, NM, PA PROCRIT 4000unit/ml, 20000unit/ml $0 (2 QL (12 vials / 28 days, NM, PA PROCRIT 10000unit/ml $0 (2 QL (36 vials / 84 days, NM, PA PROCRIT 40000unit/ml $0 (2 QL (6 vials / 28 days, NM, PA PROMACTA $0 (2 NM tranexamic acid SOLN; TABS $0 (1 ZARXIO $0 (2 NM, PA 27

Platelet Modifying Agents - BLOOD THINNERS AGGRENOX $0 (2 anagrelide hcl $0 (1 aspirin-dipyridamole $0 (1 BRILINTA $0 (2 cilostazol $0 (1 clopidogrel bisulfate $0 (1 Cardiovascular Agents - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS Alpha-adrenergic Agonists - DRUGS TO TREAT HIGH BLOOD PRESSURE clonidine hcl PTWK; TABS $0 (1 methyldopa 250mg $0 (1 PA midodrine hcl $0 (1 Alpha-adrenergic Blocking Agents - DRUGS TO TREAT HIGH BLOOD PRESSURE DEMSER $0 (2 doxazosin mesylate $0 (1 prazosin hcl $0 (1 terazosin hcl $0 (1 Angiotensin II Receptor Antagonists - DRUGS TO TREAT HIGH BLOOD PRESSURE BENICAR $0 (2 candesartan cilexetil $0 (1 eprosartan mesylate $0 (1 irbesartan $0 (1 losartan potassium $0 (1 telmisartan $0 (1 valsartan $0 (1 Angiotensin-converting Enzyme (ACE Inhibitors - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS $0 (1 captopril TABS $0 (1 enalapril maleate TABS $0 (1 fosinopril sodium $0 (1 lisinopril TABS $0 (1 moexipril hcl $0 (1 perindopril erbumine $0 (1 quinapril hcl $0 (1 ramipril $0 (1 28

trandolapril $0 (1 Antiarrhythmics - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl SOLN 50mg/ml $0 (1 amiodarone hcl TABS $0 (1 disopyramide phosphate $0 (1 PA flecainide acetate $0 (1 mexiletine hcl $0 (1 MULTAQ $0 (2 pacerone $0 (1 procainamide hcl SOLN 100mg/ml $0 (1 PROCAINAMIDE HCL SOLN 500mg/ml $0 (1 propafenone hcl $0 (1 QUINIDINE GLUCONATE SOLN $0 (2 quinidine gluconate TBCR $0 (1 quinidine sulfate TABS $0 (1 TIKOSYN $0 (2 NM Antihypertensive Combinations - DRUGS TO TREAT HIGH BLOOD PRESSURE amiloride & hydrochlorothiazide $0 (1 amlod/benazp cap 2.5-10mg $0 (1 QL (30 caps / 30 days amlod/benazp cap 5-10mg $0 (1 QL (30 caps / 30 days amlod/benazp cap 5-20mg $0 (1 QL (30 caps / 30 days amlod/benazp cap 5-40mg $0 (1 amlod/benazp cap 10-20mg $0 (1 QL (30 caps / 30 days amlod/benazp cap 10-40mg $0 (1 amlodipine besylate-valsartan $0 (1 amlodipine-valsartan-hydrochlorothiazide $0 (1 atenolol & chlorthalidone $0 (1 AZOR $0 (2 benazepril & hydrochlorothiazide $0 (1 BENICAR HCT $0 (2 bisoprolol & hydrochlorothiazide $0 (1 candesartan cilexetil-hydrochlorothiazide $0 (1 captopril & hydrochlorothiazide $0 (1 clorpres $0 (2 enalapril maleate & hydrochlorothiazide $0 (1 fosinopril sodium & hydrochlorothiazide $0 (1 irbesartan-hydrochlorothiazide $0 (1 lisinopril & hydrochlorothiazide $0 (1 losartan potassium & hydrochlorothiazide $0 (1 methyldopa & hydrochlorothiazide $0 (1 PA 29

metoprolol & hydrochlorothiazide $0 (1 moexipril-hydrochlorothiazide $0 (1 propranolol & hydrochlorothiazide $0 (1 quinapril-hydrochlorothiazide $0 (1 spironolactone & hydrochlorothiazide $0 (1 telmisartan-amlodipine $0 (1 telmisartan-hydrochlorothiazide $0 (1 trandolapril-verapamil hcl $0 (1 triamterene & hydrochlorothiazide CAPS $0 (1 triamterene & hydrochlorothiazide TABS $0 (1 TRIBENZOR $0 (2 valsartan-hydrochlorothiazide $0 (1 Beta-adrenergic Blocking Agents - DRUGS TO TREAT HIGH BLOOD PRESSURE acebutolol hcl CAPS $0 (1 atenolol TABS $0 (1 betaxolol hcl $0 (1 bisoprolol fumarate $0 (1 carvedilol $0 (1 COREG CR $0 (2 labetalol hcl SOLN; TABS $0 (1 metoprolol succinate $0 (1 metoprolol tartrate SOLN; TABS $0 (1 nadolol TABS $0 (1 pindolol $0 (1 propranolol hcl CP24; SOLN; TABS $0 (1 sorine $0 (1 sotalol hcl $0 (1 sotalol hcl (afib/afl $0 (1 timolol maleate TABS $0 (1 Calcium Channel Blocking Agents - DRUGS TO TREAT HIGH BLOOD PRESSURE afeditab cr $0 (1 amlodipine besylate TABS $0 (1 cartia $0 (1 dilt $0 (1 diltiazem hcl CP12 $0 (1 diltiazem hcl SOLN 50mg/10ml $0 (1 DILTIAZEM HCL SOLR $0 (1 diltiazem hcl TABS $0 (1 diltiazem hcl coated beads CP24 $0 (1 30

diltiazem hcl extended release beads $0 (1 felodipine $0 (1 isradipine $0 (1 nicardipine hcl CAPS $0 (1 nifedical $0 (1 nifedipine TB24 $0 (1 nimodipine CAPS $0 (1 taztia $0 (1 verapamil hcl CP24; SOLN; TABS; TBCR $0 (1 Cardiovascular Agents, Combinations - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS amlodipine besylate-atorvastatin calcium $0 (1 NORTHERA $0 (2 NM triamterene & hydrochlorothiazide CAPS $0 (1 Cardiovascular Agents, Other - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS digitek.25mg $0 (1 PA digitek.125mg $0 (1 digoxin SOLN $0 (1 PA digoxin TABS 125mcg $0 (1 digoxin TABS 250mcg $0 (1 PA eplerenone $0 (1 pentoxifylline TBCR $0 (1 RANEXA $0 (2 reserpine TABS $0 (1 PA TEKTURNA $0 (2 Diuretics, Carbonic Anhydrase Inhibitors - DRUGS TO TREAT HIGH BLOOD PRESSURE acetazolamide CP12; TABS $0 (1 acetazolamide sodium $0 (1 methazolamide TABS $0 (2 Diuretics, Loop - DRUGS TO TREAT HIGH BLOOD PRESSURE bumetanide $0 (1 FUROSEMIDE SOLN $0 (1 furosemide TABS $0 (1 furosemide inj 10 mg/ml $0 (1 furosemide oral soln 10 mg/ml $0 (1 torsemide $0 (1 Diuretics, Potassium-sparing - DRUGS TO TREAT HIGH BLOOD PRESSURE 31

amiloride hcl TABS $0 (1 spironolactone TABS $0 (1 Diuretics, Thiazide - DRUGS TO TREAT HIGH BLOOD PRESSURE chlorothiaz inj 500mg $0 (1 chlorothiazide $0 (1 chlorthalidone 25mg, 50mg $0 (1 hydrochlorothiazide CAPS; TABS $0 (1 indapamide $0 (1 methyclothiazide $0 (1 metolazone $0 (1 Dyslipidemics, Fibric Acid Derivatives - DRUGS TO TREAT HIGH CHOLESTEROL choline fenofibrate $0 (1 fenofibrate CAPS; TABS $0 (1 fenofibrate micronized $0 (1 gemfibrozil TABS $0 (1 Dyslipidemics, HMG CoA Reductase Inhibitors - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium TABS $0 (1 QL (30 tabs / 30 days fluvastatin sodium CAPS $0 (1 lovastatin $0 (1 pravastatin sodium $0 (1 simvastatin TABS $0 (1 Dyslipidemics, Other - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine light $0 (1 colestipol hcl GRAN; TABS $0 (1 JUXTAPID 5mg, 10mg, 20mg $0 (2 NM JUXTAPID 30mg, 40mg, 60mg $0 (2 NM, PA KYNAMRO $0 (2 NM niacin (antihyperlipidemic $0 (1 niacor $0 (1 omega-3-acid ethyl esters $0 (1 prevalite $0 (1 ZETIA $0 (2 QL (30 tabs / 30 days Vasodilators, Direct-acting Arterial - DRUGS TO TREAT HIGH BLOOD PRESSURE hydralazine hcl SOLN; TABS $0 (1 minoxidil TABS $0 (1 Vasodilators, Direct-acting Arterial/Venous - DRUGS TO TREAT HIGH BLOOD PRESSURE 32

isosorbide dinitrate $0 (1 isosorbide mononitrate $0 (1 minitran $0 (1 nitroglycerin PT24 $0 (1 nitroglycerin SOLN.4mg/spray $0 (2 NITROSTAT $0 (2 Central Nervous System Agents - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine-dextroamphetamine TABS $0 (1 dexedrine TABS 5mg $0 (2 dexedrine TABS 10mg $0 (1 dextroamphetamine sulfate TABS 5mg, $0 (1 10mg zenzedi $0 (2 Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines clonidine hcl (adhd $0 (1 dexmethylphenidate hcl TABS $0 (1 guanfacine hcl (adhd $0 (1 PA metadate $0 (1 methylphenidate hcl SOLN $0 (1 methylphenidate hcl TABS $0 (1 methylphenidate hcl TB24 27mg $0 (2 PA methylphenidate hcl TBCR 20mg $0 (1 STRATTERA $0 (2 Central Nervous System, Other - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS riluzole $0 (1 tetrabenazine $0 (1 NM, PA XENAZINE $0 (2 NM, PA Fibromyalgia Agents - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS LYRICA CAPS 100mg, 150mg $0 (2 QL (120 caps / 30 days SAVELLA $0 (2 QL (60 tabs / 30 days SAVELLA TITRATION PACK $0 (2 Multiple Sclerosis Agents - DRUGS TO TREAT MULTIPLE SCLEROSIS AMPYRA $0 (2 NM, PA AVONEX $0 (2 QL (4 injections / 30 days, NM, PA AVONEX PEN $0 (2 QL (4 injections / 30 days, NM, PA 33