2015 Comprehensive Formulary

Transcripción

1 ESSENTIAL 2015 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. This formulary was updated on 11/01/2015. For more recent information or other questions, please contact First United American - Essential (PDP) at or, for TTY users, , weekdays from 8:00am to 8:00pm Eastern, or visit Formulario integral de medicamentos aprobados para 2015 (Lista de medicamentos cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS CUBIERTOS POR ESTE PLAN Nota a los miembros actuales: El formulario no es el mismo del ano pasado. Revise este document para asegurarse de que todavia contiene los medicamentos que usted toma. Este formulario se ha actualizado el 11/01/2015. Para información más reciente o otras preguntas, comuníquese con First United American - Essential (PDP) servicio al cliente a o, para los usuarios de TTY, , de lunes a viernes, de 8:00 am a 8:00 pm, Eastern, o visite Y0063_15CFORM_ESS_NY NA561 Y0063_15CFORM_ESS_SPAN_NY Last Updated 11/01/2015 CMS Accepted. File Sub ID 15318, v. 15

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3 2015 First United American - Essential Comprehensive Formulary When this drug list (formulary) refers to we, us, or our, it means First United American Life Insurance Company. When it refers to plan or our plan, it means First United American - Essential. This document includes a list of the drugs (formulary) for our plan which is current as of 11/01/2015. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. What is the First United American - Essential Formulary? A formulary is a list of covered drugs selected by First United American - Essential in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. First United American - Essential will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a First United American - Essential network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 11/01/2015. To get updated information about the drugs covered by First United American - Essential, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular/Hypertensive/Lipids. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 62. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. i

4 What are generic drugs? First United American - Essential covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: First United American - Essential requires you (or your physician) to get prior authorization for certain drugs. This means that you will need to get approval from First United American - Essential before you fill your prescriptions. If you don t get approval, First United American - Essential may not cover the drug. Quantity Limits: For certain drugs, First United American - Essential limits the amount of the drug that we will cover. For example, First United American - Essential provides 30 pills per prescription for Zetia. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, First United American - Essential requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, First United American - Essential may not cover Drug B unless you try Drug A first. If Drug A does not work for you, First United American - Essential will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization, quantity limits and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask First United American - Essential to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the First United American - Essential s formulary? below for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that First United American - Essential does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by First United American - Essential. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by First United American - Essential. You can ask First United American - Essential to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the First United American - Essential Formulary? You can ask First United American - Essential to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level (if this drug is not on the specialty tier). If approved this would lower the amount you must pay for your drug. ii

5 You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, First United American - Essential limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, First United American - Essential will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. What if there is a change in my level of care? A level of care change is defined as when enrollees: Enter long term care (LTC) facilities from hospitals or other settings; Leave LTC facilities and return to the community; Are discharged from a hospital to a home; End a skilled nursing facility (SNF) stay covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under their Part D plan formulary; Revert from hospice status to standard Medicare Part A and B benefits; and Are discharged from psychiatric hospitals with medication regimens that are highly individualized. While Part A does provide reimbursement for a limited supply to facilitate beneficiary discharge, you must be permitted to have a full outpatient supply available to continue therapy once this limited supply is exhausted. Level of Care supplies will be available for your prescription, when appropriate, that are received at retail, home infusion, or mail order. We do not use an early-refill restriction to limit appropriate and necessary access to your Part D benefit. In instances where you are admitted to, or discharged from, a long term care facility, we allow you to access a refill upon admission or discharge. However, we may use early-refill restrictions for safety reasons. iii

6 For more information For more detailed information about your First United American - Essential prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about First United American - Essential, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit First United American - Essential's Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by First United American - Essential. If you have trouble finding your drug in the list, turn to the Index that begins on page 62. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PRILOSEC) and generic drugs are listed in lower case italics (e.g., omeprazole). The information in the Requirements/Limits column tells you if First United American - Essential has any special requirements for coverage of your drug. iv

7 Formulario integral de medicamentos aprobados para 2015 Cuando esta lista de medicamentos (formulario) se refiere a nosotros nos o nuestro, que significa First United American Life Insurance Company. Cuando se refiere al plan o nuestro plan, que significa First United American - Essential. Este documento incluye una lista de los medicamentos (formulario) para nuestro plan que sera vigente al partir de 11/01/2015. Para un formulario actualizada, por favor contáctenos. Nuestra información de contacto, fechas, y formulario que aparecen en las portadas y contraportadas han sido actualizados. Generalmente se debe usar farmacias dentro de la red para usar su beneficio de medicamentos recetados. Tanto los beneficios, formularios, red de farmacias, y/o copagos/coaseguro pueden tener cambios el 01 de enero de 2016, y de tiempo a tiempo durante el ãno. Qué es el formulario de First United American - Essential? Un formulario de medicamentos aprobados es una lista de medicamentos cubiertos, seleccionados por la cobertura para recetas médicas (PDP) de First United American - Essential con el asesoramiento de un equipo de proveedores de atención médica, que representa las terapias con medicamentos considerados parte necesarios en un programa de tratamiento de calidad. En general First United American - Essential cubrirá los medicamentos incluidos en nuestro formulario de medicamentos aprobados siempre que los mismos sean médicamente necesarios, y se adquieran en una farmacia de la red de First United American - Essential y se sigan otras normas del plan. Para obtener más información sobre cómo adquirir sus medicamentos con receta, consulte su Evidencia de cobertura. Puede cambiar el formulario de medicamentos aprobados? En general, si está tomando un medicamento en nuestro formulario de 2015, que estaba cubierto a principios del año, no descontinuaremos ni reduciremos la cobertura de dicho medicamento durante 2015, excepto cuando exista un medicamento genérico nuevo, más económico o cuando se haya publicado información negativa respecto a la efectividad o seguridad del medicamento. Otros tipos de cambios en el formulario, como cuando se elimina un producto, no afectarán a los miembros que actualmente estén tomando dicho medicamento. Seguirá disponible al mismo costo compartido para aquellos miembros que lo tomen durante el resto del año de la cobertura. Consideramos que es importante que tenga acceso continuo durante el resto del año de la cobertura, a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto en los casos en los que pueda ahorrar dinero adicional o en los que podamos garantizar su seguridad. Si quitamos medicamentos de nuestro formulario de medicamentos aprobados, o agregamos autorizaciones previas, límites de cantidad y/o restricciones de tratamiento escalonado para un medicamento o pasamos un medicamento a una categoría de costo compartido superior, debemos notificar de esta situación a los afiliados afectados, al menos 60 días antes de que el cambio entre en vigencia, o en cuanto el afiliado solicite una reposición del medicamento, en cuyo momento el miembro recibirá un suministro de 60 días del mismo. Si la Administración de Alimentos y Medicamentos considera que un medicamento de nuestro formulario de medicamentos aprobados no es seguro o el fabricante del medicamento lo retira del mercado, quitaremos el medicamento de nuestro formulario de medicamentos aprobados de inmediato y notificaremos el cambio a los afiliados que toman el medicamento. El formulario de medicamentos aprobados que se adjunta entra en vigencia a partir del 11/01/2015. Para obtener información actualizada acerca de los medicamentos cubiertos por First United American - Essential, por favor. Cómo utilizo el formulario de medicamentos aprobados? Hay dos maneras de encontrar su medicamento dentro del formulario de medicamentos aprobados: Condicion Medica El formulario de medicamentos aprobados comienza en la página 1. Los medicamentos incluidos en este formulario de medicamentos aprobados están agrupados en categorías dependiendo de los tipos de afecciones que tratan. Por ejemplo, los medicamentos utilizados para tratar una afección v

8 cardiaca incluidos en la categoría Cardiovascular/Hipertenso/Lípidos. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página 1. Luego busque su medicamento bajo el nombre de la categoría. Listado alfabético Si no está seguro en qué categoría buscar, debe buscar su medicamento en el Índice que comienza en la página 62. El Índice presenta una lista por orden alfabético de todos los medicamentos incluidos en este documento. En el Índice se incluyen tanto medicamentos de marca como medicamentos genéricos. Busque en el Índice para encontrar su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información sobre la cobertura. Diríjase a la página indicada en el Índice y busque el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? First United American - Essential cubrirá tanto medicamentos genéricos como de marca. Un medicamento genérico es un medicamento que ha sido aprobado por la FDA, quien ha declarado que contiene el mismo ingrediente o ingredientes activos que el medicamento de marca. Generalmente, los medicamentos genéricos cuestan menos que los de marca. Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos y límites pueden incluir: Autorización previa: First United American - Essential requiere que usted [o su médico] obtenga una autorización previa para ciertos medicamentos. Esto significa que deberá obtener la aprobación de First United American - Essential antes de adquirir su medicamento. Si no obtiene la aprobación, puede ser que First United American - Essential no cubra el medicamento. Límites de cantidad: En el caso de ciertos medicamentos, First United American - Essential limita la cantidad de medicamento que cubriremos. Por ejemplo, First United American - Essential suministra 30 pastillas de Zetia por receta. Esto puede ser además del suministro estándar de uno a tres meses. Tratamiento escalonado: En algunos casos, First United American - Essential requiere que usted primero pruebe ciertos medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su afección, First United American - Essential puede no cubrir el Medicamento B a menos que usted pruebe primero el Medicamento A. Si el medicamento A no le sirve, First United American - Essential cubrirá el Medicamento B. Puede averiguar si su medicamento tiene algún requisito o límite adicional buscándolo en el formulario de medicamentos con receta que comienza en la página 1. También puede obtener más información sobre las restricciones que se aplican a medicamentos específicos cubiertos visitando nuestro sitio web. Hemos publicado documentos en la red de internet que explican las restricciones de nuestra Autorización Previa, Límites de Cantidad de Medicamentos y Terapia Escalonada. También puede pedir que se le envie una copia. Nuestra información de contacto, junto con la fecha en la que se actualizó por última vez el formulario, aparece en la portada y la contraportada páginas. Puede solicitarle a First United American - Essential que haga una excepción a estas restricciones o límites, o para obtener una lista de medicamentos similares, que pueden tratar su condición de la salud. Consulte la sección Cómo solicito una excepción al formulario de medicamentos aprobados de First United American - Essential? debajo para obtener información sobre cómo solicitar una excepción. Qué sucede si mi medicamento no aparece en el formulario de medicamentos aprobados? Si su medicamento no está incluido en este formulario de medicamentos aprobados, debe comunicarse primero con Servicio al cliente y preguntar si su medicamento está cubierto. Si se entera que First United American - Essential no cubre su medicamento, tiene dos opciones: vi

9 Puede pedirle a Servicio al cliente una lista de medicamentos similares que estén cubiertos por First United American - Essential. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por First United American - Essential. Puede pedirle a First United American - Essential que haga una excepción y cubra su medicamento. Consulte las secciones que siguen para obtener información sobre cómo solicitar una excepción. Cómo solicito una excepción al formulario de medicamentos aprobados de First United American - Essential? Puede solicitarle a First United American - Essential que haga una excepción a nuestras normas de cobertura. Existen varios tipos de excepciones que puede solicitarnos que hagamos. Puede pedirnos que cubramos su medicamento aunque no esté incluido en nuestro formulario de medicamentos aprobados. Si aprobada, esta droga se cubre con un nivel de participación en los gastos predeterminado, y no sería capaz de pedir que suministrar el medicamento a un costo más bajo nivel de participación. Usted puede pedirnos que cubramos un medicamento del formulario a un nivel mas bajo del gasto (si este medicamento no está en la categoría de medicamentos especializados). Si se aprueba esto reduciría la cantidad que debe pagar por su medicamento. Puede pedirnos que no apliquemos las restricciones o límites de cobertura sobre su medicamento. Por ejemplo, para ciertos medicamentos, First United American - Essential limita la cantidad de medicamento que cubriremos. Si su medicamento tiene un límite de cantidad puede pedirnos que no apliquemos el límite y cubramos más. En general, First United American - Essential sólo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el formulario de medicamentos aprobados del Plan, el medicamento de categoría inferior o las restricciones de utilización adicionales no son eficaces para el tratamiento de su afección y/o le causaran algún efecto médico adverso. Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una excepción al formulario de medicamentos aprobados, la categorización, o la restricción de utilización. Cuando solicite una excepción al formulario de medicamentos aprobados, la categorización, o la restricción de utilización, debe enviar un certificado de su prescriptor o médico que respalde su solicitud. En general, debemos tomar una decisión dentro de las 72 horas posteriores a recepción del certificado médico. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que su salud podría verse seriamente afectada por esperar 72 horas una decisión. Si su solicitud de aceleración se acepta, le daremos una decisión a más tardar en 24 horas, después de recibir el certificado de su médico en apoyo al uso del medicamento. Qué puedo hacer antes de hablar con mi médico acerca de cambiar mis medicamentos o de solicitar una excepción? Como miembro nuevo o continuo de nuestro plan, es posible que esté tomando medicamentos que no se encuentren en nuestro formulario. O podría estar tomando un medicamento que sí esté comprendido en el formulario, pero su habilidad para obtenerlo podría estar limitada. Por ejemplo, es posible que necesite una autorización previa nuestra antes de adquirir su medicamento. Debe hablar con su médico para decidir si debe cambiar a un medicamento apropiado que se encuentre cubierto o solicitar una excepción del formulario para que podamos cubrir el medicamento que está tomando. Mientras habla con su médico para determinar el curso de acción adecuado para usted, podemos proporcionarle el medicamento, en ciertos casos, durante los primeros 90 días en los que sea miembro del plan. Para cada uno de sus medicamentos que no se encuentre en el formulario o si su habilidad para obtener los medicamentos está limitada, cubriremos un suministro temporal de 30 días (a menos que cuente con una receta que establezca menos días) cuando acuda a una farmacia de la red. Después de su primer suministro por 30 días, no le pagaremos por estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días. vii

10 Si es residente de una institución de cuidados a largo plazo, cubriremos un suministro de transición temporal de 93 días, consistente con incremento de dispensación (a menos que tenga una receta por menos días). Cubriremos más de una renovación de este medicamento durante los primeros 90 días en que sea miembro de nuestro plan. Si necesita un medicamento que no se encuentra en nuestro formulario o si su habilidad para obtenerlo es limitada, pero ya han pasado los primeros 90 días de su afiliación al plan, cubriremos un suministro de emergencia del medicamento, por 31 días (a menos que tenga una receta por menos días) mientras solicita una excepción al formulario. Que si hay un cambio en mi nivel de cuidado? Un nivel de cambio del cuidado se define como cuando inscribidos sean: Internados en LTC (cuidado de largo plazo) de hospitales o de otros ajustes; Retirados de LTC (cuidado de largo plazo) y vuelvan a la comunidad; Dar de alta de un hospital a un hogar; Terminados el cuidado en un Centro de Enfermería (SNF) bajo parte A de Medicare (donde se cubren todas las cargas de la farmacia), y debe invertir a la cobertura debajo de su formulario del plan de la parte D; Invertidos de Hospicio a las ventajas estándar de la parte A y de B beneficios de Medicare; y Se descargan de hospitales psiquiátricos con los regímenes de medicación que son altamente individualizados. Mientras que la Parte A proporciona el reembolso para un suministro de drogas limitado para facilitar el descargo de beneficiario, usted debe ser permitido para tener un suministro completo del paciente no internado disponible para continuar terapia cuando un suministro de droga limitada termine. El nivel de cuidado estará disponible para su prescripción, cuando es apropiado, que se reciben en la venta al por menor, la infusión casera, o el pedido por correo. No utilizamos restricciones de rellenos tempranos o limitamos acceso apropiado necesario a sus beneficios de la parte D. En los casos a donde se ingrese o se de alta de una facilidad de largo plazo, permitimos que usted tenga acceso a un repuesio sobre la admisión o la descarga. Sin embargo, podemos utilizar restricciones de rellenos tempranos por razones de la seguridad. Para más información Para obtener información más detallada acerca de la cobertura de medicamentos con receta de First United American - Essential, consulte su Evidencia de cobertura y otros materiales del plan. Si tiene preguntas sobre First United American - Essential, por favor de contáctarse con nosotros. Nuestra información de contacto, junto con la fecha, que hemos actualizado el formulario aparece en las portadas y contraportada. Si tiene preguntas generales acerca de la cobertura de Medicare de medicamentos con receta, llame a Medicare al MEDICARE ( ) las 24 horas los 7 días de la semana. Los usuarios de TTY/TDD deben comunicarse al O, visite Formulario de medicamentos aprobados de First United American - Essential El formulario de medicamentos aprobados que comienza en la página 1 brinda información de cobertura de los medicamentos cubiertos por First United American - Essential. Si tiene algún problema para encontrar su medicamento en la lista, diríjase al Índice que comienza en la página 62. El nombre del medicamento se encuentra en la primera columna de la tabla. Los medicamentos de marca aparecen en mayúscula (por ej., PRILOSEC) y los medicamentos genéricos aparecen en letra cursiva minúscula (por ej., omeprazole). La información en la columna Notas le informa si First United American - Essential tiene algún requisito especial para la cobertura de su medicamento. viii

11 Preferred Retail Cost-Sharing Costo de Compartimiento Minorista Preferida 30-Day supply at a Preferred Retail Pharmacy Un suministro de 30 días en una Farmacia Minorista Preferida 90-Day Supply at a Preferred Retail Pharmacy Un suministro de 90 días en una Farmacia Minorista Preferida 90-Day Supply using the plan s Preferred Mailorder service Suministro de 90 días, utilizando el servicio de correspondencia Preferida del plan Cost Sharing Tier 1 (Generic) Costo de compartimiento Nivel 1 (Genéricas) $0 $0 $0 Cost Sharing Tier 2 (Non-Preferred Generic) Costo de compartimiento Nivel 2 (Genéricas No Preferidas) $3 $9 $99 Cost Sharing Tier 3 (Preferred Brand) Costo de compartimiento Nivel 3 (Marca Preferida) $30 $90 $135 Cost Sharing Tier 4 (Non-Preferred Brand) Costo de compartimiento Nivel 4 (Marca No Preferidas) 40% A long term supply is not available for drugs in Tier 4. Un suministro a largo plazo no es disponible para las drogas en el Nivel 4. A long term supply is not available for drugs in Tier 4. Un suministro a largo plazo no es disponible para las drogas en el Nivel 4. Cost Sharing Tier 5 (Specialty) Costo de compartimiento Nivel 5 (Especialidad) 27% A long term supply is not available for drugs in Tier 5. Un suministro a largo plazo no es disponible para las drogas en el Nivel 5. A long term supply is not available for drugs in Tier 5. Un suministro a largo plazo no es disponible para las drogas en el Nivel 5. ix

12 Standard Retail Cost-Sharing Costo de Compartimiento Minorista Estándar 30-Day supply at a Standard Retail Pharmacy Un suministro de 30 días en una farmacia minorista estandar 90-Day supply at a Standard Retail Pharmacy Un suministro de 90 días en una farmacia minorista estandar 90-Day Supply using the plan s Standard Mail-order service Suministro de 90 días, utilizando el servicio de correspondencia Estándar del plan Cost Sharing Tier 1 (Preferred Generic) Costo de compartimiento Nivel 1 (Genéricas) $10 $30 $30 Cost Sharing Tier 2 (Non-Preferred Generic) Costo de compartimiento Nivel 2 (Genéricas No Preferidas) Cost Sharing Tier 3 (Preferred Brand) Costo de compartimiento Nivel 3 (Marca Preferida) $33 $99 $99 $45 $135 $135 Cost Sharing Tier 4 (Non-Preferred Brand) Costo de compartimiento Nivel 4 (Marca No Preferidas) 50% A long term supply is not available for drugs in Tier 4. Un suministro a largo plazo no es disponible para las drogas en el Nivel 4. A long term supply is not available for drugs in Tier 4. Un suministro a largo plazo no es disponible para las drogas en el Nivel 4. Cost Sharing Tier 5 (Specialty) Costo de compartimiento Nivel 5 (Especialidad) 27% A long term supply is not available for drugs in Tier 5. Un suministro a largo plazo no es disponible para las drogas en el Nivel 5. A long term supply is not available for drugs in Tier 5. Un suministro a largo plazo no es disponible para las drogas en el Nivel 5. x

13 Below is a list of abbreviations that may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug. LIST OF ABBREVIATIONS B/D: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Access. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. NM: Not available at mail-order. This prescription is not available through the mail-order pharmacy. These prescriptions can only be filled at a retail pharmacy or other specialized pharmacy (where available). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. xi

14 La siguiente es una lista de abreviaturas que pueden aparecer en las siguientes páginas en la columna Notas para indicarle si su medicamento está sujeto a algún requisito especial de cobertura. Lista de abreviaturas (del inglés) B/D: Este medicamento recetado podría estar cubierto bajo Medicare Parte B o Parte D, dependiendo de las circunstancias. Puede ser necesario que se presente información que describa la utilización y las circunstancias en las que se administrará el medicamento, para que se pueda tomar una determinación. LA: Acceso limitado. Este medicamento recetado puede estar disponible solamente en ciertas farmacias. Para obtener más información, llame al servicio de Atención al cliente. NM: No está disponible por correo. Esta prescripción no está disponible a través de la farmacia de pedido por correo. Esta recetas sólo pueden ser llenadas en una farmacia minorista o en otra farmacia especializada (donde estén disponibles). PA: Autorización previa. El Plan requiere que usted o su médico obtengan autorización previa para obtener ciertos medicamentos. Esto significa que deberá obtener aprobación antes de que se surtan sus recetas. Si no obtiene aprobación, podríamos no cubrir el medicamento. QL: Límite de cantidad. En el caso de ciertos medicamentos, el Plan limita la cantidad del medicamento que cubriremos. ST: Tratamiento escalonado. En algunos casos, el Plan requiere que primero pruebe ciertos medicamentos para el tratamiento de su afección médica antes de que podamos cubrir otro medicamento para tratar esa afección. Por ejemplo, si puede utilizarse tanto un medicamento A como un medicamento B en el tratamiento de la misma afección médica, es posible que no cubramos el medicamento B a menos que usted pruebe. xii

15 Commonly Prescribed Therapeutic Drug Categories (Categorías de productos farmacoterapéuticos que se recetan comúnmente) Drug Name Drug Tier Requirements/Limits (Nombre del ANALGESICS GOUT allopurinol tab 1 colchicine w/ probenecid 2 COLCRYS 3 QL (120 tabs / 30 days) probenecid 2 ULORIC 3 ST NSAIDS celecoxib CAPS 2 QL (60 caps / 30 days) diclofenac potassium 2 diclofenac sodium TB24; TBEC 2 diflunisal 2 etodolac 2 etodolac er 2 flurbiprofen TABS 2 ibuprofen SUSP 2 ibuprofen TABS 400mg, 600mg 1 ibuprofen tab 800 mg 1 ketoprofen CAPS 2 MELOXICAM SUSP 2 meloxicam TABS 1 nabumetone TABS 2 NAPRELAN 4 naproxen SUSP 2 naproxen TABS; TBEC 1 naproxen sodium TABS 275mg, 550mg 1 piroxicam CAPS 2 sulindac TABS 1 OPIOID ANALGESICS acetaminophen w/ codeine SOLN 2 QL (5000 ml / 30 days) acetaminophen w/ codeine TABS 2 QL (400 tabs / 30 days) butorphanol tartrate SOLN 1mg/ml, 2 2mg/ml hydroco/apap tab 5-325mg 2 QL (360 tabs / 30 days) hydroco/apap tab QL (360 tabs / 30 days) hydroco/apap tab mg 2 QL (360 tabs / 30 days) 1

16 (Nombre del hydrocodone-acetaminophen QL (5400 ml / 30 days) mg/15ml hydrocodone-ibuprofen tab mg 2 QL (150 tabs / 30 days) lorcet hd tab mg 2 QL (360 tabs / 30 days) lorcet plus tab QL (360 tabs / 30 days) lorcet tab 5-325mg 2 QL (360 tabs / 30 days) lortab tab 5-325mg 2 QL (360 tabs / 30 days) lortab tab QL (360 tabs / 30 days) lortab tab mg 2 QL (360 tabs / 30 days) tramadol hcl TABS 2 QL (240 tabs / 30 days) tramadol-acetaminophen 2 QL (240 tabs / 30 days) OPIOID ANALGESICS, CII DURAMORPH 2 B/D endocet 2 QL (360 tabs / 30 days) fentanyl 12mcg/hr, 25mcg/hr 2 QL (10 patches / 30 days) fentanyl 50mcg/hr, 75mcg/hr, 2 QL (10 patches / mcg/hr days), PA fentanyl citrate LPOP 5 QL (120 lozenges / 30 days), PA FENTORA 5 QL (120 tabs / 30 days), PA hydromorphon inj 10mg/ml 2 B/D hydromorphone hcl LIQD 2 hydromorphone hcl TABS 2 QL (270 tabs / 30 days) LAZANDA SPR 100MCG 5 QL (30 bottles / 30 days), PA LAZANDA SPR 400MCG 5 QL (30 bottles / 30 days), PA methadone hcl CONC 2 QL (120 ml / 30 days) methadone hcl SOLN 5mg/5ml, 2 QL (600 ml / 30 days) 10mg/5ml methadone hcl TABS 2 QL (240 tabs / 30 days) morphine ext-rel tab 15mg, 30mg, 2 QL (90 tabs / 30 days) 60mg, 100mg morphine ext-rel tab 200mg 2 QL (60 tabs / 30 days) MORPHINE SUL INJ 1mg/ml, 4mg/ml, 2 B/D 10mg/ml, 15mg/ml morphine sul inj.5mg/ml, 1mg/ml 2 B/D morphine sulfate CP24 10mg, 20mg, 2 QL (60 caps / 30 days) 30mg, 50mg, 60mg morphine sulfate CP24 80mg 5 QL (60 caps / 30 days) 2

17 (Nombre del MORPHINE SULFATE SOLN 2mg/ml, 2 B/D 8mg/ml MORPHINE SULFATE TABS 2 QL (180 tabs / 30 days) morphine sulfate beads 2 QL (60 caps / 30 days) morphine sulfate cap 100mg er 5 QL (60 caps / 30 days) MORPHINE SULFATE ORAL SOL 2 oxycodone hcl CAPS 2 QL (180 caps / 30 days) OXYCODONE HCL CONC 2 oxycodone hcl SOLN 2 oxycodone hcl TABS 2 QL (180 tabs / 30 days) oxycodone hcl tab 5 mg 2 QL (180 tabs / 30 days) oxycodone w/ acetaminophen QL (360 tabs / 30 days) 325mg oxycodone w/ acetaminophen 5-325mg 2 QL (360 tabs / 30 days) oxycodone w/ acetaminophen QL (360 tabs / 30 days) 325mg oxycodone w/ acetaminophen 10-2 QL (360 tabs / 30 days) 325mg roxicet soln 3 QL (1800 ml / 30 days) roxicet tabs 2 QL (360 tabs / 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) 2 B/D lidocaine inj 0.5% 2 B/D lidocaine inj 1% 2 B/D lidocaine inj 1.5% 2 B/D lidocaine inj 2% 2 B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 2 gentamicin in saline 2 gentamicin sulfate SOLN 2 neomycin sulfate TABS 2 paromomycin sulfate CAPS 2 streptomycin sulfate SOLR 2 sulfadiazine TABS 4 tobramycin NEBU 5 B/D, NM tobramycin sulfate SOLN; SOLR 2 tobramycin sulfate in saline 3 ANTI-INFECTIVES - MISCELLANEOUS 3

18 (Nombre del ALBENZA 4 ALINIA 4 atovaquone SUSP 5 AZACTAM 4 AZACTAM/DEX INJ 1GM 4 AZACTAM/DEX INJ 2GM 5 aztreonam 2 BILTRICIDE 3 CAYSTON 5 NM, LA, PA clindamycin cap 75mg 1 clindamycin cap 300mg 1 clindamycin hcl cap 150 mg 1 clindamycin phosphate inj 2 clindamycin sol 75mg/5ml 2 colistimethate sodium SOLR 2 CUBICIN 5 dapsone TABS 2 DARAPRIM 4 imipenem-cilastatin 2 INVANZ 4 ivermectin TABS 2 linezolid SOLN 5 LINEZOLID TABS 5 meropenem 2 methenamine hippurate 2 metronidazole TABS 1 metronidazole in nacl 2 NEBUPENT 4 B/D nitrofurantoin macrocrystal 4 PA; 90 day limit if >64 yr nitrofurantoin monohyd macro 4 PA; 90 day limit if >64 yr PENTAM SIVEXTRO 5 sulfamethoxazole-trimethoprim 1 sulfamethoxazole-trimethoprim inj 2 SYNERCID 5 trimethoprim TABS 1 TYGACIL 5 vancomycin hcl CAPS 5 vancomycin hcl SOLR 2 4

19 (Nombre del ZYVOX SUSR; TABS 5 ANTIFUNGALS ABELCET 5 B/D AMBISOME 5 B/D amphotericin b SOLR 2 B/D CANCIDAS 5 ERAXIS 5 fluconazole SUSR; TABS 2 fluconazole in dextrose 2 fluconazole in nacl 2 flucytosine CAPS 5 griseofulvin microsize 2 griseofulvin ultramicrosize 2 itraconazole CAPS 2 PA ketoconazole TABS 2 PA MYCAMINE 5 NOXAFIL SUSP; TBEC 5 nystatin TABS 2 terbinafine hcl TABS 1 QL (90 tabs / 365 days) voriconazole SOLR 2 voriconazole SUSR; TABS 5 ANTIMALARIALS atovaquone-proguanil hcl 2 chloroquine phosphate TABS 2 COARTEM 3 mefloquine hcl 2 PRIMAQUINE PHOSPHATE 3 quinine sulfate CAPS 2 PA ANTIRETROVIRAL AGENTS abacavir sulfate 2 APTIVUS 5 CRIXIVAN 4 didanosine 2 EDURANT 5 EMTRIVA 3 EPIVIR SOLN 3 FUZEON 5 NM INTELENCE 25mg 4 INTELENCE 100mg, 200mg 5 INVIRASE CAPS 4 5

20 (Nombre del INVIRASE TABS 5 ISENTRESS CHEW 25mg 3 ISENTRESS CHEW 100mg 5 ISENTRESS PACK 3 ISENTRESS TABS 5 lamivudine 2 LEXIVA SUSP 4 LEXIVA TABS 5 NEVIRAPINE SUSP 2 nevirapine TABS; TB24 2 NORVIR 3 PREZISTA SUSP 5 PREZISTA TABS 75mg, 150mg 3 PREZISTA TABS 600mg, 800mg 5 RESCRIPTOR 4 RETROVIR IV INFUSION 3 REYATAZ 5 SELZENTRY 5 stavudine 2 SUSTIVA CAPS 3 SUSTIVA TABS 5 TIVICAY 5 TYBOST 4 VIDEX PEDIATRIC 4 VIRACEPT 5 VIRAMUNE XR 100mg 4 VIREAD 5 VITEKTA 5 ZIAGEN SOLN 4 zidovudine 2 ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine 5 ATRIPLA 5 COMPLERA 5 EPZICOM 5 EVOTAZ 5 KALETRA SOL 5 KALETRA TAB MG 3 KALETRA TAB MG 5 lamivudine-zidovudine 5 6

21 (Nombre del PREZCOBIX 5 STRIBILD 5 TRIUMEQ 5 TRUVADA 5 QL (30 tabs / 30 days) ANTITUBERCULAR AGENTS CAPASTAT SULFATE 5 cycloserine CAPS 2 ethambutol hcl TABS 2 isoniazid TABS 1 isoniazid inj 100 mg/ml 2 isoniazid syp 50mg/5ml 2 paser d/r 3 PRIFTIN 4 pyrazinamide 2 rifabutin 2 rifampin CAPS; SOLR 2 RIFATER 4 SIRTURO 5 LA, PA TRECATOR 4 ANTIVIRALS acyclovir CAPS; TABS 1 acyclovir SUSP 2 acyclovir sodium 2 B/D adefovir dipivoxil 5 BARACLUDE SOLN 3 entecavir 5 EPIVIR HBV SOLN 4 famciclovir TABS 2 ganciclovir inj 500mg 2 B/D HARVONI 5 NM, PA lamivudine (hbv) 2 moderiba 800 dose pack 5 NM, PA moderiba pak 600/day 5 NM, PA moderiba pak 1000/day 5 NM, PA moderiba pak 1200/day 5 NM, PA moderiba tab 200mg 2 NM, PA OLYSIO 5 NM, PA REBETOL SOLN 5 NM, PA RELENZA DISKHALER 3 ribapak mis 600/day 5 NM, PA 7

22 (Nombre del ribasphere CAPS 2 NM, PA ribasphere TABS 200mg, 400mg 2 NM, PA ribasphere TABS 600mg 5 NM, PA ribasphere ribapak NM, PA ribasphere ribapak NM, PA ribasphere ribapak NM, PA ribavirin 200mg 2 NM, PA rimantadine hydrochloride 2 SOVALDI 5 NM, PA TAMIFLU 3 TYZEKA 5 valacyclovir hcl TABS 2 VALCYTE SOLR 5 valganciclovir hcl 5 VICTRELIS 5 NM, PA CEPHALOSPORINS cefaclor 2 cefaclor monohydrate er 3 cefadroxil 2 cefazolin in d5w 3 cefazolin inj 2 cefazolin sodium 1gm, 20gm 2 cefdinir 2 cefepime hcl 2 cefixime 2 cefotaxime sodium 1gm, 2gm, 500mg 2 cefoxitin sodium 2 cefpodoxime proxetil 2 cefprozil 2 ceftazidime 2 CEFTAZIDIME/DEXTROSE 4 ceftriaxone sodium SOLR 1gm, 2gm, 2 10gm, 250mg, 500mg cefuroxime axetil 1 cefuroxime sodium 1.5gm, 7.5gm, 2 750mg cephalexin CAPS 250mg, 500mg 1 cephalexin SUSR 2 SUPRAX CAPS 3 suprax CHEW 4 suprax SUSR 100mg/5ml, 200mg/5ml 3 8

23 (Nombre del SUPRAX SUSR 500mg/5ml 3 tazicef SOLR 2 tazicef vial 2 TEFLARO 4 ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 2 azithromycin SOLR 500mg 2 azithromycin SUSR 2 azithromycin TABS 250mg 1 azithromycin TABS 500mg, 600mg 2 clarithromycin TABS 2 clarithromycin er 2 clarithromycin for susp 2 DIFICID 5 e.e.s. 2 e.e.s E.E.S. GRANULES 4 ery-tab 4 ERYPED ERYPED erythrocin lactobionate 500mg 4 erythrocin stearate 2 erythromycin base 2 erythromycin cap 250mg ec 2 ZMAX 3 FLUOROQUINOLONES AVELOX 4 AVELOX ABC PACK 4 ciprofloxacin SUSR 2 ciprofloxacin er 2 ciprofloxacin hcl tab 1 ciprofloxacin in d5w 2 ciprofloxacin inj 2 levofloxacin TABS 2 levofloxacin in d5w 2 levofloxacin inj 25mg/ml 2 levofloxacin oral soln 25 mg/ml 2 PENICILLINS amoxicillin 1 amoxicillin & pot clavulanate 2 9

24 (Nombre del ampicillin & sulbactam sodium 2 ampicillin cap 250 mg 1 ampicillin cap 500 mg 1 ampicillin for susp 125 mg/5ml 1 ampicillin for susp 250 mg/5ml 1 ampicillin inj 2 ampicillin sodium 2 BICILLIN L-A 4 dicloxacillin sodium 2 nafcillin sodium 1gm 2 nafcillin sodium 2gm, 10gm 5 oxacillin sodium 1gm, 2gm 2 oxacillin sodium 10gm 5 PENICILLIN G POT IN DEXTROSE 4 penicillin g potassium 2 penicillin g procaine 3 penicillin g sodium 2 penicillin v potassium 1 penicilln gk inj 5mu 2 piperacillin sodium-tazobactam sodium 2 TETRACYCLINES doxy inj 2 doxycycline (monohydrate) CAPS 2 50mg, 100mg doxycycline (monohydrate) TABS 2 doxycycline hyclate CAPS; SOLR; TABS 2 minocycline hcl CAPS 2 VIBRAMYCIN SYRP 4 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU 4 B/D BUSULFEX 4 B/D CYCLOPHOSPHAMIDE CAPS 4 B/D cyclophosphamide SOLR 2 B/D dacarbazine 2 B/D EMCYT 4 GLEOSTINE 4 HEXALEN 5 IFEX 3gm 4 B/D 10

25 (Nombre del ifosfamide inj 1gm 2 B/D ifosfamide inj 1gm/20ml 2 B/D IFOSFAMIDE INJ 3GM 4 B/D ifosfamide inj 3gm/60ml 2 B/D LEUKERAN 4 LOMUSTINE 2 melphalan hcl 5 B/D MUSTARGEN 4 B/D TREANDA 5 B/D, NM ANTHRACYCLINES adriamycin 2 B/D daunorubicin hcl 2 B/D doxorubicin hcl for inj 50 mg 2 B/D doxorubicin hcl liposomal inj 2mg/ml 5 B/D doxorubicin inj 50mg 2 B/D epirubicin hcl 2 B/D idarubicin hcl 5 B/D ANTIBIOTICS bleomycin sulfate 2 B/D mitomycin SOLR 2 B/D ANTIMETABOLITES adrucil 2 B/D ALIMTA 5 B/D azacitidine 5 B/D, NM cladribine 5 B/D cytarabine 20mg/ml 2 B/D fludarabine phosphate 2 B/D fluorouracil SOLN 2 B/D GEMCITABINE HCL SOLN 5 B/D gemcitabine hcl SOLR 5 B/D mercaptopurine TABS 2 methotrexate sodium inj 2 B/D NIPENT 5 B/D PURIXAN 5 TABLOID 4 ANTIMITOTIC, TAXOIDS DOCETAXEL INJ 20MG/2ML 2 B/D DOCETAXEL INJ 20MG/ML 5 B/D DOCETAXEL INJ 80MG/4ML 5 B/D 11

26 (Nombre del DOCETAXEL INJ 80MG/8ML 5 B/D docetaxel inj 140mg/7ml 5 B/D DOCETAXEL INJ 160MG/16ML 5 B/D DOCETAXEL INJ 200MG/20ML 5 B/D paclitaxel 2 B/D ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 3 B/D vincasar 2 B/D vincristine sulfate 2 B/D vinorelbine tartrate 2 B/D BIOLOGIC RESPONSE MODIFIERS AVASTIN 5 B/D, NM ERIVEDGE 5 NM, LA, PA FARYDAK 5 NM, LA, PA HERCEPTIN 5 B/D, NM IBRANCE 5 NM, LA, PA ISTODAX 5 B/D, NM KADCYLA 5 B/D, NM LYNPARZA 5 NM, PA PROLEUKIN 5 B/D, NM RITUXAN 500mg/50ml 5 NM, PA VELCADE 5 B/D, NM ZOLINZA 5 NM, PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS 2 bicalutamide 2 DEPO-PROVERA INJ 400/ML 4 B/D exemestane 2 FARESTON 5 FASLODEX 5 B/D flutamide 2 letrozole TABS 2 leuprolide acetate KIT 2 NM, PA LUPR DEP-PED INJ 30MG (3-MONTH) 5 NM, PA LUPRON DEPOT 3.75mg 5 NM, PA LUPRON DEPOT INJ MG 5 NM, PA LUPRON DEPOT-PED 5 NM, PA LYSODREN 3 MEGACE ES 5 PA 12

27 (Nombre del megestrol acetate TABS 4 PA megestrol acetate sus 40mg/ml 4 PA MEGESTROL ACETATE SUS 625MG/5ML 5 PA NILANDRON 5 SOLTAMOX 4 tamoxifen citrate TABS 1 TRELSTAR DEP INJ 3.75MG 5 NM, PA TRELSTAR LA INJ 11.25MG 5 NM, PA XTANDI 5 NM, LA, PA ZYTIGA 5 NM, PA KINASE INHIBITORS AFINITOR 5 NM, PA AFINITOR DISPERZ 5 NM, PA BOSULIF 5 NM, PA CAPRELSA 5 NM, LA, PA COMETRIQ 5 NM, PA GILOTRIF TAB 20MG 5 NM, LA, PA GILOTRIF TAB 30MG 5 NM, LA, PA GILOTRIF TAB 40MG 5 NM, LA, PA GLEEVEC 5 NM, PA ICLUSIG 5 NM, LA, PA IMBRUVICA CAP 140MG 5 NM, LA, PA INLYTA 5 NM, LA, PA IRESSA 5 NM, LA, PA JAKAFI 5 NM, LA, PA LENVIMA 10MG DAILY DOSE 5 NM, LA, PA LENVIMA 14MG DAILY DOSE 5 NM, LA, PA LENVIMA 20MG DAILY DOSE 5 NM, LA, PA LENVIMA 24MG DAILY DOSE 5 NM, LA, PA MEKINIST 5 NM, PA NEXAVAR 5 NM, LA, PA SPRYCEL 5 NM, PA STIVARGA 5 NM, LA, PA SUTENT 5 NM, PA TAFINLAR 5 NM, PA TARCEVA 5 NM, PA TASIGNA 5 NM, PA TYKERB 5 NM, LA, PA VOTRIENT 5 NM, PA 13

28 (Nombre del XALKORI 5 NM, LA, PA ZELBORAF 5 NM, LA, PA ZYDELIG 5 NM, LA, PA ZYKADIA 5 NM, LA, PA MISCELLANEOUS bexarotene 5 NM, PA DROXIA 3 hydroxyurea CAPS 2 MATULANE 5 mitoxantrone hcl 2 B/D, NM POMALYST CAP 1MG 5 NM, LA, PA POMALYST CAP 2MG 5 NM, LA, PA POMALYST CAP 3MG 5 NM, LA, PA POMALYST CAP 4MG 5 NM, LA, PA SYLATRON KIT 296MCG 5 NM, PA SYLATRON KIT 444MCG 5 NM, PA SYLATRON KIT 888MCG 5 NM, PA TARGRETIN CAPS 5 NM, PA tretinoin (chemotherapy) 5 TRISENOX 5 B/D PLATINUM-BASED AGENTS carboplatin 2 B/D cisplatin 2 B/D oxaliplatin 5 B/D PROTECTIVE AGENTS amifostine crystalline 5 B/D dexrazoxane 250mg 5 B/D ELITEK 5 B/D leucovorin calcium SOLR 2 B/D leucovorin calcium TABS 2 leucovorin calcium for inj 500 mg 2 B/D mesna 2 B/D MESNEX TABS 5 TOPOISOMERASE INHIBITORS etoposide SOLN 500mg/25ml 2 B/D irinotecan hcl 5 B/D toposar 1gm/50ml 2 B/D topotecan hcl SOLR 5 B/D CARDIOVASCULAR 14

29 (Nombre del ACE INHIBITOR COMBINATIONS amlodipine--benazepril hcl cap QL (30 caps / 30 days) mg amlodipine-benazepril hcl cap QL (30 caps / 30 days) mg amlodipine-benazepril hcl cap 5-10 mg 1 QL (30 caps / 30 days) amlodipine-benazepril hcl cap 5-20 mg 1 QL (30 caps / 30 days) amlodipine-benazepril hcl cap 5-40 mg 1 QL (30 caps / 30 days) amlodipine-benazepril hcl cap 10-40mg 1 benazepril & hydrochlorothiazide 1 captopril & hydrochlorothiazide 1 enalapril maleate & hydrochlorothiazide 1 fosinopril sodium & hydrochlorothiazide 1 lisinopril & hydrochlorothiazide 1 moexipril-hydrochlorothiazide 1 quinapril-hydrochlorothiazide 1 ACE INHIBITORS benazepril hcl TABS 1 captopril TABS 1 enalapril maleate TABS 1 fosinopril sodium 1 lisinopril TABS 1 moexipril hcl 1 perindopril erbumine 1 quinapril hcl 1 ramipril 1 trandolapril 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 2 spironolactone TABS 1 ALPHA BLOCKERS doxazosin mesylate 1mg, 2mg, 4mg 2 QL (30 tabs / 30 days) doxazosin mesylate 8mg 2 prazosin hcl 1 terazosin hcl 1 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab mg 1 QL (30 tabs / 30 days) 15

30 (Nombre del amlodipine besylate-valsartan tab 5-1 QL (30 tabs / 30 days) 320 mg amlodipine besylate-valsartan tab 10-1 QL (30 tabs / 30 days) 160 mg amlodipine besylate-valsartan tab mg amlodipine-valsartanhydrochlorothiazide 1 QL (30 tabs / 30 days) mg amlodipine-valsartanhydrochlorothiazide 1 QL (60 tabs / 30 days) mg amlodipine-valsartanhydrochlorothiazide 1 QL (30 tabs / 30 days) mg amlodipine-valsartanhydrochlorothiazide 1 QL (30 tabs / 30 days) mg amlodipine-valsartanhydrochlorothiazide mg AZOR 10-40MG 3 AZOR TAB 5-20MG 3 QL (30 tabs / 30 days) AZOR TAB 5-40MG 3 QL (30 tabs / 30 days) AZOR TAB 10-20MG 3 QL (30 tabs / 30 days) BENICAR HCT 40-25MG 3 BENICAR HCT TAB MG 3 QL (30 tabs / 30 days) BENICAR HCT TAB MG 3 QL (30 tabs / 30 days) losartan-hctz mg 1 QL (30 tabs / 30 days) losartan-hctz mg 1 QL (30 tabs / 30 days) losartan-hctz mg 1 TRIBENZOR40- TAB 10-25MG 3 TRIBENZOR TAB MG 3 QL (30 tabs / 30 days) TRIBENZOR TAB MG 3 QL (30 tabs / 30 days) TRIBENZOR TAB MG 3 QL (30 tabs / 30 days) TRIBENZOR TAB QL (30 tabs / 30 days) valsartan & hctz tab mg 1 QL (30 tabs / 30 days) valsartan & hctz tab mg 1 QL (30 tabs / 30 days) valsartan & hctz tab mg 1 QL (30 tabs / 30 days) valsartan & hctz tab mg 1 valsartan & hctz tab mg 1 ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 5mg 3 QL (60 tabs / 30 days) BENICAR 20mg 3 QL (30 tabs / 30 days) BENICAR 40mg 3 16

31 (Nombre del losartan potassium 25mg, 50mg 1 QL (60 tabs / 30 days) losartan potassium 100mg 1 valsartan 40mg, 80mg, 160mg 1 QL (60 tabs / 30 days) valsartan 320mg 1 ANTIARRHYTHMICS amiodarone hcl SOLN 2 amiodarone hcl TABS 100mg, 400mg 2 amiodarone hcl TABS 200mg 1 disopyramide phosphate 4 PA flecainide acetate 2 mexiletine hcl 2 MULTAQ 4 NORPACE CR 4 PA pacerone 100mg, 400mg 2 pacerone 200mg 1 propafenone hcl 2 quinidine gluconate TBCR 2 quinidine sulfate TABS 1 sorine 2 sotalol hcl 2 sotalol hcl (afib/afl) 2 TIKOSYN 4 NM ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium TABS 1 QL (30 tabs / 30 days) CRESTOR 3 QL (30 tabs / 30 days) LESCOL 4 LESCOL XL 4 lovastatin 10mg 1 QL (30 tabs / 30 days) lovastatin 20mg 1 QL (120 tabs / 30 days) lovastatin 40mg 1 QL (60 tabs / 30 days) pravastatin sodium 1 QL (30 tabs / 30 days) simvastatin TABS 1 QL (30 tabs / 30 days) ANTILIPEMICS, MISCELLANEOUS cholestyramine 2 cholestyramine light 2 choline fenofibrate 2 colestipol hcl 2 fenofibrate TABS 48mg, 54mg, 145mg, 2 160mg 17

32 (Nombre del fenofibrate micronized 2 fenofibrate micronized cap 2 gemfibrozil TABS 2 niacin (antihyperlipidemic) 500mg 2 QL (90 tabs / 30 days) niacin (antihyperlipidemic) 750mg, mg niacor 2 omega-3-acid ethyl esters 2 prevalite 2 VASCEPA 4 WELCHOL 3 ZETIA TAB 10MG 3 BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 1 bisoprolol & hydrochlorothiazide 1 metoprolol & hctz tab 50-25mg 2 metoprolol & hctz tab mg 2 metoprolol & hctz tab mg 2 propranolol & hydrochlorothiazide 2 BETA-BLOCKERS acebutolol hcl CAPS 1 atenolol TABS 1 bisoprolol fumarate 2 BYSTOLIC 4 carvedilol 1 labetalol hcl TABS 2 metoprolol succinate 25mg, 50mg 2 QL (60 tabs / 30 days) metoprolol succinate 100mg 2 QL (45 tabs / 30 days) metoprolol succinate 200mg 2 metoprolol tartrate SOLN 2 metoprolol tartrate TABS 1 nadolol TABS 2 pindolol 2 propranolol cap er 2 propranolol hcl SOLN 2 propranolol hcl TABS 1 timolol maleate TABS 2 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS CADUET 4 18

33 (Nombre del CALCIUM CHANNEL BLOCKERS afeditab cr 30mg 2 QL (60 tabs / 30 days) afeditab cr 60mg 2 amlodipine besylate TABS 2.5mg, 5mg 1 QL (45 tabs / 30 days) amlodipine besylate TABS 10mg 1 cartia xt cap 120/24hr 2 cartia xt cap 180/24hr 2 cartia xt cap 240/24hr 2 cartia xt cap 300/24hr 2 dilt-cd cap 2 dilt-xr cap 2 diltiazem cap 2 diltiazem cap 120mg/24hr 2 diltiazem cap er/12hr 2 diltiazem hcl SOLN 2 diltiazem hcl TABS 1 diltiazem hcl coated beads cp24 120mg 2 diltiazem hcl coated beads cp24 180mg 2 diltiazem hcl coated beads cp24 240mg 2 diltiazem hcl coated beads cp24 300mg 2 diltiazem hcl coated beads cp24 360mg 2 diltzac 2 felodipine 2.5mg 2 QL (30 tabs / 30 days) felodipine 5mg 2 QL (60 tabs / 30 days) felodipine 10mg 2 isradipine 2 nicardipine hcl CAPS 2 nifedical 30mg 2 QL (30 tabs / 30 days) nifedical 60mg 2 nifedipine TB24 30mg 2 QL (60 tabs / 30 days) nifedipine TB24 60mg, 90mg 2 nifedipine er 30mg 2 QL (30 tabs / 30 days) nifedipine er 60mg, 90mg 2 nimodipine CAPS 2 NYMALIZE 5 taztia 2 verapamil cap er 100mg, 120mg, 2 180mg, 200mg, 240mg, 300mg VERAPAMIL CAP ER 360mg 2 verapamil hcl SOLN 2 19

34 (Nombre del verapamil hcl TABS 1 verapamil tab er 2 DIGITALIS GLYCOSIDES digitek.25mg 2 PA digitek.125mg 2 QL (30 tabs / 30 days) digoxin SOLN 2 digoxin TABS 125mcg 2 QL (30 tabs / 30 days) digoxin TABS 250mcg 2 PA DIGOXIN SOL 50MCG/ML 2 PA LANOXIN TABS 125mcg 3 QL (30 tabs / 30 days) LANOXIN TABS 250mcg 3 PA DIRECT RENIN INHIBITORS/COMBINATIONS TEKAMLO TAB 150-5MG 3 QL (30 tabs / 30 days) TEKAMLO TAB MG 3 QL (30 tabs / 30 days) TEKTURNA 150mg 3 QL (30 tabs / 30 days) TEKTURNA 300mg 3 TEKTURNA HCT TAB MG 3 QL (30 tabs / 30 days) TEKTURNA HCT TAB MG 3 QL (60 tabs / 30 days) TEKTURNA HCT TAB MG 3 QL (30 tabs / 30 days) TEKTURNA HCT TAB MG 3 DIURETICS acetazolamide CP12; TABS 2 amiloride & hydrochlorothiazide 1 amiloride hcl 2 bumetanide SOLN 2 bumetanide TABS 1 chlorothiazide 1 chlorthalidone 25mg, 50mg 1 DIURIL SUS 250/5ML 3 DYRENIUM 4 EDECRIN 4 furosemide SOLN 8mg/ml 2 furosemide SOLN 10mg/ml 1 furosemide TABS 1 furosemide inj 2 hydrochlorothiazide CAPS; TABS 1 indapamide 1 methazolamide TABS 2 methyclothiazide 2 20

35 (Nombre del metolazone 2 spironolactone & hydrochlorothiazide 1 torsemide inj 20mg/2ml 2 torsemide inj 50mg/5ml 2 torsemide tabs 1 triamterene & hydrochlorothiazide 1 TABS triamterene & hydrochlorothiazide cap mg MISCELLANEOUS clonidine hcl PTWK 2 clonidine hcl TABS 1 DEMSER 5 hydralazine hcl SOLN; TABS 2 midodrine hcl 2 minoxidil TABS 2 RANEXA 3 NITRATES isosorb mononitrate tab 1 isosorbide dinitrate 2 isosorbide mononitrate er tab 1 minitran 2 nitro-bid 3 NITRO-DUR DIS 0.3MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 nitroglycerin PT24 2 NITROLINGUAL PUMPSPRAY 3 NITROSTAT 3 PULMONARY ARTERIAL HYPERTENSION ADCIRCA 5 QL (60 tabs / 30 days), NM, PA ADEMPAS 5 QL (90 tabs / 30 days), NM, PA LETAIRIS 5 QL (30 tabs / 30 days), NM, LA, PA REMODULIN 5 B/D, NM, LA REVATIO SUSR 5 QL (2 bottles / 30 days), NM, PA sildenafil citrate (pulmonary hypertension) TABS 5 QL (90 tabs / 30 days), NM, PA 21

36 (Nombre del TRACLEER 62.5mg 5 QL (120 tabs / 30 days), NM, LA, PA TRACLEER 125mg 5 QL (60 tabs / 30 days), NM, LA, PA VENTAVIS 5 B/D, NM CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC 2 QL (300 ml / 30 days) alprazolam tab 0.5mg 1 QL (240 tabs / 30 days) alprazolam tab 0.25mg 1 QL (480 tabs / 30 days) alprazolam tab 1mg 1 QL (120 tabs / 30 days) alprazolam tab 2mg 1 QL (150 tabs / 30 days) buspirone hcl TABS 2 fluvoxamine maleate TABS 25mg, 2 QL (45 tabs / 30 days) 50mg fluvoxamine maleate TABS 100mg 2 lorazepam CONC 2 QL (150 ml / 30 days) lorazepam SOLN 2 lorazepam TABS 1 QL (150 tabs / 30 days) ANTICONVULSANTS APTIOM 200mg 4 QL (180 tabs / 30 days) APTIOM 400mg 4 QL (90 tabs / 30 days) APTIOM 600mg 4 QL (60 tabs / 30 days) APTIOM 800mg 4 QL (30 tabs / 30 days) BANZEL SUS 40MG/ML 5 PA BANZEL TAB 200MG 4 PA BANZEL TAB 400MG 5 PA carbamazepine CHEW; TABS 1 carbamazepine CP12; SUSP; TB12 2 CELONTIN 4 clonazepam TABS 1mg 1 QL (600 tabs / 30 days) clonazepam TABS 2mg 1 QL (300 tabs / 30 days) clonazepam TABS.5mg 1 QL (1200 tabs / 30 days) clonazepam TBDP 1mg 2 QL (600 tabs / 30 days) clonazepam TBDP 2mg 2 QL (300 tabs / 30 days) clonazepam TBDP.5mg 2 QL (1200 tabs / 30 days) clonazepam TBDP.25mg 2 QL (2400 tabs / 30 days) 22

37 (Nombre del clonazepam TBDP.125mg 2 QL (4800 tabs / 30 days) clorazepate dipotassium 3.75mg, 7.5mg 2 QL (120 tabs / 30 days), PA clorazepate dipotassium 15mg 2 QL (180 tabs / 30 days), PA diazepam CONC 2 QL (240 ml / 30 days), PA diazepam SOLN 2 QL (1200 ml / 30 days), PA diazepam TABS 1 QL (120 tabs / 30 days), PA DIAZEPAM GEL 2 diazepam inj 2 dilantin 3 DILANTIN-125 SUS 125/5ML 3 divalproex sodium 2 epitol 1 ethosuximide CAPS; SOLN 2 felbamate SUSP 5 felbamate TABS 400mg 2 felbamate TABS 600mg 5 FYCOMPA 2mg 4 QL (180 tabs / 30 days), PA FYCOMPA 4mg 4 QL (90 tabs / 30 days), PA FYCOMPA 6mg 4 QL (60 tabs / 30 days), PA FYCOMPA 8mg, 10mg, 12mg 4 QL (30 tabs / 30 days), PA gabapentin CAPS 100mg 1 QL (1080 caps / 30 days) gabapentin CAPS 300mg 1 QL (360 caps / 30 days) gabapentin CAPS 400mg 1 QL (270 caps / 30 days) gabapentin SOLN 2 QL (2160 ml / 30 days) gabapentin TABS 600mg 2 QL (180 tabs / 30 days) gabapentin TABS 800mg 2 QL (120 tabs / 30 days) GABITRIL 12mg, 16mg 4 lamotrigine CHEW; TB24 2 lamotrigine TABS 1 levetiracetam SOLN; TABS; TB

38 (Nombre del LEVETIRACETAM IN NACL 4 levetiracetam inj 500/5ml 2 LYRICA CAPS 25mg, 50mg, 75mg, 3 QL (120 caps / 30 days) 100mg, 150mg LYRICA CAPS 200mg 3 QL (90 caps / 30 days) LYRICA CAPS 225mg, 300mg 3 QL (60 caps / 30 days) LYRICA SOLN 3 QL (946 ml / 30 days) ONFI 4 PA oxcarbazepine 2 PEGANONE 4 phenobarbital ELIX; TABS 4 PA PHENOBARBITAL SODIUM 65mg/ml 4 PA phenobarbital sodium 130mg/ml 4 PA phenytek 3 phenytoin CHEW; SUSP 2 phenytoin sodium SOLN 2 phenytoin sodium extended 2 POTIGA 50mg 4 POTIGA 200mg 4 QL (180 tabs / 30 days) POTIGA 300mg, 400mg 4 QL (90 tabs / 30 days) primidone TABS 2 SABRIL PACK 5 QL (180 packets / 30 days), NM, LA, PA SABRIL TABS 5 QL (180 tabs / 30 days), NM, LA, PA TEGRETOL 4 TEGRETOL-XR 4 tiagabine hcl 2 topiramate CPSP; TABS 2 valproate sodium SOLN; SYRP 2 valproic acid CAPS 2 VIMPAT SOLN 10mg/ml 4 QL (1200 ml / 30 days) VIMPAT SOLN 200mg/20ml 4 VIMPAT TABS 50mg 4 QL (180 tabs / 30 days) VIMPAT TABS 100mg, 150mg, 200mg 4 QL (60 tabs / 30 days) zonisamide CAPS 2 ANTIDEMENTIA donepezil hydrochloride TABS 5mg 2 QL (30 tabs / 30 days) donepezil hydrochloride TABS 10mg, 23mg 2 24

39 (Nombre del donepezil hydrochloride TBDP 5mg 2 QL (30 tabs / 30 days) donepezil hydrochloride TBDP 10mg 2 EXELON PATCHES 4 QL (30 patches / 30 days) galantamine hydrobromide CP24 8mg, 2 QL (30 caps / 30 days) 16mg galantamine hydrobromide CP24 24mg 2 galantamine hydrobromide SOLN 2 galantamine hydrobromide TABS 4mg 2 QL (180 tabs / 30 days) galantamine hydrobromide TABS 8mg 2 QL (90 tabs / 30 days) galantamine hydrobromide TABS 12mg 2 memantine hcl 5mg 2 PA; PA if <30 yr MEMANTINE HCL 10mg 2 PA; PA if <30 yr NAMENDA SOL 10MG/5ML 3 PA; PA if <30 yr NAMENDA TAB 4 PA; PA if <30 yr NAMENDA XR 4 PA; PA if <30 yr NAMENDA XR TITRATION PACK 4 PA; PA if <30 yr NAMZARIC 4 RIVASTIGMINE PATCH 2 QL (30 patches / 30 days) rivastigmine tartrate 2 ANTIDEPRESSANTS amitriptyline hcl TABS 4 PA amoxapine tab 25mg 2 amoxapine tab 50mg 2 amoxapine tab 100mg 2 amoxapine tab 150mg 2 BRINTELLIX 5mg 4 QL (120 tabs / 30 days) BRINTELLIX 10mg 4 QL (60 tabs / 30 days) BRINTELLIX 20mg 4 QL (30 tabs / 30 days) bupropion hcl TABS 2 bupropion hcl TB12 2 bupropion hcl TB24 150mg 2 QL (90 tabs / 30 days) bupropion hcl TB24 300mg 2 QL (30 tabs / 30 days) citalopram hydrobromide SOLN 2 citalopram hydrobromide TABS 10mg, 1 QL (45 tabs / 30 days) 20mg citalopram hydrobromide TABS 40mg 1 QL (30 tabs / 30 days) clomipramine hcl CAPS 4 PA desipramine hcl TABS 2 25

40 (Nombre del doxepin hcl CAPS; CONC 4 PA duloxetine hcl CPEP 20mg, 30mg, 2 QL (60 caps / 30 days) 60mg EMSAM 5 QL (30 patches / 30 days), PA escitalopram oxalate SOLN 2 QL (600 ml / 30 days) escitalopram oxalate TABS 5mg, 10mg 2 QL (45 tabs / 30 days) escitalopram oxalate TABS 20mg 2 QL (60 tabs / 30 days) FETZIMA 20mg 4 QL (180 caps / 30 days) FETZIMA 40mg 4 QL (90 caps / 30 days) FETZIMA 80mg, 120mg 4 QL (30 caps / 30 days) FETZIMA TITRATION PACK 4 fluoxetine cap 10mg 1 QL (30 caps / 30 days) fluoxetine cap 20mg 1 QL (120 caps / 30 days) fluoxetine cap 40mg 1 fluoxetine sol 20mg/5ml 2 fluoxetine tab 10mg 1 QL (45 tabs / 30 days) fluoxetine tab 20mg 1 imipramine hcl TABS 4 PA maprotiline hcl 2 MARPLAN TAB 10MG 4 QL (180 tabs / 30 days) mirtazapine TABS 7.5mg 2 QL (45 tabs / 30 days) mirtazapine TABS 15mg 1 QL (45 tabs / 30 days) mirtazapine TABS 30mg, 45mg 1 mirtazapine TBDP 15mg 2 QL (30 tabs / 30 days) mirtazapine TBDP 30mg, 45mg 2 nefazodone hcl 2 nortriptyline hcl CAPS 1 nortriptyline hcl SOLN 2 paroxetine hcl TABS 10mg, 20mg, 1 QL (45 tabs / 30 days) 40mg paroxetine hcl TABS 30mg 1 QL (60 tabs / 30 days) PAXIL SUSP 4 QL (900 ml / 30 days) phenelzine sulfate TABS 2 PRISTIQ 3 QL (30 tabs / 30 days) protriptyline hcl 2 sertraline hcl CONC 2 sertraline hcl TABS 25mg, 50mg 1 QL (45 tabs / 30 days) sertraline hcl TABS 100mg 1 26

41 (Nombre del SURMONTIL CAP 25MG 4 QL (240 caps / 30 days), PA SURMONTIL CAP 50MG 4 QL (120 caps / 30 days), PA SURMONTIL CAP 100MG 4 QL (60 caps / 30 days), PA tranylcypromine sulfate 2 trazodone hcl TABS 50mg, 100mg, 1 150mg venlafaxine hcl CP mg, 75mg 2 QL (30 caps / 30 days) venlafaxine hcl CP24 150mg 2 QL (60 caps / 30 days) venlafaxine hcl TABS 2 VIIBRYD KIT 4 VIIBRYD TABS 4 QL (30 tabs / 30 days) VIIBRYD STARTER PACK 4 ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS 2 APOKYN 5 NM, LA, PA AZILECT 3 benztropine mesylate SOLN 2 benztropine mesylate TABS 4 PA bromocriptine mesylate CAPS; TABS 2 carbidopa-levodopa 2 CARBIDOPA/LEVODOPA/ENTACAPONE 2 entacapone 2 NEUPRO 4 pramipexole dihydrochloride TABS 2 ropinirole hydrochloride TABS 2 selegiline hcl CAPS; TABS 2 STALEVO 50 4 STALEVO 75 4 STALEVO STALEVO STALEVO STALEVO ANTIPSYCHOTICS ABILIFY DISCMELT 5 QL (60 tabs / 30 days) ABILIFY INJ 9.75MG 4 QL (4 ml / 1 day) ABILIFY MAIN INJ 300MG 5 QL (1 vial / 28 days) ABILIFY MAIN INJ 400MG 5 QL (1 vial / 28 days) 27

42 (Nombre del ABILIFY MAINTENA 5 QL (1 syringe / 28 days) ABILIFY SOLN 5 ABILIFY TABS 5 QL (30 tabs / 30 days) aripiprazole SOLN 5 aripiprazole TABS 5 QL (30 tabs / 30 days) chlorpromazine hcl SOLN 50mg/2ml 4 chlorpromazine hcl TABS 2 clozapine 25mg, 50mg 2 clozapine 100mg 2 QL (270 tabs / 30 days) clozapine 200mg 2 QL (135 tabs / 30 days) CLOZAPINE ODT 12.5mg, 25mg 2 PA CLOZAPINE ODT 100mg 2 QL (270 tabs / 30 days), PA CLOZAPINE ODT 150MG 2 QL (180 tabs / 30 days), PA CLOZAPINE ODT 200MG 2 QL (135 tabs / 30 days), PA FANAPT 4 QL (60 tabs / 30 days), ST FANAPT TITRATION PACK 4 ST FAZACLO TAB 12.5/ODT 4 PA FAZACLO TAB 25MG ODT 4 PA FAZACLO TAB 100/ODT 4 QL (270 tabs / 30 days), PA FAZACLO TAB 150MG 4 QL (180 tabs / 30 days), PA FAZACLO TAB 200MG 4 QL (135 tabs / 30 days), PA fluphenazine decanoate SOLN 2 fluphenazine hcl 2 GEODON SOLR 4 QL (6 ml / 3 days) haloperidol TABS 2 haloperidol decanoate SOLN 2 haloperidol lactate 2 haloperidol lactate oral conc 2 mg/ml 2 INVEGA 1.5mg, 3mg, 9mg 5 QL (30 tabs / 30 days) INVEGA 6mg 5 QL (60 tabs / 30 days) INVEGA SUST INJ 39 MG/0.25 ML 4 QL (1 injection / 28 days) INVEGA SUST INJ 78 MG/0.5 ML 5 QL (1 injection / 28 days) 28

43 (Nombre del INVEGA SUST INJ 117 MG/0.75 ML 5 QL (1 injection / 28 days) INVEGA SUST INJ 156MG/ML 5 QL (1 injection / 28 days) INVEGA SUST INJ 234 MG/1.5 ML 5 QL (1 injection / 28 days) LATUDA 20mg 5 QL (240 tabs / 30 days) LATUDA 40mg, 120mg 5 QL (30 tabs / 30 days) LATUDA 60mg, 80mg 5 QL (60 tabs / 30 days) loxapine succinate 2 olanzapine SOLR 2 QL (3 vials / 1 day) olanzapine TABS 2.5mg, 5mg, 7.5mg 2 QL (30 tabs / 30 days) olanzapine TABS 10mg, 15mg, 20mg 2 QL (60 tabs / 30 days) olanzapine TBDP 5mg 2 QL (30 tabs / 30 days) olanzapine TBDP 10mg, 15mg 2 QL (60 tabs / 30 days) olanzapine TBDP 20mg 5 QL (60 tabs / 30 days) ORAP 4 perphenazine TABS 2 quetiapine fumarate 2 QL (90 tabs / 30 days) REXULTI 1mg 5 QL (90 tabs / 30 days), ST REXULTI 2mg 5 QL (60 tabs / 30 days), ST REXULTI 3mg, 4mg 5 QL (30 tabs / 30 days), ST REXULTI.5mg 5 QL (180 tabs / 30 days), ST REXULTI.25mg 5 QL (360 tabs / 30 days), ST RISPERDAL INJ 12.5MG 4 QL (2 injections / 28 days) RISPERDAL INJ 25MG 4 QL (2 injections / 28 days) RISPERDAL INJ 37.5MG 5 QL (2 injections / 28 days) RISPERDAL INJ 50MG 5 QL (2 injections / 28 days) risperidone SOLN 2 QL (240 ml / 30 days) risperidone TABS 1mg, 2mg, 3mg 2 QL (60 tabs / 30 days) risperidone TABS 4mg 2 QL (120 tabs / 30 days) risperidone TABS.25mg,.5mg 2 QL (90 tabs / 30 days) 29

44 (Nombre del risperidone TBDP 1mg, 2mg, 3mg 2 QL (60 tabs / 30 days) risperidone TBDP 4mg 2 QL (120 tabs / 30 days) risperidone TBDP.25mg,.5mg 2 QL (90 tabs / 30 days) SAPHRIS 2.5mg 4 QL (240 tabs / 30 days) SAPHRIS 5mg 4 QL (120 tabs / 30 days) SAPHRIS 10mg 4 QL (60 tabs / 30 days) SEROQUEL XR 50mg 4 QL (120 tabs / 30 days) SEROQUEL XR 150mg, 200mg 4 QL (30 tabs / 30 days) SEROQUEL XR 300mg, 400mg 4 QL (60 tabs / 30 days) thioridazine hcl TABS 4 PA thiothixene 2 trifluoperazine hcl 2 VERSACLOZ 5 QL (600 ml / 30 days), PA ziprasidone hcl 20mg, 40mg 2 QL (60 caps / 30 days) ziprasidone hcl 60mg, 80mg 2 QL (90 caps / 30 days) ZYPREXA RELPREVV 5 B/D ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap 2 QL (90 caps / 30 days) sr 24hr 5 mg amphetamine-dextroamphetamine cap 2 QL (90 caps / 30 days) sr 24hr 10 mg amphetamine-dextroamphetamine cap 2 QL (30 caps / 30 days) sr 24hr 15 mg amphetamine-dextroamphetamine cap 2 QL (30 caps / 30 days) sr 24hr 20 mg amphetamine-dextroamphetamine cap 2 QL (30 caps / 30 days) sr 24hr 25 mg amphetamine-dextroamphetamine cap 2 QL (30 caps / 30 days) sr 24hr 30 mg amphetamine-dextroamphetamine tab 2 QL (360 tabs / 30 days) 5 mg amphetamine-dextroamphetamine tab 2 QL (240 tabs / 30 days) 7.5 mg amphetamine-dextroamphetamine tab 2 QL (180 tabs / 30 days) 10 mg amphetamine-dextroamphetamine tab 2 QL (144 tabs / 30 days) 12.5 mg amphetamine-dextroamphetamine tab 15 mg 2 QL (120 tabs / 30 days) 30

45 (Nombre del amphetamine-dextroamphetamine tab 2 QL (90 tabs / 30 days) 20 mg amphetamine-dextroamphetamine tab 2 QL (60 tabs / 30 days) 30 mg guanfacine hcl (adhd) 4 metadate tab 20mg er 2 QL (90 tabs / 30 days) methylphenidate hcl TABS 5mg, 10mg 2 QL (180 tabs / 30 days) methylphenidate hcl TABS 20mg 2 QL (90 tabs / 30 days) methylphenidate hcl er tabs 10mg 2 QL (90 tabs / 30 days) methylphenidate hcl er tabs 20mg 2 QL (90 tabs / 30 days) methylphenidate hcl oral soln 5mg/5ml 2 QL (1800 ml / 30 days) methylphenidate hcl oral soln 2 QL (900 ml / 30 days) 10mg/5ml STRATTERA 10mg, 18mg, 25mg 4 QL (120 caps / 30 days) STRATTERA 40mg 4 QL (60 caps / 30 days) STRATTERA 60mg, 80mg, 100mg 4 QL (30 caps / 30 days) HYPNOTICS ROZEREM 4 QL (30 tabs / 30 days) SILENOR 3mg 3 QL (60 tabs / 30 days) SILENOR 6mg 3 QL (30 tabs / 30 days) temazepam 7.5mg 2 QL (30 caps / 30 days), PA; 90 day limit if >64 yr temazepam 15mg 2 QL (60 caps / 30 days), PA; 90 day limit if >64 yr zolpidem tartrate TABS 4 QL (30 tabs / 30 days), PA; 90 day limit if >64 yr MIGRAINE cafergot 4 dihydroergotamine mesylate 1mg/ml 2 naratriptan hcl 2 QL (9 tabs / 30 days) RELPAX 3 QL (12 tabs / 30 days) rizatriptan benzoate 2 QL (18 tabs / 30 days) SUMATRIPTAN SOLN 5mg/act 2 QL (24 inhalers / 30 days) SUMATRIPTAN SOLN 20mg/act 2 QL (12 inhalers / 30 days) sumatriptan succinate SOAJ; SOSY 2 QL (6 ml / 30 days) 31

46 (Nombre del SUMATRIPTAN SUCCINATE SOCT 2 QL (6 ml / 30 days) sumatriptan succinate TABS 2 QL (9 tabs / 30 days) SUMATRIPTAN SUCCINATE INJ SOAJ 2 QL (6 ml / 30 days) 4mg/0.5ml sumatriptan succinate inj SOAJ 2 QL (6 ml / 30 days) 6mg/0.5ml sumatriptan succinate inj SOLN 2 QL (6 ml / 30 days) zolmitriptan TABS 2 QL (12 tabs / 30 days) zolmitriptan odt 2 QL (12 tabs / 30 days) MISCELLANEOUS LITHIUM 3 lithium carbonate CAPS; TABS 1 lithium carbonate er 2 NUEDEXTA 3 PA pyridostigmine bromide TABS 2 riluzole 2 TETRABENAZINE 12.5mg 5 QL (240 tabs / 30 days), NM, PA TETRABENAZINE 25mg 5 QL (120 tabs / 30 days), NM, PA XENAZINE 12.5mg 5 QL (240 tabs / 30 days), NM, LA, PA XENAZINE 25mg 5 QL (120 tabs / 30 days), NM, LA, PA MULTIPLE SCLEROSIS AGENTS BETASERON 5 QL (14 syringes / 28 days), NM, PA COPAXONE INJ 40MG/ML 5 QL (12 syringes / 28 days), NM, PA COPAXONE KIT 20MG/ML 5 QL (30 syringes / 30 days), NM, PA GILENYA CAP 0.5MG 5 QL (28 caps / 28 days), NM, PA glatopa 5 QL (30 syringes / 30 days), NM, PA TYSABRI 5 NM, LA, PA MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1 cyclobenzaprine hcl TABS 5mg, 10mg 4 PA dantrolene sodium CAPS 2 32

47 (Nombre del tizanidine hcl TABS 2 NARCOLEPSY/CATAPLEXY NUVIGIL 50mg 4 QL (150 tabs / 30 days), PA NUVIGIL 150mg 4 QL (60 tabs / 30 days), PA NUVIGIL 200mg, 250mg 4 QL (30 tabs / 30 days), PA XYREM 5 QL (540 ml / 30 days), LA, PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium 2 buprenorphine hcl SUBL 2 PA buprenorphine hcl-naloxone hcl sl 2 QL (120 tabs / 30 days), PA buproban 2 CHANTIX 4 PA CHANTIX CONTINUING MONTH 4 PA CHANTIX STARTER PACK 4 PA disulfiram TABS 2 naloxone hcl SOLN 2 naltrexone hcl TABS 2 NICOTROL INHALER 4 NICOTROL NS 4 SUBOXONE MIS 2-0.5MG 4 QL (4 boxes / 30 days), PA SUBOXONE MIS 4-1MG 4 QL (4 boxes / 30 days), PA SUBOXONE MIS 8-2MG 4 QL (4 boxes / 30 days), PA SUBOXONE MIS 12-3MG 4 QL (2 boxes / 30 days), PA ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM 4 QL (30 patches / 30 days), PA oxandrolone TABS 2 PA TESTIM 3 QL (300 grams / 30 days), PA testosterone cypionate SOLN 2 33

48 (Nombre del testosterone enanthate SOLN 2 ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 3 GAUZE PADS 2" X 2" 3 HUMULIN R INJ U B/D INSULIN PEN NEEDLE 3 INSULIN SAFETY NEEDLES 3 INSULIN SYRINGE 3 LANTUS 3 LANTUS SOLOSTAR 3 LEVEMIR 3 LEVEMIR FLEXTOUCH 3 NOVOLIN 70/30 3 RELION not covered NOVOLIN N 3 RELION not covered NOVOLIN R 3 RELION not covered NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 70/30 3 NOVOLOG MIX 70/30 PREFILL 3 NOVOLOG PENFILL 3 SYMLINPEN 60 4 QL (8 pens / 30 days), PA SYMLINPEN QL (4 pens / 30 days), PA TOUJEO SOLOSTAR 3 TRULICITY 4 QL (4 pens / 28 days) VICTOZA 3 QL (3 pens / 30 days) ANTIDIABETICS, ORAL acarbose 2 FARXIGA 5mg 3 QL (60 tabs / 30 days) FARXIGA 10mg 3 QL (30 tabs / 30 days) glimepiride 1mg 1 QL (240 tabs / 30 days) glimepiride 2mg 1 QL (120 tabs / 30 days) glimepiride 4mg 1 QL (60 tabs / 30 days) glip/metform tab 5-500mg 1 QL (120 tabs / 30 days) glipizide TABS 5mg 1 QL (240 tabs / 30 days) glipizide TABS 10mg 1 QL (120 tabs / 30 days) glipizide TB24 2.5mg 1 QL (240 tabs / 30 days) glipizide TB24 5mg 1 QL (120 tabs / 30 days) glipizide TB24 10mg 1 QL (60 tabs / 30 days) 34

49 (Nombre del glipizide-metformin hcl tab mg 1 QL (240 tabs / 30 days) glipizide-metformin hcl tab mg 1 QL (120 tabs / 30 days) INVOKAMET TAB MG 3 QL (120 tabs / 30 days) INVOKAMET TAB QL (60 tabs / 30 days) INVOKAMET TAB QL (60 tabs / 30 days) INVOKAMET TAB QL (60 tabs / 30 days) INVOKANA 100mg 3 QL (90 tabs / 30 days) INVOKANA 300mg 3 QL (30 tabs / 30 days) JANUMET 3 QL (60 tabs / 30 days) JANUMET XR TAB MG 3 QL (60 tabs / 30 days) JANUMET XR TAB QL (60 tabs / 30 days) JANUMET XR TAB QL (30 tabs / 30 days) JANUVIA 3 QL (30 tabs / 30 days) JENTADUETO 3 QL (60 tabs / 30 days) metformin hcl TABS 500mg 1 QL (150 tabs / 30 days) metformin hcl TABS 850mg 1 QL (90 tabs / 30 days) metformin hcl TABS 1000mg 1 QL (75 tabs / 30 days) metformin hcl TB24 500mg 1 QL (120 tabs / 30 days) metformin hcl TB24 750mg 1 QL (60 tabs / 30 days) nateglinide 1 QL (90 tabs / 30 days) pioglitazone hcl 1 QL (30 tabs / 30 days) repaglinide 2mg 1 QL (240 tabs / 30 days) repaglinide.5mg, 1mg 1 QL (120 tabs / 30 days) RIOMET 4 QL (946 ml / 30 days) TRADJENTA 3 QL (30 tabs / 30 days) XIGDUO XR TAB 5-500MG 3 QL (60 tabs / 30 days) XIGDUO XR TAB MG 3 QL (60 tabs / 30 days) XIGDUO XR TAB MG 3 QL (30 tabs / 30 days) XIGDUO XR TAB MG 3 QL (30 tabs / 30 days) BISPHOSPHONATES alendronate sodium TABS 5mg, 10mg 1 alendronate sodium TABS 35mg, 70mg 1 QL (4 tabs / 28 days) alendronate sodium TABS 40mg 2 FOSAMAX PLUS D 4 ibandronate sodium TABS 2 B/D, QL (1 tab / 30 days) pamidronate disodium SOLN 2 B/D zoledronic inj 4mg/5ml 5 B/D, NM ZOMETA SOLN 5 B/D, NM 35

50 (Nombre del CALCIUM RECEPTOR AGONISTS SENSIPAR 30mg 3 QL (120 tabs / 30 days), NM SENSIPAR 60mg 5 QL (60 tabs / 30 days), NM SENSIPAR 90mg 5 QL (120 tabs / 30 days), NM CHELATING AGENTS CHEMET 4 DEPEN TITRATABS 5 EXJADE 5 NM, LA, PA kionex 2 sodium polystyrene sulfonate 2 sps susp 15gm/60ml 2 SYPRINE 5 CONTRACEPTIVES altavera 2 apri 28 day 2 aranelle 28 2 aubra 28 day 2 aviane 28 2 balziva 28 day 2 briellyn 28 day 2 camila 28 day 2 cryselle 28 2 cyclafem 1/35 28 day 2 cyclafem 7/7/7 28 day 2 cyred tab 2 deblitane 28 day 2 delyla 28 day 2 desogestrel-ethinyl estradiol (biphasic) 2 drospirenone-ethinyl estradiol 2 ELLA 3 emoquette 2 enpresse 28 day 2 errin 28 day 2 falmina 28 day 2 GIANVI 2 gildagia 2 gildess 1.5/30 21 day 2 36

51 (Nombre del heather 2 introvale 91 day 2 JOLESSA TAB MG 2 JOLIVETTE 2 junel 1.5/30 21 day 2 junel 1/20 21 day 2 junel fe 1.5/30 28 day 2 junel fe 1/20 28 day 2 kariva 28 day 2 kimidess 28 day 2 larin 1.5/30 2 larin 1/20 2 larin fe 1.5/30 2 larin fe 1/20 2 LEENA 2 lessina 28 day 2 levonest 28 day 2 levonorgestrel & eth estradiol 2 levonorgestrel (emergency oc) 2 levonorgestrel-ethinyl estradiol (91-2 day) levora 0.15/30 28 day 2 loryna 28 day 2 low-ogestrel 28 day 2 lutera 28 day 2 lyza 2 marlissa 28 day 2 medroxyprogesterone acetate mg/ml microgestin 1.5/30 21 day 2 microgestin 1/20 21 day 2 microgestin fe 1.5/30 28 day 2 microgestin fe 1/20 28 day 2 MONONESSA 2 my way 2 myzilra 2 necon 0.5/35 28 day 2 necon 1/35 28 day 2 NECON 7/7/7 2 necon 10/11 28 day 3 37

52 (Nombre del NECON TAB 1/ next choice one dose 2 nikki 28 day 2 NORA-BE TAB 2 norethindrone (contraceptive) 2 norgestimate-ethinyl estradiol 2 (triphasic) norlyroc 28 day 2 nortrel 0.5/35 28 day 2 nortrel 1/35 21 day 2 nortrel 1/35 28 day 2 nortrel 7/7/7 28 day 2 NUVARING 4 OCELLA TAB MG 2 orsythia 28 day 2 philith 2 pimtrea pack 2 pirmella 1/35 28 day 2 portia 28 day 2 previfem 28 day 2 quasense 91 day 2 reclipsen 28 day 2 sharobel 28 day 2 SOLIA 2 sprintec 28 day 2 sronyx 2 tarina fe tab 1/20 2 tri-legest 28 day 2 tri-previfem 28 day 2 tri-sprintec 28 day 2 TRINESSA 2 trivora 28 day 2 velivet 28 day 2 vestura 2 viorele 2 vyfemia 28 day 2 xulane 2 zarah 2 zenchent 28 day 2 ENDOMETRIOSIS 38

53 (Nombre del danazol CAPS 2 SYNAREL 5 ENZYME REPLACEMENTS ADAGEN 5 NM, LA, PA ALDURAZYME 5 NM, LA, PA CARBAGLU 5 NM, LA, PA CERDELGA 5 NM, PA CEREZYME 5 NM, PA CYSTADANE 5 NM CYSTAGON 4 NM, PA FABRAZYME 5 NM, PA KUVAN 5 NM, PA levocarnitine (metabolic modifiers) 2 B/D LUMIZYME 5 NM, PA MYOZYME 5 NM, PA NAGLAZYME 5 NM, LA, PA ORFADIN 5 NM, PA sodium phenylbutyrate 5 NM ZAVESCA 5 NM, LA, PA ESTROGENS COMBIPATCH 4 PA estradiol PTWK 4 PA estradiol TABS 4 PA ESTRADIOL VALERATE OIL 10mg/ml, 2 40mg/ml estradiol valerate OIL 20mg/ml 2 PREMARIN CREAM 4 VAGIFEM 4 GLUCOCORTICOIDS a-hydrocort 2 cortisone acetate TABS 2 dexamethasone CONC; ELIX; SOLN 2 dexamethasone TABS 1 dexamethasone sodium phosphate 2 fludrocortisone acetate TABS 2 hydrocortisone TABS 2 methylpr ace inj 40mg/ml 2 B/D methylpr ace inj 80mg/ml 2 B/D methylpr ss inj 1gm 2 B/D 39

54 (Nombre del methylpr ss inj 40mg 2 B/D methylpr ss inj 125mg 2 B/D methylpred pak 4mg 2 B/D methylpred tab 4mg 2 B/D methylpred tab 8mg 2 B/D methylpred tab 16mg 2 B/D methylpred tab 32mg 2 B/D pred sod pho sol 5mg/5ml 2 B/D prednisolone sol 15mg/5ml 2 B/D prednisolone sol 25mg/5ml 1 B/D prednisolone syp 15mg/5ml 1 B/D prednisone con 5mg/ml 3 B/D prednisone pak 5mg 1 B/D prednisone pak 10mg 1 B/D prednisone sol 5mg/5ml 2 B/D prednisone tab 1mg 1 B/D prednisone tab 2.5mg 1 B/D prednisone tab 5mg 1 B/D prednisone tab 10mg 1 B/D prednisone tab 20mg 1 B/D prednisone tab 50mg 1 B/D SOLU-CORTEF 250mg 3 GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 3 GLUCAGON EMERGENCY KIT 3 PROGLYCEM SUS 50MG/ML 4 HUMAN GROWTH HORMONES GENOTROPIN 5 NM, PA GENOTROPIN MINIQUICK.2mg 4 NM, PA GENOTROPIN MINIQUICK.4mg,.6mg, 5 NM, PA.8mg, 1mg, 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg NORDITROPIN FLEXPRO 5 NM, PA NORDITROPIN NORDIFLEX PEN 5 NM, PA TEV-TROPIN 5 NM, PA MISCELLANEOUS cabergoline 2 calcitonin (salmon) 2 FORTICAL 3 40

55 (Nombre del INCRELEX 5 NM, LA, PA methylergonovine maleate TABS 2 MIACALCIN 200unit/ml 4 B/D octreotide acetate 50mcg/ml, 2 NM, PA 100mcg/ml, 200mcg/ml octreotide acetate 500mcg/ml, 5 NM, PA 1000mcg/ml PROLIA 4 QL (1 syringe / 180 days), NM raloxifene hcl 2 SANDOSTATIN LAR DEPOT 5 NM, PA SOMATULINE DEPOT 5 NM, PA SOMAVERT 5 NM, LA, PA XGEVA 5 NM, PA PARATHYROID HORMONES FORTEO 5 QL (1 pen / 28 days), NM, PA PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) 2 FOSRENOL CHEW 5 PHOSLYRA 3 RENVELA PAK 0.8GM 5 RENVELA PAK 2.4GM 5 RENVELA TAB 800MG 3 PROGESTINS medroxyprogesterone acetate tab 1 norethindrone acetate TABS 2 THYROID AGENTS levothyroxine sodium TABS 1 LEVOXYL 1 liothyronine sodium TABS 2 methimazole TABS 1 propylthiouracil TABS 2 SYNTHROID 4 UNITHROID 1 VASOPRESSINS desmopressin acetate spray 2 desmopressin acetate spray refrigerated 2 desmopressin acetate tabs 2 41

56 (Nombre del desmopressin inj 4mcg/ml 2 DESMOPRESSIN SOL 0.01% 2 GASTROINTESTINAL ANTIEMETICS compro 2 dronabinol 2.5mg, 5mg 2 B/D, QL (60 caps / 30 days) dronabinol 10mg 5 B/D, QL (60 caps / 30 days) EMEND CAP 40MG 4 B/D EMEND CAP 80MG 4 B/D EMEND CAP 125MG 4 B/D EMEND PAK 80 & B/D granisetron hcl SOLN 2 granisetron hcl TABS 2 B/D meclizine hcl TABS 2 metoclopramide hcl SOLN; TABS 1 metoclopramide inj 2 ondansetron hcl SOLN 2 ondansetron hcl TABS 2 B/D ondansetron hcl inj 2 ondansetron hcl oral soln 2 B/D ondansetron odt 2 B/D prochlorperazine inj 2 prochlorperazine maleate TABS 1 prochlorperazine supp 2 promethazine hcl SOLN 25mg/ml, 4 PA 50mg/ml TRANSDERM-SCOP 4 QL (10 patches / 30 days), PA ANTISPASMODICS CUVPOSA 4 dicyclomine hcl CAPS; TABS 1 dicyclomine hcl SOLN 2 glycopyrrolate TABS 2 glycopyrrolate inj 2 H2-RECEPTOR ANTAGONISTS famotidine SOLN 40mg/4ml, 2 200mg/20ml famotidine SUSR 2 42

57 (Nombre del famotidine TABS 20mg, 40mg 1 famotidine inj 2 ranitidine hcl SOLN 2 ranitidine hcl TABS 150mg, 300mg 1 ranitidine hcl inj 2 ranitidine syrup 2 INFLAMMATORY BOWEL DISEASE APRISO 3 ASACOL HD 4 balsalazide disodium 2 budesonide ec 5 CANASA 4 colocort enema 100mg 2 DELZICOL 4 DIPENTUM 5 HYDROCORTISONE (INTRARECTAL) 2 LIALDA 4 mesalamine enema 2 mesalamine w/ cleanser 2 PENTASA 4 sulfasalazine TABS 2 sulfasalazine ec 2 UCERIS TB24 5 LAXATIVES constulose 2 enulose 2 gaviltye-g 1 gavilyte-c 1 gavilyte-h 2 gavilyte-n 2 generlac 2 GOLYTELY 3 lactulose 2 lactulose (encephalopathy) 2 MOVIPREP 4 NULYTELY/FLAVOR PACKS 3 peg 3350-kcl-sod bicarb-sod chloridesod 1 sulfate peg 3350-potassium chloride-sod bicarbonate-sod chloride 2 43

58 (Nombre del PEG 3350/ELECTROLYTES 1 polyethylene glycol 3350 PACK; POWD 2 RELISTOR 4 PA SUPREP BOWEL PREP 4 trilyte 2 MISCELLANEOUS alosetron hcl 5 PA AMITIZA CAP 8MCG 3 QL (60 caps / 30 days) AMITIZA CAP 24MCG 3 QL (60 caps / 30 days) cromolyn sodium (mastocytosis) 5 diphenoxylate w/ atropine LIQD 2 diphenoxylate w/ atropine TABS 1 LINZESS CAP 145MCG 3 QL (60 caps / 30 days) LINZESS CAP 290MCG 3 QL (30 caps / 30 days) loperamide hcl CAPS 1 LOTRONEX 5 PA misoprostol TABS 2 MOVANTIK 12.5mg 3 QL (60 tabs / 30 days) MOVANTIK 25mg 3 QL (30 tabs / 30 days) SUCRAID 5 sucralfate TABS 2 ursodiol CAPS; TABS 2 XIFAXAN 550mg 5 PA PANCREATIC ENZYMES CREON 3 ZENPEP 4 PROTON PUMP INHIBITORS DEXILANT 3 QL (30 caps / 30 days) esomeprazole magnesium 2 QL (30 caps / 30 days) esomeprazole sodium inj 2 NEXIUM CAP 20MG 3 QL (30 caps / 30 days) NEXIUM CAP 40MG 3 QL (30 caps / 30 days) NEXIUM GRA 2.5MG DR 3 NEXIUM GRA 5MG DR 3 NEXIUM GRA 10MG DR 3 QL (30 packets / 30 days) NEXIUM GRA 20MG DR 3 QL (30 packets / 30 days) 44

59 (Nombre del NEXIUM GRA 40MG DR 3 QL (30 packets / 30 days) omeprazole CPDR 10mg, 40mg 1 QL (30 caps / 30 days) omeprazole CPDR 20mg 1 QL (60 caps / 30 days) pantoprazole sodium tbec 2 QL (30 tabs / 30 days) GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl 2 QL (30 tabs / 30 days) AVODART 3 QL (30 caps / 30 days) finasteride TABS 5mg 2 JALYN 3 QL (30 caps / 30 days) tamsulosin hcl 2 QL (60 caps / 30 days) MISCELLANEOUS bethanechol chloride TABS 2 ELMIRON 4 POTASSIUM CITRATE (ALKALINIZER) 2 540mg, 1080mg URINARY ANTISPASMODICS MYRBETRIQ 25mg 4 QL (60 tabs / 30 days) MYRBETRIQ 50mg 4 QL (30 tabs / 30 days) oxybutynin chloride SYRP 1 oxybutynin chloride TABS 2 oxybutynin chloride TB24 5mg 2 QL (30 tabs / 30 days) oxybutynin chloride TB24 10mg, 15mg 2 QL (60 tabs / 30 days) TOLTERODINE TARTRATE CAP ER 2 QL (30 caps / 30 days) tolterodine tartrate tabs 2 TOVIAZ 3 QL (30 tabs / 30 days) trospium chloride TABS 2 QL (60 tabs / 30 days) VESICARE 4 QL (30 tabs / 30 days) VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal 2 metronidazole vaginal 2 terconazole vaginal 2 VANDAZOLE 2 zazole.4% 2 ZAZOLE.8% 2 HEMATOLOGIC ANTICOAGULANTS COUMADIN 4 45

60 (Nombre del ELIQUIS 3 enoxaparin sodium 30mg/0.3ml, 2 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml enoxaparin sodium 100mg/ml, 5 120mg/0.8ml, 150mg/ml fondaparinux sodium 2.5mg/0.5ml 2 fondaparinux sodium 5mg/0.4ml, 5 7.5mg/0.6ml, 10mg/0.8ml heparin sod inj 1000/ml 2 B/D HEPARIN SOD INJ 2000/ML 3 B/D HEPARIN SOD INJ 2500/ML 3 B/D heparin sod inj 5000/ml 2 B/D heparin sod inj 10000/ml 2 B/D heparin sod inj 20000/ml 2 B/D HEPARIN SODIUM/D5W 3 HEPARIN SODIUM/NACL 0.45% 3 jantoven 1 PRADAXA 3 warfarin sodium 1 XARELTO 3 XARELTO STARTER PACK 3 HEMATOPOIETIC GROWTH FACTORS GRANIX 5 NM, PA LEUKINE 5 NM, PA MOZOBIL 5 NM, PA NEULASTA 5 NM, PA NEUMEGA 5 NM NEUPOGEN 5 NM, PA PROCRIT 2000unit/ml, 3000unit/ml, 3 NM, PA 4000unit/ml, 10000unit/ml PROCRIT 20000unit/ml, 40000unit/ml 5 NM, PA MISCELLANEOUS anagrelide hcl 2 cilostazol 2 CINRYZE 5 NM, LA, PA FIRAZYR 5 NM, PA pentoxifylline TBCR 2 PROMACTA 12.5mg 5 QL (360 tabs / 30 days), NM, LA, PA 46

61 (Nombre del PROMACTA 25mg 5 QL (180 tabs / 30 days), NM, LA, PA PROMACTA 50mg 5 QL (90 tabs / 30 days), NM, LA, PA PROMACTA 75mg 5 QL (60 tabs / 30 days), NM, LA, PA tranexamic acid SOLN; TABS 2 PLATELET AGGREGATION INHIBITORS AGGRENOX 4 ASPIRIN-DIPYRIDAMOLE 2 BRILINTA 3 clopidogrel bisulfate 75mg 2 QL (30 tabs / 30 days) EFFIENT 4 ZONTIVITY 4 IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) CIMZIA 5 NM, PA CIMZIA STARTER KIT 5 NM, PA HUMIRA 5 NM, PA HUMIRA KIT 40MG/0.8 5 NM, PA HUMIRA PEN 5 NM, PA HUMIRA PEN-CROHNS DISEASE 5 NM, PA HUMIRA PEN-PSORIASIS STAR 5 NM, PA hydroxychloroquine sulfate 1 leflunomide TABS 2 methotrexate sodium tabs 2 REMICADE 5 NM, PA IMMUNOGLOBULINS BIVIGAM 5 NM, PA CARIMUNE NANOFILTERED 5 NM, PA FLEBOGAMMA 5 NM, PA FLEBOGAMMA DIF 5 NM, PA GAMASTAN S/D 3 B/D, NM GAMMAGARD LIQUID 5 NM, PA GAMMAGARD S/D 5 NM, PA GAMMAKED 5 NM, PA GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 5 NM, PA 10gm/200ml GAMUNEX-C 5 NM, PA GAMUNEX-C 1GM/10ML 5 NM, PA 47

62 (Nombre del OCTAGAM 1gm/20ml, 2gm/20ml, 5 NM, PA 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml PRIVIGEN 5 NM, PA IMMUNOMODULATORS ACTIMMUNE 5 NM, LA, PA ARCALYST 5 NM, PA INTRON-A INJ 10MU 5 B/D, NM INTRON-A INJ 18MU 5 B/D, NM INTRON-A INJ 25MU 5 B/D, NM INTRON-A INJ 50MU 5 B/D, NM PEG-INTRON 5 NM, PA PEG-INTRON REDIPEN 5 NM, PA PEGASYS 5 NM, PA PEGASYS PROCLICK 5 NM, PA REVLIMID 5 NM, LA, PA THALOMID 5 NM, PA IMMUNOSUPPRESSANTS azathioprine TABS 2 B/D cyclosporine CAPS; SOLN 2 B/D cyclosporine modified (for 2 B/D microemulsion) gengraf 2 B/D mycophenolate mofetil CAPS; TABS 2 B/D mycophenolate mofetil SUSR 5 B/D mycophenolate sodium 180mg 2 B/D mycophenolate sodium 360mg 5 B/D NEORAL 3 B/D NULOJIX 5 B/D PROGRAF CAPS 5mg 5 B/D PROGRAF CAPS.5mg, 1mg 4 B/D RAPAMUNE SOLN 5 B/D SANDIMMUNE CAPS 3 B/D SANDIMMUNE SOLN 100mg/ml 3 B/D SIROLIMUS TABS 1mg 2 B/D SIROLIMUS TABS 2mg 5 B/D sirolimus TABS.5mg 2 B/D tacrolimus CAPS 5mg 5 B/D tacrolimus CAPS.5mg, 1mg 2 B/D ZORTRESS TAB 0.5MG 5 B/D 48

63 (Nombre del ZORTRESS TAB 0.25MG 4 B/D ZORTRESS TAB 0.75MG 5 B/D VACCINES ACTHIB 3 ADACEL 3 BCG VACCINE 3 BEXSERO 3 BOOSTRIX 3 CERVARIX 3 COMVAX 3 DAPTACEL 3 DIPHTHERIA/TETANUS TOXOID 3 B/D ENGERIX-B SUSP 3 B/D GARDASIL 3 GARDASIL 9 3 HAVRIX 3 HIBERIX 3 IMOVAX RABIES (H.D.C.V.) 3 INFANRIX 3 IPOL INACTIVATED IPV 3 IXIARO 3 KINRIX 3 M-M-R II 3 MENACTRA 3 MENOMUNE-A/C/Y/W MENVEO 3 PEDVAX HIB 3 PROQUAD 3 QUADRACEL 3 RABAVERT 3 RECOMBIVAX HB 3 B/D ROTARIX 3 ROTATEQ 3 SYNAGIS 5 NM TENIVAC 3 B/D TETANUS TOXOID ADSORBED 3 B/D TETANUS/DIPHTHERIA TOXOID 3 B/D TRUMENBA 3 TWINRIX INJ 3 49

64 (Nombre del TYPHIM VI 3 VAQTA 3 VARIVAX 3 YF-VAX 3 ZOSTAVAX 3 QL (1 vial per lifetime) NUTRITIONAL/SUPPLEMENTS ELECTROLYTES KLOR-CON 8 2 KLOR-CON 10 2 klor-con m15 2 klor-con m20 2 klor-con pow 20meq 2 klor-con spr cap 2 MAGNESIUM SULFATE SOLN 3 4gm/50ml, 20gm/500ml magnesium sulfate SOLN 50% 2 MAGNESIUM SULFATE SOLN 50% 2 MAGNESIUM SULFATE IN D5W 3 potassium chloride CPCR 2 potassium chloride SOLN 10%, 20% 1 potassium chloride TBCR 8meq 2 POTASSIUM CHLORIDE TBCR 20meq 2 POTASSIUM CHLORIDE ER 2 potassium chloride microencapsulated 2 crystals cr SODIUM CHLORIDE SOLN 2.5meq/ml 2 SODIUM FLUORIDE CHEW; TAB; (0.5 F) MG/ML SOLN TPN ELECTROLYTES 4 B/D IV NUTRITION AMINOSYN 4 B/D AMINOSYN 7%/ELECTROLYTES 4 B/D AMINOSYN 8.5%/ELECTROLYTE 4 B/D AMINOSYN II 4 B/D AMINOSYN II 8.5%/ELECTROL 4 B/D AMINOSYN M 4 B/D AMINOSYN-HBC 4 B/D AMINOSYN-PF 4 B/D AMINOSYN-PF 7% 4 B/D AMINOSYN-RF 4 B/D 50

65 (Nombre del CLINIMIX 2.75%/DEXTROSE 5% 4 B/D CLINIMIX 4.25%/DEXTROSE 5% 4 B/D CLINIMIX 4.25%/DEXTROSE 25% 4 B/D CLINIMIX 5%/DEXTROSE 15% 4 B/D CLINIMIX 5%/DEXTROSE 20% 4 B/D CLINIMIX 5%/DEXTROSE 25% 4 B/D CLINIMIX INJ 4.25/D10 4 B/D CLINIMIX INJ 4.25/D20 4 B/D FREAMINE HBC 6.9% 4 B/D FREAMINE III 4 B/D HEPATAMINE 4 B/D INTRALIPID INJ 20% 3 B/D INTRALIPID INJ 30% 3 B/D NEPHRAMINE 4 B/D NUTRILIPID EMU 20% 3 B/D premasol sol 6% 2 B/D premasol sol 10% 4 B/D PROCALAMINE 4 B/D PROSOL 4 B/D travasol 10 4 B/D TROPHAMINE INJ 10% 4 B/D IV REPLACEMENT SOLUTIONS DEXTROSE 2.5%/NACL 0.45% 2 DEXTROSE 5% 2 DEXTROSE 5% /ELECTROLYTE 3 DEXTROSE 5%/LACTATED RING 2 DEXTROSE 5%/NACL 0.2% 2 DEXTROSE 5%/NACL 0.3% 2 DEXTROSE 5%/NACL 0.9% 2 DEXTROSE 5%/NACL 0.33% 2 DEXTROSE 5%/NACL 0.45% 2 DEXTROSE 5%/NACL 0.225% 2 DEXTROSE 5%/POTASSIUM CHL 2 DEXTROSE 10% FLEX CONTAIN 2 DEXTROSE 10%/NACL 0.2% 3 DEXTROSE 10%/NACL 0.45% 2 DEXTROSE 50% 2 dextrose inj 70% 2 IONOSOL-B/DEXTROSE 5% 4 51

66 (Nombre del IONOSOL-MB/DEXTROSE 5% 4 ISOLYTE P 4 isolyte s 4 KCL0.15%/D5W/NACL0.2% 2 KCL0.15%/D5W/NACL0.225% 3 KCL 0.3%/D5W/NACL 0.9% 2 KCL 0.3%/D5W/NACL 0.45% 2 KCL 0.15%/D5W/NACL 0.9% 2 KCL 0.075%/D5W/NACL 0.45% 2 KCL IN NACL INJ KCL/D5W INJ 0.3% 2 KCL/D5W/NACL INJ.15/.33% 2 KCL/D5W/NACL INJ.15/.45% 2 KCL/NACL INJ LACTATED RINGER'S INJ 1 normosol-m 2 NORMOSOL-R 4 NORMOSOL-R IN D5W 4 PLASMA-LYTE A 4 PLASMA-LYTE-56/D5W 4 PLASMA-LYTE POTASSIUM CHLORIDE SOLN 2 10meq/100ml, 20meq/100ml potassium chloride SOLN.4meq/ml, 2 2meq/ml, 10meq/50ml, 40meq/100ml POTASSIUM CHLORIDE 0.15% 2 POTASSIUM CHLORIDE 0.22% 2 potassium chloride in nacl 2 RINGER'S 2 SODIUM CHLORIDE SOLN 3%, 5% 2 SODIUM CHLORIDE 0.45% VIA 2 SODIUM CHLORIDE INJ 0.9% 2 VITAMINS calcitriol CAPS 2 B/D calcitriol inj 2 B/D calcitriol oral soln 1 mcg/ml 2 B/D paricalcitol CAPS 2 B/D PRENATAL VITAMIN/FOLIC ACID > MG (GENERIC) OPHTHALMIC 52

67 (Nombre del ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 2 blephamide OINT 4 neomycin-polymy-dexameth 2 neomycin-polymyxin-hc (ophth) 2 sulfacetamide sod-prednisolone 2 TOBRADEX OINT 3 TOBRADEX ST 3 tobramycin-dexamethasone 2 ZYLET 3 ANTI-INFECTIVES bacitracin (ophthalmic) 2 bacitracin-polymyxin b (ophth) 2 BESIVANCE 3 CILOXAN OINT 3 ciprofloxacin hcl (ophth) 2 erythromycin (ophth) 1 gatifloxacin (ophth) 2 gentak 2 gentamicin sulfate (ophth) OINT 2 gentamicin sulfate (ophth) SOLN 1 ilotycin 1 MOXEZA 3 NATACYN 4 neomycin-bacitracin zn-polymyxin 2 neomycin-polymyxin-gramicidin 2 ofloxacin (ophth) 1 polymyxin b-trimethoprim 1 sulfacetamide sodium (ophth) OINT 2 sulfacetamide sodium (ophth) SOLN 1 tobramycin (ophth) 1 TOBREX OINT 4 trifluridine SOLN 2 VIGAMOX 3 ANTI-INFLAMMATORIES ALREX 3 bromfenac sodium (ophth) 2 BROMFENAC SODIUM (OPHTH)(ONCE- 2 DAILY) 53

68 (Nombre del dexamethasone sodium phosphate 2 (ophth) diclofenac sodium (ophth) 2 DUREZOL 3 FLUOROMETHOLONE 2 flurbiprofen sodium 1 ILEVRO 3 ketorolac tromethamine (ophth) 2 LOTEMAX 3 MAXIDEX 3 NEVANAC 3 PREDNISOLONE ACETATE (OPHTH) 2 prednisolone sodium phosphate (ophth) 3 ANTIALLERGICS azelastine drop 0.05% 2 BEPREVE 3 cromolyn sodium (ophth) 1 LASTACAFT 4 PATADAY 3 PATANOL 3 PAZEO 3 ANTIGLAUCOMA ALPHAGAN P SOL 0.1% 3 AZOPT 3 betaxolol hcl (ophth) 2 BETOPTIC-S 3 brimonidine sol 0.2% 1 BRIMONIDINE SOL 0.15% 2 carteolol hcl (ophth) 1 COMBIGAN 3 dorzolamide hcl 2 dorzolamide hcl-timolol maleate 2 ISTALOL 3 latanoprost SOLN 2 levobunolol hcl.5% 2 LEVOBUNOLOL HCL.25% 2 LUMIGAN 3 metipranolol 2 PHOSPHOLINE IODIDE 3 54

69 (Nombre del PILOCARPINE HCL SOLN 2 SIMBRINZA 3 timolol maleate (ophth) 1 TIMOLOL MALEATE GEL 2 TRAVATAN Z 3 MISCELLANEOUS naphazoline 0.1% 1 PROLENSA 3 proparacaine hcl SOLN 1 RESTASIS 3 QL (64 vials / 30 days) RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA 3 QL (1 inhaler / 30 days) COMBIVENT RESPIMAT 4 QL (2 inhalers / 30 days) ipratropium-albuterol nebu 2 B/D ANTICHOLINERGICS ATROVENT HFA 4 QL (2 inhalers / 30 days) ipratropium bromide SOLN 2 B/D ipratropium bromide (nasal) 2 SPIRIVA HANDIHALER 3 QL (30 caps / 30 days) SPIRIVA RESPIMAT 2.5mcg/act 3 QL (1 inhaler / 30 days) TUDORZA PRESSAIR 3 QL (1 inhaler / 30 days) TUDORZA PRESSAIR (INSTITUTIONAL PACK) 400MCG/ACT 3 QL (2 inhalers / 30 days) ANTIHISTAMINES ASTEPRO 3 azelastine hcl SOLN 2 azelastine spr 0.1% 2 cetirizine syrup 2 diphenhydramine inj 2 hydroxyzine hcl inj 4 PA levocetirizine dihydrochloride 2 olopatadine hcl (nasal) 2 BETA AGONISTS albuterol sulfate NEBU 2 B/D albuterol sulfate SYRP 1 albuterol sulfate TABS; TB

70 (Nombre del FORADIL AEROLIZER 3 QL (60 caps / 30 days) levalbuterol conc 1.25mg/0.5ml 2 B/D PERFOROMIST 4 B/D PROAIR HFA 3 QL (2 inhalers / 30 days) PROVENTIL HFA 4 QL (2 inhalers / 30 days) SEREVENT DISKUS 3 QL (1 inhaler / 30 days) terbutaline sulfate SOLN; TABS 2 XOPENEX HFA 3 QL (2 inhalers / 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW; PACK; 2 TABS zafirlukast 2 MAST CELL STABILIZERS cromolyn sodium nebu 2 B/D MISCELLANEOUS acetylcysteine SOLN 10%, 20% 2 B/D ARALAST NP 5 NM, LA, PA AUVI-Q 3 DALIRESP 4 EPIPEN 2-PAK 3 EPIPEN-JR 2-PAK 3 ORKAMBI 5 NM, PA PROLASTIN-C 5 NM, LA, PA PULMOZYME 5 B/D, NM XOLAIR 5 NM, LA, PA ZEMAIRA 5 NM, LA, PA NASAL STEROIDS flunisolide (nasal) 2 QL (2 bottles / 30 days) fluticasone propionate (nasal) 2 QL (1 bottle / 30 days) NASONEX 3 QL (2 bottles / 30 days) STEROID INHALANTS ASMANEX TWISTHALER 14 MET 3 QL (2 inhalers / 30 days) ASMANEX TWISTHALER 30 MET 3 QL (2 inhalers / 30 days) ASMANEX TWISTHALER 60 MET 3 QL (2 inhalers / 30 days) 56

71 (Nombre del ASMANEX TWISTHALER 120 ME 3 QL (2 inhalers / 30 days) budesonide (inhalation).25mg/2ml, 2 B/D.5mg/2ml FLOVENT DISKUS 50mcg/blist, 100mcg/blist 3 QL (2 inhalers / 30 days) FLOVENT DISKUS 250mcg/blist 3 QL (4 inhalers / 30 days) FLOVENT HFA 3 QL (2 inhalers / 30 days) PULMICORT FLEXHALER 4 QL (2 inhalers / 30 days) QVAR 40mcg/act 3 QL (1 inhaler / 30 days) QVAR 80mcg/act 3 QL (2 inhalers / 30 days) STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 3 QL (1 inhaler / 30 days) ADVAIR HFA 3 QL (1 inhaler / 30 days) BREO ELLIPTA 3 QL (1 inhaler / 30 days) DULERA 4 QL (1 inhaler / 30 days) SYMBICORT 3 QL (1 inhaler / 30 days) XANTHINES aminophylline inj 2 elixophyllin 4 theo-24 4 theophylline SOLN; TB24 2 theophylline TB12 1 TOPICAL DERMATOLOGY, ACNE adapalene CREA 2 adapalene GEL.1% 2 amnesteem 2 AVITA 2 benzoyl peroxide-erythromycin 2 claravis 2 clindamax 2 clindamycin phosphate (topical) GEL; 2 LOTN; SOLN; SWAB ery pad 2% 2 erythromycin (acne aid) 2 57

72 (Nombre del myorisan 2 sulfacetamide sodium (acne) 2 tretinoin CREA 2 tretinoin GEL.01%,.025% 2 zenatane 2 DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) 1 mupirocin OINT 1 SILVER SULFADIAZINE CREA 2 SSD 2 SULFAMYLON CREA 4 DERMATOLOGY, ANTIFUNGALS ciclopirox CREA; GEL; SUSP 2 ciclopirox shampoo 1% 2 clotrimazole (topical) CREA 2 clotrimazole (topical) SOLN 1 econazole nitrate CREA 2 ketoconazole cream 2 NAFTIN GEL 4 nyamyc 2 nystatin (topical) 2 nystop 2 DERMATOLOGY, ANTIPRURITIC procto-pak 2 proctosol hc cre 2.5% 1 proctozone hc 1 PRUDOXIN CRE 5% 2 DERMATOLOGY, ANTIPSORIATICS acitretin 5 PA calcipotriene CREA; OINT; SOLN 2 calcitrene oin 0.005% 2 8-MOP 4 TAZORAC CREA 4 PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1 selenium sulfide LOTN 1 DERMATOLOGY, ANTIVIRALS acyclovir topical 2 DENAVIR 4 58

73 (Nombre del DERMATOLOGY, CORTICOSTEROIDS ala-cort 1 alclometasone dipropionate 2 amcinonide CREA; LOTN 2 amcinonide OINT 4 betamethasone dipropionate (topical) 2 betamethasone dipropionate 2 augmented betamethasone valerate CREA; LOTN; 2 OINT clobetasol propionate CREA 2 clobetasol propionate GEL 2 clobetasol propionate OINT 2 clobetasol propionate SOLN 2 cormax 2 DESONIDE CREA 2 desonide LOTN; OINT 2 desoximetasone CREA 2 desoximetasone GEL 2 DESOXIMETASONE OINT.05% 2 desoximetasone OINT.25% 2 diflorasone diacetate 2 fluocinolone acetonide CREA; OIL; 2 OINT; SOLN fluocinolone acetonide body oil 2 fluocinonide CREA.05% 2 fluocinonide GEL 2 fluocinonide OINT 2 fluocinonide SOLN 2 fluocinonide emulsified base 2 fluticasone propionate CREA 2 fluticasone propionate OINT 2 halobetasol propionate 2 hydrocortisone (topical) CREA; OINT 1 hydrocortisone (topical) LOTN 2 hydrocortisone butyrate 2 hydrocortisone valerate 2 LOKARA LOTN 0.05% 2 mometasone furoate CREA; OINT; 2 SOLN 59

74 (Nombre del TACLONEX 4 texacort soln 2.5% 4 triamcinolone acetonide (topical) 1 CREA; OINT triamcinolone acetonide (topical) LOTN 2 triderm 1 DERMATOLOGY, LOCAL ANESTHETICS lidocaine PTCH 2 QL (3 patches / 1 day), PA lidocaine hcl GEL 2 lidocaine hcl SOLN 4% 1 lidocaine oint 5% 2 lidocaine-prilocaine 2 B/D DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN 2 ELIDEL 4 PA fluorouracil (topical) CREA 5% 2 fluorouracil (topical) SOLN 2 imiquimod CREA 2 laclotion lotn 12% 2 metronidazole (topical) CREA; LOTN 2 metronidazole gel 0.75% 2 PANRETIN 5 podofilox SOLN 2 rosadan cre 0.75% 2 TARGRETIN GEL 5 NM, PA VALCHLOR 5 NM, LA, PA VOLTAREN 3 DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 4 malathion 2 permethrin 2 DERMATOLOGY, WOUND CARE AGENTS acetic acid.25% 1 REGRANEX 5 PA SANTYL 4 SODIUM CHLORIDE 0.9% 1 STERILE WATER IRRIGATION 2 MOUTH/THROAT/DENTAL AGENTS 60

75 (Nombre del cevimeline hcl 2 chlorhexidine gluconate (mouth-throat) 1 clotrimazole TROC 2 lidocaine hcl (mouth-throat) 1 nystatin (mouth-throat) 2 periogard 1 pilocarpine hcl (oral) 2 triamcinolone acetonide (mouth) 2 OTIC acetic acid (otic) 2 acetic acid-aluminum acetate 2 CIPRODEX 3 fluocinolone acetonide (otic) 2 neomycin-polymyxin-hc (otic) 2 ofloxacin (otic) 2 61

76 Index 8 8-MOP A abacavir sulfate... 5 abacavir sulfate-lamivudine-zidovudine 6 ABELCET... 5 ABILIFY DISCMELT ABILIFY INJ 9.75MG ABILIFY MAIN INJ 300MG ABILIFY MAIN INJ 400MG ABILIFY MAINTENA ABILIFY SOLN ABILIFY TABS acamprosate calcium acarbose acebutolol hcl acetaminophen w/ codeine... 1 acetazolamide acetic acid acetic acid (otic) acetic acid-aluminum acetate acetylcysteine acitretin ACTHIB ACTIMMUNE acyclovir... 7 acyclovir sodium... 7 acyclovir topical ADACEL ADAGEN adapalene ADCIRCA adefovir dipivoxil... 7 ADEMPAS adriamycin adrucil ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR AFINITOR DISPERZ AGGRENOX a-hydrocort ala-cort ALBENZA... 4 albuterol sulfate alclometasone dipropionate ALCOHOL SWABS ALDURAZYME alendronate sodium alfuzosin hcl ALIMTA ALINIA... 4 allopurinol tab... 1 alosetron hcl ALPHAGAN P SOL 0.1% alprazolam alprazolam tab 0.25mg alprazolam tab 0.5mg alprazolam tab 1mg alprazolam tab 2mg ALREX altavera amantadine hcl AMBISOME... 5 amcinonide amifostine crystalline amikacin sulfate... 3 amiloride & hydrochlorothiazide amiloride hcl aminophylline inj AMINOSYN AMINOSYN 7%/ELECTROLYTES AMINOSYN 8.5%/ELECTROLYTE AMINOSYN II AMINOSYN II 8.5%/ELECTROL AMINOSYN M AMINOSYN-HBC AMINOSYN-PF AMINOSYN-PF 7% AMINOSYN-RF amiodarone hcl AMITIZA CAP 24MCG AMITIZA CAP 8MCG amitriptyline hcl amlodipine besylate amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg

77 amlodipine besylate-valsartan tab mg amlodipine besylate-valsartan tab mg amlodipine--benazepril hcl cap mg amlodipine-benazepril hcl cap 10-40mg amlodipine-benazepril hcl cap mg amlodipine-benazepril hcl cap 5-10 mg 15 amlodipine-benazepril hcl cap 5-20 mg 15 amlodipine-benazepril hcl cap 5-40 mg 15 amlodipine-valsartan-hydrochlorothiazide mg amlodipine-valsartan-hydrochlorothiazide mg amlodipine-valsartan-hydrochlorothiazide mg amlodipine-valsartan-hydrochlorothiazide mg amlodipine-valsartan-hydrochlorothiazide mg ammonium lactate amnesteem amoxapine tab 100mg amoxapine tab 150mg amoxapine tab 25mg amoxapine tab 50mg amoxicillin... 9 amoxicillin & pot clavulanate... 9 amphetamine-dextroamphetamine cap sr 24hr 10 mg amphetamine-dextroamphetamine cap sr 24hr 15 mg amphetamine-dextroamphetamine cap sr 24hr 20 mg amphetamine-dextroamphetamine cap sr 24hr 25 mg amphetamine-dextroamphetamine cap sr 24hr 30 mg amphetamine-dextroamphetamine cap sr 24hr 5 mg amphetamine-dextroamphetamine tab 10 mg amphetamine-dextroamphetamine tab 12.5 mg amphetamine-dextroamphetamine tab 15 mg amphetamine-dextroamphetamine tab 20 mg amphetamine-dextroamphetamine tab 30 mg amphetamine-dextroamphetamine tab 5 mg amphetamine-dextroamphetamine tab 7.5 mg amphotericin b... 5 ampicillin & sulbactam sodium ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5ml ampicillin for susp 250 mg/5ml ampicillin inj ampicillin sodium anagrelide hcl anastrozole ANDRODERM ANORO ELLIPTA APOKYN apri 28 day APRISO APTIOM APTIVUS... 5 ARALAST NP aranelle ARCALYST aripiprazole ASACOL HD ASMANEX TWISTHALER 120 ME ASMANEX TWISTHALER 14 MET ASMANEX TWISTHALER 30 MET ASMANEX TWISTHALER 60 MET ASPIRIN-DIPYRIDAMOLE ASTEPRO atenolol atenolol & chlorthalidone atorvastatin calcium atovaquone... 4 atovaquone-proguanil hcl... 5 ATRIPLA... 6 ATROVENT HFA aubra 28 day AUVI-Q

78 AVASTIN AVELOX... 9 AVELOX ABC PACK... 9 aviane AVITA AVODART azacitidine AZACTAM... 4 AZACTAM/DEX INJ 1GM... 4 AZACTAM/DEX INJ 2GM... 4 azathioprine azelastine drop 0.05% azelastine hcl azelastine spr 0.1% AZILECT azithromycin... 9 AZITHROMYCIN... 9 AZOPT AZOR 10-40MG AZOR TAB 10-20MG AZOR TAB 5-20MG AZOR TAB 5-40MG aztreonam... 4 B bacitracin (ophthalmic) bacitracin-polymyxin b (ophth) bacitracin-poly-neomycin-hc baclofen balsalazide disodium balziva 28 day BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG BARACLUDE... 7 BCG VACCINE benazepril & hydrochlorothiazide benazepril hcl BENICAR BENICAR HCT 40-25MG BENICAR HCT TAB MG BENICAR HCT TAB MG benzoyl peroxide-erythromycin benztropine mesylate BEPREVE BESIVANCE betamethasone dipropionate (topical).. 59 betamethasone dipropionate augmented betamethasone valerate BETASERON betaxolol hcl (ophth) bethanechol chloride BETOPTIC-S bexarotene BEXSERO bicalutamide BICILLIN L-A BICNU BILTRICIDE... 4 bisoprolol & hydrochlorothiazide bisoprolol fumarate BIVIGAM bleomycin sulfate blephamide BOOSTRIX BOSULIF BREO ELLIPTA briellyn 28 day BRILINTA BRIMONIDINE SOL 0.15% brimonidine sol 0.2% BRINTELLIX bromfenac sodium (ophth) BROMFENAC SODIUM (OPHTH)(ONCE- DAILY) bromocriptine mesylate budesonide (inhalation) budesonide ec bumetanide buprenorphine hcl buprenorphine hcl-naloxone hcl sl buproban bupropion hcl buspirone hcl BUSULFEX butorphanol tartrate... 1 BYSTOLIC C cabergoline CADUET cafergot calcipotriene calcitonin (salmon) calcitrene oin 0.005%

79 calcitriol calcitriol inj calcitriol oral soln 1 mcg/ml calcium acetate (phosphate binder) camila 28 day CANASA CANCIDAS... 5 CAPASTAT SULFATE... 7 CAPRELSA captopril captopril & hydrochlorothiazide CARBAGLU carbamazepine CARBIDOPA/LEVODOPA/ENTACAPONE. 27 carbidopa-levodopa carboplatin CARIMUNE NANOFILTERED carteolol hcl (ophth) cartia xt cap 120/24hr cartia xt cap 180/24hr cartia xt cap 240/24hr cartia xt cap 300/24hr carvedilol CAYSTON... 4 cefaclor... 8 cefaclor monohydrate er... 8 cefadroxil... 8 cefazolin in d5w... 8 cefazolin inj... 8 cefazolin sodium... 8 cefdinir... 8 cefepime hcl... 8 cefixime... 8 cefotaxime sodium... 8 cefoxitin sodium... 8 cefpodoxime proxetil... 8 cefprozil... 8 ceftazidime... 8 CEFTAZIDIME/DEXTROSE... 8 ceftriaxone sodium... 8 cefuroxime axetil... 8 cefuroxime sodium... 8 celecoxib... 1 CELONTIN cephalexin... 8 CERDELGA CEREZYME CERVARIX cetirizine syrup cevimeline hcl CHANTIX CHANTIX CONTINUING MONTH CHANTIX STARTER PACK CHEMET chlorhexidine gluconate (mouth-throat) chloroquine phosphate... 5 chlorothiazide chlorpromazine hcl chlorthalidone cholestyramine cholestyramine light choline fenofibrate ciclopirox ciclopirox shampoo 1% cilostazol CILOXAN CIMZIA CIMZIA STARTER KIT CINRYZE CIPRODEX ciprofloxacin... 9 ciprofloxacin er... 9 ciprofloxacin hcl (ophth) ciprofloxacin hcl tab... 9 ciprofloxacin in d5w... 9 ciprofloxacin inj... 9 cisplatin citalopram hydrobromide cladribine claravis clarithromycin... 9 clarithromycin er... 9 clarithromycin for susp... 9 clindamax clindamycin cap 300mg... 4 clindamycin cap 75mg... 4 clindamycin hcl cap 150 mg... 4 clindamycin phosphate (topical) clindamycin phosphate inj... 4 clindamycin phosphate vaginal clindamycin sol 75mg/5ml... 4 CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 25%

80 CLINIMIX 4.25%/DEXTROSE 5% CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX INJ 4.25/D CLINIMIX INJ 4.25/D clobetasol propionate clomipramine hcl clonazepam... 22, 23 clonidine hcl clopidogrel bisulfate clorazepate dipotassium clotrimazole clotrimazole (topical) clozapine CLOZAPINE ODT CLOZAPINE ODT 150MG CLOZAPINE ODT 200MG COARTEM... 5 colchicine w/ probenecid... 1 COLCRYS... 1 colestipol hcl colistimethate sodium... 4 colocort enema 100mg COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ COMPLERA... 6 compro COMVAX constulose COPAXONE INJ 40MG/ML COPAXONE KIT 20MG/ML cormax cortisone acetate COUMADIN CREON CRESTOR CRIXIVAN... 5 cromolyn sodium (mastocytosis) cromolyn sodium (ophth) cromolyn sodium nebu cryselle CUBICIN... 4 CUVPOSA cyclafem 1/35 28 day cyclafem 7/7/7 28 day cyclobenzaprine hcl cyclophosphamide CYCLOPHOSPHAMIDE cycloserine... 7 cyclosporine cyclosporine modified (for microemulsion) cyred tab CYSTADANE CYSTAGON cytarabine D dacarbazine DALIRESP danazol dantrolene sodium dapsone... 4 DAPTACEL DARAPRIM... 4 daunorubicin hcl deblitane 28 day delyla 28 day DELZICOL DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA INJ 400/ML desipramine hcl desmopressin acetate spray desmopressin acetate spray refrigerated desmopressin acetate tabs desmopressin inj 4mcg/ml DESMOPRESSIN SOL 0.01% desogestrel-ethinyl estradiol (biphasic) 36 desonide DESONIDE desoximetasone DESOXIMETASONE dexamethasone dexamethasone sodium phosphate dexamethasone sodium phosphate (ophth) DEXILANT dexrazoxane DEXTROSE 10% FLEX CONTAIN

81 DEXTROSE 10%/NACL 0.2% DEXTROSE 10%/NACL 0.45% DEXTROSE 2.5%/NACL 0.45% DEXTROSE 5% DEXTROSE 5% /ELECTROLYTE DEXTROSE 5%/LACTATED RING DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/NACL 0.3% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/POTASSIUM CHL DEXTROSE 50% dextrose inj 70% diazepam DIAZEPAM GEL diazepam inj diclofenac potassium... 1 diclofenac sodium... 1 diclofenac sodium (ophth) dicloxacillin sodium dicyclomine hcl didanosine... 5 DIFICID... 9 diflorasone diacetate diflunisal... 1 digitek digoxin DIGOXIN SOL 50MCG/ML dihydroergotamine mesylate dilantin DILANTIN-125 SUS 125/5ML dilt-cd cap diltiazem cap diltiazem cap 120mg/24hr diltiazem cap er/12hr diltiazem hcl diltiazem hcl coated beads cp24 120mg diltiazem hcl coated beads cp24 180mg diltiazem hcl coated beads cp24 240mg diltiazem hcl coated beads cp24 300mg diltiazem hcl coated beads cp24 360mg dilt-xr cap diltzac DIPENTUM diphenhydramine inj diphenoxylate w/ atropine DIPHTHERIA/TETANUS TOXOID disopyramide phosphate disulfiram DIURIL SUS 250/5ML divalproex sodium docetaxel inj 140mg/7ml DOCETAXEL INJ 160MG/16ML DOCETAXEL INJ 200MG/20ML DOCETAXEL INJ 20MG/2ML DOCETAXEL INJ 20MG/ML DOCETAXEL INJ 80MG/4ML DOCETAXEL INJ 80MG/8ML donepezil hydrochloride... 24, 25 dorzolamide hcl dorzolamide hcl-timolol maleate doxazosin mesylate doxepin hcl doxorubicin hcl for inj 50 mg doxorubicin hcl liposomal inj 2mg/ml.. 11 doxorubicin inj 50mg doxy inj doxycycline (monohydrate) doxycycline hyclate dronabinol drospirenone-ethinyl estradiol DROXIA DULERA duloxetine hcl DURAMORPH... 2 DUREZOL DYRENIUM E e.e.s e.e.s E.E.S. GRANULES... 9 econazole nitrate EDECRIN EDURANT... 5 EFFIENT ELIDEL ELIQUIS

82 ELITEK elixophyllin ELLA ELMIRON EMCYT EMEND CAP 125MG EMEND CAP 40MG EMEND CAP 80MG EMEND PAK 80 & emoquette EMSAM EMTRIVA... 5 enalapril maleate enalapril maleate & hydrochlorothiazide endocet... 2 ENGERIX-B enoxaparin sodium enpresse 28 day entacapone entecavir... 7 enulose EPIPEN 2-PAK EPIPEN-JR 2-PAK epirubicin hcl epitol EPIVIR... 5 EPIVIR HBV... 7 eplerenone EPZICOM... 6 ERAXIS... 5 ERIVEDGE errin 28 day ery pad 2% ERYPED ERYPED ery-tab... 9 erythrocin lactobionate... 9 erythrocin stearate... 9 erythromycin (acne aid) erythromycin (ophth) erythromycin base... 9 erythromycin cap 250mg ec... 9 escitalopram oxalate esomeprazole magnesium esomeprazole sodium inj estradiol estradiol valerate ESTRADIOL VALERATE ethambutol hcl... 7 ethosuximide etodolac... 1 etodolac er... 1 etoposide EURAX EVOTAZ... 6 EXELON PATCHES exemestane EXJADE F FABRAZYME falmina 28 day famciclovir... 7 famotidine... 42, 43 famotidine inj FANAPT FANAPT TITRATION PACK FARESTON FARXIGA FARYDAK FASLODEX FAZACLO TAB 100/ODT FAZACLO TAB 12.5/ODT FAZACLO TAB 150MG FAZACLO TAB 200MG FAZACLO TAB 25MG ODT felbamate felodipine fenofibrate fenofibrate micronized fenofibrate micronized cap fentanyl... 2 fentanyl citrate... 2 FENTORA... 2 FETZIMA FETZIMA TITRATION PACK finasteride FIRAZYR FLEBOGAMMA FLEBOGAMMA DIF flecainide acetate FLOVENT DISKUS FLOVENT HFA fluconazole

83 fluconazole in dextrose... 5 fluconazole in nacl... 5 flucytosine... 5 fludarabine phosphate fludrocortisone acetate flunisolide (nasal) fluocinolone acetonide fluocinolone acetonide (otic) fluocinolone acetonide body oil fluocinonide fluocinonide emulsified base FLUOROMETHOLONE fluorouracil fluorouracil (topical) fluoxetine cap 10mg fluoxetine cap 20mg fluoxetine cap 40mg fluoxetine sol 20mg/5ml fluoxetine tab 10mg fluoxetine tab 20mg fluphenazine decanoate fluphenazine hcl flurbiprofen... 1 flurbiprofen sodium flutamide fluticasone propionate fluticasone propionate (nasal) fluvoxamine maleate fondaparinux sodium FORADIL AEROLIZER FORTEO FORTICAL FOSAMAX PLUS D fosinopril sodium fosinopril sodium & hydrochlorothiazide FOSRENOL FREAMINE HBC 6.9% FREAMINE III furosemide furosemide inj FUZEON... 5 FYCOMPA G gabapentin GABITRIL galantamine hydrobromide GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX GAMUNEX-C GAMUNEX-C 1GM/10ML ganciclovir inj 500mg... 7 GARDASIL GARDASIL gatifloxacin (ophth) GAUZE PADS 2" X 2" gaviltye-g gavilyte-c gavilyte-h gavilyte-n gemcitabine hcl GEMCITABINE HCL gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin in saline... 3 gentamicin sulfate... 3 gentamicin sulfate (ophth) gentamicin sulfate (topical) GEODON GIANVI gildagia gildess 1.5/30 21 day GILENYA CAP 0.5MG GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG glatopa GLEEVEC GLEOSTINE glimepiride glip/metform tab 5-500mg glipizide glipizide-metformin hcl tab mg glipizide-metformin hcl tab mg GLUCAGEN HYPOKIT

84 GLUCAGON EMERGENCY KIT glycopyrrolate glycopyrrolate inj GOLYTELY granisetron hcl GRANIX griseofulvin microsize... 5 griseofulvin ultramicrosize... 5 guanfacine hcl (adhd) H halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate haloperidol lactate oral conc 2 mg/ml.. 28 HARVONI... 7 HAVRIX heather heparin sod inj 1000/ml heparin sod inj 10000/ml HEPARIN SOD INJ 2000/ML heparin sod inj 20000/ml HEPARIN SOD INJ 2500/ML heparin sod inj 5000/ml HEPARIN SODIUM/D5W HEPARIN SODIUM/NACL 0.45% HEPATAMINE HERCEPTIN HEXALEN HIBERIX HUMIRA HUMIRA KIT 40MG/ HUMIRA PEN HUMIRA PEN-CROHNS DISEASE HUMIRA PEN-PSORIASIS STAR HUMULIN R INJ U hydralazine hcl hydrochlorothiazide hydroco/apap tab mg... 1 hydroco/apap tab 5-325mg... 1 hydroco/apap tab hydrocodone-acetaminophen mg/15ml... 2 hydrocodone-ibuprofen tab mg 2 hydrocortisone HYDROCORTISONE (INTRARECTAL) hydrocortisone (topical) hydrocortisone butyrate hydrocortisone valerate hydromorphon inj 10mg/ml... 2 hydromorphone hcl... 2 hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl inj I ibandronate sodium IBRANCE ibuprofen... 1 ibuprofen tab 800 mg... 1 ICLUSIG idarubicin hcl IFEX ifosfamide inj 1gm ifosfamide inj 1gm/20ml IFOSFAMIDE INJ 3GM ifosfamide inj 3gm/60ml ILEVRO ilotycin IMBRUVICA CAP 140MG imipenem-cilastatin... 4 imipramine hcl imiquimod IMOVAX RABIES (H.D.C.V.) INCRELEX indapamide INFANRIX INLYTA INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE INTELENCE... 5 INTRALIPID INJ 20% INTRALIPID INJ 30% INTRON-A INJ 10MU INTRON-A INJ 18MU INTRON-A INJ 25MU INTRON-A INJ 50MU introvale 91 day INVANZ... 4 INVEGA INVEGA SUST INJ 117 MG/0.75 ML INVEGA SUST INJ 156MG/ML INVEGA SUST INJ 234 MG/1.5 ML INVEGA SUST INJ 39 MG/0.25 ML

85 INVEGA SUST INJ 78 MG/0.5 ML INVIRASE... 5, 6 INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB INVOKAMET TAB MG INVOKANA IONOSOL-B/DEXTROSE 5% IONOSOL-MB/DEXTROSE 5% IPOL INACTIVATED IPV ipratropium bromide ipratropium bromide (nasal) ipratropium-albuterol nebu IRESSA irinotecan hcl ISENTRESS... 6 ISOLYTE P isolyte s isoniazid... 7 isoniazid inj 100 mg/ml... 7 isoniazid syp 50mg/5ml... 7 isosorb mononitrate tab isosorbide dinitrate isosorbide mononitrate er tab isradipine ISTALOL ISTODAX itraconazole... 5 ivermectin... 4 IXIARO J JAKAFI JALYN jantoven JANUMET JANUMET XR TAB JANUMET XR TAB JANUMET XR TAB MG JANUVIA JENTADUETO JOLESSA TAB MG JOLIVETTE junel 1.5/30 21 day junel 1/20 21 day junel fe 1.5/30 28 day junel fe 1/20 28 day K KADCYLA KALETRA SOL... 6 KALETRA TAB MG... 6 KALETRA TAB MG... 6 kariva 28 day KCL 0.075%/D5W/NACL 0.45% KCL 0.15%/D5W/NACL 0.9% KCL 0.3%/D5W/NACL 0.45% KCL 0.3%/D5W/NACL 0.9% KCL IN NACL INJ KCL/D5W INJ 0.3% KCL/D5W/NACL INJ.15/.33% KCL/D5W/NACL INJ.15/.45% KCL/NACL INJ KCL0.15%/D5W/NACL0.2% KCL0.15%/D5W/NACL0.225% ketoconazole... 5 ketoconazole cream ketoconazole shampoo ketoprofen... 1 ketorolac tromethamine (ophth) kimidess 28 day KINRIX kionex KLOR-CON KLOR-CON klor-con m klor-con m klor-con pow 20meq klor-con spr cap KUVAN L labetalol hcl laclotion lotn 12% LACTATED RINGER'S INJ lactulose lactulose (encephalopathy) lamivudine... 6 lamivudine (hbv)... 7 lamivudine-zidovudine... 6 lamotrigine LANOXIN LANTUS LANTUS SOLOSTAR larin 1.5/ larin 1/

86 larin fe 1.5/ larin fe 1/ LASTACAFT latanoprost LATUDA LAZANDA SPR 100MCG... 2 LAZANDA SPR 400MCG... 2 LEENA leflunomide LENVIMA 10MG DAILY DOSE LENVIMA 14MG DAILY DOSE LENVIMA 20MG DAILY DOSE LENVIMA 24MG DAILY DOSE LESCOL LESCOL XL lessina 28 day LETAIRIS letrozole leucovorin calcium leucovorin calcium for inj 500 mg LEUKERAN LEUKINE leuprolide acetate levalbuterol conc 1.25mg/0.5ml LEVEMIR LEVEMIR FLEXTOUCH levetiracetam LEVETIRACETAM IN NACL levetiracetam inj 500/5ml levobunolol hcl LEVOBUNOLOL HCL levocarnitine (metabolic modifiers) levocetirizine dihydrochloride levofloxacin... 9 levofloxacin in d5w... 9 levofloxacin inj 25mg/ml... 9 levofloxacin oral soln 25 mg/ml... 9 levonest 28 day levonorgestrel & eth estradiol levonorgestrel (emergency oc) levonorgestrel-ethinyl estradiol (91-day) levora 0.15/30 28 day levothyroxine sodium LEVOXYL LEXIVA... 6 LIALDA lidocaine lidocaine hcl lidocaine hcl (local anesth.)... 3 lidocaine hcl (mouth-throat) lidocaine inj 0.5%... 3 lidocaine inj 1%... 3 lidocaine inj 1.5%... 3 lidocaine inj 2%... 3 lidocaine oint 5% lidocaine-prilocaine linezolid... 4 LINEZOLID... 4 LINZESS CAP 145MCG LINZESS CAP 290MCG liothyronine sodium lisinopril lisinopril & hydrochlorothiazide LITHIUM lithium carbonate lithium carbonate er LOKARA LOTN 0.05% LOMUSTINE loperamide hcl lorazepam lorcet hd tab mg... 2 lorcet plus tab lorcet tab 5-325mg... 2 lortab tab mg... 2 lortab tab 5-325mg... 2 lortab tab loryna 28 day losartan potassium losartan-hctz mg losartan-hctz mg losartan-hctz mg LOTEMAX LOTRONEX lovastatin low-ogestrel 28 day loxapine succinate LUMIGAN LUMIZYME LUPR DEP-PED INJ 30MG (3-MONTH).. 12 LUPRON DEPOT LUPRON DEPOT INJ MG LUPRON DEPOT-PED lutera 28 day

87 LYNPARZA LYRICA LYSODREN lyza M magnesium sulfate MAGNESIUM SULFATE MAGNESIUM SULFATE IN D5W malathion maprotiline hcl marlissa 28 day MARPLAN TAB 10MG MATULANE MAXIDEX meclizine hcl medroxyprogesterone acetate 150 mg/ml medroxyprogesterone acetate tab mefloquine hcl... 5 MEGACE ES megestrol acetate megestrol acetate sus 40mg/ml MEGESTROL ACETATE SUS 625MG/5ML MEKINIST meloxicam... 1 MELOXICAM... 1 melphalan hcl memantine hcl MEMANTINE HCL MENACTRA MENOMUNE-A/C/Y/W MENVEO mercaptopurine meropenem... 4 mesalamine enema mesalamine w/ cleanser mesna MESNEX metadate tab 20mg er metformin hcl methadone hcl... 2 methazolamide methenamine hippurate... 4 methimazole methotrexate sodium inj methotrexate sodium tabs methyclothiazide methylergonovine maleate methylphenidate hcl methylphenidate hcl er tabs 10mg methylphenidate hcl er tabs 20mg methylphenidate hcl oral soln methylpr ace inj 40mg/ml methylpr ace inj 80mg/ml methylpr ss inj 125mg methylpr ss inj 1gm methylpr ss inj 40mg methylpred pak 4mg methylpred tab 16mg methylpred tab 32mg methylpred tab 4mg methylpred tab 8mg metipranolol metoclopramide hcl metoclopramide inj metolazone metoprolol & hctz tab mg metoprolol & hctz tab mg metoprolol & hctz tab 50-25mg metoprolol succinate metoprolol tartrate metronidazole... 4 metronidazole (topical) metronidazole gel 0.75% metronidazole in nacl... 4 metronidazole vaginal mexiletine hcl MIACALCIN microgestin 1.5/30 21 day microgestin 1/20 21 day microgestin fe 1.5/30 28 day microgestin fe 1/20 28 day midodrine hcl minitran minocycline hcl minoxidil mirtazapine misoprostol mitomycin mitoxantrone hcl M-M-R II moderiba 800 dose pack... 7 moderiba pak 1000/day

88 moderiba pak 1200/day... 7 moderiba pak 600/day... 7 moderiba tab 200mg... 7 moexipril hcl moexipril-hydrochlorothiazide mometasone furoate MONONESSA montelukast sodium morphine ext-rel tab... 2 morphine sul inj... 2 MORPHINE SUL INJ... 2 morphine sulfate... 2 MORPHINE SULFATE... 3 morphine sulfate beads... 3 morphine sulfate cap 100mg er... 3 MORPHINE SULFATE ORAL SOL... 3 MOVANTIK MOVIPREP MOXEZA MOZOBIL MULTAQ mupirocin MUSTARGEN my way MYCAMINE... 5 mycophenolate mofetil mycophenolate sodium myorisan MYOZYME MYRBETRIQ myzilra N nabumetone... 1 nadolol nafcillin sodium NAFTIN NAGLAZYME naloxone hcl naltrexone hcl NAMENDA SOL 10MG/5ML NAMENDA TAB NAMENDA XR NAMENDA XR TITRATION PACK NAMZARIC naphazoline 0.1% NAPRELAN... 1 naproxen... 1 naproxen sodium... 1 naratriptan hcl NASONEX NATACYN nateglinide NEBUPENT... 4 necon 0.5/35 28 day necon 1/35 28 day necon 10/11 28 day NECON 7/7/ NECON TAB 1/ nefazodone hcl neomycin sulfate... 3 neomycin-bacitracin zn-polymyxin neomycin-polymy-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc (ophth) neomycin-polymyxin-hc (otic) NEORAL NEPHRAMINE NEULASTA NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine... 6 NEVIRAPINE... 6 NEXAVAR NEXIUM CAP 20MG NEXIUM CAP 40MG NEXIUM GRA 10MG DR NEXIUM GRA 2.5MG DR NEXIUM GRA 20MG DR NEXIUM GRA 40MG DR NEXIUM GRA 5MG DR next choice one dose niacin (antihyperlipidemic) niacor nicardipine hcl NICOTROL INHALER NICOTROL NS nifedical nifedipine nifedipine er nikki 28 day NILANDRON nimodipine

89 NIPENT nitro-bid NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.8MG/HR nitrofurantoin macrocrystal... 4 nitrofurantoin monohyd macro... 4 nitroglycerin NITROLINGUAL PUMPSPRAY NITROSTAT NORA-BE TAB NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN norethindrone (contraceptive) norethindrone acetate norgestimate-ethinyl estradiol (triphasic) norlyroc 28 day normosol-m NORMOSOL-R NORMOSOL-R IN D5W NORPACE CR nortrel 0.5/35 28 day nortrel 1/35 21 day nortrel 1/35 28 day nortrel 7/7/7 28 day nortriptyline hcl NORVIR... 6 NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 PREFILL NOVOLOG PENFILL NOXAFIL... 5 NUEDEXTA NULOJIX NULYTELY/FLAVOR PACKS NUTRILIPID EMU 20% NUVARING NUVIGIL nyamyc NYMALIZE nystatin... 5 nystatin (mouth-throat) nystatin (topical) nystop O OCELLA TAB MG OCTAGAM octreotide acetate ofloxacin (ophth) ofloxacin (otic) olanzapine olopatadine hcl (nasal) OLYSIO... 7 omega-3-acid ethyl esters omeprazole ondansetron hcl ondansetron hcl inj ondansetron hcl oral soln ondansetron odt ONFI ORAP ORFADIN ORKAMBI orsythia 28 day oxacillin sodium oxaliplatin oxandrolone oxcarbazepine oxybutynin chloride oxycodone hcl... 3 OXYCODONE HCL... 3 oxycodone hcl tab 5 mg... 3 oxycodone w/ acetaminophen mg... 3 oxycodone w/ acetaminophen mg... 3 oxycodone w/ acetaminophen 5-325mg 3 oxycodone w/ acetaminophen mg... 3 P pacerone paclitaxel pamidronate disodium PANRETIN pantoprazole sodium tbec paricalcitol paromomycin sulfate... 3 paroxetine hcl paser d/r... 7 PATADAY

90 PATANOL PAXIL PAZEO PEDVAX HIB PEG 3350/ELECTROLYTES peg 3350-kcl-sod bicarb-sod chloride-sod sulfate peg 3350-potassium chloride-sod bicarbonate-sod chloride PEGANONE PEGASYS PEGASYS PROCLICK PEG-INTRON PEG-INTRON REDIPEN PENICILLIN G POT IN DEXTROSE penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium penicilln gk inj 5mu PENTAM PENTASA pentoxifylline PERFOROMIST perindopril erbumine periogard permethrin perphenazine phenelzine sulfate phenobarbital phenobarbital sodium PHENOBARBITAL SODIUM phenytek phenytoin phenytoin sodium phenytoin sodium extended philith PHOSLYRA PHOSPHOLINE IODIDE PILOCARPINE HCL pilocarpine hcl (oral) pimtrea pack pindolol pioglitazone hcl piperacillin sodium-tazobactam sodium 10 pirmella 1/35 28 day piroxicam... 1 PLASMA-LYTE A PLASMA-LYTE PLASMA-LYTE-56/D5W podofilox polyethylene glycol polymyxin b-trimethoprim POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG portia 28 day potassium chloride... 50, 52 POTASSIUM CHLORIDE... 50, 52 POTASSIUM CHLORIDE 0.15% POTASSIUM CHLORIDE 0.22% POTASSIUM CHLORIDE ER potassium chloride in nacl potassium chloride microencapsulated crystals cr POTASSIUM CITRATE (ALKALINIZER). 45 POTIGA PRADAXA pramipexole dihydrochloride pravastatin sodium prazosin hcl pred sod pho sol 5mg/5ml PREDNISOLONE ACETATE (OPHTH) prednisolone sodium phosphate (ophth) prednisolone sol 15mg/5ml prednisolone sol 25mg/5ml prednisolone syp 15mg/5ml prednisone con 5mg/ml prednisone pak 10mg prednisone pak 5mg prednisone sol 5mg/5ml prednisone tab 10mg prednisone tab 1mg prednisone tab 2.5mg prednisone tab 20mg prednisone tab 50mg prednisone tab 5mg PREMARIN CREAM premasol sol 10% premasol sol 6% PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

91 prevalite previfem 28 day PREZCOBIX... 7 PREZISTA... 6 PRIFTIN... 7 PRIMAQUINE PHOSPHATE... 5 primidone PRISTIQ PRIVIGEN PROAIR HFA probenecid... 1 PROCALAMINE prochlorperazine inj prochlorperazine maleate prochlorperazine supp PROCRIT procto-pak proctosol hc cre 2.5% proctozone hc PROGLYCEM SUS 50MG/ML PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA... 46, 47 promethazine hcl propafenone hcl proparacaine hcl propranolol & hydrochlorothiazide propranolol cap er propranolol hcl propylthiouracil PROQUAD PROSOL protriptyline hcl PROVENTIL HFA PRUDOXIN CRE 5% PULMICORT FLEXHALER PULMOZYME PURIXAN pyrazinamide... 7 pyridostigmine bromide Q QUADRACEL quasense 91 day quetiapine fumarate quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate... 5 QVAR R RABAVERT raloxifene hcl ramipril RANEXA ranitidine hcl ranitidine hcl inj ranitidine syrup RAPAMUNE REBETOL SOLN... 7 reclipsen 28 day RECOMBIVAX HB REGRANEX RELENZA DISKHALER... 7 RELISTOR RELPAX REMICADE REMODULIN RENVELA PAK 0.8GM RENVELA PAK 2.4GM RENVELA TAB 800MG repaglinide RESCRIPTOR... 6 RESTASIS RETROVIR IV INFUSION... 6 REVATIO REVLIMID REXULTI REYATAZ... 6 ribapak mis 600/day... 7 ribasphere... 8 ribasphere ribapak ribasphere ribapak ribasphere ribapak ribavirin 200mg... 8 rifabutin... 7 rifampin... 7 RIFATER... 7 riluzole rimantadine hydrochloride... 8 RINGER'S

92 RIOMET RISPERDAL INJ 12.5MG RISPERDAL INJ 25MG RISPERDAL INJ 37.5MG RISPERDAL INJ 50MG risperidone... 29, 30 RITUXAN RIVASTIGMINE PATCH rivastigmine tartrate rizatriptan benzoate ropinirole hydrochloride rosadan cre 0.75% ROTARIX ROTATEQ roxicet soln... 3 roxicet tabs... 3 ROZEREM S SABRIL SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS selegiline hcl selenium sulfide SELZENTRY... 6 SENSIPAR SEREVENT DISKUS SEROQUEL XR sertraline hcl sharobel 28 day sildenafil citrate (pulmonary hypertension) SILENOR SILVER SULFADIAZINE SIMBRINZA simvastatin sirolimus SIROLIMUS SIRTURO... 7 SIVEXTRO... 4 SODIUM CHLORIDE... 50, 52 SODIUM CHLORIDE 0.45% VIA SODIUM CHLORIDE 0.9% SODIUM CHLORIDE INJ 0.9% SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN sodium phenylbutyrate sodium polystyrene sulfonate SOLIA SOLTAMOX SOLU-CORTEF SOMATULINE DEPOT SOMAVERT sorine sotalol hcl sotalol hcl (afib/afl) SOVALDI... 8 SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone & hydrochlorothiazide.. 21 sprintec 28 day SPRYCEL sps susp 15gm/60ml sronyx SSD STALEVO STALEVO STALEVO STALEVO STALEVO STALEVO stavudine... 6 STERILE WATER IRRIGATION STIVARGA STRATTERA streptomycin sulfate... 3 STRIBILD... 7 SUBOXONE MIS 12-3MG SUBOXONE MIS 2-0.5MG SUBOXONE MIS 4-1MG SUBOXONE MIS 8-2MG SUCRAID sucralfate sulfacetamide sodium (acne) sulfacetamide sodium (ophth) sulfacetamide sod-prednisolone sulfadiazine... 3 sulfamethoxazole-trimethoprim... 4 sulfamethoxazole-trimethoprim inj... 4 SULFAMYLON sulfasalazine sulfasalazine ec

93 sulindac... 1 SUMATRIPTAN sumatriptan succinate... 31, 32 SUMATRIPTAN SUCCINATE sumatriptan succinate inj SUMATRIPTAN SUCCINATE INJ suprax... 8 SUPRAX... 8, 9 SUPREP BOWEL PREP SURMONTIL CAP 100MG SURMONTIL CAP 25MG SURMONTIL CAP 50MG SUSTIVA... 6 SUTENT SYLATRON KIT 296MCG SYLATRON KIT 444MCG SYLATRON KIT 888MCG SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID... 4 SYNTHROID SYPRINE T TABLOID TACLONEX tacrolimus TAFINLAR TAMIFLU... 8 tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN CAPS TARGRETIN GEL tarina fe tab 1/ TASIGNA tazicef... 9 tazicef vial... 9 TAZORAC taztia TEFLARO... 9 TEGRETOL TEGRETOL-XR TEKAMLO TAB MG TEKAMLO TAB 150-5MG TEKTURNA TEKTURNA HCT TAB MG TEKTURNA HCT TAB MG TEKTURNA HCT TAB MG TEKTURNA HCT TAB MG temazepam TENIVAC terazosin hcl terbinafine hcl... 5 terbutaline sulfate terconazole vaginal TESTIM testosterone cypionate testosterone enanthate TETANUS TOXOID ADSORBED TETANUS/DIPHTHERIA TOXOID TETRABENAZINE TEV-TROPIN texacort soln 2.5% THALOMID theo theophylline thioridazine hcl thiothixene tiagabine hcl TIKOSYN timolol maleate timolol maleate (ophth) TIMOLOL MALEATE GEL TIVICAY... 6 tizanidine hcl TOBRADEX TOBRADEX ST tobramycin... 3 tobramycin (ophth) tobramycin sulfate... 3 tobramycin sulfate in saline... 3 tobramycin-dexamethasone TOBREX TOLTERODINE TARTRATE CAP ER tolterodine tartrate tabs topiramate toposar topotecan hcl torsemide inj 20mg/2ml torsemide inj 50mg/5ml torsemide tabs

94 TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TRACLEER TRADJENTA tramadol hcl... 2 tramadol-acetaminophen... 2 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine sulfate travasol TRAVATAN Z trazodone hcl TREANDA TRECATOR... 7 TRELSTAR DEP INJ 3.75MG TRELSTAR LA INJ 11.25MG tretinoin tretinoin (chemotherapy) triamcinolone acetonide (mouth) triamcinolone acetonide (topical) triamterene & hydrochlorothiazide triamterene & hydrochlorothiazide cap mg TRIBENZOR TAB MG TRIBENZOR TAB TRIBENZOR TAB MG TRIBENZOR TAB MG TRIBENZOR40- TAB 10-25MG triderm trifluoperazine hcl trifluridine tri-legest 28 day trilyte trimethoprim... 4 TRINESSA tri-previfem 28 day TRISENOX tri-sprintec 28 day TRIUMEQ... 7 trivora 28 day TROPHAMINE INJ 10% trospium chloride TRULICITY TRUMENBA TRUVADA... 7 TUDORZA PRESSAIR TUDORZA PRESSAIR (INSTITUTIONAL PACK) 400MCG/ACT TWINRIX INJ TYBOST... 6 TYGACIL... 4 TYKERB TYPHIM VI TYSABRI TYZEKA... 8 U UCERIS ULORIC... 1 UNITHROID ursodiol V VAGIFEM valacyclovir hcl... 8 VALCHLOR VALCYTE... 8 valganciclovir hcl... 8 valproate sodium valproic acid valsartan valsartan & hctz tab mg valsartan & hctz tab mg valsartan & hctz tab mg valsartan & hctz tab mg valsartan & hctz tab mg vancomycin hcl... 4 VANDAZOLE VAQTA VARIVAX VASCEPA VELCADE velivet 28 day venlafaxine hcl VENTAVIS verapamil cap er VERAPAMIL CAP ER verapamil hcl... 19, 20 verapamil tab er VERSACLOZ VESICARE vestura VIBRAMYCIN VICTOZA

95 VICTRELIS... 8 VIDEX PEDIATRIC... 6 VIGAMOX VIIBRYD VIIBRYD STARTER PACK VIMPAT vinblastine sulfate vincasar vincristine sulfate vinorelbine tartrate viorele VIRACEPT... 6 VIRAMUNE XR... 6 VIREAD... 6 VITEKTA... 6 VOLTAREN voriconazole... 5 VOTRIENT vyfemia 28 day W warfarin sodium WELCHOL X XALKORI XARELTO XARELTO STARTER PACK XENAZINE XGEVA XIFAXAN XIGDUO XR TAB MG XIGDUO XR TAB MG XIGDUO XR TAB MG XIGDUO XR TAB 5-500MG XOLAIR XOPENEX HFA XTANDI xulane XYREM Y YF-VAX Z zafirlukast zarah ZAVESCA zazole ZAZOLE ZELBORAF ZEMAIRA zenatane zenchent 28 day ZENPEP ZETIA TAB 10MG ZIAGEN... 6 zidovudine... 6 ziprasidone hcl ZMAX... 9 zoledronic inj 4mg/5ml ZOLINZA zolmitriptan zolmitriptan odt zolpidem tartrate ZOMETA zonisamide ZONTIVITY ZORTRESS TAB 0.25MG ZORTRESS TAB 0.5MG ZORTRESS TAB 0.75MG ZOSTAVAX ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX... 5 ES11 81

96 This formulary was updated on 11/01/2015. For more recent information or other questions, please contact First United American - Essential (PDP) at or, for TTY users, , weekdays from 8:00am to 8:00pm Eastern, or visit First United American - Essential (PDP) is a PDP plan with a Medicare contract. Enrollment in First United American - Essential (PDP) depends on contract renewal. Este formulario condensado se actualizó en 11/01/2015 y no es una lista completa de medicamentos cubiertos por nuestro plan. Para una lista completa o otras preguntas, por favor de contactar a First United American - Essential (PDP) en o, para los usuarios de TTY, , lunes a viernes de 8:00 am a 8:00 pm en su zona horaria local o visite First United American - Essential (PDP) es un plan de medicamentos recetados con un contrato de Medicare. La inscripción en First United American - Essential (PDP) depende de la renovación del contrato. *NA561* *NA561* First United American Life Insurance Company. All rights reserved.