CCH Senior Select ro r H S

Transcription

1 P CCH Senior Select ro r H S 東華 H S or l r i t o Co ere r S H S C C S H S C H S H S ro e or l r ile S i ion er ion er 9 i or l r te on 0/09/208 or ore recent in or tion or ot er e tion le e cont ct C ine e Co nit He lt l n e er Ser ice t or or er e en ee ro to or i it CCH He lt l n co e ic re 2

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Chinese Community Health Plan (CCHP). When it refers to plan or our plan, it means CCHP Senior Select Program (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of 0/09/8. 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, 209, and from time to time during the year. What is the CCHP Senior Select Program (HMO SNP) Formulary? A formulary is a list of covered drugs selected by CCHP Senior Select Program (HMO SNP) 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. CCHP Senior Select Program (HMO SNP) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a CCHP Senior Select Program (HMO SNP) 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 209 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 209 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) 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. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the CCHP Senior Select Program (HMO SNP) Formulary?

3 Drugs removed from the market. 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 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 30-day supply of the drug. The enclosed formulary is current as of 0/09/8. To get updated information about the drugscovered by CCHP Senior Select Program (HMO SNP), please contact us. Our contact information appearson the front and back cover pages. If we make any mid-year non-maintenance changes to the formulary, wewill send an errata sheet to you. You can also find the changes on our website at How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents-Misc. If you know what your drug is used for, look for the category name in the list that begins on page number. 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 -. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? CCHP Senior Select Program (HMO SNP) 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.

4 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: CCHP Senior Select Program (HMO SNP) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from CCHP Senior Select Program (HMO SNP) before you fill your prescriptions. If you don t get approval, CCHP Senior Select Program (HMO SNP) may not cover the drug. Quantity Limits: For certain drugs, CCHP Senior Select Program (HMO SNP) limits the amount of the drug that CCHP Senior Select Program (HMO SNP) will cover. For example, CCHP Senior Select Program (HMO SNP) provides 30 tablets per prescription for INVOKANA. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, CCHP Senior Select Program (HMO SNP) 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, CCHP Senior Select Program (HMO SNP) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CCHP Senior Select Program (HMO SNP) 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. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask CCHP Senior Select Program (HMO SNP) 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 CCHP Senior Select Program (HMO SNP) s formulary? on page for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. CCHP Senior Select Program (HMO SNP) pays for certain OTC drugs. FREESTYLE LITE METER FREESTYLE FREEDOM LITE METER FREESTYLE LITE TEST STRIPS FREESTYLE INSULINX METER FREESTYLE INSULINX TEST STRIPS FREESTYLE CONTROL SOLUTION PRECISION XTRA METER PRECISION XTRA TEST STRIPS MEDISENSE CONTROL SOLUTION LANCETS LANCET DEVICES LANCET KIT KETOTIFEN FUMARATE 0.025% EYE DROPS ARTIFICIAL TEARS CCHP Senior Select Program (HMO SNP) will provide these OTC drugs at no cost to you. The cost to CCHP Senior Select Program (HMO SNP) of these OTC drugs will not count toward your total Part D drug costs (that is, the cost of the OTC drugs does not count for the coverage gap.

5 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that CCHP Senior Select Program (HMO SNP) does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by CCHP Senior Select Program (HMO SNP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by CCHP Senior Select Program (HMO SNP). You can ask CCHP Senior Program (HMO) 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 CCHP Senior Select Program (HMO SNP) s Formulary? You can ask CCHP Senior Select Program (HMO SNP) 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 waive coverage restrictions or limits on your drug. For example, for certain drugs, CCHP Senior Select Program (HMO SNP) 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, CCHP Senior Select Program (HMO SNP) will only approve your request for an exception if the alternative drugs included on the plan s formulary, 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 or utilization restriction exception. When you request a formulary 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

6 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. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30-day supply of medication. 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 and 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 3-day emergency supply of that drug while you pursue a formulary exception. For more information For more detailed information about your CCHP Senior Select Program (HMO SNP) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about CCHP Senior Select Program (HMO SNP), 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 CCHP Senior Select Program (HMO SNP) s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by CCHP Senior Select Program (HMO SNP). If you have trouble finding your drug in the list, turn to the Index that begins on page - The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., VYVANSE) and generic drugs are listed in lower-case italics (e.g., alendronate). The second column of the chart lists the drug tier. Note: For more information about the cost-sharing for your drugs, please review your Evidence of Coverage or call Member Services Center at TTY users should call The information in the Requirements/Limits column tells you if CCHP Senior Select Program (HMO SNP) has any special requirements for coverage of your drug. Limited Distribution (LD): These drugs are restricted to certain pharmacies by the Food and Drug Administration. These drugs may only be available at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Member Services at , seven days a week from 8:00 a.m. to 8:00 p.m. TTY users should call Non-Mail-Order Drug (NM): These drugs are limited to a 30-day supply for both Retail and Mail Order Pharmacies.

7 Prior Authorization (PA): Prior Authorization may apply for these drugs. This means that you (or your physician) will need to get approval from CCHP Senior Select Program (HMO SNP) before you fill your prescription. If you don t get approval, CCHP Senior Select Program (HMO SNP) may not cover the drug. Prior Authorization Restriction for Part B vs Part D Determination (PA_BvD): These drugs may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from CCHP Senior Select Program (HMO SNP) to determine whether the drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, CCHP Senior Select Program (HMO SNP) may not cover this drug. Prior Authorization Restriction for New Starts Only (PA_NSO): If this drug is new to the member, you (or your physician) are required to get prior authorization from CCHP Senior Select Program (HMO SNP) before you fill your prescription for this drug. Without prior approval, CCHP Senior Select Program (HMO SNP) may not cover this drug. Quantity Limits (QL): For certain drugs, CCHP Senior Select Program (HMO SNP) limits the amount of the drug that is covered. This could include a: per fill, daily, monthly, or yearly limitation. Step Therapy (ST): In some cases, CCHP Senior Select Program (HMO SNP) 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, CCHP Senior Select Program (HMO SNP) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CCHP Senior Select Program (HMO SNP) will then cover Drug B.

8 Table of Contents Analgesics... 3 Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents... 7 Antianxiety Agents... 8 Antibacterials... 9 Anticancer Agents... 7 Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents... 4 Antiparkinsonian Agents... 4 Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders... 5 Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives... 67

9 Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents... 9 Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents... 0 Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents

10 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 20-2 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml buprenorphine transdermal patch weekly 0 mcg/hour, 5 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butorphanol tartrate injection solution /ml, 2 /ml butorphanol tartrate nasal spray,nonaerosol 0 /ml codeine sulfate oral tablet 5, 30, 60 DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, MG/ML EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 00-4 MG, MG, MG, 50-2 MG, MG, MG endocet oral tablet 0-325, 5-325, fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT 00 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution /5 ml QL (4980 per 30 days) QL (390 per 30 days) (Tylenol-Codeine #3) QL (390 per 30 days) (Tylenol-Codeine #4) QL (390 per 30 days) (Buprenex) (Butrans) QL (4 per 28 days) QL (0 per 30 days) QL (240 per 30 days) PA BvD QL (60 per 30 days) QL (360 per 30 days) (Actiq) PA; QL (20 per 30 days) (Duragesic) QL (0 per 30 days) PA; QL (20 per 30 days) (Hycet) QL (5400 per 30 days) 3

11 hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (390 per 30 days) hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (360 per 30 days) hydrocodone-acetaminophen oral tablet (Verdrocet) QL (360 per 30 days) hydrocodone-acetaminophen oral tablet 5- (Vicodin) QL (390 per 30 days) 300 hydrocodone-acetaminophen oral tablet 5- (Lorcet (hydrocodone)) QL (360 per 30 days) 325 hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (390 per 30 days) hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (360 per 30 days) hydrocodone-ibuprofen oral tablet (Ibudone) QL (480 per 30 days), hydrocodone-ibuprofen oral tablet QL (480 per 30 days) hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone injection syringe 2 /ml (Dilaudid) hydromorphone oral liquid /ml (Dilaudid) QL (2400 per 30 days) hydromorphone oral tablet 2 (Dilaudid) QL (450 per 30 days) hydromorphone oral tablet 4 (Dilaudid) QL (240 per 30 days) hydromorphone oral tablet 8 (Dilaudid) QL (20 per 30 days) hydromorphone oral tablet extended (Exalgo ER) QL (30 per 30 days) release 24 hr 2, 6, 32, 8 HYSINGLA ER ORAL TABLET,ORAL QL (30 per 30 days) ONLY,EXT.REL.24 HR 00 MG, 20 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG ibuprofen-oxycodone oral tablet QL (240 per 30 days) levorphanol tartrate oral tablet 2 QL (240 per 30 days) lorcet (hydrocodone) oral tablet QL (360 per 30 days) lorcet hd oral tablet QL (360 per 30 days) lorcet plus oral tablet QL (360 per 30 days) meperidine oral tablet 00 (Demerol) QL (360 per 30 days) meperidine oral tablet 50 QL (720 per 30 days) methadone oral solution 0 /5 ml QL (800 per 30 days) methadone oral solution 5 /5 ml QL (3600 per 30 days) methadone oral tablet 0, 5 (Dolophine) QL (360 per 30 days) 4

12 morphine concentrate oral solution 00 QL (80 per 30 days) /5 ml (20 /ml) morphine injection syringe 2 /ml PA BvD morphine intravenous cartridge 2 /ml PA BvD morphine oral capsule, er multiphase 24 QL (60 per 30 days) hr 20, 30, 45, 60, 75, 90 morphine oral capsule,extend.release (Kadian) QL (60 per 30 days) pellets 0, 00, 20, 30, 50, 60, 80 morphine oral solution 0 /5 ml QL (800 per 30 days) morphine oral solution 20 /5 ml (4 QL (900 per 30 days) /ml) MORPHINE ORAL TABLET 5 MG, 30 QL (80 per 30 days) MG morphine oral tablet extended release 00 (MS Contin) QL (20 per 30 days), 5, 200, 30, 60 NUCYNTA ER ORAL TABLET QL (60 per 30 days) EXTENDED RELEASE 2 HR 00 MG, 50 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 00 MG, 75 QL (80 per 30 days) MG NUCYNTA ORAL TABLET 50 MG QL (360 per 30 days) oxycodone oral capsule 5 QL (360 per 30 days) oxycodone oral concentrate 20 /ml QL (270 per 30 days) oxycodone oral solution 5 /5 ml QL (5400 per 30 days) oxycodone oral tablet 0, 20 QL (80 per 30 days) oxycodone oral tablet 5, 30 (Roxicodone) QL (80 per 30 days) oxycodone oral tablet 5 (Roxicodone) QL (360 per 30 days) oxycodone-acetaminophen oral solution 5- QL (800 per 30 days) 325 /5 ml oxycodone-acetaminophen oral tablet 0- (Endocet) QL (360 per 30 days) 325, , 5-325, oxycodone-aspirin oral tablet QL (360 per 30 days) OXYCONTIN ORAL TABLET,ORAL QL (60 per 30 days) ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (20 per 30 days) ONLY,EXT.REL.2 HR 80 MG oxymorphone oral tablet 0, 5 (Opana) QL (360 per 30 days) 5

13 oxymorphone oral tablet extended release QL (60 per 30 days) 2 hr 0, 5, 20, 30, 40, 5, 7.5 pentazocine-naloxone oral tablet QL (360 per 30 days) tramadol oral tablet 50 (Ultram) QL (240 per 30 days) tramadol oral tablet extended release 24 QL (60 per 30 days) hr 00, 200, 300 tramadol oral tablet, er multiphase 24 hr QL (60 per 30 days) 00, 200, 300 tramadol-acetaminophen oral tablet (Ultracet) QL (360 per 30 days) 325 vicodin es oral tablet QL (390 per 30 days) vicodin hp oral tablet QL (390 per 30 days) vicodin oral tablet QL (390 per 30 days) Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 00, 200, (Celebrex) QL (60 per 30 days) 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 diclofenac sodium topical drops.5 % diclofenac sodium topical gel % (Voltaren) QL (000 per 30 days) diclofenac sodium topical gel 3 % (Solaraze) PA NSO diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 etodolac oral capsule 200, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release 24 hr 400, 500, 600 flurbiprofen oral tablet 00, 50 ibu oral tablet 400, 600, 800 ibuprofen oral suspension 00 /5 ml (Child Ibuprofen) 6

14 ibuprofen oral tablet 400, 600, 800 (IBU) INDOCIN ORAL SUSPENSION 25 MG/5 ML indomethacin oral capsule 25, 50 indomethacin oral capsule, extended release 75 ketorolac injection cartridge 5 /ml ketorolac injection solution 5 /ml, 30 /ml ( ml) ketorolac injection syringe 5 /ml ketorolac intramuscular cartridge 60 /2 ml ketorolac oral tablet 0 QL (20 per 5 days) meloxicam oral tablet 5, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral suspension 25 /5 ml (Naprosyn) naproxen oral tablet 250, 375 naproxen oral tablet 500 (Naprosyn) naproxen sodium oral tablet 275 naproxen sodium oral tablet 550 (Anaprox DS) piroxicam oral capsule 0, 20 (Feldene) sulindac oral tablet 50, 200 Anesthetics Local Anesthetics lidocaine (pf) injection solution 20 /ml (Xylocaine-MPF) (2 %), 5 /ml (0.5 %) lidocaine hcl injection solution 20 /ml (Xylocaine) (2 %) lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive (Lidoderm) PA; QL (90 per 30 days) patch,medicated 5 % lidocaine topical ointment 5 % QL (50 per 30 days) lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % Anti-Addiction/Substance Abuse Treatment Agents 7

15 Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 buprenorphine hcl sublingual tablet 2, 8 buprenorphine-naloxone sublingual film (Suboxone) QL (90 per 30 days) 8-2 buprenorphine-naloxone sublingual tablet QL (90 per 30 days) 2-0.5, 8-2 bupropion hcl (smoking deter) oral tablet (Zyban) extended release 2 hr 50 CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) disulfiram oral tablet 250, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL (2 per 2 days) AEROSOL 4 MG/ACTUATION NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 0 MG/ML SUBOXONE SUBLINGUAL FILM 2-3 QL (60 per 30 days) MG SUBOXONE SUBLINGUAL FILM QL (90 per 30 days) MG, 4- MG, 8-2 MG ZYBAN ORAL TABLET EXTENDED RELEASE 2 HR 50 MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5,, 2 alprazolam oral tablet extended release 24 hr 0.5,, 2, 3 (Xanax) (Xanax XR) ST 8

16 alprazolam oral tablet,disintegrating 0.25, 0.5,, 2 buspirone oral tablet 0, 5, 5 chlordiazepoxide hcl oral capsule 0, 25, 5 clonazepam oral tablet 0.5,, 2 (Klonopin) clonazepam oral tablet,disintegrating 0.25, 0.25, 0.5,, 2 clorazepate dipotassium oral tablet 5, 3.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT 2.5 MG diazepam injection solution 5 /ml diazepam injection syringe 5 /ml diazepam intensol oral concentrate 5 /ml diazepam oral solution 5 /5 ml ( /ml) diazepam oral tablet 0, 2, 5 (Valium) estazolam oral tablet, 2 flurazepam oral capsule 5, 30 lorazepam injection solution 2 /ml, 4 (Ativan) /ml lorazepam injection syringe 2 /ml, 4 /ml lorazepam oral concentrate 2 /ml (Lorazepam Intensol) lorazepam oral tablet 0.5,, 2 (Ativan) meprobamate oral tablet 200, 400 ONFI ORAL SUSPENSION 2.5 MG/ML PA NSO ONFI ORAL TABLET 0 MG, 20 MG PA NSO oxazepam oral capsule 0, 5, 30 temazepam oral capsule 5, 22.5, (Restoril) 30, 7.5 triazolam oral tablet 0.25 triazolam oral tablet 0.25 (Halcion) Antibacterials Aminoglycosides amikacin injection solution 500 /2 ml 9

17 gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 60 /50 ml, 80 /00 ml, 80 /50 ml gentamicin injection solution 20 /2 ml, 40 /ml gentamicin sulfate (ped) (pf) injection solution 20 /2 ml neomycin oral tablet 500 streptomycin intramuscular recon soln gram TOBI PODHALER INHALATION PA; NM; NDS CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation (Tobi) PA; NM; NDS solution for nebulization 300 /5 ml tobramycin sulfate injection solution 0 /ml, 40 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln gram clindamycin hcl oral capsule 50, 300 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml (Cleocin in 5 % dextrose) clindamycin palmitate hcl oral recon soln (Cleocin Pediatric) 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 50 /ml clindamycin phosphate intravenous (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection recon soln 50 (Coly-Mycin M Parenteral) DALVANCE INTRAVENOUS NM; NDS SOLUTION 500 MG daptomycin intravenous recon soln 500 (Cubicin) NM; NDS lincomycin injection solution 300 /ml (Lincocin) 0

18 linezolid 600 /300 ml-0.9% nacl 600 PA; NM; NDS /300 ml linezolid in dextrose 5% intravenous piggyback 600 /300 ml (Zyvox) PA; NM; NDS linezolid oral suspension for reconstitution (Zyvox) PA; NM; NDS 00 /5 ml linezolid oral tablet 600 (Zyvox) PA; NM; NDS methenamine hippurate oral tablet gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /00 ml metronidazole oral capsule 375 (Flagyl) metronidazole oral tablet 250, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin) 00, 25, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 (Macrobid) nitrofurantoin oral suspension 25 /5 ml (Furadantin) polymyxin b sulfate injection recon soln 500,000 unit SIVEXTRO INTRAVENOUS RECON SOLN 200 MG PA; NM; NDS; QL (6 per 5 days) SIVEXTRO ORAL TABLET 200 MG PA; NM; NDS; QL (6 per 5 days) SYNERCID INTRAVENOUS RECON NM; NDS SOLN 500 MG trimethoprim oral tablet 00 vancomycin in dextrose 5 % intravenous piggyback gram/200 ml vancomycin intravenous recon soln 0 gram, 5 gram vancomycin oral capsule 25 (Vancocin) QL (56 per 0 days) vancomycin oral capsule 250 (Vancocin) NM; NDS Cephalosporins AVYCAZ INTRAVENOUS RECON SOLN 2.5 GRAM cefaclor oral capsule 250, 500 cefaclor oral suspension for reconstitution 25 /5 ml, 250 /5 ml, 375 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml cefadroxil oral tablet gram

19 cefazolin injection recon soln gram, 0 gram, 500 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefepime injection recon soln gram, 2 (Maxipime) gram cefixime oral suspension for reconstitution (Suprax) 00 /5 ml, 200 /5 ml cefotaxime injection recon soln gram, 500 cefotaxime injection recon soln 2 gram (Claforan) cefotetan injection recon soln gram, 2 (Cefotan) gram cefoxitin intravenous recon soln gram, 0 gram, 2 gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 200 cefprozil oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln 2 gram, 6 (TAZICEF) gram ceftriaxone injection recon soln gram, 0 gram, 2 gram, 250, 500 cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 250, 500 (Keflex) cephalexin oral suspension for reconstitution 25 /5 ml, 250 /5 ml cephalexin oral tablet 250, 500 SUPRAX ORAL CAPSULE 400 MG tazicef injection recon soln gram, 2 gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG NM; NDS 2

20 ZERBAXA INTRAVENOUS RECON SOLN.5 GRAM Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250 (6 pack), 500 (3 pack) azithromycin oral tablet 250, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 25 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 clarithromycin oral tablet extended release 24 hr 500 E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION 400 MG/5 ML ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG ery-tab oral tablet,delayed release (dr/ec) 500 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 200 /5 ml erythromycin oral capsule,delayed release(dr/ec) 250 erythromycin oral tablet 500 Miscellaneous B-Lactam Antibiotics AZACTAM INJECTION RECON SOLN 2 GRAM aztreonam injection recon soln gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML PA; NM; NDS ertapenem injection recon soln gram (Invanz) imipenem-cilastatin intravenous recon soln 250 3

21 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN GRAM meropenem intravenous recon soln 500 (Merrem) Penicillins amoxicillin oral capsule 250, 500 amoxicillin oral suspension for reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 25, 250 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 2 hr, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 250, 500 ampicillin sodium injection recon soln gram, 0 gram, 25 ampicillin-sulbactam injection recon soln (Unasyn).5 gram, 5 gram, 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML BICILLIN C-R INTRAMUSCULAR SYRINGE,200,000 UNIT/ 2 ML(600K/600K),,200,000 UNIT/ 2 ML(900K/300K) 4

22 BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, 500 nafcillin 2 gm vial sterile, latex-free 2 gram nafcillin injection recon soln gram, 0 gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 0 gram penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 20 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 25 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 piperacillin-tazobactam intravenous recon (Zosyn) soln gram, 4.5 gram, 40.5 gram ZOSYN 2.25 GRAM VIAL P/F,LTX- FR,INNER,SUV 2.25 GRAM ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML, GRAM/50 ML Quinolones AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK 400 MG/250 ML ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase 24 hr,000, 500 ciprofloxacin hcl oral tablet 250, 500 (Cipro) ciprofloxacin hcl oral tablet 750 ciprofloxacin in 5 % dextrose intravenous piggyback 200 /00 ml 5

23 ciprofloxacin oral (Cipro) suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 25 /ml levofloxacin oral solution 250 /0 ml levofloxacin oral tablet 250 levofloxacin oral tablet 500, 750 (Levaquin) moxifloxacin 400 /250 ml bag 400 /250 ml moxifloxacin in nacl (iso-osm) intravenous (Avelox in NaCl (isoosmotic)) piggyback 400 /250 ml moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) Tetracyclines demeclocycline oral tablet 50, 300 doxy-00 intravenous recon soln 00 doxycycline hyclate oral capsule 00, (Morgidox) 50 doxycycline hyclate oral tablet 00, 20 doxycycline hyclate oral tablet 50, 75 (Acticlate) doxycycline hyclate oral tablet 50 (Targadox) doxycycline monohydrate oral capsule 00 (Mondoxyne NL), 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 25 /5 ml doxycycline monohydrate oral tablet 00 (Avidoxy) 6

24 doxycycline monohydrate oral tablet 50, 75 minocycline oral capsule 00, 75 minocycline oral capsule 50 (Minocin) minocycline oral tablet 00, 50, 75 okebo oral capsule 00 tetracycline oral capsule 250, 500 tigecycline intravenous recon soln 50 (Tygacil) NM; NDS Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS NM; NDS SUSPENSION FOR RECONSTITUTION 00 MG adriamycin intravenous solution 20 /0 PA BvD ml adrucil intravenous solution 2.5 gram/50 PA BvD ml AFINITOR DISPERZ ORAL TABLET PA NSO; NM; NDS FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 0 MG, 2.5 MG, 5 MG, 7.5 MG PA NSO; NM; NDS; QL (30 per 30 days) ALECENSA ORAL CAPSULE 50 MG PA NSO; NM; NDS ALIMTA INTRAVENOUS RECON NM; NDS SOLN 500 MG ALIQOPA INTRAVENOUS RECON PA NSO; NM; NDS SOLN 60 MG ALUNBRIG ORAL TABLET 80 MG, PA NSO; NM; NDS 30 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (23) PA NSO; NM; NDS anastrozole oral tablet (Arimidex) ARRANON INTRAVENOUS SOLUTION 250 MG/50 ML AVASTIN INTRAVENOUS SOLUTION NM; NDS 25 MG/ML azacitidine injection recon soln 00 (Vidaza) NM; NDS BAVENCIO INTRAVENOUS NM; NDS SOLUTION 20 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG PA NSO; NM; NDS 7

25 BESPONSA INTRAVENOUS RECON PA NSO; NM; NDS SOLN 0.9 MG (0.25 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) PA NSO; NM; NDS bicalutamide oral tablet 50 (Casodex) BICNU INTRAVENOUS RECON SOLN NM; NDS 00 MG bleomycin injection recon soln 30 unit PA BvD BORTEZOMIB INTRAVENOUS NM; NDS RECON SOLN 3.5 MG BOSULIF ORAL TABLET 00 MG, 400 PA NSO; NM; NDS MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG, 75 MG PA NSO; NM; NDS; QL (80 per 30 days) busulfan intravenous solution 60 /0 ml (Busulfex) CABOMETYX ORAL TABLET 20 MG, PA NSO; NM; NDS 40 MG, 60 MG CALQUENCE ORAL CAPSULE 00 MG PA NSO; NM; NDS; QL (60 per 30 days) CAPRELSA ORAL TABLET 00 MG, PA NSO; NM; NDS 300 MG carboplatin intravenous solution 0 /ml cisplatin intravenous solution /ml cladribine intravenous solution 0 /0 ml PA BvD clofarabine intravenous solution 20 /20 ml (Clolar) COMETRIQ ORAL CAPSULE 00 PA NSO; NM; NDS MG/DAY(80 MG X-20 MG X), 40 MG/DAY(80 MG X-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) COSMEGEN INTRAVENOUS RECON NM; NDS SOLN 0.5 MG COTELLIC ORAL TABLET 20 MG PA NSO; NM; NDS CYCLOPHOSPHAMIDE ORAL PA BvD CAPSULE 25 MG, 50 MG CYRAMZA INTRAVENOUS PA NSO; NM; NDS SOLUTION 0 MG/ML cytarabine (pf) injection solution 00 /5 PA BvD ml (20 /ml), 2 gram/20 ml (00 /ml) cytarabine injection solution 20 /ml PA BvD dacarbazine intravenous recon soln 00, 200 8

26 dactinomycin intravenous recon soln 0.5 (Cosmegen) NM; NDS DARZALEX INTRAVENOUS PA NSO; NM; NDS SOLUTION 20 MG/ML daunorubicin intravenous recon soln 20 daunorubicin intravenous solution 5 /ml decitabine intravenous recon soln 50 (Dacogen) NM; NDS docetaxel intravenous solution 60 /8 NM; NDS ml (20 /ml) docetaxel intravenous solution 20 /2 ml (0 /ml), 80 /8 ml (0 /ml) docetaxel intravenous solution 20 /ml (Taxotere) NM; NDS ( ml), 80 /4 ml (20 /ml) doxorubicin intravenous recon soln 0, (Adriamycin) PA BvD 50 doxorubicin intravenous solution 0 /5 (Adriamycin) PA BvD ml, 2 /ml, 20 /0 ml, 50 /25 ml doxorubicin, peg-liposomal intravenous (Doxil) NM; NDS suspension 2 /ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) EMCYT ORAL CAPSULE 40 MG EMPLICITI INTRAVENOUS RECON PA NSO; NM; NDS SOLN 300 MG, 400 MG epirubicin intravenous recon soln 50 epirubicin intravenous solution 200 (Ellence) /00 ml ERBITUX INTRAVENOUS SOLUTION NM; NDS 00 MG/50 ML, 200 MG/00 ML ERIVEDGE ORAL CAPSULE 50 MG PA NSO; NM; NDS ERLEADA ORAL TABLET 60 MG PA NSO; NM; NDS ERWINAZE INJECTION RECON SOLN PA NSO; NM; NDS 0,000 UNIT 9

27 ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG etoposide intravenous solution 20 /ml (Toposar) exemestane oral tablet 25 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG PA NSO; NM; NDS; QL (6 per 2 days) FASLODEX INTRAMUSCULAR NM; NDS SYRINGE 250 MG/5 ML FIRMAGON KIT W DILUENT PA NSO SYRINGE SUBCUTANEOUS RECON SOLN 20 MG, 80 MG fludarabine intravenous recon soln 50 fludarabine intravenous solution 50 /2 ml fluorouracil intravenous solution PA BvD gram/20 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/00 ml, 500 /0 ml flutamide oral capsule 25 FOLOTYN INTRAVENOUS PA NSO; NM; NDS SOLUTION 20 MG/ML ( ML), 40 MG/2 ML (20 MG/ML) gemcitabine intravenous recon soln (Gemzar) gram, 200 gemcitabine intravenous recon soln 2 gram gemcitabine intravenous solution gram/26.3 ml (38 /ml), 00 /ml, 2 gram/52.6 ml (38 /ml), 200 /5.26 ml (38 /ml) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA NSO; NM; NDS; QL (30 per 30 days) GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG HALAVEN INTRAVENOUS NM; NDS SOLUTION MG/2 ML (0.5 MG/ML) HERCEPTIN INTRAVENOUS RECON NM; NDS SOLN 50 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG NM; NDS hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG PA NSO; NM; NDS; QL (2 per 28 days) 20

28 ICLUSIG ORAL TABLET 5 MG, 45 MG PA NSO; NM; NDS idarubicin intravenous solution /ml (Idamycin PFS) IDHIFA ORAL TABLET 00 MG, 50 MG PA NSO; NM; NDS; QL (30 per 30 days) ifosfamide intravenous recon soln gram, (Ifex) 3 gram ifosfamide intravenous solution gram/20 ml, 3 gram/60 ml imatinib oral tablet 00, 400 (Gleevec) PA NSO; NM; NDS IMBRUVICA ORAL CAPSULE 40 MG, 70 MG PA NSO; NM; NDS; QL (20 per 30 days) IMBRUVICA ORAL TABLET 40 MG PA NSO; NM; NDS; QL (20 per 30 days) IMBRUVICA ORAL TABLET 280 MG PA NSO; NM; NDS; QL (60 per 30 days) IMBRUVICA ORAL TABLET 420 MG, 560 MG PA NSO; NM; NDS; QL (30 per 30 days) IMFINZI INTRAVENOUS SOLUTION PA NSO; NM; NDS 50 MG/ML INLYTA ORAL TABLET MG, 5 MG PA NSO; NM; NDS; QL (240 per 30 days) IRESSA ORAL TABLET 250 MG PA NSO; NM; NDS irinotecan intravenous solution 00 /5 (Camptosar) ml, 40 /2 ml irinotecan intravenous solution 500 /25 ml ISTODAX INTRAVENOUS RECON PA NSO; NM; NDS SOLN 0 MG/2 ML JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG PA NSO; NM; NDS; QL (60 per 30 days) JEVTANA INTRAVENOUS SOLUTION NM; NDS 0 MG/ML (FIRST DILUTION) KADCYLA INTRAVENOUS RECON PA NSO; NM; NDS SOLN 00 MG, 60 MG KEYTRUDA INTRAVENOUS PA NSO; NM; NDS SOLUTION 25 MG/ML KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X )-2.5 MG PA NSO; NM; NDS; QL (49 per 28 days) KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG PA NSO; NM; NDS; QL (70 per 28 days) 2

29 KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X ) KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2) KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 0 MG/ML LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), 2 MG/DAY (4 MG X 3), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 4 MG, 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit /0.2 ml PA NSO; NM; NDS; QL (9 per 28 days) PA NSO; NM; NDS; QL (2 per 28 days) PA NSO; NM; NDS; QL (42 per 28 days) PA NSO; NM; NDS; QL (63 per 28 days) PA NSO; NM; NDS PA NSO; NM; NDS PA NSO; NM; NDS; QL (90 per 30 days) LONSURF ORAL TABLET MG, PA NSO; NM; NDS MG LUPRON DEPOT (3 MONTH) NM; NDS INTRAMUSCULAR SYRINGE KIT.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) NM; NDS INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) NM; NDS INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR NM; NDS SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG PA NSO; NM; NDS LYNPARZA ORAL TABLET 00 MG, PA NSO; NM; NDS 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG NM; NDS megestrol oral tablet 20, 40 PA NSO 22

30 MEKINIST ORAL TABLET 0.5 MG, 2 PA NSO; NM; NDS MG MEKTOVI ORAL TABLET 5 MG PA NSO; NM; NDS; QL (80 per 30 days) melphalan hcl intravenous recon soln 50 (Alkeran) NM; NDS mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln gram methotrexate sodium (pf) injection solution 25 /ml methotrexate sodium injection solution 25 /ml methotrexate sodium oral tablet 2.5 mitomycin intravenous recon soln 20, (Mutamycin) 40, 5 mitoxantrone intravenous concentrate 2 /ml MUSTARGEN INJECTION RECON SOLN 0 MG mutamycin intravenous recon soln 20, 40, 5 MYLOTARG INTRAVENOUS RECON PA NSO; NM; NDS SOLN 4.5 MG ( MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG PA NSO; NM; NDS; QL (80 per 30 days) NEXAVAR ORAL TABLET 200 MG PA NSO; NM; NDS nilutamide oral tablet 50 (Nilandron) NINLARO ORAL CAPSULE 2.3 MG, 3 PA NSO; NM; NDS MG, 4 MG ODOMZO ORAL CAPSULE 200 MG PA NSO; NM; NDS OPDIVO INTRAVENOUS SOLUTION PA NSO; NM; NDS 00 MG/0 ML, 240 MG/24 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 00, 50 oxaliplatin intravenous solution 00 /20 ml, 50 /0 ml (5 /ml) paclitaxel intravenous concentrate 6 /ml PERJETA INTRAVENOUS SOLUTION 420 MG/4 ML (30 MG/ML) PA NSO; NM; NDS 23

31 POMALYST ORAL CAPSULE MG, 2 PA NSO; NM; NDS MG, 3 MG, 4 MG POTELIGEO INTRAVENOUS PA NSO; NM; NDS SOLUTION 4 MG/ML PROLEUKIN INTRAVENOUS RECON NM; NDS SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG PA NSO; NM; NDS; QL (30 per 30 days) RITUXAN INTRAVENOUS NM; NDS CONCENTRATE 0 MG/ML romidepsin intravenous recon soln 0 (Istodax) PA NSO; NM; NDS /2 ml RUBRACA ORAL TABLET 200 MG, PA NSO; NM; NDS 250 MG, 300 MG RYDAPT ORAL CAPSULE 25 MG PA NSO; NM; NDS SOLTAMOX ORAL SOLUTION 0 PA NSO MG/5 ML SPRYCEL ORAL TABLET 00 MG, 40 PA NSO; NM MG, 20 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG PA NSO; NM; NDS; QL (20 per 30 days) SUTENT ORAL CAPSULE 2.5 MG, 25 PA NSO; NM; NDS MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON NM; NDS SOLN 00 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON NM; NDS SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA NSO; NM; NDS; QL (20 per 30 days) TAGRISSO ORAL TABLET 40 MG, 80 PA NSO; NM; NDS MG tamoxifen oral tablet 0, 20 TARCEVA ORAL TABLET 00 MG, PA NSO; NM; NDS 50 MG, 25 MG TARGRETIN TOPICAL GEL % NM; NDS TASIGNA ORAL CAPSULE 50 MG, PA NSO; NM; NDS 200 MG, 50 MG TECENTRIQ INTRAVENOUS SOLUTION,200 MG/20 ML (60 MG/ML) PA NSO; NM; NDS 24

32 temsirolimus intravenous recon soln 30 (Torisel) NM; NDS /3 ml (0 /ml) (first) thiotepa injection recon soln 5 (Tepadina) TIBSOVO ORAL TABLET 250 MG PA NSO; NM; NDS topotecan intravenous recon soln 4 (Hycamtin) topotecan intravenous solution 4 /4 ml ( /ml) TORISEL INTRAVENOUS RECON NM; NDS SOLN 30 MG/3 ML (0 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON PA NSO; NM; NDS SOLN 00 MG, 25 MG TRELSTAR 3.75 MG VIAL INNER, NM; NDS SDV 3.75 MG TRELSTAR INTRAMUSCULAR NM; NDS SYRINGE.25 MG/2 ML, 22.5 MG/2 ML, 3.75 MG/2 ML tretinoin (chemotherapy) oral capsule 0 TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG TRISENOX INTRAVENOUS SOLUTION 2 MG/ML TYKERB ORAL TABLET 250 MG PA NSO; NM; NDS VECTIBIX INTRAVENOUS NM; NDS SOLUTION 00 MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML) VELCADE INJECTION RECON SOLN NM; NDS 3.5 MG VENCLEXTA ORAL TABLET 0 MG, PA NSO 50 MG VENCLEXTA ORAL TABLET 00 MG PA NSO; NM; NDS VENCLEXTA STARTING PACK ORAL PA NSO; NM; NDS TABLETS,DOSE PACK 0 MG-50 MG- 00 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG PA NSO; NM; NDS; QL (60 per 30 days) vinblastine intravenous solution /ml PA BvD vincasar pfs intravenous solution 2 /2 ml PA BvD vincristine intravenous solution /ml, 2 (Vincasar PFS) PA BvD /2 ml 25

33 vinorelbine intravenous solution 0 /ml, (Navelbine) 50 /5 ml VOTRIENT ORAL TABLET 200 MG PA NSO; NM; NDS VYXEOS INTRAVENOUS RECON PA BvD; NM; NDS SOLN MG XALKORI ORAL CAPSULE 200 MG, PA NSO; NM; NDS 250 MG XATMEP ORAL SOLUTION 2.5 MG/ML XTANDI ORAL CAPSULE 40 MG PA NSO; NM; NDS; QL (20 per 30 days) YERVOY INTRAVENOUS SOLUTION PA NSO; NM; NDS 200 MG/40 ML (5 MG/ML), 50 MG/0 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON PA NSO; NM; NDS SOLN MG YONSA ORAL TABLET 25 MG PA NSO; NM; NDS; QL (20 per 30 days) ZALTRAP INTRAVENOUS SOLUTION PA NSO; NM; NDS 00 MG/4 ML (25 MG/ML) ZANOSAR INTRAVENOUS RECON SOLN GRAM ZEJULA ORAL CAPSULE 00 MG PA NSO; NM; NDS ZELBORAF ORAL TABLET 240 MG PA NSO; NM; NDS ZOLINZA ORAL CAPSULE 00 MG PA NSO; NM; NDS ZYDELIG ORAL TABLET 00 MG, 50 PA NSO; NM; NDS MG ZYKADIA ORAL CAPSULE 50 MG PA NSO; NM; NDS ZYTIGA ORAL TABLET 250 MG, 500 MG PA NSO; NM; NDS Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml propantheline oral tablet 5 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 PA NSO MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 NM; NDS MG/ML BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG NM; NDS 26

34 BRIVIACT INTRAVENOUS PA NSO SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 PA NSO MG/ML BRIVIACT ORAL TABLET 0 MG, 00 PA NSO; QL (60 per 30 MG, 25 MG, 50 MG, 75 MG days) carbamazepine oral capsule, er (Carbatrol) multiphase 2 hr 00, 200, 300 carbamazepine oral suspension 00 /5 (Tegretol) ml carbamazepine oral tablet 200 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 2 hr 00, 200, 400 carbamazepine oral tablet,chewable 00 CELONTIN ORAL CAPSULE 300 MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 25 divalproex oral tablet extended release 24 (Depakote ER) hr 250, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 25, 250, 500 ethosuximide oral capsule 250 (Zarontin) ethosuximide oral solution 250 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 400, 600 (Felbatol) fosphenytoin injection solution 00 (Cerebyx) pe/2 ml, 500 pe/0 ml FYCOMPA ORAL SUSPENSION 0.5 PA NSO MG/ML FYCOMPA ORAL TABLET 0 MG, 2 PA NSO MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 00, 300, (Neurontin) 400 gabapentin oral solution 250 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 25 MG (35) LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 25 MG (84) -00 MG (4) 27

35 LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 25 MG (42) -00 MG (7) LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 25 MG (2) -50 MG (7) LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(4)-00MG (4)-200 MG (7) LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 25MG (4)-50 MG (4)-00MG (7) lamotrigine oral tablet 00, 50, 200, 25 lamotrigine oral tablet extended release 24hr 00, 200, 25, 250, 300, 50 lamotrigine oral tablet, chewable dispersible 25, 5 lamotrigine oral tablet,disintegrating 00, 200, 25, 50 lamotrigine oral tablets,dose pack 25 (35) lamotrigine oral tablets,dose pack 25 (42) -00 (7) lamotrigine oral tablets,dose pack 25 (84) -00 (4) levetiracetam in nacl (iso-os) intravenous piggyback,000 /00 ml,,500 /00 ml, 500 /00 ml levetiracetam intravenous solution 500 /5 ml (Lamictal) (Lamictal XR) (Lamictal) (Lamictal ODT) (Lamictal Starter (Blue) Kit) (Lamictal Starter (Orange) Kit) (Lamictal Starter (Green) Kit) (Keppra) levetiracetam oral solution 00 /ml (Keppra) levetiracetam oral tablet,000, 250 (Keppra), 500, 750 levetiracetam oral tablet extended release (Keppra XR) 24 hr 500, 750 LYRICA ORAL CAPSULE 00 MG, 50 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG 28

36 LYRICA ORAL SOLUTION 20 MG/ML oxcarbazepine oral suspension 300 /5 ml (60 /ml) (Trileptal) oxcarbazepine oral tablet 50, 300, (Trileptal) 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 /5 ml (4 /ml) phenobarbital oral tablet 00, 5, 6.2, 30, 32.4, 60, 64.8, 97.2 phenytoin oral suspension 25 /5 ml (Dilantin-25) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 00 phenytoin sodium extended oral capsule (Phenytek) 200, 300 phenytoin sodium intravenous solution 50 /ml primidone oral tablet 250, 50 (Mysoline) ROWEEPRA ORAL TABLET,000 MG, 500 MG, 750 MG SABRIL ORAL POWDER IN PACKET PA NSO; NM; NDS 500 MG SABRIL ORAL TABLET 500 MG PA NSO; NM; NDS SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 250 MG, 500 MG, 750 MG PA NSO tiagabine oral tablet 2, 6, 2, (Gabitril) 4 topiramate oral capsule, sprinkle 5, (Topamax) 25 topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) PA NSO 00, 50, 200, 25, 50 topiramate oral tablet 00, 200, 25, 50 (Topamax) valproate sodium intravenous solution 500 (Depacon) /5 ml (00 /ml) valproic acid (as sodium salt) oral solution 250 /5 ml (Depakene) 29

37 valproic acid oral capsule 250 (Depakene) vigabatrin oral powder in packet 500 (Sabril) PA NSO VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG QL (60 per 30 days) zonisamide oral capsule 00, 25 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 0, 5 (Aricept) QL (60 per 30 days) donepezil oral tablet 23 (Aricept) QL (30 per 30 days) donepezil oral tablet,disintegrating 0, ST; QL (30 per 30 days) 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) 24 hr 6, 24, 8 galantamine oral solution 4 /ml galantamine oral tablet 2, 4, 8 (Razadyne) memantine oral capsule,sprinkle,er 24hr (Namenda XR) 4, 2, 28, 7 memantine oral solution 2 /ml memantine oral tablet 0, 5 (Namenda) rivastigmine tartrate oral capsule.5, 3, 4.5, 6 rivastigmine transdermal patch 24 hour (Exelon) ST 3.3 /24 hour, 4.6 /24 hr, 9.5 /24 hr Antidepressants Antidepressants amitriptyline oral tablet 0, 00, 50, 25, 50, 75 amitriptyline-chlordiazepoxide oral tablet 2.5-5, 25-0 amoxapine oral tablet 00, 50, 25, 50 bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release (Wellbutrin XL) 24 hr 50, 300 bupropion hcl oral tablet sustainedrelease (Wellbutrin SR) 2 hr 00, 50, 200 citalopram oral solution 0 /5 ml 30

38 citalopram oral tablet 0, 20, 40 (Celexa) clomipramine oral capsule 25, 50, (Anafranil) 75 desipramine oral tablet 0, 25 (Norpramin) desipramine oral tablet 00, 50, 50, 75 DESVENLAFAXINE FUMARATE ST ORAL TABLET EXTENDED RELEASE 24HR 00 MG, 50 MG DESVENLAFAXINE ORAL TABLET ST EXTENDED RELEASE 24 HR 00 MG, 50 MG doxepin oral capsule 0, 00, 50, 25, 50, 75 doxepin oral concentrate 0 /ml duloxetine oral capsule,delayed (Cymbalta) QL (60 per 30 days) release(dr/ec) 20, 30, 60 duloxetine oral capsule,delayed ST; QL (30 per 30 days) release(dr/ec) 40 EMSAM TRANSDERMAL PATCH 24 ST HOUR 2 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 0, 20 (Lexapro), 5 FETZIMA ORAL CAPSULE,EXT REL ST; QL (30 per 30 days) 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL ST; QL (30 per 30 days) CAPSULE,EXTENDED RELEASE 24 HR 20 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 0, 20, 40 (Prozac) fluoxetine oral solution 20 /5 ml (4 /ml) fluoxetine oral tablet 0, 20 (Sarafem) fluvoxamine oral capsule,extended release ST 24hr 00, 50 fluvoxamine oral tablet 00, 25, 50 3

39 imipramine hcl oral tablet 0, 25, (Tofranil) 50 imipramine pamoate oral capsule 00, 25, 50, 75 maprotiline oral tablet 25, 50, 75 MARPLAN ORAL TABLET 0 MG ST mirtazapine oral tablet 5, 30 (Remeron) mirtazapine oral tablet 45, 7.5 mirtazapine oral tablet,disintegrating 5 (Remeron SolTab), 30, 45 nefazodone oral tablet 00, 50, 200, 250, 50 nortriptyline oral capsule 0, 25, (Pamelor) 50, 75 nortriptyline oral solution 0 /5 ml olanzapine-fluoxetine oral capsule 2-25 (Symbyax), 2-50, 3-25, 6-25, 6-50 paroxetine hcl oral tablet 0, 20, (Paxil) 30, 40 paroxetine hcl oral tablet extended release (Paxil CR) 24 hr 2.5, 25, 37.5 PAXIL ORAL SUSPENSION 0 MG/5 ML perphenazine-amitriptyline oral tablet 2-0, 2-25, 4-0, 4-25, 4-50 phenelzine oral tablet 5 (Nardil) protriptyline oral tablet 0, 5 sertraline oral concentrate 20 /ml (Zoloft) sertraline oral tablet 00, 25, 50 (Zoloft) tranylcypromine oral tablet 0 (Parnate) trazodone oral tablet 00, 50, 300, 50 trimipramine oral capsule 00, 25, (Surmontil) 50 TRINTELLIX ORAL TABLET 0 MG, ST; QL (30 per 30 days) 20 MG, 5 MG venlafaxine oral capsule,extended release (Effexor XR) 24hr 50, 37.5, 75 venlafaxine oral tablet 00, 25, 37.5, 50, 75 32

40 venlafaxine oral tablet extended release 24hr 50, 225, 37.5, 75 VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (23) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 00, 25, 50 (Precose) AVANDIA ORAL TABLET 2 MG, 4 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN MG GLYSET ORAL TABLET 00 MG, 25 MG, 50 MG INVOKAMET ORAL TABLET 50-,000 MG, MG, 50-,000 MG, MG 33 ST; QL (30 per 30 days) ST; QL (30 per 30 days) QL (60 per 30 days) INVOKAMET XR ORAL TABLET, IR - QL (60 per 30 days) ER, BIPHASIC 24HR 50-,000 MG, MG, 50-,000 MG, MG INVOKANA ORAL TABLET 00 MG, QL (30 per 30 days) 300 MG JANUMET ORAL TABLET 50-,000 QL (60 per 30 days) MG, MG JANUMET XR ORAL TABLET, ER QL (60 per 30 days) MULTIPHASE 24 HR 00-,000 MG, 50-,000 MG, MG JANUVIA ORAL TABLET 00 MG, 25 QL (30 per 30 days) MG, 50 MG JARDIANCE ORAL TABLET 0 MG, 25 QL (30 per 30 days) MG KOMBIGLYZE XR ORAL TABLET, ER QL (30 per 30 days) MULTIPHASE 24 HR 2.5-,000 MG, 5-,000 MG, MG KORLYM ORAL TABLET 300 MG PA; NM; NDS metformin oral tablet,000, 500, (Glucophage) 850 metformin oral tablet extended release 24 hr 500, 750 (Glucophage XR)

41 miglitol oral tablet 00, 25, 50 (Glyset) nateglinide oral tablet 20, 60 (Starlix) ONGLYZA ORAL TABLET 2.5 MG, 5 MG QL (30 per 30 days) pioglitazone oral tablet 5, 30, 45 (Actos) pioglitazone-glimepiride oral tablet 30-2 (DUETACT), 30-4 pioglitazone-metformin oral tablet (Actoplus MET), repaglinide oral tablet 0.5 repaglinide oral tablet, 2 (Prandin) SYNJARDY ORAL TABLET 2.5-,000 QL (60 per 30 days) MG, MG, 5-,000 MG, MG SYNJARDY XR ORAL TABLET, IR - QL (30 per 30 days) ER, BIPHASIC 24HR 0-,000 MG, 25-,000 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML,.5 MG/0.5 ML VICTOZA SUBCUTANEOUS PEN INJECTOR 0.6 MG/0. ML (8 MG/3 ML) Insulins LANTUS SOLOSTAR U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS U-00 INSULIN SUBCUTANEOUS SOLUTION 00 UNIT/ML NOVOLIN 70/30 U-00 INSULIN SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N NPH U-00 INSULIN SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R REGULAR U-00 INSULN INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML 34

42 NOVOLOG MIX U-00 INSULN SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U-00 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG PENFILL U-00 INSULIN SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG U-00 INSULIN ASPART SUBCUTANEOUS SOLUTION 00 UNIT/ML TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (.5 ML) Sulfonylureas chlorpropamide oral tablet 00, 250 glimepiride oral tablet, 2, 4 (Amaryl) glipizide oral tablet 0, 5 (Glucotrol) glipizide oral tablet extended release 24hr (Glucotrol XL) 0, 2.5, 5 glipizide-metformin oral tablet , , glyburide micronized oral tablet.5, 3 (Glynase), 6 glyburide oral tablet.25, 2.5, 5 glyburide-metformin oral tablet , , tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 Antifungals Antifungals ABELCET INTRAVENOUS PA BvD SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS PA BvD SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 PA BvD 35

43 CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG NM; NDS ciclopirox topical cream 0.77 % (Ciclodan) ciclopirox topical gel 0.77 % ciclopirox topical shampoo % (Loprox) ciclopirox topical solution 8 % (Ciclodan) ciclopirox topical suspension 0.77 % (Loprox (as olamine)) clotrimazole mucous membrane troche 0 clotrimazole topical cream % (Antifungal (clotrimazole)) clotrimazole topical solution % clotrimazole-betamethasone topical cream (Lotrisone) % clotrimazole-betamethasone topical lotion % econazole topical cream % ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 00 MG, 50 MG ERTACZO TOPICAL CREAM 2 % fluconazole in nacl (iso-osm) intravenous piggyback 200 /00 ml, 400 /200 ml fluconazole oral suspension for (Diflucan) reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 50, (Diflucan) 200, 50 flucytosine oral capsule 250, 500 (Ancobon) NM; NDS griseofulvin microsize oral suspension 25 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 25, 250 itraconazole oral capsule 00 (Sporanox) PA ketoconazole oral tablet 200 ketoconazole topical cream 2 % ketoconazole topical foam 2 % (Extina) ketoconazole topical shampoo 2 % (Nizoral) MYCAMINE INTRAVENOUS RECON SOLN 00 MG, 50 MG naftifine topical cream % naftifine topical cream 2 % (Naftin) 36

44 NOXAFIL ORAL SUSPENSION 200 PA; NM; NDS MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED PA; NM; NDS RELEASE (DR/EC) 00 MG nyamyc topical powder 00,000 unit/gram nystatin oral powder 50 million unit nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 unit/gram (Nyamyc) nystop topical powder 00,000 unit/gram terbinafine hcl oral tablet 250 voriconazole intravenous solution 200 (Vfend IV) PA voriconazole oral suspension for reconstitution 200 /5 ml (40 /ml) (Vfend) PA; NM; NDS voriconazole oral tablet 200, 50 (Vfend) PA; NM; NDS Antigout Agents Antigout Agents, Other allopurinol oral tablet 00, 300 (Zyloprim) colchicine oral capsule 0.6 (Mitigare) colchicine oral tablet 0.6 (Colcrys) PA MITIGARE ORAL CAPSULE 0.6 MG probenecid oral tablet 500 probenecid-colchicine oral tablet ULORIC ORAL TABLET 40 MG, 80 MG ST Antihistamines Antihistamines carbinoxamine maleate oral liquid 4 /5 ml carbinoxamine maleate oral tablet 4 cetirizine oral solution /ml (All Day Allergy (cetirizine)) clemastine oral tablet 2.68 cyproheptadine oral syrup 2 /5 ml cyproheptadine oral tablet 4 desloratadine oral tablet 5 (Clarinex) diphenhydramine hcl injection solution 50 /ml 37

45 diphenhydramine hcl injection syringe 50 /ml hydroxyzine hcl intramuscular solution 25 /ml, 50 /ml hydroxyzine hcl oral solution 0 /5 ml hydroxyzine hcl oral tablet 0, 25, 50 levocetirizine oral solution 2.5 /5 ml (Xyzal) levocetirizine oral tablet 5 (24HR Allergy Relief) promethazine oral syrup 6.25 /5 ml promethazine vc oral syrup /5 ml Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL VAGINAL CREAM 5 % clindamycin phosphate vaginal cream 2 % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 Antimigraine Agents Antimigraine Agents dihydroergotamine injection solution (D.H.E.45) /ml dihydroergotamine nasal spray,nonaerosol (Migranal) QL (6 per 30 days) 0.5 /pump act. (4 /ml) naratriptan oral tablet, 2.5 (Amerge) QL (8 per 30 days) rizatriptan oral tablet 0 (Maxalt) QL (36 per 60 days) rizatriptan oral tablet 5 QL (36 per 60 days) rizatriptan oral tablet,disintegrating 0 (Maxalt-MLT) QL (36 per 60 days), 5 sumatriptan nasal spray,non-aerosol 20 (Imitrex) QL (2 per 30 days) /actuation, 5 /actuation sumatriptan succinate oral tablet 00, (Imitrex) QL (8 per 30 days) 25, 50 sumatriptan succinate subcutaneous (Imitrex STATdose Kit QL (5 per 30 days) cartridge 4 /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous pen injector 4 /0.5 ml, 6 /0.5 ml Refill) (Imitrex STATdose Pen) QL (5 per 30 days) 38

46 sumatriptan succinate subcutaneous (Imitrex) QL (5 per 30 days) solution 6 /0.5 ml zolmitriptan oral tablet 2.5, 5 (Zomig) QL (8 per 30 days) zolmitriptan oral tablet,disintegrating 2.5 (Zomig ZMT) QL (8 per 30 days), 5 ZOMIG NASAL SPRAY,NON- QL (6 per 30 days) AEROSOL 2.5 MG ZOMIG NASAL SPRAY,NON- QL (2 per 30 days) AEROSOL 5 MG Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN GRAM dapsone oral tablet 00, 25 ethambutol oral tablet 00 ethambutol oral tablet 400 (Myambutol) isoniazid injection solution 00 /ml isoniazid oral solution 50 /5 ml isoniazid oral tablet 00, 300 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 rifabutin oral capsule 50 (Mycobutin) RIFAMATE ORAL CAPSULE MG rifampin intravenous recon soln 600 (Rifadin) rifampin oral capsule 50, 300 (Rifadin) RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG PA; NM; NDS TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO (NETUPITANT) ORAL CAPSULE MG aprepitant oral capsule 25, 40, 80 aprepitant oral capsule,dose pack 25 ()- 80 (2) PA BvD; QL ( per 7 days) (Emend) PA BvD; QL (3 per 2 days) (Emend) PA BvD; QL (3 per 2 days) CESAMET ORAL CAPSULE MG PA compro rectal suppository 25 39

47 dronabinol oral capsule 0, 2.5, 5 (Marinol) PA granisetron (pf) intravenous solution 00 mcg/ml granisetron hcl intravenous solution /ml, /ml ( ml) granisetron hcl oral tablet PA BvD; QL (30 per 30 days) meclizine oral tablet 2.5 meclizine oral tablet 25 (Dramamine Less Drowsy) ondansetron hcl (pf) injection solution 4 /2 ml ondansetron hcl (pf) injection syringe 4 /2 ml ondansetron hcl intravenous solution 2 /ml ondansetron hcl oral solution 4 /5 ml (Zofran) PA BvD ondansetron hcl oral tablet 24 PA BvD ondansetron hcl oral tablet 4, 8 (Zofran) PA BvD ondansetron oral tablet,disintegrating 4 (Zofran ODT) PA BvD, 8 phenadoz rectal suppository 2.5 PHENERGAN RECTAL SUPPOSITORY 2.5 MG, 25 MG, 50 MG prochlorperazine edisylate injection solution 0 /2 ml (5 /ml) prochlorperazine maleate oral tablet 0 (Compazine), 5 prochlorperazine rectal suppository 25 (Compazine) promethazine injection solution 25 /ml, (Phenergan) 50 /ml promethazine oral tablet 2.5, 25, 50 promethazine rectal suppository 2.5, (Phenadoz) 25 promethazine rectal suppository 50 (Phenergan) promethegan rectal suppository 25, 50 scopolamine base transdermal patch 3 day (Transderm-Scop) over 3 days TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY MG OVER 3 DAYS 40

48 trimethobenzamide oral capsule 300 (Tigan) PA VARUBI ORAL TABLET 90 MG PA BvD Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG NM; NDS ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5 ml (Mepron) NM; NDS atovaquone-proguanil oral tablet (Malarone) atovaquone-proguanil oral tablet (Malarone Pediatric) chloroquine phosphate oral tablet 250, 500 COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG NM; NDS EMVERM ORAL TABLET,CHEWABLE NM; NDS 00 MG hydroxychloroquine oral tablet 200 (Plaquenil) ivermectin oral tablet 3 (Stromectol) mefloquine oral tablet 250 NEBUPENT INHALATION RECON PA BvD SOLN 300 MG paromomycin oral capsule 250 PENTAM INJECTION RECON SOLN 300 MG PA BvD PRIMAQUINE ORAL TABLET 26.3 MG quinine sulfate oral capsule 324 (Qualaquin) tinidazole oral tablet 250 tinidazole oral tablet 500 (Tindamax) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML NM; NDS benztropine injection solution 2 /2 ml (Cogentin) benztropine oral tablet 0.5,, 2 bromocriptine oral capsule 5 (Parlodel) bromocriptine oral tablet 2.5 (Parlodel) 4

49 cabergoline oral tablet 0.5 carbidopa oral tablet 25 (Lodosyn) carbidopa-levodopa oral tablet 0-00 (Sinemet), 25-00, carbidopa-levodopa oral tablet extended (Sinemet CR) release 25-00, carbidopa-levodopa oral tablet,disintegrating 0-00, 25-00, carbidopa-levodopa-entacapone oral (Stalevo 50) tablet carbidopa-levodopa-entacapone oral (Stalevo 75) tablet carbidopa-levodopa-entacapone oral (Stalevo 00) tablet carbidopa-levodopa-entacapone oral (Stalevo 25) tablet carbidopa-levodopa-entacapone oral (Stalevo 50) tablet carbidopa-levodopa-entacapone oral (Stalevo 200) tablet entacapone oral tablet 200 (Comtan) NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.25, 0.25 (Mirapex), 0.5, 0.75,,.5 pramipexole oral tablet extended release (Mirapex ER) 24 hr 0.375, 0.75,.5, 2.25, 3, 3.75, 4.5 rasagiline oral tablet 0.5, (Azilect) ropinirole oral tablet 0.25, 0.5, (Requip), 2, 3, 4, 5 ropinirole oral tablet extended release 24 (Requip XL) hr 2, 2, 4, 6, 8 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 tolcapone oral tablet 00 (Tasmar) trihexyphenidyl oral elixir 0.4 /ml trihexyphenidyl oral tablet 2, 5 42

50 Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG PA NSO PA NSO aripiprazole oral solution /ml aripiprazole oral tablet 0, 5, 2, 20, 30, 5 (Abilify) aripiprazole oral tablet,disintegrating 0, 5 PA NSO; QL (60 per 30 days) ARISTADA INITIO INTRAMUSCULAR PA NSO; NM; NDS SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML ARISTADA INTRAMUSCULAR PA NSO; NM; NDS SUSPENSION,EXTENDED REL SYRING,064 MG/3.9 ML, 44 MG/.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML chlorpromazine injection solution 25 /ml chlorpromazine oral tablet 0, 00, 200, 25, 50 clozapine oral tablet 00, 25 (Clozaril) clozapine oral tablet 200, 50 clozapine oral tablet,disintegrating 00, 2.5, 50, 200, 25 (FazaClo) FANAPT ORAL TABLET MG, 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG PA NSO; QL (60 per 30 days) FANAPT ORAL TABLETS,DOSE PACK MG(2)-2MG(2)- 4MG(2)- PA NSO; QL (60 per 30 days) 6MG(2) fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5 ml fluphenazine hcl oral tablet, 0, 2.5, 5 43

51 GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol dec 50 /ml vial mdv 50 (Haldol Decanoate) /ml haloperidol decanoate intramuscular (Haldol Decanoate) solution 00 /ml haloperidol decanoate intramuscular solution 00 /ml ( ml) haloperidol decanoate intramuscular (Haldol Decanoate) solution 50 /ml haloperidol lactate injection solution 5 (Haldol) /ml haloperidol lactate intramuscular syringe 5 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5,, 0, 2, 20, 5 INVEGA SUSTENNA PA NSO INTRAMUSCULAR SYRINGE 7 MG/0.75 ML, 56 MG/ML, 234 MG/.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG, 80 MG PA NSO; QL (30 per 30 days) loxapine succinate oral capsule 0, 25, 5, 50 NUPLAZID ORAL CAPSULE 34 MG PA NSO; NM; NDS NUPLAZID ORAL TABLET 0 MG, 7 MG PA NSO; NM; NDS olanzapine intramuscular recon soln 0 (Zyprexa) olanzapine oral tablet 0, 5, 2.5 (Zyprexa), 20, 5, 7.5 olanzapine oral tablet,disintegrating 0 (Zyprexa Zydis), 5, 20, 5 paliperidone oral tablet extended release (Invega) PA NSO 24hr.5, 3, 6, 9 perphenazine oral tablet 6, 2, 4, 8 pimozide oral tablet, 2 (Orap) quetiapine oral tablet 00, 200, 25, 300, 400, 50 (Seroquel) 44

52 quetiapine oral tablet extended release 24 hr 50, 200, 300, 400, 50 (Seroquel XR) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, MG, 2 MG, 3 MG, 4 MG PA NSO; QL (30 per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 2.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML PA NSO risperidone oral solution /ml (Risperdal) risperidone oral tablet 0.25, 0.5, (Risperdal), 2, 3, 4 risperidone oral tablet,disintegrating 0.25, 0.5,, 2, 3, 4 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG, 5 MG PA NSO; QL (60 per 30 days) SAPHRIS 0 MG TAB SUBLINGUAL OUTER 0 MG PA NSO; QL (60 per 30 days) SAPHRIS 5 MG TAB SUBLINGUAL OUTER 5 MG PA NSO; QL (60 per 30 days) SAPHRIS SUBLINGUAL TABLET 2.5 MG PA NSO; QL (60 per 30 days) thioridazine oral tablet 0, 00, 25, 50 thiothixene oral capsule, 0, 2, 5 trifluoperazine oral tablet, 0, 2, 5 VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG PA NSO; NM; NDS; QL (30 per 30 days) VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- 3 MG (6) PA NSO; QL (30 per 30 days) ziprasidone hcl oral capsule 20, 40, 60, 80 (Geodon) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG, 300 MG, 405 MG Antivirals (Systemic) Antiretrovirals abacavir oral solution 20 /ml (Ziagen) 45

53 abacavir oral tablet 300 (Ziagen) abacavir-lamivudine oral tablet (Epzicom) NM; NDS abacavir-lamivudine-zidovudine oral (Trizivir) tablet APTIVUS ORAL CAPSULE 250 MG NM; NDS APTIVUS ORAL SOLUTION 00 NM; NDS MG/ML atazanavir oral capsule 50, 200, (Reyataz) NM; NDS 300 ATRIPLA ORAL TABLET NM; NDS MG BIKTARVY ORAL TABLET NM; NDS MG CIMDUO ORAL TABLET MG NM; NDS COMPLERA ORAL TABLET NM; NDS 300 MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG NM; NDS didanosine oral capsule,delayed (Videx EC) release(dr/ec) 25, 200, 250, 400 EDURANT ORAL TABLET 25 MG NM; NDS efavirenz oral capsule 200, 50 (Sustiva) efavirenz oral tablet 600 (Sustiva) EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EVOTAZ ORAL TABLET MG NM; NDS fosamprenavir oral tablet 700 (Lexiva) FUZEON SUBCUTANEOUS RECON NM; NDS SOLN 90 MG GENVOYA ORAL TABLET NM; NDS MG INTELENCE ORAL TABLET 00 MG, NM; NDS 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG NM; NDS 46

54 ISENTRESS HD ORAL TABLET 600 NM; NDS MG ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG NM; NDS ISENTRESS ORAL NM; NDS TABLET,CHEWABLE 00 MG ISENTRESS ORAL TABLET,CHEWABLE 25 MG JULUCA ORAL TABLET MG NM; NDS KALETRA ORAL SOLUTION NM; NDS MG/5 ML KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG NM; NDS lamivudine oral solution 0 /ml (Epivir) lamivudine oral tablet 00 (Epivir HBV) lamivudine oral tablet 50, 300 (Epivir) lamivudine-zidovudine oral tablet (Combivir) NM LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG NM; NDS lopinavir-ritonavir oral solution (Kaletra) NM; NDS /5 ml nevirapine oral suspension 50 /5 ml (Viramune) nevirapine oral tablet 200 (Viramune) nevirapine oral tablet extended release 24 (Viramune XR) hr 00, 400 NORVIR ORAL CAPSULE 00 MG NORVIR ORAL POWDER IN PACKET 00 MG NORVIR ORAL SOLUTION 80 MG/ML ODEFSEY ORAL TABLET NM; NDS MG PREZCOBIX ORAL TABLET NM; NDS MG-MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG NM; NDS 47

55 RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML REYATAZ ORAL CAPSULE 50 MG, NM; NDS 200 MG, 300 MG REYATAZ ORAL POWDER IN NM; NDS PACKET 50 MG ritonavir oral tablet 00 (Norvir) SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 50 MG, NM; NDS 300 MG, 75 MG SELZENTRY ORAL TABLET 25 MG stavudine oral capsule 5, 20, 30 (Zerit), 40 stavudine oral recon soln /ml (Zerit) STRIBILD ORAL TABLET NM; NDS MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG SYMFI LO ORAL TABLET NM; NDS MG SYMFI ORAL TABLET NM; NDS MG SYMTUZA ORAL TABLET NM; NDS MG tenofovir disoproxil fumarate oral tablet (Viread) 300 TIVICAY ORAL TABLET 0 MG, 25 MG TIVICAY ORAL TABLET 50 MG NM; NDS TRIUMEQ ORAL TABLET NM; NDS MG TRUVADA ORAL TABLET NM; NDS MG, MG, MG, MG VIDEX 2 GM PEDIATRIC SOLN 0 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) 48

56 VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 25 MG VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE ORAL SUSPENSION 50 MG/5 ML VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG ZERIT ORAL RECON SOLN MG/ML ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 00 (Retrovir) zidovudine oral syrup 0 /ml (Retrovir) zidovudine oral tablet 300 Antivirals, Miscellaneous oseltamivir oral capsule 30, 45, 75 oseltamivir oral suspension for reconstitution 6 /ml RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION 49 NM; NDS NM; NDS (Tamiflu) QL (84 per 80 days) (Tamiflu) QL (56 per 80 days) rimantadine oral tablet 00 (Flumadine) SYNAGIS INTRAMUSCULAR PA; NM; NDS SOLUTION 50 MG/0.5 ML Hcv Antivirals EPCLUSA ORAL TABLET MG PA; NM; NDS; QL (30 per 30 days) HARVONI ORAL TABLET MG PA; NM; NDS; QL (30 per 30 days) MAVYRET ORAL TABLET MG PA; NM; NDS; QL (84 per 28 days) SOVALDI ORAL TABLET 400 MG PA; NM; NDS; QL (30 per 30 days) VOSEVI ORAL TABLET MG PA; NM; NDS; QL (28 per 28 days) ZEPATIER ORAL TABLET MG PA; NM; NDS; QL (30 per 30 days) Interferons INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML)

57 INTRON A INJECTION RECON SOLN NM; NDS 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 NM; NDS MILLION UNIT/ML INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML PEGASYS PROCLICK PA; NM; NDS SUBCUTANEOUS PEN INJECTOR 35 MCG/0.5 ML, 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS PA; NM; NDS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS PA; NM; NDS SYRINGE 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT PA NSO; NM; NDS 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 (Zovirax) acyclovir oral suspension 200 /5 ml (Zovirax) acyclovir oral tablet 400, 800 (Zovirax) acyclovir sodium intravenous solution 50 PA BvD /ml adefovir oral tablet 0 (Hepsera) PA; NM; NDS BARACLUDE ORAL SOLUTION 0.05 PA; NM; NDS MG/ML cidofovir intravenous solution 75 /ml entecavir oral tablet 0.5, (Baraclude) PA famciclovir oral tablet 25, 250, 500 ganciclovir sodium intravenous recon soln (Cytovene) PA BvD 500 MODERIBA MG DOSEPACK NM; NDS 400 MG (7)- 400 MG (7) MODERIBA MG DOSEPACK NM; NDS 600 MG (7)- 600 MG (7) MODERIBA DOSE PACK ORAL NM; NDS TABLETS,DOSE PACK MG (28)-MG (28), MG (28)-MG (28) MODERIBA ORAL TABLET 200 MG ribasphere oral capsule 200 ribasphere oral tablet 200 ribasphere oral tablet 400 NM ribasphere oral tablet 600 NM; NDS 50

58 ribasphere ribapak NM; NDS (7)- 400 (7) ribasphere ribapak NM; NDS (7)- 600 (7) ribasphere ribapak oral tablets,dose pack (28)- (28), (28)- (28) NM; NDS ribavirin oral capsule 200 (Ribasphere) ribavirin oral tablet 200 (Moderiba) valacyclovir oral tablet gram, 500 (Valtrex) valganciclovir oral recon soln 50 /ml (Valcyte) NM; NDS valganciclovir oral tablet 450 (Valcyte) NM; NDS VIRAZOLE INHALATION RECON SOLN 6 GRAM NM; NDS Blood Products/Modifiers/Volume Expanders Anticoagulants ELIQUIS ORAL TABLET 2.5 MG, 5 MG ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS) enoxaparin subcutaneous solution 300 (Lovenox) QL (5 per 7 days) /3 ml enoxaparin subcutaneous syringe 00 (Lovenox) QL (34 per 7 days) /ml, 50 /ml enoxaparin subcutaneous syringe 20 (Lovenox) QL (28 per 7 days) /0.8 ml, 80 /0.8 ml enoxaparin subcutaneous syringe 30 (Lovenox) QL ( per 7 days) /0.3 ml enoxaparin subcutaneous syringe 40 (Lovenox) QL (4 per 7 days) /0.4 ml enoxaparin subcutaneous syringe 60 (Lovenox) QL (2 per 7 days) /0.6 ml fondaparinux subcutaneous syringe 0 (Arixtra) PA; NM; NDS /0.8 ml, 5 /0.4 ml, 7.5 /0.6 ml fondaparinux subcutaneous syringe 2.5 (Arixtra) PA /0.5 ml FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA UNIT/ML NM; NDS 5

59 FRAGMIN SUBCUTANEOUS SYRINGE 0,000 ANTI-XA UNIT/ML, 2,500 ANTI-XA UNIT/0.5 ML, 5,000 ANTI-XA UNIT/0.6 ML, 8,000 ANTI- XA UNIT/0.72 ML, 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML, 7,500 ANTI-XA UNIT/0.3 ML heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(00 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) injection cartridge 5,000 unit/ml ( ml) heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml heparin, porcine (pf) injection solution,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml jantoven oral tablet, 0, 2, 2.5, 3, 4, 5, 6, 7.5 warfarin oral tablet, 0, 2, 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 0 MG, 5 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (42)- 20 MG (9) Blood Formation Modifiers ARANESP (IN POLYSORBATE) INJECTION SOLUTION 00 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 0 MCG/0.4 ML, 00 MCG/0.5 ML, 50 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML BERINERT INTRAVENOUS KIT 500 UNIT (0 ML) PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD (Coumadin) PA BvD PA BvD PA; NM; NDS 52

60 CINRYZE INTRAVENOUS RECON PA; NM; NDS SOLN 500 UNIT (5 ML) EPOGEN INJECTION SOLUTION PA BvD 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE NM; NDS 300 MCG/0.5 ML, 480 MCG/0.8 ML MOZOBIL SUBCUTANEOUS NM; NDS SOLUTION 24 MG/.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS NM; NDS SYRINGE 6 MG/0.6ML PROCRIT INJECTION SOLUTION PA BvD 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML PROMACTA ORAL TABLET 2.5 MG, PA; NM; NDS 25 MG, 50 MG, 75 MG RUCONEST INTRAVENOUS RECON PA; NM; NDS SOLN 2,00 UNIT ZARXIO INJECTION SYRINGE 300 NM; NDS MCG/0.5 ML, 480 MCG/0.8 ML Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 (Agrylin) anagrelide oral capsule tranexamic acid intravenous solution (Cyklokapron),000 /0 ml (00 /ml) tranexamic acid oral tablet 650 (Lysteda) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er (Aggrenox) multiphase 2 hr BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00, 50 clopidogrel oral tablet 75 (Plavix) dipyridamole oral tablet 25, 50, 75 EFFIENT ORAL TABLET 0 MG, 5 MG pentoxifylline oral tablet extended release 400 Caloric Agents Caloric Agents 53

61 AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D5W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 4.25%/D0W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 54

62 CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % dextrose 5 % in water (d5w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 20 % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 55

63 PLENAMINE INTRAVENOUS PARENTERAL SOLUTION 5 % PREMASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % TROPHAMINE 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0., 0.2, PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD (Catapres) 0.3 clonidine transdermal patch weekly 0. (Catapres-TTS-) /24 hr clonidine transdermal patch weekly 0.2 (Catapres-TTS-2) /24 hr clonidine transdermal patch weekly 0.3 (Catapres-TTS-3) /24 hr doxazosin oral tablet, 2, 4, 8 (Cardura) guanfacine oral tablet, 2 methyldopa oral tablet 250, 500 methyldopa-hydrochlorothiazide oral tablet 250-5, midodrine oral tablet 0, 2.5, 5 NORTHERA ORAL CAPSULE 00 MG, 200 MG, 300 MG PA; NM; NDS phenoxybenzamine oral capsule 0 (Dibenzyline) prazosin oral capsule, 2, 5 (Minipress) Angiotensin Ii Receptor Antagonists candesartan oral tablet 6, 32, 4, 8 candesartan-hydrochlorothiazid oral tablet 6-2.5, , ENTRESTO ORAL TABLET MG, 49-5 MG, MG (Atacand) (Atacand HCT) PA 56

64 eprosartan oral tablet 600 irbesartan oral tablet 50, 300, 75 (Avapro) irbesartan-hydrochlorothiazide oral tablet , (Avalide) losartan oral tablet 00, 25, 50 (Cozaar) losartan-hydrochlorothiazide oral tablet (Hyzaar) , 00-25, telmisartan oral tablet 20, 40, 80 (Micardis) telmisartan-amlodipine oral tablet 40-0 (Twynsta), 40-5, 80-0, 80-5 telmisartan-hydrochlorothiazid oral tablet (Micardis HCT) , , valsartan oral tablet 60, 320, 40 (Diovan), 80 valsartan-hydrochlorothiazide oral tablet (Diovan HCT) , 60-25, , , Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 0, 20, 40 (Lotensin) benazepril oral tablet 5 benazepril-hydrochlorothiazide oral tablet (Lotensin HCT) 0-2.5, , benazepril-hydrochlorothiazide oral tablet captopril oral tablet 00, 2.5, 25, 50 captopril-hydrochlorothiazide oral tablet 25-5, 25-25, 50-5, enalapril maleate oral tablet 0, 2.5 (Vasotec), 20, 5 enalapril-hydrochlorothiazide oral tablet (Vaseretic) 0-25 enalapril-hydrochlorothiazide oral tablet EPANED ORAL SOLUTION MG/ML PA fosinopril oral tablet 0, 20, 40 fosinopril-hydrochlorothiazide oral tablet 0-2.5, lisinopril oral tablet 0, 20, 5 (Prinivil) 57

65 lisinopril oral tablet 2.5, 30, 40 (Zestril) lisinopril-hydrochlorothiazide oral tablet (Zestoretic) 0-2.5, , moexipril oral tablet 5, 7.5 moexipril-hydrochlorothiazide oral tablet 5-2.5, 5-25, perindopril erbumine oral tablet 2, 4, 8 quinapril oral tablet 0, 20, 40, (Accupril) 5 quinapril-hydrochlorothiazide oral tablet (Accuretic) 0-2.5, , ramipril oral capsule.25, 0, 2.5 (Altace), 5 trandolapril oral tablet, 2, 4 trandolapril-verapamil oral tablet, ir - er, biphasic 24hr -240 trandolapril-verapamil oral tablet, ir - er, (Tarka) biphasic 24hr 2-80, 2-240, Antiarrhythmic Agents amiodarone intravenous solution 50 /ml amiodarone oral tablet 00, 200, (Pacerone) 400 disopyramide phosphate oral capsule 00 (Norpace), 50 dofetilide oral capsule 25 mcg, 250 mcg, (Tikosyn) 500 mcg flecainide oral tablet 00, 50, 50 mexiletine oral capsule 50, 200, 250 MULTAQ ORAL TABLET 400 MG NEXTERONE INTRAVENOUS SOLUTION 50 MG/00 ML (.5 MG/ML), 360 MG/200 ML (.8 MG/ML) pacerone oral tablet 200, 400 procainamide injection solution 00 /ml, 500 /ml procainamide intravenous syringe 00 /ml 58

66 propafenone oral capsule,extended release (Rythmol SR) 2 hr 225, 325, 425 propafenone oral tablet 50, 225, 300 quinidine gluconate injection solution 80 /ml quinidine gluconate oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 Beta-Adrenergic Blocking Agents acebutolol oral capsule 200, 400 atenolol oral tablet 00, 25, 50 (Tenormin) atenolol-chlorthalidone oral tablet (Tenoretic 00) atenolol-chlorthalidone oral tablet (Tenoretic 50) betaxolol oral tablet 0, 20 bisoprolol fumarate oral tablet 0, 5 carvedilol oral tablet 2.5, 25, (Coreg) 3.25, 6.25 labetalol oral tablet 00, 200, 300 metoprolol succinate oral tablet extended (Toprol XL) release 24 hr 00, 200, 25, 50 metoprolol ta-hydrochlorothiaz oral tablet 00-25, metoprolol ta-hydrochlorothiaz oral tablet (Lopressor HCT) metoprolol tartrate intravenous syringe 5 /5 ml metoprolol tartrate oral tablet 00, 50 (Lopressor) metoprolol tartrate oral tablet 25, 75 nadolol oral tablet 20, 40, 80 (Corgard) nadolol-bendroflumethiazide oral tablet (Corzide) 40-5, 80-5 pindolol oral tablet 0, 5 propranolol oral capsule,extended release 24 hr 20, 60, 60, 80 (Inderal LA) 59

67 propranolol oral solution 20 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 20, 40, 60, 80 propranolol-hydrochlorothiazid oral tablet 40-25, sorine oral tablet 20, 60, 240, 80 sotalol af oral tablet 20, 60, 80 sotalol oral tablet 20, 60, 240 (Betapace), 80 timolol maleate oral tablet 0, 20, 5 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 24hr 20, 80, 240, 300 diltiazem hcl intravenous recon soln 00 diltiazem hcl intravenous solution 5 /ml diltiazem hcl oral capsule,extended release 2 hr 20, 60, 90 diltiazem hcl oral capsule,extended (Taztia XT) release 24 hr 360 diltiazem hcl oral capsule,extended (Tiazac) release 24 hr 420 diltiazem hcl oral capsule,extended (Cardizem CD) release 24hr 20, 80, 240, 300 diltiazem hcl oral tablet 20, 30, (Cardizem) 60 diltiazem hcl oral tablet 90 dilt-xr oral capsule,ext.rel 24h degradable 20, 80, 240 matzim la oral tablet extended release 24 hr 80, 240, 300, 360, 420 taztia xt oral capsule,extended release 24 hr 20, 80, 240, 300, 360 verapamil intravenous solution 2.5 /ml verapamil oral capsule, 24 hr er pellet ct 00, 200, 300 (Verelan PM) 60

68 verapamil oral capsule,ext rel. pellets 24 (Verelan) hr 20, 80, 240, 360 verapamil oral tablet 20, 80 (Calan) verapamil oral tablet 40 verapamil oral tablet extended release 20 (Calan SR), 80, 240 Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 PA MG DEMSER ORAL CAPSULE 250 MG NM; NDS digitek oral tablet 25 mcg QL (30 per 30 days) digitek oral tablet 250 mcg digox oral tablet 25 mcg QL (30 per 30 days) digox oral tablet 250 mcg digoxin injection syringe 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML digoxin oral tablet 25 mcg (Digitek) QL (30 per 30 days) digoxin oral tablet 250 mcg (Digitek) epinephrine injection auto-injector 0.5 (EpiPen Jr) QL (2 per 5 days) /0.3 ml epinephrine injection auto-injector 0.3 (Auvi-Q) QL (2 per 5 days) /0.3 ml EPIPEN 2-PAK INJECTION AUTO- QL (2 per 5 days) INJECTOR 0.3 MG/0.3 ML EPIPEN JR 2-PAK INJECTION AUTO- QL (2 per 5 days) INJECTOR 0.5 MG/0.3 ML FIRAZYR SUBCUTANEOUS SYRINGE PA; NM; NDS 30 MG/3 ML hydralazine injection solution 20 /ml hydralazine oral tablet 0, 00, 25, 50 RANEXA ORAL TABLET EXTENDED RELEASE 2 HR,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30, 60 amlodipine oral tablet 0, 2.5, 5 (Norvasc) amlodipine-benazepril oral capsule 0-20, 0-40, 5-0, 5-20, 5-40 (Lotrel) 6

69 amlodipine-benazepril oral capsule amlodipine-valsartan oral tablet 0-60 (Exforge), 0-320, 5-60, amlodipine-valsartan-hcthiazid oral tablet (Exforge HCT) , , , , felodipine oral tablet extended release 24 hr 0, 2.5, 5 isradipine oral capsule 2.5, 5 nicardipine intravenous solution 25 /0 (Cardene IV) ml nicardipine oral capsule 20, 30 nifedipine oral capsule 0 (Procardia) nifedipine oral capsule 20 nifedipine oral tablet extended release (Procardia XL) 24hr 30, 60, 90 nifedipine oral tablet extended release 30 (Adalat CC), 60, 90 nimodipine oral capsule 30 nisoldipine oral tablet extended release 24 (Sular) hr 7, 34, 8.5 nisoldipine oral tablet extended release 24 hr 20, 30, 40 Diuretics amiloride oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5,, 2 chlorothiazide oral tablet 250, 500 chlorothiazide sodium intravenous recon (Diuril IV) soln 500 chlorthalidone oral tablet 25, 50 ethacrynic acid oral tablet 25 (Edecrin) furosemide injection solution 0 /ml furosemide injection syringe 0 /ml furosemide oral solution 0 /ml, 40 /5 ml (8 /ml) furosemide oral tablet 20, 40, 80 (Lasix) hydrochlorothiazide oral capsule 2.5 (Microzide) 62

70 hydrochlorothiazide oral tablet 2.5, 25, 50 indapamide oral tablet.25, 2.5 methyclothiazide oral tablet 5 metolazone oral tablet 0, 2.5, 5 spironolactone oral tablet 00, 25, 50 (Aldactone) spironolacton-hydrochlorothiaz oral tablet (Aldactazide) torsemide oral tablet 0, 20 (Demadex) torsemide oral tablet 00, 5 triamterene-hydrochlorothiazid oral (Dyazide) capsule triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet (Maxzide-25) triamterene-hydrochlorothiazid oral tablet (Maxzide) Dyslipidemics amlodipine-atorvastatin oral tablet 0-0 (Caduet), 0-20, 0-40, 0-80, 5-0, 5-20, 5-40, 5-80 amlodipine-atorvastatin oral tablet 2.5-0, , atorvastatin oral tablet 0, 20, 40 (Lipitor), 80 cholestyramine (with sugar) oral powder (Questran) in packet 4 gram cholestyramine light oral powder 4 gram cholestyramine light packet 4 gram colesevelam oral powder in packet 3.75 (WelChol) gram colesevelam oral tablet 625 (WelChol) colestipol oral packet 5 gram (Colestid) colestipol oral tablet gram (Colestid) ezetimibe oral tablet 0 (Zetia) QL (30 per 30 days) ezetimibe-simvastatin oral tablet 0-0 (Vytorin 0-0) ezetimibe-simvastatin oral tablet 0-20 (Vytorin 0-20) ezetimibe-simvastatin oral tablet 0-40 (Vytorin 0-40) ezetimibe-simvastatin oral tablet 0-80 (Vytorin 0-80) 63

71 fenofibrate micronized oral capsule 30, 34, 200, 43, 67 fenofibrate nanocrystallized oral tablet (Tricor) 45, 48 fenofibrate oral capsule 50, 50 (Lipofen) fenofibrate oral tablet 60, 54 fenofibric acid (choline) oral (Trilipix) capsule,delayed release(dr/ec) 35, 45 fluvastatin oral capsule 20, 40 (Lescol) fluvastatin oral tablet extended release 24 (Lescol XL) hr 80 gemfibrozil oral tablet 600 (Lopid) JUXTAPID ORAL CAPSULE 0 MG, 20 PA; NM; NDS MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS PA; NM; NDS SYRINGE 200 MG/ML lovastatin oral tablet 0, 20, 40 niacin oral tablet extended release 24 hr (Niaspan Extended-,000, 500, 750 Release) niacor oral tablet 500 omega-3 acid ethyl esters oral capsule (Lovaza) gram pravastatin oral tablet 0 pravastatin oral tablet 20, 40, 80 (Pravachol) prevalite oral powder in packet 4 gram REPATHA SYRINGE PA; NM; NDS; QL (2 SUBCUTANEOUS SYRINGE 40 per 28 days) MG/ML rosuvastatin oral tablet 0, 20, 40 (Crestor), 5 simvastatin oral tablet 0, 20, 40 (Zocor), 80 simvastatin oral tablet 5 WELCHOL ORAL POWDER IN PACKET 3.75 GRAM Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 25, 50 (Inspra) TEKTURNA ORAL TABLET 50 MG, 300 MG Vasodilators 64

72 BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 0, 20, 30 isosorbide dinitrate oral tablet 5 (Isordil Titradose) isosorbide dinitrate oral tablet extended (ISOCHRON) release 40 isosorbide mononitrate oral tablet 0, 20 isosorbide mononitrate oral tablet extended release 24 hr 20, 30, 60 minoxidil oral tablet 0, 2.5 nitroglycerin sublingual tablet 0.3, 0.4 (Nitrostat), 0.6 nitroglycerin transdermal patch 24 hour 0. /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr (Minitran) Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 2 HR 0 MG atomoxetine oral capsule 0, 00, 8, 25, 40, 60, 80 AUBAGIO ORAL TABLET 4 MG, 7 MG AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML dalfampridine oral tablet extended release 2 hr 0 dexmethylphenidate oral capsule,er biphasic , 5, 20, 25, 30, 35, 40, 5 PA; NM; NDS; QL (60 per 30 days) (Strattera) QL (60 per 30 days) PA; NM; NDS; QL (28 per 28 days) PA; NM; NDS PA; NM; NDS PA; NM; NDS PA; NM; NDS (Ampyra) PA; NM; NDS; QL (60 per 30 days) (Focalin XR) dexmethylphenidate oral tablet 0, 2.5 (Focalin), 5 dextroamphetamine oral capsule, extended (Dexedrine Spansule) release 0, 5, 5 dextroamphetamine oral tablet 0, 5 (Zenzedi) 65

73 dextroamphetamine-amphetamine oral (Adderall XR) capsule,extended release 24hr 0, 5, 20, 25, 30, 5 dextroamphetamine-amphetamine oral tablet 0, 2.5, 5, 20, 30, 5, 7.5 (Adderall) EXTAVIA SUBCUTANEOUS KIT 0.3 PA; NM; NDS MG GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG PA; NM; NDS; QL (28 per 28 days) glatiramer subcutaneous syringe 20 /ml, 40 /ml (Copaxone) PA; NM; NDS; QL (30 per 30 days) guanfacine oral tablet extended release 24 (Intuniv ER) hr, 2, 3, 4 lithium carbonate oral capsule 50, 300, 600 lithium carbonate oral tablet 300 lithium carbonate oral tablet extended (Lithobid) release 300 lithium carbonate oral tablet extended release 450 lithium citrate oral solution 8 meq/5 ml metadate er oral tablet extended release 20 methamphetamine oral tablet 5 (Desoxyn) PA methylphenidate hcl oral capsule, er biphasic , 20, 30, 40, 50, 60 methylphenidate hcl oral capsule,er (Ritalin LA) biphasic , 40 methylphenidate hcl oral solution 0 /5 (Methylin) ml, 5 /5 ml methylphenidate hcl oral tablet 0, 20 (Ritalin), 5 methylphenidate hcl oral tablet extended release 0 methylphenidate hcl oral tablet extended (Metadate ER) release 20 methylphenidate hcl oral tablet extended (Concerta) release 24hr 8, 27, 36, 54 methylphenidate hcl oral tablet extended release 24hr 72 (Relexxii) 66

74 methylphenidate hcl oral tablet,chewable 0, 2.5, 5 PLEGRIDY SUBCUTANEOUS PEN PA; NM; NDS INJECTOR 25 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 25 MCG/0.5 ML PA; NM; NDS riluzole oral tablet 50 (Rilutek) TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG (4)- 240 MG (46), 240 MG PA; NM; NDS; QL (4 per 30 days) PA; NM; NDS; QL (60 per 30 days) tetrabenazine oral tablet 2.5, 25 (Xenazine) PA; NM; NDS VYVANSE ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG Contraceptives Contraceptives alyacen /35 (28) oral tablet -35 -mcg amethia oral tablets,dose pack,3 month mcg (84)/0 mcg (7) amethyst oral tablet mcg apri oral tablet aranelle (28) oral tablet 0.5// mcg ashlyna oral tablets,dose pack,3 month mcg (84)/0 mcg (7) aubra oral tablet mcg aviane oral tablet mcg balziva (28) oral tablet mcg bekyree (28) oral tablet x2 /0.0 x 5 blisovi 24 fe oral tablet -20 mcg (24)/75 (4) blisovi fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) blisovi fe /20 (28) oral tablet -20 mcg (2)/75 (7) briellyn oral tablet mcg 67

75 camila oral tablet 0.35 caziant (28) oral tablet 0./.25/ mcg cryselle (28) oral tablet mcg cyclafem /35 (28) oral tablet -35 mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg deblitane oral tablet 0.35 delyla (28) oral tablet mcg desog-e.estradiol/e.estradiol oral tablet (Azurette (28)) x2 /0.0 x 5 drospirenone-e.estradiol-lm.fa oral tablet (Beyaz) (24) (4) drospirenone-ethinyl estradiol oral tablet (Gianvi (28)) drospirenone-ethinyl estradiol oral tablet (Ocella) emoquette oral tablet enpresse oral tablet (6)/75-40 (5)/25-30(0) errin oral tablet 0.35 ethynodiol diac-eth estradiol oral tablet - (Kelnor /35 (28)) 35 -mcg ethynodiol diac-eth estradiol oral tablet - (Kelnor -50) 50 -mcg falmina (28) oral tablet mcg femynor oral tablet mcg gianvi (28) oral tablet introvale oral tablets,dose pack,3 month mcg jolivette oral tablet 0.35 juleber oral tablet junel.5/30 (2) oral tablet.5-30 mcg junel /20 (2) oral tablet -20 -mcg junel fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) junel fe /20 (28) oral tablet -20 mcg (2)/75 (7) junel fe 24 oral tablet -20 mcg (24)/75 (4) 68

76 kaitlib fe oral tablet,chewable mcg(24) and 75 (4) kariva (28) oral tablet x2 /0.0 x 5 kelnor /35 (28) oral tablet -35 -mcg kelnor -50 oral tablet -50 -mcg kimidess (28) oral tablet x2 /0.0 x 5 l norgest/e.estradiol-e.estrad oral (Fayosim) tablets,dose pack,3 month mcg/ mcg l norgest/e.estradiol-e.estrad oral (Amethia) tablets,dose pack,3 month mcg (84)/0 mcg (7) larin.5/30 (2) oral tablet.5-30 mcg larin /20 (2) oral tablet -20 -mcg larin fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) larin fe /20 (28) oral tablet -20 mcg (2)/75 (7) larissia oral tablet mcg layolis fe oral tablet,chewable mcg(24) and 75 (4) leena 28 oral tablet 0.5// mcg lessina oral tablet mcg levonest (28) oral tablet (6)/75-40 (5)/25-30(0) levonorgestrel-ethinyl estrad oral tablet (Aubra) mcg levonorgestrel-ethinyl estrad oral tablet (Altavera (28)) levonorgestrel-ethinyl estrad oral tablet (Amethyst) mcg levonorgestrel-ethinyl estrad oral (Introvale) tablets,dose pack,3 month mcg levonorg-eth estrad triphasic oral tablet (Enpresse) (6)/75-40 (5)/25-30(0) levora-28 oral tablet loryna (28) oral tablet low-ogestrel (28) oral tablet mcg lutera (28) oral tablet mcg 69

77 lyza oral tablet 0.35 marlissa oral tablet microgestin.5/30 (2) oral tablet mcg microgestin /20 (2) oral tablet -20 mcg microgestin fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) microgestin fe /20 (28) oral tablet - 20 mcg (2)/75 (7) mili oral tablet mcg mononessa (28) oral tablet mcg necon 0.5/35 (28) oral tablet mcg necon 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg nikki (28) oral tablet nora-be oral tablet 0.35 noreth-ethinyl estradiol-iron oral (Wymzya Fe) tablet,chewable mcg(2) and 75 (7) noreth-ethinyl estradiol-iron oral (Generess Fe) tablet,chewable mcg(24) and 75 (4) norethindrone (contraceptive) oral tablet (Camila) 0.35 norethindrone ac-eth estradiol oral tablet (Junel /20 (2)) -20 -mcg norethindrone-e.estradiol-iron oral tablet (Blisovi Fe /20 (28)) -20 mcg (2)/75 (7) norethindrone-e.estradiol-iron oral tablet (Blisovi 24 Fe) -20 mcg (24)/75 (4) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen LO 0.8/0.25/ mcg (28)) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen (28)) 0.8/0.25/ mcg (28) norgestimate-ethinyl estradiol oral tablet (Estarylla) mcg norlyroc oral tablet 0.35 nortrel 0.5/35 (28) oral tablet mcg nortrel /35 (2) oral tablet -35 -mcg 70

78 nortrel /35 (28) oral tablet -35 -mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg NUVARING VAGINAL RING MG/24 HR ocella oral tablet orsythia oral tablet mcg pimtrea (28) oral tablet x2 /0.0 x 5 pirmella oral tablet -35 -mcg portia oral tablet previfem oral tablet mcg quasense oral tablets,dose pack,3 month mcg reclipsen (28) oral tablet setlakin oral tablets,dose pack,3 month mcg sharobel oral tablet 0.35 sprintec (28) oral tablet mcg sronyx oral tablet mcg tarina fe /20 (28) oral tablet -20 mcg (2)/75 (7) tri-legest fe oral tablet -20(5)/-30(7) /-35mcg (9) tri-lo-estarylla oral tablet 0.8/0.25/ mcg tri-lo-sprintec oral tablet 0.8/0.25/ mcg tri-mili oral tablet 0.8/0.25/ mcg (28) trinessa (28) oral tablet 0.8/0.25/ mcg (28) tri-previfem (28) oral tablet 0.8/0.25/ mcg (28) tri-sprintec (28) oral tablet 0.8/0.25/ mcg (28) trivora (28) oral tablet (6)/75-40 (5)/25-30(0) tulana oral tablet 0.35 velivet triphasic regimen (28) oral tablet 0./.25/ mcg vestura (28) oral tablet

79 vienva oral tablet mcg vyfemla (28) oral tablet mcg wymzya fe oral tablet,chewable mcg(2) and 75 (7) xulane transdermal patch weekly mcg/24 hr zarah oral tablet zenchent (28) oral tablet mcg zovia /35e (28) oral tablet -35 -mcg Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 (Evoxac) chlorhexidine gluconate mucous (Paroex Oral Rinse) membrane mouthwash 0.2 % paroex oral rinse mucous membrane mouthwash 0.2 % periogard mucous membrane mouthwash 0.2 % pilocarpine hcl oral tablet 5, 7.5 (Salagen (pilocarpine)) triamcinolone acetonide dental paste 0. % (Oralone) Dermatological Agents Dermatological Agents, Other acitretin oral capsule 0, 7.5, 25 (Soriatane) NM; NDS acyclovir topical ointment 5 % (Zovirax) ST ALCOHOL PADS TOPICAL PADS, MEDICATED ammonium lactate topical cream 2 % (Geri-Hydrolac) ammonium lactate topical lotion 2 % (AmLactin) calcipotriene scalp solution % calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcitrene) calcipotriene-betamethasone topical (Taclonex) ointment % calcitriol topical ointment 3 mcg/gram (Vectical) claravis oral capsule 0, 20, 30, 40 COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 50 MG/ML PA; NM; NDS 72

80 COSENTYX PEN (2 PENS) PA; NM; NDS SUBCUTANEOUS PEN INJECTOR 50 MG/ML DENAVIR TOPICAL CREAM % doxepin topical cream 5 % (Prudoxin) FINACEA TOPICAL FOAM 5 % FINACEA TOPICAL GEL 5 % fluorouracil topical cream 0.5 % (Carac) fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution 2 %, 5 % imiquimod topical cream in packet 5 % (Aldara) isotretinoin oral capsule 0, 20, 30 (Absorica), 40 mafenide acetate topical packet 50 gram (Sulfamylon) methoxsalen oral capsule,liqd-filled,rapid (Oxsoralen Ultra) rel 0 myorisan oral capsule 0, 20, 40 PANRETIN TOPICAL GEL 0. % NM; NDS PICATO TOPICAL GEL 0.05 % NM; NDS; QL (3 per 0 days) PICATO TOPICAL GEL 0.05 % NM; NDS; QL (2 per 0 days) podofilox topical solution 0.5 % REGRANEX TOPICAL GEL 0.0 % NM; NDS; QL (30 per 5 days) SANTYL TOPICAL OINTMENT 250 UNIT/GRAM SULFAMYLON TOPICAL CREAM 85 MG/G UVADEX INJECTION SOLUTION 20 MCG/ML VALCHLOR TOPICAL GEL 0.06 % PA NSO; NM; NDS; QL (240 per 30 days) zenatane oral capsule 0, 20, 30, 40 Dermatological Antibacterials clindamycin phosphate topical foam % (Evoclin) clindamycin phosphate topical gel % (Cleocin T) clindamycin phosphate topical lotion % (Cleocin T) clindamycin phosphate topical solution % (Cleocin T) 73

81 clindamycin phosphate topical swab % (Cleocin T) clindamycin-benzoyl peroxide topical gel (Duac).2 %( % base) -5 % clindamycin-benzoyl peroxide topical gel -5 % (Benzaclin) clindamycin-tretinoin topical gel (Veltin) % ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % (Erygel) erythromycin with ethanol topical solution 2 % erythromycin-benzoyl peroxide topical gel (Aktipak) 3-5 % gentamicin topical cream 0. % gentamicin topical ointment 0. % metronidazole topical cream 0.75 % (MetroCream) metronidazole topical gel 0.75 % (Rosadan) metronidazole topical gel % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) mupirocin calcium topical cream 2 % (Bactroban) mupirocin topical ointment 2 % (Centany) neomycin-polymyxin b gu irrigation solution ,000 unit/ml selenium sulfide topical lotion 2.5 % silver sulfadiazine topical cream % (Silvadene) ssd topical cream % sulfacetamide sodium (acne) topical (Klaron) suspension 0 % Dermatological Anti-Inflammatory Agents ala-cort topical cream %, 2.5 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % amcinonide topical cream 0. % PA amcinonide topical ointment 0. % PA betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % 74

82 betamethasone valerate topical cream 0. % betamethasone valerate topical foam 0.2 (Luxiq) PA % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical (Diprolene) ointment 0.05 % clobetasol scalp solution 0.05 % (Cormax) PA clobetasol topical cream 0.05 % (Temovate) PA clobetasol topical foam 0.05 % (Olux) PA clobetasol topical gel 0.05 % PA clobetasol topical lotion 0.05 % (Clobex) PA clobetasol topical ointment 0.05 % (Temovate) PA clobetasol topical shampoo 0.05 % (Clobex) PA clobetasol topical spray,non-aerosol 0.05 (Clobex) PA % clobetasol-emollient topical cream 0.05 % PA clobetasol-emollient topical foam 0.05 % (Olux-E) PA CLODAN TOPICAL SHAMPOO 0.05 % PA cormax scalp solution 0.05 % PA DESONATE TOPICAL GEL 0.05 % PA desonide topical cream 0.05 % (DesOwen) PA desonide topical lotion 0.05 % (DesOwen) PA desonide topical ointment 0.05 % desoximetasone topical cream 0.25 % (Topicort) desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.25 % (Topicort) diflorasone topical cream 0.05 % (Psorcon) diflorasone topical ointment 0.05 % ELIDEL TOPICAL CREAM % fluocinolone 0.0% body oil 0.0 % (Derma-Smoothe/FS Body Oil) 75

83 fluocinolone and shower cap scalp oil 0.0 (Derma-Smoothe/FS % Scalp Oil) fluocinolone topical cream 0.0 % fluocinolone topical cream % (Synalar) fluocinolone topical ointment % (Synalar) fluocinolone topical solution 0.0 % (Synalar) fluocinonide topical cream 0.05 % fluocinonide topical cream 0. % (Vanos) fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluticasone topical cream 0.05 % (Cutivate) fluticasone topical lotion 0.05 % (Cutivate) PA fluticasone topical ointment % halobetasol propionate topical cream 0.05 (Ultravate) % halobetasol propionate topical ointment (Ultravate) 0.05 % hydrocort buty 0.% lipo cream 0. % (Locoid Lipocream) PA hydrocortisone butyrate topical cream 0. (Locoid) PA % hydrocortisone butyrate topical ointment 0. % hydrocortisone butyrate topical solution (Locoid) 0. % hydrocortisone topical cream %, 2.5 % (Ala-Cort) hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment % (Anti-Itch (HC)) hydrocortisone topical ointment 2.5 % hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % mometasone topical cream 0. % (Elocon) mometasone topical ointment 0. % (Elocon) mometasone topical solution 0. % prednicarbate topical cream 0. % prednicarbate topical ointment 0. % (Dermatop) procto-med hc topical cream with perineal applicator 2.5 % 76

84 procto-pak topical cream with perineal applicator % proctosol hc topical cream with perineal applicator 2.5 % proctozone-hc topical cream with perineal applicator 2.5 % tacrolimus topical ointment 0.03 %, 0. % (Protopic) triamcinolone acetonide topical aerosol (Kenalog) 0.47 /gram triamcinolone acetonide topical cream % triamcinolone acetonide topical cream 0. (Triderm) %, 0.5 % triamcinolone acetonide topical lotion %, 0. % triamcinolone acetonide topical ointment %, 0. %, 0.5 % tridesilon topical cream 0.05 % PA Dermatological Retinoids adapalene 0.3% gel pump 0.3 % (Differin) PA adapalene topical cream 0. % (Differin) PA adapalene topical gel 0. %, 0.3 % (Differin) PA avita topical cream % PA avita topical gel % PA tazarotene topical cream 0. % (Avage) tretinoin microspheres topical gel 0.04 %, (Retin-A Micro) PA 0. % tretinoin topical cream % (Avita) PA tretinoin topical cream 0.05 %, 0. % (Retin-A) PA tretinoin topical gel 0.0 % (Retin-A) PA tretinoin topical gel % (Avita) PA tretinoin topical gel 0.05 % (Atralin) PA Scabicides And Pediculicides EURAX TOPICAL CREAM 0 % EURAX TOPICAL LOTION 0 % lindane topical shampoo % malathion topical lotion 0.5 % (Ovide) permethrin topical cream 5 % (Elimite) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE ML 29 GAUGE X /2" 77

85 BD UF NANO PEN NEEDLE 4MMX32G 32 GAUGE X 5/32" BD VEO INS 0.3 ML 6MMX3G (/2) 0.3 ML 3 GAUGE X 5/64" BD VEO INS SYRING ML 6MMX3G ML 3 GAUGE X 5/64" BD VEO INS SYRN 0.5 ML 6MMX3G /2 ML 3 GAUGE X 5/64" GAUZE PAD TOPICAL BANDAGE 2 X 2 " INSULIN SYRINGE-NEEDLE U-00 SYRINGE 0.3 ML 29 GAUGE INSULIN SYRINGE-NEEDLE U-00 SYRINGE ML 29 GAUGE X /2" INSULIN SYRINGE-NEEDLE U-00 SYRINGE /2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X /2" (Ultilet Insulin Syringe) (Advocate Syringes) (Lite Touch Insulin Syringe) (st Tier Unifine Pentips) VGO 40 DISPOSABLE DEVICE Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR PA; NM; NDS SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS NM; NDS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON NM; NDS SOLN 400 UNIT CHENODAL ORAL TABLET 250 MG NM; NDS CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2,000-38,000-60,000 UNIT, 24,000-76,000-20,000 UNIT, 3,000-9,500-5,000 UNIT, 36,000-4,000-80,000 UNIT, 6,000-9,000-30,000 UNIT CYSTAGON ORAL CAPSULE 50 MG, PA 50 MG ELAPRASE INTRAVENOUS NM; NDS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON NM; NDS SOLN.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG NM; NDS 78

86 KUVAN ORAL POWDER IN PACKET PA; NM; NDS 00 MG, 500 MG KUVAN ORAL TABLET,SOLUBLE 00 PA; NM; NDS MG LUMIZYME INTRAVENOUS RECON NM; NDS SOLN 50 MG miglustat oral capsule 00 (Zavesca) PA; NM; NDS NAGLAZYME INTRAVENOUS NM; NDS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 0 MG, 2 PA; NM; NDS MG, 5 MG PANCREAZE ORAL ST CAPSULE,DELAYED RELEASE(DR/EC) 0,500-35,500-6,500 UNIT, 6,800-56,800-98,400 UNIT, 2,600-6,200-0,850 UNIT, 2,000-54,700-83,900 UNIT, 4,200-4,200-24,600 UNIT PULMOZYME INHALATION PA BvD; NM; NDS SOLUTION MG/ML STRENSIQ SUBCUTANEOUS PA; NM; NDS SOLUTION 00 MG/ML, 40 MG/ML SUCRAID ORAL SOLUTION 8,500 PA; NM; NDS UNIT/ML VPRIV INTRAVENOUS RECON SOLN 400 UNIT NM; NDS Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous ALOMIDE OPHTHALMIC (EYE) DROPS 0. % apraclonidine ophthalmic (eye) drops 0.5 (Iopidine) % atropine ophthalmic (eye) drops % (Isopto Atropine) azelastine nasal aerosol,spray 37 mcg (0. %) azelastine nasal spray,non-aerosol 0.5 % (Astepro) (205.5 mcg) azelastine ophthalmic (eye) drops 0.05 % cromolyn ophthalmic (eye) drops 4 % CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % epinastine ophthalmic (eye) drops 0.05 % (Elestat) PA; NM; NDS; QL (60 per 30 days) 79

87 ipratropium bromide nasal spray,nonaerosol 0.03 %, 42 mcg (0.06 %) LACRISERT OPHTHALMIC (EYE) INSERT 5 MG olopatadine nasal spray,non-aerosol 0.6 (Patanase) % olopatadine ophthalmic (eye) drops 0. % (Patanol) ST olopatadine ophthalmic (eye) drops 0.2 % (Pataday) ST PAZEO OPHTHALMIC (EYE) DROPS ST; QL (2.5 per 30 days) 0.7 % proparacaine ophthalmic (eye) drops 0.5 % Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (ear) solution 2 % AZASITE OPHTHALMIC (EYE) QL (2.5 per 30 days) DROPS % bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) (AK-Poly-Bac) ointment 500-0,000 unit/gram BESIVANCE OPHTHALMIC (EYE) ST; QL (5 per 30 days) DROPS,SUSPENSION 0.6 % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic (eye) drops (Ciloxan) 0.3 % COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION MG/ML erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) gatifloxacin ophthalmic (eye) drops 0.5 % (Zymaxid) ST gentak ophthalmic (eye) ointment 0.3 % (3 /gram) gentamicin ophthalmic (eye) drops 0.3 % hydrocortisone-acetic acid otic (ear) drops -2 % levofloxacin ophthalmic (eye) drops 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 (Vigamox) % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % 80

88 neomycin-bacitracin-poly-hc ophthalmic (Neo-Polycin HC) (eye) ointment ,000 -unit/g- % neomycin-bacitracin-polymyxin (Neo-Polycin) ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) drops,suspension 3.5/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) ointment 3.5 /g- 0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic (eye) drops.75-0,000 unit-0.025/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-0, unit/ml neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-0,000- /mlunit/ml-% neomycin-polymyxin-hc otic (ear) solution 3.5-0,000- /ml-unit/ml-% ofloxacin ophthalmic (eye) drops 0.3 % (Ocuflox) ofloxacin otic (ear) drops 0.3 % polycin ophthalmic (eye) ointment 500-0,000 unit/gram polymyxin b sulf-trimethoprim ophthalmic (Polytrim) (eye) drops 0,000 unit- /ml sulfacetamide sodium ophthalmic (eye) (Bleph-0) drops 0 % sulfacetamide sodium ophthalmic (eye) ointment 0 % sulfacetamide-prednisolone ophthalmic (eye) drops 0 %-0.23 % (0.25 %) tobramycin ophthalmic (eye) drops 0.3 % (Tobrex) tobramycin-dexamethasone ophthalmic (TobraDex) (eye) drops,suspension % trifluridine ophthalmic (eye) drops % (Viroptic) ZIRGAN OPHTHALMIC (EYE) GEL 0.5 % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % 8

89 Eye, Ear, Nose, Throat Anti- Inflammatory Agents ALOCRIL OPHTHALMIC (EYE) DROPS 2 % ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % bromfenac ophthalmic (eye) drops 0.09 % dexamethasone sodium phosphate ophthalmic (eye) drops 0. % diclofenac sodium ophthalmic (eye) drops 0. % DUREZOL OPHTHALMIC (EYE) QL (0 per 30 days) DROPS 0.05 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) QL (50 per 5 days) fluocinolone acetonide oil otic (ear) drops (DermOtic Oil) 0.0 % fluorometholone ophthalmic (eye) (FML Liquifilm) drops,suspension 0. % flurbiprofen sodium ophthalmic (eye) drops 0.03 % fluticasone nasal spray,suspension 50 (24 Hour Allergy Relief) QL (32 per 5 days) mcg/actuation ILEVRO OPHTHALMIC (EYE) QL (3 per 30 days) DROPS,SUSPENSION 0.3 % ketorolac ophthalmic (eye) drops 0.4 % (Acular LS) ketorolac ophthalmic (eye) drops 0.5 % (Acular) LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % prednisolone acetate ophthalmic (eye) (Omnipred) drops,suspension % prednisolone sodium phosphate ophthalmic (eye) drops % RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % PA; ST 82

90 Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral combo pack cimetidine hcl oral solution 300 /5 ml cimetidine oral tablet 200 (Acid Reducer (cimetidine)) cimetidine oral tablet 300, 400, 800 DEXILANT ORAL CAPSULE,BIPHASE ST; QL (30 per 30 days) DELAYED RELEAS 30 MG, 60 MG esomeprazole sodium intravenous recon soln 20 esomeprazole sodium intravenous recon (Nexium IV) soln 40 famotidine (pf)-nacl (iso-os) intravenous piggyback 20 /50 ml famotidine intravenous solution 0 /ml famotidine oral suspension 40 /5 ml (8 (Pepcid) /ml) famotidine oral tablet 20 (Acid Controller) famotidine oral tablet 40 (Pepcid) lansoprazole oral capsule,delayed (Heartburn Treatment 24 release(dr/ec) 5 Hour) lansoprazole oral capsule,delayed (Prevacid) release(dr/ec) 30 misoprostol oral tablet 00 mcg, 200 mcg (Cytotec) nizatidine oral capsule 50, 300 nizatidine oral solution 50 /0 ml omeprazole oral capsule,delayed release(dr/ec) 0, 20, 40 pantoprazole intravenous recon soln 40 (Protonix) pantoprazole oral tablet,delayed release (Protonix) (dr/ec) 20, 40 rabeprazole oral tablet,delayed release (Aciphex) (dr/ec) 20 ranitidine hcl oral capsule 50, 300 ranitidine hcl oral syrup 5 /ml ranitidine hcl oral tablet 50 (Acid Control (ranitidine)) 83

91 ranitidine hcl oral tablet 300 (Zantac) sucralfate oral tablet gram (Carafate) Gastrointestinal Agents, Other CARBAGLU ORAL TABLET, PA DISPERSIBLE 200 MG CHOLBAM ORAL CAPSULE 250 MG, PA; NM; NDS 50 MG constulose oral solution 0 gram/5 ml cromolyn oral concentrate 00 /5 ml (Gastrocrom) dicyclomine oral capsule 0 dicyclomine oral solution 0 /5 ml dicyclomine oral tablet 20 diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet 2.5- (Lomotil) enulose oral solution 0 gram/5 ml GATTEX 30-VIAL SUBCUTANEOUS PA; NM; NDS KIT 5 MG generlac oral solution 0 gram/5 ml glycopyrrolate injection solution 0.2 /ml glycopyrrolate oral tablet (Robinul) glycopyrrolate oral tablet 2 (Robinul Forte) kionex (with sorbitol) oral suspension gram/60 ml lactulose oral solution 0 gram/5 ml (Constulose) LINZESS ORAL CAPSULE 45 MCG, 290 MCG, 72 MCG QL (30 per 30 days) loperamide oral capsule 2 (Anti-Diarrheal (loperamide)) methscopolamine oral tablet 2.5, 5 metoclopramide hcl injection solution 5 /ml metoclopramide hcl injection syringe 5 /ml metoclopramide hcl oral solution 5 /5 ml metoclopramide hcl oral tablet 0, 5 (Reglan) MOVANTIK ORAL TABLET 2.5 MG, 25 MG PA 84

92 PYLERA ORAL CAPSULE MG RAVICTI ORAL LIQUID. GRAM/ML PA; NM; NDS RELISTOR SUBCUTANEOUS PA SOLUTION 2 MG/0.6 ML RELISTOR SUBCUTANEOUS PA SYRINGE 2 MG/0.6 ML, 8 MG/0.4 ML sod polystyren sulf 5 g/60 ml sorbitol free 5 gram/60 ml sodium phenylbutyrate oral powder 0.94 (Buphenyl) gram/gram sodium polystyrene sulfonate oral powder sps (with sorbitol) oral suspension 5-20 gram/60 ml ursodiol oral capsule 300 (Actigall) ursodiol oral tablet 250 (URSO 250) ursodiol oral tablet 500 (URSO Forte) VELTASSA ORAL POWDER IN QL (30 per 30 days) PACKET 6.8 GRAM, 25.2 GRAM, 8.4 GRAM Laxatives gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 420 gram OSMOPREP ORAL TABLET.5 GRAM peg 3350-electrolytes oral recon soln 236- (GaviLyte-G) gram peg 3350-electrolytes oral recon soln 240- (Colyte with Flavor gram Packs) peg-electrolyte soln oral recon soln 420 (GaviLyte-N) gram polyethylene glycol 3350 oral powder 7 (ClearLax) gram/dose polyethylene glycol 3350 powd 7 gm (ClearLax) packets (rx) 7 gram trilyte with flavor packets oral recon soln 420 gram Phosphate Binders calcium acetate oral capsule 667 calcium acetate oral tablet 667 (Calphron) 85

93 RENAGEL ORAL TABLET 800 MG RENVELA ORAL TABLET 800 MG sevelamer carbonate oral powder in (Renvela) packet 0.8 gram, 2.4 gram sevelamer carbonate oral tablet 800 (Renvela) VELPHORO ORAL TABLET,CHEWABLE 500 MG QL (80 per 30 days) Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 /5 ml oxybutynin chloride oral tablet 5 oxybutynin chloride oral tablet extended (Ditropan XL) release 24hr 0, 5 oxybutynin chloride oral tablet extended release 24hr 5 tolterodine oral capsule,extended release (Detrol LA) 24hr 2, 4 tolterodine oral tablet, 2 (Detrol) trospium oral capsule,extended release 24hr 60 trospium oral tablet 20 VESICARE ORAL TABLET 0 MG, 5 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 (Uroxatral) hr 0 dutasteride oral capsule 0.5 (Avodart) dutasteride-tamsulosin oral capsule, er (Jalyn) multiphase 24 hr finasteride oral tablet 5 (Proscar) tamsulosin oral capsule 0.4 (Flomax) terazosin oral capsule, 0, 2, 5 Heavy Metal Antagonists Heavy Metal Antagonists CHEMET ORAL CAPSULE 00 MG DEPEN TITRATABS ORAL TABLET 250 MG 86

94 EXJADE ORAL TABLET, NM; NDS DISPERSIBLE 25 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 00 PA; NM; NDS MG/ML FERRIPROX ORAL TABLET 500 MG PA; NM; NDS JADENU ORAL TABLET 80 MG, 360 NM; NDS MG, 90 MG JADENU SPRINKLE ORAL GRANULES IN PACKET 80 MG, 360 NM; NDS MG, 90 MG SYPRINE ORAL CAPSULE 250 MG PA; NM; NDS trientine oral capsule 250 (Syprine) PA; NM; NDS Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANADROL-50 ORAL TABLET 50 MG NM; NDS ANDRODERM TRANSDERMAL PA; QL (60 per 30 days) PATCH 24 HOUR 2 MG/24 HOUR ANDRODERM TRANSDERMAL PA; QL (30 per 30 days) PATCH 24 HOUR 4 MG/24 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/.25 GRAM (.62 %) PA; QL (50 per 30 days) ANDROGEL TRANSDERMAL GEL IN PACKET.62 % (20.25 MG/.25 GRAM) PA; QL (37.5 per 30 days) ANDROGEL TRANSDERMAL GEL IN PACKET.62 % (40.5 MG/2.5 GRAM) PA; QL (50 per 30 days) danazol oral capsule 00, 200, 50 oxandrolone oral tablet 0, 2.5 (Oxandrin) testosterone cypionate intramuscular oil (Depo-Testosterone) 00 /ml testosterone cypionate intramuscular oil (Depo-Testosterone) 200 /ml testosterone enanthate intramuscular oil 200 /ml Estrogens And Antiestrogens amabelz oral tablet , -0.5 estradiol oral tablet 0.5,, 2 (Estrace) 87

95 estradiol transdermal patch semiweekly (Alora) /24 hr, 0.05 /24 hr, /24 hr, 0. /24 hr estradiol transdermal patch semiweekly (Minivelle) /24 hr estradiol transdermal patch weekly (Climara) /24 hr, /24 hr, 0.05 /24 hr, 0.06 /24 hr, /24 hr, 0. /24 hr estradiol valerate intramuscular oil 20 (Delestrogen) /ml, 40 /ml estradiol-norethindrone acet oral tablet (Activella) , -0.5 ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR) estropipate oral tablet 0.75,.5, 3 fyavolv oral tablet mcg, -5 -mcg jinteli oral tablet -5 -mcg mimvey lo oral tablet mimvey oral tablet -0.5 norethindrone ac-eth estradiol oral tablet (Femhrt Low Dose) mcg norethindrone ac-eth estradiol oral tablet (Fyavolv) -5 -mcg PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG,.25 MG PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET MG (4)/ 0.625MG-5MG(4) PREMPRO ORAL TABLET MG, MG, MG, MG raloxifene oral tablet 60 (Evista) Glucocorticoids/Mineralocorticoids cortisone oral tablet 25 DEXAMETHASONE INTENSOL ORAL DROPS MG/ML dexamethasone oral elixir 0.5 /5 ml (Decadron) dexamethasone oral tablet 0.5, 0.75, 4, 6 (Decadron) 88

96 dexamethasone oral tablet,.5, 2 dexamethasone sodium phos (pf) injection solution 0 /ml dexamethasone sodium phosphate injection solution 0 /ml, 4 /ml dexamethasone sodium phosphate injection syringe 4 /ml fludrocortisone oral tablet 0. hydrocortisone oral tablet 0, 20, 5 (Cortef) KENALOG INJECTION SUSPENSION 0 MG/ML, 40 MG/ML MEDROL ORAL TABLET 2 MG methylprednisolone acetate injection (Depo-Medrol) suspension 40 /ml, 80 /ml methylprednisolone oral tablet 6, 32 (Medrol), 4, 8 methylprednisolone oral tablets,dose pack 4 (Medrol (Pak)) methylprednisolone sodium succ injection PA BvD recon soln 40 methylprednisolone sodium succ (Solu-Medrol) PA BvD intravenous recon soln,000 prednisolone 5 /5 ml soln a/f, d/f 5 /5 ml (3 /ml) prednisolone oral solution 5 /5 ml prednisolone sodium phosphate oral solution 5 base/5 ml (6.7 /5 ml) prednisolone sodium phosphate oral (Orapred ODT) tablet,disintegrating 0, 5, 30 PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 /5 ml prednisone oral tablet, 2.5, 5, 50 prednisone oral tablet 0 prednisone oral tablet 20 (Deltasone) prednisone oral tablets,dose pack 0, 0 (48 pack), 5, 5 (48 pack) SOLU-CORTEF (PF) INJECTION RECON SOLN 250 MG/2 ML 89

97 triamcinolone acetonide injection (Kenalog) suspension 40 /ml Pituitary desmopressin 0 mcg/0. ml spr 0 (DDAVP) mcg/spray (0. ml) desmopressin injection solution 4 mcg/ml (DDAVP) desmopressin nasal solution 0. /ml (DDAVP) (refrigerate) desmopressin nasal spray,non-aerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0., 0.2 (DDAVP) INCRELEX SUBCUTANEOUS PA; NM; NDS SOLUTION 0 MG/ML LUPRON DEPOT-PED NM; NDS INTRAMUSCULAR KIT.25 MG, 5 MG NORDITROPIN FLEXPRO PA; NM; NDS SUBCUTANEOUS PEN INJECTOR 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (0 MG/ML), 30 MG/3 ML (0 MG/ML), 5 MG/.5 ML (3.3 MG/ML) octreotide acetate injection solution,000 mcg/ml, 200 mcg/ml octreotide acetate injection solution 00 (Sandostatin) mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 50 mcg/ml ( ml), 500 mcg/ml ( ml) SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML ( ML), 0.6 MG/ML ( ML), 0.9 MG/ML ( ML) SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 20 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 5 MG, 20 MG, 25 MG, 30 MG STIMATE NASAL SPRAY,NON- AEROSOL 50 MCG/SPRAY (0. ML) SYNAREL NASAL SPRAY,NON- AEROSOL 2 MG/ML Progestins PA; NM; NDS; QL (60 per 30 days) NM; NDS PA; NM; NDS 90 NM; NDS

98 CRINONE VAGINAL GEL 4 %, 8 % PA hydroxyprogesterone caproate intramuscular oil 250 /ml PA NSO; NM; NDS medroxyprogesterone intramuscular (Depo-Provera) suspension 50 /ml medroxyprogesterone intramuscular (Depo-Provera) syringe 50 /ml medroxyprogesterone oral tablet 0, 2.5, 5 (Provera) megestrol oral suspension 400 /0 ml (40 /ml) PA norethindrone acetate oral tablet 5 (Aygestin) progesterone micronized oral capsule 00 (Prometrium), 200 Thyroid And Antithyroid Agents levothyroxine oral tablet 00 mcg, 2 (Levo-T) mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine intravenous solution 0 (Triostat) mcg/ml liothyronine oral tablet 25 mcg, 5 mcg, 50 (Cytomel) mcg methimazole oral tablet 0, 5 (Tapazole) propylthiouracil oral tablet 50 THYROLAR- ORAL TABLET MCG THYROLAR-/2 ORAL TABLET MCG THYROLAR-/4 ORAL TABLET MCG THYROLAR-2 ORAL TABLET MCG THYROLAR-3 ORAL TABLET MCG Immunological Agents Immunological Agents ARCALYST SUBCUTANEOUS RECON SOLN 220 MG ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, MG, 5 MG PA; NM; NDS PA BvD 9

99 ATGAM INTRAVENOUS SOLUTION PA BvD; NM; NDS 50 MG/ML azathioprine oral tablet 50 (Imuran) PA BvD azathioprine sodium injection recon soln PA BvD 00 BIVIGAM INTRAVENOUS SOLUTION PA; NM; NDS 0 % CARIMUNE NF NANOFILTERED PA; NM; NDS INTRAVENOUS RECON SOLN 6 GRAM CIMZIA POWDER FOR RECONST PA; NM; NDS SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE PA; NM; NDS KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution 250 (Sandimmune) PA BvD /5 ml cyclosporine modified oral capsule 00 (Gengraf) PA BvD, 25 cyclosporine modified oral capsule 50 PA BvD cyclosporine modified oral solution 00 (Gengraf) PA BvD /ml cyclosporine oral capsule 00, 25 (Sandimmune) PA BvD ENBREL SUBCUTANEOUS RECON PA; NM; NDS SOLN 25 MG ( ML) ENBREL SUBCUTANEOUS SYRINGE PA; NM; NDS 25 MG/0.5ML (0.5), 50 MG/ML (0.98 ML) ENBREL SURECLICK PA; NM; NDS SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) FLEBOGAMMA DIF INTRAVENOUS PA; NM; NDS SOLUTION 0 % GAMASTAN S/D INTRAMUSCULAR PA SOLUTION 5-8 % RANGE GAMMAGARD LIQUID INJECTION PA; NM; NDS SOLUTION 0 % GAMMAGARD S-D (IGA < MCG/ML) PA; NM; NDS INTRAVENOUS RECON SOLN 0 GRAM, 5 GRAM GAMMAKED INJECTION SOLUTION 0 GRAM/00 ML (0 %) PA; NM; NDS 92

100 GAMMAPLEX (WITH SORBITOL) PA; NM; NDS INTRAVENOUS SOLUTION 5 % GAMUNEX-C INJECTION SOLUTION PA; NM; NDS 20 GRAM/200 ML (0 %) gengraf oral capsule 00, 25, 50 PA BvD gengraf oral solution 00 /ml PA BvD HUMIRA PEDIATRIC CROHN'S PA; NM; NDS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK), 80 MG/0.8 ML, 80 MG/0.8 ML- 40 MG/0.4 ML HUMIRA PEN CROHN'S-UC-HS PA; NM; NDS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML, 80 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS PA; NM; NDS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA PEN SUBCUTANEOUS PEN PA; NM; NDS INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE PA; NM; NDS KIT 0 MG/0. ML, 0 MG/0.2 ML, 20 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) PA BvD INTRAMUSCULAR SOLUTION 50 UNIT/ML IMOGAM RABIES-HT (PF) PA BvD INTRAMUSCULAR SOLUTION 50 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 00 MG/0.67 ML PA; NM; NDS; QL (8.76 per 28 days) leflunomide oral tablet 0, 20 (Arava) mycophenolate mofetil hcl intravenous (CellCept Intravenous) PA BvD recon soln 500 mycophenolate mofetil oral capsule 250 (CellCept) PA BvD mycophenolate mofetil oral suspension for (CellCept) PA BvD reconstitution 200 /ml mycophenolate mofetil oral tablet 500 (CellCept) PA BvD 93

101 mycophenolate sodium oral tablet,delayed (Myfortic) PA BvD release (dr/ec) 80, 360 NULOJIX INTRAVENOUS RECON PA BvD; NM; NDS SOLN 250 MG OCTAGAM INTRAVENOUS PA; NM; NDS SOLUTION 0 %, 5 % ORENCIA (WITH MALTOSE) PA; NM; NDS INTRAVENOUS RECON SOLN 250 MG ORENCIA CLICKJECT PA; NM; NDS SUBCUTANEOUS AUTO-INJECTOR 25 MG/ML ORENCIA SUBCUTANEOUS PA; NM; NDS SYRINGE 25 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML PRIVIGEN INTRAVENOUS PA; NM; NDS SOLUTION 0 % PROGRAF INTRAVENOUS SOLUTION PA BvD 5 MG/ML RAPAMUNE ORAL SOLUTION PA BvD MG/ML REMICADE INTRAVENOUS RECON PA; NM; NDS SOLN 00 MG RIDAURA ORAL CAPSULE 3 MG SIMPONI ARIA INTRAVENOUS PA; NM; NDS SOLUTION 2.5 MG/ML SIMPONI SUBCUTANEOUS PEN PA; NM; NDS INJECTOR 00 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE PA; NM; NDS 00 MG/ML, 50 MG/0.5 ML sirolimus oral tablet 0.5,, 2 (Rapamune) PA BvD tacrolimus oral capsule 0.5,, 5 (Prograf) PA BvD THYMOGLOBULIN INTRAVENOUS PA BvD; NM; NDS RECON SOLN 25 MG TYSABRI INTRAVENOUS SOLUTION 300 MG/5 ML PA; NM; NDS; QL (5 per 28 days) XELJANZ ORAL TABLET 0 MG, 5 MG PA; NM; NDS; QL (60 per 30 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR MG PA; NM; NDS; QL (30 per 30 days) ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG PA NSO Vaccines 94

102 ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF- ( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT PA BvD PA BvD PA BvD PA; AGE (Min 9 Years and Max 26 Years) PA; AGE (Min 9 Years and Max 26 Years) PA BvD 95

103 INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-0 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-0 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN,000-2,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-25LF-25 MCG- 0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT PA BvD 96

104 RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TRUMENBA INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,350 UNIT/0.5 ML PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 97

105 YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5, (Lotronex) APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR GRAM ST balsalazide oral capsule 750 (Colazal) budesonide oral (Entocort EC) NM; NDS capsule,delayed,extend.release 3 budesonide oral tablet,delayed and ext.release 9 (Uceris) PA; NM; NDS; QL (30 per 30 days) CANASA RECTAL SUPPOSITORY,000 MG colocort rectal enema 00 /60 ml DELZICOL ORAL CAPSULE (WITH ST DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 250 MG NM; NDS hydrocortisone rectal enema 00 /60 ml (Colocort) LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC).2 GRAM ST mesalamine oral tablet,delayed release (Lialda) (dr/ec).2 gram mesalamine oral tablet,delayed release (Asacol HD) (dr/ec) 800 mesalamine rectal enema 4 gram/60 ml (Rowasa) sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (dr/ec) 500 (Azulfidine EN-tabs) UCERIS RECTAL FOAM 2 MG/ACTUATION PA Irrigating Solutions Irrigating Solutions LACTATED RINGERS IRRIGATION SOLUTION PHYSIOLYTE IRRIGATION SOLUTION MEQ/L 98

106 PHYSIOSOL IRRIGATION IRRIGATION SOLUTION MEQ/L ringer's irrigation solution sodium chloride irrigation solution 0.9 % (Aqua Care Sodium water for irrigation, sterile irrigation solution Metabolic Bone Disease Agents Metabolic Bone Disease Agents Chloride) (Aqua Care Sterile Water) alendronate oral solution 70 /75 ml alendronate oral tablet 0, 35, 40, 5 alendronate oral tablet 70 (Fosamax) calcitonin (salmon) nasal spray,nonaerosol 200 unit/actuation calcitriol intravenous solution mcg/ml PA BvD calcitriol oral capsule 0.25 mcg, 0.5 mcg (Rocaltrol) PA BvD calcitriol oral solution mcg/ml (Rocaltrol) PA BvD doxercalciferol intravenous solution 4 (Hectorol) PA BvD mcg/2 ml doxercalciferol oral capsule 0.5 mcg, PA BvD mcg, 2.5 mcg etidronate disodium oral tablet 200, 400 FORTEO SUBCUTANEOUS PEN PA; NM; NDS INJECTOR 20 MCG/DOSE MCG/2.4 ML ibandronate intravenous solution 3 /3 PA BvD ml ibandronate intravenous syringe 3 /3 (Boniva) PA BvD ml ibandronate oral tablet 50 (Boniva) MIACALCIN INJECTION SOLUTION PA BvD 200 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous solution 30 /0 ml (3 /ml), 60 /0 ml (6 /ml), 90 /0 ml (9 /ml) 99 PA; NM; NDS; QL (30 per 30 days) PA BvD

107 paricalcitol hemodialysis port injection PA BvD solution 2 mcg/ml PARICALCITOL HEMODIALYSIS PA BvD PORT INJECTION SOLUTION 5 MCG/ML paricalcitol oral capsule mcg, 2 mcg (Zemplar) PA BvD paricalcitol oral capsule 4 mcg PA BvD PROLIA SUBCUTANEOUS SYRINGE PA 60 MG/ML risedronate oral tablet 50, 35, 5 (Actonel) risedronate oral tablet 30, 35 (2 pack), 35 (4 pack) SENSIPAR ORAL TABLET 30 MG, 60 PA BvD MG, 90 MG XGEVA SUBCUTANEOUS SOLUTION PA; NM; NDS 20 MG/.7 ML (70 MG/ML) zoledronic acid intravenous recon soln 4 zoledronic acid intravenous solution 4 (Zometa) /5 ml zoledronic acid-mannitol-water (Reclast) intravenous piggyback 5 /00 ml ZOMETA INTRAVENOUS PIGGYBACK 4 MG/00 ML NM; NDS Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE SUBCUTANEOUS SOLUTION 00 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON SOLN 20 MG, 400 MG BENLYSTA SUBCUTANEOUS AUTO- INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML dexrazoxane hcl intravenous recon soln (Zinecard (as HCl)) 250 ELMIRON ORAL CAPSULE 00 MG ergoloid oral tablet fomepizole intravenous solution gram/ml FUSILEV INTRAVENOUS RECON SOLN 50 MG NM; NDS NM; NDS NM; NDS NM; NDS 00

108 guanidine oral tablet 25 hydroxyzine pamoate oral capsule 00 hydroxyzine pamoate oral capsule 25, 50 (Vistaril) KEPIVANCE INTRAVENOUS RECON NM; NDS SOLN 6.25 MG leucovorin calcium injection recon soln 00, 200, 350 leucovorin calcium oral tablet 0, 5, 25, 5 levocarnitine (with sugar) oral solution (Carnitor) PA BvD 00 /ml levocarnitine oral tablet 330 (Carnitor) PA BvD LEVOLEUCOVORIN INTRAVENOUS NM; NDS RECON SOLN 75 MG levoleucovorin intravenous recon soln 50 (Fusilev) NM; NDS levoleucovorin intravenous solution 0 NM; NDS /ml LITHOSTAT ORAL TABLET 250 MG mesna intravenous solution 00 /ml (Mesnex) MESNEX ORAL TABLET 400 MG NM; NDS PROGLYCEM ORAL SUSPENSION 50 MG/ML pyridostigmine bromide oral tablet 60 (Mestinon) pyridostigmine bromide oral tablet (Mestinon Timespan) extended release 80 RECTIV RECTAL OINTMENT 0.4 % PA; QL (30 per 30 days) (W/W) SIMULECT INTRAVENOUS RECON NM; NDS SOLN 0 MG, 20 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG PA NSO; NM; NDS THIOLA ORAL TABLET 00 MG TYBOST ORAL TABLET 50 MG Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 25, 250 acetazolamide sodium injection recon soln 500 0

109 ALPHAGAN P OPHTHALMIC (EYE) ST DROPS 0. % AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION % betaxolol ophthalmic (eye) drops 0.5 % bimatoprost ophthalmic (eye) drops 0.03 % QL (5 per 30 days) brimonidine ophthalmic (eye) drops 0.5 (Alphagan P) % brimonidine ophthalmic (eye) drops 0.2 % carteolol ophthalmic (eye) drops % COMBIGAN OPHTHALMIC (EYE) DROPS % dorzolamide ophthalmic (eye) drops 2 % (Trusopt) dorzolamide-timolol ophthalmic (eye) (Cosopt) drops /ml latanoprost ophthalmic (eye) drops (Xalatan) QL (5 per 30 days) % levobunolol ophthalmic (eye) drops 0.5 % methazolamide oral tablet 25, 50 metipranolol ophthalmic (eye) drops 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.25 % pilocarpine hcl ophthalmic (eye) drops (Isopto Carpine) %, 2 %, 4 % SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION -0.2 % timolol maleate ophthalmic (eye) drops (Timoptic) 0.25 %, 0.5 % timolol maleate ophthalmic (eye) drops, (Istalol) once daily 0.5 % timolol maleate ophthalmic (eye) gel (Timoptic-XE) forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) DROPS % QL (5 per 30 days) Replacement Preparations Replacement Preparations d0 %-0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution 02

110 d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 0 % and 0.2 % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution % IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION KLOR-CON 0 ORAL TABLET EXTENDED RELEASE 0 MEQ KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ klor-con m0 oral tablet,er particles/crystals 0 meq klor-con m5 oral tablet,er particles/crystals 5 meq klor-con m20 oral tablet,er particles/crystals 20 meq klor-con sprinkle oral capsule, extended release 0 meq, 8 meq LACTATED RINGERS INTRAVENOUS PARENTERAL SOLUTION magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml 03

111 NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % NORMOSOL-R IV SOLUTION L/F, SINGLE-USE NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 48 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION potassium chlorid-d5-0.45%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 0 meq potassium chloride oral capsule, extended release 8 meq potassium chloride oral liquid 20 meq/5 ml, 40 meq/5 ml potassium chloride oral tablet extended release 0 meq, 20 meq, 8 meq potassium chloride oral tablet,er particles/crystals 0 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l (Klor-Con Sprinkle) (K-Tab) (Klor-Con M0) (Klor-Con M20) 04

112 potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended (Urocit-K 0) release 0 meq (,080 ) potassium citrate oral tablet extended (Urocit-K 5) release 5 meq potassium citrate oral tablet extended (Urocit-K 5) release 5 meq (540 ) ringer's intravenous parenteral solution sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.45 % intravenous piggyback 0.45 % sodium chloride 0.9 % intravenous parenteral solution sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml sodium lactate intravenous solution 5 meq/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER 5-2 MCG/ACTUATION, MCG/ACTUATION, 45-2 MCG/ACTUATION QL (60 per 30 days) QL (2 per 30 days) 05

113 ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE budesonide inhalation suspension for nebulization 0.25 /2 ml, 0.5 /2 ml, /2 ml DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 250 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION, 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION fluticasone-salmeterol inhalation aerosol powdr breath activated 3-4 mcg/actuation, mcg/actuation, 55-4 mcg/actuation QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 QL (30 per 30 days) QL (60 per 30 days) (Pulmicort) PA BvD; QL (20 per 30 days) QL (3 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (24 per 30 days) QL (2.2 per 30 days) (AirDuo RespiClick) QL ( per 30 days) MCG/ACTUATION Antileukotrienes montelukast oral granules in packet 4 (Singulair) montelukast oral tablet 0 (Singulair) QL (30 per 30 days) QL (30 per 30 days) 06

114 montelukast oral tablet,chewable 4, 5 (Singulair) zafirlukast oral tablet 0, 20 (Accolate) Bronchodilators albuterol sulfate inhalation solution for PA BvD nebulization 0.63 /3 ml,.25 /3 ml, 2.5 /3 ml (0.083 %), 5 /ml albuterol sulfate oral syrup 2 /5 ml albuterol sulfate oral tablet 2, 4 albuterol sulfate oral tablet extended release 2 hr 4, 8 aminophylline intravenous solution 250 /0 ml, 500 /20 ml ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution PA BvD 0.02 % ipratropium-albuterol inhalation solution PA BvD for nebulization (2.5 base)/3 ml levalbuterol hcl inhalation solution for (Xopenex) PA BvD nebulization 0.3 /3 ml, 0.63 /3 ml,.25 /3 ml levalbuterol hcl inhalation solution for (Xopenex Concentrate) PA BvD nebulization.25 /0.5 ml metaproterenol oral syrup 0 /5 ml PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION 07

115 SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST.25 MCG/ACTUATION SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION terbutaline oral tablet 2.5, 5 terbutaline subcutaneous solution /ml theophylline oral solution 80 /5 ml theophylline oral tablet extended release (Theochron) 2 hr 00, 200, 300 theophylline oral tablet extended release 2 hr 450 theophylline oral tablet extended release 24 hr 400, 600 Respiratory Tract Agents, Other acetylcysteine solution 00 /ml (0 %), PA BvD 200 /ml (20 %) ARALAST NP INTRAVENOUS RECON NM; NDS SOLN,000 MG cromolyn inhalation solution for PA BvD nebulization 20 /2 ml DALIRESP ORAL TABLET 250 MCG, 500 MCG ESBRIET ORAL CAPSULE 267 MG PA; NM; NDS GLASSIA INTRAVENOUS SOLUTION NM; NDS GRAM/50 ML (2 %) KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG PA; NM; NDS; QL (60 per 30 days) KALYDECO ORAL TABLET 50 MG PA; NM; NDS; QL (60 per 30 days) NUCALA SUBCUTANEOUS RECON PA; NM; NDS SOLN 00 MG OFEV ORAL CAPSULE 00 MG, 50 PA; NM; NDS MG ORKAMBI ORAL GRANULES IN PACKET MG, MG PA; NM; NDS; QL (20 per 30 days) 08

116 ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS RECON SOLN,000 MG XOLAIR SUBCUTANEOUS RECON SOLN 50 MG ZEMAIRA INTRAVENOUS RECON SOLN,000 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 0, 20 carisoprodol oral tablet 350 (Soma) carisoprodol-asa-codeine oral tablet carisoprodol-aspirin oral tablet chlorzoxazone oral tablet 250, 500 cyclobenzaprine oral tablet 0, 5 cyclobenzaprine oral tablet 7.5 (Fexmid) dantrolene oral capsule 00 dantrolene oral capsule 25, 50 (Dantrium) metaxall oral tablet 800 metaxalone oral tablet 400 metaxalone oral tablet 800 (Metaxall) methocarbamol oral tablet 500 (Robaxin) methocarbamol oral tablet 750 (Robaxin-750) orphenadrine citrate injection solution 30 /ml orphenadrine citrate oral tablet extended release 00 tizanidine oral capsule 2, 4, 6 (Zanaflex) tizanidine oral tablet 2 tizanidine oral tablet 4 (Zanaflex) Sleep Disorder Agents PA; NM; NDS; QL (20 per 30 days) NM; NDS PA; NM; NDS NM; NDS Sleep Disorder Agents armodafinil oral tablet 50, 200, (Nuvigil) PA; QL (30 per 30 days) 250, 50 BUTISOL ORAL TABLET 30 MG eszopiclone oral tablet, 2, 3 (Lunesta) QL (30 per 30 days) HETLIOZ ORAL CAPSULE 20 MG PA; NM; NDS; QL (30 per 30 days) modafinil oral tablet 00, 200 (Provigil) PA; QL (60 per 30 days) 09

117 ROZEREM ORAL TABLET 8 MG PA; QL (30 per 30 days) XYREM ORAL SOLUTION 500 MG/ML PA; NM; NDS; QL (540 per 30 days) zaleplon oral capsule 0, 5 (Sonata) QL (30 per 30 days) zolpidem oral tablet 0 (Ambien) QL (30 per 30 days) zolpidem oral tablet 5 (Ambien) QL (60 per 30 days) Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 20 MG PA; NM; NDS ADEMPAS ORAL TABLET 0.5 MG, PA; NM; NDS MG,.5 MG, 2 MG, 2.5 MG LETAIRIS ORAL TABLET 0 MG, 5 MG PA; NM; NDS; QL (30 per 30 days) OPSUMIT ORAL TABLET 0 MG PA; NM; NDS; QL (30 per 30 days) REMODULIN INJECTION SOLUTION MG/ML, 0 MG/ML, 2.5 MG/ML, 5 MG/ML PA BvD; NM; NDS sildenafil (antihypertensive) oral tablet 20 tadalafil (antihypertensive) oral tablet 20 TRACLEER ORAL TABLET 25 MG, 62.5 MG UPTRAVI ORAL TABLET,000 MCG,,200 MCG,,400 MCG,,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (40)- 800 MCG (60) VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 0 MCG/ML, 20 MCG/ML (Revatio) PA (Adcirca) PA; NM; NDS PA; NM; NDS; QL (60 per 30 days) PA; NM; NDS; QL (60 per 30 days) PA; NM; NDS; QL (200 per 30 days) PA; NM; NDS 0

118 INDEX A abacavir... 45, 46 abacavir-lamivudine abacavir-lamivudine-zidovudine ABELCET ABILIFY MAINTENA ABRAXANE... 7 acamprosate... 8 acarbose acebutolol acetaminophen-codeine... 3 acetazolamide... 0 acetazolamide sodium... 0 acetic acid acetylcysteine acitretin ACTHIB (PF) ACTIMMUNE acyclovir... 50, 72 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF).. 95 ADAGEN adapalene ADCIRCA... 0 adefovir ADEMPAS... 0 adriamycin... 7 adrucil... 7 ADVAIR DISKUS ADVAIR HFA afeditab cr... 6 AFINITOR... 7 AFINITOR DISPERZ... 7 AKYNZEO (NETUPITANT) 39 ala-cort ALBENZA... 4 albuterol sulfate alclometasone ALCOHOL PADS ALDURAZYME ALECENSA... 7 alendronate alfuzosin ALIMTA... 7 ALINIA... 4 ALIQOPA... 7 allopurinol ALOCRIL ALOMIDE alosetron ALPHAGAN P alprazolam... 8, 9 ALREX ALUNBRIG... 7 alyacen /35 (28) amabelz amantadine hcl... 4 AMBISOME amcinonide amethia amethyst amikacin... 9 amiloride amiloride-hydrochlorothiazide aminophylline AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone amitriptyline amitriptyline-chlordiazepoxide amlodipine... 6 amlodipine-atorvastatin amlodipine-benazepril... 6, 62 amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine amoxicil-clarithromy-lansopraz amoxicillin... 4 amoxicillin-pot clavulanate... 4 amphotericin b ampicillin... 4 ampicillin sodium... 4 ampicillin-sulbactam... 4 AMPYRA ANADROL anagrelide anastrozole... 7 ANDRODERM ANDROGEL ANORO ELLIPTA APOKYN... 4 apraclonidine I-

119 aprepitant apri APRISO APTIOM APTIVUS ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) ARCALYST... 9 aripiprazole ARISTADA ARISTADA INITIO armodafinil ARNUITY ELLIPTA ARRANON... 7 ashlyna aspirin-dipyridamole ASSURE ID INSULIN SAFETY ASTAGRAF XL... 9 atazanavir atenolol atenolol-chlorthalidone ATGAM atomoxetine atorvastatin atovaquone... 4 atovaquone-proguanil... 4 ATRIPLA atropine... 26, 79 ATROVENT HFA AUBAGIO aubra AUGMENTIN... 4 AVANDIA AVASTIN... 7 AVC VAGINAL AVELOX IN NACL (ISO- OSMOTIC)... 5 aviane avita AVONEX AVONEX (WITH ALBUMIN) AVYCAZ... azacitidine... 7 AZACTAM... 3 AZASITE azathioprine azathioprine sodium azelastine azithromycin... 3 AZOPT aztreonam... 3 B baciim... 0 bacitracin bacitracin-polymyxin b baclofen balsalazide balziva (28) BANZEL BARACLUDE BAVENCIO... 7 BCG VACCINE, LIVE (PF). 95 BD ULTRA-FINE NANO PEN NEEDLE BD VEO INSULIN SYR HALF UNIT BD VEO INSULIN SYRINGE UF bekyree (28) BELEODAQ... 7 benazepril benazepril-hydrochlorothiazide BENLYSTA benztropine... 4 BERINERT BESIVANCE BESPONSA... 8 betamethasone dipropionate.. 74 betamethasone valerate betamethasone, augmented betaxolol... 59, 02 bexarotene... 8 BEXSERO bicalutamide... 8 BICILLIN C-R... 4 BICILLIN L-A... 5 BICNU... 8 BIDIL BIKTARVY bimatoprost bisoprolol fumarate BIVIGAM bleomycin... 8 blisovi 24 fe blisovi fe.5/30 (28) blisovi fe /20 (28) BOOSTRIX TDAP BORTEZOMIB... 8 BOSULIF... 8 BRAFTOVI... 8 BREO ELLIPTA briellyn BRILINTA brimonidine BRIVIACT bromfenac bromocriptine... 4 budesonide... 98, 06 bumetanide buprenorphine... 3 buprenorphine hcl... 3, 8 buprenorphine-naloxone... 8 bupropion hcl bupropion hcl (smoking deter). 8 buspirone... 9 busulfan... 8 BUTISOL butorphanol tartrate... 3 C cabergoline CABOMETYX... 8 I-2

120 calcipotriene calcipotriene-betamethasone.. 72 calcitonin (salmon) calcitriol... 72, 99 calcium acetate CALQUENCE... 8 camila CANASA CANCIDAS candesartan candesartan-hydrochlorothiazid CAPASTAT CAPRELSA... 8 captopril captopril-hydrochlorothiazide 57 CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carbinoxamine maleate carboplatin... 8 CARIMUNE NF NANOFILTERED carisoprodol carisoprodol-asa-codeine carisoprodol-aspirin carteolol cartia xt carvedilol CAYSTON... 3 caziant (28) cefaclor... cefadroxil... cefazolin... 2 cefdinir... 2 cefepime... 2 cefixime... 2 cefotaxime... 2 cefotetan... 2 cefoxitin... 2 cefpodoxime... 2 cefprozil... 2 ceftazidime... 2 ceftriaxone... 2 cefuroxime axetil... 2 cefuroxime sodium... 2 celecoxib... 6 CELONTIN cephalexin... 2 CEREZYME CESAMET cetirizine cevimeline CHANTIX... 8 CHANTIX CONTINUING MONTH BOX... 8 CHANTIX STARTING MONTH BOX... 8 CHEMET CHENODAL chloramphenicol sod succinate... 0 chlordiazepoxide hcl... 9 chlorhexidine gluconate chloroquine phosphate... 4 chlorothiazide chlorothiazide sodium chlorpromazine chlorpropamide chlorthalidone chlorzoxazone CHOLBAM cholestyramine (with sugar).. 63 cholestyramine light ciclopirox cidofovir cilostazol CIMDUO cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRODEX ciprofloxacin... 6 ciprofloxacin (mixture)... 5 ciprofloxacin hcl... 5, 80 ciprofloxacin in 5 % dextrose 5 cisplatin... 8 citalopram... 30, 3 cladribine... 8 claravis clarithromycin... 3 clemastine clindamycin hcl... 0 clindamycin in 5 % dextrose.. 0 clindamycin palmitate hcl... 0 clindamycin phosphate... 0, 38, 73, 74 clindamycin-benzoyl peroxide clindamycin-tretinoin CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D0W SUL FREE I-3

121 CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 5 % clobetasol clobetasol-emollient CLODAN clofarabine... 8 clomipramine... 3 clonazepam... 9 clonidine clonidine hcl clopidogrel clorazepate dipotassium... 9 clotrimazole clotrimazole-betamethasone clozapine COARTEM... 4 codeine sulfate... 3 colchicine colesevelam colestipol colistin (colistimethate na)... 0 colocort COLY-MYCIN S COMBIGAN COMBIVENT RESPIMAT. 07 COMETRIQ... 8 COMPLERA compro constulose COPAXONE CORLANOR... 6 cormax cortisone COSENTYX (2 SYRINGES) 72 COSENTYX PEN (2 PENS). 73 COSMEGEN... 8 COTELLIC... 8 CREON CRINONE... 9 CRIXIVAN cromolyn... 79, 84, 08 cryselle (28) cyclafem /35 (28) cyclafem 7/7/7 (28) cyclobenzaprine CYCLOPHOSPHAMIDE... 8 cyclosporine cyclosporine modified cyproheptadine CYRAMZA... 8 CYSTAGON CYSTARAN cytarabine... 8 cytarabine (pf)... 8 D d0 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine... 8 dactinomycin... 9 dalfampridine DALIRESP DALVANCE... 0 danazol dantrolene dapsone DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin... 0 DARAPRIM... 4 DARZALEX... 9 daunorubicin... 9 deblitane decitabine... 9 delyla (28) DELZICOL demeclocycline... 6 DEMSER... 6 DENAVIR DEPEN TITRATABS DESCOVY desipramine... 3 desloratadine desmopressin desog-e.estradiol/e.estradiol DESONATE desonide desoximetasone DESVENLAFAXINE... 3 DESVENLAFAXINE FUMARATE... 3 dexamethasone... 88, 89 DEXAMETHASONE INTENSOL dexamethasone sodium phos (pf) dexamethasone sodium phosphate... 82, 89 DEXILANT dexmethylphenidate dexrazoxane hcl dextroamphetamine dextroamphetamineamphetamine dextrose 0 % and 0.2 % nacl dextrose 5 % in water (d5w).. 55 dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride I-4

122 dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride DIASTAT... 9 DIASTAT ACUDIAL... 9 diazepam... 9 diazepam intensol... 9 diclofenac potassium... 6 diclofenac sodium... 6, 82 diclofenac-misoprostol... 6 dicloxacillin... 5 dicyclomine didanosine diflorasone diflunisal... 6 digitek... 6 digox... 6 digoxin... 6 DIGOXIN... 6 dihydroergotamine DILANTIN diltiazem hcl dilt-xr DIPENTUM diphenhydramine hcl... 37, 38 diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram... 8 divalproex docetaxel... 9 dofetilide donepezil dorzolamide dorzolamide-timolol doxazosin doxepin... 3, 73 doxercalciferol doxorubicin... 9 doxorubicin, peg-liposomal... 9 doxy doxycycline hyclate... 6 doxycycline monohydrate 6, 7 dronabinol drospirenone-e.estradiol-lm.fa 68 drospirenone-ethinyl estradiol 68 DROXIA... 9 DULERA duloxetine... 3 DURAMORPH (PF)... 3 DUREZOL dutasteride dutasteride-tamsulosin E E.E.S. GRANULES... 3 econazole EDURANT efavirenz EFFIENT ELAPRASE ELIDEL ELIGARD... 9 ELIGARD (3 MONTH)... 9 ELIGARD (4 MONTH)... 9 ELIGARD (6 MONTH)... 9 ELIQUIS... 5 ELITEK ELMIRON EMBEDA... 3 EMCYT... 9 emoquette EMPLICITI... 9 EMSAM... 3 EMTRIVA EMVERM... 4 enalapril maleate enalapril-hydrochlorothiazide 57 ENBREL ENBREL SURECLICK endocet... 3 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin... 5 enpresse entacapone entecavir ENTRESTO enulose EPANED EPCLUSA epinastine epinephrine... 6 EPIPEN 2-PAK... 6 EPIPEN JR 2-PAK... 6 epirubicin... 9 EPIVIR HBV eplerenone EPOGEN eprosartan ERAXIS(WATER DILUENT) ERBITUX... 9 ergoloid ERIVEDGE... 9 ERLEADA... 9 errin ERTACZO ertapenem... 3 ERWINAZE... 9 ery pads ERYPED ERYPED ery-tab... 3 ERY-TAB... 3 ERYTHROCIN... 3 erythromycin... 3, 80 erythromycin ethylsuccinate.. 3 erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate... 3 esomeprazole sodium estazolam... 9 I-5

123 estradiol... 87, 88 estradiol valerate estradiol-norethindrone acet ESTRING estropipate eszopiclone ethacrynic acid ethambutol ethosuximide ethynodiol diac-eth estradiol.. 68 etidronate disodium etodolac... 6 ETOPOPHOS etoposide EURAX EVOTAZ exemestane EXJADE EXTAVIA ezetimibe ezetimibe-simvastatin F FABRAZYME falmina (28) famciclovir famotidine famotidine (pf)-nacl (iso-os). 83 FANAPT FARESTON FARYDAK FASLODEX felbamate felodipine femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid (choline) fentanyl... 3 fentanyl citrate... 3 FENTORA... 3 FERRIPROX FETZIMA... 3 FINACEA finasteride FIRAZYR... 6 FIRMAGON KIT W DILUENT SYRINGE FLEBOGAMMA DIF flecainide FLOVENT DISKUS FLOVENT HFA fluconazole fluconazole in nacl (iso-osm) 36 flucytosine fludarabine fludrocortisone flunisolide fluocinolone... 75, 76 fluocinolone acetonide oil fluocinolone and shower cap. 76 fluocinonide fluocinonide-e fluorometholone fluorouracil... 20, 73 fluoxetine... 3 fluphenazine decanoate fluphenazine hcl flurazepam... 9 flurbiprofen... 6 flurbiprofen sodium flutamide fluticasone... 76, 82 fluticasone-salmeterol fluvastatin fluvoxamine... 3 FOLOTYN fomepizole fondaparinux... 5 FORTEO fosamprenavir fosinopril fosinopril-hydrochlorothiazide fosphenytoin FRAGMIN... 5, 52 FREAMINE HBC 6.9 % furosemide FUSILEV FUZEON fyavolv FYCOMPA G gabapentin galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < MCG/ML) GAMMAKED GAMMAPLEX (WITH SORBITOL) GAMUNEX-C ganciclovir sodium GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n gemcitabine gemfibrozil generlac gengraf gentak gentamicin... 0, 74, 80 gentamicin in nacl (iso-osm).. 0 gentamicin sulfate (ped) (pf).. 0 GENVOYA GEODON gianvi (28) GILENYA GILOTRIF GLASSIA glatiramer I-6

124 GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glyburide glyburide micronized glyburide-metformin glycopyrrolate GLYSET granisetron (pf) granisetron hcl GRANIX griseofulvin microsize griseofulvin ultramicrosize guanfacine... 56, 66 guanidine... 0 H HALAVEN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heparin (porcine) heparin (porcine) in 5 % dex.. 52 heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN HIBERIX (PF) HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMIRA PEN PSORIASIS- UVEITIS hydralazine... 6 hydrochlorothiazide... 62, 63 hydrocodone-acetaminophen 3, 4 hydrocodone-ibuprofen... 4 hydrocortisone... 76, 89, 98 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydrocortisone-acetic acid hydromorphone... 4 hydromorphone (pf)... 4 hydroxychloroquine... 4 hydroxyprogesterone caproate9 hydroxyurea hydroxyzine hcl hydroxyzine pamoate... 0 HYPERRAB S/D (PF) HYSINGLA ER... 4 I ibandronate IBRANCE ibu... 6 ibuprofen... 6, 7 ibuprofen-oxycodone... 4 ICLUSIG... 2 idarubicin... 2 IDHIFA... 2 ifosfamide... 2 ILEVRO imatinib... 2 IMBRUVICA... 2 IMFINZI... 2 imipenem-cilastatin... 3, 4 imipramine hcl imipramine pamoate imiquimod IMOGAM RABIES-HT (PF) 93 IMOVAX RABIES VACCINE (PF) INCRELEX INCRUSE ELLIPTA indapamide INDOCIN... 7 indomethacin... 7 INFANRIX (DTAP) (PF) INLYTA... 2 INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A... 49, 50 introvale INVANZ... 4 INVEGA SUSTENNA INVIRASE INVOKAMET INVOKAMET XR INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide... 80, 07 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRESSA... 2 irinotecan... 2 ISENTRESS ISENTRESS HD ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine ISTODAX... 2 itraconazole ivermectin... 4 I-7

125 IXIARO (PF) J JADENU JADENU SPRINKLE JAKAFI... 2 jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JEVTANA... 2 jinteli jolivette juleber JULUCA junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe JUXTAPID K KADCYLA... 2 kaitlib fe KALETRA KALYDECO kariva (28) kelnor /35 (28) kelnor KENALOG KEPIVANCE... 0 ketoconazole ketorolac... 7, 82 KEYTRUDA... 2 kimidess (28) KINERET KINRIX (PF) kionex (with sorbitol) KISQALI KISQALI FEMARA CO-PACK... 2, 22 KLOR-CON KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle KOMBIGLYZE XR KORLYM KUVAN KYNAMRO KYPROLIS L l norgest/e.estradiol-e.estrad.. 69 labetalol LACRISERT LACTATED RINGERS 98, 03 lactulose LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) lamivudine lamivudine-zidovudine lamotrigine lansoprazole LANTUS SOLOSTAR U-00 INSULIN LANTUS U-00 INSULIN larin.5/30 (2) larin /20 (2) larin fe.5/30 (28) larin fe /20 (28) larissia LARTRUVO latanoprost LATUDA layolis fe leena leflunomide LENVIMA lessina LETAIRIS... 0 letrozole leucovorin calcium... 0 LEUKERAN leuprolide levalbuterol hcl levetiracetam levetiracetam in nacl (iso-os). 28 levobunolol levocarnitine... 0 levocarnitine (with sugar)... 0 levocetirizine levofloxacin... 6, 80 levofloxacin in d5w... 6 levoleucovorin... 0 LEVOLEUCOVORIN... 0 levonest (28) levonorgestrel-ethinyl estrad.. 69 levonorg-eth estrad triphasic.. 69 levora levorphanol tartrate... 4 levothyroxine... 9 LEXIVA LIALDA lidocaine... 7 lidocaine (pf)... 7 lidocaine hcl... 7 lidocaine viscous... 7 lidocaine-prilocaine... 7 lincomycin... 0 lindane linezolid... linezolid in dextrose 5%... linezolid-0.9% sodium chloride... LINZESS I-8

126 liothyronine... 9 lisinopril... 57, 58 lisinopril-hydrochlorothiazide 58 lithium carbonate lithium citrate LITHOSTAT... 0 LONSURF loperamide lopinavir-ritonavir lorazepam... 9 lorcet (hydrocodone)... 4 lorcet hd... 4 lorcet plus... 4 loryna (28) losartan losartan-hydrochlorothiazide.. 57 LOTEMAX lovastatin low-ogestrel (28) loxapine succinate LUMIZYME LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED lutera (28) LYNPARZA LYRICA... 28, 29 LYSODREN lyza M mafenide acetate magnesium sulfate malathion maprotiline marlissa MARPLAN MATULANE matzim la MAVYRET meclizine MEDROL medroxyprogesterone... 9 mefloquine... 4 megestrol... 22, 9 MEKINIST MEKTOVI meloxicam... 7 melphalan hcl memantine MENACTRA (PF) MENVEO A-C-Y-W-35-DIP (PF) meperidine... 4 meprobamate... 9 mercaptopurine meropenem... 4 mesalamine mesna... 0 MESNEX... 0 metadate er metaproterenol metaxall metaxalone metformin methadone... 4 methamphetamine methazolamide methenamine hippurate... methimazole... 9 methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen methscopolamine methyclothiazide methyldopa methyldopa-hydrochlorothiazide methylphenidate hcl... 66, 67 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole..., 38, 74 metronidazole in nacl (iso-os) mexiletine MIACALCIN microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28) microgestin fe /20 (28) midodrine miglitol miglustat mili mimvey mimvey lo minocycline... 7 minoxidil mirtazapine misoprostol MITIGARE mitomycin mitoxantrone M-M-R II (PF) modafinil MODERIBA MODERIBA DOSE PACK moexipril moexipril-hydrochlorothiazide mometasone mononessa (28) montelukast... 06, 07 I-9

127 morphine... 5 MORPHINE... 5 morphine concentrate... 5 MOVANTIK moxifloxacin... 6, 80 moxifloxacin in nacl (iso-osm)... 6 moxifloxacin-sod.ace,sul-water... 6 MOZOBIL MULTAQ mupirocin mupirocin calcium MUSTARGEN mutamycin MYCAMINE mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYLOTARG myorisan MYRBETRIQ N nabumetone... 7 nadolol nadolol-bendroflumethiazide. 59 nafcillin... 5 naftifine NAGLAZYME naloxone... 8 naltrexone... 8 naproxen... 7 naproxen sodium... 7 naratriptan NARCAN... 8 NATACYN nateglinide NATPARA NEBUPENT... 4 necon 0.5/35 (28) necon 7/7/7 (28) nefazodone neomycin... 0 neomycin-bacitracin-poly-hc. 8 neomycin-bacitracin-polymyxin... 8 neomycin-polymyxin b gu neomycin-polymyxin b- dexameth... 8 neomycin-polymyxingramicidin... 8 neomycin-polymyxin-hc... 8 NEPHRAMINE 5.4 % NERLYNX NEULASTA NEUPRO NEVANAC nevirapine NEXAVAR NEXTERONE niacin niacor nicardipine NICOTROL... 8 NICOTROL NS... 8 nifedipine nikki (28) nilutamide nimodipine NINLARO nisoldipine nitrofurantoin... nitrofurantoin macrocrystal... nitrofurantoin monohyd/m-cryst... nitroglycerin nizatidine nora-be NORDITROPIN FLEXPRO. 90 noreth-ethinyl estradiol-iron.. 70 norethindrone (contraceptive) 70 norethindrone acetate... 9 norethindrone ac-eth estradiol... 70, 88 norethindrone-e.estradiol-iron 70 norgestimate-ethinyl estradiol 70 norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28)... 7 nortrel 7/7/7 (28)... 7 nortriptyline NORVIR NOVOLIN 70/30 U-00 INSULIN NOVOLIN N NPH U-00 INSULIN NOVOLIN R REGULAR U- 00 INSULN NOVOLOG FLEXPEN U-00 INSULIN NOVOLOG MIX U-00 INSULN NOVOLOG MIX 70-30FLEXPEN U NOVOLOG PENFILL U-00 INSULIN NOVOLOG U-00 INSULIN ASPART NOXAFIL NUCALA NUCYNTA... 5 NUCYNTA ER... 5 NULOJIX NUPLAZID NUTRILIPID NUVARING... 7 nyamyc nystatin I-0

128 nystop O ocella... 7 OCTAGAM octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin... 6, 8 okebo... 7 olanzapine olanzapine-fluoxetine olopatadine omega-3 acid ethyl esters omeprazole ondansetron ondansetron hcl ondansetron hcl (pf) ONFI... 9 ONGLYZA OPDIVO OPSUMIT... 0 ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORFADIN ORKAMBI... 08, 09 orphenadrine citrate orsythia... 7 oseltamivir OSMOPREP oxacillin... 5 oxacillin in dextrose(iso-osm) 5 oxaliplatin oxandrolone oxazepam... 9 oxcarbazepine OXTELLAR XR oxybutynin chloride oxycodone... 5 oxycodone-acetaminophen... 5 oxycodone-aspirin... 5 OXYCONTIN... 5 oxymorphone... 5, 6 P pacerone paclitaxel paliperidone pamidronate PANCREAZE PANRETIN pantoprazole paricalcitol PARICALCITOL paroex oral rinse paromomycin... 4 paroxetine hcl PASER PAXIL PAZEO PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte soln PEN NEEDLE, DIABETIC.. 78 penicillin g pot in dextrose... 5 penicillin g potassium... 5 penicillin g procaine... 5 penicillin g sodium... 5 penicillin v potassium... 5 PENTACEL DTAP-IPV COMPNT (PF) PENTAM... 4 pentazocine-naloxone... 6 pentoxifylline perindopril erbumine periogard PERJETA permethrin perphenazine perphenazine-amitriptyline phenadoz phenelzine PHENERGAN phenobarbital phenoxybenzamine phenytoin phenytoin sodium phenytoin sodium extended PHOSPHOLINE IODIDE PHYSIOLYTE PHYSIOSOL IRRIGATION. 99 PICATO pilocarpine hcl... 72, 02 pimozide pimtrea (28)... 7 pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam... 5 pirmella... 7 piroxicam... 7 PLASMA-LYTE PLASMA-LYTE A PLEGRIDY PLENAMINE podofilox polycin... 8 polyethylene glycol polymyxin b sulfate... polymyxin b sulf-trimethoprim... 8 POMALYST portia... 7 potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 5 % dex potassium chloride in lr-d I-

129 potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate POTELIGEO pramipexole pravastatin prazosin PRED MILD prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 82, 89 prednisone PREDNISONE INTENSOL.. 89 PREMARIN PREMASOL 0 % PREMASOL 6 % PREMPHASE PREMPRO prevalite previfem... 7 PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE... 4 primidone PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine procainamide PROCALAMINE 3% prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc progesterone micronized... 9 PROGLYCEM... 0 PROGRAF PROLASTIN-C PROLEUKIN PROLIA PROMACTA promethazine... 38, 40 promethazine vc promethegan propafenone propantheline proparacaine propranolol... 59, 60 propranolol-hydrochlorothiazid propylthiouracil... 9 PROQUAD (PF) PROSOL 20 % protriptyline PULMOZYME PURIXAN PYLERA pyrazinamide pyridostigmine bromide... 0 Q QUADRACEL (PF) quasense... 7 quetiapine... 44, 45 quinapril quinapril-hydrochlorothiazide 58 quinidine gluconate quinidine sulfate quinine sulfate... 4 QVAR QVAR REDIHALER R RABAVERT (PF) rabeprazole raloxifene ramipril RANEXA... 6 ranitidine hcl... 83, 84 RAPAMUNE rasagiline RAVICTI reclipsen (28)... 7 RECOMBIVAX HB (PF) RECTIV... 0 REGRANEX RELENZA DISKHALER RELISTOR REMICADE REMODULIN... 0 RENAGEL RENVELA repaglinide REPATHA SYRINGE RESCRIPTOR RESTASIS RETROVIR REVLIMID REXULTI REYATAZ ribasphere ribasphere ribapak... 5 ribavirin... 5 RIDAURA rifabutin RIFAMATE rifampin RIFATER riluzole rimantadine ringer's... 99, 05 risedronate RISPERDAL CONSTA risperidone I-2

130 ritonavir RITUXAN rivastigmine rivastigmine tartrate rizatriptan romidepsin ropinirole rosuvastatin ROTARIX ROTATEQ VACCINE ROWEEPRA ROZEREM... 0 RUBRACA RUCONEST RYDAPT S SABRIL SANTYL SAPHRIS SAPHRIS (BLACK CHERRY) scopolamine base selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS sertraline setlakin... 7 sevelamer carbonate sharobel... 7 SHINGRIX (PF) SIGNIFOR sildenafil (antihypertensive). 0 silver sulfadiazine SIMBRINZA SIMPONI SIMPONI ARIA SIMULECT... 0 simvastatin sirolimus SIRTURO SIVEXTRO... sodium chloride... 99, 05 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium lactate sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate 85 SOLTAMOX SOLU-CORTEF (PF) SOMATULINE DEPOT SOMAVERT sorine sotalol sotalol af SOVALDI SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz sprintec (28)... 7 SPRITAM SPRYCEL sps (with sorbitol) sronyx... 7 ssd stavudine STIMATE STIOLTO RESPIMAT STIVARGA STRENSIQ streptomycin... 0 STRIBILD SUBOXONE... 8 SUCRAID sucralfate sulfacetamide sodium... 8 sulfacetamide sodium (acne).. 74 sulfacetamide-prednisolone... 8 sulfadiazine... 6 sulfamethoxazole-trimethoprim... 6 SULFAMYLON sulfasalazine sulindac... 7 sumatriptan sumatriptan succinate... 38, 39 SUPRAX... 2 SUSTIVA SUTENT SYLATRON SYLVANT SYMFI SYMFI LO SYMTUZA SYNAGIS SYNAREL SYNERCID... SYNJARDY SYNJARDY XR SYNRIBO SYPRINE T TABLOID tacrolimus... 77, 94 tadalafil (antihypertensive).. 0 TAFINLAR TAGRISSO tamoxifen tamsulosin TARCEVA TARGRETIN tarina fe /20 (28)... 7 TASIGNA tazarotene tazicef... 2 taztia xt TECENTRIQ TECFIDERA I-3

131 TEFLARO... 2 TEKTURNA telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid temazepam... 9 temsirolimus TENIVAC (PF) tenofovir disoproxil fumarate. 48 terazosin terbinafine hcl terbutaline terconazole testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline... 7 THALOMID... 0 theophylline THIOLA... 0 thioridazine thiotepa thiothixene THYMOGLOBULIN THYROLAR THYROLAR-/ THYROLAR-/ THYROLAR THYROLAR tiagabine TIBSOVO tigecycline... 7 timolol maleate... 60, 02 tinidazole... 4 TIVICAY tizanidine TOBI PODHALER... 0 tobramycin... 8 tobramycin in % nacl... 0 tobramycin sulfate... 0 tobramycin-dexamethasone... 8 tolazamide tolbutamide tolcapone tolterodine topiramate topotecan TORISEL torsemide TOUJEO MAX U-300 SOLOSTAR TOUJEO SOLOSTAR U-300 INSULIN TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER... 0 tramadol... 6 tramadol-acetaminophen... 6 trandolapril trandolapril-verapamil tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 0 % TRAVATAN Z trazodone TREANDA TRECATOR TRELSTAR tretinoin tretinoin (chemotherapy) tretinoin microspheres TREXALL triamcinolone acetonide.. 72, 77, 90 triamterene-hydrochlorothiazid triazolam... 9 tridesilon trientine trifluoperazine trifluridine... 8 trihexyphenidyl tri-legest fe... 7 tri-lo-estarylla... 7 tri-lo-sprintec... 7 trilyte with flavor packets trimethobenzamide... 4 trimethoprim... tri-mili... 7 trimipramine trinessa (28)... 7 TRINTELLIX tri-previfem (28)... 7 TRISENOX tri-sprintec (28)... 7 TRIUMEQ trivora (28)... 7 TROPHAMINE 0 % trospium TRULICITY TRUMENBA TRUVADA tulana... 7 TWINRIX (PF) TYBOST... 0 TYKERB TYPHIM VI TYSABRI U UCERIS ULORIC UPTRAVI... 0 ursodiol UVADEX V valacyclovir... 5 VALCHLOR valganciclovir... 5 valproate sodium valproic acid I-4

132 valproic acid (as sodium salt). 29 valsartan valsartan-hydrochlorothiazide 57 vancomycin... vancomycin in dextrose 5 %.. VAQTA (PF) VARIVAX (PF) VARUBI... 4 VECTIBIX VELCADE velivet triphasic regimen (28) 7 VELPHORO VELTASSA VENCLEXTA VENCLEXTA STARTING PACK venlafaxine... 32, 33 VENTAVIS... 0 verapamil... 60, 6 VERSACLOZ VERZENIO VESICARE vestura (28)... 7 VGO vicodin... 6 vicodin es... 6 vicodin hp... 6 VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC vienva vigabatrin VIIBRYD VIMPAT vinblastine vincasar pfs vincristine vinorelbine VIRACEPT VIRAMUNE VIRAZOLE... 5 VIREAD voriconazole VOSEVI VOTRIENT VPRIV VRAYLAR vyfemla (28) VYVANSE VYXEOS W warfarin water for irrigation, sterile WELCHOL wymzya fe X XALKORI XARELTO XATMEP XELJANZ XELJANZ XR XGEVA XOLAIR XTANDI xulane XYREM... 0 Y YERVOY YF-VAX (PF) YONDELIS YONSA Z zafirlukast zaleplon... 0 ZALTRAP ZANOSAR zarah ZARXIO ZEJULA ZELBORAF ZEMAIRA zenatane zenchent (28) ZEPATIER ZERBAXA... 3 ZERIT ZIAGEN zidovudine ziprasidone hcl ZIRGAN... 8 zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem... 0 ZOMETA ZOMIG zonisamide ZORTRESS ZOSTAVAX (PF) ZOSYN... 5 ZOSYN IN DEXTROSE (ISO- OSM)... 5 zovia /35e (28) ZYBAN... 8 ZYDELIG ZYKADIA ZYLET... 8 ZYPREXA RELPREVV ZYTIGA I-5

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