201 F L L A A HI N N AIN INF A I N A H IN HI LAN H A F F I N 8 10/09/2018 F H H H

Transcription

1 P H 東華 01 F L H L A A HI N N AIN INF A I N A H IN HI LAN H A F F I N 8 10/09/018 F H H H H0571_01 _11_FINAL_

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 Program (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 10/09/18. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 019, and from time to time during the year. What is the CCHP Senior Program (HMO) Formulary? A formulary is a list of covered drugs selected by CCHP Senior Program (HMO) 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 Program (HMO) 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 Program (HMO) 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 019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 019 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.

3 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 Program (HMO) Formulary? 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 or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 0 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 0-day supply of the drug. The enclosed formulary is current as of 10/09/18. To get updated information about the drugscovered by CCHP Senior Program (HMO), please contact us. Our contact information appears on the frontand back cover pages. If we make any mid-year non-maintenance changes to the formulary, we will 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. 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 -1. The Index provides an alphabetical list of all of the drugs included in this

4 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 Program (HMO) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: CCHP Senior Program (HMO) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from CCHP Senior Program (HMO) before you fill your prescriptions. If you don t get approval, CCHP Senior Program (HMO) may not cover the drug. Quantity Limits: For certain drugs, CCHP Senior Program (HMO) limits the amount of the drug that CCHP Senior Program (HMO) will cover. For example, CCHP Senior Program (HMO) provides 0 tablets per prescription for JARDIANCE. This may be in addition to a standard onemonth or three-month supply. Step Therapy: In some cases, CCHP Senior Program (HMO) 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 Program (HMO) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CCHP Senior Program (HMO) 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 Program (HMO) 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

5 the CCHP Senior Program (HMO) s formulary? on page exception. for information about how to request an 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 Program (HMO) 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 OPHTHALMIC SOLUTION 0.05% ARTIFICIAL TEARS CCHP Senior Program (HMO) will provide these OTC drugs at no cost to you. The cost to CCHP Senior Program (HMO) 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. 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 Program (HMO) 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 Program (HMO). 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 Program (HMO). 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.

6 How do I request an exception to the CCHP Senior Program (HMO) s Formulary? You can ask CCHP Senior Program (HMO) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, CCHP Senior Program (HMO) 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 Program (HMO) will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary 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 7 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 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

7 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 0-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 0-day supply of medication. After your first 0-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 1-day emergency supply of that drug while you pursue a formulary exception. For more information For more detailed information about your CCHP Senior Program (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about CCHP Senior Program (HMO), 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 ( ) hours a day/7 days a week. TTY users should call Or, visit CCHP Senior Program (HMO) s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by CCHP Senior Program (HMO). 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 Program (HMO) 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

8 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 0-day supply for both Retail and Mail Order Pharmacies. 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 Program (HMO) before you fill your prescription. If you don t get approval, CCHP Senior Program (HMO) 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 Program (HMO) to determine whether the drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, CCHP Senior Program (HMO) 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 Program (HMO) before you fill your prescription for this drug. Without prior approval, CCHP Senior Program (HMO) may not cover this drug. Quantity Limits (QL): For certain drugs, CCHP Senior Program (HMO) 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 Program (HMO) 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 Program (HMO) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CCHP Senior Program (HMO) will then cover Drug B.

9 This formulary was updated on 10/09/18. For more recent information or other questions, pleasecontact Chinese Community Health Plan Member Services, at or, for TTY users, , seven days a week from 8:00 a.m. to 8:00 p.m., or visit The formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary. Chinese Community Health Plan (CCHP) is a Medicare Advantage HMO plan with a Medicare contract and a California Medicaid program contract for our SNP. Enrollment in CCHP depends on contract renewal. This information is available for free in other languages. Please contact our Member Services Department at (TTY ) from 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Por favor póngase en contacto con nuestro departamento de servicio de miembro al (TTY ) de 8:00 a.m. a 8:00 p.m., siete días a la semana.

10 Table of Contents Analgesics... Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents... 8 Antianxiety Agents... 9 Antibacterials Anticancer Agents Anticholinergic Agents... 7 Anticonvulsants... 8 Antidementia Agents... Antidepressants... Antidiabetic Agents... 5 Antifungals... 8 Antigout Agents... 0 Antihistamines... 0 Anti-Infectives (Skin And Mucous Membrane)... 1 Antimigraine Agents... 1 Antimycobacterials... 1 Antinausea Agents... Antiparasite Agents... Antiparkinsonian Agents... Antipsychotic Agents... 6 Antivirals (Systemic)... 9 Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives

11 Dental And Oral Agents Dermatological Agents Devices... 8 Enzyme Replacement/Modifiers... 8 Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents... 9 Heavy Metal Antagonists... 9 Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents... 10

12 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet 00-0 acetaminophen-codeine oral tablet buprenorphine hcl injection solution 0. /ml buprenorphine hcl injection syringe 0. /ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butorphanol tartrate injection solution 1 /ml, /ml butorphanol tartrate nasal spray,nonaerosol 10 /ml codeine sulfate oral tablet 15, 0, 60 DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 100- MG, MG, 0-1. MG, 50- MG, 60-. MG, 80-. MG endocet oral tablet 10-5, 5-5, fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution /15 ml QL (980 per 0 days) QL (90 per 0 days) (Tylenol-Codeine #) QL (90 per 0 days) (Tylenol-Codeine #) QL (90 per 0 days) (Buprenex) (Butrans) QL ( per 8 days) QL (10 per 0 days) QL (0 per 0 days) PA BvD QL (60 per 0 days) QL (60 per 0 days) (Actiq) PA; QL (10 per 0 days) (Duragesic) QL (10 per 0 days) PA; QL (10 per 0 days) (Hycet) QL (500 per 0 days)

13 hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (90 per 0 days) hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (60 per 0 days) 10-5 hydrocodone-acetaminophen oral tablet (Verdrocet) QL (60 per 0 days).5-5 hydrocodone-acetaminophen oral tablet 5- (Vicodin) QL (90 per 0 days) 00 hydrocodone-acetaminophen oral tablet 5- (Lorcet (hydrocodone)) QL (60 per 0 days) 5 hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (90 per 0 days) hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (60 per 0 days) hydrocodone-ibuprofen oral tablet (Ibudone) QL (80 per 0 days), 5-00 hydrocodone-ibuprofen oral tablet QL (80 per 0 days) hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone injection syringe /ml (Dilaudid) hydromorphone oral liquid 1 /ml (Dilaudid) QL (00 per 0 days) hydromorphone oral tablet (Dilaudid) QL (50 per 0 days) hydromorphone oral tablet (Dilaudid) QL (0 per 0 days) hydromorphone oral tablet 8 (Dilaudid) QL (10 per 0 days) hydromorphone oral tablet extended (Exalgo ER) QL (0 per 0 days) release hr 1, 16,, 8 HYSINGLA ER ORAL TABLET,ORAL QL (0 per 0 days) ONLY,EXT.REL. HR 100 MG, 10 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG ibuprofen-oxycodone oral tablet 00-5 QL (0 per 0 days) KADIAN ORAL QL (60 per 0 days) CAPSULE,EXTEND.RELEASE PELLETS 00 MG, 0 MG LAZANDA NASAL SPRAY,NON- PA; QL (0 per 0 days) AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY levorphanol tartrate oral tablet QL (0 per 0 days) lorcet (hydrocodone) oral tablet 5-5 QL (60 per 0 days) lorcet hd oral tablet 10-5 QL (60 per 0 days) lorcet plus oral tablet QL (60 per 0 days)

14 meperidine (pf) injection solution 100 (Demerol (PF)) PA /ml, 50 /ml meperidine (pf) injection solution 5 PA /ml meperidine oral solution 50 /5 ml meperidine oral tablet 100 (Demerol) QL (60 per 0 days) meperidine oral tablet 50 QL (70 per 0 days) methadone injection solution 10 /ml methadone oral solution 10 /5 ml QL (1800 per 0 days) methadone oral solution 5 /5 ml QL (600 per 0 days) methadone oral tablet 10, 5 (Dolophine) QL (60 per 0 days) morphine concentrate oral solution 100 QL (180 per 0 days) /5 ml (0 /ml) morphine injection syringe /ml PA BvD morphine intravenous cartridge /ml PA BvD morphine oral capsule, er multiphase QL (60 per 0 days) hr 10, 0, 5, 60, 75, 90 morphine oral capsule,extend.release (Kadian) QL (60 per 0 days) pellets 10, 100, 0, 0, 50, 60, 80 morphine oral solution 10 /5 ml QL (1800 per 0 days) morphine oral solution 0 /5 ml ( QL (900 per 0 days) /ml) MORPHINE ORAL TABLET 15 MG, 0 QL (180 per 0 days) MG morphine oral tablet extended release 100 (MS Contin) QL (10 per 0 days), 15, 00, 0, 60 NUCYNTA ER ORAL TABLET QL (60 per 0 days) EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 75 QL (180 per 0 days) MG NUCYNTA ORAL TABLET 50 MG QL (60 per 0 days) oxycodone oral capsule 5 QL (60 per 0 days) oxycodone oral concentrate 0 /ml QL (70 per 0 days) oxycodone oral solution 5 /5 ml QL (500 per 0 days) oxycodone oral tablet 10, 0 QL (180 per 0 days) oxycodone oral tablet 15, 0 (Roxicodone) QL (180 per 0 days) oxycodone oral tablet 5 (Roxicodone) QL (60 per 0 days) oxycodone-acetaminophen oral solution 5-5 /5 ml QL (1800 per 0 days) 5

15 oxycodone-acetaminophen oral tablet 10- (Endocet) QL (60 per 0 days) 5,.5-5, 5-5, oxycodone-aspirin oral tablet QL (60 per 0 days) OXYCONTIN ORAL TABLET,ORAL QL (60 per 0 days) ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (10 per 0 days) ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10, 5 (Opana) QL (60 per 0 days) oxymorphone oral tablet extended release QL (60 per 0 days) 1 hr 10, 15, 0, 0, 0, 5, 7.5 pentazocine-naloxone oral tablet QL (60 per 0 days) PRIMLEV ORAL TABLET MG, QL (90 per 0 days) 5-00 MG, MG tramadol oral tablet 50 (Ultram) QL (0 per 0 days) tramadol oral tablet extended release QL (60 per 0 days) hr 100, 00, 00 tramadol oral tablet, er multiphase hr QL (60 per 0 days) 100, 00, 00 tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (60 per 0 days) 5 vicodin es oral tablet QL (90 per 0 days) vicodin hp oral tablet QL (90 per 0 days) vicodin oral tablet 5-00 QL (90 per 0 days) Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 100, 00, (Celebrex) QL (60 per 0 days) 00, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops 1.5 % diclofenac sodium topical gel 1 % (Voltaren) QL (1000 per 0 days) diclofenac sodium topical gel % (Solaraze) PA NSO diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mcg (Arthrotec 50) 6

16 diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 etodolac oral capsule 00, 00 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release hr 00, 500, 600 FLECTOR TRANSDERMAL PATCH 1 PA; QL (60 per 0 days) HOUR 1. % flurbiprofen oral tablet 100, 50 1 ibu oral tablet 00, 600, ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 00, 600, 800 (IBU) 1 INDOCIN ORAL SUSPENSION 5 MG/5 ML indomethacin oral capsule 5, 50 indomethacin oral capsule, extended release 75 ketorolac injection cartridge 15 /ml ketorolac injection solution 15 /ml, 0 /ml (1 ml) ketorolac injection syringe 15 /ml ketorolac intramuscular cartridge 60 / ml ketorolac oral tablet 10 QL (0 per 5 days) meloxicam oral tablet 15, 7.5 (Mobic) 1 nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 1 naproxen oral tablet 500 (Naprosyn) 1 naproxen sodium oral tablet 75 1 naproxen sodium oral tablet 550 (Anaprox DS) 1 PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 0 MG/GRAM /ACTUATION( %) piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet sulindac oral tablet 00 Anesthetics 7

17 Local Anesthetics lidocaine (pf) injection solution 0 /ml (Xylocaine-MPF) ( %), 5 /ml (0.5 %) lidocaine hcl injection solution 0 /ml (Xylocaine) ( %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution % (0 /ml) lidocaine topical adhesive (Lidoderm) PA; QL (90 per 0 days) patch,medicated 5 % lidocaine topical ointment 5 % QL (50 per 0 days) lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual film 8- buprenorphine-naloxone sublingual tablet -0.5, 8- bupropion hcl (smoking deter) oral tablet extended release 1 hr 150 CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG () (Suboxone) QL (90 per 0 days) (Zyban) disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0. /ml naloxone injection syringe 0. /ml, 1 /ml naltrexone oral tablet 50 1 QL (90 per 0 days) 8

18 NARCAN NASAL SPRAY,NON- AEROSOL MG/ACTUATION NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML SUBOXONE SUBLINGUAL FILM 1- MG SUBOXONE SUBLINGUAL FILM -0.5 MG, -1 MG, 8- MG ZYBAN ORAL TABLET EXTENDED RELEASE 1 HR 150 MG Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.5, 0.5, 1, (Xanax) 1 alprazolam oral tablet extended release (Xanax XR) hr 0.5, 1,, alprazolam oral tablet,disintegrating 0.5, 0.5, 1, buspirone oral tablet 10, 15, 5 1 chlordiazepoxide hcl oral capsule 10, 1 5, 5 clonazepam oral tablet 0.5, 1, (Klonopin) 1 clonazepam oral tablet,disintegrating 0.15, 0.5, 0.5, 1, clorazepate dipotassium oral tablet 15, 1.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) 1 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam injection solution 5 /ml diazepam injection syringe 5 /ml diazepam intensol oral concentrate 5 /ml diazepam oral solution 5 /5 ml (1 /ml) diazepam oral tablet 10,, 5 (Valium) 1 estazolam oral tablet 1, 1 QL ( per days) 9 QL (60 per 0 days) QL (90 per 0 days) ST

19 flurazepam oral capsule 15, 0 lorazepam injection solution /ml, (Ativan) /ml lorazepam injection syringe /ml, /ml lorazepam oral concentrate /ml (Lorazepam Intensol) lorazepam oral tablet 0.5, 1, (Ativan) 1 meprobamate oral tablet 00, 00 ONFI ORAL SUSPENSION.5 MG/ML PA NSO ONFI ORAL TABLET 10 MG, 0 MG PA NSO oxazepam oral capsule 10, 15, 0 temazepam oral capsule 15,.5, (Restoril) 0, 7.5 triazolam oral tablet 0.15 triazolam oral tablet 0.5 (Halcion) Antibacterials Aminoglycosides amikacin injection solution 500 / ml gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 60 /50 ml, 80 /100 ml, 80 /50 ml gentamicin injection solution 0 / ml, 0 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml neomycin oral tablet 500 streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation (Tobi) solution for nebulization 00 /5 ml tobramycin sulfate injection solution 10 /ml, 0 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram 10

20 clindamycin hcl oral capsule 150, 00 (Cleocin HCl) 1, 75 clindamycin in 5 % dextrose intravenous (Cleocin in 5 % piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml dextrose) clindamycin palmitate hcl oral recon soln (Cleocin Pediatric) 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 150 /ml clindamycin phosphate intravenous (Cleocin) solution 600 / ml colistin (colistimethate na) injection recon soln 150 (Coly-Mycin M Parenteral) DALVANCE INTRAVENOUS SOLUTION 500 MG daptomycin intravenous recon soln 500 (Cubicin) lincomycin injection solution 00 /ml (Lincocin) linezolid 600 /00 ml-0.9% nacl 600 /00 ml linezolid in dextrose 5% intravenous piggyback 600 /00 ml (Zyvox) linezolid oral suspension for reconstitution (Zyvox) 100 /5 ml linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 gram (Hiprex) metronidazole in nacl (iso-os) intravenous (Metro I.V.) piggyback 500 /100 ml metronidazole oral capsule 75 (Flagyl) metronidazole oral tablet 50, 500 (Flagyl) 1 MONUROL ORAL PACKET GRAM nitrofurantoin macrocrystal oral capsule (Macrodantin) 100, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) nitrofurantoin oral suspension 5 /5 ml (Furadantin) polymyxin b sulfate injection recon soln 500,000 unit SIVEXTRO INTRAVENOUS RECON SOLN 00 MG ; QL (6 per 15 days) 11

21 SIVEXTRO ORAL TABLET 00 MG ; QL (6 per 15 days) SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet vancomycin in dextrose 5 % intravenous piggyback 1 gram/00 ml vancomycin intravenous recon soln 10 gram, 5 gram vancomycin oral capsule 15 (Vancocin) QL (56 per 10 days) vancomycin oral capsule 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG QL (9 per days) XIFAXAN ORAL TABLET 550 MG ; QL (60 per 0 days) Cephalosporins AVYCAZ INTRAVENOUS RECON SOLN.5 GRAM cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefaclor oral tablet extended release 1 hr 500 cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefepime injection recon soln 1 gram, (Maxipime) gram cefixime oral suspension for reconstitution (Suprax) 100 /5 ml, 00 /5 ml cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln gram (Claforan) cefotetan injection recon soln 1 gram, (Cefotan) gram cefoxitin intravenous recon soln 1 gram, 10 gram, gram 1

22 cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln 1 gram (Fortaz) ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftriaxone injection recon soln 1 gram, 10 gram, gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) 1 cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 SUPRAX ORAL CAPSULE 00 MG SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 00 MG tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG ZERBAXA INTRAVENOUS RECON SOLN 1.5 GRAM Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), ( pack) azithromycin oral tablet 50, 500, 600 (Zithromax) 1 1

23 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release hr 500 DIFICID ORAL TABLET 00 MG 5 ST; NM; NDS; QL (0 per 5 days) E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 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 00 /5 ml erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 500 PCE ORAL TABLET, PARTICLES/CRYSTALS MG, 500 MG ZMAX ORAL SUSPENSION,EXTENDED REL RECON GRAM/60 ML Miscellaneous B-Lactam Antibiotics AZACTAM INJECTION RECON SOLN GRAM aztreonam injection recon soln 1 gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML ertapenem injection recon soln 1 gram (Invanz) imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon soln 500 (Primaxin IV) 1

24 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 500 (Merrem) Penicillins amoxicillin oral capsule 50, amoxicillin oral suspension for reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, amoxicillin oral tablet,chewable 15, 50 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 1 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, ampicillin sodium injection recon soln 1 gram, 10 gram ampicillin sodium injection recon soln 15 ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML BICILLIN C-R INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) 15

25 BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln 1 gram, 10 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 10 gram penicillin g pot in dextrose intravenous piggyback million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, piperacillin-tazobactam intravenous recon (Zosyn) soln.75 gram,.5 gram, 0.5 gram ZOSYN.5 GRAM VIAL P/F,LTX- FR,INNER,SUV.5 GRAM ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK.5 GRAM/50 ML,.75 GRAM/50 ML Quinolones AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK 00 MG/50 ML ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase hr 1,000, 500 ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 ciprofloxacin hcl oral tablet ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml 16

26 ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50 1 levofloxacin oral tablet 500, 750 (Levaquin) 1 moxifloxacin 00 /50 ml bag 00 /50 ml moxifloxacin in nacl (iso-osm) intravenous (Avelox in NaCl (isoosmotic)) piggyback 00 /50 ml moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) Tetracyclines demeclocycline oral tablet 150, 00 doxy-100 intravenous recon soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline hyclate oral tablet 150, 75 (Acticlate) doxycycline hyclate oral tablet 50 (Targadox) doxycycline monohydrate oral capsule 100 (Mondoxyne NL), 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) 17

27 doxycycline monohydrate oral tablet 50, 75 minocycline oral capsule 100, 75 1 minocycline oral capsule 50 (Minocin) 1 minocycline oral tablet 100, 50, 75 okebo oral capsule 100 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) VIBRAMYCIN ORAL SYRUP 50 MG/5 ML Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 0 /10 PA BvD ml adrucil intravenous solution.5 gram/50 PA BvD ml AFINITOR DISPERZ ORAL TABLET 5 PA NSO; NM; NDS FOR SUSPENSION MG, MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 5 PA NSO; NM; NDS; QL MG, 5 MG, 7.5 MG (0 per 0 days) ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS ALIMTA INTRAVENOUS RECON SOLN 500 MG ALIQOPA INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 60 MG ALUNBRIG ORAL TABLET 180 MG, 5 PA NSO; NM; NDS 0 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE 5 PA NSO; NM; NDS PACK 90 MG (7)- 180 MG () anastrozole oral tablet 1 (Arimidex) 1 ARRANON INTRAVENOUS SOLUTION 50 MG/50 ML AVASTIN INTRAVENOUS SOLUTION 5 MG/ML azacitidine injection recon soln 100 (Vidaza) BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML 18

28 BELEODAQ INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 500 MG BESPONSA INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 5 PA NSO; NM; NDS bicalutamide oral tablet 50 (Casodex) BICNU INTRAVENOUS RECON SOLN 100 MG bleomycin injection recon soln 0 unit PA BvD BORTEZOMIB INTRAVENOUS RECON SOLN.5 MG BOSULIF ORAL TABLET 100 MG, 00 5 PA NSO; NM; NDS MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG, 5 PA NSO; NM; NDS; QL 75 MG (180 per 0 days) busulfan intravenous solution 60 /10 ml (Busulfex) 1 BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML CABOMETYX ORAL TABLET 0 MG, 5 PA NSO; NM; NDS 0 MG, 60 MG CALQUENCE ORAL CAPSULE PA NSO; NM; NDS; QL MG (60 per 0 days) CAPRELSA ORAL TABLET 100 MG, 5 PA NSO; NM; NDS 00 MG carboplatin intravenous solution 10 /ml cisplatin intravenous solution 1 /ml cladribine intravenous solution 10 /10 PA BvD ml clofarabine intravenous solution 0 /0 (Clolar) ml COMETRIQ ORAL CAPSULE PA NSO; NM; NDS MG/DAY(80 MG X1-0 MG X1), 10 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COSMEGEN INTRAVENOUS RECON SOLN 0.5 MG COTELLIC ORAL TABLET 0 MG 5 PA NSO; NM; NDS CYCLOPHOSPHAMIDE ORAL PA BvD CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 10 MG/ML cytarabine (pf) injection solution 100 /5 PA BvD ml (0 /ml), gram/0 ml (100 /ml) 19

29 cytarabine injection solution 0 /ml PA BvD dacarbazine intravenous recon soln 100, 00 DACOGEN INTRAVENOUS RECON SOLN 50 MG dactinomycin intravenous recon soln 0.5 (Cosmegen) DARZALEX INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 0 MG/ML daunorubicin intravenous recon soln 0 daunorubicin intravenous solution 5 /ml decitabine intravenous recon soln 50 (Dacogen) docetaxel intravenous solution 160 /8 ml (0 /ml) docetaxel intravenous solution 0 / ml (10 /ml), 80 /8 ml (10 /ml) docetaxel intravenous solution 0 /ml (Taxotere) (1 ml), 80 / ml (0 /ml) DOXIL INTRAVENOUS SUSPENSION MG/ML doxorubicin intravenous recon soln 10, (Adriamycin) PA BvD 50 doxorubicin intravenous solution 10 /5 (Adriamycin) PA BvD ml, /ml, 0 /10 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE.5 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 5 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 00 MG, 00 MG epirubicin intravenous recon soln 50 0

30 epirubicin intravenous solution 00 /100 ml (Ellence) ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML, 00 MG/100 ML ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS ERLEADA ORAL TABLET 60 MG 5 PA NSO; NM; NDS ERWINAZE INJECTION RECON SOLN 5 PA NSO; NM; NDS 10,000 UNIT ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG 5 PA NSO; NM; NDS; QL (6 per 1 days) FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML FIRMAGON KIT W DILUENT PA NSO SYRINGE SUBCUTANEOUS RECON SOLN 10 MG, 80 MG fludarabine intravenous recon soln 50 fludarabine intravenous solution 50 / ml fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/100 ml, 500 /10 ml flutamide oral capsule 15 FOLOTYN INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 0 MG/ML (1 ML), 0 MG/ ML (0 MG/ML) gemcitabine intravenous recon soln 1 (Gemzar) gram, 00 gemcitabine intravenous recon soln gram gemcitabine intravenous solution 1 gram/6. ml (8 /ml), 100 /ml, gram/5.6 ml (8 /ml), 00 /5.6 ml (8 /ml) GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG, 5 MG 1

31 HALAVEN INTRAVENOUS SOLUTION 1 MG/ ML (0.5 MG/ML) HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 0 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 5 PA NSO; NM; NDS; QL 15 MG, 75 MG (1 per 8 days) ICLUSIG ORAL TABLET 15 MG, 5 5 PA NSO; NM; NDS MG idarubicin intravenous solution 1 /ml (Idamycin PFS) IDHIFA ORAL TABLET 100 MG, 50 5 PA NSO; NM; NDS; QL MG (0 per 0 days) ifosfamide intravenous recon soln 1 gram, (Ifex) gram ifosfamide intravenous solution 1 gram/0 ml, gram/60 ml imatinib oral tablet 100, 00 (Gleevec) 5 PA NSO; NM; NDS IMBRUVICA ORAL CAPSULE 10 5 PA NSO; NM; NDS; QL MG, 70 MG (10 per 0 days) IMBRUVICA ORAL TABLET 10 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) IMBRUVICA ORAL TABLET 80 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) IMBRUVICA ORAL TABLET 0 MG, 5 PA NSO; NM; NDS; QL 560 MG (0 per 0 days) IMFINZI INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS 50 MG/ML INLYTA ORAL TABLET 1 MG, 5 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) IRESSA ORAL TABLET 50 MG 5 PA NSO; NM; NDS irinotecan intravenous solution 100 /5 (Camptosar) ml, 0 / ml irinotecan intravenous solution 500 /5 ml ISTODAX INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 10 MG/ ML JAKAFI ORAL TABLET 10 MG, 15 MG, 5 PA NSO; NM; NDS; QL 0 MG, 5 MG, 5 MG (60 per 0 days) JEVTANA INTRAVENOUS SOLUTION 10 MG/ML (FIRST DILUTION) KADCYLA INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 100 MG, 160 MG

32 KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1) KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) KISQALI ORAL TABLET 600 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 10 MG, 0 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 1 MG/DAY ( MG X ), 1 MG/DAY(10 MG X 1- MG X 1), 18 MG/DAY (10 MG X 1- MG X), 0 MG/DAY (10 MG X ), MG/DAY(10 MG X - MG X 1), MG, 8 MG/DAY ( MG X ) letrozole oral tablet.5 (Femara) 1 LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit 1 /0. ml LONSURF ORAL TABLET MG, MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (9 per 8 days) 5 PA NSO; NM; NDS; QL (70 per 8 days) 5 PA NSO; NM; NDS; QL (91 per 8 days) 5 PA NSO; NM; NDS; QL (1 per 8 days) 5 PA NSO; NM; NDS; QL ( per 8 days) 5 PA NSO; NM; NDS; QL (6 per 8 days) 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (90 per 0 days) 5 PA NSO; NM; NDS

33 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS LYNPARZA ORAL TABLET 100 MG, 5 PA NSO; NM; NDS 150 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 0 PA NSO MEKINIST ORAL TABLET 0.5 MG, 5 PA NSO; NM; NDS MG MEKTOVI ORAL TABLET 15 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) melphalan hcl intravenous recon soln 50 (Alkeran) mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln 1 gram methotrexate sodium (pf) injection solution 5 /ml methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 mitomycin intravenous recon soln 0, (Mutamycin) 0, 5 mitoxantrone intravenous concentrate /ml MUSTARGEN INJECTION RECON SOLN 10 MG mutamycin intravenous recon soln 0, 0, 5 MYLOTARG INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NM; NDS nilutamide oral tablet 150 (Nilandron) NINLARO ORAL CAPSULE. MG, 5 PA NSO; NM; NDS MG, MG NIPENT INTRAVENOUS RECON SOLN 10 MG ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; NM; NDS

34 OPDIVO INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS 100 MG/10 ML, 0 MG/ ML, 0 MG/ ML oxaliplatin intravenous recon soln 100, 50 oxaliplatin intravenous solution 100 /0 ml, 50 /10 ml (5 /ml) paclitaxel intravenous concentrate 6 /ml PERJETA INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS 0 MG/1 ML (0 MG/ML) POMALYST ORAL CAPSULE 1 MG, 5 PA NSO; NM; NDS MG, MG, MG POTELIGEO INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION MG/ML PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML romidepsin intravenous recon soln 10 (Istodax) 5 PA NSO; NM; NDS / ml RUBRACA ORAL TABLET 00 MG, 5 PA NSO; NM; NDS 50 MG, 00 MG RYDAPT ORAL CAPSULE 5 MG 5 PA NSO; NM; NDS SOLTAMOX ORAL SOLUTION 10 PA NSO MG/5 ML SPRYCEL ORAL TABLET 100 MG, 10 PA NSO; NM MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) SUTENT ORAL CAPSULE 1.5 MG, 5 5 PA NSO; NM; NDS MG, 7.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 00 MG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG TABLOID ORAL TABLET 0 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) 5

35 TAGRISSO ORAL TABLET 0 MG, 80 5 PA NSO; NM; NDS MG tamoxifen oral tablet 10, 0 1 TARCEVA ORAL TABLET 100 MG, 5 PA NSO; NM; NDS 150 MG, 5 MG TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 5 PA NSO; NM; NDS 00 MG, 50 MG TECENTRIQ INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 1,00 MG/0 ML (60 MG/ML) temsirolimus intravenous recon soln 0 (Torisel) / ml (10 /ml) (first) thiotepa injection recon soln 15 (Tepadina) TIBSOVO ORAL TABLET 50 MG 5 PA NSO; NM; NDS toposar intravenous solution 0 /ml topotecan intravenous recon soln (Hycamtin) topotecan intravenous solution / ml (1 /ml) TORISEL INTRAVENOUS RECON SOLN 0 MG/ ML (10 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 100 MG, 5 MG TRELSTAR.75 MG VIAL INNER, SDV.75 MG TRELSTAR INTRAMUSCULAR SYRINGE 11.5 MG/ ML,.5 MG/ ML,.75 MG/ ML tretinoin (chemotherapy) oral capsule 10 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG TRISENOX INTRAVENOUS SOLUTION MG/ML TYKERB ORAL TABLET 50 MG 5 PA NSO; NM; NDS VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (0 MG/ML), 00 MG/0 ML (0 MG/ML) VELCADE INJECTION RECON SOLN.5 MG VENCLEXTA ORAL TABLET 10 MG, 50 MG PA NSO 6

36 VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; NM; NDS VENCLEXTA STARTING PACK ORAL 5 PA NSO; NM; NDS TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) vinblastine intravenous solution 1 /ml PA BvD vincasar pfs intravenous solution / PA BvD ml vincristine intravenous solution 1 /ml, (Vincasar PFS) PA BvD / ml vinorelbine intravenous solution 10 /ml, (Navelbine) 50 /5 ml VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NM; NDS VYXEOS INTRAVENOUS RECON 5 PA BvD; NM; NDS SOLN -100 MG XALKORI ORAL CAPSULE 00 MG, 5 PA NSO; NM; NDS 50 MG XATMEP ORAL SOLUTION.5 MG/ML XTANDI ORAL CAPSULE 0 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) YERVOY INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS 00 MG/0 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 1 MG YONSA ORAL TABLET 15 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) ZALTRAP INTRAVENOUS SOLUTION 5 PA NSO; NM; NDS 100 MG/ ML (5 MG/ML) ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS ZELBORAF ORAL TABLET 0 MG 5 PA NSO; NM; NDS ZOLINZA ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS ZYDELIG ORAL TABLET 100 MG, PA NSO; NM; NDS MG ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS ZYTIGA ORAL TABLET 50 MG, 500 MG 5 PA NSO; NM; NDS Anticholinergic Agents 7

37 Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml propantheline oral tablet 15 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 00 PA NSO MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 0 MG/ML BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 00 MG BRIVIACT INTRAVENOUS PA NSO SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 PA NSO MG/ML BRIVIACT ORAL TABLET 10 MG, 100 PA NSO; QL (60 per 0 MG, 5 MG, 50 MG, 75 MG days) carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr 100, 00, 00 carbamazepine oral tablet,chewable 100 CELONTIN ORAL CAPSULE 00 MG DEPACON INTRAVENOUS SOLUTION 500 MG/5 ML (100 MG/ML) DEPAKENE ORAL CAPSULE 50 MG DEPAKENE ORAL SOLUTION 50 MG/5 ML DEPAKOTE ER ORAL TABLET EXTENDED RELEASE HR 50 MG, 500 MG DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC) 15 MG, 50 MG, 500 MG DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 15 MG DILANTIN EXTENDED ORAL CAPSULE 100 MG 8

38 DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG DILANTIN ORAL CAPSULE 0 MG DILANTIN-15 ORAL SUSPENSION 15 MG/5 ML divalproex oral capsule, delayed rel (Depakote Sprinkles) sprinkle 15 divalproex oral tablet extended release (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) 1 (dr/ec) 15, 50, 500 ethosuximide oral capsule 50 (Zarontin) ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 00, 600 (Felbatol) fosphenytoin injection solution 100 pe/ ml, 500 pe/10 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 PA NSO MG/ML FYCOMPA ORAL TABLET 10 MG, 1 MG, MG, MG, 6 MG, 8 MG PA NSO gabapentin oral capsule 100, 00, (Neurontin) 1 00 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) KEPPRA ORAL SOLUTION 100 MG/ML KEPPRA ORAL TABLET 1,000 MG, 50 MG, 500 MG, 750 MG KEPPRA XR ORAL TABLET EXTENDED RELEASE HR 500 MG, 750 MG LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK 5 MG (5) LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK 5 MG (8) -100 MG (1) LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK 5 MG () -100 MG (7) 9

39 LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK 5 MG (1) -50 MG (7) LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 50 MG(1)-100MG (1)-00 MG (7) LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK 5MG (1)-50 MG (1)-100MG (7) lamotrigine oral tablet 100, 150, 00, 5 lamotrigine oral tablet extended release hr 100, 00, 5, 50, 00, 50 lamotrigine oral tablet, chewable dispersible 5, 5 lamotrigine oral tablet,disintegrating 100, 00, 5, 50 lamotrigine oral tablets,dose pack 5 (5) lamotrigine oral tablets,dose pack 5 () -100 (7) lamotrigine oral tablets,dose pack 5 (8) -100 (1) levetiracetam in nacl (iso-os) intravenous piggyback 1,000 /100 ml, 1,500 /100 ml, 500 /100 ml levetiracetam intravenous solution 500 /5 ml (Lamictal) 1 (Lamictal XR) (Lamictal) (Lamictal ODT) (Lamictal Starter (Blue) Kit) (Lamictal Starter (Orange) Kit) (Lamictal Starter (Green) Kit) (Keppra) levetiracetam oral solution 100 /ml (Keppra) levetiracetam oral tablet 1,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release (Keppra XR) hr 500, 750 LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML oxcarbazepine oral suspension 00 /5 ml (60 /ml) (Trileptal) 0

40 oxcarbazepine oral tablet 150, 00, (Trileptal) 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE HR 150 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml ( /ml) phenobarbital oral tablet 100, 15, 16., 0,., 60, 6.8, 97. PHENYTEK ORAL CAPSULE 00 MG, 00 MG phenytoin oral suspension 15 /5 ml (Dilantin-15) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) phenytoin sodium extended oral capsule (Phenytek) 1 00, 00 phenytoin sodium intravenous solution 50 /ml primidone oral tablet 50, 50 (Mysoline) ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SABRIL ORAL POWDER IN PACKET 5 PA NSO; NM; NDS 500 MG SABRIL ORAL TABLET 500 MG 5 PA NSO; NM; NDS SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 50 MG, 500 MG, 750 MG PA NSO tiagabine oral tablet 1, 16,, (Gabitril) topiramate oral capsule, sprinkle 15, (Topamax) 5 topiramate oral capsule,sprinkle,er hr (Qudexy XR) PA NSO 100, 150, 00, 5, 50 topiramate oral tablet 100, 00, 5, 50 (Topamax) 1 valproate sodium intravenous solution 500 (Depacon) /5 ml (100 /ml) valproic acid (as sodium salt) oral (Depakene) solution 50 /5 ml valproic acid oral capsule 50 (Depakene) 1

41 vigabatrin oral powder in packet 500 (Sabril) PA NSO VIMPAT INTRAVENOUS SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG QL (60 per 0 days) zonisamide oral capsule 100, 5 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 10, 5 (Aricept) 1 QL (60 per 0 days) donepezil oral tablet (Aricept) QL (0 per 0 days) donepezil oral tablet,disintegrating 10, ST; QL (0 per 0 days) 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) hr 16,, 8 galantamine oral solution /ml galantamine oral tablet 1,, 8 (Razadyne) memantine oral capsule,sprinkle,er hr (Namenda XR) 1, 1, 8, 7 memantine oral solution /ml memantine oral tablet 10, 5 (Namenda) rivastigmine tartrate oral capsule 1.5,,.5, 6 rivastigmine transdermal patch hour 1. / hour,.6 / hr, 9.5 / hr (Exelon) ST Antidepressants Antidepressants amitriptyline oral tablet 10, 100, 150, 5, 50, 75 amitriptyline-chlordiazepoxide oral tablet 1.5-5, 5-10 amoxapine oral tablet 100, 150, 5, 50 APLENZIN ORAL TABLET EXTENDED RELEASE HR 17 MG, 8 MG, 5 MG bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release (Wellbutrin XL) hr 150, 00 1 ST

42 bupropion hcl oral tablet sustainedrelease (Wellbutrin SR) 1 hr 100, 150, 00 citalopram oral solution 10 /5 ml 1 citalopram oral tablet 10, 0, 0 (Celexa) 1 clomipramine oral capsule 5, 50, (Anafranil) 75 desipramine oral tablet 10, 5 (Norpramin) desipramine oral tablet 100, 150, 50, 75 DESVENLAFAXINE FUMARATE ST ORAL TABLET EXTENDED RELEASE HR 100 MG, 50 MG DESVENLAFAXINE ORAL TABLET ST EXTENDED RELEASE HR 100 MG, 50 MG doxepin oral capsule 10, 100, 150, 5, 50, 75 doxepin oral concentrate 10 /ml duloxetine oral capsule,delayed (Cymbalta) QL (60 per 0 days) release(dr/ec) 0, 0, 60 duloxetine oral capsule,delayed ST; QL (0 per 0 days) release(dr/ec) 0 EMSAM TRANSDERMAL PATCH ST HOUR 1 MG/ HR, 6 MG/ HR, 9 MG/ HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 0 (Lexapro) 1, 5 FETZIMA ORAL CAPSULE,EXT REL ST; QL (0 per 0 days) HR DOSE PACK 0 MG ()- 0 MG (6) FETZIMA ORAL ST; QL (0 per 0 days) CAPSULE,EXTENDED RELEASE HR 10 MG, 0 MG, 0 MG, 80 MG fluoxetine oral capsule 10, 0, 0 (Prozac) 1 fluoxetine oral solution 0 /5 ml ( /ml) fluoxetine oral tablet 10, 0 (Sarafem) 1 fluvoxamine oral capsule,extended release hr 100, 150 ST

43 fluvoxamine oral tablet 100, 5, 50 imipramine hcl oral tablet 10, 5, (Tofranil) 1 50 imipramine pamoate oral capsule 100, 15, 150, 75 maprotiline oral tablet 5, 50, 75 MARPLAN ORAL TABLET 10 MG ST mirtazapine oral tablet 15, 0 (Remeron) 1 mirtazapine oral tablet 5 1 mirtazapine oral tablet 7.5 mirtazapine oral tablet,disintegrating 15 (Remeron SolTab), 0, 5 nefazodone oral tablet 100, 150, 00 nefazodone oral tablet 50, 50 nortriptyline oral capsule 10, 5, (Pamelor) 1 50, 75 nortriptyline oral solution 10 /5 ml olanzapine-fluoxetine oral capsule 1-5 (Symbyax), 1-50, -5, 6-5, 6-50 paroxetine hcl oral tablet 10, 0, (Paxil) 1 0, 0 paroxetine hcl oral tablet extended release (Paxil CR) hr 1.5, 5, 7.5 PAXIL ORAL SUSPENSION 10 MG/5 ML perphenazine-amitriptyline oral tablet - 10, -5, -10, -5, -50 PEXEVA ORAL TABLET 10 MG, 0 MG, 0 MG, 0 MG ST phenelzine oral tablet 15 (Nardil) protriptyline oral tablet 10, 5 sertraline oral concentrate 0 /ml (Zoloft) 1 sertraline oral tablet 100, 5, 50 (Zoloft) 1 tranylcypromine oral tablet 10 (Parnate) trazodone oral tablet 100, 150, 50 1 trazodone oral tablet 00

44 trimipramine oral capsule 100, 5, 50 TRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG venlafaxine oral capsule,extended release hr 150, 7.5, 75 venlafaxine oral tablet 100, 5, 7.5, 50, 75 venlafaxine oral tablet extended release hr 150, 5, 7.5, 75 VIIBRYD ORAL TABLET 10 MG, 0 MG, 0 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG () Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100, 5, 50 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE HR 15-1,000 MG, 0-1,000 MG (Surmontil) (Effexor XR) (Precose) ST; QL (0 per 0 days) 5 ST; QL (0 per 0 days) ST; QL (0 per 0 days) AVANDIA ORAL TABLET MG, MG CYCLOSET ORAL TABLET 0.8 MG GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG GLYSET ORAL TABLET 100 MG, 5 MG, 50 MG INVOKAMET ORAL TABLET 150- QL (60 per 0 days) 1,000 MG, MG, 50-1,000 MG, MG INVOKAMET XR ORAL TABLET, IR - QL (60 per 0 days) ER, BIPHASIC HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 MG, QL (0 per 0 days) 00 MG JANUMET ORAL TABLET 50-1,000 QL (60 per 0 days) MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE HR 100-1,000 MG, 50-1,000 MG, MG QL (60 per 0 days)

45 JANUVIA ORAL TABLET 100 MG, 5 QL (0 per 0 days) MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 5 QL (0 per 0 days) MG KOMBIGLYZE XR ORAL TABLET, ER QL (0 per 0 days) MULTIPHASE HR.5-1,000 MG, 5-1,000 MG, MG KORLYM ORAL TABLET 00 MG metformin oral solution 500 /5 ml (Riomet) metformin oral tablet 1,000, 500, (Glucophage) metformin oral tablet extended release (Glucophage XR) 1 hr 500, 750 miglitol oral tablet 100, 5, 50 (Glyset) nateglinide oral tablet 10, 60 (Starlix) ONGLYZA ORAL TABLET.5 MG, 5 MG QL (0 per 0 days) pioglitazone oral tablet 15, 0, 5 (Actos) 1 pioglitazone-glimepiride oral tablet 0- (DUETACT), 0- pioglitazone-metformin oral tablet (Actoplus MET), repaglinide oral tablet 0.5 repaglinide oral tablet 1, (Prandin) repaglinide-metformin oral tablet 1-500, -500 RIOMET ORAL SOLUTION 500 MG/5 ML SYMLINPEN 10 SUBCUTANEOUS PEN INJECTOR,700 MCG/.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET 1.5-1,000 QL (60 per 0 days) MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR - QL (0 per 0 days) ER, BIPHASIC HR 10-1,000 MG, 5-1,000 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML 6

46 VICTOZA SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/ ML) Insulins LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/0 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-0) NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX 70-0 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-0) NOVOLOG MIX 70-0FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO MAX U-00 SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) TOUJEO SOLOSTAR U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) Sulfonylureas chlorpropamide oral tablet 100, 50 glimepiride oral tablet 1,, (Amaryl) 1 7

47 glipizide oral tablet 10, 5 (Glucotrol) 1 glipizide oral tablet extended release hr (Glucotrol XL) 10,.5, 5 glipizide-metformin oral tablet.5-50,.5-500, glyburide micronized oral tablet 1.5, (Glynase), 6 glyburide oral tablet 1.5,.5, 5 glyburide-metformin oral tablet ,.5-500, tolazamide oral tablet 50, 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 CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % (Ciclodan) ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Ciclodan) ciclopirox topical suspension 0.77 % (Loprox (as olamine)) clotrimazole mucous membrane troche 10 clotrimazole topical cream 1 % (Antifungal (clotrimazole)) clotrimazole topical solution 1 % clotrimazole-betamethasone topical cream (Lotrisone) % clotrimazole-betamethasone topical lotion % econazole topical cream 1 % ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG, 50 MG ERTACZO TOPICAL CREAM % 8

48 EXELDERM TOPICAL CREAM 1 % EXELDERM TOPICAL SOLUTION 1 % fluconazole in nacl (iso-osm) intravenous piggyback 00 /100 ml, 00 /00 ml fluconazole oral suspension for reconstitution 10 /ml, 0 /ml (Diflucan) fluconazole oral tablet 100, 00, 50 (Diflucan) fluconazole oral tablet 150 (Diflucan) 1 flucytosine oral capsule 50, 500 (Ancobon) griseofulvin microsize oral suspension 15 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 15, 50 itraconazole oral capsule 100 (Sporanox) PA ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical foam % (Extina) ketoconazole topical shampoo % (Nizoral) MENTAX TOPICAL CREAM 1 % miconazole- vaginal suppository 00 MYCAMINE INTRAVENOUS RECON SOLN 100 MG, 50 MG naftifine topical cream 1 % naftifine topical cream % (Naftin) NOXAFIL ORAL SUSPENSION 00 MG/5 ML (0 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram nystatin oral powder 150 million unit nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram (Nyamyc) nystop topical powder 100,000 unit/gram oxiconazole topical cream 1 % (Oxistat) SPORANOX ORAL SOLUTION 10 MG/ML PA 9

49 terbinafine hcl oral tablet 50 1 voriconazole intravenous solution 00 (Vfend IV) PA voriconazole oral suspension for reconstitution 00 /5 ml (0 /ml) (Vfend) voriconazole oral tablet 00, 50 (Vfend) Antigout Agents Antigout Agents, Other allopurinol oral tablet 100, 00 (Zyloprim) 1 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 0 MG, 80 MG ST Antihistamines Antihistamines carbinoxamine maleate oral liquid /5 ml carbinoxamine maleate oral tablet cetirizine oral solution 1 /ml (All Day Allergy (cetirizine)) clemastine oral tablet.68 cyproheptadine oral syrup /5 ml cyproheptadine oral tablet desloratadine oral tablet 5 (Clarinex) diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl injection syringe 50 /ml hydroxyzine hcl intramuscular solution 5 /ml, 50 /ml hydroxyzine hcl oral solution 10 /5 ml hydroxyzine hcl oral tablet 10, 5, 50 levocetirizine oral solution.5 /5 ml (Xyzal) levocetirizine oral tablet 5 (HR Allergy Relief) 1 promethazine oral syrup 6.5 /5 ml promethazine vc oral syrup /5 ml 0

50 Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL VAGINAL CREAM 15 % CLEOCIN VAGINAL SUPPOSITORY 100 MG clindamycin phosphate vaginal cream % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0. %, 0.8 % terconazole vaginal suppository 80 Antimigraine Agents Antimigraine Agents dihydroergotamine injection solution 1 (D.H.E.5) /ml dihydroergotamine nasal spray,nonaerosol (Migranal) QL (16 per 0 days) 0.5 /pump act. ( /ml) frovatriptan oral tablet.5 (Frova) QL (18 per 0 days) naratriptan oral tablet 1,.5 (Amerge) QL (18 per 0 days) rizatriptan oral tablet 10 (Maxalt) QL (6 per 60 days) rizatriptan oral tablet 5 QL (6 per 60 days) rizatriptan oral tablet,disintegrating 10 (Maxalt-MLT) QL (6 per 60 days), 5 sumatriptan nasal spray,non-aerosol 0 (Imitrex) QL (1 per 0 days) /actuation, 5 /actuation sumatriptan succinate oral tablet 100, (Imitrex) QL (18 per 0 days) 5, 50 sumatriptan succinate subcutaneous (Imitrex STATdose Kit QL (5 per 0 days) cartridge /0.5 ml, 6 /0.5 ml Refill) sumatriptan succinate subcutaneous pen (Imitrex STATdose Pen) QL (5 per 0 days) injector /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous (Imitrex) QL (5 per 0 days) solution 6 /0.5 ml zolmitriptan oral tablet.5, 5 (Zomig) QL (18 per 0 days) zolmitriptan oral tablet,disintegrating.5 (Zomig ZMT) QL (18 per 0 days), 5 ZOMIG NASAL SPRAY,NON- QL (16 per 0 days) AEROSOL.5 MG ZOMIG NASAL SPRAY,NON- AEROSOL 5 MG QL (1 per 0 days) Antimycobacterials 1

51 Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 GRAM dapsone oral tablet 100, 5 ethambutol oral tablet 100 ethambutol oral tablet 00 (Myambutol) isoniazid injection solution 100 /ml isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, 00 1 PASER ORAL GRANULES DR FOR SUSP IN PACKET GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 (Mycobutin) RIFAMATE ORAL CAPSULE MG rifampin intravenous recon soln 600 (Rifadin) rifampin oral capsule 150, 00 (Rifadin) RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 50 MG Antinausea Agents Antinausea Agents AKYNZEO (NETUPITANT) ORAL CAPSULE MG PA BvD; QL (1 per 7 days) ANZEMET ORAL TABLET 100 MG, 50 MG PA BvD; QL (9 per days) aprepitant oral capsule 15, 0, 80 (Emend) PA BvD; QL ( per days) aprepitant oral capsule,dose pack 15 (1)- 80 () (Emend) PA BvD; QL ( per days) CESAMET ORAL CAPSULE 1 MG PA compro rectal suppository 5 dronabinol oral capsule 10,.5, 5 (Marinol) PA EMEND ORAL CAPSULE 15 MG PA BvD; QL ( per days) EMEND ORAL CAPSULE,DOSE PACK 15 MG (1)- 80 MG () PA BvD; QL ( per days) granisetron (pf) intravenous solution 100 mcg/ml

52 granisetron hcl intravenous solution 1 /ml, 1 /ml (1 ml) granisetron hcl oral tablet 1 PA BvD; QL (0 per 0 days) meclizine oral tablet meclizine oral tablet 5 (Dramamine Less 1 Drowsy) ondansetron hcl (pf) injection solution / ml ondansetron hcl (pf) injection syringe / ml ondansetron hcl intravenous solution /ml ondansetron hcl oral solution /5 ml (Zofran) PA BvD ondansetron hcl oral tablet PA BvD ondansetron hcl oral tablet, 8 (Zofran) 1 PA BvD ondansetron oral tablet,disintegrating (Zofran ODT) PA BvD, 8 phenadoz rectal suppository 1.5 PHENERGAN RECTAL SUPPOSITORY 1.5 MG, 5 MG, 50 MG prochlorperazine edisylate injection solution 10 / ml (5 /ml) prochlorperazine maleate oral tablet 10 (Compazine) 1, 5 prochlorperazine rectal suppository 5 (Compazine) promethazine injection solution 5 /ml, (Phenergan) 50 /ml promethazine oral tablet 1.5, 5, 50 promethazine rectal suppository 1.5, (Phenadoz) 5 promethazine rectal suppository 50 (Phenergan) promethegan rectal suppository 5, 50 SANCUSO TRANSDERMAL PATCH QL ( per 8 days) WEEKLY.1 MG/ HOUR scopolamine base transdermal patch day (Transderm-Scop) 1 over days TIGAN INTRAMUSCULAR SOLUTION 100 MG/ML TRANSDERM-SCOP TRANSDERMAL PATCH DAY 1 MG OVER DAYS

53 trimethobenzamide oral capsule 00 (Tigan) PA VARUBI ORAL TABLET 90 MG PA BvD Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 00 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5 ml (Mepron) atovaquone-proguanil oral tablet (Malarone) atovaquone-proguanil oral tablet (Malarone Pediatric) chloroquine phosphate oral tablet 50, 500 COARTEM ORAL TABLET 0-10 MG DARAPRIM ORAL TABLET 5 MG EMVERM ORAL TABLET,CHEWABLE 100 MG hydroxychloroquine oral tablet 00 (Plaquenil) ivermectin oral tablet (Stromectol) mefloquine oral tablet 50 NEBUPENT INHALATION RECON PA BvD SOLN 00 MG paromomycin oral capsule 50 PENTAM INJECTION RECON SOLN 00 MG PA BvD PRIMAQUINE ORAL TABLET 6. MG quinine sulfate oral capsule (Qualaquin) tinidazole oral tablet 50 tinidazole oral tablet 500 (Tindamax) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 100 APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML benztropine injection solution / ml (Cogentin) benztropine oral tablet 0.5, 1, bromocriptine oral capsule 5 (Parlodel)

54 bromocriptine oral tablet.5 (Parlodel) cabergoline oral tablet 0.5 carbidopa oral tablet 5 (Lodosyn) carbidopa-levodopa oral tablet (Sinemet), 5-100, 5-50 carbidopa-levodopa oral tablet extended (Sinemet CR) release 5-100, carbidopa-levodopa oral tablet,disintegrating , 5-100, 5-50 carbidopa-levodopa-entacapone oral (Stalevo 50) tablet carbidopa-levodopa-entacapone oral (Stalevo 75) tablet carbidopa-levodopa-entacapone oral (Stalevo 100) tablet carbidopa-levodopa-entacapone oral (Stalevo 15) tablet carbidopa-levodopa-entacapone oral (Stalevo 150) tablet carbidopa-levodopa-entacapone oral (Stalevo 00) tablet entacapone oral tablet 00 (Comtan) NEUPRO TRANSDERMAL PATCH HOUR 1 MG/ HOUR, MG/ HOUR, MG/ HOUR, MG/ HOUR, 6 MG/ HOUR, 8 MG/ HOUR pramipexole oral tablet 0.15, 0.5 (Mirapex) 1, 0.5, 0.75, 1, 1.5 pramipexole oral tablet extended release (Mirapex ER) hr 0.75, 0.75, 1.5,.5,,.75,.5 rasagiline oral tablet 0.5, 1 (Azilect) ropinirole oral tablet 0.5, 0.5, 1 (Requip) 1,,,, 5 ropinirole oral tablet extended release hr 1,,, 6, 8 (Requip XL) RYTARY ORAL CAPSULE, ST EXTENDED RELEASE MG, MG, MG, MG selegiline hcl oral capsule 5 5

55 selegiline hcl oral tablet 5 tolcapone oral tablet 100 (Tasmar) trihexyphenidyl oral elixir 0. /ml trihexyphenidyl oral tablet, 5 ZELAPAR ORAL TABLET,DISINTEGRATING 1.5 MG Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 00 MG, 00 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 00 MG, 00 MG 6 PA NSO PA NSO aripiprazole oral solution 1 /ml aripiprazole oral tablet 10, 15,, 0, 0, 5 (Abilify) aripiprazole oral tablet,disintegrating 10, 15 PA NSO; QL (60 per 0 days) ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/. ML 5 PA NSO; NM; NDS ARISTADA INTRAMUSCULAR 5 PA NSO; NM; NDS SUSPENSION,EXTENDED REL SYRING 1,06 MG/.9 ML, 1 MG/1.6 ML, 66 MG/. ML, 88 MG/. ML chlorpromazine injection solution 5 /ml chlorpromazine oral tablet 10, 100, 00, 5, 50 clozapine oral tablet 100, 5 (Clozaril) clozapine oral tablet 00, 50 clozapine oral tablet,disintegrating 100 (FazaClo), 5 clozapine oral tablet,disintegrating 1.5, 150, 00 (FazaClo) FANAPT ORAL TABLET 1 MG, 10 MG, 1 MG, MG, MG, 6 MG, 8 MG PA NSO; QL (60 per 0 days) FANAPT ORAL TABLETS,DOSE PACK 1MG()-MG()- MG()- 6MG() PA NSO; QL (60 per 0 days)

56 fluphenazine decanoate injection solution 5 /ml fluphenazine hcl injection solution.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir.5 /5 ml fluphenazine hcl oral tablet 1, 10, 1.5, 5 GEODON INTRAMUSCULAR RECON SOLN 0 MG/ML (FINAL CONC.) haloperidol dec 50 /ml vial mdv 50 (Haldol Decanoate) /ml haloperidol decanoate intramuscular (Haldol Decanoate) solution 100 /ml haloperidol decanoate intramuscular solution 100 /ml (1 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 /ml haloperidol oral tablet 0.5, 1, 10,, 0, 5 INVEGA SUSTENNA PA NSO INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, MG/1.5 ML, 9 MG/0.5 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR PA NSO SYRINGE 7 MG/0.875 ML, 10 MG/1.15 ML, 56 MG/1.75 ML, 819 MG/.65 ML LATUDA ORAL TABLET 10 MG, 0 MG, 0 MG, 60 MG, 80 MG PA NSO; QL (0 per 0 days) loxapine succinate oral capsule 10, 5, 5, 50 NUPLAZID ORAL CAPSULE MG 5 PA NSO; NM; NDS NUPLAZID ORAL TABLET 10 MG, 17 MG 5 PA NSO; NM; NDS olanzapine intramuscular recon soln 10 (Zyprexa) 7

57 olanzapine oral tablet 10, 15,.5 (Zyprexa) 1, 0, 5, 7.5 olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis), 15, 0, 5 paliperidone oral tablet extended release (Invega) PA NSO hr 1.5,, 6, 9 perphenazine oral tablet 16,,, 8 pimozide oral tablet 1, (Orap) quetiapine oral tablet 100, 00, 5 (Seroquel) 1, 00, 00, 50 quetiapine oral tablet extended release (Seroquel XR) hr 150, 00, 00, 00, 50 REXULTI ORAL TABLET 0.5 MG, 0.5 MG, 1 MG, MG, MG, MG PA NSO; QL (0 per 0 days) RISPERDAL CONSTA PA NSO INTRAMUSCULAR SYRINGE 1.5 MG/ ML, 5 MG/ ML, 7.5 MG/ ML, 50 MG/ ML RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 0.5 MG, 1 MG, MG, MG RISPERDAL ORAL SOLUTION 1 MG/ML RISPERDAL ORAL TABLET 0.5 MG, 0.5 MG, 1 MG, MG, MG, MG risperidone oral solution 1 /ml (Risperdal) risperidone oral tablet 0.5, 0.5, 1 (Risperdal) 1,,, risperidone oral tablet,disintegrating 0.5, 0.5, 1,,, SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 5 MG PA NSO; QL (60 per 0 days) SAPHRIS 10 MG TAB SUBLINGUAL OUTER 10 MG PA NSO; QL (60 per 0 days) SAPHRIS 5 MG TAB SUBLINGUAL OUTER 5 MG PA NSO; QL (60 per 0 days) SAPHRIS SUBLINGUAL TABLET.5 MG PA NSO; QL (60 per 0 days) thioridazine oral tablet 10, 100, 5, 50 8

58 thiothixene oral capsule 1, 10,, 5 trifluoperazine oral tablet 1, 10,, 5 VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE 1.5 MG, MG,.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- MG (6) ziprasidone hcl oral capsule 0, 0, 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 10 MG, 00 MG, 05 MG EDURANT ORAL TABLET 5 MG 9 5 PA NSO; NM; NDS; QL (0 per 0 days) PA NSO; QL (0 per 0 days) (Geodon) Antivirals (Systemic) Antiretrovirals abacavir oral solution 0 /ml (Ziagen) abacavir oral tablet 00 (Ziagen) abacavir-lamivudine oral tablet (Epzicom) abacavir-lamivudine-zidovudine oral (Trizivir) tablet APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION 100 MG/ML atazanavir oral capsule 150, 00, (Reyataz) 00 ATRIPLA ORAL TABLET MG BIKTARVY ORAL TABLET MG CIMDUO ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 00 MG, 00 MG DESCOVY ORAL TABLET 00-5 MG didanosine oral capsule,delayed release(dr/ec) 15, 00, 50, 00 (Videx EC)

59 efavirenz oral capsule 00, 50 (Sustiva) efavirenz oral tablet 600 (Sustiva) EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 5 MG/5 ML (5 MG/ML) EVOTAZ ORAL TABLET MG fosamprenavir oral tablet 700 (Lexiva) FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ORAL CAPSULE 00 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 00 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE 5 MG JULUCA ORAL TABLET 50-5 MG KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution 10 /ml (Epivir) lamivudine oral tablet 100 (Epivir HBV) lamivudine oral tablet 150, 00 (Epivir) lamivudine-zidovudine oral tablet (Combivir) NM LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG lopinavir-ritonavir oral solution /5 ml (Kaletra) 50

60 nevirapine oral suspension 50 /5 ml (Viramune) nevirapine oral tablet 00 (Viramune) 1 nevirapine oral tablet extended release (Viramune XR) hr 100, 00 NORVIR ORAL CAPSULE 100 MG NORVIR ORAL POWDER IN PACKET 100 MG NORVIR ORAL SOLUTION 80 MG/ML ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG RESCRIPTOR ORAL TABLET 00 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 00 MG, 00 MG REYATAZ ORAL POWDER IN PACKET 50 MG ritonavir oral tablet 100 (Norvir) SELZENTRY ORAL SOLUTION 0 MG/ML SELZENTRY ORAL TABLET 150 MG, 00 MG, 75 MG SELZENTRY ORAL TABLET 5 MG NM stavudine oral capsule 15, 0, 0 (Zerit), 0 stavudine oral recon soln 1 /ml (Zerit) STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 00 MG, 50 MG SUSTIVA ORAL TABLET 600 MG 51

61 SYMFI LO ORAL TABLET MG SYMFI ORAL TABLET MG SYMTUZA ORAL TABLET MG tenofovir disoproxil fumarate oral tablet (Viread) 00 TIVICAY ORAL TABLET 10 MG, 5 MG TIVICAY ORAL TABLET 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, 1-00 MG, MG, MG VIDEX GM PEDIATRIC SOLN 10 MG/ML (FINAL) VIDEX GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15 MG VIRACEPT ORAL TABLET 50 MG, 65 MG VIRAMUNE ORAL SUSPENSION 50 MG/5 ML VIREAD ORAL POWDER 0 MG/SCOOP (0 MG/GRAM) VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG ZERIT ORAL RECON SOLN 1 MG/ML ZIAGEN ORAL SOLUTION 0 MG/ML zidovudine oral capsule 100 (Retrovir) zidovudine oral syrup 10 /ml (Retrovir) zidovudine oral tablet 00 Antivirals, Miscellaneous oseltamivir oral capsule 0, 5, 75 (Tamiflu) QL (8 per 180 days) oseltamivir oral suspension for reconstitution 6 /ml (Tamiflu) 5

62 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION QL (56 per 180 days) rimantadine oral tablet 100 (Flumadine) SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5 ML Hcv Antivirals EPCLUSA ORAL TABLET MG ; QL (0 per 0 days) HARVONI ORAL TABLET MG ; QL (0 per 0 days) MAVYRET ORAL TABLET MG ; QL (8 per 8 days) SOVALDI ORAL TABLET 00 MG ; QL (0 per 0 days) VOSEVI ORAL TABLET MG ; QL (8 per 8 days) ZEPATIER ORAL TABLET MG ; QL (0 per 0 days) Interferons INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 15 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 5 PA NSO; NM; NDS 00 MCG, 00 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 00 (Zovirax) 1 acyclovir oral suspension 00 /5 ml (Zovirax) acyclovir oral tablet 00, 800 (Zovirax) 1 5

63 acyclovir sodium intravenous solution 50 PA BvD /ml adefovir oral tablet 10 (Hepsera) BARACLUDE ORAL SOLUTION 0.05 MG/ML cidofovir intravenous solution 75 /ml entecavir oral tablet 0.5, 1 (Baraclude) PA famciclovir oral tablet 15, 50, 500 ganciclovir sodium intravenous recon soln (Cytovene) PA BvD 500 MODERIBA MG DOSEPACK 00 MG (7)- 00 MG (7) MODERIBA MG DOSEPACK 600 MG (7)- 600 MG (7) MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK MG (8)-MG (8), MG (8)-MG (8) MODERIBA ORAL TABLET 00 MG REBETOL ORAL SOLUTION 0 MG/ML ribasphere oral capsule 00 ribasphere oral tablet 00 ribasphere oral tablet 00 NM ribasphere oral tablet 600 ribasphere ribapak (7)- 00 (7) ribasphere ribapak (7)- 00 (7) ribasphere ribapak (7)- 600 (7) ribasphere ribapak oral tablets,dose pack (8)- (8), (8)- (8), (8)- (8) ribavirin oral capsule 00 (Ribasphere) ribavirin oral tablet 00 (Moderiba) valacyclovir oral tablet 1 gram, 500 (Valtrex) valganciclovir oral recon soln 50 /ml (Valcyte) valganciclovir oral tablet 50 (Valcyte) VIRAZOLE INHALATION RECON SOLN 6 GRAM 5

64 Blood Products/Modifiers/Volume Expanders Anticoagulants COUMADIN ORAL TABLET 1 MG, 10 MG, MG,.5 MG, MG, MG, 5 MG, 6 MG, 7.5 MG ELIQUIS ORAL TABLET.5 MG, 5 MG ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (7 TABS) enoxaparin subcutaneous solution 00 (Lovenox) QL (51 per 17 days) / ml enoxaparin subcutaneous syringe 100 (Lovenox) QL ( per 17 days) /ml, 150 /ml enoxaparin subcutaneous syringe 10 (Lovenox) QL (8 per 17 days) /0.8 ml, 80 /0.8 ml enoxaparin subcutaneous syringe 0 (Lovenox) QL (11 per 17 days) /0. ml enoxaparin subcutaneous syringe 0 (Lovenox) QL (1 per 17 days) /0. ml enoxaparin subcutaneous syringe 60 (Lovenox) QL (1 per 17 days) /0.6 ml fondaparinux subcutaneous syringe 10 (Arixtra) /0.8 ml, 5 /0. ml, 7.5 /0.6 ml fondaparinux subcutaneous syringe.5 (Arixtra) PA /0.5 ml FRAGMIN SUBCUTANEOUS SOLUTION 5,000 ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 1,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI- XA UNIT/0.7 ML,,500 ANTI-XA UNIT/0. ML, 5,000 ANTI-XA UNIT/0. ML, 7,500 ANTI-XA UNIT/0. ML heparin (porcine) in 5 % dex intravenous parenteral solution 0,000 unit/500 ml (0 unit/ml), 5,000 unit/50 ml(100 unit/ml), 5,000 unit/500 ml (50 unit/ml) heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 0,000 unit/ml, 5,000 unit/ml 55 PA BvD PA BvD PA BvD

65 heparin (porcine) injection syringe 5,000 unit/ml heparin, porcine (pf) injection solution 1,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml jantoven oral tablet 1, 10,,.5,,, 5, 6, 7.5 warfarin oral tablet 1, 10,,.5,,, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 0 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG ()- 0 MG (9) Blood Formation Modifiers ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 00 MCG/ML, 5 MCG/ML, 00 MCG/ML, 0 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0. ML, 100 MCG/0.5 ML, 150 MCG/0. ML, 00 MCG/0. ML, 5 MCG/0. ML, 00 MCG/0.6 ML, 0 MCG/0. ML, 500 MCG/ML, 60 MCG/0. ML BERINERT INTRAVENOUS KIT 500 UNIT (10 ML) CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML,,000 UNIT/ML,,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 00 MCG/0.5 ML, 80 MCG/0.8 ML MOZOBIL SUBCUTANEOUS SOLUTION MG/1. ML (0 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ML,,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ML PA BvD PA BvD PA BvD 1 (Coumadin) 1 PA BvD PA BvD PA BvD PA BvD 56

66 PROMACTA ORAL TABLET 1.5 MG, 5 MG, 50 MG, 75 MG RUCONEST INTRAVENOUS RECON SOLN,100 UNIT ZARXIO INJECTION SYRINGE 00 MCG/0.5 ML, 80 MCG/0.8 ML Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 (Agrylin) anagrelide oral capsule 1 CYKLOKAPRON INTRAVENOUS SOLUTION 1,000 MG/10 ML (100 MG/ML) tranexamic acid intravenous solution (Cyklokapron) 1,000 /10 ml (100 /ml) tranexamic acid oral tablet 650 (Lysteda) Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er (Aggrenox) multiphase 1 hr 5-00 BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100, 50 1 clopidogrel oral tablet 75 (Plavix) 1 dipyridamole oral tablet 5, 50, 75 EFFIENT ORAL TABLET 10 MG, 5 MG pentoxifylline oral tablet extended release 00 ZONTIVITY ORAL TABLET.08 MG PA Caloric Agents Caloric Agents AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % PA BvD PA BvD PA BvD PA BvD PA BvD 57

67 AMINOSYN II 8.5 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES PA BvD INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN-HBC 7% INTRAVENOUS PA BvD PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE-FREE) PA BvD INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5. % INTRAVENOUS PA BvD PARENTERAL SOLUTION 5. % CLINIMIX 5%/D15W SULFITE FREE PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D5W SULFITE-FREE PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX.75%/D5W SULFIT FREE PA BvD INTRAVENOUS PARENTERAL SOLUTION.75 % CLINIMIX.5%/D10W SULF FREE PA BvD INTRAVENOUS PARENTERAL SOLUTION.5 % CLINIMIX.5%/D5W SULFIT FREE PA BvD INTRAVENOUS PARENTERAL SOLUTION.5 % CLINIMIX.5%-D0W SULF-FREE PA BvD INTRAVENOUS PARENTERAL SOLUTION.5 % CLINIMIX.5%-D5W SULF-FREE PA BvD INTRAVENOUS PARENTERAL SOLUTION.5 % CLINIMIX 5%-D0W(SULFITE-FREE) PA BvD INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E.75%/D10W SUL FREE PA BvD INTRAVENOUS PARENTERAL SOLUTION.75 % CLINIMIX E.75%/D5W SULF FREE PA BvD INTRAVENOUS PARENTERAL SOLUTION.75 % 58

68 CLINIMIX E.5%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION.5 % CLINIMIX E.5%/D5W SUL FREE INTRAVENOUS PARENTERAL SOLUTION.5 % CLINIMIX E.5%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION.5 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D0W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % 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 0 % INTRALIPID INTRAVENOUS EMULSION 0 % NEPHRAMINE 5. % INTRAVENOUS PARENTERAL SOLUTION 5. % NUTRILIPID INTRAVENOUS EMULSION 0 % PLENAMINE INTRAVENOUS PARENTERAL SOLUTION 15 % PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE % INTRAVENOUS PARENTERAL SOLUTION % 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 PA BvD 59

69 PROSOL 0 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents CARDURA XL ORAL TABLET EXTENDED RELEASE HR MG, 8 MG clonidine hcl oral tablet 0.1, 0., (Catapres) 1 0. clonidine transdermal patch weekly 0.1 (Catapres-TTS-1) / hr clonidine transdermal patch weekly 0. (Catapres-TTS-) / hr clonidine transdermal patch weekly 0. (Catapres-TTS-) / hr clorpres oral tablet , 0.-15, doxazosin oral tablet 1,,, 8 (Cardura) 1 guanfacine oral tablet 1, 1 methyldopa oral tablet 50 1 methyldopa oral tablet 500 PA BvD PA BvD PA BvD PA BvD methyldopa-hydrochlorothiazide oral tablet 50-15, 50-5 midodrine oral tablet 10,.5, 5 NORTHERA ORAL CAPSULE 100 MG, 00 MG, 00 MG phenoxybenzamine oral capsule 10 (Dibenzyline) prazosin oral capsule 1,, 5 (Minipress) Angiotensin Ii Receptor Antagonists candesartan oral tablet 16,,, 8 (Atacand) candesartan-hydrochlorothiazid oral (Atacand HCT) tablet , -1.5, -5 EDARBI ORAL TABLET 0 MG, 80 MG 60

70 EDARBYCLOR ORAL TABLET MG, 0-5 MG ENTRESTO ORAL TABLET -6 MG, PA 9-51 MG, MG eprosartan oral tablet 600 irbesartan oral tablet 150, 00, 75 (Avapro) 1 irbesartan-hydrochlorothiazide oral tablet , (Avalide) losartan oral tablet 100, 5, 50 (Cozaar) 1 losartan-hydrochlorothiazide oral tablet , 100-5, (Hyzaar) 1 olmesartan oral tablet 0, 0, 5 (Benicar) olmesartan-amlodipin-hcthiazid oral (Tribenzor) tablet , , , , olmesartan-hydrochlorothiazide oral (Benicar HCT) tablet 0-1.5, 0-1.5, 0-5 telmisartan oral tablet 0, 0, 80 (Micardis) telmisartan-amlodipine oral tablet 0-10 (Twynsta), 0-5, 80-10, 80-5 telmisartan-hydrochlorothiazid oral tablet (Micardis HCT) 0-1.5, , 80-5 valsartan oral tablet 160, 0, 0 (Diovan) 1, 80 valsartan-hydrochlorothiazide oral tablet (Diovan HCT) , 160-5, 0-1.5, 0-5, Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10, 0, 0 (Lotensin) 1 benazepril oral tablet 5 1 benazepril-hydrochlorothiazide oral tablet (Lotensin HCT) , 0-1.5, 0-5 benazepril-hydrochlorothiazide oral tablet captopril oral tablet 100, 1.5, 5, 50 captopril-hydrochlorothiazide oral tablet 5-15, 5-5, 50-15,

71 enalapril maleate oral tablet 10,.5 (Vasotec) 1, 0, 5 enalapril-hydrochlorothiazide oral tablet (Vaseretic) enalapril-hydrochlorothiazide oral tablet EPANED ORAL SOLUTION 1 MG/ML PA fosinopril oral tablet 10, 0, 0 1 fosinopril-hydrochlorothiazide oral tablet , lisinopril oral tablet 10, 0, 5 (Prinivil) 1 lisinopril oral tablet.5, 0, 0 (Zestril) 1 lisinopril-hydrochlorothiazide oral tablet (Zestoretic) , 0-1.5, 0-5 moexipril oral tablet 15, 7.5 moexipril-hydrochlorothiazide oral tablet , 15-5, perindopril erbumine oral tablet,, 8 quinapril oral tablet 10, 0, 0, (Accupril) 1 5 quinapril-hydrochlorothiazide oral tablet (Accuretic) , 0-1.5, 0-5 ramipril oral capsule 1.5, 10,.5 (Altace) 1, 5 trandolapril oral tablet 1,, trandolapril-verapamil oral tablet, ir - er, biphasic hr 1-0 trandolapril-verapamil oral tablet, ir - er, (Tarka) biphasic hr -180, -0, -0 Antiarrhythmic Agents amiodarone intravenous solution 50 /ml amiodarone oral tablet 100, 00 (Pacerone) amiodarone oral tablet 00 (Pacerone) 1 disopyramide phosphate oral capsule 100 (Norpace), 150 dofetilide oral capsule 15 mcg, 50 mcg, (Tikosyn) 500 mcg flecainide oral tablet 100, 150, 50 6

72 mexiletine oral capsule 150, 00, 50 MULTAQ ORAL TABLET 00 MG NEXTERONE INTRAVENOUS SOLUTION 150 MG/100 ML (1.5 MG/ML), 60 MG/00 ML (1.8 MG/ML) pacerone oral tablet 100, 00 pacerone oral tablet 00 1 procainamide injection solution 100 /ml, 500 /ml procainamide intravenous syringe 100 /ml propafenone oral capsule,extended release (Rythmol SR) 1 hr 5, 5, 5 propafenone oral tablet 150, 5, 00 quinidine gluconate injection solution 80 /ml quinidine gluconate oral tablet extended release quinidine sulfate oral tablet 00, 00 Beta-Adrenergic Blocking Agents acebutolol oral capsule 00, 00 atenolol oral tablet 100, 5, 50 (Tenormin) 1 atenolol-chlorthalidone oral tablet (Tenoretic 100) atenolol-chlorthalidone oral tablet 50-5 (Tenoretic 50) betaxolol oral tablet 10, 0 bisoprolol fumarate oral tablet 10, 5 carvedilol oral tablet 1.5, 5, (Coreg) 1.15, 6.5 carvedilol phosphate oral capsule, er (Coreg CR) multiphase hr 10, 0, 0, 80 labetalol oral tablet 100, 00, 00 1 metoprolol succinate oral tablet extended release hr 100, 00, 5, 50 (Toprol XL) 6

73 metoprolol ta-hydrochlorothiaz oral tablet 100-5, metoprolol ta-hydrochlorothiaz oral tablet (Lopressor HCT) 50-5 metoprolol tartrate intravenous syringe 5 /5 ml metoprolol tartrate oral tablet 100, 50 (Lopressor) 1 metoprolol tartrate oral tablet 5, 75 1 nadolol oral tablet 0, 0, 80 (Corgard) nadolol-bendroflumethiazide oral tablet (Corzide) 0-5, 80-5 pindolol oral tablet 10, 5 propranolol oral capsule,extended release (Inderal LA) hr 10, 160, 60, 80 propranolol oral solution 0 /5 ml ( /ml), 0 /5 ml (8 /ml) propranolol oral tablet 10, 0, 0 1, 80 propranolol oral tablet 60 propranolol-hydrochlorothiazid oral tablet 0-5, 80-5 sorine oral tablet 10, 160, 0, 80 sotalol af oral tablet 10, 160, 80 sotalol oral tablet 10, 160, 0 (Betapace), 80 timolol maleate oral tablet 10, 0, 5 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release hr 10, 180, 0, 00 diltiazem hcl intravenous recon soln 100 diltiazem hcl intravenous solution 5 /ml diltiazem hcl oral capsule,extended release 1 hr 10, 60, 90 diltiazem hcl oral capsule,extended (Taztia XT) release hr 60 diltiazem hcl oral capsule,extended release hr 0 (Tiazac) 6

74 diltiazem hcl oral capsule,extended (Cardizem CD) release hr 10, 180, 0, 00 diltiazem hcl oral tablet 10, 0, (Cardizem) 1 60 diltiazem hcl oral tablet 90 1 dilt-xr oral capsule,ext.rel h degradable 10, 180, 0 matzim la oral tablet extended release hr 180, 0, 00, 60, 0 taztia xt oral capsule,extended release hr 10, 180, 0, 00, 60 verapamil intravenous solution.5 /ml verapamil oral capsule, hr er pellet ct (Verelan PM) 100, 00, 00 verapamil oral capsule,ext rel. pellets (Verelan) hr 10, 180, 0, 60 verapamil oral tablet 10, 80 (Calan) 1 verapamil oral tablet 0 1 verapamil oral tablet extended release 10 (Calan SR), 180, 0 Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 PA MG DEMSER ORAL CAPSULE 50 MG digitek oral tablet 15 mcg QL (0 per 0 days) digitek oral tablet 50 mcg digox oral tablet 15 mcg QL (0 per 0 days) digox oral tablet 50 mcg digoxin injection syringe 50 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML digoxin oral tablet 15 mcg (Digitek) QL (0 per 0 days) digoxin oral tablet 50 mcg (Digitek) epinephrine injection auto-injector 0.15 (Auvi-Q) ST; QL ( per 15 days) /0.15 ml epinephrine injection auto-injector 0.15 (EpiPen Jr) QL ( per 15 days) /0. ml epinephrine injection auto-injector 0. /0. ml ST; QL ( per 15 days) 65

75 epinephrine injection auto-injector 0. (Auvi-Q) QL ( per 15 days) /0. ml EPIPEN -PAK INJECTION AUTO- QL ( per 15 days) INJECTOR 0. MG/0. ML EPIPEN JR -PAK INJECTION AUTO- QL ( per 15 days) INJECTOR 0.15 MG/0. ML FIRAZYR SUBCUTANEOUS SYRINGE 0 MG/ ML hydralazine injection solution 0 /ml hydralazine oral tablet 10, 100, 5, 50 LANOXIN INJECTION SOLUTION 50 MCG/ML RANEXA ORAL TABLET EXTENDED RELEASE 1 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 0, 60 amlodipine oral tablet 10,.5, 5 (Norvasc) 1 amlodipine-benazepril oral capsule 10-0 (Lotrel), 10-0, 5-10, 5-0, 5-0 amlodipine-benazepril oral capsule.5-10 amlodipine-olmesartan oral tablet 10-0 (Azor), 10-0, 5-0, 5-0 amlodipine-valsartan oral tablet (Exforge), 10-0, 5-160, 5-0 amlodipine-valsartan-hcthiazid oral tablet (Exforge HCT) , , , , felodipine oral tablet extended release hr 10,.5, 5 isradipine oral capsule.5, 5 nicardipine intravenous solution 5 /10 (Cardene IV) ml nicardipine oral capsule 0, 0 nifedipine oral capsule 10 (Procardia) nifedipine oral capsule 0 nifedipine oral tablet extended release (Procardia XL) hr 0, 60, 90 nifedipine oral tablet extended release 0, 60, 90 (Adalat CC) 66

76 nimodipine oral capsule 0 nisoldipine oral tablet extended release (Sular) hr 17,, 8.5 nisoldipine oral tablet extended release hr 0, 0, 0 nisoldipine oral tablet extended release hr 5.5 Diuretics amiloride oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 bumetanide injection solution 0.5 /ml bumetanide oral tablet 0.5, 1, chlorothiazide oral tablet 50, 500 chlorothiazide sodium intravenous recon (Diuril IV) soln 500 chlorthalidone oral tablet 5, 50 ethacrynic acid oral tablet 5 (Edecrin) furosemide injection solution 10 /ml furosemide injection syringe 10 /ml furosemide oral solution 10 /ml, 0 /5 ml (8 /ml) furosemide oral tablet 0, 0, 80 (Lasix) 1 hydrochlorothiazide oral capsule 1.5 (Microzide) 1 hydrochlorothiazide oral tablet 1.5, 1 5, 50 indapamide oral tablet 1.5,.5 1 methyclothiazide oral tablet 5 metolazone oral tablet 10,.5, 5 spironolactone oral tablet 100, 5, 50 (Aldactone) spironolacton-hydrochlorothiaz oral tablet (Aldactazide) 5-5 torsemide oral tablet 10, 0 (Demadex) 1 torsemide oral tablet 100, 5 1 triamterene-hydrochlorothiazid oral (Dyazide) 1 capsule triamterene-hydrochlorothiazid oral capsule

77 triamterene-hydrochlorothiazid oral tablet (Maxzide-5) triamterene-hydrochlorothiazid oral tablet (Maxzide) Dyslipidemics ALTOPREV ORAL TABLET EXTENDED RELEASE HR 0 MG, 0 MG, 60 MG amlodipine-atorvastatin oral tablet (Caduet), 10-0, 10-0, 10-80, 5-10, 5-0, 5-0, 5-80 amlodipine-atorvastatin oral tablet.5-10,.5-0,.5-0 atorvastatin oral tablet 10, 0, 0 (Lipitor) 1, 80 cholestyramine (with sugar) oral powder (Questran) in packet gram cholestyramine light oral powder gram cholestyramine light packet gram colesevelam oral powder in packet.75 (WelChol) gram colesevelam oral tablet 65 (WelChol) colestipol oral packet 5 gram (Colestid) colestipol oral tablet 1 gram (Colestid) ezetimibe oral tablet 10 (Zetia) QL (0 per 0 days) ezetimibe-simvastatin oral tablet (Vytorin 10-10) ezetimibe-simvastatin oral tablet 10-0 (Vytorin 10-0) ezetimibe-simvastatin oral tablet 10-0 (Vytorin 10-0) ezetimibe-simvastatin oral tablet (Vytorin 10-80) fenofibrate micronized oral capsule 10, 1, 00,, 67 fenofibrate nanocrystallized oral tablet (Tricor) 15, 8 fenofibrate oral capsule 150, 50 (Lipofen) fenofibrate oral tablet 160, 5 fenofibrate oral tablet 0 (Fenoglide) fenofibric acid (choline) oral (Trilipix) capsule,delayed release(dr/ec) 15, 5 fenofibric acid oral tablet 105, 5 (Fibricor) fluvastatin oral capsule 0, 0 (Lescol) 68

78 fluvastatin oral tablet extended release (Lescol XL) hr 80 gemfibrozil oral tablet 600 (Lopid) 1 JUXTAPID ORAL CAPSULE 10 MG, 0 MG, 0 MG, 0 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SYRINGE 00 MG/ML lovastatin oral tablet 10, 0, 0 1 niacin oral tablet extended release hr (Niaspan Extended- 1,000, 500, 750 Release) niacor oral tablet 500 omega- acid ethyl esters oral capsule 1 (Lovaza) gram pravastatin oral tablet 10 1 pravastatin oral tablet 0, 0, 80 (Pravachol) 1 prevalite oral powder in packet gram REPATHA SYRINGE SUBCUTANEOUS SYRINGE 10 MG/ML ; QL ( per 8 days) rosuvastatin oral tablet 10, 0, 0 (Crestor) 1, 5 simvastatin oral tablet 10, 0, 0 (Zocor) 1, 80 simvastatin oral tablet 5 1 VASCEPA ORAL CAPSULE 0.5 GRAM, PA 1 GRAM WELCHOL ORAL POWDER IN PACKET.75 GRAM Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 5, 50 (Inspra) TEKTURNA HCT ORAL TABLET MG, MG, MG, 00-5 MG TEKTURNA ORAL TABLET 150 MG, 00 MG Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 10, 0 isosorbide dinitrate oral tablet 0 isosorbide dinitrate oral tablet 5 (Isordil Titradose) 69

79 isosorbide dinitrate oral tablet extended (ISOCHRON) release 0 isosorbide mononitrate oral tablet 10, 1 0 isosorbide mononitrate oral tablet extended release hr 10, 0, 60 minoxidil oral tablet 10,.5 NITRO-DUR TRANSDERMAL PATCH HOUR 0. MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet 0., 0. (Nitrostat) 1, 0.6 nitroglycerin transdermal patch hour (Minitran) 0.1 /hr, 0. /hr, 0. /hr, 0.6 /hr nitroglycerin translingual spray,nonaerosol 00 mcg/spray (Nitrolingual) Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 1 HR 10 MG atomoxetine oral capsule 10, 100, 18, 5, 0, 60, 80 AUBAGIO ORAL TABLET 1 MG, 7 MG AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 0 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 0 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 0 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0. MG COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML, 0 MG/ML dalfampridine oral tablet extended release 1 hr 10 DAYTRANA TRANSDERMAL PATCH HOUR 10 MG/9 HR, 15 MG/9 HR, 0 MG/9 HR, 0 MG/9 HR dexmethylphenidate oral capsule,er biphasic , 15, 0, 5, 0, 5, 0, 5 ; QL (60 per 0 days) (Strattera) QL (60 per 0 days) ; QL (8 per 8 days) (Ampyra) ; QL (60 per 0 days) (Focalin XR) 70

80 dexmethylphenidate oral tablet 10,.5, 5 (Focalin) dextroamphetamine oral capsule, extended (Dexedrine Spansule) release 10, 15, 5 dextroamphetamine oral tablet 10, 5 (Zenzedi) dextroamphetamine-amphetamine oral (Adderall XR) capsule,extended release hr 10, 15, 0, 5, 0, 5 dextroamphetamine-amphetamine oral tablet 10, 1.5, 15, 0, 0, 5, 7.5 (Adderall) EXTAVIA SUBCUTANEOUS KIT 0. MG GILENYA ORAL CAPSULE 0.5 MG, 0.5 MG ; QL (8 per 8 days) glatiramer subcutaneous syringe 0 /ml, 0 /ml (Copaxone) ; QL (0 per 0 days) guanfacine oral tablet extended release (Intuniv ER) 1 hr 1,,, lithium carbonate oral capsule 150, 1 00, 600 lithium carbonate oral tablet 00 1 lithium carbonate oral tablet extended (Lithobid) release 00 lithium carbonate oral tablet extended release 50 lithium citrate oral solution 8 meq/5 ml metadate er oral tablet extended release 0 methamphetamine oral tablet 5 (Desoxyn) PA methylphenidate hcl oral capsule, er biphasic , 0, 0, 0, 50, 60 methylphenidate hcl oral capsule,er (Ritalin LA) biphasic , 0 methylphenidate hcl oral capsule,er biphasic methylphenidate hcl oral solution 10 /5 (Methylin) ml, 5 /5 ml methylphenidate hcl oral tablet 10, 0, 5 (Ritalin) 71

81 methylphenidate hcl oral tablet extended release 10 methylphenidate hcl oral tablet extended (Metadate ER) release 0 methylphenidate hcl oral tablet extended (Concerta) release hr 18, 7, 6, 5 methylphenidate hcl oral tablet extended (Relexxii) release hr 7 methylphenidate hcl oral tablet,chewable 10,.5, 5 PLEGRIDY SUBCUTANEOUS PEN INJECTOR 15 MCG/0.5 ML, 6 MCG/0.5 ML- 9 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 15 MCG/0.5 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE MCG/0.5 ML, MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR MCG/0.5 ML, MCG/0.5 ML, 8.8MCG/0.ML- MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.ML- MCG/0.5ML (6) riluzole oral tablet 50 (Rilutek) RITALIN LA ORAL CAPSULE,ER BIPHASIC MG SAVELLA ORAL TABLET 100 MG, QL (60 per 0 days) 1.5 MG, 5 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 1.5 MG (5)-5 MG(8)-50 MG() TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10 MG ; QL (1 per 0 days) TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10 MG (1)- 0 MG (6), 0 MG ; QL (60 per 0 days) tetrabenazine oral tablet 1.5, 5 (Xenazine) VYVANSE ORAL CAPSULE 10 MG, 0 MG, 0 MG, 0 MG, 50 MG, 60 MG, 70 MG 7

82 Contraceptives Contraceptives alyacen 1/5 (8) oral tablet 1-5 -mcg amethia oral tablets,dose pack, month mcg (8)/10 mcg (7) amethyst oral tablet 90-0 mcg apri oral tablet aranelle (8) oral tablet 0.5/1/0.5-5 mcg ashlyna oral tablets,dose pack, month mcg (8)/10 mcg (7) aubra oral tablet mcg aviane oral tablet mcg balziva (8) oral tablet mcg bekyree (8) oral tablet x1 /0.01 x 5 blisovi fe oral tablet 1-0 mcg ()/75 () blisovi fe 1.5/0 (8) oral tablet mcg (1)/75 (7) blisovi fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) briellyn oral tablet mcg camila oral tablet 0.5 caziant (8) oral tablet 0.1/.15/ mcg cryselle (8) oral tablet mcg cyclafem 1/5 (8) oral tablet 1-5 mcg cyclafem 7/7/7 (8) oral tablet 0.5/0.75/1-5 mcg deblitane oral tablet 0.5 delyla (8) oral tablet mcg desog-e.estradiol/e.estradiol oral tablet (Azurette (8)) x1 /0.01 x 5 drospirenone-e.estradiol-lm.fa oral tablet (Beyaz) () () drospirenone-ethinyl estradiol oral tablet (Gianvi (8)) -0.0 drospirenone-ethinyl estradiol oral tablet (Ocella) -0.0 emoquette oral tablet

83 enpresse oral tablet 50-0 (6)/75-0 (5)/15-0(10) errin oral tablet 0.5 ethynodiol diac-eth estradiol oral tablet 1- (Kelnor 1/5 (8)) 5 -mcg ethynodiol diac-eth estradiol oral tablet 1- (Kelnor 1-50) 50 -mcg falmina (8) oral tablet mcg femynor oral tablet mcg gianvi (8) oral tablet -0.0 introvale oral tablets,dose pack, month mcg jolivette oral tablet 0.5 juleber oral tablet junel 1.5/0 (1) oral tablet mcg junel 1/0 (1) oral tablet 1-0 -mcg junel fe 1.5/0 (8) oral tablet mcg (1)/75 (7) junel fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) junel fe oral tablet 1-0 mcg ()/75 () kaitlib fe oral tablet,chewable 0.8-5mcg() and 75 () kariva (8) oral tablet x1 /0.01 x 5 kelnor 1/5 (8) oral tablet 1-5 -mcg kelnor 1-50 oral tablet mcg kimidess (8) oral tablet x1 /0.01 x 5 l norgest/e.estradiol-e.estrad oral (Fayosim) tablets,dose pack, month mcg/ mcg l norgest/e.estradiol-e.estrad oral (Amethia) tablets,dose pack, month mcg (8)/10 mcg (7) larin 1.5/0 (1) oral tablet mcg larin 1/0 (1) oral tablet 1-0 -mcg larin fe 1.5/0 (8) oral tablet mcg (1)/75 (7) 7

84 larin fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) larissia oral tablet mcg layolis fe oral tablet,chewable 0.8-5mcg() and 75 () leena 8 oral tablet 0.5/1/ mcg lessina oral tablet mcg levonest (8) oral tablet 50-0 (6)/75-0 (5)/15-0(10) levonorgestrel-ethinyl estrad oral tablet (Aubra) mcg levonorgestrel-ethinyl estrad oral tablet (Altavera (8)) levonorgestrel-ethinyl estrad oral tablet (Amethyst) 90-0 mcg levonorgestrel-ethinyl estrad oral (Introvale) tablets,dose pack, month mcg levonorg-eth estrad triphasic oral tablet (Enpresse) 50-0 (6)/75-0 (5)/15-0(10) levora-8 oral tablet loryna (8) oral tablet -0.0 low-ogestrel (8) oral tablet 0.-0 mcg lutera (8) oral tablet mcg lyza oral tablet 0.5 marlissa oral tablet microgestin 1.5/0 (1) oral tablet mcg microgestin 1/0 (1) oral tablet 1-0 mcg microgestin fe 1.5/0 (8) oral tablet mcg (1)/75 (7) microgestin fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) mili oral tablet mcg mononessa (8) oral tablet mcg necon 0.5/5 (8) oral tablet mcg necon 7/7/7 (8) oral tablet 0.5/0.75/1-5 mcg nikki (8) oral tablet

85 nora-be oral tablet 0.5 noreth-ethinyl estradiol-iron oral (Wymzya Fe) tablet,chewable 0.-5mcg(1) and 75 (7) noreth-ethinyl estradiol-iron oral (Generess Fe) tablet,chewable 0.8-5mcg() and 75 () norethindrone (contraceptive) oral tablet (Camila) 0.5 norethindrone ac-eth estradiol oral tablet (Junel 1/0 (1)) 1-0 -mcg norethindrone-e.estradiol-iron oral tablet (Blisovi Fe 1/0 (8)) 1-0 mcg (1)/75 (7) norethindrone-e.estradiol-iron oral tablet (Blisovi Fe) 1-0 mcg ()/75 () norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen LO 0.18/0.15/0.5-5 mcg (8)) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen (8)) 0.18/0.15/0.5-5 mcg (8) norgestimate-ethinyl estradiol oral tablet (Estarylla) mcg norlyroc oral tablet 0.5 nortrel 0.5/5 (8) oral tablet mcg nortrel 1/5 (1) oral tablet 1-5 -mcg nortrel 1/5 (8) oral tablet 1-5 -mcg nortrel 7/7/7 (8) oral tablet 0.5/0.75/1-5 mcg NUVARING VAGINAL RING MG/ HR ocella oral tablet -0.0 ogestrel (8) oral tablet mcg orsythia oral tablet mcg pimtrea (8) oral tablet x1 /0.01 x 5 pirmella oral tablet 1-5 -mcg portia oral tablet previfem oral tablet mcg quasense oral tablets,dose pack, month mcg reclipsen (8) oral tablet

86 setlakin oral tablets,dose pack, month mcg sharobel oral tablet 0.5 sprintec (8) oral tablet mcg sronyx oral tablet mcg tarina fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) tri-legest fe oral tablet 1-0(5)/1-0(7) /1-5mcg (9) tri-lo-estarylla oral tablet 0.18/0.15/0.5-5 mcg tri-lo-sprintec oral tablet 0.18/0.15/0.5-5 mcg tri-mili oral tablet 0.18/0.15/0.5-5 mcg (8) trinessa (8) oral tablet 0.18/0.15/0.5-5 mcg (8) tri-previfem (8) oral tablet 0.18/0.15/0.5-5 mcg (8) tri-sprintec (8) oral tablet 0.18/0.15/0.5-5 mcg (8) trivora (8) oral tablet 50-0 (6)/75-0 (5)/15-0(10) tulana oral tablet 0.5 velivet triphasic regimen (8) oral tablet 0.1/.15/ mcg vestura (8) oral tablet -0.0 vienva oral tablet mcg vyfemla (8) oral tablet mcg wymzya fe oral tablet,chewable 0.- 5mcg(1) and 75 (7) xulane transdermal patch weekly mcg/ hr zarah oral tablet -0.0 zenchent (8) oral tablet mcg zovia 1/5e (8) oral tablet 1-5 -mcg Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 0 (Evoxac) chlorhexidine gluconate mucous (Paroex Oral Rinse) membrane mouthwash 0.1 % 77

87 paroex oral rinse mucous membrane mouthwash 0.1 % periogard mucous membrane mouthwash 0.1 % pilocarpine hcl oral tablet 5, 7.5 (Salagen (pilocarpine)) triamcinolone acetonide dental paste 0.1 % (Oralone) Dermatological Agents Dermatological Agents, Other acitretin oral capsule 10, 17.5, 5 (Soriatane) acyclovir topical ointment 5 % (Zovirax) ST ALCOHOL PADS TOPICAL PADS, MEDICATED ammonium lactate topical cream 1 % (Geri-Hydrolac) ammonium lactate topical lotion 1 % (AmLactin) AZELEX TOPICAL CREAM 0 % PA calcipotriene scalp solution % calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcitrene) calcipotriene-betamethasone topical (Taclonex) ointment % calcitriol topical ointment mcg/gram (Vectical) claravis oral capsule 10, 0, 0, 0 CONDYLOX TOPICAL GEL 0.5 % COSENTYX ( SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML COSENTYX PEN ( PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML DENAVIR TOPICAL CREAM 1 % doxepin topical cream 5 % (Prudoxin) FINACEA TOPICAL FOAM 15 % FINACEA TOPICAL GEL 15 % fluorouracil topical cream 0.5 % (Carac) fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution %, 5 % imiquimod topical cream in metered-dose (Zyclara) pump.75 % imiquimod topical cream in packet 5 % (Aldara) 78

88 isotretinoin oral capsule 10, 0, 0 (Absorica), 0 mafenide acetate topical packet 50 gram (Sulfamylon) methoxsalen oral capsule,liqd-filled,rapid (Oxsoralen Ultra) rel 10 myorisan oral capsule 10, 0, 0, 0 PANRETIN TOPICAL GEL 0.1 % PICATO TOPICAL GEL % ; QL ( per 10 days) PICATO TOPICAL GEL 0.05 % ; QL ( per 10 days) podofilox topical solution 0.5 % REGRANEX TOPICAL GEL 0.01 % ; QL (0 per 15 days) SANTYL TOPICAL OINTMENT 50 UNIT/GRAM SULFAMYLON TOPICAL CREAM 85 MG/G UVADEX INJECTION SOLUTION 0 MCG/ML VALCHLOR TOPICAL GEL % 5 PA NSO; NM; NDS; QL (0 per 0 days) XERESE TOPICAL CREAM 5-1 % zenatane oral capsule 10, 0, 0, 0 ZOVIRAX TOPICAL CREAM 5 % ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP.5 %,.75 % Dermatological Antibacterials clindamycin phosphate topical foam 1 % (Evoclin) clindamycin phosphate topical gel 1 % (Cleocin T) clindamycin phosphate topical lotion 1 % (Cleocin T) clindamycin phosphate topical solution 1 (Cleocin T) % clindamycin phosphate topical swab 1 % (Cleocin T) clindamycin-benzoyl peroxide topical gel (Duac) 1. %(1 % base) -5 % clindamycin-benzoyl peroxide topical gel 1-5 % (Benzaclin) clindamycin-tretinoin topical gel (Veltin) % 79

89 ery pads topical swab % erythromycin with ethanol topical gel % (Erygel) erythromycin with ethanol topical solution % erythromycin-benzoyl peroxide topical gel (Aktipak) -5 % gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % metronidazole topical cream 0.75 % (MetroCream) metronidazole topical gel 0.75 % (Rosadan) metronidazole topical gel 1 % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) mupirocin calcium topical cream % (Bactroban) mupirocin topical ointment % (Centany) neomycin-polymyxin b gu irrigation solution 0-00,000 unit/ml neuac topical gel 1. %(1 % base) -5 % selenium sulfide topical lotion.5 % silver sulfadiazine topical cream 1 % (Silvadene) ssd topical cream 1 % sulfacetamide sodium (acne) topical (Klaron) suspension 10 % Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 %,.5 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % amcinonide topical cream 0.1 % PA amcinonide topical lotion 0.1 % amcinonide topical ointment 0.1 % PA APEXICON E TOPICAL CREAM 0.05 PA % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0.1 % betamethasone valerate topical foam 0.1 % (Luxiq) PA 80

90 betamethasone valerate topical lotion 0.1 % betamethasone valerate topical ointment 0.1 % 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 % CAPEX TOPICAL SHAMPOO 0.01 % 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 CLODERM TOPICAL CREAM 0.1 % PA CORDRAN TAPE LARGE ROLL TOPICAL TAPE MCG/CM 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 0.05 % (Topicort) desoximetasone topical cream 0.5 % (Topicort) desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 % (Topicort) desoximetasone topical ointment 0.5 % (Topicort) diflorasone topical cream 0.05 % (Psorcon) diflorasone topical ointment 0.05 % ELIDEL TOPICAL CREAM 1 % 81

91 fluocinolone 0.01% body oil 0.01 % (Derma-Smoothe/FS Body Oil) fluocinolone and shower cap scalp oil 0.01 (Derma-Smoothe/FS % Scalp Oil) fluocinolone topical cream 0.01 % fluocinolone topical cream 0.05 % (Synalar) fluocinolone topical ointment 0.05 % (Synalar) fluocinolone topical solution 0.01 % (Synalar) fluocinonide topical cream 0.05 % fluocinonide topical cream 0.1 % (Vanos) fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % flurandrenolide topical cream 0.05 % (Cordran) 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 % HALOG TOPICAL CREAM 0.1 % PA HALOG TOPICAL OINTMENT 0.1 % PA hydrocort buty 0.1% lipo cream 0.1 % (Locoid Lipocream) PA hydrocortisone butyrate topical cream 0.1 (Locoid) PA % hydrocortisone butyrate topical ointment 0.1 % hydrocortisone butyrate topical solution (Locoid) 0.1 % hydrocortisone topical cream 1 %,.5 % (Ala-Cort) hydrocortisone topical lotion.5 % hydrocortisone topical ointment 1 % (Anti-Itch (HC)) hydrocortisone topical ointment.5 % hydrocortisone valerate topical cream 0. % hydrocortisone valerate topical ointment 0. % mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % 8

92 PANDEL TOPICAL CREAM 0.1 % PA prednicarbate topical cream 0.1 % prednicarbate topical ointment 0.1 % (Dermatop) procto-med hc topical cream with perineal applicator.5 % procto-pak topical cream with perineal applicator 1 % proctosol hc topical cream with perineal applicator.5 % proctozone-hc topical cream with perineal applicator.5 % tacrolimus topical ointment 0.0 %, 0.1 % (Protopic) triamcinolone acetonide topical aerosol (Kenalog) 0.17 /gram triamcinolone acetonide topical cream 0.05 % triamcinolone acetonide topical cream 0.1 (Triderm) %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0.1 % triamcinolone acetonide topical ointment 0.05 %, 0.1 %, 0.5 % tridesilon topical cream 0.05 % PA ULTRAVATE TOPICAL LOTION 0.05 % Dermatological Retinoids adapalene 0.% gel pump 0. % (Differin) PA adapalene topical cream 0.1 % (Differin) PA adapalene topical gel 0.1 %, 0. % (Differin) PA adapalene-benzoyl peroxide topical gel (Epiduo) PA with pump % avita topical cream 0.05 % PA avita topical gel 0.05 % PA RETIN-A MICRO PUMP TOPICAL GEL PA WITH PUMP 0.06 %, 0.08 % tazarotene topical cream 0.1 % (Avage) TAZORAC TOPICAL GEL 0.05 %, 0.1 % tretinoin microspheres topical gel 0.0 %, (Retin-A Micro) PA 0.1 % tretinoin topical cream 0.05 % (Avita) PA tretinoin topical cream 0.05 %, 0.1 % (Retin-A) PA 8

93 tretinoin topical gel 0.01 % (Retin-A) PA tretinoin topical gel 0.05 % (Avita) PA tretinoin topical gel 0.05 % (Atralin) PA Scabicides And Pediculicides ELIMITE TOPICAL CREAM 5 % EURAX TOPICAL CREAM 10 % EURAX TOPICAL LOTION 10 % lindane topical shampoo 1 % malathion topical lotion 0.5 % (Ovide) permethrin topical cream 5 % (Elimite) SKLICE TOPICAL LOTION 0.5 % QL (117 per 15 days) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 9 GAUGE X 1/" BD UF NANO PEN NEEDLE MMXG GAUGE X 5/" BD VEO INS 0. ML 6MMX1G (1/) 0. ML 1 GAUGE X 15/6" BD VEO INS SYRING 1 ML 6MMX1G 1 ML 1 GAUGE X 15/6" BD VEO INS SYRN 0.5 ML 6MMX1G 1/ ML 1 GAUGE X 15/6" GAUZE PAD TOPICAL BANDAGE X " INSULIN SYRINGE-NEEDLE U-100 (Ultilet Insulin Syringe) SYRINGE 0. ML 9 GAUGE INSULIN SYRINGE-NEEDLE U-100 (Advocate Syringes) SYRINGE 1 ML 9 GAUGE X 1/" INSULIN SYRINGE-NEEDLE U-100 (Lite Touch Insulin SYRINGE 1/ ML 8 GAUGE Syringe) PEN NEEDLE, DIABETIC NEEDLE 9 (1st Tier Unifine GAUGE X 1/" Pentips) VGO 0 DISPOSABLE DEVICE Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 50 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 00 UNIT 8

94 CHENODAL ORAL TABLET 50 MG CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 1,000-8,000-60,000 UNIT,,000-76,000-10,000 UNIT,,000-9,500-15,000 UNIT, 6,000-11, ,000 UNIT, 6,000-19,000-0,000 UNIT CYSTAGON ORAL CAPSULE 150 MG, PA 50 MG ELAPRASE INTRAVENOUS SOLUTION 6 MG/ ML ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 5 MG KUVAN ORAL POWDER IN PACKET 100 MG, 500 MG KUVAN ORAL TABLET,SOLUBLE 100 MG LUMIZYME INTRAVENOUS RECON SOLN 50 MG miglustat oral capsule 100 (Zavesca) NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, MG, 5 MG PANCREAZE ORAL ST CAPSULE,DELAYED RELEASE(DR/EC) 10,500-5,500-61,500 UNIT, 16,800-56,800-98,00 UNIT,,600-6,00-10,850 UNIT, 1,000-5,700-8,900 UNIT,,00-1,00-,600 UNIT PERTZYE ORAL CAPSULE,DELAYED ST RELEASE(DR/EC) 16,000-57,500-60,500 UNIT,,000-86,50-90,750 UNIT,,000-1,75-15,15 UNIT, 8,000-8,750-0,50 UNIT PULMOZYME INHALATION 5 PA BvD; NM; NDS SOLUTION 1 MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 0 MG/ML 85

95 SUCRAID ORAL SOLUTION 8,500 UNIT/ML VPRIV INTRAVENOUS RECON SOLN 00 UNIT ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-,000 -,000 UNIT, 10,000-,000-55,000 UNIT, 15,000-7,000-6,000 UNIT, 15,000-51,000-8,000 UNIT, 0,000-6,000-8,000 UNIT, 5,000-79, ,000 UNIT, 5,000-85,000-16,000 UNIT,,000-10,000-1,000-UNIT,,000-10,000-16,000 UNIT, 0,000-16, ,000 UNIT, 5,000-17,000-7,000 UNIT, 5,000-17,000-,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous ALOMIDE OPHTHALMIC (EYE) ST DROPS 0.1 % apraclonidine ophthalmic (eye) drops 0.5 (Iopidine) % atropine ophthalmic (eye) drops 1 % (Isopto Atropine) azelastine nasal aerosol,spray 17 mcg (0.1 %) azelastine nasal spray,non-aerosol 0.15 % (Astepro) (05.5 mcg) azelastine ophthalmic (eye) drops 0.05 % BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % cromolyn ophthalmic (eye) drops % CYSTARAN OPHTHALMIC (EYE) DROPS 0. % ; QL (60 per 0 days) EMADINE OPHTHALMIC (EYE) DROPS 0.05 % epinastine ophthalmic (eye) drops 0.05 % (Elestat) ipratropium bromide nasal spray,nonaerosol 0.0 %, mcg (0.06 %) LACRISERT OPHTHALMIC (EYE) INSERT 5 MG LASTACAFT OPHTHALMIC (EYE) DROPS 0.5 % 86

96 olopatadine nasal spray,non-aerosol 0.6 (Patanase) % olopatadine ophthalmic (eye) drops 0.1 % (Patanol) ST olopatadine ophthalmic (eye) drops 0. % (Pataday) ST PAZEO OPHTHALMIC (EYE) DROPS ST; QL (.5 per 0 days) 0.7 % proparacaine ophthalmic (eye) drops 0.5 % Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (ear) solution % AZASITE OPHTHALMIC (EYE) QL (.5 per 0 days) DROPS 1 % bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) (AK-Poly-Bac) ointment ,000 unit/gram BESIVANCE OPHTHALMIC (EYE) ST; QL (5 per 0 days) DROPS,SUSPENSION 0.6 % CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.-1 % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic (eye) drops (Ciloxan) 0. % 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. % ( /gram) gentamicin ophthalmic (eye) drops 0. % hydrocortisone-acetic acid otic (ear) drops 1- % levofloxacin ophthalmic (eye) drops 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 (Vigamox) % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % 87

97 neomycin-bacitracin-poly-hc ophthalmic (Neo-Polycin HC) (eye) ointment ,000 -unit/g- 1% neomycin-bacitracin-polymyxin (Neo-Polycin) ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) drops,suspension.5/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) ointment.5 /g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops ,000 unit-0.05/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension.5-10, unit/ml neomycin-polymyxin-hc otic (ear) drops,suspension.5-10,000-1 /mlunit/ml-% neomycin-polymyxin-hc otic (ear) solution.5-10,000-1 /ml-unit/ml-% ofloxacin ophthalmic (eye) drops 0. % (Ocuflox) ofloxacin otic (ear) drops 0. % polycin ophthalmic (eye) ointment ,000 unit/gram polymyxin b sulf-trimethoprim ophthalmic (Polytrim) (eye) drops 10,000 unit- 1 /ml sulfacetamide sodium ophthalmic (eye) (Bleph-10) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0. % (0.5 %) tobramycin ophthalmic (eye) drops 0. % (Tobrex) tobramycin-dexamethasone ophthalmic (TobraDex) (eye) drops,suspension % trifluridine ophthalmic (eye) drops 1 % (Viroptic) ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % 88

98 Eye, Ear, Nose, Throat Anti- Inflammatory Agents ALOCRIL OPHTHALMIC (EYE) DROPS % ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % BECONASE AQ NASAL SPRAY,NON- ST; QL (50 per 15 days) AEROSOL MCG (0.0 %) bromfenac ophthalmic (eye) drops 0.09 % dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % DUREZOL OPHTHALMIC (EYE) QL (10 per 0 days) DROPS 0.05 % flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) QL (50 per 15 days) fluocinolone acetonide oil otic (ear) drops (DermOtic Oil) 0.01 % fluorometholone ophthalmic (eye) (FML Liquifilm) drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops 0.0 % fluticasone nasal spray,suspension 50 ( Hour Allergy Relief) QL ( per 15 days) mcg/actuation ILEVRO OPHTHALMIC (EYE) QL ( per 0 days) DROPS,SUSPENSION 0. % ketorolac ophthalmic (eye) drops 0. % (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 % mometasone nasal spray,non-aerosol 50 (Nasonex) ST; QL ( per 15 days) mcg/actuation NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % OMNARIS NASAL SPRAY,NON- ST; QL (5 per 15 days) AEROSOL 50 MCG PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % 89

99 prednisolone acetate ophthalmic (eye) drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % PROLENSA OPHTHALMIC (EYE) DROPS 0.07 % QNASL NASAL HFA AEROSOL INHALER 0 MCG/ACTUATION QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % ZETONNA NASAL HFA AEROSOL INHALER 7 MCG/ACTUATION Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral (Omnipred) combo pack cimetidine hcl oral solution 00 /5 ml cimetidine oral tablet 00 (Acid Reducer (cimetidine)) 90 QL ( per 0 days) ST; QL (9.8 per 15 days) ST; QL (17. per 15 days) PA; ST ST; QL (1. per 15 days) cimetidine oral tablet 00, 00, 800 DEXILANT ORAL CAPSULE,BIPHASE ST; QL (0 per 0 days) DELAYED RELEAS 0 MG, 60 MG esomeprazole sodium intravenous recon soln 0 esomeprazole sodium intravenous recon (Nexium IV) soln 0 famotidine (pf)-nacl (iso-os) intravenous piggyback 0 /50 ml famotidine intravenous solution 10 /ml famotidine oral suspension 0 /5 ml (8 (Pepcid) /ml) famotidine oral tablet 0 (Acid Controller) 1 famotidine oral tablet 0 (Pepcid) 1 lansoprazole oral capsule,delayed (Heartburn Treatment release(dr/ec) 15 Hour) lansoprazole oral capsule,delayed (Prevacid) release(dr/ec) 0 misoprostol oral tablet 100 mcg, 00 mcg (Cytotec) nizatidine oral capsule 150, 00

100 nizatidine oral solution 150 /10 ml omeprazole oral capsule,delayed release(dr/ec) 10 omeprazole oral capsule,delayed 1 release(dr/ec) 0, 0 pantoprazole intravenous recon soln 0 (Protonix) pantoprazole oral tablet,delayed release (Protonix) 1 (dr/ec) 0, 0 rabeprazole oral tablet,delayed release (Aciphex) (dr/ec) 0 ranitidine hcl injection solution 50 / (Zantac) ml (5 /ml) ranitidine hcl oral capsule 150, 00 1 ranitidine hcl oral syrup 15 /ml 1 ranitidine hcl oral tablet 150 (Acid Control 1 (ranitidine)) ranitidine hcl oral tablet 00 (Zantac) 1 sucralfate oral tablet 1 gram (Carafate) Gastrointestinal Agents, Other AMITIZA ORAL CAPSULE MCG, 8 PA MCG BENTYL INTRAMUSCULAR SOLUTION 10 MG/ML CARBAGLU ORAL TABLET, PA DISPERSIBLE 00 MG CHOLBAM ORAL CAPSULE 50 MG, 50 MG constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 /5 ml (Gastrocrom) CUVPOSA ORAL SOLUTION 1 MG/5 ML (0. MG/ML) dicyclomine intramuscular solution 10 (Bentyl) /ml dicyclomine oral capsule 10 1 dicyclomine oral solution 10 /5 ml dicyclomine oral tablet 0 1 diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet (Lomotil) 91

101 enulose oral solution 10 gram/15 ml GATTEX 0-VIAL SUBCUTANEOUS KIT 5 MG generlac oral solution 10 gram/15 ml glycopyrrolate injection solution 0. /ml glycopyrrolate oral tablet 1 (Robinul) glycopyrrolate oral tablet (Robinul Forte) kionex (with sorbitol) oral suspension gram/60 ml lactulose oral solution 10 gram/15 ml (Constulose) LINZESS ORAL CAPSULE 15 MCG, 90 MCG, 7 MCG QL (0 per 0 days) loperamide oral capsule (Anti-Diarrheal 1 (loperamide)) methscopolamine oral tablet.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 10, 5 (Reglan) 1 MOVANTIK ORAL TABLET 1.5 MG, PA 5 MG PYLERA ORAL CAPSULE MG RAVICTI ORAL LIQUID 1.1 GRAM/ML RELISTOR SUBCUTANEOUS PA SOLUTION 1 MG/0.6 ML RELISTOR SUBCUTANEOUS PA SYRINGE 1 MG/0.6 ML, 8 MG/0. ML sod polystyren sulf 15 g/60 ml sorbitol free 15 gram/60 ml 1 sodium phenylbutyrate oral powder 0.9 (Buphenyl) gram/gram sodium polystyrene sulfonate oral powder 1 sps (with sorbitol) oral suspension gram/60 ml ursodiol oral capsule 00 (Actigall) ursodiol oral tablet 50 (URSO 50) 9

102 ursodiol oral tablet 500 (URSO Forte) VELTASSA ORAL POWDER IN QL (0 per 0 days) PACKET 16.8 GRAM, 5. GRAM, 8. GRAM Laxatives gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 0 gram OSMOPREP ORAL TABLET 1.5 GRAM peg 50-electrolytes oral recon soln 6- (GaviLyte-G) gram peg 50-electrolytes oral recon soln 0- (Colyte with Flavor gram Packs) peg-electrolyte soln oral recon soln 0 (GaviLyte-N) gram polyethylene glycol 50 oral powder 17 (ClearLax) gram/dose polyethylene glycol 50 powd 17 gm (ClearLax) packets (rx) 17 gram trilyte with flavor packets oral recon soln 0 gram Phosphate Binders calcium acetate oral capsule 667 calcium acetate oral tablet 667 (Calphron) RENAGEL ORAL TABLET 800 MG RENVELA ORAL TABLET 800 MG sevelamer carbonate oral powder in (Renvela) packet 0.8 gram,. gram sevelamer carbonate oral tablet 800 (Renvela) VELPHORO ORAL TABLET,CHEWABLE 500 MG QL (180 per 0 days) Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 10, 5 (Urecholine), 5, 50 darifenacin oral tablet extended release (Enablex) ST hr 15, 7.5 flavoxate oral tablet 100 9

103 GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %) MYRBETRIQ ORAL TABLET EXTENDED RELEASE HR 5 MG, 50 MG oxybutynin chloride oral syrup 5 /5 ml oxybutynin chloride oral tablet 5 oxybutynin chloride oral tablet extended (Ditropan XL) release hr 10, 5 oxybutynin chloride oral tablet extended release hr 15 OXYTROL TRANSDERMAL PATCH SEMIWEEKLY.9 MG/ HR ST tolterodine oral capsule,extended release (Detrol LA) hr, tolterodine oral tablet 1, (Detrol) TOVIAZ ORAL TABLET EXTENDED ST RELEASE HR MG, 8 MG trospium oral capsule,extended release hr 60 trospium oral tablet 0 VESICARE ORAL TABLET 10 MG, 5 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release (Uroxatral) 1 hr 10 dutasteride oral capsule 0.5 (Avodart) dutasteride-tamsulosin oral capsule, er (Jalyn) multiphase hr finasteride oral tablet 5 (Proscar) 1 RAPAFLO ORAL CAPSULE MG, 8 MG tamsulosin oral capsule 0. (Flomax) 1 terazosin oral capsule 1, 10,, 1 5 Heavy Metal Antagonists Heavy Metal Antagonists CHEMET ORAL CAPSULE 100 MG DEPEN TITRATABS ORAL TABLET 50 MG 9

104 EXJADE ORAL TABLET, DISPERSIBLE 15 MG, 50 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG JADENU ORAL TABLET 180 MG, 60 MG, 90 MG JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG, 60 MG, 90 MG SYPRINE ORAL CAPSULE 50 MG trientine oral capsule 50 (Syprine) Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANADROL-50 ORAL TABLET 50 MG ANDRODERM TRANSDERMAL PA; QL (60 per 0 days) PATCH HOUR MG/ HOUR ANDRODERM TRANSDERMAL PA; QL (0 per 0 days) PATCH HOUR MG/ HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 0.5 MG/1.5 GRAM (1.6 %) PA; QL (150 per 0 days) ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (0.5 MG/1.5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (0.5 MG/.5 GRAM) AXIRON TRANSDERMAL SOLUTION IN METERED PUMP W/APP 0 MG/ACTUATION (1.5 ML) PA; QL (7.5 per 0 days) PA; QL (150 per 0 days) PA; QL (180 per 0 days) danazol oral capsule 100, 00, 50 METHITEST ORAL TABLET 10 MG PA methyltestosterone oral capsule 10 (Android) PA oxandrolone oral tablet 10,.5 (Oxandrin) testosterone cypionate intramuscular oil (Depo-Testosterone) 100 /ml testosterone cypionate intramuscular oil (Depo-Testosterone) 00 /ml testosterone enanthate intramuscular oil 00 /ml 95

105 testosterone transdermal gel in metereddose pump 10 /0.5 gram /actuation (Fortesta) PA; QL (10 per 0 days) testosterone transdermal gel in metereddose pump 1.5 / 1.5 gram (1 %) (Vogelxo) PA; QL (00 per 0 days) testosterone transdermal gel in packet 1 % (5 /.5gram), 1 % (50 /5 gram) (AndroGel) PA; QL (00 per 0 days) Estrogens And Antiestrogens amabelz oral tablet , ANGELIQ ORAL TABLET MG, MG CLIMARA PRO TRANSDERMAL PATCH WEEKLY MG/ HR COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/ HR, MG/ HR DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML estradiol oral tablet 0.5, 1, (Estrace) 1 estradiol transdermal patch semiweekly (Alora) 0.05 / hr, 0.05 / hr, / hr, 0.1 / hr estradiol transdermal patch semiweekly (Minivelle) / hr estradiol transdermal patch weekly 0.05 (Climara) / hr, / hr, 0.05 / hr, 0.06 / hr, / hr, 0.1 / hr estradiol vaginal cream 0.01 % (0.1 (Estrace) /gram) estradiol vaginal tablet 10 mcg (Vagifem) estradiol valerate intramuscular oil 0 (Delestrogen) /ml, 0 /ml estradiol-norethindrone acet oral tablet (Activella) , ESTRING VAGINAL RING MG (7.5 ST MCG / HOUR) estropipate oral tablet 0.75, 1.5, 96

106 EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL 1.5 MG/SPRAY (1.7%) FEMRING VAGINAL RING 0.05 MG/ ST HR, 0.1 MG/ HR fyavolv oral tablet mcg, 1-5 -mcg jinteli oral tablet 1-5 -mcg MENEST ORAL TABLET 0. MG, 0.65 MG, 1.5 MG MENOSTAR TRANSDERMAL PATCH WEEKLY 1 MCG/ HR mimvey lo oral tablet mimvey oral tablet norethindrone ac-eth estradiol oral tablet (Femhrt Low Dose) mcg norethindrone ac-eth estradiol oral tablet (Fyavolv) 1-5 -mcg PREFEST ORAL TABLET 1 MG (15)/1 MG MG (15) PREMARIN INJECTION RECON SOLN 5 MG PREMARIN ORAL TABLET 0. MG, 0.5 MG, 0.65 MG, 0.9 MG, 1.5 MG PREMARIN VAGINAL CREAM 0.65 ST MG/GRAM PREMPHASE ORAL TABLET 0.65 MG (1)/ 0.65MG-5MG(1) PREMPRO ORAL TABLET MG, MG, MG, MG raloxifene oral tablet 60 (Evista) yuvafem vaginal tablet 10 mcg Glucocorticoids/Mineralocorticoids cortisone oral tablet 5 DEPO-MEDROL INJECTION SUSPENSION 0 MG/ML DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML dexamethasone oral elixir 0.5 /5 ml (Decadron) dexamethasone oral tablet 0.5, 0.75 (Decadron) 1,, 6 dexamethasone oral tablet 1, dexamethasone oral tablet

107 dexamethasone sodium phos (pf) injection solution 10 /ml dexamethasone sodium phosphate injection solution 10 /ml, /ml dexamethasone sodium phosphate injection syringe /ml dexpak 1 day oral tablets,dose pack 1.5 (51 tabs) fludrocortisone oral tablet 0.1 hydrocortisone oral tablet 10, 0, 5 (Cortef) KENALOG INJECTION SUSPENSION 10 MG/ML, 0 MG/ML MEDROL ORAL TABLET MG methylprednisolone acetate injection (Depo-Medrol) suspension 0 /ml, 80 /ml methylprednisolone oral tablet 16, (Medrol),, 8 methylprednisolone oral tablets,dose pack (Medrol (Pak)) methylprednisolone sodium succ injection PA BvD recon soln 0 methylprednisolone sodium succ (Solu-Medrol) PA BvD intravenous recon soln 1,000 MILLIPRED ORAL SOLUTION 10 MG/5 ML MILLIPRED ORAL TABLET 5 MG prednisolone 15 /5 ml soln a/f, d/f 15 /5 ml ( /ml) prednisolone oral solution 15 /5 ml prednisolone sodium phosphate oral solution 10 /5 ml, 5 /5 ml (5 /ml) prednisolone sodium phosphate oral (Veripred 0) solution 0 /5 ml ( /ml) prednisolone sodium phosphate oral solution 5 base/5 ml (6.7 /5 ml) prednisolone sodium phosphate oral (Orapred ODT) tablet,disintegrating 10, 15, 0 PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 /5 ml prednisone oral tablet 1,.5, 5,

108 prednisone oral tablet 10 1 prednisone oral tablet 0 (Deltasone) 1 prednisone oral tablets,dose pack 10, 10 (8 pack), 5, 5 (8 pack) SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/ ML SOLU-CORTEF (PF) INJECTION RECON SOLN 50 MG/ ML SOLU-MEDROL INTRAVENOUS RECON SOLN GRAM PA BvD triamcinolone acetonide injection (Kenalog) suspension 0 /ml VERIPRED 0 ORAL SOLUTION 0 MG/5 ML ( MG/ML) Pituitary desmopressin 10 mcg/0.1 ml spr 10 (DDAVP) mcg/spray (0.1 ml) desmopressin injection solution mcg/ml (DDAVP) desmopressin nasal solution 0.1 /ml (DDAVP) (refrigerate) desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1, 0. (DDAVP) INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.5 MG, 15 MG NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 0 MG/ ML (10 MG/ML), 5 MG/1.5 ML (. MG/ML) octreotide acetate injection solution 1,000 mcg/ml, 00 mcg/ml octreotide acetate injection solution 100 (Sandostatin) mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) 99

109 SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 0 MG, 0 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0. MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 10 MG/0.5 ML, 60 MG/0. ML, 90 MG/0. ML SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 0 MG, 5 MG, 0 MG STIMATE NASAL SPRAY,NON- AEROSOL 150 MCG/SPRAY (0.1 ML) SYNAREL NASAL SPRAY,NON- AEROSOL MG/ML Progestins ; QL (60 per 0 days) 100 CRINONE VAGINAL GEL %, 8 % PA hydroxyprogesterone caproate intramuscular oil 50 /ml 5 PA NSO; NM; NDS medroxyprogesterone intramuscular (Depo-Provera) suspension 150 /ml medroxyprogesterone intramuscular (Depo-Provera) syringe 150 /ml medroxyprogesterone oral tablet 10,.5, 5 (Provera) 1 megestrol oral suspension 00 /10 ml PA (0 /ml) megestrol oral suspension 65 /5 ml (Megace ES) PA norethindrone acetate oral tablet 5 (Aygestin) progesterone micronized oral capsule 100 (Prometrium), 00 Thyroid And Antithyroid Agents levothyroxine oral tablet 100 mcg, 11 mcg, 15 mcg, 17 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 00 mcg, 50 mcg, 75 mcg, 88 mcg (Levo-T) liothyronine intravenous solution 10 mcg/ml liothyronine oral tablet 5 mcg, 5 mcg, 50 mcg (Triostat) (Cytomel)

110 methimazole oral tablet 10, 5 (Tapazole) 1 propylthiouracil oral tablet 50 THYROLAR-1 ORAL TABLET MCG THYROLAR-1/ ORAL TABLET MCG THYROLAR-1/ ORAL TABLET MCG THYROLAR- ORAL TABLET MCG THYROLAR- ORAL TABLET MCG TIROSINT ORAL CAPSULE 1 MCG Immunological Agents Immunological Agents ARCALYST SUBCUTANEOUS RECON SOLN 0 MG ASTAGRAF XL ORAL PA BvD CAPSULE,EXTENDED RELEASE HR 0.5 MG, 1 MG, 5 MG ATGAM INTRAVENOUS SOLUTION 5 PA BvD; NM; NDS 50 MG/ML azathioprine oral tablet 50 (Imuran) PA BvD azathioprine sodium injection recon soln PA BvD 100 BIVIGAM INTRAVENOUS SOLUTION 10 % CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 00 MG (00 MG X VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 00 MG/ ML (00 MG/ML X ) cyclosporine intravenous solution 50 (Sandimmune) PA BvD /5 ml cyclosporine modified oral capsule 100 (Gengraf) PA BvD, 5 cyclosporine modified oral capsule 50 PA BvD cyclosporine modified oral solution 100 (Gengraf) PA BvD /ml cyclosporine oral capsule 100, 5 (Sandimmune) PA BvD 101

111 ENBREL SUBCUTANEOUS RECON SOLN 5 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 5 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET PA BvD EXTENDED RELEASE HR 0.75 MG, 1 MG, MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 % GAMASTAN S/D INTRAMUSCULAR PA SOLUTION % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM GAMMAKED INJECTION SOLUTION 10 GRAM/100 ML (10 %) GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % GAMUNEX-C INJECTION SOLUTION 0 GRAM/00 ML (10 %) gengraf oral capsule 100, 5, 50 PA BvD gengraf oral solution 100 /ml PA BvD HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 0 MG/0.8 ML, 0 MG/0.8 ML (6 PACK), 80 MG/0.8 ML, 80 MG/0.8 ML- 0 MG/0. ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0.8 ML, 80 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0.8 ML, 80 MG/0.8 ML-0 MG/0. ML 10

112 HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0. ML, 0 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 10 MG/0. ML, 0 MG/0. ML, 0 MG/0. ML, 0 MG/0. ML, 0 MG/0.8 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML IMOGAM RABIES-HT (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML PA BvD PA BvD ; QL (18.76 per 8 days) leflunomide oral tablet 10, 0 (Arava) mycophenolate mofetil hcl intravenous (CellCept Intravenous) PA BvD recon soln 500 mycophenolate mofetil oral capsule 50 (CellCept) PA BvD mycophenolate mofetil oral suspension for (CellCept) PA BvD reconstitution 00 /ml mycophenolate mofetil oral tablet 500 (CellCept) PA BvD mycophenolate sodium oral tablet,delayed (Myfortic) PA BvD release (dr/ec) 180, 60 MYFORTIC ORAL TABLET,DELAYED PA BvD RELEASE (DR/EC) 180 MG, 60 MG NULOJIX INTRAVENOUS RECON 5 PA BvD; NM; NDS SOLN 50 MG OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 50 MG ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 15 MG/ML ORENCIA SUBCUTANEOUS SYRINGE 15 MG/ML, 50 MG/0. ML, 87.5 MG/0.7 ML PRIVIGEN INTRAVENOUS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML PA BvD 10

113 PROGRAF ORAL CAPSULE 0.5 MG, 1 PA BvD MG, 5 MG RAPAMUNE ORAL SOLUTION 1 PA BvD MG/ML RAPAMUNE ORAL TABLET 0.5 MG, 1 PA BvD MG, MG REMICADE INTRAVENOUS RECON SOLN 100 MG RIDAURA ORAL CAPSULE MG SIMPONI ARIA INTRAVENOUS SOLUTION 1.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML, 50 MG/0.5 ML sirolimus oral tablet 0.5, 1, (Rapamune) PA BvD tacrolimus oral capsule 0.5, 1, 5 (Prograf) PA BvD THYMOGLOBULIN INTRAVENOUS 5 PA BvD; NM; NDS RECON SOLN 5 MG TYSABRI INTRAVENOUS SOLUTION 00 MG/15 ML ; QL (15 per 8 days) XELJANZ ORAL TABLET 10 MG, 5 MG ; QL (60 per 0 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE HR 11 MG ; QL (0 per 0 days) ZORTRESS ORAL TABLET 0.5 MG, PA NSO 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE LF- ( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG PA BvD 10

114 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 0 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,0 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,0 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION 0-8- UNIT/0.5 ML IPOL INJECTION SYRINGE 0-8- UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML PA BvD PA BvD PA; AGE (Min 9 Years and Max 6 Years) PA; AGE (Min 9 Years and Max 6 Years) PA BvD 105

115 KINRIX (PF) INTRAMUSCULAR SUSPENSION 5 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 5 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION MCG/0.5 ML MENVEO A-C-Y-W-15-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-1,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-5LF-5 MCG- 10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-8 MCG- 5 LF UNIT/0.5ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-8 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 0 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION ML SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML 106 PA BvD PA BvD PA BvD

116 TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5- LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-5 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION - LF UNIT/0.5 ML TRUMENBA INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 70 ELISA UNIT- 0 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 5 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 5 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 5 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,50 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP.7 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,00 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents PA BvD PA BvD PA BvD PA BvD alosetron oral tablet 0.5, 1 (Lotronex) APRISO ORAL CAPSULE,EXTENDED RELEASE HR 0.75 GRAM ST balsalazide oral capsule 750 (Colazal) 107

117 budesonide oral (Entocort EC) capsule,delayed,extend.release budesonide oral tablet,delayed and ext.release 9 (Uceris) ; QL (0 per 0 days) CANASA RECTAL SUPPOSITORY 1,000 MG colocort rectal enema 100 /60 ml DELZICOL ORAL CAPSULE (WITH ST DEL REL TABLETS) 00 MG DIPENTUM ORAL CAPSULE 50 MG hydrocortisone rectal enema 100 /60 ml (Colocort) LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1. GRAM ST mesalamine oral tablet,delayed release (Lialda) (dr/ec) 1. gram mesalamine oral tablet,delayed release (Asacol HD) (dr/ec) 800 mesalamine rectal enema gram/60 ml (Rowasa) PENTASA ORAL CAPSULE, EXTENDED RELEASE 50 MG, 500 MG ST sulfasalazine oral tablet 500 (Azulfidine) 1 sulfasalazine oral tablet,delayed release (dr/ec) 500 (Azulfidine EN-tabs) 1 UCERIS RECTAL FOAM MG/ACTUATION PA Irrigating Solutions Irrigating Solutions LACTATED RINGERS IRRIGATION SOLUTION PHYSIOLYTE IRRIGATION SOLUTION MEQ/L PHYSIOSOL IRRIGATION IRRIGATION SOLUTION MEQ/L ringer's irrigation solution sodium chloride irrigation solution 0.9 % (Aqua Care Sodium Chloride) water for irrigation, sterile irrigation solution (Aqua Care Sterile Water) Metabolic Bone Disease Agents Metabolic Bone Disease Agents 108

118 alendronate oral solution 70 /75 ml alendronate oral tablet 10, 5, 5 1 alendronate oral tablet 0 alendronate oral tablet 70 (Fosamax) 1 calcitonin (salmon) nasal spray,nonaerosol 00 unit/actuation calcitriol intravenous solution 1 mcg/ml PA BvD calcitriol oral capsule 0.5 mcg, 0.5 mcg (Rocaltrol) PA BvD calcitriol oral solution 1 mcg/ml (Rocaltrol) PA BvD doxercalciferol intravenous solution (Hectorol) PA BvD mcg/ ml doxercalciferol oral capsule 0.5 mcg, 1 PA BvD mcg,.5 mcg etidronate disodium oral tablet 00, 00 FORTEO SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE MCG/. ML ibandronate intravenous solution / PA BvD ml ibandronate intravenous syringe / (Boniva) PA BvD ml ibandronate oral tablet 150 (Boniva) 1 MIACALCIN INJECTION SOLUTION PA BvD 00 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 5 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous solution 0 /10 ml ( /ml), 90 /10 ml (9 /ml) ; QL (0 per 0 days) PA BvD pamidronate intravenous solution 60 PA BvD /10 ml (6 /ml) paricalcitol hemodialysis port injection PA BvD solution mcg/ml PARICALCITOL HEMODIALYSIS PA BvD PORT INJECTION SOLUTION 5 MCG/ML paricalcitol oral capsule 1 mcg, mcg (Zemplar) PA BvD paricalcitol oral capsule mcg PA BvD 109

119 PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML risedronate oral tablet 150, 5, 5 risedronate oral tablet 0, 5 (1 pack), 5 ( pack) SENSIPAR ORAL TABLET 0 MG, 60 MG, 90 MG XGEVA SUBCUTANEOUS SOLUTION 10 MG/1.7 ML (70 MG/ML) zoledronic acid intravenous recon soln zoledronic acid intravenous solution /5 ml zoledronic acid-mannitol-water intravenous piggyback 5 /100 ml ZOMETA INTRAVENOUS PIGGYBACK MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE SUBCUTANEOUS (Actonel) (Zometa) (Reclast) SOLUTION 100 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON SOLN 10 MG, 00 MG BENLYSTA SUBCUTANEOUS AUTO- INJECTOR 00 MG/ML BENLYSTA SUBCUTANEOUS SYRINGE 00 MG/ML dexrazoxane hcl intravenous recon soln (Zinecard (as HCl)) 50 ELMIRON ORAL CAPSULE 100 MG ergoloid oral tablet 1 fomepizole intravenous solution 1 gram/ml PA PA BvD FUSILEV INTRAVENOUS RECON SOLN 50 MG guanidine oral tablet 15 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 5, 50 (Vistaril) KEPIVANCE INTRAVENOUS RECON SOLN 6.5 MG 110

120 leucovorin calcium injection recon soln 100, 00, 50 leucovorin calcium oral tablet 10, 15, 5, 5 levocarnitine (with sugar) oral solution (Carnitor) PA BvD 100 /ml levocarnitine oral tablet 0 (Carnitor) PA BvD LEVOLEUCOVORIN INTRAVENOUS RECON SOLN 175 MG levoleucovorin intravenous recon soln 50 (Fusilev) levoleucovorin intravenous solution 10 /ml LITHOSTAT ORAL TABLET 50 MG mesna intravenous solution 100 /ml (Mesnex) MESNEX ORAL TABLET 00 MG MESTINON ORAL SYRUP 60 MG/5 ML PROGLYCEM ORAL SUSPENSION 50 MG/ML pyridostigmine bromide oral tablet 60 (Mestinon) pyridostigmine bromide oral tablet (Mestinon Timespan) extended release 180 RECTIV RECTAL OINTMENT 0. % PA; QL (0 per 0 days) (W/W) SIMULECT INTRAVENOUS RECON SOLN 10 MG, 0 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 00 MG, 50 MG 5 PA NSO; NM; NDS THIOLA ORAL TABLET 100 MG TYBOST ORAL TABLET 150 MG Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 15, 50 acetazolamide sodium injection recon soln 500 ALPHAGAN P OPHTHALMIC (EYE) ST DROPS 0.1 % AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % 111

121 betaxolol ophthalmic (eye) drops 0.5 % bimatoprost ophthalmic (eye) drops 0.0 % QL (5 per 0 days) brimonidine ophthalmic (eye) drops 0.15 (Alphagan P) % brimonidine ophthalmic (eye) drops 0. % carteolol ophthalmic (eye) drops 1 % COMBIGAN OPHTHALMIC (EYE) DROPS % dorzolamide ophthalmic (eye) drops % (Trusopt) dorzolamide-timolol ophthalmic (eye) (Cosopt) drops.-6.8 /ml latanoprost ophthalmic (eye) drops (Xalatan) 1 QL (5 per 0 days) % levobunolol ophthalmic (eye) drops 0.5 % LUMIGAN OPHTHALMIC (EYE) QL (5 per 0 days) DROPS 0.01 % methazolamide oral tablet 5, 50 metipranolol ophthalmic (eye) drops 0. % PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.15 % pilocarpine hcl ophthalmic (eye) drops 1 (Isopto Carpine) %, %, % SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION 1-0. % timolol maleate ophthalmic (eye) drops (Timoptic) 0.5 %, 0.5 % timolol maleate ophthalmic (eye) drops, (Istalol) once daily 0.5 % timolol maleate ophthalmic (eye) gel (Timoptic-XE) forming solution 0.5 %, 0.5 % TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE 0.5 %, 0.5 % TIMOPTIC OPHTHALMIC (EYE) DROPS 0.5 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) QL (5 per 0 days) DROPS 0.00 % ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE % ST; QL (0 per 0 days) Replacement Preparations 11

122 Replacement Preparations d10 %-0.5 % sodium chloride intravenous parenteral solution d.5 %-0.5 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.5 % sodium chloride intravenous parenteral solution dextrose 10 % and 0. % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0. % sod chloride intravenous parenteral solution dextrose 5%-0. % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution 5-0. % 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 kcl 10 meq in d5w-0.5% nacl singleuse,l/f 0 meq/l KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq klor-con m0 oral tablet,er particles/crystals 0 meq klor-con sprinkle oral capsule, extended release 10 meq, 8 meq 11

123 LACTATED RINGERS INTRAVENOUS PARENTERAL SOLUTION magnesium sulfate injection solution meq/ml (50 %) magnesium sulfate injection syringe meq/ml 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. INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 18 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION potassium chlorid-d5-0.5%nacl intravenous parenteral solution 10 meq/l, 0 meq/l, 0 meq/l, 0 meq/l potassium chloride in 5 % dex intravenous parenteral solution 0 meq/l, 0 meq/l potassium chloride in lr-d5 intravenous parenteral solution 0 meq/l potassium chloride in lr-d5 intravenous parenteral solution 0 meq/l potassium chloride intravenous solution meq/ml potassium chloride oral capsule, extended release 10 meq potassium chloride oral capsule, extended release 8 meq potassium chloride oral liquid 0 meq/15 ml, 0 meq/15 ml potassium chloride oral tablet extended release 10 meq, 0 meq, 8 meq potassium chloride oral tablet,er particles/crystals 10 meq potassium chloride oral tablet,er particles/crystals 0 meq (Klor-Con Sprinkle) (K-Tab) (Klor-Con M10) (Klor-Con M0) 11

124 potassium chloride-0.5 % nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.%nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.%nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 0 meq/l potassium citrate oral tablet extended (Urocit-K 10) release 10 meq (1,080 ) potassium citrate oral tablet extended (Urocit-K 15) release 15 meq potassium citrate oral tablet extended (Urocit-K 5) release 5 meq (50 ) ringer's intravenous parenteral solution sodium chloride 0.5 % intravenous parenteral solution 0.5 % sodium chloride 0.5 % intravenous piggyback 0.5 % sodium chloride 0.9 % intravenous parenteral solution sodium chloride % intravenous parenteral solution % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution.5 meq/ml sodium lactate intravenous solution 5 meq/ml TPN ELECTROLYTES II IV SOLN 5'S,0ML/50ML FTV MEQ/0 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/0 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE QL (60 per 0 days) 115

125 ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, 0-1 MCG/ACTUATION, 5-1 MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 00 MCG/ACTUATION, 50 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, 00-5 MCG/DOSE budesonide inhalation suspension for nebulization 0.5 / ml, 0.5 / ml, 1 / ml DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, 00-5 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION fluticasone-salmeterol inhalation aerosol powdr breath activated 11-1 mcg/actuation, -1 mcg/actuation, 55-1 mcg/actuation QVAR INHALATION AEROSOL 0 MCG/ACTUATION, 80 MCG/ACTUATION QL (1 per 0 days) QL (0 per 0 days) QL (60 per 0 days) (Pulmicort) PA BvD; QL (10 per 0 days) QL (1 per 0 days) QL (60 per 0 days) QL (60 per 0 days) QL ( per 0 days) QL (1. per 0 days) (AirDuo RespiClick) QL (1 per 0 days) QL (0 per 0 days) 116

126 QVAR REDIHALER INHALATION QL (0 per 0 days) HFA AEROSOL BREATH ACTIVATED 0 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet (Singulair) montelukast oral tablet 10 (Singulair) 1 montelukast oral tablet,chewable, 5 (Singulair) 1 zafirlukast oral tablet 10, 0 (Accolate) zileuton oral tablet, er multiphase 1 hr (Zyflo CR) 600 ZYFLO ORAL TABLET 600 MG Bronchodilators albuterol sulfate inhalation solution for PA BvD nebulization 0.6 / ml, 1.5 / ml,.5 / ml (0.08 %), 5 /ml albuterol sulfate oral syrup /5 ml albuterol sulfate oral tablet, albuterol sulfate oral tablet extended release 1 hr, 8 aminophylline intravenous solution 50 /10 ml, 500 /0 ml ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION BROVANA INHALATION SOLUTION PA BvD FOR NEBULIZATION 15 MCG/ ML COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 6.5 MCG/ACTUATION ipratropium bromide inhalation solution PA BvD 0.0 % ipratropium-albuterol inhalation solution for nebulization (.5 base)/ ml PA BvD 117

127 levalbuterol hcl inhalation solution for (Xopenex) PA BvD nebulization 0.1 / ml, 0.6 / ml, 1.5 / ml levalbuterol hcl inhalation solution for (Xopenex Concentrate) PA BvD nebulization 1.5 /0.5 ml metaproterenol oral syrup 10 /5 ml metaproterenol oral tablet 10, 0 PERFOROMIST INHALATION PA BvD SOLUTION FOR NEBULIZATION 0 MCG/ ML PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.5 MCG/ACTUATION SPIRIVA RESPIMAT INHALATION MIST.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION MIST.5-.5 MCG/ACTUATION terbutaline oral tablet.5, 5 terbutaline subcutaneous solution 1 /ml THEO- ORAL CAPSULE,EXTENDED RELEASE HR 100 MG, 00 MG, 00 MG, 00 MG theophylline oral solution 80 /15 ml theophylline oral tablet extended release (Theochron) 1 hr 100, 00, 00 theophylline oral tablet extended release 1 hr 50 theophylline oral tablet extended release hr 00, 600 Respiratory Tract Agents, Other acetylcysteine solution 100 /ml (10 %), 00 /ml (0 %) PA BvD 118

128 ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG cromolyn inhalation solution for PA BvD nebulization 0 / ml DALIRESP ORAL TABLET 50 MCG, 500 MCG ESBRIET ORAL CAPSULE 67 MG GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML ( %) KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG ; QL (60 per 0 days) KALYDECO ORAL TABLET 150 MG ; QL (60 per 0 days) NUCALA SUBCUTANEOUS RECON SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL GRANULES IN PACKET MG, MG ; QL (10 per 0 days) ORKAMBI ORAL TABLET MG, MG ; QL (10 per 0 days) PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG XOLAIR SUBCUTANEOUS RECON SOLN 150 MG ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10, 0 carisoprodol oral tablet 50 (Soma) carisoprodol-asa-codeine oral tablet carisoprodol-aspirin oral tablet 00-5 chlorzoxazone oral tablet 50, 500 cyclobenzaprine oral tablet 10, 5 1 cyclobenzaprine oral tablet 7.5 (Fexmid) dantrolene oral capsule 100 dantrolene oral capsule 5, 50 (Dantrium) metaxall oral tablet 800 metaxalone oral tablet

129 metaxalone oral tablet 800 (Metaxall) methocarbamol oral tablet 500 (Robaxin) 1 methocarbamol oral tablet 750 (Robaxin-750) 1 orphenadrine citrate injection solution 0 /ml orphenadrine citrate oral tablet extended release 100 tizanidine oral capsule,, 6 (Zanaflex) tizanidine oral tablet tizanidine oral tablet (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150, 00, 50, 50 (Nuvigil) PA; QL (0 per 0 days) BUTISOL ORAL TABLET 0 MG eszopiclone oral tablet 1,, (Lunesta) QL (0 per 0 days) HETLIOZ ORAL CAPSULE 0 MG ; QL (0 per 0 days) modafinil oral tablet 100, 00 (Provigil) PA; QL (60 per 0 days) ROZEREM ORAL TABLET 8 MG PA; QL (0 per 0 days) XYREM ORAL SOLUTION 500 MG/ML ; QL (50 per 0 days) zaleplon oral capsule 10, 5 (Sonata) QL (0 per 0 days) zolpidem oral tablet 10 (Ambien) QL (0 per 0 days) zolpidem oral tablet 5 (Ambien) QL (60 per 0 days) Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 0 MG ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, MG,.5 MG LETAIRIS ORAL TABLET 10 MG, 5 MG ; QL (0 per 0 days) OPSUMIT ORAL TABLET 10 MG ; QL (0 per 0 days) REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML,.5 MG/ML, 5 MG/ML 5 PA BvD; NM; NDS REVATIO INTRAVENOUS SOLUTION 10 MG/1.5 ML REVATIO ORAL TABLET 0 MG sildenafil (antihypertensive) intravenous solution 10 /1.5 ml (Revatio) 10

130 sildenafil (antihypertensive) oral tablet 0 tadalafil (antihypertensive) oral tablet 0 TRACLEER ORAL TABLET 15 MG, 6.5 MG UPTRAVI ORAL TABLET 1,000 MCG, 1,00 MCG, 1,00 MCG, 1,600 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLETS,DOSE PACK 00 MCG (10)- 800 MCG (60) VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 0 MCG/ML (Revatio) PA (Adcirca) ; QL (60 per 0 days) ; QL (60 per 0 days) ; QL (00 per 0 days) 11

131

132 INDEX A abacavir... 9 abacavir-lamivudine... 9 abacavir-lamivudine-zidovudine... 9 ABELCET... 8 ABILIFY MAINTENA... 6 ABRAXANE acamprosate... 8 acarbose... 5 acebutolol... 6 acetaminophen-codeine... acetazolamide acetazolamide sodium acetic acid acetylcysteine acitretin ACTHIB (PF) ACTIMMUNE ACTOPLUS MET XR... 5 acyclovir... 5, 78 acyclovir sodium... 5 ADACEL(TDAP ADOLESN/ADULT)(PF) 10 ADAGEN... 8 adapalene... 8 adapalene-benzoyl peroxide... 8 ADCIRCA adefovir... 5 ADEMPAS adriamycin adrucil ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR AFINITOR DISPERZ AKYNZEO (NETUPITANT) ala-cort ALBENZA... albuterol sulfate alclometasone ALCOHOL PADS ALDURAZYME... 8 ALECENSA alendronate alfuzosin... 9 ALIMTA ALINIA... ALIQOPA allopurinol... 0 ALOCRIL ALOMIDE alosetron ALPHAGAN P alprazolam... 9 ALPRAZOLAM INTENSOL. 9 ALREX ALTOPREV ALUNBRIG alyacen 1/5 (8)... 7 amabelz amantadine hcl... AMBISOME... 8 amcinonide amethia... 7 amethyst... 7 amikacin amiloride amiloride-hydrochlorothiazide aminophylline AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5. % amiodarone... 6 AMITIZA amitriptyline... amitriptyline-chlordiazepoxide... amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-olmesartan amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amoxapine... amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphotericin b... 8 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANADROL I-1

133 anagrelide anastrozole ANDRODERM ANDROGEL ANGELIQ ANORO ELLIPTA ANZEMET... APEXICON E APLENZIN... APOKYN... apraclonidine aprepitant... apri... 7 APRISO APTIOM... 8 APTIVUS... 9 ARALAST NP aranelle (8)... 7 ARANESP (IN POLYSORBATE) ARCALYST aripiprazole... 6 ARISTADA... 6 ARISTADA INITIO... 6 armodafinil ARNUITY ELLIPTA ARRANON ashlyna... 7 aspirin-dipyridamole ASSURE ID INSULIN SAFETY... 8 ASTAGRAF XL atazanavir... 9 atenolol... 6 atenolol-chlorthalidone... 6 ATGAM atomoxetine atorvastatin atovaquone... atovaquone-proguanil... ATRIPLA... 9 atropine... 8, 86 ATROVENT HFA AUBAGIO aubra... 7 AUGMENTIN AVANDIA... 5 AVASTIN AVC VAGINAL... 1 AVELOX IN NACL (ISO- OSMOTIC) aviane... 7 avita... 8 AVONEX AVONEX (WITH ALBUMIN) AVYCAZ... 1 AXIRON azacitidine AZACTAM... 1 AZASITE azathioprine azathioprine sodium azelastine AZELEX azithromycin... 1 AZOPT aztreonam... 1 B baciim bacitracin bacitracin-polymyxin b baclofen balsalazide balziva (8)... 7 BANZEL... 8 BARACLUDE... 5 BAVENCIO BCG VACCINE, LIVE (PF) 10 BD ULTRA-FINE NANO PEN NEEDLE... 8 BD VEO INSULIN SYR HALF UNIT... 8 BD VEO INSULIN SYRINGE UF... 8 BECONASE AQ bekyree (8)... 7 BELEODAQ benazepril benazepril-hydrochlorothiazide BENLYSTA BENTYL benztropine... BEPREVE BERINERT BESIVANCE BESPONSA betamethasone dipropionate betamethasone valerate... 80, 81 betamethasone, augmented BETASERON betaxolol... 6, 11 bethanechol chloride... 9 bexarotene BEXSERO bicalutamide BICILLIN C-R BICILLIN L-A BICNU BIDIL BIKTARVY... 9 bimatoprost bisoprolol fumarate... 6 BIVIGAM bleomycin blisovi fe... 7 blisovi fe 1.5/0 (8)... 7 blisovi fe 1/0 (8)... 7 BOOSTRIX TDAP BORTEZOMIB BOSULIF BRAFTOVI BREO ELLIPTA briellyn... 7 I-

134 BRILINTA brimonidine BRIVIACT... 8 bromfenac bromocriptine..., 5 BROVANA budesonide , 116 bumetanide buprenorphine... buprenorphine hcl..., 8 buprenorphine-naloxone... 8 bupropion hcl..., bupropion hcl (smoking deter). 8 buspirone... 9 busulfan BUSULFEX BUTISOL butorphanol tartrate... C cabergoline... 5 CABOMETYX calcipotriene calcipotriene-betamethasone.. 78 calcitonin (salmon) calcitriol... 78, 109 calcium acetate... 9 CALQUENCE camila... 7 CANASA CANCIDAS... 8 candesartan candesartan-hydrochlorothiazid CAPASTAT... CAPEX CAPRELSA captopril captopril-hydrochlorothiazide 61 CARBAGLU carbamazepine... 8 carbidopa... 5 carbidopa-levodopa... 5 carbidopa-levodopa-entacapone... 5 carbinoxamine maleate... 0 carboplatin CARDURA XL CARIMUNE NF NANOFILTERED carisoprodol carisoprodol-asa-codeine carisoprodol-aspirin carteolol cartia xt... 6 carvedilol... 6 carvedilol phosphate... 6 CAYSTON... 1 caziant (8)... 7 cefaclor... 1 cefadroxil... 1 cefazolin... 1 cefdinir... 1 cefepime... 1 cefixime... 1 cefotaxime... 1 cefotetan... 1 cefoxitin... 1 cefpodoxime... 1 cefprozil... 1 ceftazidime... 1 ceftriaxone... 1 cefuroxime axetil... 1 cefuroxime sodium... 1 celecoxib... 6 CELONTIN... 8 cephalexin... 1 CEREZYME... 8 CESAMET... cetirizine... 0 cevimeline CHANTIX... 8 CHANTIX CONTINUING MONTH BOX... 8 CHANTIX STARTING MONTH BOX... 8 CHEMET... 9 CHENODAL chloramphenicol sod succinate chlordiazepoxide hcl... 9 chlorhexidine gluconate chloroquine phosphate... chlorothiazide chlorothiazide sodium chlorpromazine... 6 chlorpropamide... 7 chlorthalidone chlorzoxazone CHOLBAM cholestyramine (with sugar) cholestyramine light ciclopirox... 8 cidofovir... 5 cilostazol CIMDUO... 9 cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRO HC CIPRODEX ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl... 16, 87 ciprofloxacin in 5 % dextrose 16 cisplatin citalopram... cladribine claravis clarithromycin... 1 clemastine... 0 CLEOCIN... 1 CLIMARA PRO I-

135 clindamycin hcl clindamycin in 5 % dextrose.. 11 clindamycin palmitate hcl clindamycin phosphate... 11, 1, 79 clindamycin-benzoyl peroxide clindamycin-tretinoin CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE CLINIMIX.75%/D5W SULFIT FREE CLINIMIX.5%/D10W SULF FREE CLINIMIX.5%/D5W SULFIT FREE CLINIMIX.5%-D0W SULF-FREE CLINIMIX.5%-D5W SULF-FREE CLINIMIX 5%- D0W(SULFITE-FREE) CLINIMIX E.75%/D10W SUL FREE CLINIMIX E.75%/D5W SULF FREE CLINIMIX E.5%/D10W SUL FREE CLINIMIX E.5%/D5W SUL FREE CLINIMIX E.5%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D0W SULFIT FREE CLINIMIX E 5%/D5W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol-emollient CLODAN CLODERM clofarabine clomipramine... clonazepam... 9 clonidine clonidine hcl clopidogrel clorazepate dipotassium... 9 clorpres clotrimazole... 8 clotrimazole-betamethasone.. 8 clozapine... 6 COARTEM... codeine sulfate... colchicine... 0 colesevelam colestipol colistin (colistimethate na) colocort COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 117 COMETRIQ COMPLERA... 9 compro... CONDYLOX constulose COPAXONE CORDRAN TAPE LARGE ROLL CORLANOR cormax cortisone COSENTYX ( SYRINGES) 78 COSENTYX PEN ( PENS). 78 COSMEGEN COTELLIC COUMADIN CREON CRINONE CRIXIVAN... 9 cromolyn... 86, 91, 119 cryselle (8)... 7 CUVPOSA cyclafem 1/5 (8)... 7 cyclafem 7/7/7 (8)... 7 cyclobenzaprine CYCLOPHOSPHAMIDE CYCLOSET... 5 cyclosporine cyclosporine modified CYKLOKAPRON cyproheptadine... 0 CYRAMZA CYSTAGON CYSTARAN cytarabine... 0 cytarabine (pf) D d10 %-0.5 % sodium chloride d.5 %-0.5 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.5 % sodium chloride dacarbazine... 0 DACOGEN... 0 dactinomycin... 0 dalfampridine DALIRESP DALVANCE danazol dantrolene dapsone... DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin DARAPRIM... darifenacin... 9 I-

136 DARZALEX... 0 daunorubicin... 0 DAYTRANA deblitane... 7 decitabine... 0 DELESTROGEN delyla (8)... 7 DELZICOL demeclocycline DEMSER DENAVIR DEPACON... 8 DEPAKENE... 8 DEPAKOTE... 8 DEPAKOTE ER... 8 DEPAKOTE SPRINKLES... 8 DEPEN TITRATABS... 9 DEPO-ESTRADIOL DEPO-MEDROL DESCOVY... 9 desipramine... desloratadine... 0 desmopressin desog-e.estradiol/e.estradiol... 7 DESONATE desonide desoximetasone DESVENLAFAXINE... DESVENLAFAXINE FUMARATE... dexamethasone DEXAMETHASONE INTENSOL dexamethasone sodium phos (pf) dexamethasone sodium phosphate... 89, 98 DEXILANT dexmethylphenidate... 70, 71 dexpak 1 day dexrazoxane hcl dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0. % nacl dextrose 5 % in water (d5w).. 59 dextrose 5 %-lactated ringers dextrose 5%-0. % sod chloride dextrose 5%-0. % sod.chloride dextrose with sodium chloride DIASTAT... 9 DIASTAT ACUDIAL... 9 diazepam... 9 diazepam intensol... 9 diclofenac potassium... 6 diclofenac sodium... 6, 89 diclofenac-misoprostol... 6, 7 dicloxacillin dicyclomine didanosine... 9 DIFICID... 1 diflorasone diflunisal... 7 digitek digox digoxin DIGOXIN dihydroergotamine... 1 DILANTIN... 9 DILANTIN EXTENDED... 8 DILANTIN INFATABS... 9 DILANTIN diltiazem hcl... 6, 65 dilt-xr DIPENTUM diphenhydramine hcl... 0 diphenoxylate-atropine dipyridamole disopyramide phosphate... 6 disulfiram... 8 divalproex... 9 docetaxel... 0 dofetilide... 6 donepezil... dorzolamide dorzolamide-timolol doxazosin doxepin..., 78 doxercalciferol DOXIL... 0 doxorubicin... 0 doxorubicin, peg-liposomal... 0 doxy doxycycline hyclate doxycycline monohydrate 17, 18 dronabinol... drospirenone-e.estradiol-lm.fa 7 drospirenone-ethinyl estradiol 7 DROXIA... 0 DULERA duloxetine... DURAMORPH (PF)... DUREZOL dutasteride... 9 dutasteride-tamsulosin... 9 E E.E.S. GRANULES... 1 econazole... 8 EDARBI EDARBYCLOR EDURANT... 9 efavirenz EFFIENT ELAPRASE ELIDEL ELIGARD... 0 ELIGARD ( MONTH)... 0 ELIGARD ( MONTH)... 0 ELIGARD (6 MONTH)... 0 ELIMITE... 8 ELIQUIS I-5

137 ELITEK ELMIRON EMADINE EMBEDA... EMCYT... 0 EMEND... emoquette... 7 EMPLICITI... 0 EMSAM... EMTRIVA EMVERM... enalapril maleate... 6 enalapril-hydrochlorothiazide 6 ENBREL ENBREL SURECLICK endocet... ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse... 7 entacapone... 5 entecavir... 5 ENTRESTO enulose... 9 ENVARSUS XR EPANED... 6 EPCLUSA... 5 epinastine epinephrine... 65, 66 EPIPEN -PAK EPIPEN JR -PAK epirubicin... 0, 1 EPIVIR HBV eplerenone EPOGEN eprosartan ERAXIS(WATER DILUENT)... 8 ERBITUX... 1 ergoloid ERIVEDGE... 1 ERLEADA... 1 errin... 7 ERTACZO... 8 ertapenem... 1 ERWINAZE... 1 ery pads ERYPED ERYPED ery-tab... 1 ERY-TAB... 1 ERYTHROCIN... 1 erythromycin... 1, 87 erythromycin ethylsuccinate.. 1 erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate... esomeprazole sodium estazolam... 9 estradiol estradiol valerate estradiol-norethindrone acet.. 96 ESTRING estropipate eszopiclone ethacrynic acid ethambutol... ethosuximide... 9 ethynodiol diac-eth estradiol. 7 etidronate disodium etodolac... 7 ETOPOPHOS... 1 etoposide... 1 EURAX... 8 EVAMIST EVOTAZ EXELDERM... 9 exemestane... 1 EXJADE EXTAVIA ezetimibe ezetimibe-simvastatin F FABRAZYME falmina (8)... 7 famciclovir... 5 famotidine famotidine (pf)-nacl (iso-os). 90 FANAPT... 6 FARESTON... 1 FARYDAK... 1 FASLODEX... 1 felbamate... 9 felodipine FEMRING femynor... 7 fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fentanyl... fentanyl citrate... FENTORA... FERRIPROX FETZIMA... FINACEA finasteride... 9 FIRAZYR FIRMAGON KIT W DILUENT SYRINGE... 1 flavoxate... 9 FLEBOGAMMA DIF flecainide... 6 FLECTOR... 7 FLOVENT DISKUS FLOVENT HFA fluconazole... 9 fluconazole in nacl (iso-osm). 9 flucytosine... 9 fludarabine... 1 fludrocortisone flunisolide I-6

138 fluocinolone... 8 fluocinolone acetonide oil fluocinolone and shower cap.. 8 fluocinonide... 8 fluocinonide-e... 8 fluorometholone fluorouracil... 1, 78 fluoxetine... fluphenazine decanoate... 7 fluphenazine hcl... 7 flurandrenolide... 8 flurazepam flurbiprofen... 7 flurbiprofen sodium flutamide... 1 fluticasone... 8, 89 fluticasone-salmeterol fluvastatin... 68, 69 fluvoxamine..., FOLOTYN... 1 fomepizole fondaparinux FORTEO fosamprenavir fosinopril... 6 fosinopril-hydrochlorothiazide... 6 fosphenytoin... 9 FRAGMIN FREAMINE HBC 6.9 % frovatriptan... 1 furosemide FUSILEV FUZEON fyavolv FYCOMPA... 9 G gabapentin... 9 galantamine... GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMMAKED GAMMAPLEX (WITH SORBITOL) GAMUNEX-C ganciclovir sodium... 5 GARDASIL 9 (PF) gatifloxacin GATTEX 0-VIAL... 9 GAUZE PAD... 8 gavilyte-c... 9 gavilyte-g... 9 gavilyte-n... 9 GELNIQUE... 9 gemcitabine... 1 gemfibrozil generlac... 9 gengraf gentak gentamicin... 10, 80, 87 gentamicin in nacl (iso-osm). 10 gentamicin sulfate (ped) (pf). 10 GENVOYA GEODON... 7 gianvi (8)... 7 GILENYA GILOTRIF... 1 GLASSIA glatiramer GLEOSTINE... 1 glimepiride... 7 glipizide... 8 glipizide-metformin... 8 GLUCAGEN HYPOKIT... 5 GLUCAGON EMERGENCY KIT (HUMAN)... 5 glyburide... 8 glyburide micronized... 8 glyburide-metformin... 8 glycopyrrolate... 9 GLYSET... 5 granisetron (pf)... granisetron hcl... GRANIX griseofulvin microsize... 9 griseofulvin ultramicrosize... 9 guanfacine... 60, 71 guanidine H HALAVEN... halobetasol propionate... 8 HALOG... 8 haloperidol... 7 haloperidol decanoate... 7 haloperidol lactate... 7 HARVONI... 5 HAVRIX (PF) heparin (porcine)... 55, 56 heparin (porcine) in 5 % dex.. 55 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 hydrochlorothiazide hydrocodone-acetaminophen, hydrocodone-ibuprofen... hydrocortisone... 8, 98, 108 hydrocortisone butyrate... 8 hydrocortisone butyr-emollient... 8 hydrocortisone valerate... 8 hydrocortisone-acetic acid I-7

139 hydromorphone... hydromorphone (pf)... hydroxychloroquine... hydroxyprogesterone caproate hydroxyurea... hydroxyzine hcl... 0 hydroxyzine pamoate HYPERRAB S/D (PF) HYSINGLA ER... I ibandronate IBRANCE... ibu... 7 ibuprofen... 7 ibuprofen-oxycodone... ICLUSIG... idarubicin... IDHIFA... ifosfamide... ILEVRO imatinib... IMBRUVICA... IMFINZI... imipenem-cilastatin... 1 imipramine hcl... imipramine pamoate... imiquimod IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) INCRELEX INCRUSE ELLIPTA indapamide INDOCIN... 7 indomethacin... 7 INFANRIX (DTAP) (PF) INLYTA... INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A... 5 introvale... 7 INVANZ INVEGA SUSTENNA... 7 INVEGA TRINZA... 7 INVIRASE INVOKAMET... 5 INVOKAMET XR... 5 INVOKANA... 5 IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide... 86, 117 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRESSA... irinotecan... ISENTRESS ISENTRESS HD ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid... isosorbide dinitrate... 69, 70 isosorbide mononitrate isotretinoin isradipine ISTODAX... itraconazole... 9 ivermectin... IXIARO (PF) J JADENU JADENU SPRINKLE JAKAFI... jantoven JANUMET... 5 JANUMET XR... 5 JANUVIA... 6 JARDIANCE... 6 JEVTANA... jinteli jolivette... 7 juleber... 7 JULUCA junel 1.5/0 (1)... 7 junel 1/0 (1)... 7 junel fe 1.5/0 (8)... 7 junel fe 1/0 (8)... 7 junel fe... 7 JUXTAPID K KADCYLA... KADIAN... kaitlib fe... 7 KALETRA KALYDECO kariva (8)... 7 kelnor 1/5 (8)... 7 kelnor KENALOG KEPIVANCE KEPPRA... 9 KEPPRA XR... 9 ketoconazole... 9 ketorolac... 7, 89 KEYTRUDA... kimidess (8)... 7 KINERET KINRIX (PF) kionex (with sorbitol)... 9 KISQALI... KISQALI FEMARA CO-PACK... KLOR-CON KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle KOMBIGLYZE XR... 6 I-8

140 KORLYM... 6 KUVAN KYNAMRO KYPROLIS... L l norgest/e.estradiol-e.estrad... 7 labetalol... 6 LACRISERT LACTATED RINGERS , 11 lactulose... 9 LAMICTAL STARTER (BLUE) KIT... 9 LAMICTAL STARTER (GREEN) KIT... 9 LAMICTAL STARTER (ORANGE) KIT... 9 LAMICTAL XR STARTER (BLUE)... 0 LAMICTAL XR STARTER (GREEN)... 0 LAMICTAL XR STARTER (ORANGE)... 0 lamivudine lamivudine-zidovudine lamotrigine... 0 LANOXIN lansoprazole LANTUS SOLOSTAR U-100 INSULIN... 7 LANTUS U-100 INSULIN... 7 larin 1.5/0 (1)... 7 larin 1/0 (1)... 7 larin fe 1.5/0 (8)... 7 larin fe 1/0 (8) larissia LARTRUVO... LASTACAFT latanoprost LATUDA... 7 layolis fe LAZANDA... leena leflunomide LENVIMA... lessina LETAIRIS letrozole... leucovorin calcium LEUKERAN... leuprolide... levalbuterol hcl levetiracetam... 0 levetiracetam in nacl (iso-os). 0 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine... 0 levofloxacin... 17, 87 levofloxacin in d5w levoleucovorin LEVOLEUCOVORIN levonest (8) levonorgestrel-ethinyl estrad. 75 levonorg-eth estrad triphasic. 75 levora levorphanol tartrate... levothyroxine LEXIVA LIALDA lidocaine... 8 lidocaine (pf)... 8 lidocaine hcl... 8 lidocaine viscous... 8 lidocaine-prilocaine... 8 lincomycin lindane... 8 linezolid linezolid in dextrose 5% linezolid-0.9% sodium chloride LINZESS... 9 liothyronine lisinopril... 6 lisinopril-hydrochlorothiazide 6 lithium carbonate lithium citrate LITHOSTAT LONSURF... loperamide... 9 lopinavir-ritonavir lorazepam lorcet (hydrocodone)... lorcet hd... lorcet plus... loryna (8) losartan losartan-hydrochlorothiazide. 61 LOTEMAX lovastatin low-ogestrel (8) loxapine succinate... 7 LUMIGAN LUMIZYME LUPRON DEPOT... LUPRON DEPOT ( MONTH)... LUPRON DEPOT ( MONTH)... LUPRON DEPOT (6 MONTH)... LUPRON DEPOT-PED lutera (8) LYNPARZA... LYRICA... 0 LYSODREN... lyza M mafenide acetate magnesium sulfate malathion... 8 maprotiline... marlissa MARPLAN... MATULANE... matzim la I-9

141 MAVYRET... 5 meclizine... MEDROL medroxyprogesterone mefloquine... megestrol..., 100 MEKINIST... MEKTOVI... meloxicam... 7 melphalan hcl... memantine... MENACTRA (PF) MENEST MENOSTAR MENTAX... 9 MENVEO A-C-Y-W-15-DIP (PF) meperidine... 5 meperidine (pf)... 5 meprobamate mercaptopurine... meropenem mesalamine mesna MESNEX MESTINON metadate er metaproterenol metaxall metaxalone , 10 metformin... 6 methadone... 5 methamphetamine methazolamide methenamine hippurate methimazole METHITEST methocarbamol methotrexate sodium... methotrexate sodium (pf)... methoxsalen methscopolamine... 9 methyclothiazide methyldopa methyldopa-hydrochlorothiazide methylphenidate hcl... 71, 7 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ methyltestosterone metipranolol metoclopramide hcl... 9 metolazone metoprolol succinate... 6 metoprolol ta-hydrochlorothiaz... 6 metoprolol tartrate... 6 metronidazole... 11, 1, 80 metronidazole in nacl (iso-os) 11 mexiletine... 6 MIACALCIN miconazole microgestin 1.5/0 (1) microgestin 1/0 (1) microgestin fe 1.5/0 (8) microgestin fe 1/0 (8) midodrine miglitol... 6 miglustat mili MILLIPRED mimvey mimvey lo minocycline minoxidil mirtazapine... misoprostol MITIGARE... 0 mitomycin... mitoxantrone... M-M-R II (PF) modafinil MODERIBA... 5 MODERIBA DOSE PACK... 5 moexipril... 6 moexipril-hydrochlorothiazide... 6 mometasone... 8, 89 mononessa (8) montelukast MONUROL morphine... 5 MORPHINE... 5 morphine concentrate... 5 MOVANTIK... 9 moxifloxacin... 17, 87 moxifloxacin in nacl (iso-osm) moxifloxacin-sod.ace,sul-water MOZOBIL MULTAQ... 6 mupirocin mupirocin calcium MUSTARGEN... mutamycin... MYCAMINE... 9 mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYFORTIC MYLOTARG... myorisan MYRBETRIQ... 9 N nabumetone... 7 nadolol... 6 nadolol-bendroflumethiazide. 6 nafcillin naftifine... 9 NAGLAZYME naloxone... 8 naltrexone... 8 naproxen... 7 I-10

142 naproxen sodium... 7 naratriptan... 1 NARCAN... 9 NATACYN nateglinide... 6 NATPARA NEBUPENT... necon 0.5/5 (8) necon 7/7/7 (8) nefazodone... neomycin neomycin-bacitracin-poly-hc. 88 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc NEPHRAMINE 5. % NERLYNX... neuac NEULASTA NEUPRO... 5 NEVANAC nevirapine NEXAVAR... NEXTERONE... 6 niacin niacor nicardipine NICOTROL... 9 NICOTROL NS... 9 nifedipine nikki (8) nilutamide... nimodipine NINLARO... NIPENT... nisoldipine NITRO-DUR nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin nizatidine... 90, 91 nora-be NORDITROPIN FLEXPRO. 99 noreth-ethinyl estradiol-iron.. 76 norethindrone (contraceptive) 76 norethindrone acetate norethindrone ac-eth estradiol... 76, 97 norethindrone-e.estradiol-iron 76 norgestimate-ethinyl estradiol 76 norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortrel 0.5/5 (8) nortrel 1/5 (1) nortrel 1/5 (8) nortrel 7/7/7 (8) nortriptyline... NORVIR NOVOLIN 70/0 U-100 INSULIN... 7 NOVOLIN N NPH U-100 INSULIN... 7 NOVOLIN R REGULAR U- 100 INSULN... 7 NOVOLOG FLEXPEN U-100 INSULIN... 7 NOVOLOG MIX 70-0 U-100 INSULN... 7 NOVOLOG MIX 70-0FLEXPEN U NOVOLOG PENFILL U-100 INSULIN... 7 NOVOLOG U-100 INSULIN ASPART... 7 NOXAFIL... 9 NUCALA NUCYNTA... 5 NUCYNTA ER... 5 NULOJIX NUPLAZID... 7 NUTRILIPID NUVARING nyamyc... 9 nystatin... 9 nystop... 9 O ocella OCTAGAM octreotide acetate ODEFSEY ODOMZO... OFEV ofloxacin... 17, 88 ogestrel (8) okebo olanzapine... 7, 8 olanzapine-fluoxetine... olmesartan olmesartan-amlodipin-hcthiazid olmesartan-hydrochlorothiazide olopatadine omega- acid ethyl esters omeprazole OMNARIS ondansetron... ondansetron hcl... ondansetron hcl (pf)... ONFI ONGLYZA... 6 OPDIVO... 5 I-11

143 OPSUMIT ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORFADIN ORKAMBI orphenadrine citrate orsythia oseltamivir... 5 OSMOPREP... 9 oxacillin oxacillin in dextrose(iso-osm) 16 oxaliplatin... 5 oxandrolone oxazepam oxcarbazepine... 0, 1 oxiconazole... 9 OXTELLAR XR... 1 oxybutynin chloride... 9 oxycodone... 5 oxycodone-acetaminophen... 5, 6 oxycodone-aspirin... 6 OXYCONTIN... 6 oxymorphone... 6 OXYTROL... 9 P pacerone... 6 paclitaxel... 5 paliperidone... 8 pamidronate PANCREAZE PANDEL... 8 PANRETIN pantoprazole paricalcitol PARICALCITOL paroex oral rinse paromomycin... paroxetine hcl... PASER... PAXIL... PAZEO PCE... 1 PEDIARIX (PF) PEDVAX HIB (PF) peg 50-electrolytes... 9 PEGANONE... 1 PEGASYS... 5 PEGASYS PROCLICK... 5 peg-electrolyte soln... 9 PEN NEEDLE, DIABETIC.. 8 penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENNSAID... 7 PENTACEL DTAP-IPV COMPNT (PF) PENTAM... PENTASA pentazocine-naloxone... 6 pentoxifylline PERFOROMIST perindopril erbumine... 6 periogard PERJETA... 5 permethrin... 8 perphenazine... 8 perphenazine-amitriptyline... PERTZYE PEXEVA... phenadoz... phenelzine... PHENERGAN... phenobarbital... 1 phenoxybenzamine PHENYTEK... 1 phenytoin... 1 phenytoin sodium... 1 phenytoin sodium extended... 1 PHOSPHOLINE IODIDE PHYSIOLYTE PHYSIOSOL IRRIGATION 108 PICATO pilocarpine hcl... 78, 11 pimozide... 8 pimtrea (8) pindolol... 6 pioglitazone... 6 pioglitazone-glimepiride... 6 pioglitazone-metformin... 6 piperacillin-tazobactam pirmella piroxicam... 7 PLASMA-LYTE PLASMA-LYTE A PLEGRIDY... 7 PLENAMINE podofilox polycin polyethylene glycol polymyxin b sulfate polymyxin b sulf-trimethoprim POMALYST... 5 portia potassium chlorid-d5-0.5%nacl potassium chloride potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.5 % nacl potassium chloride-d5-0.%nacl... 11, 115 potassium chloride-d5-0.%nacl potassium chloride-d5-0.9%nacl potassium citrate POTELIGEO... 5 pramipexole... 5 pravastatin I-1

144 prazosin PRED MILD prednicarbate... 8 prednisolone prednisolone acetate prednisolone sodium phosphate... 90, 98 prednisone... 98, 99 PREDNISONE INTENSOL.. 98 PREFEST PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prevalite previfem PREZCOBIX PREZISTA PRIFTIN... PRIMAQUINE... primidone... 1 PRIMLEV... 6 PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid... 0 probenecid-colchicine... 0 procainamide... 6 PROCALAMINE % prochlorperazine... prochlorperazine edisylate... prochlorperazine maleate... PROCRIT procto-med hc... 8 procto-pak... 8 proctosol hc... 8 proctozone-hc... 8 progesterone micronized PROGLYCEM PROGRAF... 10, 10 PROLASTIN-C PROLENSA PROLEUKIN... 5 PROLIA PROMACTA promethazine... 0, promethazine vc... 0 promethegan... propafenone... 6 propantheline... 8 proparacaine propranolol... 6 propranolol-hydrochlorothiazid... 6 propylthiouracil PROQUAD (PF) PROSOL 0 % protriptyline... PULMOZYME PURIXAN... 5 PYLERA... 9 pyrazinamide... pyridostigmine bromide Q QNASL QUADRACEL (PF) quasense quetiapine... 8 quinapril... 6 quinapril-hydrochlorothiazide 6 quinidine gluconate... 6 quinidine sulfate... 6 quinine sulfate... QVAR QVAR REDIHALER R RABAVERT (PF) rabeprazole raloxifene ramipril... 6 RANEXA ranitidine hcl RAPAFLO... 9 RAPAMUNE rasagiline... 5 RAVICTI... 9 REBETOL... 5 REBIF (WITH ALBUMIN).. 7 REBIF REBIDOSE... 7 REBIF TITRATION PACK.. 7 reclipsen (8) RECOMBIVAX HB (PF) RECTIV REGRANEX RELENZA DISKHALER... 5 RELISTOR... 9 REMICADE REMODULIN RENAGEL... 9 RENVELA... 9 repaglinide... 6 repaglinide-metformin... 6 REPATHA SYRINGE RESCRIPTOR RESTASIS RETIN-A MICRO PUMP... 8 RETROVIR REVATIO REVLIMID... 5 REXULTI... 8 REYATAZ ribasphere... 5 ribasphere ribapak... 5 ribavirin... 5 RIDAURA rifabutin... RIFAMATE... rifampin... RIFATER... riluzole... 7 rimantadine... 5 ringer's , 115 RIOMET... 6 risedronate RISPERDAL... 8 I-1

145 RISPERDAL CONSTA... 8 RISPERDAL M-TAB... 8 risperidone... 8 RITALIN LA... 7 ritonavir RITUXAN... 5 rivastigmine... rivastigmine tartrate... rizatriptan... 1 romidepsin... 5 ropinirole... 5 rosuvastatin ROTARIX ROTATEQ VACCINE ROWEEPRA... 1 ROZEREM RUBRACA... 5 RUCONEST RYDAPT... 5 RYTARY... 5 S SABRIL... 1 SANCUSO... SANDOSTATIN LAR DEPOT SANTYL SAPHRIS... 8 SAPHRIS (BLACK CHERRY)... 8 SAVELLA... 7 scopolamine base... selegiline hcl... 5, 6 selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS sertraline... setlakin sevelamer carbonate... 9 sharobel SHINGRIX (PF) SIGNIFOR sildenafil (antihypertensive) 10, 11 silver sulfadiazine SIMBRINZA SIMPONI SIMPONI ARIA SIMULECT simvastatin sirolimus SIRTURO... SIVEXTRO... 11, 1 SKLICE... 8 sodium chloride , 115 sodium chloride 0.5 % sodium chloride 0.9 % sodium chloride % sodium chloride 5 % sodium lactate sodium phenylbutyrate... 9 sodium polystyrene (sorb free)... 9 sodium polystyrene sulfonate 9 SOLTAMOX... 5 SOLU-CORTEF (PF) SOLU-MEDROL SOMATULINE DEPOT SOMAVERT sorine... 6 sotalol... 6 sotalol af... 6 SOVALDI... 5 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX... 9 sprintec (8) SPRITAM... 1 SPRYCEL... 5 sps (with sorbitol)... 9 sronyx ssd stavudine STIMATE STIOLTO RESPIMAT STIVARGA... 5 STRENSIQ streptomycin STRIBILD SUBOXONE... 9 SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne).. 80 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine sulindac... 7 sumatriptan... 1 sumatriptan succinate... 1 SUPRAX... 1 SUSTIVA SUTENT... 5 SYLATRON... 5 SYLVANT... 5 SYMFI... 5 SYMFI LO... 5 SYMLINPEN SYMLINPEN SYMTUZA... 5 SYNAGIS... 5 SYNAREL SYNERCID... 1 SYNJARDY... 6 SYNJARDY XR... 6 SYNRIBO... 5 SYPRINE T TABLOID... 5 I-1

146 tacrolimus... 8, 10 tadalafil (antihypertensive) TAFINLAR... 5 TAGRISSO... 6 tamoxifen... 6 tamsulosin... 9 TARCEVA... 6 TARGRETIN... 6 tarina fe 1/0 (8) TASIGNA... 6 tazarotene... 8 tazicef... 1 TAZORAC... 8 taztia xt TECENTRIQ... 6 TECFIDERA... 7 TEFLARO... 1 TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid temazepam temsirolimus... 6 TENIVAC (PF) tenofovir disoproxil fumarate. 5 terazosin... 9 terbinafine hcl... 0 terbutaline terconazole... 1 testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine... 7 tetracycline THALOMID THEO theophylline THIOLA thioridazine... 8 thiotepa... 6 thiothixene... 9 THYMOGLOBULIN THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine... 1 TIBSOVO... 6 TIGAN... tigecycline timolol maleate... 6, 11 TIMOPTIC TIMOPTIC OCUDOSE (PF) tinidazole... TIROSINT TIVICAY... 5 tizanidine TOBI PODHALER tobramycin tobramycin in 0.5 % nacl tobramycin sulfate tobramycin-dexamethasone tolazamide... 8 tolbutamide... 8 tolcapone... 6 tolterodine... 9 topiramate... 1 toposar... 6 topotecan... 6 TORISEL... 6 torsemide TOUJEO MAX U-00 SOLOSTAR... 7 TOUJEO SOLOSTAR U-00 INSULIN... 7 TOVIAZ... 9 TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER tramadol... 6 tramadol-acetaminophen... 6 trandolapril... 6 trandolapril-verapamil... 6 tranexamic acid TRANSDERM-SCOP... tranylcypromine... TRAVASOL 10 % TRAVATAN Z trazodone... TREANDA... 6 TRECATOR... TRELSTAR... 6 tretinoin... 8, 8 tretinoin (chemotherapy)... 6 tretinoin microspheres... 8 TREXALL... 6 triamcinolone acetonide.. 78, 8, 99 triamterene-hydrochlorothiazid... 67, 68 triazolam tridesilon... 8 trientine trifluoperazine... 9 trifluridine trihexyphenidyl... 6 tri-legest fe tri-lo-estarylla tri-lo-sprintec trilyte with flavor packets... 9 trimethobenzamide... trimethoprim... 1 tri-mili trimipramine... 5 trinessa (8) TRINTELLIX... 5 tri-previfem (8) TRISENOX... 6 I-15

147 tri-sprintec (8) TRIUMEQ... 5 trivora (8) TROPHAMINE 10 % TROPHAMINE 6% trospium... 9 TRULICITY... 6 TRUMENBA TRUVADA... 5 tulana TWINRIX (PF) TYBOST TYKERB... 6 TYPHIM VI TYSABRI U UCERIS ULORIC... 0 ULTRAVATE... 8 UPTRAVI ursodiol... 9, 9 UVADEX V valacyclovir... 5 VALCHLOR valganciclovir... 5 valproate sodium... 1 valproic acid... 1 valproic acid (as sodium salt). 1 valsartan valsartan-hydrochlorothiazide 61 vancomycin... 1 vancomycin in dextrose 5 %.. 1 VAQTA (PF) VARIVAX (PF) VARUBI... VASCEPA VECTIBIX... 6 VELCADE... 6 velivet triphasic regimen (8) 77 VELPHORO... 9 VELTASSA... 9 VENCLEXTA... 6, 7 VENCLEXTA STARTING PACK... 7 venlafaxine... 5 VENTAVIS verapamil VERIPRED VERSACLOZ... 9 VERZENIO... 7 VESICARE... 9 vestura (8) VGO VIBRAMYCIN vicodin... 6 vicodin es... 6 vicodin hp... 6 VICTOZA... 7 VIDEX GRAM PEDIATRIC... 5 VIDEX GRAM PEDIATRIC... 5 VIDEX EC... 5 vienva vigabatrin... VIIBRYD... 5 VIMPAT... vinblastine... 7 vincasar pfs... 7 vincristine... 7 vinorelbine... 7 VIRACEPT... 5 VIRAMUNE... 5 VIRAZOLE... 5 VIREAD... 5 voriconazole... 0 VOSEVI... 5 VOTRIENT... 7 VPRIV VRAYLAR... 9 vyfemla (8) VYVANSE... 7 VYXEOS... 7 W warfarin water for irrigation, sterile WELCHOL wymzya fe X XALKORI... 7 XARELTO XATMEP... 7 XELJANZ XELJANZ XR XERESE XGEVA XIFAXAN... 1 XOLAIR XTANDI... 7 xulane XYREM Y YERVOY... 7 YF-VAX (PF) YONDELIS... 7 YONSA... 7 yuvafem Z zafirlukast zaleplon ZALTRAP... 7 ZANOSAR... 7 zarah ZARXIO ZEJULA... 7 ZELAPAR... 6 ZELBORAF... 7 ZEMAIRA zenatane zenchent (8) ZENPEP ZEPATIER... 5 ZERBAXA... 1 ZERIT... 5 ZETONNA I-16

148 ZIAGEN... 5 zidovudine... 5 zileuton ZIOPTAN (PF) ziprasidone hcl... 9 ZIRGAN ZMAX... 1 zoledronic acid zoledronic acid-mannitol-water ZOLINZA... 7 zolmitriptan... 1 zolpidem ZOMETA ZOMIG... 1 zonisamide... ZONTIVITY ZORTRESS ZOSTAVAX (PF) ZOSYN ZOSYN IN DEXTROSE (ISO- OSM) zovia 1/5e (8) ZOVIRAX ZYBAN... 9 ZYCLARA ZYDELIG... 7 ZYFLO ZYKADIA... 7 ZYLET ZYPREXA RELPREVV... 9 ZYTIGA... 7 I-17

149 Discrimination is Against the Law Chinese Community Health Plan (CCHP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Chinese Community Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact CCHP Member Services. If you believe that CCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with us in person, by phone, by mail, or by fax at: CCHP Member Services 5 Grant Ave, Suite 700, San Francisco, CA , TTY Fax You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 00 Independence Avenue SW. Room 509F, HHH Building Washington, DC 001, , (TDD) Complaint forms are available at (CCHP (CCHP (CCHP o o ( o o (CCHP (CCHP