Mercy Care Table of Contents

Transcription

1 List

2 Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...5 *ALTERNATIVE MEDICINES*... 8 *AMINOGLYCOSIDES*... 8 *ANALGESICS - ANTI-INFLAMMATORY*... 8 *ANALGESICS - NONNARCOTIC*...11 *ANALGESICS - OPIOID* *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS*...15 *ANTACIDS*...16 *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...17 *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ANTICOAGULANTS* *ANTICONVULSANTS*...22 *ANTIDEPRESSANTS*...25 *ANTIDIABETICS* *ANTIDIARRHEAL/PROBIOTIC AGENTS* *ANTIDIARRHEALS*...33 *ANTIDOTES AND SPECIFIC ANTAGONISTS*...33 *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS*...34 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS*...36 *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.* *ANTIMALARIALS*...41 *ANTIMYASTHENIC AGENTS* *ANTIMYASTHENIC/CHOLINERGIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...42 *ANTI-OBESITY AGENT COMBINATIONS**...46 *ANTIRKINSON AGENTS*...46 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTIRETROVIRALS ADJUVANTS*** *ANTIVIRALS*...53 *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.* *CEPHALOSPORINS*...61 *CHEMICALS*...62 *CONTRACEPTIVES*...63 *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*

3 *CYCLIN-DEPENDENT KINASES (CDK) INHIBITORS*** *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*...79 *DIGESTIVE AIDS*...80 *DIRECT-ACTING P2Y12 INHIBITORS*** *DIURETICS*...80 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...81 *ESTROGENS*...83 *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...85 *GENITOURINARY AGENTS - MISCELLANEOUS* *GLYCOPEPTIDES***...87 *GOUT AGENTS*...87 *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS*...88 *HEMOSTATICS*...90 *HETITIS C AGENT - COMBINATIONS*** *HYPNOTICS* *LAXATIVES* *MACROLIDES*...94 *MEDICAL DEVICES*...95 *MIGRAINE PRODUCTS*...97 *MINERALS & ELECTROLYTES*...98 *MOUTH/THROAT/DENTAL AGENTS* *MULTIVITAMINS* *MUSCULOSKELETAL THERAPY AGENTS* *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *NEUROMUSCULAR AGENTS* *NUTRIENTS* *OPHTHALMIC AGENTS* *OTIC AGENTS* *OXYTOCICS* *SSIVE IMMUNIZING AGENTS* *PENICILLINS* *POSTHERPETIC NEURALGIA (PHN)/NEUROTHIC IN AGENTS*** *PRENATAL MV & MINERALS W/FA WITHOUT IRON*** *PROGESTINS* *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* *RESPIRATORY AGENTS - MISC.* *SEROTONIN MODULATORS*** *SGLT2 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS*** *SINUS NODE INHIBITORS** *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES* *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISSMODICS* *VACCINES* *VAGINAL PRODUCTS*

4 *VASOPRESSORS* *VITAMINS*

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6 Mercy Care Drug Name Reference Status Restrictions *ADHD/ANTI- NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3, 4 KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR 0.1 MG *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10, 100, 18, 25, 40, 60, 80 *Amphetamine Mixtures*** ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 30, 5, 7.5 *Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG *Analeptics*** caffeine citrate oral solution 20 /ml caffeine citrated powder Intuniv CloNIDine HCl ER Strattera Adderall Amphetamine- Dextroamphet ER Adderall Dexedrine Zenzedi QLL (1 EA per 1 ; QLL (4 EA per 1 ; QLL (1 EA per 1 ; QLL (2 EA per 1 ; QLL (1 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ; QLL (1 EA per 1 ; QLL (1 EA per 1 ; 5

7 caffeine powder *Anorexiant Combinations*** QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR MG, MG, MG, MG *Anorexiants Non- Amphetamine*** benzphetamine hcl oral tablet 25 Regimex benzphetamine hcl oral tablet 50 Didrex diethylpropion hcl er oral tablet extended release 24 hour 75 diethylpropion hcl oral tablet 25 phendimetrazine tartrate er oral capsule extended release 24 hour 105 phendimetrazine tartrate oral tablet 35 phentermine hcl oral capsule 15 phentermine hcl oral capsule 30 phentermine hcl oral capsule 37.5 Adipex-P phentermine hcl oral tablet 37.5 Adipex-P *Lipase Inhibitors*** ALLI ORAL CAPSULE 60 MG *Serotonin 2C Receptor Agonists*** BELVIQ ORAL TABLET 10 MG *Stimulants - Misc.*** APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG armodafinil oral tablet 150, 200, Nuvigil 250 ; QLL (1 EA per 1 ; QLL (3 EA per 1 ; QLL (3 EA per 1 ; QLL (1 EA per 1 ; QLL (3 EA per 1 ; QLL (1 EA per 1 ; QLL (3 EA per 1 ; QLL (2 EA per 1 ; QLL (1 EA per 1 ; QLL (1 EA per 1 ; QLL (1 EA per 1 ; OTC; QLL (6 EA per 1 ; QLL (2 EA per 1 QLL (1 EA per 1 ; ; QLL (1 EA per 1 6

8 armodafinil oral tablet 50 Nuvigil DAYTRANA TRANSDERMAL TCH 10 MG/9HR, 15 MG/9HR, 20 MG/9HR, 30 MG/9HR FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG METHYLIN ORAL SOLUTION 10 MG/5ML, 5 MG/5ML methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 10, 20, 30, 40 methylphenidate hcl er (la) oral capsule extended release 24 hour 60 methylphenidate hcl er oral tablet extended release 18 methylphenidate hcl er oral tablet extended release 24 hour 18, 27, 36, 54 methylphenidate hcl er oral tablet extended release 27 methylphenidate hcl er oral tablet extended release 36 methylphenidate hcl er oral tablet extended release 54 methylphenidate hcl oral tablet 10, 20, 5 QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE 20 MG, 30 MG, 40 MG Dexmethylphenidate HCl Dexmethylphenidate HCl ER Methylphenidate HCl Ritalin LA Concerta Concerta Concerta Concerta Ritalin ; QLL (2 EA per 1 QLL (1 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ; QLL (10 ML per 1 ; AL (Min 6 Years) QLL (1 EA per 1 ; QLL (1 EA per 1 ; QLL (1 EA per 1 ; NDC is Non-; QLL (2 EA per 1 ; AL (Min 6 Years) QLL (2 EA per 1 ; NDC is Non-; QLL (2 EA per 1 ; AL (Min 6 Years) NDC is Non-; QLL (2 EA per 1 ; AL (Min 6 Years) NDC is Non-; QLL (2 EA per 1 ; AL (Min 6 Years) QLL (3 EA per 1 ; QLL (1 EA per 1 ; 7

9 QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED 25 MG/5ML RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG *ALTERNATIVE MEDICINES* *Alternative Medicine - Lu's*** Ritalin LA lutein esters oral capsule 18.6 OTC lutein oral capsule 20, 40, 6 OTC lutein oral tablet 10, 20, 6 OTC *Alternative Medicine Combinations - Two Ingredients*** omega-3 gummies oral tablet chewable OTC *AMINOGLYCOSIDES* *Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML KITABIS K INHALATION NEBULIZATION SOLUTION 300 MG/5ML neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 *ANALGESICS - ANTI- INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML Tobramycin QLL (5 ML per 1 ; QLL (1 EA per 1 ; 8

10 HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN- INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 CeleBREX ST; QLL (4 EA per 1 celecoxib oral capsule 200 CeleBREX ST; QLL (2 EA per 1 celecoxib oral capsule 400 CeleBREX ST; QLL (1 EA per 1 celecoxib oral capsule 50 CeleBREX ST; QLL (8 EA per 1 *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 40 /ml Infants Advil OTC diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400 Lodine etodolac oral tablet 500 fenoprofen calcium oral tablet 600 Nalfon flurbiprofen oral tablet 100, 50 ibuprofen junior strength oral tablet chewable 100 Advil Junior Strength OTC ibuprofen oral capsule 200 Advil OTC ibuprofen oral suspension 100 /5ml Childrens Advil ibuprofen oral tablet 200 Advil OTC 9

11 ibuprofen oral tablet 400, 600, 800 IBU INDOCIN ORAL SUSPENSION 25 MG/5ML INDOCIN RECTAL SUPPOSITORY 50 MG indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 ketoprofen capsule 50 oral 50 ketoprofen capsule 75 oral 75 ketoprofen er oral capsule extended release 24 hour 200 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 QLL (20 EA per 30 days) meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral suspension 125 /5ml Naprosyn naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral capsule 220 Aleve OTC naproxen sodium oral tablet 220 Aleve OTC naproxen sodium oral tablet 275 oxaprozin oral tablet 600 Daypro piroxicam oral capsule 10, 20 Feldene sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 Arava *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML 10

12 ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics Other*** ACEPHEN RECTAL SUPPOSITORY 325 MG acetaminophen er oral tablet extended release 650 acetaminophen extra strength oral liquid 500 /15ml acetaminophen junior strength oral tablet dispersible 160 OTC Midol OTC Chloraseptic Sore Throat OTC OTC acetaminophen oral liquid 160 /5ml Little Remedies for Fever OTC acetaminophen oral solution 160 /5ml OTC acetaminophen oral tablet 325 Pharbetol OTC acetaminophen oral tablet 500 Healthy Mama Shake That Ache OTC acetaminophen oral tablet chewable 160 Mapap Childrens OTC acetaminophen oral tablet chewable 80 Childrens Medi-Tabs OTC acetaminophen rapid tabs child oral tablet Mapap Childrens dispersible 80 OTC acetaminophen rectal suppository 120, Acephen 650 OTC childrens acetaminophen oral suspension 160 /5ml Mapap Childrens OTC childrens aspirin free oral elixir 80 /2.5ml Medi-Tabs Childrens OTC nortemp infants oral suspension 80 /0.8ml OTC *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet Tencon 11

13 butalbital-apap-caffeine oral capsule Fioricet butalbital-apap-caffeine oral capsule Esgic butalbital-apap-caffeine oral tablet Esgic butalbital-asa-caffeine oral capsule Fiorinal butalbital-aspirin-caffeine oral tablet *Salicylate Combinations*** buffered aspirin oral tablet 325 Bufferin OTC choline-mag trisalicylate oral liquid 500 /5ml *Salicylates*** aspirin ec oral tablet delayed release 325 Bayer Aspirin Regimen OTC aspirin ec oral tablet delayed release 81 Aspir-Low OTC aspirin oral tablet 325 Bayer Advanced Aspirin Reg St OTC aspirin oral tablet chewable 81 Bayer Low Dose OTC aspirin rectal suppository 300, 600 OTC diflunisal oral tablet 500 salsalate oral tablet 500, 750 *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet Tylenol with Codeine #4 butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule Ascomp-Codeine 12

14 *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral tablet Lorcet HD hydrocodone-acetaminophen oral tablet Lorcet hydrocodone-acetaminophen oral tablet Lorcet Plus hydrocodone-ibuprofen oral tablet Ibudone, hydrocodone-ibuprofen oral tablet *Opioid Agonists*** EMBEDA ORAL CAPSULE EXTENDED RELEASE MG, MG, MG, 50-2 MG, MG, MG fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr fentanyl transdermal patch 72 hour 50 mcg/hr fentanyl transdermal patch 72 hour 75 mcg/hr Actiq Duragesic-100 Duragesic-12 Duragesic-25 Duragesic-50 Duragesic-75 hydromorphone hcl oral liquid 1 /ml Dilaudid hydromorphone hcl oral tablet 2, 4, 8 Dilaudid meperidine hcl oral tablet 100, 50 morphine sulfate (concentrate) oral solution 20 /ml morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 MS Contin ; QLL (2 EA per 1 ; QLL (0.5 EA per 1 ; QLL (0.5 EA per 1 ; QLL (0.5 EA per 1 ; QLL (0.5 EA per 1 ; QLL (0.5 EA per 1 13

15 morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl oral capsule 5 oxycodone hcl oral concentrate 100 /5ml oxycodone hcl oral solution 5 /5ml oxycodone hcl oral tablet 10, 20 oxycodone hcl oral tablet 15, 30, 5 Roxicodone tramadol hcl er oral tablet extended release 24 hour 100, 200, 300 tramadol hcl oral tablet 50 Ultram XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG *Opioid Combinations*** oxycodone-acetaminophen oral solution /5ml oxycodone-acetaminophen oral tablet , , 5-325, oxycodone-aspirin oral tablet oxycodone-ibuprofen oral tablet *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 Endocet BUTRANS TRANSDERMAL TCH WEEKLY 10 MCG/HR, 15 MCG/HR, Buprenorphine 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG *Tramadol Combinations*** tramadol-acetaminophen oral tablet Ultracet 325 ; Required unless the member is pregnant- the prescriber must note the following ICD-10 codes on the prescription: 1. O09.91, 2. O09.92, 3. O09.93, 4. O09.91 QLL (4 EA per 28 days) 14

16 *ANDROGENS-ANABOLIC* *Androgens*** ANDRODERM TRANSDERMAL TCH 24 HOUR 2 MG/24HR, 4 MG/24HR ANDROXY ORAL TABLET 10 MG danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular solution 100 /ml, 200 /ml Depo-Testosterone testosterone enanthate intramuscular solution 200 /ml testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump testosterone transdermal gel /1.25gm (1.62%), 25 /2.5gm (1%), 40.5 /2.5gm (1.62%), 50 /5gm (1%) AndroGel testosterone transdermal gel /act AndroGel Pump (1.62%) testosterone transdermal solution 30 /act *ANORECTAL AGENTS* *Intrarectal Steroids*** CORTIFOAM RECTAL FOAM 10 % hydrocortisone rectal enema 100 /60ml Colocort *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % *Rectal Anesthetic/Steroids*** hydrocortisone ace-pramoxine rectal cream 1-1 % Analpram-HC hydrocortisone ace-pramoxine rectal cream % Analpram HC lidocaine-hydrocortisone ace rectal cream % lidocaine-hydrocortisone ace rectal kit %, 3-1 %, % PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** hydrocortisone rectal cream 1 % Procto-Pak hydrocortisone rectal cream 2.5 % Anusol-HC 15

17 *ANTACIDS* *Antacid & Simethicone*** antacid & antigas oral suspension /5ml Almacone OTC antacid/simethicone ds oral suspension /5ml MINTOX PLUS ORAL TABLET CHEWABLE MG *Antacid Combinations*** heartburn antacid ex st oral tablet chewable *Antacids - Aluminum Salts*** aluminum hydroxide gel oral suspension 320 /5ml *Antacids - Bicarbonate*** sodium bicarbonate oral powder sodium bicarbonate oral tablet 325, 650 *Antacids - Calcium Salts*** calcium carbonate antacid oral suspension 1250 /5ml calcium carbonate antacid oral tablet 648 calcium carbonate antacid oral tablet chewable 500 calcium carbonate antacid oral tablet chewable 750 TITRALAC ORAL TABLET CHEWABLE 420 MG *Antacids - Magnesium Salts*** Almacone Double Strength OTC OTC Acid Gone OTC OTC OTC OTC OTC Cal-Gest Antacid OTC Antacid Flavor Chews OTC OTC magnesium oxide oral capsule 400 OTC magnesium oxide oral tablet 250, 400 OTC magnesium oxide oral tablet 420 Maox OTC URO-MAG ORAL CAPSULE 140 MG OTC *ANTHELMINTICS* *Anthelmintics*** ALBENZA ORAL TABLET 200 MG Albendazole ST EMVERM ORAL TABLET CHEWABLE 100 MG 16

18 ivermectin oral tablet 3 Stromectol pinworm medicine oral suspension 144 (50 base) /ml praziquantel oral tablet 600 Biltricide reeses pinworm medicine oral tablet 180 *ANTIANGINAL AGENTS* *Antianginals-Other*** RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG *Nitrates*** DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin er oral capsule extended release 2.5, 6.5, 9 Nitro-Time nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 Nitrostat nitroglycerin transdermal patch 24 hour Minitran 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 5, 7.5 buspirone hcl oral tablet 30 hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 OTC OTC QLL (4 EA per 1 ; QLL (2 EA per 1 ; QLL (10 ML per 1 QLL (8 EA per 1 17

19 hydroxyzine pamoate oral capsule 100 QLL (4 EA per 1 hydroxyzine pamoate oral capsule 25, 50 Vistaril QLL (4 EA per 1 *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25, 0.5, 1 Xanax XR Xanax alprazolam oral tablet 2 Xanax alprazolam oral tablet dispersible 0.25, 0.5, 1 alprazolam oral tablet dispersible 2 chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15 clorazepate dipotassium oral tablet 3.75 clorazepate dipotassium oral tablet 7.5 Tranxene-T diazepam oral concentrate 5 /ml Diazepam Intensol diazepam oral solution 5 /5ml diazepam oral tablet 10, 2, 5 Valium lorazepam oral concentrate 2 /ml LORazepam Intensol lorazepam oral tablet 0.5, 1 Ativan lorazepam oral tablet 2 Ativan oxazepam oral capsule 10, 15, 30 *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, Norpace QLL (1 EA per 1 ; QLL (4 ML per 1 ; QLL (4 EA per 1 ; QLL (2 EA per 1 ; QLL (4 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ; QLL (4 EA per 1 ; QLL (4 EA per 1 ; QLL (8 ML per 1 ; QLL (10 ML per 1 ; AL (Min 6 Years) QLL (4 EA per 1 ; QLL (2 ML per 1 ; QLL (4 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ;

20 NORCE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 100, 200 dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg MULTAQ ORAL TABLET 400 MG *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT BEVESPI AEROSPHERE INHALATION AEROSOL MCG/ACT COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT Rythmol SR Pacerone Tikosyn ; QLL (2 EA per 1 ST ST; AL (Min 4 Years and Max 12 Years) ST 19

21 ipratropium-albuterol inhalation solution (3) /3ml STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5%, 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG levalbuterol hcl inhalation nebulization solution 0.31 /3ml, 0.63 /3ml, 1.25 /3ml SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT ipratropium bromide inhalation solution 0.02 % SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG *Leukotriene Receptor Antagonists*** ST QLL (1 EA per 1 Xopenex AL (Max 4 Years) QLL (4 GM per 30 days) montelukast sodium oral packet 4 Singulair QLL (1 EA per 1 ; AL (Max 4 Years) montelukast sodium oral tablet 10 Singulair QLL (1 EA per 1 20

22 montelukast sodium oral tablet chewable 4, 5 Singulair QLL (1 EA per 1 *Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT PULMICORT INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML, 1 MG/2ML QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthines*** theophylline er oral tablet extended release 12 hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml *ANTICOAGULANTS* *Coumarin Anticoagulants*** warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG Budesonide Theochron Coumadin AL (Max 4 Years) While supplies last QLL (2 EA per 1 21

23 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO STARTER CK ORAL TABLET THERAPY CK 15 & 20 MG *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml *Low Molecular Weight Heparins*** enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous solution 100 /ml, 150 /ml enoxaparin sodium subcutaneous solution 120 /0.8ml, 80 /0.8ml enoxaparin sodium subcutaneous solution 30 /0.3ml enoxaparin sodium subcutaneous solution 40 /0.4ml enoxaparin sodium subcutaneous solution 60 /0.6ml *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** Lovenox Lovenox Lovenox Lovenox Lovenox Lovenox QLL (2 EA per 1 QLL (51 EA per 30 days) QLL (6 ML per 1 QLL (2 ML per 1 QLL (1.6 ML per 1 QLL (0.6 ML per 1 QLL (0.8 ML per 1 QLL (1.2 ML per 1 QLL (2 EA per 1 clobazam oral suspension 2.5 /ml Onfi clobazam oral tablet 10, 20 Onfi clonazepam oral tablet 0.5, 1 KlonoPIN QLL (4 EA per 1 ; clonazepam oral tablet 2 KlonoPIN QLL (2 EA per 1 ; clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1 QLL (4 EA per 1 ; 22

24 clonazepam oral tablet dispersible 2 QLL (2 EA per 1 ; diazepam rectal gel 10, 20 Diastat AcuDial QLL (2 EA Max Qty Per Fill Retail) diazepam rectal gel 2.5 Diastat Pediatric QLL (2 EA Max Qty Per Fill Retail) *Anticonvulsants - Misc.*** BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG carbamazepine er oral capsule extended release 12 hour 100, 200, 300 Carbatrol carbamazepine er oral tablet extended release 12 hour 100, 200, 400 TEGretol-XR carbamazepine oral suspension 100 /5ml TEGretol carbamazepine oral tablet 200 Epitol carbamazepine oral tablet chewable 100 gabapentin oral capsule 100, 300, 400 Neurontin gabapentin oral solution 250 /5ml Neurontin gabapentin oral tablet 600, 800 Neurontin lamotrigine er oral tablet extended release 24 hour 100, 200, 25, 250, LaMICtal XR 300, 50 lamotrigine oral tablet 100, 150, 200, 25 LaMICtal lamotrigine oral tablet chewable 25, 5 LaMICtal lamotrigine oral tablet dispersible 100, 200, 25, 50 LaMICtal ODT levetiracetam er oral tablet extended release 24 hour 500, 750 Keppra XR levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 Keppra LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML 23

25 oxcarbazepine oral suspension 300 /5ml Trileptal oxcarbazepine oral tablet 150, 300, 600 Trileptal primidone oral tablet 250, 50 Mysoline topiramate oral capsule sprinkle 15, 25 Topamax Sprinkle topiramate oral tablet 100, 200, 25 Topamax, 50 VIMT ORAL SOLUTION 10 MG/ML VIMT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100, 25 Zonegran zonisamide oral capsule 50 *Carbamates*** felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol *Gaba Modulators*** tiagabine hcl oral tablet 12, 2, 4 Gabitril QLL (4 EA per 1 tiagabine hcl oral tablet 16 Gabitril QLL (3.5 EA per 1 *Hydantoins*** DILANTIN ORAL CAPSULE 30 MG phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 Dilantin phenytoin sodium extended oral capsule 200, 300 Phenytek *Succinimides*** CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250, 500 Depakote ER divalproex sodium oral capsule delayed release sprinkle 125 Depakote Sprinkles 24

26 divalproex sodium oral tablet delayed release 125, 250, 500 Depakote valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30 Remeron QLL (1 EA per 1 ; mirtazapine oral tablet 45, 7.5 QLL (1 EA per 1 ; mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150, 300 bupropion hcl oral tablet 100, 75 maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** nefazodone hcl oral tablet 100, 250, 50 nefazodone hcl oral tablet 150 nefazodone hcl oral tablet 200 trazodone hcl oral tablet 100 trazodone hcl oral tablet 150 trazodone hcl oral tablet 300 trazodone hcl oral tablet 50 VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD STARTER CK ORAL KIT 10 & 20 MG Remeron SolTab Wellbutrin SR Wellbutrin XL QLL (1 EA per 1 ; QLL (2 EA per 1 ; QLL (1 EA per 1 ; QLL (4 EA per 1 ; QLL (2 EA per 1 ; QLL (4 EA per 1 ; QLL (3 EA per 1 ; QLL (4 EA per 1 ; QLL (2 EA per 1 ; QLL (1 EA per 1 ; QLL (3 EA per 1 ; 25

27 *Monoamine Oxidase Inhibitors (Maois)*** EMSAM TRANSDERMAL TCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 10 MG phenelzine sulfate oral tablet 15 Nardil tranylcypromine sulfate oral tablet 10 Parnate *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10 citalopram hydrobromide oral tablet 20, 40 escitalopram oxalate oral solution 5 /5ml escitalopram oxalate oral tablet 10, 20 CeleXA CeleXA Lexapro escitalopram oxalate oral tablet 5 Lexapro fluoxetine hcl oral capsule 10, 40 PROzac fluoxetine hcl oral capsule 20 PROzac fluoxetine hcl oral capsule delayed release 90 fluoxetine hcl oral solution 20 /5ml fluvoxamine maleate er oral capsule extended release 24 hour 100 fluvoxamine maleate er oral capsule extended release 24 hour 150 fluvoxamine maleate oral tablet 100 fluvoxamine maleate oral tablet 25 fluvoxamine maleate oral tablet QLL (20 ML per 1 ; AL (Min 6 Years) QLL (2 EA per 1 ; QLL (1 EA per 1 ; QLL (20 ML per 1 ; AL (Min 6 Years) QLL (1 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ; QLL (4 EA per 1 ; QLL (20 ML per 1 ; AL (Min 6 Years) QLL (3 EA per 1 ; QLL (2 EA per 1 ; QLL (3 EA per 1 ; QLL (2 EA per 1 ; QLL (6 EA per 1 ;

28 paroxetine hcl er oral tablet extended release 24 hour 12.5, 25, 37.5 paroxetine hcl oral tablet 10, 20, 30 Paxil CR Paxil paroxetine hcl oral tablet 40 Paxil XIL ORAL SUSPENSION 10 MG/5ML PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100 Zoloft sertraline hcl oral tablet 25 Zoloft sertraline hcl oral tablet 50 Zoloft *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** desvenlafaxine succinate er oral tablet extended release 24 hour 100, 25, 50 duloxetine hcl oral capsule delayed release particles 20, 30 duloxetine hcl oral capsule delayed release particles 60 venlafaxine hcl er oral capsule extended release 24 hour 150 venlafaxine hcl er oral capsule extended release 24 hour 37.5, 75 venlafaxine hcl oral tablet 100, 37.5, 50 venlafaxine hcl oral tablet 25 venlafaxine hcl oral tablet 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 Pristiq Cymbalta Cymbalta Effexor XR Effexor XR QLL (3 EA per 1 ; QLL (1 EA per 1 ; QLL (1.5 EA per 1 QLL (30 ML per 1 ; AL (Min 6 Years) QLL (10 ML per 1 ; AL (Min 6 Years) QLL (2 EA per 1 ; QLL (3 EA per 1 ; QLL (4 EA per 1 ; QLL (4 EA per 1 ; QLL (4 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ; QLL (3 EA per 1 ; QLL (3 EA per 1 ; QLL (4 EA per 1 ; QLL (5 EA per 1 ; 27

29 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 Anafranil desipramine hcl oral tablet 10, 25 Norpramin desipramine hcl oral tablet 100, 150, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml QLL (3 EA per 1 ; QLL (6 ML per 1 ; imipramine hcl oral tablet 10, 25, 50 Tofranil imipramine pamoate oral capsule 100, 125, 150, 75 nortriptyline hcl oral capsule 10, 25, 50, 75 Pamelor nortriptyline hcl oral solution 10 /5ml protriptyline hcl oral tablet 10, 5 trimipramine maleate oral capsule 100, 25, 50 Surmontil *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 Precose *Antidiabetic - Amylin Analogs*** SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 Glucophage XR metformin hcl oral solution 500 /5ml Riomet metformin hcl oral tablet 1000, 500, 850 Glucophage *Diabetic Other*** BD GLUCOSE ORAL TABLET CHEWABLE 5 GM 28 OTC

30 GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG Dex4 Quick Dissolve glucose oral tablet chewable 4 gm Glucose *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG JANUVIA ORAL TABLET 25 MG JANUVIA ORAL TABLET 50 MG ONGLYZA ORAL TABLET 2.5 MG ONGLYZA ORAL TABLET 5 MG TRADJENTA ORAL TABLET 5 MG *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG JENTADUETO ORAL TABLET MG, MG, MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG *Human Insulin*** HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML QLL (1 EA per 30 days) QLL (1 EA per 30 days) OTC ; QLL (1 EA per 1 ; QLL (4 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ; QLL (1 EA per 1 ; QLL (1 EA per 1 ; QLL (2 EA per 1 ; QLL (1 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ; QLL (2 EA per 1 ; QLL (1 EA per 1 29

31 HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML OTC OTC OTC 30

32 NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS PEN- INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 10 MCG/0.04ML BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 5 MCG/0.02ML VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR 18 MG/3ML *Meglitinide Analogues*** nateglinide oral tablet 120, 60 Starlix repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 Prandin *Meglitinide-Biguanide Combinations*** repaglinide-metformin hcl oral tablet 1-500, *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet , , ; QLL (4 EA per 28 days) ; QLL (4 EA per 28 days) ; QLL (2.4 ML per 30 days) ; QLL (1.2 ML per 30 days) ; QLL (9 ML per 28 days) ST; QLL (1 EA per 1 ST; QLL (1 EA per 1 31

33 *Sulfonylureas*** glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 Glucotrol XL hour 10, 2.5, 5 glipizide oral tablet 10, 5 Glucotrol glyburide micronized oral tablet 1.5, 3 Glynase, 6 glyburide oral tablet 1.25, 2.5, 5 *Thiazolidinedione-Biguanide Combinations*** ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG pioglitazone hcl-metformin hcl oral tablet Actoplus Met , *Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG pioglitazone hcl oral tablet 15, 30, Actos 45 *ANTIDIARRHEAL/PROBIOTI C AGENTS* *Antidiarrheal/Probiotic Agents - Misc.*** bismuth oral tablet chewable 262 Pepto-Bismol OTC cvs bismuth oral tablet 262 Kaopectate OTC eql stomach relief oral tablet 262 Kaopectate OTC gnp pink bismuth oral tablet 262 Kaopectate OTC KAOPECTATE ORAL TABLET 262 MG Kaopectate OTC pink bismuth maximum strength oral suspension 525 /15ml pink bismuth oral suspension 262 /15ml Kaopectate Extra Strength ST; QLL (1 EA per 1 OTC Kao-Tin OTC ra pink bismuth oral tablet 262 Kaopectate OTC sb bismuth oral tablet 262 Kaopectate OTC sm stomach relief oral tablet 262 Kaopectate OTC SOOTHE ORAL TABLET 262 MG Kaopectate OTC tgt stomach relief oral tablet 262 Kaopectate OTC 32

34 *ANTIDIARRHEALS* *Antidiarrheal Agents - Misc.*** bismuth oral tablet chewable 262 Pepto-Bismol OTC cvs bismuth oral tablet 262 Kaopectate OTC eql stomach relief oral tablet 262 Kaopectate OTC gnp pink bismuth oral tablet 262 Kaopectate OTC KAOPECTATE ORAL TABLET 262 MG Kaopectate OTC pink bismuth maximum strength oral suspension 525 /15ml pink bismuth oral suspension 262 /15ml Kaopectate Extra Strength OTC Kao-Tin OTC ra pink bismuth oral tablet 262 Kaopectate OTC sb bismuth oral tablet 262 Kaopectate OTC sm stomach relief oral tablet 262 Kaopectate OTC SOOTHE ORAL TABLET 262 MG Kaopectate OTC tgt stomach relief oral tablet 262 Kaopectate OTC *Antiperistaltic Agents*** diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet Lomotil hm loperamide hcl oral capsule 2 Imodium A-D OTC loperamide hcl oral liquid 1 /5ml OTC loperamide hcl oral suspension 1 /7.5ml Imodium A-D OTC loperamide hcl oral tablet 2 Imodium A-D OTC *ANTIDOTES AND SPECIFIC ANTAGONISTS* *Antidotes And Specific Antagonists*** sm ipecac syrup oral syrup OTC *ANTIDOTES* *Antidotes*** sm ipecac syrup oral syrup OTC *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml, 4 /10ml 33

35 naloxone hcl injection solution cartridge 0.4 /ml naloxone hcl injection solution prefilled syringe 2 /2ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** ANZEMET ORAL TABLET 100 MG, 50 MG granisetron hcl oral tablet 1 ondansetron hcl oral tablet 24 ; QLL (1 EA per 1 ondansetron hcl oral tablet 4, 8 Zofran QLL (3 EA per 1 ondansetron oral tablet dispersible 4 QLL (6 EA per 1 ondansetron oral tablet dispersible 8 QLL (3 EA per 1 *Antiemetics - Anticholinergic*** meclizine hcl oral tablet 12.5 meclizine hcl oral tablet 25 Dramamine Less Drowsy meclizine hcl oral tablet chewable 25 trimethobenzamide hcl oral capsule 300 Tigan *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** aprepitant oral capsule 125, 40, 80 Emend aprepitant oral capsule 80 & 125 Emend Tri-Pack *ANTIFUNGALS* *Antifungals*** bio-statin oral capsule unit, unit Maximum day supply per fill is 21 days.; QLL (6 EA per 21 days) Maximum day supply per fill is 21 days.; QLL (6 EA per 21 days) 34

36 bio-statin oral powder griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 nystatin oral tablet unit terbinafine hcl oral tablet 250 LamISIL QLL (90 EA per 365 days) *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 *ANTIHISTAMINES* *Antihistamines - Alkylamines*** chlorpheniramine maleate er oral tablet extended release 12 chlorpheniramine maleate oral tablet 4 RES-BR ORAL TABLET EXTENDED RELEASE 12 HOUR 11 MG *Antihistamines - Ethanolamines*** Diflucan QLL (20 ML per 1 Diflucan QLL (2 EA per 1 Chlor-Trimeton Allergy OTC Chlor-Trimeton OTC aler-dryl oral tablet 50 OTC childrens allergy oral liquid 12.5 /5ml Banophen OTC clemastine fumarate oral tablet 1.34 Dayhist Allergy 12 Hour Relief OTC clemastine fumarate oral tablet 2.68 diphenhydramine hcl oral capsule 25, 50 Banophen diphenhydramine hcl oral liquid 6.25 /ml Vanamine PD OTC diphenhydramine hcl oral tablet 25 Alka-Seltzer Plus Allergy OTC eq allergy relief childrens oral elixir 12.5 /5ml OTC gnp allergy relief oral tablet chewable 12.5 *Antihistamines - Non- Sedating*** allergy relief oral tablet dispersible 10 Alavert Benadryl Allergy Childrens OTC OTC; QLL (1 EA per 1 35

37 cetirizine hcl childrens oral solution 1 /ml KLS Aller-Tec Childrens cetirizine hcl oral tablet 10 KLS Aller-Tec cetirizine hcl oral tablet 5 cetirizine hcl oral tablet chewable 10, 5 fexofenadine hcl childrens oral suspension 30 /5ml Wal-Zyr Childrens Allegra Allergy Childrens fexofenadine hcl oral tablet 180 Allegra Allergy fexofenadine hcl oral tablet 60 Allegra Allergy loratadine childrens oral solution 5 /5ml loratadine childrens oral tablet chewable 5 Claritin Claritin loratadine oral capsule 10 Claritin OTC; QLL (5 ML per 1 OTC; QLL (1 EA per 1 OTC; QLL (1 EA per 1 OTC; QLL (1 EA per 1 OTC; QLL (5 ML per 1 OTC; QLL (1 EA per 1 OTC; QLL (2 EA per 1 OTC; QLL (5 ML per 1 OTC; QLL (2 EA per 1 OTC; QLL (1 EA per 1 loratadine oral tablet 10 Claritin OTC loratadine oral tablet chewable 5 Claritin OTC; QLL (2 EA per 1 ra allergy relief childrens oral tablet Claritin chewable 5 *Antihistamines - Phenothiazines*** promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5 Phenadoz, 25 promethazine hcl rectal suppository 50 Promethegan *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *Antihyperlipidemics - Misc.*** omega-3-acid ethyl esters oral capsule 1 Lovaza gm OTC; QLL (2 EA per 1 ST; QLL (4 EA per 1 triklo oral capsule 1 gm Lovaza QLL (4 EA per 1 36

38 *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite cholestyramine light oral powder 4 gm/dose Prevalite cholestyramine oral packet 4 gm Questran cholestyramine oral powder 4 gm/dose Questran colestipol hcl oral granules 5 gm Colestid colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 145, 48 Tricor fenofibrate oral tablet 160 Triglide fenofibrate oral tablet 54 fenofibric acid oral tablet 105, 35 Fibricor gemfibrozil oral tablet 600 Lopid *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20 Lipitor, 40, 80 QLL (1 EA per 1 fluvastatin sodium er oral tablet extended release 24 hour 80 Lescol XL QLL (1 EA per 1 fluvastatin sodium oral capsule 20 Lescol QLL (1 EA per 1 fluvastatin sodium oral capsule 40 QLL (1 EA per 1 lovastatin oral tablet 10, 20 QLL (1 EA per 1 lovastatin oral tablet 40 Mevacor QLL (1 EA per 1 pravastatin sodium oral tablet 10 QLL (1 EA per 1 pravastatin sodium oral tablet 20, 40, 80 Pravachol QLL (1 EA per 1 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors*** Crestor ST; QLL (1 EA per 1 Zocor QLL (1 EA per 1 ezetimibe oral tablet 10 Zetia ST; QLL (1 EA per 1 37

39 *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5- Lotrel 20 amlodipine besy-benazepril hcl oral capsule , 5-40 *Ace Inhibitors & Thiazide/Thiazide-Like*** captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet Vaseretic enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet , lisinopril-hydrochlorothiazide oral tablet , , Zestoretic moexipril-hydrochlorothiazide oral tablet , 15-25, quinapril-hydrochlorothiazide oral tablet , , Accuretic *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40 Lotensin benazepril hcl oral tablet 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 Vasotec ENED ORAL SOLUTION 1 MG/ML fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 20, 5 Prinivil lisinopril oral tablet 2.5, 30, 40 Zestril moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2, 4, 8 38

40 quinapril hcl oral tablet 10, 20, 40 Accupril, 5 ramipril oral capsule 1.25, 10, 2.5, 5 Altace trandolapril oral tablet 1, 2 trandolapril oral tablet 4 Mavik *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet , *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet , , 5-160, Exforge QLL (1 EA per 1 *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet , , Atacand HCT QLL (1 EA per 1 losartan potassium-hctz oral tablet , , Hyzaar valsartan-hydrochlorothiazide oral tablet , , , Diovan HCT , *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16, 32 Atacand, 4, 8 QLL (1 EA per 1 irbesartan oral tablet 150, 300, 75 Avapro losartan potassium oral tablet 100, 25 Cozaar, 50 telmisartan oral tablet 20, 40, 80 Micardis QLL (1 EA per 1 valsartan oral tablet 160, 320, 40, 80 Diovan *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 Catapres 39

41 clonidine hcl transdermal patch weekly 0.1 /24hr, 0.2 /24hr, 0.3 /24hr QLL (4 EA per 28 days); AL (Min 6 Years) guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, Cardura 4, 8 prazosin hcl oral capsule 1, 2, 5 Minipress terazosin hcl oral capsule 1, 10, 2, 5 *Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet Tenoretic 100 atenolol-chlorthalidone oral tablet Tenoretic 50 bisoprolol-hydrochlorothiazide oral tablet Ziac , , metoprolol-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet Lopressor HCT nadolol-bendroflumethiazide oral tablet 40-5, 80-5 Corzide propranolol-hctz oral tablet 40-25, *Selective Aldosterone Receptor Antagonists (Saras)*** eplerenone oral tablet 25, 50 Inspra *Vasodilators*** hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *ANTI-INFECTIVE AGENTS - MISC.* *Anti-Infective Agents - Misc.*** metronidazole oral capsule 375 Flagyl metronidazole oral tablet 250, 500 Flagyl 40

42 trimethoprim oral tablet 100 *Anti-Infective Misc. - Combinations*** sulfamethoxazole-trimethoprim oral suspension /5ml Sulfatrim Pediatric sulfamethoxazole-trimethoprim oral tablet Bactrim sulfamethoxazole-trimethoprim oral tablet Bactrim DS *Antiprotozoal Agents*** atovaquone oral suspension 750 /5ml Mepron QLL (10 ML per 1 *Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides*** clindamycin hcl oral capsule 150, 300 Cleocin, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml Cleocin *Oxazolidinones*** linezolid oral suspension reconstituted 100 /5ml Zyvox linezolid oral tablet 600 Zyvox *ANTIMALARIALS* *Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet , Malarone COARTEM ORAL TABLET MG *Antimalarials*** chloroquine phosphate oral tablet 250, 500 DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 Plaquenil mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 quinine sulfate oral capsule 324 Qualaquin 41

43 *ANTIMYASTHENIC AGENTS* *Antimyasthenic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *Antimyasthenic/Cholinergic Agents*** pyridostigmine bromide oral tablet 60 Mestinon *ANTIMYASTHENIC/CHOLIN ERGIC AGENTS* pyridostigmine bromide oral tablet 60 Mestinon *ANTIMYCOBACTERIAL AGENTS* *Anti Tb Combinations*** RIFAMATE ORAL CAPSULE MG *Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 Myambutol isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 Mycobutin rifampin oral capsule 150, 300 Rifadin *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* *Antiandrogens*** bicalutamide oral tablet 50 Casodex flutamide oral capsule 125 *Antiestrogens*** FARESTON ORAL TABLET 60 MG tamoxifen citrate oral tablet 10, 20 *Antimetabolites*** capecitabine oral tablet 150 Xeloda ; Maximum day supply per fill is 21 days.; QLL (140 EA per 21 days) 42

44 capecitabine oral tablet 500 Xeloda ; Maximum day supply per fill is 21 days.; QLL (154 EA per 21 days) mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 methotrexate sodium (pf) injection solution 1 gm/40ml methotrexate sodium (pf) injection solution 250 /10ml methotrexate sodium (pf) injection solution 50 /2ml methotrexate sodium injection solution 250 /10ml methotrexate sodium injection solution 50 /2ml PURIXAN ORAL SUSPENSION 2000 MG/100ML TABLOID ORAL TABLET 40 MG *Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 MG *Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CAPSULE 100 MG *Antineoplastic - Mtor Kinase Inhibitors*** AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG *Antineoplastic - Multikinase Inhibitors*** NEXAVAR ORAL TABLET 200 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG *Antineoplastic - Proteasome Inhibitors*** VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG QLL (160 ML per 30 days) QLL (40 ML per 30 days) QLL (8 ML per 30 days) QLL (40 ML per 30 days) QLL (8 ML per 30 days) 43

45 *Antineoplastic - Tyrosine Kinase Inhibitors*** CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG, 300 MG ICLUSIG ORAL TABLET 15 MG, 45 MG imatinib mesylate oral tablet 100, 400 IMBRUVICA ORAL CAPSULE 140 MG, 70 MG ; QLL (1 EA per 1 Gleevec INLYTA ORAL TABLET 1 MG, 5 MG IRESSA ORAL TABLET 250 MG SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG TYKERB ORAL TABLET 250 MG VOTRIENT ORAL TABLET 200 MG XALKORI ORAL CAPSULE 200 MG, 250 MG *Antineoplastics Misc.*** ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML ALFERON N INJECTION SOLUTION UNIT/ML hydroxyurea oral capsule 500 Hydrea INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT MATULANE ORAL CAPSULE 50 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG *Aromatase Inhibitors*** anastrozole oral tablet 1 Arimidex 44 ; QLL (1 EA per 1