Prescription Drug Formulary (Tier 5)

Transcription

1 Get More Than Original Medicare 019 Prescription Formulary ( 5) Ofered by This formulary was updated on 10/01/018. For more recent information or other questions, please contact Community Health Plan of Washington Customer Service at or for T-T-Y users, toll free at 7-1-1, 7 days a week, 8 a.m. to 8 p.m. or visit our website at healthfrst.chpw.org. H586_RX_96_019_v_01_Formulary_5_C

2 Community HealthFirst TM Medicare Advantage Plan 019 Formulary List of Covered s PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID , Version 1 This formulary was updated on 10/01/018. For more recent information or other questions, please contact Community Health Plan of Washington Customer Service at or, for TTY users, Toll-free at 7-1-1, 7 days a week, 8 a.m. to 8 p.m. or visit our website at healthfirst.chpw.org. Community Health Plan of Washington is an HMO Plan with a Medicare contract and a contract with the Washington State Medicaid Program. Enrollment in Community Health Plan of Washington depends on contract renewal. Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 7-1-1). H586_RX_96_019_v_01_Formulary_5_C 1

3 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 Community Health Plan of Washington. When it refers to plan or our plan, it means Community HealthFirst Medicare Advantage 5 Plan. This document includes a list of the drugs (formulary) for our plan which is current as of 10/01/018. 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 Community HealthFirst Medicare Advantage Plan Formulary? A formulary is a list of covered drugs selected by Community HealthFirst Medicare Advantage Plan 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. Community HealthFirst Medicare Advantage Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Community HealthFirst Medicare Advantage Plan 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:

4 s removed from the market. If the Food and 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 new generic drug 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. 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 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. The enclosed formulary is current as of 10/01/018. To get updated information about the drugs covered by Community Health Plan of Washington, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 15. 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, Hypertension/Lipids. If you know what your drug is used for, look for the category name in the list that begins 15. 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 89. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Community HealthFirst Medicare Advantage Plan 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: 3

5 Prior Authorization: Community HealthFirst Medicare Advantage Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets (different quantity limits for different strengths) per prescription for citalopram 10mg tablets. This may be in addition to a standard one-month or threemonth supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 15. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization restriction 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 us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Community HealthFirst Medicare Advantage Plan formulary? on page 5 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Community HealthFirst Medicare Advantage Plan does not cover your drug, you have two options: You can ask Customer Services for a list of similar drugs that are covered by Community HealthFirst Medicare Advantage Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. 4

6 How do I request an exception to the Community HealthFirst Medicare Advantage Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan 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. 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the Generally, we 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 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. 5

7 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 91 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. Community Health Plan of Washington ensures that members with level of care changes have access to transition fills as required. Please see the Community Health Plan of Washington Transition Policy ( for more information. For more information For more detailed information about your Community HealthFirst Medicare Advantage Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Community HealthFirst Medicare Advantage Plan, 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 ( ) 4 hours a day/7 days a week. TTY users should call Or, visit medicare.gov. Community HealthFirst Medicare Advantage Plan s Formulary The formulary that begins on page 15 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 89. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin ). The information in the column tells you if our plan has any special requirements for coverage of your drug. 6

8 List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for shortterm prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. 7

9 Plan Community HealthFirst Medicare Advantage Formulario 019 Lista de medicamentos cubiertos LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE SE CUBREN EN ESTE PLAN Formulario aprobado por la HPMS; Ident. de presentación del formulario: , versión 1 Este formulario fue actualizado el 10/01/018. Para obtener información actualizada o hacer alguna pregunta, comuníquese con el Servicio al cliente de Community Health Plan of Washington al (los usuarios de TTY deben llamar al 7-1-1, sin cargo), los 7 días de la semana de 8:00 a. m. a 8:00 p. m. También puede visitar nuestro sitio web en healthfirst.chpw.org. Community Health Plan of Washington es un plan HMO que tiene un contrato con Medicare y un contrato. La inscripción en Community Health Plan of Washington depende de la renovación del contrato. 8

10 Nota a los miembros existentes: Este formulario ha cambiado desde el año pasado. Revise este documento para asegurarse de que todavía incluye los medicamentos que usted toma. Cuando esta lista de medicamentos (formulario) dice nosotros nos o nuestro, hace referencia a Community Health Plan of Washington. Cuando menciona plan o nuestro plan, se refiere al Plan Community HealthFirst Medicare Advantage. Este documento incluye una lista de los medicamentos (formulario) para nuestro plan que rige a partir del 10/01/018. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y la contraportada. En general, usted debe utilizar farmacias de nuestra red para aprovechar sus beneficios de medicamentos con receta. Los beneficios, el formulario, la red de farmacias o los copagos/coseguros pueden cambiar el 1 de enero de 018, u ocasionalmente durante el año. Qué es el formulario del Plan Community HealthFirst Medicare Advantage? Un formulario es una lista de medicamentos cubiertos seleccionados por el Plan Community HealthFirst Medicare Advantage, en colaboración con un equipo de proveedores de atención médica, que representa las terapias con receta que se consideran una parte necesaria de un programa de tratamiento de calidad. El Plan Community HealthFirst Medicare Advantage generalmente cubrirá los medicamentos que se mencionan en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta se presente en una farmacia de la red del Plan Community HealthFirst Medicare Advantage, y se cumpla con otras normas del plan. Para obtener más información sobre cómo surtir sus recetas, revise su Evidencia de cobertura. El formulario (lista de medicamentos) puede cambiar? En general, si usted toma un medicamento que se encuentra en nuestro formulario de 017 que estaba cubierto a principio de año, no suspenderemos ni reduciremos la cobertura del medicamento durante el año de cobertura 018, a menos que un nuevo medicamento genérico más económico esté disponible, o cuando se divulgue información negativa sobre la seguridad o eficiencia de un medicamento. Otros tipos de cambios en el formulario, como la eliminación de un medicamento de nuestro formulario, no afectarán a los miembros que actualmente estén en tratamiento con ese medicamento. Seguirá disponible con el mismo costo compartido para los miembros que lo utilicen durante el resto del año de cobertura. Creemos que es importante que continúe teniendo acceso durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto en los casos en que usted pueda ahorrar más dinero o que nosotros podamos garantizar su seguridad. A continuación hay cambios en la lista de medicamentos que también afectarán a los miembros que actualmente toman un medicamento: 9

11 Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentos considera que un medicamento de nuestro formulario no es seguro o el fabricante del medicamento lo retira del mercado, inmediatamente lo eliminaremos de nuestro formulario y notificaremos a los miembros que toman el medicamento. Otros cambios. Es posible que hagamos otros cambios que afecten a los miembros que actualmente toman un medicamento. Por ejemplo, podemos agregar un nuevo medicamento genérico para reemplazar un medicamento de marca actualmente incluido en el formulario o agregar nuevas restricciones al medicamento de marca o moverlo a otro nivel de costo diferente. Podemos agregar un medicamento genérico que no sea nuevo en el mercado para reemplazar un medicamento de marca actualmente incluido en el formulario o agregar nuevas restricciones al medicamento de marca o moverlo a otro nivel de costo diferente. O podemos hacer cambios basados en nuevas guías clínicas. Si eliminamos medicamentos de nuestro formulario, agregamos autorizaciones previas, límites de cantidad y / o restricciones de terapia escalonada para un medicamento, debemos notificar a los miembros afectados por el cambio al menos 30 días antes de que el cambio entre en vigencia, o en el momento en que el miembro solicite un relleno del medicamento, en cuyo momento el miembro recibirá un surtido de 30 días del medicamento. El formulario adjunto es actual a partir del 10/01/018. Para obtener información actualizada sobre los medicamentos cubiertos por Community Health Plan of Washington, contáctenos. Nuestra información de contacto aparece en las páginas de portada y contraportada. Cómo utilizo el formulario? Existen dos maneras de encontrar su medicamento dentro del formulario: Afección médica El formulario comienza en la página 15. Los medicamentos en este formulario están agrupados en dos categorías según el tipo de afecciones médicas que tratan. Por ejemplo, los medicamentos que se utilizan para tratar una afección cardíaca se enumeran bajo la categoría: Cardiovascular, hipertensión/lípidos. Si usted sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienza en la página 15. Luego busque su medicamento bajo el nombre de la categoría. Lista por orden alfabético Si usted no está seguro en qué categoría debe buscar, busque su medicamento en el índice que comienza en la página 89. El índice ofrece una lista por orden alfabético de todos los medicamentos incluidos en este documento. En el índice se enumeran los medicamentos de marca y los medicamentos genéricos. Busque en el índice y encuentre su medicamento. Al lado del nombre de su medicamento, verá el número de página donde puede encontrar información de cobertura. Diríjase a la página que figura en el índice y encuentre el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? El Plan Community HealthFirst Medicare Advantage cubre medicamentos de marca y medicamentos genéricos. Un medicamento genérico está aprobado por la FDA y tiene el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los medicamentos de marca. 10

12 Existe alguna restricción en mi cobertura? Algunos medicamentos cubiertos tienen requisitos adicionales o límites en la cobertura. Estos requisitos pueden incluir lo siguiente: Autorización previa: El Plan Community HealthFirst Medicare Advantage requiere que usted obtenga una autorización previa para ciertos medicamentos. Esto significa que deberá obtener nuestra aprobación antes de surtir sus recetas. Si usted no obtiene la aprobación, puede que nuestro plan no cubra el medicamento. Límites de cantidades: para ciertos medicamentos, nuestro plan limita la cantidad de medicamento que cubriremos. Por ejemplo, nuestro plan ofrece citalopram de 10 mg (límites de cantidad diferentes para diferentes dosis) por receta de 10 tabletas. Esto puede ser adicional a un surtido de un mes o de 3 meses. Tratamiento escalonado: en algunos casos, nuestro plan requiere que primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para su afección. Por ejemplo, si el medicamento A y el medicamento B tratan la misma afección médica, es posible que no cubramos el medicamento B a menos que pruebe el medicamento A primero. Si el medicamento A no funciona para usted, entonces cubriremos el medicamento B. Puede averiguar si su medicamento tiene límites o requisitos adicionales al consultar el formulario que comienza en la página 15. También puede obtener más información sobre las restricciones que se aplican a medicamentos cubiertos específicos si visita nuestro sitio web. Hemos publicado documentos en línea que explican nuestras restricciones de autorización previa y tratamiento escalonado. También puede solicitar que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y la contraportada. Puede solicitar que hagamos una excepción a estos límites o restricciones, o que le demos una lista de medicamentos similares que puedan utilizarse para tratar su afección médica. Consulte la sección Cómo solicito una excepción al formulario del Plan Community HealthFirst Medicare Advantage? en la página 1 para obtener más información sobre cómo solicitar una excepción. 11

13 Qué pasa si mi medicamento no está en el formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe comunicarse con Servicio al cliente y preguntar si su medicamento está cubierto. Si se le comunica que el Plan Community HealthFirst Medicare Advantage no cubre su medicamento, tiene dos opciones: Puede solicitar a Servicio al cliente una lista de medicamentos similares cubiertos por el Plan Community HealthFirst Medicare Advantage. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que cubra nuestro plan. Puede solicitar que hagamos una excepción y cubramos su medicamento. Consulte la siguiente información sobre cómo solicitar una excepción. Cómo solicito una excepción al formulario del Plan Community HealthFirst Medicare Advantage? Puede solicitar que hagamos una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos. Puede pedirnos que cubramos un medicamento incluso si no se encuentra en nuestro formulario. Si se aprueba, este medicamento se cubrirá a un nivel de costo compartido predeterminado, y usted no podrá solicitarnos que proporcionemos el medicamento a un nivel de costo compartido menor. Nos puede pedir que no apliquemos los límites o restricciones de cobertura impuestos de su medicamento. Por ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad de medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, nos puede solicitar que renunciemos al límite y que cubramos una cantidad mayor. En general, solo aprobaremos su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, o las restricciones de uso adicionales, no son tan efectivos para el tratamiento de su afección o si estos pueden causarle efectos médicos adversos. Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial sobre una excepción a nuestro formulario o a las restricciones de uso. Cuando solicita una excepción a nuestro formulario o a las restricciones de uso, debe presentar una declaración de su médico o una persona autorizada a emitir recetas que respalde su solicitud. En general, debemos tomar nuestra decisión dentro de las 7 horas de haber recibido la declaración de respaldo de la persona autorizada a emitir recetas. Puede solicitar una apelación acelerada (rápida) si usted o su médico creen que su salud podría verse gravemente perjudicada si espera hasta 7 horas para que se tome una decisión. Si se le otorga la apelación acelerada, debemos comunicarle una decisión antes de las 4 horas después de haber recibido la declaración de respaldo de su médico u otra persona autorizada a emitir recetas. 1

14 Qué debo hacer antes de que pueda hablar con mi médico sobre cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o existente de nuestro plan, es posible que tome medicamentos que no están en nuestro formulario. O tal vez está tomando un medicamento que se encuentra en nuestro formulario, pero tiene acceso limitado para obtenerlo. Por ejemplo, tal vez necesite nuestra autorización previa antes de surtir su receta. Debe consultar con su médico para decidir si debe cambiar a un medicamento apropiado que cubramos o solicitar una excepción a nuestro formulario para que cubramos el medicamento que toma. Mientras consulta con su médico para determinar la acción correcta para usted, es posible que en ciertos casos cubramos su medicamento durante los primeros 90 días de su membresía en nuestro plan. Para cada uno de los medicamentos que no estén en nuestro formulario, o si su acceso a estos medicamentos es limitado, cubriremos un suministro temporal de 34 días (a menos que tenga una receta escrita para menos días) en una farmacia de nuestra red. Luego de su primer suministro de 34 días, no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan durante menos de 90 días. Si es residente de un centro de atención a largo plazo y necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero ya ha pasado los primeros 91 días de membresía en nuestro plan, cubriremos un surtido de emergencia de 31 días de ese medicamento mientras pide una excepción al formulario. Community Health Plan of Washington garantiza que los miembros con cambios en el nivel de atención tengan acceso a los cambios de transición según sea necesario. Consulte la normas de transición de Community Health Plan of Washington ( para obtener más información. Para más información Para obtener información más detallada sobre la cobertura de medicamentos con receta del Plan Community HealthFirst Medicare Advantage, revise su Evidencia de cobertura y otros materiales del plan. Si tiene alguna pregunta sobre el Plan Community HealthFirst Medicare Advantage, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y la contraportada. Si tiene preguntas generales sobre la cobertura de medicamentos de Medicare, llame a Medicare al MEDICARE ( ), las 4 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al O visite medicare.gov. 13

15 Formulario del Plan Community HealthFirst Medicare Advantage El formulario que comienza en la próxima página ofrece información de cobertura sobre los medicamentos cubiertos en nuestro plan. Si tiene problemas para encontrar su medicamento en la lista, diríjase al índice que comienza en la página 89. La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están escritos en mayúscula (por ejemplo, ADAGEN) y los medicamentos genéricos están escritos en minúscula cursiva (por ejemplo, warfarina). La información en la columna de Requisitos/límites indica si su plan tiene algún requisito especial para la cobertura de su medicamento. A continuación, presentamos una lista de abreviaturas que pueden aparecer en la columna de Requisitos/límites que indica si existe algún requisito especial para la cobertura de su medicamento. Lista de abreviaturas B/D PA: este medicamento con receta puede estar cubierto por la Parte B o D de Medicare según las circunstancias. Es posible que se deba presentar información que describa el uso y la administración de un medicamento para tomar una determinación. LA (Limited Availability): disponibilidad limitada. Es posible que este medicamento solo esté disponible en determinadas farmacias. Para obtener más información, comuníquese con Servicio al cliente. MO (Mail-Order): medicamento de venta por correo. Este medicamento con receta está disponible a través de nuestro servicio de pedido por correo, así como a través de nuestras farmacias minoristas de la red. Considere utilizar el servicio de pedido por correo para sus medicamentos a largo plazo (medicamentos de mantenimiento), como los medicamentos para la presión arterial alta. Las farmacias minoristas de la red pueden ser más adecuadas para medicamentos a corto plazo (como los antibióticos). PA (Prior Authorization): autorización previa. El Plan requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted deberá obtener aprobación antes de surtir sus recetas. Si usted no obtiene la aprobación, puede que no cubramos el medicamento. QL (Quantity Limit): límite de cantidades. Para ciertos medicamentos, el Plan limita la cantidad del medicamento que cubriremos. ST (Step Therapy): tratamiento escalonado. En algunos casos, el Plan requiere que usted pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para su afección. Por ejemplo, si el medicamento A y el medicamento B tratan la misma afección médica, es posible que no cubramos el medicamento B a menos que pruebe el medicamento A primero. Si el medicamento A no funciona para usted, entonces cubriremos el medicamento B. 14

16 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 5 B/D PA; MO AMBISOME 5 B/D PA; MO amphotericin b 4 B/D PA; MO caspofungin 5 B/D PA clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) piggyback 00 mg/100 ml fluconazole in nacl (iso-osm) piggyback 400 mg/00 ml 5 flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole oral MYCAMINE NOXAFIL ORAL 15 Name nystatin oral suspension nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole voriconazole oral ANTIVIRALS abacavir abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 00 mg/5 ml acyclovir oral tablet acyclovir sodium recon soln 500 mg acyclovir sodium solution B/D PA 4 B/D PA; MO adefovir amantadine hcl APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 150 mg, 00 mg 5

17 Name atazanavir oral capsule 300 mg ATRIPLA BARACLUDE ORAL SOLUTION BIKTARVY cidofovir 5 B/D PA; MO CIMDUO COMPLERA CRIXIVAN ORAL CAPSULE 00 MG, 400 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 00 mg, 50 mg, 400 mg EDURANT efavirenz oral capsule 00 mg efavirenz oral capsule 50 mg efavirenz oral tablet EMTRIVA entecavir EPCLUSA (8 per 8 EPIVIR HBV ORAL SOLUTION EVOTAZ famciclovir fosamprenavir Name FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium B/D PA; MO GENVOYA HARVONI (8 per 8 INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 100 MG ISENTRESS ORAL TABLET,CHEWAB LE 5 MG JULUCA KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine lamivudinezidovudine 16

18 Name LEXIVA ORAL SUSPENSION lopinavir-ritonavir moderiba moderiba oral tablets,dose pack 00 mg (8)- 400 mg (8), mg (8)-mg (8) moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7) moderiba dose pack oral tablets,dose pack 600 mg (7)- 600 mg (7) moderiba dose pack oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8) nevirapine oral tablet nevirapine oral tablet extended release 4 hr NORVIR ORAL CAPSULE NORVIR ORAL POWDER IN PACKET NORVIR ORAL SOLUTION 5 3 ODEFSEY oseltamivir PREVYMIS INTRAVENOUS 5 Name PREVYMIS ORAL ; QL (30 PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 00 mg (8)- 400 mg (8) ribasphere ribapak oral tablets,dose pack 00 mg (7)- 400 mg (7) 17

19 Name ribasphere ribapak oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) ribasphere ribapak oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8), mg (8)-mg (8) ribavirin oral capsule ribavirin oral tablet 00 mg 5 rimantadine ritonavir SELZENTRY stavudine oral capsule STRIBILD SYMFI SYMFI LO SYMTUZA SYNAGIS ; LA tenofovir disoproxil fumarate TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 5 MG, 50 MG TRIUMEQ TROGARZO ; LA Name TRUVADA valacyclovir oral tablet 1 gram valacyclovir oral tablet 500 mg ; QL (10 ; QL (60 valganciclovir VEMLIDY VIDEX GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 15 MG VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION VIREAD ORAL POWDER VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG ZERIT ORAL RECON SOLN 4 MO 4 MO 4 MO zidovudine CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml 18

20 Name cefaclor oral suspension for reconstitution 375 mg/5 ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) piggyback 1 gram/50 ml, gram/50 ml cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram, 100 gram, 0 gram, 300 g cefazolin cefdinir cefepime cefepime in dextrose,iso-osm piggyback 1 gram/50 ml Name cefepime in dextrose,iso-osm piggyback gram/100 ml cefixime cefotaxime injection recon soln 1 gram, gram, 500 mg cefotaxime injection recon soln 10 gram cefotetan cefoxitin in dextrose, iso-osm cefoxitin recon soln 1 gram, gram cefoxitin recon soln 10 gram cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, gram, 50 mg, 500 mg ceftriaxone injection recon soln 10 gram ceftriaxone 19

21 Name cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium recon soln 1.5 gram cefuroxime sodium recon soln 7.5 gram cephalexin SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 4 MO 4 4 MO TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin e.e.s. 400 oral tablet ery-tab oral tablet,delayed release (dr/ec) 50 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG Name erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 1,000 mg/4 ml, 500 mg/ ml atovaquone atovaquoneproguanil aztreonam baciim 0

22 Name bacitracin intramuscular BENZNIDAZOLE 3 BETHKIS 5 B/D PA; MO; QL (4 per 8 CAPASTAT 4 CAYSTON ; LA; QL (84 per 8 chloramphenicol sod succinate chloroquine phosphate clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate COARTEM colistin (colistimethate na) dapsone oral daptomycin recon soln 500 mg DARAPRIM 5 PA; MO EMVERM ertapenem 1 Name ethambutol gentamicin in nacl (iso-osm) piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) piggyback 80 mg/100 ml gentamicin injection gentamicin sulfate (ped) (pf) hydroxychloroquine imipenem-cilastatin IMPAVIDO INVANZ INJECTION INVANZ INTRAVENOUS isoniazid injection 4 MO isoniazid oral ivermectin lincomycin linezolid linezolid in dextrose 5% linezolid-0.9% sodium chloride mefloquine meropenem metro i.v

23 Name metronidazole in nacl (iso-os) metronidazole oral NEBUPENT 3 B/D PA; MO; QL (1 per 8 neomycin paromomycin 4 MO PASER PENTAM 4 MO polymyxin b sulfate praziquantel PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin rifampin SIRTURO ; LA STREPTOMYCIN SYNERCID 5 tigecycline 5 tinidazole tobramycin in 0.5 % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution 5 B/D PA; MO; QL (80 per 8 TRECATOR Name VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK vancomycin vancomycin oral capsule 15 mg vancomycin oral capsule 50 mg XIFAXAN ORAL TABLET 00 MG XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15 mg, 50 mg amoxicillin-pot clavulanate ampicillin oral capsule 500 mg ampicillin sodium injection ampicillin sodium ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram 3 ; QL (9 per 30 ; QL (60

24 Name ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam recon soln 1.5 gram ampicillin-sulbactam recon soln 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin in dextrose iso-osm piggyback 1 gram/50 ml nafcillin in dextrose iso-osm piggyback gram/100 ml nafcillin injection recon soln 1 gram, gram nafcillin injection recon soln 10 gram nafcillin oxacillin in dextrose(iso-osm) piggyback 1 gram/50 ml Name oxacillin in dextrose(iso-osm) piggyback gram/50 ml oxacillin injection recon soln 1 gram oxacillin injection recon soln 10 gram oxacillin injection recon soln gram penicillin g potassium penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml 5 penicillin g sodium penicillin v potassium pfizerpen-g piperacillintazobactam recon soln.5 gram, gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral 3

25 Name ciprofloxacin in 5 % dextrose levofloxacin in d5w piggyback 50 mg/50 ml levofloxacin in d5w piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin levofloxacin oral moxifloxacin in nacl (iso-osm) moxifloxacin oral ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine 4 MO sulfamethoxazoletrimethoprim sulfatrim TETRACYCLINES demeclocycline 4 MO doxy-100 doxycycline hyclate doxycycline hyclate oral capsule Name doxycycline hyclate oral tablet 100 mg, 150 mg, 0 mg, 75 mg doxycycline hyclate oral tablet 50 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet mondoxyne nl morgidox okebo oral capsule 75 mg tetracycline URINARY TRACT AGENTS methenamine hippurate methenamine mandelate nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst trimethoprim 4

26 Name ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl recon soln 50 mg dexrazoxane hcl recon soln 500 mg 5 B/D PA 5 B/D PA; MO ELITEK KEPIVANCE leucovorin calcium injection recon soln 100 mg, 00 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral LEVOLEUCOVORI N INTRAVENOUS RECON SOLN 175 MG levoleucovorin recon soln 50 mg levoleucovorin solution B/D PA; MO B/D PA 5 B/D PA 5 B/D PA 5 B/D PA mesna B/D PA; MO MESNEX ORAL VISTOGARD XGEVA 5 B/D PA; MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS Name ABRAXANE 5 B/D PA; MO adriamycin solution adrucil solution.5 gram/50 ml adrucil solution 5 gram/100 ml, 500 mg/10 ml B/D PA B/D PA B/D PA; MO AFINITOR (30 per 30 AFINITOR DISPERZ 5 PA; MO ALECENSA (40 per 30 ALIMTA 5 B/D PA; MO ALIQOPA 5 B/D PA; MO; LA ALUNBRIG ORAL TABLET 180 MG, 90 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLETS,DOSE PACK (30 per 30 (60 per 30 (30 per 30 anastrozole ARRANON 5 B/D PA ARZERRA 5 B/D PA; MO AVASTIN 5 B/D PA; MO azacitidine 5 B/D PA; MO azathioprine B/D PA; MO azathioprine sodium B/D PA 5

27 Name BAVENCIO 5 B/D PA; MO; LA BELEODAQ 5 B/D PA; MO BENDEKA 5 B/D PA; MO BESPONSA 5 B/D PA; MO; LA bexarotene 5 PA; MO bicalutamide BICNU 5 B/D PA; MO bleomycin B/D PA; MO BLINCYTO INTRAVENOUS KIT 5 B/D PA; MO BORTEZOMIB 5 B/D PA; MO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 400 MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG BRAFTOVI ORAL CAPSULE 75 MG (90 per 30 (30 per 30 5 PA; MO; LA; QL (10 per 30 5 PA; MO; LA; QL (180 per 30 busulfan 5 B/D PA CABOMETYX 5 PA; MO; LA CALQUENCE 5 PA; MO; LA; QL (60 per 30 CAPRELSA ORAL TABLET 100 MG 5 PA; MO; LA; QL (60 per 30 Name CAPRELSA ORAL TABLET 300 MG carboplatin solution 5 PA; MO; LA; QL (30 per 30 B/D PA; MO cisplatin B/D PA; MO cladribine 5 B/D PA; MO clofarabine 5 B/D PA COMETRIQ 5 PA; MO COSMEGEN 5 B/D PA; MO COTELLIC 5 PA; MO; LA; QL (63 per 8 cyclophosphamide cyclophosphamide oral capsule cyclosporine cyclosporine modified cyclosporine oral capsule B/D PA; MO B/D PA; MO B/D PA B/D PA; MO B/D PA; MO CYRAMZA 5 B/D PA; MO cytarabine B/D PA; MO cytarabine (pf) injection solution 100 mg/5 ml (0 mg/ml), gram/0 ml (100 mg/ml) cytarabine (pf) injection solution 0 mg/ml B/D PA; MO B/D PA dacarbazine B/D PA; MO dactinomycin B/D PA 6

28 Name DARZALEX 5 B/D PA; MO; LA daunorubicin solution B/D PA decitabine 5 B/D PA; MO docetaxel solution 160 mg/16 ml (10 mg/ml), 0 mg/ ml (10 mg/ml) docetaxel solution 160 mg/8 ml (0 mg/ml), 0 mg/ml (1 ml), 80 mg/4 ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) DOCETAXEL INTRAVENOUS SOLUTION 0 MG/ML doxorubicin recon soln 10 mg doxorubicin recon soln 50 mg doxorubicin solution doxorubicin, pegliposomal 5 B/D PA 5 B/D PA; MO 5 B/D PA B/D PA B/D PA; MO B/D PA; MO 5 B/D PA; MO DROXIA EMCYT EMPLICITI 5 B/D PA; MO epirubicin solution B/D PA; MO ERBITUX 5 B/D PA; MO Name ERIVEDGE (30 per 30 ERLEADA 5 PA; MO ERWINAZE 5 B/D PA; MO ETOPOPHOS 4 B/D PA; MO etoposide B/D PA; MO exemestane FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 0 MG (1 per 1 (6 per 1 FASLODEX 5 B/D PA; MO FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG 5 B/D PA; MO 3 B/D PA; MO floxuridine B/D PA fludarabine recon soln fludarabine solution fluorouracil B/D PA; MO B/D PA B/D PA; MO 7

29 Name flutamide FOLOTYN 5 B/D PA; MO GAZYVA 5 B/D PA; MO gemcitabine recon soln 1 gram, 00 mg gemcitabine recon soln gram gemcitabine solution 1 gram/6.3 ml (38 mg/ml), 00 mg/5.6 ml (38 mg/ml) GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML gemcitabine solution gram/5.6 ml (38 mg/ml) gengraf oral capsule 100 mg, 5 mg B/D PA; MO B/D PA B/D PA; MO 3 B/D PA B/D PA B/D PA; MO gengraf oral solution B/D PA; MO GILOTRIF (30 per 30 GLEOSTINE HALAVEN 5 B/D PA; MO HERCEPTIN 5 B/D PA; MO HEXALEN hydroxyurea IBRANCE (1 per 8 Name ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG (60 per 30 (30 per 30 idarubicin B/D PA IDHIFA 5 PA; MO; LA; QL (30 per 30 ifosfamide recon soln ifosfamide solution imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE 140 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET B/D PA; MO B/D PA (180 per 30 (60 per 30 (10 per 30 (30 per 30 (30 per 30 IMFINZI 5 B/D PA; MO; LA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG (180 per 30 (10 per 30 8

30 Name IRESSA (30 per 30 irinotecan solution 100 mg/5 ml irinotecan solution 40 mg/ ml irinotecan solution 500 mg/5 ml B/D PA; MO 5 B/D PA; MO 5 B/D PA ISTODAX 5 B/D PA; MO IXEMPRA 5 B/D PA; MO JAKAFI (60 per 30 JEVTANA 5 B/D PA; MO KADCYLA 5 PA; MO KEYTRUDA INTRAVENOUS SOLUTION 5 PA; MO KISQALI 5 PA; MO KISQALI FEMARA CO-PACK KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG 5 PA; MO 5 B/D PA; MO LARTRUVO 5 B/D PA; MO; LA LENVIMA 5 PA; MO letrozole LEUKERAN leuprolide subcutaneous kit Name LONSURF 5 PA; MO LUPRON DEPOT 5 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED LUPRON DEPOT- PED (NTH) LYNPARZA ORAL CAPSULE LYNPARZA ORAL TABLET 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO (480 per 30 (10 per 30 LYSODREN MARQIBO 3 B/D PA; MO MATULANE megestrol oral suspension 400 mg/10 ml (10 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml), 65 mg/5 ml PA PA; MO megestrol oral tablet PA; MO MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET MG (90 per 30 (30 per 30 9

31 Name MEKTOVI 5 PA; MO; LA; QL (180 per 30 melphalan B/D PA; MO melphalan hcl 5 B/D PA mercaptopurine methotrexate sodium B/D PA; MO methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin recon soln 0 mg, 5 mg mitomycin recon soln 40 mg B/D PA B/D PA; MO B/D PA; MO 5 B/D PA; MO mitoxantrone B/D PA; MO MUSTARGEN 4 B/D PA; MO mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium B/D PA B/D PA; MO 5 B/D PA; MO B/D PA; MO B/D PA; MO MYLOTARG 5 B/D PA; MO; LA NERLYNX 5 PA; MO; LA 30 Name NEXAVAR 5 PA; MO; LA; QL (10 per 30 nilutamide NINLARO ORAL CAPSULE.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG (6 per 8 (4 per 8 (3 per 8 NULOJIX 5 B/D PA; MO octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml) octreotide acetate injection syringe 500 mcg/ml (1 ml) ODOMZO 5 PA; MO; LA; QL (30 per 30 ONCASPAR 5 B/D PA; MO ONIVYDE 5 B/D PA; MO OPDIVO 5 PA; MO oxaliplatin recon soln 100 mg oxaliplatin recon soln 50 mg B/D PA; MO B/D PA

32 Name oxaliplatin solution B/D PA; MO paclitaxel B/D PA; MO PERJETA 5 B/D PA; MO POMALYST 5 PA; MO; LA PORTRAZZA 5 B/D PA; MO PROGRAF INTRAVENOUS 3 B/D PA; MO PURIXAN RAPAMUNE ORAL SOLUTION 5 B/D PA; MO REVLIMID 5 PA; MO; LA; QL (8 per 8 RITUXAN 5 PA; MO RITUXAN HYCELA 5 PA; MO ROMIDEPSIN 5 B/D PA RUBRACA 5 PA; MO; LA; QL (10 per 30 RYDAPT 5 PA; MO SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 3 B/D PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG 3 B/D PA Name SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet mg 3 B/D PA; MO B/D PA; MO 5 B/D PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 0 MG SPRYCEL ORAL TABLET 70 MG (30 per 30 (90 per 30 (60 per 30 STIVARGA (84 per 8 SUTENT (30 per 30 SYLVANT 5 B/D PA; MO SYNRIBO 5 B/D PA; MO TABLOID tacrolimus oral B/D PA; MO TAFINLAR (10 per 30 TAGRISSO 5 PA; MO; LA; QL (30 per 30 31

33 Name tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 5 MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG, 00 MG TASIGNA ORAL CAPSULE 50 MG (30 per 30 (60 per 30 5 PA; MO (11 per 8 (10 per 30 TECENTRIQ 5 B/D PA; MO; LA TEMODAR INTRAVENOUS 5 B/D PA; MO THALOMID 5 PA; MO thiotepa 5 B/D PA; MO TIBSOVO 5 PA; MO toposar B/D PA; MO topotecan recon soln topotecan solution 5 B/D PA 5 B/D PA; MO TORISEL 5 B/D PA; MO TREANDA INTRAVENOUS RECON SOLN 5 B/D PA; MO TRELSTAR 5 B/D PA; MO tretinoin (chemotherapy) Name TRISENOX INTRAVENOUS SOLUTION MG/ML 5 B/D PA; MO TYKERB 5 PA; MO; LA; QL (180 per 30 UNITUXIN 5 B/D PA; MO VALSTAR 5 B/D PA; MO VANTAS 4 B/D PA; MO VECTIBIX 5 B/D PA; MO VELCADE 5 B/D PA; MO VENCLEXTA ORAL TABLET 10 MG, 50 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK 3 PA; MO; LA 5 PA; MO; LA 5 PA; MO; LA; QL (4 per 180 VERZENIO 5 PA; MO; LA; QL (60 per 30 vinblastine solution vincasar pfs solution 1 mg/ml vincasar pfs solution mg/ ml B/D PA; MO B/D PA B/D PA; MO vincristine B/D PA; MO vinorelbine B/D PA; MO VOTRIENT (10 per 30 3

34 Name VYXEOS 5 B/D PA; MO XALKORI (60 per 30 XATMEP 5 B/D PA; MO XERMELO 5 PA; MO; LA; QL (90 per 30 XTANDI (10 per 30 YERVOY 5 B/D PA; MO YONDELIS 5 B/D PA; MO YONSA 5 PA; QL (10 ZALTRAP 5 B/D PA; MO ZANOSAR 4 B/D PA; MO ZEJULA 5 PA; MO; LA; QL (90 per 30 ZELBORAF (40 per 30 ZOLADEX 4 B/D PA; MO ZOLINZA ZORTRESS 5 B/D PA; MO ZYDELIG (60 per 30 ZYKADIA (150 per 30 ZYTIGA ORAL TABLET 50 MG (10 per 30 Name ZYTIGA ORAL TABLET 500 MG (60 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 00 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG 4 MO BANZEL BRIVIACT INTRAVENOUS BRIVIACT ORAL carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg, 1 mg clonazepam oral tablet mg 4 1 MO 1 MO PA; MO; QL (90 per 30 PA; MO; QL (300 per 30 33

35 Name clonazepam oral tablet,disintegrating 0.15 mg, 0.5 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating mg PA; MO; QL (90 per 30 PA; MO; QL (300 per 30 DIASTAT 4 MO DIASTAT ACUDIAL 4 MO diazepam rectal DILANTIN 30 MG divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 4 hr divalproex oral tablet,delayed release (dr/ec) 1 MO epitol ethosuximide felbamate oral suspension felbamate oral tablet fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg 1 PA; MO; QL (1080 per 30 1 PA; MO; QL (360 per Name gabapentin oral capsule 400 mg gabapentin oral solution 50 mg/5 ml gabapentin oral solution 50 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg lamotrigine oral tablet lamotrigine oral tablet extended release 4hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack levetiracetam in nacl (iso-os) piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) piggyback 500 mg/100 ml levetiracetam 1 PA; MO; QL (70 per 30 PA; MO; QL (160 per 30 PA; QL (160 1 PA; MO; QL (180 per 30 1 PA; MO; QL (10 per 30 1 MO 4 MO 4 MO

36 Name levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 4 hr LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 5 MG, 300 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 0 MG 3 PA; MO; QL (90 per 30 3 PA; MO; QL (60 per 30 3 PA; MO; QL (900 per 30 (480 per 30 (60 per 30 oxcarbazepine PEGANONE phenobarbital PA; MO phenobarbital sodium injection solution 130 mg/ml phenobarbital sodium injection solution 65 mg/ml Name phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium solution primidone roweepra roweepra xr SABRIL ORAL TABLET ; LA SPRITAM 4 MO subvenite subvenite starter (blue) kit subvenite starter (green) kit subvenite starter (orange) kit tiagabine 4 MO topiramate oral capsule, sprinkle topiramate oral tablet PA; MO 1 PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 50 mg/5 ml 35

37 Name valproic acid (as sodium salt) oral solution 50 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) vigabatrin ; LA vigadrone ; LA VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 3 zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA benztropine injection benztropine oral PA; MO bromocriptine 4 MO carbidopa carbidopa-levodopa 4 MO entacapone NEUPRO 4 MO pramipexole rasagiline ropinirole selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection 36 Name dihydroergotamine nasal ; QL (8 per 8 eletriptan ; QL (18 per 8 ergotamine-caffeine migergot naratriptan ; QL (18 per 8 rizatriptan ; QL (36 per 8 sumatriptan nasal spray,non-aerosol 0 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution carbidopa-levodopaentacapone sumatriptannaproxen ; QL (18 per 8 ; QL (36 per 8 ; QL (18 per 8 ; QL (8 per 8 ; QL (8 per 8 ; QL (8 per 8 ; QL (18 per 8 zolmitriptan ; QL (18 per 8 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA

38 Name donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 3 mg donepezil oral tablet,disintegrating 1 MO 4 MO 1 MO galantamine GILENYA ORAL CAPSULE 0.5 MG glatiramer subcutaneous syringe 0 mg/ml glatiramer subcutaneous syringe 40 mg/ml glatopa subcutaneous syringe 0 mg/ml glatopa subcutaneous syringe 40 mg/ml 5 PA; MO (30 per 30 (1 per 8 (30 per 30 (1 per 8 LEMTRADA 5 PA; MO memantine oral capsule,sprinkle,er 4hr memantine oral solution memantine oral tablet PA; MO PA; MO PA; MO NAMZARIC 3 PA; MO NUEDEXTA 3 PA; MO OCREVUS 5 PA; MO; LA RADICAVA 5 PA; MO rivastigmine rivastigmine tartrate TECFIDERA 5 PA; MO; LA 37 Name tetrabenazine oral tablet 1.5 mg tetrabenazine oral tablet 5 mg (40 per 30 (10 per 30 TYSABRI 5 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral tablet 10 mg, 0 mg cyclobenzaprine oral tablet 4 PA; MO dantrolene LIORESAL INTRATHECAL SOLUTION,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP neostigmine methylsulfate solution 0.5 mg/ml neostigmine methylsulfate solution 1 mg/ml pyridostigmine bromide regonol revonto 3 B/D PA; MO 3 B/D PA

39 Name tizanidine NARCOTIC ANALGESICS acetaminophen-caffdihydrocod oral capsule acetaminophencodeine oral solution 10 mg-1 mg /5 ml (5 ml), 300 mg-30 mg /1.5 ml acetaminophencodeine oral solution 10-1 mg/5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg,.5-35 mg, 5-35 mg, mg ; QL (300 QL (4500 per 30 ; QL (4500 ; QL (360 ; QL (180 ; QL (66 QL (66 per 30 ; QL (4000 QL (000 per 30 ; QL (360 Name fentanyl citrate (10 per 30 fentanyl citrate (pf) injection fentanyl citrate (pf) syringe 100 mcg/ ml (50 mcg/ml) fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr fentanyl transdermal patch 7 hour 87.5 mcg/hour hydrocodoneacetaminophen oral solution mg/15 ml hydrocodoneacetaminophen oral tablet mg, mg, mg hydrocodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg hydrocodoneibuprofen oral tablet mg, 5-00 mg, mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml ; QL (400 QL (400 per 30 PA; MO; QL (10 per 30 (10 per 30 ; QL (5550 ; QL (390 ; QL (360 ; QL (50 ; QL (40 38

40 Name hydromorphone (pf) injection solution mg/ml hydromorphone injection solution 1 mg/ml hydromorphone injection solution mg/ml hydromorphone injection solution 4 mg/ml hydromorphone injection syringe 1 mg/ml hydromorphone injection syringe mg/ml hydromorphone injection syringe 4 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 4 hr 1 mg, 8 mg hydromorphone oral tablet extended release 4 hr 16 mg, 3 mg QL (100 per 30 QL (400 per 30 ; QL (100 ; QL (600 QL (400 per 30 QL (100 per 30 ; QL (600 ; QL (400 ; QL (180 PA; MO; QL (60 per 30 (60 per 30 ibuprofen-oxycodone ; QL (8 levorphanol tartrate ; QL (10 Name lorcet (hydrocodone) ; QL (360 lorcet hd ; QL (360 lorcet plus oral tablet mg methadone injection solution ; QL (360 QL (150 per 30 methadone intensol PA; MO; QL (90 per 30 methadone oral concentrate methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg methadose oral concentrate morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ml PA; MO; QL (90 per 30 PA; MO; QL (600 per 30 PA; MO; QL (100 per 30 PA; MO; QL (10 per 30 PA; MO; QL (40 per 30 PA; MO; QL (90 per 30 QL (4000 per 30 ; QL (000 39

41 Name morphine (pf) patient control.analgesia soln 150 mg/30 ml morphine (pf) patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine injection solution 8 mg/ml morphine injection syringe 10 mg/ml morphine injection syringe mg/ml morphine injection syringe 4 mg/ml morphine injection syringe 5 mg/ml morphine injection syringe 8 mg/ml morphine cartridge 10 mg/ml morphine cartridge mg/ml morphine cartridge 4 mg/ml morphine solution 10 mg/ml morphine syringe mg/ml B/D PA; MO; QL (400 per 30 B/D PA; QL (000 per 30 ; QL (900 QL (50 per 30 ; QL (00 ; QL (1000 ; QL (500 QL (400 per 30 QL (50 per 30 QL (00 per 30 QL (1000 per 30 QL (500 per 30 ; QL (00 QL (1000 per 30 Name morphine syringe 4 mg/ml morphine oral capsule, er multiphase 4 hr morphine oral capsule,extend.relea se pellets morphine oral solution QL (500 per 30 PA; MO; QL (60 per 30 PA; MO; QL (90 per 30 ; QL (900 morphine oral tablet ; QL (180 morphine oral tablet extended release 100 mg morphine oral tablet extended release 15 mg, 00 mg, 30 mg, 60 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 0 mg, 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg PA; MO; QL (60 per 30 PA; MO; QL (10 per 30 ; QL (360 ; QL (180 ; QL (100 ; QL (180 ; QL (360 ; QL (360 oxycodone-aspirin ; QL (360 40

42 Name oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg ; QL (360 ; QL (180 vicodin ; QL (390 vicodin es ; QL (390 vicodin hp ; QL (390 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet -0.5 mg buprenorphinenaloxone sublingual tablet 8- mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution mg/ml butorphanol tartrate nasal ; QL (360 ; QL (90 ; QL (857 ; QL (48 ; QL (10 per 8 celecoxib clonidine (pf) epidural solution 5,000 mcg/10 ml diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel 1 % ; QL (300 per 8 ; QL (1000 per 8 Name diclofenacmisoprostol diflunisal etodolac fenoprofen oral tablet flurbiprofen ibu 1 MO ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule 5 mg ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg 1 MO meclofenamate mefenamic acid meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg 1 MO 1 MO; QL (30 nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 0 mg/ml ; QL (00 ; QL (100 naloxone naltrexone 41

43 Name naproxen oral suspension naproxen oral tablet 1 MO naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 75 mg, 550 mg naproxen sodium oral tablet, er multiphase 4 hr NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION oxaprozin piroxicam profeno salsalate 1 MO SUBOXONE SUBLINGUAL FILM 1-3 MG SUBOXONE SUBLINGUAL FILM -0.5 MG SUBOXONE SUBLINGUAL FILM 4-1 MG, 8- MG ; QL ( per 8 ; QL (60 ; QL (360 ; QL (90 sulindac 1 MO tolmetin tramadol oral tablet ; QL (40 tramadolacetaminophen ; QL (40 VIVITROL 4 Name PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ADASUVE 3 LA amitriptyline PA; MO amoxapine PA; MO aripiprazole oral solution aripiprazole oral tablet aripiprazole oral tablet,disintegrating ; QL (30 ; QL (60 ARISTADA ARISTADA INITIO 5 armodafinil 4 PA; MO atomoxetine bupropion hcl oral tablet bupropion hcl oral tablet extended release 1 hr bupropion hcl oral tablet extended release 4 hr 150 mg bupropion hcl oral tablet extended release 4 hr 300 mg 1 MO ; QL (60 ; QL (90 ; QL (30 buspirone chlorpromazine citalopram oral solution citalopram oral tablet 1 MO; QL (30 clomipramine 4 PA; MO

44 Name clonidine hcl oral tablet extended release 1 hr clorazepate dipotassium oral tablet 15 mg clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg PA; MO; QL (180 per 30 PA; MO; QL (90 per 30 clozapine oral tablet clozapine oral tablet,disintegrating 100 mg, 1.5 mg, 5 mg desipramine PA; MO desvenlafaxine succinate dextroamphetamine oral solution dextroamphetamineamphetamine diazepam injection solution diazepam injection syringe ; QL (30 PA PA; MO diazepam intensol PA; MO; QL (40 per 30 diazepam oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ml) PA; MO; QL (40 per 30 PA; MO; QL (100 per 30 diazepam oral tablet PA; MO; QL (10 per 30 Name doxepin oral 4 PA; MO duloxetine oral capsule,delayed release(dr/ec) 0 mg, 30 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg ; QL (60 ; QL (90 EMSAM ergoloid 4 MO escitalopram oxalate oral solution escitalopram oxalate oral tablet 1 MO; QL (30 eszopiclone 4 ST; MO; QL (30 per 30 FANAPT ORAL TABLET 1 MG, MG, 4 MG FANAPT ORAL TABLET 10 MG, 1 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 150 MG, 00 MG FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 4 HR 4 MO; QL (60 ; QL (60 4 MO; QL (8 per MO; QL (8 per 8 4 MO; QL (30 43

45 Name flumazenil fluoxetine oral capsule 10 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 0 mg, 60 mg fluphenazine decanoate 1 MO; QL (30 1 MO 1 MO; QL (60 ; QL (4 per 8 ; QL (30 fluphenazine hcl fluvoxamine oral capsule,extended release 4hr fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 5 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULA R 4 MO; QL (60 ; QL (90 ; QL (30 ; QL (60 4 MO guanidine haloperidol 1 MO haloperidol decanoate Name haloperidol lactate injection haloperidol lactate intramuscular haloperidol lactate oral HETLIOZ (30 per 30 imipramine hcl 4 PA; MO imipramine pamoate 4 PA; MO INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 34 MG/1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.5 ML 4 MO INVEGA TRINZA KHEDEZLA ORAL TABLET EXTENDED RELEASE 4HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 4HR 50 MG LATUDA ORAL TABLET 10 MG, 0 MG, 40 MG, 60 MG 4 MO; QL (10 4 MO; QL (30 ; QL (30 44

46 Name LATUDA ORAL TABLET 80 MG ; QL (60 lithium carbonate 1 MO lithium citrate oral solution 8 meq/5 ml lorazepam injection solution lorazepam injection syringe PA; MO PA lorazepam intensol PA; MO; QL (150 per 30 lorazepam oral concentrate lorazepam oral tablet 0.5 mg, 1 mg lorazepam oral tablet mg PA; MO; QL (150 per 30 PA; MO; QL (90 per 30 PA; MO; QL (150 per 30 loxapine succinate maprotiline MARPLAN metadate er methylphenidate hcl oral capsule,er biphasic methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release methylphenidate hcl oral tablet,chewable 45 Name mirtazapine oral tablet mirtazapine oral tablet,disintegrating 1 MO modafinil PA; MO nefazodone nortriptyline PA; MO NUPLAZID 5 PA; MO olanzapine intramuscular olanzapine oral ; QL (30 olanzapinefluoxetine paliperidone oral tablet extended release 4hr 1.5 mg, 3 mg paliperidone oral tablet extended release 4hr 6 mg paliperidone oral tablet extended release 4hr 9 mg paroxetine hcl oral tablet 10 mg, 0 mg, 40 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet extended release 4 hr paroxetine mesylate(menop.sym ) PAXIL ORAL SUSPENSION ; QL (30 ; QL (60 ; QL (30 1 MO; QL (30 1 MO; QL (60 ; QL (60 ; QL (30 4 MO

47 Name perphenazine phenelzine pimozide procentra protriptyline quetiapine oral tablet 100 mg, 00 mg, 5 mg, 50 mg quetiapine oral tablet 300 mg, 400 mg quetiapine oral tablet extended release 4 hr 150 mg, 00 mg quetiapine oral tablet extended release 4 hr 300 mg, 400 mg, 50 mg ; QL (90 ; QL (60 ; QL (30 ; QL (60 REXULTI ; QL (30 RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 1.5 MG/ ML, 5 MG/ ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/ ML, 50 MG/ ML risperidone oral solution Name risperidone oral tablet 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg risperidone oral tablet,disintegrating 4 mg 1 MO; QL (60 1 MO; QL (10 ; QL (60 ; QL (10 ROZEREM ; QL (30 SAPHRIS (BLACK CHERRY) sertraline oral concentrate sertraline oral tablet 100 mg, 50 mg sertraline oral tablet 5 mg 4 MO; QL (60 1 MO; QL (60 1 MO; QL (30 thioridazine 4 MO thiothixene 1 MO tranylcypromine 4 MO trazodone 1 MO trifluoperazine trimipramine 4 PA; MO TRINTELLIX ; QL (30 venlafaxine oral capsule,extended release 4hr 150 mg, 37.5 mg ; QL (30 46

48 Name venlafaxine oral capsule,extended release 4hr 75 mg venlafaxine oral tablet venlafaxine oral tablet extended release 4hr VERSACLOZ 5 VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG (3) VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK ; QL (90 ; QL (90 ; QL (30 ; QL (30 ; QL (30 per 180 ; QL (30 4 MO; QL (7 per 30 XYREM 5 PA; MO; LA zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg 4 ST; MO; QL (60 per 30 4 ST; MO; QL (30 per 30 ziprasidone hcl ; QL (60 zolpidem oral tablet ST; MO; QL (30 per 30 Name ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 10 MG ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 300 MG, 405 MG CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS adenosine amiodarone solution amiodarone syringe B/D PA; MO B/D PA amiodarone oral dofetilide flecainide ibutilide fumarate lidocaine (pf) in d7.5w lidocaine (pf) solution lidocaine (pf) syringe 47

49 Name lidocaine in 5 % dextrose (pf) parenteral solution 4 mg/ml (0.4 %), 8 mg/ml (0.8 %) mexiletine pacerone oral tablet 100 mg, 00 mg, 400 mg procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml propafenone quinidine gluconate quinidine sulfate oral tablet sorine oral tablet 10 mg, 160 mg, 80 mg sorine oral tablet 40 mg sotalol af sotalol oral SOTYLIZE ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr amiloride amlodipine 1 MO Name 1 MO atenolol 1 MO benazepril 1 MO betaxolol oral bisoprolol fumarate 1 MO bumetanide candesartan captopril amiloridehydrochlorothiazide amlodipinebenazepril amlodipineolmesartan amlodipinevalsartan amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide cartia xt carvedilol 1 MO carvedilol phosphate chlorothiazide chlorothiazide sodium chlorthalidone oral tablet 5 mg, 50 mg 1 MO 48

50 Name clonidine 4 MO; QL (4 per 8 clonidine (pf) epidural solution 1,000 mcg/10 ml (100 mcg/ml) clonidine hcl oral tablet 1 MO DEMSER 5 PA; MO diltiazem hcl diltiazem hcl oral capsule,ext.rel 4h degradable diltiazem hcl oral capsule,extended release 1 hr diltiazem hcl oral capsule,extended release 4 hr diltiazem hcl oral capsule,extended release 4hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 4 hr 1 MO dilt-xr doxazosin oral tablet 1 mg, mg, 4 mg doxazosin oral tablet 8 mg 1 MO; QL (30 1 MO; QL (60 enalapril maleate 1 MO enalaprilat solution 49 Name 1 MO eplerenone epoprostenol (glycine) B/D PA; MO eprosartan esmolol solution ethacrynate sodium 5 ethacrynic acid felodipine fosinopril 1 MO furosemide injection furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 1 MO hydralazine hydrochlorothiazide 1 MO indapamide irbesartan 1 MO enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide 1 MO isradipine labetalol solution labetalol syringe 0 mg/4 ml (5 mg/ml) labetalol oral

51 Name lisinopril 1 MO 1 MO losartan 1 MO lisinoprilhydrochlorothiazide losartanhydrochlorothiazide mannitol 0 % mannitol 5 % solution 1 MO matzim la methyclothiazide methyldopa metolazone metoprolol succinate 1 MO metoprolol tartrate solution metoprolol tartrate syringe metoprolol tartrate oral 1 MO minoxidil oral moexipril 1 MO nadolol nicardipine solution nicardipine oral nifedipine oral tablet extended release 50 Name nifedipine oral tablet extended release 4hr nimodipine nisoldipine olmesartan 1 MO osmitrol 15 % osmitrol 0 % perindopril erbumine 1 MO 1 MO phenoxybenzamine 5 PA; MO phentolamine injection recon soln pindolol prazosin propranolol propranolol oral capsule,extended release 4 hr propranolol oral solution propranolol oral tablet 1 MO quinapril 1 MO metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide nadololbendroflumethiazide olmesartanamlodipin-hcthiazid olmesartanhydrochlorothiazide propranololhydrochlorothiazid quinaprilhydrochlorothiazide ramipril 1 MO REMODULIN 5 PA; MO; LA

52 Name spironolactone 1 MO taztia xt TEKTURNA TEKTURNA HCT telmisartan terazosin oral capsule 1 mg, mg, 5 mg terazosin oral capsule 10 mg 1 MO; QL (30 1 MO; QL (60 timolol maleate oral torsemide oral trandolapril 1 MO 1 MO UPTRAVI 5 PA; MO; LA valsartan 1 MO spironolactonhydrochlorothiaz telmisartanamlodipine telmisartanhydrochlorothiazid trandolaprilverapamil triamterenehydrochlorothiazid valsartanhydrochlorothiazide 1 MO veletri B/D PA; MO verapamil solution verapamil syringe verapamil oral capsule, 4 hr er pellet ct 51 Name verapamil oral capsule,ext rel. pellets 4 hr 10 mg, 180 mg, 40 mg verapamil oral capsule,ext rel. pellets 4 hr 360 mg 1 MO verapamil oral tablet 1 MO verapamil oral tablet extended release COAGULATION THERAPY AMICAR aminocaproic acid aspirin-dipyridamole BRILINTA CEPROTIN (BLUE BAR) CEPROTIN (GREEN BAR) cilostazol clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg dipyridamole 1 MO PA dipyridamole oral DOPTELET 5 PA; MO; LA ELIQUIS enoxaparin fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

53 Name fondaparinux subcutaneous syringe.5 mg/0.5 ml heparin (porcine) in 5 % dex parenteral solution 0,000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex parenteral solution 5,000 unit/50 ml(100 unit/ml), 5,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) heparin (porcine) injection cartridge heparin (porcine) injection solution heparin (porcine) injection syringe 5,000 unit/ml HEPARIN(PORCIN E) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 1,500 UNIT/50 ML heparin(porcine) in 0.45% nacl parenteral solution 5,000 unit/50 ml, 5,000 unit/500 ml heparin, porcine (pf) injection 3 jantoven 1 MO 5 Name NPLATE pentoxifylline PRADAXA 4 MO prasugrel PROMACTA 5 PA; MO; LA protamine warfarin 1 MO XARELTO LIPID/CHOLESTEROL LOWERING AGENTS ; QL (30 atorvastatin 1 MO; QL (30 cholestyramine (with sugar) cholestyramine light colesevelam colestipol ezetimibe amlodipineatorvastatin ezetimibesimvastatin fenofibrate micronized fenofibrate nanocrystallized fenofibrate oral tablet ; QL (30 fenofibric acid fenofibric acid (choline) fluvastatin oral capsule 0 mg ; QL (30

54 Name fluvastatin oral capsule 40 mg fluvastatin oral tablet extended release 4 hr ; QL (60 ; QL (30 gemfibrozil 1 MO JUXTAPID 5 PA; MO; LA lovastatin oral tablet 10 mg lovastatin oral tablet 0 mg, 40 mg niacin oral tablet extended release 4 hr PRALUENT SUBCUTANEOUS PEN INJECTOR 150 MG/ML PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 75 MG/ML 1 MO; QL (30 1 MO; QL (60 ( per 8 (4 per 8 pravastatin 1 MO; QL (30 prevalite REPATHA (3 per 8 REPATHA PUSHTRONEX REPATHA SURECLICK (3.5 per 8 (3 per 8 rosuvastatin 1 MO; QL (30 simvastatin 1 MO; QL (30 VASCEPA 4 MO Name MISCELLANEOUS CARDIOVASCULAR AGENTS cardioplegic soln CORLANOR 3 PA; MO digitek digox digoxin oral solution 50 mcg/ml digoxin oral tablet dobutamine B/D PA dobutamine in d5w parenteral solution 1,000 mg/50 ml (4,000 mcg/ml), 50 mg/50 ml (1 mg/ml) dobutamine in d5w parenteral solution 500 mg/50 ml (,000 mcg/ml) dopamine in 5 % dextrose solution 00 mg/50 ml (800 mcg/ml), 400 mg/50 ml (1,600 mcg/ml), 400 mg/500 ml (800 mcg/ml), 800 mg/500 ml (1,600 mcg/ml) dopamine in 5 % dextrose solution 800 mg/50 ml (3,00 mcg/ml) B/D PA; MO B/D PA B/D PA B/D PA; MO 53

55 Name dopamine solution 00 mg/5 ml (40 mg/ml), 800 mg/5 ml (160 mg/ml) dopamine solution 400 mg/10 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml) B/D PA B/D PA; MO ENTRESTO ; QL (60 LANOXIN ORAL TABLET MCG, 6.5 MCG milrinone B/D PA; MO milrinone in 5 % dextrose norepinephrine bitartrate B/D PA; MO RANEXA sodium nitroprusside VECAMYL 5 NITRATES isosorbide dinitrate oral tablet isosorbide dinitrate oral tablet extended release isosorbide mononitrate 1 MO nitro-bid Name nitroglycerin in 5 % dextrose solution 100 mg/50 ml (400 mcg/ml), 50 mg/50 ml (00 mcg/ml) nitroglycerin in 5 % dextrose solution 5 mg/50 ml (100 mcg/ml) nitroglycerin nitroglycerin sublingual nitroglycerin transdermal patch 4 hour nitroglycerin translingual spray,non-aerosol B/D PA B/D PA; MO B/D PA DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 10 mg acitretin oral capsule 17.5 mg, 5 mg calcipotriene scalp ; QL (10 calcipotriene topical cream calcipotriene topical ointment calcipotrienebetamethasone 4 MO; QL (10 ; QL (10 ; QL (400 54

56 Name calcitrene ; QL (10 calcitriol topical 4 MO selenium sulfide topical lotion MISCELLANEOUS DERMATOLOGICALS ammonium lactate carbocaine (pf) injection solution 15 mg/ml (1.5 %) chloroprocaine (pf) diclofenac sodium topical gel 3 % (100 per 8 doxepin topical ; QL (45 DUPIXENT 5 PA; MO fluorouracil topical cream 5 % fluorouracil topical solution glydo ; QL (60 imiquimod lidocaine (pf) injection solution 10 mg/ml (1 %), 0 mg/ml ( %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 15 mg/ml (1.5 %) lidocaine hcl injection solution 55 Name lidocaine hcl laryngotracheal lidocaine hcl mucous membrane jelly lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated lidocaine topical ointment ; QL (60 ; QL (60 PA; MO; QL (90 per 30 4 MO; QL (36 lidocaine viscous lidocaineepinephrine injection solution 0.5 %-1:00,000, 1.5 %- 1:00,000, %- 1:00,000 lidocaineepinephrine injection solution 1 %-1:100,000, %- 1:100,000 lidocaine-prilocaine topical cream ; QL (30 methoxsalen PANRETIN podofilox polocaine injection solution 1 % (10 mg/ml) polocaine-mpf prudoxin ; QL (45

57 Name REGRANEX SANTYL silver sulfadiazine ssd tacrolimus topical PA; MO; QL (100 per 30 UVADEX 4 B/D PA VALCHLOR THERAPY FOR ACNE amnesteem claravis 4 MO clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution dapsone topical erythromycin with ethanol topical solution erythromycin with ethanol topical swab isotretinoin metronidazole topical myorisan oral capsule 10 mg, 0 mg, 40 mg myorisan oral capsule 30 mg 56 Name rosadan topical cream rosadan topical gel tazarotene PA; MO TAZORAC TOPICAL CREAM 0.05 % TAZORAC TOPICAL GEL 3 PA; MO 3 PA; MO tretinoin topical PA; MO zenatane 4 MO TOPICAL ANTIBACTERIALS gentamicin topical mafenide acetate mupirocin mupirocin calcium sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM SULFAMYLON TOPICAL PACKET TOPICAL ANTIFUNGALS ciclodan topical solution ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension ; QL (90 per 8 ; QL (45 per 8 ; QL (10 per 8 ; QL (60 per 8

58 Name clotrimazole topical cream clotrimazole topical solution clotrimazolebetamethasone topical cream clotrimazolebetamethasone topical lotion ; QL (45 per 8 ; QL (30 per 8 ; QL (45 per 8 ; QL (60 per 8 econazole ; QL (85 per 8 ketoconazole topical cream ketoconazole topical foam ketoconazole topical shampoo ; QL (60 per 8 ; QL (100 per 8 ; QL (10 per 8 naftifine ; QL (60 per 8 nyamyc nystatin topical cream nystatin topical ointment nystatin topical powder nystatintriamcinolone ; QL (30 per 8 ; QL (30 per 8 ; QL (60 per 8 nystop oxiconazole ; QL (60 per 8 TOPICAL ANTIVIRALS acyclovir topical 4 PA; MO; QL (30 per 30 Name DENAVIR ZOVIRAX TOPICAL CREAM (5 TOPICAL CORTICOSTEROIDS ala-cort topical cream alclometasone betamethasone dipropionate betamethasone valerate betamethasone, augmented clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical spray,non-aerosol clobetasol-emollient topical cream clobetasol-emollient topical foam ; QL (10 per 8 ; QL (100 per 8 ; QL (10 per 8 ; QL (118 per 8 ; QL (10 per 8 ; QL (36 per 8 ; QL (15 per 8 ; QL (10 per 8 ; QL (100 per 8 desonide 4 MO fluocinolone fluocinolone and shower cap 57

59 Name fluocinonide ; QL (10 fluocinonide-e ; QL (10 fluocinonideemollient halobetasol propionate hydrocortisone butyrate topical lotion hydrocortisone topical cream 1 %,.5 % hydrocortisone topical lotion.5 % hydrocortisone topical ointment 1 %,.5 % hydrocortisone-min oil-wht pet QL (10 per 30 mometasone topical nolix topical cream prednicarbate triamcinolone acetonide topical aerosol triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.05 %, 0.1 %, 0.5 % Name trianex triderm topical cream TOPICAL SCABICIDES / PEDICULICIDES lindane topical shampoo malathion permethrin topical cream DIAGNOSTICS / MISCELLANEOUS AGENTS ANTIDOTES acetylcysteine IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringer's irrigation MISCELLANEOUS AGENTS acamprosate 4 MO acetic acid irrigation ADAGEN alendronate oral tablet 40 mg 1 MO; QL (30 anagrelide ARALAST NP ; LA caffeine citrate caffeine citrate oral CARBAGLU ; LA 58

60 Name cevimeline CHEMET 3 PA; MO CLINIMIX 4.5%/D5W SULFIT FREE d10 %-0.45 % sodium chloride d.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 3 B/D PA deferoxamine B/D PA; MO dextrose 10 % and 0. % nacl dextrose 10 % in water (d10w) dextrose 0 % in water (d0w) dextrose 5 % in water (d5w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %- lactated ringers dextrose 5%-0. % sod chloride dextrose 5%-0.3 % sod.chloride Name dextrose 50 % in water (d50w) parenteral solution dextrose 50 % in water (d50w) syringe dextrose 70 % in water (d70w) dextrose with sodium chloride disulfiram etidronate disodium oral tablet 400 mg EXJADE 5 PA; MO; LA FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET 5 PA 5 PA; MO INCRELEX ; LA kionex (with sorbitol) lanthanum levocarnitine (with sugar) levocarnitine oral tablet midodrine NORTHERA 5 PA; MO ORFADIN ORAL CAPSULE 10 MG, MG, 5 MG ORFADIN ORAL CAPSULE 0 MG ORFADIN ORAL SUSPENSION 5 LA ; LA ; LA 59

61 Name pilocarpine hcl oral PROLASTIN-C INTRAVENOUS RECON SOLN PROLASTIN-C INTRAVENOUS SOLUTION 5 LA ; LA RAVICTI riluzole risedronate oral tablet 30 mg sevelamer carbonate oral powder in packet sevelamer carbonate oral tablet sodium benzoate-sod phenylacet sodium chloride 0.9 % sodium chloride irrigation sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate oral sodium polystyrene sulfonate rectal enema 30 gram/10 ml ; QL (30 5 SOLIRIS 5 PA; MO sps (with sorbitol) oral sps (with sorbitol) rectal 60 Name THIOLA trientine 5 PA; MO VELTASSA water for irrigation, sterile XIAFLEX XURIDEN zoledronic acidmannitol-water SMOKING DETERRENTS bupropion hcl (smoking deter) PA; MO CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX NICOTROL 4 MO NICOTROL NS 4 MO EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal ; QL (60 chlorhexidine gluconate mucous membrane denta 5000 plus dentagel ipratropium bromide nasal ; QL (30

62 Name olopatadine nasal ; QL (30.5 oralone paroex oral rinse periogard sf sf 5000 plus triamcinolone acetonide dental MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) ciprofloxacin hcl otic (ear) floxin otic (ear) drops fluocinolone acetonide oil hydrocortisoneacetic acid ofloxacin otic (ear) OTIC STEROID / ANTIBIOTIC CIPRODEX neomycinpolymyxin-hc otic (ear) ENDOCRINE/DIABETES ADRENAL HORMONES betamethasone acet,sod phos cortisone decadron deltasone oral tablet 0 mg B/D PA; MO 61 Name dexamethasone intensol dexamethasone oral elixir dexamethasone oral solution dexamethasone oral tablet dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection 1 MO fludrocortisone hydrocortisone oral methylprednisolone acetate methylprednisolone oral tablet methylprednisolone oral tablets,dose pack methylprednisolone sodium succ injection recon soln 15 mg, 40 mg methylprednisolone sodium succ B/D PA; MO millipred dp millipred oral tablet 4 B/D PA; MO prednisolone oral solution 15 mg/5 ml

63 Name prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 0 mg/5 ml (4 mg/ml), 5 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating B/D PA; MO prednisone intensol B/D PA; MO prednisone oral solution prednisone oral tablet prednisone oral tablets,dose pack triamcinolone acetonide injection 1 B/D PA; MO 1 MO veripred 0 ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg propylthiouracil DIABETES THERAPY acarbose oral tablet 100 mg acarbose oral tablet 5 mg acarbose oral tablet 50 mg ; QL (90 ; QL (360 ; QL (180 ALCOHOL PADS BYDUREON 3 PA; MO; QL (4 per 8 6 Name BYDUREON BCISE BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(50 MCG/ML).4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (50 MCG/ML) 1. ML 3 PA; MO; QL (4 per 8 3 PA; MO; QL (.4 per 30 3 PA; MO; QL (1. per 30 CYCLOSET 4 MO; QL (180 FREESTYLE FREEDOM FREESTYLE FREEDOM LITE FREESTYLE INSULINX FREESTYLE INSULINX TEST STRIPS FREESTYLE LITE METER FREESTYLE LITE STRIPS 3 FREESTYLE TEST GAUZE PADS X glimepiride oral tablet 1 mg glimepiride oral tablet mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg 1 MO; QL (40 1 MO; QL (10 1 MO; QL (60 1 MO; QL (10

64 Name Name glipizide oral tablet 5 mg 1 MO; QL (40 HUMALOG U-100 INSULIN glipizide oral tablet extended release 4hr 10 mg glipizide oral tablet extended release 4hr.5 mg glipizide oral tablet extended release 4hr 5 mg glipizide-metformin oral tablet.5-50 mg glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) HUMALOG JUNIOR KWIKPEN U-100 HUMALOG KWIKPEN INSULIN HUMALOG MIX INSULN U MO; QL (60 1 MO; QL (40 1 MO; QL (10 1 MO; QL (40 1 MO; QL (10 HUMULIN 70/30 U-100 INSULIN HUMULIN 70/30 U-100 KWIKPEN HUMULIN N NPH INSULIN KWIKPEN HUMULIN N NPH U-100 INSULIN HUMULIN R REGULAR U-100 INSULN HUMULIN R U-500 (CONC) INSULIN HUMULIN R U-500 (CONC) KWIKPEN INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML 9 GAUGE, 1 ML 9 GAUGE X 1/", 1/ ML 8 GAUGE INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG ; QL (60 HUMALOG MIX KWIKPEN HUMALOG MIX 75-5 KWIKPEN INVOKAMET ORAL TABLET MG ; QL (10 HUMALOG MIX 75-5(U- 100)INSULN 63

65 Name INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 4HR 150-1,000 MG, MG, 50-1,000 MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 4HR MG INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG ; QL (60 ; QL (10 ; QL (90 ; QL (30 JANUMET ; QL (60 JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 100-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 50-1,000 MG ; QL (30 ; QL (60 JANUVIA ; QL (30 JARDIANCE ; QL (30 JENTADUETO ; QL (60 JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 4HR.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 4HR 5-1,000 MG ; QL (60 ; QL (30 Name LANTUS SOLOSTAR U-100 INSULIN LANTUS U-100 INSULIN metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 4 hr 500 mg metformin oral tablet extended release 4 hr 750 mg miglitol oral tablet 100 mg miglitol oral tablet 5 mg miglitol oral tablet 50 mg nateglinide oral tablet 10 mg nateglinide oral tablet 60 mg NEEDLES, INSULIN DISP.,SAFETY 1 MO; QL (75 1 MO; QL (150 1 MO; QL (90 1 MO; QL (10 1 MO; QL (75 ; QL (90 ; QL (360 ; QL (180 ; QL (90 ; QL (180 NOVOFINE 3 NOVOFINE AUTOCOVER ONETOUCH ULTRA BLUE TEST STRIP 64

66 Name ONETOUCH ULTRA ONETOUCH ULTRAMINI ONETOUCH VERIO ONETOUCH VERIO IQ METER ONETOUCH VERIO SYSTEM OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.5 MG OR 0.5 MG( MG/1.5 ML) OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/0.75 ML ( MG/1.5 ML) 3 PA; MO; QL (1.5 per 8 3 PA; MO; QL (3 per 8 pioglitazone 1 MO; QL (30 PRECISION PCX PLUS TEST PRECISION PCX TEST PRECISION Q-I-D TEST PRECISION XTRA MONITOR ; QL (30 ; QL (90 3 PROGLYCEM repaglinide oral tablet 0.5 mg ; QL (960 Name repaglinide oral tablet 1 mg repaglinide oral tablet mg pioglitazoneglimepiride pioglitazonemetformin repaglinidemetformin ; QL (480 ; QL (40 ; QL (150 RIOMET ; QL (765 SYMLINPEN 10 (10.8 per 30 SYMLINPEN 60 (6 SYNJARDY ORAL TABLET 1.5-1,000 MG, MG, 5-1,000 MG SYNJARDY ORAL TABLET MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 4HR 10-1,000 MG, 1.5-1,000 MG, 5-1,000 MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 4HR 5-1,000 MG tolazamide oral tablet 50 mg tolazamide oral tablet 500 mg ; QL (60 ; QL (10 ; QL (60 ; QL (30 ; QL (10 ; QL (60 tolbutamide ; QL (180 TOUJEO MAX U- 300 SOLOSTAR 65

67 Name TOUJEO SOLOSTAR U-300 INSULIN TRADJENTA ; QL (30 TRULICITY 4 PA; MO; QL ( per 8 VGO 0 VGO 30 VGO 40 VICTOZA -PAK 3 PA; MO; QL (9 VICTOZA 3-PAK 3 PA; MO; QL (9 MISCELLANEOUS HORMONES ALDURAZYME ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 0.5 MG/1.5 GRAM (1.6 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (0.5 MG/1.5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (40.5 MG/.5 GRAM) 3 PA; MO; QL (150 per 30 3 PA; MO; QL (37.5 per 30 3 PA; MO; QL (150 per 30 cabergoline calcitonin (salmon) Name calcitriol solution 1 mcg/ml calcitriol oral CERDELGA CEREZYME INTRAVENOUS RECON SOLN 400 UNIT clomiphene citrate PA; MO danazol 4 MO desmopressin injection desmopressin nasal spray with pump desmopressin nasal spray,non-aerosol desmopressin oral doxercalciferol doxercalciferol oral ELAPRASE FABRAZYME KANUMA KORLYM 5 PA; MO KUVAN 5 PA; MO LUMIZYME methyltestosterone oral capsule MIACALCIN INJECTION 4 MO miglustat ; LA MYALEPT 5 PA; MO; LA NAGLAZYME ; LA 66

68 Name NATPARA 5 PA; MO; LA oxandrolone oral tablet 10 mg oxandrolone oral tablet.5 mg PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG/0.5 ML PALYNZIQ SUBCUTANEOUS SYRINGE.5 MG/0.5 ML PALYNZIQ SUBCUTANEOUS SYRINGE 0 MG/ML 5 PA; MO PA; MO 5 PA; MO; LA; QL (15 per 30 5 PA; MO; LA; QL (4 per 30 5 PA; MO; LA; QL (60 per 30 pamidronate paricalcitol solution mcg/ml paricalcitol solution 5 mcg/ml paricalcitol oral 4 MO SAMSCA 5 PA; MO SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 MG SOMAVERT STIMATE STRENSIQ ; LA SYNAREL testosterone cypionate PA; MO 67 Name testosterone enanthate testosterone transdermal gel testosterone transdermal gel in metered-dose pump 1.5 mg/ 1.5 gram (1 %) testosterone transdermal gel in packet testosterone transdermal solution in metered pump w/app PA; MO PA; MO; QL (300 per 30 PA; MO; QL (300 per 30 PA; MO; QL (300 per 30 PA; MO; QL (180 per 30 VIMIZIM ; LA zoledronic acid solution THYROID HORMONES levothyroxine recon soln 00 mcg, 500 mcg B/D PA; MO levothyroxine oral 1 MO levoxyl oral tablet 100 mcg, 11 mcg, 15 mcg, 137 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 50 mcg, 75 mcg, 88 mcg 1 MO liothyronine unithroid 1 MO GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS

69 Name atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml, 0.1 mg/ml dicyclomine intramuscular dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet diphenoxylateatropine glycopyrrolate injection glycopyrrolate oral tablet 1 mg, mg loperamide oral capsule opium tincture paregoric MISCELLANEOUS GASTROINTESTINAL AGENTS alosetron aprepitant B/D PA; MO balsalazide budesonide oral CHENODAL 5 PA; LA CHOLBAM ORAL CAPSULE 50 MG CHOLBAM ORAL CAPSULE 50 MG 5 PA; MO (10 per Name colocort compro constulose CORTIFOAM CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 1,000-38,000-60,000 UNIT, 4,000-76,000-10,000 UNIT, 3,000-9,500-15,000 UNIT, 6,000-19,000-30,000 UNIT CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 36, , ,000 UNIT cromolyn oral CYSTADANE dimenhydrinate injection solution DIPENTUM dronabinol oral capsule 10 mg dronabinol oral capsule.5 mg, 5 mg droperidol injection solution EMEND ORAL SUSPENSION FOR RECONSTITUTIO N 5 B/D PA; MO 4 B/D PA; MO 3 B/D PA; MO ENTYVIO 5 PA; MO enulose

70 Name GATTEX 30-VIAL 5 PA; MO GATTEX ONE- VIAL 5 PA; MO gavilyte-c gavilyte-g gavilyte-n generlac granisetron (pf) granisetron hcl granisetron hcl oral B/D PA; MO hydrocortisone rectal hydrocortisone topical cream with perineal applicator hydrocortisonepramoxine rectal cream 1-1 % lactulose LINZESS meclizine oral tablet 1.5 mg, 5 mg mesalamine oral tablet,delayed release (dr/ec) 1. gram mesalamine rectal mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl injection syringe Name metoclopramide hcl oral solution metoclopramide hcl oral tablet metoclopramide hcl oral tablet,disintegrating 1 MO MOVANTIK OCALIVA 5 PA; MO; LA; QL (30 per 30 ondansetron B/D PA; MO ondansetron hcl (pf) ondansetron hcl ondansetron hcl oral solution ondansetron hcl oral tablet 4 mg ondansetron hcl oral tablet 4 mg, 8 mg palonosetron solution 0.5 mg/5 ml peg electrolytes oral recon soln gram peg electrolytes oral recon soln gram peg-electrolyte B/D PA; MO B/D PA B/D PA; MO 69

71 Name PENTASA ORAL CAPSULE, EXTENDED RELEASE 50 MG PENTASA ORAL CAPSULE, EXTENDED RELEASE 500 MG polyethylene glycol 3350 prochlorperazine prochlorperazine edisylate injection solution 10 mg/ ml (5 mg/ml) prochlorperazine maleate oral 1 MO procto-med hc procto-pak proctosol hc topical proctozone-hc RECTIV RELISTOR SUBCUTANEOUS SOLUTION RELISTOR SUBCUTANEOUS SYRINGE REMICADE 5 PA; MO scopolamine base SUCRAID sulfasalazine trilyte with flavor packets ursodiol VARUBI ORAL 3 B/D PA; MO 70 Name VIBERZI VIOKACE ULCER THERAPY amoxicilclarithromylansopraz ; QL (11 cimetidine cimetidine hcl oral esomeprazole magnesium oral capsule,delayed release(dr/ec) 0 mg esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg esomeprazole sodium recon soln 0 mg esomeprazole sodium recon soln 40 mg ; QL (30 famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine solution famotidine oral suspension famotidine oral tablet 0 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) 15 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg 1 MO ; QL (30

72 Name misoprostol nizatidine omeprazole oral capsule,delayed release(dr/ec) 10 mg, 0 mg omeprazole oral capsule,delayed release(dr/ec) 40 mg pantoprazole pantoprazole oral tablet,delayed release (dr/ec) 0 mg pantoprazole oral tablet,delayed release (dr/ec) 40 mg ranitidine hcl injection ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg 1 MO; QL (30 1 MO 1 MO; QL (30 1 MO 1 MO 1 MO sucralfate oral tablet IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 5 B/D PA; MO ARCALYST 5 PA; MO AVONEX (WITH ALBUMIN) (4 per 8 Name AVONEX INTRAMUSCULA R PEN INJECTOR KIT AVONEX INTRAMUSCULA R SYRINGE KIT BETASERON SUBCUTANEOUS KIT (4 per 8 (4 per 8 (15 per 8 GRANIX 5 PA; MO ILARIS (PF) SUBCUTANEOUS SOLUTION INTRON A INJECTION RECON SOLN INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML LEUKINE INJECTION RECON SOLN 5 PA; MO; LA 5 B/D PA; MO 3 B/D PA; MO 5 B/D PA; MO MOZOBIL 5 B/D PA; MO NEULASTA 5 PA; MO NEUPOGEN 5 PA; MO OMNITROPE 5 PA; MO 71

73 Name PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION PEGASYS SUBCUTANEOUS SYRINGE PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 15 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 15 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 3,000 UNIT/ML, 4,000 UNIT/ML ; QL ( per 8 ; QL (4 per 8 ; QL ( per 8 ; QL (4 per 8 (1 per 8 (1 per 180 (1 per 8 (1 per PA; MO 7 Name PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 40,000 UNIT/ML 5 PA; MO PROLEUKIN 5 B/D PA; MO REBIF (WITH ALBUMIN) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.ML- MCG/0.5ML (6) REBIF TITRATION PACK (6 per 8 (6 per 8 (4. per 180 (4. per 180 SYLATRON ZARXIO 5 PA; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT )(PF) BCG VACCINE, LIVE (PF) BEXSERO BOOSTRIX TDAP BOTOX 3 PA; MO DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) 3 B/D PA; MO

74 Name ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE fomepizole 3 B/D PA; MO GAMASTAN S/D GARDASIL 9 (PF) GRASTEK 3 PA; MO HAVRIX (PF) INTRAMUSCULA R SUSPENSION HAVRIX (PF) INTRAMUSCULA R SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULA R SYRINGE 70 ELISA UNIT/0.5 ML HIBERIX (PF) HIZENTRA 5 B/D PA; MO HYPERHEP B S/D INTRAMUSCULA R SOLUTION 0 UNIT/ML HYPERHEP B S/D INTRAMUSCULA R SOLUTION 0 UNIT/ML (5 ML) HYPERHEP B S/D INTRAMUSCULA R SYRINGE HYPERHEP B S-D NEONATAL 3 3 HYQVIA 5 B/D PA; MO IMOVAX RABIES VACCINE (PF) Name INFANRIX (DTAP) (PF) IPOL IXIARO (PF) KINRIX (PF) INTRAMUSCULA R SUSPENSION KINRIX (PF) INTRAMUSCULA R SYRINGE MENACTRA (PF) INTRAMUSCULA R SOLUTION MENVEO A-C-Y- W-135-DIP (PF) 3 M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PRIVIGEN 5 PA; MO PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) RAGWITEK RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 10 MCG/ML 3 B/D PA; MO 3 B/D PA; MO

75 Name RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 5 MCG/0.5 ML ROTARIX 3 ROTATEQ VACCINE 3 B/D PA SHINGRIX (PF) STAMARIL (PF) 3 TENIVAC (PF) TETANUS,DIPHTH ERIA TOX PED(PF) TETANUS- DIPHTHERIA TOXOIDS-TD TICE BCG 3 B/D PA; MO TRUMENBA TWINRIX (PF) INTRAMUSCULA R SYRINGE TYPHIM VI INTRAMUSCULA R SOLUTION TYPHIM VI INTRAMUSCULA R SYRINGE 3 VAQTA (PF) VARIVAX (PF) VARIZIG INTRAMUSCULA R SOLUTION YF-VAX (PF) ZOSTAVAX (PF) Name MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol 1 MO allopurinol sodium aloprim COLCRYS 4 ST; MO KRYSTEXXA MITIGARE probenecid probenecidcolchicine ULORIC 3 ST; MO OSTEOPOROSIS THERAPY alendronate oral solution alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg ; QL (186 1 MO; QL (30 1 MO; QL (4 per 8 FORTEO (.4 per 8 ibandronate PA; MO ibandronate oral ; QL (1 per 30 PROLIA 3 PA; MO raloxifene risedronate oral tablet 150 mg ; QL (1 per 30 74

76 Name risedronate oral tablet 35 mg, 35 mg (1 pack), 35 mg (4 pack) risedronate oral tablet 5 mg risedronate oral tablet,delayed release (dr/ec) ; QL (4 per 8 ; QL (30 ; QL (4 per 8 TYMLOS (1.56 per 30 OTHER RHEUMATOLOGICALS ACTEMRA 5 PA; MO BENLYSTA 5 PA; MO CUPRIMINE DEPEN TITRATABS ENBREL MINI (8 per 8 ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE ENBREL SURECLICK HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK) (16 per 8 (8 per 8 (8 per 8 (6 per 180 Name HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 80 MG/0.8 ML HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML (3 per 180 ( per 180 HUMIRA PEN (4 per 8 HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA PEN PSORIASIS- UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS- UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML- 40 MG/0.4 ML (6 per PA; QL (3 per 180 (4 per PA; QL (3 per

77 Name HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 10 MG/0. ML, 0 MG/0. ML, 0 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML, 40 MG/0.8 ML ( per 8 (4 per 8 leflunomide ; QL (30 ORENCIA 5 PA; MO ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT 5 PA; MO 5 PA; MO OTEZLA 5 PA; MO OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)- 0 MG (4)-30 MG (47) 5 PA; MO RIDAURA OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila deblitane DEPO-PROVERA INTRAMUSCULA R SUSPENSION 400 MG/ML errin estradiol oral 4 PA; MO 76 Name estradiol transdermal patch semiweekly estradiol transdermal patch weekly estradiol vaginal estradiol valerate intramuscular oil 0 mg/ml, 40 mg/ml estradiolnorethindrone acet PA; MO; QL (8 per 8 PA; MO; QL (4 per 8 PA; MO heather hydroxyprogesterone caproate incassia jencycla jolivette lyza medroxyprogesteron e MENEST ORAL TABLET 0.3 MG, 0.65 MG, 1.5 MG 3 PA; MO nora-be norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol oral tablet mg-mcg, 1-5 mg-mcg 4 PA; MO norlyda norlyroc progesterone

78 Name progesterone micronized sharobel yuvafem MISCELLANEOUS OB/GYN clindamycin phosphate vaginal metronidazole vaginal miconazole-3 vaginal suppository MIRENA ; LA NEXPLANON terconazole tranexamic acid oral vandazole xulane ORAL CONTRACEPTIVES / RELATED AGENTS altavera (8) alyacen 1/35 (8) alyacen 7/7/7 (8) amethyst apri aranelle (8) aubra aviane azurette (8) bekyree (8) camrese caziant (8) chateal Name cryselle (8) cyclafem 1/35 (8) cyclafem 7/7/7 (8) cyred dasetta 1/35 (8) dasetta 7/7/7 (8) daysee delyla (8) desoge.estradiol/e.estradio l desogestrel-ethinyl estradiol drospirenonee.estradiol-lm.fa oral tablet mg (1) (7) drospirenone-ethinyl estradiol elinest emoquette enpresse enskyce estarylla ethynodiol diac-eth estradiol falmina (8) femynor gianvi (8) introvale isibloom jolessa juleber 77

79 Name kariva (8) kelnor 1/35 (8) kimidess (8) kurvelo l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.10 mg-0 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7) l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.15 mg-0 mcg/ 0.15 mg-5 mcg larin 1.5/30 (1) larin 1/0 (1) larin 4 fe larin fe 1.5/30 (8) larin fe 1/0 (8) larissia lessina levonest (8) levonorgestrelethinyl estrad levonorg-eth estrad triphasic levora-8 lillow loryna (8) low-ogestrel (8) lutera (8) marlissa 78 Name microgestin 1.5/30 (1) microgestin 1/0 (1) microgestin fe 1.5/30 (8) microgestin fe 1/0 (8) mili mono-linyah myzilra nikki (8) norethindrone ac-eth estradiol oral tablet 1-0 mg-mcg norethindronee.estradiol-iron oral tablet 1 mg-0 mcg (1)/75 mg (7) norgestimate-ethinyl estradiol nortrel 0.5/35 (8) nortrel 1/35 (1) nortrel 1/35 (8) nortrel 7/7/7 (8) ogestrel (8) orsythia philith pimtrea (8) pirmella portia previfem quasense rajani

80 Name reclipsen (8) setlakin sprintec (8) sronyx tarina fe 1/0 (8) tilia fe tri femynor tri-estarylla tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trinessa (8) trinessa lo tri-previfem (8) tri-sprintec (8) trivora (8) velivet triphasic regimen (8) vestura (8) vienva viorele (8) wera (8) zarah zovia 1/35e (8) OXYTOCICS methergine methylergonovine injection 79 Name methylergonovine oral oxytocin injection solution OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac bacitracin ophthalmic (eye) bacitracinpolymyxin b ophthalmic (eye) ciprofloxacin hcl ophthalmic (eye) erythromycin ophthalmic (eye) gatifloxacin gentak ophthalmic (eye) ointment gentamicin ophthalmic (eye) drops levofloxacin ophthalmic (eye) moxifloxacin ophthalmic (eye) NATACYN neomycinbacitracinpolymyxin neomycinpolymyxingramicidin neo-polycin ofloxacin ophthalmic (eye)

81 Name polycin tobramycin ANTIVIRALS trifluridine ZIRGAN 4 MO BETA-BLOCKERS betaxolol ophthalmic (eye) carteolol levobunolol ophthalmic (eye) drops 0.5 % metipranolol timolol maleate ophthalmic (eye) drops timolol maleate ophthalmic (eye) drops, once daily timolol maleate ophthalmic (eye) gel forming solution MISCELLANEOUS OPHTHALMOLOGICS atropine ophthalmic (eye) drops azelastine ophthalmic (eye) balanced salt 1 MO BLEPHAMIDE 4 MO BLEPHAMIDE S.O.P. 4 MO bss 80 Name cromolyn ophthalmic (eye) CYSTARAN epinastine EYLEA JETREA (PF) INTRAVITREAL SOLUTION 0.15 MG/0.1 ML (1.5 MG/ML) LUCENTIS INTRAVITREAL SOLUTION 0.3 MG/0.05 ML LUCENTIS INTRAVITREAL SYRINGE olopatadine ophthalmic (eye) PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic (eye) drops 1 %, %, 4 % sulfacetamide sodium ophthalmic (eye) polymyxin b sulftrimethoprim sulfacetamideprednisolone ; LA 4 MO XIIDRA ; QL (60 NON-STEROIDAL ANTI- INFLAMMATORY AGENTS bromfenac diclofenac sodium ophthalmic (eye) flurbiprofen sodium

82 Name ketorolac ophthalmic (eye) ORAL DRUGS FOR GLAUCOMA acetazolamide acetazolamide sodium methazolamide OTHER GLAUCOMA DRUGS bimatoprost ophthalmic (eye) dorzolamide dorzolamide-timolol latanoprost miostat STEROID-ANTIBIOTIC COMBINATIONS neomycin-polymyxin b-dexameth neomycinbacitracin-poly-hc neomycinpolymyxin-hc ophthalmic (eye) neo-polycin hc tobramycindexamethasone STEROIDS dexamethasone sodium phosphate ophthalmic (eye) fluorometholone OZURDEX prednisolone acetate Name prednisolone sodium phosphate ophthalmic (eye) SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % apraclonidine brimonidine RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS adrenalin injection cetirizine oral solution 1 mg/ml diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral elixir EPINEPHRINE INJECTION AUTO- INJECTOR 0.15 MG/0.3 ML, 0.3 MG/0.3 ML (MANUFACTURE D BY MYLAN SPECIALTY) PA ; QL (4 per 30 EPIPEN ; QL (4 per 30 EPIPEN -PAK ; QL (4 per 30 81

83 Name EPIPEN JR ; QL (4 per 30 EPIPEN JR -PAK ; QL (4 per 30 hydroxyzine hcl oral tablet levocetirizine oral solution levocetirizine oral tablet promethazine injection solution PA; MO ; QL (30 4 MO promethazine oral 4 PA; MO PULMONARY AGENTS acetylcysteine B/D PA; MO ADEMPAS 5 PA; MO; LA albuterol sulfate inhalation solution for nebulization albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release 1 hr aminophylline solution 500 mg/0 ml ARCAPTA NEOHALER B/D PA; MO 4 MO 4 MO ; QL (30 ASMANEX HFA ; QL (13 Name ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 0 MCG (30 DOSES), 0 MCG (60 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (10 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (14 DOSES) ; QL (1 per 30 3 QL (4 per 8 ; QL ( per 30 3 QL ( per 8 ATROVENT HFA ; QL (5.8 budesonide inhalation B/D PA; MO CINRYZE 5 PA; MO COMBIVENT RESPIMAT ; QL (8 per 30 cromolyn inhalation B/D PA; MO DALIRESP 4 PA; MO 8

84 Name DULERA ; QL (13 ESBRIET ORAL CAPSULE ESBRIET ORAL TABLET 67 MG ESBRIET ORAL TABLET 801 MG (70 per 30 (70 per 30 (90 per 30 FASENRA 5 PA; MO FIRAZYR 5 PA; MO flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) ; QL (50 fluticasone nasal ; QL (16 HAEGARDA 5 PA; MO; LA INCRUSE ELLIPTA ipratropium bromide inhalation ipratropiumalbuterol KALYDECO ORAL GRANULES IN PACKET KALYDECO ORAL TABLET ; QL (30 B/D PA; MO B/D PA; MO (56 per 8 (60 per 30 LETAIRIS 5 PA; MO; LA levalbuterol hcl B/D PA; MO metaproterenol mometasone nasal ; QL (34 Name montelukast OFEV (60 per 30 OPSUMIT 5 PA; MO; LA ORKAMBI ORAL TABLET (11 per 8 PERFOROMIST 3 B/D PA; MO PROAIR HFA ; QL (17 PROAIR RESPICLICK ; QL ( per 30 PULMOZYME 5 B/D PA; MO QVAR ; QL (17.4 QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 80 MCG/ACTUATION SEREVENT DISKUS sildenafil (pulmonary arterial hypertension) solution 10 mg/1.5 ml ; QL (10.6 ; QL (1. ; QL (60 5 PA 83

85 Name sildenafil (pulmonary arterial hypertension) oral tablet 0 mg SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT STRIVERDI RESPIMAT PA; MO; QL (90 per 30 ; QL (4 per 30 ; QL (90 per 90 ; QL (4 per 30 ; QL (4 per 30 SYMBICORT ; QL (10. SYMDEKO (56 per 8 terbutaline THEO-4 theophylline in dextrose 5 % parenteral solution 400 mg/500 ml theophylline oral elixir theophylline oral solution theophylline oral tablet extended release 1 hr theophylline oral tablet extended release 4 hr TRACLEER ORAL TABLET triamcinolone acetonide nasal 5 PA; MO; LA ; QL ( Name TYVASO 5 B/D PA; MO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT 5 B/D PA 5 B/D PA; MO 5 B/D PA; MO XOLAIR 5 PA; MO; LA; QL (6 per 8 zafirlukast UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS flavoxate MYRBETRIQ oxybutynin chloride tolterodine trospium BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin dutasteride dutasteridetamsulosin finasteride oral tablet 5 mg tamsulosin 1 MO MISCELLANEOUS UROLOGICALS alprostadil bethanechol chloride CYSTAGON ; LA

86 Name ELMIRON glycine urologic glycine urologic solution K-PHOS NO K-PHOS ORIGINAL potassium citrate RENACIDIN IRRIGATION SOLUTION GRAM/100 ML VITAMINS, HEMATINICS / ELECTROLYTES BLOOD DERIVATIVES albumin, human 5 % alburx (human) 5 % alburx (human) 5 % albutein 5 % albutein 5 % buminate 5 % plasbumin 5 % plasbumin 5 % ELECTROLYTES calcium acetate oral capsule calcium acetate oral tablet 667 mg calcium chloride calcium gluconate 85 Name effer-k oral tablet, effervescent 5 meq k-effervescent klor-con klor-con 10 klor-con 8 klor-con m10 klor-con m15 klor-con m0 klor-con sprinkle klor-con/ef k-tab oral tablet extended release 8 meq lactated ringers magnesium chloride injection MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML magnesium sulfate in water parenteral solution magnesium sulfate in water piggyback gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water piggyback 4 gram/100 ml (4 %) magnesium sulfate injection solution 3

87 Name magnesium sulfate injection syringe NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE potassium acetate solution meq/ml potassium bicarb and chloride potassium bicarbcitric acid potassium chloridd5-0.45%nacl parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chloridd5-0.45%nacl parenteral solution 0 meq/l potassium chloride in 0.9%nacl parenteral solution 0 meq/l, 40 meq/l potassium chloride in 5 % dex parenteral solution 0 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 parenteral solution 0 meq/l 3 Name potassium chloride in lr-d5 parenteral solution 40 meq/l potassium chloride in water piggyback 10 meq/100 ml, 10 meq/50 ml potassium chloride in water piggyback 0 meq/100 ml, 0 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride solution potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral packet potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals potassium chloride % nacl potassium chlorided5-0.%nacl parenteral solution 0 meq/l 1 MO 1 MO 1 MO 86

88 Name potassium chlorided5-0.%nacl parenteral solution 30 meq/l, 40 meq/l potassium chlorided5-0.3%nacl parenteral solution 0 meq/l potassium chlorided5-0.9%nacl parenteral solution 0 meq/l potassium chlorided5-0.9%nacl parenteral solution 40 meq/l potassium phosphate m-/d-basic ringer's sodium acetate sodium bicarbonate solution 1 meq/ml (8.4 %) sodium bicarbonate syringe 10 meq/10 ml (8.4 %), 7.5 % (0.9 meq/ml) sodium bicarbonate syringe 8.4 % (1 meq/ml) sodium chloride 0.45 % parenteral solution Name sodium chloride 0.45 % piggyback sodium chloride 3 % sodium chloride 5 % sodium chloride sodium lactate sodium phosphate MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 10 % 3 B/D PA AMINOSYN 7 % WITH ELECTROLYTES 3 B/D PA AMINOSYN 8.5 % 3 B/D PA AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 87

89 Name AMINOSYN-PF 7 % (SULFITE- FREE) AMINOSYN-RF 5. % CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE CLINIMIX.75%/D5W SULFIT FREE CLINIMIX 4.5%/D10W SULF FREE CLINIMIX 4.5%- D0W SULF-FREE CLINIMIX 4.5%- D5W SULF-FREE CLINIMIX 5%- D0W(SULFITE- FREE) cysteine (l-cysteine) solution electrolyte-48 in d5w 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA B/D PA freamine iii 10 % B/D PA HEPATAMINE 8% 3 B/D PA intralipid emulsion 0 % B/D PA Name IONOSOL-MB IN D5W ISOLYTE S PH ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 3 NEPHRAMINE 5.4 % NORMOSOL-R PH 7.4 PLASMA-LYTE 148 PLASMA-LYTE A 3 plasmanate B/D PA plenamine B/D PA premasol 10 % B/D PA; MO PREMASOL 6 % 3 B/D PA travasol 10 % 4 B/D PA; MO TROPHAMINE 10 % B/D PA; MO TROPHAMINE 6% 3 B/D PA VITAMINS / HEMATINICS fluoride (sodium) oral tablet prenatal vitamin oral tablet 4 MO 4 MO 88

90 Index A abacavir abacavir-lamivudine abacavir-lamivudinezidovudine ABELCET ABILIFY MAINTENA... 4 ABRAXANE... 5 acamprosate acarbose... 6 acebutolol acetaminophen-caffdihydrocod acetaminophen-codeine acetazolamide acetazolamide sodium acetic acid... 58, 61 acetylcysteine... 58, 8 acitretin ACTEMRA ACTHIB (PF)... 7 ACTIMMUNE acyclovir... 15, 57 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF) 7 ADAGEN ADASUVE... 4 adefovir ADEMPAS... 8 adenosine adrenalin adriamycin... 5 adrucil... 5 afeditab cr AFINITOR... 5 AFINITOR DISPERZ... 5 ak-poly-bac ala-cort ALBENZA... 0 albumin, human 5 % alburx (human) 5 % alburx (human) 5 % albutein 5 % albutein 5 % albuterol sulfate... 8 alclometasone ALCOHOL PADS... 6 ALDURAZYME ALECENSA... 5 alendronate... 58, 74 alfuzosin ALIMTA... 5 ALINIA... 0 ALIQOPA... 5 allopurinol allopurinol sodium aloprim alosetron ALPHAGAN P alprostadil altavera (8) ALUNBRIG... 5 alyacen 1/35 (8) alyacen 7/7/7 (8) amantadine hcl AMBISOME amethyst AMICAR amikacin... 0 amiloride amiloride-hydrochlorothiazide aminocaproic acid aminophylline... 8 AMINOSYN 10 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5. % amiodarone amitriptyline... 4 amlodipine amlodipine-atorvastatin... 5 amlodipine-benazepril amlodipine-olmesartan amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amnesteem amoxapine... 4 amoxicil-clarithromy-lansopraz amoxicillin... amoxicillin-pot clavulanate.. amphotericin b ampicillin... ampicillin sodium... ampicillin-sulbactam..., 3 AMPYRA anagrelide anastrozole... 5 ANDROGEL APOKYN apraclonidine aprepitant apri APTIOM APTIVUS ARALAST NP aranelle (8) ARCALYST ARCAPTA NEOHALER... 8 aripiprazole... 4 ARISTADA... 4 ARISTADA INITIO... 4 armodafinil... 4 ARRANON... 5 ARZERRA... 5 ASMANEX HFA... 8 ASMANEX TWISTHALER 8 89

91 aspirin-dipyridamole atazanavir... 15, 16 atenolol atenolol-chlorthalidone atomoxetine... 4 atorvastatin... 5 atovaquone... 0 atovaquone-proguanil... 0 ATRIPLA atropine... 68, 80 ATROVENT HFA... 8 aubra AUGMENTIN... 3 AVASTIN... 5 aviane AVONEX AVONEX (WITH ALBUMIN) azacitidine... 5 azathioprine... 5 azathioprine sodium... 5 azelastine... 60, 80 azithromycin... 0 aztreonam... 0 azurette (8) B baciim... 0 bacitracin... 1, 79 bacitracin-polymyxin b baclofen balanced salt balsalazide BANZEL BARACLUDE BAVENCIO... 6 BCG VACCINE, LIVE (PF) 7 bekyree (8) BELEODAQ... 6 benazepril benazepril-hydrochlorothiazide BENDEKA... 6 BENLYSTA BENZNIDAZOLE... 1 benztropine BESPONSA... 6 betamethasone acet,sod phos 61 betamethasone dipropionate. 57 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 48, 80 bethanechol chloride BETHKIS... 1 bexarotene... 6 BEXSERO... 7 bicalutamide... 6 BICILLIN C-R... 3 BICILLIN L-A... 3 BICNU... 6 BIKTARVY bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin... 6 BLEPHAMIDE BLEPHAMIDE S.O.P BLINCYTO... 6 BOOSTRIX TDAP... 7 BORTEZOMIB... 6 BOSULIF... 6 BOTOX... 7 BRAFTOVI... 6 BRILINTA brimonidine BRIVIACT bromfenac bromocriptine bss budesonide... 68, 8 bumetanide buminate 5 % buprenorphine hcl buprenorphine-naloxone bupropion hcl... 4 bupropion hcl (smoking deter) buspirone... 4 busulfan... 6 butorphanol tartrate BYDUREON... 6 BYDUREON BCISE... 6 BYETTA... 6 C cabergoline CABOMETYX... 6 caffeine citrate calcipotriene calcipotriene-betamethasone 54 calcitonin (salmon) calcitrene calcitriol... 55, 66 calcium acetate calcium chloride calcium gluconate CALQUENCE... 6 camila camrese candesartan candesartan-hydrochlorothiazid CAPASTAT... 1 CAPRELSA... 6 captopril captopril-hydrochlorothiazide CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone carbocaine (pf) carboplatin... 6 cardioplegic soln carteolol cartia xt carvedilol carvedilol phosphate caspofungin CAYSTON... 1 caziant (8) cefaclor... 18, 19 cefadroxil cefazolin cefazolin in dextrose (iso-os) 19 cefdinir cefepime cefepime in dextrose,iso-osm

92 cefixime cefotaxime cefotetan cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil ceftazidime ceftriaxone ceftriaxone in dextrose,iso-os cefuroxime axetil... 0 cefuroxime sodium... 0 celecoxib CELONTIN cephalexin... 0 CEPROTIN (BLUE BAR) CEPROTIN (GREEN BAR) 51 CERDELGA CEREZYME cetirizine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX chateal CHEMET CHENODAL chloramphenicol sod succinate... 1 chlorhexidine gluconate chloroprocaine (pf) chloroquine phosphate... 1 chlorothiazide chlorothiazide sodium chlorpromazine... 4 chlorthalidone CHOLBAM cholestyramine (with sugar). 5 cholestyramine light... 5 ciclodan ciclopirox cidofovir cilostazol CIMDUO cimetidine cimetidine hcl CINRYZE... 8 CIPRODEX ciprofloxacin... 3 ciprofloxacin (mixture)... 3 ciprofloxacin hcl... 3, 61, 79 ciprofloxacin in 5 % dextrose... 4 cisplatin... 6 citalopram... 4 cladribine... 6 claravis clarithromycin... 0 clindamycin hcl... 1 clindamycin in 5 % dextrose 1 clindamycin palmitate hcl... 1 clindamycin pediatric... 1 clindamycin phosphate.. 1, 56, 77 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE CLINIMIX.75%/D5W SULFIT FREE CLINIMIX 4.5%/D10W SULF FREE CLINIMIX 4.5%/D5W SULFIT FREE CLINIMIX 4.5%-D0W SULF-FREE CLINIMIX 4.5%-D5W SULF-FREE CLINIMIX 5%- D0W(SULFITE-FREE).. 88 clobetasol clobetasol-emollient clofarabine... 6 clomiphene citrate clomipramine... 4 clonazepam... 33, 34 clonidine clonidine (pf)... 41, 49 clonidine hcl... 43, 49 clopidogrel clorazepate dipotassium clotrimazole... 15, 57 clotrimazole-betamethasone. 57 clozapine COARTEM... 1 COLCRYS colesevelam... 5 colestipol... 5 colistin (colistimethate na)... 1 colocort COMBIVENT RESPIMAT.. 8 COMETRIQ... 6 COMPLERA compro constulose CORLANOR CORTIFOAM cortisone COSMEGEN... 6 COTELLIC... 6 CREON CRESEMBA CRIXIVAN cromolyn... 68, 80, 8 cryselle (8) CUPRIMINE cyclafem 1/35 (8) cyclafem 7/7/7 (8) cyclobenzaprine cyclophosphamide... 6 CYCLOSET... 6 cyclosporine... 6 cyclosporine modified... 6 CYRAMZA... 6 cyred CYSTADANE CYSTAGON CYSTARAN cysteine (l-cysteine) cytarabine... 6 cytarabine (pf)... 6 D d10 %-0.45 % sodium chloride d.5 %-0.45 % sodium chloride

93 d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine... 6 dactinomycin... 6 DALIRESP... 8 danazol dantrolene dapsone... 1, 56 DAPTACEL (DTAP PEDIATRIC) (PF)... 7 daptomycin... 1 DARAPRIM... 1 DARZALEX... 7 dasetta 1/35 (8) dasetta 7/7/7 (8) daunorubicin... 7 daysee deblitane decadron decitabine... 7 deferoxamine deltasone delyla (8) demeclocycline... 4 DEMSER DENAVIR denta 5000 plus dentagel DEPEN TITRATABS DEPO-PROVERA DESCOVY desipramine desmopressin desog-e.estradiol/e.estradiol. 77 desogestrel-ethinyl estradiol. 77 desonide desvenlafaxine succinate dexamethasone dexamethasone intensol dexamethasone sodium phos (pf) dexamethasone sodium phosphate... 61, 81 dexrazoxane hcl... 5 dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0. % nacl dextrose 10 % in water (d10w) dextrose 0 % in water (d0w) dextrose 5 % in water (d5w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w). 59 dextrose 5 %-lactated ringers59 dextrose 5%-0. % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride DIASTAT DIASTAT ACUDIAL diazepam... 34, 43 diazepam intensol diclofenac potassium diclofenac sodium... 41, 55, 80 diclofenac-misoprostol dicloxacillin... 3 dicyclomine didanosine diflunisal digitek digox digoxin dihydroergotamine DILANTIN 30 MG diltiazem hcl dilt-xr dimenhydrinate DIPENTUM diphenhydramine hcl diphenoxylate-atropine dipyridamole disulfiram divalproex dobutamine dobutamine in d5w docetaxel... 7 DOCETAXEL... 7 dofetilide donepezil dopamine dopamine in 5 % dextrose DOPTELET dorzolamide dorzolamide-timolol doxazosin doxepin... 43, 55 doxercalciferol doxorubicin... 7 doxorubicin, peg-liposomal.. 7 doxy doxycycline hyclate... 4 doxycycline monohydrate... 4 dronabinol droperidol drospirenone-e.estradiol-lm.fa drospirenone-ethinyl estradiol DROXIA... 7 DULERA duloxetine DUPIXENT duramorph (pf) dutasteride dutasteride-tamsulosin E e.e.s econazole EDURANT efavirenz effer-k ELAPRASE electrolyte-48 in d5w eletriptan elinest ELIQUIS

94 ELITEK... 5 ELMIRON EMCYT... 7 EMEND emoquette EMPLICITI... 7 EMSAM EMTRIVA EMVERM... 1 enalapril maleate enalaprilat enalapril-hydrochlorothiazide ENBREL ENBREL MINI ENBREL SURECLICK endocet ENGERIX-B (PF)... 7 ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone entecavir ENTRESTO ENTYVIO enulose EPCLUSA epinastine EPINEPHRINE EPIPEN EPIPEN -PAK EPIPEN JR... 8 EPIPEN JR -PAK... 8 epirubicin... 7 epitol EPIVIR HBV eplerenone epoprostenol (glycine) eprosartan ERBITUX... 7 ergoloid ergotamine-caffeine ERIVEDGE... 7 ERLEADA... 7 errin ertapenem... 1 ERWINAZE... 7 ery-tab... 0 ERY-TAB... 0 ERYTHROCIN... 0 erythrocin (as stearate)... 0 erythromycin... 0, 79 erythromycin ethylsuccinate. 0 erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole magnesium esomeprazole sodium estarylla estradiol estradiol valerate estradiol-norethindrone acet. 76 eszopiclone ethacrynate sodium ethacrynic acid ethambutol... 1 ethosuximide ethynodiol diac-eth estradiol 77 etidronate disodium etodolac ETOPOPHOS... 7 etoposide... 7 EVOTAZ exemestane... 7 EXJADE EYLEA ezetimibe... 5 ezetimibe-simvastatin... 5 F FABRAZYME falmina (8) famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 70 FANAPT FARESTON... 7 FARYDAK... 7 FASENRA FASLODEX... 7 FAZACLO felbamate felodipine femynor fenofibrate... 5 fenofibrate micronized... 5 fenofibrate nanocrystallized. 5 fenofibric acid... 5 fenofibric acid (choline)... 5 fenoprofen fentanyl fentanyl citrate fentanyl citrate (pf) FERRIPROX FETZIMA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE... 7 flavoxate flecainide floxin floxuridine... 7 fluconazole fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm)15 flucytosine fludarabine... 7 fludrocortisone flumazenil flunisolide fluocinolone fluocinolone acetonide oil fluocinolone and shower cap 57 fluocinonide fluocinonide-e fluocinonide-emollient fluoride (sodium) fluorometholone fluorouracil... 7, 55 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide... 8 fluticasone

95 fluvastatin... 5, 53 fluvoxamine FOLOTYN... 8 fomepizole fondaparinux... 51, 5 FORTEO fosamprenavir fosinopril fosinopril-hydrochlorothiazide fosphenytoin freamine iii 10 % FREESTYLE FREEDOM... 6 FREESTYLE FREEDOM LITE... 6 FREESTYLE INSULINX... 6 FREESTYLE INSULINX TEST STRIPS... 6 FREESTYLE LITE METER 6 FREESTYLE LITE STRIPS 6 FREESTYLE TEST... 6 furosemide FUZEON FYCOMPA G gabapentin galantamine GAMASTAN S/D ganciclovir sodium GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD... 6 gavilyte-c gavilyte-g gavilyte-n GAZYVA... 8 gemcitabine... 8 GEMCITABINE... 8 gemfibrozil generlac gengraf... 8 gentak gentamicin... 1, 56, 79 gentamicin in nacl (iso-osm) 1 gentamicin sulfate (ped) (pf) 1 GENVOYA GEODON gianvi (8) GILENYA GILOTRIF... 8 glatiramer glatopa GLEOSTINE... 8 glimepiride... 6 glipizide... 6, 63 glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glycine urologic glycine urologic solution glycopyrrolate glydo granisetron (pf) granisetron hcl GRANIX GRASTEK griseofulvin microsize griseofulvin ultramicrosize guanidine H HAEGARDA HALAVEN... 8 halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heather heparin (porcine)... 5 heparin (porcine) in 5 % dex 5 heparin (porcine) in nacl (pf) 5 heparin(porcine) in 0.45% nacl... 5 HEPARIN(PORCINE) IN 0.45% NACL... 5 heparin, porcine (pf)... 5 HEPATAMINE 8% HERCEPTIN... 8 HETLIOZ HEXALEN... 8 HIBERIX (PF) HIZENTRA HUMALOG JUNIOR KWIKPEN U HUMALOG KWIKPEN INSULIN HUMALOG MIX INSULN U HUMALOG MIX KWIKPEN HUMALOG MIX 75-5 KWIKPEN HUMALOG MIX 75-5(U- 100)INSULN HUMALOG U-100 INSULIN HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S- UC-HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN 70/30 U-100 INSULIN HUMULIN 70/30 U-100 KWIKPEN HUMULIN N NPH INSULIN KWIKPEN HUMULIN N NPH U-100 INSULIN HUMULIN R REGULAR U- 100 INSULN HUMULIN R U-500 (CONC) INSULIN HUMULIN R U-500 (CONC) KWIKPEN hydralazine hydrochlorothiazide hydrocodone-acetaminophen 38 hydrocodone-ibuprofen hydrocortisone... 58, 61, 69 hydrocortisone butyrate hydrocortisone-acetic acid hydrocortisone-min oil-wht pet

96 hydrocortisone-pramoxine hydromorphone hydromorphone (pf)... 38, 39 hydroxychloroquine... 1 hydroxyprogesterone caproate hydroxyurea... 8 hydroxyzine hcl... 8 HYPERHEP B S/D HYPERHEP B S-D NEONATAL HYQVIA I ibandronate IBRANCE... 8 ibu ibuprofen ibuprofen-oxycodone ibutilide fumarate ICLUSIG... 8 idarubicin... 8 IDHIFA... 8 ifosfamide... 8 ILARIS (PF) imatinib... 8 IMBRUVICA... 8 IMFINZI... 8 imipenem-cilastatin... 1 imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES VACCINE (PF) IMPAVIDO... 1 incassia INCRELEX INCRUSE ELLIPTA indapamide INFANRIX (DTAP) (PF) INLYTA... 8 INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U INTELENCE intralipid INTRON A introvale INVANZ... 1 INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR INVOKANA IONOSOL-MB IN D5W IPOL ipratropium bromide... 60, 83 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRESSA... 9 irinotecan... 9 ISENTRESS ISENTRESS HD isibloom ISOLYTE S PH ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid... 1 isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine ISTODAX... 9 itraconazole ivermectin... 1 IXEMPRA... 9 IXIARO (PF) J JAKAFI... 9 jantoven... 5 JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR JETREA (PF) JEVTANA... 9 jolessa jolivette juleber JULUCA JUXTAPID K KADCYLA... 9 KALETRA KALYDECO KANUMA kariva (8) k-effervescent kelnor 1/35 (8) KEPIVANCE... 5 ketoconazole... 15, 57 ketoprofen ketorolac KEYTRUDA... 9 KHEDEZLA kimidess (8) KINRIX (PF) kionex (with sorbitol) KISQALI... 9 KISQALI FEMARA CO- PACK... 9 klor-con klor-con klor-con klor-con m klor-con m klor-con m klor-con sprinkle klor-con/ef KORLYM K-PHOS NO K-PHOS ORIGINAL KRYSTEXXA k-tab kurvelo KUVAN KYPROLIS... 9 L l norgest/e.estradiol-e.estrad. 78 labetalol lactated ringers... 58, 85 lactulose lamivudine lamivudine-zidovudine lamotrigine

97 LANOXIN lansoprazole lanthanum LANTUS SOLOSTAR U-100 INSULIN LANTUS U-100 INSULIN.. 64 larin 1.5/30 (1) larin 1/0 (1) larin 4 fe larin fe 1.5/30 (8) larin fe 1/0 (8) larissia LARTRUVO... 9 latanoprost LATUDA... 44, 45 leflunomide LEMTRADA LENVIMA... 9 lessina LETAIRIS letrozole... 9 leucovorin calcium... 5 LEUKERAN... 9 LEUKINE leuprolide... 9 levalbuterol hcl levetiracetam... 34, 35 levetiracetam in nacl (iso-os) 34 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine... 8 levofloxacin... 4, 79 levofloxacin in d5w... 4 levoleucovorin... 5 LEVOLEUCOVORIN... 5 levonest (8) levonorgestrel-ethinyl estrad 78 levonorg-eth estrad triphasic 78 levora levorphanol tartrate levothyroxine levoxyl LEXIVA lidocaine lidocaine (pf) in d7.5w lidocaine (pf)... 47, 55 lidocaine hcl lidocaine in 5 % dextrose (pf) lidocaine viscous lidocaine-epinephrine lidocaine-prilocaine lillow lincomycin... 1 lindane linezolid... 1 linezolid in dextrose 5%... 1 linezolid-0.9% sodium chloride... 1 LINZESS LIORESAL liothyronine lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate LONSURF... 9 loperamide lopinavir-ritonavir lorazepam lorazepam intensol lorcet (hydrocodone) lorcet hd lorcet plus loryna (8) losartan losartan-hydrochlorothiazide 50 lovastatin low-ogestrel (8) loxapine succinate LUCENTIS LUMIZYME LUPRON DEPOT... 9 LUPRON DEPOT (3 MONTH)... 9 LUPRON DEPOT (4 MONTH)... 9 LUPRON DEPOT (6 MONTH)... 9 LUPRON DEPOT-PED... 9 LUPRON DEPOT-PED (3 MONTH)... 9 lutera (8) LYNPARZA... 9 LYRICA LYSODREN... 9 lyza M mafenide acetate magnesium chloride magnesium sulfate... 85, 86 MAGNESIUM SULFATE IN D5W magnesium sulfate in water.. 85 malathion mannitol 0 % mannitol 5 % maprotiline marlissa MARPLAN MARQIBO... 9 MATULANE... 9 matzim la meclizine meclofenamate medroxyprogesterone mefenamic acid mefloquine... 1 megestrol... 9 MEKINIST... 9 MEKTOVI meloxicam melphalan melphalan hcl memantine MENACTRA (PF) MENEST MENVEO A-C-Y-W-135-DIP (PF) mercaptopurine meropenem... 1 mesalamine mesalamine with cleansing wipe mesna... 5 MESNEX... 5 MESTINON metadate er metaproterenol

98 metformin methadone methadone intensol methadose methazolamide methenamine hippurate... 4 methenamine mandelate... 4 methergine methimazole... 6 methotrexate sodium methotrexate sodium (pf) methoxsalen methyclothiazide methyldopa methylergonovine methylphenidate hcl methylprednisolone methylprednisolone acetate.. 61 methylprednisolone sodium succ methyltestosterone metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metro i.v metronidazole..., 56, 77 metronidazole in nacl (iso-os)... mexiletine MIACALCIN miconazole microgestin 1.5/30 (1) microgestin 1/0 (1) microgestin fe 1.5/30 (8) microgestin fe 1/0 (8) midodrine migergot miglitol miglustat mili millipred millipred dp milrinone milrinone in 5 % dextrose minocycline... 4 minoxidil miostat MIRENA mirtazapine misoprostol MITIGARE mitomycin mitoxantrone M-M-R II (PF) modafinil moderiba moderiba dose pack moexipril moexipril-hydrochlorothiazide mometasone... 58, 83 mondoxyne nl... 4 mono-linyah montelukast morgidox... 4 morphine morphine (pf)... 39, 40 morphine concentrate MOVANTIK moxifloxacin... 4, 79 moxifloxacin in nacl (iso-osm)... 4 MOZOBIL mupirocin mupirocin calcium MUSTARGEN MYALEPT MYCAMINE mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYLOTARG myorisan MYRBETRIQ myzilra N nabumetone nadolol nadolol-bendroflumethiazide 50 nafcillin... 3 nafcillin in dextrose iso-osm 3 naftifine NAGLAZYME nalbuphine naloxone naltrexone NAMZARIC naproxen... 4 naproxen sodium... 4 naratriptan NARCAN... 4 NATACYN nateglinide NATPARA NEBUPENT... NEEDLES, INSULIN DISP.,SAFETY nefazodone neomycin... neomycin-bacitracin-poly-hc 81 neomycin-bacitracinpolymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc. 61, 81 neo-polycin neo-polycin hc neostigmine methylsulfate NEPHRAMINE 5.4 % NERLYNX NEULASTA NEUPOGEN NEUPRO nevirapine NEXAVAR NEXPLANON niacin nicardipine NICOTROL NICOTROL NS nifedipine nikki (8) nilutamide nimodipine

99 NINLARO nisoldipine nitro-bid nitrofurantoin... 4 nitrofurantoin macrocrystal.. 4 nitrofurantoin monohyd/mcryst... 4 nitroglycerin nitroglycerin in 5 % dextrose 54 nizatidine nolix nora-be norepinephrine bitartrate norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol... 76, 78 norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol norlyda norlyroc NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortrel 0.5/35 (8) nortrel 1/35 (1) nortrel 1/35 (8) nortrel 7/7/7 (8) nortriptyline NORVIR NOVOFINE NOVOFINE AUTOCOVER 64 NOXAFIL NPLATE... 5 NUEDEXTA NULOJIX NUPLAZID nyamyc nystatin... 15, 57 nystatin-triamcinolone nystop O OCALIVA OCREVUS octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin... 4, 61, 79 ogestrel (8) okebo... 4 olanzapine olanzapine-fluoxetine olmesartan olmesartan-amlodipinhcthiazid olmesartanhydrochlorothiazide olopatadine... 61, 80 omeprazole OMNITROPE ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) ONETOUCH ULTRA BLUE TEST STRIP ONETOUCH ULTRA ONETOUCH ULTRAMINI. 65 ONETOUCH VERIO ONETOUCH VERIO IQ METER ONETOUCH VERIO SYSTEM ONFI ONIVYDE OPDIVO opium tincture OPSUMIT oralone ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORFADIN ORKAMBI orsythia oseltamivir osmitrol 15 % osmitrol 0 % OTEZLA OTEZLA STARTER oxacillin... 3 oxacillin in dextrose(iso-osm)... 3 oxaliplatin... 30, 31 oxandrolone oxaprozin... 4 oxcarbazepine oxiconazole oxybutynin chloride oxycodone oxycodone-acetaminophen oxycodone-aspirin oxymorphone oxytocin OZEMPIC OZURDEX P pacerone paclitaxel paliperidone palonosetron PALYNZIQ pamidronate PANRETIN pantoprazole paregoric paricalcitol paroex oral rinse paromomycin... paroxetine hcl paroxetine mesylate(menop.sym) PASER... PAXIL PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS... 7 PEGASYS PROCLICK... 7 peg-electrolyte PEGINTRON... 7 penicillin g potassium

100 penicillin g procaine... 3 penicillin g sodium... 3 penicillin v potassium... 3 PENTACEL (PF) PENTAM... PENTASA pentoxifylline... 5 PERFOROMIST perindopril erbumine periogard PERJETA permethrin perphenazine pfizerpen-g... 3 phenelzine phenobarbital phenobarbital sodium phenoxybenzamine phentolamine phenytoin phenytoin sodium phenytoin sodium extended.. 35 philith PHOSPHOLINE IODIDE pilocarpine hcl... 60, 80 pimozide pimtrea (8) pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam... 3 pirmella piroxicam... 4 plasbumin 5 % plasbumin 5 % PLASMA-LYTE PLASMA-LYTE A plasmanate PLEGRIDY... 7 plenamine podofilox polocaine polocaine-mpf polycin polyethylene glycol polymyxin b sulfate... polymyxin b sulf-trimethoprim POMALYST portia PORTRAZZA potassium acetate potassium bicarb and chloride potassium bicarb-citric acid.. 86 potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride in water.. 86 potassium chloride-0.45 % nacl potassium chloride-d5-0.%nacl... 86, 87 potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate potassium phosphate m-/dbasic PRADAXA... 5 PRALUENT PEN pramipexole prasugrel... 5 pravastatin praziquantel... prazosin PRECISION PCX PLUS TEST PRECISION PCX TEST PRECISION Q-I-D TEST PRECISION XTRA MONITOR prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 6, 81 prednisone... 6 prednisone intensol... 6 premasol 10 % PREMASOL 6 % prenatal vitamin oral tablet prevalite previfem PREVYMIS PREZCOBIX PREZISTA PRIFTIN... PRIMAQUINE... primidone PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine procainamide procentra prochlorperazine prochlorperazine edisylate prochlorperazine maleate oral PROCRIT... 7 procto-med hc procto-pak proctosol hc proctozone-hc profeno... 4 progesterone progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLEUKIN... 7 PROLIA PROMACTA... 5 promethazine... 8 propafenone propranolol propranolol-hydrochlorothiazid propylthiouracil... 6 PROQUAD (PF) protamine... 5 protriptyline

101 prudoxin PULMOZYME PURIXAN pyrazinamide... pyridostigmine bromide Q QUADRACEL (PF) quasense quetiapine quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate... QVAR QVAR REDIHALER R RABAVERT (PF) RADICAVA RAGWITEK rajani raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE rasagiline RAVICTI REBIF (WITH ALBUMIN). 7 REBIF REBIDOSE... 7 REBIF TITRATION PACK 7 reclipsen (8) RECOMBIVAX HB (PF)... 73, 74 RECTIV regonol REGRANEX RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENACIDIN repaglinide repaglinide-metformin REPATHA REPATHA PUSHTRONEX 53 REPATHA SURECLICK RESCRIPTOR RETROVIR REVLIMID revonto REXULTI REYATAZ ribasphere ribasphere ribapak... 17, 18 ribavirin RIDAURA rifabutin... rifampin... riluzole rimantadine ringer's... 58, 87 RIOMET risedronate... 60, 74, 75 RISPERDAL CONSTA risperidone ritonavir RITUXAN RITUXAN HYCELA rivastigmine rivastigmine tartrate rizatriptan ROMIDEPSIN ropinirole rosadan rosuvastatin ROTARIX ROTATEQ VACCINE roweepra roweepra xr ROZEREM RUBRACA RYDAPT S SABRIL salsalate... 4 SAMSCA SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) scopolamine base selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS sertraline setlakin sevelamer carbonate sf 61 sf 5000 plus sharobel SHINGRIX (PF) SIGNIFOR sildenafil (pulmonary arterial hypertension)... 83, 84 silver sulfadiazine SIMULECT simvastatin sirolimus SIRTURO... sodium acetate sodium benzoate-sod phenylacet sodium bicarbonate sodium chloride... 60, 87 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium lactate sodium nitroprusside sodium phenylbutyrate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate SOLIRIS SOLTAMOX SOMATULINE DEPOT SOMAVERT sorine sotalol sotalol af SOTYLIZE SPIRIVA RESPIMAT

102 SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX sprintec (8) SPRITAM SPRYCEL sps (with sorbitol) sronyx ssd STAMARIL (PF) stavudine STIMATE STIOLTO RESPIMAT STIVARGA STRENSIQ STREPTOMYCIN... STRIBILD STRIVERDI RESPIMAT SUBOXONE... 4 subvenite subvenite starter (blue) kit subvenite starter (green) kit.. 35 subvenite starter (orange) kit 35 SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne) 56 sulfacetamide-prednisolone.. 80 sulfadiazine... 4 sulfamethoxazole-trimethoprim... 4 SULFAMYLON sulfasalazine sulfatrim... 4 sulindac... 4 sumatriptan sumatriptan succinate sumatriptan-naproxen SUPRAX... 0 SUTENT SYLATRON... 7 SYLVANT SYMBICORT SYMDEKO SYMFI SYMFI LO SYMLINPEN SYMLINPEN SYMTUZA SYNAGIS SYNAREL SYNERCID... SYNJARDY SYNJARDY XR SYNRIBO T TABLOID tacrolimus... 31, 56 TAFINLAR TAGRISSO tamoxifen... 3 tamsulosin TARCEVA... 3 TARGRETIN... 3 tarina fe 1/0 (8) TASIGNA... 3 tazarotene TAZORAC taztia xt TECENTRIQ... 3 TECFIDERA TEFLARO... 0 TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid TEMODAR... 3 TENIVAC (PF) tenofovir disoproxil fumarate terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline... 4 THALOMID... 3 THEO theophylline theophylline in dextrose 5 % 84 THIOLA thioridazine thiotepa... 3 thiothixene tiagabine TIBSOVO... 3 TICE BCG tigecycline... tilia fe timolol maleate... 51, 80 tinidazole... TIVICAY tizanidine tobramycin tobramycin in 0.5 % nacl.. tobramycin sulfate... tobramycin-dexamethasone.. 81 tolazamide tolbutamide tolcapone tolmetin... 4 tolterodine topiramate toposar... 3 topotecan... 3 TORISEL... 3 torsemide TOUJEO MAX U-300 SOLOSTAR TOUJEO SOLOSTAR U-300 INSULIN TRACLEER TRADJENTA tramadol... 4 tramadol-acetaminophen... 4 trandolapril trandolapril-verapamil tranexamic acid tranylcypromine

103 travasol 10 % trazodone TREANDA... 3 TRECATOR... TRELSTAR... 3 tretinoin (chemotherapy)... 3 tretinoin topical tri femynor triamcinolone acetonide 58, 61, 6, 84 triamterene-hydrochlorothiazid trianex triderm trientine tri-estarylla trifluoperazine trifluridine tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte with flavor packets trimethoprim... 4 trimipramine trinessa (8) trinessa lo TRINTELLIX tri-previfem (8) TRISENOX... 3 tri-sprintec (8) TRIUMEQ trivora (8) TROGARZO TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA TWINRIX (PF) TYKERB... 3 TYMLOS TYPHIM VI TYSABRI TYVASO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT U ULORIC unithroid UNITUXIN... 3 UPTRAVI ursodiol UVADEX V valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt)... 35, 36 valsartan valsartan-hydrochlorothiazide VALSTAR... 3 vancomycin... VANCOMYCIN IN 0.9 % SODIUM CHL... vandazole VANTAS... 3 VAQTA (PF) VARIVAX (PF) VARIZIG VARUBI VASCEPA VECAMYL VECTIBIX... 3 VELCADE... 3 veletri velivet triphasic regimen (8) VELTASSA VEMLIDY VENCLEXTA... 3 VENCLEXTA STARTING PACK... 3 venlafaxine... 46, 47 verapamil veripred VERSACLOZ VERZENIO... 3 vestura (8) VGO VGO VGO VIBERZI vicodin vicodin es vicodin hp VICTOZA -PAK VICTOZA 3-PAK VIDEX GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC vienva vigabatrin vigadrone VIIBRYD VIMIZIM VIMPAT vinblastine... 3 vincasar pfs... 3 vincristine... 3 vinorelbine... 3 VIOKACE viorele (8) VIRACEPT VIRAMUNE VIREAD VISTOGARD... 5 VIVITROL... 4 voriconazole VOTRIENT... 3 VRAYLAR VYXEOS W warfarin... 5 water for irrigation, sterile wera (8) X XALKORI XARELTO... 5 XATMEP XERMELO

104 XGEVA... 5 XIAFLEX XIFAXAN... XIIDRA XOLAIR XTANDI xulane XURIDEN XYREM Y YERVOY YF-VAX (PF) YONDELIS YONSA yuvafem Z zafirlukast zaleplon ZALTRAP ZANOSAR zarah ZARXIO... 7 ZEJULA ZELBORAF zenatane ZERIT zidovudine ziprasidone hcl ZIRGAN ZOLADEX zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan zolpidem zonisamide ZORTRESS ZOSTAVAX (PF) zovia 1/35e (8) ZOVIRAX ZYDELIG ZYKADIA ZYPREXA RELPREVV ZYTIGA

105 Ofered by Prospective Members: Current Members: (TTY Relay: Dial 7-1-1) 8:00 a.m. to 8:00 p.m., 7 days a week rd Ave, Suite 400 Seattle, WA This formulary directory was updated on 10/01/018. For more recent information or other questions, please contact Customer Service at or, for T-T-Y users, Dial 7-1-1, 7 days a week, 8 a.m. to 8 p.m. or visit Changes to our formulary may occur during the beneft year. An updated formulary is located on our website at You may also call Customer Service for updated information.