Medicaid Drug Formulary January 2019

Transcription

1 Medicaid Drug Formulary January 2019 Key * Generic Available AG Age Limits F Females Only M Males Only OTC Over the Counter P Preventive PA Prior Authorization QL Quantity Limit SP Specialty Pharmacy ST Step Therapy MHP G-3245 Beecher Road Flint, Michigan tel (888) fax (877) McLarenHealthPlan.org Rev. 1/2019

2 Table of Contents Allergy...3 Antiemesis/Antivertigo... 8 Asthma And Copd... 9 Autonomic Nervous System Disorders...13 Behavioral Health - Antidepressants Behavioral Health - Other Cardiovascular Disease - Arrhythmia Cardiovascular Disease - Cardiac Stimulant Cardiovascular Disease - Hypertension Cardiovascular Disease - Lipid Irregularity...50 Cardiovascular Disease - Miscellaneous Agents Cardiovascular Disease - Vasodilation...52 Contraception/Oxytocics...53 Dermatology - Acne...61 Dermatology - Antiinfective...62 Dermatology - Antiinflammatory Dermatology - Miscellaneous Dermatology - Psoriasis/Eczema Diabetes Ear - General Disorders...78 Electrolyte Regulation...78 Endocrine Disorder - Other...79 Endocrine Disorder - Thyroid...81 Eye - General Disorders Eye - Glaucoma...84 Eye - Miscellaneous Gout And Related Diseases Hematological Disorders Hormonal Deficiency Immunization Immunosuppression/Modulation Infectious Disease - Bacterial Infectious Disease - Fungal Infectious Disease - Miscellaneous Infectious Disease - Parasitic Infectious Disease - Viral Inflammatory Disease Local Anesthesia Lower Gastrointestinal Disorders - Bowel Inflammat Lower Gastrointestinal Disorders - Other Medical Supplies Miscellaneous Agents Neoplastic Disease

3 Neurological Disease - Miscellaneous Oral/Pharyngeal Disorders Other Drugs Other Respiratory Disorders Pain Management - Analgesics Parkinsons Disease Seizure Disorder Skeletal Muscle Disorder Smoking Cessation Upper Gastrointestinal Disorders - Digestive Upper Gastrointestinal Disorders - Spastic Disease Upper Gastrointestinal Disorders - Ulcer Disease Urinary Tract - Functional Disorders Vaginal Disorders Vitamin And/Or Mineral Deficiency

4 Allergy Antihistamines - 1St Generation ALER-CAP ORAL CAPSULE 25 MG Age (Max 64 Years) ALER-TAB ORAL TABLET 25 MG Age (Max 64 Years) ALLER-CHLOR ORAL TABLET 4 MG ALLER-G-TIME ORAL TABLET 25 MG Age (Max 64 Years) ALLERGY (CHLORPHENIRAMINE) ORAL TABLET 4 MG ALLERGY (DIPHENHYDRAMINE) ORAL Age (Max 64 Years) CAPSULE 25 MG ALLERGY (DIPHENHYDRAMINE) ORAL LIQUID 12.5 MG/5 ML ALLERGY (DIPHENHYDRAMINE) ORAL TABLET 25 MG ; Age (Max 64 Years) ALLERGY 4-HOUR ORAL TABLET 4 MG ALLERGY MEDICATION ORAL CAPSULE 25 Age (Max 64 Years) MG ALLERGY MEDICINE ORAL CAPSULE 25 Age (Max 64 Years) MG ALLERGY MEDICINE ORAL LIQUID 12.5 MG/5 ML ALLERGY MEDICINE ORAL TABLET 25 MG Age (Max 64 Years) ALLERGY ORAL TABLET 25 MG ; Age (Max 64 Years) ALLERGY RELIEF (CLEMASTINE) ORAL TABLET 1.34 MG ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET 4 MG ALLERGY RELIEF(CHLORPHENIRAMN) ORAL TABLET EXTENDED RELEASE 12 MG ALLERGY RELIEF(DIPHENHYDRAMIN) Age (Max 64 Years) ORAL CAPSULE 25 MG ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL LIQUID 12.5 MG/5 ML ALLERGY RELIEF(DIPHENHYDRAMIN) ORAL TABLET 25 MG ; Age (Max 64 Years) ALLERGY-TIME ORAL TABLET 4 MG ALLERHIST (CLEMASTINE) ORAL TABLET 1.34 MG ALLERHIST-1 ORAL TABLET 1.34 MG ANTIHIST ORAL ELIXIR 12.5 MG/5 ML 3

5 ANTIHISTAMINE ORAL CAPSULE 25 MG Age (Max 64 Years) ANTIHISTAMINE ORAL TABLET 25 MG Age (Max 64 Years) ARBINOXA ORAL LIQUID 4 MG/5 ML ARBINOXA ORAL TABLET 4 MG BANOPHEN ALLERGY ORAL LIQUID 12.5 MG/5 ML BANOPHEN ORAL CAPSULE 25 MG, 50 MG Age (Max 64 Years) BANOPHEN ORAL LIQUID 12.5 MG/5 ML BANOPHEN ORAL TABLET 25 MG Age (Max 64 Years) BENADRYL ALLERGY ORAL TABLET 25 MG Age (Max 64 Years) carbinoxamine maleate oral liquid 4 mg/5 ml carbinoxamine maleate oral tablet 4 mg CHILDREN'S ALLERGY (DIPHENHYD) ORAL ELIXIR 12.5 MG/5 ML CHILDREN'S ALLERGY (DIPHENHYD) ORAL LIQUID 12.5 MG/5 ML CHILDREN'S WAL-DRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML CHLORHIST ORAL TABLET 4 MG CHLORPHEN SR ORAL TABLET EXTENDED RELEASE 12 MG chlorpheniramine maleate oral tablet 4 mg (Aller-Chlor) chlorpheniramine maleate oral tablet extended (Allergy release 12 mg Relief(chlorpheniramn)) CHLORTABS ORAL TABLET 4 MG clemastine oral syrup 0.67 mg/5 ml clemastine oral tablet 1.34 mg (Allergy Relief (clemastine)) clemastine oral tablet 2.68 mg COMPLETE ALLERGY MEDICINE ORAL Age (Max 64 Years) CAPSULE 25 MG COMPLETE ALLERGY MEDICINE ORAL Age (Max 64 Years) TABLET 25 MG COMPLETE ALLERGY ORAL CAPSULE 25 Age (Max 64 Years) MG COMPLETE ALLERGY ORAL LIQUID 12.5 MG/5 ML COMPLETE ALLERGY ORAL TABLET 25 Age (Max 64 Years) MG cyproheptadine oral syrup 2 mg/5 ml Age (Max 64 Years) cyproheptadine oral tablet 4 mg Age (Max 64 Years) DAILYHIST-1 ORAL TABLET 1.34 MG DAYHIST ALLERGY ORAL TABLET 1.34 MG DAYHIST ORAL TABLET 1.34 MG DIPHEDRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML DIPHEDRYL ORAL CAPSULE 25 MG Age (Max 64 Years) DIPHEDRYL ORAL LIQUID 12.5 MG/5 ML DIPHEDRYL ORAL TABLET 25 MG Age (Max 64 Years) 4

6 DIPHEN ORAL TABLET 25 MG Age (Max 64 Years) DIPHENHIST ORAL CAPSULE 25 MG Age (Max 64 Years) DIPHENHIST ORAL LIQUID 12.5 MG/5 ML DIPHENHIST ORAL TABLET 25 MG Age (Max 64 Years) diphenhydramine hcl injection solution 50 Age (Max 64 Years) mg/ml diphenhydramine hcl injection syringe 50 Age (Max 64 Years) mg/ml diphenhydramine hcl oral capsule 25 mg (Aler-Cap) Age (Max 64 Years) diphenhydramine hcl oral capsule 50 mg (Banophen) Age (Max 64 Years) diphenhydramine hcl oral elixir 12.5 mg/5 ml (Children's Allergy (diphenhyd)) diphenhydramine hcl oral liquid 12.5 mg/5 ml (Allergy (diphenhydramine)) diphenhydramine hcl oral syrup 12.5 mg/5 ml ED-CHLORTAN ORAL TABLET 4 MG GERI-DRYL ORAL CAPSULE 25 MG Age (Max 64 Years) GERI-DRYL ORAL LIQUID 12.5 MG/5 ML GERI-DRYL ORAL TABLET 25 MG Age (Max 64 Years) hydroxyzine hcl oral solution 10 mg/5 ml Age (Max 12 Years) hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 Age (Max 64 Years) mg hydroxyzine pamoate oral capsule 100 mg Age (Max 64 Years) hydroxyzine pamoate oral capsule 25 mg, 50 (Vistaril) Age (Max 64 Years) mg MEDI-PHEDRYL ORAL CAPSULE 25 MG Age (Max 64 Years) MEDI-PHEDRYL ORAL LIQUID 12.5 MG/5 ML NIGHTTIME ALLERGY RELIEF ORAL Age (Max 64 Years) TABLET 25 MG PALGIC ORAL LIQUID 4 MG/5 ML PHARBECHLOR ORAL TABLET 4 MG PHARBEDRYL ORAL CAPSULE 25 MG, 50 Age (Max 64 Years) MG promethazine oral syrup 6.25 mg/5 ml Age (Min 2 Years and Max 64 Years) promethazine oral tablet 12.5 mg, 25 mg, 50 mg Age (Min 2 Years and Max 64 Years) Q-DRYL ORAL CAPSULE 25 MG Age (Max 64 Years) Q-DRYL ORAL LIQUID 12.5 MG/5 ML QUENALIN ORAL SYRUP 12.5 MG/5 ML SILADRYL SA ORAL LIQUID 12.5 MG/5 ML SILPHEN COUGH ORAL SYRUP 12.5 MG/5 ML TOTAL ALLERGY MEDICINE ORAL TABLET Age (Max 64 Years) 25 MG VALU-DRYL ALLERGY ORAL CAPSULE 25 MG Age (Max 64 Years) 5

7 VALU-DRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML VALU-DRYL ALLERGY ORAL TABLET 25 Age (Max 64 Years) MG VALU-DRYL CHILD'S ALLERGY ORAL ELIXIR 12.5 MG/5 ML VICKS QLEARQUIL NIGHTTIME RLF ORAL Age (Max 64 Years) TABLET 25 MG WAL-DRYL ALLERGY ORAL CAPSULE 25 Age (Max 64 Years) MG WAL-DRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML WAL-DRYL ALLERGY ORAL TABLET 25 MG Age (Max 64 Years) WAL-FINATE ORAL TABLET 4 MG Antihistamines - 2Nd Generation 24HOUR ALLERGY ORAL TABLET 10 MG QL (1 EA per 1 day) ALL DAY ALLERGY (CETIRIZINE) ORAL SOLUTION 1 MG/ML QL (300 ML per 30 days); Age (Max 12 Years) ALL DAY ALLERGY (CETIRIZINE) ORAL QL (1 EA per 1 day) TABLET 10 MG ALL DAY ALLERGY RELIEF(CETIR) ORAL QL (1 EA per 1 day) TABLET 10 MG ALLERCLEAR ORAL TABLET 10 MG QL (1 EA per 1 day) ALLERGY RELIEF (CETIRIZINE) ORAL SOLUTION 1 MG/ML QL (300 ML per 30 days); Age (Max 12 Years) ALLERGY RELIEF (CETIRIZINE) ORAL QL (1 EA per 1 day) TABLET 10 MG ALLERGY RELIEF (LORATADINE) ORAL SOLUTION 5 MG/5 ML QL (10 ML per 1 day); Age (Max 12 Years) ALLERGY RELIEF (LORATADINE) ORAL QL (1 EA per 1 day) TABLET 10 MG ALLERGY RELIEF (LORATADINE) ORAL QL (1 EA per 1 day) TABLET,DISINTEGRATING 10 MG ALLER-TEC ORAL TABLET 10 MG QL (1 EA per 1 day) cetirizine oral solution 1 mg/ml (All Day Allergy (cetirizine)) QL (300 ML per 30 days); Age (Max 12 Years) cetirizine oral solution 5 mg/5 ml QL (300 ML per 30 days); Age (Max 12 Years) cetirizine oral tablet 10 mg (24Hour Allergy) QL (1 EA per 1 day) cetirizine oral tablet 5 mg QL (1 EA per 1 day) CHILD ALLERGY RELF(CETIRIZINE) ORAL SOLUTION 1 MG/ML QL (300 ML per 30 days); Age (Max 12 Years) CHILDREN'S ALLERGY COMPLETE ORAL SOLUTION 1 MG/ML QL (300 ML per 30 days); Age (Max 12 Years) CHILDREN'S ALLERGY RELIEF(LOR) ORAL SOLUTION 5 MG/5 ML QL (10 ML per 1 day); Age (Max 12 Years) CHILDREN'S ALLERGY(CETIRIZINE) ORAL SOLUTION 1 MG/ML QL (300 ML per 30 days); Age (Max 12 Years) CHILDREN'S ALLER-TEC ORAL SOLUTION 1 MG/ML QL (300 ML per 30 days); Age (Max 12 Years) 6

8 CHILDREN'S CETIRIZINE ORAL SOLUTION 1 MG/ML QL (300 ML per 30 days); Age (Max 12 Years) CHILDREN'S WAL-ZYR ORAL SOLUTION 1 MG/ML QL (300 ML per 30 days); Age (Max 12 Years) CHILD'S ALL DAY ALLERGY(CETIR) ORAL SOLUTION 1 MG/ML QL (300 ML per 30 days); Age (Max 12 Years) CLARITIN ORAL TABLET 10 MG QL (1 EA per 1 day) LORADAMED ORAL TABLET 10 MG QL (1 EA per 1 day) loratadine oral solution 5 mg/5 ml (Allergy Relief (loratadine)) QL (10 ML per 1 day); Age (Max 12 Years) loratadine oral tablet 10 mg (Allerclear) QL (1 EA per 1 day) NON-DROWSY ALLERGY ORAL TABLET 10 QL (1 EA per 1 day) MG VICKS QLEARQUIL ALLERGY ORAL QL (1 EA per 1 day) TABLET 10 MG WAL-ITIN ORAL SOLUTION 5 MG/5 ML QL (10 ML per 1 day); Age (Max 12 Years) WAL-ITIN ORAL TABLET 10 MG QL (1 EA per 1 day) WAL-ZYR (CETIRIZINE) ORAL SOLUTION 1 MG/ML QL (300 ML per 30 days); Age (Max 12 Years) WAL-ZYR (CETIRIZINE) ORAL TABLET 10 QL (1 EA per 1 day) MG Nasal Antihistamine azelastine nasal aerosol,spray 137 mcg (0.1 QL (30 ML per 30 days) %) Nasal Anti-Inflammatory Steroids 24 HOUR ALLERGY RELIEF NASAL QL (16 ML per 30 days) SPRAY,SUSPENSION 50 MCG/ACTUATION 24 HOUR NASAL ALLERGY NASAL QL (16.9 ML per 30 days) AEROSOL,SPRAY 55 MCG ALLER-FLO NASAL SPRAY,SUSPENSION QL (16 ML per 30 days) 50 MCG/ACTUATION ALLERGY RELIEF (FLUTICASONE) NASAL QL (16 ML per 30 days) SPRAY,SUSPENSION 50 MCG/ACTUATION CHILDRENS 24 HR ALLERGY RELIEF QL (16 ML per 30 days) NASAL SPRAY,SUSPENSION 50 MCG/ACTUATION CHILDREN'S NASACORT NASAL QL (16.9 ML per 30 days) AEROSOL,SPRAY 55 MCG CLARISPRAY NASAL SPRAY,SUSPENSION QL (16 ML per 30 days) 50 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg QL (25 ML per 30 days) (0.025 %) fluticasone nasal spray,suspension 50 (24 Hour Allergy Relief) QL (16 GM per 30 days) mcg/actuation NASAL ALLERGY NASAL AEROSOL,SPRAY QL (16.9 ML per 30 days) 55 MCG triamcinolone acetonide nasal aerosol,spray 55 mcg (24 Hour Nasal Allergy) QL (16.9 ML per 30 days) 7

9 Nasal Mast Cell Stabilizers Agents cromolyn nasal spray,non-aerosol 5.2 mg/spray (4 %) NASAL ALLERGY SYMPTOM CONTROL NASAL SPRAY,NON-AEROSOL 5.2 MG/SPRAY (4 %) (Nasal Allergy Symptom Control) Antiemesis/Antivertigo Antiemetic/Antivertigo Agents AMBIZINE ORAL TABLET 25 MG COMPRO RECTAL SUPPOSITORY 25 MG QL (2 EA per 1 day) dimenhydrinate oral tablet 50 mg (Dramamine) DRAMAMINE LESS DROWSY ORAL TABLET 25 MG DRAMAMINE ORAL TABLET 50 MG DRIMINATE ORAL TABLET 50 MG dronabinol oral capsule 10 mg, 2.5 mg, 5 mg (Marinol) PA granisetron hcl oral tablet 1 mg ST: Requires prior prescription for Ondansetron HCL, Ondansetron, or Zuplenz within the past 180 days; QL (4 EA per 30 days) meclizine oral tablet 12.5 mg meclizine oral tablet 25 mg (Dramamine Less Drowsy) meclizine oral tablet,chewable 25 mg (Motion Sickness Relief(mecliz)) MEDI-MECLIZINE ORAL TABLET 25 MG MOTION RELIEF (MECLIZINE) ORAL TABLET 25 MG MOTION SICKNESS (MECLIZINE) ORAL TABLET 25 MG MOTION SICKNESS II ORAL TABLET 25 MG MOTION SICKNESS ORAL TABLET 50 MG MOTION SICKNESS RELIEF II ORAL TABLET 25 MG MOTION SICKNESS RELIEF ORAL TABLET 50 MG MOTION SICKNESS RELIEF(MECLIZ) ORAL TABLET 25 MG MOTION SICKNESS RELIEF(MECLIZ) ORAL TABLET,CHEWABLE 25 MG MOTION-TIME ORAL TABLET,CHEWABLE 25 MG ondansetron hcl oral solution 4 mg/5 ml (Zofran) QL (10 ML per 1 day); Age (Max 12 Years) ondansetron hcl oral tablet 24 mg QL (1 EA per 1 day) ondansetron hcl oral tablet 4 mg, 8 mg (Zofran) QL (3 EA per 1 day) ondansetron oral tablet,disintegrating 4 mg, 8 mg QL (3 EA per 1 day) 8

10 PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG Age (Min 1 Years and Max 64 Years) prochlorperazine maleate oral tablet 10 mg, 5 (Compazine) QL (4 EA per 1 day) mg prochlorperazine rectal suppository 25 mg (Compazine) QL (2 EA per 1 day) promethazine rectal suppository 12.5 mg, 25 mg (Phenadoz) Age (Min 1 Years and Max 64 Years) promethazine rectal suppository 50 mg (Phenergan) Age (Min 1 Years and Max 64 Years) PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG Age (Min 1 Years and Max 64 Years) TRAVEL SICKNESS (MECLIZINE) ORAL TABLET,CHEWABLE 25 MG TRAVEL SICKNESS ORAL TABLET 50 MG TRAVEL-EASE (MECLIZINE) ORAL TABLET 25 MG VERTICALM ORAL TABLET 25 MG WAL-DRAM 2 ORAL TABLET 25 MG WAL-DRAM ORAL TABLET 50 MG Asthma And Copd Anticholinergic, Orally Inhaled Short Acting ATROVENT HFA INHALATION HFA QL (12.9 GM per 30 days) AEROSOL INHALER 17 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % Anticholinergics, Orally Inhaled Long Acting INCRUSE ELLIPTA INHALATION BLISTER QL (30 EA per 30 days) WITH DEVICE 62.5 MCG/ACTUATION Beta-Adrenergic Agents albuterol sulfate oral syrup 2 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg terbutaline oral tablet 2.5 mg, 5 mg Beta-Adrenergic Agents, Inhaled, Short Acting albuterol sulfate inhalation solution for QL (225 ML per 30 days) nebulization 0.63 mg/3 ml, 1.25 mg/3 ml albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Beta-Adrenergic Agents, Orally Inhaled,Long Acting SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE (Xopenex HFA) ST: Requires prior prescription for Ventolin within the past 180 days; QL (15 GM per 25 days) QL (18 GM per 25 days) QL (60 EA per 30 days) 9

11 Beta-Adrenergic And Anticholinergic Combinations COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml Beta-Adrenergic And Glucocorticoid Combinations fluticasone-salmeterol inhalation aerosol powdr breath activated mcg/actuation, mcg/actuation, mcg/actuation SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION Glucocorticoids, Orally Inhaled ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113 MCG/ACTUATION, 232 MCG/ACTUATION, 55 MCG/ACTUATION budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION QL (4 GM per 30 days) QL (18 ML per 1 day) (AirDuo RespiClick) QL (1 EA per 30 days) QL (10.2 GM per 30 days); Age (Max 12 Years) QL (1 EA per 30 days) (Pulmicort) QL (4 ML per 1 day); Age (Max 6 Years) QL (12 GM per 30 days); Age (Max 12 Years) QL (10.6 GM per 30 days); Age (Max 12 Years) QL (1 EA per 30 days) QL (10.6 GM per 30 days) Leukotriene Receptor Antagonists montelukast oral granules in packet 4 mg (Singulair) QL (1 EA per 1 day); Age (Max 5 Years) montelukast oral tablet 10 mg (Singulair) QL (1 EA per 1 day) montelukast oral tablet,chewable 4 mg, 5 mg (Singulair) QL (1 EA per 1 day) Mast Cell Stabilizers, Orally Inhaled cromolyn inhalation solution for nebulization 20 mg/2 ml Respiratory Aids,Devices,Equipment ACE AEROSOL CLOUD ENHANCER QL (4 EA per 365 days) SPACER AEROBIKA OSCILLATING PEP SYSTM DEVICE AEROCHAMBER MINI SPACER QL (4 EA per 365 days) AEROCHAMBER MV SPACER QL (4 EA per 365 days) AEROCHAMBER PLUS FLOW-VU SPACER QL (4 EA per 365 days) AEROCHAMBER PLUS FLOW-VU,L MSK SPACER QL (4 EA per 365 days) 10

12 AEROCHAMBER PLUS FLOW-VU,M MSK QL (4 EA per 365 days) SPACER AEROCHAMBER PLUS FLOW-VU,S MSK QL (4 EA per 365 days) SPACER AEROCHAMBER PLUS Z STAT LG MSK QL (4 EA per 365 days) SPACER AEROCHAMBER PLUS Z STAT MD MSK QL (4 EA per 365 days) SPACER AEROCHAMBER PLUS Z STAT SM MSK QL (4 EA per 365 days) SPACER AEROCHAMBER PLUS Z STAT SPACER QL (4 EA per 365 days) AEROCHAMBER WITH FLOWSIGNAL QL (4 EA per 365 days) SPACER AEROCHAMBER Z-STAT PLUS-FLW SG QL (4 EA per 365 days) SPACER AEROTRACH PLUS SPACER QL (4 EA per 365 days) AIRZONE PEAK FLOW METER DEVICE ASSESS FULL RANGE PEAK METER DEVICE ASTHMA CHECK METER DEVICE ASTHMAMENTOR PEAK FLOW METER DEVICE BREATHE RIGHT TOPICAL STRIP BREATHE RIGHT VAPOR TOPICAL STRIP BREATHERITE MDI SPACER SPACER QL (4 EA per 365 days) BREATHERITE VALVED MDI CHAMBER QL (4 EA per 365 days) SPACER BREATHERITE VALVED MDI SPACER QL (4 EA per 365 days) SPACER COMPACT SPACE CHAMBER PLUS QL (4 EA per 365 days) SPACER EASIVENT HOLDING CHAMBER SPACER QL (4 EA per 365 days) EASIVENT MASK LARGE DEVICE QL (4 EA per 365 days) EASIVENT MASK MEDIUM DEVICE QL (4 EA per 365 days) EASIVENT MASK SMALL DEVICE QL (4 EA per 365 days) E-Z SPACER SPACER QL (4 EA per 365 days) FLUTTER DEVICE IN-CHECK NASAL WITH MASK DEVICE IN-CHECK ORAL FLOW METER DEVICE INSPIRACHAMBER SPACER QL (4 EA per 365 days) INSPIRACHAMBER WITH MASK-LARGE QL (4 EA per 365 days) SPACER INSPIRACHAMBER WITH MASK-MED QL (4 EA per 365 days) SPACER INSPIRACHAMBER WITH MASK-SMALL QL (4 EA per 365 days) SPACER LITE TOUCH-MEDIUM MASK DEVICE QL (4 EA per 365 days) LITEAIRE MDI CHAMBER SPACER QL (4 EA per 365 days) LITETOUCH-LARGE MASK DEVICE QL (4 EA per 365 days) 11

13 LITETOUCH-SMALL MASK DEVICE QL (4 EA per 365 days) MICROCHAMBER SPACER QL (4 EA per 365 days) MICROLIFE PEAK FLOW METER DEVICE MICROSPACER SPACER QL (4 EA per 365 days) MINI WRIGHT PEAK FLOW METER DEVICE MISTASSIST KIT DEVICE MONAGHAN Z STAT CHAMBER SPACER QL (4 EA per 365 days) MONAGHAN Z STAT CHAMBER-LG MSK QL (4 EA per 365 days) SPACER MONAGHAN Z STAT CHAMBER-MD MSK QL (4 EA per 365 days) SPACER MONAGHAN Z STAT CHAMBER-SM MSK QL (4 EA per 365 days) SPACER MOUTHPIECE DEVICE QL (4 EA per 365 days) NASAL STRIPS LARGE TOPICAL STRIP NASAL STRIPS MEDIUM TOPICAL STRIP NASAL STRIPS MEDIUM-LARGE TOPICAL STRIP NASAL STRIPS SMALL-MEDIUM TOPICAL STRIP NASAL STRIPS TOPICAL STRIP ONE WAY VALVED MOUTHPIECE DEVICE QL (4 EA per 365 days) OPTICHAMBER ADULT MASK-LARGE QL (4 EA per 365 days) DEVICE OPTICHAMBER DIAMOND LG MASK QL (4 EA per 365 days) SPACER OPTICHAMBER DIAMOND VHC SPACER QL (4 EA per 365 days) OPTICHAMBER DIAMOND-MED MSK QL (4 EA per 365 days) SPACER OPTICHAMBER DIAMOND-SML MASK QL (4 EA per 365 days) SPACER PANDA MASK DEVICE QL (4 EA per 365 days) PEAK AIR PEAK FLOW METER DEVICE PEDIATRIC MEDIUM MASK DEVICE QL (4 EA per 365 days) PEDIATRIC PANDA MASK DEVICE QL (4 EA per 365 days) PEDIATRIC SMALL MASK DEVICE QL (4 EA per 365 days) PERSONAL BEST FULL RANGE DEVICE PIKO 1 DEVICE POCKET CHAMBER SPACER QL (4 EA per 365 days) POCKET PEAK FLOW METER DEVICE PRIMEAIRE SPACER QL (4 EA per 365 days) PROCHAMBER SPACER QL (4 EA per 365 days) PROVENT NASAL DEVICE PROVENT STARTER NASAL DEVICE QUAKE VIBRATORY PEP DEVICE RITEFLO AEROCHAMBER SPACER QL (4 EA per 365 days) SIDESTREAM PEDIATRIC FACE MASK DEVICE QL (4 EA per 365 days) 12

14 SILICONE MASK - INFANT DEVICE QL (4 EA per 365 days) SILICONE MASK - PEDIATRIC DEVICE QL (4 EA per 365 days) SPACE CHAMBER PLUS SPACER QL (4 EA per 365 days) TRUZONE PEAK FLOW METER DEVICE VORTEX ADULT MASK DEVICE QL (4 EA per 365 days) VORTEX FROG MASK-CHILD DEVICE QL (4 EA per 365 days) VORTEX HOLDING CHAMBER SPACER QL (4 EA per 365 days) VORTEX LADYBUG MASK-TODDLER QL (4 EA per 365 days) DEVICE VORTEX VHC FROG MASK-CHILD SPACER QL (4 EA per 365 days) VORTEX VHC LADYBUG MASK-TODDLR QL (4 EA per 365 days) SPACER Xanthines caffeine citrate oral solution 60 mg/3 ml (20 Age (Max 2 Years) mg/ml) THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 300 MG theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 12 hr (Theochron) 100 mg, 200 mg, 300 mg theophylline oral tablet extended release 12 hr 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg Autonomic Nervous System Disorders Alzheimer's Therapy, Nmda Receptor Antagonists memantine oral tablet 10 mg, 5 mg (Namenda) QL (2 EA per 1 day); Age (Min 40 Years) memantine oral tablets,dose pack 5-10 mg (Namenda Titration Pak) QL (49 EA per 365 days); Age (Min 40 Years) Cholinesterase Inhibitors donepezil oral tablet 10 mg (Aricept) QL (2 EA per 1 day); Age (Min 40 Years) donepezil oral tablet 5 mg (Aricept) QL (1 EA per 1 day); Age (Min 40 Years) pyridostigmine bromide oral tablet 60 mg (Mestinon) rivastigmine tartrate oral capsule 1.5 mg, 3 Age (Min 40 Years) mg, 4.5 mg, 6 mg Behavioral Health - Antidepressants Alpha-2 Receptor Antagonist Antidepressants mirtazapine oral tablet 15 mg, 30 mg (Remeron) mirtazapine oral tablet 45 mg, 7.5 mg 13

15 mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg REMERON ORAL TABLET 15 MG, 30 MG, 45 MG REMERON SOLTAB ORAL TABLET,DISINTEGRATING 15 MG, 30 MG, 45 MG (Remeron SolTab) Maois - Non-Selective & Irreversible MARPLAN ORAL TABLET 10 MG NARDIL ORAL TABLET 15 MG PARNATE ORAL TABLET 10 MG phenelzine oral tablet 15 mg (Nardil) tranylcypromine oral tablet 10 mg (Parnate) Norepinephrine And Dopamine Reuptake Inhib (Ndris) APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG BUDEPRION SR ORAL TABLET SUSTAINED-RELEASE 12 HR 150 MG bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg (Wellbutrin XL) 14

16 bupropion hcl oral tablet extended release 24 hr 450 mg bupropion hcl oral tablet sustained-release 12 hr 100 mg, 150 mg, 200 mg FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG WELLBUTRIN ORAL TABLET 100 MG, 75 MG WELLBUTRIN SR ORAL TABLET SUSTAINED-RELEASE 12 HR 100 MG, 150 MG, 200 MG WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG (Forfivo XL) (Wellbutrin SR) Selective Serotonin Reuptake Inhibitor (Ssris) BRISDELLE ORAL CAPSULE 7.5 MG CELEXA ORAL TABLET 10 MG, 20 MG, 40 MG citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 20 mg, 40 mg (Celexa) escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg (Lexapro) 15

17 fluoxetine oral capsule 10 mg, 20 mg, 40 mg (Prozac) fluoxetine oral capsule,delayed release(dr/ec) 90 mg fluoxetine oral solution 20 mg/5 ml (4 mg/ml) fluoxetine oral tablet 10 mg, 20 mg (Sarafem) fluoxetine oral tablet 60 mg fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg LEXAPRO ORAL SOLUTION 5 MG/5 ML LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG LUVOX CR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 150 MG paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg, 37.5 mg paroxetine mesylate(menop.sym) oral capsule 7.5 mg (Paxil) (Paxil CR) (Brisdelle) 16

18 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 MG, 25 MG, 37.5 MG PAXIL ORAL SUSPENSION 10 MG/5 ML PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG PROZAC WEEKLY ORAL CAPSULE,DELAYED RELEASE(DR/EC) 90 MG SARAFEM ORAL TABLET 10 MG, 20 MG sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 25 mg, 50 mg (Zoloft) st. john's wort oral capsule 150 mg, 300 mg st. john's wort oral tablet 300 mg ZOLOFT ORAL CONCENTRATE 20 MG/ML ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG 17

19 Serotonin-2 Antagonist/Reuptake Inhibitors (Saris) nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg OLEPTRO ER ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg Serotonin-Norepinephrine Reuptake-Inhib (Snris) CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 30 MG, 60 MG desvenlafaxine fumarate oral tablet extended release 24hr 100 mg, 50 mg desvenlafaxine oral tablet extended release 24 hr 100 mg, 50 mg desvenlafaxine oral tablet extended release 24hr 100 mg, 50 mg desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG, 37.5 MG, 75 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) (Khedezla) (Pristiq) (Cymbalta) 18

20 FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG IRENKA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 40 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 50 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg Ssri & 5Ht1a Partial Agonist Antidepressant VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40 MG (16) Ssri & Serotonin Receptor Modulator Antidepressant BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG (Effexor XR) 19

21 Tricyclic Antidepressant/Benzodiazepine Combinatns amitriptyline-chlordiazepoxide oral tablet mg, mg Tricyclic Antidepressant/Phenothiazine Combinatns perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg ANAFRANIL ORAL CAPSULE 25 MG, 50 MG, 75 MG clomipramine oral capsule 25 mg, 50 mg, 75 mg (Anafranil) desipramine oral tablet 10 mg, 25 mg (Norpramin) desipramine oral tablet 100 mg, 150 mg, 50 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml imipramine hcl oral tablet 10 mg, 25 mg, 50 mg (Tofranil) 20

22 imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg NORPRAMIN ORAL TABLET 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg (Pamelor) nortriptyline oral solution 10 mg/5 ml PAMELOR ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG protriptyline oral tablet 10 mg, 5 mg SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG TOFRANIL ORAL TABLET 10 MG, 25 MG, 50 MG TOFRANIL-PM ORAL CAPSULE 100 MG, 125 MG, 150 MG, 75 MG trimipramine oral capsule 100 mg, 25 mg, 50 mg (Surmontil) VIVACTIL ORAL TABLET 10 MG, 5 MG 21

23 Behavioral Health - Other Adrenergics, Aromatic, Non-Catecholamine ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG ADZENYS ER ORAL SUSPEN, IR - ER, BIPHASIC 24HR 1.25 MG/ML ADZENYS XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 12.5 MG, 15.7 MG, 18.8 MG, 3.1 MG, 6.3 MG, 9.4 MG amphetamine sulfate oral tablet 10 mg, 5 mg (Evekeo) DESOXYN ORAL TABLET 5 MG DEXEDRINE ORAL TABLET 10 MG, 5 MG DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 10 MG, 15 MG, 5 MG dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg (Dexedrine Spansule) dextroamphetamine oral solution 5 mg/5 ml (ProCentra) dextroamphetamine oral tablet 10 mg, 5 mg (Zenzedi) dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg (Adderall XR) 22

24 dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 24HR 2.5 MG/ML (Adderall) EVEKEO ORAL TABLET 10 MG, 5 MG methamphetamine oral tablet 5 mg (Desoxyn) MYDAYIS ORAL CAPSULE, ER TRIPHASIC 24 HR 12.5 MG, 25 MG, 37.5 MG, 50 MG PROCENTRA ORAL SOLUTION 5 MG/5 ML VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG ZENZEDI ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 30 MG, 5 MG, 7.5 MG Anti-Alcoholic Preparations acamprosate oral tablet,delayed release (dr/ec) 333 mg ANTABUSE ORAL TABLET 250 MG, 500 MG CAMPRAL ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG 23

25 disulfiram oral tablet 250 mg, 500 mg (Antabuse) VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 380 MG Anti-Anxiety - Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg (Xanax) (Xanax XR) ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg clorazepate dipotassium oral tablet 7.5 mg (Tranxene T-Tab) diazepam injection solution 5 mg/ml diazepam injection syringe 5 mg/ml 24

26 DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML Drug Status Notes diazepam oral concentrate 5 mg/ml (Diazepam Intensol) diazepam oral solution 5 mg/5 ml (1 mg/ml), 5 mg/5 ml (1 mg/ml, 5 ml) diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML lorazepam oral concentrate 2 mg/ml (Lorazepam Intensol) lorazepam oral tablet 0.5 mg, 1 mg, 2 mg (Ativan) NIRAVAM ORAL TABLET,DISINTEGRATING 0.25 MG, 0.5 MG, 1 MG, 2 MG oxazepam oral capsule 10 mg, 15 mg, 30 mg TRANXENE T-TAB ORAL TABLET 15 MG, 3.75 MG, 7.5 MG VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR 0.5 MG, 1 MG, 2 MG, 3 MG 25

27 Anti-Anxiety Drugs buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg meprobamate oral tablet 200 mg, 400 mg Anti-Mania Drugs EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg lithium carbonate oral tablet extended release 450 mg lithium citrate oral solution 8 meq/5 ml, 8 meq/5 ml (5 ml) LITHOBID ORAL TABLET EXTENDED RELEASE 300 MG (Lithobid) Antipsych,Dopamine Antag.,Diphenylbutylpiperidines ORAP ORAL TABLET 1 MG, 2 MG pimozide oral tablet 1 mg, 2 mg (Orap) 26

28 Antipsychotic-Atypical,D3/D2 Partial Ag-5Ht Mixed VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) Antipsychotics, Atyp, D2 Partial Agonist/5Ht Mixed ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG, 15 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG ABILIFY ORAL SOLUTION 1 MG/ML ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG aripiprazole oral solution 1 mg/ml aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet,disintegrating 10 mg, 15 mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML, 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG (Abilify) 27

29 Antipsychotics, Dopamine & Serotonin Antagonists ADASUVE INHALATION AEROSOL POWDR BREATH ACTIVATED 10 MG loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg LOXITANE ORAL CAPSULE 5 MG Antipsychotics,Atypical,Dopamine,& Serotonin Antag clozapine oral tablet 100 mg, 25 mg (Clozaril) clozapine oral tablet 200 mg, 50 mg clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg (FazaClo) CLOZARIL ORAL TABLET 100 MG, 25 MG FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)-6MG(2) FAZACLO ORAL TABLET,DISINTEGRATING 100 MG, 12.5 MG, 150 MG, 200 MG, 25 MG GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80 MG 28

30 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 6 MG, 9 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 410 MG/1.315 ML, 546 MG/1.75 ML, 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG olanzapine intramuscular recon soln 10 mg (Zyprexa) olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 6 mg, 9 mg quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 150 mg, 200 mg, 300 mg, 400 mg, 50 mg RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG (Zyprexa) (Zyprexa Zydis) (Invega) (Seroquel) (Seroquel XR) RISPERDAL ORAL SOLUTION 1 MG/ML 29

31 RISPERDAL ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG risperidone oral solution 1 mg/ml (Risperdal) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 5 MG SAPHRIS SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG SEROQUEL ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET, EXT REL 24HR DOSE PACK 50 MG(3)-200 MG (1)-300 MG(11) VERSACLOZ ORAL SUSPENSION 50 MG/ML ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA INTRAMUSCULAR RECON SOLN 10 MG ZYPREXA ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG (Risperdal) (Geodon) 30

32 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG, 405 MG ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING 10 MG, 15 MG, 20 MG, 5 MG Antipsychotics,Dopamine Antagonists, Thioxanthenes thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg Antipsychotics,Dopamine Antagonists,Butyrophenones droperidol injection solution 2.5 mg/ml HALDOL DECANOATE INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/ML HALDOL INJECTION SOLUTION 5 MG/ML haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml (Haldol Decanoate) haloperidol lactate injection solution 5 mg/ml (Haldol) haloperidol lactate intramuscular syringe 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg 31

33 Antipsychotics,Dopamine Antagonst,Dihydroindolones molindone oral tablet 10 mg, 25 mg, 5 mg Anti-Psychotics,Phenothiazines chlorpromazine injection solution 25 mg/ml chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg Barbiturates AMYTAL INJECTION RECON SOLN 500 MG 32

34 BUTISOL ORAL TABLET 30 MG NEMBUTAL SODIUM INJECTION SOLUTION 50 MG/ML pentobarbital sodium injection solution 50 mg/ml phenobarbital in 0.9 % sod chl intravenous solution 10 mg/ml (1 ml) (Nembutal Sodium) phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital sodium injection solution 130 mg/ml, 65 mg/ml SECONAL SODIUM ORAL CAPSULE 100 MG Central Nervous System Stimulants ammonia aromatic inhalation solution 15 % (w/v) ammonia aromatic inhalation spirit DOPRAM INTRAVENOUS SOLUTION 20 MG/ML doxapram intravenous solution 20 mg/ml (Dopram) 33

35 Hypnotics, Melatonin Mt1/Mt2 Receptor Agonists HETLIOZ ORAL CAPSULE 20 MG ROZEREM ORAL TABLET 8 MG Monoamine Oxidase(Mao) Inhibitors EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR Narcolepsy And Sleep Disorder Therapy Agents armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg (Nuvigil) modafinil oral tablet 100 mg, 200 mg (Provigil) NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50 MG PROVIGIL ORAL TABLET 100 MG, 200 MG Narcotic Antagonists naloxone injection solution 0.4 mg/ml QL (2 ML per 90 days) naloxone injection syringe 0.4 mg/ml, 1 mg/ml QL (2 ML per 90 days) naltrexone oral tablet 50 mg NARCAN NASAL SPRAY,NON-AEROSOL 4 QL (2 EA per 90 days) MG/ACTUATION REVIA ORAL TABLET 50 MG Sedative-Hypnotics - Benzodiazepines ATIVAN INJECTION SOLUTION 2 MG/ML, 4 MG/ML 34

36 DORAL ORAL TABLET 15 MG estazolam oral tablet 1 mg, 2 mg flurazepam oral capsule 15 mg, 30 mg HALCION ORAL TABLET 0.25 MG lorazepam in 0.9% sod chloride intravenous solution 100 mg/100 ml (1 mg/ml) lorazepam in dextrose 5 % intravenous solution 100 mg/100 ml (1 mg/ml) lorazepam injection solution 2 mg/ml, 4 mg/ml (Ativan) lorazepam injection syringe 2 mg/ml, 4 mg/ml midazolam oral syrup 2 mg/ml quazepam oral tablet 15 mg (Doral) RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5 MG temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg (Restoril) triazolam oral tablet mg 35

37 triazolam oral tablet 0.25 mg (Halcion) Sedative-Hypnotics,Non-Barbiturate ALKA-SELTZER PLUS ALLERGY ORAL TABLET 25 MG AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE 12.5 MG, 6.25 MG AMBIEN ORAL TABLET 10 MG, 5 MG BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG COMPOZ ORAL TABLET 25 MG dexmedetomidine in 0.9 % nacl intravenous solution 200 mcg/50 ml (4 mcg/ml), 400 mcg/100 ml (4 mcg/ml) dexmedetomidine in 0.9 % nacl intravenous syringe 20 mcg/10 ml (2 mcg/ml) dexmedetomidine in dextrose 5% intravenous solution 200 mcg/50 ml (4 mcg/ml), 400 mcg/100 ml (4 mcg/ml) dexmedetomidine intravenous solution 100 mcg/ml (Precedex in 0.9 % sodium chlor) (Precedex) diphenhydramine hcl oral tablet 25 mg (Alka-Seltzer Plus Allergy) EDLUAR SUBLINGUAL TABLET 10 MG, 5 MG 36

38 eszopiclone oral tablet 1 mg, 2 mg, 3 mg (Lunesta) EZ NITE SLEEP ORAL CAPSULE 25 MG ; Age (Max 64 Years) EZ NITE SLEEP ORAL LIQUID 50 MG/30 ML INTERMEZZO SUBLINGUAL TABLET 1.75 MG, 3.5 MG LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG LYDIA PINKHAM HERBAL ORAL ELIXIR MEDI-SLEEP ORAL TABLET 25 MG MKO (MIDAZOLAM-KETAMINE-ONDAN) SUBLINGUAL TROCHE MG NIGHTIME SLEEP ORAL CAPSULE 50 MG NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 25 MG NIGHTTIME SLEEP AID (DIPHEN) ORAL CAPSULE 50 MG NIGHTTIME SLEEP AID (DIPHEN) ORAL LIQUID 50 MG/30 ML ; Age (Max 64 Years) 37

39 NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET 25 MG NIGHTTIME SLEEP-AID (DOXYLAMN) ORAL TABLET 25 MG NYTOL ORAL TABLET 25 MG NYT-TIME SLEEP ORAL TABLET 25 MG ORMIR ORAL CAPSULE 50 MG PRECEDEX IN 0.9 % SODIUM CHLOR INTRAVENOUS SOLUTION 200 MCG/50 ML (4 MCG/ML), 400 MCG/100 ML (4 MCG/ML), 80 MCG/20 ML (4 MCG/ML) PRECEDEX INTRAVENOUS SOLUTION 100 MCG/ML REST SIMPLY NIGHTTIME SLEEP ORAL TABLET 25 MG RESTFULLY SLEEP ORAL TABLET 25 MG SILENOR ORAL TABLET 3 MG, 6 MG SIMPLY SLEEP ORAL TABLET 25 MG SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 25 MG ; Age (Max 64 Years) 38

40 SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG SLEEP AID (DIPHENHYDRAMINE) ORAL LIQUID 50 MG/30 ML SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET 25 MG SLEEP AID (DOXYLAMINE) ORAL TABLET 25 MG SLEEP AID MAX STR (DIPHENHYDR) ORAL CAPSULE 50 MG SLEEP II ORAL TABLET 25 MG SLEEP ORAL TABLET 25 MG SLEEP TABLET (DIPHENHYDRAMINE) ORAL TABLET 25 MG SLEEP TIME ORAL CAPSULE 25 MG ; Age (Max 64 Years) SLEEP TIME ORAL LIQUID 50 MG/30 ML SLEEPGELS ORAL CAPSULE 50 MG SLEEPING ORAL CAPSULE 50 MG 39

41 SLEEP-TABS ORAL TABLET 25 MG SONATA ORAL CAPSULE 10 MG, 5 MG tryptophan oral capsule 500 mg tryptophan oral tablet 500 mg ULTRA SLEEP (DOXYLAMINE SUCC) ORAL TABLET 25 MG UNISOM (DIPHENHYDRAMINE) ORAL LIQUID 50 MG/30 ML UNISOM (DOXYLAMINE) ORAL TABLET 25 MG UNISOM SLEEPGELS ORAL CAPSULE 50 MG UNISOM SLEEPMELTS ORAL TABLET,DISINTEGRATING 25 MG WAL-SLEEP Z ORAL CAPSULE 25 MG ; Age (Max 64 Years) WAL-SLEEP Z ORAL LIQUID 50 MG/30 ML WAL-SLEEP Z ORAL TABLET,DISINTEGRATING 25 MG 40

42 WAL-SOM (DIPHENHYDRAMINE) ORAL CAPSULE 50 MG WAL-SOM (DIPHENHYDRAMINE) ORAL TABLET,DISINTEGRATING 25 MG WAL-SOM (DOXYLAMINE) ORAL TABLET 25 MG zaleplon oral capsule 10 mg, 5 mg zolpidem oral tablet 10 mg, 5 mg (Ambien) zolpidem oral tablet,ext release multiphase 12.5 mg, 6.25 mg (Ambien CR) zolpidem sublingual tablet 1.75 mg, 3.5 mg (Intermezzo) ZOLPIMIST ORAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML) Z-SLEEP ORAL CAPSULE 25 MG ; Age (Max 64 Years) Z-SLEEP ORAL LIQUID 50 MG/30 ML ZZZQUIL ORAL CAPSULE 25 MG ; Age (Max 64 Years) ZZZQUIL ORAL LIQUID 50 MG/30 ML 41

43 Selective Serotonin 5-Ht2a Inverse Agonists (Ssia) NUPLAZID ORAL TABLET 17 MG Ssri &Antipsych,Atyp,Dopamine&Serotonin Antag Comb olanzapine-fluoxetine oral capsule mg, mg, 3-25 mg, 6-25 mg, 6-50 mg SYMBYAX ORAL CAPSULE MG, MG, 3-25 MG, 6-25 MG, 6-50 MG Tx For Adhd - Selective Alpha-2A Receptor Agonist clonidine hcl oral tablet extended release 12 hr 0.1 mg guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR 1 MG, 2 MG, 3 MG, 4 MG KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR 0.1 MG Tx For Attention Deficit- Hyperact(Adhd)/Narcolepsy APTENSIO XR ORAL CAP,ER SPRINKLE,BIPHASIC MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG CONCERTA ORAL TABLET EXTENDED RELEASE 24HR 18 MG, 27 MG, 36 MG, 54 MG COTEMPLA XR-ODT ORAL TABLET,DISINTEG ER BIPHASE 24H 17.3 MG, 25.9 MG, 8.6 MG DAYTRANA TRANSDERMAL PATCH 24 HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9 HR, 30 MG/9 HR (Symbyax) (Kapvay) (Intuniv ER) 42

44 dexmethylphenidate oral capsule,er biphasic mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5 MG FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG METADATE CD ORAL CAPSULE, ER BIPHASIC MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG METHYLIN ORAL SOLUTION 10 MG/5 ML, 5 MG/5 ML METHYLIN ORAL TABLET,CHEWABLE 10 MG, 2.5 MG, 5 MG methylphenidate hcl oral capsule, er biphasic mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er biphasic mg, 20 mg, 30 mg, 40 mg methylphenidate hcl oral capsule,er biphasic mg methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg (Focalin XR) (Focalin) (Ritalin LA) (Methylin) (Ritalin) 43

45 methylphenidate hcl oral tablet extended release 10 mg methylphenidate hcl oral tablet extended release 20 mg methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet extended release 24hr 72 mg methylphenidate hcl oral tablet,chewable 10 mg, 2.5 mg, 5 mg QUILLICHEW ER ORAL TABLET,CHEW,IR- ER.BIPHASIC24HR 20 MG, 30 MG, 40 MG QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) RELEXXII ORAL TABLET EXTENDED RELEASE 24HR 72 MG RITALIN LA ORAL CAPSULE,ER BIPHASIC MG, 20 MG, 30 MG, 40 MG, 60 MG RITALIN ORAL TABLET 10 MG, 20 MG, 5 MG RITALIN SR ORAL TABLET EXTENDED RELEASE 20 MG Tx For Attention Deficit-Hyperact.(Adhd), Nri- Type atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg (Metadate ER) (Concerta) (Relexxii) (Strattera) 44

46 STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG Cardiovascular Disease - Arrhythmia Antiarrhythmics amiodarone oral tablet 100 mg, 200 mg, 400 (Pacerone) mg disopyramide phosphate oral capsule 100 mg, (Norpace) Age (Max 64 Years) 150 mg flecainide oral tablet 100 mg, 150 mg, 50 mg mexiletine oral capsule 150 mg, 200 mg, 250 mg PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG propafenone oral tablet 150 mg, 225 mg, 300 mg quinidine sulfate oral tablet 200 mg, 300 mg quinidine sulfate oral tablet extended release 300 mg Cardiovascular Disease - Cardiac Stimulant Digitalis Glycosides DIGITEK ORAL TABLET 125 MCG, 250 MCG DIGOX ORAL TABLET 125 MCG, 250 MCG digoxin oral tablet 125 mcg, 250 mcg (Digitek) Cardiovascular Disease - Hypertension Ace Inhibitor/Calcium Channel Blocker Combination amlodipine-benazepril oral capsule mg, (Lotrel) QL (1 EA per 1 day) mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-benazepril oral capsule mg QL (1 EA per 1 day) Ace Inhibitor/Thiazide & Thiazide-Like Diuretic enalapril-hydrochlorothiazide oral tablet (Vaseretic) QL (2 EA per 1 day) mg enalapril-hydrochlorothiazide oral tablet QL (2 EA per 1 day) mg lisinopril-hydrochlorothiazide oral tablet 10- (Zestoretic) QL (2 EA per 1 day) 12.5 mg, mg, mg quinapril-hydrochlorothiazide oral tablet 10- (Accuretic) 12.5 mg, mg, mg Alpha/Beta-Adrenergic Blocking Agents carvedilol oral tablet 12.5 mg, 25 mg, (Coreg) mg, 6.25 mg labetalol oral tablet 100 mg, 200 mg, 300 mg Alpha-Adrenergic Blocking Agents doxazosin oral tablet 1 mg, 2 mg, 4 mg (Cardura) QL (1 EA per 1 day) doxazosin oral tablet 8 mg (Cardura) QL (2 EA per 1 day) prazosin oral capsule 1 mg (Minipress) prazosin oral capsule 2 mg, 5 mg (Minipress) QL (2 EA per 1 day) 45

47 terazosin oral capsule 1 mg, 5 mg QL (1 EA per 1 day) terazosin oral capsule 10 mg, 2 mg QL (2 EA per 1 day) Angiotensin Receptor Antag./Thiazide Diuretic Comb irbesartan-hydrochlorothiazide oral tablet 150- (Avalide) QL (1 EA per 1 day) 12.5 mg, mg losartan-hydrochlorothiazide oral tablet 100- (Hyzaar) QL (1 EA per 1 day) 12.5 mg, mg, mg valsartan-hydrochlorothiazide oral tablet 160- (Diovan HCT) QL (1 EA per 1 day) 12.5 mg, mg, mg, mg, mg Angiotensin Receptor Antgnst & Calc.Channel Blockr amlodipine-valsartan oral tablet mg, (Exforge) mg, mg, mg Antihypertensives, Ace Inhibitors benazepril oral tablet 10 mg, 20 mg (Lotensin) QL (1.5 EA per 1 day) benazepril oral tablet 40 mg (Lotensin) QL (2 EA per 1 day) benazepril oral tablet 5 mg QL (1.5 EA per 1 day) captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 5 (Vasotec) QL (1.5 EA per 1 day) mg enalapril maleate oral tablet 20 mg (Vasotec) QL (2 EA per 1 day) EPANED ORAL SOLUTION 1 MG/ML Age (Max 12 Years) fosinopril oral tablet 10 mg, 20 mg QL (1.5 EA per 1 day) fosinopril oral tablet 40 mg QL (2 EA per 1 day) lisinopril oral tablet 10 mg, 20 mg, 5 mg (Prinivil) QL (1.5 EA per 1 day) lisinopril oral tablet 2.5 mg, 30 mg (Zestril) QL (1.5 EA per 1 day) lisinopril oral tablet 40 mg (Zestril) QL (2 EA per 1 day) perindopril erbumine oral tablet 2 mg, 4 mg QL (1.5 EA per 1 day) QBRELIS ORAL SOLUTION 1 MG/ML Age (Max 12 Years) quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 (Accupril) QL (1 EA per 1 day) mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, (Altace) QL (1 EA per 1 day) 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg QL (1 EA per 1 day) Antihypertensives, Angiotensin Receptor Antagonist irbesartan oral tablet 150 mg, 300 mg, 75 mg (Avapro) QL (1 EA per 1 day) losartan oral tablet 100 mg, 25 mg, 50 mg (Cozaar) QL (1 EA per 1 day) valsartan oral tablet 160 mg, 40 mg, 80 mg (Diovan) QL (2 EA per 1 day) valsartan oral tablet 320 mg (Diovan) QL (1 EA per 1 day) Antihypertensives, Sympatholytic clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 (Catapres) mg guanfacine oral tablet 1 mg, 2 mg QL (2 EA per 1 day) methyldopa oral tablet 250 mg, 500 mg Age (Max 64 Years) 46

48 methyldopa-hydrochlorothiazide oral tablet mg, mg Antihypertensives, Vasodilators hydralazine injection solution 20 mg/ml hydralazine oral tablet 10 mg, 25 mg, 50 mg QL (4 EA per 1 day) hydralazine oral tablet 100 mg QL (3 EA per 1 day) minoxidil oral tablet 10 mg, 2.5 mg Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg (Tenormin) betaxolol oral tablet 10 mg, 20 mg bisoprolol fumarate oral tablet 10 mg QL (2 EA per 1 day) bisoprolol fumarate oral tablet 5 mg QL (1.5 EA per 1 day) HEMANGEOL ORAL SOLUTION 4.28 MG/ML Age (Max 4 Years) metoprolol succinate oral tablet extended (Toprol XL) QL (1.5 EA per 1 day) release 24 hr 100 mg, 25 mg, 50 mg metoprolol succinate oral tablet extended (Toprol XL) QL (2 EA per 1 day) release 24 hr 200 mg metoprolol tartrate oral tablet 100 mg, 50 mg (Lopressor) QL (3 EA per 1 day) metoprolol tartrate oral tablet 25 mg QL (3 EA per 1 day) nadolol oral tablet 20 mg, 40 mg, 80 mg (Corgard) propranolol oral capsule,extended release 24 (Inderal LA) QL (2 EA per 1 day) hr 120 mg, 160 mg propranolol oral capsule,extended release 24 (Inderal LA) QL (4 EA per 1 day) hr 60 mg propranolol oral capsule,extended release 24 (Inderal LA) QL (3 EA per 1 day) hr 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg SORINE ORAL TABLET 120 MG, 160 MG, QL (2 EA per 1 day) 240 MG, 80 MG SOTALOL AF ORAL TABLET 120 MG, 160 QL (2 EA per 1 day) MG, 80 MG sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 (Betapace) QL (2 EA per 1 day) mg Beta-Adrenergic Blocking Agents/Thiazide & Related atenolol-chlorthalidone oral tablet mg (Tenoretic 100) atenolol-chlorthalidone oral tablet mg (Tenoretic 50) bisoprolol-hydrochlorothiazide oral tablet 10- (Ziac) QL (2 EA per 1 day) 6.25 mg bisoprolol-hydrochlorothiazide oral tablet 2.5- (Ziac) QL (1.5 EA per 1 day) 6.25 mg, mg Calcium Channel Blocking Agents AFEDITAB CR ORAL TABLET EXTENDED QL (1 EA per 1 day) RELEASE 30 MG, 60 MG amlodipine oral tablet 10 mg, 2.5 mg, 5 mg (Norvasc) QL (1 EA per 1 day) 47

49 CARTIA XT ORAL CAPSULE,EXTENDED QL (1 EA per 1 day) RELEASE 24HR 120 MG, 240 MG, 300 MG CARTIA XT ORAL CAPSULE,EXTENDED QL (2 EA per 1 day) RELEASE 24HR 180 MG DILT-CD ORAL CAPSULE,EXTENDED QL (1 EA per 1 day) RELEASE 24HR 120 MG, 240 MG, 300 MG DILT-CD ORAL CAPSULE,EXTENDED QL (2 EA per 1 day) RELEASE 24HR 180 MG diltiazem hcl oral capsule,ext.rel 24h (DILT-XR) QL (1 EA per 1 day) degradable 120 mg, 180 mg, 240 mg diltiazem hcl oral capsule,extended release 24 (Taztia XT) QL (1 EA per 1 day) hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral capsule,extended release 24 (Tiazac) QL (1 EA per 1 day) hr 420 mg diltiazem hcl oral capsule,extended release (Cardizem CD) QL (1 EA per 1 day) 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral capsule,extended release (Cardizem CD) QL (2 EA per 1 day) 24hr 180 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg (Cardizem) diltiazem hcl oral tablet 90 mg diltiazem hcl oral tablet extended release 24 hr (Cardizem LA) QL (1 EA per 1 day) 180 mg, 300 mg DILT-XR ORAL CAPSULE,EXT.REL 24H QL (1 EA per 1 day) DEGRADABLE 120 MG, 180 MG, 240 MG DILTZAC ER ORAL CAPSULE,EXTENDED QL (1 EA per 1 day) RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG felodipine oral tablet extended release 24 hr QL (2 EA per 1 day) 10 mg felodipine oral tablet extended release 24 hr QL (1 EA per 1 day) 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg QL (2 EA per 1 day) MATZIM LA ORAL TABLET EXTENDED QL (1 EA per 1 day) RELEASE 24 HR 180 MG, 300 MG nicardipine oral capsule 20 mg, 30 mg QL (1 EA per 1 day) NIFEDICAL XL ORAL TABLET EXTENDED QL (1 EA per 1 day) RELEASE 24HR 30 MG, 60 MG nifedipine oral capsule 10 mg (Procardia) QL (4 EA per 1 day); Age (Max 64 Years) nifedipine oral capsule 20 mg QL (4 EA per 1 day); Age (Max 64 Years) nifedipine oral tablet extended release 24hr 30 (Procardia XL) QL (1 EA per 1 day) mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, (Adalat CC) QL (1 EA per 1 day) 60 mg, 90 mg nimodipine oral capsule 30 mg TAZTIA XT ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG QL (1 EA per 1 day) 48