Stanford Health Care Advantage 2018 Abridged Formulary Partial List of Covered Drugs

Transcription

1 Stanford Health Care Advantage 018 Abridged Formulary Partial List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN , 1 This abridged formulary was updated on 06/01/018. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact Stanford Health Care Advantage Member Care Services, at or, for TTY users, 711, 8 am to 8 pm, seven days a week (except Thanksgiving and Christmas) from October 1 through February 14 and Monday through Friday (except holi from February 15 through September 0, or visit StanfordHealthCareAdvantage.org.

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12 Table of Contents Analgesics... Anesthetics... 5 Anti-Addiction/Substance Abuse Treatment Agents...6 Antianxiety Agents...6 Antibacterials... 7 Anticancer Agents Anticholinergic Agents... 1 Anticonvulsants...1 Antidementia Agents...15 Antidepressants Antidiabetic Agents Antifungals...18 Antigout Agents Antihistamines...19 Anti-Infectives (Skin And Mucous Membrane)...19 Antimigraine Agents...0 Antimycobacterials...0 Antinausea Agents...0 Antiparasite Agents...1 Antiparkinsonian Agents...1 Antipsychotic Agents...1 Antivirals (Systemic)... Blood Products/Modifiers/Volume Expanders... 5 Caloric Agents...6 Cardiovascular Agents... 7 Central Nervous System Agents... Contraceptives... Dental And Oral Agents...6 Dermatological Agents...6 Devices... 8 Enzyme Replacement/Modifiers...9 Eye, Ear, Nose, Throat Agents...40 Gastrointestinal Agents Genitourinary Agents...4 Heavy Metal Antagonists... 4 Hormonal Agents, Stimulant/Replacement/Modifying

13 Immunological Agents...47 Inflammatory Bowel Disease Agents...50 Irrigating Solutions...51 Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents...5 Replacement Preparations...5 Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents...56 Vitamins And Minerals... 56

14 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10- QL (700 per 0 1 /5 ml acetaminophen-codeine oral tablet QL (60 per 0 acetaminophen-codeine oral tablet 00-0 (Tylenol-Codeine #) QL (60 per 0 acetaminophen-codeine oral tablet (Tylenol-Codeine #4) QL (180 per 0 butalbital-acetaminophen-caff oral (Capacet) QL (180 per 0 capsule butalbital-acetaminophen-caff oral tablet (Esgic) QL (180 per endocet oral tablet 10-5 QL (40 per 0 endocet oral tablet 5-5 QL (60 per 0 endocet oral tablet QL (00 per 0 hydrocodone-acetaminophen oral solution (Hycet) QL (700 per /15 ml hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (90 per hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (60 per hydrocodone-acetaminophen oral tablet (Verdrocet) QL (60 per hydrocodone-acetaminophen oral tablet (Vicodin) QL (90 per hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) QL (60 per hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (90 per hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (60 per lorcet (hydrocodone) oral tablet 5-5 QL (60 per 0 lorcet hd oral tablet 10-5 QL (60 per 0 lorcet plus oral tablet QL (60 per 0 morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml carpuject outer,l/f,p/f, sdv 4 /ml

15 morphine 8 /ml carpuject sdv, l/f, outer 8 /ml morphine concentrate oral solution 100 QL (180 per 0 /5 ml (0 /ml) morphine intravenous syringe 10 /ml, /ml, 4 /ml, 8 /ml morphine oral solution 10 /5 ml QL (700 per 0 morphine oral solution 0 /5 ml (4 QL (00 per 0 /ml) MORPHINE ORAL TABLET 15 MG 4 QL (180 per 0 MORPHINE ORAL TABLET 0 MG 4 QL (10 per 0 morphine oral tablet extended release 100 (MS Contin) QL (60 per 0, 00, 60 morphine oral tablet extended release 15 (MS Contin) QL (90 per 0, 0 morphine sulfate 10 /ml vial 10 /ml oxycodone oral capsule 5 QL (180 per 0 oxycodone oral concentrate 0 /ml QL (10 per 0 oxycodone oral solution 5 /5 ml QL (100 per 0 oxycodone oral tablet 10 QL (180 per 0 oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 oxycodone oral tablet 0 QL (10 per 0 oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 0 hr 10, 15, 0, 0, 40, 60 oxycodone oral tablet,oral only,ext.rel.1 hr 80 (OxyContin) 5 NM; NDS; QL (10 per 0 oxycodone-acetaminophen oral tablet 10- (Endocet) QL (40 per 0 5 oxycodone-acetaminophen oral tablet (Endocet) QL (60 per 0.5-5, 5-5 oxycodone-acetaminophen oral tablet (Endocet) QL (00 per OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR 80 MG QL (10 per 0 4

16 tramadol oral tablet 50 (Ultram) 1 GC; QL (40 per 0 vicodin es oral tablet QL (90 per 0 vicodin hp oral tablet QL (90 per 0 vicodin oral tablet 5-00 QL (90 per 0 zebutal oral capsule QL (180 per 0 Nonsteroidal Anti-Inflammatory Agents diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 ibu oral tablet 600, GC ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, (IBU) 1 GC 800 indomethacin oral capsule 5 1 GC; QL (40 per 0 indomethacin oral capsule 50 1 GC; QL (10 per 0 indomethacin oral capsule, extended QL (60 per 0 release 75 meloxicam oral tablet 15, 7.5 (Mobic) 1 GC nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 1 GC naproxen oral tablet 500 (Naprosyn) 1 GC naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75, 500 Anesthetics Local Anesthetics lidocaine hcl injection solution 0 /ml (Xylocaine) ( %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 0 lidocaine topical ointment 5 % PA; QL (90 per 0 5

17 lidocaine viscous mucous membrane solution % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents BUNAVAIL BUCCAL FILM.1-0. QL (0 per 0 MG BUNAVAIL BUCCAL FILM QL (60 per 0 MG, 6.-1 MG buprenorphine hcl sublingual tablet, QL (90 per 0 8 buprenorphine-naloxone sublingual tablet QL (90 per 0-0.5, 8- CHANTIX CONTINUING MONTH QL (168 per 84 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (168 per 84 MG CHANTIX STARTING MONTH QL (5 per 8 BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) SUBOXONE SUBLINGUAL FILM QL (60 per 0 1- MG, 8- MG SUBOXONE SUBLINGUAL FILM - QL (0 per MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET QL (0 per MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET QL (60 per MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 GC; QL (10 per 0 alprazolam oral tablet (Xanax) 1 GC; QL (150 per 0 alprazolam oral tablet extended release (Xanax XR) QL (10 per 0 4 hr 0.5, 1, alprazolam oral tablet extended release 4 hr (Xanax XR) QL (90 per 0 6

18 clonazepam oral tablet 0.5, 1 (Klonopin) 1 GC; QL (90 per 0 clonazepam oral tablet (Klonopin) 1 GC; QL (00 per 0 clonazepam oral tablet,disintegrating QL (90 per , 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG 4 diazepam intensol oral concentrate 5 QL (100 per 0 /ml diazepam oral solution 5 /5 ml (1 QL (100 per 0 /ml) diazepam oral tablet 10,, 5 (Valium) 1 GC; QL (10 per 0 lorazepam oral concentrate /ml (Lorazepam Intensol) QL (150 per 0 lorazepam oral tablet 0.5, 1 (Ativan) 1 GC; QL (90 per 0 lorazepam oral tablet (Ativan) 1 GC; QL (150 per 0 Antibacterials Aminoglycosides BETHKIS INHALATION 5 PA BvD; NM; NDS SOLUTION FOR NEBULIZATION 00 MG/4 ML neomycin oral tablet GC TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG Antibacterials, Miscellaneous clindamycin hcl oral capsule 150, 00, 75 (Cleocin HCl) 5 NM; NDS; QL (4 per 8 metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin) QL (10 per 0 100, 5, 50 nitrofurantoin monohyd/m-cryst oral (Macrobid) QL (60 per 0 capsule 100 trimethoprim oral tablet GC 7

19 XIFAXAN ORAL TABLET 00 MG 5 PA; NM; NDS; QL (9 per 0 XIFAXAN ORAL TABLET 550 MG 5 PA; NM; NDS Cephalosporins cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 cefuroxime axetil oral tablet 50, 500 cephalexin oral capsule 50, 500 (Keflex) 1 GC cephalexin oral capsule 750 (Keflex) cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 ( pack) azithromycin oral tablet 50, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 NM; LA; NDS 8

20 INVANZ INJECTION RECON SOLN 4 1 GRAM Penicillins amoxicillin oral capsule 50, GC amoxicillin oral suspension for 1 GC reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, GC amoxicillin oral tablet,chewable 15, 1 GC 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , dicloxacillin oral capsule 50, 500 penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 Quinolones ciprofloxacin hcl oral tablet 100, GC ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 GC levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml 9

21 levofloxacin oral tablet 50, 500, (Levaquin) 750 ofloxacin oral tablet 00, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 GC tablet Tetracyclines doxy-100 intravenous recon soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline hyclate oral tablet,delayed release (dr/ec) 100, 75 doxycycline hyclate oral tablet,delayed (Soloxide) release (dr/ec) 150 doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 00, 50 MINOCIN INTRAVENOUS RECON SOLN 100 MG minocycline oral capsule 100, 50, (Minocin) 75 minocycline oral tablet 100, 50, 75 minocycline oral tablet extended release 4 hr 15, 45, 90 (CoreMino) Anticancer Agents Anticancer Agents AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG 5 PA NSO; NM; NDS; QL (11 per 8 AFINITOR ORAL TABLET 10 MG 5 PA NSO; NM; NDS; QL (56 per 8 10

22 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; NM; NDS; QL (8 per 8 anastrozole oral tablet 1 (Arimidex) 1 GC bicalutamide oral tablet 50 (Casodex) DROXIA ORAL CAPSULE 00 MG, 00 MG, 400 MG ELIGARD ( MONTH) 4 SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) 4 SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) 4 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS 4 SYRINGE 7.5 MG (1 MONTH) ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS; QL (0 per 0 exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG 5 NM; NDS hydroxyurea oral capsule 500 (Hydrea) INLYTA ORAL TABLET 1 MG 5 PA NSO; NM; NDS; QL (180 per 0 INLYTA ORAL TABLET 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG 4 leuprolide subcutaneous kit 1 /0. ml LUPRON DEPOT ( MONTH) 5 NM; NDS INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT (4 MONTH) 5 NM; NDS INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) 5 NM; NDS INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG 5 NM; NDS 11

23 LYSODREN ORAL TABLET 500 MG 5 NM; NDS megestrol oral tablet 0, 40 mercaptopurine oral tablet 50 methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (10 per 0 paclitaxel intravenous concentrate 6 /ml POMALYST ORAL CAPSULE 1 MG, MG, MG, 4 MG 5 PA NSO; NM; NDS; QL (1 per 8 PURIXAN ORAL SUSPENSION 0 MG/ML 5 NM; NDS REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NM; LA; NDS 4 5 PA NSO; NM; NDS; QL (0 per 0 SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (60 per 0 STIVARGA ORAL TABLET 40 MG 5 PA NSO; NM; NDS; QL (84 per 8 SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 7.5 MG, 50 MG 5 PA NSO; NM; NDS; QL (0 per 0 TABLOID ORAL TABLET 40 MG 4 tamoxifen oral tablet 10, 0 TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 TARCEVA ORAL TABLET 150 MG 5 PA NSO; NM; NDS; QL (90 per 0 TASIGNA ORAL CAPSULE 150 MG, 00 MG 5 PA NSO; NM; NDS; QL (11 per 8 tretinoin (chemotherapy) oral capsule 10 5 NM; NDS TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 4 PA BvD; ST 1

24 TYKERB ORAL TABLET 50 MG 5 NM; NDS VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (10 per 0 XALKORI ORAL CAPSULE 00 MG, 50 MG 5 PA NSO; NM; NDS; QL (60 per 0 XTANDI ORAL CAPSULE 40 MG 5 PA NSO; NM; NDS; QL (10 per 0 ZELBORAF ORAL TABLET 40 MG 5 PA NSO; NM; NDS; QL (40 per 0 ZYTIGA ORAL TABLET 50 MG, 500 MG Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml propantheline oral tablet 15 Anticonvulsants Anticonvulsants carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr 100, 00, 400 carbamazepine oral tablet,chewable 100 DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, delayed rel sprinkle 15 (Depakote Sprinkles) divalproex oral tablet extended release 4 (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 15, 50, 500 epitol oral tablet 00 gabapentin oral capsule 100, 00, (Neurontin) 400 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) 5 PA NSO; NM; NDS; QL (10 per 0 1

25 GRALISE 0-DAY STARTER PACK 4 ST; QL (78 per 0 ORAL TABLET EXTENDED RELEASE 4 HR 00 MG (9)- 600 MG (69) GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 00 MG, 600 MG 4 ST; QL (90 per 0 lamotrigine oral tablet 100, 150, (Lamictal) 00, 5 lamotrigine oral tablet extended release (Lamictal XR) 4hr 100, 00, 5, 50, 00, 50 lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 lamotrigine oral tablet,disintegrating 100 (Lamictal ODT), 00, 5, 50 levetiracetam intravenous solution 500 (Keppra) /5 ml levetiracetam oral solution 100 /ml (Keppra) levetiracetam oral tablet 1,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 (Keppra XR) LYRICA ORAL CAPSULE 100 MG, QL (90 per MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML QL (900 per 0 phenytoin sodium extended oral capsule (Dilantin Extended) 100 phenytoin sodium extended oral capsule (Phenytek) 00, 00 ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG 4 ST; QL (60 per 0 SPRITAM ORAL TABLET FOR SUSPENSION 50 MG, 500 MG, 750 MG topiramate oral capsule, sprinkle 15, 5 (Topamax) 4 ST; QL (10 per 0 14

26 topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) 100, 150, 00, 5, 50 topiramate oral tablet 100, 00, (Topamax) 50 topiramate oral tablet 5 (Topamax) 1 GC TROKENDI XR ORAL 4 QL (0 per 0 CAPSULE,EXTENDED RELEASE 4HR 100 MG, 5 MG, 50 MG TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 5 NM; NDS; QL (60 per 0 4HR 00 MG Antidementia Agents Antidementia Agents donepezil oral tablet 10,, 5 (Aricept) QL (0 per 0 donepezil oral tablet,disintegrating 10 QL (0 per 0, 5 memantine oral capsule,sprinkle,er 4hr (Namenda XR) QL (0 per 0 14, 1, 8, 7 memantine oral solution /ml QL (60 per 0 memantine oral tablet 10, 5 (Namenda) QL (60 per 0 memantine oral tablets,dose pack 5-10 (Namenda Titration QL (49 per 8 Pak) NAMENDA XR ORAL QL (8 per 8 CAP,SPRINKLE,ER 4HR DOSE PACK MG NAMENDA XR ORAL QL (0 per 0 CAPSULE,SPRINKLE,ER 4HR 14 MG, 1 MG, 8 MG, 7 MG Antidepressants Antidepressants amitriptyline oral tablet 10, 100, 150, 5, 50, 75 bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release (Wellbutrin SR) 1 hr 100, 150, 00 bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr 150, 00 citalopram oral solution 10 /5 ml QL (600 per 0 citalopram oral tablet 10, 0, 40 (Celexa) 1 GC; QL (0 per 0 15

27 escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, (Lexapro) 1 GC 0, 5 fluoxetine oral capsule 10, 0, 40 (Prozac) 1 GC fluoxetine oral capsule,delayed QL (4 per 8 release(dr/ec) 90 fluoxetine oral solution 0 /5 ml (4 /ml) fluoxetine oral tablet 10, 0 (Sarafem) FLUOXETINE ORAL TABLET 60 4 MG paroxetine hcl oral tablet 10, 0, (Paxil) 1 GC 0, 40 paroxetine hcl oral tablet extended (Paxil CR) release 4 hr 1.5, 5, 7.5 PAXIL ORAL SUSPENSION 10 4 MG/5 ML sertraline oral concentrate 0 /ml (Zoloft) sertraline oral tablet 100, 5, 50 (Zoloft) 1 GC trazodone oral tablet 100, 50 1 GC trazodone oral tablet 150, 00 venlafaxine oral capsule,extended release (Effexor XR) QL (0 per 0 4hr 150 venlafaxine oral capsule,extended release (Effexor XR) QL (90 per 0 4hr 7.5, 75 venlafaxine oral tablet 100, 5, 7.5, 50, 75 venlafaxine oral tablet extended release 4hr 150, 7.5, 75 venlafaxine oral tablet extended release 4 4hr 5 Antidiabetic Agents Antidiabetic Agents, Miscellaneous INVOKANA ORAL TABLET 100 ST; QL (60 per 0 MG INVOKANA ORAL TABLET 00 MG ST; QL (0 per 0 16

28 JANUMET ORAL TABLET 50-1,000 QL (60 per 0 MG, MG JANUMET XR ORAL TABLET, ER QL (0 per 0 MULTIPHASE 4 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER QL (60 per 0 MULTIPHASE 4 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, QL (0 per 0 5 MG, 50 MG metformin oral tablet 1,000 (Glucophage) 6 GC; QL (75 per 0 metformin oral tablet 500 (Glucophage) 6 GC; QL (150 per 0 metformin oral tablet 850 (Glucophage) 6 GC; QL (90 per 0 metformin oral tablet extended release 4 hr 500 (Glucophage XR) 6 GC; QL (10 per 0 metformin oral tablet extended release 4 hr 750 (Glucophage XR) 6 GC; QL (90 per 0 pioglitazone oral tablet 15, 0, 45 (Actos) QL (0 per 0 TRADJENTA ORAL TABLET 5 MG QL (0 per 0 VICTOZA SUBCUTANEOUS PEN QL (9 per 0 INJECTOR 0.6 MG/0.1 ML (18 MG/ ML) Insulins HUMALOG JUNIOR KWIKPEN U- 4 ST; QL (0 per SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML HUMALOG KWIKPEN INSULIN 4 ST; QL (0 per 8 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 00 UNIT/ML ( ML) HUMALOG U-100 INSULIN 4 ST; QL (0 per 8 SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN 4 ST; QL (40 per 8 SUBCUTANEOUS SOLUTION 100 UNIT/ML LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) QL (0 per 8 17

29 LANTUS U-100 INSULIN QL (40 per 8 SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 QL (0 per 8 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG PENFILL U-100 QL (0 per 8 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN QL (40 per 8 ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR U-00 QL (1.5 per 8 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1, (Amaryl) 6 GC; QL (0 per 0 glimepiride oral tablet 4 (Amaryl) 6 GC; QL (60 per 0 glipizide oral tablet 10 (Glucotrol) 6 GC; QL (10 per 0 glipizide oral tablet 5 (Glucotrol) 6 GC; QL (60 per 0 glipizide oral tablet extended release 4hr 10 (Glucotrol XL) 6 GC; QL (60 per 0 glipizide oral tablet extended release 4hr.5, 5 Antifungals Antifungals clotrimazole mucous membrane troche 10 clotrimazole topical cream 1 % (Glucotrol XL) 6 GC; QL (0 per 0 (Antifungal (clotrimazole)) clotrimazole topical solution 1 % clotrimazole-betamethasone topical (Lotrisone) cream % clotrimazole-betamethasone topical lotion % 18

30 fluconazole oral suspension for (Diflucan) reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 150, (Diflucan) 00, 50 ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical shampoo % (Nizoral) nyamyc topical powder 100,000 unit/gram nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 (Nyamyc) unit/gram nystop topical powder 100,000 unit/gram terbinafine hcl oral tablet 50 1 GC Antigout Agents Antigout Agents, Other allopurinol oral tablet 100, 00 (Zyloprim) 1 GC COLCRYS ORAL TABLET 0.6 MG Antihistamines Antihistamines hydroxyzine hcl intramuscular solution 5 /ml, 50 /ml hydroxyzine hcl oral solution 10 /5 ml hydroxyzine hcl oral tablet 10, 5, 50 levocetirizine oral solution.5 /5 ml (Xyzal) levocetirizine oral tablet 5 (Xyzal) 1 GC Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0.4 % (Terazol 7) terconazole vaginal cream 0.8 % terconazole vaginal suppository 80 19

31 Antimigraine Agents Antimigraine Agents rizatriptan oral tablet 10 (Maxalt) QL (18 per 8 rizatriptan oral tablet 5 QL (18 per 8 rizatriptan oral tablet,disintegrating 10 (Maxalt-MLT) QL (18 per 8, 5 sumatriptan succinate oral tablet 100, (Imitrex) QL (18 per 8 5, 50 sumatriptan succinate subcutaneous (Imitrex STATdose Kit QL (4 per 8 cartridge 4 /0.5 ml, 6 /0.5 ml Refill) sumatriptan succinate subcutaneous pen (Imitrex STATdose QL (4 per 8 injector 4 /0.5 ml, 6 /0.5 ml Pen) sumatriptan succinate subcutaneous (Imitrex) QL (4 per 8 solution 6 /0.5 ml Antimycobacterials Antimycobacterials dapsone oral tablet 100, 5 isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, 00 1 GC rifampin intravenous recon soln 600 (Rifadin) rifampin oral capsule 150, 00 (Rifadin) Antinausea Agents Antinausea Agents meclizine oral tablet 1.5 meclizine oral tablet 5 (Dramamine Less Drowsy) ondansetron oral tablet,disintegrating 4 (Zofran ODT) PA BvD, 8 phenadoz rectal suppository 1.5 prochlorperazine maleate oral tablet 10, 5 (Compazine) 1 GC promethazine injection solution 5 /ml, (Phenergan) 50 /ml promethazine oral tablet 1.5, 5, 50 promethazine rectal suppository 1.5, (Phenadoz) 5 promethazine rectal suppository 50 (Phenergan) promethegan rectal suppository 5, 50 0

32 Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 00 MG 5 NM; NDS atovaquone-proguanil oral tablet (Malarone) atovaquone-proguanil oral tablet (Malarone Pediatric) hydroxychloroquine oral tablet 00 (Plaquenil) mefloquine oral tablet 50 Antiparkinsonian Agents Antiparkinsonian Agents benztropine injection solution / ml (Cogentin) benztropine oral tablet 0.5, 1, carbidopa-levodopa oral tablet (Sinemet), 5-100, 5-50 carbidopa-levodopa oral tablet extended (Sinemet CR) release 5-100, carbidopa-levodopa oral tablet,disintegrating , 5-100, 5-50 pramipexole oral tablet 0.15, 0.5 (Mirapex), 0.75, 1, 1.5 pramipexole oral tablet 0.5 (Mirapex) 1 GC ropinirole oral tablet 0.5, 0.5, 1 (Requip),,, 4, 5 ropinirole oral tablet extended release 4 (Requip XL) hr 1,, 4, 6, 8 Antipsychotic Agents Antipsychotic Agents chlorpromazine injection solution 5 /ml chlorpromazine oral tablet 10, 100, 00, 5, 50 clozapine oral tablet 100 (Clozaril) QL (70 per 0 clozapine oral tablet 00 QL (15 per 0 clozapine oral tablet 5 (Clozaril) QL (90 per 0 clozapine oral tablet 50 QL (90 per 0 clozapine oral tablet,disintegrating 100, 1.5, 5 (FazaClo) ST; QL (90 per 0 1

33 clozapine oral tablet,disintegrating 150 (FazaClo) ST; QL (180 per 0 clozapine oral tablet,disintegrating 00 (FazaClo) ST; QL (10 per 0 haloperidol oral tablet 0.5, 1, 10,, 0, 5 LATUDA ORAL TABLET 10 MG, QL (0 per 0 0 MG, 40 MG, 60 MG, 80 MG olanzapine intramuscular recon soln 10 (Zyprexa) QL (0 per 0 olanzapine oral tablet 10, 15,.5 (Zyprexa) QL (0 per 0, 0, 5, 7.5 olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis) QL (0 per 0, 15, 0, 5 quetiapine oral tablet 100, 00, 5 (Seroquel) QL (90 per 0, 00, 400, 50 quetiapine oral tablet extended release 4 (Seroquel XR) QL (0 per 0 hr 150, 00, 50 quetiapine oral tablet extended release 4 (Seroquel XR) QL (60 per 0 hr 00, 400 risperidone oral solution 1 /ml (Risperdal) QL (480 per 0 risperidone oral tablet 0.5, 0.5, 1 (Risperdal) QL (60 per 0,,, 4 risperidone oral tablet,disintegrating 0.5 QL (60 per 0, 1, risperidone oral tablet,disintegrating 0.5 (Risperdal M-TAB) QL (60 per 0 risperidone oral tablet,disintegrating QL (10 per 0, 4 VERSACLOZ ORAL SUSPENSION 50 MG/ML 5 ST; NM; NDS; QL (540 per 0 ziprasidone hcl oral capsule 0, 40 (Geodon) QL (60 per 0, 60, 80 Antivirals (Systemic) Antiretrovirals atazanavir oral capsule 150, 00, (Reyataz) 5 NM; NDS 00 ATRIPLA ORAL TABLET NM; NDS 00 MG COMPLERA ORAL TABLET MG 5 NM; NDS

34 EPIVIR HBV ORAL SOLUTION 5 4 MG/5 ML (5 MG/ML) INTELENCE ORAL TABLET NM; NDS MG, 00 MG INTELENCE ORAL TABLET 5 MG ISENTRESS HD ORAL TABLET NM; NDS MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG 5 NM; NDS ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 5 MG KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG 5 NM; NDS lamivudine oral solution 10 /ml (Epivir) lamivudine oral tablet 100 (Epivir HBV) lamivudine oral tablet 150, 00 (Epivir) lamivudine-zidovudine oral tablet 150- (Combivir) 00 lopinavir-ritonavir oral solution (Kaletra) /5 ml NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZISTA ORAL SUSPENSION MG/ML PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 5 NM; NDS 800 MG REYATAZ ORAL POWDER IN PACKET 50 MG 5 NM; NDS ritonavir oral tablet 100 (Norvir) STRIBILD ORAL TABLET NM; NDS MG tenofovir disoproxil fumarate oral tablet 00 (Viread) 5 NM; NDS

35 TRUVADA ORAL TABLET NM; NDS MG, 1-00 MG, MG, MG VIREAD ORAL POWDER 40 5 NM; NDS MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 5 NM; NDS 00 MG, 50 MG Antivirals, Miscellaneous oseltamivir oral capsule 0 (Tamiflu) QL (84 per 180 oseltamivir oral capsule 45 (Tamiflu) QL (48 per 180 oseltamivir oral capsule 75 (Tamiflu) QL (4 per 180 oseltamivir oral suspension for (Tamiflu) QL (540 per 180 reconstitution 6 /ml SYNAGIS INTRAMUSCULAR 5 PA; NM; NDS SOLUTION 100 MG/ML, 50 MG/0.5 ML TAMIFLU ORAL SUSPENSION QL (540 per 180 FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 0 MG, 60 MG, 90 MG 5 PA; NM; NDS; QL (8 per 8 EPCLUSA ORAL TABLET MG 5 PA; NM; NDS; QL (8 per 8 HARVONI ORAL TABLET MG 5 PA; NM; NDS; QL (0 per 0 MAVYRET ORAL TABLET MG 5 PA; NM; NDS; QL (84 per 8 OLYSIO ORAL CAPSULE 150 MG 5 PA; NM; NDS; QL (8 per 8 SOVALDI ORAL TABLET 400 MG 5 PA; NM; NDS; QL (8 per 8 TECHNIVIE ORAL TABLET MG 5 PA; NM; NDS; QL (56 per 8 VIEKIRA PAK ORAL TABLETS,DOSE PACK 1.5 MG-75 MG -50 MG/50 MG VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 4HR 8. MG-50 MG-. MG-00 MG VOSEVI ORAL TABLET MG 5 PA; NM; NDS; QL (11 per 8 5 PA; NM; NDS; QL (84 per 8 5 PA; NM; NDS; QL (8 per 8 4

36 ZEPATIER ORAL TABLET MG 5 PA; NM; NDS; QL (0 per 0 Interferons INTRON A INJECTION RECON 5 PA NSO; NM; NDS SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 5 PA NSO; NM; NDS 10 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK 5 NM; NDS SUBCUTANEOUS PEN INJECTOR 15 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS 5 NM; NDS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS 5 NM; NDS SYRINGE 180 MCG/0.5 ML Nucleosides And Nucleotides acyclovir oral capsule 00 (Zovirax) acyclovir oral suspension 00 /5 ml (Zovirax) acyclovir oral tablet 400, 800 (Zovirax) famciclovir oral tablet 15, 50, 500 valacyclovir oral tablet 1 gram, 500 (Valtrex) Blood Products/Modifiers/Volume Expanders Anticoagulants enoxaparin subcutaneous solution 00 (Lovenox) / ml enoxaparin subcutaneous syringe 100 /ml, 10 /0.8 ml, 150 /ml, 0 /0. ml, 40 /0.4 ml, 60 /0.6 ml, 80 /0.8 ml (Lovenox) jantoven oral tablet 1, 10,, 1 GC.5,, 4, 5, 6, 7.5 warfarin oral tablet 1, 10,, (Coumadin) 1 GC.5,, 4, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 0 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (4)- 0 MG (9) 5

37 Blood Formation Modifiers EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML EPOGEN INJECTION SOLUTION,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML,,000 UNIT/ML, 4,000 UNIT/ML NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 00 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 00 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML,,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PA; QL (1 per 8 PA; QL (1 per 8 5 NM; NDS 5 NM; NDS 5 NM; NDS PA; QL (1 per 8 5 PA; NM; NDS; QL (1 per 8 5 PA; NM; NDS; QL (6 per 8 Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 (Agrylin) anagrelide oral capsule 1 tranexamic acid intravenous solution (Cyklokapron) 1,000 /10 ml (100 /ml) tranexamic acid oral tablet 650 (Lysteda) QL (0 per 0 Platelet-Aggregation Inhibitors cilostazol oral tablet 100, 50 clopidogrel oral tablet 00 (Plavix) clopidogrel oral tablet 75 (Plavix) 1 GC prasugrel oral tablet 10, 5 (Effient) QL (0 per 0 Caloric Agents Caloric Agents CLINIMIX 5%-D0W(SULFITE- 4 PA BvD FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 4.5%/D5W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % 4 PA BvD 6

38 CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D0W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % dextrose 5 % in water (d5w) intravenous piggyback 5 % INTRALIPID INTRAVENOUS EMULSION 0 %, 0 % NUTRILIPID INTRAVENOUS EMULSION 0 % PLENAMINE INTRAVENOUS PARENTERAL SOLUTION 15 % PROSOL 0 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1, 0., 0. doxazosin oral tablet 1,, 4, 8 Angiotensin Ii Receptor Antagonists irbesartan oral tablet 150, 00, 75 irbesartan-hydrochlorothiazide oral tablet , losartan oral tablet 100, 5, 50 losartan-hydrochlorothiazide oral tablet , 100-5, valsartan-hydrochlorothiazide oral tablet , 160-5, 0-1.5, 0-5, PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD (Catapres) 1 GC (Cardura) (Avapro) 6 GC (Avalide) (Cozaar) 6 GC (Hyzaar) 6 GC (Diovan HCT) 7

39 Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10, 5 6 GC benazepril oral tablet 0, 40 (Lotensin) 6 GC enalapril maleate oral tablet 10,.5 (Vasotec), 0, 5 lisinopril oral tablet 10, 0, 5 (Prinivil) 6 GC lisinopril oral tablet.5, 0, 40 (Zestril) 6 GC lisinopril-hydrochlorothiazide oral tablet (Zestoretic) 6 GC , 0-1.5, 0-5 QBRELIS ORAL SOLUTION 1 4 ST MG/ML ramipril oral capsule 1.5, 10,.5 (Altace) 6 GC, 5 Antiarrhythmic Agents amiodarone intravenous solution 50 /ml amiodarone oral tablet 100, 400 (Pacerone) amiodarone oral tablet 00 (Pacerone) 1 GC flecainide oral tablet 100, 150, 50 pacerone oral tablet 100, 400 pacerone oral tablet 00 1 GC propafenone oral capsule,extended (Rythmol SR) release 1 hr 5, 5, 45 propafenone oral tablet 150, 5, 00 Beta-Adrenergic Blocking Agents atenolol oral tablet 100, 5, 50 (Tenormin) 1 GC carvedilol oral tablet 1.5, 5, (Coreg) 1 GC.15, 6.5 metoprolol succinate oral tablet extended release 4 hr 100, 00, 5, 50 (Toprol XL) metoprolol tartrate intravenous solution 5 (Lopressor) /5 ml metoprolol tartrate intravenous syringe 5 /5 ml metoprolol tartrate oral tablet 100, 50 (Lopressor) 1 GC metoprolol tartrate oral tablet 5 1 GC 8

40 propranolol intravenous solution 1 /ml propranolol oral capsule,extended release (Inderal LA) 4 hr 10, 160, 60, 80 propranolol oral solution 0 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 10, 0, 40, 60, 80 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 4hr 10, 180, 40, 00 diltiazem hcl intravenous solution 5 /ml diltiazem hcl oral capsule,extended release 1 hr 10, 60, 90 diltiazem hcl oral capsule,extended (Taztia XT) release 4 hr 60 diltiazem hcl oral capsule,extended (Tiazac) release 4 hr 40 diltiazem hcl oral capsule,extended (Cardizem CD) release 4hr 10, 180, 40, 00 diltiazem hcl oral tablet 10, 0, (Cardizem) 1 GC 60 diltiazem hcl oral tablet 90 1 GC dilt-xr oral capsule,ext.rel 4h degradable 10, 180, 40 matzim la oral tablet extended release 4 hr 180, 40, 00, 60, 40 taztia xt oral capsule,extended release 4 hr 10, 180, 40, 00, 60 verapamil oral capsule, 4 hr er pellet ct (Verelan PM) 100, 00, 00 verapamil oral capsule,ext rel. pellets 4 (Verelan) hr 10, 180, 40, 60 verapamil oral tablet 10, 80 (Calan) 1 GC verapamil oral tablet 40 1 GC verapamil oral tablet extended release 10, 180, 40 (Calan SR) 1 GC 9

41 Cardiovascular Agents, Miscellaneous digitek oral tablet 15 mcg, 50 mcg digox oral tablet 15 mcg, 50 mcg digoxin 0.5 /ml syringe 50 mcg/ml digoxin injection solution 50 mcg/ml (Lanoxin) DIGOXIN ORAL SOLUTION 50 MCG/ML digoxin oral tablet 15 mcg, 50 mcg (Digitek) epinephrine injection auto-injector 0.15 /0. ml epinephrine injection auto-injector 0. /0. ml (EpiPen Jr) Mylan generic preferred; QL (4 per 0 (Auvi-Q) Mylan generic preferred; QL (4 per 0 QL (4 per 0 EPIPEN -PAK INJECTION AUTO- INJECTOR 0. MG/0. ML EPIPEN JR -PAK INJECTION QL (4 per 0 AUTO-INJECTOR 0.15 MG/0. ML hydralazine injection solution 0 /ml hydralazine oral tablet 10, 100, 5, 50 LANOXIN ORAL TABLET QL (0 per 0 MCG LANOXIN ORAL TABLET MCG RANEXA ORAL TABLET EXTENDED RELEASE 1 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 0, 60 amlodipine oral tablet 10,.5, 5 (Norvasc) 1 GC amlodipine-benazepril oral capsule 10-0 (Lotrel), 10-40, 5-10, 5-0, 5-40 amlodipine-benazepril oral capsule.5-10 nifedipine oral capsule 10 (Procardia) nifedipine oral capsule 0 0

42 nifedipine oral tablet extended release (Procardia XL) 4hr 0, 60, 90 nifedipine oral tablet extended release 0 (Adalat CC), 60, 90 Diuretics furosemide injection solution 10 /ml furosemide injection syringe 10 /ml furosemide oral solution 10 /ml, 40 /5 ml (8 /ml) furosemide oral tablet 0, 40, 80 (Lasix) 1 GC hydrochlorothiazide oral capsule 1.5 (Microzide) 1 GC hydrochlorothiazide oral tablet 1.5, 1 GC 5, 50 spironolactone oral tablet 100 (Aldactone) spironolactone oral tablet 5, 50 (Aldactone) 1 GC triamterene-hydrochlorothiazid oral (Dyazide) 1 GC capsule triamterene-hydrochlorothiazid oral capsule 50-5 triamterene-hydrochlorothiazid oral (Maxzide-5) 1 GC tablet triamterene-hydrochlorothiazid oral (Maxzide) 1 GC tablet Dyslipidemics atorvastatin oral tablet 10, 0, 40 (Lipitor) 6 GC, 80 fenofibrate micronized oral capsule 10, 14, 00, 4, 67 fenofibrate oral tablet 160, 54 gemfibrozil oral tablet 600 (Lopid) 1 GC lovastatin oral tablet 10, 0, 40 6 GC pravastatin oral tablet 10 pravastatin oral tablet 0, 40, 80 (Pravachol) simvastatin oral tablet 10, 0, 40 (Zocor) 6 GC, 5 simvastatin oral tablet 80 (Zocor) 6 GC; QL (0 per 0 1

43 Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 5, 50 (Inspra) TEKTURNA ORAL TABLET 150 ST MG, 00 MG Vasodilators isosorbide dinitrate oral tablet 10, 0, 0 isosorbide dinitrate oral tablet 5 (Isordil Titradose) isosorbide dinitrate oral tablet extended (ISOCHRON) release 40 isosorbide mononitrate oral tablet 10 isosorbide mononitrate oral tablet 0 1 GC isosorbide mononitrate oral tablet extended release 4 hr 10, 60 isosorbide mononitrate oral tablet 1 GC extended release 4 hr 0 Central Nervous System Agents Central Nervous System Agents AVONEX INTRAMUSCULAR PEN 5 PA; NM; NDS INJECTOR KIT 0 MCG/0.5 ML AVONEX INTRAMUSCULAR 5 PA; NM; NDS SYRINGE KIT 0 MCG/0.5 ML dexmethylphenidate oral tablet 10, (Focalin) QL (60 per 0.5, 5 dextroamphetamine oral capsule, (Dexedrine Spansule) QL (10 per 0 extended release 10, 15, 5 dextroamphetamine oral tablet 10, 5 (Zenzedi) QL (180 per 0 dextroamphetamine-amphetamine oral (Adderall XR) QL (0 per 0 capsule,extended release 4hr 10, 15, 5 dextroamphetamine-amphetamine oral (Adderall XR) QL (60 per 0 capsule,extended release 4hr 0, 5, 0 dextroamphetamine-amphetamine oral (Adderall) QL (60 per 0 tablet 10, 1.5, 15, 0, 0, 5, 7.5 lithium carbonate oral capsule 150, 1 GC 00 lithium carbonate oral capsule 600

44 lithium carbonate oral tablet 00 lithium carbonate oral tablet extended (Lithobid) release 00 lithium carbonate oral tablet extended release 450 methylphenidate hcl oral capsule, er QL (0 per 0 biphasic , 0, 40, 50, 60 methylphenidate hcl oral capsule, er QL (60 per 0 biphasic methylphenidate hcl oral capsule,er (Ritalin LA) QL (0 per 0 biphasic , 40 methylphenidate hcl oral capsule,er (Ritalin LA) QL (60 per 0 biphasic methylphenidate hcl oral capsule,er biphasic QL (0 per 0 methylphenidate hcl oral solution 10 /5 (Methylin) QL (900 per 0 ml, 5 /5 ml methylphenidate hcl oral tablet 10, 0 (Ritalin) QL (90 per 0, 5 methylphenidate hcl oral tablet extended QL (90 per 0 release 10 methylphenidate hcl oral tablet extended (Metadate ER) QL (90 per 0 release 0 methylphenidate hcl oral tablet extended (Concerta) QL (0 per 0 release 4hr 18, 7, 54 methylphenidate hcl oral tablet extended (Concerta) QL (60 per 0 release 4hr 6 SAVELLA ORAL TABLET 100 MG, QL (60 per MG, 5 MG, 50 MG SAVELLA ORAL TABLETS,DOSE QL (60 per 0 PACK 1.5 MG (5)-5 MG(8)-50 MG(4) Contraceptives Contraceptives altavera (8) oral tablet aubra oral tablet mcg aviane oral tablet mcg blisovi 4 fe oral tablet 1-0 mcg (4)/75 (4)

45 blisovi fe 1.5/0 (8) oral tablet mcg (1)/75 (7) blisovi fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) delyla (8) oral tablet mcg drospirenone-ethinyl estradiol oral tablet (Gianvi (8)) -0.0 drospirenone-ethinyl estradiol oral tablet (Ocella) -0.0 enpresse oral tablet 50-0 (6)/75-40 (5)/15-0(10) falmina (8) oral tablet mcg femynor oral tablet mcg gianvi (8) oral tablet -0.0 introvale oral tablets,dose pack, month QL (91 per mcg junel fe 1.5/0 (8) oral tablet mcg (1)/75 (7) junel fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) junel fe 4 oral tablet 1-0 mcg (4)/75 (4) kurvelo oral tablet larin fe 1.5/0 (8) oral tablet mcg (1)/75 (7) larin fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) larissia oral tablet mcg lessina oral tablet mcg levonest (8) oral tablet 50-0 (6)/75-40 (5)/15-0(10) levonorgestrel-ethinyl estrad oral tablet (Aubra) mcg levonorgestrel-ethinyl estrad oral tablet (Altavera (8)) QL (91 per levonorgestrel-ethinyl estrad oral (Introvale) QL (91 per 84 tablets,dose pack, month mcg levonorg-eth estrad triphasic oral tablet (Enpresse) QL (91 per (6)/75-40 (5)/15-0(10) levora-8 oral tablet

46 loryna (8) oral tablet -0.0 lutera (8) oral tablet mcg marlissa oral tablet microgestin fe 1.5/0 (8) oral tablet GC -0 mcg (1)/75 (7) microgestin fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) mononessa (8) oral tablet mcg nikki (8) oral tablet -0.0 noreth-estrad-fe 1-0.0(1) (Blisovi Fe 1/0 (8)) mcg (1)/75 (7) norethindrone-e.estradiol-iron oral tablet (Blisovi 4 Fe) 1-0 mcg (4)/75 (4) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen LO 0.18/0.15/0.5-5 mcg (8)) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen (8)) 0.18/0.15/0.5-5 mcg (8) norgestimate-ethinyl estradiol oral tablet (Estarylla) mcg ocella oral tablet -0.0 orsythia oral tablet mcg portia oral tablet previfem oral tablet mcg quasense oral tablets,dose pack, month QL (91 per mcg setlakin oral tablets,dose pack, month QL (91 per mcg sprintec (8) oral tablet mcg sronyx oral tablet mcg tarina fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) tri-legest fe oral tablet 1-0(5)/1-0(7) /1-5mcg (9) tri-lo-estarylla oral tablet 0.18/0.15/0.5-5 mcg tri-lo-sprintec oral tablet 0.18/0.15/0.5-5 mcg trinessa (8) oral tablet 0.18/0.15/0.5-5 mcg (8) 5

47 tri-previfem (8) oral tablet 0.18/0.15/0.5-5 mcg (8) tri-sprintec (8) oral tablet 0.18/0.15/0.5-5 mcg (8) trivora (8) oral tablet 50-0 (6)/75-40 (5)/15-0(10) vestura (8) oral tablet -0.0 vienva oral tablet mcg zarah oral tablet -0.0 Dental And Oral Agents Dental And Oral Agents chlorhexidine gluconate mucous (Paroex Oral Rinse) membrane mouthwash 0.1 % periogard mucous membrane mouthwash 0.1 % triamcinolone acetonide dental paste 0.1 (Oralone) % Dermatological Agents Dermatological Agents, Other acyclovir topical ointment 5 % (Zovirax) QL (0 per 0 ammonium lactate topical cream 1 % (Geri-Hydrolac) ammonium lactate topical lotion 1 % (AmLactin) calcipotriene scalp solution % calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcitrene) diclofenac sodium topical drops 1.5 % QL (00 per 0 diclofenac sodium topical gel % (Solaraze) 5 PA; NM; NDS; QL (100 per 8 FLECTOR TRANSDERMAL PA PATCH 1 HOUR 1. % fluorouracil topical cream 0.5 % (Carac) 5 NM; NDS fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution %, 5 % imiquimod topical cream in packet 5 % (Aldara) PA NSO; QL (4 per 0 PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 0 MG/GRAM /ACTUATION( %) TOLAK TOPICAL CREAM 4 % 4 VOLTAREN TOPICAL GEL 1 % 5 PA; NM; NDS; QL (4 per 8 6

48 ZOVIRAX TOPICAL CREAM 5 % 5 NM; NDS; QL (5 per 4 Dermatological Antibacterials clindamycin phosphate topical foam 1 % (Evoclin) clindamycin phosphate topical gel 1 % (Cleocin T) clindamycin phosphate topical lotion 1 % (Cleocin T) clindamycin phosphate topical solution 1 (Cleocin T) % clindamycin phosphate topical swab 1 % (Cleocin T) clindamycin-benzoyl peroxide topical gel (Duac) 1. %(1 % base) -5 % clindamycin-benzoyl peroxide topical gel (Benzaclin) 1-5 % metronidazole topical cream 0.75 % (MetroCream) metronidazole topical gel 0.75 % (Rosadan) metronidazole topical gel 1 % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) neuac topical gel 1. %(1 % base) -5 % Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 % ala-cort topical cream.5 % 1 GC ala-scalp topical lotion % clobetasol 0.05% cream 0.05 % (Temovate) clobetasol scalp solution 0.05 % (Cormax) clobetasol topical foam 0.05 % (Olux) clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % desonide topical cream 0.05 % (DesOwen) desonide topical lotion 0.05 % (DesOwen) desonide topical ointment 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % hydrocortisone topical cream 1 %,.5 % (Ala-Cort) 1 GC hydrocortisone topical lotion.5 % hydrocortisone topical ointment 1 % (Anti-Itch (HC)) 1 GC hydrocortisone topical ointment.5 % 1 GC 7

49 mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % procto-med hc topical cream with perineal applicator.5 % procto-pak topical cream with perineal applicator 1 % proctosol hc topical cream with perineal applicator.5 % proctozone-hc topical cream with perineal applicator.5 % triamcinolone acetonide topical cream 1 GC 0.05 % triamcinolone acetonide topical cream 0.1 (Triderm) %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0.1 % triamcinolone acetonide topical ointment 1 GC 0.05 % triamcinolone acetonide topical ointment 0.1 %, 0.5 % tridesilon topical cream 0.05 % Dermatological Retinoids adapalene topical cream 0.1 % (Differin) adapalene topical gel 0.1 % (Differin) tretinoin topical cream 0.05 % (Avita) PA tretinoin topical cream 0.05 %, 0.1 % (Retin-A) PA tretinoin topical gel 0.01 % (Retin-A) PA tretinoin topical gel 0.05 % (Avita) PA Scabicides And Pediculicides malathion topical lotion 0.5 % (Ovide) permethrin topical cream 5 % (Elimite) Devices Devices BD UF NANO PEN NEEDLE 4MMXG GAUGE X 5/" BD VEO INS SYRN 0.5 ML 6MMX1G 1/ ML 1 GAUGE X 15/64" 8

50 INSULIN SYRINGE-NEEDLE U-100 SYRINGE 1/ ML 8 GAUGE PEN NEEDLE, DIABETIC NEEDLE 9 GAUGE X 1/" Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 1,000-8,000-60,000 UNIT, 4,000-76,000-10,000 UNIT,,000-9,500-15,000 UNIT, 6, , ,000 UNIT, 6,000-19,000-0,000 UNIT FABRAZYME INTRAVENOUS RECON SOLN 5 MG, 5 MG KUVAN ORAL TABLET,SOLUBLE 100 MG ORFADIN ORAL CAPSULE 10 MG, MG, 0 MG, 5 MG ORFADIN ORAL SUSPENSION 4 MG/ML PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500-60,500 UNIT PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 4,000-14,75-15,15 UNIT, 8,000-8,750-0,50 UNIT PULMOZYME INHALATION SOLUTION 1 MG/ML ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-4,000-55,000 UNIT, 15,000-51,000-8,000 UNIT, 0,000-6,000-84,000 UNIT, 5,000-79, ,000 UNIT, 5,000-85,000-16,000 UNIT,,000-10,000-16,000 UNIT, 40,000-16, ,000 UNIT, 5,000-17,000-7,000 UNIT, 5,000-17,000-4,000 UNIT (Lite Touch Insulin Syringe) (1st Tier Unifine Pentips) 5 NM; NDS 5 NM; NDS 5 PA; NM; NDS 5 PA; NM; NDS 5 NM; NDS 4 5 PA BvD; NM; NDS 9

51 Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous azelastine nasal aerosol,spray 17 mcg QL (0 per 5 (0.1 %) azelastine nasal spray,non-aerosol 0.15 % (Astepro) QL (0 per 5 (05.5 mcg) azelastine ophthalmic (eye) drops 0.05 % cromolyn ophthalmic (eye) drops 4 % ipratropium bromide nasal spray,nonaerosol QL (0 per % ipratropium bromide nasal spray,nonaerosol 4 mcg (0.06 %) QL (15 per 10 olopatadine nasal spray,non-aerosol 0.6 (Patanase) QL (0.5 per 0 % olopatadine ophthalmic (eye) drops 0.1 (Patanol) % Eye, Ear, Nose, Throat Anti-Infectives Agents CIPRODEX OTIC (EAR) DROPS,SUSPENSION % erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) gentak ophthalmic (eye) ointment 0. % ( /gram) gentamicin ophthalmic (eye) drops 0. % MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 (Vigamox) % neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) drops,suspension.5/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) ointment.5 /g- 10,000 unit/g-0.1 % neomycin-polymyxin-hc ophthalmic (eye) drops,suspension.5-10, unit-/ml 40

52 neomycin-polymyxin-hc otic (ear) drops,suspension.5-10,000-1 /mlunit/ml-% neomycin-polymyxin-hc otic (ear) solution.5-10,000-1 /ml-unit/ml-% ofloxacin ophthalmic (eye) drops 0. % (Ocuflox) ofloxacin otic (ear) drops 0. % (Floxin) TOBRADEX OPHTHALMIC (EYE) 4 OINTMENT % TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION % tobramycin-dexamethasone ophthalmic (TobraDex) (eye) drops,suspension % Eye, Ear, Nose, Throat Anti-Inflammatory Agents fluticasone nasal spray,suspension 50 (4 Hour Allergy 1 GC mcg/actuation Relief) ketorolac ophthalmic (eye) drops 0.4 % (Acular LS) ketorolac ophthalmic (eye) drops 0.5 % (Acular) prednisolone acetate ophthalmic (eye) (Omnipred) drops,suspension 1 % RESTASIS OPHTHALMIC (EYE) QL (60 per 0 DROPPERETTE 0.05 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants famotidine oral suspension 40 /5 ml (8 (Pepcid) /ml) famotidine oral tablet 0 (Acid Controller) 1 GC famotidine oral tablet 40 (Pepcid) 1 GC omeprazole oral capsule,delayed release(dr/ec) 10 omeprazole oral capsule,delayed 1 GC release(dr/ec) 0, 40 pantoprazole intravenous recon soln 40 (Protonix) pantoprazole oral tablet,delayed release (Protonix) 1 GC (dr/ec) 0, 40 ranitidine hcl injection solution 50 / (Zantac) ml (5 /ml) ranitidine hcl oral syrup 15 /ml 41

53 ranitidine hcl oral tablet 150 (Acid Control 1 GC (ranitidine)) ranitidine hcl oral tablet 00 (Zantac) 1 GC Gastrointestinal Agents, Other constulose oral solution 10 gram/15 ml dicyclomine oral capsule 10 dicyclomine oral solution 10 /5 ml dicyclomine oral tablet 0 diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet.5- (Lomotil) 0.05 enulose oral solution 10 gram/15 ml generlac oral solution 10 gram/15 ml lactulose oral solution 10 gram/15 ml (Constulose) loperamide oral capsule (Anti-Diarrheal (loperamide)) metoclopramide hcl injection solution 5 /ml metoclopramide hcl oral solution 5 /5 1 GC ml metoclopramide hcl oral tablet 10, 5 (Reglan) 1 GC ursodiol oral capsule 00 (Actigall) ursodiol oral tablet 50 (URSO 50) ursodiol oral tablet 500 (URSO Forte) Laxatives gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram peg 50-electrolytes oral recon soln 6- (GaviLyte-G) gram peg 50-electrolytes oral recon soln 40- (Colyte with Flavor 1 GC gram Packs) polyethylene glycol 50 oral powder 17 (ClearLax) gram/dose Phosphate Binders calcium acetate oral capsule 667 calcium acetate oral tablet 667 (Calphron) 4

54 PHOSLYRA ORAL SOLUTION MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, 800 MG sevelamer carbonate oral powder in (Renvela) packet 0.8 gram,.4 gram sevelamer carbonate oral tablet 800 (Renvela) Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride oral syrup 5 /5 ml 1 GC oxybutynin chloride oral tablet 5 oxybutynin chloride oral tablet extended (Ditropan XL) release 4hr 10, 15, 5 VESICARE ORAL TABLET 10 MG, 5 MG Genitourinary Agents, Miscellaneous finasteride oral tablet 5 (Proscar) 1 GC tamsulosin oral capsule,extended release (Flomax) 4hr 0.4 Heavy Metal Antagonists Heavy Metal Antagonists CUPRIMINE ORAL CAPSULE 50 5 PA; NM; NDS MG DEPEN TITRATABS ORAL 5 PA; NM; NDS TABLET 50 MG EXJADE ORAL TABLET, 5 PA; NM; NDS DISPERSIBLE 15 MG, 50 MG, 500 MG JADENU ORAL TABLET 180 MG, 60 MG, 90 MG 5 PA; NM; NDS JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG, 60 MG, 90 MG Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM TRANSDERMAL PATCH 4 HOUR MG/4 HOUR, 4 MG/4 HR 5 PA; NM; NDS PA; QL (0 per 0 4