Formulary for North Dakota Medicaid Expansion Members

Transcription

1 Formulary for North Dakota Medicaid Expansion Members Please refer to the following list (formulary) of commonly prescribed medications that are covered by insurance. This is not a complete list; to view the full list, please log in in to your secure member portal at sanfordhealthplan. com/memberlogin and select the Find a pharmacy/link to Express Scripts tab located under My Information. When reviewing the list, please use the guide on page 3. For more information about your pharmacy benefits, covered drugs, copays and more, please check your Summary of Benefits and Coverage and Certificate of Coverage. This information can also be found online or by contacting our Pharmacy Management Team at (855) ; TTY (877) between 8 am and 5 pm CT Monday through Friday. HP-73 8/8

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3 TABLE OF CONTENTS LIST OF ABBREVIATIONS...3 ANTI-INFECTIVES...5 ANTINEOPLASTIC/ IMMUNOSUPPRESSANT DRUGS... AUTONOMIC/ CNS DRUGS, NEUROLOGY/ PSYCHOLOGY... CARDIOVASCULAR / HYPERTENSION / LIPIDS...7 DERMATOLOGICALS / TOPICAL THERAPY...34 MISCELLANEOUS AGENTS...4 EAR, NOSE, THROAT MEDICATIONS...44 ENDOCRINE / DIABETES...45 GASTROENTEROLOGY...50 IMMUNOLOGY & BIOTECHNOLOGY...55 MUSCULOSKELETAL / RHEUMATOLOGY...56 OBSTETRICS / GYNECOLOGY...57 OPHTHALMOLOGY...64 RESPIRATORY & ALLERGY...67 UROLOGICALS...7 VITAMINS / HEMATINICS / ELECTROLYTES...73 INDEX...79 HP-73 Formulary NDME 08-8

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5 List of Abbreviations Tier: $0: These drugs take a $0 copay : Generics (these drugs take a $0 copay) : Brands (these drugs take a $3 copay) 5: Affordable Care Act. These drugs may take a $0 copay (no member cost-share) if the member meets specific conditions (such as age or gender). ACA: Affordable Care Act As part of the Affordable Care Act, certain drugs are available at a $0 copay (no member cost-share) if the member meets specific conditions (such as age or gender). If the member does not meet the specific conditions, the usual copay and member cost-share will apply. LA: PA: QL: SP: ST: Limited Availability May only be available at certain pharmacies. For more information, please contact Sanford Health Plan. Pre-Approval Needed You or your attending healthcare professional must get pre-approval for the medicine with Sanford Health Plan before you can get the prescription filled. Quantity Limit/Number Allowed The Plan may limit the amount of medicine you can receive of certain covered medications. Specialty Medications Specialty medications are typically used to treat complex medical conditions. These medications may require frequent dosing adjustments, close monitoring, special training, or compliance assistance. In addition, specialty medications may need special handling and/or administration, and may have limited or exclusive product availability and distribution. Step-Therapy With certain medications, you must first try lower cost and/or generic versions before high cost options are covered. If the first step medication does not work or you have side effects, the next step may be covered. 3

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7 Formulary North Dakota Medicaid Expansion ANTI-INFECTIVES Antifungal Agents clotrimazole mucous membrane troche 0 fluconazole oral susp for recon 0 /ml, 40 /ml fluconazole oral tablet 00, 50, 00, 50 flucytosine oral capsule 50, 500 griseofulvin microsize oral suspension 5 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 5, 50 itraconazole oral capsule 00 ketoconazole oral tablet 00 nystatin oral powder 50 million unit, 500 million unit nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit terbinafine hcl oral tablet 50 voriconazole oral susp for recon 00 /5 ml (40 /ml) voriconazole oral tablet 00, 50 Antivirals abacavir oral solution 0 /ml QL abacavir oral tablet 300 abacavir-lamivudine oral tablet abacavir-lamivudinezidovudine oral tablet acyclovir oral capsule 00 acyclovir oral suspension 00 /5 ml acyclovir oral tablet 400, 800 adefovir oral tablet 0 amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 00 APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION 00 MG/ML atazanavir oral capsule 50, 00, 300 ATRIPLA ORAL TABLET MG BIKTARVY ORAL TABLET MG CIMDUO ORAL TABLET MG COMBIVIR ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 00 MG, 400 MG DESCOVY ORAL TABLET 00-5 MG 5

8 didanosine oral capsule, delayed release(dr/ec) 5, 00, 50, 400 EDURANT ORAL TABLET 5 MG efavirenz oral capsule 00, 50 efavirenz oral tablet 600 EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLUTION 0 MG/ML entecavir oral tablet 0.5, EPCLUSA ORAL TABLET MG EPIVIR HBV ORAL SOLUTION 5 MG/5 ML (5 MG/ML) EVOTAZ ORAL TABLET MG famciclovir oral tablet 5, 50, 500 fosamprenavir oral tablet 700 GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, 00 MG, 5 MG INVIRASE ORAL CAPSULE 00 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG PA; SP QL ISENTRESS ORAL TABLET, CHEWABLE 00 MG, 5 MG JULUCA ORAL TABLET 50-5 MG lamivudine oral solution 0 /ml lamivudine oral tablet 00, 300 lamivudine oral tablet 50 lamivudine-zidovudine oral tablet LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution /5 ml MAVYRET ORAL TABLET MG MODERIBA DOSE PACK ORAL TABLETS MODERIBA ORAL TABLET 00 MG nevirapine oral suspension 50 /5 ml nevirapine oral tablet 00 nevirapine oral tablet extended release 4 hr 00, 400 NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG ODEFSEY ORAL TABLET MG oseltamivir oral capsule 30, 45, 75 oseltamivir oral susp for recon 6 /ml QL PA; SP; QL QL QL 6

9 PREVYMIS ORAL TABLET 40 MG, 480 MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION RESCRIPTOR ORAL TABLET 00 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG REYATAZ ORAL POWDER IN PACKET 50 MG RIBASPHERE ORAL CAPSULE 00 MG RIBASPHERE ORAL TABLET 00 MG, 400 MG, 600 MG RIBASPHERE RIBAPAK ORAL TABLETS, DOSE PACK ribavirin inhalation recon soln 6 gram ribavirin oral capsule 00 ribavirin oral tablet 00 rimantadine oral tablet 00 SELZENTRY ORAL SOLUTION 0 MG/ML SELZENTRY TABLET 50MG, 5 MG, 300 MG, 75 MG stavudine oral capsule 5, 0, 30, 40 STRIBILD ORAL TABLET MG SYMFI LO ORAL TABLET MG QL QL SYMFI ORAL TABLET MG tenofovir disoproxil fumarate tablet 300 TIVICAY ORAL TABLET 0 MG, 5 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG valacyclovir oral tablet gram, 500 valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 450 VEMLIDY ORAL TABLET 5 MG VIDEX GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIRACEPT ORAL TABLET 50 MG, 65 MG zidovudine oral capsule 00 zidovudine syrup 0 /ml zidovudine tablet 300 Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral susp for recon 5 /5 ml, 50 /5 ml, 375 /5 ml cefaclor oral tablet extended release hr 500 cefadroxil oral capsule 500 7

10 cefadroxil oral susp for recon 50 /5 ml, 500 /5 ml cefadroxil tablet gram cefdinir capsule 300 cefdinir oral susp for recon 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00, 400 cefixime oral susp for recon 00 /5 ml, 00 /5 ml cefpodoxime oral susp for recon 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral susp for recon 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 cefuroxime axetil oral tablet 50, 500 cephalexin oral capsule 50, 500, 750 cephalexin oral susp for recon 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 Erythromycins / Other Macrolides azithromycin oral packet gram azithromycin oral susp for recon 00 /5 ml, 00 /5 ml azithromycin oral tablet 50, 500, 600 clarithromycin oral susp for recon 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 E.E.S. 400 ORAL TABLET 400 MG ERYPED 00 ORAL SUSP FOR RECON 00 MG/5 ML ERYPED 400 ORAL SUSP FOR RECON 400 MG/5 ML ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 50 MG, 333 MG ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 500 MG ERYTHROCIN (AS STEARATE) ORAL TABLET 50 MG erythromycin ethylsuccinate oral susp for recon 00 /5 ml erythromycin ethylsuccinate oral tablet 400 erythromycin oral capsule, delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Miscellaneous Antiinfectives ALBENZA ORAL TABLET 00 MG ALINIA ORAL SUSP FOR RECON 00 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5 ml atovaquone-proguanil oral tablet 50-00,

11 benznidazole oral tablet 00,.5 QL BETHKIS INHALATION SOLN FOR NEBULIZATION 300 SP; QL MG/4 ML BILTRICIDE ORAL TABLET 600 MG chloroquine phosphate tablet 50, 500 clindamycin hcl capsule 50, 300, 75 clindamycin palmitate hcl oral recon soln 75 /5 ml COARTEM ORAL TABLET 0-0 MG cycloserine oral capsule 50 dapsone oral tablet 00, 5 ethambutol oral tablet 00, 400 hydroxychloroquine oral tablet 00 isoniazid oral solution 50 /5 ml isoniazid oral tablet 00, 300 ivermectin tablet 3 KITABIS PAK INHALATION SOLN FOR NEBULIZATION SP; QL 300 MG/5 ML linezolid oral susp for recon 00 /5 ml PA linezolid oral tablet 600 PA mefloquine oral tablet 50 metronidazole oral capsule 375 metronidazole oral tablet 50, 500 NEBUPENT INHALATION RECON SOLN 300 MG neomycin oral tablet 500 paromomycin oral capsule 50 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM praziquantel oral tablet 600 PRIFTIN ORAL TABLET 50 MG primaquine oral tablet 6.3 pyrazinamide oral tablet 500 quinine sulfate oral capsule 34 rifabutin oral capsule 50 RIFAMATE ORAL CAPSULE MG rifampin oral capsule 50, 300 RIFATER ORAL TABLET MG SIVEXTRO ORAL TABLET 00 MG tinidazole oral tablet 50, 500 TRECATOR ORAL TABLET 50 MG XIFAXAN ORAL TABLET 00 MG, 550 MG Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral susp for recon 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml QL PA 9

12 amoxicillin oral tablet 500, 875 amoxicillin oral tablet, chewable 5, 50 amoxicillin-pot clavulanate oral susp for recon /5 ml, /5 ml, /5ml, /5 ml amoxicillin-pot clavulanate oral tablet 50-5, 500-5, amoxicillin-pot clavulanate oral tablet extended release hr, amoxicillin-pot clavulanate oral tablet, chewable , ampicillin oral capsule 50, 500 AUGMENTIN ORAL SUSP FOR RECON MG/5 ML dicloxacillin oral capsule 50, 500 penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 Quinolones BAXDELA ORAL TABLET 450 MG ciprofloxacin (mixture) oral tablet, er multiphase 4 hr,000, 500 ciprofloxacin hcl oral tablet 00, 50, 500, 750 PA ciprofloxacin oral suspension, microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500, 750 moxifloxacin oral tablet 400 ofloxacin oral tablet 300, 400 Sulfa's / Related Agents sulfadiazine oral tablet 500 sulfamethoxazoletrimethoprim oral susp /5 ml sulfamethoxazoletrimethoprim oral tablet , SULFATRIM ORAL SUSP MG/5 ML Tetracyclines AVIDOXY ORAL TABLET 00 MG COREMINO ORAL TABLET EXTENDED RELEASE 4 HR 35 MG, 45 MG, 90 MG demeclocycline oral tablet 50, 300 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00, 50, 0, 50, 75 doxycycline hyclate oral tablet, delayed release (dr/ec) 00, 50, 00, 50, 75 0

13 doxycycline monohydrate oral capsule 00, 50, 50, 75 doxycycline monohydrate oral susp for recon 5 /5 ml doxycycline monohydrate oral tablet 00, 50, 50, 75 minocycline oral capsule 00, 50, 75 minocycline oral tablet 00, 50, 75 MONDOXYNE NL ORAL CAPSULE 00 MG, 50 MG, 75 MG MORGIDOX ORAL CAPSULE 00 MG OKEBO ORAL CAPSULE 75 MG SOLOXIDE ORAL TABLET, DELAYED RELEASE (DR/EC) 50 MG tetracycline oral capsule 50, 500 Urinary Tract Agents methenamine hippurate oral tablet gram methenamine mandelate oral tablet 0.5 g, gram MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule 00, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 nitrofurantoin oral suspension 5 /5 ml PRIMSOL ORAL SOLUTION 50 MG/5 ML trimethoprim oral tablet 00 Vancomycin FIRVANQ ORAL RECON SOLN 5 MG/ML, 50 MG/ML vancomycin oral capsule 5, 50 ANTINEOPLASTIC/ IMMUNOSUPPRESSANT DRUGS Adjunctive Agents leucovorin calcium oral tablet 0, 5, 5, 5 MESNEX ORAL TABLET 400 MG Antineoplastic / Immunosuppressant Drugs anastrozole tablet azathioprine tablet 50 bicalutamide oral tablet 50 cyclosporine modified oral capsule 00, 5, 50 cyclosporine modified oral solution 00 /ml cyclosporine oral capsule 00, 5 DROXIA ORAL CAPSULE 00 MG, 300 MG, 400 MG EMCYT ORAL CAPSULE 40 MG exemestane oral tablet 5 FARESTON ORAL TABLET 60 MG

14 flutamide oral capsule 5 GENGRAF ORAL CAPSULE 00 MG, 5 MG GENGRAF ORAL SOLUTION 00 MG/ML hydroxyurea oral capsule 500 letrozole oral tablet.5 megestrol oral suspension 400 /0 ml (40 /ml), 65 /5 ml megestrol oral tablet 0, 40 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln gram methotrexate sodium (pf) injection solution 5 /ml methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 mycophenolate mofetil oral capsule 50 mycophenolate mofetil oral susp for recon 00 /ml mycophenolate mofetil oral tablet 500 mycophenolate sodium oral tablet, delayed release (dr/ec) 80, 360 nilutamide oral tablet 50 octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml, 00 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 50 mcg/ml ( ml), 500 mcg/ml ( ml) PURIXAN ORAL SUSPENSION 0 MG/ML RAPAMUNE ORAL SOLUTION MG/ML SANDIMMUNE ORAL SOLUTION 00 MG/ML sirolimus oral tablet 0.5,, tacrolimus oral capsule 0.5,, 5 tamoxifen oral tablet 0, 0 TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG XERMELO ORAL TABLET 50 MG ZORTRESS ORAL TABLET 0.5 MG, 0.5 MG, 0.75 MG SP SP SP PA; SP; QL AUTONOMIC/ CNS DRUGS, NEUROLOGY/ PSYCHOLOGY Anticonvulsants APTIOM TABLET 00 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 00 MG, 400 MG BRIVIACT ORAL SOLUTION 0 MG/ML

15 BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG carbamazepine capsule, er multiphase hr 00, 00, 300 carbamazepine oral suspension 00 /5 ml carbamazepine oral tablet 00 carbamazepine tablet extended release hr 00, 00, 400 carbamazepine oral tablet, chewable 00 CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5,, clonazepam oral tablet, disinteg 0.5, 0.5, 0.5,, DIASTAT RECTAL KIT.5 MG diazepam rectal kit ,.5, DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, del-rel sprinkle 5 divalproex oral tablet extended release 4 hr 50, 500 divalproex oral tablet, delayed release (dr/ec) 5, 50, 500 ethosuximide oral capsule 50 ethosuximide oral solution 50 /5 ml felbamate oral suspension 600 /5 ml felbamate oral tablet 400, 600 FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 0 MG, MG, MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 00, 300, 400 gabapentin oral solution 50 /5 ml gabapentin oral tablet 600, 800 GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 4 HR 300 MG (9)- 600 MG (69) GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 300 MG, 600 MG LAMICTAL ODT ORAL TABLET, DISINTEGRATING 00 MG, 00 MG, 5 MG, 50 MG LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK 5 MG () -50 MG (7) LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 50 MG (4) -00 MG (4) LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 5 MG(4)-50 MG (4)- 00 MG (7) LAMICTAL XR TABLET EXTENDED RELEASE 4HR 00 MG, 00 MG, 5 MG, 50 MG, 300 MG, 50 MG 3

16 LAMICTAL XR STARTER (BLUE) TABLET EXTENDED REL,DOSE PACK 5 MG () -50 MG (7) LAMICTAL XR STARTER (GREEN)TABLET EXTENDED REL,DOSE PACK 50 MG(4)-00MG (4)-00 MG (7) LAMICTAL XR STARTER (ORANGE) TABLET EX REL, DOSE PACK 5MG (4)-50 MG (4)-00MG (7) lamotrigine tablet 00, 50, 00, 5 lamotrigine oral tablet disintegrating, dose pk 5 () -50 (7), 5 (4)-50 (4)-00 (7), 50 (4) -00 (4) lamotrigine oral tablet extended release 4hr 00, 00, 5, 50, 300, 50 lamotrigine oral tablet, chewable dispersible 5, 5 lamotrigine oral tablet, disintegrating 00, 00, 5, 50 lamotrigine oral tablets, dose pack 5 (35), 5 (4) -00 (7), 5 (84) -00 (4) levetiracetam oral solution 00 /ml, 500 /5 ml (5 ml) levetiracetam oral tablet,000, 50, 500, 750 levetiracetam oral tablet extended release 4 hr LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 5 MG, 300 MG, QL 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML QL ONFI ORAL SUSPENSION.5 MG/ML ONFI ORAL TABLET 0 MG, 0 MG oxcarbazepine oral suspension 300 /5 ml (60 /ml) oxcarbazepine oral tablet 50, 300, 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 4 HR 50 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml (4 /ml) phenobarbital oral tablet 00, 5, 6., 30, 3.4, 60, 64.8, 97. phenytoin oral suspension 5 /5 ml phenytoin oral tablet, chewable 50 phenytoin sodium extended oral capsule 00, 00, 300 primidone oral tablet 50, 50 ROWEEPRA TABLET,000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 4 HR 500 MG, 750 MG SABRIL TABLET 500 MG SP; LA 500, 750 4

17 SPRITAM TABLET FOR SUSPENSION,000 MG, 50 MG, 500 MG, 750 MG SUBVENITE TABLET 00MG, 50 MG, 00 MG, 5 MG SUBVENITE STARTER (BLUE) KIT ORAL TABLETS, DOSE PACK 5 MG (35) SUBVENITE STARTER (GREEN) KIT ORAL TABLETS, DOSE PACK 5 MG (84) -00 MG (4) SUBVENITE STARTER (ORANGE) KIT ORAL TABLETS, DOSE PACK 5 MG (4) -00 MG (7) tiagabine oral tablet, 6,, 4 topiramate oral capsule, sprinkle 5, 5 topiramate oral capsule, sprinkle, er 4hr 00, 50, 00, 5, 50 topiramate tablet 00, 00, 5, 50 TROKENDI XR ORAL CAPSULE, EXT-RELEASE 4HR 00 MG, 00 MG, 5 MG, 50 MG valproic acid (as sodium salt) oral solution 50 /5 ml valproic acid oral capsule 50 vigabatrin oral powder in packet 500 VIGADRONE POWDER IN PACKET 500 MG (ORAL) VIMPAT ORAL SOLUTION 0 MG/ML SP; LA SP VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG zonisamide oral capsule 00, 5, 50 Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML benztropine oral tablet 0.5,, bromocriptine oral capsule 5 bromocriptine oral tablet.5 carbidopa oral tablet 5 carbidopa-levodopa oral tablet 0-00, 5-00, 5-50 carbidopa-levodopa oral tablet extended release 5-00, carbidopa-levodopa oral tablet, disintegrating 0-00, 5-00, 5-50 carbidopa-levodopaentacapone oral tablet , , , , , ELDEPRYL ORAL CAPSULE 5 MG entacapone oral tablet 00 NEUPRO TRANSDERMAL PATCH 4 HOUR MG/4 HOUR, MG/4 HOUR, 3 MG/4 HOUR, 4 MG/4 HOUR, 6 MG/4 HOUR, 8 MG/4 HOUR SP; LA 5

18 pramipexole oral tablet 0.5, 0.5, 0.5, 0.75,,.5 pramipexole oral tablet extended release 4 hr 0.375, 0.75,.5,.5, 3, 3.75, 4.5 rasagiline oral tablet 0.5, ropinirole oral tablet 0.5, 0.5,,, 3, 4, 5 ropinirole oral tablet extended release 4 hr,, 4, 6, 8 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 tolcapone oral tablet 00 trihexyphenidyl oral elixir 0.4 /ml trihexyphenidyl oral tablet, 5 Migraine / Cluster Headache Therapy dihydroergotamine injection solution /ml QL dihydroergotamine nasal spray, non-aerosol 0.5 QL /pump act. (4 /ml) ERGOMAR SUBLINGUAL TABLET MG ergotamine-caffeine oral tablet -00 isometh-dichloralacetaminophen oral capsule isomethepten-cafacetaminophen oral tablet MIGERGOT RECTAL SUPPOSITORY -00 MG RELPAX ORAL TABLET 0 MG, 40 MG QL rizatriptan oral tablet 0, 5 QL rizatriptan oral tablet, disintegrating 0, 5 QL sumatriptan succinate oral tablet 00, 5, 50 QL Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE HR PA;SP;LA;QL 0 MG AUBAGIO ORAL TABLET 4 MG, 7 MG PA; SP; QL COPAXONE 0 MG/ML SUBCUTANEOUS SYRINGE PA; SP; QL donepezil oral tablet 0, 3, 5 PA EXELON TRANSDERMAL PATCH 4 HOUR 3.3 MG/4 HOUR, 4.6 MG/4 PA HR, 9.5 MG/4 HR galantamine oral capsule, ext rel. pellets 4 PA hr 6, 4, 8 galantamine oral solution 4 /ml PA galantamine oral tablet, 4, 8 PA GILENYA ORAL CAPSULE 0.5 MG PA; SP; QL HORIZANT ORAL TABLET EXTENDED RELEASE 300 MG, 600 MG memantine oral capsule, sprinkle, er 4hr 4,, 8, 7 ST 6

19 memantine oral solution /ml PA memantine oral tablet 0, 5 PA memantine oral tablets, dose pack 5-0 PA NUEDEXTA ORAL CAPSULE 0-0 MG QL rivastigmine tartrate oral capsule.5, 3, 4.5 PA, 6 tetrabenazine oral tablet.5, 5 PA; SP Muscle Relaxants / Antispasmodic Therapy baclofen oral tablet 0, 0 carisoprodol oral tablet 50, 350 carisoprodol-asa-codeine oral tablet PA; QL carisoprodol-aspirin oral tablet chlorzoxazone oral tablet 50, 500 cyclobenzaprine oral tablet 0, 5, 7.5 dantrolene oral capsule 00, 5, 50 meprobamate oral tablet 00, 400 MESTINON ORAL SYRUP 60 MG/5 ML METAXALL ORAL TABLET 800 MG metaxalone oral tablet 400, 800 methocarbamol oral tablet 500, 750 orphenadrine citrate oral tablet extended release 00 pyridostigmine bromide oral tablet 60 pyridostigmine bromide oral tablet extended release 80 tizanidine oral capsule, 4, 6 tizanidine oral tablet, 4 Narcotic Analgesics acetaminophen-caffdihydrocod oral capsule acetaminophen-codeine oral solution 0- /5 ml acetaminophen-codeine oral tablet 300-5, , ASCOMP WITH CODEINE ORAL CAPSULE MG BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE MG butalbital-acetaminopcaf-cod oral capsule , butalbitalacetaminophen oral tablet , butalbitalacetaminophen-caff oral capsule , butalbitalacetaminophen-caff oral tablet PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL 7

20 butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet BUTRANS TRANSDERMAL PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 0 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR CAPACET ORAL CAPSULE MG CAPITAL WITH CODEINE ORAL SUSPENSION 0- MG/5 ML codeine sulfate oral tablet 5, 30, 60 DISKETS ORAL TABLET,SOLUBLE 40 MG EMBEDA ORAL CAPSULE, ORAL ONLY, EXT.REL PELL 00-4 MG, MG, 30-. MG, 50- MG, MG, MG ENDOCET ORAL TABLET 0-35 MG,.5-35 MG, 5-35 MG, MG fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL hydrocodoneacetaminophen oral tablet 0-300, 0-35,.5-35, 5-300, 5-35, , hydrocodone-ibuprofen oral tablet 0-00, 5-00, hydromorphone oral tablet, 4, 8 hydromorphone rectal suppository 3 ibuprofen-oxycodone oral tablet levorphanol tartrate oral tablet LORCET (HYDROCODONE) ORAL TABLET 5-35 MG LORCET HD ORAL TABLET 0-35 MG LORCET PLUS ORAL TABLET MG meperidine oral solution 50 /5 ml meperidine oral tablet 00, 50 METHADOSE ORAL CONCENTRATE 0 MG/ML METHADOSE ORAL TABLET,SOLUBLE 40 MG morphine concentrate oral solution 00 /5 ml (0 /ml) morphine oral solution 0 /5 ml, 0 /5 ml (4 /ml) morphine oral tablet 5, 30 PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL hydrocodoneacetaminophen oral PA; QL solution /5 ml 8

21 morphine oral tablet extended release 00, 5, 00, 30, 60 morphine rectal suppository 0, 0, 30, 5 oxycodone oral capsule 5 oxycodone oral concentrate 0 /ml oxycodone oral solution 5 /5 ml oxycodone oral tablet 0, 5, 0, 30, 5 oxycodoneacetaminophen oral tablet 0-35,.5-35, 5-35, oxycodone-aspirin oral tablet oxymorphone oral tablet 0, 5 PHRENILIN FORTE(WITH CAFFEINE) ORAL CAPSULE MG TENCON ORAL TABLET MG VICODIN ES ORAL TABLET MG VICODIN HP ORAL TABLET MG VICODIN ORAL TABLET MG XYLON 0 ORAL TABLET 0-00 MG ZEBUTAL ORAL CAPSULE MG Non-Narcotic Analgesics ADULT ASPIRIN REGIMEN ORAL TABLET, DELAYED RELEASE (DR/EC) 8 MG PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL PA; QL ADULT LOW DOSE ASPIRIN ORAL TABLET, DELAYED RELEASE (DR/EC) 8 MG ASPIR-8 ORAL TABLET, DELAYED RELEASE (DR/EC) 8 MG ASPIRIN CHILDRENS ORAL TABLET, CHEWABLE 8 MG ASPIRIN LOW DOSE ORAL TABLET, DELAYED RELEASE (DR/EC) 8 MG aspirin oral tablet 35 aspirin oral tablet, chewable 8 aspirin oral tablet, delayed release (dr/ec) 35, 8 aspirin, buffered oral tablet 35 ASPIR-LOW ORAL TABLET, DELAYED RELEASE (DR/EC) 8 MG ASPIR-TRIN ORAL TABLET, DELAYED RELEASE (DR/EC) 35 MG BAYER ASPIRIN ORAL TABLET 35 MG BUFFERIN ORAL TABLET 35 MG buprenorphine-naloxone sublingual film 8- QL buprenorphine-naloxone sublingual tablet -0.5 QL, 8- butorphanol tartrate nasal spray, non-aerosol PA; QL 0 /ml celecoxib oral capsule 00, 00, 400, 50 CHILDREN'S ASPIRIN ORAL TABLET, CHEWABLE 8 MG 9

22 choline, magnesium salicylate oral liquid 500 /5 ml diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release 4 hr 00 diclofenac sodium oral tablet, del-release (dr/ec) 5, 50, 75 diclofenac sodium topical drops.5 % diclofenac sodium topical gel % diclofenac-misoprostol oral tablet, ir, delayed rel, biphasic mcg, mcg diflunisal oral tablet 500 E.C. PRIN ORAL TABLET, DELAYED RELEASE (DR/EC) 35 MG ECOTRIN LOW STRENGTH ORAL TABLET, DELAYED RELEASE (DR/EC) 8 MG ECOTRIN ORAL TABLET, DELAYED RELEASE (DR/EC) 35 MG ENTERIC COATED ASPIRIN ORAL TABLET, DELAYED RELEASE (DR/EC) 8 MG etodolac oral capsule 00, 300 etodolac oral tablet 400, 500 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 QL FLECTOR TRANSDERMAL PATCH HOUR.3 % flurbiprofen oral tablet 00, 50 IBU ORAL TABLET 400 MG, 600 MG, 800 MG ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 5, 50 indomethacin oral capsule, extended release 75 ketoprofen oral capsule 50, 75 ketoprofen oral capsule, ext rel. pellets 4 hr 00 ketorolac injection cartridge 5 /ml, 30 /ml ketorolac injection solution 5 /ml, 30 /ml, 30 /ml ( ml) ketorolac injection syringe 5 /ml, 30 /ml ketorolac intramuscular cartridge 60 / ml ketorolac intramuscular solution 60 / ml ketorolac intramuscular syringe 60 / ml ketorolac oral tablet 0 LITE COAT ASPIRIN ORAL TABLET 35 MG meclofenamate oral capsule 00, 50 mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml QL QL 0

23 meloxicam oral tablet 5, 7.5 nabumetone oral tablet 500, 750 naltrexone oral tablet 50 naproxen oral suspension 5 /5 ml naproxen oral tablet 50, 375, 500 naproxen oral tablet, delayed release (dr/ec) 375, 500 naproxen sodium oral tablet 550 naproxen sodium oral tablet, er multiphase 4 hr 375, 500 NARCAN NASAL SPRAY, NON-AEROSOL 4 MG/ACTUATION NUCYNTA ER ORAL TABLET EXTENDED RELEASE HR 00 MG, 50 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 00 MG, 50 MG, 75 MG oxaprozin oral tablet 600 PENNSAID TOPICAL SOLUTION IN METERED- DOSE PUMP 0 MG/GRAM /ACT( %) pentazocine-naloxone oral tablet piroxicam oral capsule 0, 0 PROFENO ORAL TABLET 600 MG salsalate oral tablet 500, 750 sulindac oral tablet 50, 00 QL PA; QL PA; QL QL PA; QL tolmetin oral capsule 400 tolmetin oral tablet 00, 600 tramadol oral capsule, er biphase 4 hr tramadol oral capsule, er biphase 4 hr , 00 tramadol oral tablet 50 tramadolacetaminophen oral tablet TRI-BUFFERED ASPIRIN ORAL TABLET 35 MG ZUBSOLV SUBLINGUAL TABLET MG, MG,.4-.9 MG, MG, MG, MG Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG ADDERALL XR ORAL CAPSULE, EXTENDED RELEASE 4HR 0 MG, 5 MG, 0 MG, 5 MG, 30 MG, 5 MG ADZENYS ER ORAL SUSPEN, IR - ER, BIPHASIC 4HR.5 MG/ML PA; QL PA; QL PA; QL PA; QL PA; QL

24 ADZENYS XR-ODT ORAL TABLET, DISINTEG ER BIPHASE 4H.5 MG, 5.7 MG, 8.8 MG, 3. MG, 6.3 MG, 9.4 MG ALPRAZOLAM INTENSOL ORAL CONCENTRATE MG/ML alprazolam oral tablet 0.5, 0.5,, alprazolam oral tablet extended release 4 hr 0.5,,, 3 alprazolam oral tablet, disintegrating 0.5, 0.5,, amitriptyline oral tablet 0, 00, 50, 5, 50, 75 amitriptylinechlordiazepoxide oral tablet.5-5, 5-0 amoxapine oral tablet 00, 50, 5, 50 APTENSIO XR ORAL CAP, ER SPRINKLE, BIPHASIC MG, 5 MG, 0 MG, 30 MG, 40 MG, 50 MG, 60 MG aripiprazole oral solution /ml aripiprazole oral tablet 0, 5,, 0, 30, 5 aripiprazole oral tablet, disinteg 0, 5 ARISTADA SUSPENSION, EXTENDED REL SYRINGE INTRAMUSCULAR,064 MG/3.9 ML, 44 MG/.6 ML, 66 MG/.4 ML, 88 MG/3. ML QL QL armodafinil oral tablet 50, 00, 50, 50 atomoxetine oral capsule 0, 00, 8, 5, 40, 60, 80 bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release hr 00, 50, 00 bupropion hcl oral tablet extended release 4 hr 50, 300 buspirone oral tablet 0, 5, 30, 5, 7.5 chlordiazepoxide hcl oral capsule 0, 5, 5 chlorpromazine oral tablet 0, 00, 00, 5, 50 citalopram oral solution 0 /5 ml citalopram oral tablet 0, 0, 40 clomipramine oral capsule 5, 50, 75 clorazepate dipotassium oral tablet 5, 3.75, 7.5 clozapine oral tablet 00, 00, 5, 50 clozapine oral tablet, disintegrating 00,.5, 5 clozapine oral tablet, disinteg 50, 00 QL QL

25 COTEMPLA XR-ODT ORAL TABLET, DISINTEG ER BIPHASE 4H 7.3 MG, 5.9 MG, 8.6 MG DAYTRANA 4 HOUR TRANSDERMAL PATCH 0 MG/9 HR, 5 MG/9 HR, 0 MG/9 HR, 30 MG/9 HR desipramine oral tablet 0, 00, 50, 5, 50, 75 desvenlafaxine succinate oral tablet extended release 4 hr 00, 5, 50 dexmethylphenidate oral tablet 0,.5, 5 dextroamphetamine oral capsule, ext-release 0, 5, 5 dextroamphetamine oral tablet 0, 5 dextroamphetamineamphetamine oral tablet 0,.5, 5, 0, 30, 5, 7.5 DIAZEPAM INTENSOL ORAL CONC. 5 MG/ML diazepam oral solution 5 /5 ml ( /ml) diazepam oral tablet 0,, 5 doxepin oral capsule 0, 00, 50, 5, 50, 75 doxepin oral concentrate 0 /ml duloxetine oral capsule, del-release(dr/ec) 0, 30, 40, 60 DYANAVEL XR ORAL SUSPEN, IR - ER, BIPHASIC 4HR.5 MG/ML ergoloid oral tablet escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 0, 0, 5 estazolam oral tablet, eszopiclone oral tablet,, 3 QL EVEKEO ORAL TABLET 0 MG, 5 MG FANAPT ORAL TABLET MG, 0 MG, MG, QL MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS, DOSE PACK MG()- QL MG()- 4MG()-6MG() FAZACLO ORAL TABLET, DISINTEG 50 MG, 00 MG FETZIMA ORAL CAPSULE, EXT REL 4HR DOSE PACK 0 MG ()- 40 MG (6) FETZIMA ORAL CAPSULE, EXT RELEASE 4HR 0MG, 0 MG, 40 MG, 80 MG fluoxetine oral capsule 0, 0, 40 fluoxetine oral capsule, del-release(dr/ec) 90 fluoxetine oral solution 0 /5 ml (4 /ml) fluoxetine oral tablet 0, 0, 60 fluphenazine decanoate injection solution 5 /ml fluphenazine hcl injection solution.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir.5 /5 ml 3

26 fluphenazine hcl oral tablet, 0,.5, 5 flurazepam oral capsule 5, 30 fluvoxamine oral capsule, extended release 4hr 00, 50 fluvoxamine oral tablet 00, 5, 50 FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 5 MG, 0 MG, 5 MG, 30 MG, 35 MG, 40 MG, 5 MG guanfacine oral tablet extended release 4 hr,, 3, 4 guanidine tablet 5 haloperidol decanoate intramuscular solution 00 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate /ml haloperidol oral tablet 0.5,, 0,, 0, 5 imipramine hcl oral tablet 0, 5, 50 imipramine pamoate oral capsule 00, 5, 50, 75 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML, 56 MG/ML, 34 MG/.5 ML, 39 MG/0.5 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 73 MG/0.875 ML, 40 MG/.35 ML, 546 MG/.75 ML, 89 MG/.65 ML LATUDA ORAL TABLET 0 MG, 0 MG, 40 MG, 60 MG, 80 MG lithium carbonate oral capsule 50, 300, 600 lithium carbonate oral tablet 300 lithium carbonate oral tablet extended release 300, 450 lithium citrate oral solution 8 meq/5 ml LORAZEPAM INTENSOL ORAL CONC. MG/ML lorazepam oral concentrate /ml lorazepam oral tablet 0.5,, loxapine succinate oral capsule 0, 5, 5, 50 maprotiline oral tablet 5, 50, 75 methamphetamine oral tablet 5 methylphenidate hcl oral capsule, er biphasic , 0, 30, 40, 50, 60 methylphenidate hcl oral capsule, er biphasic , 0, 30, 40, 60 methylphenidate hcl oral solution 0 /5 ml, 5 /5 ml QL 4

27 methylphenidate hcl oral tablet 0, 0, 5 methylphenidate hcl oral tablet extended release 0, 0 methylphenidate hcl oral tablet extended release 4hr 8, 7, 36, 54 methylphenidate hcl oral tablet, chewable 0,.5, 5 midazolam oral syrup /ml mirtazapine oral tablet 5, 30, 45, 7.5 mirtazapine oral tablet, disintegrating 5, 30, 45 modafinil oral tablet 00, 00 QL MYDAYIS ORAL CAPSULE, ER TRIPHASIC 4 HR.5 MG, 5 MG, 37.5 MG, 50 MG nefazodone oral tablet 00, 50, 00, 50, 50 nortriptyline capsule 0, 5, 50, 75 nortriptyline oral solution 0 /5 ml NUPLAZID TABLET 7 MG ST; SP; QL olanzapine intramuscular recon soln 0 olanzapine oral tablet 0, 5,.5, 0, 5, 7.5 olanzapine oral tablet, disintegrating 0, 5, 0, 5 olanzapine-fluoxetine oral capsule -5, -50, 3-5, 6-5, 6-50 oxazepam oral capsule 0, 5, 30 paliperidone oral tablet extended release 4hr.5, 3, 6, 9 paroxetine hcl oral tablet 0, 0, 30, 40 QL paroxetine hcl oral tablet extended release 4 hr.5, 5, 37.5 paroxetine mesylate (menop. sym) oral capsule 7.5 PAXIL ORAL SUSPENSION 0 MG/5 ML perphenazine oral tablet 6,, 4, 8 perphenazineamitriptyline oral tablet - 0, -5, 4-0, 4-5, 4-50 PEXEVA TABLET 0 MG, 0 MG, 30 MG, 40 MG phenelzine tablet 5 pimozide oral tablet, PROCENTRA ORAL SOLUTION 5 MG/5 ML protriptyline oral tablet 0, 5 quazepam tablet 5 quetiapine oral tablet 00, 00, 5, 300 QL, 400, 50 quetiapine oral tablet extended release 4 hr 50, 00, 300, 400, 50 QL 5

28 QUILLICHEW ER ORAL TABLET, CHEW, IR-ER. BIPHASIC4HR 0 MG, 30 MG, 40 MG QUILLIVANT XR ORAL SUSPENSION, EXT REL 4HR, RECON 5 MG/ML (5 MG/5 ML) REXULTI ORAL TABLET 0.5 MG, 0.5 MG, MG, MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE.5 MG/ ML, 5 MG/ ML, 37.5 MG/ ML, 50 MG/ ML risperidone oral solution /ml risperidone oral tablet 0.5, 0.5,,, 3, 4 risperidone oral tablet, disinteg 0.5, 0.5,,, 3, 4 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG,.5 MG, 5 MG SECONAL SODIUM ORAL CAPSULE 00 MG sertraline oral concentrate 0 /ml sertraline oral tablet 00, 5, 50 temazepam capsule 5,., 30, 7.5 thioridazine tablet 0, 00, 5, 50 thiothixene oral capsule, 0,, 5 tranylcypromine oral tablet 0 trazodone tablet 00, 50, 300, 50 QL QL triazolam oral tablet 0.5, 0.5 trifluoperazine oral tablet, 0,, 5 trimipramine oral capsule 00, 5, 50 TRINTELLIX ORAL TABLET 0 MG, 0 MG, 5 MG venlafaxine oral capsule, extended release 4hr 50, 37.5, 75 venlafaxine oral tablet 00, 5, 37.5, 50, 75 venlafaxine oral tablet extended release 4hr 50, 37.5, 75 VIIBRYD ORAL TABLET 0 MG, 0 MG, 40 MG VIIBRYD ORAL TABLETS, DOSE PACK 0 MG (7)- 0 MG (3) VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- 3 MG (6) VYVANSE CAPSULE 0MG, 0MG, 30MG, 40MG, 50MG, 60MG, 70MG VYVANSE TABLET, CHEWABLE 0MG, 0MG, 30MG,40MG,50MG,60MG zaleplon oral capsule 0, 5 ziprasidone hcl oral capsule 0, 40, 60, 80 zolpidem oral tablet 0, 5 QL QL QL QL QL QL QL 6

29 zolpidem oral tablet, ext release multiphase.5, 6.5 ZYPREXA RELPREVV INTRAMUSCULAR SUSP FOR RECONSTITUTION 0 MG, 300 MG, 405 MG QL CARDIOVASCULAR / HYPERTENSION / LIPIDS Antiarrhythmic Agents amiodarone oral tablet 00, 00, 400 disopyramide phosphate capsule 00, 50 dofetilide capsule 5 mcg, 50 mcg, 500 mcg flecainide oral tablet 00, 50, 50 mexiletine oral capsule 50, 00, 50 MULTAQ TABLET 400 MG NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 00 MG, 50 MG PACERONE ORAL TABLET 00 MG, 00 MG, 400 MG propafenone oral capsule, extended release hr 5, 35, 45 propafenone oral tablet 50, 5, 300 quinidine gluconate injection solution 80 /ml quinidine gluconate oral tablet extended release 34 quinidine sulfate oral tablet 00, 300 SOTALOL AF ORAL TABLET 0 MG, 60 MG, 80 MG sotalol oral tablet 0, 60, 40, 80 Antihypertensive Therapy acebutolol oral capsule 00, 400 AFEDITAB CR ORAL TABLET EXTENDED RELEASE 30 MG, 60 MG amiloride oral tablet 5 amiloridehydrochlorothiazide oral tablet 5-50 amlodipine oral tablet 0,.5, 5 amlodipine-benazepril oral capsule 0-0, 0-40,.5-0, 5-0, 5-0, 5-40 amlodipine-olmesartan oral tablet 0-0, 0-40, 5-0, 5-40 amlodipine-valsartan oral tablet 0-60, 0-30, 5-60, 5-30 amlodipine-valsartanhcthiazid oral tablet , , , , atenolol oral tablet 00, 5, 50 atenolol-chlorthalidone oral tablet 00-5, 50-5 benazepril oral tablet 0, 0, 40, 5 benazeprilhydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5,

30 betaxolol oral tablet 0, 0 BIDIL TABLET MG bisoprolol fumarate oral tablet 0, 5 bisoprololhydrochlorothiazide oral tablet 0-6.5,.5-6.5, bumetanide oral tablet 0.5,, BYSTOLIC ORAL TABLET 0 MG,.5 MG, 0 MG, 5 MG candesartan oral tablet 6, 3, 4, 8 candesartanhydrochlorothiazide oral tablet 6-.5, 3-.5, 3-5 captopril tablet 00,.5, 5, 50 captoprilhydrochlorothiazide oral tablet 5-5, 5-5, 50-5, 50-5 CARTIA XT ORAL CAPSULE, EXTENDED RELEASE 4HR 0 MG, 80 MG, 40 MG, 300 MG carvedilol oral tablet.5, 5, 3.5, 6.5 carvedilol phosphate oral capsule, er multiphase 4 hr 0, 0, 40, 80 chlorothiazide oral tablet 50, 500 chlorthalidone oral tablet 5, 50 clonidine hcl oral tablet 0., 0., 0.3 clonidine transdermal patch weekly 0. /4 hr, 0. /4 hr, 0.3 /4 hr CLORPRES ORAL TABLET 0.-5 MG, 0.-5 MG CLORPRES ORAL TABLET MG diltiazem hcl oral capsule, ext. rel 4h degradable 0, 80, 40 diltiazem hcl oral capsule, extended release hr 0, 60, 90 diltiazem hcl oral capsule, extended release 4 hr 0, 80, 40, 300, 360, 40 diltiazem hcl capsule, extended release 4hr 0, 80, 40, 300, 360 diltiazem hcl tablet 0, 30, 60, 90 diltiazem hcl oral tablet extended release 4 hr 80, 40, 300, 360, 40 DILT-XR ORAL CAPSULE, EXT.REL 4H DEGRADABLE 0 MG, 80 MG, 40 MG DIURIL ORAL SUSPENSION 50 MG/5 ML doxazosin oral tablet,, 4, 8 enalapril maleate tablet 0,.5, 0, 5 enalaprilhydrochlorothiazide oral tablet 0-5, 5-.5 QL 8

31 eplerenone oral tablet 5, 50 eprosartan tablet 600 ethacrynic acid oral tablet 5 felodipine oral tablet extended release 4 hr 0,.5, 5 fosinopril oral tablet 0, 0, 40 fosinoprilhydrochlorothiazide tablet 0-.5, 0-.5 furosemide oral soln 0 /ml, 40/5 ml (8/ml) furosemide oral tablet 0, 40, 80 guanfacine oral tablet, hydralazine tablet 0, 00, 5, 50 hydrochlorothiazide oral capsule.5 hydrochlorothiazide oral tablet.5, 5, 50 indapamide oral tablet.5,.5 irbesartan oral tablet 50, 300, 75 irbesartanhydrochlorothiazide oral tablet 50-.5, isradipine oral capsule.5, 5 labetalol oral tablet 00, 00, 300 lisinopril oral tablet 0,.5, 0, 30, 40, 5 lisinoprilhydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5 losartan oral tablet 00, 5, 50 losartanhydrochlorothiazide oral tablet 00-.5, 00-5, MATZIM LA ORAL TABLET EXTENDED RELEASE 4 HR 80 MG, 40 MG, 300 MG, 360 MG, 40 MG methyclothiazide oral tablet 5 methyldopa oral tablet 50, 500 methyldopahydrochlorothiazid tablet 50-5, 50-5 metolazone oral tablet 0,.5, 5 metoprolol succinate oral tablet extended release 4 hr 00, 00, 5, 50 metoprolol tartratehydrochlorothiazide oral tablet 00-5, 00-50, 50-5 metoprolol tartrate oral tablet 00, 5, 37.5, 50, 75 minoxidil oral tablet 0,.5 moexipril oral tablet 5, 7.5 moexiprilhydrochlorothiazide oral tablet 5-.5, 5-5,

32 nadolol oral tablet 0, 40, 80 nadololbendroflumethiazide oral tablet 40-5, 80-5 nicardipine oral capsule 0, 30 nifedipine oral capsule 0, 0 nifedipine oral tablet extended release 4hr 30, 60, 90 nifedipine oral tablet extended release 30, 60, 90 nimodipine oral capsule 30 nisoldipine oral tablet extended release 4 hr 7, 0, 5.5, 30, 34, 40, 8.5 olmesartan oral tablet 0, 40, 5 olmesartan-amlodipinehcthiazid oral tablet , , , , olmesartanhydrochlorothiazide oral tablet 0-.5, 40-.5, 40-5 ORENITRAM ORAL TABLET EXTENDED RELEASE 0.5 MG, 0.5 MG, MG,.5 MG, 5 MG perindopril erbumine oral tablet, 4, 8 phenoxybenzamine oral capsule 0 pindolol oral tablet 0, 5 PA; SP prazosin oral capsule,, 5 propranolol oral capsule, extended release 4 hr 0, 60, 60, 80 propranolol oral solution 0 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 0, 40, 60, 80 propranololhydrochlorothiazide oral tablet 40-5, 80-5 quinapril oral tablet 0, 0, 40, 5 quinaprilhydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5 ramipril oral capsule.5, 0,.5, 5 RESECTISOL URETHRAL SOLUTION 5 % spironolactone oral tablet 00, 5, 50 spironolactonehydrochlorothiazide oral tablet 5-5 TAZTIA XT ORAL CAPSULE, EXTENDED RELEASE 4 HR 0 MG, 80 MG, 40 MG, 300 MG, 360 MG TEKTURNA HCT ORAL TABLET MG, 50-5 MG, MG, MG TEKTURNA ORAL TABLET 50 MG, 300 MG telmisartan oral tablet 0, 40, 80 30

33 telmisartan-amlodipine oral tablet 40-0, 40-5, 80-0, 80-5 telmisartanhydrochlorothiazide oral tablet 40-.5, 80-.5, 80-5 terazosin oral capsule, 0,, 5 timolol maleate oral tablet 0, 0, 5 torsemide oral tablet 0, 00, 0, 5 trandolapril oral tablet,, 4 trandolapril-verapamil oral tablet, ir - er, biphasic 4hr -40, -80, -40, 4-40 triamterenehydrochlorothiaz capsule , 50-5 triamterenehydrochlorothiazid tablet ,75-50 valsartan oral tablet 60, 30, 40, 80 valsartanhydrochlorothiazide oral tablet 60-.5, 60-5, 30-.5, 30-5, verapamil oral capsule, 4 hr er pellet ct 00, 00, 300 verapamil capsule,ext rel. pellets 4 hr 0, 80, 40, 360 verapamil oral tablet 0, 40, 80 verapamil oral tablet extended release 0, 80, 40 Cardiac Glycosides DIGITEK ORAL TABLET 5 MCG, 50 MCG DIGOX ORAL TABLET 5 MCG, 50 MCG digoxin oral solution 50 mcg/ml digoxin oral tablet 5 mcg, 50 mcg Coagulation Therapy AGGRENOX ORAL CAPSULE, ER MULTIPHASE HR 5-00 MG AMICAR ORAL SOLUTION 50 MG/ML (5 %) AMICAR ORAL TABLET,000 MG, 500 MG BEVYXXA ORAL CAPSULE 40 MG, 80 MG BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00, 50 clopidogrel oral tablet 75 dipyridamole oral tablet 5, 50, 75 ELIQUIS ORAL TABLET.5 MG, 5 MG ELIQUIS ORAL TABLETS, DOSE PACK 5 MG (74 TABS) enoxaparin subcutaneous solution 300 /3 ml QL 3

34 enoxaparin subcutaneous syringe 00 /ml, 0 /0.8 ml, 50 /ml, 30 /0.3 ml, 40 /0.4 ml, 60 /0.6 ml, 80 /0.8 ml fondaparinux subcutaneous syringe 0 /0.8 ml,.5 /0.5 ml, 5 /0.4 ml, 7.5 /0.6 ml heparin (porcine) injection cartridge 5,000 unit/ml ( ml) heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 0,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml JANTOVEN ORAL TABLET MG, 0 MG, MG,.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG MEPHYTON ORAL TABLET 5 MG pentoxifylline oral tablet extended release 400 phytonadione (vitamin k) oral tablet 5 PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG PROMACTA TABLET.5 MG, 5MG, 50MG, 75MG warfarin tablet, 0,,.5, 3, 4, 5, 6, 7.5 PA; SP; LA; QL XARELTO ORAL TABLET 0 MG, 5 MG, 0 MG XARELTO TABLETS, DOSE PACK 5MG(4)- 0MG(9) Lipid/Cholesterol Lowering Agents amlodipine-atorvastatin oral tablet 0-0, 0-0, 0-40, 0-80,.5-0,.5-0, QL.5-40, 5-0, 5-0, 5-40, 5-80 atorvastatin oral tablet 0, 0 ; QL atorvastatin oral tablet 40, 80 QL cholestyramine (with sugar) oral powder 4gm QL cholestyramine (with sugar) oral powder in QL packet 4 gram CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM QL CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM colesevelam oral tablet 65 colestipol granules 5gram colestipol packet 5 gram colestipol tablet gram ezetimibe tablet 0 QL ezetimibe-simvastatin oral tablet 0-0, 0-0, 0-40, 0-80 fenofibrate micronized capsule 30, 34, 00, 43, 67 fenofibrate nanocrystallized oral tablet 45, 48 fenofibrate tablet 0, 60, 40, 54 QL 3

35 fenofibric acid (choline) oral capsule, del-rel (dr/ec) 35, 45 fenofibric acid oral tablet 05, 35 fluvastatin oral capsule 0, 40 ; QL fluvastatin oral tablet extrelease 4 hr 80 ; QL gemfibrozil tablet 600 lovastatin oral tablet 0, 0, 40 ; QL niacin oral tablet extrelease 4 hr,000, 500, 750 omega-3 acid ethyl esters oral capsule gram PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML, 75 PA; SP MG/ML pravastatin oral tablet 0, 0, 40, 80 ; QL PREVALITE ORAL POWDER 4 GRAM QL PREVALITE ORAL POWDER IN PACKET 4 GRAM REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 40 PA; SP; QL MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN PA; SP; QL INJECTOR 40 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE PA; SP; QL 40 MG/ML rosuvastatin oral tablet 0, 5 ; QL rosuvastatin oral tablet 0, 40 QL simvastatin oral tablet 0, 0, 40, 5 ; QL simvastatin oral tablet 80 QL TRIKLO ORAL CAPSULE GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 65 MG Miscellaneous Cardiovascular Agents CORLANOR ORAL TABLET 5 MG, 7.5 MG ENTRESTO ORAL TABLET 4-6 MG, 49-5 MG, 97- PA 03 MG RANEXA ORAL TABLET EXTENDED RELEASE HR,000 MG, 500 MG Nitrates DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 40 MG ISORDIL TABLET 40 MG isosorbide dinitrate oral tablet 0, 0, 30, 5 isosorbide dinitrate oral tablet extended release 40 isosorbide mononitrate oral tablet 0, 0 isosorbide mononitrate oral tablet extended release 4 hr 0, 30, 60 NITRO-BID TRANSDERMAL OINTMENT % nitroglycerin oral capsule, extended release.5, 6.5, 9 nitroglycerin sublingual tablet 0.3, 0.4,

36 nitroglycerin transdermal patch 4 hour 0. /hr, 0. /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual spray, non-aerosol 400 mcg/spray DERMATOLOGICALS / TOPICAL THERAPY Antipsoriatic / Antiseborrheic acitretin oral capsule 0, 7.5, 5 calcipotriene scalp solution % calcipotriene topical cream % calcipotriene topical ointment % calcipotrienebetamethasone topical QL ointment % CALCITRENE TOPICAL OINTMENT % calcitriol topical ointment 3 mcg/gram coal tar topical solution 0 % COSENTYX ( SYRINGES) SUBCUTANEOUS SYRINGE PA; SP; QL 50 MG/ML COSENTYX PEN ( PENS) SUBCUTANEOUS PEN PA; SP; QL INJECTOR 50 MG/ML DRITHOCREME HP TOPICAL CREAM % EPIFOAM TOPICAL FOAM - % PRAMOSONE E TOPICAL CREAM.5- % PRAMOSONE TOPICAL PRAMOSONE TOPICAL LOTION - %,.5- % PRAMOSONE TOPICAL OINTMENT - %,.5- % SEB-PREV TOPICAL CLEANSER 0 % selenium sulfide topical lotion.5 % selenium sulfide topical shampoo.5 %,.3 % SORILUX TOPICAL FOAM % sulfacetamide sodium topical cleanser 0 % sulfacetamide sodium topical cleanser, gel 0 % sulfacetamide sodium topical shampoo 0 % TACLONEX TOPICAL SUSPENSION % QL Burn Therapy silver sulfadiazine topical cream % SSD TOPICAL CREAM % Keratolytics salicylic acid erceramides topical kit, cleanser & cream er 6 % salicylic acid topical cream 6 % salicylic acid topical cream, extended release 6 % salicylic acid topical foam 6 % salicylic acid topical gel 6 % salicylic acid topical lotion 6 % salicylic acid topical lotion, extended release 6 % CREAM - %,.5- % 34

37 salicylic acid topical shampoo 6 % SALVAX TOPICAL FOAM 6 % Miscellaneous Dermatologicals CARAC TOPICAL CREAM 0.5 % CEM-UREA TOPICAL GEL 45 % CONDYLOX TOPICAL GEL 0.5 % diclofenac sodium topical gel 3 % doxepin topical cream 5 % DRYSOL DAB-O-MATIC TOPICAL SOLUTION 0 % DRYSOL TOPICAL SOLUTION 0 % DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/ ML PA; SP; QL ELIDEL TOPICAL CREAM % EUCRISA TOPICAL OINTMENT % PA; QL FLUOROPLEX TOPICAL CREAM % fluorouracil topical cream 5 % fluorouracil topical solution %, 5 % guaiacol liquid imiquimod topical cream in packet 5 % QL IODOFLEX TOPICAL PADS, MEDICATED 0.9 % IODOSORB TOPICAL GEL 0.9 % methoxsalen oral capsule, liquid-filled, rapid rel 0 MONSEL'S TOPICAL SOLUTION 0. TO 0. GRAM/ML IRON MONSEL'S TOPICAL SOLUTION WITH APPLICATOR 0. TO 0. GRAM/ML PANRETIN TOPICAL GEL 0. % phenol liquid podofilox topical solution 0.5 % PRUDOXIN TOPICAL CREAM 5 % RADIAGEL TOPICAL GEL REGRANEX TOPICAL GEL 0.0 % QL silver nitrate applicators topical stick 75-5 % silver nitrate topical ointment 0 % silver nitrate topical solution 0.5 %, 0 %, 5 %, 50 % SOLARAZE TOPICAL GEL 3 % PA SP ANTIPRURITIC TOPICAL GEL tacrolimus topical ointment 0.03 %, 0. % TRI-CHLOR TOPICAL SOLUTION 80 % UMECTA TOPICAL FOAM 40 % UREA NAIL STICK TOPICAL SOLUTION 50 % urea topical cream 39 %, 40 %, 45 %, 47 %, 50 % urea topical foam 35 % urea topical gel 45 % urea topical lotion 40 %, 45 % 35

38 ZONALON TOPICAL CREAM 5 % ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP.5 %, 3.75 % ZYCLARA TOPICAL CREAM IN PACKET 3.75 % Therapy For Acne ACANYA TOPICAL GEL WITH PUMP.-.5 % ACZONE TOPICAL GEL 5 % ACZONE TOPICAL GEL WITH PUMP 7.5 % adapalene topical gel 0.3 % adapalene topical gel with pump 0.3 % adapalene-benzoyl peroxide topical gel with pump % AVAR TOPICAL CLEANSER 0-5 % (W/W) AVITA TOPICAL CREAM 0.05 % AZELEX TOPICAL CREAM 0 % BP 0- TOPICAL CLEANSER 0- % CLARAVIS ORAL CAPSULE 0 MG, 0 MG, 30 MG, 40 MG CLEANSING WASH TOPICAL CLEANSER % CLINDACIN P TOPICAL SWAB % CLINDAGEL TOPICAL GEL, ONCE DAILY % clindamycin phosphate topical foam % clindamycin phosphate topical gel % QL QL PA clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin-benzoyl peroxide topical gel -5 %,. %( % base) -5 % clindamycin-benzoyl peroxide topical gel with pump -5 % clindamycin-tretinoin topical gel % dapsone topical gel 5 % DIFFERIN TOPICAL GEL 0.3 % EPIDUO FORTE TOPICAL GEL WITH PUMP % ERY PADS TOPICAL SWAB % ERYGEL TOPICAL GEL % erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % erythromycin with ethanol topical swab % erythromycin-benzoyl peroxide topical gel 3-5 % FINACEA TOPICAL FOAM 5 % FINACEA TOPICAL GEL 5 % isotretinoin oral capsule 0, 0, 30, 40 metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, % 36

39 metronidazole topical gel with pump % metronidazole topical lotion 0.75 % MYORISAN CAPSULE 0MG,0MG,30MG,40MG NEUAC TOPICAL GEL. %( % BASE) -5 % NORITATE TOPICAL CREAM % NUOX TOPICAL GEL 6-3 % ROSADAN TOPICAL CREAM 0.75 % ROSADAN TOPICAL GEL 0.75 % ROSULA CLEANSING CLOTHS TOPICAL PADS, MEDICATED 0-5 % SSS 0-5 TOPICAL CREAM 0-5 % (W/W) SSS 0-5 TOPICAL FOAM 0-5 % sulfacetamide sodiumsulfur topical cleanser 0- %, 0-5 % (w/w), 9-4 %, %, % sulfacetamide sodiumsulfur topical cream 0- %, 0-5 % (w/w), % sulfacetamide sodiumsulfur topical lotion 0-5 % (w/v), 0-5 % (w/w), % sulfacetamide sodiumsulfur topical pads, medicated 0-4 % sulfacetamide sodiumsulfur topical suspension 0-5 %, 8-4 % sulfacetamide sod-sulfururea topical cleanser % sulfacetamide-sulfurcleansr3 topical kit % SULFACLEANSE 8-4 TOPICAL SUSP 8-4 % sulfact na-sul-avobnz-otnocsa topical combo pack, cleanser and cream 9 %-4.5 % -spf 5 tazarotene topical cream 0. % TAZORAC TOPICAL CREAM 0.05 % TAZORAC TOPICAL GEL 0.05 %, 0. % tretinoin microspheres topical gel 0.04 %, 0. % tretinoin microspheres topical gel with pump 0.04 %, 0. % tretinoin topical cream 0.05 %, 0.05 %, 0. % tretinoin topical gel 0.0 %, 0.05 %, 0.05 % VANOXIDE-HC TOPICAL SUSPENSION % ZENATANE CAPSULE 0 MG, 0MG, 30MG, 40MG Topical Anesthetics GLYDO MUCOUS MEMBRANE JELLY IN APPLICATOR % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane jelly in applicator % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine hclhydrocortisone ac topical cream % PA PA PA PA 37