OPTIMA HEALTH OPTIMA FAMILY CARE (JANUARY MARCH 2019) PRESCRIPTION DRUG FORMULARY WITH MEDICAID EXPANSION (XP) Effective: January 1, 2019

Transcription

1 OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY OPTIMA FAMILY CARE WITH MEDICAID EXPANSION (XP) (JANUARY MARCH 2019) Revised: 1/2/2019

2 Table of Contents Analgesics - Drugs for Pain... 3 Analgesics - Drugs for Pain and Inflammation... 5 Anesthetics... 6 Anti-Addiction / Substance Abuse Treatment Agents... 6 Antibacterials... 7 Anticoagulants Anticonvulsants - Drugs for Seizures Antidementia Agents - Drugs for Alzheimer's Disease and Dementia Antidepressants Antiemetics - Drugs for Nausea and Vomiting Antifungals Antigout Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics - Drugs for Cancer Antiparasitics Antiparkinson Agents Antiplatelets Antipsychotics - Drugs for Mood Disorders Antivirals Anxiolytics - Drugs for Anxiety Bipolar Agents - Drugs for Mood Disorders Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders Cardiovascular Agents - Drugs for Heart and Circulation Conditions Central Nervous System Agents - Drugs for Attention Deficit Disorder Central Nervous System Agents - Drugs for Multiple Sclerosis Central Nervous System Agents - Miscellaneous Dental and Oral Agents - Drugs for Mouth and Throat Conditions Dermatological Agents - Drugs for Skin Conditions Diabetes - Antidiabetic Agents Diabetes - Glucose Monitoring Diabetes - Glycemic Agents Diabetes - Insulins Electrolytes / Minerals / Metals / Vitamins Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

3 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions Genetic or Enzyme Disorder: Drugs for Replacement, Modifiers, Treatment Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs for Prostate Conditions Hormonal Agents - Adrenal Hormonal Agents - Men's Health Hormonal Agents - Osteoporosis Hormonal Agents - Parathyroid Hormonal Agents - Pituitary Hormonal Agents - Sex Hormones and Birth Control Hormonal Agents - Thyroid Immunological Agents - Drugs for Immune System Stimulation or Suppression Immunological Agents - Drugs for Vaccination Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents - Drugs for Osteoporosis Miscellaneous Therapeutic Agents Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation Ophthalmic Agents - Drugs for Glaucoma Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions Otic Agents - Drugs for Ear Conditions Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm Sleep Disorder Agents

4 Analgesics - Drugs for Pain acetaminophen childrens oral tablet chewable 160 acetaminophen er oral tablet extended release 650 acetaminophen oral liquid 160 /5ml acetaminophen oral solution 160 /5ml, 325 /10.15ml, 650 /20.3ml acetaminophen oral tablet 325, 500 acetaminophen rectal suppository 120 acetaminophen-codeine #2 oral tablet QL (10 EA per 1 day) acetaminophen-codeine #3 oral tablet QL (10 EA per 1 day) acetaminophen-codeine #4 oral tablet QL (10 EA per 1 day) acetaminophen-codeine oral solution /5ml acetaminophen-codeine oral tablet , apap oral elixir 160 /5ml 3 QL (150 ML per 1 day) QL (10 EA per 1 day) butalbital-acetaminophen oral tablet QL (6 EA per 1 day) butalbital-apap oral tablet QL (6 EA per 1 day) butalbital-apap-caff-cod oral capsule butalbital-apap-caffeine oral capsule , QL (6 EA per 1 day) QL (6 EA per 1 day) butalbital-apap-caffeine oral tablet QL (6 EA per 1 day) butalbital-asa-caffeine oral capsule butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR PA; QL (4 EA per 28 days) capacet oral capsule QL (6 EA per 1 day) childrens acetaminophen oral suspension 160 /5ml childrens apap oral tablet chewable 80 childrens non-asa pain relief oral tablet chewable 80 childrens non-aspirin oral tablet chewable 80 duraxin oral capsule

5 endocet oral tablet QL (6 EA per 1 day) endocet oral tablet , QL (12 EA per 1 day) endocet oral tablet QL (8 EA per 1 day) esgic oral capsule QL (6 EA per 1 day) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral solution /5ml, /10ml, /15ml hydrocodone-acetaminophen oral tablet , hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet , 5-325, hydrocodone-acetaminophen oral tablet hydrocodone-ibuprofen oral tablet , 5-200, PA; QL (10 EA per 34 days) PA; QL (10 EA per 30 days) QL (6 ML per 1 day) QL (180 ML per 1 day) QL (6 EA per 1 day) QL (9 EA per 1 day) QL (12 EA per 1 day) QL (8 EA per 1 day) QL (5 EA per 1 day) hydromorphone hcl oral tablet 2 QL (11 EA per 1 day) hydromorphone hcl oral tablet 4 QL (5 EA per 1 day) hydromorphone hcl oral tablet 8 QL (2 EA per 1 day) ibudone oral tablet QL (5 EA per 1 day) infants pain reliever oral suspension 80 /0.8ml lorcet hd oral tablet QL (9 EA per 1 day) lorcet oral tablet QL (12 EA per 1 day) lorcet plus oral tablet QL (12 EA per 1 day) marten-tab oral tablet QL (6 EA per 1 day) morphine sulfate (concentrate) oral solution 100 /5ml, 20 /ml morphine sulfate er oral tablet extended release 100, 200, 60 morphine sulfate er oral tablet extended release 15, 30 QL (4 ML per 1 day) PA; QL (2 EA per 1 day) PA; QL (3 EA per 1 day) morphine sulfate oral solution 10 /5ml QL (30 ML per 1 day) morphine sulfate oral solution 20 /5ml QL (22 ML per 1 day) morphine sulfate oral tablet 15 QL (6 EA per 1 day) morphine sulfate oral tablet 30 QL (3 EA per 1 day) 4

6 NALOCET ORAL TABLET MG oxycodone hcl oral capsule 5 QL (6 EA per 1 day) oxycodone hcl oral solution 5 /5ml QL (30 ML per 1 day) oxycodone hcl oral tablet 10, 5 QL (6 EA per 1 day) oxycodone hcl oral tablet 15 QL (4 EA per 1 day) oxycodone hcl oral tablet 20 QL (3 EA per 1 day) oxycodone hcl oral tablet 30 QL (2 EA per 1 day) oxycodone-acetaminophen oral tablet QL (6 EA per 1 day) oxycodone-acetaminophen oral tablet , oxycodone-acetaminophen oral tablet QL (12 EA per 1 day) QL (8 EA per 1 day) phrenilin forte oral capsule QL (6 EA per 1 day) tencon oral tablet QL (6 EA per 1 day) tramadol hcl oral tablet 50 QL (8 EA per 1 day) verdrocet oral tablet QL (12 EA per 1 day) vicodin es oral tablet QL (6 EA per 1 day) vicodin hp oral tablet QL (6 EA per 1 day) vicodin oral tablet QL (8 EA per 1 day) xylon oral tablet QL (5 EA per 1 day) zebutal oral capsule QL (6 EA per 1 day) Analgesics - Drugs for Pain and Inflammation advil junior strength oral tablet 100 aspirin childrens oral tablet chewable 81 aspirin ec low dose oral tablet delayed release 81 aspirin low dose oral tablet chewable 81 aspirin oral tablet 325 aspirin oral tablet delayed release 325 bayer aspirin ec low dose oral tablet delayed release 81 bayer aspirin oral tablet 325 childrens ibuprofen oral suspension 40 /ml choline-mag trisalicylate oral liquid 500 /5ml diclofenac sodium oral tablet delayed release 25, 50, 75 gnp all day pain relief oral tablet 220 ibuprofen oral capsule 200 5

7 ibuprofen oral tablet 200, 400, 600, 800 meloxicam oral tablet 15, 7.5 naproxen dr oral tablet delayed release 375 QL (2.67 EA per 1 day) naproxen dr oral tablet delayed release 500 QL (2 EA per 1 day) naproxen oral tablet 250 QL (6 EA per 1 day) naproxen oral tablet 375 QL (4 EA per 1 day) naproxen oral tablet 500 QL (3 EA per 1 day) naproxen sodium oral tablet 220 salsalate oral tablet 500, 750 sulindac oral tablet 150, 200 VOLTAREN TRANSDERMAL GEL 1 % Anesthetics cocaine hcl external solution 4 % ethyl chloride external aerosol glydo external gel 2 % lidocaine external ointment 5 % lidocaine external patch 5 % QL (3 EA per 1 day) lidocaine hcl external cream 3 % lidocaine hcl external gel 2 % lidocaine hcl external lotion 3 % lidocaine hcl external solution 4 % lidocaine pak external ointment 5 % lidocaine-prilocaine external cream % lido-k external lotion 3 % lidopin external cream 3 % premium lidocaine external ointment 5 % Anti-Addiction / Substance Abuse Treatment Agents acamprosate calcium oral tablet delayed release 333 buprenorphine hcl sublingual tablet sublingual 2 buprenorphine hcl sublingual tablet sublingual 8 bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG 6 PA; QL (3 EA per 1 day) PA; QL (2 EA per 1 day) QL (183 EA per 365 days) QL (183 EA per 365 days)

8 CHANTIX ORAL TABLET 0.5 MG, 1 MG QL (183 EA per 365 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 disulfiram oral tablet 250, 500 naloxone hcl injection solution 0.4 /ml, 4 /10ml naloxone hcl injection solution cartridge 0.4 /ml naloxone hcl injection solution prefilled syringe 2 /2ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML 7 QL (183 EA per 365 days) nicotine polacrilex mouth/throat gum 2, 4 QL (183 EA per 365 days) nicotine polacrilex mouth/throat lozenge 2, 4 nicotine step 1 transdermal patch 24 hour 21 /24hr nicotine step 2 transdermal patch 24 hour 14 /24hr nicotine step 3 transdermal patch 24 hour 7 /24hr SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG QL (183 EA per 365 days) QL (183 EA per 365 days) QL (183 EA per 365 days) QL (183 EA per 365 days) PA; QL (1 EA per 1 day) SUBOXONE SUBLINGUAL FILM MG PA; QL (3 EA per 1 day) SUBOXONE SUBLINGUAL FILM 8-2 MG PA; QL (2 EA per 1 day) VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG Antibacterials amoxicillin oral capsule 250, 500 amoxicillin oral suspension reconstituted 125 /5ml, 200 /5ml, 250 /5ml, 400 /5ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 125, 250 amoxicillin-potassium clavulanate er oral tablet extended release 12 hour amoxicillin-potassium clavulanate oral suspension reconstituted /5ml, /5ml, /5ml, /5ml amoxicillin-potassium clavulanate oral tablet , , amoxicillin-potassium clavulanate oral tablet chewable ,

9 ampicillin oral capsule 500 AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML avidoxy oral tablet 100 azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 /5ml, 200 /5ml azithromycin oral tablet 250, 500, 600 bacitracin external ointment 500 unit/gm cefaclor oral capsule 250, 500 cefadroxil oral capsule 500 cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefixime oral suspension reconstituted 100 /5ml, 200 /5ml cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 cefuroxime axetil oral tablet 250, 500 cephalexin oral capsule 250, 500, 750 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml cephalexin oral tablet 250, 500 ciprofloxacin hcl oral tablet 100, 250, 500, 750 ciprofloxacin oral suspension reconstituted 250 /5ml (5%), 500 /5ml (10%) clarithromycin oral suspension reconstituted 125 /5ml clarithromycin oral tablet 250, 500 clarithromycin suspension reconstituted 250 /5ml oral 250 /5ml clarithromycin suspension reconstituted 250 /5ml oral 250 /5ml CLEOCIN VAGINAL SUPPOSITORY 100 MG clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml CLINDESSE VAGINAL CREAM 2 % 8 PA PA

10 coremino oral tablet extended release 24 hour 135, 45, 90 demeclocycline hcl oral tablet 150, 300 dicloxacillin sodium oral capsule 250, 500 doxycycline hyclate oral capsule 100, 50 doxycycline hyclate oral tablet 100, 20 doxycycline hyclate oral tablet delayed release 100, 150, 75 doxycycline monohydrate oral capsule 100, 150, 50, 75 doxycycline monohydrate oral suspension reconstituted 25 /5ml doxycycline monohydrate oral tablet 100, 150, 50, 75 e.e.s. 400 oral tablet 400 ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG erythromycin base oral capsule delayed release particles 250 erythromycin ethylsuccinate oral tablet 400 gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % levofloxacin oral tablet 250, 500, 750 linezolid in sodium chloride intravenous solution /300ml-% linezolid intravenous solution 600 /300ml linezolid oral suspension reconstituted 100 /5ml linezolid oral tablet 600 methenamine hippurate oral tablet 1 gm methenamine mandelate oral tablet 0.5 gm, 1 gm metronidazole oral tablet 250, 500 metronidazole vaginal gel 0.75 % minocycline hcl er oral tablet extended release 24 hour 135, 45, 90 minocycline hcl oral capsule 100, 50, 75 9 ST

11 minocycline hcl oral tablet 100, 50, 75 mondoxyne nl oral capsule 100, 50, 75 morgidox oral capsule 100, 50 mupirocin calcium external cream 2 % mupirocin external ointment 2 % nitrofurantoin macrocrystal oral capsule 100, 25, 50 nitrofurantoin monohydrate macrocrystals oral capsule 100 nitrofurantoin oral suspension 25 /5ml okebo oral capsule 75 penicillin v potassium oral solution reconstituted 125 /5ml, 250 /5ml penicillin v potassium oral tablet 250, 500 silver nitrate external ointment 10 % silver nitrate external solution 0.5 %, 10 %, 25 %, 50 % silver sulfadiazine external cream 1 % soloxide oral tablet delayed release 150 ST ssd external cream 1 % sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet , sulfatrim pediatric oral suspension /5ml tetracycline hcl oral capsule 250, 500 trimethoprim oral tablet 100 vancomycin hcl oral capsule 125, 250 vandazole vaginal gel 0.75 % VIBRAMYCIN ORAL SYRUP 50 MG/5ML XIMINO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 135 MG, 45 MG, 90 MG Anticoagulants ELIQUIS ORAL TABLET 2.5 MG, 5 MG ELIQUIS STARTER PACK ORAL TABLET 5 MG enoxaparin sodium injection solution 300 /3ml Non- PA 10

12 enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml heparin (porcine) in d5w intravenous solution 40-5 unit/ml-%, 50-5 unit/ml-% heparin (porcine) in nacl injection solution unit/ml-%, unit/ml-%, unit/ml- % heparin sod (porcine) in d5w intravenous solution 100 unit/ml, 40-5 unit/ml-% heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml heparin sodium/d5w intravenous solution 50-5 unit/ml-% jantoven oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6 warfarin sodium oral tablet 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG Anticonvulsants - Drugs for Seizures carbamazepine er oral capsule extended release 12 hour 100, 200, 300 carbamazepine er oral tablet extended release 12 hour 100, 200, 400 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 carbamazepine oral tablet chewable 100 DIASTAT PEDIATRIC RECTAL GEL 2.5 MG diazepam rectal gel 10, 20 DILANTIN ORAL CAPSULE 100 MG, 30 MG divalproex sodium er oral tablet extended release 24 hour 250, 500 divalproex sodium oral capsule delayed release sprinkle 125 divalproex sodium oral tablet delayed release 125, 250,

13 epitol oral tablet 200 ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml felbamate oral suspension 600 /5ml felbamate oral tablet 400, 600 gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml, 300 /6ml gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET 12 MG, 16 MG, 2 MG, 4 MG lamotrigine er oral tablet extended release 24 hour 100, 200, 25, 300, 50 lamotrigine er oral tablet extended release 24 hour 250 lamotrigine oral tablet 100, 150, 200, 25 lamotrigine oral tablet chewable 25, 5 levetiracetam er oral tablet extended release 24 hour 500, 750 levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 250, 500, 750 oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 300, 600 phenobarbital oral elixir 20 /5ml phenobarbital oral solution 20 /5ml phenobarbital oral tablet 100, 15, 16.2, 30, 32.4, 60, 64.8, 97.2 phenytoin infatabs oral tablet chewable 50 phenytoin oral suspension 125 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 100, 200, 300 primidone oral tablet 250, 50 roweepra oral tablet 1000, 750 roweepra oral tablet 500 subvenite oral tablet 100, 150, 200, 25 12

14 tiagabine hcl oral tablet 12, 16 PA topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 100, 200, 25, 50 valproate sodium oral solution 250 /5ml valproic acid oral capsule 250 valproic acid oral solution 250 /5ml VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG zonisamide oral capsule 100, 25, 50 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia donepezil hcl oral tablet 10, 23, 5 donepezil hcl oral tablet dispersible 10, 5 EXELON TRANSDERMAL PATCH 24 HOUR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR memantine hcl oral tablet 10, 5 Antidepressants amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 bupropion hcl er (sr) oral tablet extended release 12 hour 100 bupropion hcl er (sr) oral tablet extended release 12 hour 150 bupropion hcl er (sr) oral tablet extended release 12 hour 200 bupropion hcl er (xl) oral tablet extended release 24 hour 150 bupropion hcl er (xl) oral tablet extended release 24 hour QL (4.5 EA per 1 day) QL (3 EA per 1 day) QL (2.25 EA per 1 day) QL (3 EA per 1 day) QL (1.5 EA per 1 day) bupropion hcl oral tablet 100 QL (4.5 EA per 1 day) bupropion hcl oral tablet 75 QL (6 EA per 1 day) chlordiazepoxide-amitriptyline oral tablet 10-25, citalopram hydrobromide oral solution 10 /5ml QL (40 ML per 1 day) citalopram hydrobromide oral tablet 10 QL (4 EA per 1 day) citalopram hydrobromide oral tablet 20 QL (2 EA per 1 day) citalopram hydrobromide oral tablet 40 QL (1 EA per 1 day)

15 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 desvenlafaxine succinate er oral tablet extended release 24 hour 100 desvenlafaxine succinate er oral tablet extended release 24 hour 25 desvenlafaxine succinate er oral tablet extended release 24 hour 50 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml duloxetine hcl oral capsule delayed release particles 20 duloxetine hcl oral capsule delayed release particles 30 duloxetine hcl oral capsule delayed release particles QL (1 EA per 1 day) QL (4 EA per 1 day) QL (2 EA per 1 day) QL (6 EA per 1 day) QL (4 EA per 1 day) QL (2 EA per 1 day) escitalopram oxalate oral tablet 10 QL (2 EA per 1 day) escitalopram oxalate oral tablet 20 QL (1 EA per 1 day) escitalopram oxalate oral tablet 5 QL (4 EA per 1 day) fluoxetine hcl (pmdd) oral capsule 10 QL (8 EA per 1 day) fluoxetine hcl (pmdd) oral capsule 20 QL (4 EA per 1 day) fluoxetine hcl oral capsule 10 QL (8 EA per 1 day) fluoxetine hcl oral capsule 20 QL (4 EA per 1 day) fluoxetine hcl oral capsule 40 QL (2 EA per 1 day) fluoxetine hcl oral solution 20 /5ml QL (20 ML per 1 day) fluvoxamine maleate oral tablet 100 QL (3 EA per 1 day) fluvoxamine maleate oral tablet 25 QL (12 EA per 1 day) fluvoxamine maleate oral tablet 50 QL (6 EA per 1 day) imipramine hcl oral tablet 10, 25, 50 imipramine pamoate oral capsule 100, 125, 150, 75 maprotiline hcl oral tablet 25, 50, 75 mirtazapine oral tablet 15 QL (4 EA per 1 day) mirtazapine oral tablet 30 QL (2 EA per 1 day) mirtazapine oral tablet 45 QL (1.33 EA per 1 day) mirtazapine oral tablet 7.5 QL (8 EA per 1 day) mirtazapine oral tablet dispersible 15 QL (4 EA per 1 day) mirtazapine oral tablet dispersible 30 QL (2 EA per 1 day)

16 mirtazapine oral tablet dispersible 45 QL (1.33 EA per 1 day) nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml paroxetine hcl oral tablet 10 QL (6 EA per 1 day) paroxetine hcl oral tablet 20 QL (3 EA per 1 day) paroxetine hcl oral tablet 30 QL (2 EA per 1 day) paroxetine hcl oral tablet 40 QL (1.5 EA per 1 day) perphenazine-amitriptyline oral tablet 2-10, 2-25, 4-10, 4-25, 4-50 protriptyline hcl oral tablet 10, 5 sertraline hcl oral tablet 100 QL (2 EA per 1 day) sertraline hcl oral tablet 25 QL (8 EA per 1 day) sertraline hcl oral tablet 50 QL (4 EA per 1 day) trazodone hcl oral tablet 100 QL (6 EA per 1 day) trazodone hcl oral tablet 150 QL (4 EA per 1 day) trazodone hcl oral tablet 300 QL (2 EA per 1 day) trazodone hcl oral tablet 50 QL (12 EA per 1 day) venlafaxine hcl er oral capsule extended release 24 hour 150 venlafaxine hcl er oral capsule extended release 24 hour 37.5 venlafaxine hcl er oral capsule extended release 24 hour QL (3 EA per 1 day) QL (12 EA per 1 day) QL (6 EA per 1 day) venlafaxine hcl oral tablet 100 QL (4.5 EA per 1 day) venlafaxine hcl oral tablet 25 QL (18 EA per 1 day) venlafaxine hcl oral tablet 37.5 QL (12 EA per 1 day) venlafaxine hcl oral tablet 50 QL (9 EA per 1 day) venlafaxine hcl oral tablet 75 QL (6 EA per 1 day) Antiemetics - Drugs for Nausea and Vomiting dronabinol oral capsule 10, 2.5, 5 PA meclizine hcl oral tablet 12.5, 25 metoclopramide hcl oral solution 10 /10ml, 5 /5ml metoclopramide hcl oral tablet 10, 5 motion sickness relief oral tablet chewable 25 ondansetron hcl oral tablet 24, 4, 8 ondansetron odt oral tablet dispersible 4, 8 perphenazine oral tablet 16 QL (4 EA per 1 day)

17 perphenazine oral tablet 2 QL (32 EA per 1 day) perphenazine oral tablet 4 QL (16 EA per 1 day) perphenazine oral tablet 8 QL (8 EA per 1 day) prochlorperazine maleate oral tablet 10, 5 travel sickness oral tablet chewable 25 Antifungals ALOE VESTA CLEAR ANTIFUNGAL EXTERNAL OINTMENT 2 % antifungal external aerosol 1 % AVC VAGINAL VAGINAL CREAM 15 % bio-statin oral powder ciclodan external solution 8 % ciclopirox external solution 8 % clotrimazole external cream 1 % clotrimazole solution 1 % external (otc) 1 % PA clotrimazole solution 1 % external (rx) 1 % clotrimazole vaginal cream 1 % exoderm external lotion 25-1 % fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 griseofulvin microsize oral suspension 125 /5ml GYNAZOLE-1 VAGINAL CREAM 2 % ketoconazole external cream 2 % ketoconazole external shampoo 2 % micaderm external cream 2 % miconazole 1 vaginal kit 1200 & 2 & % miconazole 3 vaginal suppository 200 miconazole 7 vaginal suppository 100 miconazole nitrate external cream 2 % nyamyc external powder unit/gm nyata external powder unit/gm nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystatin mouth/throat suspension unit/ml 16

18 nystatin oral tablet unit nystop external powder unit/gm podactin external cream 2 % terbinafine hcl external cream 1 % terbinafine hcl oral tablet 250 terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 tgt clotrimazole external cream 1 % tolnaftate external powder 1 % Antigout Agents allopurinol oral tablet 100, 300 COLCHICINE ORAL CAPSULE 0.6 MG colchicine-probenecid oral tablet MITIGARE ORAL CAPSULE 0.6 MG probenecid oral tablet 500 Antimigraine Agents CAFERGOT ORAL TABLET MG dihydroergotamine mesylate injection solution 1 /ml dihydroergotamine mesylate nasal solution 4 /ml ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG ergotamine-caffeine oral tablet MIGERGOT RECTAL SUPPOSITORY MG 17 QL (8 ML per 30 days) RELPAX ORAL TABLET 20 MG, 40 MG QL (12 EA per 30 days) rizatriptan benzoate oral tablet 10, 5 QL (12 EA per 30 days) rizatriptan benzoate oral tablet dispersible 10, 5 QL (12 EA per 30 days) sumatriptan nasal solution 20 /act QL (6 EA per 30 days) sumatriptan nasal solution 5 /act QL (12 EA per 30 days) sumatriptan succinate oral tablet 100 QL (9 EA per 30 days) sumatriptan succinate oral tablet 25, 50 QL (18 EA per 30 days) sumatriptan succinate refill subcutaneous solution cartridge 4 /0.5ml, 6 /0.5ml sumatriptan succinate subcutaneous solution 6 /0.5ml sumatriptan succinate subcutaneous solution auto-injector 4 /0.5ml, 6 /0.5ml QL (8 ML per 30 days) QL (8 ML per 30 days) QL (8 ML per 30 days)

19 sumatriptan succinate subcutaneous solution prefilled syringe 6 /0.5ml Antimyasthenic Agents guanidine hcl oral tablet 125 MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 pyridostigmine bromide oral tablet 60 Antimycobacterials cycloserine oral capsule 250 dapsone oral tablet 100, 25 ethambutol hcl oral tablet 100, 400 isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 RIFAMATE ORAL CAPSULE MG rifampin oral capsule 150, 300 Antineoplastics - Drugs for Cancer anastrozole oral tablet 1 bexarotene oral capsule 75 bicalutamide oral tablet 50 BRAFTOVI ORAL CAPSULE 50 MG, 75 MG CALQUENCE ORAL CAPSULE 100 MG Non- PA capecitabine oral tablet 150, 500 CAPRELSA ORAL TABLET 100 MG, 300 MG COPIKTRA ORAL CAPSULE 15 MG, 25 MG cyclophosphamide oral capsule 25, 50 DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG EMCYT ORAL CAPSULE 140 MG ERIVEDGE ORAL CAPSULE 150 MG PA ERLEADA ORAL TABLET 60 MG PA etoposide oral capsule 50 exemestane oral tablet 25 FARESTON ORAL TABLET 60 MG flutamide oral capsule QL (8 ML per 30 days)

20 GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 imatinib mesylate oral tablet 400 IMBRUVICA ORAL CAPSULE 140 MG PA INLYTA ORAL TABLET 1 MG, 5 MG IRESSA ORAL TABLET 250 MG PA JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG letrozole oral tablet 2.5 leucovorin calcium oral tablet 10, 15, 25, 5 LEUKERAN ORAL TABLET 2 MG LONSURF ORAL TABLET MG, MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG MEKTOVI ORAL TABLET 15 MG melphalan oral tablet 2 mercaptopurine oral tablet 50 MYLERAN ORAL TABLET 2 MG nilutamide oral tablet 150 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PA TABLOID ORAL TABLET 40 MG TALZENNA ORAL CAPSULE 0.25 MG, 1 MG tamoxifen citrate oral tablet 10, 20 TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TARGRETIN EXTERNAL GEL 1 % temozolomide oral capsule 100, 140, 180, 20, 250, 5 THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG tretinoin oral capsule 10 VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG Non- XALKORI ORAL CAPSULE 200 MG, 250 MG PA 19 PA PA PA

21 YONSA ORAL TABLET 125 MG ZELBORAF ORAL TABLET 240 MG PA ZYTIGA ORAL TABLET 250 MG, 500 MG Antiparasitics atovaquone oral suspension 750 /5ml atovaquone-proguanil hcl oral tablet , chloroquine phosphate oral tablet 250, 500 DARAPRIM ORAL TABLET 25 MG PA EMVERM ORAL TABLET CHEWABLE 100 MG hydroxychloroquine sulfate oral tablet 200 ivermectin oral tablet 3 lice killing external shampoo % lice treatment external liquid 1 % lindane external shampoo 1 % malathion external lotion 0.5 % mefloquine hcl oral tablet 250 NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG permethrin external cream 5 % pinworm medicine oral suspension 144 (50 base) /ml primaquine phosphate oral tablet 26.3 quinine sulfate oral capsule 324 spinosad external suspension 0.9 % sulfurated lime external solution Antiparkinson Agents amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML benztropine mesylate oral tablet 0.5, 1, 2 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 carbidopa oral tablet 25 20

22 carbidopa-levodopa er oral tablet extended release , carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet dispersible , , carbidopa-levodopa-entacapone oral tablet , , , , , entacapone oral tablet 200 GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 137 MG, 68.5 MG pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 tolcapone oral tablet 100 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 Antiplatelets BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100, 50 clopidogrel bisulfate oral tablet 300 clopidogrel bisulfate oral tablet 75 dipyridamole oral tablet 25, 50, 75 prasugrel hcl oral tablet 10, 5 Antipsychotics - Drugs for Mood Disorders Non- aripiprazole oral tablet 10 QL (3 EA per 1 day) aripiprazole oral tablet 15 QL (2 EA per 1 day) aripiprazole oral tablet 2 QL (15 EA per 1 day) aripiprazole oral tablet 20 QL (1.5 EA per 1 day) aripiprazole oral tablet 30 QL (1 EA per 1 day) aripiprazole oral tablet 5 QL (6 EA per 1 day) ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 675 MG/2.4ML ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML 21 PA

23 chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 clozapine oral tablet 100 QL (9 EA per 1 day) clozapine oral tablet 200 QL (4.5 EA per 1 day) clozapine oral tablet 25 QL (36 EA per 1 day) clozapine oral tablet 50 QL (18 EA per 1 day) clozapine oral tablet dispersible 12.5 QL (75 EA per 1 day) fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate 2 /ml QL (15 ML per 1 day) haloperidol oral tablet 0.5 QL (60 EA per 1 day) haloperidol oral tablet 1 QL (30 EA per 1 day) haloperidol oral tablet 10 QL (3 EA per 1 day) haloperidol oral tablet 2 QL (15 EA per 1 day) haloperidol oral tablet 20 QL (1.5 EA per 1 day) haloperidol oral tablet 5 QL (6 EA per 1 day) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML LATUDA ORAL TABLET 120 MG QL (1.33 EA per 1 day) LATUDA ORAL TABLET 20 MG QL (8 EA per 1 day) LATUDA ORAL TABLET 40 MG QL (4 EA per 1 day) LATUDA ORAL TABLET 60 MG QL (2.67 EA per 1 day) LATUDA ORAL TABLET 80 MG QL (2 EA per 1 day) loxapine succinate oral capsule 10 QL (25 EA per 1 day) loxapine succinate oral capsule 25 QL (10 EA per 1 day) loxapine succinate oral capsule 5 QL (50 EA per 1 day) loxapine succinate oral capsule 50 QL (5 EA per 1 day) olanzapine intramuscular solution reconstituted 10 olanzapine oral tablet 10 QL (4 EA per 1 day) olanzapine oral tablet 15 QL (2.67 EA per 1 day) olanzapine oral tablet 2.5 QL (16 EA per 1 day) 22

24 olanzapine oral tablet 20 QL (2 EA per 1 day) olanzapine oral tablet 5 QL (8 EA per 1 day) olanzapine oral tablet 7.5 QL (5.33 EA per 1 day) olanzapine oral tablet dispersible 10 QL (4 EA per 1 day) olanzapine oral tablet dispersible 15 QL (2.67 EA per 1 day) olanzapine oral tablet dispersible 20 QL (2 EA per 1 day) olanzapine oral tablet dispersible 5 QL (8 EA per 1 day) quetiapine fumarate er oral tablet extended release 24 hour 150 quetiapine fumarate er oral tablet extended release 24 hour 200 quetiapine fumarate er oral tablet extended release 24 hour 300 quetiapine fumarate er oral tablet extended release 24 hour 400 quetiapine fumarate er oral tablet extended release 24 hour ST; QL (5.33 EA per 1 day) ST; QL (4 EA per 1 day) ST; QL (2.67 EA per 1 day) ST; QL (2 EA per 1 day) ST; QL (16 EA per 1 day) quetiapine fumarate oral tablet 100 QL (8 EA per 1 day) quetiapine fumarate oral tablet 200 QL (4 EA per 1 day) quetiapine fumarate oral tablet 25 QL (32 EA per 1 day) quetiapine fumarate oral tablet 300 QL (2.67 EA per 1 day) quetiapine fumarate oral tablet 400 QL (2 EA per 1 day) quetiapine fumarate oral tablet 50 QL (16 EA per 1 day) RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG risperidone m-tab oral tablet dispersible 0.5 QL (16 EA per 1 day) risperidone m-tab oral tablet dispersible 1 QL (8 EA per 1 day) risperidone m-tab oral tablet dispersible 2 QL (4 EA per 1 day) risperidone m-tab oral tablet dispersible 3 QL (2.67 EA per 1 day) risperidone m-tab oral tablet dispersible 4 QL (2 EA per 1 day) risperidone oral solution 1 /ml QL (8 ML per 1 day) risperidone oral tablet 0.25 QL (32 EA per 1 day) risperidone oral tablet 0.5 QL (16 EA per 1 day) risperidone oral tablet 1 QL (8 EA per 1 day) risperidone oral tablet 2 QL (4 EA per 1 day) risperidone oral tablet 3 QL (2.67 EA per 1 day) risperidone oral tablet 4 QL (2 EA per 1 day) risperidone oral tablet dispersible 0.25 QL (32 EA per 1 day) risperidone oral tablet dispersible 0.5 QL (16 EA per 1 day)

25 risperidone oral tablet dispersible 1 QL (8 EA per 1 day) risperidone oral tablet dispersible 2 QL (4 EA per 1 day) risperidone oral tablet dispersible 3 QL (2.67 EA per 1 day) risperidone oral tablet dispersible 4 QL (2 EA per 1 day) thioridazine hcl oral tablet 10 QL (80 EA per 1 day) thioridazine hcl oral tablet 100 QL (8 EA per 1 day) thioridazine hcl oral tablet 25 QL (32 EA per 1 day) thioridazine hcl oral tablet 50 QL (16 EA per 1 day) thiothixene oral capsule 1 QL (1 EA per 1 day) thiothixene oral capsule 10 QL (6 EA per 1 day) thiothixene oral capsule 2 QL (30 EA per 1 day) thiothixene oral capsule 5 QL (12 EA per 1 day) trifluoperazine hcl oral tablet 1 QL (1 EA per 1 day) trifluoperazine hcl oral tablet 10 QL (4 EA per 1 day) trifluoperazine hcl oral tablet 2 QL (20 EA per 1 day) trifluoperazine hcl oral tablet 5 QL (8 EA per 1 day) ziprasidone hcl oral capsule 20 QL (8 EA per 1 day) ziprasidone hcl oral capsule 40 QL (4 EA per 1 day) ziprasidone hcl oral capsule 60 QL (2.67 EA per 1 day) ziprasidone hcl oral capsule 80 QL (2 EA per 1 day) Antivirals abacavir sulfate oral solution 20 /ml abacavir sulfate oral tablet 300 abacavir sulfate-lamivudine oral tablet abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule 200 acyclovir oral suspension 200 /5ml acyclovir oral tablet 400, 800 APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML atazanavir sulfate oral capsule 150, 200, 300 ATRIPLA ORAL TABLET MG BIKTARVY ORAL TABLET MG CIMDUO ORAL TABLET MG COMPLERA ORAL TABLET MG 24

26 CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule delayed release 200, 250, 400 EDURANT ORAL TABLET 25 MG efavirenz oral capsule 200, 50 efavirenz oral tablet 600 EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML entecavir oral tablet 0.5, 1 EVOTAZ ORAL TABLET MG famciclovir oral tablet 125, 250, 500 fosamprenavir calcium oral tablet 700 FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG JULUCA ORAL TABLET MG PA KALETRA ORAL TABLET MG, MG lamivudine oral solution 10 /ml lamivudine oral tablet 100, 150, 300 lamivudine-zidovudine oral tablet LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution /5ml MAVYRET ORAL TABLET MG PA 25

27 moderiba oral tablet 200 nevirapine er oral tablet extended release 24 hour 100, 400 nevirapine oral suspension 50 /5ml nevirapine oral tablet 200 NORVIR ORAL CAPSULE 100 MG NORVIR ORAL PACKET 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET MG oseltamivir phosphate oral suspension reconstituted 6 /ml PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML PREVYMIS ORAL TABLET 240 MG, 480 MG Non- PA PREZCOBIX ORAL TABLET MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG REBETOL ORAL SOLUTION 40 MG/ML RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER RESCRIPTOR ORAL TABLET 100 MG, 200 MG REYATAZ ORAL PACKET 50 MG ribasphere oral capsule 200 ribasphere oral tablet 200, 400, 600 ribasphere ribapak oral tablet 400, 600 ribavirin oral capsule 200 ribavirin oral tablet 200 rimantadine hcl oral tablet 100 SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG stavudine oral capsule 15, 20, 30, 40 STRIBILD ORAL TABLET MG SYMFI LO ORAL TABLET MG PA SYMFI ORAL TABLET MG SYMTUZA ORAL TABLET MG 26

28 TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML tenofovir disoproxil fumarate oral tablet 300 TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG Non- TRIUMEQ ORAL TABLET MG PA TRUVADA ORAL TABLET MG, MG, MG, MG TYBOST ORAL TABLET 150 MG valacyclovir hcl oral tablet 1 gm, 500 valganciclovir hcl oral solution reconstituted 50 /ml valganciclovir hcl oral tablet 450 VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM VIRACEPT ORAL TABLET 250 MG, 625 MG VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG ZERIT ORAL SOLUTION RECONSTITUTED 1 MG/ML zidovudine oral capsule 100 zidovudine oral syrup 50 /5ml zidovudine oral tablet 300 ZOVIRAX EXTERNAL CREAM 5 % Anxiolytics - Drugs for Anxiety alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25, 0.5, 1, 2 alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 alprazolam xr oral tablet extended release 24 hour 0.5, 1, 2, 3 buspirone hcl oral tablet 10, 15, 30, 5,

29 chlordiazepoxide hcl oral capsule 10, 25, 5 clonazepam oral tablet 0.5, 1, 2 clorazepate dipotassium oral tablet 15, 3.75, 7.5 diazepam intensol oral concentrate 5 /ml diazepam oral concentrate 5 /ml diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 lorazepam intensol oral concentrate 2 /ml lorazepam oral concentrate 2 /ml lorazepam oral tablet 0.5, 1, 2 meprobamate oral tablet 200, 400 midazolam hcl oral syrup 2 /ml oxazepam oral capsule 10, 15, 30 quazepam oral tablet 15 Bipolar Agents - Drugs for Mood Disorders lithium carbonate er oral tablet extended release 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders AMICAR ORAL SOLUTION 0.25 GM/ML anagrelide hcl oral capsule 0.5, 1 ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60 MCG/0.3ML HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML Non- PA 28

30 PROCRIT INJECTION SOLUTION UNIT/ML, 2000 UNIT/ML, UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, UNIT/ML Cardiovascular Agents - Drugs for Heart and Circulation Conditions acetazolamide er oral capsule extended release 12 hour 500 acetazolamide oral tablet 125, 250 afeditab cr oral tablet extended release 24 hour 30, 60 ALDACTAZIDE ORAL TABLET MG amiloride hcl oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 amiodarone hcl oral tablet 100, 200, 400 amlodipine besylate oral tablet 10, 2.5, 5 amlodipine besylate-benazepril hcl oral capsule 10-20, 10-40, , 5-10, 5-20, 5-40 amlodipine besylate-valsartan oral tablet , , 5-160, atenolol oral tablet 100, 25, 50 atenolol-chlorthalidone oral tablet , atorvastatin calcium oral tablet 10, 20, 40, 80 benazepril hcl oral tablet 10, 20, 40, 5 benazepril-hydrochlorothiazide oral tablet , , 20-25, bisoprolol fumarate oral tablet 10, 5 bisoprolol-hydrochlorothiazide oral tablet , , bumetanide oral tablet 0.5, 1, 2 cartia xt oral capsule extended release 24 hour 120, 180, 240, 300 carvedilol oral tablet 12.5, 25, 3.125, 6.25 CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY 0.1 MG/24HR CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY 0.2 MG/24HR 29

31 CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY 0.3 MG/24HR chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 25, 50 cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose clonidine hcl oral tablet 0.1, 0.2, 0.3 colestipol hcl oral tablet 1 gm digitek oral tablet 125 mcg, 250 mcg digox oral tablet 125 mcg, 250 mcg digoxin oral solution 0.05 /ml digoxin oral tablet 125 mcg, 250 mcg DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE 40 MG diltiazem cd oral capsule extended release 24 hour 120, 180, 240, 300 diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 diltiazem hcl er oral capsule extended release 24 hour 120, 180, 240 diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 120, 180, 240 disopyramide phosphate oral capsule 100, 150 DIURIL ORAL SUSPENSION 250 MG/5ML dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg doxazosin mesylate oral tablet 1, 2, 4, 8 enalapril maleate oral tablet 10, 2.5, 20, 5 30

32 enalapril-hydrochlorothiazide oral tablet 10-25, ENTRESTO ORAL TABLET MG, MG, MG eplerenone oral tablet 25, 50 ezetimibe oral tablet 10 fenofibrate oral tablet 145, 48 flecainide acetate oral tablet 100, 150, 50 furosemide oral solution 10 /ml, 8 /ml furosemide oral tablet 20, 40, 80 gemfibrozil oral tablet 600 guanfacine hcl oral tablet 1, 2 hydralazine hcl oral tablet 10, 100, 25, 50 hydrochlorothiazide oral capsule 12.5 hydrochlorothiazide oral tablet 12.5, 25, 50 indapamide oral tablet 1.25, 2.5 isosorbide dinitrate er oral tablet extended release 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 labetalol hcl oral tablet 100, 200, 300 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 lisinopril-hydrochlorothiazide oral tablet , , losartan potassium oral tablet 100, 25, 50 losartan potassium-hctz oral tablet , , lovastatin oral tablet 10, 20, 40 methyclothiazide oral tablet 5 methyldopa oral tablet 250, 500 metolazone oral tablet 10, 2.5, 5 metoprolol succinate er oral tablet extended release 24 hour 100, 200, 25, PA; QL (2 EA per 1 day)

33 metoprolol tartrate oral tablet 100, 25, 37.5, 50, 75 mexiletine hcl oral capsule 150, 200, 250 midodrine hcl oral tablet 10, 2.5, 5 minitran transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr minoxidil oral tablet 10, 2.5 MULTAQ ORAL TABLET 400 MG niacin er (antihyperlipidemic) oral tablet extended release 1000, 500, 750 nifedipine er oral tablet extended release 24 hour 30, 60, 90 nifedipine er osmotic release oral tablet extended release 24 hour 30, 60, 90 nifedipine oral capsule 10, 20 nimodipine oral capsule 30 NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin er oral capsule extended release 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual solution 0.4 /spray NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG nitro-time oral capsule extended release 2.5, 6.5, 9 NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG pentoxifylline er oral tablet extended release 400 phenoxybenzamine hcl oral capsule 10 pravastatin sodium oral tablet 10, 20, 40, 80 prazosin hcl oral capsule 1, 2, 5 prevalite oral packet 4 gm prevalite oral powder 4 gm/dose 32

34 propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 propafenone hcl oral tablet 150, 225, 300 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 20, 40, 60, 80 quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 ramipril oral capsule 1.25, 10, 2.5, 5 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 5, 80 sorine oral tablet 120, 160, 240, 80 sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 spironolactone oral tablet 100, 25, 50 spironolactone-hctz oral tablet taztia xt oral capsule extended release 24 hour 120, 180, 240, 300, 360 torsemide oral tablet 10, 100, 20, 5 triamterene-hctz oral capsule , triamterene-hctz oral tablet , valsartan oral tablet 160, 320, 40, 80 valsartan-hydrochlorothiazide oral tablet , , , , verapamil hcl er oral tablet extended release 120, 180, 240 verapamil hcl oral tablet 120, 40, 80 WELCHOL ORAL TABLET 625 MG 33 ST

35 Central Nervous System Agents - Drugs for Attention Deficit Disorder ADDERALL ORAL TABLET 10 MG Non- PA; QL (6 EA per 1 day) ADDERALL ORAL TABLET 12.5 MG Non- PA; QL (4.8 EA per 1 day) ADDERALL ORAL TABLET 15 MG Non- PA; QL (4 EA per 1 day) ADDERALL ORAL TABLET 20 MG Non- PA; QL (3 EA per 1 day) ADDERALL ORAL TABLET 30 MG Non- PA; QL (2 EA per 1 day) ADDERALL ORAL TABLET 5 MG Non- PA; QL (12 EA per 1 day) ADDERALL ORAL TABLET 7.5 MG Non- PA; QL (8 EA per 1 day) ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 15 MG ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 30 MG ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG ADZENYS ER ORAL SUSPENSION EXTENDED RELEASE 1.25 MG/ML ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 12.5 MG ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 15.7 MG ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 18.8 MG ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 3.1 MG ADZENYS XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 6.3 MG, 9.4 MG amphetamine-dextroamphetamine er oral capsule extended release 24 hour 10 amphetamine-dextroamphetamine er oral capsule extended release 24 hour 15 amphetamine-dextroamphetamine er oral capsule extended release 24 hour 20 amphetamine-dextroamphetamine er oral capsule extended release 24 hour 25 amphetamine-dextroamphetamine er oral capsule extended release 24 hour 30 Non- Non- Non- Non- Non- Non- Non- Non- Non- Non- Non- 34 QL (6 EA per 1 day) QL (4 EA per 1 day) QL (3 EA per 1 day) QL (2.4 EA per 1 day) QL (2 EA per 1 day) QL (12 EA per 1 day) PA; QL (15 ML per 1 day) PA; QL (1.89 EA per 1 day) PA; QL (1.5 EA per 1 day) PA; QL (1.2 EA per 1 day) PA; QL (6.06 EA per 1 day) PA; QL (2.98 EA per 1 day) PA; QL (6 EA per 1 day) PA; QL (4 EA per 1 day) PA; QL (3 EA per 1 day) PA; QL (2.4 EA per 1 day) PA; QL (2 EA per 1 day)

36 amphetamine-dextroamphetamine er oral capsule extended release 24 hour 5 amphetamine-dextroamphetamine oral tablet 10 amphetamine-dextroamphetamine oral tablet 12.5 amphetamine-dextroamphetamine oral tablet 15 amphetamine-dextroamphetamine oral tablet 20 amphetamine-dextroamphetamine oral tablet 30 amphetamine-dextroamphetamine oral tablet 5 amphetamine-dextroamphetamine oral tablet 7.5 APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 15 MG APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 30 MG APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 50 MG APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 60 MG Non- Non- Non- Non- Non- Non- Non- Non- 35 PA; QL (12 EA per 1 day) QL (6 EA per 1 day) QL (4.8 EA per 1 day) QL (4 EA per 1 day) QL (3 EA per 1 day) QL (2 EA per 1 day) QL (12 EA per 1 day) QL (8 EA per 1 day) PA; QL (6 EA per 1 day) PA; QL (4 EA per 1 day) PA; QL (3 EA per 1 day) PA; QL (2 EA per 1 day) PA; QL (1.5 EA per 1 day) PA; QL (1.2 EA per 1 day) PA; QL (1 EA per 1 day) atomoxetine hcl oral capsule 10 QL (10 EA per 1 day) atomoxetine hcl oral capsule 100 QL (1 EA per 1 day) atomoxetine hcl oral capsule 18 QL (5.56 EA per 1 day) atomoxetine hcl oral capsule 25 QL (4 EA per 1 day) atomoxetine hcl oral capsule 40 QL (2.25 EA per 1 day) atomoxetine hcl oral capsule 60 QL (1.67 EA per 1 day) atomoxetine hcl oral capsule 80 QL (1.25 EA per 1 day) CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG CONCERTA ORAL TABLET EXTENDED RELEASE 27 MG CONCERTA ORAL TABLET EXTENDED RELEASE 36 MG QL (4 EA per 1 day) QL (2.67 EA per 1 day) QL (2 EA per 1 day)

37 CONCERTA ORAL TABLET EXTENDED RELEASE 54 MG COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 17.3 MG COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 25.9 MG COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE 8.6 MG DAYTRANA TRANSDERMAL PATCH 10 MG/9HR DAYTRANA TRANSDERMAL PATCH 15 MG/9HR DAYTRANA TRANSDERMAL PATCH 20 MG/9HR DAYTRANA TRANSDERMAL PATCH 30 MG/9HR Non- Non- Non- 36 QL (1.33 EA per 1 day) PA; QL (3 EA per 1 day) PA; QL (2 EA per 1 day) PA; QL (6 EA per 1 day) QL (3 EA per 1 day) QL (2 EA per 1 day) QL (1.5 EA per 1 day) QL (1 EA per 1 day) DESOXYN ORAL TABLET 5 MG Non- PA; QL (5 EA per 1 day) DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 15 MG DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG dexmethylphenidate hcl er oral capsule extended release 24 hour 10 dexmethylphenidate hcl er oral capsule extended release 24 hour 15 dexmethylphenidate hcl er oral capsule extended release 24 hour 20 dexmethylphenidate hcl er oral capsule extended release 24 hour 25 dexmethylphenidate hcl er oral capsule extended release 24 hour 30 dexmethylphenidate hcl er oral capsule extended release 24 hour 35 dexmethylphenidate hcl er oral capsule extended release 24 hour 40 dexmethylphenidate hcl er oral capsule extended release 24 hour 5 Non- Non- Non- Non- Non- Non- Non- Non- Non- Non- Non- PA; QL (6 EA per 1 day) PA; QL (4 EA per 1 day) PA; QL (12 EA per 1 day) PA; QL (4 EA per 1 day) PA; QL (2.67 EA per 1 day) PA; QL (2 EA per 1 day) PA; QL (1.6 EA per 1 day) PA; QL (1.33 EA per 1 day) PA; QL (1.14 EA per 1 day) PA; QL (1 EA per 1 day) PA; QL (8 EA per 1 day) dexmethylphenidate hcl oral tablet 10 Non- PA; QL (2 EA per 1 day) dexmethylphenidate hcl oral tablet 2.5 Non- PA; QL (8 EA per 1 day) dexmethylphenidate hcl oral tablet 5 Non- PA; QL (4 EA per 1 day) dextroamphetamine sulfate er oral capsule extended release 24 hour 10 Non- PA; QL (6 EA per 1 day)