Golden State Medicare Health Plan San Luis Obispo and Contra Costa Counties

Transcription

1 2019 Golden State Medicare Health Plan San Luis Obispo and Contra Costa Counties This Formulary was updated on 10/22/2018. For more recent information or other questions, please contact Golden State Medicare Health Plan at (877) or, for TTY users, 711, 8am to 8pm Monday through Friday and daily during the enrollment periods, or visit Drug Formulary Este formulario abreviado se actualizó el 10/22/2018. Para obtener información más reciente o otras preguntas, por favor póngase en contacto con Golden State Medicare Health Plan al (877) o bien, para los usuarios de TTY, 711, 8am a 8pm de lunes a viernes y todos los dias durante los períodos de inscripción H2241_1085_1_C_2019 Accepted

2 Golden State Medicare Health Plan 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Golden State Medicare Health Plan. When it refers to plan or our plan, it means Golden State (H). This document includes list of the drugs (formulary) for our plan which is current as of 10/22/2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year. Golden State Medicare Health Plan is an H plan with a Medicare contract. Enrollment in Golden State Medicare Health Plan depends on contract renewal. H2241_1085_C_2019 Accepted Formulary ID: Version Number: 6 Last Updated: October 2018

3 Golden State Medicare Health Plan 2019 Formulario (Lista de medicamentos cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS DROGAS QUE CONTEMPLAS EN ESTE PLAN Nota para los miembros existentes: Este formulario ha cambiado desde el año pasado. Revise este documento para asegurarse de que aún contiene los medicamentos que toma. Cuando esta lista de medicamentos (formulario) se refiere a "nosotros", "nosotros" o "nuestro", significa Golden State Medicare Health Plan. Cuando se refiere a "plan" o "nuestro plan", significa Golden State Medicare Health Plan. Este documento incluye una lista de los medicamentos (formulario) de nuestro plan que está vigente el 10/22/2018. Para obtener un formulario actualizado, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha en que actualizamos por última vez el formulario, aparece en las portadas de la portada y la parte de atrás. En general, debe utilizar las farmacias de la red para usar su beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias y/o copagos/coseguro pueden cambiar el 1 de enero de 2020 y de vez en cuando durante el año. Golden State Medicare Health Plan es un plan H con un contrato de Medicare. La inscripción en Golden State Medicare Health Plan depende de la renovación del contrato. El Formulario puede cambiar en cualquier momento. Usted recibirá un aviso cuando sea necesario. ID del Formulario: Número de version: 6 Última actualización: October 2018

4 3

5 4

6 What is the Golden State Medicare Health Plan Formulary? A formulary is a list of covered drugs selected by Golden State Medicare Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Golden State Medicare Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Golden State Medicare Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Golden State Medicare Health Plan Formulary? Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive 60-day supply of the drug. The enclosed formulary is current as of October To get updated information about the drugs covered by Golden State Medicare Health Plan, please contact us. Our contact information appears on the 5

7 front and back cover pages. In the event of mid-year non-maintenance formulary changes, Golden State Medicare Health Plan will provide all members notice of those changes in a manner consistent with Medicare Requirements. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 19. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 19. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 119. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Golden State Medicare Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Golden State Medicare Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Golden State Medicare Health Plan before you fill your prescriptions. If you don t get approval, Golden State Medicare Health Plan may not cover the drug. Quantity Limits: For certain drugs, Golden State Medicare Health Plan limits the amount of the drug that Golden State Medicare Health Plan will cover. For example, Golden State Medicare Health Plan provides 30 units per prescription for LAZANDA. This may be in addition to a standard onemonth or three-month supply. 6

8 Step Therapy: In some cases, Golden State Medicare Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Golden State Medicare Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Golden State Medicare Health Plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 19. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Golden State Medicare Health Plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Golden State Medicare Health Plan s formulary? on page 7 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Golden State Medicare Health Plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Golden State Medicare Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Golden State Medicare Health Plan. You can ask Golden State Medicare Health Plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Golden State Medicare Health Plan s Formulary? You can ask Golden State Medicare Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, 7

9 Golden State Medicare Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Golden State Medicare Health Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90- days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 31-day supply of medication. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90-days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90-days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. If you are moving from one level of care to another as defined by one of the following situations: members transitioning from hospital to home, members transitioning from skilled nursing benefit and reverting to the Part D benefit, members terminating a hospice election and reverting to Part A and Part D benefit, or 8

10 members discharged from chronic psychiatric hospital to home, a temporary, one time up to 31-day supply prescription fill for Part D eligible non-formulary drugs will be provided at a specialty tier copay. The authorization will be granted through an exception process at or prior to the transition pharmacy transaction. For more information For more detailed information about your Golden State Medicare Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Golden State Medicare Health Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Golden State Medicare Health Plan s Formulary The formulary below provides coverage information about the drugs covered by Golden State Medicare Health Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 119. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., glipizide). The information in the Requirements/Limits column tells you if Golden State Medicare Health Plan has any special requirements for coverage of your drug. The second column of the drug list indicates the drug tier level : Preferred Generic Drugs : Generic Drugs : Preferred Brand Drugs : Non-Preferred Brand Drugs : Specialty Drugs Copayment or coinsurance for the formulary drug tiers are noted in the following format: 9

11 31 Day Retail/90 Day Retail/90 Day Mail Order Golden State Medicare Health Plan Drug Preferred Generic Drug Generic Drug Preferred Brand Drug Non-Preferred Brand Drug Specialty 31 Day Retail $5 $10 $45 $95 33% 90 Day Retail $15 $30 $135 $285 33% 90 Day Mail Order $10 $20 $90 $190 33% Golden State Medicare Health Plan Coverage Gap Specifications We provide additional coverage of Preferred Generics and Generics in the Coverage Gap. Through the Coverage Gap, Preferred Generics and Generics have unchanged copays, with 31- day retail fills available at $5 and $10, respectively. Please refer to our Evidence of Coverage for more information about this coverage. : Preferred Generics List of Abbreviations : Generics : Preferred Brands : Non-Preferred Drugs : Specialty BvD: Part B vs. Part D-This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. CCP: This medication may also qualify for Chronic Condition Program Coverage: This program includes some medications that are on the Formulary with reduced $0 copay, as long as the following is met 1) Member attests to having the chronic condition, 2) Member has a face-to-face encounter for an Annual Well Visit 3) Signed documentation confirming the qualifying diagnosis, 4) Member is enrolled for Mail order Pharmacy 5) 90 day prescriptions by evaluating provider sent to mail order pharmacy for the meds on the CCP list GC: This prescription drug is covered during the gap period. HI: Home Infusion HRM: High Risk Medication (PA required for ages 65 or over). LA: This prescription drug is limited to certain pharmacies : Mail Order Eligible-This prescription may also be available via mail order pharmacy services. 10

12 : Prior Authorization-You (or your physician) are required to get prior authorization before you fill your prescription for this drug. Without prior approval, we may not cover this drug. PA2: Prior Authorization (New Starts Only)-You (or your physician) are required to get prior authorization before you fill your prescription for this drug unless you are a previous user of the drug. If you have a history of using this medication, you will not need prior authorization. QL: Quantity Limit-There is a limit on the amount of this drug that is covered per prescription, or within a specific time frame. ST1: Step Therapy-In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. ST2: Step Therapy (New Starts Only)-In some cases, you may be required to first try certain drugs to treat your medical condition before we will cover another drug for that condition unless you are a previous user of the drug. If you have a history of using this medication, you will not need to try other medications first. 11

13 Qué es el Formulario de Golden State Medicare Health Plan? Un formulario es una lista de medicamentos cubiertos seleccionados por Golden State Medicare Health Plan en consulta con un equipo de proveedores de atención médica, que representa las terapias con receta que se cree que son una parte necesaria de un programa de tratamiento de calidad. Golden State Medicare Health Plan. Generalmente cubrirá los medicamentos que figuran en nuestro formulario siempre y cuando el medicamento sea médicamente necesario, la receta se llene en una farmacia de la red y se aplican otras reglas del plan. Para obtener más información sobre cómo llenar sus recetas, revise su Evidencia de cobertura. Puede cambiar el Formulario (lista de medicamentos)? Generalmente, si toma un medicamento de nuestro formulario 2019 que estaba cubierto a principios de año, no interrumpiremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2019, excepto cuando esté disponible un medicamento genérico nuevo y menos costoso, cuando Se divulga nueva información sobre la seguridad o eficacia de un medicamento, o el medicamento se retira del mercado. (Consulte las viñetas a continuación para obtener más información sobre los cambios que afectan a los miembros que actualmente toman el medicamento). Otros tipos de cambios al formulario, como eliminar un medicamento de nuestro formulario, no afectarán a los miembros que actualmente toman el medicamento. Seguirá estando disponible al mismo costo compartido para aquellos miembros que lo tomen por el resto del año de cobertura. A continuación hay cambios en la lista de medicamentos que también afectarán a los miembros que actualmente toman un medicamento. Nuevos medicamentos genéricos. Podemos eliminar de inmediato un medicamento de marca en nuestra Lista de medicamentos si lo reemplazamos con un nuevo medicamento genérico que aparecerá en el mismo nivel de participación en los costos o menor y con las mismas restricciones o menos. Además, al agregar el nuevo medicamento genérico, podemos decidir mantener el medicamento de marca en nuestra Lista de medicamentos, pero moverlo inmediatamente a un nivel de costo compartido diferente o agregar nuevas restricciones. Si actualmente está tomando ese medicamento de marca, es posible que no le informemos con anticipación antes de hacer ese cambio, pero luego le brindaremos o Si realizamos dicho cambio, usted o quien prescribe pueden solicitarnos que hagamos una excepción y seguimos cubriendo el medicamento de marca por usted. El aviso que le proporcionamos también incluirá información sobre los pasos que puede seguir para solicitar una excepción, y también puede encontrar información en la sección a continuación titulada " Cómo solicito una excepción al Golden State Medicare Health Plan Formulario? Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentos considera que un medicamento de nuestro formulario no es seguro o el fabricante del medicamento lo retira del mercado, inmediatamente lo eliminaremos de nuestro formulario y notificaremos a los miembros que toman el medicamento. Otros cambios. Es posible que hagamos otros cambios que afecten a los miembros que actualmente toman un medicamento. Por ejemplo, podemos agregar un medicamento genérico que no sea nuevo en el mercado para reemplazar un medicamento de marca actualmente incluido en el formulario o agregar nuevas restricciones al medicamento de marca o moverlo a un nivel diferente de costo compartido. O podemos hacer cambios basados en nuevas pautas clínicas. Si eliminamos medicamentos de nuestro formulario, o agregamos autorizaciones previas, límites de cantidad y / o restricciones de terapia escalonada en un medicamento o trasladamos un medicamento a un nivel de costo compartido más alto, debemos notificar a los miembros afectados el cambio al menos 30 días antes del el cambio entra en vigencia, o en el momento en que el miembro solicita un 12

14 reabastecimiento del medicamento, en cuyo momento el miembro recibirá un suministro de 60 días del medicamento. El formulario adjunto está vigente a partir de Octubre de Para obtener información actualizada sobre los medicamentos cubiertos por Golden State Medicare Health Plan, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de portada y contraportada. En caso de cambios en el formulario a mitad de año que no sean de mantenimiento, el Plan de salud de Golden State Medicare proporcionará a todos los miembros un aviso de esos cambios de manera consistente con los Requisitos de Medicare. Cómo uso el Formulario? Hay dos maneras de encontrar su medicamento dentro del formulario: Condición Médica El formulario comienza en la página 19. Los medicamentos en este formulario se agrupan en categorías dependiendo del tipo de condiciones médicas que se utilizan para tratar. Por ejemplo, los fármacos usados para tratar una afección cardíaca se enumeran bajo la categoría, "Agentes Cardiovasculares". Si sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que empieza 19. Luego busque bajo el nombre de la categoría para su medicamento. Listado Alfabético Si no está seguro de qué categoría debe buscar, debe buscar su medicamento en el índice que comienza en la página 119. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos genéricos figuran en el Índice. Busque en el índice y busque su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información sobre la cobertura. Vaya a la página que aparece en el índice y busque el nombre de su medicamento en la primera columna de la lista. Qué son los medicamentos genéricos? Golden State Medicare Health Plan cubre tanto los medicamentos de marca como los medicamentos genéricos. Un medicamento genérico es aprobado por la FDA como tener el mismo ingrediente activo que el medicamento de marca. Generalmente, los medicamentos genéricos cuestan menos que los medicamentos de marca. Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos y límites pueden incluir: Autorización previa: Golden State Medicare Health Plan requiere que usted o su médico obtenga autorización previa para ciertos medicamentos. Esto significa que deberá obtener la 13

15 aprobación de Golden State Medicare Health Plan antes de llenar sus recetas. Si no obtiene la aprobación, Golden State Medicare Health Plan puede no cubrir el medicamento. Límites de Cantidad: Para ciertos medicamentos, Golden State Medicare Health Plan limita la cantidad de medicamento que cubrirá el Golden State Medicare Health Plan. Por ejemplo, Golden State Medicare Health Plan proporciona 30 unidades por receta para LAZANDA. Esto puede ser adicional a un suministro estándar de un mes o tres meses. Terapia escalonada: En algunos casos, Golden State Medicare Health Plan requiere que primero pruebe ciertos medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa condición. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que el Golden State Medicare Health Plan no cubra el medicamento B a menos que pruebe el medicamento A en primer lugar. Si el medicamento A no funciona para usted, Golden State Medicare Health Plan entonces cubrirá el medicamento B. Puede averiguar si su medicamento tiene algún requisito o límite adicional al consultar el formulario que comienza en la página 19. También puede obtener más información sobre las restricciones aplicadas a medicamentos cubiertos específicos visitando nuestro sitio web. Hemos publicado documentos en línea que explican nuestra autorización previa y restricciones de terapia escalonada. También puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha en que actualizamos por última vez el formulario, aparece en las portadas de la portada y la parte de atrás. Puede pedirle a Golden State Medicare Health Plan que haga una excepción a estas restricciones o límites o para una lista de otros medicamentos similares que pueden tratar su condición de salud. Consulte la sección " Cómo solicito una excepción al formulario de Golden State Medicare Health Plan?" En la página 15 para obtener información sobre cómo solicitar una excepción. Qué pasa si mi medicamento no está en el Formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe comunicarse con Servicios para Miembros y preguntar si su medicamento está cubierto. Si usted aprende que Golden State Medicare Health Plan no cubre su medicamento, tiene dos opciones: Puede solicitar a Servicios para Miembros una lista de medicamentos similares que están cubiertos por Golden State Medicare Health Plan. Cuando reciba la lista, muéstrele a su médico y pídale que prescriba un medicamento similar que esté cubierto por Golden State Medicare Health Plan. Puede pedirle a Golden State Medicare Health Plan que haga una excepción y cubra su medicamento. Consulte a continuación para obtener información acerca de cómo solicitar una excepción. Cómo solicito una excepción al Formulario de Golden State Medicare Health Plan? Puede pedirle a Golden State Medicare Health Plan que haga una excepción a nuestras reglas de cobertura. Hay varios tipos de excepciones que puedes pedirnos que hagamos. Puede solicitarnos que cubramos un 14

16 medicamento aunque no esté en nuestro formulario. Si se aprueba, este medicamento se cubrirá a un nivel de costo compartido predeterminado y no podrá solicitarnos que proporcionemos el medicamento a un nivel de costo compartido más bajo. Puede solicitarnos que cubramos un medicamento del formulario a un nivel de costo compartido más bajo si este medicamento no se encuentra en el nivel de especialidad. Si se aprueba esto reduciría la cantidad que debe pagar por su medicamento. Puede solicitarnos que renunciemos a las restricciones o límites de cobertura de su medicamento. Por ejemplo, para ciertos medicamentos, Golden State Medicare Health Plan limita la cantidad de medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede solicitarnos que renunciemos al límite y cubramos una cantidad mayor. Generalmente, Golden State Medicare Health Plan sólo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento de bajo costo compartido o las restricciones de utilización adicionales no fueran tan efectivos para tratar su afección y/o causar que usted tenga efectos médicos adversos. Debe comunicarse con nosotros para solicitar una decisión de cobertura inicial de un formulario o una excepción de restricción de utilización. Cuando solicite una excepción de restricción de formularios o utilización, debe presentar una declaración de su médico que apoya su solicitud. Generalmente, debemos tomar nuestra decisión dentro de las 72 horas de recibir la declaración de respaldo de su médico recetante. Usted puede solicitar una excepción acelerada (rápida) si usted o su médico creen que su salud podría resultar gravemente dañada si espera hasta 72 horas para tomar una decisión. Si su solicitud para agilizar se concede, debemos darle una decisión a más tardar 24 horas después de que recibamos una declaración de respaldo de su médico u otro prescriptor. Qué debo hacer antes de que pueda hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o continuo de nuestro plan, puede estar tomando medicamentos que no están en nuestro formulario. O bien, puede estar tomando un medicamento que está en nuestro formulario, pero su capacidad para obtenerlo es limitada. Por ejemplo, es posible que necesite una autorización previa de nosotros antes de poder comprar su receta. Usted debe hablar con su médico para decidir si debe cambiar a 15

17 un medicamento adecuado que cubramos o solicitar una excepción al formulario para cubrir el medicamento que toma. Mientras habla con su médico para determinar el curso correcto de acción para usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en que usted es miembro de nuestro plan. Para cada uno de sus medicamentos que no están en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, cubriremos un suministro temporal de 31 días (a menos que tenga una receta escrita por menos días) cuando vaya a una red farmacia. Después de su primer suministro de 31 días, no pagaremos por estos medicamentos, aunque haya sido miembro del plan menos de 90 días. Si usted es residente de un centro de cuidados a largo plazo, le permitiremos rellenar su receta hasta que le hayamos proporcionado por lo menos 91 y puede ser hasta un suministro de transición de 98 días, de acuerdo con el incremento de dispensación. a menos que tenga una receta escrita por menos días). Cubriremos más de un reabastecimiento de estos medicamentos durante los primeros 90 días en que usted sea miembro de nuestro plan. Si necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero usted ha superado los primeros debe ser por lo menos 90 días de ser miembro de nuestro plan, cubriremos un 31 día de emergencia de ese medicamento (a menos que tenga una receta para menos días) mientras persigue una excepción al formulario. Si usted es residente de un centro de cuidado a largo plazo, le permitirá rellenar su receta hasta que le proporcionemos al menos 91 y puede ser hasta un suministro de transición de 98 días, de acuerdo con el incremento de dispensación, tener una receta escrita por menos días). Cubriremos más de una recarga de estos medicamentos durante los primeros 90 días en que usted sea miembro de nuestro plan. Si necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero usted ha superado los primeros 90 días de pertenencia a nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento (a menos que usted tiene una receta por menos días) mientras persigue una excepción al formulario. Si se está moviendo de un nivel de cuidado a otro como se define en una de las siguientes situaciones: los miembros de la transición del hospital al hogar, los miembros de la transición de la prestación de enfermería especializada y revertir a la Parte D beneficio, A y Parte D, o los miembros dados de alta de un hospital psiquiátrico crónico a su casa, se le proporcionará un suministro temporal, una vez hasta 31 días de suministro de medicamentos recetados no facultativos de la Parte D en un copago de nivel especial. La autorización se otorgará mediante un proceso de excepción en o antes de la transacción de la farmacia de transición. Para más información Para obtener información más detallada sobre su cobertura de medicamentos recetados de Golden State Medicare Health Plan, revise su Evidencia de Cobertura y otros materiales del plan. Si tiene preguntas sobre Golden State Medicare Health Plan, póngase en contacto con nosotros. Nuestra información de contacto, junto con la fecha en que actualizamos por última vez el formulario, aparece en las portadas de la portada y la parte de atrás. Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al MEDICARE ( ) 24 horas al día/7 días a la semana. Los usuarios de TTY deben llamar al O, visite 16

18 Golden State Medicare Health Plan Formulario El formulario debajo proporciona información de cobertura sobre los medicamentos cubiertos por Golden State Medicare Health Plan. Si tiene problemas para encontrar el medicamento en la lista, vaya al Índice que comienza en la página 119. La primera columna del gráfico enumera el nombre del medicamento. Los medicamentos de marca están marcados en mayúsculas (por ejemplo, JANUVIA) y los fármacos genéricos se enumeran en cursivas minúsculas (por ejemplo, glipizida). La información en la columna Requisitos/Límites le indica si Golden State Medicare Health Plan tiene requisitos especiales para la cobertura de su medicamento. La segunda columna de la lista de medicamentos indica el nivel del nivel del fármaco Nivel 1: Medicamentos genéricos preferidos Nivel 2: Medicamentos Genéricos Nivel 3: Medicamentos de marca preferidos Nivel 4: Medicamentos de marca no preferidos Nivel 5: Medicamentos especializados Copago o coseguro para los niveles de fármaco del formulario se anotan en el siguiente formato: Venta al por menor de 31 días/venta al por menor de 90 días/correo postal de 90 días Golden State Medicare Health Plan 31 días al por menor 90 días al por menor Orden por correo de 90 días Nivel 1 Medicamentos Genéricos Preferidos Nivel 2 Medicamentos Genéricos Nivel 3 Medicamentos de marca Preferidos Nivel 4 Medicamentos de marca no Preferidos Nivel 5 Medicamento s Especializado s $5 $10 $45 $95 33% $15 $30 $135 $285 33% $10 $20 $90 $190 33% Lista de Abreviaciones BvD: Parte B vs. Parte D: este medicamento con receta puede estar cubierto por la Parte B o D de Medicare, según las circunstancias. 17

19 CCP: miembro califica y se inscribe en el programa Golden State Chronic Condition, algunos medicamentos que figuran en el formulario pueden tener un copago reducido o cero ($ 0), siempre que los términos de la participación se cumple, que incluyen (pero no están limitadas a) 1) El miembro da fe de tener una o más condiciones crónicas que califican, 2) El miembro completa una visita personal para el bienestar y la evaluación dentro de los 90 días de la inscripción, con un informe de la visita confirmando que el miembro tiene una condición crónica calificada, 3) El miembro está inscrito con un pedido por correo aprobado o una farmacia minorista, 4) El miembro recibió recetas de 90 días y resurtidos apropiados que se envían a una farmacia aprobada. 5) El miembro completa todos los exámenes de detección recomendados, pruebas de laboratorio y seguimiento relacionados con su salud. GC: Este medicamento con receta está cubierto durante el período de brecha. HI: Infusión en el hogar HRM: Medicamento de alto riesgo (se requiere PA para personas de 65 años o más). LA: Este medicamento con receta está limitado a ciertas farmacias : Elegible para pedidos por correo: esta receta también puede estar disponible a través de servicios de farmacia para pedidos por correo. : Autorización previa: usted (o su médico) deben obtener una autorización previa antes de surtir su receta para este medicamento. Sin aprobación previa, es posible que no cubramos este medicamento. PA2: Autorización previa (solo nuevos comienzos): usted (o su médico) deben obtener una autorización previa antes de surtir su receta para este medicamento a menos que usted sea un usuario anterior del medicamento. Si tiene un historial de uso de este medicamento, no necesitará autorización previa. QL: Límite de cantidad: hay un límite en la cantidad de este medicamento que está cubierto por receta, o dentro de un marco de tiempo específico. ST1: Terapia escalonada: en algunos casos, es posible que deba probar ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa afección. ST2: Terapia escalonada (solo nuevos comienzos): en algunos casos, es posible que deba probar ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa afección a menos que sea un usuario anterior del medicamento. Si tiene un historial de uso de este medicamento, primero no tendrá que probar otros medicamentos. 18

20 Index of Drugs Golden State 2019 Formulary Drug Name Drug Tier Requirements/Limits ANALGESICS ANALGESICS butalbital-acetaminophen oral tablet mg ; ; HRM butalbital-acetaminophen oral tablet mg ; ; HRM; QL (360 EA per 30 butalbital-apap-caffeine oral capsule mg ; ; HRM butalbital-apap-caffeine oral capsule mg ; ; HRM; QL (360 EA per 30 PHRENILIN FORTE ORAL CAPSULE MG ; ; HRM TENCON ORAL TABLET MG ; ; HRM; QL (360 EA per 30 ZEBUTAL ORAL CAPSULE MG ; ; HRM; QL (360 EA per 30 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg ; QL (60 EA per 30 diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release 24 hour 100 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg diclofenac sodium transdermal gel 1 % ; QL (1000 GM per 30 diclofenac sodium transdermal gel 3 % diclofenac-misoprostol oral tablet delayed release mg, mg diflunisal oral tablet 500 mg etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg fenoprofen calcium oral capsule 400 mg fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg IBU ORAL TABLET 600 MG, 800 MG ibuprofen oral suspension 100 mg/5ml 19

21 ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin er oral capsule extended release 75 mg ; ; HRM indomethacin oral capsule 25 mg, 50 mg ; ; HRM ketoprofen er oral capsule extended release 24 hour 200 mg ketorolac tromethamine oral tablet 10 mg ; ; HRM; QL (20 EA per 30 meclofenamate sodium oral capsule 100 mg, 50 mg mefenamic acid oral capsule 250 mg meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen oral suspension 125 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium er oral tablet extended release 24 hour 375 mg naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg PROFENO ORAL TABLET 600 MG sulindac oral tablet 150 mg, 200 mg tolmetin sodium oral capsule 400 mg tolmetin sodium oral tablet 600 mg OPIOID ANALGESICS, LONG-ACTING buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5 MCG/HR EMBEDA ORAL CAPSULE EXTENDED RELEASE MG, MG, MG, 50-2 MG, MG, MG fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr ; QL (4 EA per 28 ; QL (4 EA per 28 20

22 fentanyl transdermal patch 72 hour 87.5 mcg/hr hydromorphone hcl er oral tablet er 24 hour abusedeterrent 12 mg, 8 mg hydromorphone hcl er oral tablet er 24 hour abusedeterrent 16 mg, 32 mg levorphanol tartrate oral tablet 2 mg methadone hcl oral solution 10 mg/5ml, 5 mg/5ml methadone hcl oral tablet 10 mg, 5 mg morphine sulfate er beads oral capsule extended release 24 hour 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine sulfate er oral capsule extended release 24 hour 100 mg morphine sulfate er oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg oxymorphone hcl er oral tablet extended release 12 hour 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg tramadol hcl er oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG OPIOID ANALGESICS, SHORT-ACTING ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 100 MCG, 200 MCG, 300 MCG, 400 MCG, 600 MCG, 800 MCG 21 ST1; acetaminophen-codeine #3 oral tablet mg acetaminophen-codeine oral solution mg/5ml acetaminophen-codeine oral tablet mg, mg ASCOMP-CODEINE ORAL CAPSULE MG butalbital-apap-caff-cod oral capsule mg, mg butalbital-asa-caff-codeine oral capsule mg ; ; HRM ; ; HRM ; ; HRM

23 butorphanol tartrate nasal solution 10 mg/ml codeine sulfate oral tablet 15 mg, 30 mg, 60 mg duramorph injection solution 0.5 mg/ml, 1 mg/ml ENDOCET ORAL TABLET MG, MG, MG fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg 22 hydromorphone hcl injection solution 2 mg/ml hydromorphone hcl oral liquid 1 mg/ml hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT LORCET HD ORAL TABLET MG LORCET ORAL TABLET MG LORCET PLUS ORAL TABLET MG morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate injection solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml morphine sulfate oral tablet 15 mg, 30 mg oxycodone hcl oral capsule 5 mg oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution 5 mg/5ml oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg oxycodone-acetaminophen oral tablet mg, mg, mg, mg

24 oxycodone-aspirin oral tablet mg oxycodone-ibuprofen oral tablet mg oxymorphone hcl oral tablet 10 mg, 5 mg pentazocine-naloxone hcl oral tablet mg ; ; HRM PRIMLEV ORAL TABLET MG PRIMLEV ORAL TABLET MG, MG tramadol hcl oral tablet 50 mg tramadol-acetaminophen oral tablet mg VICODIN ES ORAL TABLET MG VICODIN HP ORAL TABLET MG VICODIN ORAL TABLET MG ANESTHETICS LOCAL ANESTHETICS lidocaine external ointment 5 % ; ; QL (150 GM per 30 lidocaine external patch 5 % ; lidocaine hcl external gel 2 % ; ; QL (30 ML per 30 lidocaine hcl external solution 4 % ; ; QL (50 ML per 30 lidocaine-prilocaine external cream % ; ; QL (30 GM per 30 PLIAGLIS EXTERNAL CREAM 7-7 % ; ; QL (30 GM per 30 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI-CRAVING acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 250 mg, 500 mg VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 380 MG OPIOID DEPENDENCE TREATMENTS buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg ; QL (360 EA per 30 ; QL (90 EA per 30 LUCEMYRA ORAL TABLET 0.18 MG QL (480 EA per 30 23

25 naltrexone hcl oral tablet 50 mg SUBOXONE SUBLINGUAL FILM 12-3 MG ; QL (60 EA per 30 SUBOXONE SUBLINGUAL FILM MG ; QL (360 EA per 30 SUBOXONE SUBLINGUAL FILM 4-1 MG ; QL (180 EA per 30 SUBOXONE SUBLINGUAL FILM 8-2 MG ; QL (90 EA per 30 OPIOID REVERSAL AGENTS naloxone hcl injection solution 0.4 mg/ml naloxone hcl injection solution cartridge 0.4 mg/ml naloxone hcl injection solution prefilled syringe 2 mg/2ml NARCAN NASAL LIQUID 4 MG/0.1ML SKING CESSATION AGENTS bupropion hcl er (smoking det) oral tablet extended release 12 hour 150 mg CHANTIX CONTINUING NTH PAK ORAL TABLET 1 MG ; QL (60 EA per 30 ; QL (504 EA per 365 CHANTIX ORAL TABLET 0.5 MG, 1 MG ; QL (504 EA per 365 CHANTIX STARTING NTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 ; QL (504 EA per 365 NICOTROL INHALATION INHALER 10 MG ; QL (2688 EA per 365 NICOTROL NS NASAL SOLUTION 10 MG/ML ; QL (360 ML per 365 ANTIBACTERIALS AMINOGLYCOSIDES amikacin sulfate injection solution 500 mg/2ml GENTAK OPHTHALMIC OINTMENT 0.3 % gentamicin in saline intravenous solution mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-% gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % gentamicin sulfate injection solution 40 mg/ml gentamicin sulfate ophthalmic solution 0.3 % neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 250 mg streptomycin sulfate intramuscular solution reconstituted 1 gm tobramycin ophthalmic solution 0.3 % 24

26 tobramycin sulfate injection solution 10 mg/ml, 80 mg/2ml TOBREX OPHTHALMIC OINTMENT 0.3 % ANTIBACTERIALS, OTHER bacitracin ophthalmic ointment 500 unit/gm BACTROBAN NASAL NASAL OINTMENT 2 % CLEOCIN VAGINAL SUPPOSITORY 100 MG CLINDACIN-P EXTERNAL SWAB 1 % clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate external foam 1 % clindamycin phosphate external gel 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % clindamycin phosphate in d5w intravenous solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml clindamycin phosphate vaginal cream 2 % CLINDESSE VAGINAL CREAM 2 % colistimethate sodium (cba) injection solution reconstituted 150 mg CORTISPORIN EXTERNAL CREAM CORTISPORIN EXTERNAL OINTMENT 1 % DALVANCE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG daptomycin intravenous solution reconstituted 500 mg linezolid intravenous solution 600 mg/300ml linezolid oral suspension reconstituted 100 mg/5ml QL (1800 ML per 28 linezolid oral tablet 600 mg QL (56 EA per 28 methenamine hippurate oral tablet 1 gm metronidazole in nacl intravenous solution mg/100ml-% metronidazole oral capsule 375 mg 25

27 metronidazole oral tablet 250 mg metronidazole oral tablet 500 mg metronidazole vaginal gel 0.75 % NUROL ORAL PACKET 3 GM mupirocin calcium external cream 2 % mupirocin external ointment 2 % nitrofurantoin macrocrystal oral capsule 100 mg ; QL (360 EA per 365 nitrofurantoin macrocrystal oral capsule 25 mg ; QL (1440 EA per 365 nitrofurantoin macrocrystal oral capsule 50 mg ; QL (720 EA per 365 nitrofurantoin monohyd macro oral capsule 100 mg ; QL (180 EA per 365 nitrofurantoin oral suspension 25 mg/5ml ; QL (7200 ML per 365 polymyxin b sulfate injection solution reconstituted unit silver sulfadiazine external cream 1 % SIVEXTRO INTRAVENOUS SOLUTION RECONSTITUTED 200 MG QL (6 EA per 30 SIVEXTRO ORAL TABLET 200 MG QL (6 EA per 30 SSD EXTERNAL CREAM 1 % SULFAMYLON EXTERNAL CREAM 85 MG/GM tigecycline intravenous solution reconstituted 50 mg trimethoprim oral tablet 100 mg vancomycin hcl intravenous solution reconstituted 10 gm, 1000 mg, 500 mg vancomycin hcl oral capsule 125 mg vancomycin hcl oral capsule 250 mg VANDAZOLE VAGINAL GEL 0.75 % XIFAXAN ORAL TABLET 200 MG, 550 MG BETA-LACTAM, CEPHALOSPORINS AVYCAZ INTRAVENOUS SOLUTION RECONSTITUTED 2.5 (2-0.5) GM cefaclor er oral tablet extended release 12 hour 500 mg cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml, 375 mg/5ml cefadroxil oral capsule 500 mg 26

28 cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefepime hcl injection solution reconstituted 1 gm, 2 gm cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml cefotaxime sodium injection solution reconstituted 1 gm, 2 gm, 500 mg cefotetan disodium injection solution reconstituted 1 gm, 2 gm cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg ceftriaxone sodium intravenous solution reconstituted 10 gm cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg cefuroxime sodium intravenous solution reconstituted 1.5 gm cephalexin oral capsule 250 mg, 500 mg, 750 mg cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml 27

29 cephalexin oral tablet 250 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG TAZICEF INJECTION SOLUTION RECONSTITUTED 1 GM, 2 GM, 6 GM TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG BETA-LACTAM, OTHER 28 aztreonam injection solution reconstituted 1 gm doripenem intravenous solution reconstituted 500 mg imipenem-cilastatin intravenous solution reconstituted 250 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM meropenem intravenous solution reconstituted 1 gm, 500 mg VABOMERE INTRAVENOUS SOLUTION RECONSTITUTED 2 (1-1) GM BETA-LACTAM, PENICILLINS amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 125 mg, 250 mg amoxicillin-pot clavulanate er oral tablet extended release 12 hour mg amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 500 mg ampicillin sodium injection solution reconstituted 1 gm, 125 mg

30 ampicillin sodium intravenous solution reconstituted 10 gm ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (2-1) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML BICILLIN C-R 900/300 INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN C-R INTRAMUSCULAR SUSPENSION UNIT/2ML BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML dicloxacillin sodium oral capsule 250 mg, 500 mg nafcillin sodium injection solution reconstituted 1 gm nafcillin sodium intravenous solution reconstituted 10 gm oxacillin sodium injection solution reconstituted 1 gm, 10 gm, 2 gm penicillin g pot in dextrose intravenous solution unit/ml, unit/ml penicillin g potassium injection solution reconstituted unit penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml penicillin v potassium oral tablet 250 mg, 500 mg piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, ( ) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm ZOSYN INTRAVENOUS SOLUTION GM/50ML, GM/50ML MACROLIDES AZASITE OPHTHALMIC SOLUTION 1 % azithromycin intravenous solution reconstituted 500 mg azithromycin oral packet 1 gm 29

31 azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin er oral tablet extended release 24 hour 500 mg clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg DIFICID ORAL TABLET 200 MG ery external pad 2 % ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ERYTHROCIN STEARATE ORAL TABLET 250 MG erythromycin base oral capsule delayed release particles 250 mg erythromycin base oral tablet 250 mg, 500 mg erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin external gel 2 % erythromycin external solution 2 % erythromycin ophthalmic ointment 5 mg/gm QUINOLONES BAXDELA INTRAVENOUS SOLUTION RECONSTITUTED 300 MG BAXDELA ORAL TABLET 450 MG BESIVANCE OPHTHALMIC SUSPENSION 0.6 % CILOXAN OPHTHALMIC OINTMENT 0.3 % ciprofloxacin hcl ophthalmic solution 0.3 % ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg 30

32 ciprofloxacin hcl otic solution 0.2 % ciprofloxacin in d5w intravenous solution 200 mg/100ml ciprofloxacin oral suspension reconstituted 250 mg/5ml (5%), 500 mg/5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hour 1000 mg, 500 mg gatifloxacin ophthalmic solution 0.5 % levofloxacin in d5w intravenous solution 500 mg/100ml, 750 mg/150ml levofloxacin intravenous solution 25 mg/ml levofloxacin ophthalmic solution 0.5 % levofloxacin oral solution 25 mg/ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg moxifloxacin hcl in nacl intravenous solution 400 mg/250ml moxifloxacin hcl ophthalmic solution 0.5 % moxifloxacin hcl oral tablet 400 mg ofloxacin ophthalmic solution 0.3 % ofloxacin oral tablet 300 mg, 400 mg ofloxacin otic solution 0.3 % SULFONAMIDES 31 sulfacetamide sodium (acne) external lotion 10 % sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg TETRACYCLINES demeclocycline hcl oral tablet 150 mg, 300 mg DORYX MPC ORAL TABLET DELAYED RELEASE 120 MG DOXY 100 INTRAVENOUS SOLUTION RECONSTITUTED 100 MG doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg, 75 mg

33 doxycycline hyclate oral tablet 150 mg doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 200 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension reconstituted 25 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline hcl er oral tablet extended release 24 hour 115 mg, 65 mg minocycline hcl er oral tablet extended release 24 hour 135 mg, 45 mg, 90 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg minocycline hcl oral tablet 100 mg, 50 mg, 75 mg RGIDOX ORAL CAPSULE 50 MG SOLOXIDE ORAL TABLET DELAYED RELEASE 150 MG tetracycline hcl oral capsule 250 mg, 500 mg VIBRAMYCIN ORAL SYRUP 50 MG/5ML ANTICONVULSANTS ANTICONVULSANTS, OTHER APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG levetiracetam er oral tablet extended release 24 hour 500 mg, 750 mg levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg ROWEEPRA ORAL TABLET 1000 MG, 500 MG, 750 MG ROWEEPRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG, 750 MG 32

34 SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG CALCIUM CHANNEL DIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 50 MG, 75 MG ; QL (90 EA per 30 LYRICA ORAL CAPSULE 300 MG ; QL (60 EA per 30 LYRICA ORAL SOLUTION 20 MG/ML ; QL (900 ML per 30 zonisamide oral capsule 100 mg, 25 mg, 50 mg GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS clonazepam oral tablet 0.5 mg, 1 mg ; QL (90 EA per 30 clonazepam oral tablet 2 mg ; QL (300 EA per 30 clonazepam oral tablet dispersible mg, 0.25 mg, 0.5 mg, 1 mg ; QL (90 EA per 30 clonazepam oral tablet dispersible 2 mg ; QL (300 EA per 30 DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG DIASTAT PEDIATRIC RECTAL GEL 2.5 MG divalproex sodium er oral tablet extended release 24 hour 250 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 125 mg divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg gabapentin oral capsule 100 mg, 300 mg ; CCP; QL (360 EA per 30 gabapentin oral capsule 400 mg ; CCP; QL (270 EA per 30 gabapentin oral solution 250 mg/5ml ; QL (2160 ML per 30 gabapentin oral tablet 600 mg ; CCP; QL (180 EA per 30 gabapentin oral tablet 800 mg ; CCP; QL (150 EA per 30 GABITRIL ORAL TABLET 12 MG, 16 MG ONFI ORAL SUSPENSION 2.5 MG/ML ONFI ORAL TABLET 10 MG, 20 MG 33

35 phenobarbital oral elixir 20 mg/5ml PA2; ; HRM phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg PA2; ; HRM primidone oral tablet 250 mg, 50 mg SABRIL ORAL TABLET 500 MG PA2 tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg valproate sodium oral solution 250 mg/5ml valproic acid oral capsule 250 mg vigabatrin oral packet 500 mg PA2 GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 mg/5ml felbamate oral tablet 400 mg, 600 mg lamotrigine er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg 34 lamotrigine oral tablet chewable 25 mg, 5 mg lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50 mg lamotrigine starter kit-blue oral kit 25 (35) mg lamotrigine starter kit-green oral kit 25 (84)-100(14) mg lamotrigine starter kit-orange oral kit 25 (42)-100 (7) mg topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg, 200 mg, 25 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 25 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg SODIUM CHANNEL AGENTS BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg carbamazepine er oral tablet extended release 12 hour 100 mg, 200 mg, 400 mg carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 100 mg

36 CARBATROL ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG DILANTIN ORAL CAPSULE 100 MG, 30 MG DILANTIN ORAL SUSPENSION 125 MG/5ML EPITOL ORAL TABLET 200 MG oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg PEGANONE ORAL TABLET 250 MG PHENYTEK ORAL CAPSULE 200 MG, 300 MG phenytoin oral suspension 125 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg TEGRETOL ORAL SUSPENSION 100 MG/5ML TEGRETOL ORAL TABLET 200 MG TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 400 MG VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG VIMPAT ORAL TABLET 50 MG ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates oral tablet 1 mg ; ; HRM CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 10 mg, 5 mg donepezil hcl oral tablet 23 mg donepezil hcl oral tablet dispersible 10 mg, 5 mg galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg galantamine hydrobromide oral solution 4 mg/ml galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg 35

37 rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hr N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl er oral capsule extended release 24 hour 14 mg, 21 mg, 28 mg, 7 mg memantine hcl oral solution 2 mg/ml memantine hcl oral tablet 10 mg, 5 (28)-10 (21) mg, 5 mg ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER APLENZIN ORAL TABLET EXTENDED RELEASE 24 HOUR 174 MG, 348 MG, 522 MG bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg ; QL (30 EA per 30 ST2; QL (30 EA per 30 ; CCP; QL (90 EA per 30 bupropion hcl oral tablet 100 mg, 75 mg mirtazapine oral tablet 15 mg mirtazapine oral tablet 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg NOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 10 MG ; QL (90 EA per 30 ; QL (30 EA per 30 phenelzine sulfate oral tablet 15 mg tranylcypromine sulfate oral tablet 10 mg ST2; QL (30 EA per 30 SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg desvenlafaxine er oral tablet extended release 24 hour 100 mg desvenlafaxine er oral tablet extended release 24 hour 50 mg ; CCP ST2; ; QL (120 EA per 30 ST2; ; QL (30 EA per 30 36

38 desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg desvenlafaxine succinate er oral tablet extended release 24 hour 50 mg duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg duloxetine hcl oral capsule delayed release particles 30 mg, 40 mg ; CCP; QL (120 EA per 30 ; QL (30 EA per 30 ; CCP; QL (30 EA per 30 ; CCP; QL (60 EA per 30 ; CCP; QL (90 EA per 30 escitalopram oxalate oral solution 5 mg/5ml ; CCP escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg ; CCP FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MG fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg ; CCP ST2; ; QL (30 EA per 30 ST2; ; QL (56 EA per 365 fluoxetine hcl oral capsule delayed release 90 mg ; QL (4 EA per 28 fluoxetine hcl oral solution 20 mg/5ml fluoxetine hcl oral tablet 10 mg, 20 mg ; CCP fluoxetine hcl oral tablet 60 mg fluvoxamine maleate er oral capsule extended release 24 hour 100 mg, 150 mg ; QL (60 EA per 30 fluvoxamine maleate oral tablet 100 mg, 50 mg ; CCP fluvoxamine maleate oral tablet 25 mg maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg olanzapine-fluoxetine hcl oral capsule mg, mg, 6-50 mg olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg paroxetine hcl er oral tablet extended release 24 hour 12.5 mg, 25 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg ; QL (30 EA per 30 ; QL (90 EA per 30 PA2; ; HRM PA2; ; HRM; CCP paroxetine mesylate oral capsule 7.5 mg ; QL (30 EA per 30 PAXIL ORAL SUSPENSION 10 MG/5ML PA2; ; HRM 37

39 PEXEVA ORAL TABLET 10 MG, 20 MG, 40 MG PA2; ; HRM; QL (30 EA per 30 PEXEVA ORAL TABLET 30 MG PA2; ; HRM; QL (60 EA per 30 sertraline hcl oral concentrate 20 mg/ml sertraline hcl oral tablet 100 mg, 50 mg ; CCP sertraline hcl oral tablet 25 mg trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine hcl er oral capsule extended release 24 hour 150 mg venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hour 150 mg, 225 mg venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG TRICYCLICS amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg ; QL (30 EA per 30 ; CCP ; CCP ; CCP ; QL (30 EA per 30 ; QL (60 EA per 365 PA2; ; HRM amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg PA2; ; HRM chlordiazepoxide-amitriptyline oral tablet mg, mg PA2; ; HRM clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg PA2; ; HRM desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg PA2; ; HRM PA2; ; HRM doxepin hcl oral concentrate 10 mg/ml PA2; ; HRM imipramine hcl oral tablet 10 mg, 25 mg, 50 mg PA2; ; HRM imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg PA2; ; HRM 38

40 nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg PA2; ; HRM nortriptyline hcl oral solution 10 mg/5ml PA2; ; HRM perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg PA2; ; HRM protriptyline hcl oral tablet 10 mg, 5 mg PA2; ; HRM trimipramine maleate oral capsule 100 mg, 25 mg, 50 mg ANTIEMETICS ANTIEMETICS, OTHER PA2; ; HRM COMPRO RECTAL SUPPOSITORY 25 MG meclizine hcl oral tablet 12.5 mg, 25 mg ; ; HRM PHENADOZ RECTAL SUPPOSITORY 12.5 MG ; ; HRM prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine hcl oral syrup 6.25 mg/5ml ; ; HRM promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg ; ; HRM promethazine hcl rectal suppository 12.5 mg, 25 mg, 50 mg PROMETHEGAN RECTAL SUPPOSITORY 25 MG, 50 MG ; ; HRM ; ; HRM scopolamine transdermal patch 72 hour 1 mg/3days ; ; HRM trimethobenzamide hcl oral capsule 300 mg BvD; EMETOGENIC THERAPY ADJUNCTS aprepitant oral capsule 125 mg GC; BvD; ; QL (2 EA per 30 aprepitant oral capsule 40 mg GC; BvD; ; QL (1 EA per 30 aprepitant oral capsule 80 & 125 mg GC; BvD; ; QL (6 EA per 30 aprepitant oral capsule 80 mg GC; BvD; ; QL (8 EA per 30 dronabinol oral capsule 10 mg ; QL (60 EA per 30 dronabinol oral capsule 2.5 mg, 5 mg ; ; QL (60 EA per 30 EMEND ORAL SUSPENSION RECONSTITUTED 125 MG BvD; ; QL (6 EA per 30 granisetron hcl oral tablet 1 mg GC; BvD; ; QL (30 EA per 30 ondansetron hcl oral solution 4 mg/5ml GC; BvD; ; QL (450 ML per 30 ondansetron hcl oral tablet 24 mg GC; BvD; ; QL (14 EA per 28 39

41 ondansetron hcl oral tablet 4 mg, 8 mg GC; BvD; ondansetron oral tablet dispersible 4 mg, 8 mg GC; BvD; SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR QL (2 EA per 30 SYNDROS ORAL SOLUTION 5 MG/ML ; QL (120 ML per 30 ANTIFUNGALS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 mg caspofungin acetate intravenous solution reconstituted 50 mg, 70 mg BvD BvD BvD; ciclopirox external gel 0.77 % ciclopirox external shampoo 1 % ciclopirox external solution 8 % ; ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % clotrimazole external cream 1 % clotrimazole external solution 1 % clotrimazole mouth/throat lozenge 10 mg clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % CRESEMBA ORAL CAPSULE 186 MG econazole nitrate external cream 1 % ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG EXELDERM EXTERNAL CREAM 1 % EXELDERM EXTERNAL SOLUTION 1 % fluconazole in sodium chloride intravenous solution mg/100ml-%, mg/200ml-% fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg 40

42 griseofulvin microsize oral suspension 125 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 41 GYNAZOLE-1 VAGINAL CREAM 2 % itraconazole oral capsule 100 mg ; JUBLIA EXTERNAL SOLUTION 10 % ketoconazole external cream 2 % ketoconazole external foam 2 % ketoconazole external shampoo 2 % ketoconazole oral tablet 200 mg MENTAX EXTERNAL CREAM 1 % miconazole 3 vaginal suppository 200 mg MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG naftifine hcl external cream 1 %, 2 % NAFTIN EXTERNAL GEL 1 %, 2 % NATACYN OPHTHALMIC SUSPENSION 5 % NOXAFIL ORAL SUSPENSION 40 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG NYAMYC 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 nystatin oral tablet unit nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% NYSTOP EXTERNAL POWDER UNIT/GM oxiconazole nitrate external cream 1 % OXISTAT EXTERNAL LOTION 1 % SPORANOX ORAL SOLUTION 10 MG/ML terbinafine hcl oral tablet 250 mg ; QL (84 EA per 180

43 terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg voriconazole intravenous solution reconstituted 200 mg voriconazole oral suspension reconstituted 40 mg/ml voriconazole oral tablet 200 mg, 50 mg ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 100 mg, 300 mg ; CCP colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg colchicine-probenecid oral tablet mg COLCRYS ORAL TABLET 0.6 MG probenecid oral tablet 500 mg ULORIC ORAL TABLET 40 MG, 80 MG ST1; ANTI-INFLAMMATORY AGENTS GLUCOCORTICOIDS PROCTO-MED HC RECTAL CREAM 2.5 % PROCTO-PAK RECTAL CREAM 1 % PROCTOSOL HC RECTAL CREAM 2.5 % PROCTOZONE-HC RECTAL CREAM 2.5 % triamcinolone acetonide external aerosol solution mg/gm ANTIMIGRAINE AGENTS ERGOT ALKALOIDS dihydroergotamine mesylate nasal solution 4 mg/ml QL (8 ML per 30 ergotamine-caffeine oral tablet mg MIGERGOT RECTAL SUPPOSITORY MG SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS almotriptan malate oral tablet 12.5 mg, 6.25 mg ; QL (12 EA per 30 eletriptan hydrobromide oral tablet 20 mg, 40 mg ; QL (12 EA per 30 frovatriptan succinate oral tablet 2.5 mg ; QL (12 EA per 30 naratriptan hcl oral tablet 1 mg, 2.5 mg ; QL (9 EA per 30 rizatriptan benzoate oral tablet 10 mg, 5 mg ; QL (18 EA per 30 rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg 42 ; QL (18 EA per 30

44 sumatriptan nasal solution 20 mg/act, 5 mg/act ; QL (12 EA per 30 sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg sumatriptan succinate refill subcutaneous solution cartridge 4 mg/0.5ml sumatriptan succinate refill subcutaneous solution cartridge 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution autoinjector 4 mg/0.5ml sumatriptan succinate subcutaneous solution autoinjector 6 mg/0.5ml ; QL (9 EA per 30 ; QL (8 ML per 30 ; QL (5 ML per 30 ; QL (5 ML per 30 ; QL (8 ML per 30 ; QL (5 ML per 30 sumatriptan-naproxen sodium oral tablet mg ; QL (9 EA per 30 zolmitriptan oral tablet 2.5 mg, 5 mg ; QL (12 EA per 30 zolmitriptan oral tablet dispersible 2.5 mg ; QL (12 EA per 30 zolmitriptan oral tablet dispersible 5 mg ; QL (9 EA per 30 ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine hcl oral tablet 125 mg MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide er oral tablet extended release 180 mg pyridostigmine bromide oral tablet 60 mg ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone oral tablet 100 mg, 25 mg 43 rifabutin oral capsule 150 mg ANTITUBERCULARS ethambutol hcl oral tablet 100 mg, 400 mg isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg PASER ORAL PACKET 4 GM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifampin intravenous solution reconstituted 600 mg rifampin oral capsule 150 mg, 300 mg

45 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS ALKYLATING AGENTS cyclophosphamide oral capsule 25 mg, 50 mg BvD; GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HEXALEN ORAL CAPSULE 50 MG KISQALI FEMARA 200 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 400 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG KISQALI FEMARA 600 DOSE ORAL TABLET THERAPY PACK 200 & 2.5 MG LEUKERAN ORAL TABLET 2 MG MATULANE ORAL CAPSULE 50 MG 44 VALCHLOR EXTERNAL GEL % PA2 ANTIANDROGENS bicalutamide oral tablet 50 mg PA2; QL (91 EA per 28 PA2; QL (91 EA per 28 PA2; QL (91 EA per 28 ERLEADA ORAL TABLET 60 MG PA2; QL (120 EA per 30 flutamide oral capsule 125 mg nilutamide oral tablet 150 mg XTANDI ORAL CAPSULE 40 MG PA2 YONSA ORAL TABLET 125 MG PA2 ZYTIGA ORAL TABLET 250 MG, 500 MG PA2 ANTIANGIOGENIC AGENTS POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG ANTIESTROGENS/DIFIERS EMCYT ORAL CAPSULE 140 MG FARESTON ORAL TABLET 60 MG SOLTAX ORAL SOLUTION 10 MG/5ML PA2 PA2 PA2

46 tamoxifen citrate oral tablet 10 mg, 20 mg ; CCP ANTIMETABOLITES DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG fluorouracil external cream 0.5 % fluorouracil external cream 5 % fluorouracil external solution 2 %, 5 % hydroxyurea oral capsule 500 mg ; CCP LONSURF ORAL TABLET MG PA2; QL (100 EA per 28 LONSURF ORAL TABLET MG PA2; QL (80 EA per 28 mercaptopurine oral tablet 50 mg PURIXAN ORAL SUSPENSION 2000 MG/100ML 45 TABLOID ORAL TABLET 40 MG ANTINEOPLASTICS, OTHER COTELLIC ORAL TABLET 20 MG PA2; QL (90 EA per 30 FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG KISQALI 200 DOSE ORAL TABLET 200 MG PA2; QL (63 EA per 28 KISQALI 400 DOSE ORAL TABLET 200 MG PA2; QL (63 EA per 28 KISQALI 600 DOSE ORAL TABLET 200 MG PA2; QL (63 EA per 28 leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg PA2 PA2 LYNPARZA ORAL CAPSULE 50 MG PA2 LYNPARZA ORAL TABLET 100 MG, 150 MG PA2 NERLYNX ORAL TABLET 40 MG PA2; QL (180 EA per 30 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG RYDAPT ORAL CAPSULE 25 MG PA2; QL (240 EA per 30 SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG PA2 PA2 PA2 ZOLINZA ORAL CAPSULE 100 MG PA2 AROMATASE INHIBITORS, 3RD GENERATION PA2; QL (60 EA per 30

47 anastrozole oral tablet 1 mg exemestane oral tablet 25 mg letrozole oral tablet 2.5 mg ENZYME INHIBITORS ZYDELIG ORAL TABLET 100 MG, 150 MG PA2 LECULAR TARGET INHIBITORS AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG 46 PA2 PA2; QL (30 EA per 30 ALECENSA ORAL CAPSULE 150 MG PA2; QL (240 EA per 30 ALUNBRIG ORAL TABLET 180 MG, 90 MG PA2; QL (30 EA per 30 ALUNBRIG ORAL TABLET 30 MG PA2; QL (120 EA per 30 ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MG BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA2; QL (60 EA per 365 CALQUENCE ORAL CAPSULE 100 MG PA2; QL (60 EA per 30 CAPRELSA ORAL TABLET 100 MG PA2; QL (60 EA per 30 PA2 PA2 CAPRELSA ORAL TABLET 300 MG PA2 COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG PA2 PA2 PA2 ERIVEDGE ORAL CAPSULE 150 MG PA2 GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG PA2; QL (30 EA per 30 ICLUSIG ORAL TABLET 15 MG PA2; QL (60 EA per 30 ICLUSIG ORAL TABLET 45 MG PA2 IDHIFA ORAL TABLET 100 MG, 50 MG PA2; QL (30 EA per 30 imatinib mesylate oral tablet 100 mg, 400 mg PA2 IMBRUVICA ORAL CAPSULE 140 MG, 70 MG PA2 IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG PA2

48 INLYTA ORAL TABLET 1 MG, 5 MG PA2 IRESSA ORAL TABLET 250 MG PA2 JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG LENVIMA 10 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 MG LENVIMA 14 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 MG LENVIMA 18 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 & 4 (2) MG LENVIMA 20 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) MG LENVIMA 24 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 10 (2) & 4 MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 4 (2) MG PA2; QL (60 EA per PA2 PA2 PA2 PA2 PA2 PA2 MEKINIST ORAL TABLET 0.5 MG, 2 MG PA2 NEXAVAR ORAL TABLET 200 MG PA2 ODOMZO ORAL CAPSULE 200 MG PA2 RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG PA2; QL (120 EA per 30 PA2 STIVARGA ORAL TABLET 40 MG PA2 SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG PA2 TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA2 TAGRISSO ORAL TABLET 40 MG, 80 MG PA2; QL (30 EA per 30 TARCEVA ORAL TABLET 100 MG, 150 MG PA2; QL (30 EA per 30 TARCEVA ORAL TABLET 25 MG PA2; QL (90 EA per 30 TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG PA2 TYKERB ORAL TABLET 250 MG PA2 VENCLEXTA ORAL TABLET 10 MG, 50 MG PA2; VENCLEXTA ORAL TABLET 100 MG PA2 VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 10 & 50 & 100 MG PA2 VOTRIENT ORAL TABLET 200 MG PA2 XALKORI ORAL CAPSULE 200 MG, 250 MG PA2

49 ZEJULA ORAL CAPSULE 100 MG PA2; QL (90 EA per 30 ZELBORAF ORAL TABLET 240 MG PA2 ZYKADIA ORAL CAPSULE 150 MG PA2 RETINOIDS bexarotene oral capsule 75 mg PA2 PANRETIN EXTERNAL GEL 0.1 % TARGRETIN EXTERNAL GEL 1 % PA2 tretinoin oral capsule 10 mg TREATMENT ADJUNCTS MESNEX ORAL TABLET 400 MG ANTIPARASITICS ANTHELMINTICS ALBENZA ORAL TABLET 200 MG benznidazole oral tablet 100 mg, 12.5 mg ivermectin oral tablet 3 mg ANTIPROTOZOALS ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5ml atovaquone-proguanil hcl oral tablet mg, mg chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mg mefloquine hcl oral tablet 250 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG BvD; primaquine phosphate oral tablet 26.3 mg quinine sulfate oral capsule 324 mg ; tinidazole oral tablet 250 mg, 500 mg PEDICULICIDES/SCABICIDES EURAX EXTERNAL CREAM 10 % 48

50 EURAX EXTERNAL LOTION 10 % lindane external shampoo 1 % malathion external lotion 0.5 % permethrin external cream 5 % SKLICE EXTERNAL LOTION 0.5 % ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg ; ; HRM trihexyphenidyl hcl oral elixir 0.4 mg/ml ; ; HRM trihexyphenidyl hcl oral tablet 2 mg, 5 mg ; ; HRM ANTIPARKINSON AGENTS, OTHER entacapone oral tablet 200 mg GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 137 MG, 68.5 MG tolcapone oral tablet 100 mg DOPAMINE AGONISTS APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3ML bromocriptine mesylate oral capsule 5 mg bromocriptine mesylate oral tablet 2.5 mg NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR pramipexole dihydrochloride er oral tablet extended release 24 hour mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg pramipexole dihydrochloride oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2 mg, 4 mg, 6 mg, 8 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg ; QL (90 ML per 30 ST1; DOPAMINE PRECURSORS/L- AMINO ACID DECARBOXYLASE INHIBITORS carbidopa oral tablet 25 mg carbidopa-levodopa er oral tablet extended release mg, mg carbidopa-levodopa oral tablet mg, mg, mg 49

51 carbidopa-levodopa oral tablet dispersible mg, mg, mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg RYTARY ORAL CAPSULE EXTENDED RELEASE MG, MG, MG, MG NOAMINE OXIDASE B (MAO-B) INHIBITORS 50 rasagiline mesylate oral tablet 0.5 mg, 1 mg ST1; selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG ANTIPSYCHOTICS 1ST GENERATION/TYPICAL chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg haloperidol decanoate intramuscular solution 100 mg/ml, 100 mg/ml 1 ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg pimozide oral tablet 1 mg, 2 mg thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg PA2; ; HRM thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg

52 2ND GENERATION/ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 300 MG, 400 MG aripiprazole oral solution 1 mg/ml ; QL (750 ML per 30 aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg ; QL (30 EA per 30 aripiprazole oral tablet 2 mg, 5 mg ; QL (60 EA per 30 aripiprazole oral tablet dispersible 10 mg, 15 mg QL (60 EA per 30 ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG ST2; ; QL (60 EA per 30 FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 78 MG/0.5ML INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML 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, 20 MG, 40 MG, 60 MG ST2; QL (60 EA per 30 ST2; ; QL (8 EA per 180 ; QL (60 EA per 30 QL (30 EA per 30 LATUDA ORAL TABLET 80 MG QL (60 EA per 30 NUPLAZID ORAL TABLET 17 MG PA2; QL (60 EA per 30 olanzapine intramuscular solution reconstituted 10 mg olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg ; QL (30 EA per 30 ; QL (30 EA per 30 ; QL (30 EA per 30 51

53 paliperidone er oral tablet extended release 24 hour 6 mg paliperidone er oral tablet extended release 24 hour 9 mg quetiapine fumarate er oral tablet extended release 24 hour 150 mg, 300 mg, 400 mg, 50 mg quetiapine fumarate er oral tablet extended release 24 hour 200 mg quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 50 mg QL (60 EA per 30 QL (30 EA per 30 ; QL (60 EA per 30 ; QL (90 EA per 30 ; QL (90 EA per 30 quetiapine fumarate oral tablet 300 mg, 400 mg ; QL (60 EA per 30 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG QL (30 EA per 30 risperidone oral solution 1 mg/ml ; QL (240 ML per 30 risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG TREATMENT-RESISTANT ; QL (60 EA per 30 ; QL (60 EA per 30 QL (60 EA per 30 ST2; QL (30 EA per 30 ST2; ; QL (14 EA per 365 ; QL (60 EA per 30 clozapine oral tablet 100 mg, 25 mg ; QL (270 EA per 30 clozapine oral tablet 200 mg ; QL (120 EA per 30 clozapine oral tablet 50 mg ; QL (180 EA per 30 clozapine oral tablet dispersible 100 mg, 25 mg ; QL (270 EA per 30 clozapine oral tablet dispersible 12.5 mg ; QL (90 EA per 30 52

54 clozapine oral tablet dispersible 150 mg ; QL (180 EA per 30 clozapine oral tablet dispersible 200 mg QL (120 EA per 30 VERSACLOZ ORAL SUSPENSION 50 MG/ML QL (540 ML per 30 ANTISPASTICITY AGENTS ANTISPASTICITY AGENTS baclofen oral tablet 10 mg, 20 mg, 5 mg dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg tizanidine hcl oral tablet 2 mg, 4 mg ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS PREVYMIS ORAL TABLET 240 MG, 480 MG valganciclovir hcl oral solution reconstituted 50 mg/ml valganciclovir hcl oral tablet 450 mg ZIRGAN OPHTHALMIC GEL 0.15 % ANTI-HEPATITIS B (HBV) AGENTS adefovir dipivoxil oral tablet 10 mg BARACLUDE ORAL SOLUTION 0.05 MG/ML QL (600 ML per 30 entecavir oral tablet 0.5 mg, 1 mg QL (30 EA per 30 EPIVIR HBV ORAL SOLUTION 5 MG/ML INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT PA2 PA2 lamivudine oral tablet 100 mg VEMLIDY ORAL TABLET 25 MG ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG ; QL (168 EA per 365 EPCLUSA ORAL TABLET MG ; QL (84 EA per 365 HARVONI ORAL TABLET MG ; QL (168 EA per 365 MAVYRET ORAL TABLET MG ; QL (336 EA per 365 SOVALDI ORAL TABLET 400 MG ; QL (336 EA per 365 TECHNIVIE ORAL TABLET MG ; QL (168 EA per

55 VIEKIRA PAK ORAL TABLET THERAPY PACK &250 MG VIEKIRA XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG ; QL (672 EA per 365 ; QL (504 EA per 365 VOSEVI ORAL TABLET MG ; QL (84 EA per 365 ZEPATIER ORAL TABLET MG ; QL (112 EA per 365 ANTI-HEPATITIS C (HCV) AGENTS, OTHER DERIBA 1200 DOSE PACK ORAL TABLET 600 MG DERIBA 800 DOSE PACK ORAL TABLET 400 MG DERIBA ORAL TABLET 200 MG PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML REBETOL ORAL SOLUTION 40 MG/ML RIBASPHERE ORAL CAPSULE 200 MG RIBASPHERE ORAL TABLET 200 MG RIBASPHERE ORAL TABLET 400 MG, 600 MG RIBASPHERE RIBAPAK ORAL TABLET 400 MG, 600 MG RIBASPHERE RIBAPAK ORAL TABLET THERAPY PACK 200 & 400 MG, 400 & 600 MG ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg ANTIHERPETIC AGENTS acyclovir external ointment 5 % acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5ml acyclovir oral tablet 400 mg, 800 mg acyclovir sodium intravenous solution 50 mg/ml BvD; DENAVIR EXTERNAL CREAM 1 % famciclovir oral tablet 125 mg, 250 mg, 500 mg trifluridine ophthalmic solution 1 % valacyclovir hcl oral tablet 1 gm, 500 mg ; QL (120 EA per 30 ZOVIRAX EXTERNAL CREAM 5 % 54

56 ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI) BIKTARVY ORAL TABLET MG QL (30 EA per 30 GENVOYA ORAL TABLET MG QL (30 EA per 30 ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG ISENTRESS ORAL TABLET CHEWABLE 25 MG JULUCA ORAL TABLET MG QL (30 EA per 30 STRIBILD ORAL TABLET MG QL (30 EA per TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 25 MG, 50 MG TRIUMEQ ORAL TABLET MG QL (30 EA per 30 ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI) ATRIPLA ORAL TABLET MG QL (30 EA per 30 COMPLERA ORAL TABLET MG QL (30 EA per 30 EDURANT ORAL TABLET 25 MG efavirenz oral capsule 200 mg efavirenz oral capsule 50 mg efavirenz oral tablet 600 mg INTELENCE ORAL TABLET 100 MG, 200 MG INTELENCE ORAL TABLET 25 MG nevirapine er oral tablet extended release 24 hour 100 mg, 400 mg nevirapine oral tablet 200 mg ODEFSEY ORAL TABLET MG QL (30 EA per 30 RESCRIPTOR ORAL TABLET 100 MG, 200 MG SUSTIVA ORAL CAPSULE 200 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET 600 MG SYMFI LO ORAL TABLET MG QL (30 EA per 30 SYMFI ORAL TABLET MG QL (30 EA per 30 VIRAMUNE ORAL SUSPENSION 50 MG/5ML ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) abacavir sulfate oral solution 20 mg/ml abacavir sulfate oral tablet 300 mg

57 abacavir sulfate-lamivudine oral tablet mg QL (30 EA per 30 abacavir-lamivudine-zidovudine oral tablet mg QL (60 EA per 30 CIMDUO ORAL TABLET MG QL (30 EA per 30 DESCOVY ORAL TABLET MG QL (30 EA per 30 didanosine oral capsule delayed release 200 mg, 250 mg, 400 mg EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML lamivudine oral solution 10 mg/ml lamivudine oral tablet 150 mg, 300 mg lamivudine-zidovudine oral tablet mg ; QL (60 EA per 30 stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg tenofovir disoproxil fumarate oral tablet 300 mg TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG VIDEX ORAL SOLUTION RECONSTITUTED 4 GM 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 mg zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 300 mg ANTI-HIV AGENTS, OTHER FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL TABLET 400 MG SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 150 MG, 300 MG, 75 MG QL (30 EA per SELZENTRY ORAL TABLET 25 MG TYBOST ORAL TABLET 150 MG QL (60 EA per 30

58 ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML atazanavir sulfate oral capsule 150 mg, 200 mg, 300 mg CRIXIVAN ORAL CAPSULE 200 MG, 400 MG EVOTAZ ORAL TABLET MG QL (30 EA per 30 fosamprenavir calcium oral tablet 700 mg INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution mg/5ml NORVIR ORAL CAPSULE 100 MG NORVIR ORAL PACKET 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZCOBIX ORAL TABLET MG QL (30 EA per 30 PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL PACKET 50 MG ritonavir oral tablet 100 mg VIRACEPT ORAL TABLET 250 MG, 625 MG ANTI-INFLUENZA AGENTS amantadine hcl oral capsule 100 mg amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 100 mg oseltamivir phosphate oral capsule 30 mg ; QL (168 EA per 365 oseltamivir phosphate oral capsule 45 mg ; QL (84 EA per 365 oseltamivir phosphate oral capsule 75 mg ; QL (110 EA per 365 oseltamivir phosphate oral suspension reconstituted 6 mg/ml ; QL (1080 ML per

59 RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 100 mg ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg ; QL (240 EA per 365 ; CCP meprobamate oral tablet 200 mg, 400 mg ; ; HRM BENZODIAZEPINES alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg alprazolam er oral tablet extended release 24 hour 2 mg alprazolam er oral tablet extended release 24 hour 3 mg ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML ; ; QL (30 EA per 30 ; ; QL (150 EA per 30 ; ; QL (90 EA per 30 ; alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg ; ; QL (120 EA per 30 alprazolam oral tablet 2 mg ; ; QL (150 EA per 30 alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg ; ; QL (120 EA per 30 alprazolam oral tablet dispersible 2 mg ; ; QL (150 EA per 30 chlordiazepoxide hcl oral capsule 10 mg ; ; QL (900 EA per 30 chlordiazepoxide hcl oral capsule 25 mg ; ; QL (360 EA per 30 chlordiazepoxide hcl oral capsule 5 mg ; ; QL (120 EA per 30 clorazepate dipotassium oral tablet 15 mg ; QL (180 EA per 30 clorazepate dipotassium oral tablet 3.75 mg ; QL (720 EA per 30 clorazepate dipotassium oral tablet 7.5 mg ; QL (360 EA per 30 DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML diazepam oral solution 1 mg/ml diazepam oral solution 5 mg/5ml diazepam oral tablet 10 mg ; QL (120 EA per 30 58

60 diazepam oral tablet 2 mg ; QL (300 EA per 30 diazepam oral tablet 5 mg ; QL (240 EA per 30 estazolam oral tablet 1 mg, 2 mg ; ; QL (30 EA per 30 lorazepam oral concentrate 2 mg/ml ; lorazepam oral tablet 0.5 mg, 1 mg ; ; QL (90 EA per 30 lorazepam oral tablet 2 mg ; ; QL (150 EA per 30 oxazepam oral capsule 10 mg, 15 mg, 30 mg ; ; QL (120 EA per 30 temazepam oral capsule 15 mg, 30 mg ; ; QL (30 EA per 30 temazepam oral capsule 22.5 mg, 7.5 mg ; ; QL (30 EA per 30 BIPOLAR AGENTS OD STABILIZERS EQUETRO ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 200 MG, 300 MG lithium carbonate er oral tablet extended release 300 mg, 450 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium oral solution 8 meq/5ml BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose oral tablet 100 mg, 25 mg, 50 mg ; CCP BYDUREON BCISE SUBCUTANEOUS AUTO- INJECTOR 2 MG/0.85ML BYDUREON SUBCUTANEOUS PEN-INJECTOR 2 MG BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED ER 2 MG ST1; ; CCP; QL (3.4 ML per 28 CYCLOSET ORAL TABLET 0.8 MG glimepiride oral tablet 1 mg, 2 mg, 4 mg ; CCP glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg ST1; ; CCP; QL (4 EA per 28 ST1; ; CCP; QL (4 EA per 28 ; CCP glipizide oral tablet 10 mg, 5 mg ; CCP 59

61 glipizide-metformin hcl oral tablet mg, mg, mg ; CCP glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg ; ; HRM; CCP glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg ; ; HRM; CCP glyburide-metformin oral tablet mg, mg, mg ; ; HRM; CCP GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG ST1; ; CCP INVOKAMET ORAL TABLET MG, MG, MG, MG INVOKAMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG, MG ST1; ; CCP ST1; ; CCP INVOKANA ORAL TABLET 100 MG, 300 MG ST1; ; CCP JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG ST1; ; CCP ST1; ; CCP ST1; ; CCP JARDIANCE ORAL TABLET 10 MG, 25 MG ST1; ; CCP JENTADUETO ORAL TABLET MG, MG, MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG metformin hcl er oral tablet extended release 24 hour 500 mg, 750 mg ST1; ; CCP ST1; ; CCP ST1; ; CCP ; CCP metformin hcl oral tablet 1000 mg, 500 mg, 850 mg ; CCP miglitol oral tablet 100 mg, 25 mg, 50 mg ; CCP nateglinide oral tablet 120 mg, 60 mg ; CCP ONGLYZA ORAL TABLET 2.5 MG, 5 MG ST1; ; CCP pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg ; CCP pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg pioglitazone hcl-metformin hcl oral tablet mg, mg ; CCP ; CCP repaglinide oral tablet 0.5 mg, 1 mg, 2 mg ; CCP 60

62 repaglinide-metformin hcl oral tablet mg, mg RIOMET ORAL SOLUTION 500 MG/5ML SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5ML SYNJARDY ORAL TABLET MG, MG, MG, MG SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG ; CCP 61 ST1; ; CCP ST1; ; CCP; QL (30 EA per 30 ST1; ; CCP; QL (60 EA per 30 tolazamide oral tablet 250 mg, 500 mg ; CCP tolbutamide oral tablet 500 mg ; CCP TRADJENTA ORAL TABLET 5 MG ST1; ; CCP TRULICITY SUBCUTANEOUS SOLUTION PEN- INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR 18 MG/3ML GLYCEMIC AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG ST1; ; CCP; QL (2 ML per 28 ST1; ; CCP; QL (9 ML per 30 PROGLYCEM ORAL SUSPENSION 50 MG/ML INSULINS HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (75-25) 100 UNIT/ML ; CCP ; CCP ; CCP ; CCP ; CCP

63 HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR (70-30) 100 UNIT/ML ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP 62

64 NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML BLOOD PRODUCTS/DIFIERS/VOLUME EXPANDERS ANTICOAGULANTS COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ELIQUIS ORAL TABLET 2.5 MG ; CCP; QL (60 EA per 30 ELIQUIS ORAL TABLET 5 MG ; CCP; QL (90 EA per 30 ELIQUIS STARTER PACK ORAL TABLET 5 MG enoxaparin sodium subcutaneous solution 100 mg/ml, 150 mg/ml enoxaparin sodium subcutaneous solution 120 mg/0.8ml, 80 mg/0.8ml enoxaparin sodium subcutaneous solution 30 mg/0.3ml enoxaparin sodium subcutaneous solution 40 mg/0.4ml enoxaparin sodium subcutaneous solution 60 mg/0.6ml fondaparinux sodium subcutaneous solution 10 mg/0.8ml fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml fondaparinux sodium subcutaneous solution 5 mg/0.4ml fondaparinux sodium subcutaneous solution 7.5 mg/0.6ml FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML ; CCP; QL (148 EA per 365 ; QL (35 ML per 90 ; QL (28 ML per 90 ; QL (10.5 ML per 90 ; QL (14 ML per 90 ; QL (21 ML per 90 QL (28 ML per 90 ; QL (17.5 ML per 90 QL (14 ML per 90 QL (21 ML per 90 QL (35 ML per 90 63

65 FRAGMIN SUBCUTANEOUS SOLUTION UNIT/0.5ML FRAGMIN SUBCUTANEOUS SOLUTION UNIT/0.6ML FRAGMIN SUBCUTANEOUS SOLUTION UNT/0.72ML FRAGMIN SUBCUTANEOUS SOLUTION 2500 UNIT/0.2ML, 5000 UNIT/0.2ML FRAGMIN SUBCUTANEOUS SOLUTION 7500 UNIT/0.3ML FRAGMIN SUBCUTANEOUS SOLUTION UNIT/3.8ML heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg QL (17.5 ML per 90 QL (21 ML per 90 QL (25.3 ML per 90 ; QL (7 ML per 90 QL (10.5 ML per 90 QL (22.8 ML per 90 ; CCP ; CCP; QL (60 EA per 30 ; CCP XARELTO ORAL TABLET 10 MG, 20 MG ; CCP; QL (30 EA per 30 XARELTO ORAL TABLET 15 MG ; CCP; QL (60 EA per 30 XARELTO STARTER PACK ORAL TABLET THERAPY PACK 15 & 20 MG BLOOD FORMATION DIFIERS anagrelide hcl oral capsule 0.5 mg, 1 mg ; CCP ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML ARANESP (ALBUMIN FREE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 10 MCG/0.4ML, 25 MCG/0.42ML, 40 MCG/0.4ML, 60 MCG/0.3ML ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 300 MCG/0.6ML, 500 MCG/ML GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML ; CCP; QL (102 EA per ; ; ST1

66 LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML PROCRIT INJECTION SOLUTION UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION UNIT/ML, UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG ZARXIO INJECTION SOLUTION PREFILLED SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML HESTASIS AGENTS 65 ST1 ST1 ; TAVALISSE ORAL TABLET 100 MG, 150 MG ; QL (60 EA per 30 tranexamic acid oral tablet 650 mg PLATELET DIFYING AGENTS aspirin-dipyridamole er oral capsule extended release 12 hour mg BRILINTA ORAL TABLET 60 MG, 90 MG ; CCP cilostazol oral tablet 100 mg, 50 mg ; CCP clopidogrel bisulfate oral tablet 75 mg ; CCP dipyridamole oral tablet 25 mg, 50 mg, 75 mg ; ; HRM prasugrel hcl oral tablet 10 mg, 5 mg ; CCP CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg ; CCP clonidine hcl transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr guanfacine hcl oral tablet 1 mg, 2 mg ; ; HRM methyldopa oral tablet 250 mg, 500 mg ; ; HRM methyldopa-hydrochlorothiazide oral tablet mg, mg ; ; HRM midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg

67 ALPHA-ADRENERGIC BLOCKING AGENTS phenoxybenzamine hcl oral capsule 10 mg prazosin hcl oral capsule 1 mg, 2 mg, 5 mg ; CCP ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg candesartan cilexetil-hctz oral tablet mg, mg, mg ; CCP ; CCP EDARBI ORAL TABLET 40 MG, 80 MG ; CCP EDARBYCLOR ORAL TABLET MG, MG ; CCP eprosartan mesylate oral tablet 600 mg ; CCP irbesartan oral tablet 150 mg, 300 mg, 75 mg ; CCP irbesartan-hydrochlorothiazide oral tablet mg, mg ; CCP losartan potassium oral tablet 100 mg, 25 mg, 50 mg ; CCP losartan potassium-hctz oral tablet mg, mg, mg olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg olmesartan medoxomil-hctz oral tablet mg, mg, mg ; CCP ; CCP ; CCP telmisartan oral tablet 20 mg, 40 mg, 80 mg ; CCP telmisartan-hctz oral tablet mg, mg, mg ; CCP valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg ; CCP valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS ; CCP benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg ; CCP benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg ; CCP captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg ; CCP captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg enalapril-hydrochlorothiazide oral tablet mg, mg ; CCP ; CCP ; CCP fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg ; CCP 66

68 fosinopril sodium-hctz oral tablet mg, mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg ; CCP ; CCP ; CCP moexipril hcl oral tablet 15 mg, 7.5 mg ; CCP moexipril-hydrochlorothiazide oral tablet mg, mg, mg ; CCP perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg ; CCP quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg ; CCP quinapril-hydrochlorothiazide oral tablet mg, mg, mg ; CCP ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg ; CCP trandolapril oral tablet 1 mg, 2 mg, 4 mg ; CCP trandolapril-verapamil hcl er oral tablet extended release mg, mg, mg, mg ANTIARRHYTHMICS ; CCP amiodarone hcl oral tablet 100 mg, 400 mg ; CCP amiodarone hcl oral tablet 200 mg ; CCP disopyramide phosphate oral capsule 100 mg, 150 mg dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg ; ; HRM flecainide acetate oral tablet 100 mg, 150 mg, 50 mg mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg ; CCP MULTAQ ORAL TABLET 400 MG NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG ; ; HRM; CCP PACERONE ORAL TABLET 200 MG ; CCP PACERONE ORAL TABLET 400 MG ; CCP propafenone hcl er oral capsule extended release 12 hour 225 mg, 325 mg, 425 mg propafenone hcl oral tablet 150 mg, 225 mg, 300 mg quinidine gluconate er oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG 67 ; CCP sotalol hcl (af) oral tablet 120 mg ; CCP

69 sotalol hcl oral tablet 160 mg, 240 mg, 80 mg ; CCP BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl oral capsule 200 mg, 400 mg ; CCP atenolol oral tablet 100 mg, 25 mg, 50 mg ; CCP atenolol-chlorthalidone oral tablet mg, mg ; CCP betaxolol hcl oral tablet 10 mg, 20 mg ; CCP bisoprolol fumarate oral tablet 10 mg, 5 mg ; CCP bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg carvedilol phosphate er oral capsule extended release 24 hour 10 mg, 20 mg, 40 mg, 80 mg DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HOUR MG, MG, MG INNOPRAN XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG ; CCP ; CCP ; CCP ; CCP labetalol hcl oral tablet 100 mg, 200 mg, 300 mg ; CCP metoprolol succinate er oral tablet extended release 24 hour 100 mg, 200 mg, 25 mg, 50 mg 68 ; CCP metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg ; CCP metoprolol-hydrochlorothiazide oral tablet mg, mg, mg ; CCP nadolol oral tablet 20 mg, 40 mg, 80 mg ; CCP nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg pindolol oral tablet 10 mg, 5 mg ; CCP propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg ; CCP propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml propranolol hcl oral tablet 10 mg ; CCP propranolol hcl oral tablet 20 mg, 40 mg, 80 mg ; CCP propranolol hcl oral tablet 60 mg propranolol-hctz oral tablet mg propranolol-hctz oral tablet mg ; CCP

70 timolol maleate oral tablet 10 mg, 20 mg, 5 mg ; CCP CALCIUM CHANNEL BLOCKING AGENTS AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG, 60 MG amlodipine besy-benazepril hcl oral capsule mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg ; CCP ; CCP amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg ; CCP amlodipine besylate-valsartan oral tablet mg, mg, mg, mg amlodipine-atorvastatin oral tablet mg, mg, mg, mg, mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg amlodipine-valsartan-hctz oral tablet mg, mg, mg, mg, mg CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG diltiazem hcl er beads oral capsule extended release 24 hour 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5 mg ; CCP ; CCP isradipine oral capsule 2.5 mg, 5 mg MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG, 240 MG, 300 MG, 360 MG, 420 MG nicardipine hcl oral capsule 20 mg, 30 mg nifedipine er oral tablet extended release 24 hour 30 mg, 90 mg nifedipine er oral tablet extended release 24 hour 60 mg ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP ; CCP 69

71 nifedipine er osmotic release oral tablet extended release 24 hour 30 mg, 60 mg, 90 mg ; CCP nifedipine oral capsule 10 mg, 20 mg ; ; HRM nimodipine oral capsule 30 mg nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg NYMALIZE ORAL SOLUTION 30 MG/10ML TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG telmisartan-amlodipine oral tablet mg, 40-5 mg, mg, 80-5 mg verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg 70 ; CCP ; CCP ; CCP ; CCP verapamil hcl oral tablet 120 mg, 40 mg, 80 mg ; CCP CARDIOVASCULAR AGENTS, OTHER CORLANOR ORAL TABLET 5 MG, 7.5 MG ; ; QL (60 EA per 30 DEMSER ORAL CAPSULE 250 MG DIGITEK ORAL TABLET 125 MCG ; CCP; QL (30 EA per 30 DIGITEK ORAL TABLET 250 MCG ; ; HRM DIGOX ORAL TABLET 125 MCG ; CCP; QL (30 EA per 30 DIGOX ORAL TABLET 250 MCG ; ; HRM digoxin oral solution 0.05 mg/ml ; ; HRM digoxin oral tablet 125 mcg ; CCP; QL (30 EA per 30 digoxin oral tablet 250 mcg ; ; HRM ENTRESTO ORAL TABLET MG, MG, MG ; CCP; QL (60 EA per 30 LANOXIN ORAL TABLET 125 MCG ; CCP; QL (30 EA per 30 LANOXIN ORAL TABLET 250 MCG ; ; HRM; CCP LANOXIN ORAL TABLET 62.5 MCG ; CCP; QL (60 EA per 30 NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG pentoxifylline er oral tablet extended release 400 mg

72 PRALUENT SUBCUTANEOUS SOLUTION PEN- INJECTOR 150 MG/ML, 75 MG/ML RANEXA ORAL TABLET EXTENDED RELEASE 12 HOUR 1000 MG, 500 MG REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE 420 MG/3.5ML REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 140 MG/ML REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MG/ML DIURETICS, LOOP ; ; CCP; QL (2 ML per 28 ; CCP ; ; CCP; QL (3.5 ML per 28 ; ; CCP; QL (3 ML per 28 ; ; CCP; QL (3 ML per 28 bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, 2 mg ; CCP ethacrynic acid oral tablet 25 mg furosemide injection solution 10 mg/ml, 10 mg/ml (4ml syringe) furosemide oral solution 10 mg/ml, 8 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 mg ; CCP torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg ; CCP DIURETICS, POTASSIUM-SPARING ALDACTAZIDE ORAL TABLET MG amiloride hcl oral tablet 5 mg amiloride-hydrochlorothiazide oral tablet 5-50 mg ; CCP DYRENIUM ORAL CAPSULE 100 MG, 50 MG eplerenone oral tablet 25 mg, 50 mg ; CCP spironolactone oral tablet 100 mg, 25 mg, 50 mg ; CCP spironolactone-hctz oral tablet mg ; CCP triamterene-hctz oral capsule mg triamterene-hctz oral tablet mg, mg ; CCP DIURETICS, THIAZIDE chlorothiazide oral tablet 250 mg chlorothiazide oral tablet 500 mg ; CCP chlorthalidone oral tablet 25 mg, 50 mg DIURIL ORAL SUSPENSION 250 MG/5ML hydrochlorothiazide oral capsule 12.5 mg ; CCP hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg ; CCP 71

73 indapamide oral tablet 1.25 mg, 2.5 mg ; CCP methyclothiazide oral tablet 5 mg ; CCP metolazone oral tablet 10 mg, 2.5 mg, 5 mg ; CCP DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg ; CCP fenofibrate oral capsule 150 mg, 50 mg ; CCP fenofibrate oral tablet 120 mg, 160 mg, 40 mg ; CCP fenofibrate oral tablet 145 mg, 48 mg fenofibrate oral tablet 54 mg ; CCP fenofibric acid oral capsule delayed release 135 mg, 45 mg ; CCP fenofibric acid oral tablet 105 mg, 35 mg ; CCP gemfibrozil oral tablet 600 mg ; CCP DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 80 mg fluvastatin sodium er oral tablet extended release 24 hour 80 mg ; CCP ; CCP fluvastatin sodium oral capsule 20 mg, 40 mg ; CCP LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG ST1; ; CCP lovastatin oral tablet 10 mg, 20 mg, 40 mg ; CCP pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg ; CCP ; CCP simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg ; CCP simvastatin oral tablet 80 mg ; ; CCP DYSLIPIDEMICS, OTHER cholestyramine light oral powder 4 gm/dose ; CCP cholestyramine oral packet 4 gm colesevelam hcl oral tablet 625 mg ; CCP colestipol hcl oral packet 5 gm colestipol hcl oral tablet 1 gm ezetimibe oral tablet 10 mg ; CCP ezetimibe-simvastatin oral tablet mg, mg, mg ; CCP 72

74 ezetimibe-simvastatin oral tablet mg ; ; CCP JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML niacin er (antihyperlipidemic) oral tablet extended release 1000 mg, 500 mg, 750 mg ; QL (30 EA per 30 ; QL (4 ML per 28 NIACOR ORAL TABLET 500 MG omega-3-acid ethyl esters oral capsule 1 gm PREVALITE ORAL PACKET 4 GM ; CCP VASCEPA ORAL CAPSULE 0.5 GM, 1 GM VASODILATORS, DIRECT-ACTING ARTERIAL hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg ; CCP minoxidil oral tablet 10 mg, 2.5 mg ; CCP VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS BIDIL ORAL TABLET MG ISORDIL TITRADOSE ORAL TABLET 40 MG ; CCP isosorbide dinitrate er oral tablet extended release 40 mg ; CCP isosorbide dinitrate oral tablet 10 mg, 5 mg ; CCP isosorbide dinitrate oral tablet 20 mg, 30 mg isosorbide mononitrate er oral tablet extended release 24 hour 120 mg, 30 mg, 60 mg ; CCP isosorbide mononitrate oral tablet 10 mg, 20 mg ; CCP MINITRAN TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT 2 % NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual solution 0.4 mg/spray CENTRAL NERVOUS SYSTEM AGENTS ; CCP ; CCP ; CCP ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES 73

75 amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 15 mg dextroamphetamine sulfate er oral capsule extended release 24 hour 5 mg ; ; QL (30 EA per 30 ; ; QL (90 EA per 30 ; ; QL (180 EA per 30 ; ; QL (120 EA per 30 ; ; QL (60 EA per 30 dextroamphetamine sulfate oral tablet 10 mg ; ; QL (180 EA per 30 dextroamphetamine sulfate oral tablet 5 mg ; ; QL (90 EA per 30 ZENZEDI ORAL TABLET 10 MG ; ; QL (180 EA per 30 ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG ; ; QL (90 EA per 30 ZENZEDI ORAL TABLET 30 MG ; ; QL (60 EA per 30 ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES atomoxetine hcl oral capsule 10 mg ; QL (60 EA per 30 atomoxetine hcl oral capsule 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg clonidine hcl er oral tablet extended release 12 hour 0.1 mg dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg methylphenidate hcl er oral tablet extended release 10 mg ; QL (30 EA per ; ; QL (30 EA per 30 ; ; QL (60 EA per 30 ; ; QL (90 EA per 30 ; ; QL (30 EA per 30 ; ; QL (30 EA per 30 ; ; QL (30 EA per 30 ; ; QL (180 EA per 30

76 methylphenidate hcl er oral tablet extended release 20 mg methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg methylphenidate hcl er oral tablet extended release 24 hour 36 mg methylphenidate hcl er oral tablet extended release 72 mg methylphenidate hcl oral solution 10 mg/5ml, 5 mg/5ml ; ; QL (90 EA per 30 ; ; QL (30 EA per 30 ; ; QL (60 EA per 30 ; ; QL (30 EA per 30 ; methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg ; ; QL (90 EA per 30 methylphenidate hcl oral tablet chewable 10 mg ; ; QL (180 EA per 30 methylphenidate hcl oral tablet chewable 2.5 mg, 5 mg CENTRAL NERVOUS SYSTEM, OTHER ; ; QL (90 EA per 30 AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG ; QL (120 EA per 30 butalbital-apap-caffeine oral tablet mg ; ; HRM butalbital-aspirin-caffeine oral capsule mg ; ; HRM INGREZZA ORAL CAPSULE 40 MG ; QL (60 EA per 30 INGREZZA ORAL CAPSULE 80 MG ; QL (30 EA per 30 NUEDEXTA ORAL CAPSULE MG ; riluzole oral tablet 50 mg ; tetrabenazine oral tablet 12.5 mg, 25 mg VANATOL LQ ORAL SOLUTION MG/15ML FIBROMYALGIA AGENTS SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG MULTIPLE SCLEROSIS AGENTS AMPYRA ORAL TABLET EXTENDED RELEASE 12 HOUR 10 MG ; HRM ; QL (60 EA per 30 ; QL (110 EA per 365 ; QL (60 EA per 30 AUBAGIO ORAL TABLET 14 MG, 7 MG ; QL (30 EA per 30 AVONEX INTRAMUSCULAR KIT 30 MCG ; QL (4 EA per 28 AVONEX PEN INTRAMUSCULAR AUTO- INJECTOR KIT 30 MCG/0.5ML ; QL (4 EA per 28 75

77 AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT 30 MCG/0.5ML ; QL (4 EA per 28 BETASERON SUBCUTANEOUS KIT 0.3 MG ; QL (15 EA per 30 COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML ; QL (30 ML per 30 ; QL (12 ML per 28 EXTAVIA SUBCUTANEOUS KIT 0.3 MG ; QL (15 EA per 30 GILENYA ORAL CAPSULE 0.5 MG ; QL (30 EA per 30 glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 20 MG/ML GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40 MG/ML PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML PLEGRIDY SUBCUTANEOUS SOLUTION PEN- INJECTOR 125 MCG/0.5ML PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MCG/0.5ML REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO- INJECTOR 6X8.8 & 6X22 MCG REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG ; QL (30 ML per 30 ; QL (12 ML per 28 ; QL (30 ML per 30 ; QL (12 ML per 28 ; QL (2 ML per 365 ; QL (2 ML per 365 ; QL (1 ML per 28 ; QL (1 ML per 28 ; QL (6 ML per 28 ; QL (8.4 ML per 365 ; QL (6 ML per 28 ; QL (8.4 ML per 365 TECFIDERA ORAL 120 & 240 MG ; QL (120 EA per 365 TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG ; QL (60 EA per 30 76

78 DENTAL AND ORAL AGENTS DENTAL AND ORAL AGENTS cevimeline hcl oral capsule 30 mg chlorhexidine gluconate mouth/throat solution 0.12 % lidocaine viscous mouth/throat solution 2 % PERIOGARD UTH/THROAT SOLUTION 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 mg triamcinolone acetonide mouth/throat paste 0.1 % DERMATOLOGICAL AGENTS DERMATOLOGICAL AGENTS acitretin oral capsule 10 mg, 17.5 mg, 25 mg adapalene external cream 0.1 % adapalene external gel 0.1 %, 0.3 % adapalene-benzoyl peroxide external gel % ammonium lactate external cream 12 % ammonium lactate external lotion 12 % AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG ; AVITA EXTERNAL CREAM % ; AVITA EXTERNAL GEL % ; benzoyl peroxide-erythromycin external gel 5-3 % calcipotriene external cream % calcipotriene external ointment % calcipotriene external solution % calcipotriene-betameth diprop external ointment % calcitriol external ointment 3 mcg/gm CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 40 MG CLARAVIS ORAL CAPSULE 30 MG QL (400 GM per 30 ; clindamycin phos-benzoyl perox external gel % clindamycin phos-benzoyl perox external gel 1-5 % clindamycin-tretinoin external gel % CONDYLOX EXTERNAL GEL 0.5 % 77

79 COSENTYX 300 DOSE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML COSENTYX SENSOREADY 300 DOSE SUBCUTANEOUS SOLUTION AUTO- INJECTOR 150 MG/ML 78 dapsone external gel 5 % diclofenac sodium transdermal solution 1.5 % ; doxepin hcl external cream 5 % ; ; QL (90 GM per 30 DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300 MG/2ML ELIDEL EXTERNAL CREAM 1 % EPIDUO FORTE EXTERNAL GEL % FINACEA EXTERNAL FOAM 15 % FINACEA EXTERNAL GEL 15 % hydrocortisone ace-pramoxine rectal cream 1-1 % imiquimod external cream 5 % isotretinoin oral capsule 10 mg, 20 mg, 40 mg ; isotretinoin oral capsule 30 mg methoxsalen rapid oral capsule 10 mg metronidazole external cream 0.75 % metronidazole external gel 0.75 % metronidazole external gel 1 % metronidazole external lotion 0.75 % MIRVASO EXTERNAL GEL 0.33 % ; MYORISAN ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG ; QL (8 ML per 28 ; NEUAC EXTERNAL GEL % NORITATE EXTERNAL CREAM 1 % PENNSAID TRANSDERMAL SOLUTION 2 % PICATO EXTERNAL GEL %, 0.05 % podofilox external solution 0.5 % RECTIV RECTAL OINTMENT 0.4 % REGRANEX EXTERNAL GEL 0.01 % SANTYL EXTERNAL OINTMENT 250 UNIT/GM selenium sulfide external lotion 2.5 % SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 210 MG/1.5ML

80 STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML TACLONEX EXTERNAL SUSPENSION % tacrolimus external ointment 0.03 %, 0.1 % TALTZ SUBCUTANEOUS SOLUTION AUTO- INJECTOR 80 MG/ML TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 80 MG/ML QL (400 GM per 30 tazarotene external cream 0.1 % TAZORAC EXTERNAL CREAM 0.05 % TAZORAC EXTERNAL GEL 0.05 %, 0.1 % TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML tretinoin external cream %, 0.05 %, 0.1 % ; tretinoin external gel 0.01 %, %, 0.05 % ; tretinoin microsphere external gel 0.04 %, 0.1 % ; VEREGEN EXTERNAL OINTMENT 15 % ZENATANE ORAL CAPSULE 10 MG, 20 MG, 40 MG ZENATANE ORAL CAPSULE 30 MG ZYCLARA PUMP EXTERNAL CREAM 2.5 %, 3.75 % ELECTROLYTES/MINERALS/METALS/VITAMINS ELECTROLYTE/MINERAL REPLACEMENT AMINOSYN II/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 % AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 % AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 8.5 % CARBAGLU ORAL TABLET 200 MG CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS SOLUTION 2.75 % CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 % ; GC; BvD; BvD; GC; BvD; BvD; BvD; 79

81 CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 % CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 % BvD; BvD; BvD; BvD; BvD; BvD; BvD; BvD; BvD; BvD; BvD; BvD; BvD; BvD; dextrose intravenous solution 10 %, 5 % dextrose-nacl intravenous solution %, %, %, %, %, %, %, % IONOSOL-MB IN D5W INTRAVENOUS SOLUTION ISOLYTE-P IN D5W INTRAVENOUS SOLUTION 80 ISOLYTE-S INTRAVENOUS SOLUTION kcl in dextrose-nacl intravenous solution meq/l-%-%, meq/l-%-%, meq/l-%- %, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%

82 kcl-lactated ringers-d5w intravenous solution 20 meq/l KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ KLOR-CON M10 ORAL TABLET EXTENDED RELEASE 10 MEQ KLOR-CON M15 ORAL TABLET EXTENDED RELEASE 15 MEQ KLOR-CON M20 ORAL TABLET EXTENDED RELEASE 20 MEQ KLOR-CON ORAL PACKET 20 MEQ ; CCP KLOR-CON ORAL TABLET EXTENDED RELEASE 8 MEQ KLOR-CON SPRINKLE ORAL CAPSULE EXTENDED RELEASE 10 MEQ, 8 MEQ magnesium sulfate injection solution 50 %, 50 % (10ml syringe) NORSOL-M IN D5W INTRAVENOUS SOLUTION NORSOL-R IN D5W INTRAVENOUS SOLUTION NORSOL-R PH 7.4 INTRAVENOUS SOLUTION PLASMA-LYTE 148 INTRAVENOUS SOLUTION 81 PLASMA-LYTE A INTRAVENOUS SOLUTION potassium chloride crys er oral tablet extended release 10 meq potassium chloride crys er oral tablet extended release 20 meq potassium chloride er oral capsule extended release 10 meq, 8 meq potassium chloride er oral tablet extended release 10 meq, 20 meq, 8 meq potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-% potassium chloride in nacl intravenous solution meq/l-%, meq/l-%, meq/l-% potassium chloride intravenous solution 10 meq/100ml, 2 meq/ml, 2 meq/ml (20 ml) potassium chloride intravenous solution 20 meq/100ml, 40 meq/100ml ; CCP ; CCP ; CCP ; CCP

83 potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) potassium citrate er oral tablet extended release 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg) PROCALAMINE INTRAVENOUS SOLUTION 3 % ; CCP BvD; sodium chloride injection solution 2.5 meq/ml sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 % sodium fluoride oral tablet 2.2 (1 f) mg sodium lactate intravenous solution 5 meq/ml TPN ELECTROLYTES INTRAVENOUS SOLUTION ELECTROLYTE/MINERAL/METAL DIFIERS DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG 82 FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG JADENU ORAL TABLET 180 MG, 360 MG, 90 MG JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG, 90 MG JYNARQUE ORAL TABLET THERAPY PACK 45 & 15 MG, 60 & 30 MG, 90 & 30 MG KIONEX ORAL SUSPENSION 15 GM/60ML QL (56 EA per 28 SAMSCA ORAL TABLET 15 MG QL (30 EA per 60 SAMSCA ORAL TABLET 30 MG QL (60 EA per 30 sodium polystyrene sulfonate oral powder SPS ORAL SUSPENSION 15 GM/60ML trientine hcl oral capsule 250 mg PHOSPHATE BINDERS AURYXIA ORAL TABLET 1 GM 210 MG(FE) calcium acetate (phos binder) oral capsule 667 mg calcium acetate (phos binder) oral tablet 667 mg lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750 mg RENAGEL ORAL TABLET 800 MG

84 sevelamer carbonate oral packet 0.8 gm, 2.4 gm sevelamer carbonate oral tablet 800 mg VELPHORO ORAL TABLET CHEWABLE 500 MG VITAMINS prenatal oral tablet 27-1 mg RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30 MCG GASTROINTESTINAL AGENTS ANTISPASDICS, GASTROINTESTINAL CUVPOSA ORAL SOLUTION 1 MG/5ML dicyclomine hcl oral capsule 10 mg ; ; HRM dicyclomine hcl oral solution 10 mg/5ml ; ; HRM dicyclomine hcl oral tablet 20 mg ; ; HRM glycopyrrolate oral tablet 1 mg, 2 mg methscopolamine bromide oral tablet 2.5 mg, 5 mg propantheline bromide oral tablet 15 mg ; ; HRM GASTROINTESTINAL AGENTS, OTHER amoxicill-clarithro-lansopraz oral CHENODAL ORAL TABLET 250 MG CHOLBAM ORAL CAPSULE 250 MG, 50 MG cromolyn sodium oral concentrate 100 mg/5ml diphenoxylate-atropine oral liquid mg/5ml ; ; HRM diphenoxylate-atropine oral tablet mg ; ; HRM GATTEX SUBCUTANEOUS KIT 5 MG loperamide hcl oral capsule 2 mg metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 10 mg, 5 mg metoclopramide hcl oral tablet dispersible 10 mg, 5 mg OCALIVA ORAL TABLET 10 MG, 5 MG ; QL (30 EA per 30 RELISTOR ORAL TABLET 150 MG ; QL (90 EA per 30 RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 12 MG/0.6ML (0.6ML SYRINGE) RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML ; QL (18 ML per 30 ; QL (12 ML per 30 83

85 ursodiol oral tablet 250 mg, 500 mg XERMELO ORAL TABLET 250 MG ; QL (90 EA per 30 HISTAMINE2 (H2) RECEPTOR ANTAGONISTS cimetidine hcl oral solution 300 mg/5ml cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg famotidine oral suspension reconstituted 40 mg/5ml famotidine oral tablet 20 mg, 40 mg nizatidine oral capsule 150 mg, 300 mg nizatidine oral solution 15 mg/ml ranitidine hcl oral capsule 150 mg, 300 mg ranitidine hcl oral syrup 75 mg/5ml ranitidine hcl oral tablet 150 mg, 300 mg ; CCP IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl oral tablet 0.5 mg, 1 mg AMITIZA ORAL CAPSULE 24 MCG, 8 MCG ; QL (60 EA per 30 LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG LAXATIVES constulose oral solution 10 gm/15ml enulose oral solution 10 gm/15ml GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240 GM GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM ; QL (30 EA per 30 generlac oral solution 10 gm/15ml KRISTALOSE ORAL PACKET 10 GM, 20 GM lactulose oral solution 10 gm/15ml VIPREP ORAL SOLUTION RECONSTITUTED 100 GM peg 3350/electrolytes oral solution reconstituted 240 gm peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm peg-3350/electrolytes oral solution reconstituted 236 gm 84

86 polyethylene glycol 3350 oral powder SUPREP BOWEL PREP KIT ORAL SOLUTION GM/177ML TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM PROTECTANTS CARAFATE ORAL SUSPENSION 1 GM/10ML misoprostol oral tablet 100 mcg, 200 mcg sucralfate oral tablet 1 gm PROTON PUMP INHIBITORS DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG esomeprazole magnesium oral capsule delayed release 20 mg, 40 mg ; CCP; QL (30 EA per 30 ; CCP; QL (30 EA per 30 lansoprazole oral capsule delayed release 15 mg ; CCP; QL (30 EA per 30 lansoprazole oral capsule delayed release 30 mg ; QL (30 EA per 30 lansoprazole oral tablet dispersible 15 mg, 30 mg ; QL (30 EA per 30 omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg omeprazole-sodium bicarbonate oral capsule mg, mg omeprazole-sodium bicarbonate oral packet mg, mg pantoprazole sodium oral tablet delayed release 20 mg, 40 mg ; CCP; QL (30 EA per 30 QL (30 EA per 30 QL (60 EA per 30 ; CCP; QL (30 EA per 30 rabeprazole sodium oral tablet delayed release 20 mg ; QL (30 EA per 30 GENETIC OR ENZYME DISORDER: REPLACEMENT, DIFIERS, TREATMENT GENETIC OR ENZYME DISORDER: REPLACEMENT, DIFIERS, TREATMENT CERDELGA ORAL CAPSULE 84 MG CREON ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, 6000 UNIT CYSTADANE ORAL POWDER CYSTAGON ORAL CAPSULE 150 MG, 50 MG KUVAN ORAL PACKET 100 MG, 500 MG KUVAN ORAL TABLET SOLUBLE 100 MG miglustat oral capsule 100 mg 85

87 ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG ORFADIN ORAL SUSPENSION 4 MG/ML RAVICTI ORAL LIQUID 1.1 GM/ML sodium phenylbutyrate oral powder 3 gm/tsp sodium phenylbutyrate oral tablet 500 mg SUCRAID ORAL SOLUTION 8500 UNIT/ML XURIDEN ORAL PACKET 2 GM ; QL (120 EA per 30 ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, UNIT GENITOURINARY AGENTS ANTISPASDICS, URINARY darifenacin hydrobromide er oral tablet extended release 24 hour 15 mg, 7.5 mg 86 ; CCP flavoxate hcl oral tablet 100 mg GELNIQUE PUMP TRANSDERMAL GEL 10 % MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR 25 MG, 50 MG oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg, 5 mg ; CCP oxybutynin chloride oral syrup 5 mg/5ml oxybutynin chloride oral tablet 5 mg tolterodine tartrate er oral capsule extended release 24 hour 2 mg, 4 mg ; CCP tolterodine tartrate oral tablet 1 mg, 2 mg ; CCP trospium chloride er oral capsule extended release 24 hour 60 mg trospium chloride oral tablet 20 mg VESICARE ORAL TABLET 10 MG, 5 MG ; CCP BENIGN PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl er oral tablet extended release 24 hour 10 mg CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG, 8 MG ; CCP doxazosin mesylate oral tablet 1 mg, 4 mg doxazosin mesylate oral tablet 2 mg, 8 mg ; CCP

88 dutasteride oral capsule 0.5 mg ; CCP dutasteride-tamsulosin hcl oral capsule mg ; CCP finasteride oral tablet 5 mg ; CCP RAPAFLO ORAL CAPSULE 4 MG, 8 MG ; CCP tamsulosin hcl oral capsule 0.4 mg ; CCP terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg ; CCP GENITOURINARY AGENTS, OTHER bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg ELMIRON ORAL CAPSULE 100 MG HORNAL AGENTS, STIMULANT/REPLACEMENT/DIFYING (ADRENAL) HORNAL AGENTS, STIMULANT/REPLACEMENT/DIFYING (ADRENAL) ala-cort external cream 2.5 % alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % amcinonide external cream 0.1 % amcinonide external lotion 0.1 % amcinonide external ointment 0.1 % APEXICON E EXTERNAL CREAM 0.05 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0.1 % betamethasone valerate external foam 0.12 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % CAPEX EXTERNAL SHAMPOO 0.01 % clobetasol prop emollient base external cream 0.05 % clobetasol propionate e external cream 0.05 % 87

89 clobetasol propionate external cream 0.05 % clobetasol propionate external foam 0.05 % clobetasol propionate external gel 0.05 % clobetasol propionate external liquid 0.05 % clobetasol propionate external lotion 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external shampoo 0.05 % clobetasol propionate external solution 0.05 % CLODAN EXTERNAL SHAMPOO 0.05 % CORDRAN EXTERNAL TAPE 4 MCG/SQCM cortisone acetate oral tablet 25 mg DESONATE EXTERNAL GEL 0.05 % desonide external cream 0.05 % desonide external lotion 0.05 % desonide external ointment 0.05 % desoximetasone external cream 0.05 %, 0.25 % desoximetasone external gel 0.05 % desoximetasone external ointment 0.05 %, 0.25 % DEXAMETHASONE INTENSOL ORAL CONCENTRATE 1 MG/ML dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % EMFLAZA ORAL SUSPENSION MG/ML EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG 88 fludrocortisone acetate oral tablet 0.1 mg fluocinolone acetonide external cream 0.01 %, % fluocinolone acetonide external ointment % fluocinolone acetonide external solution 0.01 % fluocinolone acetonide scalp external oil 0.01 % fluocinonide emulsified base external cream 0.05 % fluocinonide external cream 0.1 %

90 fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % flurandrenolide external cream 0.05 % flurandrenolide external ointment 0.05 % fluticasone propionate external cream 0.05 % fluticasone propionate external lotion 0.05 % fluticasone propionate external ointment % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % hydrocortisone butyrate external cream 0.1 % hydrocortisone butyrate external ointment 0.1 % hydrocortisone butyrate external solution 0.1 % hydrocortisone external cream 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment 2.5 % hydrocortisone oral tablet 10 mg, 20 mg, 5 mg hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % MEDROL ORAL TABLET 2 MG methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg methylprednisolone oral tablet therapy pack 4 mg MILLIPRED ORAL TABLET 5 MG mometasone furoate external cream 0.1 % mometasone furoate external ointment 0.1 % mometasone furoate external solution 0.1 % NOLIX EXTERNAL CREAM 0.05 % PANDEL EXTERNAL CREAM 0.1 % prednicarbate external cream 0.1 % prednicarbate external ointment 0.1 % prednisolone oral solution 15 mg/5ml prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML 89

91 prednisone oral solution 5 mg/5ml prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5 mg (21), 5 mg (48) RAYOS ORAL TABLET DELAYED RELEASE 1 MG, 2 MG, 5 MG SYNALAR EXTERNAL CREAM % triamcinolone acetonide external cream %, 0.1 %, 0.5 % triamcinolone acetonide external lotion %, 0.1 % triamcinolone acetonide external ointment %, 0.1 %, 0.5 % TRIDERM EXTERNAL CREAM 0.1 % UCERIS RECTAL FOAM 2 MG/ACT HORNAL AGENTS, STIMULANT/REPLACEMENT/DIFYING (PITUITARY) HORNAL AGENTS, STIMULANT/REPLACEMENT/DIFYING (PITUITARY) desmopressin ace spray refrig nasal solution 0.01 % desmopressin acetate oral tablet 0.1 mg, 0.2 mg EGRIFTA SUBCUTANEOUS SOLUTION RECONSTITUTED 1 MG GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.2 MG GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED 0.4 MG, 0.6 MG, 0.8 MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG, 2 MG GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED 12 MG, 5 MG ; QL (60 EA per 30 ; HP ACTHAR INJECTION GEL 80 UNIT/ML HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION 10 MG/2ML 90

92 NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION 20 MG/2ML NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION 5 MG/2ML OMNITROPE SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 5 MG/1.5ML SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 MG SAIZENPREP INJECTION SOLUTION RECONSTITUTED 8.8 MG SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG STIMATE NASAL SOLUTION 1.5 MG/ML ZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED 8.8 MG HORNAL AGENTS, STIMULANT/REPLACEMENT/DIFYING (PROSTAGLANDINS) HORNAL AGENTS, STIMULANT/REPLACEMENT/DIFYING (PROSTAGLANDINS) KORLYM ORAL TABLET 300 MG ; QL (120 EA per 30 HORNAL AGENTS, STIMULANT/REPLACEMENT/DIFYING (SEX HORNES/DIFIERS) ANABOLIC STEROIDS ANADROL-50 ORAL TABLET 50 MG oxandrolone oral tablet 10 mg ; QL (60 EA per 30 oxandrolone oral tablet 2.5 mg ; ; QL (240 EA per 30 ANDROGENS ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24HR, 4 MG/24HR ANDROGEL PUMP TRANSDERMAL GEL MG/ACT (1.62%) ANDROGEL TRANSDERMAL GEL MG/1.25GM (1.62%), 40.5 MG/2.5GM (1.62%) ; ; ; danazol oral capsule 100 mg, 200 mg, 50 mg methitest oral tablet 10 mg ; methyltestosterone oral capsule 10 mg STRIANT BUCCAL 30 MG ; testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution 200 mg/ml ; ; 91

93 testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%) ; testosterone transdermal solution 30 mg/act ; ESTROGENS ALTAVERA ORAL TABLET MG-MCG alyacen 1/35 oral tablet 1-35 mg-mcg AMABELZ ORAL TABLET MG, MG AMETHIA LO ORAL TABLET & 0.01 MG ; ; HRM ; QL (91 EA per 91 AMETHIA ORAL TABLET &0.01 MG ; QL (91 EA per 91 APRI ORAL TABLET MG-MCG ARANELLE ORAL TABLET 0.5/1/ MG- MCG ASHLYNA ORAL TABLET &0.01 MG ; QL (91 EA per 91 AUBRA ORAL TABLET MG-MCG AVIANE ORAL TABLET MG-MCG BALZIVA ORAL TABLET MG-MCG BLISOVI 24 FE ORAL TABLET 1-20 MG- MCG(24) BLISOVI FE 1.5/30 ORAL TABLET MG- MCG BLISOVI FE 1/20 ORAL TABLET 1-20 MG-MCG briellyn oral tablet mg-mcg CAMRESE LO ORAL TABLET & 0.01 MG CAZIANT ORAL TABLET 0.1/0.125/ MG CLIMARA PRO TRANSDERMAL PATCH WEEKLY MG/DAY COMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY MG/DAY, MG/DAY ; QL (91 EA per 91 ; ; HRM ; ; HRM CRYSELLE-28 ORAL TABLET MG-MCG CYCLAFEM 1/35 ORAL TABLET 1-35 MG-MCG CYCLAFEM 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG DELYLA ORAL TABLET MG-MCG DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML 92

94 desogestrel-ethinyl estradiol oral tablet /0.01 mg (21/5), mg-mcg DIVIGEL TRANSDERMAL GEL 1 MG/GM ; ; HRM drospiren-eth estrad-levomefol oral tablet mg drospirenone-ethinyl estradiol oral tablet mg, mg ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM (0.06%) EQUETTE ORAL TABLET MG-MCG ; ; HRM ENPRESSE-28 ORAL TABLET ENSKYCE ORAL TABLET MG-MCG ESTARYLLA ORAL TABLET MG-MCG estradiol oral tablet 0.5 mg ; ; HRM estradiol oral tablet 1 mg, 2 mg ; ; HRM estradiol transdermal patch twice weekly mg/24hr, mg/24hr, 0.05 mg/24hr, mg/24hr, 0.1 mg/24hr estradiol transdermal patch weekly mg/24hr, mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, mg/24hr, 0.1 mg/24hr ; ; HRM ; ; HRM estradiol vaginal cream 0.1 mg/gm estradiol vaginal tablet 10 mcg estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg, mg ; ; HRM ESTRING VAGINAL RING 2 MG ; QL (1 EA per 90 estropipate oral tablet 0.75 mg ; ; HRM ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg FALMINA ORAL TABLET MG-MCG FAYOSIM ORAL TABLET DAYS ; QL (91 EA per 91 FEMRING VAGINAL RING 0.05 MG/24HR, 0.1 MG/24HR FEMYNOR ORAL TABLET MG-MCG FYAVOLV ORAL TABLET MG-MCG, 1-5 MG-MCG ; QL (1 EA per 90 ; ; HRM GIANVI ORAL TABLET MG 93

95 INTROVALE ORAL TABLET MG ; QL (91 EA per 91 ISIBLOOM ORAL TABLET MG-MCG JINTELI ORAL TABLET 1-5 MG-MCG ; ; HRM JULEBER ORAL TABLET MG-MCG JUNEL 1.5/30 ORAL TABLET MG-MCG JUNEL 1/20 ORAL TABLET 1-20 MG-MCG JUNEL FE 1.5/30 ORAL TABLET MG- MCG JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG JUNEL FE 24 ORAL TABLET 1-20 MG-MCG(24) KAITLIB FE ORAL TABLET CHEWABLE MG-MCG KARIVA ORAL TABLET /0.01 MG (21/5) KELNOR 1/35 ORAL TABLET 1-35 MG-MCG KELNOR 1/50 ORAL TABLET 1-50 MG-MCG KIMIDESS ORAL TABLET /0.01 MG (21/5) KURVELO ORAL TABLET MG-MCG LARIN 1.5/30 ORAL TABLET MG-MCG LARIN 1/20 ORAL TABLET 1-20 MG-MCG LARIN FE 1.5/30 ORAL TABLET MG- MCG LARIN FE 1/20 ORAL TABLET 1-20 MG-MCG LARISSIA ORAL TABLET MG-MCG LAYOLIS FE ORAL TABLET CHEWABLE MG-MCG LEENA ORAL TABLET 0.5/1/ MG-MCG LESSINA ORAL TABLET MG-MCG LEVONEST ORAL TABLET levonorgest-eth est & eth est oral tablet days levonorgest-eth estrad 91-day oral tablet & 0.01 mg, &0.01 mg, mg levonorgestrel-ethinyl estrad oral tablet mgmcg, mg-mcg, mcg ; QL (91 EA per 91 ; QL (91 EA per 91 levonorg-eth estrad triphasic oral tablet LEVORA 0.15/30 (28) ORAL TABLET MG-MCG 94

96 LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG LORYNA ORAL TABLET MG LOW-OGESTREL ORAL TABLET MG- MCG 95 LUTERA ORAL TABLET MG-MCG marlissa oral tablet mg-mcg MELODETTA 24 FE ORAL TABLET CHEWABLE 1-20 MG-MCG(24) MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG MIBELAS 24 FE ORAL TABLET CHEWABLE 1-20 MG-MCG(24) MICROGESTIN 1.5/30 ORAL TABLET MG-MCG MICROGESTIN 1/20 ORAL TABLET 1-20 MG- MCG MICROGESTIN FE 1.5/30 ORAL TABLET MG-MCG MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG PA2; ; HRM MILI ORAL TABLET MG-MCG MIMVEY LO ORAL TABLET MG ; ; HRM MIMVEY ORAL TABLET MG ; ; HRM NONESSA ORAL TABLET MG-MCG NECON 0.5/35 (28) ORAL TABLET MG- MCG NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG- MCG NIKKI ORAL TABLET MG norethin ace-eth estrad-fe oral tablet 1-20 mgmcg(24) norethindrone acet-ethinyl est oral tablet 1-20 mgmcg norethindrone acet-ethinyl est oral tablet chewable 1-20 mg-mcg(24) norethindrone-eth estradiol oral tablet mgmcg, 1-5 mg-mcg norethin-eth estradiol-fe oral tablet chewable mg-mcg, mg-mcg ; ; HRM

97 norgestimate-eth estradiol oral tablet mg-mcg norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg NORTREL 0.5/35 (28) ORAL TABLET MG- MCG NORTREL 1/35 (21) ORAL TABLET 1-35 MG- MCG NORTREL 1/35 (28) ORAL TABLET 1-35 MG- MCG NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG OCELLA ORAL TABLET MG OGESTREL ORAL TABLET MG-MCG ORSYTHIA ORAL TABLET MG-MCG PIMTREA ORAL TABLET /0.01 MG (21/5) PIRMELLA 1/35 ORAL TABLET 1-35 MG-MCG PORTIA-28 ORAL TABLET MG-MCG PREMARIN ORAL TABLET 0.3 MG ; ; HRM PREMARIN ORAL TABLET 0.45 MG, MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM MG/GM ; ; HRM PREMPHASE ORAL TABLET MG ; ; HRM PREMPRO ORAL TABLET MG, MG, MG, MG ; ; HRM PREVIFEM ORAL TABLET MG-MCG QUASENSE ORAL TABLET MG ; QL (91 EA per 91 RECLIPSEN ORAL TABLET MG-MCG RIVELSA ORAL TABLET DAYS ; QL (91 EA per 91 SETLAKIN ORAL TABLET MG ; QL (91 EA per 91 SPRINTEC 28 ORAL TABLET MG-MCG SRONYX ORAL TABLET MG-MCG SYEDA ORAL TABLET MG TARINA FE 1/20 ORAL TABLET 1-20 MG-MCG TRI-LEGEST FE ORAL TABLET 1-20/1-30/1-35 MG-MCG 96

98 TRI-LO-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-25 MCG TRI-LO-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-25 MCG TRI-MILI ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRIVORA (28) ORAL TABLET TRI-VYLIBRA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TYDEMY ORAL TABLET MG VELIVET ORAL TABLET 0.1/0.125/ MG VIENVA ORAL TABLET MG-MCG VYFEMLA ORAL TABLET MG-MCG VYLIBRA ORAL TABLET MG-MCG WYMZYA FE ORAL TABLET CHEWABLE MG-MCG XULANE TRANSDERMAL PATCH WEEKLY MCG/24HR 97 YUVAFEM VAGINAL TABLET 10 MCG ZARAH ORAL TABLET MG ZENCHENT ORAL TABLET MG-MCG ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG PROGESTINS CAMILA ORAL TABLET 0.35 MG CRINONE VAGINAL GEL 4 %, 8 % ; DEBLITANE ORAL TABLET 0.35 MG DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML ERRIN ORAL TABLET 0.35 MG ; QL (10 ML per 28 ; QL (0.65 ML per 90

99 INCASSIA ORAL TABLET 0.35 MG JOLIVETTE ORAL TABLET 0.35 MG LYZA ORAL TABLET 0.35 MG medroxyprogesterone acetate intramuscular suspension 150 mg/ml medroxyprogesterone acetate intramuscular suspension prefilled syringe 150 mg/ml medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg ; QL (1 ML per 90 ; QL (1 ML per 90 ; CCP megestrol acetate oral suspension 40 mg/ml PA2; ; HRM megestrol acetate oral suspension 625 mg/5ml PA2; HRM megestrol acetate oral tablet 20 mg, 40 mg PA2; ; HRM NORA-BE ORAL TABLET 0.35 MG norethindrone acetate oral tablet 5 mg norethindrone oral tablet 0.35 mg NORLYROC ORAL TABLET 0.35 MG progesterone micronized oral capsule 100 mg progesterone micronized oral capsule 200 mg ; CCP SHAROBEL ORAL TABLET 0.35 MG SELECTIVE ESTROGEN RECEPTOR DIFYING AGENTS OSPHENA ORAL TABLET 60 MG ; ; QL (30 EA per 30 raloxifene hcl oral tablet 60 mg ; CCP HORNAL AGENTS, STIMULANT/REPLACEMENT/DIFYING (THYROID) HORNAL AGENTS, STIMULANT/REPLACEMENT/DIFYING (THYROID) LEVO-T ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg ; CCP ; CCP ; CCP 98

100 SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG THYROLAR-1 ORAL TABLET 60 MG THYROLAR-1/2 ORAL TABLET 30 MG THYROLAR-1/4 ORAL TABLET 15 MG THYROLAR-2 ORAL TABLET 120 MG THYROLAR-3 ORAL TABLET 180 MG TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG HORNAL AGENTS, SUPPRESSANT (ADRENAL) HORNAL AGENTS, SUPPRESSANT (ADRENAL) LYSODREN ORAL TABLET 500 MG HORNAL AGENTS, SUPPRESSANT (PITUITARY) HORNAL AGENTS, SUPPRESSANT (PITUITARY) ; CCP ; CCP cabergoline oral tablet 0.5 mg ELIGARD SUBCUTANEOUS KIT 22.5 MG PA2; ; QL (1 EA per 84 ELIGARD SUBCUTANEOUS KIT 30 MG PA2; ; QL (1 EA per 112 ELIGARD SUBCUTANEOUS KIT 45 MG PA2; ; QL (1 EA per 168 ELIGARD SUBCUTANEOUS KIT 7.5 MG PA2; ; QL (1 EA per 28 FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG leuprolide acetate injection kit 1 mg/0.2ml PA2 LUPANETA PACK COMBINATION KIT & 5 MG LUPANETA PACK COMBINATION KIT 3.75 & 5 MG LUPRON DEPOT (1-NTH) INTRAMUSCULAR KIT 3.75 MG, 7.5 MG LUPRON DEPOT (3-NTH) INTRAMUSCULAR KIT MG, 22.5 MG PA2; QL (4 EA per 365 PA2; ; QL (1 EA per 28 ; QL (1 EA per 84 ; QL (1 EA per 28 PA2; QL (1 EA per 28 PA2; QL (1 EA per 84 99

101 LUPRON DEPOT (4-NTH) INTRAMUSCULAR KIT 30 MG LUPRON DEPOT (6-NTH) INTRAMUSCULAR KIT 45 MG octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 60 MG/0.2ML, 90 MG/0.3ML SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG SYNAREL NASAL SOLUTION 2 MG/ML TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED MG TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 22.5 MG TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 3.75 MG HORNAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS PA2; QL (1 EA per 112 PA2; QL (1 EA per 168 ; 100 ; QL (60 ML per 30 PA2 methimazole oral tablet 10 mg, 5 mg PA2; QL (1 EA per 84 PA2; QL (1 EA per 168 PA2; QL (1 EA per 28 propylthiouracil oral tablet 50 mg ; CCP IMMUNOLOGICAL AGENTS ANGIOEDEMA AGENTS BERINERT INTRAVENOUS KIT 500 UNIT FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML RUCONEST INTRAVENOUS SOLUTION RECONSTITUTED 2100 UNIT IMMUNE SUPPRESSANTS ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG BvD; BvD

102 AZASAN ORAL TABLET 100 MG, 75 MG BvD; azathioprine oral tablet 50 mg GC; BvD; BENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 200 MG/ML CIMZIA PREFILLED SUBCUTANEOUS KIT 2 X 200 MG/ML 101 CIMZIA SUBCUTANEOUS KIT 2 X 200 MG cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg GC; BvD; cyclosporine modified oral solution 100 mg/ml GC; BvD; cyclosporine oral capsule 100 mg, 25 mg GC; BvD; ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75 MG, 1 MG ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG BvD; GENGRAF ORAL CAPSULE 100 MG, 25 MG GC; BvD; GENGRAF ORAL SOLUTION 100 MG/ML GC; BvD; HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/0.8ML (6 PACK), 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML HUMIRA PEN-PS/UV STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML BvD

103 KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.67ML methotrexate oral tablet 2.5 mg ; CCP methotrexate sodium (pf) injection solution 50 mg/2ml 102 ; CCP mycophenolate mofetil oral capsule 250 mg GC; BvD; mycophenolate mofetil oral suspension reconstituted 200 mg/ml mycophenolate mofetil oral tablet 500 mg GC; BvD; mycophenolate sodium oral tablet delayed release 180 mg, 360 mg ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML BvD BvD; ; QL (4 ML per 28 RAPAMUNE ORAL SOLUTION 1 MG/ML BvD RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 10 MG/0.2ML RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 12.5 MG/0.25ML RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 15 MG/0.3ML RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 17.5 MG/0.35ML RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 20 MG/0.4ML RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 22.5 MG/0.45ML RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 25 MG/0.5ML RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 30 MG/0.6ML RASUVO SUBCUTANEOUS SOLUTION AUTO- INJECTOR 7.5 MG/0.15ML SANDIMMUNE ORAL SOLUTION 100 MG/ML BvD; SIMPONI SUBCUTANEOUS SOLUTION AUTO- INJECTOR 100 MG/ML, 50 MG/0.5ML SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML ; ; QL (0.8 ML per 28 ; ; QL (1 ML per 28 ; ; QL (1.2 ML per 28 ; ; QL (1.4 ML per 28 ; ; QL (1.6 ML per 28 ; ; QL (1.8 ML per 28 ; ; QL (2 ML per 28 ; ; QL (2.4 ML per 28 ; ; QL (0.6 ML per 28

104 sirolimus oral tablet 0.5 mg, 1 mg BvD; sirolimus oral tablet 2 mg BvD tacrolimus oral capsule 0.5 mg, 1 mg GC; BvD; tacrolimus oral capsule 5 mg BvD; TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG XATMEP ORAL SOLUTION 2.5 MG/ML ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG IMMUNIZING AGENTS, PASSIVE BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 6 GM FLEBOGAMMA DIF INTRAVENOUS SOLUTION 5 GM/50ML GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML GAMMAGARD S/D LESS IGA INTRAVENOUS SOLUTION RECONSTITUTED 10 GM, 5 GM GAMMAKED INJECTION SOLUTION 1 GM/10ML GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/100ML, 10 GM/200ML, 20 GM/200ML, 5 GM/50ML GAMUNEX-C INJECTION SOLUTION 1 GM/10ML OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 2 GM/20ML PRIVIGEN INTRAVENOUS SOLUTION 20 GM/200ML IMMUNODULATORS ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 162 MG/0.9ML ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/1.14ML, 200 MG/1.14ML 103 PA2 ; QL (3.6 ML per 28 PA2

105 leflunomide oral tablet 10 mg, 20 mg OLUMIANT ORAL TABLET 2 MG OTEZLA ORAL TABLET 30 MG OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30 MG RIDAURA ORAL CAPSULE 3 MG 104 XELJANZ ORAL TABLET 10 MG, 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED ADACEL INTRAMUSCULAR SUSPENSION (PREFILLED SYRINGE), LF- MCG/0.5 bcg vaccine injection injectable BEXSERO INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE BOOSTRIX INTRAMUSCULAR SUSPENSION , (0.5ML SYRINGE) DAPTACEL INTRAMUSCULAR SUSPENSION LF-MCG/0.5 diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML GARDASIL 9 INTRAMUSCULAR SUSPENSION GARDASIL 9 INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 1440 EL U/ML 1 ML, 720 EL U/0.5ML, 720 EL U/0.5ML 0.5 ML HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG IVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML INFANRIX INTRAMUSCULAR SUSPENSION BvD; BvD; IPOL INJECTION INJECTABLE IXIARO INTRAMUSCULAR SUSPENSION

106 KINRIX INTRAMUSCULAR SUSPENSION, INJECTION 0.5 ML 105 MENACTRA INTRAMUSCULAR INJECTABLE MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED M-M-R II SUBCUTANEOUS INJECTABLE PEDIARIX INTRAMUSCULAR SUSPENSION PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML PROQUAD SUBCUTANEOUS INJECTABLE QUADRACEL INTRAMUSCULAR SUSPENSION RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 10 MCG/ML (1ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION RECONSTITUTED BvD; BvD; ROTATEQ ORAL SOLUTION SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU tetanus-diphtheria toxoids td intramuscular suspension 2-2 lf/0.5ml TRUMENBA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE TWINRIX INTRAMUSCULAR SUSPENSION TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML, 25 MCG/0.5ML (0.5ML SYRINGE) VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 25 UNIT/0.5ML 0.5 ML, 50 UNIT/ML, 50 UNIT/ML 1 ML VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2ML YF-VAX SUBCUTANEOUS INJECTABLE ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED UNT/0.65ML ;

107 INFLAMMATORY BOWEL DISEASE AGENTS AMINOSALICYLATES APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR GM balsalazide disodium oral capsule 750 mg CANASA RECTAL SUPPOSITORY 1000 MG DIPENTUM ORAL CAPSULE 250 MG mesalamine oral tablet delayed release 1.2 gm, 800 mg mesalamine rectal enema 4 gm GLUCOCORTICOIDS budesonide er oral tablet extended release 24 hour 9 mg budesonide oral capsule delayed release particles 3 mg COLOCORT RECTAL ENEMA 100 MG/60ML hydrocortisone rectal enema 100 mg/60ml SULFONAMIDES sulfasalazine oral tablet 500 mg sulfasalazine oral tablet delayed release 500 mg METABOLIC BONE DISEASE AGENTS METABOLIC BONE DISEASE AGENTS alendronate sodium oral solution 70 mg/75ml ; CCP alendronate sodium oral tablet 10 mg, 35 mg, 40 mg, 5 mg ; CCP alendronate sodium oral tablet 70 mg ; CCP; QL (4 EA per 28 BINOSTO ORAL TABLET EFFERVESCENT 70 MG ; CCP; QL (4 EA per 28 calcitonin (salmon) nasal solution 200 unit/act ; QL (3.7 ML per 30 calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml doxercalciferol oral capsule 0.5 mcg doxercalciferol oral capsule 1 mcg, 2.5 mcg etidronate disodium oral tablet 200 mg, 400 mg ; CCP FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML ; ; CCP 106

108 FOSAMAX PLUS D ORAL TABLET MG- UNIT, MG-UNIT ST1; ; CCP; QL (4 EA per 28 ibandronate sodium oral tablet 150 mg ; CCP; QL (1 EA per 28 NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG, 25 MCG, 50 MCG, 75 MCG paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML ; QL (2 EA per 28 ; QL (2 ML per 365 risedronate sodium oral tablet 150 mg ; QL (1 EA per 28 risedronate sodium oral tablet 30 mg, 5 mg ; CCP risedronate sodium oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack) ; CCP; QL (4 EA per 28 risedronate sodium oral tablet delayed release 35 mg ; CCP; QL (4 EA per 28 SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 MG TYMLOS SUBCUTANEOUS SOLUTION PEN- INJECTOR 3120 MCG/1.56ML XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS AMINOSYN II INTRAVENOUS SOLUTION 10 % AMINOSYN-HBC INTRAVENOUS SOLUTION 7 % AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 % AMINOSYN-RF INTRAVENOUS SOLUTION 5.2 % ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT CLINISOL SF INTRAVENOUS SOLUTION 15 % COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML 107 BvD; BvD; BvD; BvD; ; CCP; QL (200 EA per 30 cvs gauze sterile pad 2"x2" ENDARI ORAL PACKET 5 GM EXEL COMFORT POINT PEN NEEDLE 29G X 12MM BvD; ; CCP; QL (200 EA per 30 ; CCP; QL (200 EA per 30

109 FREAMINE HBC INTRAVENOUS SOLUTION 6.9 % global alcohol prep ease pad 70 % HAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED 2000 UNIT, 3000 UNIT HEPATAMINE INTRAVENOUS SOLUTION 8 % BvD; 108 BvD; INTRALIPID INTRAVENOUS EMULSION 20 % GC; BvD; KEVEYIS ORAL TABLET 50 MG ; QL (120 EA per 30 levocarnitine oral solution 1 gm/10ml levocarnitine oral tablet 330 mg MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED 11.3 MG NEPHRAMINE INTRAVENOUS SOLUTION 5.4 % BvD; nutrilipid intravenous emulsion 20 % GC; BvD; PLENAMINE INTRAVENOUS SOLUTION 15 % BvD; preferred plus insulin syringe 28g x 1/2" 0.5 ml ; CCP; QL (200 EA per 30 PREMASOL INTRAVENOUS SOLUTION 10 %, 6 % BvD; PROSOL INTRAVENOUS SOLUTION 20 % BvD; RELI-ON INSULIN SYRINGE 29G 0.3 ML ; CCP; QL (200 EA per 30 sodium chloride irrigation solution 0.9 % TRAVASOL INTRAVENOUS SOLUTION 10 % BvD; TROPHAMINE INTRAVENOUS SOLUTION 10 % OPHTHALMIC AGENTS OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS BvD; bimatoprost ophthalmic solution 0.03 % ; CCP; QL (5 ML per 30 COMBIGAN OPHTHALMIC SOLUTION % latanoprost ophthalmic solution % ; QL (2.5 ML per 25 LUMIGAN OPHTHALMIC SOLUTION 0.01 % ; CCP; QL (2.5 ML per 25 TRAVATAN Z OPHTHALMIC SOLUTION % OPHTHALMIC AGENTS, OTHER atropine sulfate ophthalmic solution 1 % bacitracin-polymyxin b ophthalmic ointment unit/gm ; QL (2.5 ML per 25

110 CYSTARAN OPHTHALMIC SOLUTION 0.44 % ; QL (60 ML per 28 LACRISERT OPHTHALMIC INSERT 5 MG neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution polymyxin b-trimethoprim ophthalmic solution unit/ml-% proparacaine hcl ophthalmic solution 0.5 % RESTASIS OPHTHALMIC EMULSION 0.05 % XIIDRA OPHTHALMIC SOLUTION 5 % ; QL (60 EA per 30 OPHTHALMIC ANTI-ALLERGY AGENTS ALOCRIL OPHTHALMIC SOLUTION 2 % azelastine hcl ophthalmic solution 0.05 % BEPREVE OPHTHALMIC SOLUTION 1.5 % BROMSITE OPHTHALMIC SOLUTION % cromolyn sodium ophthalmic solution 4 % EMADINE OPHTHALMIC SOLUTION 0.05 % epinastine hcl ophthalmic solution 0.05 % olopatadine hcl ophthalmic solution 0.1 %, 0.2 % PAZEO OPHTHALMIC SOLUTION 0.7 % OPHTHALMIC ANTIGLAUCOMA AGENTS acetazolamide er oral capsule extended release 12 hour 500 mg acetazolamide oral tablet 125 mg, 250 mg ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % apraclonidine hcl ophthalmic solution 0.5 % AZOPT OPHTHALMIC SUSPENSION 1 % betaxolol hcl ophthalmic solution 0.5 % BETIL OPHTHALMIC SOLUTION 0.25 %, 0.5 % BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % ; CCP carteolol hcl ophthalmic solution 1 % 109

111 COSOPT PF OPHTHALMIC SOLUTION MG/ML dorzolamide hcl ophthalmic solution 2 % dorzolamide hcl-timolol mal ophthalmic solution mg/ml 110 IOPIDINE OPHTHALMIC SOLUTION 1 % levobunolol hcl ophthalmic solution 0.5 % methazolamide oral tablet 25 mg, 50 mg metipranolol ophthalmic solution 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED % pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % SIMBRINZA OPHTHALMIC SUSPENSION % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 %, 0.5 % ; CCP timolol maleate ophthalmic solution 0.5 % (daily) OPHTHALMIC ANTI-INFLAMMATORIES ALOMIDE OPHTHALMIC SOLUTION 0.1 % ALREX OPHTHALMIC SUSPENSION 0.2 % bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % BLEPHAMIDE OPHTHALMIC SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % dexamethasone sodium phosphate ophthalmic solution 0.1 % diclofenac sodium ophthalmic solution 0.1 % DUREZOL OPHTHALMIC EMULSION 0.05 % FLAREX OPHTHALMIC SUSPENSION 0.1 % fluorometholone ophthalmic suspension 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % FML FORTE OPHTHALMIC SUSPENSION 0.25 % FML OPHTHALMIC OINTMENT 0.1 % ILEVRO OPHTHALMIC SUSPENSION 0.3 % ; QL (6 ML per 30

112 ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % LOTEMAX OPHTHALMIC GEL 0.5 % ; QL (20 GM per 365 LOTEMAX OPHTHALMIC OINTMENT 0.5 % ; QL (14 GM per 365 LOTEMAX OPHTHALMIC SUSPENSION 0.5 % MAXIDEX OPHTHALMIC SUSPENSION 0.1 % neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-hc ophthalmic suspension PRED MILD OPHTHALMIC SUSPENSION 0.12 % 111 PRED-G OPHTHALMIC SUSPENSION % PRED-G S.O.P. OPHTHALMIC OINTMENT % prednisolone acetate ophthalmic suspension 1 % prednisolone sodium phosphate ophthalmic solution 1 % PROLENSA OPHTHALMIC SOLUTION 0.07 % ; QL (12 ML per 365 sulfacetamide-prednisolone ophthalmic solution % TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC SUSPENSION % tobramycin-dexamethasone ophthalmic suspension % ZYLET OPHTHALMIC SUSPENSION % OTIC AGENTS OTIC AGENTS acetic acid otic solution 2 % CIPRO HC OTIC SUSPENSION % CIPRODEX OTIC SUSPENSION % COLY-MYCIN S OTIC SUSPENSION MG/ML fluocinolone acetonide otic oil 0.01 % hydrocortisone-acetic acid otic solution 1-2 %

113 neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension RESPIRATORY TRACT/PULNARY AGENTS ANTIHISTAMINES azelastine hcl nasal solution 0.1 %, 0.15 % ; QL (60 ML per 30 cetirizine hcl oral solution 1 mg/ml cyproheptadine hcl oral syrup 2 mg/5ml ; ; HRM cyproheptadine hcl oral tablet 4 mg ; ; HRM desloratadine oral tablet 5 mg DYMISTA NASAL SUSPENSION MCG/ACT ; QL (23 GM per 30 hydroxyzine hcl oral syrup 10 mg/5ml ; ; HRM hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg ; ; HRM hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg levocetirizine dihydrochloride oral solution 2.5 mg/5ml ; ; HRM levocetirizine dihydrochloride oral tablet 5 mg olopatadine hcl nasal solution 0.6 % ; QL (30.5 GM per 30 SEMPREX-D ORAL CAPSULE 8-60 MG ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, MCG/INH budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml ; CCP; QL (1 EA per 30 ; CCP; QL (1 EA per 30 ; CCP; QL (1 EA per 30 ; CCP; QL (26 GM per 30 ; CCP; QL (60 EA per 30 BvD; ; QL (120 ML per 30 budesonide inhalation suspension 1 mg/2ml GC; BvD; ; CCP; QL (120 ML per

114 FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT ; CCP; QL (60 EA per 30 ; CCP; QL (240 EA per 30 ; CCP; QL (24 GM per 30 ; CCP; QL (21.2 GM per 30 flunisolide nasal solution 25 mcg/act (0.025%) ; QL (50 ML per 30 fluticasone propionate nasal suspension 50 mcg/act mometasone furoate nasal suspension 50 mcg/act ; QL (34 GM per 30 NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 100 MG QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT triamcinolone acetonide nasal aerosol 55 mcg/act ANTILEUKOTRIENES montelukast sodium oral packet 4 mg ; QL (3 EA per 28 montelukast sodium oral tablet 10 mg ; CCP montelukast sodium oral tablet chewable 4 mg, 5 mg ; CCP zafirlukast oral tablet 10 mg, 20 mg ; CCP zileuton er oral tablet extended release 12 hour 600 mg ; CCP; QL (21.2 GM per 30 ST1 ZYFLO ORAL TABLET 600 MG ST1 BRONCHODILATORS, ANTICHOLINERGIC ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH ; CCP; QL (25.8 GM per 30 ; QL (8 GM per 30 ; CCP; QL (30 EA per 30 ipratropium bromide inhalation solution 0.02 % GC; BvD; ; CCP; QL (312.5 ML per 30 ipratropium bromide nasal solution 0.03 %, 0.06 % ; CCP ipratropium-albuterol inhalation solution (3) mg/3ml GC; BvD; ; QL (540 ML per

115 SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT TUDORZA PRESSAIR INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCG/ACT TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT (30 ACTUATE) BRONCHODILATORS, SYMPATHOMIMETIC albuterol sulfate er oral tablet extended release 12 hour 4 mg, 8 mg albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 mg/3ml ; QL (30 EA per 30 ; CCP; QL (4 GM per 30 ; QL (4 GM per 30 ST1; ; CCP; QL (60 EA per 30 ST1; ; CCP; QL (60 EA per 30 ; CCP GC; BvD; ; CCP; QL (525 ML per 30 GC; BvD; ; QL (100 EA per 30 albuterol sulfate oral syrup 2 mg/5ml albuterol sulfate oral tablet 2 mg, 4 mg ; CCP epinephrine injection solution 0.3 mg/0.3ml ST1; epinephrine injection solution auto-injector 0.15 mg/0.15ml epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml EPIPEN 2-PAK INJECTION SOLUTION AUTO- INJECTOR 0.3 MG/0.3ML EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.3ML levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml levalbuterol hcl inhalation nebulization solution 1.25 mg/3ml GC; BvD; ; CCP; QL (375 ML per 30 ST1; GC; BvD; ; CCP; QL (540 ML per 30 GC; BvD; ; QL (90 EA per 30 GC; BvD; ; CCP; QL (270 ML per 30 levalbuterol tartrate inhalation aerosol 45 mcg/act ; QL (30 GM per 30 metaproterenol sulfate oral syrup 10 mg/5ml metaproterenol sulfate oral tablet 10 mg, 20 mg 114

116 PERFOROMIST INHALATION NEBULIZATION SOLUTION 20 MCG/2ML PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT BvD; ; CCP; QL (120 ML per 30 terbutaline sulfate oral tablet 2.5 mg, 5 mg CYSTIC FIBROSIS AGENTS BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG ; CCP; QL (17 GM per 30 ; CCP; QL (2 EA per 30 ; CCP; QL (60 EA per 30 ; QL (4 GM per BvD KALYDECO ORAL PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG ORKAMBI ORAL TABLET MG, MG PULZYME INHALATION SOLUTION 1 MG/ML SYMDEKO ORAL TABLET THERAPY PACK & 150 MG TOBI PODHALER INHALATION CAPSULE 28 MG tobramycin inhalation nebulization solution 300 mg/5ml MAST CELL STABILIZERS cromolyn sodium inhalation nebulization solution 20 mg/2ml PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE ; QL (112 EA per 28 ; QL (56 EA per 28 QL (224 EA per 56 BvD BvD; DALIRESP ORAL TABLET 250 MCG, 500 MCG ; ; CCP theophylline er oral tablet extended release 12 hour 100 mg, 200 mg, 300 mg theophylline er oral tablet extended release 24 hour 400 mg, 600 mg theophylline oral solution 80 mg/15ml PULNARY ANTIHYPERTENSIVES

117 ADCIRCA ORAL TABLET 20 MG ; QL (60 EA per 30 ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG ; QL (90 EA per 30 LETAIRIS ORAL TABLET 10 MG, 5 MG ; QL (30 EA per 30 OPSUMIT ORAL TABLET 10 MG ; QL (30 EA per 30 ORENITRAM ORAL TABLET EXTENDED RELEASE MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML ; sildenafil citrate oral tablet 20 mg ; ; CCP; QL (90 EA per 30 UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCG VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML PULNARY FIBROSIS AGENTS ESBRIET ORAL TABLET 267 MG, 801 MG RESPIRATORY TRACT AGENTS, OTHER acetylcysteine inhalation solution 10 %, 20 % GC; BvD; ADVAIR DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT ; QL (60 EA per 30 ; QL (400 EA per 365 ; QL (270 ML per 30 ; CCP; QL (60 EA per 30 ; CCP; QL (24 GM per 30 ; CCP; QL (60 EA per 30 ESBRIET ORAL CAPSULE 267 MG FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30 MG/ML ; CCP; QL (17.6 GM per

118 GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML OFEV ORAL CAPSULE 100 MG, 150 MG PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG promethazine vc plain oral solution mg/5ml ; ; HRM STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS carisoprodol oral tablet 250 mg, 350 mg ; ; QL (4 GM per 30 chlorzoxazone oral tablet 500 mg ; ; HRM cyclobenzaprine hcl oral tablet 10 mg, 5 mg, 7.5 mg ; ; HRM methocarbamol oral tablet 500 mg, 750 mg ; ; HRM orphenadrine citrate er oral tablet extended release 12 hour 100 mg SLEEP DISORDER AGENTS GABA RECEPTOR DULATORS ; CCP; QL (12 GM per 30 ; CCP; QL (13.8 GM per 30 ; ; HRM eszopiclone oral tablet 1 mg, 2 mg, 3 mg ; ; HRM; QL (30 EA per 30 zaleplon oral capsule 10 mg ; ; HRM; QL (60 EA per 30 zaleplon oral capsule 5 mg ; ; HRM; QL (30 EA per 30 zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mg ; ; HRM; QL (30 EA per 30 zolpidem tartrate oral tablet 10 mg, 5 mg ; ; HRM; QL (30 EA per 30 zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg SLEEP DISORDERS, OTHER ; ; HRM; QL (30 EA per

119 armodafinil oral tablet 150 mg, 200 mg, 250 mg ; ; QL (30 EA per 30 armodafinil oral tablet 50 mg ; ; QL (60 EA per 30 BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG ; QL (30 EA per 30 HETLIOZ ORAL CAPSULE 20 MG ; QL (30 EA per 30 modafinil oral tablet 100 mg, 200 mg ; ; QL (30 EA per 30 ROZEREM ORAL TABLET 8 MG ; QL (30 EA per 30 SILENOR ORAL TABLET 3 MG, 6 MG ; QL (30 EA per 30 XYREM ORAL SOLUTION 500 MG/ML ; QL (540 ML per

120 Index A abacavir sulfate abacavir sulfate-lamivudine abacavir-lamivudine-zidovudine ABELCET ABILIFY MAINTENA ABSTRAL acamprosate calcium acarbose acebutolol hcl acetaminophen-codeine acetaminophen-codeine # acetazolamide acetazolamide er acetic acid acetylcysteine acitretin ACTEMRA ACTHIB ACTIMMUNE acyclovir acyclovir sodium ADACEL adapalene adapalene-benzoyl peroxide ADCIRCA adefovir dipivoxil ADEMPAS ADVAIR DISKUS ADVAIR HFA AFEDITAB CR AFINITOR AFINITOR DISPERZ ala-cort ALBENZA albuterol sulfate albuterol sulfate er alclometasone dipropionate ALDACTAZIDE ALECENSA alendronate sodium alfuzosin hcl er ALINIA allopurinol almotriptan malate ALOCRIL ALOMIDE alosetron hcl ALPHAGAN P alprazolam alprazolam er ALPRAZOLAM INTENSOL ALREX ALTAVERA ALUNBRIG alyacen 1/ AMABELZ amantadine hcl AMBISOME amcinonide AMETHIA AMETHIA LO amikacin sulfate amiloride hcl amiloride-hydrochlorothiazide AMINOSYN II AMINOSYN II/ELECTROLYTES AMINOSYN/ELECTROLYTES AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl AMITIZA amitriptyline hcl amlodipine besy-benazepril hcl amlodipine besylate amlodipine besylate-valsartan amlodipine-atorvastatin amlodipine-valsartan-hctz ammonium lactate AMNESTEEM amoxapine amoxicill-clarithro-lansopraz amoxicillin amoxicillin-pot clavulanate amoxicillin-pot clavulanate er amphetamine-dextroamphet er amphetamine-dextroamphetamine 74 amphotericin b ampicillin ampicillin sodium... 28, 29 ampicillin-sulbactam sodium AMPYRA ANADROL anagrelide hcl anastrozole ANDRODERM ANDROGEL ANDROGEL PUMP ANORO ELLIPTA APEXICON E APLENZIN APOKYN apraclonidine hcl aprepitant APRI APRISO APTIOM APTIVUS ARALAST NP ARANELLE ARANESP (ALBUMIN FREE) ARCALYST aripiprazole ARISTADA armodafinil ASCOMP-CODEINE ASHLYNA ASMANEX 120 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ASMANEX HFA aspirin-dipyridamole er ASSURE ID INSULIN SAFETY SYR ASTAGRAF XL atazanavir sulfate atenolol atenolol-chlorthalidone atomoxetine hcl atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRIPLA atropine sulfate ATROVENT HFA AUBAGIO AUBRA AUGMENTIN AURYXIA AUSTEDO AVIANE AVITA AVONEX AVONEX PEN AVONEX PREFILLED AVYCAZ AZASAN AZASITE azathioprine azelastine hcl , 112 azithromycin... 29,

121 AZOPT aztreonam B bacitracin bacitracin-polymyxin b bacitra-neomycin-polymyxin-hc baclofen BACTOCILL IN DEXTROSE BACTROBAN NASAL balsalazide disodium BALZIVA BANZEL BARACLUDE BAXDELA bcg vaccine BELSOMRA benazepril hcl benazepril-hydrochlorothiazide BENLYSTA benznidazole benzoyl peroxide-erythromycin benztropine mesylate BEPREVE BERINERT BESIVANCE betamethasone dipropionate betamethasone dipropionate aug betamethasone valerate BETASERON betaxolol hcl... 68, 109 bethanechol chloride BETHKIS BETIL BETOPTIC-S bexarotene BEXSERO bicalutamide BICILLIN C-R BICILLIN C-R 900/ BICILLIN L-A BIDIL BIKTARVY bimatoprost BINOSTO bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM BLEPHAMIDE BLEPHAMIDE S.O.P BLISOVI 24 FE BLISOVI FE 1.5/ BLISOVI FE 1/ BOOSTRIX BOSULIF BREO ELLIPTA briellyn BRILINTA brimonidine tartrate BRIVIACT bromocriptine mesylate BROMSITE budesonide , 112 budesonide er bumetanide buprenorphine buprenorphine hcl buprenorphine hcl-naloxone hcl bupropion hcl bupropion hcl er (smoking det) bupropion hcl er (sr) bupropion hcl er (xl) buspirone hcl butalbital-acetaminophen butalbital-apap-caff-cod butalbital-apap-caffeine... 19, 75 butalbital-asa-caff-codeine butalbital-aspirin-caffeine butorphanol tartrate BUTRANS BYDUREON BYDUREON BCISE BYSTOLIC C cabergoline CABOMETYX calcipotriene calcipotriene-betameth diprop calcitonin (salmon) calcitriol... 77, 106 calcium acetate (phos binder) CALQUENCE CAMILA CAMRESE LO CANASA candesartan cilexetil candesartan cilexetil-hctz CAPEX CAPRELSA captopril captopril-hydrochlorothiazide CARAFATE CARBAGLU carbamazepine carbamazepine er CARBATROL carbidopa carbidopa-levodopa... 49, 50 carbidopa-levodopa er carbidopa-levodopa-entacapone CARDIZEM LA CARDURA XL CARIMUNE NF carisoprodol carteolol hcl CARTIA XT carvedilol carvedilol phosphate er caspofungin acetate CAYSTON CAZIANT cefaclor cefaclor er cefadroxil... 26, 27 cefazolin sodium cefdinir cefepime hcl cefixime cefotaxime sodium cefotetan disodium cefoxitin sodium cefpodoxime proxetil cefprozil ceftazidime ceftriaxone sodium cefuroxime axetil cefuroxime sodium celecoxib CELONTIN cephalexin... 27, 28 CERDELGA cetirizine hcl cevimeline hcl CHANTIX CHANTIX CONTINUING NTH PAK CHANTIX STARTING NTH PAK CHENODAL chlordiazepoxide hcl chlordiazepoxide-amitriptyline chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorpromazine hcl chlorthalidone chlorzoxazone CHOLBAM cholestyramine cholestyramine light

122 ciclopirox ciclopirox olamine cilostazol CILOXAN CIMDUO cimetidine cimetidine hcl CIMZIA CIMZIA PREFILLED CINRYZE CIPRO HC CIPRODEX ciprofloxacin ciprofloxacin hcl... 30, 31 ciprofloxacin in d5w ciprofloxacin-ciproflox hcl er citalopram hydrobromide CLARAVIS clarithromycin clarithromycin er CLEOCIN CLIMARA PRO CLINDACIN-P clindamycin hcl clindamycin palmitate hcl clindamycin phos-benzoyl perox clindamycin phosphate clindamycin phosphate in d5w clindamycin-tretinoin CLINDESSE CLINIMIX E/DEXTROSE (2.75/10) CLINIMIX E/DEXTROSE (2.75/5) CLINIMIX E/DEXTROSE (4.25/10) CLINIMIX E/DEXTROSE (4.25/25) CLINIMIX E/DEXTROSE (4.25/5) CLINIMIX E/DEXTROSE (5/15). 80 CLINIMIX E/DEXTROSE (5/20). 80 CLINIMIX E/DEXTROSE (5/25). 80 CLINIMIX/DEXTROSE (2.75/5).. 80 CLINIMIX/DEXTROSE (4.25/10) 80 CLINIMIX/DEXTROSE (4.25/20) 80 CLINIMIX/DEXTROSE (4.25/25) 80 CLINIMIX/DEXTROSE (4.25/5).. 80 CLINIMIX/DEXTROSE (5/15) CLINIMIX/DEXTROSE (5/20) CLINIMIX/DEXTROSE (5/25) CLINISOL SF clobetasol prop emollient base clobetasol propionate clobetasol propionate e CLODAN clomipramine hcl clonazepam clonidine hcl clonidine hcl er clopidogrel bisulfate clorazepate dipotassium clotrimazole clotrimazole-betamethasone clozapine... 52, 53 COARTEM codeine sulfate colchicine colchicine-probenecid COLCRYS colesevelam hcl colestipol hcl colistimethate sodium (cba) COLOCORT COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ (100 MG DAILY DOSE) COMETRIQ (140 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) COMFORT ASSIST INSULIN SYRINGE COMPLERA COMPRO CONDYLOX constulose COPAXONE CORDRAN CORLANOR cortisone acetate CORTISPORIN COSENTYX 300 DOSE COSENTYX SENSOREADY 300 DOSE COSOPT PF COTELLIC COUMADIN CREON CRESEMBA CRINONE CRIXIVAN cromolyn sodium... 83, 109, 115 CRYSELLE CUVPOSA cvs gauze sterile CYCLAFEM 1/ CYCLAFEM 7/7/ cyclobenzaprine hcl cyclophosphamide CYCLOSET cyclosporine cyclosporine modified cyproheptadine hcl CYSTADANE CYSTAGON CYSTARAN D DAKLINZA DALIRESP DALVANCE danazol dantrolene sodium dapsone... 43, 78 DAPTACEL daptomycin DARAPRIM darifenacin hydrobromide er DEBLITANE DELYLA demeclocycline hcl DEMSER DENAVIR DEPEN TITRATABS DEPO-ESTRADIOL DEPO-PROVERA DEPO-SUBQ PROVERA DESCOVY desipramine hcl desloratadine desmopressin ace spray refrig desmopressin acetate desogestrel-ethinyl estradiol DESONATE desonide desoximetasone desvenlafaxine er desvenlafaxine succinate er dexamethasone DEXAMETHASONE INTENSOL 88 dexamethasone sodium phosphate DEXILANT dexmethylphenidate hcl dexmethylphenidate hcl er dextroamphetamine sulfate

123 dextroamphetamine sulfate er dextrose dextrose-nacl DIASTAT ACUDIAL DIASTAT PEDIATRIC diazepam... 58, 59 DIAZEPAM INTENSOL diclofenac potassium diclofenac sodium... 19, 78, 110 diclofenac sodium er diclofenac-misoprostol dicloxacillin sodium dicyclomine hcl didanosine DIFICID diflorasone diacetate diflunisal DIGITEK DIGOX digoxin dihydroergotamine mesylate DILANTIN DILANTIN INFATABS diltiazem hcl diltiazem hcl er diltiazem hcl er beads diltiazem hcl er coated beads dilt-xr DIPENTUM diphenoxylate-atropine diphtheria-tetanus toxoids dt dipyridamole disopyramide phosphate disulfiram DIURIL divalproex sodium divalproex sodium er DIVIGEL dofetilide donepezil hcl doripenem DORYX MPC dorzolamide hcl dorzolamide hcl-timolol mal doxazosin mesylate doxepin hcl... 38, 78 doxercalciferol DOXY doxycycline hyclate... 31, 32 doxycycline monohydrate dronabinol drospiren-eth estrad-levomefol drospirenone-ethinyl estradiol DROXIA DULERA duloxetine hcl DUPIXENT duramorph DUREZOL dutasteride dutasteride-tamsulosin hcl DUTOPROL DYMISTA DYRENIUM E econazole nitrate EDARBI EDARBYCLOR EDURANT efavirenz EGRIFTA ELESTRIN eletriptan hydrobromide ELIDEL ELIGARD ELIQUIS ELIQUIS STARTER PACK ELMIRON EMADINE EMBEDA EMCYT EMEND EMFLAZA EQUETTE EMSAM EMTRIVA enalapril maleate enalapril-hydrochlorothiazide ENBREL ENBREL SURECLICK ENDARI ENDOCET ENGERIX-B enoxaparin sodium ENPRESSE ENSKYCE entacapone entecavir ENTRESTO enulose ENVARSUS XR EPCLUSA EPIDUO FORTE epinastine hcl epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK EPITOL EPIVIR HBV eplerenone eprosartan mesylate EQUETRO ERAXIS ergoloid mesylates ergotamine-caffeine ERIVEDGE ERLEADA ERRIN ery ERYPED ERY-TAB ERYTHROCIN LACTOBIONATE ERYTHROCIN STEARATE erythromycin erythromycin base erythromycin ethylsuccinate ESBRIET escitalopram oxalate esomeprazole magnesium ESTARYLLA estazolam estradiol estradiol valerate estradiol-norethindrone acet ESTRING estropipate eszopiclone ethacrynic acid ethambutol hcl ethosuximide ethynodiol diac-eth estradiol etidronate disodium etodolac etodolac er EURAX... 48, 49 EVOTAZ EXEL COMFORT POINT PEN NEEDLE EXELDERM exemestane EXJADE EXTAVIA ezetimibe ezetimibe-simvastatin... 72, 73 F FALMINA famciclovir famotidine

124 FANAPT FANAPT TITRATION PACK FARESTON FARYDAK FASENRA FAYOSIM felbamate felodipine er FEMRING FEMYNOR fenofibrate fenofibrate micronized fenofibric acid fenoprofen calcium fentanyl... 20, 21 fentanyl citrate FENTORA FERRIPROX FETZIMA FETZIMA TITRATION FINACEA finasteride FIRAZYR FIRMAGON FLAREX flavoxate hcl FLEBOGAMMA DIF flecainide acetate FLOVENT DISKUS FLOVENT HFA fluconazole fluconazole in sodium chloride flucytosine fludrocortisone acetate flunisolide fluocinolone acetonide... 88, 111 fluocinolone acetonide scalp fluocinonide... 88, 89 fluocinonide emulsified base fluorometholone fluorouracil fluoxetine hcl fluphenazine decanoate fluphenazine hcl flurandrenolide flurbiprofen flurbiprofen sodium flutamide fluticasone propionate... 89, 113 fluvastatin sodium fluvastatin sodium er fluvoxamine maleate fluvoxamine maleate er FML FML FORTE fondaparinux sodium FORTEO FOSAMAX PLUS D fosamprenavir calcium fosinopril sodium fosinopril sodium-hctz FRAGMIN... 63, 64 FREAMINE HBC frovatriptan succinate furosemide FUZEON FYAVOLV FYCOMPA G gabapentin GABITRIL galantamine hydrobromide galantamine hydrobromide er GAMMAGARD GAMMAGARD S/D LESS IGA GAMMAKED GAMMAPLEX GAMUNEX-C GARDASIL gatifloxacin GATTEX GAVILYTE-C GAVILYTE-G GAVILYTE-N WITH FLAVOR PACK GELNIQUE PUMP gemfibrozil generlac GENGRAF GENOTROPIN GENOTROPIN MINIQUICK GENTAK gentamicin in saline gentamicin sulfate GENVOYA GEODON GIANVI GILENYA GILOTRIF GLASSIA glatiramer acetate GLATOPA GLEOSTINE glimepiride glipizide glipizide er glipizide-metformin hcl global alcohol prep ease GLUCAGEN HYPOKIT GLUCAGON EMERGENCY glyburide glyburide micronized glyburide-metformin glycopyrrolate GLYXAMBI GOCOVRI granisetron hcl GRANIX griseofulvin microsize griseofulvin ultramicrosize guanfacine hcl guanfacine hcl er guanidine hcl GYNAZOLE H HAEGARDA halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX heparin sodium (porcine) HEPATAMINE HETLIOZ HEXALEN HIBERIX HP ACTHAR HUMALOG HUMALOG JUNIOR KWIKPEN 61 HUMALOG KWIKPEN HUMALOG MIX 50/ HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/ HUMALOG MIX 75/25 KWIKPEN HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN-CD/UC/HS STARTER HUMIRA PEN-PS/UV STARTER HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N

125 HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) HUMULIN R U-500 KWIKPEN hydralazine hcl hydrochlorothiazide hydrocodone-acetaminophen hydrocodone-ibuprofen hydrocortisone... 89, 106 hydrocortisone ace-pramoxine hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid hydromorphone hcl hydromorphone hcl er hydromorphone hcl pf hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl hydroxyzine pamoate I ibandronate sodium IBRANCE IBU ibuprofen... 19, 20 ICLUSIG IDHIFA ILEVRO imatinib mesylate IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IVAX RABIES INCASSIA INCRELEX INCRUSE ELLIPTA indapamide indomethacin indomethacin er INFANRIX INGREZZA INLYTA INNOPRAN XL INTELENCE INTRALIPID INTRON A INTROVALE INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR INVOKANA IONOSOL-MB IN D5W IOPIDINE IPOL ipratropium bromide ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRESSA ISENTRESS... 55, 56 ISENTRESS HD ISIBLOOM ISOLYTE-P IN D5W ISOLYTE-S isoniazid ISORDIL TITRADOSE isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er isotretinoin isradipine itraconazole ivermectin IXIARO J JADENU JADENU SPRINKLE JAKAFI JANTOVEN JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JINTELI JOLIVETTE JUBLIA JULEBER JULUCA JUNEL 1.5/ JUNEL 1/ JUNEL FE 1.5/ JUNEL FE 1/ JUNEL FE JUXTAPID JYNARQUE K KAITLIB FE KALETRA KALYDECO KARIVA kcl in dextrose-nacl kcl-lactated ringers-d5w KELNOR 1/ KELNOR 1/ ketoconazole ketoprofen er ketorolac tromethamine... 20, 111 KEVEYIS KEVZARA KIMIDESS KINERET KINRIX KIONEX KISQALI 200 DOSE KISQALI 400 DOSE KISQALI 600 DOSE KISQALI FEMARA 200 DOSE KISQALI FEMARA 400 DOSE KISQALI FEMARA 600 DOSE KLOR-CON KLOR-CON KLOR-CON M KLOR-CON M KLOR-CON M KLOR-CON SPRINKLE KOMBIGLYZE XR KORLYM KRISTALOSE KURVELO KUVAN KYNAMRO L labetalol hcl LACRISERT lactulose lamivudine... 53, 56 lamivudine-zidovudine lamotrigine lamotrigine er lamotrigine starter kit-blue lamotrigine starter kit-green lamotrigine starter kit-orange LANOXIN lansoprazole lanthanum carbonate LANTUS LANTUS SOLOSTAR LARIN 1.5/ LARIN 1/ LARIN FE 1.5/

126 LARIN FE 1/ LARISSIA latanoprost LATUDA LAYOLIS FE LAZANDA LEENA leflunomide LENVIMA 10 MG DAILY DOSE. 47 LENVIMA 14 MG DAILY DOSE. 47 LENVIMA 18 MG DAILY DOSE. 47 LENVIMA 20 MG DAILY DOSE. 47 LENVIMA 24 MG DAILY DOSE. 47 LENVIMA 8 MG DAILY DOSE LESSINA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide acetate levalbuterol hcl levalbuterol tartrate LEVEMIR LEVEMIR FLEXTOUCH levetiracetam levetiracetam er levobunolol hcl levocarnitine levocetirizine dihydrochloride levofloxacin levofloxacin in d5w LEVONEST levonorgest-eth est & eth est levonorgest-eth estrad 91-day levonorgestrel-ethinyl estrad levonorg-eth estrad triphasic LEVORA 0.15/30 (28) levorphanol tartrate LEVO-T levothyroxine sodium LEVOXYL LEXIVA lidocaine lidocaine hcl lidocaine viscous lidocaine-prilocaine lindane linezolid LINZESS liothyronine sodium lisinopril lisinopril-hydrochlorothiazide lithium lithium carbonate lithium carbonate er LIVALO LO LOESTRIN FE LONSURF loperamide hcl lopinavir-ritonavir lorazepam LORCET LORCET HD LORCET PLUS LORYNA losartan potassium losartan potassium-hctz LOTEMAX lovastatin LOW-OGESTREL loxapine succinate LUCEMYRA LUMIGAN LUPANETA PACK LUPRON DEPOT (1-NTH) LUPRON DEPOT (3-NTH) LUPRON DEPOT (4-NTH) LUPRON DEPOT (6-NTH) LUTERA LYNPARZA LYRICA LYSODREN LYZA M magnesium sulfate malathion maprotiline hcl marlissa MARPLAN MATULANE MATZIM LA MAVYRET MAXIDEX meclizine hcl meclofenamate sodium MEDROL medroxyprogesterone acetate mefenamic acid mefloquine hcl megestrol acetate MEKINIST MELODETTA 24 FE meloxicam memantine hcl memantine hcl er MENACTRA MENEST MENTAX MENVEO meprobamate mercaptopurine meropenem mesalamine MESNEX MESTINON METADATE ER metaproterenol sulfate metformin hcl metformin hcl er methadone hcl methazolamide methenamine hippurate methimazole methitest methocarbamol methotrexate methotrexate sodium (pf) methoxsalen rapid methscopolamine bromide methyclothiazide methyldopa methyldopa-hydrochlorothiazide methylphenidate hcl methylphenidate hcl er... 74, 75 methylphenidate hcl er (cd) methylphenidate hcl er (la) methylprednisolone methyltestosterone metipranolol metoclopramide hcl metolazone metoprolol succinate er metoprolol tartrate metoprolol-hydrochlorothiazide metronidazole... 25, 26, 78 metronidazole in nacl mexiletine hcl MIBELAS 24 FE miconazole MICROGESTIN 1.5/ MICROGESTIN 1/ MICROGESTIN FE 1.5/ MICROGESTIN FE 1/ midodrine hcl MIGERGOT miglitol miglustat MILI

127 MILLIPRED MIMVEY MIMVEY LO MINITRAN minocycline hcl minocycline hcl er minoxidil mirtazapine MIRVASO misoprostol M-M-R II modafinil DERIBA DERIBA 1200 DOSE PACK DERIBA 800 DOSE PACK moexipril hcl moexipril-hydrochlorothiazide mometasone furoate... 89, 113 NONESSA montelukast sodium NUROL RGIDOX morphine sulfate morphine sulfate (concentrate) morphine sulfate er morphine sulfate er beads VIPREP moxifloxacin hcl moxifloxacin hcl in nacl MULTAQ mupirocin mupirocin calcium MYALEPT MYCAMINE mycophenolate mofetil mycophenolate sodium MYORISAN MYRBETRIQ N nabumetone nadolol nadolol-bendroflumethiazide nafcillin sodium naftifine hcl NAFTIN naloxone hcl naltrexone hcl naproxen naproxen dr naproxen sodium naproxen sodium er naratriptan hcl NARCAN NATACYN nateglinide NATPARA NEBUPENT NECON 0.5/35 (28) NECON 7/7/ nefazodone hcl neomycin sulfate neomycin-bacitracin zn-polymyx. 109 neomycin-polymyxin-dexameth neomycin-polymyxin-gramicidin. 109 neomycin-polymyxin-hc , 112 NEPHRAMINE NERLYNX NEUAC NEULASTA NEUPOGEN NEUPRO nevirapine nevirapine er NEXAVAR niacin er (antihyperlipidemic) NIACOR nicardipine hcl NICOTROL NICOTROL NS nifedipine nifedipine er nifedipine er osmotic release NIKKI nilutamide nimodipine NINLARO nisoldipine er NITRO-BID NITRO-DUR nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd macro nitroglycerin nizatidine NOLIX NORA-BE NORDITROPIN FLEXPRO norethin ace-eth estrad-fe norethindrone norethindrone acetate norethindrone acet-ethinyl est norethindrone-eth estradiol norethin-eth estradiol-fe norgestimate-eth estradiol norgestim-eth estrad triphasic NORITATE NORLYROC NORSOL-M IN D5W NORSOL-R IN D5W NORSOL-R PH NORPACE CR NORTHERA NORTREL 0.5/35 (28) NORTREL 1/35 (21) NORTREL 1/35 (28) NORTREL 7/7/ nortriptyline hcl NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN62 NOVOLOG PENFILL NOXAFIL NUCALA NUEDEXTA NUPLAZID nutrilipid NUTROPIN AQ NUSPIN NUTROPIN AQ NUSPIN NUTROPIN AQ NUSPIN NYAMYC NYMALIZE nystatin nystatin-triamcinolone NYSTOP O OCALIVA OCELLA OCTAGAM octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin OGESTREL olanzapine olanzapine-fluoxetine hcl olmesartan medoxomil olmesartan medoxomil-hctz olopatadine hcl , 112 OLUMIANT omega-3-acid ethyl esters omeprazole omeprazole-sodium bicarbonate OMNITROPE

128 ondansetron ondansetron hcl... 39, 40 ONFI ONGLYZA OPSUMIT ORENCIA ORENCIA CLICKJECT ORENITRAM ORFADIN ORKAMBI orphenadrine citrate er ORSYTHIA oseltamivir phosphate OSPHENA OTEZLA oxacillin sodium oxandrolone oxaprozin oxazepam oxcarbazepine oxiconazole nitrate OXISTAT oxybutynin chloride oxybutynin chloride er oxycodone hcl oxycodone-acetaminophen oxycodone-aspirin oxycodone-ibuprofen oxymorphone hcl oxymorphone hcl er P PACERONE paliperidone er... 51, 52 PANDEL PANRETIN pantoprazole sodium paricalcitol paromomycin sulfate paroxetine hcl paroxetine hcl er paroxetine mesylate PASER PAXIL PAZEO PEDIARIX PEDVAX HIB peg 3350/electrolytes peg 3350-kcl-na bicarb-nacl peg-3350/electrolytes PEGANONE PEGASYS PEGASYS PROCLICK penicillin g pot in dextrose penicillin g potassium penicillin g sodium penicillin v potassium PENNSAID PENTAM pentazocine-naloxone hcl pentoxifylline er PERFOROMIST perindopril erbumine PERIOGARD permethrin perphenazine perphenazine-amitriptyline PEXEVA PHENADOZ phenelzine sulfate phenobarbital phenoxybenzamine hcl PHENYTEK phenytoin phenytoin sodium extended PHOSPHOLINE IODIDE PHRENILIN FORTE PICATO pilocarpine hcl... 77, 110 pimozide PIMTREA pindolol pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so PIRMELLA 1/ piroxicam PLASMA-LYTE PLASMA-LYTE A PLEGRIDY PLEGRIDY STARTER PACK PLENAMINE PLIAGLIS podofilox polyethylene glycol polymyxin b sulfate polymyxin b-trimethoprim POMALYST PORTIA potassium chloride... 81, 82 potassium chloride crys er potassium chloride er potassium chloride in dextrose potassium chloride in nacl potassium citrate er PRADAXA PRALUENT pramipexole dihydrochloride pramipexole dihydrochloride er prasugrel hcl pravastatin sodium prazosin hcl PRED MILD PRED-G PRED-G S.O.P prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 89, 111 prednisone PREDNISONE INTENSOL preferred plus insulin syringe PREMARIN PREMASOL PREMPHASE PREMPRO prenatal PREVALITE PREVIFEM PREVYMIS PREZCOBIX PREZISTA PRIFTIN primaquine phosphate primidone PRIMLEV PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid PROCALAMINE prochlorperazine prochlorperazine maleate PROCRIT PROCTO-MED HC PROCTO-PAK PROCTOSOL HC PROCTOZONE-HC PROFENO progesterone micronized PROGLYCEM PROLASTIN-C PROLENSA PROLIA PROMACTA promethazine hcl promethazine vc plain PROMETHEGAN

129 propafenone hcl propafenone hcl er propantheline bromide proparacaine hcl propranolol hcl propranolol hcl er propranolol-hctz propylthiouracil PROQUAD PROSOL protriptyline hcl PULZYME PURIXAN pyrazinamide pyridostigmine bromide pyridostigmine bromide er Q QUADRACEL QUASENSE quetiapine fumarate quetiapine fumarate er quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate er quinidine sulfate quinine sulfate QVAR REDIHALER R RABAVERT rabeprazole sodium raloxifene hcl ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE rasagiline mesylate RASUVO RAVICTI RAYALDEE RAYOS REBETOL REBIF REBIF REBIDOSE REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK RECLIPSEN RECOMBIVAX HB RECTIV REGRANEX RELENZA DISKHALER RELI-ON INSULIN SYRINGE RELISTOR RENAGEL repaglinide repaglinide-metformin hcl REPATHA REPATHA PUSHTRONEX SYSTEM REPATHA SURECLICK RESCRIPTOR RESTASIS REVATIO REVLIMID REXULTI REYATAZ RIBASPHERE RIBASPHERE RIBAPAK ribavirin RIDAURA rifabutin rifampin RIFATER riluzole rimantadine hcl RIOMET risedronate sodium RISPERDAL CONSTA risperidone ritonavir rivastigmine rivastigmine tartrate RIVELSA rizatriptan benzoate ropinirole hcl ropinirole hcl er rosuvastatin calcium ROTARIX ROTATEQ ROWEEPRA ROWEEPRA XR ROZEREM RUBRACA RUCONEST RYDAPT RYTARY S SABRIL SAIZEN SAIZENPREP SAMSCA SANCUSO SANDIMMUNE SANTYL SAPHRIS SAVELLA SAVELLA TITRATION PACK scopolamine selegiline hcl selenium sulfide SELZENTRY SEMPREX-D SENSIPAR SEREVENT DISKUS SEROSTIM sertraline hcl SETLAKIN sevelamer carbonate SHAROBEL SHINGRIX SIGNIFOR sildenafil citrate SILENOR SILIQ silver sulfadiazine SIMBRINZA SIMPONI simvastatin sirolimus SIRTURO SIVEXTRO SKLICE sodium chloride... 82, 108 sodium fluoride sodium lactate sodium phenylbutyrate sodium polystyrene sulfonate SOLOXIDE SOLTAX SOMATULINE DEPOT SOMAVERT SORINE sotalol hcl sotalol hcl (af) SOVALDI SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone-hctz SPORANOX SPRINTEC SPRITAM SPRYCEL SPS SRONYX SSD stavudine STELARA

130 STIMATE STIOLTO RESPIMAT STIVARGA streptomycin sulfate STRIANT STRIBILD STRIVERDI RESPIMAT SUBOXONE SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne) sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine sulindac sumatriptan sumatriptan succinate sumatriptan succinate refill sumatriptan-naproxen sodium SUPRAX SUPREP BOWEL PREP KIT SUSTIVA SUTENT SYEDA SYLATRON SYMBICORT SYMDEKO SYMFI SYMFI LO SYMLINPEN SYMLINPEN SYNALAR SYNAREL SYNDROS SYNJARDY SYNJARDY XR SYNRIBO SYNTHROID T TABLOID TACLONEX tacrolimus... 79, 103 TAFINLAR TAGRISSO TALTZ tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN TARINA FE 1/ TASIGNA TAVALISSE tazarotene TAZICEF TAZORAC TAZTIA XT TECFIDERA TECHNIVIE TEFLARO TEGRETOL TEGRETOL-XR telmisartan telmisartan-amlodipine telmisartan-hctz temazepam TENCON TENIVAC tenofovir disoproxil fumarate terazosin hcl terbinafine hcl terbutaline sulfate terconazole testosterone testosterone cypionate testosterone enanthate tetanus-diphtheria toxoids td tetrabenazine tetracycline hcl THALOMID theophylline theophylline er thioridazine hcl thiothixene THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine hcl tigecycline timolol maleate... 69, 110 tinidazole TIROSINT TIVICAY tizanidine hcl TOBI PODHALER TOBRADEX TOBRADEX ST tobramycin... 24, 115 tobramycin sulfate tobramycin-dexamethasone TOBREX tolazamide tolbutamide tolcapone tolmetin sodium tolterodine tartrate tolterodine tartrate er topiramate topiramate er torsemide TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR TPN ELECTROLYTES TRADJENTA tramadol hcl tramadol hcl er tramadol hcl er (biphasic) tramadol-acetaminophen trandolapril trandolapril-verapamil hcl er tranexamic acid tranylcypromine sulfate TRAVASOL TRAVATAN Z trazodone hcl TRECATOR TRELSTAR MIXJECT TREMFYA TRESIBA FLEXTOUCH tretinoin... 48, 79 tretinoin microsphere TREXALL triamcinolone acetonide... 42, 77, 90, 113 triamterene-hctz TRIDERM trientine hcl trifluoperazine hcl trifluridine trihexyphenidyl hcl TRI-LEGEST FE TRI-LO-ESTARYLLA TRI-LO-SPRINTEC TRILYTE trimethobenzamide hcl trimethoprim TRI-MILI trimipramine maleate TRINESSA (28) TRINTELLIX TRI-PREVIFEM TRI-SPRINTEC TRIUMEQ TRIVORA (28) TRI-VYLIBRA

131 TROPHAMINE trospium chloride trospium chloride er TRULICITY TRUMENBA TRUVADA TUDORZA PRESSAIR TWINRIX TYBOST TYDEMY TYKERB TYMLOS TYPHIM VI U UCERIS ULORIC UNITHROID UPTRAVI ursodiol V VABOMERE valacyclovir hcl VALCHLOR valganciclovir hcl valproate sodium valproic acid valsartan valsartan-hydrochlorothiazide VANATOL LQ vancomycin hcl VANDAZOLE VAQTA VARIVAX VARIZIG VASCEPA VELIVET VELPHORO VEMLIDY VENCLEXTA VENCLEXTA STARTING PACK 47 venlafaxine hcl venlafaxine hcl er VENTAVIS verapamil hcl verapamil hcl er VEREGEN VERSACLOZ VERZENIO VESICARE VIBRAMYCIN VICODIN VICODIN ES VICODIN HP VICTOZA VIDEX VIDEX EC VIEKIRA PAK VIEKIRA XR VIENVA vigabatrin VIIBRYD VIIBRYD STARTER PACK VIMPAT VIRACEPT VIRAMUNE VIREAD VIVITROL voriconazole VOSEVI VOTRIENT VRAYLAR VYFEMLA VYLIBRA W warfarin sodium WYMZYA FE X XALKORI XARELTO XARELTO STARTER PACK XATMEP XELJANZ XELJANZ XR XERMELO XGEVA XIFAXAN XIIDRA XOLAIR XTAMPZA ER XTANDI XULANE XURIDEN XYREM Y YF-VAX YONSA YUVAFEM Z zafirlukast zaleplon ZARAH ZARXIO ZEBUTAL ZEJULA ZELAPAR ZELBORAF ZEMAIRA ZENATANE ZENCHENT ZENPEP ZENZEDI ZEPATIER ZERIT zidovudine zileuton er ziprasidone hcl ZIRGAN ZOLINZA zolmitriptan zolpidem tartrate zolpidem tartrate er zonisamide ZORBTIVE ZORTRESS ZOSTAVAX ZOSYN ZOVIA 1/35E (28) ZOVIRAX ZYCLARA PUMP ZYDELIG ZYFLO ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA

132 131

133 This formulary was updated on 10/22/2018. For more recent information or other questions, please contact Golden State Medicare Health Plan at (877) or, for TTY users, 711, 8 AM to 8 PM Monday through Friday and daily during the enrollment periods, or visit Este formulario abreviado se actualize el 10/22/2018. Para obtener información más reciente o otras preguntas, por favor póngase en contacto con Golden State Medicare Health Plan al (877) o bien, para los usuarios de TTY, 711, 8 am a 8 pm de lunes a viernes y todos los dias durante los períodos de inscripción, o viste Member Services: (562) Local (877) Toll Free 711 TTY/TDD Golden State Medicare Health Plan is an H plan with a Medicare contract. Enrollment in Golden State Medicare Health Plan depends on contract renewal.