OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY

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1 OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY SMALL GROUP STANDARD FORMULARY (50 or Less Employees) (January March 09) Effective: January, 09 Revised: //09

2 Table of Contents Analgesics - Drugs for Pain... Analgesics - Drugs for Pain and Inflammation... 8 Anesthetics... 0 Anti-Addiction / Substance Abuse Treatment Agents... Antibacterials... Anticoagulants... 7 Anticonvulsants - Drugs for Seizures... 8 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia... Antidepressants... Antiemetics - Drugs for Nausea and Vomiting... 7 Antifungals... 7 Antigout Agents... 9 Antimigraine Agents... 0 Antimyasthenic Agents... Antimycobacterials... Antineoplastics - Drugs for Cancer... Antiparasitics... 5 Antiparkinson Agents... 6 Antiplatelets... 7 Antipsychotics - Drugs for Mood Disorders... 7 Antivirals... Anxiolytics - Drugs for Anxiety... 6 Bipolar Agents - Drugs for Mood Disorders... 7 Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders... 7 Cardiovascular Agents - Drugs for Heart and Circulation Conditions... 8 Central Nervous System Agents - Drugs for Attention Deficit Disorder Central Nervous System Agents - Drugs for Multiple Sclerosis Central Nervous System Agents - Miscellaneous... 6 Dental and Oral Agents - Drugs for Mouth and Throat Conditions... 6 Dermatological Agents - Drugs for Skin Conditions... 6 Diabetes - Antidiabetic Agents... 7 Diabetes - Glycemic Agents... 7 Diabetes - Insulins... 7 Electrolytes / Minerals / Metals / Vitamins Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer... 8 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions... 85

3 Genetic or Enzyme Disorder: Drugs for Replacement, Modifiers, Treatment Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions Genitourinary Agents - Drugs for Prostate Conditions... 9 Hormonal Agents - Adrenal... 9 Hormonal Agents - Men's Health Hormonal Agents - Osteoporosis Hormonal Agents - Parathyroid Hormonal Agents - Pituitary Hormonal Agents - Prostaglandins Hormonal Agents - Sex Hormones and Birth Control Hormonal Agents - Thyroid Immunological Agents - Drugs for Immune System Stimulation or Suppression Immunological Agents - Drugs for Vaccination... 0 Inflammatory Bowel Disease Agents... Metabolic Bone Disease Agents - Drugs for Osteoporosis... Miscellaneous Therapeutic Agents... Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation... 5 Ophthalmic Agents - Drugs for Glaucoma... 7 Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions... 8 Otic Agents - Drugs for Ear Conditions... 0 Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold... Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions... Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis... 6 Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension... 7 Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm... 7 Sleep Disorder Agents... 8

4 Analgesics - Drugs for Pain ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 00 MCG, 00 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG Effective: January, 09 PA; QL ( EA per day) acetaminophen-codeine # oral tablet 00-5 mg QL (0 EA per day) acetaminophen-codeine # oral tablet 00-0 mg QL (0 EA per day) acetaminophen-codeine # oral tablet mg QL (0 EA per day) acetaminophen-codeine oral solution 0- mg/5ml acetaminophen-codeine oral tablet 00-5 mg, mg QL (50 ML per day) QL (0 EA per day) ALLZITAL ORAL TABLET 5-5 MG ST; QL ( EA per day) apap-caff-dihydrocodeine oral capsule mg PA; QL (0 EA per day) ascomp-codeine oral capsule mg QL (6 EA per day) BELBUCA BUCCAL FILM 50 MCG, 00 MCG, 50 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG PA; QL ( EA per day) butalbital-acetaminophen oral tablet 50-5 mg QL (6 EA per day) butalbital-apap oral tablet 50-5 mg QL (6 EA per day) butalbital-apap-caff-cod oral capsule mg, mg butalbital-apap-caffeine oral capsule mg, mg QL (6 EA per day) QL (6 EA per day) butalbital-apap-caffeine oral tablet mg QL (6 EA per day) butalbital-asa-caff-codeine oral capsule mg butalbital-asa-caffeine oral capsule mg butalbital-aspirin-caffeine oral capsule mg butalbital-aspirin-caffeine oral tablet mg QL (6 EA per day) butorphanol tartrate nasal solution 0 mg/ml PA; QL ( ML per day) capacet oral capsule mg QL (6 EA per day) carisoprodol-aspirin-codeine oral tablet mg codeine sulfate oral tablet 5 mg QL ( EA per day) codeine sulfate oral tablet 0 mg QL ( EA per day) codeine sulfate oral tablet 60 mg QL (6 EA per day) duraxin oral capsule mg EMBEDA ORAL CAPSULE EXTENDED RELEASE 00- MG, 80-. MG QL ( EA per day)

5 EMBEDA ORAL CAPSULE EXTENDED RELEASE MG, 0-. MG, 50- MG, 60-. MG Effective: January, 09 QL ( EA per day) endocet oral tablet 0-5 mg QL (6 EA per day) endocet oral tablet.5-5 mg, 5-5 mg QL ( EA per day) endocet oral tablet mg QL (8 EA per day) esgic oral capsule mg QL (6 EA per day) fentanyl citrate buccal lozenge on a handle 00 mcg, 600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 7.5 mcg/hr, 50 mcg/hr, 6.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr FENTORA BUCCAL TABLET 00 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution 0-5 mg/5ml hydrocodone-acetaminophen oral solution.5-08 mg/5ml, 5-7 mg/0ml, mg/5ml hydrocodone-acetaminophen oral tablet 0-00 mg, mg hydrocodone-acetaminophen oral tablet 0-5 mg hydrocodone-acetaminophen oral tablet.5-5 mg hydrocodone-acetaminophen oral tablet 5-00 mg hydrocodone-acetaminophen oral tablet 5-5 mg, mg PA; QL ( EA per day) QL (0 EA per 0 days) PA; QL ( EA per day) QL (5 ML per day) QL (80 ML per day) QL (6 EA per day) QL (9 EA per day) QL ( EA per day) QL (8 EA per day) QL ( EA per day) hydrocodone-ibuprofen oral tablet 0-00 mg QL (5 EA per day) hydrocodone-ibuprofen oral tablet 5-00 mg, mg hydromorphone hcl er oral tablet er hour abuse-deterrent mg, 6 mg, mg, 8 mg QL (5 EA per day) PA; QL ( EA per day) hydromorphone hcl oral liquid mg/ml QL ( ML per day) hydromorphone hcl oral tablet mg QL ( EA per day) hydromorphone hcl oral tablet mg QL (5 EA per day) hydromorphone hcl oral tablet 8 mg QL ( EA per day) hydromorphone hcl rectal suppository mg QL ( EA per day) HYSINGLA ER ORAL TABLET ER HOUR ABUSE-DETERRENT 00 MG, 0 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG PA; QL ( EA per day) ibudone oral tablet 5-00 mg QL (5 EA per day)

6 KADIAN ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG KADIAN ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG LAZANDA NASAL SOLUTION 00 MCG/ACT, 00 MCG/ACT, 00 MCG/ACT Effective: January, 09 5 QL ( EA per day) QL ( EA per day) PA; QL ( EA per day) lorcet hd oral tablet 0-5 mg QL (9 EA per day) lorcet oral tablet 5-5 mg QL ( EA per day) lorcet plus oral tablet mg QL ( EA per day) marten-tab oral tablet 50-5 mg QL (6 EA per day) MEDROX-RX EXTERNAL OINTMENT % meperidine hcl oral solution 50 mg/5ml QL (90 ML per day) meperidine hcl oral tablet 00 mg QL (9 EA per day) meperidine hcl oral tablet 50 mg QL (8 EA per day) meperidine-promethazine oral capsule 50-5 mg QL (8 EA per day) methadone hcl intensol oral concentrate 0 mg/ml QL ( ML per day) methadone hcl oral concentrate 0 mg/ml QL ( ML per day) methadone hcl oral solution 0 mg/5ml QL (5 ML per day) methadone hcl oral solution 5 mg/5ml QL (0 ML per day) methadone hcl oral tablet 0 mg, 5 mg QL (6 EA per day) methadone hcl oral tablet soluble 0 mg methadose oral concentrate 0 mg/ml QL ( ML per day) methadose oral tablet soluble 0 mg methadose sugar-free oral concentrate 0 mg/ml QL ( ML per day) morphine sulfate (concentrate) oral solution 00 mg/5ml, 0 mg/ml morphine sulfate er beads oral capsule extended release hour 0 mg, 0 mg, 5 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release hour 0 mg, 0 mg, 50 mg morphine sulfate er oral capsule extended release hour 00 mg, 60 mg, 80 mg morphine sulfate er oral capsule extended release hour 0 mg morphine sulfate er oral tablet extended release 00 mg, 00 mg, 60 mg morphine sulfate er oral tablet extended release 5 mg, 0 mg QL ( ML per day) QL ( EA per day) QL ( EA per day) QL ( EA per day) QL ( EA per day) QL ( EA per day) QL ( EA per day) morphine sulfate oral solution 0 mg/5ml QL (0 ML per day)

7 morphine sulfate oral solution 0 mg/5ml QL ( ML per day) morphine sulfate oral tablet 5 mg QL (6 EA per day) morphine sulfate oral tablet 0 mg QL ( EA per day) morphine sulfate rectal suppository 0 mg, 5 mg QL (6 EA per day) morphine sulfate rectal suppository 0 mg QL ( EA per day) morphine sulfate rectal suppository 0 mg QL ( EA per day) NUCYNTA ER ORAL TABLET EXTENDED RELEASE HOUR 00 MG, 50 MG, 00 MG, 50 MG, 50 MG Effective: January, 09 6 PA; QL ( EA per day) NUCYNTA ORAL TABLET 00 MG PA; QL ( EA per day) NUCYNTA ORAL TABLET 50 MG PA; QL ( EA per day) NUCYNTA ORAL TABLET 75 MG PA; QL ( EA per day) OPANA ER ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG, 5 MG, 0 MG, 0 MG, 0 MG, 5 MG, 7.5 MG OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG OXAYDO ORAL TABLET ABUSE-DETERRENT 7.5 MG OXYCODONE HCL ER ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG, 5 MG OXYCODONE HCL ER ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG OXYCODONE HCL ER ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG, 60 MG, 80 MG OXYCODONE HCL ER TABLET ER HOUR ABUSE-DETERRENT 0 MG ORAL 0 MG OXYCODONE HCL ER TABLET ER HOUR ABUSE-DETERRENT 0 MG ORAL 0 MG PA; QL ( EA per day) PA; QL ( EA per day) PA; QL (8 EA per day) PA; QL ( EA per day) PA; QL ( EA per day) PA; QL ( EA per day) PA; QL ( EA per day) PA; QL ( EA per day) oxycodone hcl oral capsule 5 mg QL (6 EA per day) oxycodone hcl oral concentrate 00 mg/5ml QL ( ML per day) oxycodone hcl oral solution 5 mg/5ml QL (0 ML per day) oxycodone hcl oral tablet 0 mg, 5 mg QL (6 EA per day) oxycodone hcl oral tablet 5 mg QL ( EA per day) oxycodone hcl oral tablet 0 mg QL ( EA per day) oxycodone hcl oral tablet 0 mg QL ( EA per day) oxycodone-acetaminophen oral solution 5-5 mg/5ml QL (60 ML per day) oxycodone-acetaminophen oral tablet 0-5 mg QL (6 EA per day) oxycodone-acetaminophen oral tablet.5-5 mg, 5-5 mg QL ( EA per day)

8 oxycodone-acetaminophen oral tablet mg QL (8 EA per day) oxycodone-aspirin oral tablet mg QL ( EA per day) oxycodone-ibuprofen oral tablet 5-00 mg QL ( EA per day) OXYCONTIN ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG, 5 MG OXYCONTIN ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG OXYCONTIN ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG, 0 MG, 60 MG OXYCONTIN ORAL TABLET ER HOUR ABUSE-DETERRENT 80 MG oxymorphone hcl er oral tablet extended release hour 0 mg, 5 mg, 0 mg, 0 mg, 0 mg, 5 mg, 7.5 mg PA; QL ( EA per day) PA; QL ( EA per day) PA; QL ( EA per day) PA; QL ( EA per day) PA; QL ( EA per day) oxymorphone hcl oral tablet 0 mg PA; QL ( EA per day) oxymorphone hcl oral tablet 5 mg PA; QL (6 EA per day) pentazocine-naloxone hcl oral tablet mg QL ( EA per day) phrenilin forte oral capsule mg QL (6 EA per day) PRIMLEV ORAL TABLET 0-00 MG QL (6 EA per day) PRIMLEV ORAL TABLET 5-00 MG QL ( EA per day) PRIMLEV ORAL TABLET MG QL (8 EA per day) REMATEX EXTERNAL CREAM % SUBSYS SUBLINGUAL LIQUID 00 MCG, 00 (600 X ) MCG, 600 (800 X ) MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG PA; QL ( EA per day) tencon oral tablet 50-5 mg QL (6 EA per day) tramadol hcl er (biphasic) oral tablet extended release hour 00 mg, 00 mg, 00 mg TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG, 00 MG, 00 MG tramadol hcl er oral capsule extended release hour 50 mg tramadol hcl er oral tablet extended release hour 00 mg, 00 mg, 00 mg QL ( EA per day) QL ( EA per day) ST; QL ( EA per day) QL ( EA per day) tramadol hcl oral tablet 50 mg QL (8 EA per day) tramadol-acetaminophen oral tablet mg QL (8 EA per day) TREZIX ORAL CAPSULE MG PA; QL (0 EA per day) VANATOL LQ ORAL SOLUTION MG/5ML QL (90 ML per day) VANATOL S ORAL SOLUTION MG/5ML QL (90 ML per day) Effective: January, 09 7

9 verdrocet oral tablet.5-5 mg QL ( EA per day) vicodin es oral tablet mg QL (6 EA per day) vicodin hp oral tablet 0-00 mg QL (6 EA per day) vicodin oral tablet 5-00 mg QL (8 EA per day) xylon oral tablet 0-00 mg QL (5 EA per day) ZAMICET ORAL SOLUTION 0-5 MG/5ML QL (5 ML per day) zebutal oral capsule mg QL (6 EA per day) Analgesics - Drugs for Pain and Inflammation aspirin oral tablet 5 mg aspirin oral tablet delayed release 5 mg bayer aspirin oral tablet 5 mg CAMBIA ORAL PACKET 50 MG ST; QL (9 EA per 0 days) CELEBREX ORAL CAPSULE 00 MG QL ( EA per day) CELEBREX ORAL CAPSULE 00 MG QL ( EA per day) CELEBREX ORAL CAPSULE 00 MG QL ( EA per day) CELEBREX ORAL CAPSULE 50 MG QL (8 EA per day) celecoxib oral capsule 00 mg QL ( EA per day) celecoxib oral capsule 00 mg QL ( EA per day) celecoxib oral capsule 00 mg QL ( EA per day) celecoxib oral capsule 50 mg QL (8 EA per day) choline-mag trisalicylate oral liquid 500 mg/5ml diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release hour 00 mg diclofenac sodium oral tablet delayed release 5 mg, 50 mg, 75 mg diclofenac sodium transdermal gel % diclofenac sodium transdermal solution.5 % diclofenac-misoprostol oral tablet delayed release mg, mg diflunisal oral tablet 500 mg etodolac er oral tablet extended release hour 00 mg, 500 mg, 600 mg etodolac oral capsule 00 mg, 00 mg etodolac oral tablet 00 mg, 500 mg fenoprofen calcium oral capsule 00 mg fenoprofen calcium oral tablet 600 mg fenortho oral capsule 00 mg Effective: January, 09 8

10 flurbiprofen oral tablet 00 mg, 50 mg IBUPROFEN COMFORT PAC COMBINATION KIT 800 MG ibuprofen oral tablet 00 mg, 600 mg, 800 mg INDOCIN ORAL SUSPENSION 5 MG/5ML INDOCIN RECTAL SUPPOSITORY 50 MG indomethacin er oral capsule extended release 75 mg indomethacin oral capsule 5 mg, 50 mg inflammacin combination therapy pack 75 & 0.05 mg-% isometheptene-caffeine-apap oral tablet mg isometheptene-dichloral-apap oral capsule mg ketoprofen er oral capsule extended release hour 00 mg ketoprofen oral capsule 5 mg, 50 mg, 75 mg ketorolac tromethamine oral tablet 0 mg QL (0 EA per day) klofensaid ii transdermal solution.5 % LEXIXRYL TRANSDERMAL THERAPY PACK.5 % meclofenamate sodium oral capsule 00 mg, 50 mg mefenamic acid oral capsule 50 mg MELOXICAM COMFORT PAC COMBINATION KIT 5 MG meloxicam oral tablet 5 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg NAPROSYN ORAL SUSPENSION 5 MG/5ML QL (60 ML per day) NAPROXEN COMFORT PAC COMBINATION KIT 500 MG naproxen dr oral tablet delayed release 75 mg QL (.67 EA per day) naproxen dr oral tablet delayed release 500 mg QL ( EA per day) naproxen oral suspension 5 mg/5ml QL (60 ML per day) naproxen oral tablet 50 mg QL (6 EA per day) naproxen oral tablet 75 mg QL ( EA per day) naproxen oral tablet 500 mg QL ( EA per day) naproxen sodium er oral tablet extended release hour 75 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 mg Effective: January, 09 9

11 nodolor oral capsule mg nudiclo tabpak combination therapy pack 75 & 0.05 mg-% oxaprozin oral tablet 600 mg QL ( EA per day) piroxicam oral capsule 0 mg, 0 mg previdolrx plus analgesic combination therapy pack 75 & 0.05 mg-% profeno oral tablet 600 mg salsalate oral tablet 500 mg, 750 mg sulindac oral tablet 50 mg, 00 mg tolmetin sodium oral capsule 00 mg tolmetin sodium oral tablet 00 mg, 600 mg VIVLODEX ORAL CAPSULE 0 MG, 5 MG PA xenaflamm combination therapy pack 75 & 0.05 mg-% XRYLIX TRANSDERMAL THERAPY PACK.5 % Anesthetics ACCUCAINE COMBINATION KIT % ethyl chloride external aerosol lidocaine external ointment 5 % lidocaine external patch 5 % QL ( EA per day) lidocaine hcl external cream %,.88 % lidocaine hcl external lotion % lidocaine hcl external solution % lidocaine pak external ointment 5 % lidocaine-prilocaine external cream.5-.5 % LIDOCAINE-TETRINE EXTERNAL CREAM 7-7 % lido-k external lotion % lidopin external cream % LIDOPIN EXTERNAL CREAM.5 % LIDORX EXTERNAL GEL % LIDOTREX EXTERNAL GEL % LIDOVEX EXTERNAL CREAM.75 % LIDOZION EXTERNAL LOTION % premium lidocaine external ointment 5 % REGENECARE EXTERNAL GEL % Effective: January, 09 0

12 relador pak external kit.5-.5 % relador pak plus external kit.5-.5 % RENUU EXTERNAL PATCH -5-0 % SILVERA PAIN RELIEF EXTERNAL PATCH % SYNERA EXTERNAL PATCH MG SYNVEXIA TC EXTERNAL CREAM - % TRANZAREL EXTERNAL GEL % VELMA PAIN RELIEF EXTERNAL PATCH 6-- % VELTRIX EXTERNAL CREAM - % Anti-Addiction / Substance Abuse Treatment Agents acamprosate calcium oral tablet delayed release mg buprenorphine hcl sublingual tablet sublingual mg buprenorphine hcl sublingual tablet sublingual 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual -0.5 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8- mg bupropion hcl er (smoking det) oral tablet extended release hour 50 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET MG Effective: January, 09 QL ( EA per day) QL ( EA per day) QL ( EA per day) QL ( EA per day) QL (8 EA per 65 days) QL (8 EA per 65 days) CHANTIX ORAL TABLET 0.5 MG, MG QL (8 EA per 65 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X & MG X disulfiram oral tablet 50 mg, 500 mg EVZIO INJECTION SOLUTION AUTO- INJECTOR 0. MG/0.ML, MG/0.ML naloxone hcl injection solution 0. mg/ml, mg/0ml naloxone hcl injection solution cartridge 0. mg/ml naloxone hcl injection solution prefilled syringe mg/ml naltrexone hcl oral tablet 50 mg NARCAN NASAL LIQUID MG/0.ML QL (8 EA per 65 days) PA; QL (.6 ML per 0 days) nicotine polacrilex mouth/throat gum mg, mg QL (8 EA per 65 days)

13 nicotine polacrilex mouth/throat lozenge mg, mg nicotine step transdermal patch hour mg/hr nicotine step transdermal patch hour mg/hr nicotine step transdermal patch hour 7 mg/hr QL (8 EA per 65 days) QL (8 EA per 65 days) QL (8 EA per 65 days) QL (8 EA per 65 days) NICOTROL INHALATION INHALER 0 MG QL (8 EA per 65 days) NICOTROL NS NASAL SOLUTION 0 MG/ML QL (8 ML per 65 days) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/0.5ML SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/.5ML QL ( ML per 0 days) ; QL ( ML per 0 days) SUBOXONE SUBLINGUAL FILM - MG QL ( EA per day) SUBOXONE SUBLINGUAL FILM -0.5 MG QL ( EA per day) SUBOXONE SUBLINGUAL FILM - MG QL ( EA per day) SUBOXONE SUBLINGUAL FILM 8- MG QL ( EA per day) VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 80 MG Antibacterials ALTABAX EXTERNAL OINTMENT % amoxicillin oral capsule 50 mg, 500 mg amoxicillin oral suspension reconstituted 5 mg/5ml, 00 mg/5ml, 50 mg/5ml, 00 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 5 mg, 50 mg amoxicillin-potassium clavulanate er oral tablet extended release hour mg amoxicillin-potassium clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-potassium clavulanate oral tablet 50-5 mg, mg, mg amoxicillin-potassium clavulanate oral tablet chewable mg, mg ampicillin oral capsule 500 mg AVIDOXY DK COMBINATION KIT 00 MG avidoxy oral tablet 00 mg azithromycin oral packet gm Effective: January, 09

14 azithromycin oral suspension reconstituted 00 mg/5ml, 00 mg/5ml azithromycin oral tablet 50 mg, 500 mg, 600 mg BACTROBAN NASAL NASAL OINTMENT % benzalkonium chloride external solution 50 % CEDAX ORAL CAPSULE 00 MG CEDAX ORAL SUSPENSION RECONSTITUTED 80 MG/5ML cefaclor er oral tablet extended release hour 500 mg cefaclor oral capsule 50 mg, 500 mg cefaclor oral suspension reconstituted 5 mg/5ml, 50 mg/5ml, 75 mg/5ml cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 50 mg/5ml, 500 mg/5ml cefadroxil oral tablet gm cefdinir oral capsule 00 mg cefdinir oral suspension reconstituted 5 mg/5ml, 50 mg/5ml cefditoren pivoxil oral tablet 00 mg, 00 mg cefixime oral suspension reconstituted 00 mg/5ml, 00 mg/5ml cefpodoxime proxetil oral suspension reconstituted 00 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 00 mg, 00 mg cefprozil oral suspension reconstituted 5 mg/5ml, 50 mg/5ml cefprozil oral tablet 50 mg, 500 mg ceftibuten oral capsule 00 mg ceftibuten oral suspension reconstituted 80 mg/5ml CEFTIN ORAL SUSPENSION RECONSTITUTED 5 MG/5ML, 50 MG/5ML ceftriaxone sodium injection solution reconstituted 00 gm cefuroxime axetil oral tablet 50 mg, 500 mg CENTANY AT EXTERNAL KIT % cephalexin oral capsule 50 mg, 500 mg cephalexin oral capsule 750 mg Effective: January, 09

15 cephalexin oral suspension reconstituted 5 mg/5ml, 50 mg/5ml cephalexin oral tablet 50 mg, 500 mg ciprofloxacin hcl oral tablet 00 mg, 50 mg, 500 mg, 750 mg ciprofloxacin oral suspension reconstituted 50 mg/5ml (5%), 500 mg/5ml (0%) ciprofloxacin-ciproflox hcl er oral tablet extended release hour 000 mg, 500 mg clarithromycin er oral tablet extended release hour 500 mg clarithromycin oral suspension reconstituted 5 mg/5ml, 50 mg/5ml clarithromycin oral tablet 50 mg, 500 mg CLEOCIN VAGINAL SUPPOSITORY 00 MG clindamycin hcl oral capsule 50 mg, 00 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate vaginal cream % coremino oral tablet extended release hour 5 mg, 5 mg, 90 mg demeclocycline hcl oral tablet 50 mg, 00 mg dicloxacillin sodium oral capsule 50 mg, 500 mg DIFICID ORAL TABLET 00 MG PA doxycycline hyclate oral capsule 00 mg, 50 mg doxycycline hyclate oral tablet 00 mg, 0 mg doxycycline hyclate oral tablet delayed release 00 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule 00 mg, 50 mg doxycycline monohydrate oral capsule 50 mg, 75 mg doxycycline monohydrate oral suspension reconstituted 5 mg/5ml doxycycline monohydrate oral tablet 00 mg, 50 mg, 50 mg, 75 mg e.e.s. 00 oral tablet 00 mg ERYPED 00 ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 50 MG, MG, 500 MG Effective: January, 09 ST

16 ERYTHROCIN STEARATE ORAL TABLET 50 MG erythromycin base oral capsule delayed release particles 50 mg erythromycin base oral tablet 50 mg, 500 mg erythromycin ethylsuccinate oral suspension reconstituted 00 mg/5ml erythromycin ethylsuccinate oral tablet 00 mg FACTIVE ORAL TABLET 0 MG FIRVANQ ORAL SOLUTION RECONSTITUTED 5 MG/ML, 50 MG/ML gentamicin sulfate external cream 0. % gentamicin sulfate external ointment 0. % hydrogen peroxide solution 0 % IODOFLEX EXTERNAL PAD 0.9 % IODOSORB EXTERNAL GEL 0.9 % levofloxacin oral solution 5 mg/ml levofloxacin oral tablet 50 mg, 500 mg, 750 mg linezolid oral suspension reconstituted 00 mg/5ml linezolid oral tablet 600 mg lugols external solution methenamine hippurate oral tablet gm methenamine mandelate oral tablet 0.5 gm, gm metronidazole oral capsule 75 mg metronidazole oral tablet 50 mg, 500 mg metronidazole vaginal gel 0.75 % MINOCIN ORAL CAPSULE 00 MG, 50 MG minocycline hcl er oral tablet extended release hour 5 mg, 65 mg minocycline hcl er oral tablet extended release hour 5 mg, 5 mg, 90 mg minocycline hcl oral capsule 00 mg, 50 mg minocycline hcl oral capsule 75 mg minocycline hcl oral tablet 00 mg, 50 mg, 75 mg mondoxyne nl oral capsule 00 mg, 50 mg mondoxyne nl oral capsule 75 mg MONUROL ORAL PACKET GM AL (Max 7 Years) ST Effective: January, 09 5

17 MORGIDOX COMBINATION KIT X 00 MG, X 00 MG morgidox oral capsule 00 mg, 50 mg moxifloxacin hcl oral tablet 00 mg mupirocin calcium external cream % mupirocin external ointment % neomycin sulfate oral tablet 500 mg nitrofurantoin macrocrystal oral capsule 00 mg, 50 mg nitrofurantoin macrocrystal oral capsule 5 mg nitrofurantoin monohydrate macrocrystals oral capsule 00 mg nitrofurantoin oral suspension 5 mg/5ml NUTRIDOX ORAL KIT 75 MG ofloxacin oral tablet 00 mg, 00 mg okebo oral capsule 75 mg paromomycin sulfate oral capsule 50 mg PCE ORAL TABLET DELAYED RELEASE MG, 500 MG penicillin v potassium oral solution reconstituted 5 mg/5ml, 50 mg/5ml penicillin v potassium oral tablet 50 mg, 500 mg PRIMSOL ORAL SOLUTION 50 MG/5ML silver nitrate external ointment 0 % silver nitrate external solution 0.5 %, 0 %, 5 %, 50 % silver sulfadiazine external cream % SIVEXTRO ORAL TABLET 00 MG soloxide oral tablet delayed release 50 mg ST ssd external cream % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim oral suspension 00-0 mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg SULFAMYLON EXTERNAL CREAM 85 MG/GM sulfatrim pediatric oral suspension 00-0 mg/5ml SUPRAX ORAL CAPSULE 00 MG Effective: January, 09 6

18 SUPRAX ORAL SUSPENSION RECONSTITUTED 00 MG/5ML, 00 MG/5ML, 500 MG/5ML SUPRAX ORAL TABLET CHEWABLE 00 MG, 00 MG tetracycline hcl oral capsule 50 mg, 500 mg tinidazole oral tablet 50 mg, 500 mg trimethoprim oral tablet 00 mg TRIMPEX ORAL SOLUTION 50 MG/5ML vandazole vaginal gel 0.75 % XIFAXAN ORAL TABLET 00 MG, 550 MG PA; QL ( EA per 0 days) ZYVOX ORAL SUSPENSION RECONSTITUTED 00 MG/5ML Effective: January, 09 7 ST ZYVOX ORAL TABLET 600 MG ST Anticoagulants ELIQUIS ORAL TABLET.5 MG, 5 MG ELIQUIS STARTER PACK ORAL TABLET 5 MG enoxaparin sodium injection solution 00 mg/ml enoxaparin sodium subcutaneous solution 00 mg/ml, 0 mg/0.8ml, 50 mg/ml, 0 mg/0.ml, 0 mg/0.ml, 60 mg/0.6ml, 80 mg/0.8ml fondaparinux sodium subcutaneous solution 0 mg/0.8ml,.5 mg/0.5ml, 5 mg/0.ml, 7.5 mg/0.6ml FRAGMIN SUBCUTANEOUS SOLUTION 0000 UNIT/ML, 500 UNIT/0.5ML, 5000 UNIT/0.6ML, 8000 UNT/0.7ML, 500 UNIT/0.ML, 5000 UNIT/0.ML, 7500 UNIT/0.ML, UNIT/.8ML heparin (porcine) in d5w intravenous solution 0-5 unit/ml-%, 50-5 unit/ml-% heparin (porcine) in nacl injection solution unit/ml-%, -0.9 unit/ml-%, unit/ml- % heparin sod (porcine) in d5w intravenous solution 00 unit/ml, 0-5 unit/ml-% heparin sodium (porcine) injection solution 000 unit/ml, 0000 unit/ml, 0000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml heparin sodium/d5w intravenous solution 50-5 unit/ml-%

19 jantoven oral tablet mg, 0 mg, mg,.5 mg, mg, mg, 5 mg, 6 mg, 7.5 mg SAVAYSA ORAL TABLET 5 MG, 0 MG, 60 MG warfarin sodium oral tablet mg, 0 mg, mg,.5 mg, mg, mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 0 MG, 5 MG, 0 MG XARELTO STARTER PACK ORAL TABLET THERAPY PACK 5 & 0 MG Anticonvulsants - Drugs for Seizures APTIOM ORAL TABLET 00 MG, 00 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 0 MG/ML BANZEL ORAL TABLET 00 MG, 00 MG Effective: January, 09 8 PA ST BRIVIACT ORAL SOLUTION 0 MG/ML ST BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG carbamazepine er oral capsule extended release hour 00 mg, 00 mg, 00 mg carbamazepine er oral tablet extended release hour 00 mg, 00 mg, 00 mg carbamazepine oral suspension 00 mg/5ml carbamazepine oral tablet 00 mg carbamazepine oral tablet chewable 00 mg CARBATROL ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG, 00 MG, 00 MG CELONTIN ORAL CAPSULE 00 MG ST ST DEPAKENE ORAL CAPSULE 50 MG ST DEPAKOTE ER ORAL TABLET EXTENDED RELEASE HOUR 50 MG, 500 MG DEPAKOTE ORAL TABLET DELAYED RELEASE 5 MG, 50 MG, 500 MG DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE 5 MG DIASTAT ACUDIAL RECTAL GEL 0 MG, 0 MG DIASTAT PEDIATRIC RECTAL GEL.5 MG diazepam rectal gel 0 mg,.5 mg, 0 mg DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG ST ST ST ST DILANTIN ORAL CAPSULE 00 MG ST

20 DILANTIN ORAL CAPSULE 0 MG DILANTIN ORAL SUSPENSION 5 MG/5ML ST divalproex sodium er oral tablet extended release hour 50 mg, 500 mg divalproex sodium oral capsule delayed release sprinkle 5 mg divalproex sodium oral tablet delayed release 5 mg, 50 mg, 500 mg epitol oral tablet 00 mg ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5ml felbamate oral suspension 600 mg/5ml felbamate oral tablet 00 mg, 600 mg FELBATOL ORAL SUSPENSION 600 MG/5ML ST FELBATOL ORAL TABLET 00 MG, 600 MG ST FYCOMPA ORAL SUSPENSION 0.5 MG/ML ST FYCOMPA ORAL TABLET 0 MG, MG, MG, MG, 6 MG, 8 MG gabapentin oral capsule 00 mg, 00 mg, 00 mg gabapentin oral solution 50 mg/5ml, 00 mg/6ml gabapentin oral tablet 600 mg, 800 mg ST GABITRIL ORAL TABLET MG, MG ST KEPPRA ORAL SOLUTION 00 MG/ML ST KEPPRA ORAL TABLET 000 MG, 50 MG, 500 MG, 750 MG KEPPRA XR ORAL TABLET EXTENDED RELEASE HOUR 500 MG, 750 MG LAMICTAL ODT ORAL KIT 5 & 50 & 00 MG, 5 ()-50 (7) MG, 50 ()-00() MG LAMICTAL ODT ORAL TABLET DISPERSIBLE 00 MG, 00 MG, 5 MG, 50 MG LAMICTAL ORAL TABLET 00 MG, 50 MG, 00 MG, 5 MG LAMICTAL ORAL TABLET CHEWABLE 5 MG, 5 MG LAMICTAL XR ORAL KIT 5 & 50 & 00 MG, 5 ()-50 (7) MG, 50 & 00 & 00 MG LAMICTAL XR ORAL TABLET EXTENDED RELEASE HOUR 00 MG, 00 MG, 5 MG, 50 MG, 00 MG, 50 MG ST ST ST ST ST ST ST Effective: January, 09 9

21 lamotrigine er oral tablet extended release hour 00 mg, 00 mg, 5 mg, 50 mg, 00 mg, 50 mg lamotrigine oral kit 5 & 50 & 00 mg, 5 ()-50 (7) mg, 50 ()-00() mg lamotrigine oral tablet 00 mg, 50 mg, 00 mg, 5 mg lamotrigine oral tablet chewable 5 mg, 5 mg lamotrigine oral tablet dispersible 00 mg, 00 mg, 5 mg, 50 mg lamotrigine starter kit-blue oral kit 5 (5) mg lamotrigine starter kit-green oral kit 5 (8)- 00() mg lamotrigine starter kit-orange oral kit 5 ()-00 (7) mg levetiracetam er oral tablet extended release hour 500 mg, 750 mg levetiracetam oral solution 00 mg/ml levetiracetam oral tablet 000 mg, 50 mg, 500 mg, 750 mg MYSOLINE ORAL TABLET 50 MG, 50 MG ST NEURONTIN ORAL CAPSULE 00 MG, 00 MG, 00 MG Effective: January, 09 0 ST NEURONTIN ORAL SOLUTION 50 MG/5ML ST NEURONTIN ORAL TABLET 600 MG, 800 MG ST ONFI ORAL SUSPENSION.5 MG/ML ST ONFI ORAL TABLET 0 MG, 0 MG ST oxcarbazepine oral suspension 00 mg/5ml oxcarbazepine oral tablet 50 mg, 00 mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE HOUR 50 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 mg/5ml phenobarbital oral solution 0 mg/5ml phenobarbital oral tablet 00 mg, 5 mg, 6. mg, 0 mg,. mg, 60 mg, 6.8 mg, 97. mg PHENYTEK ORAL CAPSULE 00 MG, 00 MG ST phenytoin infatabs oral tablet chewable 50 mg phenytoin oral suspension 5 mg/5ml phenytoin oral tablet chewable 50 mg

22 phenytoin sodium extended oral capsule 00 mg, 00 mg, 00 mg primidone oral tablet 50 mg, 50 mg roweepra oral tablet 000 mg, 500 mg, 750 mg roweepra xr oral tablet extended release hour 500 mg, 750 mg SABRIL ORAL PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 000 MG, 50 MG, 500 MG, 750 MG subvenite oral tablet 00 mg, 50 mg, 00 mg, 5 mg subvenite starter kit-blue oral kit 5 (5) mg subvenite starter kit-green oral kit 5 (8)- 00() mg subvenite starter kit-orange oral kit 5 ()-00 (7) mg Effective: January, 09 ST TEGRETOL ORAL SUSPENSION 00 MG/5ML ST TEGRETOL ORAL TABLET 00 MG ST TEGRETOL-XR ORAL TABLET EXTENDED RELEASE HOUR 00 MG, 00 MG, 00 MG tiagabine hcl oral tablet mg, mg TOPAMAX ORAL TABLET 00 MG, 00 MG, 5 MG, 50 MG TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 5 MG, 5 MG topiramate er oral capsule er hour sprinkle 00 mg topiramate er oral capsule er hour sprinkle 50 mg topiramate er oral capsule er hour sprinkle 00 mg topiramate er oral capsule er hour sprinkle 5 mg topiramate er oral capsule er hour sprinkle 50 mg topiramate oral capsule sprinkle 5 mg, 5 mg topiramate oral tablet 00 mg, 00 mg, 5 mg, 50 mg ST ST TRILEPTAL ORAL SUSPENSION 00 MG/5ML ST TRILEPTAL ORAL TABLET 50 MG, 00 MG, 600 MG PA; QL ( EA per day) PA; QL (.66 EA per day) PA; QL ( EA per day) PA; QL (6 EA per day) PA; QL (8 EA per day) ST

23 valproate sodium oral solution 50 mg/5ml valproic acid oral capsule 50 mg valproic acid oral solution 50 mg/5ml vigabatrin oral packet 500 mg vigadrone oral packet 500 mg VIMPAT ORAL SOLUTION 0 MG/ML ST VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG ST ZARONTIN ORAL CAPSULE 50 MG ST ZARONTIN ORAL SOLUTION 50 MG/5ML ST ZONEGRAN ORAL CAPSULE 00 MG, 5 MG ST zonisamide oral capsule 00 mg, 5 mg, 50 mg Antidementia Agents - Drugs for Alzheimer's Disease and Dementia donepezil hcl oral tablet 0 mg, 5 mg donepezil hcl oral tablet mg donepezil hcl oral tablet dispersible 0 mg, 5 mg galantamine hydrobromide er oral capsule extended release hour 6 mg, mg, 8 mg galantamine hydrobromide oral solution mg/ml galantamine hydrobromide oral tablet mg, mg, 8 mg memantine hcl er oral capsule extended release hour mg, mg, 8 mg, 7 mg memantine hcl oral solution mg/ml memantine hcl oral tablet 0 mg, 5 (8)-0 () mg, 5 mg NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE HOUR 7 & & &8 MG NAMZARIC ORAL CAPSULE ER HOUR THERAPY PACK 7 & & &8-0 MG NAMZARIC ORAL CAPSULE EXTENDED RELEASE HOUR -0 MG, -0 MG, 8-0 MG, 7-0 MG rivastigmine tartrate oral capsule.5 mg, mg,.5 mg, 6 mg rivastigmine transdermal patch hour. mg/hr,.6 mg/hr, 9.5 mg/hr Antidepressants ST Effective: January, 09

24 amitriptyline hcl oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg amoxapine oral tablet 00 mg, 50 mg, 5 mg, 50 mg APLENZIN ORAL TABLET EXTENDED RELEASE HOUR 7 MG, 8 MG, 5 MG bupropion hcl er (sr) oral tablet extended release hour 00 mg bupropion hcl er (sr) oral tablet extended release hour 50 mg bupropion hcl er (sr) oral tablet extended release hour 00 mg bupropion hcl er (xl) oral tablet extended release hour 50 mg bupropion hcl er (xl) oral tablet extended release hour 00 mg Effective: January, 09 QL (.5 EA per day) QL ( EA per day) QL (.5 EA per day) QL ( EA per day) QL (.5 EA per day) bupropion hcl oral tablet 00 mg QL (.5 EA per day) bupropion hcl oral tablet 75 mg QL (6 EA per day) chlordiazepoxide-amitriptyline oral tablet 0-5 mg, 5-.5 mg citalopram hydrobromide oral solution 0 mg/5ml QL (0 ML per day) citalopram hydrobromide oral tablet 0 mg QL ( EA per day) citalopram hydrobromide oral tablet 0 mg QL ( EA per day) citalopram hydrobromide oral tablet 0 mg QL ( EA per day) clomipramine hcl oral capsule 5 mg, 50 mg, 75 mg desipramine hcl oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE HOUR 00 MG DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE HOUR 50 MG DESVENLAFAXINE FUMARATE ER ORAL TABLET EXTENDED RELEASE HOUR 00 MG DESVENLAFAXINE FUMARATE ER ORAL TABLET EXTENDED RELEASE HOUR 50 MG desvenlafaxine succinate er oral tablet extended release hour 00 mg desvenlafaxine succinate er oral tablet extended release hour 5 mg desvenlafaxine succinate er oral tablet extended release hour 50 mg QL ( EA per day) QL ( EA per day) QL ( EA per day) QL ( EA per day) ST; QL ( EA per day) ST; QL ( EA per day) ST; QL ( EA per day)

25 doxepin hcl oral capsule 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg doxepin hcl oral concentrate 0 mg/ml duloxetine hcl oral capsule delayed release particles 0 mg duloxetine hcl oral capsule delayed release particles 0 mg duloxetine hcl oral capsule delayed release particles 0 mg duloxetine hcl oral capsule delayed release particles 60 mg EMSAM TRANSDERMAL PATCH HOUR MG/HR, 6 MG/HR, 9 MG/HR QL (6 EA per day) QL ( EA per day) QL ( EA per day) escitalopram oxalate oral solution 5 mg/5ml QL (0 ML per day) escitalopram oxalate oral tablet 0 mg QL ( EA per day) escitalopram oxalate oral tablet 0 mg QL ( EA per day) escitalopram oxalate oral tablet 5 mg QL ( EA per day) FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 80 MG FETZIMA TITRATION ORAL CAPSULE ER HOUR THERAPY PACK 0 & 0 MG ST; QL ( EA per day) ST; QL (6 EA per day) ST; QL ( EA per day) ST; QL (.5 EA per day) ST; QL ( EA per 0 days) fluoxetine hcl (pmdd) oral capsule 0 mg QL (8 EA per day) fluoxetine hcl (pmdd) oral capsule 0 mg QL ( EA per day) fluoxetine hcl (pmdd) oral tablet 0 mg QL (8 EA per day) fluoxetine hcl (pmdd) oral tablet 0 mg QL ( EA per day) fluoxetine hcl oral capsule 0 mg QL (8 EA per day) fluoxetine hcl oral capsule 0 mg QL ( EA per day) fluoxetine hcl oral capsule 0 mg QL ( EA per day) fluoxetine hcl oral capsule delayed release 90 mg QL ( EA per day) fluoxetine hcl oral solution 0 mg/5ml QL (0 ML per day) fluoxetine hcl oral tablet 0 mg QL (8 EA per day) fluoxetine hcl oral tablet 0 mg QL ( EA per day) fluoxetine hcl oral tablet 60 mg QL (. EA per day) fluvoxamine maleate er oral capsule extended release hour 00 mg QL ( EA per day) Effective: January, 09

26 fluvoxamine maleate er oral capsule extended release hour 50 mg QL ( EA per day) fluvoxamine maleate oral tablet 00 mg QL ( EA per day) fluvoxamine maleate oral tablet 5 mg QL ( EA per day) fluvoxamine maleate oral tablet 50 mg QL (6 EA per day) imipramine hcl oral tablet 0 mg, 5 mg, 50 mg imipramine pamoate oral capsule 00 mg, 5 mg, 50 mg imipramine pamoate oral capsule 75 mg KHEDEZLA ORAL TABLET EXTENDED RELEASE HOUR 00 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE HOUR 50 MG maprotiline hcl oral tablet 5 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 0 MG QL ( EA per day) QL ( EA per day) mirtazapine oral tablet 5 mg QL ( EA per day) mirtazapine oral tablet 0 mg QL ( EA per day) mirtazapine oral tablet 5 mg QL (. EA per day) mirtazapine oral tablet 7.5 mg QL (8 EA per day) mirtazapine oral tablet dispersible 5 mg QL ( EA per day) mirtazapine oral tablet dispersible 0 mg QL ( EA per day) mirtazapine oral tablet dispersible 5 mg QL (. EA per day) NARDIL ORAL TABLET 5 MG ST nefazodone hcl oral tablet 00 mg, 50 mg, 00 mg, 50 mg, 50 mg nortriptyline hcl oral capsule 0 mg, 5 mg, 50 mg, 75 mg nortriptyline hcl oral solution 0 mg/5ml olanzapine-fluoxetine hcl oral capsule -5 mg, -50 mg, -5 mg, 6-5 mg, 6-50 mg paroxetine hcl er oral tablet extended release hour.5 mg paroxetine hcl er oral tablet extended release hour 5 mg paroxetine hcl er oral tablet extended release hour 7.5 mg QL (5 EA per day) QL (.5 EA per day) QL (.67 EA per day) paroxetine hcl oral tablet 0 mg QL (6 EA per day) paroxetine hcl oral tablet 0 mg QL ( EA per day) paroxetine hcl oral tablet 0 mg QL ( EA per day) paroxetine hcl oral tablet 0 mg QL (.5 EA per day) Effective: January, 09 5

27 perphenazine-amitriptyline oral tablet -0 mg, - 5 mg, -0 mg, -5 mg, -50 mg PEXEVA ORAL TABLET 0 MG, 0 MG, 0 MG, 0 MG phenelzine sulfate oral tablet 5 mg PRISTIQ ORAL TABLET EXTENDED RELEASE HOUR 00 MG PRISTIQ ORAL TABLET EXTENDED RELEASE HOUR 5 MG PRISTIQ ORAL TABLET EXTENDED RELEASE HOUR 50 MG protriptyline hcl oral tablet 0 mg, 5 mg Effective: January, 09 6 ST; QL ( EA per day) ST; QL ( EA per day) ST; QL ( EA per day) sertraline hcl oral concentrate 0 mg/ml QL (0 ML per day) sertraline hcl oral tablet 00 mg QL ( EA per day) sertraline hcl oral tablet 5 mg QL (8 EA per day) sertraline hcl oral tablet 50 mg QL ( EA per day) tranylcypromine sulfate oral tablet 0 mg trazodone hcl oral tablet 00 mg QL (6 EA per day) trazodone hcl oral tablet 50 mg QL ( EA per day) trazodone hcl oral tablet 00 mg QL ( EA per day) trazodone hcl oral tablet 50 mg QL ( EA per day) trimipramine maleate oral capsule 00 mg, 5 mg, 50 mg TRINTELLIX ORAL TABLET 0 MG ST; QL ( EA per day) TRINTELLIX ORAL TABLET 0 MG ST; QL ( EA per day) TRINTELLIX ORAL TABLET 5 MG ST; QL ( EA per day) venlafaxine hcl er oral capsule extended release hour 50 mg venlafaxine hcl er oral capsule extended release hour 7.5 mg venlafaxine hcl er oral capsule extended release hour 75 mg venlafaxine hcl er oral tablet extended release hour 50 mg venlafaxine hcl er oral tablet extended release hour 5 mg venlafaxine hcl er oral tablet extended release hour 7.5 mg venlafaxine hcl er oral tablet extended release hour 75 mg QL ( EA per day) QL ( EA per day) QL (6 EA per day) QL ( EA per day) QL ( EA per day) QL ( EA per day) QL (6 EA per day) venlafaxine hcl oral tablet 00 mg QL (.5 EA per day) venlafaxine hcl oral tablet 5 mg QL (8 EA per day)

28 venlafaxine hcl oral tablet 7.5 mg QL ( EA per day) venlafaxine hcl oral tablet 50 mg QL (9 EA per day) venlafaxine hcl oral tablet 75 mg QL (6 EA per day) VIIBRYD ORAL TABLET 0 MG ST; QL ( EA per day) VIIBRYD ORAL TABLET 0 MG ST; QL ( EA per day) VIIBRYD ORAL TABLET 0 MG ST; QL ( EA per day) VIIBRYD STARTER PACK ORAL KIT 0 & 0 MG Antiemetics - Drugs for Nausea and Vomiting Effective: January, 09 7 ST; QL ( EA per 0 days) AKYNZEO ORAL CAPSULE MG QL ( EA per 8 days) ANZEMET ORAL TABLET 00 MG, 50 MG QL (0 EA per day) aprepitant oral capsule 5 mg, 0 mg, 80 mg QL ( EA per day) aprepitant oral capsule 80 & 5 mg QL ( EA per day) CESAMET ORAL CAPSULE MG compro rectal suppository 5 mg dronabinol oral capsule 0 mg,.5 mg, 5 mg granisetron hcl oral tablet mg QL (5 EA per day) meclizine hcl oral tablet 5 mg metoclopramide hcl oral solution 0 mg/0ml, 5 mg/5ml metoclopramide hcl oral tablet 0 mg, 5 mg metoclopramide hcl oral tablet dispersible 0 mg, 5 mg ondansetron hcl oral solution mg/5ml ondansetron hcl oral tablet mg, mg, 8 mg ondansetron odt oral tablet dispersible mg, 8 mg ST perphenazine oral tablet 6 mg QL ( EA per day) perphenazine oral tablet mg QL ( EA per day) perphenazine oral tablet mg QL (6 EA per day) perphenazine oral tablet 8 mg QL (8 EA per day) prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 5 mg scopolamine transdermal patch 7 hour mg/days SYNDROS ORAL SOLUTION 5 MG/ML PA trimethobenzamide hcl oral capsule 00 mg VARUBI ORAL TABLET 90 MG QL ( EA per 8 days) Antifungals

29 AVC VAGINAL VAGINAL CREAM 5 % BIO-STATIN ORAL CAPSULE UNIT, UNIT bio-statin oral powder CICLODAN CREAM EXTERNAL KIT 0.77 % ciclodan external cream 0.77 % ciclodan external solution 8 % ciclopirox external gel 0.77 % ciclopirox external shampoo % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % clotrimazole mouth/throat lozenge 0 mg clotrimazole mouth/throat troche 0 mg CRESEMBA ORAL CAPSULE 86 MG econazole nitrate external cream % ERTACZO EXTERNAL CREAM % ST EXELDERM EXTERNAL CREAM % ST EXELDERM EXTERNAL SOLUTION % ST exoderm external lotion 5- % fluconazole oral suspension reconstituted 0 mg/ml, 0 mg/ml fluconazole oral tablet 00 mg, 50 mg, 00 mg, 50 mg flucytosine oral capsule 50 mg, 500 mg griseofulvin microsize oral suspension 5 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 5 mg, 50 mg GYNAZOLE- VAGINAL CREAM % itraconazole oral capsule 00 mg JUBLIA EXTERNAL SOLUTION 0 % PA KERYDIN EXTERNAL SOLUTION 5 % PA ketoconazole external cream % ketoconazole external foam % ketoconazole external shampoo % ketoconazole oral tablet 00 mg Effective: January, 09 8

30 KETODAN EXTERNAL KIT % LOPROX EXTERNAL KIT 0.77 % LULICONAZOLE EXTERNAL CREAM % ST LUZU EXTERNAL CREAM % ST MENTAX EXTERNAL CREAM % miconazole vaginal suppository 00 mg naftifine hcl external cream %, % NAFTIN EXTERNAL GEL %, % ST NOXAFIL ORAL SUSPENSION 0 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 00 MG nyamyc external powder unit/gm nyata external powder unit/gm nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystatin mouth/throat suspension unit/ml nystatin oral tablet unit nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% nystop external powder unit/gm ONMEL ORAL TABLET 00 MG ORAVIG BUCCAL TABLET 50 MG ST oxiconazole nitrate external cream % OXISTAT EXTERNAL LOTION % ST PENLAC EXTERNAL SOLUTION 8 % SPORANOX ORAL SOLUTION 0 MG/ML terbinafine hcl oral tablet 50 mg terconazole vaginal cream 0. %, 0.8 % terconazole vaginal suppository 80 mg voriconazole oral suspension reconstituted 0 mg/ml voriconazole oral tablet 00 mg, 50 mg XOLEGEL COREPAK EXTERNAL KIT & % Antigout Agents allopurinol oral tablet 00 mg, 00 mg Effective: January, 09 9

31 COLCHICINE ORAL CAPSULE 0.6 MG COLCHICINE ORAL TABLET 0.6 MG colchicine-probenecid oral tablet mg probenecid oral tablet 500 mg ULORIC ORAL TABLET 0 MG, 80 MG ST Antimigraine Agents AIMOVIG 0 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 70 MG/ML AIMOVIG SUBCUTANEOUS SOLUTION AUTO- INJECTOR 70 MG/ML Effective: January, 09 0 ; QL ( ML per 0 days) ; QL ( ML per 0 days) almotriptan malate oral tablet.5 mg, 6.5 mg ST; QL ( EA per 0 days) AXERT ORAL TABLET.5 MG, 6.5 MG QL ( EA per 0 days) dihydroergotamine mesylate injection solution mg/ml dihydroergotamine mesylate nasal solution mg/ml QL (8 ML per 0 days) eletriptan hydrobromide oral tablet 0 mg, 0 mg ST; QL ( EA per 0 days) ERGOMAR SUBLINGUAL TABLET SUBLINGUAL MG ergotamine-caffeine oral tablet -00 mg FROVA ORAL TABLET.5 MG QL ( EA per 0 days) frovatriptan succinate oral tablet.5 mg ST; QL ( EA per 0 days) IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO- INJECTOR 6 MG/0.5ML MIGERGOT RECTAL SUPPOSITORY -00 MG QL (8 ML per 0 days) naratriptan hcl oral tablet mg,.5 mg QL (9 EA per 0 days) RELPAX ORAL TABLET 0 MG, 0 MG ST; QL ( EA per 0 days) rizatriptan benzoate oral tablet 0 mg, 5 mg QL ( EA per 0 days) rizatriptan benzoate oral tablet dispersible 0 mg, 5 mg QL ( EA per 0 days) sumatriptan nasal solution 0 mg/act QL (6 EA per 0 days) sumatriptan nasal solution 5 mg/act QL ( EA per 0 days) sumatriptan succinate oral tablet 00 mg QL (9 EA per 0 days) sumatriptan succinate oral tablet 5 mg, 50 mg QL (8 EA per 0 days) sumatriptan succinate refill subcutaneous solution cartridge mg/0.5ml, 6 mg/0.5ml sumatriptan succinate subcutaneous solution 6 mg/0.5ml sumatriptan succinate subcutaneous solution auto-injector mg/0.5ml, 6 mg/0.5ml QL (8 ML per 0 days) QL (8 ML per 0 days) QL (8 ML per 0 days)

32 sumatriptan succinate subcutaneous solution prefilled syringe 6 mg/0.5ml sumatriptan-naproxen sodium oral tablet mg TREXIMET ORAL TABLET MG ST Effective: January, 09 QL (8 ML per 0 days) zolmitriptan oral tablet.5 mg, 5 mg QL ( EA per 0 days) zolmitriptan oral tablet dispersible.5 mg, 5 mg QL ( EA per 0 days) ZOMIG NASAL SOLUTION 5 MG ST; QL ( EA per 0 days) Antimyasthenic Agents guanidine hcl oral tablet 5 mg pyridostigmine bromide er oral tablet extended release 80 mg pyridostigmine bromide oral tablet 60 mg Antimycobacterials cycloserine oral capsule 50 mg dapsone oral tablet 00 mg, 5 mg ethambutol hcl oral tablet 00 mg, 00 mg isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 00 mg, 00 mg PASER ORAL PACKET GM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 50 mg RIFAMATE ORAL CAPSULE MG rifampin oral capsule 50 mg, 00 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG PA TRECATOR ORAL TABLET 50 MG Antineoplastics - Drugs for Cancer abiraterone acetate oral tablet 50 mg AFINITOR DISPERZ ORAL TABLET SOLUBLE MG, MG, 5 MG AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG anastrozole oral tablet mg bexarotene oral capsule 75 mg bicalutamide oral tablet 50 mg

33 BOSULIF ORAL TABLET 00 MG, 00 MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG, 75 MG CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG CALQUENCE ORAL CAPSULE 00 MG capecitabine oral tablet 50 mg, 500 mg CAPRELSA ORAL TABLET 00 MG, 00 MG COMETRIQ (00 MG DAILY DOSE) ORAL KIT X 80 & X 0 MG COMETRIQ (0 MG DAILY DOSE) ORAL KIT X 80 & X 0 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 0 MG COPIKTRA ORAL CAPSULE 5 MG, 5 MG COTELLIC ORAL TABLET 0 MG cyclophosphamide oral capsule 5 mg cyclophosphamide oral capsule 50 mg DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG EMCYT ORAL CAPSULE 0 MG ERIVEDGE ORAL CAPSULE 50 MG ERLEADA ORAL TABLET 60 MG etoposide oral capsule 50 mg exemestane oral tablet 5 mg FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 0 MG flutamide oral capsule 5 mg GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG GLEEVEC ORAL TABLET 00 MG GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 0 MG, 5 MG HEXALEN ORAL CAPSULE 50 MG HYCAMTIN ORAL CAPSULE 0.5 MG, MG hydroxyurea oral capsule 500 mg IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG Effective: January, 09 QL ( EA per day) QL (56 EA per 0 days) QL ( EA per 0 days) QL (8 EA per 0 days) ICLUSIG ORAL TABLET 5 MG, 5 MG

34 imatinib mesylate oral tablet 00 mg, 00 mg IMBRUVICA ORAL CAPSULE 0 MG, 70 MG IMBRUVICA ORAL TABLET 0 MG, 80 MG, 0 MG, 560 MG INLYTA ORAL TABLET MG, 5 MG IRESSA ORAL TABLET 50 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG KISQALI 00 DOSE ORAL TABLET 00 MG KISQALI 00 DOSE ORAL TABLET 00 MG KISQALI 600 DOSE ORAL TABLET 00 MG LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK () MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 & MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 & () MG LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 () MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 () & MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK () MG letrozole oral tablet.5 mg leucovorin calcium oral tablet 0 mg, 5 mg, 5 mg, 5 mg LEUKERAN ORAL TABLET MG LONSURF ORAL TABLET 5-6. MG, MG LYNPARZA ORAL CAPSULE 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG MEKINIST ORAL TABLET 0.5 MG, MG MEKTOVI ORAL TABLET 5 MG melphalan oral tablet mg mercaptopurine oral tablet 50 mg MESNEX ORAL TABLET 00 MG Effective: January, 09

35 MYLERAN ORAL TABLET MG NEXAVAR ORAL TABLET 00 MG NILANDRON ORAL TABLET 50 MG nilutamide oral tablet 50 mg NINLARO ORAL CAPSULE. MG, MG, MG ODOMZO ORAL CAPSULE 00 MG ONIVYDE INTRAVENOUS INJECTABLE MG/0ML PANRETIN EXTERNAL GEL 0. % POMALYST ORAL CAPSULE MG, MG, MG, MG PURIXAN ORAL SUSPENSION 000 MG/00ML REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG RUBR ORAL TABLET 00 MG, 50 MG, 00 MG SOLTAMOX ORAL SOLUTION 0 MG/5ML SPRYCEL ORAL TABLET 00 MG, 0 MG, 0 MG, 50 MG, 70 MG, 80 MG Effective: January, 09 STIVARGA ORAL TABLET 0 MG SUTENT ORAL CAPSULE.5 MG, 5 MG, 7.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 00 MCG, 00 MCG, 600 MCG TABLOID ORAL TABLET 0 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG ; QL ( EA per day) TAGRISSO ORAL TABLET 0 MG, 80 MG TALZENNA ORAL CAPSULE 0.5 MG, MG tamoxifen citrate oral tablet 0 mg, 0 mg TARCEVA ORAL TABLET 00 MG, 50 MG, 5 MG TARGRETIN EXTERNAL GEL % TASIGNA ORAL CAPSULE 50 MG, 00 MG, 50 MG temozolomide oral capsule 00 mg, 0 mg, 80 mg, 0 mg, 50 mg, 5 mg THALOMID ORAL CAPSULE 00 MG, 50 MG, 00 MG, 50 MG tretinoin oral capsule 0 mg TYKERB ORAL TABLET 50 MG

36 VALCHLOR EXTERNAL GEL 0.06 % VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 0 & 50 & 00 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG VIZIMPRO ORAL TABLET 5 MG, 0 MG, 5 MG VOTRIENT ORAL TABLET 00 MG XALKORI ORAL CAPSULE 00 MG, 50 MG XTANDI ORAL CAPSULE 0 MG YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED MG YONSA ORAL TABLET 5 MG ZEJULA ORAL CAPSULE 00 MG ZELBORAF ORAL TABLET 0 MG ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG ZYKADIA ORAL CAPSULE 50 MG ZYTIGA ORAL TABLET 50 MG, 500 MG Antiparasitics ALBENZA ORAL TABLET 00 MG ST ALINIA ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5ml atovaquone-proguanil hcl oral tablet mg, mg BILTRICIDE ORAL TABLET 600 MG chloroquine phosphate oral tablet 50 mg, 500 mg COARTEM ORAL TABLET 0-0 MG crotan external lotion 0 % DARAPRIM ORAL TABLET 5 MG PA EMVERM ORAL TABLET CHEWABLE 00 MG ST EURAX EXTERNAL CREAM 0 % ST hydroxychloroquine sulfate oral tablet 00 mg IMPAVIDO ORAL CAPSULE 50 MG Effective: January, 09 5

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