Express Scripts Medicare (PDP) 2016 Formulary (List of Covered Drugs)

Transcription

1 Express Scripts Medicare (PDP) 2016 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN Formulary ID Number: 16082, v5 This formulary was updated on 08/28/2015. For more recent information or other questions, please contact Express Scripts Medicare (PDP) Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at Note to current members: This formulary has changed since last year. Please review this document to understand your plan s drug coverage. When this drug list (formulary) refers to we, us or our, it means Medco Containment Life Insurance Company. When it refers to plan or our plan, it means Express Scripts Medicare. This document includes the list of the covered drugs (formulary) for our plan, which is current as of August 28, For more recent information, please contact us. Our contact information, along with the date we last updated the formulary, appears above and on the back cover. You must use network pharmacies to fill your prescriptions to get the most from your benefit. Benefits, premium and/or copayments/coinsurance may change on January 1, The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call Express Scripts Medicare Customer Service at the numbers on the back of your member ID card for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Llame al Servicio al cliente de Express Scripts Medicare a los números que figuran al dorso de su tarjeta de identificación de miembro para obtener información adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana. This document is available in braille. Please contact Customer Service if you need plan information in another format. EME19169 CRP15_1014 F0PA4X6A

2 What is the Express Scripts Medicare formulary? The list of drugs covered by the plan is also known as the formulary. It contains a list of highly utilized Medicare Part D drugs selected by Express Scripts Medicare 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. The formulary also includes information on requirements or limits for some covered drugs that are part of Express Scripts Medicare s standard formulary rules. Your specific plan may provide coverage of additional drugs that are not listed in this formulary, and your plan may have different plan rules and coverage. For more information on your plan s specific drug coverage, please review your other plan materials, visit us on the Web at or contact Customer Service. Express Scripts Medicare will generally cover a drug as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your other plan materials. Can my drug coverage change? Generally, if you are taking a drug covered by your plan in 2016, Express Scripts Medicare will not discontinue or reduce coverage of the drug during the 2016 coverage year, except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our plan s coverage, will not affect members who are currently taking the drug. It will remain available at the same copayment or coinsurance amount for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If Express Scripts Medicare removes drugs from your plan s coverage, adds prior authorization, quantity limits, and/or step therapy restrictions on a drug, or moves a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective. If the Food and Administration (FDA) determines that a drug we cover is unsafe, or if the drug s manufacturer removes the drug from the market, we will immediately stop covering the drug and provide notice to members who are taking the drug. This enclosed formulary is current as of the date indicated on the front cover. To get updated information about the drugs covered, please visit us on the Web or contact our Customer Service department using the information provided on the front and back covers of this formulary. If there are any additional changes made to this plan s drug coverage that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time after the changes take effect. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. 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, Hypertension/Lipids. i

3 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 106. 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 column of the list. What are generic drugs? Both brand-name drugs and generic drugs are covered under this plan. A generic drug is approved by the FDA as having the same active ingredient(s) 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: You or your doctor is required to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don t get approval, the drugs may not be covered. These drugs are noted with PA next to them in the formulary. Some drugs may be covered under Part B or under Part D, depending on your medical condition. Your doctor will need to get a prior authorization for these drugs as well, so your pharmacy can process your prescription correctly. Quantity Limits: For certain drugs, the amount of the drug that will be covered by the plan is limited. The plan may limit how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. These drugs are noted with QL next to them in the formulary. Step Therapy: In some cases, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. These drugs are noted with ST next to them in the formulary. You may be able to find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 1. Note: This drug list includes all possible restrictions and limits on coverage. The requirements and limits may not apply to your plan s specific coverage. To confirm whether a particular drug is covered, visit us on the Web at or contact Customer Service. You can ask us to make an exception to these restrictions or limits. See the section How do I request an exception to the formulary? on the following page for information about how to request an exception. ii

4 What if my drug is not listed on this formulary? If your drug is not included in this list of covered drugs, you should first contact Customer Service and ask if your drug is covered. If you learn that your drug is not covered, you have two options: You can ask our Customer Service department for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers or request an exception so that the plan will cover the drug you are taking. How do I request an exception to the formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can request coverage of a drug that is not currently covered by this plan. If approved, the drug will be covered at a pre-determined cost-sharing level, and you will 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 your drug is contained in our Non-Preferred Brand tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in our Preferred Brand tier instead. If approved, this would lower the amount you must pay for your drug. You may not ask us to provide a higher level of coverage for drugs that are in our Specialty tier. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Express Scripts Medicare limits the amount of the drug it will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. You should contact us to ask for an initial coverage decision for an exception, utilization restriction exception or to ask the plan to cover a drug that is not currently covered. When you are requesting an 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 believes 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. Generally, your request for an exception will only be approved if the alternative drugs that are covered, the lower-tiered drugs or the additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. iii

5 How do I request an appeal? If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. To start an appeal, you, your doctor or your representative must contact us. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. For more information about the appeals process, you may contact Customer Service using the information provided on the front and back covers of this document. Can I get a temporary transition supply while I wait for an exception decision? As a new or continuing member in our plan, you may be taking drugs that are not covered from one year to the next. Or, you may be taking a drug that is covered 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 an 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, or while you wait for a coverage decision from us, we may cover a temporary transition supply of your drug in certain cases during the first 90 days that you are enrolled in the plan or at the start of a new coverage year. For each of your drugs that has restrictions or limitations, we will cover a temporary transition supply when you go to a network pharmacy. This temporary transition supply will be for at least 30 days, or less if your prescription is written for fewer days. In that case, you will be allowed multiple fills to provide up to a total of at least a 30-day supply of the medication. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that has restrictions or limitations but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency transition supply of that drug (unless you have a prescription written for fewer while you pursue an exception. Other times when we will cover at least a temporary 30-day transition supply (or less, if you have a prescription written for fewer include: When you enter a long-term care facility When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized Express Scripts Medicare will send you a letter within 3 business days of your filling a temporary transition supply notifying you that this was a temporary supply and explaining your options. iv

6 Other coverage that your plan may provide Your plan may also cover categories of excluded drugs that are not normally covered by a Medicare prescription drug plan and are not listed in the formulary. s in the following categories may be covered subject to the rules and limitations of your specific plan: Prescription drugs when used for anorexia, weight loss or weight gain Prescription drugs when used to promote fertility Prescription drugs when used for cosmetic purposes or to promote hair growth Prescription drugs when used for the symptomatic relief of cough or colds Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are considered Part D drugs) s, such as CAVERJECT, CIALIS, EDEX, LEVITRA, MUSE and VIAGRA, when used for the treatment of sexual or erectile dysfunction Over-the-counter (OTC) diabetic supplies Federal Legend Part B medications for example, oral chemotherapy agents (e.g., TEMODAR, XELODA ) Non-prescription drugs, also known as over-the-counter (OTC) drugs Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale. Please contact Customer Service for additional information about your plan s specific drug coverage and your cost-sharing amount. Please note: Costs for excluded drugs not normally covered by a Medicare prescription drug plan will not count toward your Medicare prescription drug yearly deductible (if applicable), total drug costs or yearly out-of-pocket expenses. Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by this plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 106. The column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR ) and generic drugs are listed in lowercase italics (e.g., atorvastatin). The information in the column tells you if there are any special requirements for coverage of that particular drug. If you are not sure whether your drug is covered, please visit our website or contact Customer Service using the information provided on the front and back covers of this formulary. Your Costs The amount you pay for a covered drug will depend on: Your coverage stage. Your plan has different stages of coverage. In each stage, the amount you pay for a drug may change. Please refer to your other plan documents for more information about your specific prescription drug benefit. The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier may have a different cost-sharing amount. The s chart on the following page explains what types of drugs are included in each tier and shows how costs may change with each tier. v

7 Your other plan materials have more information about your plan s coverage stages and list the specific cost-sharing amounts for each tier. s Includes Helpful tips 1: Generic s 2: Preferred Brand s 3: Non-Preferred Brand s 4: Specialty s This tier includes many commonly prescribed generic drugs and may include other low-cost drugs. This tier includes preferred brand-name drugs as well as some generic drugs. This tier includes non-preferred brand-name drugs as well as some generic drugs. This tier includes very high cost brand-name and generic drugs. Use 1 drugs for the lowest cost-sharing amount. s in this tier will generally have lower cost-sharing amounts than non-preferred brand drugs. Many non-preferred drugs have lower-cost alternatives in s 1 and 2. Ask your doctor if switching to a lower-cost generic or preferred brand-name drug may be right for you. To learn more about medications in this tier, you may contact a pharmacist using the information provided on the front and back covers of this formulary. If you qualify for Extra Help If you qualify for Extra Help from Medicare to help pay for your prescription drugs, your cost-sharing amounts may be lower than your plan s standard benefit. Members who qualify for Extra Help will receive a notice called Important Information for Those Who Receive Extra Help Paying for Their Prescription s ( Low Income Rider or LIS Rider ). Please read it to find out what your costs are. You can also contact Customer Service with any questions using the information listed on the front and back covers of this formulary. For more information For more detailed information about your Medicare prescription drug coverage and your plan s specific costs, please review your other plan materials. If you need additional information on network pharmacies or if you have any other questions, please contact our Customer Service department using the information provided on the front and back covers of this formulary. 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 vi

8 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. Note: The following drug list includes all possible restrictions and limitations. Depending on your plan s specific benefit, you may not experience every restriction or limit indicated in the list. To confirm your plan s specific coverage, contact Customer Service using the information provided on the front and back covers of this List of abbreviations LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, contact Customer Service using the information provided on the front and back covers of this formulary. MO: Mail-Order. This prescription drug is available through our home delivery service, as well as through our retail network pharmacies. Consider using home delivery for your long-term (maintenance) medications, such as high blood pressure medications. Retail network pharmacies may be more appropriate for short-term prescriptions, such as antibiotics. PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover this drug. QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. vii

9 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 4 PA; MO AMBISOME 4 PA; MO amphotericin b 1 PA; MO ANCOBON 4 MO CANCIDAS 4 PA; MO clotrimazole mucous membrane CRESEMBA CRESEMBA ORAL 4 MO DIFLUCAN ERAXIS(WATER DILUENT) RECON SOLN fluconazole fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml flucytosine griseofulvin microsize griseofulvin ultramicrosize GRIS-PEG (ULTRAMICROSIZ E) 1 itraconazole ketoconazole oral LAMISIL ORAL GRANULES IN PACKET LAMISIL ORAL TABLET MYCAMINE 4 MO NOXAFIL ORAL 4 MO nystatin oral suspension nystatin oral tablet ONMEL 4 MO; QL (30 SPORANOX ORAL CAPSULE SPORANOX ORAL SOLUTION SPORANOX PULSEPAK terbinafine hcl oral VFEND 4 MO VFEND IV voriconazole ANTIVIRALS abacavir abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml 1

10 acyclovir oral tablet acyclovir sodium intravenous solution 1 PA; MO adefovir amantadine hcl oral APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION 4 MO ATRIPLA 4 MO BARACLUDE ORAL SOLUTION BARACLUDE ORAL TABLET 4 4 MO cidofovir 1 PA; MO COMBIVIR 4 MO COMPLERA 4 MO COPEGUS 4 MO CRIXIVAN ORAL CAPSULE 200, 400 CYTOVENE didanosine EDURANT 4 MO EMTRIVA entecavir EPIVIR EPIVIR HBV ORAL SOLUTION EPIVIR HBV ORAL TABLET EPZICOM 4 MO EVOTAZ 4 MO famciclovir FAMVIR FLUMADINE ORAL TABLET foscarnet 1 PA; MO FUZEON SUBCUTANEOUS RECON SOLN 4 MO ganciclovir sodium HARVONI 4 PA; MO; QL (28 per 28 HEPSERA 4 MO INTELENCE ORAL TABLET 100, 200 INTELENCE ORAL TABLET 25 INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 100 ISENTRESS ORAL TABLET,CHEWAB LE 25 4 MO 2 4 MO 4 MO 4 MO 2

11 KALETRA ORAL SOLUTION KALETRA ORAL TABLET KALETRA ORAL TABLET MO 4 MO lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET 4 MO moderiba moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) nevirapine NORVIR OLYSIO 4 PA; MO; QL (28 per 28 PREZCOBIX 4 MO PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150, 75 PREZISTA ORAL TABLET 600, MO 4 MO REBETOL ORAL CAPSULE REBETOL ORAL SOLUTION RELENZA DISKHALER 4 MO RESCRIPTOR RETROVIR RETROVIR ORAL CAPSULE RETROVIR ORAL SYRUP REYATAZ ORAL CAPSULE 150, 200, 300 REYATAZ ORAL POWDER IN PACKET 4 MO 4 MO ribasphere ribasphere ribapak oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY 3

12 SOVALDI 4 PA; MO; QL (28 per 28 stavudine STRIBILD 4 MO SUSTIVA SYNAGIS INTRAMUSCULA R SOLUTION 50 /0.5 ML 4 MO; LA TAMIFLU TIVICAY 4 MO TRIUMEQ 4 MO TRIZIVIR 4 MO TRUVADA 4 MO TYBOST TYZEKA 4 MO valacyclovir ; QL (30 VALCYTE 4 MO valganciclovir VALTREX ; QL (30 VIDEX 2 GRAM PEDIATRIC VIDEX EC VIEKIRA PAK 4 PA; MO; QL (112 per 28 VIRACEPT ORAL TABLET 4 MO VIRAMUNE VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 400 VIRAZOLE 4 MO VIREAD 4 MO VISTIDE 4 PA VITEKTA 4 MO ZERIT ZIAGEN ORAL SOLUTION ZIAGEN ORAL TABLET zidovudine ZOVIRAX ORAL CAPSULE ZOVIRAX ORAL SUSPENSION CEPHALOSPORINS CEDAX ORAL CAPSULE CEDAX ORAL SUSPENSION FOR RECONSTITUTIO N 180 /5 ML CEDAX ORAL SUSPENSION FOR RECONSTITUTIO N 90 /5 ML 3 4

13 cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram cefdinir cefditoren pivoxil oral tablet 200 mg 1 cefepime CEFEPIME IN DEXTROSE 5 % cefixime cefotaxime injection recon soln 1 gram, 2 gram, 500 mg 1 cefotetan 1 cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, 2 gram 5 1 cefpodoxime cefprozil CEFTAZIDIME IN D5W ceftazidime injection recon soln 1 gram, 2 gram ceftazidime injection recon soln 6 gram CEFTIN ORAL SUSPENSION FOR RECONSTITUTIO N CEFTIN ORAL TABLET 250, 500 ceftriaxone injection recon soln 10 gram ceftriaxone injection recon soln 250 mg, 500 mg ceftriaxone intravenous recon soln cefuroxime axetil oral tablet

14 cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous cephalexin CLAFORAN INJECTION RECON SOLN 1 GRAM, 10 GRAM, 2 GRAM CLAFORAN INJECTION RECON SOLN 500 CLAFORAN RECON SOLN FORTAZ INJECTION RECON SOLN 2 GRAM FORTAZ INJECTION RECON SOLN 6 GRAM FORTAZ KEFLEX ORAL CAPSULE MAXIPIME INJECTION SPECTRACEF ORAL TABLET 400 SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 100 /5 ML, 200 /5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 /5 ML SUPRAX ORAL TABLET,CHEWAB LE TAZICEF INJECTION RECON SOLN 1 GRAM TAZICEF INJECTION RECON SOLN 2 GRAM, 6 GRAM TEFLARO ZERBAXA 4 ZINACEF INJECTION RECON SOLN 1.5 GRAM ZINACEF INJECTION RECON SOLN 750 ZINACEF RECON SOLN 7.5 GRAM ERYTHROMYCINS / OTHER MACROLIDES 3 3

15 azithromycin intravenous recon soln 500 mg azithromycin intravenous recon soln 500 mg (2 mg/ml) azithromycin oral BIAXIN ORAL SUSPENSION FOR RECONSTITUTIO N 250 /5 ML BIAXIN ORAL TABLET 1 clarithromycin DIFICID 4 MO e.e.s. 400 oral tablet E.E.S. GRANULES ERYPED 200 ERYPED 400 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN RECON SOLN erythromycin ethylsuccinate oral tablet erythromycin oral tablet PCE ZITHROMAX ZITHROMAX TRI- PAK ZITHROMAX Z- PAK ZMAX MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 500 mg/2 ml atovaquone atovaquoneproguanil AZACTAM IN DEXTROSE (ISO- OSM) PIGGYBACK 1 GRAM/50 ML AZACTAM IN DEXTROSE (ISO- OSM) PIGGYBACK 2 GRAM/50 ML 2 4 7

16 AZACTAM INJECTION RECON SOLN 1 GRAM aztreonam injection recon soln 1 gram baciim 1 bacitracin intramuscular BETHKIS 4 PA; MO; QL (224 per 28 BILTRICIDE CAPASTAT 3 CAYSTON 4 MO; LA; QL (84 per 28 chloramphenicol sod succinate chloroquine phosphate oral CLEOCIN IN 5 % DEXTROSE PIGGYBACK 300 /50 ML, 600 /50 ML CLEOCIN IN 5 % DEXTROSE PIGGYBACK 900 /50 ML CLEOCIN INJECTION 1 3 CLEOCIN ORAL clindamycin hcl clindamycin in 5 % dextrose clindamycin pediatric clindamycin phosphate intravenous solution 600 mg/4 ml 8 1 COARTEM colistin (colistimethate na) CUBICIN 4 MO DALVANCE 3 DAPSONE DARAPRIM DORIBAX RECON SOLN 500 ethambutol FLAGYL FLAGYL ER gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml 3 1

17 gentamicin injection solution 40 mg/ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral 1 imipenem-cilastatin INVANZ INJECTION isoniazid injection 1 isoniazid oral ivermectin oral KETEK LINCOCIN linezolid intravenous 1 linezolid oral MALARONE MALARONE PEDIATRIC mefloquine MEPRON 4 MO meropenem intravenous recon soln 500 mg MERREM RECON SOLN 500 metronidazole in nacl (iso-os) metronidazole oral MYAMBUTOL ORAL TABLET 400 MYCOBUTIN NEBUPENT 2 PA; MO; QL (6 per 28 neomycin paromomycin PASER PENTAM PLAQUENIL polymyxin b sulfate 1 PRIFTIN PRIMAQUINE PRIMAXIN IV pyrazinamide QUALAQUIN quinine sulfate rifabutin RIFADIN RIFAMATE rifampin intravenous rifampin oral RIFATER SIRTURO 4 MO; LA SIVEXTRO SIVEXTRO ORAL 4 MO STREPTOMYCIN INTRAMUSCULA R 4 9

18 STROMECTOL SYNERCID 4 TINDAMAX ORAL TABLET 500 tinidazole TOBI 4 PA; MO; QL (280 per 28 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in % nacl tobramycin in 0.9 % nacl intravenous piggyback 80 mg/100 ml tobramycin sulfate injection solution 4 MO; QL (224 per 28 1 PA; MO; QL (280 per 28 TRECATOR TYGACIL XIFAXAN ORAL TABLET 200 XIFAXAN ORAL TABLET 550 ZYVOX PARENTERAL SOLUTION 600 /300 ML 4 MO 4 MO ZYVOX ORAL 4 MO PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate ampicillin ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam injection recon soln 3 gram ampicillin-sulbactam intravenous recon soln 1.5 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N /5 ML 1 1 BICILLIN C-R BICILLIN L-A dicloxacillin 10

19 nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml nafcillin injection recon soln 1 gram, 10 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 2 gram PENICILLIN G POT IN DEXTROSE PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g sodium penicillin v potassium piperacillintazobactam intravenous recon soln gram, 4.5 gram UNASYN INJECTION RECON SOLN 15 GRAM UNASYN INJECTION RECON SOLN 3 GRAM ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK GRAM/50 ML ZOSYN RECON SOLN GRAM QUINOLONES 3 2 AVELOX AVELOX ABC PACK AVELOX IN NACL (ISO-OSMOTIC) 11

20 CIPRO IN D5W PIGGYBACK 400 /200 ML CIPRO ORAL SUSPENSION,MIC ROCAPSULE RECON CIPRO ORAL TABLET 250, 500 ciprofloxacin 1 ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml 3 FACTIVE LEVAQUIN ORAL levofloxacin in d5w intravenous piggyback 500 mg/100 ml levofloxacin intravenous 1 levofloxacin oral moxifloxacin ofloxacin oral tablet 400 mg 1 SULFA'S / RELATED AGENTS BACTRIM BACTRIM DS sulfadiazine oral sulfamethoxazoletrimethoprim TETRACYCLINES ADOXA ORAL CAPSULE 3 ST; MO demeclocycline oral doxy-100 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline hyclate oral tablet 50 mg doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet

21 MINOCIN ORAL CAPSULE 100, 50 3 ST; MO minocycline oral ORACEA 3 ST; MO SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105, 115, 55, 65, 80 4 ST; MO tetracycline VIBRAMYCIN ORAL CAPSULE 100 VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTIO N VIBRAMYCIN ORAL SYRUP 3 ST; MO URINARY TRACT AGENTS FURADANTIN HIPREX MACROBID MACRODANTIN ORAL CAPSULE 100, 50 MACRODANTIN ORAL CAPSULE 25 methenamine hippurate MONUROL nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst nitrofurantoin oral PRIMSOL trimethoprim VANCOMYCIN VANCOCIN 4 MO vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg vancomycin oral capsule ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 250 mg ELITEK RECON SOLN 1.5 FUSILEV 4 MO KEPIVANCE

22 leucovorin calcium injection recon soln 100 mg, 350 mg leucovorin calcium oral LEVOLEUCOVORI N CALCIUM mesna MESNEX MESNEX ORAL 4 MO XGEVA 4 MO ZINECARD (AS HCL) RECON SOLN MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 MO adrucil intravenous solution 500 mg/10 ml AFINITOR DISPERZ AFINITOR ORAL TABLET 10 AFINITOR ORAL TABLET 2.5, 5, 7.5 ALIMTA RECON SOLN PA; MO 4 PA; MO; QL (60 per 30 4 PA; MO 4 MO ALKERAN anastrozole ARIMIDEX AROMASIN ARRANON 4 ARZERRA SOLUTION 100 /5 ML 4 4 PA; MO ASTAGRAF XL 3 PA; MO AVASTIN SOLUTION 25 /ML azacitidine AZASAN 3 PA; MO azathioprine 1 PA; MO BELEODAQ 4 MO bicalutamide BICNU bleomycin injection recon soln 30 unit BOSULIF ORAL TABLET 100 BOSULIF ORAL TABLET 500 BUSULFEX 4 CAMPTOSAR SOLUTION 100 /5 ML 4 PA; MO 4 PA; MO; QL (30 per 30 14

23 CAPRELSA ORAL TABLET 100 CAPRELSA ORAL TABLET 300 carboplatin intravenous solution 4 PA; MO; LA; QL (90 per 30 4 PA; MO; LA; QL (30 per 30 CASODEX CELLCEPT CELLCEPT ORAL CAPSULE CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N CELLCEPT ORAL TABLET 2 PA; MO 3 PA; MO 4 PA; MO 4 PA; MO cisplatin cladribine CLOLAR 4 MO COMETRIQ 4 PA; MO COSMEGEN 4 MO CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule 2 PA; MO 1 PA 1 PA; MO 1 PA; MO cytarabine cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) dacarbazine intravenous recon soln 200 mg DACOGEN 4 MO daunorubicin intravenous solution DAUNOXOME 4 MO decitabine DOCEFREZ RECON SOLN 20 docetaxel intravenous solution 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) DOXIL 4 MO doxorubicin intravenous solution 50 mg/25 ml DROXIA ELIGARD 3 PA; MO ELLENCE SOLUTION 200 /100 ML ELOXATIN SOLUTION 100 /20 ML 4 MO EMCYT

24 epirubicin intravenous solution 50 mg/25 ml ERBITUX SOLUTION 100 /50 ML 4 MO ERIVEDGE 4 PA; MO; QL (30 per 30 ERWINAZE 4 MO ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 10 FARYDAK ORAL CAPSULE 15, 20 4 PA; MO; QL (12 per 21 FASLODEX 4 MO FEMARA FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fluorouracil intravenous solution 2.5 gram/50 ml 4 PA; MO; QL (6 per 21 flutamide FOLOTYN SOLUTION 40 /2 ML (20 /ML) gemcitabine intravenous recon soln 1 gram GEMZAR RECON SOLN 1 GRAM 4 MO 4 MO gengraf 1 PA; MO GILOTRIF ORAL TABLET 20 GILOTRIF ORAL TABLET 30 GILOTRIF ORAL TABLET 40 GLEEVEC ORAL TABLET 100 GLEEVEC ORAL TABLET PA; MO; QL (60 per 30 4 PA; MO; QL (40 per 30 4 PA; MO; QL (30 per 30 4 PA; MO 4 PA; MO; QL (60 per 30 GLEOSTINE HALAVEN 4 MO HERCEPTIN 4 MO HEXALEN 4 MO HYCAMTIN 4 MO HYDREA hydroxyurea 16

25 IBRANCE 4 PA; MO; QL (21 per 28 ICLUSIG ORAL TABLET 15 ICLUSIG ORAL TABLET 45 4 PA; MO; QL (90 per 30 4 PA; MO; QL (30 per 30 IDAMYCIN PFS idarubicin 1 IFEX RECON SOLN 1 GRAM ifosfamide intravenous recon soln 1 gram IMBRUVICA 4 PA; MO; QL (120 per 30 IMURAN 3 PA; MO INLYTA ORAL TABLET 1 INLYTA ORAL TABLET 5 irinotecan intravenous solution 100 mg/5 ml 4 PA; MO 4 PA; MO; QL (120 per 30 ISTODAX 4 MO IXEMPRA RECON SOLN 45 4 MO JAKAFI ORAL TABLET 10, 15, 20, 5 JAKAFI ORAL TABLET 25 4 PA; MO 4 PA; MO; QL (60 per 30 JEVTANA 4 MO KADCYLA RECON SOLN 100 KEYTRUDA RECON SOLN 4 MO 4 MO LENVIMA 4 PA; MO letrozole LEUKERAN leuprolide LOMUSTINE LUPRON DEPOT 4 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED INTRAMUSCULA R KIT 11.25, 15 4 PA; MO 4 PA; MO 4 PA; MO 4 PA; MO LYNPARZA 4 PA; MO LYSODREN MATULANE 4 MO 17

26 MEGACE MEGACE ES megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MEKINIST ORAL TABLET 2 melphalan hcl 1 4 PA; MO; QL (120 per 30 4 PA; MO; QL (30 per 30 mercaptopurine methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium oral mitomycin intravenous recon soln 20 mg 1 PA 1 PA; MO 1 PA; MO mitoxantrone MUSTARGEN mycophenolate mofetil mycophenolate sodium 1 PA; MO 1 PA; MO MYFORTIC 3 PA; MO NEORAL 3 PA; MO NEXAVAR 4 PA; MO; LA; QL (120 per 30 NILANDRON NIPENT 4 MO NULOJIX 4 PA; MO octreotide acetate injection solution ONCASPAR 4 MO OPDIVO SOLUTION 40 /4 ML oxaliplatin intravenous solution 100 mg/20 ml 4 MO paclitaxel PERJETA 4 MO POMALYST 4 MO PROGRAF PROGRAF ORAL CAPSULE 0.5, 1 PROGRAF ORAL CAPSULE 5 2 PA; MO 3 PA; MO 4 PA; MO PURIXAN 4 MO RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET 0.5, 1 2 PA; MO 3 PA; MO 18

27 RAPAMUNE ORAL TABLET 2 4 PA; MO REVLIMID 4 PA; MO; LA RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 (DOSE PACK 12), 2.5 (DOSE PACK 16), 2.5 (DOSE PACK 20), 2.5 (DOSE PACK 8) 3 PA; MO 3 PA RITUXAN 4 PA; MO SANDIMMUNE SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION SANDOSTATIN INJECTION SOLUTION 1,000 MCG/ML, 100 MCG/ML, 200 MCG/ML SANDOSTATIN INJECTION SOLUTION 50 MCG/ML, 500 MCG/ML 3 PA; MO 3 PA; MO 2 PA; MO 4 MO SANDOSTATIN LAR DEPOT INTRAMUSCULA R KIT 4 MO SIGNIFOR 4 MO SIGNIFOR LAR 4 MO SIMULECT RECON SOLN 20 2 PA; MO sirolimus 1 PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100, 20, 50, 80 SPRYCEL ORAL TABLET 140 SPRYCEL ORAL TABLET 70 4 MO 4 PA; MO 4 PA; MO; QL (30 per 30 4 PA; MO; QL (60 per 30 STIVARGA 4 PA; MO; QL (84 per 28 SUTENT ORAL CAPSULE 12.5 SUTENT ORAL CAPSULE 25, 37.5 SUTENT ORAL CAPSULE 50 4 PA; MO 4 PA; MO; QL (60 per 30 4 PA; MO; QL (30 per 30 19

28 SYLVANT RECON SOLN MO SYNRIBO 4 MO TABLOID tacrolimus oral 1 PA; MO TAFINLAR ORAL CAPSULE 50 TAFINLAR ORAL CAPSULE 75 4 PA; MO; QL (180 per 30 4 PA; MO; QL (120 per 30 tamoxifen TARCEVA ORAL TABLET 100, 25 TARCEVA ORAL TABLET PA; MO 4 PA; MO; QL (30 per 30 TARGRETIN 4 MO TASIGNA ORAL CAPSULE 150 TASIGNA ORAL CAPSULE 200 TAXOTERE SOLUTION 80 /4 ML (20 /ML) 4 PA; MO 4 PA; MO; QL (112 per 28 4 MO THALOMID 4 PA; MO toposar topotecan intravenous recon soln TORISEL 4 MO TREANDA RECON SOLN 100 TREANDA SOLUTION 45 /0.5 ML TRELSTAR DEPOT TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N TRELSTAR INTRAMUSCULA R SYRINGE /2 ML, 3.75 /2 ML TRELSTAR LA 4 tretinoin (chemotherapy) 4 MO 4 MO 4 4 MO 4 MO TREXALL 3 PA; MO TRISENOX 4 MO TYKERB 4 PA; MO; LA; QL (180 per 30 20

29 VECTIBIX SOLUTION 100 /5 ML (20 /ML) 4 PA; MO VELCADE 4 MO VIDAZA 4 MO vinblastine intravenous solution vincasar pfs intravenous solution 1 mg/ml vincristine intravenous solution 1 mg/ml vinorelbine intravenous solution 50 mg/5 ml 1 VOTRIENT 4 PA; MO; QL (120 per 30 XALKORI ORAL CAPSULE 200 XALKORI ORAL CAPSULE PA; MO 4 PA; MO; QL (60 per 30 XTANDI 4 PA; MO; QL (120 per 30 YERVOY SOLUTION 50 /10 ML (5 /ML) 4 MO ZALTRAP SOLUTION 100 /4 ML (25 /ML) 4 MO ZANOSAR ZELBORAF 4 PA; MO; QL (240 per 30 ZOLINZA 4 MO ZORTRESS ORAL TABLET 0.25 ZORTRESS ORAL TABLET 0.5, PA; MO 4 PA; MO ZYDELIG 4 PA; MO; QL (90 per 30 ZYKADIA 4 PA; MO; QL (150 per 30 ZYTIGA 4 PA; MO; QL (120 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 200, 400, 800 APTIOM ORAL TABLET 600 BANZEL ORAL SUSPENSION 4 MO 21

30 BANZEL ORAL TABLET 200 BANZEL ORAL TABLET 400 carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable 4 MO CARBATROL CELONTIN ORAL CAPSULE 300 CEREBYX INJECTION SOLUTION 500 PE/10 ML clonazepam 1 PA; MO DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES 3 DIASTAT 3 PA; MO DIASTAT ACUDIAL 3 PA; MO diazepam rectal 1 PA; MO DILANTIN 30 DILANTIN EXTENDED 100 DILANTIN INFATABS 50 DILANTIN /5 ML divalproex epitol EQUETRO ethosuximide felbamate FELBATOL fosphenytoin injection solution 100 mg pe/2 ml FYCOMPA gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12, 16 GABITRIL ORAL TABLET 2, 4 GRALISE 2 PA; MO 22

31 GRALISE 30-DAY STARTER PACK 2 PA; MO KEPPRA ORAL KEPPRA XR KLONOPIN 3 PA; MO LAMICTAL ODT LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25, 5 LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT LAMICTAL XR LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating LEVETIRACETAM IN NACL (ISO-OS) PIGGYBACK 1,000 /100 ML, 1,500 /100 ML LEVETIRACETAM IN NACL (ISO-OS) PIGGYBACK 500 /100 ML levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 2 LYRICA 2 PA; MO MYSOLINE NEURONTIN 3 PA; MO ONFI ORAL SUSPENSION ONFI ORAL TABLET 10, 20 2 PA; MO 2 PA; MO 23

32 oxcarbazepine OXTELLAR XR PEGANONE phenobarbital oral elixir phenobarbital oral tablet 100 mg phenobarbital oral tablet 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg 1 PHENYTEK phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution POTIGA primidone QUDEXY XR ORAL CAPSULE,SPRINK LE,ER 24HR 100, 200, 25, 50 QUDEXY XR ORAL CAPSULE,SPRINK LE,ER 24HR PA; MO 4 PA; MO SABRIL 4 MO; LA TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 200, 400 tiagabine TOPAMAX 3 PA; MO topiramate oral capsule, sprinkle TOPIRAMATE ORAL CAPSULE,SPRINK LE,ER 24HR topiramate oral tablet 1 PA; MO 3 PA; MO 1 PA; MO TRILEPTAL TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 100, 25, 50 TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE 24HR PA; MO 4 PA; MO 24

33 valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml VIMPAT VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 2 ZARONTIN ZONEGRAN ORAL CAPSULE 100, 25 3 PA; MO zonisamide 1 PA; MO ANTIPARKINSONISM AGENTS APOKYN 4 MO; LA AZILECT benztropine bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone COGENTIN COMTAN DUOPA 3 PA; MO ELDEPRYL entacapone LODOSYN MIRAPEX MIRAPEX ER NEUPRO pramipexole oral tablet pramipexole oral tablet extended release 24 hr 0.75 mg, 1.5 mg REQUIP REQUIP XL ropinirole RYTARY selegiline hcl SINEMET SINEMET CR STALEVO 100 STALEVO 125 STALEVO 150 STALEVO 200 STALEVO 50 STALEVO 75 TASMAR ORAL TABLET MO tolcapone ZELAPAR MIGRAINE / CLUSTER HEADACHE THERAPY ALSUMA ; QL (16 per 28 25

34 AMERGE ; QL (18 per 28 AXERT ORAL TABLET 12.5 AXERT ORAL TABLET 6.25 ; QL (24 per 28 ; QL (18 per 28 CAFERGOT dihydroergotamine injection dihydroergotamine nasal ERGOMAR ; QL (8 per 28 FROVA ; QL (27 per 28 IMITREX NASAL SPRAY,NON- AEROSOL 20 /ACTUATION IMITREX NASAL SPRAY,NON- AEROSOL 5 /ACTUATION ; QL (18 per 28 ; QL (36 per 28 IMITREX ORAL ; QL (18 per 28 IMITREX STATDOSE KIT REFILL IMITREX SUBCUTANEOUS ; QL (16 per 28 ; QL (16 per 28 MAXALT ; QL (36 per 28 MAXALT-MLT ; QL (36 per 28 migergot MIGRANAL ; QL (8 per 28 naratriptan ; QL (18 per 28 RELPAX ; QL (18 per 28 rizatriptan ; QL (36 per 28 sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution SUMAVEL DOSEPRO ; QL (18 per 28 ; QL (36 per 28 ; QL (18 per 28 ; QL (16 per 28 ; QL (16 per 28 ; QL (9 per 28 TREXIMET ; QL (18 per 28 zolmitriptan ; QL (18 per 28 ZOMIG ; QL (18 per 28 ZOMIG ZMT ; QL (18 per 28 MISCELLANEOUS NEUROLOGICAL THERAPY 26

35 AMPYRA 4 PA; MO; LA ARICEPT AUBAGIO 4 PA; MO COPAXONE SUBCUTANEOUS SYRINGE 20 /ML COPAXONE SUBCUTANEOUS SYRINGE 40 /ML 4 PA; MO; QL (30 per 30 4 PA; MO; QL (12 per 28 donepezil EXELON ORAL CAPSULE EXELON TRANSDERMAL galantamine GILENYA 4 PA; MO glatopa 1 PA; MO; QL (30 per 30 HORIZANT 3 PA; MO NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET NAMENDA TITRATION PAK 2 PA; MO 3 PA; MO 3 PA; MO NAMENDA XR 2 PA; MO NUEDEXTA RAZADYNE ER RAZADYNE ORAL TABLET rivastigmine tartrate TECFIDERA 4 PA; MO TYSABRI 4 PA; MO; LA XENAZINE 4 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen DANTRIUM ORAL CAPSULE 25, 50 dantrolene GABLOFEN INTRATHECAL SOLUTION 10,000 MCG/20ML (500 MCG/ML), 40,000 MCG/20ML (2,000 MCG/ML) GABLOFEN INTRATHECAL SYRINGE 50 MCG/ML (1 ML) LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP MESTINON ORAL TABLET 3 PA; MO 3 PA; MO 2 PA; MO 2 PA 27

36 MESTINON TIMESPAN pyridostigmine bromide oral tablet tizanidine ZANAFLEX NARCOTIC ANALGESICS ABSTRAL SUBLINGUAL TABLET 100 MCG, 200 MCG, 300 MCG ABSTRAL SUBLINGUAL TABLET 400 MCG ABSTRAL SUBLINGUAL TABLET 600 MCG ABSTRAL SUBLINGUAL TABLET 800 MCG acetaminophencodeine oral solution 300 mg-30 mg /12.5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg 4 PA; MO; QL (120 per 30 4 PA; MO; QL (116 per 30 4 PA; MO; QL (77 per 30 4 PA; MO; QL (58 per 30 1 QL (4500 per 30 ; QL (360 ; QL (180 ACTIQ 4 PA; MO; QL (120 per 30 BUPRENEX ; QL (267 buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg 1 QL (267 per 30 ; QL (300 ; QL (75 BUTRANS ; QL (4 per 28 CAPITAL WITH CODEINE codeine sulfate oral tablet DILAUDID (PF) INJECTION SOLUTION 2 /ML DILAUDID (PF) INJECTION SOLUTION 4 /ML DILAUDID ORAL LIQUID DILAUDID ORAL TABLET DILAUDID-HP (PF) INJECTION SOLUTION DOLOPHINE ORAL TABLET 10 ; QL (4500 ; QL (180 ; QL (150 ; QL (75 ; QL (1500 ; QL (180 3 QL (30 per 30 ; QL (120 28

37 DOLOPHINE ORAL TABLET 5 DURAGESIC TRANSDERMAL PATCH 72 HOUR 100 MCG/HR DURAGESIC TRANSDERMAL PATCH 72 HOUR 12 MCG/HR, 25 MCG/HR, 50 MCG/HR DURAGESIC TRANSDERMAL PATCH 72 HOUR 75 MCG/HR duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL , EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 50-2, ; QL (240 4 MO; QL (9 per 30 ; QL (10 4 MO; QL (10 ; QL ( QL (2000 per 30 4 MO; QL (60 ; QL (90 4 MO; QL (90 EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL endocet oral tablet mg, mg, mg 4 MO; QL (75 ; QL (360 endodan ; QL (360 EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 12, 8 EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 16 EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 32 fentanyl citrate buccal lozenge on a handle 1,200 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg ; QL (60 4 MO; QL (60 4 MO; QL (47 1 PA; MO; QL (39 per 30 1 PA; MO; QL (29 per 30 1 PA; MO; QL (120 per 30 1 PA; MO; QL (116 per 30 29

38 fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR FENTANYL TRANSDERMAL PATCH 72 HOUR 87.5 MCG/HOUR FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 200 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 400 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 600 MCG 1 PA; MO; QL (77 per 30 1 PA; MO; QL (58 per 30 ; QL (9 per 30 ; QL (10 ; QL (10 4 MO; QL (10 4 PA; MO; QL (120 per 30 4 PA; MO; QL (116 per 30 4 PA; MO; QL (77 per 30 FENTORA BUCCAL TABLET, EFFERVESCENT 800 MCG 4 PA; MO; QL (58 per 30 HYCET ; QL (5550 hydrocodoneacetaminophen oral solution mg/15 ml hydrocodoneacetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodoneibuprofen oral tablet mg hydromorphone (pf) injection solution 10 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 8 mg hydromorphone oral tablet extended release 24 hr 32 mg ; QL (5550 ; QL (360 ; QL (50 ; QL (120 ; QL (1500 ; QL (180 ; QL (60 ; QL (47 30

39 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 100, 80 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 120 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 20, 30, 40, 60 IBUDONE ORAL TABLET MO; QL (60 4 MO; QL (50 ; QL (60 ; QL (50 ibuprofen-oxycodone ; QL (28 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 10, 20, 30, 40, 50, 60 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 100 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 200 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 80 ; QL (90 ; QL (60 4 MO; QL (30 ; QL (75 LAZANDA 4 PA; MO; QL (23 per 30 levorphanol tartrate ; QL (120 lorcet (hydrocodone) ; QL (360 lorcet hd ; QL (360 lorcet plus oral tablet mg ; QL (360 lortab ; QL (360 lortab ; QL (360 lortab ; QL (360 methadone injection 1 QL (160 per 30 methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg morphine concentrate oral solution MORPHINE SYRINGE 10 /ML ; QL (600 ; QL (1200 ; QL (120 ; QL (240 ; QL (300 3 QL (200 per 30 31

40 morphine intravenous syringe 2 mg/ml morphine intravenous syringe 4 mg/ml MORPHINE SYRINGE 8 /ML morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.relea se pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.relea se pellets 100 mg morphine oral capsule,extend.relea se pellets 80 mg morphine oral solution 1 QL (1000 per 30 1 QL (500 per 30 3 QL (250 per 30 ; QL (50 ; QL (60 ; QL (90 ; QL (60 ; QL (75 ; QL (900 morphine oral tablet ; QL (180 morphine oral tablet extended release 100 mg ; QL (60 morphine oral tablet extended release 15 mg, 30 mg morphine oral tablet extended release 200 mg morphine oral tablet extended release 60 mg MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MS CONTIN ORAL TABLET EXTENDED RELEASE 15, 30 MS CONTIN ORAL TABLET EXTENDED RELEASE 200 MS CONTIN ORAL TABLET EXTENDED RELEASE 60 ; QL (120 ; QL (30 ; QL (100 ; QL (60 ; QL (120 ; QL (30 ; QL (100 NORCO ; QL (360 OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10, 15, 20, 5, 7.5 OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 30 ; QL (90 ; QL (67 32

41 OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 OPANA ORAL TABLET 10 OPANA ORAL TABLET 5 oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 20 mg oxycodone oral tablet 30 mg oxycodone oral tablet 5 mg OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10, 20, 40 OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 oxycodoneacetaminophen oral tablet mg, mg, mg, mg 4 MO; QL (50 ; QL (200 ; QL (180 ; QL (360 ; QL (180 ; QL (1200 ; QL (180 ; QL (134 ; QL (360 ; QL (90 4 MO; QL (60 ; QL (360 oxycodone-aspirin ; QL (360 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10, 15, 20, 30, 40 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 60 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 30 mg oxymorphone oral tablet extended release 12 hr 40 mg ; QL (90 ; QL (67 4 MO; QL (50 ; QL (200 ; QL (180 ; QL (90 ; QL (67 ; QL (50 33

42 PERCOCET ORAL TABLET , , 5-325, ; QL (360 PERCODAN ; QL (360 PRIMLEV ; QL (360 reprexain ; QL (50 ROXICET ORAL SOLUTION ROXICODONE ORAL TABLET 15 ROXICODONE ORAL TABLET 30 ROXICODONE ORAL TABLET 5 SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 200 MCG/SPRAY SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 400 MCG/SPRAY SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 600 MCG/SPRAY ; QL (800 ; QL (180 ; QL (134 ; QL (360 4 PA; MO; LA; QL (120 per 30 4 PA; MO; LA; QL (84 per 30 4 PA; MO; LA; QL (56 per 30 SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 800 MCG/SPRAY 4 PA; MO; LA; QL (42 per 30 SYNALGOS-DC ; QL (300 TREZIX ORAL CAPSULE TYLENOL- CODEINE #3 TYLENOL- CODEINE #4 vicodin es oral tablet mg vicodin hp oral tablet mg vicodin oral tablet mg ; QL (300 ; QL (360 ; QL (180 ; QL (360 ; QL (360 ; QL (360 VICOPROFEN ; QL (50 XARTEMIS XR ; QL (120 XODOL 10/300 ; QL (360 XODOL 5/300 ; QL (360 XODOL 7.5/300 ; QL (360 zamicet 1 QL (5550 per 30 ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR ; QL (90 34

43 NON-NARCOTIC ANALGESICS ANAPROX ANAPROX DS ARTHROTEC 50 ARTHROTEC 75 BUNAVAIL BUCCAL FILM BUNAVAIL BUCCAL FILM , buprenorphinenaloxone sublingual tablet mg buprenorphinenaloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal 3 PA; MO; QL (30 per 30 3 PA; MO; QL (60 per 30 1 PA; MO; QL (360 per 30 1 PA; MO; QL (90 per 30 ; QL (720 ; QL (360 ; QL (5 per 28 CAMBIA 3 ST; MO; QL (9 CELEBREX celecoxib CONZIP ; QL (30 DAYPRO diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenacmisoprostol diflunisal DUEXIS 3 ST; MO EC-NAPROSYN etodolac EVZIO ; QL (0.8 FELDENE fenoprofen oral tablet FLECTOR 3 PA; MO; QL (60 per 30 flurbiprofen ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg meclofenamate oral mefenamic acid meloxicam oral suspension 35

44 meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg MOBIC ORAL SUSPENSION MOBIC ORAL TABLET 15 MOBIC ORAL TABLET 7.5 ; QL (30 ; QL (30 nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone injection syringe 1 mg/ml ; QL (200 ; QL (100 naltrexone oral NAPRELAN CR 3 ST; MO NAPROSYN ORAL TABLET naproxen naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr NUCYNTA ER ; QL (60 NUCYNTA ORAL TABLET 100 NUCYNTA ORAL TABLET 50 ; QL (181 ; QL (362 NUCYNTA ORAL TABLET 75 ; QL (242 oxaprozin PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 3 ST; MO piroxicam PONSTEL SPRIX 3 ST; MO SUBOXONE SUBLINGUAL FILM 12-3 SUBOXONE SUBLINGUAL FILM SUBOXONE SUBLINGUAL FILM 4-1, PA; MO; QL (60 per 30 2 PA; MO; QL (360 per 30 2 PA; MO; QL (90 per 30 sulindac oral TIVORBEX 3 ST; MO; QL (90 per 30 tolmetin oral capsule tolmetin oral tablet 600 mg TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR QL (30 per 30 36

45 TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR , QL (30 per 30 tramadol oral tablet ; QL (240 tramadol oral tablet extended release 24 hr 100 mg, 200 mg tramadol oral tablet, er multiphase 24 hr 300 mg tramadolacetaminophen ; QL (30 ; QL (30 ; QL (240 ULTRACET ; QL (240 ULTRAM ; QL (240 ULTRAM ER ; QL (30 VIMOVO 3 ST; MO VIVITROL 4 MO VOLTAREN GEL TOPICAL GEL 1 % VOLTAREN-XR ZIPSOR 3 ST; MO ZORVOLEX 3 ST; MO ZUBSOLV SUBLINGUAL TABLET , PA; MO; QL (90 per 30 ZUBSOLV SUBLINGUAL TABLET PA; QL (60 PSYCHOTHERAPEUTIC DRUGS ABILIFY DISCMELT ORAL TABLET,DISINTE GRATING 10 ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING ABILIFY ORAL TABLET 10 ABILIFY ORAL TABLET 15 ABILIFY ORAL TABLET 2 ABILIFY ORAL TABLET 20 ABILIFY ORAL TABLET 30 ABILIFY ORAL TABLET 5 ; QL (90 4 MO 4 ; QL (90 ; QL (60 ; QL (450 4 MO; QL (60 4 MO; QL (30 ; QL (180 37

46 ADDERALL ORAL TABLET 20, 5, 7.5 ADDERALL XR AMBIEN 3 ST; MO; QL (30 per 30 AMBIEN CR 3 ST; MO; QL (30 per 30 amitriptyline 1 PA; MO amoxapine amphetamine salt combo ANAFRANIL 3 PA; MO APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 348 APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 522 APTENSIO XR 3 aripiprazole oral tablet 10 mg aripiprazole oral tablet 15 mg, 20 mg ; QL (90 ; QL (60 ; QL (30 ; QL (90 ; QL (60 aripiprazole oral tablet 2 mg aripiprazole oral tablet 30 mg aripiprazole oral tablet 5 mg ; QL (450 ; QL (30 ; QL (180 ATIVAN ORAL 3 PA; MO BELSOMRA 3 ST; MO; QL (30 per 30 BRINTELLIX ORAL TABLET 10 BRINTELLIX ORAL TABLET 20 BRINTELLIX ORAL TABLET 5 ; QL (60 ; QL (30 ; QL (120 BRISDELLE ; QL (30 bupropion hcl oral tablet bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 150 mg bupropion hcl oral tablet extended release 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg ; QL (120 ; QL (90 ; QL (60 ; QL (90 38

47 bupropion hcl oral tablet extended release 24 hr 300 mg ; QL (60 buspirone CELEXA ORAL TABLET 10 CELEXA ORAL TABLET 20 CELEXA ORAL TABLET 40 ; QL (120 ; QL (60 ; QL (30 chlorpromazine citalopram oral solution citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg ; QL (120 ; QL (60 ; QL (30 clomipramine 1 PA; MO clonidine hcl oral tablet extended release 12 hr clorazepate dipotassium clozapine oral tablet 100 mg, 25 mg, 50 mg clozapine oral tablet 200 mg clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg 1 PA; MO 1 1 CLOZAPINE ORAL TABLET,DISINTE GRATING 150, 200 CLOZARIL CONCERTA CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20 CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) ST; MO; QL (180 per 30 3 ST; MO; QL (120 per 30 3 ST; MO; QL (60 per 30 DAYTRANA desipramine oral DESOXYN DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24 HR 100 DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24 HR 50 3 ST; MO; QL (120 per 30 3 ST; MO; QL (240 per 30

48 dexedrine DEXEDRINE SPANSULE dexmethylphenidate dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamineamphetamine oral capsule,extended release 24hr diazepam intensol 1 PA; MO diazepam oral solution 5 mg/5 ml 1 PA; MO diazepam oral tablet 1 PA; MO doxepin oral 1 PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 150 ; QL (180 ; QL (120 ; QL (90 ; QL (60 3 ST; MO; QL (60 per 30 EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 37.5 EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 75 3 ST; MO; QL (180 per 30 3 ST; MO; QL (90 per 30 EMSAM 4 MO ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ; QL (60 ; QL (30 ; QL (120 eszopiclone 1 ST; MO; QL (30 per 30 EVEKEO 3 PA; MO FANAPT ORAL TABLET 1 FANAPT ORAL TABLET 10, 8 FANAPT ORAL TABLET 12 FANAPT ORAL TABLET 2 FANAPT ORAL TABLET 4 ; QL (720 ; QL (90 ; QL (60 ; QL (360 ; QL (180 40

49 FANAPT ORAL TABLET 6 FANAPT ORAL TABLETS,DOSE PACK FAZACLO 3 FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 120 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution ; QL (120 ; QL (8 per 28 2 ST; MO; QL (28 per 28 2 ST; MO; QL (30 per 30 2 ST; MO; QL (180 per 30 2 ST; MO; QL (90 per 30 2 ST; MO; QL (45 per 30 ; QL (240 ; QL (60 ; QL (4 per 28 fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg FLUOXETINE ORAL TABLET 60 fluphenazine decanoate ; QL (240 fluphenazine hcl fluvoxamine oral capsule,extended release 24hr 100 mg fluvoxamine oral capsule,extended release 24hr 150 mg fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg ; QL (90 ; QL (60 ; QL (90 ; QL (360 ; QL (180 FOCALIN FOCALIN XR FORFIVO XL ; QL (30 GEODON INTRAMUSCULA R GEODON ORAL CAPSULE 20 GEODON ORAL CAPSULE 40 GEODON ORAL CAPSULE 60 ; QL (240 ; QL (120 ; QL (80 41

50 GEODON ORAL CAPSULE 80 ; QL (60 guanidine HALDOL HALDOL DECANOATE haloperidol haloperidol decanoate haloperidol lactate HETLIOZ 4 PA; MO imipramine hcl 1 PA; MO imipramine pamoate 1 PA; MO INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 ; QL (240 ; QL (120 ; QL (60 ; QL (41 INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 /0.75 ML, 156 /ML, 234 /1.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 /0.25 ML, 78 /0.5 ML 4 MO IRENKA ; QL (90 KAPVAY KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 LATUDA ORAL TABLET 120 LATUDA ORAL TABLET 20 LATUDA ORAL TABLET 40 LATUDA ORAL TABLET 60, 80 LEXAPRO ORAL SOLUTION 3 ST; MO; QL (120 per 30 3 ST; MO; QL (240 per 30 4 MO; QL (30 ; QL (240 ; QL (120 ; QL (60 42

51 LEXAPRO ORAL TABLET 10 LEXAPRO ORAL TABLET 20 LEXAPRO ORAL TABLET 5 ; QL (60 ; QL (30 ; QL (120 lithium carbonate lithium citrate oral solution 8 meq/5 ml LITHOBID lorazepam intensol 1 PA; MO lorazepam oral tablet 1 PA; MO loxapine succinate LUNESTA 3 ST; MO; QL (30 per 30 maprotiline MARPLAN METADATE CD metadate er methamphetamine METHYLIN ORAL SOLUTION METHYLIN ORAL TABLET,CHEWAB LE methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg methylphenidate oral capsule,er biphasic methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr methylphenidate oral tablet,chewable mirtazapine modafinil 1 PA; MO NARDIL nefazodone NORPRAMIN nortriptyline NUVIGIL 3 PA; MO olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg, 20 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 10 mg ; QL (60 ; QL (30 ; QL (240 ; QL (120 ; QL (81 ; QL (60 43

52 olanzapine oral tablet,disintegrating 15 mg, 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapinefluoxetine ; QL (30 ; QL (120 ORAP oxazepam 1 PA; MO PAMELOR PARNATE paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 ; QL (180 ; QL (90 ; QL (60 ; QL (45 ; QL (180 ; QL (90 ; QL (60 ; QL (180 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 25 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 37.5 PAXIL ORAL SUSPENSION PAXIL ORAL TABLET 10 PAXIL ORAL TABLET 20 PAXIL ORAL TABLET 30 PAXIL ORAL TABLET 40 ; QL (90 ; QL (60 ; QL (180 ; QL (90 ; QL (60 ; QL (45 perphenazine PEXEVA ORAL TABLET 10 PEXEVA ORAL TABLET 20 PEXEVA ORAL TABLET 30 PEXEVA ORAL TABLET 40 ; QL (180 ; QL (90 ; QL (60 ; QL (45 phenelzine PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR ST; MO; QL (120 per 30 44

53 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 2 ST; MO; QL (480 per 30 2 ST; MO; QL (240 per 30 procentra protriptyline PROVIGIL 3 PA; MO PROZAC ORAL CAPSULE 10 PROZAC ORAL CAPSULE 20 PROZAC ORAL CAPSULE 40 ; QL (240 ; QL (60 PROZAC WEEKLY ; QL (4 per 28 quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg ; QL (240 ; QL (120 ; QL (902 ; QL (81 ; QL (60 ; QL (480 QUILLIVANT XR REMERON REMERON SOLTAB RESTORIL 3 PA; MO RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 12.5 /2 ML, 25 /2 ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 /2 ML, 50 /2 ML RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 0.5 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 1 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 2 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 3 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 4 RISPERDAL ORAL SOLUTION 4 MO ; QL (960 ; QL (480 ; QL (240 ; QL (161 ; QL (120 ; QL (480 45

54 RISPERDAL ORAL TABLET 0.25 RISPERDAL ORAL TABLET 0.5 RISPERDAL ORAL TABLET 1 RISPERDAL ORAL TABLET 2 RISPERDAL ORAL TABLET 3 RISPERDAL ORAL TABLET 4 risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 1 mg ; QL (1920 ; QL (960 ; QL (480 ; QL (240 ; QL (161 ; QL (120 ; QL (480 ; QL (1920 ; QL (960 ; QL (480 ; QL (240 ; QL (161 ; QL (120 ; QL (1920 ; QL (960 ; QL (480 risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ; QL (240 ; QL (161 ; QL (120 RITALIN RITALIN LA ROZEREM ; QL (30 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 SARAFEM ORAL TABLET 10, 20 SEROQUEL ORAL TABLET 100 SEROQUEL ORAL TABLET 200 SEROQUEL ORAL TABLET 25 SEROQUEL ORAL TABLET 300 ; QL (60 ; QL (240 ; QL (120 ; QL (240 ; QL (120 ; QL (902 ; QL (81 46

55 SEROQUEL ORAL TABLET 400 SEROQUEL ORAL TABLET 50 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 sertraline oral concentrate sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg ; QL (60 ; QL (480 ; QL (161 ; QL (120 ; QL (81 ; QL (60 ; QL (480 ; QL (60 ; QL (240 ; QL (120 SILENOR ; QL (30 SONATA ORAL CAPSULE 10 SONATA ORAL CAPSULE 5 3 ST; MO; QL (60 per 30 3 ST; MO; QL (30 per 30 STRATTERA SURMONTIL 3 PA; MO SYMBYAX temazepam 1 PA; MO thioridazine thiothixene TOFRANIL 3 PA; MO TOFRANIL-PM 3 PA; MO TRANXENE T- TAB ORAL TABLET 3.75, PA; MO tranylcypromine trazodone trifluoperazine VALIUM 3 PA; MO venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg ; QL (60 ; QL (180 ; QL (90 47

56 venlafaxine oral tablet 100 mg, 75 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 150 VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 37.5 VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 75 ; QL (90 ; QL (270 ; QL (180 ; QL (150 ; QL (60 ; QL (30 ; QL (180 ; QL (90 VERSACLOZ 4 LA VIIBRYD ORAL TABLET 10 VIIBRYD ORAL TABLET 20 VIIBRYD ORAL TABLET 40 ; QL (120 ; QL (60 ; QL (30 VIIBRYD ORAL TABLETS,DOSE PACK 10 (7)- 20 (7)-40 (16) ; QL (30 VYVANSE WELLBUTRIN WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 100 WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 150 WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 200 WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 300 ; QL (120 ; QL (90 ; QL (60 ; QL (90 ; QL (60 XYREM 4 MO; LA zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg 1 ST; MO; QL (60 per 30 1 ST; MO; QL (30 per 30 48

57 zenzedi oral tablet 10 mg, 5 mg ZENZEDI ORAL TABLET 15, 2.5, 20, 30, 7.5 ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg ziprasidone hcl oral capsule 80 mg ZOLOFT ORAL CONCENTRATE ZOLOFT ORAL TABLET 100 ZOLOFT ORAL TABLET 25 ZOLOFT ORAL TABLET 50 ; QL (240 ; QL (120 ; QL (80 ; QL (60 ; QL (60 ; QL (240 ; QL (120 zolpidem 1 ST; MO; QL (30 per 30 ZOLPIMIST 3 ST; QL (8 per 30 ZYPREXA INTRAMUSCULA R ZYPREXA ORAL TABLET 10 ZYPREXA ORAL TABLET 15, 20 ; QL (60 4 MO; QL (30 ZYPREXA ORAL TABLET 2.5 ZYPREXA ORAL TABLET 5 ZYPREXA ORAL TABLET 7.5 ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 210 ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 10 ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 15, 20 ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 5 ; QL (240 ; QL (120 ; QL (81 4 LA ; QL (60 4 MO; QL (30 ; QL (120 CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution amiodarone oral tablet 200 mg, 400 mg 1 PA; MO BETAPACE AF flecainide 49

58 mexiletine MULTAQ NEXTERONE 3 PA pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml propafenone quinidine gluconate quinidine sulfate oral tablet RYTHMOL ORAL TABLET 150, RYTHMOL SR sorine oral tablet 120 mg, 160 mg, 80 mg sorine oral tablet 240 mg sotalol af oral tablet 120 mg sotalol oral tablet 160 mg, 240 mg, 80 mg SOTYLIZE 2 1 TIKOSYN ANTIHYPERTENSIVE THERAPY ACCUPRIL ACCURETIC acebutolol oral ADALAT CC afeditab cr ALDACTAZIDE ALDACTONE ALTACE amiloride oral amlodipine ATACAND 3 ST; MO ATACAND HCT 3 ST; MO atenolol AVALIDE 3 ST; MO AVAPRO 3 ST; MO AZOR 2 ST; MO benazepril amiloridehydrochlorothiazide amlodipinebenazepril amlodipinevalsartan amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide BENICAR 2 ST; MO BENICAR HCT 2 ST; MO betaxolol oral 50

59 BIDIL bisoprolol fumarate bumetanide BYSTOLIC CALAN CALAN SR candesartan captopril bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide CARDENE IV IN SODIUM CHLORIDE CARDIZEM CD CARDIZEM LA CARDIZEM ORAL TABLET 120, 30, 60 CARDURA ORAL TABLET 1, 2, 4 CARDURA ORAL TABLET ST; MO; QL (30 per 30 3 ST; MO; QL (60 per 30 CARDURA XL 3 ST; MO; QL (30 per 30 cartia xt carvedilol CATAPRES CATAPRES-TTS-1 ; QL (4 per 28 CATAPRES-TTS-2 ; QL (4 per 28 CATAPRES-TTS-3 ; QL (4 per 28 chlorothiazide chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg clonidine ; QL (4 per 28 clonidine hcl oral tablet clorpres oral tablet mg, mg CLORPRES ORAL TABLET COREG COREG CR CORGARD CORZIDE COZAAR 3 ST; MO DEMADEX DEMSER diltiazem hcl intravenous 1 51

60 diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral tablet dilt-xr DIOVAN 3 ST; MO DIOVAN HCT 3 ST; MO DIURIL DIURIL IV 4 doxazosin oral tablet 1 mg, 2 mg, 4 mg doxazosin oral tablet 8 mg ; QL (30 ; QL (60 DUTOPROL DYAZIDE EDARBI 3 ST; MO EDARBYCLOR 3 ST; MO EDECRIN enalapril maleate EPANED 4 MO eplerenone eprosartan EXFORGE 3 ST; MO EXFORGE HCT 3 ST; MO felodipine fosinopril furosemide injection furosemide oral solution 10 mg/ml, 40 mg/5 ml furosemide oral tablet hydralazine hydrochlorothiazide HYZAAR 3 ST; MO indapamide INDERAL LA INNOPRAN XL INSPRA irbesartan isradipine labetalol intravenous solution labetalol oral LASIX lisinopril enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide lisinoprilhydrochlorothiazide 52

61 LOPRESSOR HCT ORAL TABLET LOPRESSOR LOPRESSOR ORAL TABLET 100 losartan losartanhydrochlorothiazide LOTENSIN ORAL TABLET 20, 40 LOTREL matzim la MAVIK MAXZIDE MAXZIDE-25 methyclothiazide methyldopa metolazone metoprolol succinate metoprolol tartrate intravenous solution metoprolol tartrate oral MICARDIS 3 ST; MO MICARDIS HCT 3 ST; MO MICROZIDE MINIPRESS minoxidil oral moexipril nadolol metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide nadololbendroflumethiazide nicardipine nifedical xl nifedipine oral tablet extended release 24hr nimodipine nisoldipine NORVASC ORENITRAM ORAL TABLET EXTENDED RELEASE ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25, 1, 2.5 perindopril erbumine 3 PA; MO 4 PA; MO pindolol prazosin oral PRINIVIL ORAL TABLET 10, 20, 5 PROCARDIA XL 53

62 propranolol intravenous propranolol oral 1 quinapril ramipril REMODULIN 4 PA; MO; LA SECTRAL spironolactone SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17, 34, 8.5 TARKA taztia xt TEKAMLO TEKTURNA TEKTURNA HCT telmisartan TENORETIC 100 TENORETIC 50 TENORMIN terazosin oral capsule 1 mg, 2 mg, 5 mg terazosin oral capsule 10 mg ; QL (30 ; QL (60 TEVETEN HCT 3 ST; MO TEVETEN ORAL TABLET ST; MO TIAZAC timolol maleate oral TOPROL XL torsemide oral trandolapril TRIBENZOR 2 ST; MO TWYNSTA 3 ST; MO valsartan propranololhydrochlorothiazid quinaprilhydrochlorothiazide spironolactonhydrochlorothiaz telmisartanamlodipine telmisartanhydrochlorothiazid trandolaprilverapamil triamterenehydrochlorothiazid valsartanhydrochlorothiazide VASERETIC VASOTEC verapamil intravenous solution verapamil oral VERELAN VERELAN PM ZEBETA 54

63 ZESTORETIC ZESTRIL ZIAC CARDIAC GLYCOSIDES digitek digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN ORAL TABLET 125 MCG, 250 MCG LANOXIN ORAL TABLET MCG, 62.5 MCG COAGULATION THERAPY AGGRENOX ARGATROBAN 4 MO ARGATROBAN IN 0.9 % SOD CHLOR SOLUTION ARIXTRA SUBCUTANEOUS SYRINGE 10 /0.8 ML, 5 /0.4 ML, 7.5 /0.6 ML ARIXTRA SUBCUTANEOUS SYRINGE 2.5 /0.5 ML 4 4 MO BRILINTA cilostazol clopidogrel COUMADIN ORAL CYKLOKAPRON dipyridamole oral EFFIENT ELIQUIS enoxaparin fondaparinux FRAGMIN SUBCUTANEOUS SOLUTION FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI- XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML, 7,500 ANTI-XA UNIT/0.3 ML FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI- XA UNIT/0.2 ML heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml) 4 MO 4 MO 1 55

64 heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) heparin (porcine) injection solution jantoven LOVENOX pentoxifylline PERSANTINE PLAVIX PLETAL PRADAXA PROMACTA 4 PA; MO; LA SAVAYSA ticlopidine tranexamic acid intravenous warfarin XARELTO ZONTIVITY LIPID/CHOLESTEROL LOWERING AGENTS ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-20, ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-40, ; QL (60 ; QL (30 ALTOPREV ; QL (30 amlodipineatorvastatin ANTARA ORAL CAPSULE 30, 90 ; QL (30 atorvastatin ; QL (30 CADUET ; QL (30 cholestyramine light oral powder in packet COLESTID ORAL GRANULES COLESTID ORAL TABLET colestipol oral granules colestipol oral tablet CRESTOR ; QL (30 fenofibrate micronized fenofibrate nanocrystallized FENOFIBRATE ORAL CAPSULE fenofibrate oral tablet 160 mg, 54 mg fenofibric acid (choline) FENOGLIDE 56

65 FIBRICOR fluvastatin oral capsule 20 mg fluvastatin oral capsule 40 mg ; QL (30 ; QL (60 gemfibrozil oral JUXTAPID 4 MO; LA KYNAMRO 4 MO; LA LESCOL ORAL CAPSULE 20 LESCOL ORAL CAPSULE 40 ; QL (30 ; QL (60 LESCOL XL ; QL (30 LIPITOR ; QL (30 LIPOFEN LIPTRUZET ; QL (30 LIVALO ; QL (30 LOFIBRA LOPID lovastatin oral tablet 10 mg lovastatin oral tablet 20 mg, 40 mg ; QL (30 ; QL (60 LOVAZA niacin oral tablet extended release 24 hr NIACOR NIASPAN EXTENDED- RELEASE omega-3 acid ethyl esters PRAVACHOL ; QL (30 pravastatin ; QL (30 prevalite oral powder QUESTRAN ORAL POWDER IN PACKET SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-20, SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-40, , ; QL (60 ; QL (30 simvastatin ; QL (30 TRICOR TRIGLIDE ORAL TABLET 160 TRILIPIX VASCEPA VYTORIN ; QL (30 VYTORIN ; QL (30 57

66 VYTORIN ; QL (30 VYTORIN ; QL (30 WELCHOL ZETIA ZOCOR ; QL (30 MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR 2 PA; MO RANEXA VECAMYL 4 NITRATES ISORDIL ISORDIL TITRADOSE ORAL TABLET 5 isosorbide dinitrate oral isosorbide mononitrate MINITRAN nitro-bid NITRO-DUR nitroglycerin intravenous nitroglycerin transdermal patch 24 hour 1 PA nitroglycerin translingual spray,non-aerosol NITROLINGUAL NITROMIST NITROSTAT DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin calcipotriene calcipotrienebetamethasone calcitriol topical COSENTYX PEN 4 PA; MO COSENTYX PEN (2 PENS) DOVONEX TOPICAL CREAM selenium sulfide topical suspension SORIATANE ORAL CAPSULE 10, 17.5, 25 4 PA; MO 4 MO SORILUX STELARA SUBCUTANEOUS SYRINGE 4 PA; MO TACLONEX VECTICAL BURN THERAPY 58

67 SILVADENE silver sulfadiazine ssd MISCELLANEOUS DERMATOLOGICALS 8-MOP ALDARA 3 ST; MO ammonium lactate topical CARAC 4 MO CONDYLOX TOPICAL GEL diclofenac sodium topical gel EFUDEX TOPICAL CREAM 1 PA; MO 3 ST; MO ELIDEL 3 PA; MO FLUOROURACIL TOPICAL CREAM 0.5 % fluorouracil topical cream 5 % fluorouracil topical solution 4 ST; MO imiquimod methoxsalen rapid OXSORALEN ULTRA 4 MO PANRETIN 4 MO PICATO 4 ST; MO podofilox PROTOPIC 3 PA; MO prudoxin REGRANEX SOLARAZE 4 PA; MO tacrolimus topical 1 PA; MO UVADEX 3 VALCHLOR 4 MO VEREGEN ZONALON ZYCLARA 4 ST; MO THERAPY FOR ACNE ABSORICA ORAL CAPSULE 10, 20, 30, 40 ABSORICA ORAL CAPSULE 25, 35 ACANYA ACZONE adapalene topical cream adapalene topical gel 3 1 PA; MO 1 PA; MO amnesteem ATRALIN 3 PA; MO avita topical cream 1 PA; MO AVITA TOPICAL GEL 3 PA; MO AZELEX BENZACLIN BENZAMYCIN 59

68 claravis CLEOCIN T CLINDACIN PAC CLINDAGEL clindamycin phosphate topical clindamycin-benzoyl peroxide topical gel 1-5 % DIFFERIN TOPICAL CREAM DIFFERIN TOPICAL GEL DIFFERIN TOPICAL LOTION 3 PA; MO 3 PA; MO 3 PA; MO DUAC EPIDUO TOPICAL GEL WITH PUMP 3 PA; MO ery pads erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycinbenzoyl peroxide EVOCLIN FABIOR FINACEA TOPICAL GEL METROCREAM METROGEL TOPICAL GEL 1 % METROLOTION metronidazole topical cream metronidazole topical gel metronidazole topical lotion MIRVASO myorisan neuac NORITATE ONEXTON RETIN-A 3 PA; MO RETIN-A MICRO 3 PA; MO RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.08 % 3 PA; MO SOOLANTRA TAZORAC 2 PA; MO tretinoin microspheres topical gel with pump 1 PA; MO tretinoin topical 1 PA; MO TRETIN-X TOPICAL CREAM % 3 PA; MO VELTIN 3 PA; MO zenatane ZIANA 3 PA; MO TOPICAL ANESTHETICS EMLA 60

69 lidocaine (pf) injection solution 5 mg/ml (0.5 %) lidocaine hcl injection solution 20 mg/ml (2 %) lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl urethral lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine-prilocaine topical cream PA; MO LIDODERM 3 PA; MO XYLOCAINE INJECTION SOLUTION 20 /ML (2 %) XYLOCAINE MUCOUS MEMBRANE SOLUTION TOPICAL ANTIBACTERIALS 3 3 ALTABAX BACTROBAN CORTISPORIN TOPICAL gentamicin topical KLARON mupirocin mupirocin calcium NEO-SYNALAR sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM SULFAMYLON TOPICAL PACKET TOPICAL ANTIFUNGALS ciclopirox clotrimazole topical clotrimazolebetamethasone econazole topical ERTACZO EXELDERM EXTINA JUBLIA KERYDIN ketoconazole topical cream ketoconazole topical shampoo 61

70 LOPROX TOPICAL SHAMPOO LOTRISONE TOPICAL CREAM LUZU MENTAX NAFTIFINE 3 NAFTIN NIZORAL TOPICAL SHAMPOO nyamyc nystatin topical nystatintriamcinolone nystop OXISTAT TOPICAL ANTIVIRALS acyclovir topical DENAVIR XERESE ZOVIRAX TOPICAL TOPICAL CORTICOSTEROIDS ala-cort topical cream ALA-SCALP 3 ST; MO alclometasone amcinonide APEXICON 3 ST apexicon e betamethasone dipropionate betamethasone valerate betamethasone, augmented CAPEX 2 ST; MO clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution clobetasol topical spray,non-aerosol clobetasol-emollient topical cream CLOBEX 3 ST; MO clodan CLODERM 3 ST; MO CORDRAN TAPE LARGE ROLL cormax topical solution CUTIVATE TOPICAL LOTION DERMATOP TOPICAL CREAM 2 ST; MO 3 ST; MO 3 ST; MO 62

71 DESONATE 3 ST; MO desonide DESOWEN 3 ST; MO desoximetasone diflorasone DIPROLENE 3 ST; MO DIPROLENE AF 3 ST; MO ELOCON 3 ST; MO fluocinolone fluocinonide topical cream 0.1 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e fluticasone topical halobetasol propionate HALOG 3 ST; MO hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone butyr-emollient hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate KENALOG TOPICAL LOCOID TOPICAL CREAM LOCOID TOPICAL LOTION LOCOID TOPICAL OINTMENT LOCOID TOPICAL SOLUTION 3 ST; MO 3 ST; MO 2 ST; MO 3 ST; MO 3 ST; MO mometasone OLUX 3 ST; MO PANDEL 2 ST; MO prednicarbate SYNALAR CREAM KIT TEMOVATE TOPICAL CREAM TEMOVATE TOPICAL OINTMENT 3 ST; MO 3 ST; MO 3 ST; MO TOPICORT 3 ST; MO triamcinolone acetonide topical aerosol 63

72 triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % trianex triderm topical cream ULTRAVATE 3 ST; MO VANOS 3 ST; MO TOPICAL ENZYMES SANTYL TOPICAL SCABICIDES / PEDICULICIDES EURAX lindane malathion OVIDE permethrin topical cream SKLICE DIAGNOSTICS / MISCELLANEOUS AGENTS IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu PHYSIOLYTE 3 PHYSIOSOL IRRIGATION ringers irrigation MISCELLANEOUS AGENTS acamprosate ACTONEL ORAL TABLET ST; MO; QL (30 per 30 ADAGEN 4 MO AGRYLIN alendronate oral tablet 40 mg ; QL (30 anagrelide ANTABUSE ARALAST NP RECON SOLN MO; LA AURYXIA 4 MO CARBAGLU 4 MO; LA CARNITOR cevimeline CHEMET CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE 2 PA 3 PA 3 PA

73 d10 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 %- lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride disulfiram etidronate disodium EVOXAC EXJADE 4 MO; LA FERRIPROX 4 MO FOSRENOL ORAL POWDER IN PACKET 3 FOSRENOL ORAL TABLET,CHEWAB LE GLASSIA 4 MO; LA INCRELEX 4 MO; LA JADENU 4 MO KAYEXALATE kionex oral powder levocarnitine (with sugar) levocarnitine intravenous levocarnitine oral tablet LITHOSTAT midodrine NORTHERA 4 MO NUTRESTORE ORFADIN 4 LA pilocarpine hcl oral PROLASTIN-C 4 MO; LA RAVICTI 4 MO RECLAST 3 PA; MO RENAGEL RENVELA RILUTEK 4 MO riluzole risedronate oral tablet 30 mg ; QL (30 SALAGEN 65

74 sodium chloride 0.9 % intravenous parenteral solution sodium chloride irrigation sodium phenylbutyrate sodium polystyrene (sorb free) SYPRINE 4 MO THIOLA VELPHORO 4 MO water for irrigation, sterile 1 ZEMAIRA 4 MO; LA zoledronic acidmannitol-water intravenous solution SMOKING DETERRENTS 1 PA; MO buproban CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX NICOTROL NICOTROL NS ZYBAN EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTEPRO NASAL SPRAY,NON- AEROSOL ; QL (60 ATROVENT ; QL (30 azelastine nasal ; QL (60 BACTROBAN NASAL chlorhexidine gluconate mucous membrane ipratropium bromide nasal ; QL (30 olopatadine ; QL (30.5 PATANASE ; QL (30.5 periogard triamcinolone acetonide dental TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS acetasol hc acetic acid otic fluocinolone acetonide oil hydrocortisoneacetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRO HC 66

75 CIPRODEX COLY-MYCIN S CORTISPORIN OTIC SOLUTION CORTISPORIN-TC neomycinpolymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. 4 PA; MO a-hydrocort CORTEF cortisone DEPO-MEDROL INJECTION SUSPENSION 20 /ML DEPO-MEDROL INJECTION SUSPENSION 40 /ML, 80 /ML dexamethasone intensol dexamethasone oral elixir dexamethasone oral tablet dexamethasone sodium phosphate injection DEXPAK 13 DAY FLO-PRED 3 fludrocortisone hydrocortisone oral KENALOG INJECTION MEDROL 3 PA; MO MEDROL (PAK) methylprednisolone acetate methylprednisolone oral tablet methylprednisolone oral tablets,dose pack methylprednisolone sodium succ injection recon soln 125 mg, 40 mg MILLIPRED ORAL SOLUTION 1 PA; MO millipred oral tablet 1 PA; MO ORAPRED ODT 3 PA; MO prednisolone sodium phosphate oral solution 15 mg/5 ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating 1 PA; MO prednisone intensol 1 PA; MO prednisone oral solution prednisone oral tablet 1 PA; MO 67

76 RAYOS 3 PA; MO SOLU-CORTEF (PF) INJECTION RECON SOLN 100 /2 ML, 250 /2 ML SOLU-MEDROL (PF) INJECTION SOLU-MEDROL (PF) RECON SOLN 500 /4 ML SOLU-MEDROL RECON SOLN 2 GRAM veripred 20 1 ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg propylthiouracil TAPAZOLE DIABETES THERAPY acarbose oral tablet 100 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg ; QL (90 ; QL (360 ; QL (180 ACTOPLUS MET ; QL (90 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-1,000 ; QL (60 ; QL (30 ACTOS ; QL (30 AFREZZA INHALATION CARTRIDGE, W/INHALATION DEVICE 4 UNIT, 4 UNIT (30)/ 8 UNIT (60), 4 UNIT (60)/ 8 UNIT (30) ALCOHOL PADS AMARYL ORAL TABLET 1 AMARYL ORAL TABLET 2 AMARYL ORAL TABLET 4 ; QL (240 ; QL (120 ; QL (60 APIDRA 3 ST; MO APIDRA SOLOSTAR AVANDAMET ORAL TABLET 2-1,000 AVANDIA ORAL TABLET 2, 4 3 ST; MO ; LA; QL (60 per 30 ; LA; QL (60 per 30 68

77 AVANDIA ORAL TABLET 8 ; LA; QL (30 per 30 BYDUREON 2 PA; MO; QL (4 per 28 BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML 2 PA; MO; QL (2.4 per 30 2 PA; MO; QL (1.2 per 30 CYCLOSET ; QL (180 DUETACT ; QL (30 FARXIGA ORAL TABLET 10 FARXIGA ORAL TABLET 5 FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 1,000 FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 500 ; QL (30 ; QL (60 ; QL (75 ; QL (150 GAUZE PADS 2X2 glimepiride oral tablet 1 mg ; QL (240 glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) GLUCOPHAGE ORAL TABLET 1,000 GLUCOPHAGE ORAL TABLET 500 ; QL (120 ; QL (60 ; QL (120 ; QL (240 ; QL (60 ; QL (240 ; QL (120 ; QL (240 ; QL (120 ; QL (75 ; QL (150 69

78 GLUCOPHAGE ORAL TABLET 850 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 GLUCOTROL ORAL TABLET 10 GLUCOTROL ORAL TABLET 5 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 5 GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 ; QL (90 ; QL (120 ; QL (75 ; QL (120 ; QL (240 ; QL (60 ; QL (240 ; QL (120 ; QL (60 GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 500 GLYSET ORAL TABLET 100 GLYSET ORAL TABLET 25 GLYSET ORAL TABLET 50 ; QL (120 ; QL (90 ; QL (360 ; QL (180 GLYXAMBI 3 ST; MO; QL (30 per 30 HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG SUBCUTANEOUS CARTRIDGE HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) 2 70

79 HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 "CONCENTRATED " INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U-100 1/2 ML INVOKAMET ; QL (60 INVOKANA ; QL (30 JANUMET ; QL (60 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000, JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 ; QL (30 ; QL (60 JANUVIA ; QL (30 JARDIANCE ; QL (30 JENTADUETO 3 ST; MO; QL (60 per 30 KAZANO 3 ST; MO; QL (60 per 30 KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000, ; QL (60 ; QL (30 LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg ; QL (75 ; QL (150 ; QL (90 ; QL (120 71

80 metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg nateglinide oral tablet 120 mg nateglinide oral tablet 60 mg NEEDLES, INSULIN DISP.,SAFETY ; QL (75 ; QL (75 ; QL (90 ; QL (180 NESINA 3 ST; MO; QL (30 per 30 NOVOFINE 32 NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG 3 ST; MO NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL 3 ST; MO 3 ST; MO 3 ST; MO 3 ST; MO ONGLYZA ; QL (30 OSENI ; QL (30 pioglitazone ; QL (30 pioglitazoneglimepiride pioglitazonemetformin ; QL (30 ; QL (90 PRANDIMET ; QL (150 PRANDIN ORAL TABLET 0.5 PRANDIN ORAL TABLET 1 PRANDIN ORAL TABLET 2 PRECOSE ORAL TABLET 100 PRECOSE ORAL TABLET 25 PRECOSE ORAL TABLET 50 ; QL (960 ; QL (480 ; QL (240 ; QL (90 ; QL (360 ; QL (180 PROGLYCEM repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg repaglinide oral tablet 2 mg ; QL (960 ; QL (480 ; QL (240 RIOMET ; QL (765 STARLIX ORAL TABLET 120 STARLIX ORAL TABLET 60 ; QL (90 ; QL (180 72

81 SYMLINPEN PA; MO; QL (18.9 per 30 SYMLINPEN 60 2 PA; MO; QL (10.5 per 30 TANZEUM 3 PA; MO; QL (2 per 28 tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg ; QL (120 ; QL (60 tolbutamide ; QL (180 TOUJEO SOLOSTAR TRADJENTA 3 ST; MO; QL (30 per 30 TRULICITY 3 PA; MO; QL (2 per 28 VGO 20 VGO 30 VGO 40 VICTOZA 3-PAK 2 PA; MO; QL (9 XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR 10-1,000 XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR , 5-1,000, ; QL (30 ; QL (60 MISCELLANEOUS HORMONES ALDURAZYME 4 MO ANADROL-50 4 PA; MO ANDRODERM 2 PA; MO ANDROGEL 2 PA; MO ANDROID AVEED AXIRON 3 PA; MO cabergoline calcitonin (salmon) calcitriol intravenous solution 1 mcg/ml calcitriol oral CERDELGA 4 MO CEREZYME RECON SOLN 400 UNIT chorionic gonadotropin, human 4 MO 1 PA; MO danazol oral DDAVP DEPO- TESTOSTERONE desmopressin injection desmopressin nasal solution desmopressin nasal spray,non-aerosol 73

82 desmopressin oral doxercalciferol intravenous doxercalciferol oral ELAPRASE 4 MO ELELYSO 4 MO FABRAZYME RECON SOLN MO FORTESTA 3 PA; MO fortical HECTOROL SOLUTION 4 MCG/2 ML HECTOROL ORAL KORLYM 4 MO KUVAN ORAL POWDER IN PACKET 500 KUVAN ORAL TABLET,SOLUBL E 4 MO 4 MO; LA LUMIZYME 4 MO METHITEST MIACALCIN MYALEPT 4 PA; MO; LA MYOZYME 4 MO NAGLAZYME 4 MO; LA NATESTO 3 PA; MO NATPARA 4 PA; MO; LA novarel 1 PA; MO oxandrolone 1 PA; MO pamidronate intravenous solution PARICALCITOL HEMODIALYSIS PORT INJECTION paricalcitol oral PREGNYL 3 PA; MO ROCALTROL SAMSCA 4 PA; MO SENSIPAR ORAL TABLET 30 SENSIPAR ORAL TABLET 60, MO SOMAVERT 4 MO STIMATE STRIANT 3 PA; MO SYNAREL 4 MO TESTIM 3 PA; MO testosterone cypionate testosterone enanthate TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP TESTOSTERONE TRANSDERMAL GEL IN PACKET 3 PA; MO 3 PA; MO 74

83 TESTRED VOGELXO TRANSDERMAL GEL VOGELXO TRANSDERMAL GEL IN METERED-DOSE PUMP 3 PA; MO 3 PA; MO VPRIV 4 MO ZAVESCA 4 MO; LA ZEMPLAR ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG zoledronic acid intravenous solution ZOMETA 4 MO THYROID HORMONES CYTOMEL LEVOTHYROXINE RECON SOLN 100 MCG levothyroxine oral 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 SYNTHROID THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 TIROSINT TRIOSTAT 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 GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection syringe 0.05 mg/ml, 0.1 mg/ml CANTIL CUVPOSA diphenoxylateatropine 75 1 FULYZAQ glycopyrrolate injection glycopyrrolate oral LOMOTIL loperamide oral capsule methscopolamine oral ROBINUL FORTE

84 ROBINUL ORAL MISCELLANEOUS GASTROINTESTINAL AGENTS ACTIGALL AKYNZEO 2 PA; MO alosetron ALOXI AMITIZA ANUSOL-HC RECTAL CREAM ANZEMET SOLUTION 100 /5 ML ANZEMET ORAL 3 PA; MO APRISO ASACOL HD AZULFIDINE AZULFIDINE EN- TABS balsalazide budesonide oral CANASA CESAMET 4 PA; MO CHENODAL 4 PA; MO; LA CIMZIA 4 PA; MO CIMZIA POWDER FOR RECONST 4 PA; MO COLAZAL colocort COLYTE WITH FLAVOR PACKS ORAL RECON SOLN GRAM compro constulose CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 6,000-19,000-30,000 UNIT CREON ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 36, , ,000 UNIT 4 MO cromolyn oral CYSTADANE 4 MO DELZICOL DIPENTUM 4 MO dronabinol 1 PA; MO EMEND EMEND ORAL 2 PA; MO ENTOCORT EC 4 MO enulose GASTROCROM 76

85 GATTEX ONE- VIAL 4 MO gavilyte-c gavilyte-g gavilyte-n generlac GIAZO 4 MO GOLYTELY granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution 1 mg/ml (1 ml) granisetron hcl oral 1 PA; MO hydrocortisone rectal enema KRISTALOSE lactulose oral solution 10 gram/15 ml LIALDA LINZESS LOTRONEX 4 MO MARINOL ORAL CAPSULE 10, 5 MARINOL ORAL CAPSULE 2.5 meclizine oral tablet 12.5 mg, 25 mg mesalamine with cleansing wipe 4 PA; MO 3 PA; MO metoclopramide hcl injection solution metoclopramide hcl oral METOZOLV ODT ORAL TABLET,DISINTE GRATING 5 MOVANTIK MOVIPREP NULYTELY WITH FLAVOR PACKS ondansetron 1 PA; MO ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg 1 1 PA; MO 1 PA 1 PA; MO OSMOPREP PANCREAZE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10,500-25,000-43,750 UNIT, 16,800-40,000-70,000 UNIT, 4,200-10,000-17,500 UNIT 77

86 PANCREAZE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 21,000-37,000-61,000 UNIT peg electrolytes oral recon soln gram 4 MO PENTASA PERTZYE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 16,000-57,500-60,500 UNIT PERTZYE ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 8,000-28,750-30,250 UNIT polyethylene glycol 3350 oral powder 4 MO PREPOPIK prochlorperazine prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral procto-pak proctosol hc proctozone-hc RECTIV REGLAN ORAL RELISTOR SUBCUTANEOUS SOLUTION RELISTOR SUBCUTANEOUS SYRINGE REMICADE 4 PA; MO SANCUSO 4 MO SFROWASA SUCLEAR SUCRAID 4 MO sulfasalazine oral tablet sulfazine ec SUPREP BOWEL PREP KIT TRANSDERM- SCOP trilyte with flavor packets UCERIS ORAL 4 MO UCERIS RECTAL ULTRESA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 13,800-27,600 UNIT 78

87 ULTRESA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20,700-41,400 UNIT, 23,000-46,000 UNIT 4 MO URSO 250 URSO FORTE ursodiol VIOKACE ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40, , ,000 UNIT ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 5,000-17,000-27,000 UNIT 4 MO ZOFRAN (AS HYDROCHLORID E) ZOFRAN (AS HYDROCHLORID E) ORAL 3 PA; MO ZOFRAN ODT 3 PA; MO ZUPLENZ 3 PA; MO ULCER THERAPY ACIPHEX ACIPHEX SPRINKLE amoxicilclarithromylansopraz carafate oral suspension CARAFATE ORAL TABLET ; QL (30 ; QL (112 cimetidine cimetidine hcl oral CYTOTEC DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 30 DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 60 esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg ; QL (30 ; QL (30 79

88 ESOMEPRAZOLE MAGNESIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40 esomeprazole sodium famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine oral suspension famotidine oral tablet 20 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) 15 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg 1 1 ; QL (30 misoprostol NEXIUM IV RECON SOLN 40 NEXIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20 NEXIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40 ; QL (30 NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 10, 2.5, 20, 5 NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 40 ; QL (30 nizatidine OMECLAMOX- PAK omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg omeprazole oral capsule,delayed release(dr/ec) 40 mg omeprazole-sodium bicarbonate oral capsule mggram omeprazole-sodium bicarbonate oral capsule mggram pantoprazole oral tablet,delayed release (dr/ec) 20 mg pantoprazole oral tablet,delayed release (dr/ec) 40 mg PEPCID ORAL SUSPENSION ; QL (80 ; QL (30 ; QL (30 ; QL (30 80

89 PEPCID ORAL TABLET 20 PREVACID ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 15 PREVACID ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 PREVACID SOLUTAB ORAL TABLET,DISINTE GRAT, DELAY REL 15 PREVACID SOLUTAB ORAL TABLET,DISINTE GRAT, DELAY REL 30 ; QL (30 ; QL (30 PREVPAC ; QL (112 PRILOSEC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10, 20 PRILOSEC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40 PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 10 ; QL (30 ; QL (900 PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 2.5 PROTONIX PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET PROTONIX ORAL TABLET,DELAYE D RELEASE (DR/EC) 20 PROTONIX ORAL TABLET,DELAYE D RELEASE (DR/EC) 40 ; QL (300 ; QL (30 PYLERA rabeprazole ranitidine hcl injection solution 25 mg/ml ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg sucralfate oral tablet ZANTAC INJECTION SOLUTION 25 /ML 81

90 ZANTAC ORAL TABLET ZEGERID ORAL CAPSULE GRAM ZEGERID ORAL CAPSULE GRAM ZEGERID ORAL PACKET 20-1,680 ZEGERID ORAL PACKET 40-1,680 ; QL (30 ; QL (30 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 4 MO ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML 4 PA; MO 3 PA; MO ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML 3 PA; MO 4 PA; MO ARCALYST 4 PA; MO AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULA R PEN INJECTOR KIT AVONEX INTRAMUSCULA R SYRINGE KIT BETASERON SUBCUTANEOUS KIT EGRIFTA SUBCUTANEOUS RECON SOLN 1 4 PA; MO; QL (4 per 28 4 PA; MO; QL (4 per 28 4 PA; MO; QL (4 per 28 4 PA; MO; QL (15 per 28 4 PA 82

91 EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML EPOGEN INJECTION SOLUTION 20,000 UNIT/ML EXTAVIA SUBCUTANEOUS KIT 3 PA; MO 4 PA; MO 4 PA; MO; QL (15 per 28 GENOTROPIN 4 PA; MO GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 /0.25 ML GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 /0.25 ML, 0.6 /0.25 ML, 0.8 /0.25 ML, 1 /0.25 ML, 1.2 /0.25 ML, 1.4 /0.25 ML, 1.6 /0.25 ML, 1.8 /0.25 ML, 2 /0.25 ML 3 PA; MO 4 PA; MO GRANIX 4 PA; MO HUMATROPE 4 PA; MO ILARIS (PF) 4 PA; MO; LA INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) INTRON A INJECTION RECON SOLN 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML LEUKINE INJECTION RECON SOLN 4 MO 4 MO MIRCERA MOZOBIL 4 MO NEULASTA SUBCUTANEOUS SYRINGE 4 PA; MO NEUMEGA 4 MO NEUPOGEN 4 PA; MO NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 /1.5 ML (6.7 /ML), 15 /1.5 ML (10 /ML), 5 /1.5 ML (3.3 /ML) NORDITROPIN NORDIFLEX 4 PA; MO 4 PA; MO 83

92 NUTROPIN AQ NUSPIN SUBCUTANEOUS CARTRIDGE 5 /2 ML (2.5 /ML) NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 4 PA; MO 4 PA; MO OMNITROPE 4 PA; MO PEGASYS 4 MO; QL (4 per 28 PEGASYS PROCLICK 4 MO; QL (4 per 28 PEGINTRON 4 MO; QL (4 per 28 PEGINTRON REDIPEN PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML 4 MO; QL (4 per 28 4 PA; MO; QL (1 per 28 4 PA; MO; QL (1 per PA; MO; QL (1 per 28 4 PA; MO; QL (1 per 180 PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML 2 PA; MO 4 PA; MO PROLEUKIN 4 MO REBIF (WITH ALBUMIN) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK 4 PA; MO; QL (6 per 28 4 PA; MO; QL (6 per 28 4 PA; MO; QL (4.2 per PA; MO; QL (12 per 28 SAIZEN 4 PA; MO SAIZEN CLICK.EASY SEROSTIM SUBCUTANEOUS RECON SOLN 4, 5, 6 4 PA; MO 4 PA; MO SYLATRON 4 MO ZOMACTON 4 PA; MO 84

93 ZORBTIVE 4 PA; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT )(PF) INTRAMUSCULA R SUSPENSION ATGAM 4 PA BCG VACCINE, LIVE (PF) BEXSERO (PF) 2 BIVIGAM 4 PA; MO BOOSTRIX TDAP BOTOX 2 PA; MO CARIMUNE NF NANOFILTERED RECON SOLN 6 GRAM CERVARIX VACCINE (PF) 2 4 PA; MO COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) DYSPORT INTRAMUSCULA R RECON SOLN 300 UNIT ENGERIX-B (PF) INTRAMUSCULA R SYRINGE 3 PA; MO 2 PA; MO ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE FLEBOGAMMA DIF SOLUTION 10 % 2 PA; MO 2 PA 4 PA; MO fomepizole GAMASTAN S/D GAMMAGARD LIQUID GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %) 4 PA; MO 4 PA; MO GAMMAPLEX 4 PA; MO GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %) 4 PA; MO GARDASIL (PF) GARDASIL 9 (PF) GRASTEK 2 PA; MO HAVRIX (PF) INTRAMUSCULA R SUSPENSION 1,440 ELISA UNIT/ML 85

94 HAVRIX (PF) INTRAMUSCULA R SYRINGE 720 ELISA UNIT/0.5 ML HYPERRAB S/D (PF) IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULA R SUSPENSION 2 3 IPOL IXIARO (PF) MENACTRA (PF) INTRAMUSCULA R SOLUTION MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y- W-135-DIP (PF) M-M-R II (PF) OCTAGAM 4 PA; MO PEDVAX HIB (PF) PRIVIGEN 4 PA; MO PROQUAD (PF) 2 QUADRACEL (PF) 2 RABAVERT (PF) RAGWITEK RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 5 MCG/0.5 ML ROTARIX 2 ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULA R SYRINGE TETANUS,DIPHTH ERIA TOX PED(PF) TETANUS- DIPHTHERIA TOXOIDS-TD THYMOGLOBULI N TRUMENBA 2 TWINRIX (PF) INTRAMUSCULA R SUSPENSION TYPHIM VI INTRAMUSCULA R SOLUTION 2 PA; MO 2 PA; MO 2 PA 4 PA 2 86

95 TYPHIM VI INTRAMUSCULA R SYRINGE VAQTA (PF) INTRAMUSCULA R SYRINGE VARIVAX (PF) VARIZIG INTRAMUSCULA R SOLUTION XEOMIN INTRAMUSCULA R RECON SOLN 50 UNIT PA; MO YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol aloprim 1 COLCHICINE ORAL colchicineprobenecid COLCRYS probenecid ULORIC 2 ST; MO ZYLOPRIM OSTEOPOROSIS THERAPY ACTONEL ORAL TABLET ST; MO; QL (1 ACTONEL ORAL TABLET 35 ACTONEL ORAL TABLET 5 alendronate oral solution alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg 3 ST; MO; QL (4 per 28 3 ST; MO; QL (30 per 30 ; QL (1286 ; QL (30 ; QL (4 per 28 ATELVIA 3 ST; MO; QL (4 per 28 BINOSTO 3 ST; MO; QL (4 per 28 BONIVA 3 PA; MO BONIVA ORAL 3 ST; MO; QL (1 EVISTA FORTEO 4 PA; MO; QL (2.4 per 28 FOSAMAX ORAL TABLET 70 FOSAMAX PLUS D ibandronate intravenous solution 3 ST; MO; QL (4 per 28 3 ST; MO; QL (4 per 28 1 PA; MO ibandronate oral ; QL (1 per 30 PROLIA 2 PA; MO raloxifene 87

96 risedronate oral tablet 150 mg risedronate oral tablet 35 mg risedronate oral tablet 35 mg (12 pack) risedronate oral tablet 5 mg risedronate oral tablet,delayed release (dr/ec) ; QL (1 per 30 ; QL (4 per 28 1 QL (4 per 28 ; QL (30 ; QL (4 per 28 OTHER RHEUMATOLOGICALS ACTEMRA 4 PA; MO ARAVA ; QL (30 BENLYSTA RECON SOLN MO CUPRIMINE 4 MO DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 /0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 /ML (0.98 ML) ENBREL SURECLICK 4 PA; MO; QL (8 per 28 4 PA; MO; QL (8 per 28 4 PA; MO; QL (4 per 28 4 PA; MO; QL (4 per 28 HUMIRA CROHN'S DIS START PCK HUMIRA SUBCUTANEOUS SYRINGE KIT 10 /0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 /0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 /0.8 ML 4 PA; MO; QL (4.8 per PA; MO; QL (0.4 per 28 4 PA; MO; QL (2 per 28 4 PA; MO; QL (3.2 per 28 KINERET 4 PA; MO leflunomide ; QL (30 ORENCIA 4 PA; MO ORENCIA (WITH MALTOSE) 4 PA; MO OTEZLA 4 PA; MO OTEZLA STARTER 4 PA; MO OTREXUP (PF) RASUVO (PF) RIDAURA 4 MO SAVELLA ORAL TABLET SAVELLA ORAL TABLETS,DOSE PACK ; QL (60 ; QL (55 SIMPONI 4 PA; MO SIMPONI ARIA 4 PA; MO 88

97 XELJANZ 4 PA; MO OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS ACTIVELLA ALORA ; QL (8 per 28 ANGELIQ ORAL TABLET AYGESTIN camila CLIMARA ; QL (4 per 28 CRINONE VAGINAL GEL 4 % CRINONE VAGINAL GEL 8 % 3 PA; MO deblitane DELESTROGEN DEPO-ESTRADIOL DEPO-PROVERA INTRAMUSCULA R SOLUTION DEPO-PROVERA INTRAMUSCULA R SUSPENSION DEPO-SUBQ PROVERA 104 DIVIGEL ; QL (30 DUAVEE ELESTRIN ; QL (52 ENJUVIA errin ESTRACE ORAL ESTRACE VAGINAL estradiol oral estradiol transdermal patch semiweekly estradiol transdermal patch weekly estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiolnorethindrone acet ; QL (8 per 28 ; QL (4 per 28 ESTRING estropipate EVAMIST ; QL (16.2 FEMHRT LOW DOSE FEMRING jolivette LOPREEZA lyza medroxyprogesteron e intramuscular suspension 89

98 medroxyprogesteron e oral MENEST MENOSTAR ; QL (4 per 28 mimvey mimvey lo MINIVELLE ; QL (8 per 28 nora-be norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol oral tablet mg-mcg, 1-5 mg-mcg norlyroc 1 NOR-QD ORTHO MICRONOR PREMARIN INJECTION PREMARIN ORAL PREMARIN VAGINAL progesterone micronized PROMETRIUM PROVERA sharobel VAGIFEM VIVELLE-DOT ; QL (8 per 28 MISCELLANEOUS OB/GYN AVC VAGINAL CLEOCIN VAGINAL CREAM CLEOCIN VAGINAL SUPPOSITORY clindamycin phosphate vaginal GYNAZOLE-1 VAGINAL CREAM LUPANETA PACK (NTH) LUPANETA PACK (NTH) 4 MO 4 MO LYSTEDA METROGEL VAGINAL metronidazole vaginal miconazole-3 vaginal suppository NUVARING NUVESSA TERAZOL 3 VAGINAL CREAM TERAZOL 7 terconazole tranexamic acid oral vandazole xulane 90

99 ORAL CONTRACEPTIVES / RELATED AGENTS amethia amethyst apri aranelle (28) ashlyna aubra aviane balziva (28) BEYAZ BREVICON (28) briellyn cryselle (28) cyclafem 1/35 (28) cyclafem 7/7/7 (28) CYCLESSA (28) delyla (28) 1 desoge.estradiol/e.estradio l DESOGEN drospirenone-ethinyl estradiol 1 emoquette enpresse falmina (28) FEMCON FE GENERESS FE gianvi (28) gildagia gildess 24 fe gildess oral tablet mg-mcg introvale junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junel fe 24 kariva (28) kelnor 1/35 (28) l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) larin 1.5/30 (21) 1 larin 1/20 (21) larin fe leena 28 lessina levonest (28) levonorgestrelethinyl estrad oral tablet mgmcg levonorgestrelethinyl estrad oral tablet mcg

100 levonorgestrelethinyl estrad oral tablets,dose pack,3 month levora-28 LO LOESTRIN FE LOESTRIN 1.5/30 (21) LOESTRIN 1/20 (21) LOESTRIN FE 1.5/30 (28-DAY) LOESTRIN FE 1/20 (28-DAY) lomedia 24 fe loryna (28) LOSEASONIQUE lutera (28) marlissa microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) MINASTRIN 24 FE MODICON (28) mononessa (28) NATAZIA necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) nikki (28) noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) norethindronee.estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) NORINYL 1+35 (28) NORINYL 1+50 (28) 1 nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) orsythia ORTHO TRI- CYCLEN (28) ORTHO TRI- CYCLEN LO (28) ORTHO-CEPT (28) ORTHO-CYCLEN (28) 92

101 ORTHO-NOVUM 1/35 (28) ORTHO-NOVUM 7/7/7 (28) OVCON-35 (28) pimtrea (28) pirmella oral tablet 1-35 mg-mcg portia previfem QUARTETTE quasense reclipsen (28) SAFYRAL SEASONIQUE sprintec (28) sronyx tarina fe tri-legest fe trinessa (28) TRI-NORINYL (28) tri-previfem (28) tri-sprintec (28) trivora (28) velivet triphasic regimen (28) vestura (28) vyfemla (28) wymzya fe YASMIN (28) YAZ (28) zenchent (28) zenchent fe zovia 1/35e (28) zovia 1/50e (28) OXYTOCICS methylergonovine oral OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin ophthalmic bacitracinpolymyxin b ophthalmic BESIVANCE CILOXAN OPHTHALMIC DROPS CILOXAN OPHTHALMIC OINTMENT ciprofloxacin hcl ophthalmic erythromycin ophthalmic garamycin ophthalmic drops gatifloxacin gentak ophthalmic ointment 1 93

102 gentamicin ophthalmic ILOTYCIN levofloxacin ophthalmic MOXEZA NATACYN neomycinbacitracinpolymyxin neomycinpolymyxingramicidin NEOSPORIN (NEO-POLYM- GRAMICID) OCUFLOX ofloxacin ophthalmic polymyxin b sulftrimethoprim POLYTRIM tobramycin TOBREX OPHTHALMIC DROPS TOBREX OPHTHALMIC OINTMENT VIGAMOX ZYMAXID ANTIVIRALS trifluridine VIROPTIC ZIRGAN BETA-BLOCKERS BETAGAN OPHTHALMIC DROPS 0.5 % betaxolol ophthalmic BETIMOL BETOPTIC S carteolol ISTALOL levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic TIMOPTIC OCUDOSE (PF) TIMOPTIC-XE CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops DIRECT ACTING MIOTICS ISOPTO CARPINE pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % 94

103 MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL ALOMIDE azelastine ophthalmic BEPREVE cromolyn ophthalmic CYSTARAN 4 MO ELESTAT EMADINE epinastine LACRISERT LASTACAFT PATADAY PATANOL PAZEO RESTASIS ; QL (60 NON-STEROIDAL ANTI- INFLAMMATORY AGENTS ACULAR ACULAR LS ACUVAIL (PF) bromfenac diclofenac sodium ophthalmic flurbiprofen sodium ILEVRO ketorolac ophthalmic NEVANAC OCUFEN PROLENSA ORAL DRUGS FOR GLAUCOMA acetazolamide oral acetazolamide sodium DIAMOX SEQUELS methazolamide oral OTHER GLAUCOMA DRUGS AZOPT bimatoprost COMBIGAN COSOPT dorzolamide dorzolamide-timolol latanoprost LUMIGAN OPHTHALMIC DROPS 0.01 % SIMBRINZA TRAVATAN Z travoprost (benzalkonium) TRUSOPT XALATAN 3 ST; MO ZIOPTAN (PF) 3 ST; MO 95

104 STEROID-ANTIBIOTIC COMBINATIONS MAXITROL neomycin-polymyxin b-dexameth neomycinbacitracin-poly-hc neomycinpolymyxin-hc ophthalmic PRED-G PRED-G S.O.P. TOBRADEX TOBRADEX ST ZYLET STEROIDS ALREX dexamethasone sodium phosphate ophthalmic DUREZOL FLAREX fluorometholone FML FORTE FML LIQUIFILM FML S.O.P. LOTEMAX MAXIDEX OMNIPRED PRED FORTE PRED MILD prednisolone acetate prednisolone sodium phosphate ophthalmic VEXOL STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE S.O.P. tobramycindexamethasone sulfacetamideprednisolone SULFONAMIDES BLEPH-10 sulfacetamide sodium ophthalmic SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % ALPHAGAN P OPHTHALMIC DROPS 0.15 % apraclonidine brimonidine IOPIDINE VASOCONSTRICTOR DECONGESTANTS naphazoline 96

105 RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS adrenalin injection solution 1 mg/ml (1:1,000) (1ml) AUVI-Q ; QL (4 per 30 cetirizine oral solution 1 mg/ml CLARINEX ORAL SYRUP CLARINEX ORAL TABLET CLARINEX-D 12 HOUR 1 ; QL (30 ; QL (60 desloratadine ; QL (30 diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl oral elixir epinephrine injection autoinjector 1 PA ; QL (4 per 30 EPIPEN 2-PAK ; QL (4 per 30 EPIPEN JR 2-PAK ; QL (4 per 30 hydroxyzine hcl oral tablet levocetirizine oral solution 1 PA; MO levocetirizine oral tablet PHENERGAN INJECTION promethazine injection solution ; QL (30 promethazine oral 1 PA; MO SEMPREX-D XYZAL ORAL SOLUTION XYZAL ORAL TABLET PULMONARY AGENTS ; QL (30 ACCOLATE acetylcysteine solution 1 PA; MO ADCIRCA 4 PA; MO; QL (60 per 30 ADEMPAS 4 PA; MO; LA ADVAIR DISKUS ; QL (60 ADVAIR HFA ; QL (12 AEROSPAN ; QL (17.8 albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml 1 PA; MO albuterol sulfate oral 97

106 ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION ALVESCO INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION aminophylline intravenous solution 250 mg/10 ml ; QL (12.2 ; QL (6.1 ANORO ELLIPTA ; QL (60 ARCAPTA NEOHALER ARNUITY ELLIPTA 1 ; QL (30 ; QL (30 ASMANEX HFA ; QL (13 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES) ; QL (30 ; QL (240 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (60 DOSES) ; QL (60 ATROVENT HFA ; QL (25.8 BECONASE AQ ; QL (50 BERINERT KIT 4 PA; MO BREO ELLIPTA ; QL (60 BROVANA 3 PA; MO budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml 1 PA; MO budesonide nasal ; QL (17.2 CINRYZE 4 PA; MO COMBIVENT RESPIMAT ; QL (8 per 30 cromolyn inhalation 1 PA; MO DALIRESP 2 PA; MO DULERA ; QL (13 DYMISTA ; QL (23 ELIXOPHYLLIN ORAL ELIXIR 80 /15 ML 98

107 ESBRIET 4 PA; MO; QL (270 per 30 FIRAZYR 4 PA; MO FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) ; QL (60 ; QL (240 ; QL (12 ; QL (24 ; QL (10.6 ; QL (50 fluticasone nasal ; QL (16 FORADIL AEROLIZER ; QL (60 INCRUSE ELLIPTA ipratropium bromide inhalation ipratropiumalbuterol ; QL (30 1 PA; MO 1 PA; MO KALBITOR 4 MO KALYDECO ORAL GRANULES IN PACKET KALYDECO ORAL TABLET 4 PA; MO; QL (56 per 28 4 PA; MO; QL (60 per 30 LETAIRIS 4 PA; MO; LA levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml 1 PA; MO metaproterenol oral montelukast NASONEX ; QL (34 OFEV 4 PA; MO; QL (60 per 30 OMNARIS ; QL (12.5 OPSUMIT 4 PA; MO; LA PERFOROMIST 2 PA; MO PROAIR HFA ; QL (17 PROAIR RESPICLICK ; QL (17 99

108 PROVENTIL HFA ; QL (13.4 PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 0.25 /2 ML, 0.5 /2 ML PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 /2 ML ; QL (2 per 30 ; QL (1 per 30 3 PA; MO 2 PA; MO PULMOZYME 4 PA; MO QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION ; QL (4.9 ; QL (8.7 QVAR ; QL (17.4 REVATIO REVATIO ORAL SUSPENSION FOR RECONSTITUTIO N REVATIO ORAL TABLET RHINOCORT AQUA 4 PA; MO 4 PA; MO; QL (224 per 30 4 PA; MO; QL (90 per 30 ; QL (17.2 RUCONEST 4 PA; MO SEREVENT DISKUS sildenafil intravenous ; QL (60 1 PA sildenafil oral 1 PA; MO; QL (90 per 30 SINGULAIR SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT STRIVERDI RESPIMAT ; QL (60 ; QL (90 per 90 ; QL (4 per 30 ; QL (4 per 30 SYMBICORT ; QL (10.2 terbutaline oral terbutaline subcutaneous THEO

109 theophylline oral solution theophylline oral tablet extended release theophylline oral tablet extended release 12 hr 1 TRACLEER 4 PA; MO; LA triamcinolone acetonide nasal TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION (30 ACTUAT) ; QL (16.5 ; QL (1 per 30 2 QL (1 per 30 TYVASO 4 PA; MO VENTAVIS 4 PA; MO VENTOLIN HFA ; QL (36 VERAMYST ; QL (10 VOSPIRE ER XOLAIR 4 PA; MO; LA; QL (6 per 28 XOPENEX 3 PA; MO XOPENEX HFA ; QL (30 zafirlukast ZETONNA ; QL (6.1 ZYFLO 4 MO ZYFLO CR 4 MO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS DETROL DETROL LA DITROPAN XL ENABLEX flavoxate GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP GELNIQUE TRANSDERMAL GEL IN PACKET ; QL (92 ; QL (30 MYRBETRIQ oxybutynin chloride oral OXYTROL ; QL (8 per 28 tolterodine TOVIAZ trospium 101

110 VESICARE BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin AVODART finasteride oral tablet 5 mg FLOMAX 3 ST; MO JALYN PROSCAR RAPAFLO 2 ST; MO tamsulosin UROXATRAL 3 ST; MO CHOLINERGIC STIMULANTS bethanechol chloride URECHOLINE MISCELLANEOUS UROLOGICALS AMMONIUM CHLORIDE CIALIS ORAL TABLET 2.5, PA; MO; QL (30 per 30 CYSTAGON ; LA ELMIRON potassium citrate PROCYSBI 4 MO UROCIT-K 10 UROCIT-K 15 UROCIT-K 5 VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate oral capsule dextrose-kcl-nacl 1 eliphos klor-con 10 klor-con 8 klor-con m15 klor-con m20 K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ k-tab oral tablet extended release 8 meq lactated ringers intravenous magnesium sulfate injection solution magnesium sulfate injection syringe NORMOSOL-R IN 5 % DEXTROSE 1 PHOSLO PHOSLYRA

111 potassium chloridd5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chloridd5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals potassium chloride % nacl potassium chlorided5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.9%nacl intravenous parenteral solution 40 meq/l ringers intravenous 1 sodium chloride 0.45 % intravenous parenteral solution sodium chloride 3 % sodium chloride 5 % 1 103

112 sodium chloride intravenous parenteral solution 2.5 meq/ml sodium lactate intravenous solution TPN ELECTROLYTES MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % PA 2 PA 2 PA 2 PA AMINOSYN II 7 % 2 PA AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE- FREE) 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA AMINOSYN-RF 5.2 % CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%- D20W SULF-FREE CLINIMIX 4.25%- D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE- FREE) CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 3 PA 3 PA 3 PA 3 PA 3 PA 104

113 CLINIMIX E 5%/D25W SULFIT FREE 3 PA CLINISOL SF 15 % 3 PA; MO FREAMINE HBC 6.9 % 2 PA HEPATAMINE 8% 2 PA intralipid intravenous emulsion 20 % INTRALIPID EMULSION 30 % IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 2 NEPHRAMINE 5.4 % NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH PA; MO 2 PA PA NUTRILIPID 3 PA PLASMA-LYTE 148 PLASMA-LYTE A 2 PLASMA-LYTE-56 IN 5 % DEXTROSE premasol 10 % 1 PA; MO PREMASOL 6 % 2 PA PROCALAMINE 3% 3 PA PROSOL 20 % 3 PA; MO travasol 10 % 1 PA; MO TROPHAMINE 10 % 2 PA; MO TROPHAMINE 6% 2 PA VITAMINS / HEMATINICS PRENATAL VITAMIN ORAL TABLET SODIUM FLUORIDE ORAL TABLET 105 3

114 Index 8 8-MOP A abacavir... 1 abacavir-lamivudinezidovudine... 1 ABELCET... 1 ABILIFY ABILIFY DISCMELT ABILIFY MAINTENA ABRAXANE ABSORICA ABSTRAL acamprosate ACANYA acarbose ACCOLATE ACCUPRIL ACCURETIC acebutolol acetaminophen-codeine acetasol hc acetazolamide acetazolamide sodium acetic acid acetylcysteine ACIPHEX ACIPHEX SPRINKLE acitretin ACTEMRA ACTHAR H.P ACTHIB (PF) ACTIGALL ACTIMMUNE ACTIQ ACTIVELLA ACTONEL... 64, 87 ACTOPLUS MET ACTOPLUS MET XR ACTOS ACULAR ACULAR LS ACUVAIL (PF) acyclovir... 1, 2, 62 acyclovir sodium... 2 ACZONE ADACEL(TDAP ADOLESN/ADULT)(PF) 85 ADAGEN ADALAT CC adapalene ADCIRCA ADDERALL ADDERALL XR adefovir... 2 ADEMPAS ADOXA adrenalin adrucil ADVAIR DISKUS ADVAIR HFA ADVICOR AEROSPAN afeditab cr AFINITOR AFINITOR DISPERZ AFREZZA AGGRENOX AGRYLIN a-hydrocort AKYNZEO ala-cort ALA-SCALP ALBENZA... 7 albuterol sulfate alclometasone ALCOHOL PADS ALDACTAZIDE ALDACTONE ALDARA ALDURAZYME alendronate... 64, 87 alfuzosin ALIMTA ALINIA... 7 ALKERAN allopurinol ALOCRIL ALOMIDE aloprim ALORA alosetron ALOXI ALPHAGAN P ALREX ALSUMA ALTABAX ALTACE ALTOPREV ALVESCO amantadine hcl... 2 AMARYL AMBIEN AMBIEN CR AMBISOME... 1 amcinonide AMERGE amethia amethyst amifostine crystalline amikacin... 7 amiloride amiloride-hydrochlorothiazide aminophylline AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 %

115 AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid AMMONIUM CHLORIDE102 ammonium lactate amnesteem amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate.. 10 amphetamine salt combo amphotericin b... 1 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANADROL ANAFRANIL anagrelide ANAPROX ANAPROX DS anastrozole ANCOBON... 1 ANDRODERM ANDROGEL ANDROID ANGELIQ ANORO ELLIPTA ANTABUSE ANTARA ANUSOL-HC ANZEMET APEXICON apexicon e APIDRA APIDRA SOLOSTAR APLENZIN APOKYN apraclonidine apri APRISO APTENSIO XR APTIOM APTIVUS... 2 ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) ARAVA ARCALYST ARCAPTA NEOHALER ARGATROBAN ARGATROBAN IN 0.9 % SOD CHLOR ARICEPT ARIMIDEX aripiprazole ARIXTRA ARNUITY ELLIPTA AROMASIN ARRANON ARTHROTEC ARTHROTEC ARZERRA ASACOL HD ashlyna ASMANEX HFA ASMANEX TWISTHALER 98 ASTAGRAF XL ASTEPRO ATACAND ATACAND HCT ATELVIA atenolol atenolol-chlorthalidone ATGAM ATIVAN atorvastatin atovaquone... 7 atovaquone-proguanil... 7 ATRALIN ATRIPLA... 2 atropine... 75, 94 ATROVENT ATROVENT HFA AUBAGIO aubra AUGMENTIN AURYXIA AUVI-Q AVALIDE AVANDAMET AVANDIA... 68, 69 AVAPRO AVASTIN AVC VAGINAL AVEED AVELOX AVELOX ABC PACK AVELOX IN NACL (ISO- OSMOTIC) aviane avita AVITA AVODART AVONEX AVONEX (WITH ALBUMIN) AXERT AXIRON AYGESTIN azacitidine AZACTAM... 8 AZACTAM IN DEXTROSE (ISO-OSM)... 7 AZASAN AZASITE azathioprine azelastine... 66, 95 AZELEX AZILECT azithromycin... 7 AZOPT AZOR aztreonam

116 AZULFIDINE AZULFIDINE EN-TABS B baciim... 8 bacitracin... 8, 93 bacitracin-polymyxin b baclofen BACTRIM BACTRIM DS BACTROBAN BACTROBAN NASAL balsalazide balziva (28) BANZEL... 21, 22 BARACLUDE... 2 BCG VACCINE, LIVE (PF) 85 BECONASE AQ BELEODAQ BELSOMRA benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA BENZACLIN BENZAMYCIN benztropine BEPREVE BERINERT BESIVANCE BETAGAN betamethasone dipropionate. 62 betamethasone valerate betamethasone, augmented BETAPACE AF BETASERON betaxolol... 50, 94 bethanechol chloride BETHKIS... 8 BETIMOL BETOPTIC S BEXSERO (PF) BEYAZ BIAXIN... 7 bicalutamide BICILLIN C-R BICILLIN L-A BICNU BIDIL BILTRICIDE... 8 bimatoprost BINOSTO bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM bleomycin BLEPH BLEPHAMIDE BLEPHAMIDE S.O.P BONIVA BOOSTRIX TDAP BOSULIF BOTOX BREO ELLIPTA BREVICON (28) briellyn BRILINTA brimonidine BRINTELLIX BRISDELLE bromfenac bromocriptine BROVANA budesonide... 76, 98 bumetanide BUNAVAIL BUPRENEX buprenorphine hcl buprenorphine-naloxone buproban bupropion hcl... 38, 39 buspirone BUSULFEX butorphanol tartrate BUTRANS BYDUREON BYETTA BYSTOLIC C cabergoline CADUET CAFERGOT CALAN CALAN SR calcipotriene calcipotriene-betamethasone 58 calcitonin (salmon) calcitriol... 58, 73 calcium acetate CAMBIA camila CAMPTOSAR CANASA CANCIDAS... 1 candesartan candesartan-hydrochlorothiazid CANTIL CAPASTAT... 8 CAPEX CAPITAL WITH CODEINE CAPRELSA captopril captopril-hydrochlorothiazide CARAC carafate CARAFATE CARBAGLU carbamazepine CARBATROL carbidopa carbidopa-levodopa carbidopa-levodopaentacapone carboplatin CARDENE IV IN SODIUM CHLORIDE CARDIZEM CARDIZEM CD CARDIZEM LA CARDURA

117 CARDURA XL CARIMUNE NF NANOFILTERED CARNITOR carteolol cartia xt carvedilol CASODEX CATAPRES CATAPRES-TTS CATAPRES-TTS CATAPRES-TTS CAYSTON... 8 CEDAX... 4 cefaclor... 5 cefadroxil... 5 cefazolin... 5 cefazolin in dextrose (iso-os). 5 cefdinir... 5 cefditoren pivoxil... 5 cefepime... 5 CEFEPIME IN DEXTROSE 5 %... 5 cefixime... 5 cefotaxime... 5 cefotetan... 5 cefoxitin... 5 cefoxitin in dextrose, iso-osm 5 cefpodoxime... 5 cefprozil... 5 ceftazidime... 5 CEFTAZIDIME IN D5W... 5 CEFTIN... 5 ceftriaxone... 5 cefuroxime axetil... 5 cefuroxime sodium... 6 CELEBREX celecoxib CELEXA CELLCEPT CELLCEPT CELONTIN cephalexin... 6 CERDELGA CEREBYX CEREZYME CERVARIX VACCINE (PF) CESAMET cetirizine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX CHEMET CHENODAL chloramphenicol sod succinate... 8 chlorhexidine gluconate chloroquine phosphate... 8 chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone cholestyramine light chorionic gonadotropin, human CIALIS ciclopirox cidofovir... 2 cilostazol CILOXAN cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRO CIPRO HC CIPRO IN D5W CIPRODEX ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl... 12, 93 ciprofloxacin in 5 % dextrose ciprofloxacin lactate cisplatin citalopram cladribine CLAFORAN... 6 claravis CLARINEX CLARINEX-D 12 HOUR clarithromycin... 7 CLEOCIN... 8, 90 CLEOCIN IN 5 % DEXTROSE... 8 CLEOCIN T CLIMARA CLINDACIN PAC CLINDAGEL clindamycin hcl... 8 clindamycin in 5 % dextrose.. 8 clindamycin pediatric... 8 clindamycin phosphate... 8, 60, 90 clindamycin-benzoyl peroxide CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) 104 CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE

118 CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol-emollient CLOBEX clodan CLODERM CLOLAR clomipramine clonazepam clonidine clonidine hcl... 39, 51 clopidogrel clorazepate dipotassium clorpres CLORPRES clotrimazole... 1, 61 clotrimazole-betamethasone. 61 clozapine CLOZAPINE CLOZARIL COARTEM... 8 codeine sulfate COGENTIN COLAZAL COLCHICINE colchicine-probenecid COLCRYS COLESTID colestipol colistin (colistimethate na)... 8 colocort COLY-MYCIN S COLYTE WITH FLAVOR PACKS COMBIGAN COMBIVENT RESPIMAT. 98 COMBIVIR... 2 COMETRIQ COMPLERA... 2 compro COMTAN COMVAX (PF) CONCERTA CONDYLOX constulose CONZIP COPAXONE COPEGUS... 2 CORDRAN TAPE LARGE ROLL COREG COREG CR CORGARD CORLANOR cormax CORTEF cortisone CORTISPORIN... 61, 67 CORTISPORIN-TC CORZIDE COSENTYX PEN COSENTYX PEN (2 PENS) 58 COSMEGEN COSOPT COUMADIN COZAAR CREON CRESEMBA... 1 CRESTOR CRINONE CRIXIVAN... 2 cromolyn... 76, 95, 98 cryselle (28) CUBICIN... 8 CUPRIMINE CUTIVATE CUVPOSA cyclafem 1/35 (28) cyclafem 7/7/7 (28) CYCLESSA (28) CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified CYKLOKAPRON CYMBALTA CYSTADANE CYSTAGON CYSTARAN cytarabine cytarabine (pf) CYTOMEL CYTOTEC CYTOVENE... 2 D d10 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine DACOGEN DALIRESP DALVANCE... 8 danazol DANTRIUM dantrolene DAPSONE... 8 DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM... 8 daunorubicin DAUNOXOME DAYPRO DAYTRANA DDAVP deblitane decitabine DELESTROGEN delyla (28) DELZICOL DEMADEX

119 demeclocycline DEMSER DENAVIR DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES.. 22 DEPEN TITRATABS DEPO-ESTRADIOL DEPO-MEDROL DEPO-PROVERA DEPO-SUBQ PROVERA DEPO-TESTOSTERONE DERMATOP desipramine desloratadine desmopressin... 73, 74 desog-e.estradiol/e.estradiol. 91 DESOGEN DESONATE desonide DESOWEN desoximetasone DESOXYN DESVENLAFAXINE DETROL DETROL LA dexamethasone dexamethasone intensol dexamethasone sodium phosphate... 67, 96 dexedrine DEXEDRINE SPANSULE.. 40 DEXILANT dexmethylphenidate DEXPAK 13 DAY dexrazoxane hcl dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0.2 % nacl dextrose 10 % in water (d10w) dextrose 5 % in water (d5w). 65 dextrose 5 %-lactated ringers65 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride dextrose-kcl-nacl DIAMOX SEQUELS DIASTAT DIASTAT ACUDIAL diazepam... 22, 40 diazepam intensol diclofenac potassium diclofenac sodium... 35, 59, 95 diclofenac-misoprostol dicloxacillin didanosine... 2 DIFFERIN DIFICID... 7 diflorasone DIFLUCAN... 1 diflunisal digitek digoxin dihydroergotamine DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN /5 ML DILAUDID DILAUDID (PF) DILAUDID-HP (PF) diltiazem hcl... 51, 52 dilt-xr DIOVAN DIOVAN HCT DIPENTUM diphenhydramine hcl diphenoxylate-atropine DIPROLENE DIPROLENE AF dipyridamole disulfiram DITROPAN XL DIURIL DIURIL IV divalproex DIVIGEL DOCEFREZ docetaxel DOLOPHINE... 28, 29 donepezil DORIBAX... 8 dorzolamide dorzolamide-timolol DOVONEX doxazosin doxepin doxercalciferol DOXIL doxorubicin doxy doxycycline hyclate doxycycline monohydrate dronabinol drospirenone-ethinyl estradiol DROXIA DUAC DUAVEE DUETACT DUEXIS DULERA duloxetine DUOPA DURAGESIC duramorph (pf) DUREZOL DUTOPROL DYAZIDE DYMISTA DYSPORT

120 E e.e.s E.E.S. GRANULES... 7 EC-NAPROSYN econazole EDARBI EDARBYCLOR EDECRIN EDURANT... 2 EFFEXOR XR EFFIENT EFUDEX EGRIFTA ELAPRASE ELDEPRYL ELELYSO ELESTAT ELESTRIN ELIDEL ELIGARD eliphos ELIQUIS ELITEK ELIXOPHYLLIN ELLENCE ELMIRON ELOCON ELOXATIN EMADINE EMBEDA EMCYT EMEND EMLA emoquette EMSAM EMTRIVA... 2 ENABLEX enalapril maleate enalapril-hydrochlorothiazide ENBREL ENBREL SURECLICK endocet endodan ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) ENJUVIA enoxaparin enpresse entacapone entecavir... 2 ENTOCORT EC enulose EPANED EPIDUO epinastine epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin epitol EPIVIR... 2 EPIVIR HBV... 2 eplerenone EPOGEN eprosartan EPZICOM... 2 EQUETRO ERAXIS(WATER DILUENT)... 1 ERBITUX ergoloid ERGOMAR ERIVEDGE errin ERTACZO ERWINAZE ery pads ERYPED ERYPED ery-tab... 7 ERY-TAB... 7 ERYTHROCIN... 7 erythrocin (as stearate)... 7 erythromycin... 7, 93 erythromycin ethylsuccinate... 7 erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate esomeprazole magnesium ESOMEPRAZOLE MAGNESIUM esomeprazole sodium ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 89 ESTRING estropipate eszopiclone ethambutol... 8 ethosuximide etidronate disodium etodolac ETOPOPHOS etoposide EURAX EVAMIST EVEKEO EVISTA EVOCLIN EVOTAZ... 2 EVOXAC EVZIO EXALGO ER EXELDERM EXELON exemestane EXFORGE EXFORGE HCT EXJADE EXTAVIA EXTINA F FABIOR FABRAZYME FACTIVE falmina (28) famciclovir... 2 famotidine famotidine (pf) famotidine (pf)-nacl (iso-os)

121 FAMVIR... 2 FANAPT... 40, 41 FARESTON FARXIGA FARYDAK FASLODEX FAZACLO felbamate FELBATOL FELDENE felodipine FEMARA FEMCON FE FEMHRT LOW DOSE FEMRING fenofibrate FENOFIBRATE fenofibrate micronized fenofibrate nanocrystallized. 56 fenofibric acid (choline) FENOGLIDE fenoprofen fentanyl FENTANYL fentanyl citrate... 29, 30 FENTORA FERRIPROX FETZIMA FIBRICOR FINACEA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE FLAGYL... 8 FLAGYL ER... 8 FLAREX flavoxate FLEBOGAMMA DIF flecainide FLECTOR FLOMAX FLO-PRED FLOVENT DISKUS FLOVENT HFA fluconazole... 1 fluconazole in dextrose(iso-o) 1 flucytosine... 1 fludarabine fludrocortisone FLUMADINE... 2 flunisolide fluocinolone fluocinolone acetonide oil fluocinonide fluocinonide-e fluorometholone fluorouracil... 16, 59 FLUOROURACIL fluoxetine FLUOXETINE fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone... 63, 99 fluvastatin fluvoxamine FML FORTE FML LIQUIFILM FML S.O.P FOCALIN FOCALIN XR FOLOTYN fomepizole fondaparinux FORADIL AEROLIZER FORFIVO XL FORTAMET FORTAZ... 6 FORTEO FORTESTA fortical FOSAMAX FOSAMAX PLUS D foscarnet... 2 fosinopril fosinopril-hydrochlorothiazide fosphenytoin FOSRENOL FRAGMIN FREAMINE HBC 6.9 % FROVA FULYZAQ FURADANTIN furosemide FUSILEV FUZEON... 2 FYCOMPA G gabapentin GABITRIL GABLOFEN galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAKED GAMMAPLEX GAMUNEX-C ganciclovir sodium... 2 garamycin GARDASIL (PF) GARDASIL 9 (PF) GASTROCROM gatifloxacin GATTEX ONE-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GELNIQUE gemcitabine gemfibrozil GEMZAR GENERESS FE generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 9, 61, 94 gentamicin in nacl (iso-osm)

122 gentamicin sulfate (pf)... 9 GEODON... 41, 42 gianvi (28) GIAZO gildagia gildess gildess 24 fe GILENYA GILOTRIF GLASSIA glatopa GLEEVEC GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) GLUCOPHAGE... 69, 70 GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUMETZA glycopyrrolate GLYSET GLYXAMBI GOLYTELY GRALISE GRALISE 30-DAY STARTER PACK granisetron (pf) granisetron hcl GRANIX GRASTEK griseofulvin microsize... 1 griseofulvin ultramicrosize... 1 GRIS-PEG (ULTRAMICROSIZE)... 1 guanidine GYNAZOLE H HALAVEN HALDOL HALDOL DECANOATE halobetasol propionate HALOG haloperidol haloperidol decanoate haloperidol lactate HARVONI... 2 HAVRIX (PF)... 85, 86 HECTOROL heparin (porcine) heparin (porcine) in 5 % dex... 55, 56 HEPATAMINE 8% HEPSERA... 2 HERCEPTIN HETLIOZ HEXALEN HIPREX HORIZANT HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA CROHN'S DIS START PCK HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U HYCAMTIN HYCET hydralazine HYDREA hydrochlorothiazide hydrocodone-acetaminophen 30 hydrocodone-ibuprofen hydrocortisone... 63, 67, 77 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydrocortisone-acetic acid hydromorphone hydromorphone (pf) hydroxychloroquine... 9 hydroxyurea hydroxyzine hcl HYPERRAB S/D (PF) HYSINGLA ER HYZAAR I ibandronate IBRANCE IBUDONE ibuprofen ibuprofen-oxycodone ICLUSIG IDAMYCIN PFS idarubicin IFEX ifosfamide ILARIS (PF) ILEVRO ILOTYCIN IMBRUVICA imipenem-cilastatin... 9 imipramine hcl imipramine pamoate imiquimod IMITREX IMITREX STATDOSE KIT REFILL IMOVAX RABIES VACCINE (PF) IMURAN INCRELEX INCRUSE ELLIPTA indapamide INDERAL LA INFANRIX (DTAP) (PF) INLYTA INNOPRAN XL

123 INSPRA INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U-100 1/2 ML INTELENCE... 2 intralipid INTRALIPID INTRON A introvale INVANZ... 9 INVEGA INVEGA SUSTENNA INVIRASE... 2 INVOKAMET INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IOPIDINE IPOL ipratropium bromide... 66, 99 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRENKA irinotecan ISENTRESS... 2 ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid... 9 ISOPTO CARPINE ISORDIL ISORDIL TITRADOSE isosorbide dinitrate isosorbide mononitrate isradipine ISTALOL ISTODAX itraconazole... 1 ivermectin... 9 IXEMPRA IXIARO (PF) J JADENU JAKAFI JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JEVTANA jolivette JUBLIA junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junel fe JUXTAPID K KADCYLA KADIAN KALBITOR KALETRA... 3 KALYDECO KAPVAY kariva (28) KAYEXALATE KAZANO KEFLEX... 6 kelnor 1/35 (28) KENALOG... 63, 67 KEPIVANCE KEPPRA KEPPRA XR KERYDIN KETEK... 9 ketoconazole... 1, 61 ketoprofen ketorolac KEYTRUDA KHEDEZLA KINERET kionex KLARON KLONOPIN klor-con klor-con klor-con m klor-con m KOMBIGLYZE XR KORLYM KRISTALOSE k-tab K-TAB KUVAN KYNAMRO L l norgest/e.estradiol-e.estrad. 91 labetalol LACRISERT lactated ringers... 64, 102 lactulose LAMICTAL LAMICTAL ODT LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT LAMICTAL XR LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) LAMISIL... 1 lamivudine... 3 lamivudine-zidovudine... 3 lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin 1.5/30 (21) larin 1/20 (21)

124 larin fe LASIX LASTACAFT latanoprost LATUDA LAZANDA leena leflunomide LENVIMA LESCOL LESCOL XL lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levalbuterol hcl LEVAQUIN LEVEMIR LEVEMIR FLEXTOUCH levetiracetam LEVETIRACETAM IN NACL (ISO-OS) levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 12, 94 levofloxacin in d5w LEVOLEUCOVORIN CALCIUM levonest (28) levonorgestrel-ethinyl estrad... 91, 92 levora levorphanol tartrate levothyroxine LEVOTHYROXINE levoxyl LEXAPRO... 42, 43 LEXIVA... 3 LIALDA lidocaine lidocaine (pf) lidocaine hcl lidocaine-prilocaine LIDODERM LINCOCIN... 9 lindane linezolid... 9 LINZESS LIORESAL liothyronine LIPITOR LIPOFEN LIPTRUZET lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate LITHOBID LITHOSTAT LIVALO LO LOESTRIN FE LOCOID LODOSYN LOESTRIN 1.5/30 (21) LOESTRIN 1/20 (21) LOESTRIN FE 1.5/30 (28- DAY) LOESTRIN FE 1/20 (28-DAY) LOFIBRA lomedia 24 fe LOMOTIL LOMUSTINE loperamide LOPID LOPREEZA LOPRESSOR LOPRESSOR HCT LOPROX lorazepam lorazepam intensol lorcet (hydrocodone) lorcet hd lorcet plus lortab lortab lortab loryna (28) losartan losartan-hydrochlorothiazide 53 LOSEASONIQUE LOTEMAX LOTENSIN LOTREL LOTRISONE LOTRONEX lovastatin LOVAZA LOVENOX loxapine succinate LUMIGAN LUMIZYME LUNESTA LUPANETA PACK (1 MONTH) LUPANETA PACK (3 MONTH) LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED lutera (28) LUZU LYNPARZA LYRICA LYSODREN LYSTEDA lyza M MACROBID MACRODANTIN magnesium sulfate MALARONE... 9 MALARONE PEDIATRIC... 9 malathion

125 maprotiline MARINOL marlissa MARPLAN MATULANE matzim la MAVIK MAXALT MAXALT-MLT MAXIDEX MAXIPIME... 6 MAXITROL MAXZIDE MAXZIDE meclizine meclofenamate MEDROL MEDROL (PAK) medroxyprogesterone... 89, 90 mefenamic acid mefloquine... 9 MEGACE MEGACE ES megestrol MEKINIST meloxicam... 35, 36 melphalan hcl MENACTRA (PF) MENEST MENOMUNE - A/C/Y/W-135 (PF) MENOSTAR MENTAX MENVEO A-C-Y-W-135-DIP (PF) MEPRON... 9 mercaptopurine meropenem... 9 MERREM... 9 mesalamine with cleansing wipe mesna MESNEX MESTINON MESTINON TIMESPAN METADATE CD metadate er metaproterenol metformin... 71, 72 methadone methamphetamine methazolamide methenamine hippurate methimazole METHITEST methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine methyclothiazide methyldopa methylergonovine METHYLIN methylphenidate methylprednisolone methylprednisolone acetate.. 67 methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate METOZOLV ODT METROCREAM METROGEL METROGEL VAGINAL METROLOTION metronidazole... 9, 60, 90 metronidazole in nacl (iso-os) 9 mexiletine MIACALCIN MICARDIS MICARDIS HCT miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) MICROZIDE midodrine migergot MIGRANAL millipred MILLIPRED mimvey mimvey lo MINASTRIN 24 FE MINIPRESS MINITRAN MINIVELLE MINOCIN minocycline minoxidil MIRAPEX MIRAPEX ER MIRCERA mirtazapine MIRVASO misoprostol mitomycin mitoxantrone M-M-R II (PF) MOBIC modafinil moderiba... 3 moderiba dose pack... 3 MODICON (28) moexipril moexipril-hydrochlorothiazide mometasone mononessa (28) montelukast MONUROL morphine MORPHINE... 31, 32 morphine concentrate MOVANTIK MOVIPREP MOXEZA moxifloxacin MOZOBIL

126 MS CONTIN MULTAQ mupirocin mupirocin calcium MUSTARGEN MYALEPT MYAMBUTOL... 9 MYCAMINE... 1 MYCOBUTIN... 9 mycophenolate mofetil mycophenolate sodium MYFORTIC myorisan MYOZYME MYRBETRIQ MYSOLINE N nabumetone nadolol nadolol-bendroflumethiazide 53 nafcillin nafcillin in dextrose iso-osm 11 NAFTIFINE NAFTIN NAGLAZYME nalbuphine naloxone naltrexone NAMENDA NAMENDA TITRATION PAK NAMENDA XR naphazoline NAPRELAN CR NAPROSYN naproxen naproxen sodium naratriptan NARDIL NASONEX NATACYN NATAZIA nateglinide NATESTO NATPARA NEBUPENT... 9 necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/7 (28) NEEDLES, INSULIN DISP.,SAFETY nefazodone neomycin... 9 neomycin-bacitracin-poly-hc 96 neomycin-bacitracinpolymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc 67, 96 NEORAL NEOSPORIN (NEO-POLYM- GRAMICID) NEO-SYNALAR NEPHRAMINE 5.4 % NESINA neuac NEULASTA NEUMEGA NEUPOGEN NEUPRO NEURONTIN NEVANAC nevirapine... 3 NEXAVAR NEXIUM NEXIUM IV NEXIUM PACKET NEXTERONE niacin NIACOR NIASPAN EXTENDED- RELEASE nicardipine NICOTROL NICOTROL NS nifedical xl nifedipine nikki (28) NILANDRON nimodipine NIPENT nisoldipine nitro-bid NITRO-DUR nitrofurantoin nitrofurantoin macrocrystal.. 13 nitrofurantoin monohyd/mcryst nitroglycerin NITROLINGUAL NITROMIST NITROSTAT nizatidine NIZORAL nora-be NORCO NORDITROPIN FLEXPRO 83 NORDITROPIN NORDIFLEX noreth-ethinyl estradiol-iron. 92 norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol norethindrone-e.estradiol-iron NORINYL 1+35 (28) NORINYL 1+50 (28) NORITATE norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORPRAMIN NOR-QD NORTHERA nortrel 0.5/35 (28)

127 nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVASC NORVIR... 3 novarel NOVOFINE NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL... 1 NUCYNTA NUCYNTA ER NUEDEXTA NULOJIX NULYTELY WITH FLAVOR PACKS NUTRESTORE NUTRILIPID NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING NUVESSA NUVIGIL nyamyc nystatin... 1, 62 nystatin-triamcinolone nystop O ocella OCTAGAM octreotide acetate OCUFEN OCUFLOX OFEV ofloxacin... 12, 66, 94 ogestrel (28) olanzapine... 43, 44 olanzapine-fluoxetine olopatadine OLUX OLYSIO... 3 OMECLAMOX-PAK omega-3 acid ethyl esters omeprazole omeprazole-sodium bicarbonate OMNARIS OMNIPRED OMNITROPE ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) ONEXTON ONFI ONGLYZA ONMEL... 1 OPANA OPANA ER... 32, 33 OPDIVO OPSUMIT ORACEA ORAP ORAPRED ODT ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM ORFADIN orsythia ORTHO MICRONOR ORTHO TRI-CYCLEN (28) 92 ORTHO TRI-CYCLEN LO (28) ORTHO-CEPT (28) ORTHO-CYCLEN (28) ORTHO-NOVUM 1/35 (28) 93 ORTHO-NOVUM 7/7/7 (28) OSENI OSMOPREP OTEZLA OTEZLA STARTER OTREXUP (PF) OVCON-35 (28) OVIDE oxacillin oxacillin in dextrose(iso-osm) oxaliplatin oxandrolone oxaprozin oxazepam oxcarbazepine OXISTAT OXSORALEN ULTRA OXTELLAR XR oxybutynin chloride oxycodone OXYCODONE oxycodone-acetaminophen oxycodone-aspirin OXYCONTIN oxymorphone OXYTROL P pacerone paclitaxel PAMELOR pamidronate PANCREAZE... 77, 78 PANDEL PANRETIN pantoprazole paricalcitol PARICALCITOL PARNATE paromomycin... 9 paroxetine hcl PASER... 9 PATADAY PATANASE PATANOL PAXIL PAXIL CR PAZEO PCE

128 PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN PENICILLIN G POT IN DEXTROSE penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENNSAID PENTAM... 9 PENTASA pentoxifylline PEPCID... 80, 81 PERCOCET PERCODAN PERFOROMIST perindopril erbumine periogard PERJETA permethrin perphenazine PERSANTINE PERTZYE PEXEVA phenelzine PHENERGAN phenobarbital PHENYTEK phenytoin phenytoin sodium phenytoin sodium extended.. 24 PHOSLO PHOSLYRA PHOSPHOLINE IODIDE PHYSIOLYTE PHYSIOSOL IRRIGATION 64 PICATO pilocarpine hcl... 65, 94 pimtrea (28) pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam PLAQUENIL... 9 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLAVIX PLEGRIDY PLETAL podofilox polyethylene glycol polymyxin b sulfate... 9 polymyxin b sulf-trimethoprim POLYTRIM POMALYST PONSTEL portia potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate POTIGA PRADAXA pramipexole PRANDIMET PRANDIN PRAVACHOL pravastatin prazosin PRECOSE PRED FORTE PRED MILD PRED-G PRED-G S.O.P prednicarbate prednisolone acetate prednisolone sodium phosphate... 67, 96 prednisone prednisone intensol PREGNYL PREMARIN premasol 10 % PREMASOL 6 % PRENATAL VITAMIN ORAL TABLET PREPOPIK PREVACID PREVACID SOLUTAB prevalite previfem PREVPAC PREZCOBIX... 3 PREZISTA... 3 PRIFTIN... 9 PRILOSEC PRIMAQUINE... 9 PRIMAXIN IV... 9 primidone PRIMLEV PRIMSOL PRINIVIL PRISTIQ... 44, 45 PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide PROCALAMINE 3% PROCARDIA XL procentra

129 prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-pak proctosol hc proctozone-hc PROCYSBI progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine PROMETRIUM propafenone propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSCAR PROSOL 20 % PROTONIX PROTOPIC protriptyline PROVENTIL HFA PROVERA PROVIGIL PROZAC PROZAC WEEKLY prudoxin PULMICORT PULMICORT FLEXHALER PULMOZYME PURIXAN PYLERA pyrazinamide... 9 pyridostigmine bromide Q QNASL QUADRACEL (PF) QUALAQUIN... 9 QUARTETTE quasense QUDEXY XR QUESTRAN quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate... 9 QVAR R RABAVERT (PF) rabeprazole RAGWITEK raloxifene ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE... 18, 19 RASUVO (PF) RAVICTI RAYOS RAZADYNE RAZADYNE ER REBETOL... 3 REBIF (WITH ALBUMIN). 84 REBIF REBIDOSE REBIF TITRATION PACK. 84 RECLAST reclipsen (28) RECOMBIVAX HB (PF) RECTIV REGLAN REGRANEX RELENZA DISKHALER... 3 RELISTOR RELPAX REMERON REMERON SOLTAB REMICADE REMODULIN RENAGEL RENVELA repaglinide reprexain REQUIP REQUIP XL RESCRIPTOR... 3 RESTASIS RESTORIL RETIN-A RETIN-A MICRO RETIN-A MICRO PUMP RETROVIR... 3 REVATIO REVLIMID REYATAZ... 3 RHEUMATREX RHINOCORT AQUA ribasphere... 3 ribasphere ribapak... 3 ribavirin... 3 RIDAURA rifabutin... 9 RIFADIN... 9 RIFAMATE... 9 rifampin... 9 RIFATER... 9 RILUTEK riluzole rimantadine... 3 ringers... 64, 103 RIOMET risedronate... 65, 88 RISPERDAL... 45, 46 RISPERDAL CONSTA RISPERDAL M-TAB risperidone RITALIN RITALIN LA RITUXAN rivastigmine tartrate rizatriptan ROBINUL

130 ROBINUL FORTE ROCALTROL ropinirole ROTARIX ROTATEQ VACCINE ROXICET ROXICODONE ROZEREM RUCONEST RYTARY RYTHMOL RYTHMOL SR S SABRIL SAFYRAL SAIZEN SAIZEN CLICK.EASY SALAGEN SAMSCA SANCUSO SANDIMMUNE SANDOSTATIN SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY) SARAFEM SAVAYSA SAVELLA SEASONIQUE SECTRAL selegiline hcl selenium sulfide SELZENTRY... 3 SEMPREX-D SENSIPAR SEREVENT DISKUS SEROQUEL... 46, 47 SEROQUEL XR SEROSTIM sertraline SFROWASA sharobel SIGNIFOR SIGNIFOR LAR sildenafil SILENOR SILVADENE silver sulfadiazine SIMBRINZA SIMCOR SIMPONI SIMPONI ARIA SIMULECT simvastatin SINEMET SINEMET CR SINGULAIR sirolimus SIRTURO... 9 SIVEXTRO... 9 SKLICE sodium chloride... 66, 104 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % SODIUM FLUORIDE sodium lactate sodium phenylbutyrate sodium polystyrene (sorb free) SOLARAZE SOLODYN SOLTAMOX SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF) SOMATULINE DEPOT SOMAVERT SONATA SOOLANTRA SORIATANE SORILUX sorine sotalol sotalol af SOTYLIZE SOVALDI... 4 SPECTRACEF... 6 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX... 1 SPORANOX PULSEPAK... 1 sprintec (28) SPRIX SPRYCEL sronyx ssd STALEVO STALEVO STALEVO STALEVO STALEVO STALEVO STARLIX stavudine... 4 STELARA STIMATE STIOLTO RESPIMAT STIVARGA STRATTERA STREPTOMYCIN... 9 STRIANT STRIBILD... 4 STRIVERDI RESPIMAT STROMECTOL SUBOXONE SUBSYS SUCLEAR SUCRAID sucralfate SULAR sulfacetamide sodium sulfacetamide sodium (acne) 61 sulfacetamide-prednisolone.. 96 sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON

131 sulfasalazine sulfazine ec sulindac sumatriptan sumatriptan succinate SUMAVEL DOSEPRO SUPRAX... 6 SUPREP BOWEL PREP KIT SURMONTIL SUSTIVA... 4 SUTENT SYLATRON SYLVANT SYMBICORT SYMBYAX SYMLINPEN SYMLINPEN SYNAGIS... 4 SYNALAR CREAM KIT SYNALGOS-DC SYNAREL SYNERCID SYNRIBO SYNTHROID SYPRINE T TABLOID TACLONEX tacrolimus... 20, 59 TAFINLAR TAMIFLU... 4 tamoxifen tamsulosin TANZEUM TAPAZOLE TARCEVA TARGRETIN tarina fe TARKA TASIGNA TASMAR TAXOTERE TAZICEF... 6 TAZORAC taztia xt TECFIDERA TEFLARO... 6 TEGRETOL TEGRETOL XR TEKAMLO TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid temazepam TEMOVATE TENIVAC (PF) TENORETIC TENORETIC TENORMIN TERAZOL TERAZOL terazosin terbinafine hcl... 1 terbutaline terconazole TESTIM TESTOSTERONE testosterone cypionate testosterone enanthate TESTRED TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetracycline TEVETEN TEVETEN HCT THALOMID THEO theophylline THIOLA thioridazine thiothixene THYMOGLOBULIN THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine TIAZAC ticlopidine TIKOSYN timolol maleate... 54, 94 TIMOPTIC OCUDOSE (PF) TIMOPTIC-XE TINDAMAX tinidazole TIROSINT TIVICAY... 4 TIVORBEX tizanidine TOBI TOBI PODHALER TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl.. 10 tobramycin in 0.9 % nacl tobramycin sulfate tobramycin-dexamethasone.. 96 TOBREX TOFRANIL TOFRANIL-PM tolazamide tolbutamide tolcapone tolmetin tolterodine TOPAMAX TOPICORT topiramate TOPIRAMATE toposar topotecan TOPROL XL TORISEL torsemide TOUJEO SOLOSTAR TOVIAZ

132 TPN ELECTROLYTES TRACLEER TRADJENTA tramadol TRAMADOL... 36, 37 tramadol-acetaminophen trandolapril trandolapril-verapamil tranexamic acid... 56, 90 TRANSDERM-SCOP TRANXENE T-TAB tranylcypromine travasol 10 % TRAVATAN Z travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELSTAR TRELSTAR DEPOT TRELSTAR LA tretinoin tretinoin (chemotherapy) tretinoin microspheres TRETIN-X TREXALL TREXIMET TREZIX triamcinolone acetonide 63, 64, 66, 101 triamterene-hydrochlorothiazid trianex TRIBENZOR TRICOR triderm trifluoperazine trifluridine TRIGLIDE tri-legest fe TRILEPTAL TRILIPIX trilyte with flavor packets trimethoprim trinessa (28) TRI-NORINYL (28) TRIOSTAT tri-previfem (28) TRISENOX tri-sprintec (28) TRIUMEQ... 4 trivora (28) TRIZIVIR... 4 TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUSOPT TRUVADA... 4 TUDORZA PRESSAIR TWINRIX (PF) TWYNSTA TYBOST... 4 TYGACIL TYKERB TYLENOL-CODEINE # TYLENOL-CODEINE # TYPHIM VI... 86, 87 TYSABRI TYVASO TYZEKA... 4 TYZINE U UCERIS ULORIC ULTRACET ULTRAM ULTRAM ER ULTRAVATE ULTRESA... 78, 79 UNASYN unithroid URECHOLINE UROCIT-K UROCIT-K UROCIT-K UROXATRAL URSO URSO FORTE ursodiol UVADEX V VAGIFEM valacyclovir... 4 VALCHLOR VALCYTE... 4 valganciclovir... 4 VALIUM valproate sodium valproic acid valproic acid (as sodium salt) valsartan valsartan-hydrochlorothiazide VALTREX... 4 VANCOCIN vancomycin vandazole VANOS VAQTA (PF) VARIVAX (PF) VARIZIG VASCEPA VASERETIC VASOTEC VECAMYL VECTIBIX VECTICAL VELCADE velivet triphasic regimen (28) VELPHORO VELTIN venlafaxine... 47, 48 VENLAFAXINE VENTAVIS VENTOLIN HFA VERAMYST verapamil VEREGEN VERELAN VERELAN PM

133 veripred VERSACLOZ VESICARE vestura (28) VEXOL VFEND... 1 VFEND IV... 1 VGO VGO VGO VIBRAMYCIN vicodin vicodin es vicodin hp VICOPROFEN VICTOZA 3-PAK VIDAZA VIDEX 2 GRAM PEDIATRIC... 4 VIDEX EC... 4 VIEKIRA PAK... 4 VIGAMOX VIIBRYD VIMOVO VIMPAT vinblastine vincasar pfs vincristine vinorelbine VIOKACE VIRACEPT... 4 VIRAMUNE... 4 VIRAMUNE XR... 4 VIRAZOLE... 4 VIREAD... 4 VIROPTIC VISTIDE... 4 VITEKTA... 4 VIVELLE-DOT VIVITROL VOGELXO VOLTAREN GEL VOLTAREN-XR voriconazole... 1 VOSPIRE ER VOTRIENT VPRIV vyfemla (28) VYTORIN VYTORIN VYTORIN VYTORIN VYVANSE W warfarin water for irrigation, sterile WELCHOL WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL wymzya fe X XALATAN XALKORI XARELTO XARTEMIS XR XELJANZ XENAZINE XEOMIN XERESE XGEVA XIFAXAN XIGDUO XR XODOL 10/ XODOL 5/ XODOL 7.5/ XOLAIR XOPENEX XOPENEX HFA XTANDI xulane XYLOCAINE XYREM XYZAL Y YASMIN (28) YAZ (28) YERVOY YF-VAX (PF) Z zafirlukast zaleplon ZALTRAP zamicet ZANAFLEX ZANOSAR ZANTAC... 81, 82 ZARONTIN ZAVESCA ZEBETA ZEGERID ZELAPAR ZELBORAF ZEMAIRA ZEMPLAR zenatane zenchent (28) zenchent fe ZENPEP zenzedi ZENZEDI ZERBAXA... 6 ZERIT... 4 ZESTORETIC ZESTRIL ZETIA ZETONNA ZIAC ZIAGEN... 4 ZIANA zidovudine... 4 ZINACEF... 6 ZINECARD (AS HCL) ZIOPTAN (PF) ziprasidone hcl ZIPSOR ZIRGAN ZITHROMAX... 7 ZITHROMAX TRI-PAK... 7 ZITHROMAX Z-PAK... 7 ZMAX... 7 ZOCOR ZOFRAN (AS HYDROCHLORIDE)

134 ZOFRAN ODT ZOHYDRO ER zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan ZOLOFT zolpidem ZOLPIMIST ZOMACTON ZOMETA ZOMIG ZOMIG ZMT ZONALON ZONEGRAN zonisamide ZONTIVITY ZORBTIVE ZORTRESS ZORVOLEX ZOSTAVAX (PF) ZOSYN ZOSYN IN DEXTROSE (ISO- OSM) zovia 1/35e (28) zovia 1/50e (28) ZOVIRAX... 4, 62 ZUBSOLV ZUPLENZ ZYBAN ZYCLARA ZYDELIG ZYFLO ZYFLO CR ZYKADIA ZYLET ZYLOPRIM ZYMAXID ZYPREXA ZYPREXA RELPREVV ZYPREXA ZYDIS ZYTIGA ZYVOX

135 With Express Scripts Medicare, you will have access to over 68,000 network pharmacies nationally. You may fill your prescriptions at a retail, home infusion, long-term care or Indian Health Service / Tribal / Urban Indian Health Program (I/T/U) pharmacy, or through our convenient home delivery service. You must use network pharmacies to fill your prescriptions to get the most out of your benefit. However, there are emergency circumstances under which you may be reimbursed for a covered prescription that is not filled at a network pharmacy. Limitations, copayments and restrictions may apply. This formulary was updated on 08/28/2015. For more recent information or other questions, please contact Express Scripts Medicare Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal Express Scripts Holding Company. All Rights Reserved. Express Scripts and E Logo are trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the property of their respective owners. F0PA4X6A