2019 HAP Formulary. List of covered drugs, cost tiers and how it all works

Transcription

1 HAP Empowered Duals (HMO SNP) 209 HAP Formulary List of covered drugs, cost tiers and how it all works PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THESE PLANS. This formulary was updated March, 209. For more updated information or other questions, please contact our Customer Service department at: HAP Empowered Duals (HMO SNP) (800) TTY: 7 Our business hours are: Prescription drug benefit related calls: Available 24 hours a day, seven days a week For all other calls: 8 a.m. to 8 p.m., seven days a week (Oct. March 3) 8 a.m. to 8 p.m., Monday through Friday (April - Sept. 30) Y0076_ALL Form 209 Formulary ID 983 Version 2

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Health Alliance Plan of Michigan. When it refers to plan or our plan, it means HAP Empowered Duals. This document includes a list of the drugs (formulary) for our plan which is current as of March, 209 For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/ coinsurance may change on January, HAP Empowered Duals (HMO SNP) is a Medicare health plan with a Medicare contract and a contract with Michigan Medicaid. Enrollment in the plan depends on contract renewal.

3 FORMULARY What is the HAP Empowered Duals (HMO SNP) Formulary? A formulary is a list of covered drugs selected by HAP Empowered Duals (HMO SNP) 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 209 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 209 coverage year except when a new, less expensive generic drug becomes available or when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.). Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking the drug. New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the HAP Medicare Advantage Formulary? Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier.). Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. The enclosed formulary is current as of March, 209. To get updated information about the drugs covered by your plan, please contact us. Our contact information appears on the front and back cover pages. Each month we will post an updated Comprehensive Medicare Formulary to our!

4 FORMULARY website at hap.org. The monthly member EOB also contains notification of formulary changes that will occur throughout the plan year to the Medicare Formulary. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. 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. If you know what your drug is used for, look for the category name in the list that begins on page. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 98. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? HAP Empowered Duals (HMO SNP) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: We require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, we limit the amount of the drug that the plan will cover. For example, we provide 30 tablets per prescription for Rozerem. This may be in addition to a standard one month or three month supply. Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the HAP Medicare Advantage formulary? on page III for information about how to request an exception. II

5 FORMULARY What if my drug is not on the Formulary? If your drug is not included in this formulary, (list of covered drugs) you should first contact Customer Service and ask if your drug is covered. If you learn that we do not cover your drug, you have two options: You can ask Customer Services for a list of similar drugs that are covered by the plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by your plan. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the HAP Empowered Duals (HMP SNP) 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 ask us to cover your drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary one month supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30 day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, III

6 FORMULARY we will cover a 3-day emergency supply of that drug while you pursue a formulary exception. past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug while you pursue a formulary exception. An Emergency Supply is defined by CMS as a onetime fill of a non-formulary drug that is necessary with respect to current members in the LTC setting. Current members that are in need of a one-time Emergency Fill or that are prescribed a nonformulary drug as a result of a level of care change are placed in transition. We have authorized our claims processor to place a manual override at the point of sale to accommodate the one time fill in this scenario. Level of care changes include the following changes from one treatment setting to another: Enter Long Term Care facility [LTC] from hospitals or other settings; Leave LTC facility and return to the community; Discharge from a hospital to a home; End a skilled nursing facility stay covered under Medicare Part A (including pharmacy charges), and revert to coverage under Part D; Revert from hospice status to standard Medicare Part A and B benefits; and Discharge from a psychiatric hospital with medication regimens that are highly individualized. For more information For more detailed information about your plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about your plan please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. day/7 days a week. TTY users should call Or, visit gov. HAP Empowered Duals (HMO SNP) Formulary The formulary that begins on page provides coverage information about the drugs covered by HAP Medicare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 98. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ADVAIR DISKUS) and generic drugs are listed in lower-case italics (e.g., gabapentin). The second column of the Drug List represents the drug s cost-sharing level, or tier. Every drug on the Drug List is in one of 5 cost-sharing tiers. In general, the higher the cost-sharing tier, the higher your cost for the drug. The information in the Requirements/Limits column tells you if we have any special requirements for coverage of your drug. If you purchase your benefits individually, you are in a 5 Tier Plan. If your benefits are provided through an employer group, you may have 5, 4, 3 or 2 cost-sharing tiers. The table below will translate how the 5 tiers shown in the Drug List are applicable to your plan s prescription drug benefit. Please refer to the chapter in your Evidence of Coverage titled, What you pay for your Part D prescription drugs. This Chapter explains the cost-sharing tiers for your plan and tells what you must pay for a drug in each cost-sharing tier in the various stages of drug coverage. If you have general questions about Medicare prescription drug coverage, please call Medicare at -800-MEDICARE ( ) 24 hours a IV

7 FORMULARY Description of Tier 5-Tier Plan 4-Tier Plan 3-Tier Plan 2-Tier Plan Preferred Generic This is the lowest costsharing tier Generic These are still generic drugs, but not the preferred generic tier 2 2 Preferred Brand This is the lowest cost non generic tier Non-Preferred Brand These are brand name drugs not in the Preferred Brand tier Specialty Tier This is the highest cost-sharing tier The HAP Empowered Duals (HMO SNP) drug coinsurance amount associated with each tier during the initial coverage stage is 25%. Individual Plan member cost-share. Members of Employer Group/Unions plans should refer to their EOC for further information regarding copayment/coinsurance amounts for each tier. Coverage Notes Abbreviations B/D This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA Limited access; This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service. Our contact information can be found on the front and back cover. PA You (or your physician) are required to get prior authorization from HAP Medicare Advantage before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL We limit the amount of this drug that is covered per 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. EA refers to each (such as tablet or capsule), GM refers to gram, and ML refers to milliliter. ST Before we will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. V

8 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG caspofungin intravenous recon soln 50, 70 clotrimazole mucous membrane troche 0 ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 00 MG, 50 MG fluconazole in dextrose(iso-o) intravenous piggyback 200 /00 ml, 400 /200 ml fluconazole in nacl (iso-osm) intravenous piggyback 200 /00 ml, 400 /200 ml fluconazole oral suspension for reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 50, 200, 50 flucytosine oral capsule 250, 500 griseofulvin microsize oral suspension 25 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 25, 250 itraconazole oral capsule 00 itraconazole oral solution 0 /ml ketoconazole oral tablet 200 MYCAMINE INTRAVENOUS RECON SOLN 00 MG, 50 MG NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG nystatin oral suspension 00,000 unit/ml PA PA

9 nystatin oral tablet 500,000 unit terbinafine hcl oral tablet 250 voriconazole intravenous solution 200 voriconazole oral suspension for reconstitution 200 /5 ml (40 /ml) voriconazole oral tablet 200, 50 ANTIVIRALS abacavir oral solution 20 /ml abacavir oral tablet 300 abacavir-lamivudine oral tablet abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule 200 acyclovir oral suspension 200 /5 ml acyclovir oral tablet 400, 800 acyclovir sodium intravenous solution 50 /ml adefovir oral tablet 0 amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 00 APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 00 MG/ML atazanavir oral capsule 50, 200, 300 ATRIPLA ORAL TABLET MG BARACLUDE ORAL SOLUTION 0.05 MG/ML PA BIKTARVY ORAL TABLET MG CIMDUO ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DELSTRIGO ORAL TABLET MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 200, 250, 400 EDURANT ORAL TABLET 25 MG 2

10 efavirenz oral capsule 200, 50 efavirenz oral tablet 600 EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 0 MG/ML entecavir oral tablet 0.5, PA EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EVOTAZ ORAL TABLET MG QL (30 per 30 days) famciclovir oral tablet 25, 250, 500 fosamprenavir oral tablet 700 FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG HARVONI ORAL TABLET MG PA INTELENCE ORAL TABLET 00 MG, 200 MG, 25 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG QL (60 per 30 days) ISENTRESS ORAL POWDER IN PACKET 00 MG ISENTRESS ORAL TABLET 400 MG QL (60 per 30 days) ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 25 MG JULUCA ORAL TABLET MG KALETRA ORAL TABLET MG, MG lamivudine oral solution 0 /ml lamivudine oral tablet 00, 50, 300 lamivudine-zidovudine oral tablet LEDIPASVIR-SOFOSBUVIR ORAL TABLET MG LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution /5 ml 3 PA MAVYRET ORAL TABLET MG PA moderiba oral tablet 200

11 nevirapine oral tablet 200 nevirapine oral tablet extended release 24 hr 00, 400 NORVIR ORAL POWDER IN PACKET 00 MG NORVIR ORAL SOLUTION 80 MG/ML ODEFSEY ORAL TABLET MG oseltamivir oral capsule 30, 45, 75 PIFELTRO ORAL TABLET 00 MG PREZCOBIX ORAL TABLET MG-MG QL (30 per 30 days) PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG REBETOL ORAL SOLUTION 40 MG/ML PA RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG REYATAZ ORAL POWDER IN PACKET 50 MG ribasphere oral capsule 200 PA ribasphere oral tablet 200, 400, 600 ribasphere ribapak oral tablets,dose pack 200 (7)- 400 (7), (28)- (28), 600 (7)- 400 (7), 600 (7)- 600 (7), (28)- (28), (28)- (28) ribavirin oral capsule 200 PA ribavirin oral tablet 200 PA rimantadine oral tablet 00 ritonavir oral tablet 00 SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 50 MG, 25 MG, 300 MG, 75 MG stavudine oral capsule 5, 20, 30, 40 STRIBILD ORAL TABLET MG 4 QL (30 per 30 days)

12 SYMFI LO ORAL TABLET MG SYMFI ORAL TABLET MG SYMTUZA ORAL TABLET MG tenofovir disoproxil fumarate oral tablet 300 TIVICAY ORAL TABLET 0 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG TYBOST ORAL TABLET 50 MG valacyclovir oral tablet gram, 500 valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 450 VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 25 MG VIRACEPT ORAL TABLET 250 MG, 625 MG VIRAMUNE ORAL SUSPENSION 50 MG/5 ML VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 50 MG, 200 MG, 250 MG ZEPATIER ORAL TABLET MG PA zidovudine oral capsule 00 zidovudine oral syrup 0 /ml zidovudine oral tablet 300 CEPHALOSPORINS AVYCAZ INTRAVENOUS RECON SOLN 2.5 GRAM cefaclor oral capsule 250, 500 cefaclor oral suspension for reconstitution 25 /5 ml, 250 /5 ml, 375 /5 ml cefaclor oral tablet extended release 2 hr 500 5

13 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln gram, 0 gram, 00 gram, 20 gram, 300 g, 500 cefazolin intravenous recon soln gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 25 /5 ml, 250 /5 ml CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML cefepime in dextrose,iso-osm intravenous piggyback gram/50 ml, 2 gram/00 ml cefepime injection recon soln gram, 2 gram cefixime oral suspension for reconstitution 00 /5 ml, 200 /5 ml CEFOTAN INJECTION RECON SOLN GRAM, 2 GRAM cefotaxime injection recon soln gram, 500 CEFOTETAN IN DEXTROSE, ISO-OSM INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML cefotetan injection recon soln gram, 2 gram cefotetan intravenous recon soln 0 gram cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml, 2 gram/50 ml cefoxitin intravenous recon soln gram, 0 gram, 2 gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 200 cefprozil oral suspension for reconstitution 25 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 6

14 CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK GRAM/50 ML, 2 GRAM/50 ML ceftazidime injection recon soln gram, 2 gram, 6 gram ceftriaxone in dextrose,iso-os intravenous piggyback gram/50 ml, 2 gram/50 ml ceftriaxone injection recon soln gram, 0 gram, 2 gram, 250, 500 CEFTRIAXONE INJECTION RECON SOLN 00 GRAM ceftriaxone intravenous recon soln gram, 2 gram cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 250, 500, 750 cephalexin oral suspension for reconstitution 25 /5 ml, 250 /5 ml cephalexin oral tablet 250, 500 SUPRAX ORAL CAPSULE 400 MG SUPRAX ORAL TABLET,CHEWABLE 00 MG, 200 MG TAZICEF INJECTION RECON SOLN GRAM, 2 GRAM, 6 GRAM TAZICEF INTRAVENOUS RECON SOLN GRAM, 2 GRAM TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG ZERBAXA INTRAVENOUS RECON SOLN.5 GRAM ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 500 azithromycin oral packet gram azithromycin oral suspension for reconstitution 00 /5 ml, 200 /5 ml azithromycin oral tablet 250, 250 (6 pack), 500, 500 (3 pack), 600 7

15 clarithromycin oral suspension for reconstitution 25 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 clarithromycin oral tablet extended release 24 hr 500 e.e.s. 400 oral tablet 400 erythrocin (as stearate) oral tablet 250 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 /5 ml erythromycin ethylsuccinate oral tablet 400 erythromycin oral tablet 250, 500 MISCELLANEOUS ANTIINFECTIVES ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG amikacin injection solution 500 /2 ml atovaquone oral suspension 750 /5 ml atovaquone-proguanil oral tablet , aztreonam injection recon soln gram, 2 gram BENZNIDAZOLE ORAL TABLET 00 MG, 2.5 MG BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML BILTRICIDE ORAL TABLET 600 MG CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML chloroquine phosphate oral tablet 250, 500 clindamycin hcl oral capsule 50, 300, 75 CLINDAMYCIN IN 0.9 % SOD CHLOR INTRAVENOUS PIGGYBACK 300 MG/50 ML, 600 MG/50 ML, 900 MG/50 ML LA 8

16 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml), 50 /ml clindamycin phosphate intravenous solution 300 /2 ml, 600 /4 ml, 900 /6 ml COARTEM ORAL TABLET MG colistin (colistimethate na) injection recon soln 50 CYCLOSERINE ORAL CAPSULE 250 MG dapsone oral tablet 00, 25 daptomycin intravenous recon soln 500 DARAPRIM ORAL TABLET 25 MG DORIPENEM INTRAVENOUS RECON SOLN 500 MG EMVERM ORAL TABLET,CHEWABLE 00 MG ertapenem injection recon soln gram ethambutol oral tablet 00, 400 gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 60 /50 ml, 80 /00 ml, 80 /50 ml gentamicin injection solution 40 /ml hydroxychloroquine oral tablet 200 imipenem-cilastatin intravenous recon soln 250, 500 INVANZ INJECTION RECON SOLN GRAM isoniazid oral solution 50 /5 ml isoniazid oral tablet 00, 300 ivermectin oral tablet 3 linezolid in dextrose 5% intravenous piggyback 600 /300 ml 9

17 linezolid oral suspension for reconstitution 00 /5 ml QL (680 per 28 days) linezolid oral tablet 600 QL (56 per 28 days) linezolid-0.9% sodium chloride intravenous parenteral solution 600 /300 ml mefloquine oral tablet 250 meropenem intravenous recon soln gram, 500 MEROPENEM-0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK GRAM/50 ML, 500 MG/50 ML metro i.v. intravenous piggyback 500 /00 ml metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml metronidazole oral capsule 375 metronidazole oral tablet 250, 500 NEBUPENT INHALATION RECON SOLN 300 MG neomycin oral tablet 500 paromomycin oral capsule 250 PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PENTAM INJECTION RECON SOLN 300 MG PRIFTIN ORAL TABLET 50 MG PRIMAQUINE ORAL TABLET 26.3 MG pyrazinamide oral tablet 500 quinine sulfate oral capsule 324 rifabutin oral capsule 50 rifampin intravenous recon soln 600 rifampin oral capsule 50, 300 RIFATER ORAL TABLET MG 0 SIRTURO ORAL TABLET 00 MG PA; LA STREPTOMYCIN INTRAMUSCULAR RECON SOLN GRAM tigecycline intravenous recon soln 50 tinidazole oral tablet 250, 500

18 TOBI PODHALER INHALATION CAPSULE 28 MG TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization 300 /5 ml tobramycin sulfate injection recon soln.2 gram tobramycin sulfate injection solution 0 /ml, 40 /ml TRECATOR ORAL TABLET 250 MG TYGACIL INTRAVENOUS RECON SOLN 50 MG VABOMERE INTRAVENOUS RECON SOLN 2 GRAM VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK GRAM/200 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK GRAM/200 ML, 500 MG/00 ML, 750 MG/50 ML VANCOMYCIN INJECTION RECON SOLN 00 GRAM vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 PA PA vancomycin oral capsule 25, 250 QL (224 per 28 days) PENICILLINS amoxicillin oral capsule 250, 500 amoxicillin oral suspension for reconstitution 25 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 25, 250 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet extended release 2 hr,

19 amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 500 ampicillin sodium injection recon soln gram, 0 gram, 25, 2 gram, 250, 500 ampicillin sodium intravenous recon soln gram, 2 gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram ampicillin-sulbactam intravenous recon soln.5 gram, 3 gram BICILLIN L-A INTRAMUSCULAR SYRINGE,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, 500 nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml, 2 gram/00 ml nafcillin injection recon soln gram, 0 gram, 2 gram nafcillin intravenous recon soln gram, 2 gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, 2 gram/50 ml oxacillin injection recon soln gram, 0 gram, 2 gram PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 20 million unit, 5 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml, 600,000 unit/ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 25 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 PIPERACILLIN-TAZOBACTAM INTRAVENOUS RECON SOLN 3.5 GRAM 2

20 piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr,000, 500 ciprofloxacin hcl oral tablet 00, 250, 500, 750 ciprofloxacin in 5 % dextrose intravenous piggyback 200 /00 ml ciprofloxacin oral suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 250 /50 ml, 500 /00 ml, 750 /50 ml levofloxacin intravenous solution 25 /ml levofloxacin oral solution 250 /0 ml levofloxacin oral tablet 250, 500, 750 MOXIFLOXACIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 400 MG/250 ML moxifloxacin oral tablet 400 MOXIFLOXACIN-SOD.ACE,SUL-WATER INTRAVENOUS PIGGYBACK 400 MG/250 ML ofloxacin oral tablet 300, 400 SULFA'S / RELATED AGENTS sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim oral tablet , sulfatrim oral suspension /5 ml TETRACYCLINES demeclocycline oral tablet 50, 300 doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon soln 00 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00, 20 doxycycline monohydrate oral capsule 00, 50 3

21 doxycycline monohydrate oral tablet 00, 50 minocycline oral capsule 00, 50, 75 minocycline oral tablet 00, 50, 75 minocycline oral tablet extended release 24 hr 35, 45, 90 morgidox oral capsule 50 tetracycline oral capsule 250, 500 URINARY TRACT AGENTS methenamine hippurate oral tablet gram MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule 00, 25, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 nitrofurantoin oral suspension 25 /5 ml trimethoprim oral tablet 00 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS leucovorin calcium oral tablet 0, 5, 25, 5 MESNEX ORAL TABLET 400 MG XGEVA SUBCUTANEOUS SOLUTION 20 MG/.7 ML (70 MG/ML) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS 4 PA abiraterone oral tablet 250 PA AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 0 MG, 2.5 MG, 5 MG, 7.5 MG PA PA ALECENSA ORAL CAPSULE 50 MG PA ALUNBRIG ORAL TABLET 80 MG, 30 MG, 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (23) PA PA anastrozole oral tablet QL (30 per 30 days)

22 ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR 0.5 MG, MG, 5 MG AZASAN ORAL TABLET 00 MG, 75 MG azathioprine oral tablet 50 bexarotene oral capsule 75 bicalutamide oral tablet 50 bleomycin injection recon soln 5 unit, 30 unit BOSULIF ORAL TABLET 00 MG PA; QL (50 per 30 days) BOSULIF ORAL TABLET 400 MG, 500 MG PA; QL (30 per 30 days) BRAFTOVI ORAL CAPSULE 50 MG, 75 MG PA; LA CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG PA; LA CALQUENCE ORAL CAPSULE 00 MG PA; LA CAPRELSA ORAL TABLET 00 MG PA; LA; QL (60 per 30 days) CAPRELSA ORAL TABLET 300 MG PA; LA; QL (30 per 30 days) COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-20 MG X), 40 MG/DAY(80 MG X-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) PA COPIKTRA ORAL CAPSULE 5 MG, 25 MG PA; LA COTELLIC ORAL TABLET 20 MG PA; LA cyclophosphamide oral capsule 25, 50 cyclosporine modified oral capsule 00, 25, 50 cyclosporine modified oral solution 00 /ml cyclosporine oral capsule 00, 25 DAURISMO ORAL TABLET 00 MG, 25 MG PA DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG ELIGARD (3 MONTH) SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG ( MONTH) 5

23 EMCYT ORAL CAPSULE 40 MG ERIVEDGE ORAL CAPSULE 50 MG PA; QL (30 per 30 days) ERLEADA ORAL TABLET 60 MG PA; QL (20 per 30 days) exemestane oral tablet 25 FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 20 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 20 MG, 80 MG flutamide oral capsule 25 PA gengraf oral capsule 00, 25 gengraf oral solution 00 /ml GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 40 MG, 5 MG hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 00 MG, 25 MG, 75 MG PA; QL (30 per 30 days) PA ICLUSIG ORAL TABLET 5 MG, 45 MG PA IDHIFA ORAL TABLET 00 MG, 50 MG PA; LA imatinib oral tablet 00, 400 PA IMBRUVICA ORAL CAPSULE 40 MG PA; QL (20 per 30 days) IMBRUVICA ORAL CAPSULE 70 MG PA; QL (30 per 30 days) IMBRUVICA ORAL TABLET 40 MG, 280 MG, 420 MG, 560 MG PA; QL (30 per 30 days) INLYTA ORAL TABLET MG PA; QL (80 per 30 days) INLYTA ORAL TABLET 5 MG PA; QL (20 per 30 days) IRESSA ORAL TABLET 250 MG PA; QL (60 per 30 days) JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 25 MG, 5 MG KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X )-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG PA; QL (60 per 30 days) PA 6

24 KISQALI ORAL TABLET 200 MG/DAY (200 MG X ), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), 2 MG/DAY (4 MG X 3), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X2), 20 MG/DAY (0 MG X 2), 24 MG/DAY(0 MG X 2-4 MG X ), 4 MG, 8 MG/DAY (4 MG X 2) letrozole oral tablet 2.5 LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit /0.2 ml LONSURF ORAL TABLET MG, MG PA PA PA LORBRENA ORAL TABLET 00 MG, 25 MG PA LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.25 MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT.25 MG, 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT.25 MG, 5 MG, 7.5 MG (PED) LYNPARZA ORAL TABLET 00 MG, 50 MG PA LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral suspension 400 /0 ml (40 /ml), 625 /5 ml 7 PA megestrol oral tablet 20, 40 PA MEKINIST ORAL TABLET 0.5 MG PA; QL (20 per 30 days) MEKINIST ORAL TABLET 2 MG PA; QL (30 per 30 days) MEKTOVI ORAL TABLET 5 MG PA; LA mercaptopurine oral tablet 50

25 methotrexate sodium (pf) injection solution 25 /ml methotrexate sodium injection solution 25 /ml methotrexate sodium oral tablet 2.5 mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension for reconstitution 200 /ml mycophenolate mofetil oral tablet 500 mycophenolate sodium oral tablet,delayed release (dr/ec) 80, 360 MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC) 80 MG, 360 MG NEORAL ORAL CAPSULE 00 MG, 25 MG NEORAL ORAL SOLUTION 00 MG/ML NERLYNX ORAL TABLET 40 MG PA; LA NEXAVAR ORAL TABLET 200 MG PA; LA; QL (20 per 30 days) nilutamide oral tablet 50 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml PA PA ODOMZO ORAL CAPSULE 200 MG PA; LA POMALYST ORAL CAPSULE MG, 2 MG, 3 MG, 4 MG PA; LA PURIXAN ORAL SUSPENSION 20 MG/ML PA RAPAMUNE ORAL SOLUTION MG/ML RAPAMUNE ORAL TABLET 0.5 MG, MG, 2 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG, 2.5 MG, 20 MG, 25 MG, 5 MG RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG PA; LA PA; LA RYDAPT ORAL CAPSULE 25 MG PA SANDIMMUNE ORAL CAPSULE 00 MG, 25 MG SANDIMMUNE ORAL SOLUTION 00 MG/ML 8

26 SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML ( ML), 0.6 MG/ML ( ML), 0.9 MG/ML ( ML) PA sirolimus oral tablet 0.5,, 2 SOLTAMOX ORAL SOLUTION 0 MG/5 ML SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 20 MG/0.5 ML, 90 MG/0.3 ML SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML SPRYCEL ORAL TABLET 00 MG, 40 MG, 20 MG, 50 MG, 70 MG, 80 MG 9 QL (0.2 per 28 days) PA STIVARGA ORAL TABLET 40 MG PA; QL (20 per 30 days) SUTENT ORAL CAPSULE 2.5 MG, 25 MG, 37.5 MG, 50 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG PA PA tacrolimus oral capsule 0.5,, 5 TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA; QL (20 per 30 days) TAGRISSO ORAL TABLET 40 MG, 80 MG PA; LA TALZENNA ORAL CAPSULE 0.25 MG, MG PA tamoxifen oral tablet 0, 20 TARCEVA ORAL TABLET 00 MG, 50 MG, 25 MG TARGRETIN TOPICAL GEL % PA; QL (30 per 30 days) TASIGNA ORAL CAPSULE 50 MG, 200 MG PA; QL (20 per 30 days) TASIGNA ORAL CAPSULE 50 MG PA THALOMID ORAL CAPSULE 00 MG, 50 MG, 200 MG, 50 MG TIBSOVO ORAL TABLET 250 MG PA TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.25 MG, 22.5 MG, 3.75 MG tretinoin (chemotherapy) oral capsule 0 TREXALL ORAL TABLET 0 MG, 5 MG, 5 MG, 7.5 MG PA TYKERB ORAL TABLET 250 MG PA; LA; QL (80 per 30 days)

27 VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG VERZENIO ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG PA; LA PA; LA PA; LA VITRAKVI ORAL CAPSULE 00 MG, 25 MG PA; LA VITRAKVI ORAL SOLUTION 20 MG/ML PA; LA VIZIMPRO ORAL TABLET 5 MG, 30 MG, 45 MG PA VOTRIENT ORAL TABLET 200 MG PA; QL (20 per 30 days) XALKORI ORAL CAPSULE 200 MG, 250 MG PA; QL (60 per 30 days) XATMEP ORAL SOLUTION 2.5 MG/ML PA XERMELO ORAL TABLET 250 MG PA; LA XOSPATA ORAL TABLET 40 MG PA; LA XTANDI ORAL CAPSULE 40 MG PA; QL (20 per 30 days) ZEJULA ORAL CAPSULE 00 MG PA; LA ZELBORAF ORAL TABLET 240 MG PA; QL (240 per 30 days) ZOLINZA ORAL CAPSULE 00 MG QL (20 per 30 days) ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG, MG ZYDELIG ORAL TABLET 00 MG, 50 MG PA ZYKADIA ORAL CAPSULE 50 MG PA ZYTIGA ORAL TABLET 250 MG PA; QL (20 per 30 days) ZYTIGA ORAL TABLET 500 MG PA AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG BRIVIACT ORAL SOLUTION 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 2 hr 00, 200,

28 carbamazepine oral suspension 00 /5 ml carbamazepine oral tablet 200 carbamazepine oral tablet extended release 2 hr 00, 200, 400 carbamazepine oral tablet,chewable 00 CELONTIN ORAL CAPSULE 300 MG clobazam oral suspension 2.5 /ml QL (480 per 30 days) clobazam oral tablet 0, 20 QL (60 per 30 days) clonazepam oral tablet 0.5,, 2 clonazepam oral tablet,disintegrating 0.25, 0.25, 0.5,, 2 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT 2.5 MG diazepam rectal kit , 2.5, DILANTIN 30 MG ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel sprinkle 25 divalproex oral tablet extended release 24 hr 250, 500 divalproex oral tablet,delayed release (dr/ec) 25, 250, 500 EPIDIOLEX ORAL SOLUTION 00 MG/ML PA; LA epitol oral tablet 200 EQUETRO ORAL CAPSULE, ER MULTIPHASE 2 HR 00 MG, 200 MG, 300 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5 ml felbamate oral suspension 600 /5 ml felbamate oral tablet 400, 600 fosphenytoin injection solution 00 pe/2 ml, 500 pe/0 ml FYCOMPA ORAL SUSPENSION 0.5 MG/ML PA FYCOMPA ORAL TABLET 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG 2 PA

29 gabapentin oral capsule 00, 300, 400 PA gabapentin oral solution 250 /5 ml PA gabapentin oral tablet 600, 800 PA GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR 300 MG (9)- 600 MG (69) GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 600 MG lamotrigine oral tablet 00, 50, 200, 25 lamotrigine oral tablet extended release 24hr 00, 200, 25, 250, 300, 50 lamotrigine oral tablet, chewable dispersible 25, 5 lamotrigine oral tablet,disintegrating 00, 200, 25, 50 lamotrigine oral tablets,dose pack 25 (35), 25 (42) -00 (7), 25 (84) -00 (4) levetiracetam oral solution 00 /ml, 500 /5 ml (5 ml) levetiracetam oral tablet,000, 250, 500, 750 levetiracetam oral tablet extended release 24 hr 500, 750 LYRICA ORAL CAPSULE 00 MG, 50 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG PA PA 22 PA LYRICA ORAL SOLUTION 20 MG/ML PA ONFI ORAL SUSPENSION 2.5 MG/ML QL (480 per 30 days) ONFI ORAL TABLET 0 MG, 20 MG QL (6 per 30 days) oxcarbazepine oral suspension 300 /5 ml (60 /ml) oxcarbazepine oral tablet 50, 300, 600 PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 /5 ml (4 /ml) phenobarbital oral tablet 00, 5, 6.2, 30, 32.4, 60, 64.8, 97.2 phenytoin oral suspension 25 /5 ml

30 phenytoin oral tablet,chewable 50 phenytoin sodium extended oral capsule 00, 200, 300 primidone oral tablet 250, 50 roweepra oral tablet,000, 500, 750 roweepra xr oral tablet extended release 24 hr 500, 750 SABRIL ORAL TABLET 500 MG LA SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 250 MG, 500 MG, 750 MG tiagabine oral tablet 2, 6, 2, 4 PA topiramate oral capsule, sprinkle 5, 25 PA topiramate oral tablet 00, 200, 25, 50 valproic acid (as sodium salt) oral solution 250 /5 ml valproic acid oral capsule 250 PA vigabatrin oral powder in packet 500 LA VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 200 MG, 50 MG zonisamide oral capsule 00, 25, 50 PA ANTIPARKINSONISM AGENTS APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML benztropine oral tablet 0.5,, 2 bromocriptine oral capsule 5 bromocriptine oral tablet 2.5 carbidopa-levodopa oral tablet 0-00, 25-00, carbidopa-levodopa oral tablet extended release 25-00, carbidopa-levodopa oral tablet,disintegrating 0-00, 25-00, QL (60 per 30 days) LA 23

31 carbidopa-levodopa-entacapone oral tablet , , , , , entacapone oral tablet 200 NEUPRO TRANSDERMAL PATCH 24 HOUR MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet 0.25, 0.25, 0.5, 0.75,,.5 pramipexole oral tablet extended release 24 hr 0.375, 0.75,.5, 2.25, 3, 3.75, 4.5 PA rasagiline oral tablet 0.5, ST ropinirole oral tablet 0.25, 0.5,, 2, 3, 4, 5 ropinirole oral tablet extended release 24 hr 2, 2, 4, 6, 8 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 tolcapone oral tablet 00 trihexyphenidyl oral elixir 0.4 /ml trihexyphenidyl oral tablet 2, 5 MIGRAINE / CLUSTER HEADACHE THERAPY AIMOVIG AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML dihydroergotamine nasal spray,non-aerosol 0.5 /pump act. (4 /ml) ERGOMAR SUBLINGUAL TABLET 2 MG migergot rectal suppository 2-00 PA PA naratriptan oral tablet, 2.5 QL (8 per 30 days) rizatriptan oral tablet 0, 5 QL (8 per 30 days) rizatriptan oral tablet,disintegrating 0, 5 QL (8 per 30 days) 24

32 sumatriptan nasal spray,non-aerosol 20 /actuation, 5 /actuation sumatriptan succinate oral tablet 00, 25, 50 sumatriptan succinate subcutaneous cartridge 4 /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous pen injector 4 /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous solution 6 /0.5 ml sumatriptan succinate subcutaneous syringe 6 /0.5 ml MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA ORAL TABLET EXTENDED RELEASE 2 HR 0 MG QL (2 per 30 days) QL (8 per 30 days) QL (9 per 30 days) QL (9 per 30 days) QL (9 per 30 days) QL (9 per 30 days) PA; LA AUBAGIO ORAL TABLET 4 MG, 7 MG PA donepezil oral tablet 0, 23, 5 donepezil oral tablet,disintegrating 0, 5 galantamine oral capsule,ext rel. pellets 24 hr 6, 24, 8 galantamine oral solution 4 /ml galantamine oral tablet 2, 4, 8 GILENYA ORAL CAPSULE 0.5 MG PA glatiramer subcutaneous syringe 20 /ml, 40 /ml 25 PA glatopa subcutaneous syringe 20 /ml, 40 /ml PA memantine oral capsule,sprinkle,er 24hr 4, 2, 28, 7 memantine oral solution 2 /ml memantine oral tablet 0, 5 MEMANTINE ORAL TABLETS,DOSE PACK 5-0 MG NUEDEXTA ORAL CAPSULE 20-0 MG PA rivastigmine tartrate oral capsule.5, 3, 4.5, 6 rivastigmine transdermal patch 24 hour 3.3 /24 hour, 4.6 /24 hr, 9.5 /24 hr QL (60 per 30 days)

33 TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 20 MG (4)- 240 MG (46), 240 MG PA; LA tetrabenazine oral tablet 2.5, 25 PA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral tablet 0, 20 BACLOFEN ORAL TABLET 5 MG chlorzoxazone oral tablet 500 cyclobenzaprine oral tablet 0, 5, 7.5 dantrolene oral capsule 00, 25, 50 MESTINON ORAL SYRUP 60 MG/5 ML metaxall oral tablet 800 metaxalone oral tablet 400, 800 methocarbamol oral tablet 500, 750 orphenadrine citrate oral tablet extended release 00 pyridostigmine bromide oral tablet 60 pyridostigmine bromide oral tablet extended release 80 tizanidine oral tablet 2, 4 NARCOTIC ANALGESICS acetaminophen-codeine oral solution 20-2 /5 ml acetaminophen-codeine oral tablet 300-5, QL (4500 per 30 days) QL (240 per 30 days) acetaminophen-codeine oral tablet QL (400 per 30 days) ascomp with codeine oral capsule buprenorphine hcl sublingual tablet 2, 8 BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 0 MCG/HOUR, 5 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule , QL (4 per 28 days) QL (80 per 30 days) 26

34 butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule codeine sulfate oral tablet 5, 30, 60 codeine-butalbital-asa-caff oral capsule duramorph (pf) injection solution 0.5 /ml, /ml endocet oral tablet 0-325, , 5-325, fentanyl citrate buccal lozenge on a handle,200 mcg,,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone-acetaminophen oral solution /5 ml hydrocodone-acetaminophen oral tablet 0-325, , 5-325, hydrocodone-ibuprofen oral tablet 0-200, 5-200, hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone injection syringe 2 /ml hydromorphone oral liquid /ml hydromorphone oral tablet 2, 4, 8 IBUDONE ORAL TABLET MG, MG 27 QL (360 per 30 days) PA QL (0 per 30 days) QL (5520 per 30 days) QL (240 per 30 days) QL (50 per 30 days) QL (50 per 30 days) ibuprofen-oxycodone oral tablet QL (300 per 30 days) LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY levorphanol tartrate oral tablet 2 PA lorcet (hydrocodone) oral tablet QL (240 per 30 days) lorcet hd oral tablet QL (240 per 30 days)

35 lorcet plus oral tablet QL (240 per 30 days) meperidine oral tablet 00, 50 methadone oral solution 0 /5 ml, 5 /5 ml PA methadone oral tablet 0, 5 PA; QL (80 per 30 days) morphine concentrate oral solution 00 /5 ml (20 /ml) morphine injection syringe 0 /ml, 2 /ml, 4 /ml, 8 /ml MORPHINE INTRAVENOUS SYRINGE 0 MG/ML, 8 MG/ML morphine intravenous syringe 2 /ml, 4 /ml morphine oral capsule, er multiphase 24 hr 20, 30, 45, 60, 75, 90 morphine oral capsule,extend.release pellets 0, 00, 20, 30, 40, 50, 60, 80 morphine oral solution 0 /5 ml, 20 /5 ml (4 /ml) 28 QL (90 per 30 days) QL (90 per 30 days) morphine oral tablet 5, 30 QL (20 per 30 days) morphine oral tablet extended release 00, 5, 200, 30, 60 QL (90 per 30 days) oxycodone oral solution 5 /5 ml QL (2400 per 30 days) oxycodone oral tablet 0, 5, 20, 30, 5 OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG oxycodone-acetaminophen oral tablet 0-325, , 5-325, oxymorphone oral tablet extended release 2 hr 0, 5, 20, 30, 40, 5, 7.5 zebutal oral capsule NON-NARCOTIC ANALGESICS buprenorphine-naloxone sublingual tablet QL (80 per 30 days) PA; QL (60 per 30 days) QL (360 per 30 days) QL (60 per 30 days) QL (20 per 30 days) buprenorphine-naloxone sublingual tablet 8-2 QL (90 per 30 days) butorphanol tartrate nasal spray,non-aerosol 0 /ml QL (5 per 28 days)

36 celecoxib oral capsule 00, 200, 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release 24 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 25, 50, 75 QL (60 per 30 days) diclofenac sodium topical drops.5 % QL (450 per 30 days) diclofenac sodium topical gel % diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mcg, mcg diflunisal oral tablet 500 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 etodolac oral tablet extended release 24 hr 400, 500, 600 fenoprofen oral tablet 600 flurbiprofen oral tablet 00, 50 ibu oral tablet 600, 800 ibuprofen oral suspension 00 /5 ml ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25, 50 indomethacin oral capsule, extended release 75 ketoprofen oral capsule 25 ketoprofen oral capsule,ext rel. pellets 24 hr 200 ketorolac oral tablet 0 meclofenamate oral capsule 00, 50 mefenamic acid oral capsule 250 meloxicam oral tablet 5, 7.5 nabumetone oral tablet 500, 750 naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 29

37 naproxen oral suspension 25 /5 ml naproxen oral tablet 250, 375, 500 naproxen oral tablet,delayed release (dr/ec) 375, 500 naproxen sodium oral tablet 275, 550 NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION oxaprozin oral tablet 600 piroxicam oral capsule 0, 20 profeno oral tablet 600 sulindac oral tablet 50, 200 tolmetin oral capsule 400 tolmetin oral tablet 200, 600 TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR MG TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR MG, 200 MG tramadol oral tablet 50 QL (240 per 30 days) tramadol oral tablet extended release 24 hr 00, 200, 300 tramadol oral tablet, er multiphase 24 hr 00, 200, QL (90 per 30 days) QL (90 per 30 days) tramadol-acetaminophen oral tablet QL (240 per 30 days) PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG alprazolam oral tablet 0.25, 0.5,, 2 alprazolam oral tablet extended release 24 hr 0.5,, 2, 3 alprazolam oral tablet,disintegrating 0.25, 0.5,, 2 amitriptyline oral tablet 0, 00, 50, 25, 50, 75 PA PA

38 amitriptyline-chlordiazepoxide oral tablet 2.5-5, 25-0 amoxapine oral tablet 00, 50, 25, 50 APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 74 MG, 348 MG, 522 MG aripiprazole oral solution /ml PA aripiprazole oral tablet 0, 5, 2, 20, 30, 5 aripiprazole oral tablet,disintegrating 0, 5 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING,064 MG/3.9 ML, 44 MG/.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML atomoxetine oral capsule 0, 00, 8, 25, 40, 60, 80 bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release 24 hr 50, 300 bupropion hcl oral tablet sustained-release 2 hr 00, 50, 200 buspirone oral tablet 0, 5, 30, 5, 7.5 PA; QL (30 per 30 days) PA PA chlorpromazine injection solution 25 /ml PA chlorpromazine oral tablet 0, 00, 200, 25, 50 citalopram oral solution 0 /5 ml citalopram oral tablet 0, 20, 40 clomipramine oral capsule 25, 50, 75 clonidine hcl oral tablet extended release 2 hr 0. clorazepate dipotassium oral tablet 5, 3.75, 7.5 clozapine oral tablet 00, 200, 25, 50 clozapine oral tablet,disintegrating 00, 2.5, 25 PA PA; QL (270 per 30 days) 3

39 CLOZAPINE ORAL TABLET,DISINTEGRATING 50 MG, 200 MG desipramine oral tablet 0, 00, 50, 25, 50, 75 desvenlafaxine succinate oral tablet extended release 24 hr 00, 25, 50 dexmethylphenidate oral capsule,er biphasic , 5, 20, 25, 30, 35, 40, 5 dexmethylphenidate oral tablet 0, 2.5, 5 dextroamphetamine oral capsule, extended release 0 dextroamphetamine oral capsule, extended release 5, 5 PA; QL (270 per 30 days) QL (30 per 30 days) QL (80 per 30 days) QL (20 per 30 days) dextroamphetamine oral tablet 0 QL (80 per 30 days) dextroamphetamine oral tablet 5 QL (20 per 30 days) dextroamphetamine-amphetamine oral capsule,extended release 24hr 0, 5, 20, 25, 30, 5 dextroamphetamine-amphetamine oral tablet 0, 2.5, 5, 20, 30, 5, 7.5 diazepam injection solution 5 /ml diazepam injection syringe 5 /ml diazepam intensol oral concentrate 5 /ml diazepam oral concentrate 5 /ml diazepam oral solution 5 /5 ml ( /ml) diazepam oral tablet 0, 2, 5 doxepin oral capsule 0, 00, 50, 25, 50, 75 doxepin oral concentrate 0 /ml duloxetine oral capsule,delayed release(dr/ec) 20, 30, 40, 60 EMSAM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR ergoloid oral tablet escitalopram oxalate oral solution 5 /5 ml QL (60 per 30 days) QL (60 per 30 days) 32

40 escitalopram oxalate oral tablet 0, 20, 5 estazolam oral tablet, 2 eszopiclone oral tablet, 2, 3 FANAPT ORAL TABLET MG, 0 MG, 2 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK MG(2)-2MG(2)- 4MG(2)-6MG(2) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG, 20 MG, 40 MG, 80 MG fluoxetine oral capsule 0, 20, 40 fluoxetine oral capsule,delayed release(dr/ec) 90 fluoxetine oral solution 20 /5 ml (4 /ml) fluoxetine oral tablet 0, 20, 60 fluphenazine decanoate injection solution 25 /ml QL (30 per 30 days) PA PA PA PA PA fluphenazine hcl injection solution 2.5 /ml PA fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5 ml fluphenazine hcl oral tablet, 0, 2.5, 5 fluvoxamine oral capsule,extended release 24hr 00, 50 fluvoxamine oral tablet 00, 25, 50 GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) guanfacine oral tablet extended release 24 hr, 2, 3, 4 guanidine oral tablet 25 haloperidol decanoate intramuscular solution 00 /ml, 00 /ml ( ml), 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate intramuscular syringe 5 /ml QL (60 per 30 days) PA 33

41 haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5,, 0, 2, 20, 5 HETLIOZ ORAL CAPSULE 20 MG PA imipramine hcl oral tablet 0, 25, 50 imipramine pamoate oral capsule 00, 25, 50, 75 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML, 56 MG/ML, 234 MG/.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML, 40 MG/.35 ML, 546 MG/.75 ML, 89 MG/2.625 ML LATUDA ORAL TABLET 20 MG, 20 MG, 40 MG, 60 MG, 80 MG lithium carbonate oral capsule 50, 300, 600 lithium carbonate oral tablet 300 lithium carbonate oral tablet extended release 300, 450 lithium citrate oral solution 8 meq/5 ml lorazepam oral tablet 0.5,, 2 loxapine succinate oral capsule 0, 25, 5, 50 maprotiline oral tablet 25, 50, 75 MARPLAN ORAL TABLET 0 MG metadate er oral tablet extended release PA PA PA methamphetamine oral tablet 5 PA methylphenidate hcl oral capsule, er biphasic , 20, 30, 40, 50, 60 methylphenidate hcl oral capsule,er biphasic , 20, 30, 40, 60 methylphenidate hcl oral solution 0 /5 ml, 5 /5 ml methylphenidate hcl oral tablet 0, 20, 5 methylphenidate hcl oral tablet extended release 0, 20

42 methylphenidate hcl oral tablet extended release 24hr 8, 27, 36, 54 methylphenidate hcl oral tablet,chewable 0, 2.5, 5 mirtazapine oral tablet 5, 30, 45, 7.5 mirtazapine oral tablet,disintegrating 5, 30, 45 modafinil oral tablet 00, 200 PA molindone oral tablet 0, 25, 5 nefazodone oral tablet 00, 50, 200, 250, 50 nortriptyline oral capsule 0, 25, 50, 75 nortriptyline oral solution 0 /5 ml NUPLAZID ORAL CAPSULE 34 MG PA NUPLAZID ORAL TABLET 0 MG, 7 MG PA olanzapine intramuscular recon soln 0 olanzapine oral tablet 0, 5, 2.5, 20, 5, 7.5 olanzapine oral tablet,disintegrating 0, 5, 20, 5 olanzapine-fluoxetine oral capsule 2-25, 2-50, 3-25, 6-25, 6-50 oxazepam oral capsule 0, 5, 30 paliperidone oral tablet extended release 24hr.5 paliperidone oral tablet extended release 24hr 3 paliperidone oral tablet extended release 24hr 6 paliperidone oral tablet extended release 24hr 9 paroxetine hcl oral tablet 0, 20, 30, 40 paroxetine hcl oral tablet extended release 24 hr 2.5, 25, 37.5 PAXIL ORAL SUSPENSION 0 MG/5 ML 35 QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) PA; QL (240 per 30 days) PA; QL (20 per 30 days) PA; QL (60 per 30 days) PA; QL (30 per 30 days)

43 perphenazine oral tablet 6, 2, 4, 8 perphenazine-amitriptyline oral tablet 2-0, 2-25, 4-0, 4-25, 4-50 PEXEVA ORAL TABLET 0 MG, 20 MG, 30 MG, 40 MG phenelzine oral tablet 5 pimozide oral tablet, 2 protriptyline oral tablet 0, 5 quetiapine oral tablet 00, 200, 25, 300, 400, 50 quetiapine oral tablet extended release 24 hr 50, 200, 300, 400, 50 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 2.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution /ml risperidone oral tablet 0.25, 0.5,, 2, 3, 4 risperidone oral tablet,disintegrating 0.25, 0.5,, 2, 3, 4 36 QL (90 per 30 days) PA; QL (60 per 30 days) PA ROZEREM ORAL TABLET 8 MG QL (30 per 30 days) SAPHRIS SUBLINGUAL TABLET 0 MG, 2.5 MG, 5 MG sertraline oral concentrate 20 /ml sertraline oral tablet 00, 25, 50 temazepam oral capsule 5, 22.5, 30, 7.5 thioridazine oral tablet 0, 00, 25, 50 thiothixene oral capsule, 0, 2, 5 tranylcypromine oral tablet 0 trazodone oral tablet 00, 50, 300, 50 triazolam oral tablet 0.25, 0.25 trifluoperazine oral tablet, 0, 2, 5 PA PA

44 trimipramine oral capsule 00, 25, 50 TRINTELLIX ORAL TABLET 0 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release 24hr 50, 37.5, 75 venlafaxine oral tablet 00, 25, 37.5, 50, 75 PA VERSACLOZ ORAL SUSPENSION 50 MG/ML PA VIIBRYD ORAL TABLET 0 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (23) VRAYLAR ORAL CAPSULE.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- 3 MG (6) PA PA PA PA XYREM ORAL SOLUTION 500 MG/ML PA; LA zaleplon oral capsule 0, 5 ziprasidone hcl oral capsule 20, 60 QL (60 per 30 days) ziprasidone hcl oral capsule 40, 80 QL (20 per 30 days) zolpidem oral tablet 0, 5 zolpidem oral tablet,ext release multiphase 2.5, 6.25 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG, 300 MG, 405 MG CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral tablet 00, 200, 400 disopyramide phosphate oral capsule 00, 50 dofetilide oral capsule 25 mcg, 250 mcg, 500 mcg flecainide oral tablet 00, 50, 50 mexiletine oral capsule 50, 200, 250 MULTAQ ORAL TABLET 400 MG pacerone oral tablet 00, 200,

45 propafenone oral capsule,extended release 2 hr 225, 325, 425 propafenone oral tablet 50, 225, 300 quinidine gluconate oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 sorine oral tablet 20, 60, 240, 80 sotalol af oral tablet 20, 60, 80 sotalol oral tablet 20, 60, 240, 80 ANTIHYPERTENSIVE THERAPY acebutolol oral capsule 200, 400 amiloride oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 amlodipine oral tablet 0, 2.5, 5 amlodipine-benazepril oral capsule 0-20, 0-40, 2.5-0, 5-0, 5-20, 5-40 amlodipine-olmesartan oral tablet 0-20, 0-40, 5-20, 5-40 amlodipine-valsartan oral tablet 0-320, 5-60 amlodipine-valsartan-hcthiazid oral tablet , , , , atenolol oral tablet 00, 25, 50 atenolol-chlorthalidone oral tablet 00-25, benazepril oral tablet 0, 20, 40, 5 benazepril-hydrochlorothiazide oral tablet 0-2.5, , 20-25, betaxolol oral tablet 0, 20 bisoprolol fumarate oral tablet 0, 5 bisoprolol-hydrochlorothiazide oral tablet , , bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5,, 2 candesartan oral tablet 6, 32, 4, 8 38

46 candesartan-hydrochlorothiazid oral tablet 6-2.5, , captopril oral tablet 00, 2.5, 25, 50 captopril-hydrochlorothiazide oral tablet 25-5, 25-25, 50-5, cartia xt oral capsule,extended release 24hr 20, 80, 240, 300 carvedilol oral tablet 2.5, 25, 3.25, 6.25 chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 25, 50 clonidine hcl oral tablet 0., 0.2, 0.3 clonidine transdermal patch weekly 0. /24 hr, 0.2 /24 hr, 0.3 /24 hr DEMSER ORAL CAPSULE 250 MG PA diltiazem hcl oral capsule,ext.rel 24h degradable 20, 80, 240 diltiazem hcl oral capsule,extended release 2 hr 20, 60, 90 diltiazem hcl oral capsule,extended release 24 hr 20, 80, 240, 300, 360, 420 diltiazem hcl oral capsule,extended release 24hr 20, 80, 240, 300, 360 diltiazem hcl oral tablet 20, 30, 60, 90 dilt-xr oral capsule,ext.rel 24h degradable 20, 80, 240 doxazosin oral tablet, 2, 4, 8 DYRENIUM ORAL CAPSULE 00 MG, 50 MG enalapril maleate oral tablet 0, 2.5, 20, 5 enalapril-hydrochlorothiazide oral tablet 0-25, eplerenone oral tablet 25, 50 eprosartan oral tablet 600 ethacrynic acid oral tablet 25 39

47 felodipine oral tablet extended release 24 hr 0, 2.5, 5 fosinopril oral tablet 0, 20, 40 fosinopril-hydrochlorothiazide oral tablet 0-2.5, furosemide injection solution 0 /ml furosemide injection syringe 0 /ml furosemide oral solution 0 /ml, 40 /5 ml (8 /ml) furosemide oral tablet 20, 40, 80 guanfacine oral tablet, 2 hydralazine oral tablet 0, 00, 25, 50 hydrochlorothiazide oral capsule 2.5 hydrochlorothiazide oral tablet 2.5, 25, 50 indapamide oral tablet.25, 2.5 irbesartan oral tablet 50, 300, 75 irbesartan-hydrochlorothiazide oral tablet , isradipine oral capsule 2.5, 5 labetalol oral tablet 00, 200, 300 lisinopril oral tablet 0, 2.5, 20, 30, 40, 5 lisinopril-hydrochlorothiazide oral tablet 0-2.5, , losartan oral tablet 00, 25, 50 losartan-hydrochlorothiazide oral tablet , 00-25, matzim la oral tablet extended release 24 hr 80, 240, 300, 360, 420 methyclothiazide oral tablet 5 metolazone oral tablet 0, 2.5, 5 metoprolol succinate oral tablet extended release 24 hr 00, 200, 25, 50 metoprolol ta-hydrochlorothiaz oral tablet 00-25, 00-50,

48 metoprolol tartrate oral tablet 00, 25, 50 minoxidil oral tablet 0, 2.5 moexipril oral tablet 5, 7.5 moexipril-hydrochlorothiazide oral tablet 5-2.5, 5-25, nadolol oral tablet 20, 40, 80 nifedipine oral capsule 0, 20 nifedipine oral tablet extended release 24hr 30, 60, 90 nifedipine oral tablet extended release 30, 60, 90 nimodipine oral capsule 30 olmesartan oral tablet 20, 40, 5 olmesartan-amlodipin-hcthiazid oral tablet , , , , olmesartan-hydrochlorothiazide oral tablet , , perindopril erbumine oral tablet 2, 4, 8 pindolol oral tablet 0, 5 prazosin oral capsule, 2, 5 propranolol oral capsule,extended release 24 hr 20, 60, 60, 80 propranolol oral solution 20 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 20, 40, 60, 80 propranolol-hydrochlorothiazid oral tablet 40-25, quinapril oral tablet 0, 20, 40, 5 quinapril-hydrochlorothiazide oral tablet 0-2.5, , ramipril oral capsule.25, 0, 2.5, 5 spironolactone oral tablet 00, 25, 50 spironolacton-hydrochlorothiaz oral tablet

49 taztia xt oral capsule,extended release 24 hr 20, 80, 240, 300, 360 TEKTURNA HCT ORAL TABLET MG, MG, MG, MG 42 PA TEKTURNA ORAL TABLET 50 MG, 300 MG PA telmisartan oral tablet 20, 40, 80 telmisartan-amlodipine oral tablet 40-0, 40-5, 80-0, 80-5 telmisartan-hydrochlorothiazid oral tablet , , terazosin oral capsule, 0, 2, 5 timolol maleate oral tablet 0, 20, 5 torsemide oral tablet 0, 00, 20, 5 trandolapril oral tablet, 2, 4 triamterene-hydrochlorothiazid oral capsule , triamterene-hydrochlorothiazid oral tablet , UPTRAVI ORAL TABLET,000 MCG,,200 MCG,,400 MCG,,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (40)- 800 MCG (60) valsartan oral tablet 60, 320, 40, 80 valsartan-hydrochlorothiazide oral tablet , 60-25, , , verapamil oral capsule, 24 hr er pellet ct 00, 200, 300 verapamil oral capsule,ext rel. pellets 24 hr 20, 80, 240, 360 verapamil oral tablet 20, 40, 80 verapamil oral tablet extended release 20, 80, 240 COAGULATION THERAPY aspirin-dipyridamole oral capsule, er multiphase 2 hr PA; LA PA; LA QL (30 per 30 days) QL (60 per 30 days)

50 BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00, 50 clopidogrel oral tablet 75 QL (30 per 30 days) COUMADIN ORAL TABLET MG, 0 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG dipyridamole oral tablet 25, 50, 75 DOPTELET (0 TAB PACK) ORAL TABLET 20 MG DOPTELET (5 TAB PACK) ORAL TABLET 20 MG ELIQUIS ORAL TABLET 2.5 MG, 5 MG ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS) enoxaparin subcutaneous syringe 00 /ml, 50 /ml enoxaparin subcutaneous syringe 20 /0.8 ml, 80 /0.8 ml PA; LA PA; LA QL (60 per 30 days) QL (48 per 30 days) enoxaparin subcutaneous syringe 30 /0.3 ml QL (8 per 30 days) enoxaparin subcutaneous syringe 40 /0.4 ml QL (24 per 30 days) enoxaparin subcutaneous syringe 60 /0.6 ml QL (36 per 30 days) fondaparinux subcutaneous syringe 0 /0.8 ml QL (24 per 30 days) fondaparinux subcutaneous syringe 2.5 /0.5 ml QL (5 per 30 days) fondaparinux subcutaneous syringe 5 /0.4 ml QL (2 per 30 days) fondaparinux subcutaneous syringe 7.5 /0.6 ml QL (8 per 30 days) heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(00 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml, 2,000 unit/,000 ml heparin (porcine) injection cartridge 5,000 unit/ml ( ml) heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml 43

51 HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 2,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml heparin, porcine (pf) injection solution,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml jantoven oral tablet, 0, 2, 2.5, 3, 4, 5, 6, 7.5 pentoxifylline oral tablet extended release 400 PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG prasugrel oral tablet 0, 5 PROMACTA ORAL TABLET 2.5 MG, 25 MG, 50 MG, 75 MG 44 PA; LA TAVALISSE ORAL TABLET 00 MG, 50 MG PA; LA warfarin oral tablet, 0, 2, 2.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 0 MG, 5 MG, 2.5 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (42)- 20 MG (9) LIPID/CHOLESTEROL LOWERING AGENTS amlodipine-atorvastatin oral tablet 0-0, 0-20, 0-40, 0-80, 2.5-0, , , 5-0, 5-20, 5-40, 5-80 atorvastatin oral tablet 0, 20, 40, 80 cholestyramine (with sugar) oral powder 4 gram cholestyramine (with sugar) oral powder in packet 4 gram cholestyramine light oral powder 4 gram cholestyramine light oral powder in packet 4 gram colesevelam oral powder in packet 3.75 gram colesevelam oral tablet 625

52 colestipol oral granules 5 gram colestipol oral packet 5 gram colestipol oral tablet gram ezetimibe oral tablet 0 ezetimibe-simvastatin oral tablet 0-0, 0-20, 0-40, 0-80 fenofibrate micronized oral capsule 30, 34, 200, 43, 67 fenofibrate nanocrystallized oral tablet 45, 48 FENOFIBRATE ORAL CAPSULE 50 MG, 50 MG fenofibrate oral tablet 60, 54 fenofibric acid oral tablet 35 fluvastatin oral capsule 20, 40 ST fluvastatin oral tablet extended release 24 hr 80 gemfibrozil oral tablet 600 JUXTAPID ORAL CAPSULE 0 MG, 20 MG, 30 MG, 40 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS SYRINGE 200 MG/ML lovastatin oral tablet 0, 20, 40 niacin oral tablet extended release 24 hr,000, 500, 750 NIACOR ORAL TABLET 500 MG omega-3 acid ethyl esters oral capsule gram PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML, 75 MG/ML pravastatin oral tablet 0, 20, 40, 80 prevalite oral powder 4 gram prevalite oral powder in packet 4 gram REPATHA SUBCUTANEOUS SYRINGE 40 MG/ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 40 MG/ML 45 ST PA; LA PA; LA PA PA PA

53 rosuvastatin oral tablet 0, 20, 40, 5 simvastatin oral tablet 0, 20, 40, 5, 80 WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 625 MG MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR ORAL TABLET 5 MG, 7.5 MG PA digitek oral tablet 25 mcg, 250 mcg digox oral tablet 25 mcg, 250 mcg digoxin oral solution 50 mcg/ml digoxin oral tablet 25 mcg, 250 mcg ENTRESTO ORAL TABLET MG, 49-5 MG, MG LANOXIN ORAL TABLET 87.5 MCG, 62.5 MCG RANEXA ORAL TABLET EXTENDED RELEASE 2 HR,000 MG, 500 MG NITRATES isosorbide dinitrate oral tablet 0, 20, 30, 5 isosorbide dinitrate oral tablet extended release 40 isosorbide mononitrate oral tablet 0, 20 isosorbide mononitrate oral tablet extended release 24 hr 20, 30, 60 MINITRAN TRANSDERMAL PATCH 24 HOUR 0. MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR nitro-bid transdermal ointment 2 % NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet 0.3, 0.4, 0.6 nitroglycerin transdermal patch 24 hour 0. /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr PA QL (60 per 30 days) 46

54 nitroglycerin translingual spray,non-aerosol 400 mcg/spray DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 0, 7.5, 25 PA calcipotriene scalp solution % calcipotriene topical cream % calcipotriene topical ointment % calcipotriene-betamethasone topical ointment % selenium sulfide topical lotion 2.5 % STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML MISCELLANEOUS DERMATOLOGICALS ammonium lactate topical cream 2 % ammonium lactate topical lotion 2 % PA PA diclofenac sodium topical gel 3 % PA ELIDEL TOPICAL CREAM % QL (30 per 30 days) FLUOROURACIL TOPICAL CREAM 0.5 % fluorouracil topical cream 5 % fluorouracil topical solution 2 %, 5 % imiquimod topical cream in packet 5 % lidocaine hcl laryngotracheal solution 4 % lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane jelly in applicator 2 % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % PA lidocaine topical ointment 5 % PA; QL (60 per 30 days) lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % 47

55 methoxsalen oral capsule,liqd-filled,rapid rel 0 PANRETIN TOPICAL GEL 0. % PA PICATO TOPICAL GEL 0.05 %, 0.05 % podofilox topical solution 0.5 % REGRANEX TOPICAL GEL 0.0 % SANTYL TOPICAL OINTMENT 250 UNIT/GRAM silver sulfadiazine topical cream % ssd topical cream % tacrolimus topical ointment 0.03 %, 0. % QL (30 per 30 days) VALCHLOR TOPICAL GEL 0.06 % PA THERAPY FOR ACNE adapalene topical cream 0. % PA adapalene topical gel 0. % PA adapalene topical solution 0. % amnesteem oral capsule 0, 20, 40 avita topical cream % PA AVITA TOPICAL GEL % PA AZELEX TOPICAL CREAM 20 % claravis oral capsule 0, 20, 30, 40 clindacin p topical swab % clindamycin phosphate topical gel % CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin-benzoyl peroxide topical gel -5 %,.2 %( % base) -5 % clindamycin-benzoyl peroxide topical gel with pump -5 % ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % 48

56 erythromycin with ethanol topical swab 2 % erythromycin-benzoyl peroxide topical gel 3-5 % FINACEA TOPICAL FOAM 5 % FINACEA TOPICAL GEL 5 % metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, % metronidazole topical gel with pump % metronidazole topical lotion 0.75 % MIRVASO TOPICAL GEL 0.33 % PA MIRVASO TOPICAL GEL WITH PUMP 0.33 % PA myorisan oral capsule 0, 20, 30, 40 neuac topical gel.2 %( % base) -5 % rosadan topical cream 0.75 % rosadan topical gel 0.75 % tazarotene topical cream 0. % PA TAZORAC TOPICAL CREAM 0.05 % PA TAZORAC TOPICAL GEL 0.05 %, 0. % PA tretinoin topical cream %, 0.05 %, 0. % PA tretinoin topical gel 0.0 %, %, 0.05 % PA zenatane oral capsule 0, 20, 30, 40 TOPICAL ANTIBACTERIALS CORTISPORIN TOPICAL OINTMENT % gentamicin topical cream 0. % gentamicin topical ointment 0. % mupirocin calcium topical cream 2 % mupirocin topical ointment 2 % sulfacetamide sodium (acne) topical suspension 0 % TOPICAL ANTIFUNGALS ciclodan topical solution 8 % ciclopirox topical cream 0.77 % ciclopirox topical gel 0.77 % ciclopirox topical shampoo % 49

57 ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % clotrimazole topical cream % clotrimazole topical solution % clotrimazole-betamethasone topical cream % clotrimazole-betamethasone topical lotion % econazole topical cream % EXELDERM TOPICAL CREAM % EXELDERM TOPICAL SOLUTION % ketoconazole topical cream 2 % ketoconazole topical foam 2 % ketoconazole topical shampoo 2 % MENTAX TOPICAL CREAM % naftifine topical cream %, 2 % NAFTIN TOPICAL GEL %, 2 % nyamyc topical powder 00,000 unit/gram nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 unit/gram nystatin-triamcinolone topical cream 00, unit/g-% nystatin-triamcinolone topical ointment 00, unit/gram-% nystop topical powder 00,000 unit/gram oxiconazole topical cream % OXISTAT TOPICAL LOTION % TOPICAL ANTIVIRALS acyclovir topical ointment 5 % DENAVIR TOPICAL CREAM % TOPICAL CORTICOSTEROIDS ala-cort topical cream %, 2.5 % alclometasone topical cream 0.05 % 50

58 alclometasone topical ointment 0.05 % amcinonide topical cream 0. % amcinonide topical lotion 0. % amcinonide topical ointment 0. % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0. % betamethasone valerate topical foam 0.2 % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % clobetasol scalp solution 0.05 % clobetasol topical cream 0.05 % clobetasol topical foam 0.05 % clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % clobetasol topical ointment 0.05 % clobetasol topical shampoo 0.05 % clobetasol topical spray,non-aerosol 0.05 % clobetasol-emollient topical cream 0.05 % clodan topical shampoo 0.05 % CORDRAN TAPE LARGE ROLL TOPICAL TAPE 4 MCG/CM2 desonide topical cream 0.05 % desonide topical lotion 0.05 % desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.25 % desoximetasone topical gel 0.05 % 5

59 desoximetasone topical ointment 0.05 %, 0.25 % desoximetasone topical spray,non-aerosol 0.25 % diflorasone topical cream 0.05 % diflorasone topical ointment 0.05 % fluocinolone and shower cap scalp oil 0.0 % fluocinolone topical cream 0.0 %, % fluocinolone topical oil 0.0 % fluocinolone topical ointment % fluocinolone topical solution 0.0 % fluocinonide topical cream 0.05 %, 0. % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluocinonide-emollient topical cream 0.05 % fluticasone topical cream 0.05 % fluticasone topical ointment % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % HALOG TOPICAL CREAM 0. % HALOG TOPICAL OINTMENT 0. % hydrocortisone topical cream %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment %, 2.5 % hydrocortisone-min oil-wht pet topical ointment % mometasone topical cream 0. % mometasone topical ointment 0. % mometasone topical solution 0. % prednicarbate topical cream 0. % prednicarbate topical ointment 0. % triamcinolone acetonide topical aerosol 0.47 /gram 52

60 triamcinolone acetonide topical cream %, 0. %, 0.5 % triamcinolone acetonide topical lotion %, 0. % triamcinolone acetonide topical ointment %, 0. %, 0.5 % triderm topical cream 0. % TOPICAL SCABICIDES / PEDICULICIDES lindane topical shampoo % malathion topical lotion 0.5 % permethrin topical cream 5 % DIAGNOSTICS / MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS acamprosate oral tablet,delayed release (dr/ec) 333 alendronate oral tablet 40 QL (30 per 30 days) anagrelide oral capsule 0.5, ARALAST NP INTRAVENOUS RECON SOLN,000 MG, 500 MG AURYXIA ORAL TABLET 20 MG IRON CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG cevimeline oral capsule 30 CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 2.75%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % d0 %-0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution 53 PA; LA LA

61 d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 0 % and 0.2 % nacl intravenous parenteral solution dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 30 % in water (d30w) intravenous parenteral solution dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback 5 % dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution % disulfiram oral tablet 250, 500 etidronate disodium oral tablet 400 EXJADE ORAL TABLET, DISPERSIBLE 25 MG, 250 MG, 500 MG 54 PA; LA FERRIPROX ORAL TABLET 500 MG PA GLASSIA INTRAVENOUS SOLUTION GRAM/50 ML (2 %) PA; LA

62 INCRELEX SUBCUTANEOUS SOLUTION 0 MG/ML kionex (with sorbitol) oral suspension gram/60 ml lanthanum oral tablet,chewable,000, 500, 750 levocarnitine (with sugar) oral solution 00 /ml levocarnitine oral tablet 330 midodrine oral tablet 0, 2.5, 5 NORTHERA ORAL CAPSULE 00 MG, 200 MG, 300 MG ORFADIN ORAL CAPSULE 0 MG, 2 MG, 20 MG, 5 MG PA; LA 55 PA; LA ORFADIN ORAL SUSPENSION 4 MG/ML PA; LA pilocarpine hcl oral tablet 5, 7.5 PROLASTIN-C INTRAVENOUS RECON SOLN,000 MG PROLASTIN-C INTRAVENOUS SOLUTION,000 MG (+/-)/20 ML PA; LA PA; LA RAVICTI ORAL LIQUID. GRAM/ML PA RENAGEL ORAL TABLET 800 MG riluzole oral tablet 50 risedronate oral tablet 30 sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram QL (540 per 30 days) sevelamer carbonate oral tablet 800 QL (540 per 30 days) sodium chloride 0.9 % intravenous parenteral solution sodium chloride 0.9 % intravenous piggyback sodium chloride irrigation solution 0.9 % sodium phenylbutyrate oral powder 0.94 gram/gram sodium polystyrene (sorb free) oral suspension 5 gram/60 ml sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 5 gram/60 ml PA

63 sodium polystyrene sulfonate rectal enema 30 gram/20 ml SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML sps (with sorbitol) oral suspension 5-20 gram/60 ml sps (with sorbitol) rectal enema gram/20 ml trientine oral capsule 250 PA VELTASSA ORAL POWDER IN PACKET 6.8 GRAM, 25.2 GRAM, 8.4 GRAM XURIDEN ORAL GRANULES IN PACKET 2 GRAM ZEMAIRA INTRAVENOUS RECON SOLN,000 MG SMOKING DETERRENTS bupropion hcl (smoking deter) oral tablet extended release 2 hr 50 CHANTIX CONTINUING MONTH BOX ORAL TABLET MG CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (42) NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 0 MG/ML EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal aerosol,spray 37 mcg (0. %) azelastine nasal spray,non-aerosol 0.5 % (205.5 mcg) BACTROBAN NASAL NASAL OINTMENT 2 % chlorhexidine gluconate mucous membrane mouthwash 0.2 % ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 mcg (0.06 %) 56 PA PA PA; LA

64 olopatadine nasal spray,non-aerosol 0.6 % oralone dental paste 0. % paroex oral rinse mucous membrane mouthwash 0.2 % periogard mucous membrane mouthwash 0.2 % triamcinolone acetonide dental paste 0. % MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) solution 2 % fluocinolone acetonide oil otic (ear) drops 0.0 % hydrocortisone-acetic acid otic (ear) drops -2 % ofloxacin otic (ear) drops 0.3 % OTIC STEROID / ANTIBIOTIC CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.2- % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION MG/ML neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-0,000- /ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution 3.5-0,000- /ml-unit/ml-% ENDOCRINE/DIABETES ADRENAL HORMONES cortisone oral tablet 25 dexamethasone intensol oral drops /ml dexamethasone oral elixir 0.5 /5 ml dexamethasone oral solution 0.5 /5 ml dexamethasone oral tablet 0.5, 0.75,,.5, 2, 4, 6 dexamethasone oral tablets,dose pack.5 (2 tabs),.5 (35 tabs),.5 (5 tabs) dexamethasone sodium phos (pf) injection solution 0 /ml dexamethasone sodium phosphate injection solution 0 /ml, 4 /ml 57

65 dexamethasone sodium phosphate injection syringe 4 /ml fludrocortisone oral tablet 0. hydrocortisone oral tablet 0, 20, 5 methylprednisolone acetate injection suspension 40 /ml, 80 /ml methylprednisolone oral tablet 6, 32, 4, 8 methylprednisolone oral tablets,dose pack 4 methylprednisolone sodium succ injection recon soln 25, 40 methylprednisolone sodium succ intravenous recon soln, millipred oral tablet 5 prednisolone oral solution 5 /5 ml prednisolone sodium phosphate oral solution 0 /5 ml, 5 /5 ml (3 /ml), 20 /5 ml (4 /ml), 25 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) prednisone intensol oral concentrate 5 /ml prednisone oral solution 5 /5 ml prednisone oral tablet, 0, 2.5, 20, 5, 50 prednisone oral tablets,dose pack 0, 0 (48 pack), 5, 5 (48 pack) veripred 20 oral solution 20 /5 ml (4 /ml) ANTITHYROID AGENTS methimazole oral tablet 0, 5 propylthiouracil oral tablet 50 DIABETES THERAPY acarbose oral tablet 00, 25, 50 alcohol pads topical pads, medicated AVANDIA ORAL TABLET 2 MG, 4 MG BYDUREON BCISE SUBCUTANEOUS AUTO- INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML ST ST

66 BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML).2 ML ST GAUZE PADS 2 X 2 QL (00 per 30 days) glimepiride oral tablet, 2, 4 glipizide oral tablet 0 QL (20 per 30 days) glipizide oral tablet 5 QL (240 per 30 days) glipizide oral tablet extended release 24hr 0 QL (60 per 30 days) glipizide oral tablet extended release 24hr 2.5 QL (240 per 30 days) glipizide oral tablet extended release 24hr 5 QL (20 per 30 days) glipizide-metformin oral tablet , , GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN MG INSULIN PEN NEEDLE QL (200 per 30 days) INSULIN SYRINGE (DISP) U ML, ML, /2 ML INVOKANA ORAL TABLET 00 MG, 300 MG ST JANUMET ORAL TABLET 50-,000 MG, MG JANUVIA ORAL TABLET 00 MG, 25 MG, 50 MG 59 QL (200 per 30 days) ST ST JARDIANCE ORAL TABLET 0 MG, 25 MG ST LANTUS SOLOSTAR U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LANTUS U-00 INSULIN SUBCUTANEOUS SOLUTION 00 UNIT/ML LEVEMIR FLEXTOUCH U-00 INSULN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) LEVEMIR U-00 INSULIN SUBCUTANEOUS SOLUTION 00 UNIT/ML metformin oral tablet,000, 500, 850 metformin oral tablet extended release 24 hr 500 QL (50 per 30 days)

67 metformin oral tablet extended release 24 hr 750 miglitol oral tablet 00, 25, 50 nateglinide oral tablet 20, 60 QL (90 per 30 days) NEEDLES, INSULIN DISP.,SAFETY QL (200 per 30 days) NOVOLIN 70/30 U-00 INSULIN SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N NPH U-00 INSULIN SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R REGULAR U-00 INSULN INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML NOVOLOG MIX U-00 INSULN SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U-00 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG PENFILL U-00 INSULIN SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG U-00 INSULIN ASPART SUBCUTANEOUS SOLUTION 00 UNIT/ML ONGLYZA ORAL TABLET 2.5 MG, 5 MG ST pioglitazone oral tablet 5, 30, 45 QL (30 per 30 days) pioglitazone-glimepiride oral tablet 30-2, 30-4 pioglitazone-metformin oral tablet 5-500, PROGLYCEM ORAL SUSPENSION 50 MG/ML repaglinide oral tablet 0.5,, 2 SYMLINPEN 20 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR,500 MCG/.5 ML SYNJARDY ORAL TABLET 2.5-,000 MG, MG, 5-,000 MG, MG 60 PA PA ST

68 SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 0-,000 MG, 2.5-,000 MG, 25-,000 MG, 5-,000 MG tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (.5 ML) ST TRADJENTA ORAL TABLET 5 MG ST TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML,.5 MG/0.5 ML VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0. ML (8 MG/3 ML) VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0. ML (8 MG/3 ML) MISCELLANEOUS HORMONES ANADROL-50 ORAL TABLET 50 MG cabergoline oral tablet 0.5 calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution mcg/ml 6 ST ST CERDELGA ORAL CAPSULE 84 MG PA danazol oral capsule 00, 200, 50 desmopressin nasal spray with pump 0 mcg/spray (0. ml) desmopressin nasal spray,non-aerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0., 0.2 doxercalciferol oral capsule 0.5 mcg, mcg, 2.5 mcg JYNARQUE ORAL TABLETS, SEQUENTIAL 45 MG (AM)/ 5 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM) PA; LA KORLYM ORAL TABLET 300 MG PA

69 KUVAN ORAL POWDER IN PACKET 00 MG PA KUVAN ORAL TABLET,SOLUBLE 00 MG PA methyltestosterone oral capsule 0 MIGLUSTAT ORAL CAPSULE 00 MG PA; LA MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.) NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE PA; LA PA; LA ORILISSA ORAL TABLET 50 MG, 200 MG PA oxandrolone oral tablet 0, 2.5 PALYNZIQ SUBCUTANEOUS SYRINGE 0 MG/0.5 ML, 2.5 MG/0.5 ML, 20 MG/ML paricalcitol oral capsule mcg, 2 mcg, 4 mcg PA; LA SAMSCA ORAL TABLET 5 MG, 30 MG PA SENSIPAR ORAL TABLET 30 MG QL (360 per 30 days) SENSIPAR ORAL TABLET 60 MG QL (80 per 30 days) SENSIPAR ORAL TABLET 90 MG QL (20 per 30 days) SOMAVERT SUBCUTANEOUS RECON SOLN 0 MG, 5 MG, 20 MG, 25 MG, 30 MG SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML testosterone cypionate intramuscular oil 00 /ml, 200 /ml testosterone enanthate intramuscular oil 200 /ml testosterone transdermal gel 50 /5 gram ( %) PA testosterone transdermal gel in metered-dose pump 2.5 /.25 gram ( %), /.25 gram (.62 %) testosterone transdermal gel in packet % (25 /2.5gram), % (50 /5 gram),.62 % (20.25 /.25 gram),.62 % (40.5 /2.5 gram) PA PA ZAVESCA ORAL CAPSULE 00 MG PA; LA THYROID HORMONES 62

70 LEVO-T ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 37 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG levothyroxine oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg levoxyl oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg SYNTHROID ORAL TABLET 00 MCG, 2 MCG, 25 MCG, 37 MCG, 50 MCG, 75 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG unithroid oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS dicyclomine oral capsule 0 dicyclomine oral solution 0 /5 ml dicyclomine oral tablet 20 diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet glycopyrrolate oral tablet, 2 loperamide oral capsule 2 methscopolamine oral tablet 2.5, 5 MYTESI ORAL TABLET,DELAYED RELEASE (DR/EC) 25 MG MISCELLANEOUS GASTROINTESTINAL AGENTS alosetron oral tablet 0.5, PA AMITIZA ORAL CAPSULE 24 MCG, 8 MCG PA aprepitant oral capsule 25, 40, 80 PA; QL (6 per 30 days) aprepitant oral capsule,dose pack 25 ()- 80 (2) PA; QL (6 per 30 days) 63

71 APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR GRAM balsalazide oral capsule 750 budesonide oral capsule,delayed,extend.release 3 budesonide oral tablet,delayed and ext.release 9 CANASA RECTAL SUPPOSITORY,000 MG 64 PA CHENODAL ORAL TABLET 250 MG LA CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) colocort rectal enema 00 /60 ml constulose oral solution 0 gram/5 ml CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 2,000-38,000-60,000 UNIT, 24,000-76,000-20,000 UNIT, 3,000-9,500-5,000 UNIT, 36,000-4,000-80,000 UNIT, 6,000-9,000-30,000 UNIT cromolyn oral concentrate 00 /5 ml DIPENTUM ORAL CAPSULE 250 MG PA PA PA dronabinol oral capsule 0, 2.5, 5 enulose oral solution 0 gram/5 ml GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 MG gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 420 gram generlac oral solution 0 gram/5 ml PA PA granisetron hcl oral tablet

72 hydrocortisone rectal enema 00 /60 ml hydrocortisone topical cream with perineal applicator %, 2.5 % lactulose oral packet 0 gram lactulose oral solution 0 gram/5 ml LINZESS ORAL CAPSULE 45 MCG, 290 MCG, 72 MCG meclizine oral tablet 2.5, 25 mesalamine oral tablet,delayed release (dr/ec).2 gram MESALAMINE ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG mesalamine rectal enema 4 gram/60 ml mesalamine rectal suppository,000 mesalamine with cleansing wipe rectal enema kit 4 gram/60 ml metoclopramide hcl oral solution 5 /5 ml metoclopramide hcl oral tablet 0, 5 65 PA MOVANTIK ORAL TABLET 2.5 MG, 25 MG PA OCALIVA ORAL TABLET 0 MG, 5 MG PA; LA ondansetron hcl oral solution 4 /5 ml ondansetron hcl oral tablet 24, 4, 8 ondansetron oral tablet,disintegrating 4, 8 peg 3350-electrolytes oral recon soln gram, gram peg-electrolyte oral recon soln 420 gram PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG polyethylene glycol 3350 oral powder 7 gram/dose polyethylene glycol 3350 oral powder in packet 7 gram prochlorperazine maleate oral oral tablet 0, 5 prochlorperazine rectal suppository 25 procto-med hc topical cream with perineal applicator 2.5 %

73 procto-pak topical cream with perineal applicator % proctosol hc topical cream with perineal applicator 2.5 % proctozone-hc topical cream with perineal applicator 2.5 % RECTIV RECTAL OINTMENT 0.4 % (W/W) RELISTOR ORAL TABLET 50 MG PA RELISTOR SUBCUTANEOUS SOLUTION 2 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 2 MG/0.6 ML, 8 MG/0.4 ML scopolamine base transdermal patch 3 day over 3 days SUCRAID ORAL SOLUTION 8,500 UNIT/ML sulfasalazine oral tablet 500 sulfasalazine oral tablet,delayed release (dr/ec) 500 SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM trilyte with flavor packets oral recon soln 420 gram trimethobenzamide oral capsule 300 UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE 9 MG UCERIS RECTAL FOAM 2 MG/ACTUATION ursodiol oral capsule 300 ursodiol oral tablet 250, 500 ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0,000-32,000-42,000 UNIT, 5,000-47,000-63,000 UNIT, 20,000-63,000-84,000 UNIT, 25,000-79,000-05,000 UNIT, 3,000-0,000-4,000-UNIT, 40,000-26,000-68,000 UNIT, 5,000-7,000-24,000 UNIT ULCER THERAPY CARAFATE ORAL SUSPENSION 00 MG/ML cimetidine hcl oral solution 300 /5 ml PA PA PA PA 66

74 cimetidine oral tablet 200, 300, 400, 800 esomeprazole magnesium oral capsule,delayed release(dr/ec) 20, 40 famotidine oral suspension 40 /5 ml (8 /ml) famotidine oral tablet 20, 40 lansoprazole oral capsule,delayed release(dr/ec) 5, 30 lansoprazole oral tablet,disintegrat, delay rel 5, 30 misoprostol oral tablet 00 mcg, 200 mcg nizatidine oral capsule 50, 300 omeprazole oral capsule,delayed release(dr/ec) 0, 20, 40 pantoprazole oral tablet,delayed release (dr/ec) 20, 40 rabeprazole oral tablet,delayed release (dr/ec) 20 ranitidine hcl injection solution 25 /ml, 50 /2 ml (25 /ml) ranitidine hcl oral syrup 5 /ml ranitidine hcl oral tablet 50, 300 sucralfate oral tablet gram IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE SUBCUTANEOUS SOLUTION 00 MCG/0.5 ML ARANESP (IN POLYSORBATE) INJECTION SOLUTION 00 MCG/ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 0 MCG/0.4 ML, 00 MCG/0.5 ML, 50 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML ARCALYST SUBCUTANEOUS RECON SOLN 220 MG PA PA PA 67

75 AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML PA PA PA BETASERON SUBCUTANEOUS KIT 0.3 MG PA EGRIFTA SUBCUTANEOUS RECON SOLN MG EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PA PA EXTAVIA SUBCUTANEOUS KIT 0.3 MG PA EXTAVIA SUBCUTANEOUS RECON SOLN 0.3 MG INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML PA PA PA LEUKINE INJECTION RECON SOLN 250 MCG PA NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML NEUPOGEN INJECTION SOLUTION 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML NEUPOGEN INJECTION SYRINGE 480 MCG/0.8 ML NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (0 MG/ML), 30 MG/3 ML (0 MG/ML), 5 MG/.5 ML (3.3 MG/ML) QL (28 per 28 days) QL (44.8 per 28 days) QL (4 per 28 days) QL (22.4 per 28 days) PA 68

76 NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 0 MG/2 ML (5 MG/ML), 20 MG/2 ML (0 MG/ML), 5 MG/2 ML (2.5 MG/ML) PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML PA PA PA PA PA PA PA PA PA PA 69

77 BIVIGAM INTRAVENOUS SOLUTION 0 % PA BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 6 GRAM CUVITRU SUBCUTANEOUS SOLUTION GRAM/5 ML (20 %), 2 GRAM/0 ML (20 %), 4 GRAM/20 ML (20 %), 8 GRAM/40 ML (20 %) DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF- MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0 %, 5 % GAMMAGARD LIQUID INJECTION SOLUTION 0 % GAMMAGARD S-D (IGA < MCG/ML) INTRAVENOUS RECON SOLN 0 GRAM, 5 GRAM GAMMAKED INJECTION SOLUTION GRAM/0 ML (0 %), 0 GRAM/00 ML (0 %), 2.5 GRAM/25 ML (0 %), 5 GRAM/50 ML (0 %) GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS SOLUTION 0 %, 0 % (00 ML), 0 % (200 ML) GAMUNEX-C INJECTION SOLUTION GRAM/0 ML (0 %), 0 GRAM/00 ML (0 %), 2.5 GRAM/25 ML (0 %), 20 GRAM/200 ML (0 %), 40 GRAM/400 ML (0 %), 5 GRAM/50 ML (0 %) GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML 70 PA PA PA PA PA PA PA PA PA

78 HAVRIX (PF) INTRAMUSCULAR SUSPENSION,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML HIZENTRA SUBCUTANEOUS SOLUTION GRAM/5 ML (20 %), 0 GRAM/50 ML (20 %), 2 GRAM/0 ML (20 %), 4 GRAM/20 ML (20 %) HYQVIA SUBCUTANEOUS SOLUTION 0 GRAM /00 ML (0 %), 2.5 GRAM /25 ML (0 %), 20 GRAM /200 ML (0 %), 30 GRAM /300 ML (0 %), 5 GRAM /50 ML (0 %) IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-0 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-0 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN,000-2,500 TCID50/0.5 ML OCTAGAM INTRAVENOUS SOLUTION 0 %, 5 % PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-25LF-25 MCG-0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML 7 PA PA PA PRIVIGEN INTRAVENOUS SOLUTION 0 % PA

79 PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TRUMENBA INTRAMUSCULAR SYRINGE 20 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML QL (2 per 999 days) 72

80 VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol oral tablet 00, 300 COLCHICINE ORAL CAPSULE 0.6 MG COLCHICINE ORAL TABLET 0.6 MG probenecid oral tablet 500 probenecid-colchicine oral tablet ULORIC ORAL TABLET 40 MG, 80 MG ST ZURAMPIC ORAL TABLET 200 MG PA OSTEOPOROSIS THERAPY 73 QL ( per 999 days) alendronate oral tablet 0, 5 QL (30 per 30 days) alendronate oral tablet 35, 70 QL (4 per 28 days) ibandronate oral tablet 50 PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML raloxifene oral tablet 60 PA risedronate oral tablet 50 QL ( per 28 days) risedronate oral tablet 35, 35 (2 pack), 35 (4 pack) QL (4 per 28 days) risedronate oral tablet 5 QL (30 per 30 days) TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,20 MCG/.56 ML) OTHER RHEUMATOLOGICALS BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML CUPRIMINE ORAL CAPSULE 250 MG DEPEN TITRATABS ORAL TABLET 250 MG ST PA

81 ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (0.98 ML) ENBREL SUBCUTANEOUS RECON SOLN 25 MG ( ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.5), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 0 MG/0. ML, 20 MG/0.2 ML, 40 MG/0.4 ML KEVZARA SUBCUTANEOUS SYRINGE 50 MG/.4 ML, 200 MG/.4 ML KINERET SUBCUTANEOUS SYRINGE 00 MG/0.67 ML leflunomide oral tablet 0, 20 PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA PA 74

82 ORENCIA SUBCUTANEOUS SYRINGE 25 MG/ML PA OTEZLA ORAL TABLET 30 MG PA OTEZLA STARTER ORAL TABLETS,DOSE PACK 0 MG (4)-20 MG (4)-30 MG (47) RIDAURA ORAL CAPSULE 3 MG SAVELLA ORAL TABLET 00 MG, 2.5 MG, 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 2.5 MG (5)-25 MG(8)-50 MG(42) SIMPONI SUBCUTANEOUS SYRINGE 00 MG/ML, 50 MG/0.5 ML PA PA; QL (60 per 30 days) PA PA XELJANZ ORAL TABLET 0 MG, 5 MG PA XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR MG OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS amabelz oral tablet , -0.5 ANGELIQ ORAL TABLET MG, 0.5- MG camila oral tablet 0.35 deblitane oral tablet 0.35 DELESTROGEN INTRAMUSCULAR OIL 0 MG/ML DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML DUAVEE ORAL TABLET MG errin oral tablet 0.35 estradiol oral tablet 0.5,, 2 estradiol transdermal patch semiweekly /24 hr, /24 hr, 0.05 /24 hr, /24 hr, 0. /24 hr estradiol transdermal patch weekly /24 hr, /24 hr, 0.05 /24 hr, 0.06 /24 hr, /24 hr, 0. /24 hr PA 75

83 estradiol vaginal cream 0.0 % (0. /gram) estradiol vaginal tablet 0 mcg QL (8 per 28 days) estradiol valerate intramuscular oil 20 /ml, 40 /ml estradiol-norethindrone acet oral tablet , -0.5 ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR) estropipate oral tablet 0.75 FEMRING VAGINAL RING 0.05 MG/24 HR, 0. MG/24 HR fyavolv oral tablet mcg, -5 -mcg heather oral tablet 0.35 jencycla oral tablet 0.35 jinteli oral tablet -5 -mcg jolivette oral tablet 0.35 lopreeza oral tablet , -0.5 lyza oral tablet 0.35 medroxyprogesterone intramuscular suspension 50 /ml medroxyprogesterone intramuscular syringe 50 /ml medroxyprogesterone oral tablet 0, 2.5, 5 MENEST ORAL TABLET 0.3 MG, MG,.25 MG, 2.5 MG MENOSTAR TRANSDERMAL PATCH WEEKLY 4 MCG/24 HR mimvey lo oral tablet mimvey oral tablet -0.5 MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, MG/24 HR, 0.05 MG/24 HR, MG/24 HR, 0. MG/24 HR nora-be oral tablet 0.35 norethindrone (contraceptive) oral tablet 0.35 norethindrone acetate oral tablet 5 76

84 norethindrone ac-eth estradiol oral tablet mcg, -5 -mcg norlyroc oral tablet 0.35 PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG,.25 MG PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET MG (4)/ 0.625MG-5MG(4) PREMPRO ORAL TABLET MG, MG, MG, MG progesterone micronized oral capsule 00, 200 sharobel oral tablet 0.35 yuvafem vaginal tablet 0 mcg QL (8 per 28 days) MISCELLANEOUS OB/GYN clindamycin phosphate vaginal cream 2 % metronidazole vaginal gel 0.75 % miconazole-3 vaginal suppository 200 terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 tranexamic acid oral tablet 650 vandazole vaginal gel 0.75 % xulane transdermal patch weekly mcg/24 hr ORAL CONTRACEPTIVES / RELATED AGENTS alyacen /35 (28) oral tablet -35 -mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg amethia lo oral tablets,dose pack,3 month mcg (84)/0 mcg (7) amethia oral tablets,dose pack,3 month mcg (84)/0 mcg (7) apri oral tablet aranelle (28) oral tablet 0.5// mcg ashlyna oral tablets,dose pack,3 month mcg (84)/0 mcg (7) 77

85 aubra eq oral tablet mcg aubra oral tablet mcg aviane oral tablet mcg azurette (28) oral tablet x2 /0.0 x 5 balziva (28) oral tablet mcg blisovi 24 fe oral tablet -20 mcg (24)/75 (4) blisovi fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) blisovi fe /20 (28) oral tablet -20 mcg (2)/75 (7) briellyn oral tablet mcg camrese lo oral tablets,dose pack,3 month mcg (84)/0 mcg (7) camrese oral tablets,dose pack,3 month mcg (84)/0 mcg (7) caziant (28) oral tablet 0./.25/ mcg chateal (28) oral tablet cryselle (28) oral tablet mcg cyclafem /35 (28) oral tablet -35 -mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg cyred eq oral tablet cyred oral tablet dasetta /35 (28) oral tablet -35 -mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg daysee oral tablets,dose pack,3 month mcg (84)/0 mcg (7) delyla (28) oral tablet mcg desog-e.estradiol/e.estradiol oral tablet x2 /0.0 x 5 desogestrel-ethinyl estradiol oral tablet drospirenone-e.estradiol-lm.fa oral tablet (24) (4) 78

86 drospirenone-ethinyl estradiol oral tablet , elinest oral tablet mcg ELLA ORAL TABLET 30 MG emoquette oral tablet enpresse oral tablet (6)/75-40 (5)/25-30(0) enskyce oral tablet estarylla oral tablet mcg ethynodiol diac-eth estradiol oral tablet -35 mcg, -50 -mcg falmina (28) oral tablet mcg fayosim oral tablets,dose pack,3 month mcg/ mcg femynor oral tablet mcg gianvi (28) oral tablet hailey 24 fe oral tablet -20 mcg (24)/75 (4) introvale oral tablets,dose pack,3 month mcg (9) isibloom oral tablet jolessa oral tablets,dose pack,3 month mcg (9) juleber oral tablet junel.5/30 (2) oral tablet mcg junel /20 (2) oral tablet -20 -mcg junel fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) junel fe /20 (28) oral tablet -20 mcg (2)/75 (7) junel fe 24 oral tablet -20 mcg (24)/75 (4) kaitlib fe oral tablet,chewable mcg(24) and 75 (4) kariva (28) oral tablet x2 /0.0 x 5 kelnor /35 (28) oral tablet -35 -mcg kelnor -50 oral tablet -50 -mcg 79

87 kurvelo (28) oral tablet l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month mcg (84)/0 mcg (7), mcg/ mcg, mcg (84)/0 mcg (7) larin.5/30 (2) oral tablet mcg larin /20 (2) oral tablet -20 -mcg larin 24 fe oral tablet -20 mcg (24)/75 (4) larin fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) larin fe /20 (28) oral tablet -20 mcg (2)/75 (7) larissia oral tablet mcg layolis fe oral tablet,chewable mcg(24) and 75 (4) leena 28 oral tablet 0.5// mcg lessina oral tablet mcg levonest (28) oral tablet (6)/75-40 (5)/25-30(0) levonorgestrel-ethinyl estrad oral tablet mcg, , mcg (28) levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month mcg (9) levonorg-eth estrad triphasic oral tablet (6)/75-40 (5)/25-30(0) levora-28 oral tablet loryna (28) oral tablet low-ogestrel (28) oral tablet mcg lutera (28) oral tablet mcg marlissa (28) oral tablet melodetta 24 fe oral tablet,chewable -20 mcg(24) /75 (4) mibelas 24 fe oral tablet,chewable -20 mcg(24) /75 (4) microgestin.5/30 (2) oral tablet mcg microgestin /20 (2) oral tablet -20 -mcg 80

88 microgestin fe.5/30 (28) oral tablet.5-30 mcg (2)/75 (7) microgestin fe /20 (28) oral tablet -20 mcg (2)/75 (7) mili oral tablet mcg mono-linyah oral tablet mcg mononessa (28) oral tablet mcg myzilra oral tablet (6)/75-40 (5)/25-30(0) necon 0.5/35 (28) oral tablet mcg nikki (28) oral tablet noreth-ethinyl estradiol-iron oral tablet,chewable mcg(2) and 75 (7), mcg(24) and 75 (4) norethindrone ac-eth estradiol oral tablet -20 -mcg norethindrone-e.estradiol-iron oral tablet -20 mcg (2)/75 (7), -20 mcg (24)/75 (4) norethindrone-e.estradiol-iron oral tablet,chewable -20 mcg(24) /75 (4) norgestimate-ethinyl estradiol oral tablet 0.8/0.25/ mcg, 0.8/0.25/ mcg (28), mcg nortrel 0.5/35 (28) oral tablet mcg nortrel /35 (2) oral tablet -35 -mcg (2) nortrel /35 (28) oral tablet -35 -mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/ - 35 mcg ocella oral tablet ogestrel (28) oral tablet mcg orsythia oral tablet mcg philith oral tablet mcg pimtrea (28) oral tablet x2 /0.0 x 5 pirmella oral tablet 0.5/0.75/ - 35 mcg, -35 -mcg portia 28 oral tablet previfem oral tablet mcg 8

89 quasense oral tablets,dose pack,3 month mcg (9) reclipsen (28) oral tablet rivelsa oral tablets,dose pack,3 month mcg/ mcg setlakin oral tablets,dose pack,3 month mcg (9) sprintec (28) oral tablet mcg sronyx oral tablet mcg syeda oral tablet tarina fe /20 (28) oral tablet -20 mcg (2)/75 (7) tarina fe -20 eq (28) oral tablet -20 mcg (2)/75 (7) tilia fe oral tablet -20(5)/-30(7) /-35mcg (9) tri-estarylla oral tablet 0.8/0.25/ mcg (28) tri-legest fe oral tablet -20(5)/-30(7) /- 35mcg (9) tri-lo-estarylla oral tablet 0.8/0.25/ mcg tri-lo-sprintec oral tablet 0.8/0.25/ mcg tri-mili oral tablet 0.8/0.25/ mcg (28) trinessa (28) oral tablet 0.8/0.25/ mcg (28) tri-previfem (28) oral tablet 0.8/0.25/ mcg (28) tri-sprintec (28) oral tablet 0.8/0.25/ mcg (28) trivora (28) oral tablet (6)/75-40 (5)/25-30(0) tri-vylibra oral tablet 0.8/0.25/ mcg (28) tydemy oral tablet (2) (7) velivet triphasic regimen (28) oral tablet 0./.25/ mcg vienva oral tablet mcg 82

90 viorele (28) oral tablet x2 /0.0 x 5 vyfemla (28) oral tablet mcg vylibra oral tablet mcg wera (28) oral tablet mcg wymzya fe oral tablet,chewable mcg(2) and 75 (7) zarah oral tablet zenchent (28) oral tablet mcg zovia /35e (28) oral tablet -35 -mcg OXYTOCICS methergine oral tablet 0.2 OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac ophthalmic (eye) ointment 500-0,000 unit/gram AZASITE OPHTHALMIC (EYE) DROPS % bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment 500-0,000 unit/gram ciprofloxacin hcl ophthalmic (eye) drops 0.3 % erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) gatifloxacin ophthalmic (eye) drops 0.5 % gentak ophthalmic (eye) ointment 0.3 % (3 /gram) gentamicin ophthalmic (eye) drops 0.3 % levofloxacin ophthalmic (eye) drops 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin-gramicidin ophthalmic (eye) drops.75-0,000 unit-0.025/ml 83

91 neo-polycin ophthalmic (eye) ointment ,000 -unit-unit/g ofloxacin ophthalmic (eye) drops 0.3 % polycin ophthalmic (eye) ointment 500-0,000 unit/gram polymyxin b sulf-trimethoprim ophthalmic (eye) drops 0,000 unit- /ml tobramycin ophthalmic (eye) drops 0.3 % TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % ANTIVIRALS trifluridine ophthalmic (eye) drops % ZIRGAN OPHTHALMIC (EYE) GEL 0.5 % BETA-BLOCKERS betaxolol ophthalmic (eye) drops 0.5 % BETIMOL OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 % BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % carteolol ophthalmic (eye) drops % levobunolol ophthalmic (eye) drops 0.5 % timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % timolol maleate ophthalmic (eye) drops, once daily 0.5 % timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL OPHTHALMIC (EYE) DROPS 2 % atropine ophthalmic (eye) drops % azelastine ophthalmic (eye) drops 0.05 % BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT % cromolyn ophthalmic (eye) drops 4 % 84

92 CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % epinastine ophthalmic (eye) drops 0.05 % LACRISERT OPHTHALMIC (EYE) INSERT 5 MG olopatadine ophthalmic (eye) drops 0. % OXERVATE OPHTHALMIC (EYE) DROPS % PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.25 % pilocarpine hcl ophthalmic (eye) drops %, 2 %, 4 % proparacaine ophthalmic (eye) drops 0.5 % RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS 0.05 % RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % sulfacetamide sodium ophthalmic (eye) drops 0 % sulfacetamide-prednisolone ophthalmic (eye) drops 0 %-0.23 % (0.25 %) XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % NON-STEROIDAL ANTI-INFLAMMATORY AGENTS bromfenac ophthalmic (eye) drops 0.09 % diclofenac sodium ophthalmic (eye) drops 0. % flurbiprofen sodium ophthalmic (eye) drops 0.03 % ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 % ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % ORAL DRUGS FOR GLAUCOMA acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 25, 250 methazolamide oral tablet 25, PA PA

93 OTHER GLAUCOMA DRUGS AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION % bimatoprost ophthalmic (eye) drops 0.03 % COMBIGAN OPHTHALMIC (EYE) DROPS % dorzolamide ophthalmic (eye) drops 2 % dorzolamide-timolol (pf) ophthalmic (eye) dropperette % dorzolamide-timolol ophthalmic (eye) drops /ml latanoprost ophthalmic (eye) drops % STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 -unit/g-% neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 /g-0,000 unit/g-0. % neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-0, unit-/ml neo-polycin hc ophthalmic (eye) ointment ,000 -unit/g-% TOBRADEX OPHTHALMIC (EYE) OINTMENT % tobramycin-dexamethasone ophthalmic (eye) drops,suspension % STEROIDS ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % dexamethasone sodium phosphate ophthalmic (eye) drops 0. % DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % fluorometholone ophthalmic (eye) drops,suspension 0. % FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % 86

94 FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0. % LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % prednisolone acetate ophthalmic (eye) drops,suspension % prednisolone sodium phosphate ophthalmic (eye) drops % SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC (EYE) DROPS 0. % apraclonidine ophthalmic (eye) drops 0.5 % brimonidine ophthalmic (eye) drops 0.5 %, 0.2 % IOPIDINE OPHTHALMIC (EYE) DROPPERETTE % RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS carbinoxamine maleate oral liquid 4 /5 ml carbinoxamine maleate oral tablet 4 cetirizine oral solution /ml clemastine oral tablet 2.68 cyproheptadine oral tablet 4 desloratadine oral tablet 5 desloratadine oral tablet,disintegrating 2.5, 5 EPINEPHRINE INJECTION AUTO-INJECTOR 0.5 MG/0.5 ML, 0.5 MG/0.3 ML, 0.3 MG/0.3 ML hydroxyzine hcl oral solution 0 /5 ml 87

95 hydroxyzine hcl oral tablet 0, 25, 50 hydroxyzine pamoate oral capsule 00, 25, 50 levocetirizine oral solution 2.5 /5 ml levocetirizine oral tablet 5 phenadoz rectal suppository 2.5, 25 phenergan rectal suppository 2.5, 25, 50 promethazine oral syrup 6.25 /5 ml promethazine oral tablet 2.5, 25, 50 promethazine rectal suppository 2.5, 25, 50 promethegan rectal suppository 2.5, 25, 50 PULMONARY AGENTS acetylcysteine solution 00 /ml (0 %), 200 /ml (20 %) ADCIRCA ORAL TABLET 20 MG PA ADEMPAS ORAL TABLET 0.5 MG, MG,.5 MG, 2 MG, 2.5 MG ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER 5-2 MCG/ACTUATION, MCG/ACTUATION, 45-2 MCG/ACTUATION albuterol sulfate inhalation solution for nebulization 0.63 /3 ml,.25 /3 ml, 2.5 /3 ml (0.083 %), 2.5 /0.5 ml, 5 /ml albuterol sulfate oral syrup 2 /5 ml albuterol sulfate oral tablet 2, 4 albuterol sulfate oral tablet extended release 2 hr 4, 8 ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG PA; LA 88

96 ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION BECONASE AQ NASAL SPRAY,NON- AEROSOL 42 MCG (0.042 %) BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE BROVANA INHALATION SOLUTION FOR NEBULIZATION 5 MCG/2 ML budesonide inhalation suspension for nebulization 0.25 /2 ml, 0.5 /2 ml, /2 ml CINQAIR INTRAVENOUS SOLUTION 0 MG/ML CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION cromolyn inhalation solution for nebulization 20 /2 ml DALIRESP ORAL TABLET 250 MCG, 500 MCG PA PA PA ESBRIET ORAL CAPSULE 267 MG PA ESBRIET ORAL TABLET 267 MG, 80 MG PA FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluticasone nasal spray,suspension 50 mcg/actuation PA PA 89

97 FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED 3-4 MCG/ACTUATION, MCG/ACTUATION, 55-4 MCG/ACTUATION HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT, 3,000 UNIT INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION 90 PA; LA ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization (2.5 base)/3 ml KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG PA KALYDECO ORAL TABLET 50 MG PA LETAIRIS ORAL TABLET 0 MG, 5 MG PA; LA levalbuterol hcl inhalation solution for nebulization 0.3 /3 ml, 0.63 /3 ml,.25 /0.5 ml,.25 /3 ml LEVALBUTEROL TARTRATE INHALATION HFA AEROSOL INHALER 45 MCG/ACTUATION metaproterenol oral syrup 0 /5 ml metaproterenol oral tablet 0, 20 mometasone nasal spray,non-aerosol 50 mcg/actuation montelukast oral granules in packet 4 montelukast oral tablet 0 montelukast oral tablet,chewable 4, 5 NUCALA SUBCUTANEOUS RECON SOLN 00 MG PA; LA OFEV ORAL CAPSULE 00 MG, 50 MG PA OPSUMIT ORAL TABLET 0 MG PA; LA ORKAMBI ORAL GRANULES IN PACKET MG, MG ORKAMBI ORAL TABLET MG, MG PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PA PA

98 PROVENTIL HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 80 MCG/ACTUATION, 90 MCG/ACTUATION PULMOZYME INHALATION SOLUTION MG/ML QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE sildenafil (pulmonary arterial hypertension) oral tablet 20 SPIRIVA RESPIMAT INHALATION MIST.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION SYMDEKO ORAL TABLETS, SEQUENTIAL MG (D)/ 50 MG (N) TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2 ML (50 MG/ML) terbutaline oral tablet 2.5, 5 theophylline oral elixir 80 /5 ml theophylline oral solution 80 /5 ml theophylline oral tablet extended release 2 hr 00, 200, 300, 450 theophylline oral tablet extended release 24 hr 400, PA PA PA; LA TRACLEER ORAL TABLET 25 MG, 62.5 MG PA; LA TRACLEER ORAL TABLET FOR SUSPENSION 32 MG TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG PA; LA PA

99 TYVASO INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML (0.6 MG/ML) TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION.74 MG/2.9 ML VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 0 MCG/ML, 20 MCG/ML VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION XOLAIR SUBCUTANEOUS RECON SOLN 50 MG XOLAIR SUBCUTANEOUS SYRINGE 50 MG/ML, 75 MG/0.5 ML zafirlukast oral tablet 0, 20 UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS flavoxate oral tablet 00 MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 /5 ml oxybutynin chloride oral tablet 5 oxybutynin chloride oral tablet extended release 24hr 0, 5, 5 tolterodine oral capsule,extended release 24hr 2, 4 tolterodine oral tablet, 2 trospium oral capsule,extended release 24hr 60 trospium oral tablet 20 BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin oral tablet extended release 24 hr 0 dutasteride oral capsule 0.5 PA PA PA PA PA 92 PA; LA PA; LA ST; QL (30 per 30 days)

100 finasteride oral tablet 5 silodosin oral capsule 4, 8 tamsulosin oral capsule 0.4 MISCELLANEOUS UROLOGICALS bethanechol chloride oral tablet 0, 25, 5, 50 CYSTAGON ORAL CAPSULE 50 MG, 50 MG LA ELMIRON ORAL CAPSULE 00 MG potassium citrate oral tablet extended release 0 meq (,080 ), 5 meq, 5 meq (540 ) VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate oral capsule 667 calcium acetate oral tablet 667 klor-con 0 oral tablet extended release 0 meq klor-con 8 oral tablet extended release 8 meq klor-con m0 oral tablet,er particles/crystals 0 meq klor-con m5 oral tablet,er particles/crystals 5 meq klor-con m20 oral tablet,er particles/crystals 20 meq klor-con oral packet 20 meq klor-con sprinkle oral capsule, extended release 0 meq, 8 meq MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK GRAM/00 ML magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/,000 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml 93

101 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 0 meq/l, 20 meq/l, 30 meq/l, 40 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 in water intravenous piggyback 0 meq/00 ml, 0 meq/50 ml, 20 meq/00 ml, 20 meq/50 ml, 30 meq/00 ml, 40 meq/00 ml potassium chloride intravenous solution 2 meq/ml, 2 meq/ml (20 ml) potassium chloride oral capsule, extended release 0 meq, 8 meq potassium chloride oral liquid 20 meq/5 ml, 40 meq/5 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 0 meq, 20 meq, 8 meq potassium chloride oral tablet,er particles/crystals 0 meq, 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.45 % intravenous piggyback 0.45 % sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % 94

102 sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml sodium lactate intravenous intravenous solution 5 meq/ml MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN II 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D5W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % 95

103 CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 4.25%/D0W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 4.25%/D0W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % electrolyte-48 in d5w intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % freamine iii 0 % intravenous parenteral solution 0 % 96

104 HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 30 % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 48 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION plenamine intravenous parenteral solution 5 % premasol 0 % intravenous parenteral solution 0 % PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PROCALAMINE 3% INTRAVENOUS PARENTERAL SOLUTION 3 % travasol 0 % intravenous parenteral solution 0 % TROPHAMINE 0 % INTRAVENOUS PARENTERAL SOLUTION 0 % VITAMINS / HEMATINICS fluoride (sodium) oral tablet (2.2 sod. fluoride) fluoride (sodium) oral tablet,chewable (2.2 sod. fluoride) prenatal vitamin oral tablet oral tablet 27 iron- 97

105 Index A abacavir... 2 abacavir-lamivudine... 2 abacavir-lamivudinezidovudine... 2 ABELCET... ABILIFY MAINTENA abiraterone... 4 acamprosate acarbose acebutolol acetaminophen-codeine acetazolamide acetic acid acetylcysteine acitretin ACTHIB (PF) ACTIMMUNE acyclovir... 2, 50 acyclovir sodium... 2 ADACEL(TDAP ADOLESN/ADULT)(PF) 69 adapalene ADCIRCA adefovir... 2 ADEMPAS ADVAIR DISKUS ADVAIR HFA AFINITOR... 4 AFINITOR DISPERZ... 4 AIMOVIG AUTOINJECTOR AIMOVIG AUTOINJECTOR (2 PACK) ak-poly-bac ala-cort ALBENZA... 8 albuterol sulfate alclometasone... 50, 5 alcohol pads ALECENSA... 4 alendronate... 53, 73 alfuzosin ALINIA... 8 allopurinol ALOCRIL alosetron ALPHAGAN P alprazolam ALREX ALUNBRIG... 4 alyacen /35 (28) alyacen 7/7/7 (28) amabelz amantadine hcl... 2 AMBISOME... amcinonide... 5 amethia amethia lo amikacin... 8 amiloride amiloride-hydrochlorothiazide AMINOSYN 0 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amitriptyline-chlordiazepoxide... 3 amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-olmesartan amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amnesteem amoxapine... 3 amoxicillin... amoxicillin-pot clavulanate., 2 amphotericin b... ampicillin... 2 ampicillin sodium... 2 ampicillin-sulbactam... 2 AMPYRA ANADROL anagrelide anastrozole... 4 ANGELIQ ANORO ELLIPTA APLENZIN... 3 APOKYN apraclonidine aprepitant apri APRISO APTIOM APTIVUS... 2 ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) ARCALYST ARCAPTA NEOHALER aripiprazole... 3 ARISTADA... 3 ascomp with codeine ashlyna aspirin-dipyridamole ASTAGRAF XL... 5 atazanavir... 2 atenolol atenolol-chlorthalidone atomoxetine... 3 atorvastatin atovaquone... 8 atovaquone-proguanil... 8 ATRIPLA... 2 atropine ATROVENT HFA AUBAGIO aubra aubra eq AURYXIA AVANDIA aviane

106 avita AVITA AVONEX AVONEX (WITH ALBUMIN) AVYCAZ... 5 AZASAN... 5 AZASITE azathioprine... 5 azelastine... 56, 84 AZELEX azithromycin... 7 AZOPT aztreonam... 8 azurette (28) B bacitracin bacitracin-polymyxin b baclofen BACLOFEN BACTROBAN NASAL balsalazide balziva (28) BANZEL BARACLUDE... 2 BCG VACCINE, LIVE (PF) 69 BECONASE AQ benazepril benazepril-hydrochlorothiazide BENLYSTA BENZNIDAZOLE... 8 benztropine betamethasone dipropionate. 5 betamethasone valerate... 5 betamethasone, augmented... 5 BETASERON betaxolol... 38, 84 bethanechol chloride BETHKIS... 8 BETIMOL BETOPTIC S bexarotene... 5 BEXSERO bicalutamide... 5 BICILLIN L-A... 2 BIKTARVY... 2 BILTRICIDE... 8 bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM bleomycin... 5 BLEPHAMIDE BLEPHAMIDE S.O.P blisovi 24 fe blisovi fe.5/30 (28) blisovi fe /20 (28) BOOSTRIX TDAP BOSULIF... 5 BRAFTOVI... 5 BREO ELLIPTA briellyn BRILINTA brimonidine BRIVIACT bromfenac bromocriptine BROVANA budesonide... 64, 89 bumetanide BUPRENORPHINE buprenorphine hcl buprenorphine-naloxone bupropion hcl... 3 bupropion hcl (smoking deter) buspirone... 3 butalbital compound w/codeine butalbital-acetaminop-caf-cod butalbital-acetaminophen-caff butalbital-aspirin-caffeine butorphanol tartrate BYDUREON BYDUREON BCISE BYETTA C cabergoline... 6 CABOMETYX... 5 calcipotriene calcipotriene-betamethasone 47 calcitonin (salmon)... 6 calcitriol... 6 calcium acetate CALQUENCE... 5 camila camrese camrese lo CANASA CANCIDAS... candesartan candesartan-hydrochlorothiazid CAPRELSA... 5 captopril captopril-hydrochlorothiazide CARAFATE CARBAGLU carbamazepine... 20, 2 carbidopa-levodopa carbidopa-levodopaentacapone carbinoxamine maleate CARIMUNE NF NANOFILTERED carteolol cartia xt carvedilol caspofungin... CAYSTON... 8 caziant (28) cefaclor... 5 cefadroxil... 6 cefazolin... 6 cefazolin in dextrose (iso-os).. 6 cefdinir... 6 cefepime... 6 CEFEPIME IN DEXTROSE 5 %... 6 cefepime in dextrose,iso-osm. 6 cefixime... 6 CEFOTAN... 6 cefotaxime... 6 cefotetan... 6 CEFOTETAN IN DEXTROSE, ISO-OSM... 6 cefoxitin... 6 cefoxitin in dextrose, iso-osm. 6 cefpodoxime... 6 cefprozil... 6 ceftazidime... 7 CEFTAZIDIME IN D5W... 7 ceftriaxone... 7 CEFTRIAXONE... 7 ceftriaxone in dextrose,iso-os. 7 99

107 cefuroxime axetil... 7 cefuroxime sodium... 7 celecoxib CELONTIN... 2 cephalexin... 7 CERDELGA... 6 cetirizine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX chateal (28) CHENODAL chlorhexidine gluconate chloroquine phosphate... 8 chlorothiazide chlorpromazine... 3 chlorthalidone chlorzoxazone cholestyramine (with sugar). 44 cholestyramine light ciclodan ciclopirox... 49, 50 cilostazol CIMDUO... 2 cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CIMZIA STARTER KIT CINQAIR CINRYZE CIPRO HC CIPRODEX ciprofloxacin... 3 ciprofloxacin (mixture)... 3 ciprofloxacin hcl... 3, 83 ciprofloxacin in 5 % dextrose... 3 citalopram... 3 claravis clarithromycin... 8 clemastine clindacin p clindamycin hcl... 8 CLINDAMYCIN IN 0.9 % SOD CHLOR... 8 clindamycin in 5 % dextrose.. 9 clindamycin palmitate hcl... 9 clindamycin pediatric... 9 clindamycin phosphate... 9, 48, 77 CLINDAMYCIN PHOSPHATE clindamycin-benzoyl peroxide CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 4.25%/D0W 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).. 96 CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D0W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 5 % clobazam... 2 clobetasol... 5 clobetasol-emollient... 5 clodan... 5 clomipramine... 3 clonazepam... 2 clonidine clonidine hcl... 3, 39 clopidogrel clorazepate dipotassium... 3 clotrimazole..., 50 clotrimazole-betamethasone. 50 clozapine... 3 CLOZAPINE COARTEM... 9 codeine sulfate codeine-butalbital-asa-caff COLCHICINE colesevelam colestipol colistin (colistimethate na)... 9 colocort COLY-MYCIN S COMBIGAN COMBIVENT RESPIMAT.. 89 COMETRIQ... 5 COMPLERA... 2 constulose COPIKTRA... 5 CORDRAN TAPE LARGE ROLL... 5 CORLANOR cortisone CORTISPORIN COTELLIC... 5 COUMADIN CREON CRIXIVAN... 2 cromolyn... 64, 84, 89 cryselle (28) CUPRIMINE CUVITRU cyclafem /35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclophosphamide... 5 CYCLOSERINE... 9 cyclosporine... 5 cyclosporine modified... 5 cyproheptadine cyred cyred eq CYSTAGON CYSTARAN D d0 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride

108 d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride DALIRESP danazol... 6 dantrolene dapsone... 9 DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin... 9 DARAPRIM... 9 dasetta /35 (28) dasetta 7/7/7 (28) DAURISMO... 5 daysee deblitane DELESTROGEN DELSTRIGO... 2 delyla (28) demeclocycline... 3 DEMSER DENAVIR DEPEN TITRATABS DEPO-ESTRADIOL DEPO-PROVERA DESCOVY... 2 desipramine desloratadine desmopressin... 6 desog-e.estradiol/e.estradiol. 78 desogestrel-ethinyl estradiol. 78 desonide... 5 desoximetasone... 5, 52 desvenlafaxine succinate dexamethasone dexamethasone intensol dexamethasone sodium phos (pf) dexamethasone sodium phosphate... 57, 58, 86 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextrose 0 % and 0.2 % nacl dextrose 0 % in water (d0w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w). 54 dextrose 5 %-lactated ringers54 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride DIASTAT... 2 DIASTAT ACUDIAL... 2 diazepam... 2, 32 diazepam intensol diclofenac potassium diclofenac sodium... 29, 47, 85 diclofenac-misoprostol dicloxacillin... 2 dicyclomine didanosine... 2 diflorasone diflunisal digitek digox digoxin dihydroergotamine DILANTIN 30 MG... 2 diltiazem hcl dilt-xr DIPENTUM diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram divalproex... 2 dofetilide donepezil DOPTELET (0 TAB PACK) DOPTELET (5 TAB PACK) DORIPENEM... 9 dorzolamide dorzolamide-timolol dorzolamide-timolol (pf) doxazosin doxepin doxercalciferol... 6 doxy doxycycline hyclate... 3 doxycycline monohydrate... 3, 4 dronabinol drospirenone-e.estradiol-lm.fa drospirenone-ethinyl estradiol DROXIA... 5 DUAVEE duloxetine duramorph (pf) DUREZOL dutasteride DYRENIUM E e.e.s econazole EDURANT... 2 efavirenz... 3 EGRIFTA electrolyte-48 in d5w ELIDEL ELIGARD... 5 ELIGARD (3 MONTH)... 5 ELIGARD (4 MONTH)... 5 ELIGARD (6 MONTH)... 5 elinest ELIQUIS ELLA ELMIRON EMCYT... 6 emoquette EMSAM EMTRIVA... 3 EMVERM... 9 enalapril maleate enalapril-hydrochlorothiazide ENBREL

109 ENBREL MINI ENBREL SURECLICK endocet ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone entecavir... 3 ENTRESTO enulose EPIDIOLEX... 2 epinastine EPINEPHRINE epitol... 2 EPIVIR HBV... 3 eplerenone EPOGEN eprosartan EQUETRO... 2 ERAXIS(WATER DILUENT)... ergoloid ERGOMAR ERIVEDGE... 6 ERLEADA... 6 errin ertapenem... 9 ery pads ERYTHROCIN... 8 erythrocin (as stearate)... 8 erythromycin... 8, 83 erythromycin ethylsuccinate.. 8 erythromycin with ethanol.. 48, 49 erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate... 32, 33 esomeprazole magnesium estarylla estazolam estradiol... 75, 76 estradiol valerate estradiol-norethindrone acet. 76 ESTRING estropipate eszopiclone ethacrynic acid ethambutol... 9 ethosuximide... 2 ethynodiol diac-eth estradiol 79 etidronate disodium etodolac EVOTAZ... 3 EXELDERM exemestane... 6 EXJADE EXTAVIA ezetimibe ezetimibe-simvastatin F falmina (28) famciclovir... 3 famotidine FANAPT FARESTON... 6 FARYDAK... 6 FASENRA fayosim felbamate... 2 felodipine FEMRING femynor fenofibrate FENOFIBRATE fenofibrate micronized fenofibrate nanocrystallized. 45 fenofibric acid fenoprofen fentanyl fentanyl citrate FERRIPROX FETZIMA FINACEA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE... 6 flavoxate FLEBOGAMMA DIF flecainide FLOVENT DISKUS FLOVENT HFA fluconazole... fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm). flucytosine... fludrocortisone flunisolide fluocinolone fluocinolone acetonide oil fluocinolone and shower cap 52 fluocinonide fluocinonide-e fluocinonide-emollient fluoride (sodium) fluorometholone fluorouracil FLUOROURACIL fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide... 6 fluticasone... 52, 89 FLUTICASONE- SALMETEROL fluvastatin fluvoxamine FML FORTE FML S.O.P fondaparinux fosamprenavir... 3 fosinopril fosinopril-hydrochlorothiazide fosphenytoin... 2 FREAMINE HBC 6.9 % freamine iii 0 % furosemide FUZEON... 3 fyavolv FYCOMPA... 2 G gabapentin galantamine GAMMAGARD LIQUID GAMMAGARD S-D (IGA < MCG/ML) GAMMAKED GAMMAPLEX GAMMAPLEX (WITH SORBITOL) GAMUNEX-C GARDASIL 9 (PF) gatifloxacin

110 GATTEX 30-VIAL GATTEX ONE-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n gemfibrozil generlac gengraf... 6 gentak gentamicin... 9, 49, 83 gentamicin in nacl (iso-osm).. 9 GENVOYA... 3 GEODON gianvi (28) GILENYA GILOTRIF... 6 GLASSIA glatiramer glatopa GLEOSTINE... 6 glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glycopyrrolate GRALISE GRALISE 30-DAY STARTER PACK granisetron hcl griseofulvin microsize... griseofulvin ultramicrosize... guanfacine... 33, 40 guanidine H HAEGARDA hailey 24 fe halobetasol propionate HALOG haloperidol haloperidol decanoate haloperidol lactate... 33, 34 HARVONI... 3 HAVRIX (PF)... 7 heather heparin (porcine) heparin (porcine) in 5 % dex 43 heparin (porcine) in nacl (pf) 43 heparin(porcine) in 0.45% nacl HEPARIN(PORCINE) IN 0.45% NACL heparin, porcine (pf) HEPATAMINE 8% HETLIOZ HIBERIX (PF)... 7 HIZENTRA... 7 HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN CROHNS-UC- HS START HUMIRA PEN PSOR- UVEITS-ADOL HS HUMIRA(CF) HUMIRA(CF) PEDI CROHNS STARTER HUMIRA(CF) PEN HUMIRA(CF) PEN CROHNS-UC-HS HUMIRA(CF) PEN PSOR- UV-ADOL HS hydralazine hydrochlorothiazide hydrocodone-acetaminophen 27 hydrocodone-ibuprofen hydrocortisone... 52, 58, 65 hydrocortisone-acetic acid hydrocortisone-min oil-wht pet hydromorphone hydromorphone (pf) hydroxychloroquine... 9 hydroxyurea... 6 hydroxyzine hcl... 87, 88 hydroxyzine pamoate HYQVIA... 7 I ibandronate IBRANCE... 6 ibu IBUDONE ibuprofen ibuprofen-oxycodone ICLUSIG... 6 IDHIFA... 6 ILEVRO imatinib... 6 IMBRUVICA... 6 imipenem-cilastatin... 9 imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES VACCINE (PF)... 7 INCRELEX INCRUSE ELLIPTA indapamide indomethacin INFANRIX (DTAP) (PF)... 7 INLYTA... 6 INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U INTELENCE... 3 INTRALIPID INTRON A introvale INVANZ... 9 INVEGA SUSTENNA INVEGA TRINZA INVIRASE... 3 INVOKANA IOPIDINE IPOL... 7 ipratropium bromide... 56, 90 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRESSA... 6 ISENTRESS... 3 ISENTRESS HD... 3 isibloom isoniazid... 9 isosorbide dinitrate isosorbide mononitrate isradipine itraconazole... ivermectin... 9 IXIARO (PF)... 7 J JAKAFI... 6 jantoven JANUMET JANUVIA JARDIANCE

111 jencycla jinteli jolessa jolivette juleber JULUCA... 3 junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe JUXTAPID JYNARQUE... 6 K kaitlib fe KALETRA... 3 KALYDECO kariva (28) kelnor /35 (28) kelnor ketoconazole..., 50 ketoprofen ketorolac... 29, 85 KEVZARA KINERET KINRIX (PF)... 7 kionex (with sorbitol) KISQALI... 7 KISQALI FEMARA CO- PACK... 6 klor-con klor-con klor-con klor-con m klor-con m klor-con m klor-con sprinkle KORLYM... 6 kurvelo (28) KUVAN KYNAMRO L l norgest/e.estradiol-e.estrad. 80 labetalol LACRISERT lactulose lamivudine... 3 lamivudine-zidovudine... 3 lamotrigine LANOXIN lansoprazole lanthanum LANTUS SOLOSTAR U-00 INSULIN LANTUS U-00 INSULIN.. 59 larin.5/30 (2) larin /20 (2) larin 24 fe larin fe.5/30 (28) larin fe /20 (28) larissia latanoprost LATUDA layolis fe LAZANDA LEDIPASVIR-SOFOSBUVIR... 3 leena leflunomide LENVIMA... 7 lessina LETAIRIS letrozole... 7 leucovorin calcium... 4 LEUKERAN... 7 LEUKINE leuprolide... 7 levalbuterol hcl LEVALBUTEROL TARTRATE LEVEMIR FLEXTOUCH U- 00 INSULN LEVEMIR U-00 INSULIN 59 levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 3, 83 levofloxacin in d5w... 3 levonest (28) levonorgestrel-ethinyl estrad 80 levonorg-eth estrad triphasic 80 levora levorphanol tartrate LEVO-T levothyroxine levoxyl LEXIVA... 3 lidocaine lidocaine hcl lidocaine viscous lidocaine-prilocaine lindane linezolid... 0 linezolid in dextrose 5%... 9 linezolid-0.9% sodium chloride... 0 LINZESS liothyronine lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate LONSURF... 7 loperamide lopinavir-ritonavir... 3 lopreeza lorazepam LORBRENA... 7 lorcet (hydrocodone) lorcet hd lorcet plus loryna (28) losartan losartan-hydrochlorothiazide 40 LOTEMAX lovastatin low-ogestrel (28) loxapine succinate LUPRON DEPOT... 7 LUPRON DEPOT (3 MONTH)... 7 LUPRON DEPOT (4 MONTH)... 7 LUPRON DEPOT (6 MONTH)... 7 LUPRON DEPOT-PED... 7 LUPRON DEPOT-PED (3 MONTH)... 7 lutera (28) LYNPARZA... 7 LYRICA LYSODREN... 7 lyza M magnesium sulfate MAGNESIUM SULFATE IN D5W

112 magnesium sulfate in water.. 93 malathion maprotiline marlissa (28) MARPLAN MATULANE... 7 matzim la MAVYRET... 3 MAXIDEX meclizine meclofenamate medroxyprogesterone mefenamic acid mefloquine... 0 megestrol... 7 MEKINIST... 7 MEKTOVI... 7 melodetta 24 fe meloxicam memantine MEMANTINE MENACTRA (PF)... 7 MENEST MENOSTAR MENTAX MENVEO A-C-Y-W-35-DIP (PF)... 7 meperidine mercaptopurine... 7 meropenem... 0 MEROPENEM-0.9% SODIUM CHLORIDE... 0 mesalamine MESALAMINE mesalamine with cleansing wipe MESNEX... 4 MESTINON metadate er metaproterenol metaxall metaxalone metformin... 59, 60 methadone methamphetamine methazolamide methenamine hippurate... 4 methergine methimazole methocarbamol methotrexate sodium... 8 methotrexate sodium (pf)... 8 methoxsalen methscopolamine methyclothiazide methylphenidate hcl... 34, 35 methylprednisolone methylprednisolone acetate.. 58 methylprednisolone sodium succ methyltestosterone metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate... 4 metro i.v... 0 metronidazole... 0, 49, 77 metronidazole in nacl (iso-os)... 0 mexiletine mibelas 24 fe miconazole microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28)... 8 microgestin fe /20 (28)... 8 midodrine migergot miglitol MIGLUSTAT mili... 8 millipred mimvey mimvey lo MINITRAN MINIVELLE minocycline... 4 minoxidil... 4 mirtazapine MIRVASO misoprostol M-M-R II (PF)... 7 modafinil moderiba... 3 moexipril... 4 moexipril-hydrochlorothiazide... 4 molindone mometasone... 52, 90 mono-linyah... 8 mononessa (28)... 8 montelukast MONUROL... 4 morgidox... 4 morphine MORPHINE morphine concentrate MOVANTIK moxifloxacin... 3, 83 MOXIFLOXACIN IN NACL (ISO-OSM)... 3 MOXIFLOXACIN- SOD.ACE,SUL-WATER. 3 MULTAQ mupirocin mupirocin calcium MYALEPT MYCAMINE... mycophenolate mofetil... 8 mycophenolate sodium... 8 MYFORTIC... 8 myorisan MYRBETRIQ MYTESI myzilra... 8 N nabumetone nadolol... 4 nafcillin... 2 nafcillin in dextrose iso-osm 2 naftifine NAFTIN naloxone naltrexone naproxen naproxen sodium naratriptan NARCAN NATACYN nateglinide NATPARA NEBUPENT... 0 necon 0.5/35 (28)... 8 NEEDLES, INSULIN DISP.,SAFETY nefazodone neomycin... 0 neomycin-bacitracin-poly-hc 86 05

113 neomycin-bacitracinpolymyxin neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc 57, 86 neo-polycin neo-polycin hc NEORAL... 8 NEPHRAMINE 5.4 % NERLYNX... 8 neuac NEULASTA NEUPOGEN NEUPRO NEVANAC nevirapine... 4 NEXAVAR... 8 niacin NIACOR NICOTROL NICOTROL NS nifedipine... 4 nikki (28)... 8 nilutamide... 8 nimodipine... 4 NINLARO... 8 nitro-bid NITRO-DUR nitrofurantoin... 4 nitrofurantoin macrocrystal.. 4 nitrofurantoin monohyd/mcryst... 4 nitroglycerin... 46, 47 nizatidine nora-be NORDITROPIN FLEXPRO 68 noreth-ethinyl estradiol-iron. 8 norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol... 77, 8 norethindrone-e.estradiol-iron... 8 norgestimate-ethinyl estradiol... 8 norlyroc NORMOSOL-M IN 5 % DEXTROSE NORTHERA nortrel 0.5/35 (28)... 8 nortrel /35 (2)... 8 nortrel /35 (28)... 8 nortrel 7/7/7 (28)... 8 nortriptyline NORVIR... 4 NOVOLIN 70/30 U-00 INSULIN NOVOLIN N NPH U-00 INSULIN NOVOLIN R REGULAR U- 00 INSULN NOVOLOG FLEXPEN U-00 INSULIN NOVOLOG MIX U-00 INSULN NOVOLOG MIX 70-30FLEXPEN U NOVOLOG PENFILL U-00 INSULIN NOVOLOG U-00 INSULIN ASPART NOXAFIL... NUCALA NUEDEXTA NUPLAZID NUTROPIN AQ NUSPIN nyamyc nystatin..., 2, 50 nystatin-triamcinolone nystop O OCALIVA ocella... 8 OCTAGAM... 7 octreotide acetate... 8 ODEFSEY... 4 ODOMZO... 8 OFEV ofloxacin... 3, 57, 84 ogestrel (28)... 8 olanzapine olanzapine-fluoxetine olmesartan... 4 olmesartan-amlodipinhcthiazid... 4 olmesartanhydrochlorothiazide... 4 olopatadine... 57, 85 omega-3 acid ethyl esters omeprazole ondansetron ondansetron hcl ONFI ONGLYZA OPSUMIT oralone ORENCIA ORFADIN ORILISSA ORKAMBI orphenadrine citrate orsythia... 8 oseltamivir... 4 OTEZLA OTEZLA STARTER oxacillin... 2 oxacillin in dextrose(iso-osm)... 2 oxandrolone oxaprozin oxazepam oxcarbazepine OXERVATE oxiconazole OXISTAT oxybutynin chloride oxycodone OXYCODONE oxycodone-acetaminophen oxymorphone P pacerone paliperidone PALYNZIQ PANRETIN pantoprazole paricalcitol paroex oral rinse paromomycin... 0 paroxetine hcl PASER... 0 PAXIL PEDIARIX (PF)... 7 PEDVAX HIB (PF)... 7 peg 3350-electrolytes

114 PEGANONE PEGASYS PEGASYS PROCLICK peg-electrolyte PEGINTRON PENICILLIN G POT IN DEXTROSE... 2 penicillin g potassium... 2 penicillin g procaine... 2 penicillin g sodium... 2 penicillin v potassium... 2 PENTAM... 0 PENTASA pentoxifylline perindopril erbumine... 4 periogard permethrin perphenazine perphenazine-amitriptyline PEXEVA phenadoz phenelzine phenergan phenobarbital phenytoin... 22, 23 phenytoin sodium extended.. 23 philith... 8 PHOSPHOLINE IODIDE PICATO PIFELTRO... 4 pilocarpine hcl... 55, 85 pimozide pimtrea (28)... 8 pindolol... 4 pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam... 3 PIPERACILLIN- TAZOBACTAM... 2 pirmella... 8 piroxicam PLASMA-LYTE PLASMA-LYTE A plenamine podofilox polycin polyethylene glycol polymyxin b sulf-trimethoprim POMALYST... 8 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 in water.. 94 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 PRADAXA PRALUENT PEN pramipexole prasugrel pravastatin prazosin... 4 PRED MILD prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 58, 87 prednisone prednisone intensol PREMARIN premasol 0 % PREMASOL 6 % PREMPHASE PREMPRO prenatal vitamin oral tablet prevalite previfem... 8 PREZCOBIX... 4 PREZISTA... 4 PRIFTIN... 0 PRIMAQUINE... 0 primidone PRIVIGEN... 7 PROAIR HFA probenecid probenecid-colchicine PROCALAMINE 3% prochlorperazine prochlorperazine maleate oral PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc profeno progesterone micronized PROGLYCEM PROLASTIN-C PROLIA PROMACTA promethazine promethegan propafenone proparacaine propranolol... 4 propranolol-hydrochlorothiazid... 4 propylthiouracil PROQUAD (PF) protriptyline PROVENTIL HFA... 9 PULMICORT FLEXHALER... 9 PULMOZYME... 9 PURIXAN... 8 pyrazinamide... 0 pyridostigmine bromide Q QUADRACEL (PF) quasense quetiapine quinapril... 4 quinapril-hydrochlorothiazide... 4 quinidine gluconate quinidine sulfate quinine sulfate... 0 QVAR REDIHALER... 9 R RABAVERT (PF) rabeprazole raloxifene ramipril... 4 RANEXA

115 ranitidine hcl RAPAMUNE... 8 rasagiline RAVICTI REBETOL... 4 REBIF (WITH ALBUMIN). 69 REBIF REBIDOSE REBIF TITRATION PACK 69 reclipsen (28) RECOMBIVAX HB (PF) RECTIV REGRANEX RELENZA DISKHALER... 4 RELISTOR RENAGEL repaglinide REPATHA REPATHA SURECLICK RESCRIPTOR... 4 RESTASIS RESTASIS MULTIDOSE REVLIMID... 8 REXULTI REYATAZ... 4 ribasphere... 4 ribasphere ribapak... 4 ribavirin... 4 RIDAURA rifabutin... 0 rifampin... 0 RIFATER... 0 riluzole rimantadine... 4 risedronate... 55, 73 RISPERDAL CONSTA risperidone ritonavir... 4 rivastigmine rivastigmine tartrate rivelsa rizatriptan ropinirole rosadan rosuvastatin ROTARIX ROTATEQ VACCINE roweepra roweepra xr ROZEREM RUBRACA... 8 RYDAPT... 8 S SABRIL SAMSCA SANDIMMUNE... 8 SANTYL SAPHRIS SAVELLA scopolamine base selegiline hcl selenium sulfide SELZENTRY... 4 SENSIPAR SEREVENT DISKUS... 9 sertraline setlakin sevelamer carbonate sharobel SHINGRIX (PF) SIGNIFOR... 9 sildenafil (pulmonary arterial hypertension)... 9 silodosin silver sulfadiazine SIMPONI simvastatin sirolimus... 9 SIRTURO... 0 sodium chloride... 55, 95 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium lactate intravenous sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate... 55, 56 SODIUM POLYSTYRENE SULFONATE SOLTAMOX... 9 SOMATULINE DEPOT... 9 SOMAVERT sorine sotalol sotalol af SPIRIVA RESPIMAT... 9 SPIRIVA WITH HANDIHALER... 9 spironolactone... 4 spironolacton-hydrochlorothiaz... 4 sprintec (28) SPRITAM SPRYCEL... 9 sps (with sorbitol) sronyx ssd stavudine... 4 STELARA STIOLTO RESPIMAT... 9 STIVARGA... 9 STREPTOMYCIN... 0 STRIBILD... 4 SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne) 49 sulfacetamide-prednisolone.. 85 sulfadiazine... 3 sulfamethoxazole-trimethoprim... 3 sulfasalazine sulfatrim... 3 sulindac sumatriptan sumatriptan succinate SUPRAX... 7 SUPREP BOWEL PREP KIT SUTENT... 9 syeda SYLATRON SYMBICORT... 9 SYMDEKO... 9 SYMFI... 5 SYMFI LO... 5 SYMLINPEN SYMLINPEN SYMTUZA... 5 SYNAREL SYNJARDY SYNJARDY XR... 6 SYNRIBO... 9 SYNTHROID T TABLOID... 9 tacrolimus... 9, 48 TAFINLAR

116 TAGRISSO... 9 TAKHZYRO... 9 TALZENNA... 9 tamoxifen... 9 tamsulosin TARCEVA... 9 TARGRETIN... 9 tarina fe /20 (28) tarina fe -20 eq (28) TASIGNA... 9 TAVALISSE tazarotene TAZICEF... 7 TAZORAC taztia xt TECFIDERA TEFLARO... 7 TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid temazepam TENIVAC (PF) tenofovir disoproxil fumarate. 5 terazosin terbinafine hcl... 2 terbutaline... 9 terconazole testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline... 4 THALOMID... 9 theophylline... 9 thioridazine thiothixene tiagabine TIBSOVO... 9 tigecycline... 0 tilia fe timolol maleate... 42, 84 tinidazole... 0 TIVICAY... 5 tizanidine TOBI PODHALER... TOBRADEX tobramycin tobramycin in % nacl.. tobramycin sulfate... tobramycin-dexamethasone.. 86 TOBREX tolazamide... 6 tolbutamide... 6 tolcapone tolmetin tolterodine topiramate torsemide TOUJEO MAX U-300 SOLOSTAR... 6 TOUJEO SOLOSTAR U-300 INSULIN... 6 TRACLEER... 9 TRADJENTA... 6 tramadol TRAMADOL tramadol-acetaminophen trandolapril tranexamic acid tranylcypromine travasol 0 % trazodone TRECATOR... TRELEGY ELLIPTA... 9 TRELSTAR... 9 tretinoin (chemotherapy)... 9 tretinoin topical TREXALL... 9 triamcinolone acetonide 52, 53, 57 triamterene-hydrochlorothiazid triazolam triderm trientine tri-estarylla trifluoperazine trifluridine trihexyphenidyl tri-legest fe tri-lo-estarylla tri-lo-sprintec trilyte with flavor packets trimethobenzamide trimethoprim... 4 tri-mili trimipramine trinessa (28) TRINTELLIX tri-previfem (28) tri-sprintec (28) TRIUMEQ... 5 trivora (28) tri-vylibra TROPHAMINE 0 % trospium TRULICITY... 6 TRUMENBA TRUVADA... 5 TWINRIX (PF) TYBOST... 5 tydemy TYGACIL... TYKERB... 9 TYMLOS TYPHIM VI TYVASO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT U UCERIS ULORIC unithroid UPTRAVI ursodiol V VABOMERE... valacyclovir... 5 VALCHLOR valganciclovir... 5 valproic acid valproic acid (as sodium salt) valsartan valsartan-hydrochlorothiazide vancomycin... VANCOMYCIN... VANCOMYCIN IN 0.9 % SODIUM CHL... 09

117 VANCOMYCIN IN DEXTROSE 5 %... vandazole VAQTA (PF) VARIVAX (PF) velivet triphasic regimen (28) VELTASSA VENCLEXTA VENCLEXTA STARTING PACK venlafaxine VENTAVIS VENTOLIN HFA verapamil veripred VERSACLOZ VERZENIO VICTOZA 2-PAK... 6 VICTOZA 3-PAK... 6 VIDEX 2 GRAM PEDIATRIC... 5 VIDEX 4 GRAM PEDIATRIC... 5 VIDEX EC... 5 vienva vigabatrin VIIBRYD VIMPAT viorele (28) VIRACEPT... 5 VIRAMUNE... 5 VIREAD... 5 VITRAKVI VIZIMPRO voriconazole... 2 VOTRIENT VRAYLAR vyfemla (28) vylibra W warfarin WELCHOL wera (28) wymzya fe X XALKORI XARELTO XATMEP XELJANZ XELJANZ XR XERMELO XGEVA... 4 XIIDRA XOLAIR XOSPATA XTANDI xulane XURIDEN XYREM Y YF-VAX (PF) yuvafem Z zafirlukast zaleplon zarah ZARXIO ZAVESCA zebutal ZEJULA ZELBORAF ZEMAIRA zenatane zenchent (28) ZENPEP ZEPATIER... 5 ZERBAXA... 7 zidovudine... 5 ziprasidone hcl ZIRGAN ZOLINZA zolpidem zonisamide ZORTRESS ZOSTAVAX (PF) zovia /35e (28) ZURAMPIC ZYDELIG ZYKADIA ZYPREXA RELPREVV ZYTIGA

118 This formulary was updated March, 209. For more recent information or other questions, please contact our Customer Services department at: HAP Empowered Duals (HMO SNP) (800) Our business hours are: Prescription drug benefit related calls: Available 24 hours a day, seven days a week For all other calls: 8 a.m. to 8 p.m., seven days a week (Oct. March 3) 8 a.m. to 8 p.m., Monday through Friday (April - Sept. 30) W. Grand Boulevard, Detroit, Michigan Health Alliance Plan of Michigan A Nonprofit Company