2016 COMPREHENSIVE FORMULARY

Size: px
Start display at page:

Download "2016 COMPREHENSIVE FORMULARY"

Transcription

1 016 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) MEDICARE ADVANTAGE PLANS Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 11/01/016. For more recent information or other questions, please contact Easy Choice at the telephone number listed on the inside front and back covers of this formulary or visit EASY CHOICE HEALTH PLAN Easy Choice Plus (HMO) H H HPMS Approved Formulary File Submission ID: Version Number: 16 Y0070_NA09587_WCM_FOR_ENG_FINAL_06 CMS Approved WellCare 016 NA_11_16 EC6V06FOR73881E_1116

2 We re always just a phone call away! If you re ready to enroll or have enrollment questions, call , 8 a.m. to 8 p.m., 7 days a week. If you re already a member, call the number for your state/plan listed below. California: Easy Choice Plus Plan (HMO) Hours of operation are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 1, representatives are available Monday Sunday, 8 a.m. to 8 p.m., or visit us anytime at Nurse Advice Line ( hours, 7 days a week) TTY for all of the above

3 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 Easy Choice. When it refers to plan or our plan, it means 016 Easy Choice. This document includes a list of the drugs (formulary) for our plan which is current as of 11/01/016. 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 co-payments/coinsurance may change on January 1, 017, and from time to time during the year. WHAT IS THE EASY CHOICE PLUS (HMO) COMPREHENSIVE FORMULARY? A formulary is a list of covered drugs. Easy Choice selects the drugs by working with a team of health care providers. The list contains the prescription medications we believe are a necessary part of a quality treatment program. Easy Choice will generally cover the drugs listed in our formulary as long as: 1. the drug is medically necessary,. the prescription is filled at an Easy Choice network pharmacy, and 3. other plan rules are followed. For more information on how to fill your prescriptions, please see your Evidence of Coverage. CAN THE FORMULARY (DRUG LIST) CHANGE? In general, if you are taking a drug on our 016 formulary that was covered at the beginning of the year, we will not stop or reduce coverage of the drug during the 016 coverage year. However, there are some cases when we may stop or reduce coverage. These are: when a new, less expensive generic drug becomes available or when new negative information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. For those members, it will remain available at the same cost share for the remainder of the coverage year. We think it s important that you can continue to get the formulary drugs that were available when you chose our plan for the remainder of the coverage year. The only exceptions are for cases in which you can save additional money or we can ensure your safety. When we make certain changes to our formulary, we must notify the members who will be affected by the changes. This includes if we: remove drugs from our formulary; add restrictions on a drug such as prior authorization, quantity limits and/or step therapy; 016 Comprehensive Formulary I EC6V06FOR73881E_1116

4 move a drug to a higher cost-sharing tier. If we make any of these changes, we must notify affected members at least 60 days before the change goes into effect. We will also notify the member at the time he or she asks for a refill of the drug. In that case, the member will receive a 60-day supply of the drug. If the Food and Administration announces that a drug on our formulary is unsafe, or a drug manufacturer removes a drug from the market, we will immediately remove the drug from our formulary and notify members who take the drug. The enclosed formulary is current as of 11/01/016. To get updated information about the drugs covered by Easy Choice, please visit our website at or call Customer Service at the telephone number listed for your state/plan on the inside front and back cover pages of this formulary. Every month, our printed comprehensive formulary will be updated. Please contact Customer Service or visit our website at for more information. HOW DO I USE THE FORMULARY? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. 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 13. 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? Easy Choice 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: 016 Comprehensive Formulary II

5 Prior Authorization: Easy Choice requires 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 we will cover. For example, Easy Choice provides 18 tablets for 30 days per prescription for rizatriptan 5mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Easy Choice requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at We have posted online documents that explain our prior authorization restriction 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 Easy Choice 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 Easy Choice formulary? on page IV for information about how to request an exception. WHAT IF MY DRUG IS NOT ON THE FORMULARY? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. You can contact Customer Service at the telephone number listed for your state/plan on the inside front and back covers of this formulary. If you learn that Easy Choice does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Easy Choice. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Easy Choice. You can ask Easy Choice to make an exception and cover your drug. See below for information about how to request an exception. WHICH VACCINES DO WE COVER? Your prescription benefit may cover many vaccines. For details, see the Immunological Agents section. The cost for vaccines varies, depending on the facility where you receive them. For best coverage, use a network pharmacy. All commercially available vaccines are covered under Part D, except for those that are covered under Medicare Part B, such as influenza or pneumococcal vaccines. 016 Comprehensive Formulary III

6 HOW DO I REQUEST AN EXCEPTION TO THE EASY CHOICE PLUS (HMO) FORMULARY? You can ask Easy Choice to make an exception to our coverage rules. There are several types of formulary exceptions that you can ask us to make. Initial Coverage Decision Exception You can ask us to cover your drug even if it is not on our formulary. If your request is approved, the drug will be covered at a pre-determined cost-sharing level. You would not be able to ask us to provide the drug at a lower cost-sharing level. Utilization Restriction Exception You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the amount of the drug that we cover is limited. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. ing Exception You can ask us to cover a formulary drug at a lower cost-sharing level if the drug is not on the preferred generic, preferred brand or specialty tier. If approved, this would lower the amount you must pay for your drug. Generally, Easy Choice will only approve your request for an exception if: the alternative drugs included on the plan s formulary would not be as effective in treating your condition; the lower cost-sharing drug would not be as effective in treating your condition; the additional utilization restrictions would not be as effective in treating your condition and/or; the alternative drugs would cause you to have adverse medical effects. You should contact us to ask us for a formulary exception for an initial coverage decision, a tiering exception or a utilization restriction exception. When you request any of these exceptions, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescribing physician 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 7 hours for a decision. If your request for a fast review is granted, we must give you a decision no later than hours after we get your prescriber s or prescribing physician s supporting statement. 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 016 Comprehensive Formulary IV

7 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 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. 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, we will allow you to refill your prescription until we have provided you with a 93-day transition supply that meets the dispensing instructions (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 93 days you are a member of our plan. If 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 93 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you seek a formulary exception. If you experience a level of care change (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can call our Provider Service Center and request a one-time override. This one-time override will be up to a 31-day supply (unless you have a prescription written for fewer days). FOR MORE INFORMATION For more details about your Easy Choice prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Easy Choice, please contact us. Our contact information, along with the date we last updated the formulary, is on the inside front and back covers of this document. Or visit If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day, 7 days a week. TTY users should call Or visit EASY CHOICE FORMULARY The comprehensive formulary that begins on page 1 provides coverage information about the drugs covered by Easy Choice. If you have trouble finding your drug in the list, turn to the Index that begins on page 13. The first column of the chart lists the drug name. Brand-name drugs are UPPERCASE (e.g., COUMADIN) and generic drugs are listed in lowercase italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if Easy Choice has any special requirements for coverage of your drug. ED stands for Excluded Part D : This prescription drug is not normally covered in a Medicare Prescription Plan. The amount you pay when you fill a prescription for this drug does not count toward your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving Extra Help to 016 Comprehensive Formulary V

8 pay for your prescriptions, you will not get any Extra Help to pay for this drug. NM means the drug is not available via your monthly mail service benefit. This is noted in the Requirements/Limits column of your formulary. You may be able to receive more than one month s supply of most of the drugs on your formulary via mail service at a reduced cost share. Please see Chapter 5 of your Evidence of Coverage for more information.** PA stands for Prior Authorization: Please see page III for details. B/D stands for Covered under Medicare B or D: This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from Easy Choice to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Easy Choice may not cover this drug. QL stands for Quantity Limits: Please see page III for details. LA stands for Limited Access medication. This medication may be available from certain other pharmacies. For more information, please refer to the Specialty Pharmacy section of your Pharmacy Directory or contact Customer Service at the telephone number listed for your state/plan on the inside front and back cover pages of this formulary. ST stands for Step Therapy: Please see page III for details. ^ = may be available for up to a 30-day supply only. ** You have the choice to sign up for automated mail service delivery. You can get prescription drugs shipped to your home through our network mail service delivery program. You should expect to receive your prescription drugs within 7 10 business days from the time that the mail service pharmacy receives the order. If you do not receive your prescription drugs within this time, please contact us at the telephone number listed on the inside front and back covers of this formulary or visit DRUG TIER CO-PAYMENT/COINSURANCE AMOUNTS The Easy Choice formulary is divided into five tiers. 1: Preferred Generic s s that are available at the lowest cost share for this plan. : Generic s s that Easy Choice offers at a higher cost to you than preferred generics. 3: Preferred Brand s s that Easy Choice may be able to offer at a lower cost to you than non-preferred brand drugs. : Non-Preferred Brand s s that Easy Choice offers at a higher cost to you than preferred brands. 5: Specialty s Some injectables and other high-cost drugs. ^ Indicates specialty drugs are available for up to a 30-day supply only. Brand drugs may be available in s 3, and 5. Generic drugs are available in all s. Consult your Evidence of Coverage or Summary of Benefits for your applicable co-pays/ coinsurance and deductible amounts. 016 Comprehensive Formulary VI

9 HOW TO READ FORMULARY LISTINGS: Requirements/Limits CENTRAL NERVOUS SYSTEM ANTICONVULSANTS Therapeutic Class BANZEL TAB 00MG _ PA BANZEL TAB 00MG PA carbamazepine cap sr 1hr 100 mg carbamazepine cap sr 1hr 00 mg Therapeutic Category of ^ = may be available for up to a 30-day supply only Name of UPPERCASE = Brand s lowercase italics = Generic s Find your drug quickly in the Index at the back of the book. Requirements/Limits Codes: ED = Excluded LA = Limited Access NM = Not Available by Mail Service PA = Prior Authorization B/D = Covered under Medicare B or D QL = Quantity Limits ST = Step Therapy 016 Comprehensive Formulary VII

10 ANALGESICS GOUT allopurinol oral tablet 100 mg, 300 mg 1 ALOPRIM INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG colchicine-probenecid oral tablet mg COLCRYS ORAL TABLET 0.6 MG 3 QL (10 EA per 30 days) probenecid oral tablet 500 mg ULORIC ORAL TABLET 0 MG, 80 MG 3 ST ZURAMPIC ORAL TABLET 00 MG PA MISCELLANEOUS diclofenac-misoprostol oral tablet delayed release mg, mg DUEXIS ORAL TABLET MG VIMOVO ORAL TABLET DELAYED RELEASE MG, MG NSAIDS celecoxib oral capsule 100 mg, 00 mg, 00 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium er oral tablet extended release hr* 100 mg diclofenac sodium oral tablet delayed release 5 mg, 50 mg, 75 mg diflunisal oral tablet 500 mg etodolac er oral tablet extended release hr* 00 mg, 500 mg, 600 mg etodolac oral capsule 00 mg, 300 mg etodolac oral tablet 00 mg, 500 mg fenoprofen calcium oral capsule 00 mg fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 00 mg, 600 mg, 800 mg 1 1

11 ketoprofen er oral capsule extended release hour 00 mg ketoprofen oral capsule 50 mg, 75 mg mefenamic acid oral capsule 50 mg meloxicam oral suspension 7.5 mg/5ml meloxicam oral tablet 15 mg, 7.5 mg 1 nabumetone oral tablet 500 mg, 750 mg NAPRELAN ORAL TABLET EXTENDED RELEASE HR* 375 MG, 750 MG naproxen dr oral tablet delayed release 375 mg, 500 mg 1 naproxen oral suspension 15 mg/5ml naproxen oral tablet 50 mg, 375 mg, 500 mg 1 NAPROXEN SODIUM ER ORAL TABLET EXTENDED RELEASE HR* 375 MG, 500 MG naproxen sodium oral tablet 75 mg, 550 mg 1 oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 0 mg sulindac oral tablet 150 mg, 00 mg 1 tolmetin sodium oral capsule 00 mg tolmetin sodium oral tablet 00 mg, 600 mg VIVLODEX ORAL CAPSULE 10 MG, 5 MG ZIPSOR ORAL CAPSULE 5 MG ZORVOLEX ORAL CAPSULE 18 MG, 35 MG OPIOID ANALGESICS, CII ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 100 MCG, 00 MCG, 300 MCG, 00 MCG, 600 MCG, 800 MCG PA; QL (10 EA per 30 days) codeine sulfate oral tablet 15 mg QL (70 EA per 30 days) codeine sulfate oral tablet 30 mg QL (360 EA per 30 days) codeine sulfate oral tablet 60 mg QL (180 EA per 30 days) DILAUDID-HP INJECTION SOLUTION RECONSTITUTED 50 MG B/D duramorph injection solution 0.5 mg/ml, 1 mg/ml B/D

12 EMBEDA ORAL CAPSULE EXTENDED RELEASE* 100- MG, MG, MG, 50- MG, 60-. MG, MG QL (60 EA per 30 days) endocet oral tablet mg, 5-35 mg, mg QL (360 EA per 30 days) fentanyl citrate buccal lollipop 100 mcg, 1600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hr 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg hydrocodone-ibuprofen oral tablet mg,.5-00 mg, 5-00 mg, mg PA; QL (10 EA per 30 days) QL (10 EA per 30 days) PA; QL (10 EA per 30 days) QL (500 ML per 30 days) QL (00 EA per 30 days) QL (360 EA per 30 days) QL (150 EA per 30 days) hydromorphone hcl er oral 1 mg, 8 mg QL (60 EA per 30 days) hydromorphone hcl er oral 16 mg QL (60 EA per 30 days) HYDROMORPHONE HCL ER ORAL 3 MG QL (60 EA per 30 days) hydromorphone hcl injection solution 1 mg/ml, mg/ml, mg/ml hydromorphone hcl oral liquid 1 mg/ml B/D hydromorphone hcl oral tablet mg, mg, 8 mg QL (70 EA per 30 days) hydromorphone hcl pf injection solution 500 mg/50ml B/D HYSINGLA ER ORAL 100 MG, 10 MG, 80 MG QL (30 EA per 30 days) HYSINGLA ER ORAL 0 MG, 30 MG, 0 MG, 60 MG QL (60 EA per 30 days) ibudone oral tablet mg, 5-00 mg QL (150 EA per 30 days) INFUMORPH 00 INJECTION SOLUTION 00 MG/0ML (10 MG/ML) INFUMORPH 500 INJECTION SOLUTION 500 MG/0ML (5 MG/ML) B/D B/D 3

13 KADIAN ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG, 0 MG LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 00 MCG/ACT QL (60 EA per 30 days) PA; QL (30 EA per 30 days) levorphanol tartrate oral tablet mg QL (180 EA per 30 days) lorcet hd oral tablet mg QL (360 EA per 30 days) lorcet oral tablet 5-35 mg QL (360 EA per 30 days) lorcet plus oral tablet mg QL (360 EA per 30 days) lortab oral tablet mg, 5-35 mg, mg QL (360 EA per 30 days) METHADONE HCL INJECTION SOLUTION 10 MG/ML methadone hcl intensol oral concentrate 10 mg/ml QL (10 ML per 30 days) methadone hcl oral solution 10 mg/5ml, 5 mg/5ml QL (600 ML per 30 days) methadone hcl oral tablet 10 mg, 5 mg QL (0 EA per 30 days) morphine sulfate (concentrate) oral solution 100 mg/5ml morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml morphine sulfate (pf) intravenous* solution 10 mg/ml, 15 mg/ml, mg/ml, mg/ml, 8 mg/ml morphine sulfate er beads oral capsule extended release hour 10 mg, 30 mg, 5 mg, 60 mg, 75 mg, 90 mg morphine sulfate er oral capsule extended release hour 10 mg, 0 mg, 30 mg, 50 mg, 60 mg morphine sulfate er oral capsule extended release hour 100 mg, 80 mg morphine sulfate er oral tablet extendedrelease* 100 mg, 15 mg, 30 mg, 60 mg B/D B/D QL (60 EA per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) QL (90 EA per 30 days) morphine sulfate er oral tablet extendedrelease* 00 mg QL (60 EA per 30 days) morphine sulfate intravenous* solution 1 mg/ml B/D morphine sulfate oral solution 10 mg/5ml, 0 mg/5ml morphine sulfate oral tablet 15 mg, 30 mg QL (180 EA per 30 days) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 1 HR* 100 MG, 50 MG QL (10 EA per 30 days)

14 NUCYNTA ER ORAL TABLET EXTENDED RELEASE 1 HR* 150 MG, 00 MG, 50 MG QL (60 EA per 30 days) NUCYNTA ORAL TABLET 100 MG QL (180 EA per 30 days) NUCYNTA ORAL TABLET 50 MG QL (360 EA per 30 days) NUCYNTA ORAL TABLET 75 MG QL (0 EA per 30 days) OPANA ER ORAL 10 MG, 15 MG, 0 MG, 30 MG, 0 MG, 5 MG, 7.5 MG 3 QL (10 EA per 30 days) oxycodone hcl oral capsule 5 mg QL (180 EA per 30 days) oxycodone hcl oral concentrate 100 mg/5ml oxycodone hcl oral solution 5 mg/5ml oxycodone hcl oral tablet 10 mg, 15 mg, 0 mg, 30 mg, 5 mg QL (180 EA per 30 days) oxycodone-acetaminophen oral solution 5-35 mg/5ml QL (1800 ML per 30 days) oxycodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg QL (360 EA per 30 days) oxycodone-aspirin oral tablet mg QL (360 EA per 30 days) oxycodone-ibuprofen oral tablet 5-00 mg QL (8 EA per 30 days) oxymorphone hcl oral tablet 10 mg, 5 mg QL (180 EA per 30 days) reprexain oral tablet mg QL (150 EA per 30 days) SUBSYS SUBLINGUAL LIQUID 100 MCG, 100 (600 X ) MCG, 1600 (800 X ) MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG PA; QL (10 EA per 30 days) vicodin es oral tablet mg QL (00 EA per 30 days) vicodin hp oral tablet mg QL (00 EA per 30 days) vicodin oral tablet mg QL (00 EA per 30 days) XARTEMIS XR ORAL TABLET EXTENDEDRELEASE* MG QL (10 EA per 30 days) XTAMPZA ER ORAL 13.5 MG, 18 MG, 7 MG, 9 MG QL (10 EA per 30 days) XTAMPZA ER ORAL 36 MG QL (0 EA per 30 days) xylon oral tablet mg QL (150 EA per 30 days) zamicet oral solution mg/15ml QL (500 ML per 30 days) ZOHYDRO ER ORAL 10 MG, 15 MG, 0 MG QL (10 EA per 30 days) ZOHYDRO ER ORAL 30 MG, 0 MG, 50 MG QL (60 EA per 30 days) 5

15 OPIOID ANALGESICS acetaminophen-codeine # oral tablet mg QL (00 EA per 30 days) acetaminophen-codeine #3 oral tablet mg QL (00 EA per 30 days) acetaminophen-codeine # oral tablet mg QL (00 EA per 30 days) acetaminophen-codeine oral solution 10-1 mg/5ml QL (5000 ML per 30 days) apap-caff-dihydrocodeine oral capsule mg QL (360 EA per 30 days) aspirin-caff-dihydrocodeine oral capsule mg BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 50 MCG, 75 MCG QL (360 EA per 30 days) PA; QL (10 EA per 30 days) BELBUCA BUCCAL FILM 600 MCG, 750 MCG, 900 MCG PA; QL (60 EA per 30 days) butorphanol tartrate injection solution 1 mg/ml, mg/ml butorphanol tartrate nasal solution 10 mg/ml QL (10 ML per 30 days) BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HR, 7.5 MCG/HR BUTRANS TRANSDERMAL PATCH WEEKLY 15 MCG/HR, 0 MCG/HR 3 QL (8 EA per 8 days) 3 QL ( EA per 8 days) BUTRANS TRANSDERMAL PATCH WEEKLY 5 MCG/HR 3 QL (16 EA per 8 days) capital/codeine oral suspension 10-1 mg/5ml QL (5000 ML per 30 days) CONZIP ORAL CAPSULE EXTENDED RELEASE HOUR 100 MG CONZIP ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG CONZIP ORAL CAPSULE EXTENDED RELEASE HOUR 300 MG QL (90 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) nalbuphine hcl injection solution 10 mg/ml, 0 mg/ml tramadol hcl er (biphasic) oral tablet extended release hr* 100 mg tramadol hcl er (biphasic) oral tablet extended release hr* 00 mg, 300 mg tramadol hcl er oral capsule extended release hour 100 mg QL (90 EA per 30 days) QL (30 EA per 30 days) QL (90 EA per 30 days) tramadol hcl er oral capsule extended release hour QL (60 EA per 30 days) 00 mg 6

16 tramadol hcl er oral capsule extended release hour 300 mg tramadol hcl er oral tablet extended release hr* 100 mg tramadol hcl er oral tablet extended release hr* 00 mg tramadol hcl er oral tablet extended release hr* 300 mg QL (30 EA per 30 days) QL (90 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) tramadol hcl oral tablet 50 mg QL (0 EA per 30 days) tramadol-acetaminophen oral tablet mg QL (0 EA per 30 days) trezix oral capsule mg QL (360 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (pf) injection solution 0.5 %, 1 %, % B/D lidocaine hcl (pf) injection solution % lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %, % B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate injection solution 1 gm/ml, 500 mg/ml BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/ML gentamicin in saline intravenous* solution mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-%, -0.9 mg/ml-% gentamicin sulfate injection solution 10 mg/ml, 0 mg/ml gentamicin sulfate intravenous* solution 10 mg/ml neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 50 mg streptomycin sulfate intramuscular* solution reconstituted 1 gm sulfadiazine oral tablet 500 mg 7 B/D

17 TOBI PODHALER INHALATION CAPSULE 8 MG PA; LA tobramycin inhalation nebulization solution 300 mg/5ml B/D tobramycin sulfate injection solution 1. gm/30ml, 10 mg/ml, gm/50ml, 80 mg/ml tobramycin sulfate injection solution reconstituted 1. gm ANTIFUNGALS ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML B/D AMBISOME INTRAVENOUS* SUSPENSION RECONSTITUTED 50 MG B/D amphotericin b injection solution reconstituted 50 mg B/D CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG, 70 MG CRESEMBA INTRAVENOUS* SOLUTION RECONSTITUTED 37 MG CRESEMBA ORAL CAPSULE 186 MG ERAXIS INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 50 MG fluconazole in dextrose intravenous* solution 00 mg/100ml, 00 mg/00ml fluconazole in sodium chloride intravenous* solution mg/50ml-%, mg/100ml-%, mg/00ml-% fluconazole oral suspension reconstituted 10 mg/ml, 0 mg/ml fluconazole oral tablet 100 mg, 150 mg, 00 mg, 50 mg flucytosine oral capsule 50 mg, 500 mg griseofulvin microsize oral suspension 15 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 15 mg, 50 mg itraconazole oral capsule 100 mg PA ketoconazole oral tablet 00 mg PA LAMISIL ORAL PACKET 15 MG, MG 8

18 MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 50 MG NOXAFIL INTRAVENOUS* SOLUTION 300 MG/16.7ML NOXAFIL ORAL SUSPENSION 0 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin oral tablet unit ONMEL ORAL TABLET 00 MG PA SPORANOX ORAL SOLUTION 10 MG/ML terbinafine hcl oral tablet 50 mg 1 QL (90 EA per 365 days) voriconazole intravenous* solution reconstituted 00 mg voriconazole oral suspension reconstituted 0 mg/ml voriconazole oral tablet 00 mg, 50 mg ANTI-INFECTIVES - MISCELLANEOUS ALBENZA ORAL TABLET 00 MG ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5ml AZACTAM IN DEXTROSE INTRAVENOUS* SOLUTION 1 GM AZACTAM IN DEXTROSE INTRAVENOUS* SOLUTION GM aztreonam injection solution reconstituted 1 gm, gm BILTRICIDE ORAL TABLET 600 MG 3 CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate in d5w intravenous* solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml clindamycin phosphate injection solution 300 mg/ml, 600 mg/ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml PA; LA 9

19 clindamycin phosphate intravenous* solution 300 mg/ml, 600 mg/ml, 900 mg/6ml colistimethate sodium injection solution reconstituted 150 mg CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG DALVANCE INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG dapsone oral tablet 100 mg, 5 mg daptomycin intravenous* solution reconstituted 500 mg DARAPRIM ORAL TABLET 5 MG DORIBAX INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG, 500 MG emverm oral tablet chewable 100 mg imipenem-cilastatin intravenous* solution reconstituted 50 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM INVANZ INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM ivermectin oral tablet 3 mg LINEZOLID IN SODIUM CHLORIDE INTRAVENOUS* SOLUTION MG/300ML-% linezolid intravenous* solution 600 mg/300ml LINEZOLID ORAL SUSPENSION RECONSTITUTED 100 MG/5ML LINEZOLID ORAL TABLET 600 MG MACRODANTIN ORAL CAPSULE 5 MG PA meropenem intravenous* solution reconstituted 1 gm, 500 mg meropenem-sodium chloride intravenous* solution reconstituted 1 gm/50ml, 500 mg/50ml methenamine hippurate oral tablet 1 gm METRO INTRAVENOUS* SOLUTION MG/100ML-% 3 10

20 metronidazole in nacl intravenous* solution mg/100ml-% metronidazole oral capsule 375 mg metronidazole oral tablet 50 mg, 500 mg 1 NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG nitrofurantoin macrocrystal oral capsule 100 mg, 5 mg, 50 mg B/D PA nitrofurantoin monohyd macro oral capsule 100 mg PA nitrofurantoin oral capsule 100 mg PA nitrofurantoin oral suspension 5 mg/5ml PA PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG polymyxin b sulfate injection solution reconstituted unit PRIMSOL ORAL SOLUTION 50 MG/5ML SIVEXTRO INTRAVENOUS* SOLUTION RECONSTITUTED 00 MG SIVEXTRO ORAL TABLET 00 MG sulfamethoxazole-trimethoprim intravenous* solution mg/5ml sulfamethoxazole-trimethoprim oral suspension 00-0 mg/5ml sulfamethoxazole-trimethoprim oral tablet mg, mg SYNERCID INTRAVENOUS* SOLUTION RECONSTITUTED MG trimethoprim oral tablet 100 mg 1 TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG VANCOMYCIN HCL IN NACL INTRAVENOUS* SOLUTION GM/00ML-%, MG/100ML-%, MG/150ML-% 1 11

21 vancomycin hcl intravenous* solution reconstituted 10 gm, 1000 mg, 500 mg, 5000 mg, 750 mg vancomycin hcl oral capsule 15 mg, 50 mg XIFAXAN ORAL TABLET 00 MG ZYVOX ORAL TABLET 600 MG ANTIMALARIALS atovaquone-proguanil hcl oral tablet mg, mg chloroquine phosphate oral tablet 50 mg, 500 mg COARTEM ORAL TABLET 0-10 MG mefloquine hcl oral tablet 50 mg PRIMAQUINE PHOSPHATE ORAL TABLET 6.3 MG 3 quinine sulfate oral capsule 3 mg PA ANTIRETROVIRAL AGENTS abacavir sulfate oral tablet 300 mg APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION 100 MG/ML CRIXIVAN ORAL CAPSULE 00 MG, 00 MG didanosine oral capsule delayed release 15 mg, 00 mg, 50 mg, 00 mg EDURANT ORAL TABLET 5 MG EMTRIVA ORAL CAPSULE 00 MG 3 EMTRIVA ORAL SOLUTION 10 MG/ML 3 FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ORAL CAPSULE 00 MG INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL PACKET 100 MG 3 ISENTRESS ORAL TABLET 00 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG 1

22 ISENTRESS ORAL TABLET CHEWABLE 5 MG 3 lamivudine oral solution 10 mg/ml lamivudine oral tablet 150 mg, 300 mg LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine er oral tablet extended release hr* 100 mg, 00 mg nevirapine oral suspension 50 mg/5ml nevirapine oral tablet 00 mg NORVIR ORAL CAPSULE 100 MG 3 NORVIR ORAL SOLUTION 80 MG/ML 3 NORVIR ORAL TABLET 100 MG 3 PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 75 MG 3 PREZISTA ORAL TABLET 600 MG, 800 MG RESCRIPTOR ORAL TABLET 100 MG, 00 MG RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML 3 REYATAZ ORAL CAPSULE 150 MG, 00 MG, 300 MG REYATAZ ORAL PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 300 MG stavudine oral capsule 15 mg, 0 mg, 30 mg, 0 mg stavudine oral solution reconstituted 1 mg/ml SUSTIVA ORAL CAPSULE 00 MG, 50 MG 3 SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 10 MG 3 TIVICAY ORAL TABLET 5 MG, 50 MG TYBOST ORAL TABLET 150 MG 3 VIDEX ORAL SOLUTION RECONSTITUTED GM, GM VIRACEPT ORAL TABLET 50 MG, 65 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE HR* 100 MG VIREAD ORAL POWDER 0 MG/GM 13

23 VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG, 300 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 0 MG/ML 3 zidovudine oral capsule 100 mg zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 300 mg ANTIRETROVIRAL COMBINATION AGENTS abacavir-lamivudine-zidovudine oral tablet mg ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG DESCOVY ORAL TABLET 00-5 MG EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG GENVOYA ORAL TABLET MG KALETRA ORAL SOLUTION MG/5ML KALETRA ORAL TABLET MG 3 KALETRA ORAL TABLET MG lamivudine-zidovudine oral tablet mg ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG STRIBILD ORAL TABLET MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG QL (60 EA per 30 days) TRUVADA ORAL TABLET MG, MG, MG ANTITUBERCULAR AGENTS QL (30 EA per 30 days) CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM cycloserine oral capsule 50 mg ethambutol hcl oral tablet 100 mg, 00 mg 1

24 isoniazid injection solution 100 mg/ml isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg 1 paser oral packet gm 3 PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg rifamate oral capsule mg rifampin intravenous* solution reconstituted 600 mg rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG PA; LA TRECATOR ORAL TABLET 50 MG ANTIVIRALS acyclovir oral capsule 00 mg 1 acyclovir oral suspension 00 mg/5ml acyclovir oral tablet 00 mg, 800 mg 1 acyclovir sodium intravenous* solution 50 mg/ml B/D acyclovir sodium intravenous* solution reconstituted 500 mg adefovir dipivoxil oral tablet 10 mg BARACLUDE ORAL SOLUTION 0.05 MG/ML 3 cidofovir intravenous* solution 75 mg/ml B/D DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG PA entecavir oral tablet 0.5 mg, 1 mg EPIVIR HBV ORAL SOLUTION 5 MG/ML famciclovir oral tablet 15 mg, 50 mg, 500 mg ganciclovir sodium intravenous* solution reconstituted 500 mg B/D HARVONI ORAL TABLET MG PA lamivudine oral tablet 100 mg MODERIBA 100 DOSE PACK ORAL TABLET 600 MG 15

25 moderiba 800 dose pack oral tablet 00 mg moderiba oral 00 & 00 mg, 00 & 600 mg moderiba oral tablet 00 mg PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML, 180 MCG/ML PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 10 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEGINTRON SUBCUTANEOUS* KIT 10 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML REBETOL ORAL SOLUTION 0 MG/ML RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER ribasphere oral capsule 00 mg ribasphere oral tablet 00 mg, 00 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablet 00 & 00 mg, 00 & 600 mg, 00 mg, 600 mg ribavirin oral capsule 00 mg ribavirin oral tablet 00 mg rimantadine hcl oral tablet 100 mg SOVALDI ORAL TABLET 00 MG PA TAMIFLU ORAL CAPSULE 30 MG, 5 MG, 75 MG 3 TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML 3 TYZEKA ORAL TABLET 600 MG valacyclovir hcl oral tablet 1 gm, 500 mg VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML valganciclovir hcl oral tablet 50 mg CEPHALOSPORINS 3 PA PA PA PA AVYCAZ INTRAVENOUS* SOLUTION RECONSTITUTED.5 (-0.5) GM 16

26 cefaclor er oral tablet extended release 1 hr* 500 mg 3 cefaclor oral capsule 50 mg, 500 mg cefaclor oral suspension reconstituted 15 mg/5ml, 50 mg/5ml, 375 mg/5ml cefadroxil oral capsule 500 mg 1 cefadroxil oral suspension reconstituted 50 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 0 gm, 500 mg cefazolin sodium intravenous* solution 1-5 gm-% 3 cefazolin sodium intravenous* solution reconstituted 1 gm CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS* SOLUTION - GM/100ML-% cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cefepime hcl injection solution reconstituted 1 gm, gm CEFEPIME HCL INTRAVENOUS* SOLUTION 1 GM/50ML, GM/100ML CEFEPIME-DEXTROSE INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM/50ML, GM/50ML cefixime oral suspension reconstituted 100 mg/5ml, 00 mg/5ml cefotaxime sodium injection solution reconstituted 1 gm, gm, 500 mg cefotetan disodium injection solution reconstituted 1 gm, 10 gm, gm cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous* solution reconstituted 1 gm, gm CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS* SOLUTION RECONSTITUTED 1- GM-%, -. GM-% 3 17

27 cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 00 mg cefprozil oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cefprozil oral tablet 50 mg, 500 mg CEFTAZIDIME AND DEXTROSE INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM/50ML, GM/50ML ceftazidime injection solution reconstituted 1 gm, gm, 6 gm ceftibuten oral capsule 00 mg ceftibuten oral suspension reconstituted 180 mg/5ml CEFTIN ORAL SUSPENSION RECONSTITUTED 15 MG/5ML, 50 MG/5ML ceftriaxone sodium injection solution reconstituted 1 gm, gm, 50 mg, 500 mg ceftriaxone sodium intravenous* solution reconstituted 1 gm, 10 gm, gm cefuroxime axetil oral suspension reconstituted 15 mg/5ml cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg cefuroxime sodium intravenous* solution reconstituted 1.5 gm cephalexin oral capsule 50 mg, 500 mg 1 cephalexin oral capsule 750 mg cephalexin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cephalexin oral tablet 50 mg, 500 mg CLAFORAN IN D5W INTRAVENOUS* SOLUTION GM/50ML claforan intravenous* solution reconstituted 1 gm, gm 18

28 FORTAZ IN D5W INTRAVENOUS* SOLUTION 1-5 GM/50ML-%, -5 GM/50ML-% FORTAZ INJECTION SOLUTION RECONSTITUTED 500 MG MAXIPIME INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM, GM SUPRAX ORAL CAPSULE 00 MG 3 SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML 3 suprax oral tablet chewable 100 mg, 00 mg tazicef injection solution reconstituted 1 gm, gm, 6 gm tazicef intravenous* solution reconstituted 1 gm, gm TEFLARO INTRAVENOUS* SOLUTION RECONSTITUTED 00 MG, 600 MG ZERBAXA INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 (1-0.5) GM ZINACEF INTRAVENOUS* SOLUTION RECONSTITUTED 750 MG ERYTHROMYCINS/MACROLIDES azithromycin intravenous* solution reconstituted 500 mg azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 mg/5ml, 00 mg/5ml azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 600 mg clarithromycin er oral tablet extended release hr* 500 mg clarithromycin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml 1 clarithromycin oral tablet 50 mg, 500 mg DIFICID ORAL TABLET 00 MG e.e.s. 00 oral tablet 00 mg E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 00 MG/5ML 19

29 ERYPED 00 ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ERYPED 00 ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ery-tab oral tablet delayed release 50 mg, 333 mg, 500 mg erythrocin lactobionate intravenous* solution reconstituted 500 mg erythrocin stearate oral tablet 50 mg erythromycin base oral capsule delayed release particles 50 mg erythromycin base oral tablet 50 mg, 500 mg erythromycin ethylsuccinate oral tablet 00 mg PCE ORAL TABLET DELAYED RELEASE 333 MG, 500 MG ZMAX ORAL SUSPENSION RECONSTITUTED GM FLUOROQUINOLONES AVELOX INTRAVENOUS* SOLUTION 00 MG/50ML ciprofloxacin hcl oral tablet 100 mg, 50 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous* solution 00 mg/100ml, 00 mg/00ml ciprofloxacin intravenous* solution 00 mg/0ml, 00 mg/0ml ciprofloxacin oral suspension reconstituted 50 mg/5ml (5%), 500 mg/5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release hr* 1000 mg, 500 mg levofloxacin in d5w intravenous* solution 50 mg/50ml, 500 mg/100ml, 750 mg/150ml levofloxacin intravenous* solution 5 mg/ml levofloxacin oral solution 5 mg/ml levofloxacin oral tablet 50 mg, 500 mg, 750 mg 1 MOXIFLOXACIN HCL INTRAVENOUS* SOLUTION 00 MG/50ML 1 0

30 moxifloxacin hcl oral tablet 00 mg PENICILLINS amoxicillin oral capsule 50 mg, 500 mg 1 amoxicillin oral suspension reconstituted 15 mg/5ml, 00 mg/5ml, 50 mg/5ml, 00 mg/5ml amoxicillin oral tablet 500 mg, 875 mg 1 amoxicillin oral tablet chewable 15 mg, 50 mg 1 amoxicillin-pot clavulanate er oral tablet extended release 1 hr* mg amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 50 mg, 500 mg 1 ampicillin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml ampicillin sodium injection solution reconstituted 1 gm, 15 mg, gm, 50 mg, 500 mg ampicillin sodium intravenous* solution reconstituted 1 gm, 10 gm, gm ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, 3 (-1) gm ampicillin-sulbactam sodium intravenous* solution reconstituted 15 (10-5) gm, 3 (-1) gm AUGMENTIN ORAL SUSPENSION RECONSTITUTED MG/5ML BACTOCILL IN DEXTROSE INTRAVENOUS* SOLUTION 1 GM/50ML BACTOCILL IN DEXTROSE INTRAVENOUS* SOLUTION GM/50ML 1 1

31 BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION UNIT/ML BICILLIN C-R INTRAMUSCULAR* SUSPENSION UNIT/ML BICILLIN L-A INTRAMUSCULAR* SUSPENSION UNIT/ML, UNIT/ML, UNIT/ML dicloxacillin sodium oral capsule 50 mg, 500 mg MOXATAG ORAL TABLET EXTENDED RELEASE HR* 775 MG NAFCILLIN SODIUM IN DEXTROSE INTRAVENOUS* SOLUTION 1 GM/50ML, GM/100ML nafcillin sodium injection solution reconstituted 1 gm nafcillin sodium injection solution reconstituted 10 gm, gm nafcillin sodium intravenous* solution reconstituted 1 gm nafcillin sodium intravenous* solution reconstituted gm oxacillin sodium injection solution reconstituted 1 gm, gm oxacillin sodium injection solution reconstituted 10 gm PENICILLIN G POT IN DEXTROSE INTRAVENOUS* SOLUTION 0000 UNIT/ML, 0000 UNIT/ML, UNIT/ML penicillin g potassium injection solution reconstituted unit, unit penicillin g procaine intramuscular* suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 15 mg/5ml, 50 mg/5ml penicillin v potassium oral tablet 50 mg, 500 mg 1 pfizerpen-g injection solution reconstituted unit, unit 3 1

32 piperacillin sod-tazobactam so intravenous* solution reconstituted.5 (-0.5) gm, ( ) gm,.5 (-0.5) gm, 0.5 (36-.5) gm ZOSYN INTRAVENOUS* SOLUTION -0.5 GM/50ML, GM/50ML, -0.5 GM/100ML TETRACYCLINES demeclocycline hcl oral tablet 150 mg, 300 mg doxy 100 intravenous* solution reconstituted 100 mg doxycycline hyclate intravenous* solution reconstituted 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 0 50, 0 mg doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 00 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension reconstituted 5 mg/5ml doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline hcl er oral tablet extended release hr* 135 mg, 5 mg, 90 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg minocycline hcl oral tablet 100 mg, 50 mg, 75 mg morgidox oral capsule 50 mg SOLODYN ORAL TABLET EXTENDED RELEASE HR* 105 MG, 115 MG, 55 MG, 65 MG, 80 MG tetracycline hcl oral capsule 50 mg, 500 mg VIBRAMYCIN ORAL SYRUP 50 MG/5ML ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA INTRAVENOUS* SOLUTION 100 MG/ML B/D BICNU INTRAVENOUS* SOLUTION RECONSTITUTED 100 B/D MG 3

33 BUSULFEX INTRAVENOUS* SOLUTION 6 MG/ML B/D cyclophosphamide injection solution reconstituted 1 gm, 500 mg B/D cyclophosphamide injection solution reconstituted gm B/D CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG B/D dacarbazine intravenous* solution reconstituted 100 mg, 00 mg B/D EMCYT ORAL CAPSULE 10 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG, 5 MG HEXALEN ORAL CAPSULE 50 MG IFEX INTRAVENOUS* SOLUTION RECONSTITUTED 3 GM B/D ifosfamide intravenous* solution 1 gm/0ml, 3 gm/60ml B/D ifosfamide intravenous* solution reconstituted 1 gm B/D IFOSFAMIDE INTRAVENOUS* SOLUTION RECONSTITUTED 3 GM LEUKERAN ORAL TABLET MG B/D melphalan hcl intravenous* solution reconstituted 50 mg B/D MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG B/D thiotepa injection solution reconstituted 15 mg B/D TREANDA INTRAVENOUS* SOLUTION 180 MG/ML, 5 MG/0.5ML TREANDA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 5 MG ZANOSAR INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM ANTHRACYCLINES B/D B/D B/D daunorubicin hcl intravenous* injectable 5 mg/ml B/D doxorubicin hcl intravenous* solution mg/ml B/D doxorubicin hcl intravenous* solution reconstituted 50 mg B/D

34 doxorubicin hcl liposomal intravenous* injectable mg/ml B/D epirubicin hcl intravenous* solution 00 mg/100ml, 50 mg/5ml B/D idarubicin hcl intravenous* solution 10 mg/10ml, 0 mg/0ml, 5 mg/5ml ANTIBIOTICS B/D bleomycin sulfate injection solution reconstituted 15 unit, 30 unit B/D COSMEGEN INTRAVENOUS* SOLUTION RECONSTITUTED 0.5 MG B/D mitomycin intravenous* solution reconstituted 0 mg, 0 mg, 5 mg ANTIMETABOLITES adrucil intravenous* solution.5 gm/50ml, 5 gm/100ml, 500 mg/10ml B/D B/D ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 500 MG B/D ARRANON INTRAVENOUS* SOLUTION 5 MG/ML B/D azacitidine injection suspension reconstituted 100 mg B/D cladribine intravenous* solution 10 mg/10ml B/D CLOLAR INTRAVENOUS* SOLUTION 1 MG/ML B/D cytarabine (pf) injection solution 100 mg/ml B/D cytarabine injection solution 0 mg/ml B/D decitabine intravenous* solution reconstituted 50 mg B/D fludarabine phosphate intravenous* solution 50 mg/ml B/D fludarabine phosphate intravenous* solution reconstituted 50 mg fluorouracil intravenous* solution 1 gm/0ml,.5 gm/50ml, 5 gm/100ml, 500 mg/10ml B/D B/D GEMCITABINE HCL INTRAVENOUS* SOLUTION 1 GM/6.3ML, GM/5.6ML, 00 MG/5.6ML gemcitabine hcl intravenous* solution reconstituted 1 gm, gm, 00 mg B/D B/D 5

35 mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection solution 1 gm/0ml, 100 mg/ml, 00 mg/8ml, 50 mg/10ml, 50 mg/ml B/D methotrexate sodium injection solution 50 mg/10ml B/D methotrexate sodium injection solution 50 mg/ml B/D methotrexate sodium injection solution reconstituted 1 gm B/D NIPENT INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG B/D PURIXAN ORAL SUSPENSION 000 MG/100ML TABLOID ORAL TABLET 0 MG ANTIMITOTIC, TAXOIDS ABRAXANE INTRAVENOUS* SUSPENSION RECONSTITUTED 100 MG B/D docetaxel intravenous* concentrate 10 mg/7ml B/D DOCETAXEL INTRAVENOUS* CONCENTRATE 0 MG/ML, 80 MG/ML DOCETAXEL INTRAVENOUS* SOLUTION 160 MG/16ML, 00 MG/0ML, 80 MG/8ML B/D B/D docetaxel intravenous* solution 0 mg/ml B/D paclitaxel intravenous* concentrate 100 mg/16.7ml, 150 mg/5ml, 30 mg/5ml, 300 mg/50ml ANTIMITOTIC, VINCA ALKALOIDS B/D vinblastine sulfate intravenous* solution 1 mg/ml 3 B/D vincasar pfs intravenous* solution 1 mg/ml B/D vincristine sulfate intravenous* solution 1 mg/ml B/D vinorelbine tartrate intravenous* solution 10 mg/ml, 50 mg/5ml BIOLOGIC RESPONSE MODIFIERS B/D ARZERRA INTRAVENOUS* CONCENTRATE 100 MG/5ML, 1000 MG/50ML AVASTIN INTRAVENOUS* SOLUTION 100 MG/ML, 00 MG/16ML B/D B/D; LA 6

36 BELEODAQ INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG ERBITUX INTRAVENOUS* SOLUTION 100 MG/50ML, 00 MG/100ML PA B/D ERIVEDGE ORAL CAPSULE 150 MG PA; LA FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG PA; LA HERCEPTIN INTRAVENOUS* SOLUTION RECONSTITUTED 0 MG B/D IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG PA; LA ISTODAX INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG KADCYLA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 160 MG B/D B/D KEYTRUDA INTRAVENOUS* SOLUTION 100 MG/ML PA KEYTRUDA INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG PA LYNPARZA ORAL CAPSULE 50 MG PA; LA NINLARO ORAL CAPSULE.3 MG, 3 MG, MG PA PERJETA INTRAVENOUS* SOLUTION 0 MG/1ML PA PROLEUKIN INTRAVENOUS* SOLUTION RECONSTITUTED UNIT RITUXAN INTRAVENOUS* SOLUTION 100 MG/10ML, 500 MG/50ML B/D PA; LA TECENTRIQ INTRAVENOUS* SOLUTION 100 MG/0ML PA; LA TORISEL INTRAVENOUS* SOLUTION 5 MG/ML B/D VECTIBIX INTRAVENOUS* SOLUTION 100 MG/5ML, 00 MG/0ML VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG B/D B/D VENCLEXTA ORAL TABLET 10 MG, 50 MG PA; LA VENCLEXTA ORAL TABLET 100 MG PA; LA VENCLEXTA STARTING PACK ORAL 10 & 50 & 100 MG PA; LA YERVOY INTRAVENOUS* SOLUTION 00 MG/0ML, 50 PA MG/10ML 7

37 ZOLINZA ORAL CAPSULE 100 MG PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole oral tablet 1 mg bicalutamide oral tablet 50 mg DEPO-PROVERA INTRAMUSCULAR* SUSPENSION 00 MG/ML ELIGARD SUBCUTANEOUS* KIT.5 MG, 30 MG, 5 MG, 7.5 MG exemestane oral tablet 5 mg FARESTON ORAL TABLET 60 MG B/D B/D FASLODEX INTRAMUSCULAR* SOLUTION 50 MG/5ML B/D FIRMAGON SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG FIRMAGON SUBCUTANEOUS* SOLUTION RECONSTITUTED 80 MG flutamide oral capsule 15 mg hydroxyprogesterone caproate intramuscular* solution 1.5 gm/5ml letrozole oral tablet.5 mg B/D B/D B/D leuprolide acetate injection kit 1 mg/0.ml PA LUPRON DEPOT INTRAMUSCULAR* KIT 11.5 MG,.5 MG, 3.75 MG, 30 MG, 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR* KIT 11.5 MG, 11.5 MG (PED), 15 MG, 30 MG (PED), 7.5 MG LYSODREN ORAL TABLET 500 MG 3 megestrol acetate oral suspension 0 mg/ml PA MEGESTROL ACETATE ORAL SUSPENSION 65 MG/5ML PA megestrol acetate oral tablet 0 mg, 0 mg PA NILANDRON ORAL TABLET 150 MG nilutamide oral tablet 150 mg SOLTAMOX ORAL SOLUTION 10 MG/5ML tamoxifen citrate oral tablet 10 mg, 0 mg 1 PA PA 8

38 TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.5 MG,.5 MG, 3.75 MG XTANDI ORAL CAPSULE 0 MG PA; LA ZYTIGA ORAL TABLET 50 MG PA; LA KINASE INHIBITORS AFINITOR DISPERZ ORAL TABLET SOLUBLE MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 MG, 5 MG, 7.5 MG PA ALECENSA ORAL CAPSULE 150 MG PA; LA BOSULIF ORAL TABLET 100 MG, 500 MG PA CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG PA; LA CAPRELSA ORAL TABLET 100 MG, 300 MG PA; LA COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 0 MG COMETRIQ (10 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 0 MG PA PA PA; LA PA; LA COMETRIQ (60 MG DAILY DOSE) ORAL KIT 0 MG PA; LA COTELLIC ORAL TABLET 0 MG PA; LA GILOTRIF ORAL TABLET 0 MG, 30 MG, 0 MG PA; LA ICLUSIG ORAL TABLET 15 MG, 5 MG PA; LA imatinib mesylate oral tablet 100 mg, 00 mg PA IMBRUVICA ORAL CAPSULE 10 MG PA; LA INLYTA ORAL TABLET 1 MG, 5 MG PA; LA IRESSA ORAL TABLET 50 MG PA; LA JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG PA; LA LENVIMA 10 MG DAILY DOSE ORAL 10 MG PA; LA LENVIMA 1 MG DAILY DOSE ORAL 10 & MG PA; LA LENVIMA 18 MG DAILY DOSE ORAL 10 & () MG PA; LA LENVIMA 0 MG DAILY DOSE ORAL 10 () MG PA; LA LENVIMA MG DAILY DOSE ORAL 10 () & MG PA; LA LENVIMA 8 MG DAILY DOSE ORAL () MG PA; LA 9

39 LENVIMA 8MG DAILY DOSE ORAL () MG (60 PACK) PA; LA MEKINIST ORAL TABLET 0.5 MG, MG PA; LA NEXAVAR ORAL TABLET 00 MG PA; LA SPRYCEL ORAL TABLET 100 MG, 10 MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 0 MG PA; LA SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 37.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA; LA TAGRISSO ORAL TABLET 0 MG, 80 MG PA; LA TARCEVA ORAL TABLET 100 MG, 150 MG, 5 MG PA; LA TASIGNA ORAL CAPSULE 150 MG, 00 MG PA TYKERB ORAL TABLET 50 MG PA; LA VOTRIENT ORAL TABLET 00 MG PA; LA XALKORI ORAL CAPSULE 00 MG, 50 MG PA; LA ZELBORAF ORAL TABLET 0 MG PA; LA ZYDELIG ORAL TABLET 100 MG, 150 MG PA; LA ZYKADIA ORAL CAPSULE 150 MG PA; LA MISCELLANEOUS bexarotene oral capsule 75 mg PA DROXIA ORAL CAPSULE 00 MG, 300 MG, 00 MG 3 HALAVEN INTRAVENOUS* SOLUTION 1 MG/ML B/D hydroxyurea oral capsule 500 mg IXEMPRA KIT INTRAVENOUS* SOLUTION RECONSTITUTED 15 MG, 5 MG LONSURF ORAL TABLET MG, MG PA MATULANE ORAL CAPSULE 50 MG LA mitoxantrone hcl intravenous* concentrate 0 mg/10ml, 5 mg/1.5ml, 30 mg/15ml PA PA B/D B/D ODOMZO ORAL CAPSULE 00 MG PA; LA POMALYST ORAL CAPSULE 1 MG, MG, 3 MG, MG PA; LA 30

40 SYLATRON SUBCUTANEOUS* KIT 00 MCG, 300 MCG, X 00 MCG, X 300 MCG, 600 MCG SYNRIBO SUBCUTANEOUS* SOLUTION RECONSTITUTED 3.5 MG PA PA tretinoin oral capsule 10 mg TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML B/D UVADEX INJECTION SOLUTION 0 MCG/ML B/D PLATINUM-BASED AGENTS carboplatin intravenous* solution 150 mg/15ml, 50 mg/5ml, 50 mg/5ml, 600 mg/60ml cisplatin intravenous* solution 100 mg/100ml, 00 mg/00ml, 50 mg/50ml B/D B/D ELOXATIN INTRAVENOUS* SOLUTION 100 MG/0ML, 50 MG/10ML oxaliplatin intravenous* solution 100 mg/0ml, 50 mg/10ml oxaliplatin intravenous* solution reconstituted 100 mg, 50 mg PROTECTIVE AGENTS B/D B/D B/D amifostine intravenous* solution reconstituted 500 mg B/D dexrazoxane intravenous* solution reconstituted 50 mg B/D ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG FUSILEV INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG KEPIVANCE INTRAVENOUS* SOLUTION RECONSTITUTED 6.5 MG B/D B/D B/D leucovorin calcium injection solution reconstituted 100 mg, 00 mg, 350 mg, 50 mg, 500 mg leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg, 5 mg B/D levoleucovorin calcium intravenous* solution 175 mg/17.5ml B/D 31

41 levoleucovorin calcium intravenous* solution reconstituted 50 mg levoleucovorin calcium pf intravenous* solution 50 mg/5ml B/D B/D mesna intravenous* solution 100 mg/ml B/D MESNEX ORAL TABLET 00 MG TOPOISOMERASE INHIBITORS CAMPTOSAR INTRAVENOUS* SOLUTION 300 MG/15ML B/D ETOPOPHOS INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG B/D etoposide intravenous* solution 500 mg/5ml B/D irinotecan hcl intravenous* solution 100 mg/5ml, 0 mg/ml, 500 mg/5ml B/D toposar intravenous* solution 1 gm/50ml B/D topotecan hcl intravenous* solution reconstituted mg B/D CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besy-benazepril hcl oral capsule 10-0 mg, 10-0 mg,.5-10 mg, 5-10 mg, 5-0 mg, 5-0 mg benazepril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg, mg captopril-hydrochlorothiazide oral tablet 5-15 mg, 5-5 mg, mg, 50-5 mg enalapril-hydrochlorothiazide oral tablet 10-5 mg, mg fosinopril sodium-hctz oral tablet mg, mg lisinopril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg moexipril-hydrochlorothiazide oral tablet mg, 15-5 mg, mg quinapril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg

42 trandolapril-verapamil hcl er oral tablet extendedrelease* 1-0 mg, -180 mg, -0 mg, -0 mg ACE INHIBITORS 1 benazepril hcl oral tablet 10 mg, 0 mg, 0 mg, 5 mg 1 captopril oral tablet 100 mg, 1.5 mg, 5 mg, 50 mg 1 enalapril maleate oral tablet 10 mg,.5 mg, 0 mg, 5 mg 1 fosinopril sodium oral tablet 10 mg, 0 mg, 0 mg 1 lisinopril oral tablet 10 mg,.5 mg, 0 mg, 30 mg, 0 mg, 5 mg 1 moexipril hcl oral tablet 15 mg, 7.5 mg 1 perindopril erbumine oral tablet mg, mg, 8 mg 1 QBRELIS ORAL SOLUTION 1 MG/ML quinapril hcl oral tablet 10 mg, 0 mg, 0 mg, 5 mg 1 ramipril oral capsule 1.5 mg, 10 mg,.5 mg, 5 mg 1 trandolapril oral tablet 1 mg, mg, mg 1 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone oral tablet 5 mg, 50 mg spironolactone oral tablet 100 mg, 5 mg, 50 mg 1 ALPHA BLOCKERS doxazosin mesylate oral tablet 1 mg, mg, mg, 8 mg prazosin hcl oral capsule 1 mg, mg, 5 mg terazosin hcl oral capsule 1 mg, 10 mg, mg, 5 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan oral tablet mg, mg, mg, 5-30 mg amlodipine-valsartan-hctz oral tablet mg, mg, mg, mg, mg AZOR ORAL TABLET 10-0 MG, 10-0 MG, 5-0 MG, 5-0 MG

43 BENICAR HCT ORAL TABLET MG, MG, 0-5 MG candesartan cilexetil-hctz oral tablet mg, mg, 3-5 mg 3 1 EDARBYCLOR ORAL TABLET MG, 0-5 MG ENTRESTO ORAL TABLET -6 MG, 9-51 MG, MG irbesartan-hydrochlorothiazide oral tablet mg, mg losartan potassium-hctz oral tablet mg, mg, mg telmisartan-amlodipine oral tablet 0-10 mg, 0-5 mg, mg, 80-5 mg telmisartan-hctz oral tablet mg, mg, 80-5 mg TRIBENZOR ORAL TABLET MG, MG, MG, MG, MG valsartan-hydrochlorothiazide oral tablet mg, mg, mg, 30-5 mg, mg ANGIOTENSIN II RECEPTOR ANTAGONISTS PA BENICAR ORAL TABLET 0 MG, 0 MG, 5 MG 3 candesartan cilexetil oral tablet 16 mg, 3 mg, mg, 8 mg 1 EDARBI ORAL TABLET 0 MG, 80 MG eprosartan mesylate oral tablet 600 mg 1 irbesartan oral tablet 150 mg, 300 mg, 75 mg 1 losartan potassium oral tablet 100 mg, 5 mg, 50 mg 1 telmisartan oral tablet 0 mg, 0 mg, 80 mg 1 valsartan oral tablet 160 mg, 30 mg, 0 mg, 80 mg 1 ANTIARRHYTHMICS amiodarone hcl intravenous* solution 150 mg/3ml, 50 mg/9ml, 900 mg/18ml amiodarone hcl oral tablet 100 mg, 00 mg amiodarone hcl oral tablet 00 mg 1 3

44 disopyramide phosphate oral capsule 100 mg, 150 mg PA dofetilide oral capsule 15 mcg, 50 mcg, 500 mcg flecainide acetate oral tablet 100 mg, 150 mg, 50 mg mexiletine hcl oral capsule 150 mg, 00 mg, 50 mg MULTAQ ORAL TABLET 00 MG NORPACE CR ORAL CAPSULE EXTENDED RELEASE 1 HOUR 100 MG, 150 MG pacerone oral tablet 100 mg, 00 mg pacerone oral tablet 00 mg 1 propafenone hcl er oral capsule extended release 1 hour 5 mg, 35 mg, 5 mg propafenone hcl oral tablet 150 mg, 5 mg, 300 mg quinidine gluconate er oral tablet extendedrelease* 3 mg quinidine sulfate oral tablet 00 mg, 300 mg sorine oral tablet 10 mg, 160 mg, 0 mg, 80 mg sotalol hcl (af) oral tablet 10 mg, 160 mg, 80 mg sotalol hcl oral tablet 10 mg, 160 mg, 0 mg, 80 mg 1 TIKOSYN ORAL CAPSULE 15 MCG, 50 MCG, 500 MCG ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS ALTOPREV ORAL TABLET EXTENDED RELEASE HR* 0 MG, 0 MG, 60 MG atorvastatin calcium oral tablet 10 mg, 0 mg, 0 mg, 80 mg crestor oral tablet 10 mg, 0 mg, 0 mg, 5 mg 1 fluvastatin sodium er oral tablet extended release hr* 80 mg fluvastatin sodium oral capsule 0 mg, 0 mg 1 LESCOL XL ORAL TABLET EXTENDED RELEASE HR* 80 MG LIVALO ORAL TABLET 1 MG, MG, MG lovastatin oral tablet 10 mg, 0 mg, 0 mg 1 PA

45 pravastatin sodium oral tablet 10 mg, 0 mg, 0 mg, 80 mg rosuvastatin calcium oral tablet 10 mg, 0 mg, 0 mg, 5 mg simvastatin oral tablet 10 mg, 0 mg, 0 mg, 5 mg simvastatin oral tablet 80 mg 1 QL (30 EA per 30 days) ANTILIPEMICS, MISCELLANEOUS ANTARA ORAL CAPSULE 30 MG, 90 MG cholestyramine light oral packet gm cholestyramine light oral powder gm/dose cholestyramine oral packet gm cholestyramine oral powder gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral packet 5 gm colestipol hcl oral tablet 1 gm fenofibrate micronized oral capsule 130 mg, 13 mg, 00 mg, 3 mg, 67 mg fenofibrate oral capsule 150 mg, 50 mg fenofibrate oral tablet 10 mg, 0 mg fenofibrate oral tablet 15 mg, 160 mg, 8 mg, 5 mg fenofibric acid oral capsule delayed release 135 mg, 5 mg fenofibric acid oral tablet 105 mg, 35 mg FENOGLIDE ORAL TABLET 10 MG, 0 MG gemfibrozil oral tablet 600 mg 1 JUXTAPID ORAL CAPSULE 10 MG, 0 MG, 30 MG, 0 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS* 00 MG/ML PA niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000 mg, 500 mg, 750 mg niacor oral tablet 500 mg omega-3-acid ethyl esters oral capsule 1 gm PA; LA PRALUENT SUBCUTANEOUS* 150 MG/ML, 75 MG/ML PA 36

46 prevalite oral packet gm prevalite oral powder gm/dose TRIGLIDE ORAL TABLET 160 MG VASCEPA ORAL CAPSULE 1 GM VYTORIN ORAL TABLET MG, 10-0 MG, 10-0 MG, MG WELCHOL ORAL PACKET 3.75 GM 3 WELCHOL ORAL TABLET 65 MG 3 ZETIA ORAL TABLET 10 MG 3 BETA-BLOCKER/DIURETIC COMBINATIONS atenolol-chlorthalidone oral tablet mg, 50-5 mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg DUTOPROL ORAL TABLET EXTENDED RELEASE HR* MG, MG, MG metoprolol-hydrochlorothiazide oral tablet mg, mg, 50-5 mg nadolol-bendroflumethiazide oral tablet 0-5 mg, 80-5 mg propranolol-hctz oral tablet 0-5 mg, 80-5 mg BETA-BLOCKERS acebutolol hcl oral capsule 00 mg, 00 mg 1 atenolol oral tablet 100 mg, 5 mg, 50 mg 1 betaxolol hcl oral tablet 10 mg, 0 mg bisoprolol fumarate oral tablet 10 mg, 5 mg BYSTOLIC ORAL TABLET 10 MG,.5 MG, 0 MG, 5 MG carvedilol oral tablet 1.5 mg, 5 mg, 3.15 mg, 6.5 mg COREG CR ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 0 MG, 0 MG, 80 MG labetalol hcl intravenous* solution 5 mg/ml labetalol hcl oral tablet 100 mg, 00 mg, 300 mg ST

47 metoprolol succinate er oral tablet extended release hr* 100 mg, 00 mg, 5 mg, 50 mg metoprolol tartrate intravenous* solution 1 mg/ml, 5 mg/5ml metoprolol tartrate oral tablet 100 mg, 5 mg, 50 mg 1 nadolol oral tablet 0 mg, 0 mg, 80 mg pindolol oral tablet 10 mg, 5 mg propranolol hcl er oral capsule extended release hour 10 mg, 160 mg, 60 mg, 80 mg propranolol hcl intravenous* solution 1 mg/ml propranolol hcl oral solution 0 mg/5ml, 0 mg/5ml propranolol hcl oral tablet 10 mg, 0 mg, 0 mg, 60 mg, 80 mg 1 SOTYLIZE ORAL SOLUTION 5 MG/ML timolol maleate oral tablet 10 mg, 0 mg, 5 mg CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine-atorvastatin oral tablet mg, 10-0 mg, 10-0 mg, mg,.5-10 mg,.5-0 mg,.5-0 mg, 5-10 mg, 5-0 mg, 5-0 mg, 5-80 mg CALCIUM CHANNEL BLOCKERS afeditab cr oral tablet extended release hr* 30 mg, 60 mg 1 amlodipine besylate oral tablet 10 mg,.5 mg, 5 mg 1 CARDIZEM LA ORAL TABLET EXTENDED RELEASE HR* 10 MG cartia xt oral capsule extended release hour 10 mg, 180 mg, 0 mg, 300 mg diltiazem hcl er beads oral capsule extended release hour 10 mg, 180 mg, 0 mg, 300 mg, 360 mg, 0 mg diltiazem hcl er coated beads oral capsule extended release hour 10 mg, 180 mg, 0 mg, 300 mg, 360 mg 38

48 diltiazem hcl er oral capsule extended release 1 hour 10 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release hour 10 mg, 0 mg diltiazem hcl intravenous* solution 15 mg/5ml, 5 mg/5ml, 50 mg/10ml diltiazem hcl intravenous* solution reconstituted 100 mg diltiazem hcl oral tablet 10 mg, 30 mg, 60 mg, 90 mg 1 dilt-xr oral capsule extended release hour 10 mg, 180 mg, 0 mg felodipine er oral tablet extended release hr* 10 mg,.5 mg, 5 mg isradipine oral capsule.5 mg, 5 mg matzim la oral tablet extended release hr* 180 mg, 0 mg, 300 mg, 360 mg, 0 mg nicardipine hcl oral capsule 0 mg, 30 mg nifedical xl oral tablet extended release hr* 30 mg, 60 mg nifedipine er oral tablet extended release hr* 30 mg, 60 mg, 90 mg nifedipine er osmotic release oral tablet extended release hr* 30 mg, 60 mg, 90 mg nimodipine oral capsule 30 mg nisoldipine er oral tablet extended release hr* 17 mg, 0 mg, 5.5 mg, 30 mg, 3 mg, 0 mg, 8.5 mg NYMALIZE ORAL SOLUTION 60 MG/0ML taztia xt oral capsule extended release hour 10 mg, 180 mg, 0 mg, 300 mg, 360 mg verapamil hcl er oral capsule extended release hour 100 mg, 10 mg, 180 mg, 00 mg, 0 mg, 300 mg verapamil hcl er oral capsule extended release hour 360 mg verapamil hcl er oral tablet extendedrelease* 10 mg, 10 mg (hr), 180 mg, 0 mg 1 39

49 verapamil hcl intravenous* solution.5 mg/ml verapamil hcl oral tablet 10 mg, 0 mg, 80 mg 1 DIGITALIS GLYCOSIDES digitek oral tablet 15 mcg QL (30 EA per 30 days) digitek oral tablet 50 mcg PA digox oral tablet 15 mcg QL (30 EA per 30 days) digox oral tablet 50 mcg PA digoxin injection solution 0.5 mg/ml digoxin oral solution 0.05 mg/ml PA digoxin oral tablet 15 mcg QL (30 EA per 30 days) digoxin oral tablet 50 mcg PA LANOXIN ORAL TABLET MCG PA LANOXIN ORAL TABLET 6.5 MCG QL (60 EA per 30 days) LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA HCT ORAL TABLET MG, MG, MG, MG TEKTURNA ORAL TABLET 150 MG, 300 MG 3 DIURETICS acetazolamide er oral capsule extended release 1 hour 500 mg acetazolamide oral tablet 15 mg, 50 mg acetazolamide sodium injection solution reconstituted 500 mg ALDACTAZIDE ORAL TABLET MG amiloride hcl oral tablet 5 mg amiloride-hydrochlorothiazide oral tablet 5-50 mg 1 bumetanide injection solution 0.5 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, mg chlorothiazide oral tablet 50 mg, 500 mg chlorthalidone oral tablet 5 mg, 50 mg DIURIL ORAL SUSPENSION 50 MG/5ML 0 3

50 DYRENIUM ORAL CAPSULE 100 MG, 50 MG EDECRIN ORAL TABLET 5 MG ethacrynic acid oral tablet 5 mg furosemide injection solution 10 mg/ml furosemide injection solution 10 mg/ml (ml syringe) furosemide oral solution 10 mg/ml, 8 mg/ml 1 furosemide oral tablet 0 mg, 0 mg, 80 mg 1 hydrochlorothiazide oral capsule 1.5 mg 1 hydrochlorothiazide oral tablet 1.5 mg, 5 mg, 50 mg 1 indapamide oral tablet 1.5 mg,.5 mg 1 methazolamide oral tablet 5 mg, 50 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg,.5 mg, 5 mg spironolactone-hctz oral tablet 5-5 mg torsemide intravenous* solution 50 mg/5ml torsemide oral tablet 10 mg, 100 mg, 0 mg, 5 mg 1 triamterene-hctz oral capsule mg, 50-5 mg 1 triamterene-hctz oral tablet mg, mg 1 MISCELLANEOUS BIDIL ORAL TABLET MG 3 clonidine hcl oral tablet 0.1 mg, 0. mg, 0.3 mg 1 clonidine hcl transdermal patch weekly 0.1 mg/hr, 0. mg/hr, 0.3 mg/hr clorpres oral tablet mg, mg, mg CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 50 MG DIBENZYLINE ORAL CAPSULE 10 MG hydralazine hcl injection solution 0 mg/ml hydralazine hcl oral tablet 10 mg, 100 mg, 5 mg, 50 mg KEVEYIS ORAL TABLET 50 MG PA midodrine hcl oral tablet 10 mg,.5 mg, 5 mg 1

51 minoxidil oral tablet 10 mg,.5 mg PHENOXYBENZAMINE HCL ORAL CAPSULE 10 MG RANEXA ORAL TABLET EXTENDED RELEASE 1 HR* 1000 MG, 500 MG NITRATES DILATRATE-SR ORAL CAPSULE EXTENDED RELEASE* 0 MG 3 ISORDIL TITRADOSE ORAL TABLET 0 MG isosorbide dinitrate er oral tablet extendedrelease* 0 mg isosorbide dinitrate oral tablet 10 mg, 0 mg, 30 mg, 5 mg isosorbide mononitrate er oral tablet extended release hr* 10 mg, 30 mg, 60 mg 1 isosorbide mononitrate oral tablet 10 mg, 0 mg 1 minitran transdermal patch hr 0.1 mg/hr, 0. mg/hr, 0. mg/hr, 0.6 mg/hr nitro-bid transdermal ointment % 3 NITRO-DUR TRANSDERMAL PATCH HR 0.3 MG/HR, 0.8 MG/HR nitroglycerin sublingual tablet sublingual 0.3 mg, 0. mg, 0.6 mg nitroglycerin transdermal patch hr 0.1 mg/hr, 0. mg/hr, 0. mg/hr, 0.6 mg/hr nitroglycerin translingual aerosol, solution 00 mcg/spray nitroglycerin translingual solution 0. mg/spray NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0. MG, 0.6 MG PULMONARY ARTERIAL HYPERTENSION 3 ADCIRCA ORAL TABLET 0 MG PA ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, MG,.5 MG PA; LA LETAIRIS ORAL TABLET 10 MG, 5 MG PA; LA

52 OPSUMIT ORAL TABLET 10 MG PA; LA ORENITRAM ORAL TABLET EXTENDEDRELEASE* 0.15 MG PA; LA ORENITRAM ORAL TABLET EXTENDEDRELEASE* 0.5 MG, 1 MG,.5 MG REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML,.5 MG/ML, 5 MG/ML REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML PA; LA B/D; LA PA sildenafil citrate oral tablet 0 mg PA TRACLEER ORAL TABLET 15 MG, 6.5 MG PA; LA TYVASO INHALATION SOLUTION 0.6 MG/ML B/D UPTRAVI ORAL 00 & 800 MCG PA; LA UPTRAVI ORAL TABLET 1000 MCG, 100 MCG, 100 MCG, 1600 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG VENTAVIS INHALATION SOLUTION 10 MCG/ML, 0 MCG/ML CENTRAL NERVOUS SYSTEM ANTIANXIETY PA; LA B/D alprazolam intensol oral concentrate 1 mg/ml QL (300 ML per 30 days) alprazolam oral tablet 0.5 mg 1 QL (80 EA per 30 days) alprazolam oral tablet 0.5 mg 1 QL (0 EA per 30 days) alprazolam oral tablet 1 mg 1 QL (10 EA per 30 days) alprazolam oral tablet mg 1 QL (150 EA per 30 days) buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg fluvoxamine maleate er oral capsule extended release hour 100 mg fluvoxamine maleate er oral capsule extended release hour 150 mg QL (90 EA per 30 days) QL (60 EA per 30 days) fluvoxamine maleate oral tablet 100 mg fluvoxamine maleate oral tablet 5 mg, 50 mg QL (5 EA per 30 days) 3

53 lorazepam injection solution mg/ml, mg/ml lorazepam intensol oral concentrate mg/ml QL (150 ML per 30 days) lorazepam oral tablet 0.5 mg, 1 mg, mg 1 QL (150 EA per 30 days) ANTICONVULSANTS APTIOM ORAL TABLET 00 MG APTIOM ORAL TABLET 00 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 0 MG/ML PA BANZEL ORAL TABLET 00 MG PA BANZEL ORAL TABLET 00 MG PA BRIVIACT INTRAVENOUS* SOLUTION 50 MG/5ML PA BRIVIACT ORAL SOLUTION 10 MG/ML PA BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG carbamazepine er oral capsule extended release 1 hour 100 mg, 00 mg, 300 mg carbamazepine er oral tablet extended release 1 hr* 100 mg, 00 mg, 00 mg carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 00 mg carbamazepine oral tablet chewable 100 mg CELONTIN ORAL CAPSULE 300 MG clonazepam oral tablet 0.5 mg 1 QL (0 EA per 30 days) clonazepam oral tablet 1 mg 1 QL (10 EA per 30 days) clonazepam oral tablet mg 1 QL (300 EA per 30 days) clonazepam oral tablet dispersible 0.15 mg QL (960 EA per 30 days) clonazepam oral tablet dispersible 0.5 mg QL (80 EA per 30 days) clonazepam oral tablet dispersible 0.5 mg QL (0 EA per 30 days) clonazepam oral tablet dispersible 1 mg QL (10 EA per 30 days) clonazepam oral tablet dispersible mg QL (300 EA per 30 days) clorazepate dipotassium oral tablet 15 mg PA; QL (180 EA per 30 days) clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg PA; QL (10 EA per 30 days) diazepam gel 10 mg,.5 mg, 0 mg PA

54 diazepam injection solution 5 mg/ml diazepam intensol oral concentrate 5 mg/ml PA; QL (0 ML per 30 days) diazepam oral solution 1 mg/ml PA; QL (100 ML per 30 days) diazepam oral tablet 10 mg, mg, 5 mg 1 PA; QL (10 EA per 30 days) dilantin infatabs oral tablet chewable 50 mg 3 dilantin oral capsule 100 mg, 30 mg 3 DILANTIN ORAL SUSPENSION 15 MG/5ML 3 divalproex sodium er oral tablet extended release hr* 50 mg, 500 mg divalproex sodium oral 15 mg divalproex sodium oral tablet delayed release 15 mg, 50 mg, 500 mg epitol oral tablet 00 mg ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5ml felbamate oral suspension 600 mg/5ml felbamate oral tablet 00 mg, 600 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML PA FYCOMPA ORAL TABLET 10 MG, 1 MG, MG, MG, 6 MG, 8 MG PA gabapentin oral capsule 100 mg 1 QL (1080 EA per 30 days) gabapentin oral capsule 300 mg 1 QL (360 EA per 30 days) gabapentin oral capsule 00 mg 1 QL (70 EA per 30 days) gabapentin oral solution 50 mg/5ml QL (160 ML per 30 days) gabapentin oral tablet 600 mg QL (180 EA per 30 days) gabapentin oral tablet 800 mg QL (10 EA per 30 days) GABITRIL ORAL TABLET 1 MG, 16 MG LAMICTAL ODT ORAL KIT 5 & 50 & 100 MG, 5 (1)-50 (7) MG, 50 ()-100(1) MG LAMICTAL STARTER ORAL KIT 5 (35) MG, 5 ()-100 (7) MG, 5 (8)-100(1) MG LAMICTAL XR ORAL KIT 5 & 50 & 100 MG, 5 (1)-50 (7) MG, 50 & 100 & 00 MG 5

55 lamotrigine er oral tablet extended release hr* 100 mg, 00 mg, 5 mg, 50 mg, 300 mg, 50 mg lamotrigine oral kit 5 & 50 & 100 mg, 5 (1)-50 (7) mg, 50 ()-100(1) mg lamotrigine oral tablet 100 mg, 150 mg, 00 mg, 5 mg 1 lamotrigine oral tablet chewable 5 mg, 5 mg lamotrigine oral tablet dispersible 100 mg, 00 mg, 5 mg, 50 mg levetiracetam er oral tablet extended release hr* 500 mg, 750 mg LEVETIRACETAM IN NACL INTRAVENOUS* SOLUTION 1000 MG/100ML, 1500 MG/100ML, 500 MG/100ML levetiracetam intravenous* solution 500 mg/5ml levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 50 mg, 500 mg, 750 mg LYRICA ORAL CAPSULE 100 MG, 150 MG, 5 MG, 50 MG, 75 MG 3 QL (10 EA per 30 days) LYRICA ORAL CAPSULE 00 MG 3 QL (90 EA per 30 days) LYRICA ORAL CAPSULE 5 MG, 300 MG 3 QL (60 EA per 30 days) LYRICA ORAL SOLUTION 0 MG/ML 3 QL (96 ML per 30 days) ONFI ORAL SUSPENSION.5 MG/ML PA ONFI ORAL TABLET 10 MG PA ONFI ORAL TABLET 0 MG PA oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE HR* 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 mg/5ml PA phenobarbital oral tablet 100 mg, 15 mg, 16. mg, 30 mg, 3. mg, 60 mg, 6.8 mg, 97. mg PA phenobarbital sodium injection solution 130 mg/ml PA 6

56 PHENOBARBITAL SODIUM INJECTION SOLUTION 65 MG/ML phenytek oral capsule 00 mg, 300 mg 3 phenytoin oral suspension 15 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 00 mg, 300 mg phenytoin sodium injection solution 50 mg/ml PA POTIGA ORAL TABLET 00 MG QL (180 EA per 30 days) POTIGA ORAL TABLET 300 MG, 00 MG QL (90 EA per 30 days) POTIGA ORAL TABLET 50 MG primidone oral tablet 50 mg, 50 mg roweepra oral tablet 500 mg SABRIL ORAL PACKET 500 MG PA; LA; QL (180 EA per 30 days) SABRIL ORAL TABLET 500 MG PA; LA; QL (180 EA per 30 days) SPRITAM ORAL 1000 MG, 50 MG, 500 MG, 750 MG TEGRETOL ORAL SUSPENSION 100 MG/5ML TEGRETOL ORAL TABLET 00 MG TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 1 HR* 100 MG, 00 MG, 00 MG tiagabine hcl oral tablet mg, mg topiramate er oral 100 mg, 150 mg, 00 mg, 5 mg, 50 mg topiramate oral capsule sprinkle 15 mg, 5 mg topiramate oral tablet 100 mg, 00 mg, 5 mg, 50 mg 1 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE HOUR 100 MG, 5 MG, 50 MG TROKENDI XR ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG valproate sodium intravenous* solution 500 mg/5ml valproate sodium oral syrup 50 mg/5ml valproic acid oral capsule 50 mg VIMPAT INTRAVENOUS* SOLUTION 00 MG/0ML 7

57 VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 00 MG VIMPAT ORAL TABLET 50 MG zonisamide oral capsule 100 mg, 5 mg, 50 mg ANTIDEMENTIA donepezil hcl oral tablet 10 mg, 3 mg, 5 mg donepezil hcl oral tablet dispersible 10 mg, 5 mg exelon transdermal patch hr 13.3 mg/hr,.6 mg/hr, 9.5 mg/hr galantamine hydrobromide er oral capsule extended release hour 16 mg, mg, 8 mg galantamine hydrobromide oral solution mg/ml galantamine hydrobromide oral tablet 1 mg, mg, 8 mg memantine hcl oral solution mg/ml PA memantine hcl oral tablet 10 mg PA memantine hcl oral tablet 5 mg PA NAMENDA XR ORAL CAPSULE EXTENDED RELEASE HOUR 1 MG, 1 MG, 8 MG, 7 MG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE HOUR 7 & 1 & 1 NAMZARIC ORAL CAPSULE EXTENDED RELEASE HOUR 1-10 MG, 1-10 MG, 8-10 MG, 7-10 MG rivastigmine tartrate oral capsule 1.5 mg, 3 mg,.5 mg, 6 mg ANTIDEPRESSANTS amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg PA PA PA amoxapine oral tablet 100 mg, 150 mg, 5 mg, 50 mg APLENZIN ORAL TABLET EXTENDED RELEASE HR* 17 MG, 38 MG, 5 MG BRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG 8

58 bupropion hcl er (sr) oral tablet extended release 1 hr* 100 mg, 150 mg, 00 mg bupropion hcl er (xl) oral tablet extended release hr* 150 mg, 300 mg bupropion hcl oral tablet 100 mg, 75 mg citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg, 0 mg, 0 mg clomipramine hcl oral capsule 5 mg, 50 mg, 75 mg PA desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg 1 PA doxepin hcl oral concentrate 10 mg/ml PA duloxetine hcl oral capsule delayed release particles 0 mg, 30 mg, 60 mg EMSAM TRANSDERMAL PATCH HR 1 MG/HR, 6 MG/HR, 9 MG/HR escitalopram oxalate oral solution 5 mg/5ml escitalopram oxalate oral tablet 10 mg, 0 mg, 5 mg FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 0 MG, 0 MG, 80 MG FETZIMA TITRATION ORAL 0 & 0 MG fluoxetine hcl oral capsule 10 mg, 0 mg, 0 mg 1 fluoxetine hcl oral capsule delayed release 90 mg fluoxetine hcl oral solution 0 mg/5ml fluoxetine hcl oral tablet 10 mg, 0 mg FLUOXETINE HCL ORAL TABLET 60 MG FORFIVO XL ORAL TABLET EXTENDED RELEASE HR* 50 MG imipramine hcl oral tablet 10 mg, 5 mg, 50 mg PA imipramine pamoate oral capsule 100 mg, 15 mg, 150 mg, 75 mg PA QL (30 EA per 30 days) PA 9

59 maprotiline hcl oral tablet 5 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 30 mg, 5 mg, 7.5 mg 1 mirtazapine oral tablet dispersible 15 mg, 30 mg, 5 mg nefazodone hcl oral tablet 100 mg, 150 mg, 00 mg, 50 mg, 50 mg nortriptyline hcl oral capsule 10 mg, 5 mg, 50 mg, 75 mg nortriptyline hcl oral solution 10 mg/5ml paroxetine hcl er oral tablet extended release hr* 1.5 mg, 5 mg, 37.5 mg paroxetine hcl oral tablet 10 mg, 0 mg, 30 mg, 0 mg 1 PAXIL ORAL SUSPENSION 10 MG/5ML PEXEVA ORAL TABLET 10 MG, 0 MG, 30 MG, 0 MG phenelzine sulfate oral tablet 15 mg PRISTIQ ORAL TABLET EXTENDED RELEASE HR* 100 MG, 5 MG, 50 MG protriptyline hcl oral tablet 10 mg, 5 mg sertraline hcl oral concentrate 0 mg/ml sertraline hcl oral tablet 100 mg, 5 mg, 50 mg 1 SURMONTIL ORAL CAPSULE 100 MG, 5 MG, 50 MG PA tranylcypromine sulfate oral tablet 10 mg trazodone hcl oral tablet 100 mg, 150 mg, 50 mg 1 trazodone hcl oral tablet 300 mg trimipramine maleate oral capsule 100 mg, 5 mg, 50 mg TRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG venlafaxine hcl er oral capsule extended release hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release hr* 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release hr* 5 mg 1 3 PA 50

60 venlafaxine hcl oral tablet 100 mg, 5 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD ORAL KIT 10 & 0 & 0 MG VIIBRYD ORAL TABLET 10 MG, 0 MG, 0 MG VIIBRYD STARTER PACK ORAL KIT 10 & 0 MG ANTIPARKINSONIAN AGENTS amantadine hcl oral capsule 100 mg amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 100 mg APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML PA; LA AZILECT ORAL TABLET 0.5 MG, 1 MG 3 benztropine mesylate injection solution 1 mg/ml benztropine mesylate oral tablet 0.5 mg, 1 mg, mg PA bromocriptine mesylate oral capsule 5 mg bromocriptine mesylate oral tablet.5 mg carbidopa oral tablet 5 mg carbidopa-levodopa er oral tablet extendedrelease* mg, mg carbidopa-levodopa oral tablet mg, mg, 5-50 mg carbidopa-levodopa oral tablet dispersible mg, mg, 5-50 mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg DUOPA SUSPENSION.63-0 MG/ML B/D entacapone oral tablet 00 mg MIRAPEX ER ORAL TABLET EXTENDED RELEASE HR* MG,.5 MG, 3 MG, 3.75 MG,.5 MG MIRAPEX ORAL TABLET 0.75 MG NEUPRO TRANSDERMAL PATCH HR 1 MG/HR, MG/HR, 3 MG/HR, MG/HR, 6 MG/HR, 8 MG/HR 51

61 pramipexole dihydrochloride er oral tablet extended release hr* mg, 0.75 mg, 1.5 mg,.5 mg, 3 mg, 3.75 mg,.5 mg pramipexole dihydrochloride oral tablet 0.15 mg, 0.5 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl er oral tablet extended release hr* 1 mg, mg, mg, 6 mg, 8 mg ropinirole hcl oral tablet 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg, mg, 5 mg RYTARY ORAL CAPSULE EXTENDED RELEASE* MG, MG, MG, MG selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg ZELAPAR ORAL TABLET DISPERSIBLE 1.5 MG ANTIPSYCHOTICS ABILIFY DISCMELT ORAL TABLET DISPERSIBLE 10 MG QL (60 EA per 30 days) ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG, 300 MG (1.5ML SYRINGE), 00 MG QL (1 EA per 8 days) aripiprazole oral solution 1 mg/ml QL (900 ML per 30 days) aripiprazole oral tablet 10 mg, 15 mg, mg, 0 mg, 30 mg, 5 mg QL (30 EA per 30 days) aripiprazole oral tablet dispersible 10 mg, 15 mg QL (60 EA per 30 days) ARISTADA INTRAMUSCULAR* 1 MG/1.6ML QL (1.6 ML per 8 days) ARISTADA INTRAMUSCULAR* 66 MG/.ML QL (. ML per 8 days) ARISTADA INTRAMUSCULAR* 88 MG/3.ML QL (3. ML per 8 days) chlorpromazine hcl injection solution 5 mg/ml, 50 mg/ml chlorpromazine hcl oral tablet 10 mg, 100 mg, 00 mg, 5 mg, 50 mg clozapine oral tablet 100 mg QL (70 EA per 30 days) clozapine oral tablet 00 mg QL (135 EA per 30 days) clozapine oral tablet 5 mg, 50 mg clozapine oral tablet dispersible 100 mg PA; QL (70 EA per 30 days) 5

62 clozapine oral tablet dispersible 1.5 mg, 5 mg PA CLOZAPINE ORAL TABLET DISPERSIBLE 150 MG PA; QL (180 EA per 30 days) CLOZAPINE ORAL TABLET DISPERSIBLE 00 MG PA; QL (135 EA per 30 days) FANAPT ORAL TABLET 1 MG, 10 MG, 1 MG, MG, MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET 1 & & & 6 MG ST; QL (60 EA per 30 days) ST FAZACLO ORAL TABLET DISPERSIBLE 150 MG PA; QL (180 EA per 30 days) FAZACLO ORAL TABLET DISPERSIBLE 00 MG PA; QL (135 EA per 30 days) fluphenazine decanoate injection solution 5 mg/ml fluphenazine hcl injection solution.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir.5 mg/5ml fluphenazine hcl oral tablet 1 mg, 10 mg,.5 mg, 5 mg GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 0 MG haloperidol decanoate intramuscular* solution 100 mg/ml, 50 mg/ml QL (6 EA per 3 days) haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, mg, 0 mg, 5 mg INVEGA ORAL TABLET EXTENDED RELEASE HR* 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE HR* 6 MG QL (30 EA per 30 days) QL (60 EA per 30 days) INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 3 MG/1.5ML QL (0.75 ML per 8 days) QL (1 ML per 8 days) QL (1.5 ML per 8 days) INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 39 QL (0.5 ML per 8 days) MG/0.5ML 53

63 INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 73 MG/0.875ML INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 10 MG/1.315ML INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 56 MG/1.75ML INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 819 MG/.65ML QL (0.5 ML per 8 days) QL (0.875 ML per 90 days) QL (1.315 ML per 90 days) QL (1.75 ML per 90 days) QL (.65 ML per 90 days) LATUDA ORAL TABLET 10 MG, 0 MG QL (30 EA per 30 days) LATUDA ORAL TABLET 0 MG QL (0 EA per 30 days) LATUDA ORAL TABLET 60 MG, 80 MG QL (60 EA per 30 days) loxapine succinate oral capsule 10 mg, 5 mg, 5 mg, 50 mg molindone hcl oral tablet 10 mg, 5 mg, 5 mg NUPLAZID ORAL TABLET 17 MG PA; LA; QL (60 EA per 30 days) olanzapine intramuscular* solution reconstituted 10 mg QL (3 EA per 1 day) olanzapine oral tablet 10 mg, 15 mg, 0 mg QL (60 EA per 30 days) olanzapine oral tablet.5 mg, 5 mg, 7.5 mg QL (30 EA per 30 days) olanzapine oral tablet dispersible 10 mg, 15 mg, 0 mg QL (60 EA per 30 days) olanzapine oral tablet dispersible 5 mg QL (30 EA per 30 days) paliperidone er oral tablet extended release hr* 1.5 mg, 3 mg, 9 mg QL (30 EA per 30 days) paliperidone er oral tablet extended release hr* 6 mg QL (60 EA per 30 days) perphenazine oral tablet 16 mg, mg, mg, 8 mg pimozide oral tablet 1 mg, mg quetiapine fumarate oral tablet 100 mg, 00 mg, 5 mg, 300 mg, 00 mg, 50 mg QL (90 EA per 30 days) REXULTI ORAL TABLET 0.5 MG ST; QL (360 EA per 30 days) REXULTI ORAL TABLET 0.5 MG ST; QL (180 EA per 30 days) REXULTI ORAL TABLET 1 MG ST; QL (90 EA per 30 days) REXULTI ORAL TABLET MG ST; QL (60 EA per 30 days) 5

64 REXULTI ORAL TABLET 3 MG, MG ST; QL (30 EA per 30 days) RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 1.5 MG, 5 MG RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 37.5 MG, 50 MG QL ( EA per 8 days) QL ( EA per 8 days) risperidone oral solution 1 mg/ml QL (0 ML per 30 days) risperidone oral tablet 0.5 mg, 0.5 mg QL (90 EA per 30 days) risperidone oral tablet 1 mg, mg, 3 mg QL (60 EA per 30 days) risperidone oral tablet mg QL (10 EA per 30 days) risperidone oral tablet dispersible 0.5 mg, 0.5 mg QL (90 EA per 30 days) risperidone oral tablet dispersible 1 mg, mg, 3 mg QL (60 EA per 30 days) risperidone oral tablet dispersible mg QL (10 EA per 30 days) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG QL (60 EA per 30 days) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL.5 MG QL (0 EA per 30 days) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG QL (10 EA per 30 days) SEROQUEL XR ORAL TABLET EXTENDED RELEASE HR* 150 MG, 00 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE HR* 300 MG, 00 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE HR* 50 MG thioridazine hcl oral tablet 10 mg, 100 mg, 5 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, mg, 5 mg trifluoperazine hcl oral tablet 1 mg, 10 mg, mg, 5 mg QL (30 EA per 30 days) QL (60 EA per 30 days) QL (10 EA per 30 days) PA VERSACLOZ ORAL SUSPENSION 50 MG/ML PA; QL (600 ML per 30 days) VRAYLAR ORAL 1.5 & 3 MG ST VRAYLAR ORAL CAPSULE 1.5 MG ST; QL (10 EA per 30 days) VRAYLAR ORAL CAPSULE 3 MG ST; QL (60 EA per 30 days) VRAYLAR ORAL CAPSULE.5 MG, 6 MG ST; QL (30 EA per 30 days) ziprasidone hcl oral capsule 0 mg, 0 mg QL (60 EA per 30 days) ziprasidone hcl oral capsule 60 mg, 80 mg QL (90 EA per 30 days) 55

65 ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION RECONSTITUTED 10 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION RECONSTITUTED 05 MG ATTENTION DEFICIT HYPERACTIVITY DISORDER PA; QL ( EA per 8 days) PA; QL (1 EA per 8 days) amphetamine-dextroamphet er oral capsule extended release hour 10 mg, 5 mg amphetamine-dextroamphet er oral capsule extended release hour 15 mg, 0 mg, 5 mg, 30 mg QL (90 EA per 30 days) QL (30 EA per 30 days) amphetamine-dextroamphetamine oral tablet 10 mg QL (180 EA per 30 days) amphetamine-dextroamphetamine oral tablet 1.5 mg QL (1 EA per 30 days) amphetamine-dextroamphetamine oral tablet 15 mg QL (10 EA per 30 days) amphetamine-dextroamphetamine oral tablet 0 mg QL (90 EA per 30 days) amphetamine-dextroamphetamine oral tablet 30 mg QL (60 EA per 30 days) amphetamine-dextroamphetamine oral tablet 5 mg QL (360 EA per 30 days) amphetamine-dextroamphetamine oral tablet 7.5 mg QL (0 EA per 30 days) APTENSIO XR ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 15 MG, 0 MG, 30 MG APTENSIO XR ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG, 50 MG, 60 MG DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15 MG/9HR, 0 MG/9HR, 30 MG/9HR guanfacine hcl er oral tablet extended release hr* 1 mg, mg, 3 mg, mg QL (60 EA per 30 days) QL (30 EA per 30 days) QL (30 EA per 30 days) PA metadate er oral tablet extendedrelease* 0 mg QL (90 EA per 30 days) methylphenidate hcl er (cd) oral capsule extended release* 10 mg, 0 mg, 30 mg methylphenidate hcl er (cd) oral capsule extended release* 0 mg, 50 mg, 60 mg methylphenidate hcl er (la) oral capsule extended release hour 0 mg methylphenidate hcl er (la) oral capsule extended release hour 30 mg QL (60 EA per 30 days) QL (30 EA per 30 days) QL (60 EA per 30 days) QL (60 EA per 30 days) 56

66 methylphenidate hcl er (la) oral capsule extended release hour 0 mg methylphenidate hcl er oral tablet extended release hr* 18 mg, 7 mg, 36 mg methylphenidate hcl er oral tablet extended release hr* 5 mg methylphenidate hcl er oral tablet extendedrelease* 10 mg, 0 mg QL (30 EA per 30 days) QL (60 EA per 30 days) QL (30 EA per 30 days) QL (90 EA per 30 days) methylphenidate hcl oral solution 10 mg/5ml QL (900 ML per 30 days) methylphenidate hcl oral solution 5 mg/5ml QL (1800 ML per 30 days) methylphenidate hcl oral tablet 10 mg, 5 mg QL (180 EA per 30 days) methylphenidate hcl oral tablet 0 mg QL (90 EA per 30 days) methylphenidate hcl oral tablet chewable 10 mg,.5 mg, 5 mg QL (180 EA per 30 days) QUILLICHEW ER ORAL 0 MG QL (90 EA per 30 days) QUILLICHEW ER ORAL 30 MG QL (60 EA per 30 days) QUILLICHEW ER ORAL 0 MG QL (30 EA per 30 days) QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED 5 MG/5ML RITALIN LA ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG RITALIN LA ORAL CAPSULE EXTENDED RELEASE HOUR 60 MG QL (360 ML per 30 days) QL (180 EA per 30 days) QL (30 EA per 30 days) STRATTERA ORAL CAPSULE 10 MG, 18 MG, 5 MG QL (10 EA per 30 days) STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG QL (30 EA per 30 days) STRATTERA ORAL CAPSULE 0 MG QL (60 EA per 30 days) VYVANSE ORAL CAPSULE 10 MG, 0 MG, 30 MG QL (60 EA per 30 days) VYVANSE ORAL CAPSULE 0 MG, 50 MG, 60 MG, 70 MG QL (30 EA per 30 days) HYPNOTICS HETLIOZ ORAL CAPSULE 0 MG PA; LA ROZEREM ORAL TABLET 8 MG QL (30 EA per 30 days) SILENOR ORAL TABLET 3 MG 3 QL (60 EA per 30 days) SILENOR ORAL TABLET 6 MG 3 QL (30 EA per 30 days) 57

67 temazepam oral capsule 15 mg PA; QL (60 EA per 30 days) temazepam oral capsule 7.5 mg PA; QL (30 EA per 30 days) zolpidem tartrate oral tablet 10 mg, 5 mg PA; QL (30 EA per 30 days) MIGRAINE almotriptan malate oral tablet 1.5 mg, 6.5 mg QL (1 EA per 30 days) AXERT ORAL TABLET 1.5 MG, 6.5 MG ST; QL (1 EA per 30 days) cafergot oral tablet mg dihydroergotamine mesylate injection solution 1 mg/ml DIHYDROERGOTAMINE MESYLATE NASAL SOLUTION MG/ML ergomar sublingual tablet sublingual mg QL (8 ML per 30 days) FROVA ORAL TABLET.5 MG ST; QL (18 EA per 30 days) frovatriptan succinate oral tablet.5 mg QL (18 EA per 30 days) migergot suppository -100 mg naratriptan hcl oral tablet 1 mg,.5 mg QL (9 EA per 30 days) ONZETRA XSAIL NASAL 11 MG/NOSEPC ST; QL (16 EA per 30 days) RELPAX ORAL TABLET 0 MG, 0 MG 3 QL (1 EA per 30 days) rizatriptan benzoate oral tablet 10 mg, 5 mg QL (18 EA per 30 days) rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg QL (18 EA per 30 days) sumatriptan nasal solution 0 mg/act QL (1 EA per 30 days) sumatriptan nasal solution 5 mg/act QL ( EA per 30 days) sumatriptan succinate oral tablet 100 mg, 5 mg, 50 mg QL (9 EA per 30 days) sumatriptan succinate refill subcutaneous* mg/0.5ml QL (6 ML per 30 days) sumatriptan succinate refill subcutaneous* 6 mg/0.5ml QL (6 ML per 30 days) sumatriptan succinate subcutaneous* mg/0.5ml, 6 mg/0.5ml, 6 mg/0.5ml (auto-injector) sumatriptan succinate subcutaneous* solution 6 mg/0.5ml SUMAVEL DOSEPRO SUBCUTANEOUS* MG/0.5ML, 6 MG/0.5ML QL (6 ML per 30 days) QL (6 ML per 30 days) QL (6 ML per 30 days) TREXIMET ORAL TABLET MG ST; QL (9 EA per 30 days) 58

68 ZEMBRACE SYMTOUCH SUBCUTANEOUS* 3 MG/0.5ML ST; QL ( ML per 30 days) zolmitriptan oral tablet.5 mg, 5 mg QL (1 EA per 30 days) zolmitriptan oral tablet dispersible.5 mg, 5 mg QL (1 EA per 30 days) ZOMIG NASAL SOLUTION.5 MG, 5 MG QL (1 EA per 30 days) MISCELLANEOUS BRISDELLE ORAL CAPSULE 7.5 MG EQUETRO ORAL CAPSULE EXTENDED RELEASE 1 HOUR 100 MG, 00 MG, 300 MG GRALISE ORAL TABLET 300 MG 3 QL (180 EA per 30 days) GRALISE ORAL TABLET 600 MG 3 QL (90 EA per 30 days) GRALISE STARTER ORAL 300 & 600 MG 3 HORIZANT ORAL TABLET EXTENDEDRELEASE* 300 MG, 600 MG lithium carbonate er oral tablet extendedrelease* 300 mg, 50 mg lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg 1 LITHIUM ORAL SOLUTION 8 MEQ/5ML 3 MESTINON ORAL SYRUP 60 MG/5ML MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG NUEDEXTA ORAL CAPSULE 0-10 MG 3 PA pyridostigmine bromide er oral tablet extendedrelease* 180 mg pyridostigmine bromide oral tablet 60 mg riluzole oral tablet 50 mg SAVELLA ORAL TABLET 100 MG QL (60 EA per 30 days) SAVELLA ORAL TABLET 1.5 MG QL (80 EA per 30 days) SAVELLA ORAL TABLET 5 MG QL (0 EA per 30 days) SAVELLA ORAL TABLET 50 MG QL (10 EA per 30 days) SAVELLA TITRATION PACK ORAL 1.5 & 5 & 50 MG tetrabenazine oral tablet 1.5 mg PA; QL (0 EA per 30 days) 59 1

69 tetrabenazine oral tablet 5 mg PA; QL (10 EA per 30 days) MULTIPLE SCLEROSIS AGENTS AMPYRA ORAL TABLET EXTENDED RELEASE 1 HR* 10 MG PA; LA AUBAGIO ORAL TABLET 1 MG, 7 MG PA; LA; QL (30 EA per 30 days) AVONEX INTRAMUSCULAR* KIT 30 MCG PA; QL ( EA per 8 days) AVONEX PEN INTRAMUSCULAR* 30 MCG/0.5ML PA; QL ( EA per 8 days) AVONEX PREFILLED INTRAMUSCULAR* 30 MCG/0.5ML PA; QL ( EA per 8 days) BETASERON SUBCUTANEOUS* KIT 0.3 MG PA; QL (1 EA per 8 days) COPAXONE SUBCUTANEOUS* 0 MG/ML PA; QL (30 ML per 30 days) COPAXONE SUBCUTANEOUS* 0 MG/ML PA; QL (1 ML per 8 days) EXTAVIA SUBCUTANEOUS* KIT 0.3 MG PA; QL (15 EA per 30 days) GILENYA ORAL CAPSULE 0.5 MG PA; QL (8 EA per 8 days) LEMTRADA INTRAVENOUS* SOLUTION 1 MG/1.ML PA; LA PLEGRIDY STARTER PACK SUBCUTANEOUS* 63 & 9 MCG/0.5ML PA; QL (1 ML per 8 days) PLEGRIDY SUBCUTANEOUS* 15 MCG/0.5ML PA; QL (1 ML per 8 days) REBIF REBIDOSE SUBCUTANEOUS* MCG/0.5ML, MCG/0.5ML REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* 6X8.8 & 6X MCG PA; QL (6 ML per 8 days) PA; QL (6 ML per 8 days) REBIF SUBCUTANEOUS* MCG/0.5ML, MCG/0.5ML PA; QL (6 ML per 8 days) REBIF TITRATION PACK SUBCUTANEOUS* 6X8.8 & 6X MCG TECFIDERA ORAL 10 & 0 MG PA; LA PA; QL (6 ML per 30 days) TECFIDERA ORAL CAPSULE DELAYED RELEASE 10 MG PA; LA; QL (1 EA per 7 days) TECFIDERA ORAL CAPSULE DELAYED RELEASE 0 MG PA; LA; QL (60 EA per 30 days) TYSABRI INTRAVENOUS* CONCENTRATE 300 MG/15ML PA; LA MUSCULOSKELETAL THERAPY AGENTS baclofen oral tablet 10 mg, 0 mg BOTOX INJECTION SOLUTION RECONSTITUTED 100 UNIT, 00 UNIT dantrolene sodium oral capsule 100 mg, 5 mg, 50 mg 60 PA

70 tizanidine hcl oral capsule mg, mg, 6 mg tizanidine hcl oral tablet mg, mg XEOMIN INTRAMUSCULAR* SOLUTION RECONSTITUTED 100 UNIT, 00 UNIT PA XEOMIN INTRAMUSCULAR* SOLUTION RECONSTITUTED 50 UNIT NARCOLEPSY/CATAPLEXY PA modafinil oral tablet 100 mg PA; QL (30 EA per 30 days) modafinil oral tablet 00 mg PA; QL (60 EA per 30 days) NUVIGIL ORAL TABLET 150 MG 3 PA; QL (60 EA per 30 days) NUVIGIL ORAL TABLET 00 MG, 50 MG 3 PA; QL (30 EA per 30 days) NUVIGIL ORAL TABLET 50 MG 3 PA; QL (150 EA per 30 days) XYREM ORAL SOLUTION 500 MG/ML PA; LA; QL (50 ML per 30 days) PSYCHOTHERAPEUTIC-MISC acamprosate calcium oral tablet delayed release 333 mg BUNAVAIL BUCCAL FILM MG,.-0.7 MG PA; QL (10 EA per 30 days) BUNAVAIL BUCCAL FILM MG PA; QL (60 EA per 30 days) buprenorphine hcl sublingual tablet sublingual mg, 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual -0.5 mg, 8- mg PA PA; QL (10 EA per 30 days) buproban oral tablet extended release 1 hr* 150 mg bupropion hcl er (smoking det) oral tablet extended release 1 hr* 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X disulfiram oral tablet 50 mg, 500 mg naloxone hcl injection 0. mg/ml naloxone hcl injection solution 0. mg/ml, 1 mg/ml, mg/10ml 61

71 naltrexone hcl oral tablet 50 mg NICOTROL INHALATION INHALER 10 MG NICOTROL NS NASAL SOLUTION 10 MG/ML SARAFEM ORAL TABLET 10 MG, 0 MG SUBOXONE SUBLINGUAL FILM 1-3 MG PA; QL (60 EA per 30 days) SUBOXONE SUBLINGUAL FILM -0.5 MG, -1 MG, 8- MG VIVITROL INTRAMUSCULAR* SUSPENSION RECONSTITUTED 380 MG ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG, MG ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL MG, MG ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM TRANSDERMAL PATCH HR MG/HR, MG/HR ANDROGEL PUMP TRANSDERMAL GEL 0.5 MG/ACT (1.6%) ANDROGEL TRANSDERMAL GEL 0.5 MG/1.5GM (1.6%), 0.5 MG/.5GM (1.6%) ANDROGEL TRANSDERMAL GEL 5 MG/.5GM (1%), 50 MG/5GM (1%) PA; QL (10 EA per 30 days) PA; QL (10 EA per 30 days) PA; QL (60 EA per 30 days) PA; QL (30 EA per 30 days) PA; QL (150 GM per 30 days) PA; QL (150 GM per 30 days) PA; QL (300 GM per 30 days) AXIRON TRANSDERMAL SOLUTION 30 MG/ACT 3 PA; QL (0 ML per 30 days) depo-testosterone intramuscular* solution 100 mg/ml FORTESTA TRANSDERMAL GEL 10 MG/ACT (%) PA; QL (10 GM per 30 days) oxandrolone oral tablet 10 mg PA oxandrolone oral tablet.5 mg PA STRIANT BUCCAL 30 MG PA; QL (60 EA per 30 days) TESTIM TRANSDERMAL GEL 50 MG/5GM (1%) PA; QL (300 GM per 30 days) testosterone cypionate intramuscular* solution 100 mg/ml, 00 mg/ml 6

72 testosterone enanthate intramuscular* solution 00 mg/ml testosterone transdermal gel 10 mg/act (%) PA; QL (10 GM per 30 days) testosterone transdermal gel 1.5 mg/act (1%), 5 mg/.5gm (1%), 50 mg/5gm (1%) PA; QL (300 GM per 30 days) VOGELXO PUMP TRANSDERMAL GEL 1.5 MG/ACT (1%) PA; QL (300 GM per 30 days) VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%) PA; QL (300 GM per 30 days) ANTIDIABETICS, INJECTABLE APIDRA INJECTION SOLUTION 100 UNIT/ML APIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML ASSURE ID INSULIN SAFETY SYR 9G X 1/" 1 ML 3 BYDUREON SUBCUTANEOUS* MG 3 QL ( EA per 8 days) BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.0ML QL (. ML per 30 days) BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.0ML QL (1. ML per 30 days) COMFORT ASSIST INSULIN SYRINGE 9G X 1/" 1 ML 3 CVS GAUZE STERILE PAD "X" 3 EXEL COMFORT POINT PEN NEEDLE 9G X 1MM 3 GLOBAL ALCOHOL PREP EASE PAD 70 % 3 HUMALOG KWIKPEN SUBCUTANEOUS* 100 UNIT/ML, 100 UNIT/ML (3ML SYRINGE), 00 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS* (50-50) 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/5 KWIKPEN SUBCUTANEOUS* (75-5) 100 UNIT/ML HUMALOG MIX 75/5 SUBCUTANEOUS* SUSPENSION (75-5) 100 UNIT/ML HUMALOG SUBCUTANEOUS* 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS* (70-30) 100 UNIT/ML 63

73 HUMULIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML HUMULIN N KWIKPEN SUBCUTANEOUS* 100 UNIT/ML HUMULIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS* 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML 3 LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3 LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML 3 LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3 NOVOLIN 70/30 RELION SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N RELION SUBCUTANEOUS* SUSPENSION 100 UNIT/ML NOVOLIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML 3 NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS* 100 UNIT/ML 3 NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS* (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS* 100 UNIT/ML 3 NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3 PREFERRED PLUS INSULIN SYRINGE 8G X 1/" 0.5 ML 3 RELI-ON INSULIN SYRINGE 9G 0.3 ML B/D 6

74 SYMLINPEN 10 SUBCUTANEOUS* 700 MCG/.7ML PA SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML PA TANZEUM SUBCUTANEOUS* 30 MG, 50 MG QL ( EA per 8 days) TOUJEO SOLOSTAR SUBCUTANEOUS* 300 UNIT/ML 3 TRESIBA FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML, 00 UNIT/ML TRULICITY SUBCUTANEOUS* 0.75 MG/0.5ML, 1.5 MG/0.5ML 3 QL ( ML per 8 days) VICTOZA SUBCUTANEOUS* 18 MG/3ML 3 QL (9 ML per 30 days) ANTIDIABETICS, ORAL acarbose oral tablet 100 mg, 5 mg, 50 mg ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE HR* MG ACTOPLUS MET XR ORAL TABLET EXTENDED RELEASE HR* MG QL (60 EA per 30 days) QL (30 EA per 30 days) FARXIGA ORAL TABLET 10 MG 3 QL (30 EA per 30 days) FARXIGA ORAL TABLET 5 MG 3 QL (60 EA per 30 days) glimepiride oral tablet 1 mg 1 QL (0 EA per 30 days) glimepiride oral tablet mg 1 QL (10 EA per 30 days) glimepiride oral tablet mg 1 QL (60 EA per 30 days) glipizide er oral tablet extended release hr* 10 mg 1 QL (60 EA per 30 days) glipizide er oral tablet extended release hr*.5 mg 1 QL (0 EA per 30 days) glipizide er oral tablet extended release hr* 5 mg 1 QL (10 EA per 30 days) glipizide oral tablet 10 mg 1 QL (10 EA per 30 days) glipizide oral tablet 5 mg 1 QL (0 EA per 30 days) glipizide xl oral tablet extended release hr*.5 mg 1 QL (0 EA per 30 days) glipizide xl oral tablet extended release hr* 5 mg 1 QL (10 EA per 30 days) glipizide-metformin hcl oral tablet.5-50 mg 1 QL (0 EA per 30 days) glipizide-metformin hcl oral tablet mg, mg GLUMETZA ORAL TABLET EXTENDED RELEASE HR* 1000 MG 1 QL (10 EA per 30 days) QL (60 EA per 30 days) 65

75 GLUMETZA ORAL TABLET EXTENDED RELEASE HR* 500 MG GLYSET ORAL TABLET 100 MG, 5 MG, 50 MG QL (10 EA per 30 days) GLYXAMBI ORAL TABLET 10-5 MG, 5-5 MG QL (30 EA per 30 days) INVOKAMET ORAL TABLET MG, MG, MG 3 QL (60 EA per 30 days) INVOKAMET ORAL TABLET MG 3 QL (10 EA per 30 days) INVOKANA ORAL TABLET 100 MG 3 QL (90 EA per 30 days) INVOKANA ORAL TABLET 300 MG 3 QL (30 EA per 30 days) JANUMET ORAL TABLET MG, MG 3 QL (60 EA per 30 days) JANUMET XR ORAL TABLET EXTENDED RELEASE HR* MG JANUMET XR ORAL TABLET EXTENDED RELEASE HR* MG, MG 3 QL (30 EA per 30 days) 3 QL (60 EA per 30 days) JANUVIA ORAL TABLET 100 MG, 5 MG, 50 MG 3 QL (30 EA per 30 days) JARDIANCE ORAL TABLET 10 MG QL (60 EA per 30 days) JARDIANCE ORAL TABLET 5 MG QL (30 EA per 30 days) JENTADUETO ORAL TABLET MG, MG, MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE HR* MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE HR* MG 3 QL (60 EA per 30 days) 3 QL (60 EA per 30 days) 3 QL (30 EA per 30 days) KAZANO ORAL TABLET MG, MG QL (60 EA per 30 days) KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE HR* MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE HR* MG, MG metformin hcl er (mod) oral tablet extended release hr* 1000 mg metformin hcl er (mod) oral tablet extended release hr* 500 mg metformin hcl er (osm) oral tablet extended release hr* 1000 mg QL (60 EA per 30 days) QL (30 EA per 30 days) 1 QL (60 EA per 30 days) 1 QL (10 EA per 30 days) 1 QL (75 EA per 30 days) 66

76 metformin hcl er (osm) oral tablet extended release hr* 500 mg metformin hcl er oral tablet extended release hr* 500 mg metformin hcl er oral tablet extended release hr* 750 mg 1 QL (150 EA per 30 days) 1 QL (10 EA per 30 days) 1 QL (60 EA per 30 days) metformin hcl oral tablet 1000 mg 1 QL (75 EA per 30 days) metformin hcl oral tablet 500 mg 1 QL (150 EA per 30 days) metformin hcl oral tablet 850 mg 1 QL (90 EA per 30 days) miglitol oral tablet 100 mg, 5 mg, 50 mg nateglinide oral tablet 10 mg, 60 mg 1 QL (90 EA per 30 days) NESINA ORAL TABLET 1.5 MG QL (60 EA per 30 days) NESINA ORAL TABLET 5 MG QL (30 EA per 30 days) NESINA ORAL TABLET 6.5 MG QL (10 EA per 30 days) ONGLYZA ORAL TABLET.5 MG, 5 MG QL (30 EA per 30 days) OSENI ORAL TABLET MG QL (60 EA per 30 days) OSENI ORAL TABLET MG, MG, 5-15 MG, 5-30 MG, 5-5 MG QL (30 EA per 30 days) pioglitazone hcl oral tablet 15 mg, 30 mg, 5 mg 1 QL (30 EA per 30 days) pioglitazone hcl-glimepiride oral tablet 30- mg, 30- mg pioglitazone hcl-metformin hcl oral tablet mg, mg 1 QL (30 EA per 30 days) 1 QL (90 EA per 30 days) PRANDIMET ORAL TABLET MG, -500 MG QL (150 EA per 30 days) repaglinide oral tablet 0.5 mg, 1 mg 1 QL (10 EA per 30 days) repaglinide oral tablet mg 1 QL (0 EA per 30 days) repaglinide-metformin hcl oral tablet mg, -500 mg 1 QL (150 EA per 30 days) RIOMET ORAL SOLUTION 500 MG/5ML QL (96 ML per 30 days) SYNJARDY ORAL TABLET MG, MG, MG QL (60 EA per 30 days) SYNJARDY ORAL TABLET MG QL (10 EA per 30 days) TRADJENTA ORAL TABLET 5 MG 3 QL (30 EA per 30 days) 67

77 XIGDUO XR ORAL TABLET EXTENDED RELEASE HR* MG, MG XIGDUO XR ORAL TABLET EXTENDED RELEASE HR* MG, MG ANTIDIABETICS, TESTING SUPPLIES 3 QL (30 EA per 30 days) 3 QL (60 EA per 30 days) ONETOUCH ULTRA KIT W/DEVICE Part B ONETOUCH ULTRA BLUE IN VITRO STRIP Part B ONETOUCH ULTRA MINI KIT W/DEVICE Part B ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE Part B ONETOUCH VERIO IN VITRO STRIP Part B ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE Part B ONETOUCH VERIO KIT W/DEVICE Part B ONETOUCH VERIO SYNC SYSTEM KIT W/DEVICE Part B BISPHOSPHONATES NDC ( ); QL (1 EA per 365 days) NDC ( , , ); QL (100 EA per 5 days) NDC ( , , , , , ); QL (1 EA per 365 days) NDC ( ); QL (1 EA per 365 days) NDC ( , , ); QL (100 EA per 5 days) NDC ( ); QL (1 EA per 365 days) NDC ( ); QL (1 EA per 365 days) NDC ( ); QL (1 EA per 365 days) alendronate sodium oral solution 70 mg/75ml QL (300 ML per 8 days) alendronate sodium oral tablet 10 mg, 35 mg, 0 mg, 5 mg, 70 mg 1 BINOSTO ORAL TABLET EFFERVESCENT 70 MG FOSAMAX PLUS D ORAL TABLET MG-UNIT, MG-UNIT ST ibandronate sodium intravenous* solution 3 mg/3ml B/D; QL (3 ML per 90 days) ibandronate sodium oral tablet 150 mg B/D 68

78 pamidronate disodium intravenous* solution 30 mg/10ml, 6 mg/ml, 90 mg/10ml risedronate sodium oral tablet 150 mg, 35 mg, 35 mg ( pack) risedronate sodium oral tablet 30 mg, 35 mg (1 pack), 5 mg B/D risedronate sodium oral tablet delayed release 35 mg zoledronic acid intravenous* concentrate mg/5ml B/D zoledronic acid intravenous* solution 5 mg/100ml B/D ZOMETA INTRAVENOUS* SOLUTION MG/100ML B/D CALCIUM RECEPTOR AGONISTS SENSIPAR ORAL TABLET 30 MG 3 SENSIPAR ORAL TABLET 60 MG, 90 MG CHELATING AGENTS CHEMET ORAL CAPSULE 100 MG DEPEN TITRATABS ORAL TABLET 50 MG EXJADE ORAL TABLET SOLUBLE 15 MG, 50 MG, 500 MG PA; LA FERRIPROX ORAL SOLUTION 100 MG/ML PA; LA FERRIPROX ORAL TABLET 500 MG PA; LA JADENU ORAL TABLET 180 MG, 360 MG, 90 MG PA kionex oral powder kionex oral suspension 15 gm/60ml sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 15 gm/60ml sps oral suspension 15 gm/60ml SYPRINE ORAL CAPSULE 50 MG VELTASSA ORAL PACKET 16.8 GM, 5. GM, 8. GM LA CONTRACEPTIVES altavera oral tablet mg-mcg amethia oral tablet &0.01 mg 69

79 amethyst oral tablet 90-0 mcg apri oral tablet mg-mcg aranelle oral tablet 0.5/1/ mg-mcg ashlyna oral tablet &0.01 mg aubra oral tablet mg-mcg aviane oral tablet mg-mcg balziva oral tablet mg-mcg bekyree oral tablet /0.01 mg (1/5) BEYAZ ORAL TABLET MG blisovi fe oral tablet 1-0 mg-mcg() blisovi fe 1.5/30 oral tablet mg-mcg blisovi fe 1/0 oral tablet 1-0 mg-mcg briellyn oral tablet mg-mcg camila oral tablet 0.35 mg camrese lo oral tablet & 0.01 mg caziant oral tablet 0.1/0.15/ mg cryselle-8 oral tablet mg-mcg cyclafem 1/35 oral tablet 1-35 mg-mcg cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg cyred oral tablet mg-mcg deblitane oral tablet 0.35 mg delyla oral tablet mg-mcg DEPO-SUBQ PROVERA 10 SUBCUTANEOUS* SUSPENSION 10 MG/0.65ML desogestrel-ethinyl estradiol oral tablet /0.01 mg (1/5) drospirenone-ethinyl estradiol oral tablet mg, mg ELLA ORAL TABLET 30 MG emoquette oral tablet mg-mcg enpresse-8 oral tablet errin oral tablet 0.35 mg 70

80 estarylla oral tablet mg-mcg falmina oral tablet mg-mcg gianvi oral tablet mg gildagia oral tablet mg-mcg gildess 1.5/30 oral tablet mg-mcg gildess fe oral tablet 1-0 mg-mcg() heather oral tablet 0.35 mg introvale oral tablet mg jolessa oral tablet mg jolivette oral tablet 0.35 mg juleber oral tablet mg-mcg junel 1.5/30 oral tablet mg-mcg junel 1/0 oral tablet 1-0 mg-mcg junel fe 1.5/30 oral tablet mg-mcg junel fe 1/0 oral tablet 1-0 mg-mcg junel fe oral tablet 1-0 mg-mcg() kaitlib fe oral tablet chewable mg-mcg kariva oral tablet /0.01 mg (1/5) kelnor 1/35 oral tablet 1-35 mg-mcg kimidess oral tablet /0.01 mg (1/5) larin 1.5/30 oral tablet mg-mcg larin 1/0 oral tablet 1-0 mg-mcg larin fe 1.5/30 oral tablet mg-mcg larin fe 1/0 oral tablet 1-0 mg-mcg larissia oral tablet mg-mcg layolis fe oral tablet chewable mg-mcg leena oral tablet 0.5/1/ mg-mcg lessina oral tablet mg-mcg levonest oral tablet levonorgest-eth estrad 91-day oral tablet &0.01 mg, mg 71

81 levonorgestrel oral tablet 0.75 mg, 1.5 mg levonorgestrel-ethinyl estrad oral tablet mg-mcg, 90-0 mcg levonorg-eth estrad triphasic oral tablet levora 0.15/30 (8) oral tablet mg-mcg LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10 MCG lomedia fe oral tablet 1-0 mg-mcg() loryna oral tablet mg low-ogestrel oral tablet mg-mcg lutera oral tablet mg-mcg lyza oral tablet 0.35 mg marlissa oral tablet mg-mcg medroxyprogesterone acetate intramuscular* 150 mg/ml medroxyprogesterone acetate intramuscular* suspension 150 mg/ml microgestin 1.5/30 oral tablet mg-mcg microgestin 1/0 oral tablet 1-0 mg-mcg microgestin fe 1.5/30 oral tablet mg-mcg microgestin fe 1/0 oral tablet 1-0 mg-mcg MINASTRIN FE ORAL TABLET CHEWABLE 1-0 MG-MCG() mono-linyah oral tablet mg-mcg mononessa oral tablet mg-mcg myzilra oral tablet necon 0.5/35 (8) oral tablet mg-mcg necon 1/35 (8) oral tablet 1-35 mg-mcg necon 1/50 (8) oral tablet 1-50 mg-mcg necon 10/11 (8) oral tablet 35 mcg 3 necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg nikki oral tablet mg nora-be oral tablet 0.35 mg 7

82 norethin ace-eth estrad-fe oral tablet 1-0 mg-mcg() norethindrone oral tablet 0.35 mg norethin-eth estradiol-fe oral tablet chewable mg-mcg norgestimate-eth estradiol oral tablet mg-mcg norgestim-eth estrad triphasic oral tablet 0.18/0.15/0.5 mg-5 mcg, 0.18/0.15/0.5 mg-35 mcg norlyroc oral tablet 0.35 mg nortrel 0.5/35 (8) oral tablet mg-mcg nortrel 1/35 (1) oral tablet 1-35 mg-mcg nortrel 1/35 (8) oral tablet 1-35 mg-mcg nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg NUVARING VAGINAL RING MG/HR ocella oral tablet mg ogestrel oral tablet mg-mcg orsythia oral tablet mg-mcg ORTHO TRI-CYCLEN LO ORAL TABLET 0.18/0.15/0.5 MG-5 MCG philith oral tablet mg-mcg pimtrea oral tablet /0.01 mg (1/5) pirmella 1/35 oral tablet 1-35 mg-mcg portia-8 oral tablet mg-mcg previfem oral tablet mg-mcg QUARTETTE ORAL TABLET DAYS quasense oral tablet mg reclipsen oral tablet mg-mcg setlakin oral tablet mg sharobel oral tablet 0.35 mg sprintec 8 oral tablet mg-mcg sronyx oral tablet mg-mcg syeda oral tablet mg 73

83 tarina fe 1/0 oral tablet 1-0 mg-mcg tri-legest fe oral tablet 1-0/1-30/1-35 mg-mcg tri-linyah oral tablet 0.18/0.15/0.5 mg-35 mcg tri-lo-estarylla oral tablet 0.18/0.15/0.5 mg-5 mcg tri-lo-marzia oral tablet 0.18/0.15/0.5 mg-5 mcg tri-lo-sprintec oral tablet 0.18/0.15/0.5 mg-5 mcg trinessa (8) oral tablet 0.18/0.15/0.5 mg-35 mcg trinessa lo oral tablet 0.18/0.15/0.5 mg-5 mcg tri-previfem oral tablet 0.18/0.15/0.5 mg-35 mcg tri-sprintec oral tablet 0.18/0.15/0.5 mg-35 mcg trivora (8) oral tablet velivet oral tablet 0.1/0.15/ mg vestura oral tablet mg vienva oral tablet mg-mcg viorele oral tablet /0.01 mg (1/5) vyfemla oral tablet mg-mcg wymzya fe oral tablet chewable mg-mcg xulane transdermal patch weekly mcg/hr zarah oral tablet mg zenchent fe oral tablet chewable mg-mcg zenchent oral tablet mg-mcg zovia 1/35e (8) oral tablet 1-35 mg-mcg zovia 1/50e (8) oral tablet 1-50 mg-mcg ENDOMETRIOSIS danazol oral capsule 100 mg, 00 mg, 50 mg LUPANETA PACK COMBINATION KIT 11.5 & 5 MG, 3.75 & 5 MG SYNAREL NASAL SOLUTION MG/ML ENZYME REPLACEMENTS PA ADAGEN INTRAMUSCULAR* SOLUTION 50 UNIT/ML PA; LA ALDURAZYME INTRAVENOUS* SOLUTION.9 MG/5ML PA; LA 7

84 BUPHENYL ORAL TABLET 500 MG PA; LA CARBAGLU ORAL TABLET 00 MG PA; LA CERDELGA ORAL CAPSULE 8 MG PA CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 00 UNIT, 00 UNIT CYSTADANE ORAL POWDER LA PA; LA CYSTAGON ORAL CAPSULE 150 MG, 50 MG PA; LA ELAPRASE INTRAVENOUS* SOLUTION 6 MG/3ML PA; LA ELELYSO INTRAVENOUS* SOLUTION RECONSTITUTED 00 UNIT FABRAZYME INTRAVENOUS* SOLUTION RECONSTITUTED 35 MG, 5 MG PA PA; LA KUVAN ORAL PACKET 100 MG, 500 MG PA; LA KUVAN ORAL TABLET SOLUBLE 100 MG PA; LA levocarnitine intravenous* solution 00 mg/ml B/D levocarnitine oral solution 1 gm/10ml B/D levocarnitine oral tablet 330 mg B/D LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG MYOZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG PA; LA PA; LA NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML PA; LA ORFADIN ORAL CAPSULE 10 MG, MG, 0 MG, 5 MG PA; LA ORFADIN ORAL SUSPENSION MG/ML PA; LA PROCYSBI ORAL CAPSULE DELAYED RELEASE 5 MG, 75 MG RAVICTI ORAL LIQUID 1.1 GM/ML PA sodium phenylbutyrate oral powder 3 gm/tsp VIMIZIM INTRAVENOUS* SOLUTION 5 MG/5ML PA VPRIV INTRAVENOUS* SOLUTION RECONSTITUTED 00 UNIT PA; LA ZAVESCA ORAL CAPSULE 100 MG PA; LA PA 75

85 ESTROGENS ALORA TRANSDERMAL PATCH BIWEEKLY 0.05 MG/HR, 0.05 MG/HR, MG/HR, 0.1 MG/HR DELESTROGEN INTRAMUSCULAR* OIL 10 MG/ML depo-estradiol intramuscular* oil 5 mg/ml estrace vaginal cream 0.1 mg/gm PA estradiol oral tablet 0.5 mg, 1 mg, mg PA estradiol transdermal patch biweekly 0.05 mg/hr, mg/hr, 0.05 mg/hr, mg/hr, 0.1 mg/hr estradiol transdermal patch weekly 0.05 mg/hr, mg/hr, 0.05 mg/hr, 0.06 mg/hr, mg/hr, 0.1 mg/hr estradiol valerate intramuscular* oil 0 mg/ml, 0 mg/ml ESTRING VAGINAL RING MG FEMRING VAGINAL RING 0.05 MG/HR, 0.1 MG/HR PA PA fyavolv oral tablet 1-5 mg-mcg PA jinteli oral tablet 1-5 mg-mcg PA MENOSTAR TRANSDERMAL PATCH WEEKLY 1 MCG/HR MINIVELLE TRANSDERMAL PATCH BIWEEKLY 0.05 MG/HR, MG/HR, 0.05 MG/HR, MG/HR, 0.1 MG/HR PA PA norethindrone-eth estradiol oral tablet 1-5 mg-mcg PA PREMARIN INJECTION SOLUTION RECONSTITUTED 5 MG PREMARIN VAGINAL CREAM 0.65 MG/GM VAGIFEM VAGINAL TABLET 10 MCG GLUCOCORTICOIDS a-hydrocort injection solution reconstituted 100 mg cortisone acetate oral tablet 5 mg DEPO-MEDROL INJECTION SUSPENSION 0 MG/ML 76

86 dexamethasone intensol oral concentrate 1 mg/ml dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral solution 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, mg, mg, 6 mg dexamethasone sod phosphate pf injection solution 10 mg/ml dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml, 10 mg/30ml, 0 mg/5ml, mg/ml dexpak 10 day oral 1.5 mg (35) dexpak 13 day oral 1.5 mg (51) dexpak 6 day oral 1.5 mg (1) fludrocortisone acetate oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 0 mg, 5 mg MEDROL ORAL TABLET MG methylprednisolone acetate injection suspension 0 mg/ml, 80 mg/ml methylprednisolone oral mg methylprednisolone oral tablet 16 mg, 3 mg, mg, 8 mg methylprednisolone sodium succ injection solution reconstituted 1 gm, 15 mg, 0 mg millipred dp oral 5 mg (1), 5 mg (8) millipred oral solution 10 mg/5ml millipred oral tablet 5 mg prednisolone oral solution 15 mg/5ml 1 prednisolone sodium phosphate oral solution 15 mg/5ml, 5 mg/5ml, 6.7 (5 base) mg/5ml prednisolone sodium phosphate oral tablet dispersible 10 mg, 15 mg, 30 mg prednisone intensol oral concentrate 5 mg/ml

87 prednisone oral 10 mg (1), 10 mg (8), 5 mg (1), 5 mg (8) prednisone oral solution 5 mg/5ml prednisone oral tablet 1 mg, 10 mg,.5 mg, 0 mg, 5 mg, 50 mg RAYOS ORAL TABLET DELAYED RELEASE 1 MG, MG, 5 MG SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG, 1000 MG, 50 MG, 500 MG SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED GM veripred 0 oral solution 0 mg/5ml GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG 3 KORLYM ORAL TABLET 300 MG PA; LA PROGLYCEM ORAL SUSPENSION 50 MG/ML HUMAN GROWTH HORMONES GENOTROPIN MINIQUICK SUBCUTANEOUS* SOLUTION RECONSTITUTED 0. MG GENOTROPIN MINIQUICK SUBCUTANEOUS* SOLUTION RECONSTITUTED 0. MG, 0.6 MG, 0.8 MG, 1 MG, 1. MG, 1. MG, 1.6 MG, 1.8 MG, MG GENOTROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED 1 MG, 5 MG HUMATROPE INJECTION SOLUTION RECONSTITUTED 1 MG, MG, 5 MG, 6 MG NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS* SOLUTION 10 MG/ML NUTROPIN AQ NUSPIN 0 SUBCUTANEOUS* SOLUTION 0 MG/ML 1 3 PA PA PA PA PA PA; LA PA; LA 78

88 NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS* SOLUTION 5 MG/ML NUTROPIN AQ PEN SUBCUTANEOUS* SOLUTION 10 MG/ML, 0 MG/ML OMNITROPE SUBCUTANEOUS* SOLUTION 10 MG/1.5ML, 5 MG/1.5ML OMNITROPE SUBCUTANEOUS* SOLUTION RECONSTITUTED 5.8 MG SAIZEN CLICK.EASY INJECTION SOLUTION RECONSTITUTED 8.8 MG SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG, 8.8 MG SEROSTIM SUBCUTANEOUS* SOLUTION RECONSTITUTED MG, 5 MG, 6 MG ZOMACTON SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 5 MG ZORBTIVE SUBCUTANEOUS* SOLUTION RECONSTITUTED 8.8 MG MISCELLANEOUS AFREZZA INHALATION POWDER (30) & 8 (60) UNIT, (60) & 8 (30) UNIT, (90) & 8 (90) UNIT, UNIT, 8 (60)& 1 (30) UNIT PA; LA PA; LA PA; LA PA; LA PA; LA PA; LA PA; LA PA PA cabergoline oral tablet 0.5 mg calcitonin (salmon) nasal solution 00 unit/act chorionic gonadotropin intramuscular* solution reconstituted unit PA EGRIFTA SUBCUTANEOUS* SOLUTION RECONSTITUTED 1 MG PA; LA FORTICAL NASAL SOLUTION 00 UNIT/ACT 3 HP ACTHAR INJECTION GEL 80 UNIT/ML PA; LA; QL (1.5 ML per 1 day) INCRELEX SUBCUTANEOUS* SOLUTION 0 MG/ML PA; LA methylergonovine maleate oral tablet 0. mg MIACALCIN INJECTION SOLUTION 00 UNIT/ML B/D novarel intramuscular* solution reconstituted unit PA 79

89 octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml PA octreotide acetate injection solution 1000 mcg/ml, 00 mcg/ml, 500 mcg/ml PA pregnyl intramuscular* solution reconstituted unit PA PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML QL (1 ML per 180 days) raloxifene hcl oral tablet 60 mg SAMSCA ORAL TABLET 15 MG, 30 MG PA SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT 10 MG, 0 MG, 30 MG SIGNIFOR LAR INTRAMUSCULAR* SUSPENSION RECONSTITUTED 0 MG, 0 MG, 60 MG SIGNIFOR SUBCUTANEOUS* SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION 10 MG/0.5ML, 60 MG/0.ML, 90 MG/0.3ML SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 15 MG, 0 MG, 5 MG, 30 MG PA PA; LA PA; LA PA PA; LA XGEVA SUBCUTANEOUS* SOLUTION 10 MG/1.7ML PA PARATHYROID HORMONES FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/.ML PA NATPARA SUBCUTANEOUS* 100 MCG, 5 MCG, 50 MCG, 75 MCG PHOSPHATE BINDER AGENTS PA AURYXIA ORAL TABLET 1 GM 10 MG(FE) calcium acetate (phos binder) oral capsule 667 mg calcium acetate (phos binder) oral tablet 667 mg FOSRENOL ORAL PACKET 1000 MG, 750 MG FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG PHOSLYRA ORAL SOLUTION 667 MG/5ML RENAGEL ORAL TABLET 00 MG RENAGEL ORAL TABLET 800 MG 80

90 RENVELA ORAL PACKET 0.8 GM,. GM RENVELA ORAL TABLET 800 MG VELPHORO ORAL TABLET CHEWABLE 500 MG PROGESTINS CRINONE VAGINAL GEL %, 8 % medroxyprogesterone acetate oral tablet 10 mg,.5 mg, 5 mg 1 norethindrone acetate oral tablet 5 mg progesterone micronized oral capsule 100 mg, 00 mg THYROID AGENTS levothyroxine sodium oral tablet 100 mcg, 11 mcg, 15 mcg, 137 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg levoxyl oral tablet 100 mcg, 11 mcg, 15 mcg, 137 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 50 mcg, 75 mcg, 88 mcg 1 1 liothyronine sodium intravenous* solution 10 mcg/ml liothyronine sodium oral tablet 5 mcg, 5 mcg, 50 mcg methimazole oral tablet 10 mg, 5 mg 1 propylthiouracil oral tablet 50 mg SYNTHROID ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 137 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG TIROSINT ORAL CAPSULE 100 MCG, 11 MCG, 15 MCG, 13 MCG, 137 MCG, 150 MCG, 5 MCG, 50 MCG, 75 MCG, 88 MCG unithroid oral tablet 100 mcg, 11 mcg, 15 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg VASOPRESSINS 1 desmopressin ace rhinal tube nasal solution 0.01 % desmopressin ace spray refrig nasal solution 0.01 % desmopressin acetate injection solution mcg/ml desmopressin acetate oral tablet 0.1 mg, 0. mg 81

91 desmopressin acetate spray nasal solution 0.01 % STIMATE NASAL SOLUTION 1.5 MG/ML GASTROINTESTINAL ANTIEMETICS AKYNZEO ORAL CAPSULE MG B/D ALOXI INTRAVENOUS* SOLUTION 0.5 MG/5ML CESAMET ORAL CAPSULE 1 MG B/D; QL (60 EA per 30 days) compro suppository 5 mg dronabinol oral capsule 10 mg B/D; QL (60 EA per 30 days) dronabinol oral capsule.5 mg, 5 mg B/D; QL (60 EA per 30 days) EMEND ORAL CAPSULE 15 MG, 0 MG, 80 & 15 MG, 80 MG B/D EMEND ORAL SUSPENSION RECONSTITUTED 15 MG B/D granisetron hcl intravenous* solution 0.1 mg/ml, 1 mg/ml, mg/ml granisetron hcl oral tablet 1 mg B/D meclizine hcl oral tablet 1.5 mg, 5 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5ml 1 metoclopramide hcl oral tablet 10 mg, 5 mg 1 metoclopramide hcl oral tablet dispersible 10 mg, 5 mg ondansetron hcl injection solution mg/ml, mg/ml (ml syringe), 0 mg/0ml ondansetron hcl oral solution mg/5ml ondansetron hcl oral tablet mg, mg, 8 mg ondansetron oral tablet dispersible mg, 8 mg phenadoz suppository 1.5 mg, 5 mg PA phenergan suppository 1.5 mg, 5 mg, 50 mg PA prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 10 mg, 5 mg 1 prochlorperazine suppository 5 mg promethazine hcl injection solution 5 mg/ml, 50 mg/ml PA 8

92 promethazine hcl oral syrup 6.5 mg/5ml PA promethazine hcl oral tablet 1.5 mg, 5 mg, 50 mg PA promethazine hcl suppository 1.5 mg, 5 mg, 50 mg PA promethegan suppository 1.5 mg, 5 mg, 50 mg PA SANCUSO TRANSDERMAL PATCH 3.1 MG/HR QL ( EA per 30 days) SUSTOL SUBCUTANEOUS* 10 MG/0.ML TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 7 HR 1 MG/3DAYS PA; QL (10 EA per 30 days) VARUBI ORAL TABLET 90 MG B/D ZUPLENZ ORAL FILM MG, 8 MG ANTISPASMODICS atropine sulfate injection solution 0.05 mg/ml, 0.1 mg/ml BENTYL INTRAMUSCULAR* SOLUTION 10 MG/ML CANTIL ORAL TABLET 5 MG CUVPOSA ORAL SOLUTION 1 MG/5ML dicyclomine hcl intramuscular* solution 10 mg/ml dicyclomine hcl oral capsule 10 mg 1 dicyclomine hcl oral solution 10 mg/5ml dicyclomine hcl oral tablet 0 mg 1 glycopyrrolate injection solution 0. mg/ml, 0. mg/ml, 1 mg/5ml, mg/0ml glycopyrrolate oral tablet 1 mg, mg methscopolamine bromide oral tablet.5 mg, 5 mg H-RECEPTOR ANTAGONISTS cimetidine hcl oral solution 300 mg/5ml cimetidine oral tablet 00 mg, 300 mg, 00 mg, 800 mg famotidine intravenous* solution 0 mg/ml, 00 mg/0ml, 0 mg/ml famotidine oral suspension reconstituted 0 mg/5ml famotidine oral tablet 0 mg, 0 mg 1 83

93 famotidine premixed intravenous* solution mg/50ml-% nizatidine oral capsule 150 mg, 300 mg nizatidine oral solution 15 mg/ml ranitidine hcl injection solution 150 mg/6ml, 50 mg/ml ranitidine hcl oral capsule 150 mg, 300 mg ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg, 300 mg 1 INFLAMMATORY BOWEL DISEASE APRISO ORAL CAPSULE EXTENDED RELEASE HOUR GM ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG balsalazide disodium oral capsule 750 mg budesonide oral capsule delayed release particles 3 mg CANASA SUPPOSITORY 1000 MG colocort enema 100 mg/60ml DELZICOL ORAL CAPSULE DELAYED RELEASE 00 MG DIPENTUM ORAL CAPSULE 50 MG ENTYVIO INTRAVENOUS* SOLUTION RECONSTITUTED 300 MG GIAZO ORAL TABLET 1.1 GM hydrocortisone enema 100 mg/60ml LIALDA ORAL TABLET DELAYED RELEASE 1. GM mesalamine enema gm mesalamine oral tablet delayed release 800 mg mesalamine-cleanser kit gm PENTASA ORAL CAPSULE EXTENDED RELEASE* 50 MG, 500 MG SFROWASA ENEMA GM/60ML sulfasalazine oral tablet 500 mg sulfasalazine oral tablet delayed release 500 mg UCERIS FOAM MG/ACT 3 PA 8

94 UCERIS ORAL TABLET EXTENDED RELEASE HR* 9 MG LAXATIVES COLYTE WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 7.1 GM constulose oral solution 10 gm/15ml enulose oral solution 10 gm/15ml gavilyte-c oral solution reconstituted 0 gm 1 gavilyte-g oral solution reconstituted 36 gm 1 gavilyte-h oral kit 5-10 mg-gm gavilyte-n with flavor pack oral solution reconstituted 0 gm generlac oral solution 10 gm/15ml GOLYTELY ORAL SOLUTION RECONSTITUTED 7.1 GM, 36 GM 3 kristalose oral packet 10 gm, 0 gm 3 lactulose encephalopathy oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 0 GM 3 OSMOPREP ORAL TABLET GM peg 3350/electrolytes oral solution reconstituted 0 gm peg 3350-kcl-na bicarb-nacl oral solution reconstituted 0 gm peg-3350/electrolytes oral solution reconstituted 36 gm 1 1 polyethylene glycol 3350 oral packet polyethylene glycol 3350 oral powder PREPOPIK ORAL PACKET MG-GM-GM RELISTOR SUBCUTANEOUS* SOLUTION 1 MG/0.6ML, 1 MG/0.6ML (0.6ML SYRINGE), 8 MG/0.ML PA 85

95 SUCLEAR ORAL KIT SUPREP BOWEL PREP ORAL SOLUTION trilyte oral solution reconstituted 0 gm MISCELLANEOUS alosetron hcl oral tablet 0.5 mg, 1 mg PA AMITIZA ORAL CAPSULE MCG, 8 MCG 3 amoxicill-clarithro-lansopraz oral CARAFATE ORAL SUSPENSION 1 GM/10ML cromolyn sodium oral concentrate 100 mg/5ml diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg GATTEX SUBCUTANEOUS* KIT 5 MG PA; LA LINZESS ORAL CAPSULE 15 MCG, 90 MCG 3 loperamide hcl oral capsule mg 1 misoprostol oral tablet 100 mcg, 00 mcg MOVANTIK ORAL TABLET 1.5 MG, 5 MG 3 OMECLAMOX-PAK ORAL MG PYLERA ORAL CAPSULE MG SUCRAID ORAL SOLUTION 8500 UNIT/ML LA sucralfate oral tablet 1 gm ursodiol oral capsule 300 mg ursodiol oral tablet 50 mg, 500 mg VIBERZI ORAL TABLET 100 MG, 75 MG PA XIFAXAN ORAL TABLET 550 MG PA PANCREATIC ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 1000 UNIT, 000 UNIT, UNIT, UNIT, 6000 UNIT PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, 1000 UNIT, 00 UNIT 3 86

96 PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, 8000 UNIT ULTRESA ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, 0700 UNIT, 3000 UNIT VIOKACE ORAL TABLET 100 UNIT VIOKACE ORAL TABLET 0880 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, 0000 UNIT, 5000 UNIT, UNIT, 0000 UNIT, 5000 UNIT PROTON PUMP INHIBITORS ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 10 MG QL (60 EA per 30 days) ACIPHEX SPRINKLE ORAL CAPSULE SPRINKLE 5 MG DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG esomeprazole sodium intravenous* solution reconstituted 0 mg, 0 mg 3 QL (30 EA per 30 days) lansoprazole oral capsule delayed release 15 mg, 30 mg QL (30 EA per 30 days) nexium oral capsule delayed release 0 mg, 0 mg NEXIUM ORAL PACKET 10 MG, 0 MG, 0 MG 3 QL (30 EA per 30 days) NEXIUM ORAL PACKET.5 MG, 5 MG 3 omeprazole oral capsule delayed release 10 mg, 0 mg, 0 mg omeprazole-sodium bicarbonate oral capsule mg, mg OMEPRAZOLE-SODIUM BICARBONATE ORAL PACKET MG, MG pantoprazole sodium intravenous* solution reconstituted 0 mg pantoprazole sodium oral tablet delayed release 0 mg, 0 mg PREVACID SOLUTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG 1 QL (30 EA per 30 days) QL (30 EA per 30 days) 1 QL (30 EA per 30 days) PRILOSEC ORAL PACKET 10 MG,.5 MG 3 PROTONIX ORAL PACKET 0 MG QL (30 EA per 30 days) 87

97 rabeprazole sodium oral tablet delayed release 0 mg QL (30 EA per 30 days) ZEGERID ORAL PACKET MG, MG QL (30 EA per 30 days) GENITOURINARY AGENTS ERECTILE DYSFUNCTION VIAGRA ORAL TABLET 100 MG, 5 MG, 50 MG 3 ED; QL ( EA per 30 days) GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl er oral tablet extended release hr* 10 mg CARDURA XL ORAL TABLET EXTENDED RELEASE HR* MG, 8 MG dutasteride oral capsule 0.5 mg dutasteride-tamsulosin hcl oral capsule mg finasteride oral tablet 5 mg 1 RAPAFLO ORAL CAPSULE MG, 8 MG ST tamsulosin hcl oral capsule 0. mg MISCELLANEOUS bethanechol chloride oral tablet 10 mg, 5 mg, 5 mg, 50 mg ELMIRON ORAL CAPSULE 100 MG potassium citrate er oral tablet extendedrelease* 10 meq (1080 mg), 5 meq (50 mg) potassium citrate er oral tablet extendedrelease* 15 meq (160 mg) URINARY ANTISPASMODICS darifenacin hydrobromide er oral tablet extended release hr* 15 mg, 7.5 mg ENABLEX ORAL TABLET EXTENDED RELEASE HR* 15 MG, 7.5 MG GELNIQUE TRANSDERMAL GEL 10 %, 3 (8) % (MG/ACT) MYRBETRIQ ORAL TABLET EXTENDED RELEASE HR* 5 MG, 50 MG ST ST 88

98 oxybutynin chloride er oral tablet extended release hr* 10 mg, 15 mg, 5 mg oxybutynin chloride oral syrup 5 mg/5ml 1 oxybutynin chloride oral tablet 5 mg OXYTROL TRANSDERMAL PATCH BIWEEKLY 3.9 MG/HR tolterodine tartrate er oral capsule extended release hour mg, mg tolterodine tartrate oral tablet 1 mg, mg TOVIAZ ORAL TABLET EXTENDED RELEASE HR* MG, 8 MG trospium chloride er oral capsule extended release hour 60 mg trospium chloride oral tablet 0 mg VESICARE ORAL TABLET 10 MG, 5 MG VAGINAL ANTI-INFECTIVES AVC VAGINAL VAGINAL CREAM 15 % CLEOCIN VAGINAL SUPPOSITORY 100 MG clindamycin phosphate vaginal cream % CLINDESSE VAGINAL CREAM % metronidazole vaginal gel 0.75 % miconazole 3 vaginal suppository 00 mg NUVESSA VAGINAL GEL 1.3 % terconazole vaginal cream 0. %, 0.8 % terconazole vaginal suppository 80 mg vandazole vaginal gel 0.75 % zazole vaginal cream 0.8 % HEMATOLOGIC ANTICOAGULANTS COUMADIN ORAL TABLET 1 MG, 10 MG, MG,.5 MG, 3 MG, MG, 5 MG, 6 MG, 7.5 MG ELIQUIS ORAL TABLET.5 MG, 5 MG 3 3 enoxaparin sodium injection solution 300 mg/3ml 89

99 enoxaparin sodium subcutaneous* solution 100 mg/ml, 10 mg/0.8ml, 150 mg/ml enoxaparin sodium subcutaneous* solution 30 mg/0.3ml, 0 mg/0.ml, 60 mg/0.6ml, 80 mg/0.8ml fondaparinux sodium subcutaneous* solution 10 mg/0.8ml, 5 mg/0.ml, 7.5 mg/0.6ml fondaparinux sodium subcutaneous* solution.5 mg/0.5ml FRAGMIN SUBCUTANEOUS* SOLUTION UNIT/ML, 1500 UNIT/0.5ML, UNIT/0.6ML, UNT/0.7ML, 7500 UNIT/0.3ML, UNIT/3.8ML FRAGMIN SUBCUTANEOUS* SOLUTION 500 UNIT/0.ML, 5000 UNIT/0.ML HEPARIN (PORCINE) IN D5W INTRAVENOUS* SOLUTION 0-5 UNIT/ML-%, 50-5 UNIT/ML-% HEPARIN (PORCINE) IN NACL INJECTION SOLUTION UNIT/ML-%, UNIT/ML-% HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS* SOLUTION 100 UNIT/ML heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, 0000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml jantoven oral tablet 1 mg, 10 mg, mg,.5 mg, 3 mg, mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG 3 SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG warfarin sodium oral tablet 1 mg, 10 mg, mg,.5 mg, 3 mg, mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 0 MG 3 XARELTO STARTER PACK ORAL 15 & 0 MG 3 HEMATOPOIETIC GROWTH FACTORS ARANESP (ALBUMIN FREE) INJECTION 100 MCG/0.5ML, 150 MCG/0.3ML, 00 MCG/0.ML, 300 MCG/0.6ML, 500 MCG/ML B/D B/D PA

100 ARANESP (ALBUMIN FREE) INJECTION 5 MCG/0.ML, 0 MCG/0.ML, 60 MCG/0.3ML ARANESP (ALBUMIN FREE) INJECTION SOLUTION 10 MCG/0.ML, 5 MCG/ML, 0 MCG/ML, 60 MCG/ML 3 PA 3 PA ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75ML, 00 MCG/ML, 300 MCG/ML PA EPOGEN INJECTION SOLUTION UNIT/ML, 000 UNIT/ML, 3000 UNIT/ML, 000 UNIT/ML PA EPOGEN INJECTION SOLUTION 0000 UNIT/ML PA GRANIX SUBCUTANEOUS* 300 MCG/0.5ML, 80 MCG/0.8ML LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED 50 MCG PA PA MIRCERA INJECTION 100 MCG/0.3ML, 00 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML PA MOZOBIL SUBCUTANEOUS* SOLUTION MG/1.ML PA NEULASTA ONPRO SUBCUTANEOUS* 6 MG/0.6ML PA NEULASTA SUBCUTANEOUS* 6 MG/0.6ML PA NEUMEGA SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG NEUPOGEN INJECTION 300 MCG/0.5ML, 80 MCG/0.8ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 80 MCG/1.6ML PA PA PROCRIT INJECTION SOLUTION UNIT/ML, 000 UNIT/ML, 3000 UNIT/ML, 000 UNIT/ML 3 PA PROCRIT INJECTION SOLUTION 0000 UNIT/ML, 0000 UNIT/ML MISCELLANEOUS PA anagrelide hcl oral capsule 0.5 mg, 1 mg cilostazol oral tablet 100 mg, 50 mg CINRYZE INTRAVENOUS* SOLUTION RECONSTITUTED 500 UNIT PA; LA FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML PA 91

101 pentoxifylline er oral tablet extendedrelease* 00 mg PROMACTA ORAL TABLET 1.5 MG PA; LA; QL (360 EA per 30 days) PROMACTA ORAL TABLET 5 MG PA; LA; QL (180 EA per 30 days) PROMACTA ORAL TABLET 50 MG PA; LA; QL (90 EA per 30 days) PROMACTA ORAL TABLET 75 MG PA; LA; QL (60 EA per 30 days) RUCONEST INTRAVENOUS* SOLUTION RECONSTITUTED 100 UNIT tranexamic acid intravenous* solution 1000 mg/10ml tranexamic acid oral tablet 650 mg PLATELET AGGREGATION INHIBITORS aggrenox oral capsule extended release 1 hour 5-00 mg BRILINTA ORAL TABLET 60 MG, 90 MG 3 clopidogrel bisulfate oral tablet 300 mg clopidogrel bisulfate oral tablet 75 mg 1 DURLAZA ORAL CAPSULE EXTENDED RELEASE HOUR 16.5 MG EFFIENT ORAL TABLET 10 MG, 5 MG ZONTIVITY ORAL TABLET.08 MG IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA INTRAVENOUS* SOLUTION 00 MG/10ML, 00 MG/0ML, 80 MG/ML ACTEMRA SUBCUTANEOUS* 16 MG/0.9ML PA CIMZIA PREFILLED SUBCUTANEOUS* KIT X 00 MG/ML CIMZIA STARTER KIT SUBCUTANEOUS* KIT 6 X 00 MG/ML CIMZIA SUBCUTANEOUS* KIT X 00 MG PA ENBREL SUBCUTANEOUS* 5 MG/0.5ML, 50 MG/ML PA ENBREL SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG 9 PA PA PA PA PA

102 ENBREL SURECLICK SUBCUTANEOUS* 50 MG/ML PA HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 0 MG/0.8ML, 0 MG/0.8ML (6 PACK) HUMIRA PEN SUBCUTANEOUS* 0 MG/0.8ML PA HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 0 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* 0 MG/0.8ML HUMIRA SUBCUTANEOUS* 10 MG/0.ML, 0 MG/0.ML, 0 MG/0.8ML hydroxychloroquine sulfate oral tablet 00 mg KINERET SUBCUTANEOUS* 100 MG/0.67ML PA leflunomide oral tablet 10 mg, 0 mg methotrexate oral tablet.5 mg ORENCIA CLICKJECT SUBCUTANEOUS* 15 MG/ML PA ORENCIA INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG ORENCIA SUBCUTANEOUS* 15 MG/ML PA OTEZLA ORAL 10 & 0 & 30 MG PA OTEZLA ORAL TABLET 30 MG PA REMICADE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG RHEUMATREX ORAL TABLET.5 MG,.5 MG (DOSE PACK 1),.5 MG (DOSE PACK 16),.5 MG (DOSE PACK 0),.5 MG (DOSE PACK 8) SIMPONI ARIA INTRAVENOUS* SOLUTION 50 MG/ML PA SIMPONI SUBCUTANEOUS* 100 MG/ML, 50 MG/0.5ML PA trexall oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg B/D XELJANZ ORAL TABLET 5 MG PA XELJANZ XR ORAL TABLET EXTENDED RELEASE HR* 11 MG PA PA PA PA PA PA PA 93

103 IMMUNOGLOBULINS BIVIGAM INTRAVENOUS* SOLUTION 10 GM/100ML, 5 GM/50ML CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM, 6 GM FLEBOGAMMA DIF INTRAVENOUS* SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/00ML,.5 GM/50ML, 0 GM/00ML, 0 GM/00ML, 5 GM/100ML, 5 GM/50ML FLEBOGAMMA INTRAVENOUS* SOLUTION 0.5 GM/10ML, 10 GM/00ML,.5 GM/50ML, 5 GM/100ML PA PA PA PA GAMASTAN S/D INTRAMUSCULAR* INJECTABLE 3 B/D GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML,.5 GM/5ML, 0 GM/00ML, 30 GM/300ML, 5 GM/50ML GAMMAGARD S/D INTRAVENOUS* SOLUTION RECONSTITUTED.5 GM GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION RECONSTITUTED 10 GM, 5 GM GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML,.5 GM/5ML, 0 GM/00ML, 5 GM/50ML GAMMAPLEX INTRAVENOUS* SOLUTION 10 GM/00ML,.5 GM/50ML, 5 GM/100ML GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML,.5 GM/5ML, 0 GM/00ML, 0 GM/00ML, 5 GM/50ML OCTAGAM INTRAVENOUS* SOLUTION 1 GM/0ML, 10 GM/00ML, GM/0ML,.5 GM/50ML, 5 GM/500ML, 5 GM/100ML PRIVIGEN INTRAVENOUS* SOLUTION 10 GM/100ML, 0 GM/00ML, 0 GM/00ML, 5 GM/50ML IMMUNOMODULATORS ACTIMMUNE SUBCUTANEOUS* SOLUTION UNIT/0.5ML PA PA PA PA PA PA PA PA PA; LA 9

104 ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED 0 MG PA GRASTEK SUBLINGUAL TABLET SUBLINGUAL 800 BAU PA INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT B/D B/D RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 1 AMB A 1-U PA REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 00 MG, 50 MG IMMUNOSUPPRESSANTS PA; LA PA ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE HOUR 0.5 MG, 1 MG B/D ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE HOUR 5 MG B/D ATGAM INTRAVENOUS* INJECTABLE 50 MG/ML B/D azasan oral tablet 100 mg, 75 mg B/D azathioprine oral tablet 50 mg B/D azathioprine sodium injection solution reconstituted 100 mg B/D BENLYSTA INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG, 00 MG PA CELLCEPT INTRAVENOUS INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG B/D cyclosporine intravenous* solution 50 mg/ml B/D cyclosporine modified oral capsule 100 mg, 5 mg, 50 mg B/D cyclosporine modified oral solution 100 mg/ml B/D cyclosporine oral capsule 100 mg, 5 mg B/D ENVARSUS XR ORAL TABLET EXTENDED RELEASE HR* 0.75 MG, 1 MG, MG B/D 95

105 gengraf oral capsule 100 mg, 5 mg, 50 mg B/D gengraf oral solution 100 mg/ml B/D mycophenolate mofetil oral capsule 50 mg B/D mycophenolate mofetil oral suspension reconstituted 00 mg/ml B/D mycophenolate mofetil oral tablet 500 mg B/D mycophenolate sodium oral tablet delayed release 180 mg mycophenolate sodium oral tablet delayed release 360 mg B/D B/D NEORAL ORAL CAPSULE 100 MG, 5 MG 3 B/D NEORAL ORAL SOLUTION 100 MG/ML 3 B/D NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG B/D PROGRAF INTRAVENOUS* SOLUTION 5 MG/ML B/D PROGRAF ORAL CAPSULE 0.5 MG, 1 MG B/D PROGRAF ORAL CAPSULE 5 MG B/D RAPAMUNE ORAL SOLUTION 1 MG/ML B/D SANDIMMUNE ORAL SOLUTION 100 MG/ML 3 B/D SIMULECT INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG SIMULECT INTRAVENOUS* SOLUTION RECONSTITUTED 0 MG B/D B/D sirolimus oral tablet 0.5 mg, 1 mg B/D SIROLIMUS ORAL TABLET MG B/D tacrolimus oral capsule 0.5 mg, 1 mg B/D tacrolimus oral capsule 5 mg B/D THYMOGLOBULIN INTRAVENOUS* SOLUTION RECONSTITUTED 5 MG B/D ZORTRESS ORAL TABLET 0.5 MG B/D ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG B/D VACCINES ACTHIB INTRAMUSCULAR* SOLUTION RECONSTITUTED 3 NM 96

106 ADACEL INTRAMUSCULAR* SUSPENSION LF-MCG/0.5 3 NM BCG VACCINE INJECTION INJECTABLE 3 NM BEXSERO INTRAMUSCULAR* 3 NM BOOSTRIX INTRAMUSCULAR* SUSPENSION , (0.5ML SYRINGE) 3 NM CERVARIX INTRAMUSCULAR* SUSPENSION 3 NM COMVAX INTRAMUSCULAR* SUSPENSION MCG/0.5ML 3 NM DAPTACEL INTRAMUSCULAR* SUSPENSION NM DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR* SUSPENSION 5-5 LFU/0.5ML ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 10 MCG/0.5ML (0.5ML SYRINGE), 0 MCG/ML 3 B/D; NM 3 B/D; NM GARDASIL 9 INTRAMUSCULAR* 3 NM GARDASIL 9 INTRAMUSCULAR* SUSPENSION 3 NM GARDASIL INTRAMUSCULAR* SUSPENSION, (0.5ML SYRINGE) HAVRIX INTRAMUSCULAR* SUSPENSION 10 EL U/ML, 70 EL U/0.5ML 3 NM 3 NM HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG 3 NM IMOVAX RABIES INTRAMUSCULAR* INJECTABLE.5 UNIT/ML 3 NM INFANRIX INTRAMUSCULAR* SUSPENSION NM IPOL INJECTION INJECTABLE 3 NM IXIARO INTRAMUSCULAR* SUSPENSION 3 NM KINRIX INTRAMUSCULAR* SUSPENSION 3 NM MENACTRA INTRAMUSCULAR* INJECTABLE 3 NM MENHIBRIX INTRAMUSCULAR* SOLUTION RECONSTITUTED MCG 3 NM MENOMUNE SUBCUTANEOUS* INJECTABLE 3 NM MENVEO INTRAMUSCULAR* SOLUTION RECONSTITUTED 3 NM M-M-R II SUBCUTANEOUS* INJECTABLE 3 NM 97

107 PEDIARIX INTRAMUSCULAR* SUSPENSION 3 NM PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5 MCG/0.5ML PENTACEL INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3 NM 3 NM PROQUAD SUBCUTANEOUS* INJECTABLE 3 NM QUADRACEL INTRAMUSCULAR* SUSPENSION 3 NM RABAVERT INTRAMUSCULAR* SUSPENSION RECONSTITUTED RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 10 MCG/ML (1ML SYRINGE), 0 MCG/ML, 5 MCG/0.5ML 3 NM 3 B/D; NM ROTARIX ORAL SUSPENSION RECONSTITUTED 3 NM ROTATEQ ORAL SOLUTION 3 NM SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/0.5ML NM TENIVAC INTRAMUSCULAR* INJECTABLE 5- LFU 3 B/D; NM TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR* SUSPENSION - LF/0.5ML 3 B/D; NM TRUMENBA INTRAMUSCULAR* 3 NM TWINRIX INTRAMUSCULAR* SUSPENSION NM TYPHIM VI INTRAMUSCULAR* SOLUTION 5 MCG/0.5ML, 5 MCG/0.5ML (0.5ML SYRINGE) VAQTA INTRAMUSCULAR* SUSPENSION 5 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS* INJECTABLE 1350 PFU/0.5ML 3 NM 3 NM 3 NM YF-VAX SUBCUTANEOUS* INJECTABLE 3 NM ZOSTAVAX SUBCUTANEOUS* SOLUTION RECONSTITUTED 1900 UNT/0.65ML NUTRITIONAL/SUPPLEMENTS ELECTROLYTES 3 NM ammonium chloride intravenous* solution 5 meq/ml klor-con 10 oral tablet extendedrelease* 10 meq 98

108 klor-con m10 oral tablet extendedrelease* 10 meq klor-con m15 oral tablet extendedrelease* 15 meq klor-con m0 oral tablet extendedrelease* 0 meq klor-con oral packet 0 meq klor-con oral tablet extendedrelease* 8 meq klor-con sprinkle oral capsule extended release* 10 meq, 8 meq MAGNESIUM SULFATE IN D5W INTRAVENOUS* SOLUTION 10-5 MG/ML-%, 0-5 MG/ML-% magnesium sulfate injection solution 50 % magnesium sulfate injection solution 50 % (10ml syringe) MAGNESIUM SULFATE INTRAVENOUS* SOLUTION 0 GM/500ML, GM/100ML, GM/50ML, 0 GM/1000ML magnesium sulfate solution gm/50ml intravenous* gm/50ml MAGNESIUM SULFATE SOLUTION GM/50ML INTRAVENOUS* GM/50ML potassium chloride crys er oral tablet extendedrelease* 10 meq, 0 meq potassium chloride er oral capsule extended release* 10 meq, 8 meq potassium chloride er oral tablet extendedrelease* 10 meq, 0 meq potassium chloride er oral tablet extendedrelease* 8 meq potassium chloride oral solution 0 meq/15ml (10%), 0 meq/15ml (0%) sodium chloride injection solution.5 meq/ml sodium fluoride oral tablet. (1 f) mg TPN ELECTROLYTES INTRAVENOUS* SOLUTION B/D IV NUTRITION AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 7 %, 8.5 % B/D 99

109 AMINOSYN II/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 % B/D AMINOSYN INTRAVENOUS* SOLUTION 10 %, 8.5 % B/D AMINOSYN M INTRAVENOUS* SOLUTION 3.5 % B/D AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 7 %, 8.5 % B/D AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 % B/D AMINOSYN-PF INTRAVENOUS* SOLUTION 10 %, 7 % B/D AMINOSYN-RF INTRAVENOUS* SOLUTION 5. % B/D CLINIMIX E/DEXTROSE (.75/10) INTRAVENOUS* SOLUTION.75 % CLINIMIX E/DEXTROSE (.75/5) INTRAVENOUS* SOLUTION.75 % CLINIMIX E/DEXTROSE (.5/10) INTRAVENOUS* SOLUTION.5 % CLINIMIX E/DEXTROSE (.5/5) INTRAVENOUS* SOLUTION.5 % CLINIMIX E/DEXTROSE (.5/5) INTRAVENOUS* SOLUTION.5 % CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5 % CLINIMIX E/DEXTROSE (5/0) INTRAVENOUS* SOLUTION 5 % CLINIMIX E/DEXTROSE (5/5) INTRAVENOUS* SOLUTION 5 % CLINIMIX/DEXTROSE (.75/5) INTRAVENOUS* SOLUTION.75 % CLINIMIX/DEXTROSE (.5/10) INTRAVENOUS* SOLUTION.5 % CLINIMIX/DEXTROSE (.5/0) INTRAVENOUS* SOLUTION.5 % CLINIMIX/DEXTROSE (.5/5) INTRAVENOUS* SOLUTION.5 % B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D 100

110 CLINIMIX/DEXTROSE (.5/5) INTRAVENOUS* SOLUTION.5 % CLINIMIX/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5 % CLINIMIX/DEXTROSE (5/0) INTRAVENOUS* SOLUTION 5 % CLINIMIX/DEXTROSE (5/5) INTRAVENOUS* SOLUTION 5 % B/D B/D B/D B/D clinisol sf intravenous* solution 15 % B/D FREAMINE HBC INTRAVENOUS* SOLUTION 6.9 % B/D FREAMINE III INTRAVENOUS* SOLUTION 10 % B/D HEPATAMINE INTRAVENOUS* SOLUTION 8 % B/D INTRALIPID INTRAVENOUS* EMULSION 0 %, 30 % B/D LIPOSYN III INTRAVENOUS* EMULSION 10 % B/D NEPHRAMINE INTRAVENOUS* SOLUTION 5. % B/D NUTRILIPID INTRAVENOUS* EMULSION 0 % B/D plenamine intravenous* solution 15 % B/D premasol intravenous* solution 10 % B/D premasol intravenous* solution 6 % B/D PROCALAMINE INTRAVENOUS* SOLUTION 3 % B/D PROSOL INTRAVENOUS* SOLUTION 0 % B/D SMOFLIPID INTRAVENOUS* EMULSION 0 % B/D TRAVASOL INTRAVENOUS* SOLUTION 10 % B/D TROPHAMINE INTRAVENOUS* SOLUTION 10 % B/D IV REPLACEMENT SOLUTIONS DEXTROSE 5%/ELECTROLYTE #8 INTRAVENOUS* SOLUTION dextrose in lactated ringers intravenous* solution 5 % dextrose intravenous* solution 10 %, 5 %, 50 %, 70 % DEXTROSE-NACL INTRAVENOUS* SOLUTION % 3 dextrose-nacl intravenous* solution %, %, 5-0. %, %, %, %, %, % 3 101

111 IONOSOL-B IN D5W INTRAVENOUS* SOLUTION IONOSOL-MB IN D5W INTRAVENOUS* SOLUTION ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION ISOLYTE-S INTRAVENOUS* SOLUTION KCL IN D5W LACTATED RINGERS INTRAVENOUS* SOLUTION 0 MEQ/L kcl in dextrose-nacl intravenous* solution meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-% KCL IN DEXTROSE-NACL INTRAVENOUS* SOLUTION MEQ/L-%-% KCL-LACTATED RINGERS-D5W INTRAVENOUS* SOLUTION 0 MEQ/L lactated ringers intravenous* solution normosol-m in d5w intravenous* solution NORMOSOL-R IN D5W INTRAVENOUS* SOLUTION NORMOSOL-R PH 7. INTRAVENOUS* SOLUTION PLASMA-LYTE 18 INTRAVENOUS* SOLUTION PLASMA-LYTE A INTRAVENOUS* SOLUTION PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION potassium chloride in dextrose intravenous* solution 0-5 meq/l-%, 0-5 meq/l-% potassium chloride in nacl intravenous* solution meq/l-% potassium chloride in nacl intravenous* solution meq/l-%, meq/l-% potassium chloride intravenous* solution 0. meq/ml, 10 meq/100ml, 10 meq/50ml, 0 meq/100ml, 0 meq/100ml potassium chloride intravenous* solution meq/ml ringers intravenous* solution 3 10

112 sodium chloride intravenous* solution 0.5 %, 0.9 %, 3 %, 5 % VITAMINS calcitriol intravenous* solution 1 mcg/ml B/D calcitriol oral capsule 0.5 mcg, 0.5 mcg B/D calcitriol oral solution 1 mcg/ml B/D doxercalciferol intravenous* solution mcg/ml B/D doxercalciferol oral capsule 0.5 mcg B/D doxercalciferol oral capsule 1 mcg,.5 mcg B/D HECTOROL INTRAVENOUS* SOLUTION MCG/ML B/D paricalcitol intravenous* solution mcg/ml, 5 mcg/ml B/D paricalcitol oral capsule 1 mcg, mcg, mcg B/D prenatal oral tablet 7-1 mg ZEMPLAR INTRAVENOUS* SOLUTION MCG/ML B/D OPHTHALMIC ANTIALLERGICS ALOCRIL OPHTHALMIC SOLUTION % ALOMIDE OPHTHALMIC SOLUTION 0.1 % azelastine hcl ophthalmic solution 0.05 % BEPREVE OPHTHALMIC SOLUTION 1.5 % 3 cromolyn sodium ophthalmic solution % 1 EMADINE OPHTHALMIC SOLUTION 0.05 % epinastine hcl ophthalmic solution 0.05 % LASTACAFT OPHTHALMIC SOLUTION 0.5 % olopatadine hcl ophthalmic solution 0.1 % PATADAY OPHTHALMIC SOLUTION 0. % 3 PATANOL OPHTHALMIC SOLUTION 0.1 % PAZEO OPHTHALMIC SOLUTION 0.7 % 3 ANTIGLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % 3 AZOPT OPHTHALMIC SUSPENSION 1 % 3 103

113 betaxolol hcl ophthalmic solution 0.5 % BETIMOL OPHTHALMIC SOLUTION 0.5 %, 0.5 % BETOPTIC-S OPHTHALMIC SUSPENSION 0.5 % 3 brimonidine tartrate ophthalmic solution 0.15 % brimonidine tartrate ophthalmic solution 0. % 1 carteolol hcl ophthalmic solution 1 % 1 COMBIGAN OPHTHALMIC SOLUTION % 3 COSOPT PF OPHTHALMIC SOLUTION MG/ML dorzolamide hcl ophthalmic solution % dorzolamide hcl-timolol mal ophthalmic solution mg/ml ISTALOL OPHTHALMIC SOLUTION 0.5 % 3 latanoprost ophthalmic solution % 1 levobunolol hcl ophthalmic solution 0.5 % LUMIGAN OPHTHALMIC SOLUTION 0.01 % 3 metipranolol ophthalmic solution 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.15 % pilocarpine hcl ophthalmic solution 1 %, %, % SIMBRINZA OPHTHALMIC SUSPENSION 1-0. % 3 timolol maleate ophthalmic gel forming solution 0.5 %, 0.5 % timolol maleate ophthalmic solution 0.5 %, 0.5 % 1 TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.5 %, 0.5 % TRAVATAN Z OPHTHALMIC SOLUTION 0.00 % 3 ZIOPTAN OPHTHALMIC SOLUTION % ST ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % BLEPHAMIDE OPHTHALMIC SUSPENSION % blephamide s.o.p. ophthalmic ointment % 10

114 neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-hc ophthalmic suspension PRED-G OPHTHALMIC SUSPENSION % PRED-G S.O.P. OPHTHALMIC OINTMENT % sulfacetamide-prednisolone ophthalmic solution % TOBRADEX OPHTHALMIC OINTMENT % 3 TOBRADEX ST OPHTHALMIC SUSPENSION % 3 tobramycin-dexamethasone ophthalmic suspension % ZYLET OPHTHALMIC SUSPENSION % 3 ANTI-INFECTIVES AZASITE OPHTHALMIC SOLUTION 1 % bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm BESIVANCE OPHTHALMIC SUSPENSION 0.6 % 3 CILOXAN OPHTHALMIC OINTMENT 0.3 % 3 ciprofloxacin hcl ophthalmic solution 0.3 % erythromycin ophthalmic ointment 5 mg/gm 1 gatifloxacin ophthalmic solution 0.5 % gentak ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic solution 0.3 % 1 ilotycin ophthalmic ointment 5 mg/gm 1 levofloxacin ophthalmic solution 0.5 % MOXEZA OPHTHALMIC SOLUTION 0.5 % 3 NATACYN OPHTHALMIC SUSPENSION 5 % 105

115 neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution 0.3 % polymyxin b-trimethoprim ophthalmic solution unit/ml-% sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % tobramycin ophthalmic solution 0.3 % 1 TOBREX OPHTHALMIC OINTMENT 0.3 % trifluridine ophthalmic solution 1 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % 3 ZIRGAN OPHTHALMIC GEL 0.15 % ANTI-INFLAMMATORIES ACUVAIL OPHTHALMIC SOLUTION 0.5 % ALREX OPHTHALMIC SUSPENSION 0. % 3 bromfenac sodium (once-daily) ophthalmic solution 0.09 % bromfenac sodium ophthalmic solution 0.09 % dexamethasone sodium phosphate ophthalmic solution 0.1 % diclofenac sodium ophthalmic solution 0.1 % DUREZOL OPHTHALMIC EMULSION 0.05 % 3 FLAREX OPHTHALMIC SUSPENSION 0.1 % fluorometholone ophthalmic suspension 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % 1 FML FORTE OPHTHALMIC SUSPENSION 0.5 % FML OPHTHALMIC OINTMENT 0.1 % ILEVRO OPHTHALMIC SUSPENSION 0.3 % 3 ketorolac tromethamine ophthalmic solution 0. %, 0.5 % 1 LOTEMAX OPHTHALMIC GEL 0.5 % 3 106

116 LOTEMAX OPHTHALMIC OINTMENT 0.5 % 3 LOTEMAX OPHTHALMIC SUSPENSION 0.5 % 3 MAXIDEX OPHTHALMIC SUSPENSION 0.1 % 3 PRED MILD OPHTHALMIC SUSPENSION 0.1 % prednisolone acetate ophthalmic suspension 1 % prednisolone sodium phosphate ophthalmic solution 1 % 3 VEXOL OPHTHALMIC SUSPENSION 1 % MISCELLANEOUS LACRISERT OPHTHALMIC INSERT 5 MG naphazoline hcl ophthalmic solution 0.1 % 1 PROLENSA OPHTHALMIC SOLUTION 0.07 % 3 proparacaine hcl ophthalmic solution 0.5 % 1 RESTASIS OPHTHALMIC EMULSION 0.05 % 3 RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION MCG/ACT ipratropium-albuterol inhalation solution (3) mg/3ml STIOLTO RESPIMAT INHALATION AEROSOL, SOLUTION.5-.5 MCG/ACT UTIBRON NEOHALER INHALATION CAPSULE MCG ANTICHOLINERGICS ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 6.5 MCG/INH 3 QL (60 EA per 30 days) QL (8 GM per 30 days) B/D QL ( GM per 30 days) QL (60 EA per 30 days) QL (5.8 GM per 30 days) 3 QL (30 EA per 30 days) ipratropium bromide inhalation solution 0.0 % B/D ipratropium bromide nasal solution 0.03 %, 0.06 % 107

117 SEEBRI NEOHALER INHALATION CAPSULE 15.6 MCG QL (60 EA per 30 days) SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG QL (30 EA per 30 days) SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 1.5 MCG/ACT,.5 MCG/ACT TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 00 MCG/ACT TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 00 MCG/ACT (30 ACTUATE) ANTIHISTAMINE COMBINATIONS CLARINEX-D 1 HOUR ORAL TABLET EXTENDED RELEASE 1 HR*.5-10 MG QL ( GM per 30 days) QL (1 EA per 30 days) QL ( EA per 30 days) DYMISTA NASAL SUSPENSION MCG/ACT QL (3 GM per 30 days) SEMPREX-D ORAL CAPSULE 8-60 MG ANTIHISTAMINES ASTEPRO NASAL SOLUTION 0.15 % 3 azelastine hcl nasal solution 0.1 %, 0.15 % cetirizine hcl oral syrup 1 mg/ml CLARINEX ORAL SYRUP 0.5 MG/ML desloratadine oral tablet 5 mg desloratadine oral tablet dispersible.5 mg, 5 mg diphenhydramine hcl injection solution 50 mg/ml hydroxyzine hcl intramuscular* solution 5 mg/ml, 50 mg/ml PA levocetirizine dihydrochloride oral solution.5 mg/5ml levocetirizine dihydrochloride oral tablet 5 mg olopatadine hcl nasal solution 0.6 % BETA AGONISTS albuterol sulfate er oral tablet extended release 1 hr* mg, 8 mg albuterol sulfate inhalation nebulization solution (.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.5 mg/3ml B/D albuterol sulfate oral syrup mg/5ml 1 108

118 albuterol sulfate oral tablet mg, mg ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG QL (30 EA per 30 days) BROVANA INHALATION NEBULIZATION SOLUTION 15 MCG/ML B/D FORADIL AEROLIZER INHALATION CAPSULE 1 MCG QL (60 EA per 30 days) levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.5 mg/0.5ml levalbuterol hcl inhalation nebulization solution 1.5 mg/3ml PERFOROMIST INHALATION NEBULIZATION SOLUTION 0 MCG/ML PROAIR HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT PROAIR RESPICLICK INHALATION AEROSOL POWDER, BREATH ACTIVATED 108 (90 BASE) MCG/ACT PROVENTIL HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION AEROSOL, SOLUTION.5 MCG/ACT terbutaline sulfate injection solution 1 mg/ml terbutaline sulfate oral tablet.5 mg, 5 mg VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT B/D B/D B/D QL (17 GM per 30 days) QL ( EA per 30 days) QL (13. GM per 30 days) 3 QL (60 EA per 30 days) QL ( GM per 30 days) 3 QL (36 GM per 30 days) XOPENEX HFA INHALATION AEROSOL 5 MCG/ACT 3 QL (30 GM per 30 days) LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium oral packet mg montelukast sodium oral tablet 10 mg montelukast sodium oral tablet chewable mg, 5 mg zafirlukast oral tablet 10 mg, 0 mg ZYFLO CR ORAL TABLET EXTENDED RELEASE 1 HR* 600 MG 109

119 MAST CELL STABILIZERS cromolyn sodium inhalation nebulization solution 0 mg/ml MISCELLANEOUS B/D acetylcysteine inhalation solution 10 %, 0 % B/D ARALAST NP INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG, 500 MG PA; LA CINQAIR INTRAVENOUS* SOLUTION 100 MG/10ML PA; LA DALIRESP ORAL TABLET 500 MCG epinephrine injection 0.15 mg/0.15ml, 0.3 mg/0.3ml EPIPEN -PAK INJECTION 0.3 MG/0.3ML 3 EPIPEN JR -PAK INJECTION 0.15 MG/0.3ML 3 ESBRIET ORAL CAPSULE 67 MG PA GLASSIA INTRAVENOUS* SOLUTION 1000 MG/50ML PA; LA KALYDECO ORAL PACKET 50 MG, 75 MG PA KALYDECO ORAL TABLET 150 MG PA NUCALA SUBCUTANEOUS* SOLUTION RECONSTITUTED 100 MG PA; LA OFEV ORAL CAPSULE 100 MG, 150 MG PA ORKAMBI ORAL TABLET MG PA PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1 MG, 1000 MG PA; LA PULMOZYME INHALATION SOLUTION 1 MG/ML B/D tyzine nasal solution 0.05 % XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG ZEMAIRA INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG NASAL STEROIDS PA; LA PA; LA BECONASE AQ NASAL SUSPENSION MCG/SPRAY QL (50 GM per 30 days) budesonide nasal suspension 3 mcg/act QL (17. GM per 30 days) flunisolide nasal solution 5 mcg/act (0.05%) QL (50 ML per 30 days) fluticasone propionate nasal suspension 50 mcg/act QL (16 GM per 30 days) 110

120 NASONEX NASAL SUSPENSION 50 MCG/ACT QL (3 GM per 30 days) OMNARIS NASAL SUSPENSION 50 MCG/ACT QL (1.5 GM per 30 days) QNASL CHILDRENS NASAL AEROSOL, SOLUTION 0 MCG/ACT QL (.9 GM per 30 days) QNASL NASAL AEROSOL, SOLUTION 80 MCG/ACT QL (8.7 GM per 30 days) triamcinolone acetonide nasal aerosol 55 mcg/act QL (16.5 GM per 30 days) VERAMYST NASAL SUSPENSION 7.5 MCG/SPRAY QL (10 GM per 30 days) ZETONNA NASAL AEROSOL, SOLUTION 37 MCG/ACT QL (6.1 GM per 30 days) STEROID INHALANTS AEROSPAN INHALATION AEROSOL, SOLUTION 80 MCG/ACT ALVESCO INHALATION AEROSOL, SOLUTION 160 MCG/ACT, 80 MCG/ACT ARNUITY ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/ACT, 00 MCG/ACT ASMANEX 10 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 0 MCG/INH ASMANEX 1 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 0 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH, 0 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 0 MCG/INH QL (17.8 GM per 30 days) QL (1. GM per 30 days) 3 QL (30 EA per 30 days) QL ( EA per 30 days) QL ( EA per 30 days) QL ( EA per 30 days) QL ( EA per 30 days) ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT QL (6 GM per 30 days) ASMANEX HFA INHALATION AEROSOL 00 MCG/ACT QL (13 GM per 30 days) budesonide inhalation suspension 0.5 mg/ml, 0.5 mg/ml, 1 mg/ml FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 0 MCG/ACT B/D 3 QL (10 EA per 30 days) 3 QL (0 EA per 30 days) 3 QL ( GM per 30 days) 111

121 FLOVENT HFA INHALATION AEROSOL MCG/ACT 3 QL (1. GM per 30 days) PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT 3 QL ( EA per 30 days) PULMICORT INHALATION SUSPENSION 1 MG/ML B/D QVAR INHALATION AEROSOL, SOLUTION 0 MCG/ACT QL (8.7 GM per 30 days) QVAR INHALATION AEROSOL, SOLUTION 80 MCG/ACT QL (17. GM per 30 days) STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, 30-1 MCG/ACT, 5-1 MCG/ACT BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/INH, 00-5 MCG/INH DULERA INHALATION AEROSOL MCG/ACT, 00-5 MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT XANTHINES 3 QL (60 EA per 30 days) 3 QL (1 GM per 30 days) 3 QL (60 EA per 30 days) QL (13 GM per 30 days) 3 QL (10. GM per 30 days) aminophylline intravenous* solution 5 mg/ml elixophyllin oral elixir 80 mg/15ml theo- oral capsule extended release hour 100 mg, 00 mg, 300 mg, 00 mg theophylline er oral tablet extended release 1 hr* 100 mg, 00 mg, 300 mg, 50 mg theophylline er oral tablet extended release hr* 00 mg, 600 mg theophylline oral solution 80 mg/15ml TOPICAL DERMATOLOGY, ACNE ABSORICA ORAL CAPSULE 10 MG, 0 MG, 5 MG, 30 MG, 35 MG, 0 MG ACANYA EXTERNAL GEL % 11

122 ACZONE EXTERNAL GEL 5 %, 7.5 % adapalene external cream 0.1 % adapalene external gel 0.1 %, 0.3 % amnesteem oral capsule 10 mg, 0 mg, 0 mg ATRALIN EXTERNAL GEL 0.05 % avita external cream 0.05 % avita external gel 0.05 % AZELEX EXTERNAL CREAM 0 % benzoyl peroxide-erythromycin external gel 5-3 % claravis oral capsule 10 mg, 0 mg, 30 mg, 0 mg clindacin-p external swab 1 % CLINDAGEL EXTERNAL GEL 1 % clindamax external gel 1 % clindamycin phos-benzoyl perox external gel 1-5 %, 1.-5 % clindamycin phosphate external foam 1 % clindamycin phosphate external gel 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % clindamycin-tretinoin external gel % DIFFERIN EXTERNAL LOTION 0.1 % EPIDUO EXTERNAL GEL % EPIDUO FORTE EXTERNAL GEL % ery external pad % erythromycin external gel % erythromycin external solution % FABIOR EXTERNAL FOAM 0.1 % myorisan oral capsule 10 mg, 0 mg, 30 mg, 0 mg neuac external gel 1.-5 % ONEXTON EXTERNAL GEL % 113

123 RETIN-A MICRO PUMP EXTERNAL GEL 0.08 % sulfacetamide sodium external suspension 10 % tretinoin external cream 0.05 %, 0.05 %, 0.1 % tretinoin external gel 0.01 %, 0.05 % tretinoin external gel 0.05 % tretinoin microsphere external gel 0.0 % tretinoin microsphere external gel 0.1 % tretin-x external cream %, % VELTIN EXTERNAL GEL % zenatane oral capsule 10 mg, 0 mg, 30 mg, 0 mg ZIANA EXTERNAL GEL % DERMATOLOGY, ANTIBIOTICS BACTROBAN NASAL NASAL OINTMENT % CENTANY EXTERNAL OINTMENT % CORTISPORIN EXTERNAL CREAM CORTISPORIN EXTERNAL OINTMENT 1 % gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % mupirocin calcium external cream % mupirocin external ointment % 1 silver sulfadiazine external cream 1 % ssd external cream 1 % SULFAMYLON EXTERNAL CREAM 85 MG/GM SULFAMYLON EXTERNAL PACKET 5 % DERMATOLOGY, ANTIFUNGALS ciclopirox external gel 0.77 % ciclopirox external shampoo 1 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % clotrimazole external cream 1 % clotrimazole external solution 1 % 11

124 econazole nitrate external cream 1 % ERTACZO EXTERNAL CREAM % EXELDERM EXTERNAL CREAM 1 % EXELDERM EXTERNAL SOLUTION 1 % ketoconazole external cream % ketoconazole external foam % ketodan external foam % LUZU EXTERNAL CREAM 1 % MENTAX EXTERNAL CREAM 1 % naftifine hcl external cream 1 % naftifine hcl external cream % NAFTIN EXTERNAL CREAM 1 %, % NAFTIN EXTERNAL GEL 1 %, % nyamyc external powder unit/gm nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystop external powder unit/gm oxiconazole nitrate external cream 1 % OXISTAT EXTERNAL CREAM 1 % OXISTAT EXTERNAL LOTION 1 % DERMATOLOGY, ANTIPRURITIC CORTIFOAM FOAM 10 % doxepin hcl external cream 5 % procto-med hc cream.5 % procto-pak cream 1 % proctosol hc cream.5 % proctozone-hc cream.5 % prudoxin external cream 5 % DERMATOLOGY, ANTIPSORIATICS 8-MOP ORAL CAPSULE 10 MG 115

125 acitretin oral capsule 10 mg, 17.5 mg, 5 mg PA calcipotriene external cream % calcipotriene external ointment % calcipotriene external solution % calcitrene external ointment % calcitriol external ointment 3 mcg/gm COSENTYX SENSOREADY PEN SUBCUTANEOUS* 150 MG/ML COSENTYX SUBCUTANEOUS* 150 MG/ML PA methoxsalen rapid oral capsule 10 mg SORILUX EXTERNAL FOAM % STELARA SUBCUTANEOUS* 5 MG/0.5ML, 90 MG/ML PA TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % PA TAZORAC EXTERNAL GEL 0.05 %, 0.1 % PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole external shampoo % 1 selenium sulfide external lotion.5 % 1 DERMATOLOGY, CORTICOSTEROIDS ala cort external cream 1 % 1 alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % amcinonide external cream 0.1 % amcinonide external lotion 0.1 % amcinonide external ointment 0.1 % apexicon e external cream 0.05 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % 116 PA

126 betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0.1 % betamethasone valerate external foam 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % calcipotriene-betameth diprop external ointment % CAPEX EXTERNAL SHAMPOO 0.01 % clobetasol propionate e external cream 0.05 % clobetasol propionate emulsion external foam 0.05 % clobetasol propionate external cream 0.05 % clobetasol propionate external foam 0.05 % clobetasol propionate external gel 0.05 % clobetasol propionate external liquid 0.05 % clobetasol propionate external lotion 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external shampoo 0.05 % clobetasol propionate external solution 0.05 % clocortolone pivalate external cream 0.1 % clodan external shampoo 0.05 % CORDRAN EXTERNAL TAPE MCG/SQCM cormax scalp application external solution 0.05 % DESONATE EXTERNAL GEL 0.05 % desonide external cream 0.05 % desonide external lotion 0.05 % desonide external ointment 0.05 % desoximetasone external cream 0.05 %, 0.5 % desoximetasone external gel 0.05 % desoximetasone external ointment 0.05 % desoximetasone external ointment 0.5 % diflorasone diacetate external cream 0.05 % 117

127 diflorasone diacetate external ointment 0.05 % ENSTILAR EXTERNAL FOAM % fluocinolone acetonide body external oil 0.01 % fluocinolone acetonide external cream 0.01 %, 0.05 % fluocinolone acetonide external ointment 0.05 % fluocinolone acetonide external solution 0.01 % fluocinolone acetonide scalp external oil 0.01 % fluocinonide external cream 0.05 % fluocinonide external cream 0.1 % fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % flurandrenolide external cream 0.05 % fluticasone propionate external cream 0.05 % fluticasone propionate external lotion 0.05 % fluticasone propionate external ointment % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % HALOG EXTERNAL CREAM 0.1 % HALOG EXTERNAL OINTMENT 0.1 % hydrocortisone butyr lipo base external cream 0.1 % hydrocortisone butyrate external cream 0.1 % hydrocortisone butyrate external ointment 0.1 % hydrocortisone butyrate external solution 0.1 % hydrocortisone external cream 1 %,.5 % 1 hydrocortisone external lotion.5 % hydrocortisone external ointment 1 %,.5 % 1 hydrocortisone valerate external cream 0. % hydrocortisone valerate external ointment 0. % LOCOID EXTERNAL LOTION 0.1 % 118

128 lokara external lotion 0.05 % mometasone furoate external cream 0.1 % mometasone furoate external ointment 0.1 % mometasone furoate external solution 0.1 % PANDEL EXTERNAL CREAM 0.1 % prednicarbate external cream 0.1 % prednicarbate external ointment 0.1 % SERNIVO EXTERNAL EMULSION 0.05 % TACLONEX EXTERNAL SUSPENSION % texacort external solution.5 % TOPICORT SPRAY EXTERNAL LIQUID 0.5 % triamcinolone acetonide external aerosol, solution 0.17 mg/gm triamcinolone acetonide external cream 0.05 %, 0.1 %, 0.5 % triamcinolone acetonide external lotion 0.05 %, 0.1 % triamcinolone acetonide external ointment 0.05 %, 0.1 %, 0.5 % trianex external ointment 0.05 % triderm external cream 0.1 % 1 ULTRAVATE EXTERNAL LOTION 0.05 % DERMATOLOGY, LOCAL ANESTHETICS lidocaine external ointment 5 % lidocaine external patch 5 % lidocaine hcl external gel %, % (10ml applicator), % (5ml applicator) lidocaine hcl external solution % 1 lidocaine-prilocaine external cream.5-.5 % B/D SYNERA EXTERNAL PATCH MG DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir external ointment 5 %

129 ammonium lactate external cream 1 % ammonium lactate external lotion 1 % CONDYLOX EXTERNAL GEL 0.5 % DENAVIR EXTERNAL CREAM 1 % diclofenac sodium transdermal gel 3 % PA diclofenac sodium transdermal solution 1.5 % doxycycline oral capsule delayed release 0 mg ELIDEL EXTERNAL CREAM 1 % PA FINACEA EXTERNAL FOAM 15 % FINACEA EXTERNAL GEL 15 % FLUOROURACIL EXTERNAL CREAM 0.5 % fluorouracil external cream 5 % fluorouracil external solution %, 5 % imiquimod external cream 5 % metronidazole external cream 0.75 % metronidazole external gel 0.75 %, 1 % metronidazole external lotion 0.75 % NORITATE EXTERNAL CREAM 1 % ORACEA ORAL CAPSULE DELAYED RELEASE 0 MG PANRETIN EXTERNAL GEL 0.1 % PENNSAID TRANSDERMAL SOLUTION % PICATO EXTERNAL GEL %, 0.05 % podofilox external solution 0.5 % RECTIV OINTMENT 0. % rosadan external cream 0.75 % SOOLANTRA EXTERNAL CREAM 1 % tacrolimus external ointment 0.03 %, 0.1 % PA TARGRETIN EXTERNAL GEL 1 % PA TOLAK EXTERNAL CREAM % VALCHLOR EXTERNAL GEL % PA; LA VOLTAREN TRANSDERMAL GEL 1 % 3 10

130 XERESE EXTERNAL CREAM 5-1 % ZOVIRAX EXTERNAL CREAM 5 % ZYCLARA EXTERNAL CREAM 3.75 % ZYCLARA PUMP EXTERNAL CREAM.5 % DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX EXTERNAL CREAM 10 % EURAX EXTERNAL LOTION 10 % malathion external lotion 0.5 % permethrin external cream 5 % SKLICE EXTERNAL LOTION 0.5 % DERMATOLOGY, WOUND CARE AGENTS acetic acid irrigation solution 0.5 % 1 neomycin-polymyxin b gu irrigation solution REGRANEX EXTERNAL GEL 0.01 % PA SANTYL EXTERNAL OINTMENT 50 UNIT/GM sodium chloride irrigation solution 0.9 % 1 sterile water for irrigation irrigation solution MOUTH/THROAT/DENTAL AGENTS cevimeline hcl oral capsule 30 mg chlorhexidine gluconate mouth/throat solution 0.1 % 1 clotrimazole mouth/throat troche 10 mg lidocaine viscous mouth/throat solution % 1 nystatin mouth/throat suspension unit/ml ORAVIG BUCCAL TABLET 50 MG paroex mouth/throat solution 0.1 % 1 periogard mouth/throat solution 0.1 % 1 pilocarpine hcl oral tablet 5 mg pilocarpine hcl oral tablet 7.5 mg triamcinolone acetonide mouth/throat paste 0.1 % OTIC acetasol hc otic solution -1 % 11

131 acetic acid otic solution % acetic acid-aluminum acetate otic solution % CIPRO HC OTIC SUSPENSION 0.-1 % CIPRODEX OTIC SUSPENSION % 3 COLY-MYCIN S OTIC SUSPENSION MG/ML CORTISPORIN-TC OTIC SUSPENSION MG/ML fluocinolone acetonide otic oil 0.01 % hydrocortisone-acetic acid otic solution 1- % neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension ofloxacin otic solution 0.3 % OTOVEL OTIC SOLUTION % 1

132 Index of s 8-MOP abacavir sulfate... 1 abacavir-lamivudine-zidovudine... 1 ABELCET... 8 ABILIFY DISCMELT... 5 ABILIFY MAINTENA... 5 ABRAXANE... 6 ABSORICA ABSTRAL... acamprosate calcium ACANYA acarbose acebutolol hcl acetaminophen-codeine... 6 acetaminophen-codeine #... 6 acetaminophen-codeine # acetaminophen-codeine #... 6 acetasol hc acetazolamide... 0 acetazolamide er... 0 acetazolamide sodium... 0 acetic acid... 11, 1 acetic acid-aluminum acetate... 1 acetylcysteine ACIPHEX SPRINKLE acitretin ACTEMRA... 9 ACTHIB ACTIMMUNE... 9 ACTOPLUS MET XR ACUVAIL acyclovir... 15, 119 acyclovir sodium ACZONE ADACEL ADAGEN... 7 adapalene ADCIRCA... adefovir dipivoxil ADEMPAS... adrucil... 5 ADVAIR DISKUS ADVAIR HFA AEROSPAN afeditab cr AFINITOR... 9 AFINITOR DISPERZ... 9 AFREZZA aggrenox... 9 a-hydrocort AKYNZEO... 8 ala cort ALBENZA... 9 albuterol sulfate , 109 albuterol sulfate er alclometasone dipropionate ALDACTAZIDE... 0 ALDURAZYME... 7 ALECENSA... 9 alendronate sodium alfuzosin hcl er ALIMTA... 5 ALINIA... 9 allopurinol... 1 almotriptan malate ALOCRIL ALOMIDE ALOPRIM... 1 ALORA alosetron hcl ALOXI... 8 ALPHAGAN P alprazolam... 3 alprazolam intensol... 3 ALREX altavera ALTOPREV ALVESCO amantadine hcl AMBISOME... 8 amcinonide amethia amethyst amifostine amikacin sulfate... 7 amiloride hcl... 0 amiloride-hydrochlorothiazide... 0 aminophylline AMINOSYN AMINOSYN II AMINOSYN II/ELECTROLYTES AMINOSYN M AMINOSYN/ELECTROLYTES AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl... 3 AMITIZA amitriptyline hcl... 8 amlodipine besy-benazepril hcl... 3 amlodipine besylate amlodipine besylate-valsartan amlodipine-atorvastatin amlodipine-valsartan-hctz ammonium chloride ammonium lactate amnesteem amoxapine... 8 amoxicill-clarithro-lansopraz amoxicillin... 1 amoxicillin-pot clavulanate... 1 amoxicillin-pot clavulanate er... 1 amphetamine-dextroamphet er amphetamine-dextroamphetami ne amphotericin b... 8 ampicillin... 1 ampicillin sodium... 1 ampicillin-sulbactam sodium... 1 AMPYRA anagrelide hcl anastrozole... 8 ANDRODERM... 6 ANDROGEL... 6 ANDROGEL PUMP... 6 ANORO ELLIPTA ANTARA apap-caff-dihydrocodeine... 6

133 apexicon e APIDRA APIDRA SOLOSTAR APLENZIN... 8 APOKYN apri APRISO... 8 APTENSIO XR APTIOM... APTIVUS... 1 ARALAST NP aranelle ARANESP (ALBUMIN FREE)... 90, 91 ARCALYST ARCAPTA NEOHALER aripiprazole... 5 ARISTADA... 5 ARNUITY ELLIPTA ARRANON... 5 ARZERRA... 6 ASACOL HD... 8 ashlyna ASMANEX 10 METERED DOSES ASMANEX 1 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ASMANEX HFA aspirin-caff-dihydrocodeine... 6 ASSURE ID INSULIN SAFETY SYR ASTAGRAF XL ASTEPRO atenolol atenolol-chlorthalidone ATGAM atorvastatin calcium atovaquone... 9 atovaquone-proguanil hcl... 1 ATRALIN ATRIPLA... 1 atropine sulfate ATROVENT HFA AUBAGIO aubra AUGMENTIN... 1 AURYXIA AVASTIN... 6 AVC VAGINAL AVELOX... 0 aviane avita AVONEX AVONEX PEN AVONEX PREFILLED AVYCAZ AXERT AXIRON... 6 azacitidine... 5 AZACTAM IN DEXTROSE... 9 azasan AZASITE azathioprine azathioprine sodium azelastine hcl , 108 AZELEX AZILECT azithromycin AZOPT AZOR aztreonam... 9 bacitracin bacitracin-polymyxin b bacitra-neomycin-polymyxin-hc baclofen BACTOCILL IN DEXTROSE... 1 BACTROBAN NASAL balsalazide disodium... 8 balziva BANZEL... BARACLUDE BCG VACCINE BECONASE AQ bekyree BELBUCA... 6 BELEODAQ... 7 benazepril hcl benazepril-hydrochlorothiazide... 3 BENDEKA... 3 BENICAR BENICAR HCT... 3 BENLYSTA BENTYL benzoyl peroxide-erythromycin benztropine mesylate BEPREVE BESIVANCE betamethasone dipropionate , 117 betamethasone dipropionate aug betamethasone valerate BETASERON betaxolol hcl... 37, 10 bethanechol chloride BETHKIS... 7 BETIMOL BETOPTIC-S bexarotene BEXSERO BEYAZ bicalutamide... 8 BICILLIN C-R... BICILLIN C-R 900/ BICILLIN L-A... BICNU... 3 BIDIL... 1 BILTRICIDE... 9 BINOSTO bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM... 9 bleomycin sulfate... 5 BLEPHAMIDE blephamide s.o.p blisovi fe blisovi fe 1.5/ blisovi fe 1/ BOOSTRIX BOSULIF... 9 BOTOX BREO ELLIPTA briellyn BRILINTA... 9 brimonidine tartrate BRINTELLIX... 8

134 BRISDELLE BRIVIACT... bromfenac sodium bromfenac sodium (once-daily) bromocriptine mesylate BROVANA budesonide... 8, 110, 111 bumetanide... 0 BUNAVAIL BUPHENYL buprenorphine hcl buprenorphine hcl-naloxone hcl buproban bupropion hcl... 9 bupropion hcl er (smoking det) bupropion hcl er (sr)... 9 bupropion hcl er (xl)... 9 buspirone hcl... 3 BUSULFEX... butorphanol tartrate... 6 BUTRANS... 6 BYDUREON BYETTA 10 MCG PEN BYETTA 5 MCG PEN BYSTOLIC cabergoline CABOMETYX... 9 cafergot calcipotriene calcipotriene-betameth diprop calcitonin (salmon) calcitrene calcitriol , 116 calcium acetate (phos binder) camila CAMPTOSAR... 3 camrese lo CANASA... 8 CANCIDAS... 8 candesartan cilexetil... 3 candesartan cilexetil-hctz... 3 CANTIL CAPASTAT SULFATE... 1 CAPEX capital/codeine... 6 CAPRELSA... 9 captopril captopril-hydrochlorothiazide... 3 CARAFATE CARBAGLU carbamazepine... carbamazepine er... carbidopa carbidopa-levodopa carbidopa-levodopa er carbidopa-levodopa-entacapone carboplatin CARDIZEM LA CARDURA XL CARIMUNE NF... 9 carteolol hcl cartia xt carvedilol CAYSTON... 9 caziant cefaclor cefaclor er cefadroxil cefazolin sodium CEFAZOLIN SODIUM-DEXTROSE cefdinir cefepime hcl CEFEPIME HCL CEFEPIME-DEXTROSE cefixime cefotaxime sodium cefotetan disodium cefoxitin sodium CEFOXITIN SODIUM-DEXTROSE cefpodoxime proxetil cefprozil ceftazidime CEFTAZIDIME AND DEXTROSE ceftibuten CEFTIN ceftriaxone sodium cefuroxime axetil cefuroxime sodium celecoxib... 1 CELLCEPT INTRAVENOUS CELONTIN... CENTANY cephalexin CERDELGA CEREZYME CERVARIX CESAMET... 8 cetirizine hcl cevimeline hcl CHANTIX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH PAK CHEMET chlorhexidine gluconate chloroquine phosphate... 1 chlorothiazide... 0 chlorpromazine hcl... 5 chlorthalidone... 0 cholestyramine cholestyramine light chorionic gonadotropin ciclopirox ciclopirox olamine cidofovir cilostazol CILOXAN cimetidine cimetidine hcl CIMZIA... 9 CIMZIA PREFILLED... 9 CIMZIA STARTER KIT... 9 CINQAIR CINRYZE CIPRO HC... 1 CIPRODEX... 1 ciprofloxacin... 0 ciprofloxacin hcl... 0, 105 ciprofloxacin in d5w... 0 ciprofloxacin-ciproflox hcl er... 0 cisplatin citalopram hydrobromide... 9 cladribine... 5

135 claforan CLAFORAN IN D5W claravis CLARINEX CLARINEX-D 1 HOUR clarithromycin clarithromycin er CLEOCIN clindacin-p CLINDAGEL clindamax clindamycin hcl... 9 clindamycin palmitate hcl... 9 clindamycin phos-benzoyl perox clindamycin phosphate... 9, 10, 89, 113 clindamycin phosphate in d5w... 9 clindamycin-tretinoin CLINDESSE CLINIMIX E/DEXTROSE (.75/10) CLINIMIX E/DEXTROSE (.75/5) CLINIMIX E/DEXTROSE (.5/10) CLINIMIX E/DEXTROSE (.5/5) CLINIMIX E/DEXTROSE (.5/5) CLINIMIX E/DEXTROSE (5/15) CLINIMIX E/DEXTROSE (5/0) CLINIMIX E/DEXTROSE (5/5) CLINIMIX/DEXTROSE (.75/5) CLINIMIX/DEXTROSE (.5/10) CLINIMIX/DEXTROSE (.5/0) CLINIMIX/DEXTROSE (.5/5) CLINIMIX/DEXTROSE (.5/5) CLINIMIX/DEXTROSE (5/15) CLINIMIX/DEXTROSE (5/0) CLINIMIX/DEXTROSE (5/5) clinisol sf clobetasol propionate clobetasol propionate e clobetasol propionate emulsion clocortolone pivalate clodan CLOLAR... 5 clomipramine hcl... 9 clonazepam... clonidine hcl... 1 clopidogrel bisulfate... 9 clorazepate dipotassium... clorpres... 1 clotrimazole... 11, 11 clozapine... 5, 53 CLOZAPINE COARTEM... 1 codeine sulfate... colchicine-probenecid... 1 COLCRYS... 1 colestipol hcl colistimethate sodium colocort... 8 COLY-MYCIN S... 1 COLYTE WITH FLAVOR PACKS COMBIGAN COMBIVENT RESPIMAT COMETRIQ (100 MG DAILY DOSE)... 9 COMETRIQ (10 MG DAILY DOSE)... 9 COMETRIQ (60 MG DAILY DOSE)... 9 COMFORT ASSIST INSULIN SYRINGE COMPLERA... 1 compro... 8 COMVAX CONDYLOX constulose CONZIP... 6 COPAXONE CORDRAN COREG CR CORLANOR... 1 cormax scalp application CORTIFOAM cortisone acetate CORTISPORIN CORTISPORIN-TC... 1 COSENTYX COSENTYX SENSOREADY PEN COSMEGEN... 5 COSOPT PF COTELLIC... 9 COUMADIN CREON CRESEMBA... 8 crestor CRINONE CRIXIVAN... 1 cromolyn sodium... 86, 103, 110 cryselle CUBICIN CUVPOSA CVS GAUZE STERILE cyclafem 1/ cyclafem 7/7/ cyclophosphamide... CYCLOPHOSPHAMIDE... cycloserine... 1 cyclosporine cyclosporine modified cyred CYSTADANE CYSTAGON cytarabine... 5 cytarabine (pf)... 5 dacarbazine... DAKLINZA DALIRESP DALVANCE danazol... 7 dantrolene sodium dapsone DAPTACEL daptomycin DARAPRIM darifenacin hydrobromide er daunorubicin hcl... DAYTRANA... 56

136 deblitane decitabine... 5 DELESTROGEN delyla DELZICOL... 8 demeclocycline hcl... 3 DEMSER... 1 DENAVIR DEPEN TITRATABS depo-estradiol DEPO-MEDROL DEPO-PROVERA... 8 DEPO-SUBQ PROVERA depo-testosterone... 6 DESCOVY... 1 desipramine hcl... 9 desloratadine desmopressin ace rhinal tube desmopressin ace spray refrig desmopressin acetate desmopressin acetate spray... 8 desogestrel-ethinyl estradiol DESONATE desonide desoximetasone dexamethasone dexamethasone intensol dexamethasone sod phosphate pf dexamethasone sodium phosphate... 77, 106 DEXILANT dexpak 10 day dexpak 13 day dexpak 6 day dexrazoxane dextrose DEXTROSE 5%/ELECTROLYTE # dextrose in lactated ringers DEXTROSE-NACL dextrose-nacl diazepam..., 5 diazepam intensol... 5 DIBENZYLINE... 1 diclofenac potassium... 1 diclofenac sodium... 1, 106, 10 diclofenac sodium er... 1 diclofenac-misoprostol... 1 dicloxacillin sodium... dicyclomine hcl didanosine... 1 DIFFERIN DIFICID diflorasone diacetate , 118 diflunisal... 1 digitek... 0 digox... 0 digoxin... 0 dihydroergotamine mesylate DIHYDROERGOTAMINE MESYLATE dilantin... 5 DILANTIN... 5 dilantin infatabs... 5 DILATRATE-SR... DILAUDID-HP... diltiazem hcl diltiazem hcl er diltiazem hcl er beads diltiazem hcl er coated beads dilt-xr DIPENTUM... 8 diphenhydramine hcl diphenoxylate-atropine DIPHTHERIA-TETANUS TOXOIDS DT disopyramide phosphate disulfiram DIURIL... 0 divalproex sodium... 5 divalproex sodium er... 5 docetaxel... 6 DOCETAXEL... 6 dofetilide donepezil hcl... 8 DORIBAX dorzolamide hcl dorzolamide hcl-timolol mal doxazosin mesylate doxepin hcl... 9, 115 doxercalciferol doxorubicin hcl... doxorubicin hcl liposomal... 5 doxy doxycycline doxycycline hyclate... 3 doxycycline monohydrate... 3 dronabinol... 8 drospirenone-ethinyl estradiol DROXIA DUEXIS... 1 DULERA duloxetine hcl... 9 DUOPA duramorph... DUREZOL DURLAZA... 9 dutasteride dutasteride-tamsulosin hcl DUTOPROL DYMISTA DYRENIUM... 1 e.e.s E.E.S. GRANULES econazole nitrate EDARBI... 3 EDARBYCLOR... 3 EDECRIN... 1 EDURANT... 1 EFFIENT... 9 EGRIFTA ELAPRASE ELELYSO ELIDEL ELIGARD... 8 ELIQUIS ELITEK elixophyllin ELLA ELMIRON ELOXATIN EMADINE EMBEDA... 3 EMCYT... EMEND... 8 emoquette EMSAM... 9 EMTRIVA... 1

137 emverm ENABLEX enalapril maleate enalapril-hydrochlorothiazide... 3 ENBREL... 9 ENBREL SURECLICK endocet... 3 ENGERIX-B enoxaparin sodium... 89, 90 enpresse ENSTILAR entacapone entecavir ENTRESTO... 3 ENTYVIO... 8 enulose ENVARSUS XR EPIDUO EPIDUO FORTE epinastine hcl epinephrine EPIPEN -PAK EPIPEN JR -PAK epirubicin hcl... 5 epitol... 5 EPIVIR HBV eplerenone EPOGEN eprosartan mesylate... 3 EPZICOM... 1 EQUETRO ERAXIS... 8 ERBITUX... 7 ergomar ERIVEDGE... 7 errin ERTACZO ery ERYPED ERYPED ery-tab... 0 erythrocin lactobionate... 0 erythrocin stearate... 0 erythromycin , 113 erythromycin base... 0 erythromycin ethylsuccinate... 0 ESBRIET escitalopram oxalate... 9 esomeprazole sodium estarylla estrace estradiol estradiol valerate ESTRING ethacrynic acid... 1 ethambutol hcl... 1 ethosuximide... 5 etodolac... 1 etodolac er... 1 ETOPOPHOS... 3 etoposide... 3 EURAX EVOTAZ... 1 EXEL COMFORT POINT PEN NEEDLE EXELDERM exelon... 8 exemestane... 8 EXJADE EXTAVIA FABIOR FABRAZYME falmina famciclovir famotidine famotidine premixed... 8 FANAPT FANAPT TITRATION PACK FARESTON... 8 FARXIGA FARYDAK... 7 FASLODEX... 8 FAZACLO felbamate... 5 felodipine er FEMRING fenofibrate fenofibrate micronized fenofibric acid FENOGLIDE fenoprofen calcium... 1 fentanyl... 3 fentanyl citrate... 3 FENTORA... 3 FERRIPROX FETZIMA... 9 FETZIMA TITRATION... 9 FINACEA finasteride FIRAZYR FIRMAGON... 8 FLAREX FLEBOGAMMA... 9 FLEBOGAMMA DIF... 9 flecainide acetate FLOVENT DISKUS FLOVENT HFA , 11 fluconazole... 8 fluconazole in dextrose... 8 fluconazole in sodium chloride... 8 flucytosine... 8 fludarabine phosphate... 5 fludrocortisone acetate flunisolide fluocinolone acetonide , 1 fluocinolone acetonide body fluocinolone acetonide scalp fluocinonide fluocinonide-e fluorometholone fluorouracil... 5, 10 FLUOROURACIL fluoxetine hcl... 9 FLUOXETINE HCL... 9 fluphenazine decanoate fluphenazine hcl flurandrenolide flurbiprofen... 1 flurbiprofen sodium flutamide... 8 fluticasone propionate , 118 fluvastatin sodium fluvastatin sodium er fluvoxamine maleate... 3 fluvoxamine maleate er... 3 FML FML FORTE fondaparinux sodium... 90

138 FORADIL AEROLIZER FORFIVO XL... 9 FORTAZ FORTAZ IN D5W FORTEO FORTESTA... 6 FORTICAL FOSAMAX PLUS D fosinopril sodium fosinopril sodium-hctz... 3 FOSRENOL FRAGMIN FREAMINE HBC FREAMINE III FROVA frovatriptan succinate furosemide... 1 FUSILEV FUZEON... 1 fyavolv FYCOMPA... 5 gabapentin... 5 GABITRIL... 5 galantamine hydrobromide... 8 galantamine hydrobromide er... 8 GAMASTAN S/D... 9 GAMMAGARD... 9 GAMMAGARD S/D... 9 GAMMAGARD S/D LESS IGA... 9 GAMMAKED... 9 GAMMAPLEX... 9 GAMUNEX-C... 9 ganciclovir sodium GARDASIL GARDASIL gatifloxacin GATTEX gavilyte-c gavilyte-g gavilyte-h gavilyte-n with flavor pack GELNIQUE GEMCITABINE HCL... 5 gemcitabine hcl... 5 gemfibrozil generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin in saline... 7 gentamicin sulfate... 7, 105, 11 GENVOYA... 1 GEODON gianvi GIAZO... 8 gildagia gildess 1.5/ gildess fe GILENYA GILOTRIF... 9 GLASSIA GLEOSTINE... glimepiride glipizide glipizide er glipizide xl glipizide-metformin hcl GLOBAL ALCOHOL PREP EASE GLUCAGEN HYPOKIT GLUCAGON EMERGENCY GLUMETZA... 65, 66 glycopyrrolate GLYSET GLYXAMBI GOLYTELY GRALISE GRALISE STARTER granisetron hcl... 8 GRANIX GRASTEK griseofulvin microsize... 8 griseofulvin ultramicrosize... 8 guanfacine hcl er HALAVEN halobetasol propionate HALOG haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX heather HECTOROL HEPARIN (PORCINE) IN D5W HEPARIN (PORCINE) IN NACL HEPARIN SOD (PORCINE) IN D5W heparin sodium (porcine) heparin sodium (porcine) pf HEPATAMINE HERCEPTIN... 7 HETLIOZ HEXALEN... HIBERIX HORIZANT HP ACTHAR HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50/ HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/ HUMALOG MIX 75/5 KWIKPEN HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN-CROHNS STARTER HUMIRA PEN-PSORIASIS STARTER HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N... 6 HUMULIN N KWIKPEN... 6 HUMULIN R... 6 HUMULIN R U-500 (CONCENTRATED)... 6 HUMULIN R U-500 KWIKPEN... 6 hydralazine hcl... 1 hydrochlorothiazide... 1 hydrocodone-acetaminophen... 3 hydrocodone-ibuprofen... 3 hydrocortisone... 77, 8, 118 hydrocortisone butyr lipo base hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid... 1

139 hydromorphone hcl... 3 hydromorphone hcl er... 3 HYDROMORPHONE HCL ER... 3 hydromorphone hcl pf... 3 hydroxychloroquine sulfate hydroxyprogesterone caproate... 8 hydroxyurea hydroxyzine hcl HYSINGLA ER... 3 ibandronate sodium IBRANCE... 7 ibudone... 3 ibuprofen... 1 ICLUSIG... 9 idarubicin hcl... 5 IFEX... ifosfamide... IFOSFAMIDE... ILEVRO ilotycin imatinib mesylate... 9 IMBRUVICA... 9 imipenem-cilastatin imipramine hcl... 9 imipramine pamoate... 9 imiquimod IMOVAX RABIES INCRELEX INCRUSE ELLIPTA indapamide... 1 INFANRIX INFUMORPH INFUMORPH INLYTA... 9 INTELENCE... 1 INTRALIPID INTRON A introvale INVANZ INVEGA INVEGA SUSTENNA... 53, 5 INVEGA TRINZA... 5 INVIRASE... 1 INVOKAMET INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide ipratropium-albuterol irbesartan... 3 irbesartan-hydrochlorothiazide... 3 IRESSA... 9 irinotecan hcl... 3 ISENTRESS... 1, 13 ISOLYTE-P IN D5W ISOLYTE-S isoniazid ISORDIL TITRADOSE... isosorbide dinitrate... isosorbide dinitrate er... isosorbide mononitrate... isosorbide mononitrate er... isradipine ISTALOL ISTODAX... 7 itraconazole... 8 ivermectin IXEMPRA KIT IXIARO JADENU JAKAFI... 9 jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR jinteli jolessa jolivette juleber junel 1.5/ junel 1/ junel fe 1.5/ junel fe 1/ junel fe JUXTAPID KADCYLA... 7 KADIAN... kaitlib fe KALETRA... 1 KALYDECO kariva KAZANO KCL IN D5W LACTATED RINGERS kcl in dextrose-nacl KCL IN DEXTROSE-NACL KCL-LACTATED RINGERS-D5W kelnor 1/ KEPIVANCE ketoconazole... 8, 115, 116 ketodan ketoprofen... ketoprofen er... ketorolac tromethamine KEVEYIS... 1 KEYTRUDA... 7 kimidess KINERET KINRIX kionex klor-con klor-con klor-con m klor-con m klor-con m klor-con sprinkle KOMBIGLYZE XR KORLYM kristalose KUVAN KYNAMRO labetalol hcl LACRISERT lactated ringers lactulose lactulose encephalopathy LAMICTAL ODT... 5 LAMICTAL STARTER... 5 LAMICTAL XR... 5 LAMISIL... 8 lamivudine... 13, 15 lamivudine-zidovudine... 1 lamotrigine... 6 lamotrigine er... 6 LANOXIN... 0 LANOXIN PEDIATRIC... 0 lansoprazole... 87

140 LANTUS... 6 LANTUS SOLOSTAR... 6 larin 1.5/ larin 1/ larin fe 1.5/ larin fe 1/ larissia LASTACAFT latanoprost LATUDA... 5 layolis fe LAZANDA... leena leflunomide LEMTRADA LENVIMA 10 MG DAILY DOSE... 9 LENVIMA 1 MG DAILY DOSE... 9 LENVIMA 18 MG DAILY DOSE... 9 LENVIMA 0 MG DAILY DOSE... 9 LENVIMA MG DAILY DOSE... 9 LENVIMA 8 MG DAILY DOSE... 9 LENVIMA 8MG DAILY DOSE LESCOL XL lessina LETAIRIS... letrozole... 8 leucovorin calcium LEUKERAN... LEUKINE leuprolide acetate... 8 levalbuterol hcl LEVEMIR... 6 LEVEMIR FLEXTOUCH... 6 levetiracetam... 6 levetiracetam er... 6 LEVETIRACETAM IN NACL... 6 levobunolol hcl levocarnitine levocetirizine dihydrochloride levofloxacin... 0, 105 levofloxacin in d5w... 0 levoleucovorin calcium... 31, 3 levoleucovorin calcium pf... 3 levonest levonorgest-eth estrad 91-day levonorgestrel... 7 levonorgestrel-ethinyl estrad... 7 levonorg-eth estrad triphasic... 7 levora 0.15/30 (8)... 7 levorphanol tartrate... levothyroxine sodium levoxyl LEXIVA LIALDA... 8 lidocaine lidocaine hcl... 7, 119 lidocaine hcl (pf)... 7 lidocaine viscous lidocaine-prilocaine linezolid LINEZOLID LINEZOLID IN SODIUM CHLORIDE LINZESS liothyronine sodium LIPOSYN III lisinopril lisinopril-hydrochlorothiazide... 3 LITHIUM lithium carbonate lithium carbonate er LIVALO LO LOESTRIN FE... 7 LOCOID lokara lomedia fe... 7 LONSURF loperamide hcl lorazepam... lorazepam intensol... lorcet... lorcet hd... lorcet plus... lortab... loryna... 7 losartan potassium... 3 losartan potassium-hctz LOTEMAX , 107 lovastatin low-ogestrel... 7 loxapine succinate... 5 LUMIGAN LUMIZYME LUPANETA PACK... 7 LUPRON DEPOT... 8 LUPRON DEPOT-PED... 8 lutera... 7 LUZU LYNPARZA... 7 LYRICA... 6 LYSODREN... 8 lyza... 7 MACRODANTIN magnesium sulfate MAGNESIUM SULFATE MAGNESIUM SULFATE IN D5W malathion maprotiline hcl marlissa... 7 MARPLAN MATULANE matzim la MAXIDEX MAXIPIME meclizine hcl... 8 MEDROL medroxyprogesterone acetate... 7, 81 mefenamic acid... mefloquine hcl... 1 megestrol acetate... 8 MEGESTROL ACETATE... 8 MEKINIST meloxicam... melphalan hcl... memantine hcl... 8 MENACTRA MENHIBRIX MENOMUNE MENOSTAR MENTAX MENVEO mercaptopurine... 6 meropenem... 10

141 meropenem-sodium chloride mesalamine... 8 mesalamine-cleanser... 8 mesna... 3 MESNEX... 3 MESTINON metadate er metformin hcl metformin hcl er metformin hcl er (mod) metformin hcl er (osm)... 66, 67 METHADONE HCL... methadone hcl... methadone hcl intensol... methazolamide... 1 methenamine hippurate methimazole methotrexate methotrexate sodium... 6 methotrexate sodium (pf)... 6 methoxsalen rapid methscopolamine bromide methyclothiazide... 1 methylergonovine maleate methylphenidate hcl methylphenidate hcl er methylphenidate hcl er (cd) methylphenidate hcl er (la)... 56, 57 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl... 8 metolazone... 1 metoprolol succinate er metoprolol tartrate metoprolol-hydrochlorothiazide METRO metronidazole... 11, 89, 10 metronidazole in nacl mexiletine hcl MIACALCIN miconazole microgestin 1.5/ microgestin 1/ microgestin fe 1.5/ microgestin fe 1/ midodrine hcl... 1 migergot miglitol millipred millipred dp MINASTRIN FE... 7 minitran... MINIVELLE minocycline hcl... 3 minocycline hcl er... 3 minoxidil... MIRAPEX MIRAPEX ER MIRCERA mirtazapine misoprostol mitomycin... 5 mitoxantrone hcl M-M-R II modafinil moderiba MODERIBA 100 DOSE PACK moderiba 800 dose pack moexipril hcl moexipril-hydrochlorothiazide... 3 molindone hcl... 5 mometasone furoate mono-linyah... 7 mononessa... 7 montelukast sodium morgidox... 3 morphine sulfate... morphine sulfate (concentrate)... morphine sulfate (pf)... morphine sulfate er... morphine sulfate er beads... MOVANTIK MOVIPREP MOXATAG... MOXEZA MOXIFLOXACIN HCL... 0 moxifloxacin hcl MOZOBIL MULTAQ mupirocin mupirocin calcium MUSTARGEN... MYCAMINE... 9 mycophenolate mofetil mycophenolate sodium myorisan MYOZYME MYRBETRIQ myzilra... 7 nabumetone... nadolol nadolol-bendroflumethiazide nafcillin sodium... NAFCILLIN SODIUM IN DEXTROSE... naftifine hcl NAFTIN NAGLAZYME nalbuphine hcl... 6 naloxone hcl naltrexone hcl... 6 NAMENDA XR... 8 NAMENDA XR TITRATION PACK... 8 NAMZARIC... 8 naphazoline hcl NAPRELAN... naproxen... naproxen dr... naproxen sodium... NAPROXEN SODIUM ER... naratriptan hcl NASONEX NATACYN nateglinide NATPARA NEBUPENT necon 0.5/35 (8)... 7 necon 1/35 (8)... 7 necon 1/50 (8)... 7 necon 10/11 (8)... 7 necon 7/7/ nefazodone hcl neomycin sulfate... 7

142 neomycin-bacitracin zn-polymyx neomycin-polymyxin b gu neomycin-polymyxin-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc , 1 NEORAL NEPHRAMINE NESINA neuac NEULASTA NEULASTA ONPRO NEUMEGA NEUPOGEN NEUPRO nevirapine nevirapine er NEXAVAR nexium NEXIUM niacin er (antihyperlipidemic) niacor nicardipine hcl NICOTROL... 6 NICOTROL NS... 6 nifedical xl nifedipine er nifedipine er osmotic release nikki... 7 NILANDRON... 8 nilutamide... 8 nimodipine NINLARO... 7 NIPENT... 6 nisoldipine er nitro-bid... NITRO-DUR... nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd macro nitroglycerin... NITROSTAT... nizatidine... 8 nora-be... 7 NORDITROPIN FLEXPRO norethin ace-eth estrad-fe norethindrone norethindrone acetate norethindrone-eth estradiol norethin-eth estradiol-fe norgestimate-eth estradiol norgestim-eth estrad triphasic NORITATE norlyroc normosol-m in d5w NORMOSOL-R IN D5W NORMOSOL-R PH NORPACE CR nortrel 0.5/35 (8) nortrel 1/35 (1) nortrel 1/35 (8) nortrel 7/7/ nortriptyline hcl NORVIR novarel NOVOLIN 70/ NOVOLIN 70/30 RELION... 6 NOVOLIN N... 6 NOVOLIN N RELION... 6 NOVOLIN R... 6 NOVOLIN R RELION... 6 NOVOLOG... 6 NOVOLOG FLEXPEN... 6 NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN... 6 NOVOLOG PENFILL... 6 NOXAFIL... 9 NUCALA NUCYNTA... 5 NUCYNTA ER..., 5 NUEDEXTA NULOJIX NULYTELY WITH FLAVOR PACKS NUPLAZID... 5 NUTRILIPID NUTROPIN AQ NUSPIN NUTROPIN AQ NUSPIN NUTROPIN AQ NUSPIN NUTROPIN AQ PEN NUVARING NUVESSA NUVIGIL nyamyc NYMALIZE nystatin... 9, 115, 11 nystop ocella OCTAGAM... 9 octreotide acetate ODEFSEY... 1 ODOMZO OFEV ofloxacin , 1 ogestrel olanzapine... 5 olopatadine hcl , 108 OMECLAMOX-PAK omega-3-acid ethyl esters omeprazole omeprazole-sodium bicarbonate OMEPRAZOLE-SODIUM BICARBONATE OMNARIS OMNITROPE ondansetron... 8 ondansetron hcl... 8 ONETOUCH ULTRA ONETOUCH ULTRA BLUE ONETOUCH ULTRA MINI ONETOUCH VERIO ONETOUCH VERIO FLEX SYSTEM ONETOUCH VERIO IQ SYSTEM ONETOUCH VERIO SYNC SYSTEM ONEXTON ONFI... 6 ONGLYZA ONMEL... 9 ONZETRA XSAIL OPANA ER... 5 OPSUMIT... 3 ORACEA... 10

143 ORAVIG ORENCIA ORENCIA CLICKJECT ORENITRAM... 3 ORFADIN ORKAMBI orsythia ORTHO TRI-CYCLEN LO OSENI OSMOPREP OTEZLA OTOVEL... 1 oxacillin sodium... oxaliplatin oxandrolone... 6 oxaprozin... oxcarbazepine... 6 oxiconazole nitrate OXISTAT OXTELLAR XR... 6 oxybutynin chloride oxybutynin chloride er oxycodone hcl... 5 oxycodone-acetaminophen... 5 oxycodone-aspirin... 5 oxycodone-ibuprofen... 5 oxymorphone hcl... 5 OXYTROL pacerone paclitaxel... 6 paliperidone er... 5 pamidronate disodium PANCREAZE PANDEL PANRETIN pantoprazole sodium paricalcitol paroex paromomycin sulfate... 7 paroxetine hcl paroxetine hcl er paser PATADAY PATANOL PAXIL PAZEO PCE... 0 PEDIARIX PEDVAX HIB peg 3350/electrolytes peg 3350-kcl-na bicarb-nacl peg-3350/electrolytes PEGANONE... 6 PEGASYS PEGASYS PROCLICK PEGINTRON PEG-INTRON REDIPEN PENICILLIN G POT IN DEXTROSE... penicillin g potassium... penicillin g procaine... penicillin g sodium... penicillin v potassium... PENNSAID PENTACEL PENTAM PENTASA... 8 pentoxifylline er... 9 PERFOROMIST perindopril erbumine periogard PERJETA... 7 permethrin perphenazine... 5 PERTZYE PEXEVA pfizerpen-g... phenadoz... 8 phenelzine sulfate phenergan... 8 phenobarbital... 6 phenobarbital sodium... 6 PHENOBARBITAL SODIUM... 7 PHENOXYBENZAMINE HCL... phenytek... 7 phenytoin... 7 phenytoin sodium... 7 phenytoin sodium extended... 7 philith PHOSLYRA PHOSPHOLINE IODIDE PICATO pilocarpine hcl... 10, 11 pimozide... 5 pimtrea pindolol pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so... 3 pirmella 1/ piroxicam... PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN D5W PLEGRIDY PLEGRIDY STARTER PACK plenamine podofilox polyethylene glycol polymyxin b sulfate polymyxin b-trimethoprim POMALYST portia potassium chloride... 99, 10 potassium chloride crys er potassium chloride er potassium chloride in dextrose potassium chloride in nacl potassium citrate er POTIGA... 7 PRADAXA PRALUENT pramipexole dihydrochloride... 5 pramipexole dihydrochloride er... 5 PRANDIMET pravastatin sodium prazosin hcl PRED MILD PRED-G PRED-G S.O.P prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 77, 107 prednisone prednisone intensol... 77

144 PREFERRED PLUS INSULIN SYRINGE... 6 pregnyl PREMARIN premasol prenatal PREPOPIK PREVACID SOLUTAB prevalite previfem PREZCOBIX... 1 PREZISTA PRIFTIN PRILOSEC PRIMAQUINE PHOSPHATE... 1 primidone... 7 PRIMSOL PRISTIQ PRIVIGEN... 9 PROAIR HFA PROAIR RESPICLICK probenecid... 1 PROCALAMINE prochlorperazine... 8 prochlorperazine edisylate... 8 prochlorperazine maleate... 8 PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN... 7 PROLIA PROMACTA... 9 promethazine hcl... 8, 83 promethegan propafenone hcl propafenone hcl er proparacaine hcl propranolol hcl propranolol hcl er propranolol-hctz propylthiouracil PROQUAD PROSOL PROTONIX protriptyline hcl PROVENTIL HFA prudoxin PULMICORT PULMICORT FLEXHALER PULMOZYME PURIXAN... 6 PYLERA pyrazinamide pyridostigmine bromide pyridostigmine bromide er QBRELIS QNASL QNASL CHILDRENS QUADRACEL QUARTETTE quasense quetiapine fumarate... 5 QUILLICHEW ER QUILLIVANT XR quinapril hcl quinapril-hydrochlorothiazide... 3 quinidine gluconate er quinidine sulfate quinine sulfate... 1 QVAR RABAVERT rabeprazole sodium RAGWITEK raloxifene hcl ramipril RANEXA... ranitidine hcl... 8 RAPAFLO RAPAMUNE RAVICTI RAYOS REBETOL REBIF REBIF REBIDOSE REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK reclipsen RECOMBIVAX HB RECTIV REGRANEX RELENZA DISKHALER RELI-ON INSULIN SYRINGE... 6 RELISTOR RELPAX REMICADE REMODULIN... 3 RENAGEL RENVELA repaglinide repaglinide-metformin hcl reprexain... 5 RESCRIPTOR RESTASIS RETIN-A MICRO PUMP RETROVIR REVATIO... 3 REVLIMID REXULTI... 5, 55 REYATAZ RHEUMATREX ribasphere ribasphere ribapak ribavirin rifabutin rifamate rifampin RIFATER riluzole rimantadine hcl ringers RIOMET risedronate sodium RISPERDAL CONSTA risperidone RITALIN LA RITUXAN... 7 rivastigmine tartrate... 8 rizatriptan benzoate ropinirole hcl... 5 ropinirole hcl er... 5 rosadan rosuvastatin calcium ROTARIX ROTATEQ... 98

145 roweepra... 7 ROZEREM RUCONEST... 9 RYTARY... 5 SABRIL... 7 SAIZEN SAIZEN CLICK.EASY SAMSCA SANCUSO SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS SARAFEM... 6 SAVAYSA SAVELLA SAVELLA TITRATION PACK SEEBRI NEOHALER selegiline hcl... 5 selenium sulfide SELZENTRY SEMPREX-D SENSIPAR SEREVENT DISKUS SERNIVO SEROQUEL XR SEROSTIM sertraline hcl setlakin SFROWASA... 8 sharobel SIGNIFOR SIGNIFOR LAR sildenafil citrate... 3 SILENOR silver sulfadiazine SIMBRINZA SIMPONI SIMPONI ARIA SIMULECT simvastatin sirolimus SIROLIMUS SIRTURO SIVEXTRO SKLICE SMOFLIPID sodium chloride... 99, 103, 11 sodium fluoride sodium phenylbutyrate sodium polystyrene sulfonate SOLODYN... 3 SOLTAMOX... 8 SOLU-CORTEF SOLU-MEDROL SOMATULINE DEPOT SOMAVERT SOOLANTRA SORILUX sorine sotalol hcl sotalol hcl (af) SOTYLIZE SOVALDI SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone-hctz... 1 SPORANOX... 9 sprintec SPRITAM... 7 SPRYCEL sps sronyx ssd stavudine STELARA sterile water for irrigation STIMATE... 8 STIOLTO RESPIMAT STIVARGA STRATTERA streptomycin sulfate... 7 STRIANT... 6 STRIBILD... 1 STRIVERDI RESPIMAT SUBOXONE... 6 SUBSYS... 5 SUCLEAR SUCRAID sucralfate sulfacetamide sodium , 11 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine... 8 sulindac... sumatriptan sumatriptan succinate sumatriptan succinate refill SUMAVEL DOSEPRO SUPRAX suprax SUPREP BOWEL PREP SURMONTIL SUSTIVA SUSTOL SUTENT syeda SYLATRON SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL... 7 SYNERA SYNERCID SYNJARDY SYNRIBO SYNTHROID SYPRINE TABLOID... 6 TACLONEX tacrolimus... 96, 10 TAFINLAR TAGRISSO TAMIFLU tamoxifen citrate... 8 tamsulosin hcl TANZEUM TARCEVA TARGRETIN tarina fe 1/ TASIGNA tazicef TAZORAC taztia xt TECENTRIQ... 7 TECFIDERA TEFLARO... 19

146 TEGRETOL... 7 TEGRETOL-XR... 7 TEKTURNA... 0 TEKTURNA HCT... 0 telmisartan... 3 telmisartan-amlodipine... 3 telmisartan-hctz... 3 temazepam TENIVAC terazosin hcl terbinafine hcl... 9 terbutaline sulfate terconazole TESTIM... 6 testosterone testosterone cypionate... 6 testosterone enanthate TETANUS-DIPHTHERIA TOXOIDS TD tetrabenazine... 59, 60 tetracycline hcl... 3 texacort THALOMID theo theophylline theophylline er thioridazine hcl thiotepa... thiothixene THYMOGLOBULIN tiagabine hcl... 7 TIKOSYN timolol maleate... 38, 10 TIMOPTIC OCUDOSE TIROSINT TIVICAY tizanidine hcl TOBI PODHALER... 8 TOBRADEX TOBRADEX ST tobramycin... 8, 106 tobramycin sulfate... 8 tobramycin-dexamethasone TOBREX TOLAK tolmetin sodium... tolterodine tartrate tolterodine tartrate er TOPICORT SPRAY topiramate... 7 topiramate er... 7 toposar... 3 topotecan hcl... 3 TORISEL... 7 torsemide... 1 TOUJEO SOLOSTAR TOVIAZ TPN ELECTROLYTES TRACLEER... 3 TRADJENTA tramadol hcl... 7 tramadol hcl er... 6, 7 tramadol hcl er (biphasic)... 6 tramadol-acetaminophen... 7 trandolapril trandolapril-verapamil hcl er tranexamic acid... 9 TRANSDERM-SCOP (1.5 MG) tranylcypromine sulfate TRAVASOL TRAVATAN Z trazodone hcl TREANDA... TRECATOR TRELSTAR MIXJECT... 9 TRESIBA FLEXTOUCH tretinoin... 31, 11 tretinoin microsphere tretin-x trexall TREXIMET trezix... 7 triamcinolone acetonide , 119, 11 triamterene-hctz... 1 trianex TRIBENZOR... 3 triderm trifluoperazine hcl trifluridine TRIGLIDE tri-legest fe... 7 tri-linyah... 7 tri-lo-estarylla tri-lo-marzia... 7 tri-lo-sprintec... 7 trilyte trimethoprim trimipramine maleate trinessa (8)... 7 trinessa lo... 7 TRINTELLIX tri-previfem... 7 TRISENOX tri-sprintec... 7 TRIUMEQ... 1 trivora (8)... 7 TROKENDI XR... 7 TROPHAMINE trospium chloride trospium chloride er TRULICITY TRUMENBA TRUVADA... 1 TUDORZA PRESSAIR TWINRIX TYBOST TYGACIL TYKERB TYPHIM VI TYSABRI TYVASO... 3 TYZEKA tyzine UCERIS... 8, 85 ULORIC... 1 ULTRAVATE ULTRESA unithroid UPTRAVI... 3 ursodiol UTIBRON NEOHALER UVADEX VAGIFEM valacyclovir hcl VALCHLOR VALCYTE valganciclovir hcl valproate sodium... 7 valproic acid... 7 valsartan... 3

147 valsartan-hydrochlorothiazide... 3 vancomycin hcl... 1 VANCOMYCIN HCL IN NACL vandazole VAQTA VARIVAX VARUBI VASCEPA VECTIBIX... 7 VELCADE... 7 velivet... 7 VELPHORO VELTASSA VELTIN VENCLEXTA... 7 VENCLEXTA STARTING PACK... 7 venlafaxine hcl venlafaxine hcl er VENTAVIS... 3 VENTOLIN HFA VERAMYST verapamil hcl... 0 verapamil hcl er veripred VERSACLOZ VESICARE vestura... 7 VEXOL VIAGRA VIBERZI VIBRAMYCIN... 3 vicodin... 5 vicodin es... 5 vicodin hp... 5 VICTOZA VIDEX vienva... 7 VIGAMOX VIIBRYD VIIBRYD STARTER PACK VIMIZIM VIMOVO... 1 VIMPAT... 7, 8 vinblastine sulfate... 6 vincasar pfs... 6 vincristine sulfate... 6 vinorelbine tartrate... 6 VIOKACE viorele... 7 VIRACEPT VIRAMUNE XR VIREAD... 13, 1 VITEKTA... 1 VIVITROL... 6 VIVLODEX... VOGELXO VOGELXO PUMP VOLTAREN voriconazole... 9 VOTRIENT VPRIV VRAYLAR vyfemla... 7 VYTORIN VYVANSE warfarin sodium WELCHOL wymzya fe... 7 XALKORI XARELTO XARELTO STARTER PACK XARTEMIS XR... 5 XELJANZ XELJANZ XR XEOMIN XERESE XGEVA XIFAXAN... 1, 86 XIGDUO XR XOLAIR XOPENEX HFA XTAMPZA ER... 5 XTANDI... 9 xulane... 7 xylon... 5 XYREM YERVOY... 7 YF-VAX zafirlukast zamicet... 5 ZANOSAR... zarah... 7 ZAVESCA zazole ZEGERID ZELAPAR... 5 ZELBORAF ZEMAIRA ZEMBRACE SYMTOUCH ZEMPLAR zenatane zenchent... 7 zenchent fe... 7 ZENPEP ZERBAXA ZETIA ZETONNA ZIAGEN... 1 ZIANA zidovudine... 1 ZINACEF ZIOPTAN ziprasidone hcl ZIPSOR... ZIRGAN ZMAX... 0 ZOHYDRO ER... 5 zoledronic acid ZOLINZA... 8 zolmitriptan zolpidem tartrate ZOMACTON ZOMETA ZOMIG zonisamide... 8 ZONTIVITY... 9 ZORBTIVE ZORTRESS ZORVOLEX... ZOSTAVAX ZOSYN... 3 zovia 1/35e (8)... 7 zovia 1/50e (8)... 7 ZOVIRAX ZUBSOLV... 6 ZUPLENZ ZURAMPIC... 1 ZYCLARA ZYCLARA PUMP ZYDELIG ZYFLO CR ZYKADIA ZYLET

148 ZYPREXA RELPREVV ZYTIGA... 9 ZYVOX

149 This information is available for free in other languages. Please call our Customer Service number at , Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 1, representatives are available Monday Sunday, 8 a.m. to 8 p.m. TTY users should call Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de Servicio al Cliente al , de lunes a viernes, de 8 a.m. a 8 p.m. Entre el 1 de octubre y el 1 de febrero, los representantes están disponibles de lunes a domingo de 8 a.m. a 8 p.m. Los usuarios de TTY deben llamar al Y0070_NA0377_WCM_INS_MLT_NA_07_13_CA_1PT_PORTRAIT_FINAL 55000

150 We re always just a phone call away! If you re ready to enroll or have enrollment questions, call , 8 a.m. to 8 p.m., 7 days a week. If you re already a member, call the number for your state/plan listed below. California: Easy Choice Plus Plan (HMO) Hours of operation are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 1, representatives are available Monday Sunday, 8 a.m. to 8 p.m., or visit us anytime at Nurse Advice Line ( hours, 7 days a week) TTY for all of the above

151 Easy Choice Health Plan (HMO), a WellCare company, is a Medicare Advantage organization with a Medicare contract. Enrollment in Easy Choice (HMO) depends on contract renewal. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Some plans are available to those who have medical assistance from both the state and Medicare. Premiums, co-pays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Benefits, premiums and/or co-payments/coinsurance may change on January 1 of each year. This formulary was updated on 11/01/016. For more recent information or other questions, please contact Easy Choice at the telephone number listed on the inside front and back covers of this formulary or visit P.O. Box Tampa, FL

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans Easy Choice Health Plan Plans in the following state: CA Easy Choice Best Plan(HMO)

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare Health Plans Please Read: Plans in the following states: AR, FL, GA, KY, MS, NC, NY, SC, TN WellCare Access (HMO SNP),

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare Health Plans Plans in the following states: GA, NC, SC, TN WellCare Choice (HMO), WellCare Choice (HMO-POS) WellCare Essential

More information

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare Health Plans Plans in the following states: GA, SC WellCare Choice (HMO), WellCare

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO) WellCare Rx (HMO) Plans in the following

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO) WellCare Rx (HMO) Plans in the following

More information

2017 COMPREHENSIVE FORMULARY

2017 COMPREHENSIVE FORMULARY 017 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) MEDICARE ADVANTAGE PLANS Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 09/01/016.

More information

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following states: AR, CT, FL, IL, KY, LA, NJ, NY, TX, TN

More information

2018 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans

2018 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans 018 Comprehensive Formulary (List of Covered s) Prescription Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Classic (PDP) Please Read: This document contains information about

More information

2017 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans

2017 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Prescription Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Extra (PDP) Plans in the

More information

COMPREHENSIVE FORMULARY

COMPREHENSIVE FORMULARY 08 COMPREHENSIVE FORMULARY CARE N CARE CHOICE PREMIUM (PPO) CARE N CARE CHOICE PLUS (PPO) CARE N CARE CHOICE (PPO) CARE N CARE CLASSIC (HMO) (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS

More information

2017 COMPREHENSIVE FORMULARY

2017 COMPREHENSIVE FORMULARY 017 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) PRESCRIPTION DRUG PLANS Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 09/01/016.

More information

08:00 Anti-Infective Agents 08:00. Anti-Infective Agents

08:00 Anti-Infective Agents 08:00. Anti-Infective Agents Anti-Infective Agents Anti-Infective Agents 08:08 ANTHELMINTICS MEBENDAZOLE 100 MG ORAL CHEWABLE TABLET 00000556734 VERMOX JAI 5.0300 08:12.02 (AMINOGLYCOSIDES) GENTAMICIN SULFATE 40 MG / ML (BASE) INJECTION

More information

Memorial Hermann Advantage HMO Formulary. (List of Covered Drugs)

Memorial Hermann Advantage HMO Formulary. (List of Covered Drugs) Memorial Hermann Advantage H 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 19563,

More information

Partnership 2017 Formulary. List of Covered Drugs

Partnership 2017 Formulary. List of Covered Drugs Partnership 207 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ID 7379, Version Number 26 This formulary was updated on 0/24/207.

More information

2016 COMPREHENSIVE FORMULARY

2016 COMPREHENSIVE FORMULARY 016 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) PRESCRIPTION DRUG PLANS Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

2017 Formulary (List of Covered Drugs)

2017 Formulary (List of Covered Drugs) MedStar Medicare Choice (HMO) 2017 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00017201,

More information

Y0070_NA026578_WCM_FOR_ENG_FINAL_02 CMS Approved NA5V02FOR59890E 0915 WellCare 2015 NA_09_15

Y0070_NA026578_WCM_FOR_ENG_FINAL_02 CMS Approved NA5V02FOR59890E 0915 WellCare 2015 NA_09_15 2015 Comprehensive e Formulary (List of Covered ed Drugs) Medicare e Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated

More information

Partnership 2017 Formulary. List of Covered Drugs

Partnership 2017 Formulary. List of Covered Drugs Partnership 207 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ID 7379, Version Number 9 This formulary was updated on 5/23/207. For

More information

COMPREHENSIVE FORMULARY

COMPREHENSIVE FORMULARY COMPREHENSIVE FORMULARY HEALTHTEAM ADVANTAGE PLAN I (PPO) HEALTHTEAM ADVANTAGE PLAN II (PPO) (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

More information

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug Formulary 2017 Advantage Plus (HMO) This formulary was updated on 08/2/2016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service,

More information

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug Formulary 018 This formulary was updated on 09/5/018. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service, at 1-866-597-9560 or, for

More information

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug Formulary 018 This formulary was updated on 08/16/017. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service, at 1-866-597-9560 or,

More information

Comprehensive Formulary (List of Covered Drugs)

Comprehensive Formulary (List of Covered Drugs) 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

2015 Comprehensive Formulary (List of Covered Drugs)

2015 Comprehensive Formulary (List of Covered Drugs) 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

2015 Comprehensive Formulary (List of Covered Drugs)

2015 Comprehensive Formulary (List of Covered Drugs) 2015 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

Baptist Health Plan Advantage (HMO) 2017 Formulary (List of Covered Drugs)

Baptist Health Plan Advantage (HMO) 2017 Formulary (List of Covered Drugs) Baptist Health Plan Advantage (HMO) 2017 Formulary (List of Covered s) Formulary ID: 17202, Version 19 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary

More information

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug Formulary 016 This formulary was updated on 07/6/016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service at (866) 597-9560 or, for

More information

HAP Empowered MI Health Link Medicare-Medicaid Plan 2019 List of Covered Drugs (Formulary)

HAP Empowered MI Health Link Medicare-Medicaid Plan 2019 List of Covered Drugs (Formulary) H9712_2019 LOCD; Approved HAP Empowered MI Health Link Medicare-Medicaid Plan 2019 List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT S WE COVER IN THIS PLAN. CMS Approved

More information

Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Gain Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO)

Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Gain Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) HP19FORM05 Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Gain Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) 019 Formulary (List of Covered Drugs) PLEASE READ: THIS

More information

2017 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP)

2017 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP) Medicare GenerationRx (Employer PDP) 017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/01/017.

More information

2018 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP)

2018 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP) Medicare GenerationRx (Employer PDP) 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 07/01/018.

More information

PRESCRIPTION DRUGS FORMULARY 1. I ~~ [ tl-i I Classicare (HMO)

PRESCRIPTION DRUGS FORMULARY 1. I ~~ [ tl-i I Classicare (HMO) PRESCRIPTION DRUGS FORMULARY 1 2018 I ~~ [ tl-i I Classicare (HMO) MCS Classicare 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS

More information

2016 Formulary (List of Covered Drugs)

2016 Formulary (List of Covered Drugs) MedStar Medicare Choice (HMO) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00016319,

More information

Memorial Hermann Advantage HMO & PPO Formulary. (List of Covered Drugs)

Memorial Hermann Advantage HMO & PPO Formulary. (List of Covered Drugs) Memorial Hermann Advantage H & PPO 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File 00017383, Version

More information

2015 MEDICARE PART D DRUG FORMULARY

2015 MEDICARE PART D DRUG FORMULARY 2015 MEDICARE PART D DRUG FORMULARY 1199SEIU Medicare Advantage Formulary This formulary was updated on 08/08/2014. For more recent information or other questions, please contact EmblemHealth at 1-877-447-1199

More information

Comprehensive Formulary

Comprehensive Formulary 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug Formulary 016 This formulary was updated on 05/4/016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service at (866) 597-9560 or, for

More information

2015 Formulary (List of Covered Drugs)

2015 Formulary (List of Covered Drugs) MedStar Medicare Choice (HMO) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00015465,

More information

Empire MediBlue Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: ,

Empire MediBlue Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: , Empire MediBlue Select (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent

More information

Anthem MediBlue Access (PPO) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.

Anthem MediBlue Access (PPO) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem. Anthem MediBlue Access (PPO) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on November, 07. For more

More information

Amerivantage Dual Coordination (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP)

Amerivantage Dual Coordination (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP) Amerivantage Dual Coordination (H SNP) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08.

More information

2018 List of Covered Drugs (Formulary)

2018 List of Covered Drugs (Formulary) 208 List of Covered Drugs (Formulary) UCare s MSHO and UCare Connect + Medicare This is a list of drugs that members can get in UCare s MSHO and UCare Connect + Medicare. UCare s MSHO and UCare Connect

More information

List of Covered Drugs (Formulary)

List of Covered Drugs (Formulary) List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 7/1/2018. Member Services: 1-855-878-1784 (TTY 711)

More information

<2017> Formulary (List (List of of Covered Drugs)

<2017> Formulary (List (List of of Covered Drugs) < Logo (flush upper left corner /8 x /8 margins)> Anthem Dual Advantage (H SNP) Formulary (List (List of of Covered s) Please read: This document contains information

More information

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold $0 Deductible Rx 018 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on January,

More information

Provider Partners Illinois Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs)

Provider Partners Illinois Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs) Provider Partners Illinois Advantage Plan (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19547, Version

More information

Prescription Drug Formulary

Prescription Drug Formulary 019 Prescription Drug Formulary Essence Advantage (HMO) Essence Advantage Select (HMO) Serving the St. Louis area and Boone County, Missouri This formulary was updated on 08/3/018. For more recent information

More information

2018 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP)

2018 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP) Medicare GenerationRx (Employer PDP) 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 10/01/017.

More information

Anthem MediBlue Select (HMO) 2016 Formulary (List of Covered Drugs)

Anthem MediBlue Select (HMO) 2016 Formulary (List of Covered Drugs) Anthem MediBlue Select (H) 06 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 06. For more recent

More information

(List of Covered Drugs)

(List of Covered Drugs) Amerivantage (H) Formulary Formulary (List of Covered s) (List of Covered s) Please read: read: This This document document

More information

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold $0 Deductible Rx 018 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on August

More information

<2017> Formulary (List (List of of Covered Drugs)

<2017> Formulary (List (List of of Covered Drugs) < Logo (flush upper left corner /8 x /8 margins)> Anthem Access (Regional PPO) Formulary (List (List of of Covered s) Please read: This document contains information

More information

Superior Select Health Plans Formulary. (List of Covered Drugs)

Superior Select Health Plans Formulary. (List of Covered Drugs) Superior Select Health Plans 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 18379, Version Number 6 This formulary

More information

Anthem MediBlue Dual Advantage (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.

Anthem MediBlue Dual Advantage (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem. Anthem MediBlue Dual Advantage (H SNP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on June, 08. For

More information

H0544_058, 059, 066, 067

H0544_058, 059, 066, 067 Anthem MediBlue Select (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent

More information

Prescription Drug Formulary

Prescription Drug Formulary 019 Prescription Drug Formulary This formulary was updated on 11/07/018. For more recent information or other questions, please contact CoxHealth MedicarePlus Customer Service at 1-866-597-9560 or, for

More information

Anthem MediBlue Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: ,

Anthem MediBlue Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: , Anthem MediBlue Plus (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent

More information

Superior Select Health Plans Formulary. (List of Covered Drugs)

Superior Select Health Plans Formulary. (List of Covered Drugs) Superior Select Health Plans 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 18379, Version Number 14 This formulary

More information

2019 Comprehensive Formulary

2019 Comprehensive Formulary 2019 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 02/28/2019. For more recent information

More information

Amerivantage Classic (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO)

Amerivantage Classic (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO) Amerivantage Classic (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on September, 08. For more recent

More information

(List of Covered Drugs)

(List of Covered Drugs) Superior Select Health Plans H-POS SNP 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19550, Version Number 5

More information

Amerivantage Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Select (HMO)

Amerivantage Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Select (HMO) Amerivantage Select (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent

More information

Health First Health Plans 2016 Formulary (List of Covered Drugs)

Health First Health Plans 2016 Formulary (List of Covered Drugs) Updated: November 1, 2016 Florida Hospital SunSaver Plan (HMO-POS) Florida Hospital Explorer Plan (HMO-POS) Health First Health Plans 2016 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS

More information

Anthem MediBlue Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: ,

Anthem MediBlue Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: , Anthem MediBlue Plus (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on March, 09. For more recent

More information

Anthem MediBlue Coordination Plus (HMO) 2018 Formulary (List of Covered Drugs) Please read: ,

Anthem MediBlue Coordination Plus (HMO) 2018 Formulary (List of Covered Drugs) Please read: , Anthem MediBlue Coordination Plus (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08.

More information

2018 MEDICARE PART D DRUG FORMULARY EmblemHealth HMO 5-Tier Comprehensive Medication List

2018 MEDICARE PART D DRUG FORMULARY EmblemHealth HMO 5-Tier Comprehensive Medication List 2018 MEDICARE PART D DRUG FORMULARY EmblemHealth HMO 5-Tier Comprehensive Medication List This comprehensive formulary was updated on 09/13/2017. For more recent information or other questions, please

More information

Empire MediBlue Plus (HMO) 2018 Formulary (List of Covered Drugs) Please read: ,

Empire MediBlue Plus (HMO) 2018 Formulary (List of Covered Drugs) Please read: , Empire MediBlue Plus (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08. For more recent

More information

Amerivantage Classic (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO)

Amerivantage Classic (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO) Amerivantage Classic (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on January, 09. For more recent

More information

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold $0 Deductible Rx 017 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on August

More information

H0544_058, 059, 066, 067, 069

H0544_058, 059, 066, 067, 069 Anthem MediBlue Select (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on July, 08. For more recent

More information

S5596_003, 007, 015, 019, 058

S5596_003, 007, 015, 019, 058 Anthem Blue MedicareRx Premier (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 08. For more

More information

2018 Sharp Direct Advantage TM Comprehensive Drug List

2018 Sharp Direct Advantage TM Comprehensive Drug List 018 Sharp Direct Advantage TM Comprehensive Drug List Sharp Health Plan: Off Exchange Drug List List of covered drugs for Employer sponsored plans July 017 Sharp Health Plan 018 Formulary (List of Covered

More information

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

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

More information

Amerivantage Classic (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO)

Amerivantage Classic (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO) Amerivantage Classic (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent

More information

Geisinger Gold Standard Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold Standard Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold Standard Rx 208 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on December

More information

Anthem MediBlue Access (PPO) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.

Anthem MediBlue Access (PPO) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem. Anthem MediBlue Access (PPO) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on June, 08. For more recent

More information

2019 Formulary (List of Covered Drugs)

2019 Formulary (List of Covered Drugs) MEDICARE ADVANTAGE PLANS 2019 Formulary (List of Covered Drugs) Presbyterian Senior Care (HMO) Presbyterian Senior Care (HMO-POS) Presbyterian MediCare PPO Please Read: This document contains information

More information

Anthem Heart (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: This document contains information about the drugs we cover in this plan.

Anthem Heart (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: This document contains information about the drugs we cover in this plan. Anthem Heart (H SNP) 019 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October 1, 018. For more recent

More information

2018 List of Covered Drugs (Formulary)

2018 List of Covered Drugs (Formulary) 208 List of Covered Drugs (Formulary) UCare s MSHO and UCare Connect + Medicare This is a list of drugs that members can get in UCare s MSHO and UCare Connect + Medicare. UCare s MSHO and UCare Connect

More information

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold $0 Deductible Rx 016 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/9/16.

More information

Geisinger Gold Triple Tier Employer Group Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold Triple Tier Employer Group Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold Triple Tier Employer Group Rx 018 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was

More information

201 F L L A A HI N N AIN INF A I N A H IN HI LAN H A F F I N 8 10/09/2018 F H H H

201 F L L A A HI N N AIN INF A I N A H IN HI LAN H A F F I N 8 10/09/2018 F H H H P H 東華 01 F L H L A A HI N N AIN INF A I N A H IN HI LAN H A F F I 0001958 N 8 10/09/018 F H 1 888 775 7888 1 877 81 88 8 8 00 8 00 H H H0571_01 _11_FINAL_ Note to existing members: This formulary has

More information

Provider Partners Health Plan of Ohio (HMO SNP) 2019 Formulary (List of Covered Drugs)

Provider Partners Health Plan of Ohio (HMO SNP) 2019 Formulary (List of Covered Drugs) Provider Partners Health Plan of Ohio (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19582, Version 5

More information

2018 Sharp Direct Advantage TM Comprehensive Drug List

2018 Sharp Direct Advantage TM Comprehensive Drug List 018 Sharp Direct Advantage TM Comprehensive Drug List List of covered drugs for Sharp Direct Advantage Gold Card (HMO) & Sharp Direct Advantage Platinum Card (HMO) Sharp Direct Advantage Gold Card (HMO)

More information

2016 MEDICARE PART D DRUG FORMULARY

2016 MEDICARE PART D DRUG FORMULARY 2016 MEDICARE PART D DRUG FORMULARY 1199SEIU EmblemHealth VIP Medicare Plan Abridged Medication List This abridged formulary was updated on 11/01/2016. This is not a complete list of drugs covered by our

More information

Geisinger Gold Standard Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold Standard Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold Standard Rx 208 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on July,

More information

Geisinger Gold $0 Deductible Rx Formulary. (List of Covered Drugs)

Geisinger Gold $0 Deductible Rx Formulary. (List of Covered Drugs) Geisinger Gold $0 Deductible Rx 019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on January 1, 019.

More information

Amerivantage Dual Coordination (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP)

Amerivantage Dual Coordination (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP) Amerivantage Dual Coordination (H SNP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on June, 08. For

More information

This formulary was updated on May 1, For more recent information

This formulary was updated on May 1, For more recent information Amerivantage ESRD (H-POS SNP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 08. For more recent

More information

Amerivantage Classic (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO)

Amerivantage Classic (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO) Amerivantage Classic (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on November, 07. For more recent

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) MEDICARE ADVANTAGE PLANS 2018 Formulary (List of Covered Drugs) Presbyterian Dual Plus (HMO SNP) Please Read: This document contains information about the drugs we cover in this plan. HPMS Approved Formulary

More information

Senior Care Plus Formulary. (List of Covered Drugs)

Senior Care Plus Formulary. (List of Covered Drugs) Senior Care Plus 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: 180 Version Number:

More information

GuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan

GuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan GuildNet Gold Medicare Advantage Prescription Drug Plan Formulary 2018 This formulary was updated on 07/31/2017. For more recent information or other questions, please contact the Plan at 1-800-815-0000

More information

Amerivantage Balance (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Balance (HMO)

Amerivantage Balance (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Balance (HMO) Amerivantage Balance (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08. For more recent

More information

Senior Care Plus Formulary - MAPD. (List of Covered Drugs)

Senior Care Plus Formulary - MAPD. (List of Covered Drugs) Senior Care Plus 2018 Formulary - MAPD (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: 180 Version

More information

CCH Senior Select ro r H S

CCH Senior Select ro r H S P 9 CCH Senior Select ro r H S 東華 H S 9 or l r i t o Co ere r S H S C C S H S C H S H S ro e or l r ile S i ion 009536 er ion er 7 i or l r te on 08/23/208 or ore recent in or tion or ot er e tion le e

More information

EnvisionRxPlus Formulary. (List of Covered Drugs)

EnvisionRxPlus Formulary. (List of Covered Drugs) EnvisionRxPlus 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission 18365, Version Number

More information

OPTIMA MEDICARE. OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs

OPTIMA MEDICARE. OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs OPTIMA MEDICARE OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File

More information