What is the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Abridged Formulary?

Transcription

1 CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 019 Abridged Formulary Partial List of Covered s PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID , Version Number 8. This abridged formulary was updated on 0/7/019. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Member Services, at or, for TTY users, 711, 8 a.m. 8 p.m. local time, seven days a week, from October 1 March 31, and 8 a.m. 8 p.m. local time, Monday Friday, from April 1- September 30, or visit christushealthplan.org. H1189_MC133_C 0/8/019 1

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO). When it refers to plan or our plan, it means CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO). This document includes a partial list of the drugs (formulary) for our plan, which is current as of 03/01/019. For a complete updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 00, and from time to time during the year. What is the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Abridged Formulary? A formulary is a list of covered drugs selected by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. This document is a partial formulary and includes only some of the drugs covered by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO). For a complete listing of all prescription drugs covered by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO), please visit our website or call us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

3 Can the Formulary (drug list) change? Generally, if you are taking a drug on our 019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 019 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary? s removed from the market. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. The enclosed formulary is current as of 03/01/019. To get updated information about the drugs covered by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO), please contact us. Our contact information appears on the front and back cover pages. 3

4 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 9. 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, antihypertensive therapy. If you know what your drug is used for, look for the category name in the list that begins on page number 9. 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 66. 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? CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) 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, CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) may not cover the drug. Quantity Limits: For certain drugs, CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) limits the amount of the drug that we will cover. For example, we provide 31 tablets per prescription for AFINITOR. This may be in addition to a standard onemonth or three-month supply. Step Therapy: In some cases, CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) 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. 4

5 You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explain our prior authorization restriction, step therapy restriction, prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) 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 CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) formulary? on page 5 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) may cover your drug. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you learn that we do not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by us. You can ask CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary? You can ask CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level [if this drug is not on the specialty tier]. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. 5

6 Generally, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, [the lower cost-sharing drug] or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31 day emergency supply of that drug while you pursue a formulary exception. Enrollees whose transition window has expired and are either being admitted to a LTC setting or being discharged from a long term care setting are provided an additional transition fill due to that level of care change. While the claim will initially reject as the member is no longer transition eligible according to plan enrollment dates, the pharmacist is instructed to enter an override code to allow the transition supply to process accordingly. Early refill edits are not applied in a long term care setting. 6

7 For more information For more detailed information about your CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call 711. Or, visit CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary The abridged formulary below provides coverage information about some of the drugs covered by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on page 66. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AFINITOR) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the column tells you if we have any special requirements for coverage of your drug. Remember: This is only a partial list of drugs covered by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO). If your prescription is not in this partial formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. 7

8 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try 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. Number Name Copay for a one-month supply filled at a network pharmacy with standard cost-sharing 1 Preferred Generic $4 Generic $10 3 Preferred Brand $35 4 Non-Preferred Brand $90 5 Specialty You pay 9% of the total cost 8

9 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 5 B/D PA; MO AMBISOME 5 B/D PA; MO amphotericin b 4 B/D PA; MO caspofungin 5 B/D PA clotrimazole mucous membrane MO CRESEMBA ORAL fluconazole MO fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/00 ml MO flucytosine griseofulvin microsize griseofulvin ultramicrosize MO MO itraconazole MO ketoconazole oral MO MYCAMINE NOXAFIL ORAL nystatin oral suspension MO nystatin oral tablet MO SPORANOX ORAL SOLUTION terbinafine hcl oral MO voriconazole intravenous MO voriconazole oral ANTIVIRALS abacavir MO abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 00 mg/5 ml MO MO acyclovir oral tablet MO acyclovir sodium intravenous solution 4 B/D PA; MO adefovir amantadine hcl MO APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 150 mg, 00 mg atazanavir oral capsule 300 mg 5 MO ATRIPLA BARACLUDE ORAL SOLUTION BIKTARVY CIMDUO COMPLERA 9

10 CRIXIVAN ORAL CAPSULE 00 MG, 400 MG DELSTRIGO DESCOVY didanosine oral capsule,delayed release(dr/ec) 00 mg, 50 mg, 400 mg MO EDURANT efavirenz oral capsule 00 mg efavirenz oral capsule 50 mg MO efavirenz oral tablet EMTRIVA entecavir EPCLUSA (8 per 8 EPIVIR HBV ORAL SOLUTION EVOTAZ famciclovir MO fosamprenavir FUZEON RECON SOLN GENVOYA HARVONI (8 per 8 INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ORAL TABLET 10 ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 100 MG ISENTRESS ORAL TABLET,CHEWAB LE 5 MG JULUCA KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine MO lamivudinezidovudine LEXIVA ORAL SUSPENSION MO lopinavir-ritonavir MO moderiba MO moderiba oral tablets,dose pack mg (8)-mg (8) nevirapine oral tablet nevirapine oral tablet extended release 4 hr MO MO

11 NORVIR ORAL POWDER IN PACKET NORVIR ORAL SOLUTION ODEFSEY oseltamivir MO PIFELTRO PREVYMIS ORAL ; QL (30 per 30 PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG RELENZA DISKHALER RESCRIPTOR REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 00 mg (7)- 400 mg (7) MO MO ribasphere ribapak oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8), mg (8)-mg (8) ribavirin oral capsule ribavirin oral tablet 00 mg MO MO rimantadine MO ritonavir MO SELZENTRY stavudine oral capsule MO STRIBILD SYMFI SYMFI LO SYMTUZA tenofovir disoproxil fumarate TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 5 MG, 50 MG TRIUMEQ TRUVADA valacyclovir oral tablet 1 gram valacyclovir oral tablet 500 mg MO; QL (10 per 30 MO; QL (60 per 30 valganciclovir VEMLIDY 11

12 VIDEX 4 GRAM PEDIATRIC VIDEX EC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 15 MG VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION VIREAD ORAL POWDER VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG 4 MO 4 MO XOFLUZA zidovudine MO CEPHALOSPORINS cefaclor oral capsule MO cefaclor oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml cefaclor oral suspension for reconstitution 375 mg/5 ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml MO MO MO MO 1 cefadroxil oral tablet MO cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram MO cefdinir MO cefepime injection MO cefixime MO cefotaxime injection recon soln 1 gram, 500 mg cefotetan injection cefoxitin intravenous recon soln 1 gram, gram cefoxitin intravenous recon soln 10 gram MO cefpodoxime MO cefprozil MO ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln 6 gram ceftriaxone injection recon soln 1 gram, gram, 50 mg, 500 mg ceftriaxone injection recon soln 10 gram cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg MO MO MO MO

13 cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime sodium intravenous recon soln 7.5 gram MO cephalexin MO SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 4 MO 4 4 MO TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 600 mg azithromycin oral tablet 500 mg (3 pack) MO MO MO MO clarithromycin MO e.e.s. 400 oral tablet MO ery-tab oral tablet,delayed release (dr/ec) 50 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES MO MO MO MO MO MO ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 500 mg/ ml MO ARIKAYCE 5 PA; MO; LA 13

14 atovaquone atovaquoneproguanil aztreonam injection recon soln 1 gram BENZNIDAZOLE 3 MO MO BETHKIS 5 B/D PA; MO; QL (4 per 8 CAYSTON ; LA; QL (84 per 8 chloroquine phosphate MO clindamycin hcl MO clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin phosphate injection clindamycin phosphate intravenous solution 600 mg/4 ml MO MO MO COARTEM colistin (colistimethate na) MO dapsone oral MO DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG daptomycin intravenous recon soln 500 mg 3 DARAPRIM 5 PA; MO EMVERM ertapenem MO ethambutol MO gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 80 mg/100 ml gentamicin injection solution 40 mg/ml MO MO hydroxychloroquine MO imipenem-cilastatin MO INVANZ INJECTION 4 MO isoniazid oral MO ivermectin MO linezolid linezolid in dextrose 5% mefloquine MO meropenem MO metronidazole in nacl (iso-os) 5 MO metronidazole oral MO NEBUPENT 3 B/D PA; MO; QL (1 per 8 neomycin MO paromomycin 4 MO PASER 14

15 PENTAM 4 MO polymyxin b sulfate MO PRIFTIN PRIMAQUINE pyrazinamide MO quinine sulfate MO rifabutin MO rifampin MO SIRTURO ; LA STREPTOMYCIN tigecycline 5 tinidazole MO tobramycin in 0.5 % nacl tobramycin sulfate injection solution 5 B/D PA; MO; QL (80 per 8 MO TRECATOR vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg, 750 mg vancomycin oral capsule 15 mg vancomycin oral capsule 50 mg XIFAXAN ORAL TABLET 00 MG XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule MO MO ; QL (9 per 30 ; QL (90 per 30 MO amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15 mg, 50 mg amoxicillin-pot clavulanate ampicillin oral capsule 500 mg ampicillin sodium injection recon soln 1 gram, 10 gram, 15 mg ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML MO MO MO MO MO MO MO BICILLIN C-R BICILLIN L-A dicloxacillin MO nafcillin injection recon soln 1 gram, gram nafcillin injection recon soln 10 gram MO 15

16 oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml oxacillin injection recon soln 1 gram oxacillin injection recon soln 10 gram oxacillin injection recon soln gram penicillin g potassium injection recon soln 0 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml MO 5 MO MO MO penicillin g sodium MO penicillin v potassium piperacillintazobactam intravenous recon soln.5 gram, gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral MO MO MO MO ciprofloxacin in 5 % dextrose intravenous piggyback 00 mg/100 ml levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous MO MO MO levofloxacin oral MO moxifloxacin in nacl (iso-osm) moxifloxacin oral MO ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg MO SULFA'S / RELATED AGENTS sulfadiazine 4 MO sulfamethoxazoletrimethoprim oral TETRACYCLINES MO demeclocycline 4 MO doxy-100 MO doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 150 mg, 0 mg, 75 mg doxycycline monohydrate oral capsule MO MO MO 16

17 doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet mondoxyne nl oral capsule 100 mg, 75 mg morgidox oral capsule 50 mg MO MO MO MO MO MO tetracycline MO URINARY TRACT AGENTS methenamine hippurate MO nitrofurantoin MO nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst MO MO trimethoprim MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS leucovorin calcium oral MO MESNEX ORAL XGEVA 5 B/D PA; MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS abiraterone (10 per 30 AFINITOR (30 per 30 AFINITOR DISPERZ 5 PA; MO ALECENSA (40 per 30 ALUNBRIG ORAL TABLET 180 MG, 90 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLETS,DOSE PACK (30 per 30 (60 per 30 (30 per 30 anastrozole MO azathioprine B/D PA; MO bexarotene 5 PA; MO bicalutamide MO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 400 MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG BRAFTOVI ORAL CAPSULE 75 MG (90 per 30 (30 per 30 5 PA; MO; LA; QL (10 per 30 5 PA; MO; LA; QL (180 per 30 CABOMETYX 5 PA; MO; LA 17

18 CALQUENCE 5 PA; MO; LA; QL (60 per 30 CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG 5 PA; MO; LA; QL (60 per 30 5 PA; MO; LA; QL (30 per 30 COMETRIQ 5 PA; MO COPIKTRA 5 PA; MO; LA COTELLIC 5 PA; MO; LA; QL (63 per 8 cyclophosphamide oral capsule cyclosporine modified cyclosporine oral capsule B/D PA; MO B/D PA; MO B/D PA; MO DAURISMO 5 PA; MO DROXIA EMCYT ERIVEDGE (30 per 30 ERLEADA 5 PA; MO exemestane MO FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 0 MG (1 per 1 (6 per 1 FIRMAGON KIT W DILUENT SYRINGE RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE RECON SOLN 80 MG 5 B/D PA; MO 3 B/D PA; MO flutamide MO gengraf oral capsule 100 mg, 5 mg B/D PA; MO gengraf oral solution B/D PA; MO GILOTRIF (30 per 30 GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG hydroxyurea MO IBRANCE (1 per 8 ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG (60 per 30 (30 per 30 IDHIFA 5 PA; MO; LA; QL (30 per 30 imatinib oral tablet 100 mg (180 per 30 18

19 imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE 140 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG (60 per 30 (10 per 30 (30 per 30 (30 per 30 (180 per 30 (10 per 30 IRESSA (30 per 30 JAKAFI (60 per 30 KISQALI 5 PA; MO KISQALI FEMARA CO-PACK 5 PA; MO LENVIMA 5 PA; MO letrozole MO LEUKERAN leuprolide subcutaneous kit LONSURF 5 PA; MO LORBRENA 5 PA; MO LUPRON DEPOT 5 PA; MO LUPRON DEPOT (NTH) 5 PA; MO LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LYNPARZA ORAL TABLET 5 PA; MO 5 PA; MO (10 per 30 LYSODREN MATULANE megestrol oral suspension 400 mg/10 ml (40 mg/ml), 65 mg/5 ml PA; MO megestrol oral tablet PA; MO MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET MG (90 per 30 (30 per 30 MEKTOVI 5 PA; MO; LA; QL (180 per 30 mercaptopurine MO methotrexate sodium B/D PA; MO methotrexate sodium (pf) injection solution mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium B/D PA; MO B/D PA; MO 5 B/D PA; MO B/D PA; MO B/D PA; MO 19

20 NERLYNX 5 PA; MO; LA NEXAVAR 5 PA; MO; LA; QL (10 per 30 nilutamide NINLARO ORAL CAPSULE.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml (6 per 8 (4 per 8 (3 per 8 MO ODOMZO 5 PA; MO; LA; QL (30 per 30 POMALYST 5 PA; MO; LA PURIXAN RAPAMUNE ORAL SOLUTION 5 B/D PA; MO REVLIMID 5 PA; MO; LA; QL (8 per 8 RUBRACA 5 PA; MO; LA; QL (10 per 30 RYDAPT 5 PA; MO SANDIMMUNE ORAL SOLUTION 3 B/D PA; MO SIGNIFOR sirolimus oral tablet 0.5 mg, 1 mg B/D PA; MO sirolimus oral tablet mg 0 5 B/D PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 0 MG SPRYCEL ORAL TABLET 70 MG (30 per 30 (90 per 30 (60 per 30 STIVARGA (84 per 8 SUTENT (30 per 30 SYNRIBO 5 B/D PA; MO TABLOID tacrolimus oral B/D PA; MO TAFINLAR (10 per 30 TAGRISSO 5 PA; MO; LA; QL (30 per 30 TALZENNA 5 PA; MO tamoxifen MO TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 5 MG (30 per 30 (60 per 30

21 TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 150 MG, 00 MG TASIGNA ORAL CAPSULE 50 MG 5 PA; MO (11 per 8 (10 per 30 THALOMID 5 PA; MO TIBSOVO 5 PA; MO TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N tretinoin (chemotherapy) 5 B/D PA; MO TYKERB 5 PA; MO; LA; QL (180 per 30 VENCLEXTA ORAL TABLET 10 MG, 50 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK 3 PA; MO; LA 5 PA; MO; LA 5 PA; MO; LA; QL (4 per 180 VERZENIO 5 PA; MO; LA; QL (60 per 30 VITRAKVI 5 PA; MO; LA VIZIMPRO (30 per 30 VOTRIENT (10 per 30 XALKORI (60 per 30 XATMEP 5 B/D PA; MO XERMELO 5 PA; MO; LA; QL (90 per 30 XOSPATA 5 PA; MO; LA XTANDI (10 per 30 YONSA (10 per 30 ZEJULA 5 PA; MO; LA; QL (90 per 30 ZELBORAF (40 per 30 ZOLINZA ZORTRESS 5 B/D PA; MO ZYDELIG (60 per 30 ZYKADIA (150 per 30 ZYTIGA ORAL TABLET 50 MG ZYTIGA ORAL TABLET 500 MG (10 per 30 (60 per 30 1

22 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 00 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG 4 MO BANZEL BRIVIACT INTRAVENOUS BRIVIACT ORAL carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clobazam oral suspension 4 MO MO MO PA; MO; QL (480 per 30 clobazam oral tablet PA; MO; QL (60 per 30 clonazepam oral tablet 0.5 mg, 1 mg PA; MO; QL (90 per 30 clonazepam oral tablet mg clonazepam oral tablet,disintegrating 0.15 mg, 0.5 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating mg PA; MO; QL (300 per 30 PA; MO; QL (90 per 30 PA; MO; QL (300 per 30 DIASTAT 4 MO DIASTAT ACUDIAL 4 MO DILANTIN 30 MG divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 4 hr divalproex oral tablet,delayed release (dr/ec) MO MO EPIDIOLEX 5 PA; MO; LA epitol MO ethosuximide MO felbamate oral suspension felbamate oral tablet MO FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 100 mg 1 PA; MO; QL (1080 per 30

23 gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 50 mg/5 ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg lamotrigine oral tablet lamotrigine oral tablet extended release 4hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 4 hr LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 50 MG, 75 MG 1 PA; MO; QL (360 per 30 1 PA; MO; QL (70 per 30 PA; MO; QL (160 per 30 1 PA; MO; QL (180 per 30 1 PA; MO; QL (10 per 30 4 MO MO 4 MO MO MO MO MO 3 PA; MO; QL (90 per 30 LYRICA ORAL CAPSULE 5 MG, 300 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 0 MG 3 3 PA; MO; QL (60 per 30 3 PA; MO; QL (900 per 30 (480 per 30 (60 per 30 oxcarbazepine MO PEGANONE phenobarbital PA; MO phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended MO MO MO primidone MO roweepra MO roweepra xr MO SABRIL ORAL TABLET ; LA SPRITAM 4 MO tiagabine 4 MO topiramate oral capsule, sprinkle topiramate oral tablet PA; MO 1 PA; MO valproic acid MO valproic acid (as sodium salt) oral solution 50 mg/5 ml MO

24 vigabatrin oral powder in packet VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ; LA zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA benztropine oral PA; MO bromocriptine 4 MO carbidopa MO carbidopa-levodopa MO 4 MO entacapone MO NEUPRO 4 MO pramipexole MO rasagiline MO ropinirole MO selegiline hcl MO tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine nasal MO; QL (8 per 8 eletriptan MO; QL (18 per 8 ergotamine-caffeine MO migergot MO naratriptan MO; QL (18 per 8 rizatriptan MO; QL (36 per 8 sumatriptan nasal spray,non-aerosol 0 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml carbidopa-levodopaentacapone sumatriptannaproxen MO; QL (18 per 8 MO; QL (36 per 8 MO; QL (18 per 8 MO; QL (8 per 8 MO; QL (8 per 8 MO; QL (8 per 8 MO; QL (8 per 8 MO; QL (18 per 8 zolmitriptan MO; QL (18 per 8 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA dalfampridine 5 PA; MO donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 3 mg donepezil oral tablet,disintegrating 4 MO 4

25 galantamine MO GILENYA ORAL CAPSULE 0.5 MG glatiramer subcutaneous syringe 0 mg/ml glatiramer subcutaneous syringe 40 mg/ml glatopa subcutaneous syringe 0 mg/ml glatopa subcutaneous syringe 40 mg/ml memantine oral capsule,sprinkle,er 4hr memantine oral solution memantine oral tablet 5 PA; MO (30 per 30 (1 per 8 (30 per 30 (1 per 8 PA; MO PA; MO PA; MO NAMZARIC 3 PA; MO NUEDEXTA 3 PA; MO rivastigmine MO rivastigmine tartrate MO TECFIDERA 5 PA; MO; LA tetrabenazine oral tablet 1.5 mg tetrabenazine oral tablet 5 mg (40 per 30 (10 per 30 MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral tablet 10 mg, 0 mg MO cyclobenzaprine oral tablet 5 4 PA; MO dantrolene MO MESTINON ORAL SYRUP pyridostigmine bromide MO tizanidine MO NARCOTIC ANALGESICS acetaminophencodeine oral solution 10-1 mg/5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg buprenorphine hcl sublingual buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg, 5-35 mg, mg MO; QL (4500 per 30 MO; QL (360 per 30 MO; QL (180 per 30 MO PA; MO; QL (4 per 8 MO; QL (4000 per 30 QL (000 per 30 MO; QL (360 per 30 fentanyl citrate (10 per 30

26 fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr fentanyl transdermal patch 7 hour 87.5 mcg/hour hydrocodoneacetaminophen oral solution mg/15 ml hydrocodoneacetaminophen oral tablet mg, mg, mg hydrocodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg hydrocodoneibuprofen oral tablet mg, 5-00 mg, mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml hydromorphone injection syringe mg/ml hydromorphone oral liquid hydromorphone oral tablet PA; MO; QL (10 per 30 (10 per 30 MO; QL (5550 per 30 MO; QL (390 per 30 MO; QL (360 per 30 MO; QL (50 per 30 MO; QL (40 per 30 QL (100 per 30 MO; QL (400 per 30 MO; QL (180 per 30 hydromorphone oral tablet extended release 4 hr 1 mg, 8 mg hydromorphone oral tablet extended release 4 hr 16 mg, 3 mg PA; MO; QL (60 per 30 (60 per 30 ibuprofen-oxycodone MO; QL (8 per 30 levorphanol tartrate oral tablet mg MO; QL (10 per 30 lorcet (hydrocodone) MO; QL (360 per 30 lorcet hd MO; QL (360 per 30 lorcet plus oral tablet mg methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg morphine concentrate oral solution morphine injection syringe 10 mg/ml morphine injection syringe mg/ml morphine injection syringe 4 mg/ml MO; QL (360 per 30 PA; MO; QL (600 per 30 PA; MO; QL (100 per 30 PA; MO; QL (10 per 30 PA; MO; QL (40 per 30 MO; QL (900 per 30 MO; QL (00 per 30 MO; QL (1000 per 30 MO; QL (500 per 30 6

27 morphine injection syringe 5 mg/ml morphine injection syringe 8 mg/ml morphine oral capsule, er multiphase 4 hr morphine oral capsule,extend.relea se pellets morphine oral solution QL (400 per 30 QL (50 per 30 PA; MO; QL (60 per 30 PA; MO; QL (90 per 30 MO; QL (900 per 30 morphine oral tablet MO; QL (180 per 30 morphine oral tablet extended release oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 0 mg, 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg PA; MO; QL (10 per 30 MO; QL (360 per 30 MO; QL (180 per 30 MO; QL (100 per 30 MO; QL (180 per 30 MO; QL (360 per 30 MO; QL (360 per 30 oxycodone-aspirin MO; QL (360 per 30 oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg MO; QL (360 per 30 MO; QL (180 per 30 7 vicodin MO; QL (390 per 30 vicodin es MO; QL (390 per 30 vicodin hp MO; QL (390 per 30 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet -0.5 mg buprenorphinenaloxone sublingual tablet 8- mg butorphanol tartrate nasal MO; QL (360 per 30 MO; QL (90 per 30 MO; QL (10 per 8 celecoxib MO diclofenac potassium MO diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel 1 % diclofenacmisoprostol MO MO; QL (300 per 8 MO; QL (1000 per 8 MO diflunisal MO etodolac MO fenoprofen oral tablet MO flurbiprofen MO ibu oral tablet 600 mg, 800 mg ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg MO

28 ketoprofen oral capsule 5 mg ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg MO meclofenamate MO mefenamic acid MO meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg ; QL (30 per 30 nabumetone MO naloxone MO naltrexone MO naproxen oral suspension MO naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 75 mg, 550 mg naproxen sodium oral tablet, er multiphase 4 hr NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION MO MO MO oxaprozin MO piroxicam MO profeno SUBOXONE SUBLINGUAL FILM 1-3 MG ; QL ( per 8 ; QL (60 per 30 SUBOXONE SUBLINGUAL FILM -0.5 MG SUBOXONE SUBLINGUAL FILM 4-1 MG, 8- MG ; QL (360 per 30 ; QL (90 per 30 sulindac tolmetin oral capsule MO tolmetin oral tablet 600 mg MO tramadol oral tablet MO; QL (40 per 30 tramadolacetaminophen MO; QL (40 per 30 VIVITROL PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA amitriptyline PA; MO amoxapine PA; MO aripiprazole oral solution aripiprazole oral tablet aripiprazole oral tablet,disintegrating MO; QL (30 per 30 ; QL (60 per 30 ARISTADA armodafinil 4 PA; MO atomoxetine MO bupropion hcl oral tablet bupropion hcl oral tablet extended release 4 hr 150 mg MO; QL (90 per 30 8

29 bupropion hcl oral tablet extended release 4 hr 300 mg bupropion hcl oral tablet sustainedrelease 1 hr MO; QL (30 per 30 MO; QL (60 per 30 buspirone MO chlorpromazine oral MO citalopram oral solution citalopram oral tablet MO ; QL (30 per 30 clomipramine 4 PA; MO clonidine hcl oral tablet extended release 1 hr clorazepate dipotassium oral tablet 15 mg clorazepate dipotassium oral tablet 3.75 mg clorazepate dipotassium oral tablet 7.5 mg MO PA; MO; QL (180 per 30 PA; MO; QL (90 per 30 PA; MO; QL (360 per 30 clozapine oral tablet MO clozapine oral tablet,disintegrating 100 mg, 1.5 mg, 5 mg desipramine PA; MO desvenlafaxine succinate dextroamphetamineamphetamine MO; QL (30 per 30 MO diazepam intensol PA; MO; QL (40 per 30 diazepam oral solution 5 mg/5 ml (1 mg/ml) PA; MO; QL (100 per 30 diazepam oral tablet PA; MO; QL (10 per 30 doxepin oral 4 PA; MO duloxetine oral capsule,delayed release(dr/ec) 0 mg, 30 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg MO; QL (60 per 30 MO; QL (90 per 30 EMSAM ergoloid 4 MO escitalopram oxalate oral solution escitalopram oxalate oral tablet MO ; QL (30 per 30 eszopiclone 4 ST; MO; QL (30 per 30 FANAPT ORAL TABLET 1 MG, MG, 4 MG FANAPT ORAL TABLET 10 MG, 1 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 150 MG, 00 MG 4 MO; QL (60 per 30 ; QL (60 per 30 4 MO; QL (8 per 8 4 9

30 FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 4 HR fluoxetine oral capsule 10 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 0 mg, 60 mg fluphenazine decanoate 4 MO; QL (8 per 8 4 MO; QL (30 per 30 ; QL (30 per 30 ; QL (60 per 30 MO; QL (4 per 8 MO MO; QL (30 per 30 MO MO fluphenazine hcl MO fluvoxamine oral capsule,extended release 4hr fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 5 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULA R 4 MO; QL (60 per 30 MO; QL (90 per 30 MO; QL (30 per 30 MO; QL (60 per 30 4 MO guanidine MO haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate intramuscular haloperidol lactate oral MO MO MO HETLIOZ (30 per 30 imipramine hcl 4 PA; MO imipramine pamoate 4 PA; MO INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 34 MG/1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.5 ML 4 MO INVEGA TRINZA KHEDEZLA ORAL TABLET EXTENDED RELEASE 4HR 100 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 4HR 50 MG 4 MO; QL (10 per 30 4 MO; QL (30 per 30 30

31 LATUDA ORAL TABLET 10 MG, 0 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG ; QL (30 per 30 ; QL (60 per 30 lithium carbonate lithium citrate oral solution 8 meq/5 ml lorazepam oral concentrate lorazepam oral tablet 0.5 mg, 1 mg lorazepam oral tablet mg MO PA; MO; QL (150 per 30 PA; MO; QL (90 per 30 PA; MO; QL (150 per 30 loxapine succinate MO maprotiline MO MARPLAN metadate er MO methylphenidate hcl oral capsule,er biphasic methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release methylphenidate hcl oral tablet,chewable mirtazapine oral tablet mirtazapine oral tablet,disintegrating MO MO MO MO MO MO 31 modafinil PA; MO molindone nefazodone MO nortriptyline PA; MO NUPLAZID 5 PA; MO olanzapine intramuscular MO olanzapine oral MO; QL (30 per 30 olanzapinefluoxetine paliperidone oral tablet extended release 4hr 1.5 mg, 3 mg paliperidone oral tablet extended release 4hr 6 mg paliperidone oral tablet extended release 4hr 9 mg paroxetine hcl oral tablet 10 mg, 0 mg, 40 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet extended release 4 hr paroxetine mesylate(menop.sym ) PAXIL ORAL SUSPENSION MO MO; QL (30 per 30 MO; QL (60 per 30 ; QL (30 per 30 ; QL (30 per 30 ; QL (60 per 30 MO; QL (60 per 30 MO; QL (30 per 30 4 MO perphenazine MO PERSERIS phenelzine MO

32 pimozide MO procentra MO protriptyline MO quetiapine oral tablet 100 mg, 00 mg, 5 mg, 50 mg quetiapine oral tablet 300 mg, 400 mg quetiapine oral tablet extended release 4 hr 150 mg, 00 mg quetiapine oral tablet extended release 4 hr 300 mg, 400 mg, 50 mg MO; QL (90 per 30 MO; QL (60 per 30 MO; QL (30 per 30 MO; QL (60 per 30 REXULTI ; QL (30 per 30 RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 1.5 MG/ ML, 5 MG/ ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/ ML, 50 MG/ ML risperidone oral solution risperidone oral tablet 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg risperidone oral tablet 4 mg MO ; QL (60 per 30 ; QL (10 per 30 risperidone oral tablet,disintegrating 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg risperidone oral tablet,disintegrating 4 mg MO; QL (60 per 30 MO; QL (10 per 30 ROZEREM ; QL (30 per 30 SAPHRIS 4 MO; QL (60 per 30 sertraline oral concentrate sertraline oral tablet 100 mg, 50 mg sertraline oral tablet 5 mg MO ; QL (60 per 30 ; QL (30 per 30 thioridazine 4 MO thiothixene tranylcypromine 4 MO trazodone trifluoperazine MO trimipramine 4 PA; MO TRINTELLIX ; QL (30 per 30 venlafaxine oral capsule,extended release 4hr 150 mg, 37.5 mg venlafaxine oral capsule,extended release 4hr 75 mg venlafaxine oral tablet VIIBRYD ORAL TABLET MO; QL (30 per 30 MO; QL (90 per 30 MO; QL (90 per 30 ; QL (30 per 30 3

33 VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG (3) VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK ; QL (30 per 180 ; QL (30 per 30 4 MO; QL (7 per 30 XYREM 5 PA; MO; LA zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg 4 ST; MO; QL (60 per 30 4 ST; MO; QL (30 per 30 ziprasidone hcl MO; QL (60 per 30 zolpidem oral tablet ST; MO; QL (30 per 30 ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 10 MG CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral MO dofetilide MO flecainide MO mexiletine MO pacerone oral tablet 100 mg, 00 mg, 400 mg MO propafenone MO quinidine gluconate oral quinidine sulfate oral tablet sorine oral tablet 10 mg, 160 mg, 80 mg sorine oral tablet 40 mg sotalol af oral tablet 10 mg MO MO MO MO sotalol oral MO SOTYLIZE ANTIHYPERTENSIVE THERAPY acebutolol MO amiloride MO MO amlodipine MO MO MO atenolol MO benazepril amiloridehydrochlorothiazide amlodipinebenazepril amlodipineolmesartan amlodipinevalsartan amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide MO betaxolol oral MO 33

34 bisoprolol fumarate MO bumetanide MO candesartan MO MO captopril MO MO cartia xt MO carvedilol carvedilol phosphate MO chlorothiazide MO chlorthalidone oral tablet 5 mg, 50 mg clonidine 4 MO; QL (4 per 8 clonidine hcl oral tablet DEMSER 5 PA; MO diltiazem hcl oral capsule,extended release 1 hr diltiazem hcl oral capsule,extended release 4 hr 360 mg, 40 mg diltiazem hcl oral capsule,extended release 4hr 10 mg, 180 mg, 40 mg, 300 mg diltiazem hcl oral tablet MO MO MO dilt-xr MO doxazosin oral tablet 1 mg, mg, 4 mg doxazosin oral tablet 8 mg 34 ; QL (30 per 30 ; QL (60 per 30 enalapril maleate eplerenone MO eprosartan MO ethacrynic acid felodipine MO fosinopril MO furosemide injection MO furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet MO hydralazine oral MO hydrochlorothiazide indapamide MO irbesartan isradipine MO labetalol oral MO lisinopril losartan bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide lisinoprilhydrochlorothiazide losartanhydrochlorothiazide

35 matzim la MO methyclothiazide MO methyldopa MO metolazone MO metoprolol succinate metoprolol tartrate oral tablet 100 mg, 5 mg, 50 mg MO minoxidil oral MO moexipril MO nadolol MO MO nicardipine oral MO nifedipine oral tablet extended release nifedipine oral tablet extended release 4hr MO MO nimodipine MO nisoldipine MO olmesartan perindopril erbumine MO phenoxybenzamine 5 PA; MO pindolol MO prazosin MO propranolol oral capsule,extended release 4 hr propranolol oral solution propranolol oral tablet 35 MO MO MO quinapril MO ramipril spironolactone MO taztia xt MO TEKTURNA TEKTURNA HCT telmisartan MO terazosin oral capsule 1 mg, mg, 5 mg terazosin oral capsule 10 mg MO MO ; QL (30 per 30 ; QL (60 per 30 timolol maleate oral MO torsemide oral MO trandolapril metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide nadololbendroflumethiazide olmesartanamlodipin-hcthiazid olmesartanhydrochlorothiazide propranololhydrochlorothiazid quinaprilhydrochlorothiazide spironolactonhydrochlorothiaz telmisartanamlodipine telmisartanhydrochlorothiazid trandolaprilverapamil MO

36 triamterenehydrochlorothiazid oral capsule mg triamterenehydrochlorothiazid oral tablet UPTRAVI 5 PA; MO; LA valsartan verapamil oral capsule, 4 hr er pellet ct verapamil oral capsule,ext rel. pellets 4 hr 10 mg, 180 mg, 40 mg verapamil oral capsule,ext rel. pellets 4 hr 360 mg MO MO verapamil oral tablet verapamil oral tablet extended release MO COAGULATION THERAPY aspirin-dipyridamole MO BRILINTA cilostazol MO clopidogrel oral tablet 75 mg dipyridamole oral MO DOPTELET (10 TAB PACK) DOPTELET (15 TAB PACK) 5 PA; MO; LA 5 PA; MO; LA ELIQUIS enoxaparin subcutaneous syringe fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml fondaparinux subcutaneous syringe.5 mg/0.5 ml heparin (porcine) injection solution MO MO MO jantoven MULPLETA 5 PA; MO pentoxifylline MO PRADAXA 4 MO prasugrel MO PROMACTA ORAL TABLET 5 PA; MO; LA warfarin XARELTO LIPID/CHOLESTEROL LOWERING AGENTS valsartanhydrochlorothiazide amlodipineatorvastatin MO; QL (30 per 30 atorvastatin ; QL (30 per 30 cholestyramine (with sugar) oral powder in packet cholestyramine light oral powder MO MO colesevelam MO colestipol oral packet MO 36

37 colestipol oral tablet MO ezetimibe MO ezetimibesimvastatin fenofibrate micronized fenofibrate nanocrystallized oral tablet 145 mg, 48 mg fenofibrate oral tablet MO; QL (30 per 30 MO MO MO fenofibric acid MO fenofibric acid (choline) fluvastatin oral capsule 0 mg fluvastatin oral capsule 40 mg fluvastatin oral tablet extended release 4 hr MO MO; QL (30 per 30 MO; QL (60 per 30 MO; QL (30 per 30 gemfibrozil JUXTAPID 5 PA; MO; LA lovastatin oral tablet 10 mg lovastatin oral tablet 0 mg, 40 mg niacin oral tablet extended release 4 hr PRALUENT PEN INJECTOR 150 MG/ML ; QL (30 per 30 ; QL (60 per 30 MO ( per 8 PRALUENT PEN INJECTOR 75 MG/ML (4 per 8 pravastatin ; QL (30 per 30 prevalite oral powder in packet MO REPATHA (3 per 8 REPATHA PUSHTRONEX REPATHA SURECLICK (3.5 per 8 (3 per 8 rosuvastatin ; QL (30 per 30 simvastatin ; QL (30 per 30 VASCEPA 4 MO MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR 3 PA; MO digitek MO digox MO digoxin oral solution 50 mcg/ml MO digoxin oral tablet MO ENTRESTO ; QL (60 per 30 LANOXIN ORAL TABLET 6.5 MCG RANEXA VECAMYL 5 NITRATES 37

38 isosorbide dinitrate oral tablet isosorbide dinitrate oral tablet extended release isosorbide mononitrate MO nitro-bid MO nitroglycerin sublingual nitroglycerin transdermal patch 4 hour nitroglycerin translingual spray,non-aerosol MO MO MO DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 10 mg acitretin oral capsule 17.5 mg, 5 mg MO calcipotriene scalp MO; QL (10 per 30 calcipotriene topical cream calcipotriene topical ointment calcipotrienebetamethasone 4 MO; QL (10 per 30 MO; QL (10 per 30 MO; QL (400 per 30 calcitriol topical 4 MO selenium sulfide topical lotion MO MISCELLANEOUS DERMATOLOGICALS ammonium lactate MO diclofenac sodium topical gel 3 % (100 per 8 doxepin topical ; QL (45 per 30 DUPIXENT 5 PA; MO fluorouracil topical cream 5 % fluorouracil topical solution imiquimod topical cream in packet lidocaine hcl mucous membrane jelly lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated lidocaine topical ointment MO MO MO MO; QL (60 per 30 MO PA; MO; QL (90 per 30 4 MO; QL (36 per 30 lidocaine viscous MO lidocaine-prilocaine topical cream MO; QL (30 per 30 methoxsalen PANRETIN podofilox MO prudoxin MO; QL (45 per 30 REGRANEX SANTYL silver sulfadiazine MO 38

39 ssd MO tacrolimus topical PA; MO; QL (100 per 30 VALCHLOR THERAPY FOR ACNE amnesteem MO azelaic acid MO claravis 4 MO clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution MO MO MO dapsone topical MO erythromycin with ethanol topical solution isotretinoin metronidazole topical cream metronidazole topical gel metronidazole topical lotion MO MO MO MO myorisan MO tazarotene PA; MO TAZORAC TOPICAL CREAM 0.05 % TAZORAC TOPICAL GEL 3 PA; MO 3 PA; MO tretinoin topical PA; MO zenatane 4 MO TOPICAL ANTIBACTERIALS gentamicin topical MO mafenide acetate MO mupirocin MO mupirocin calcium MO sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM SULFAMYLON TOPICAL PACKET MO TOPICAL ANTIFUNGALS ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension clotrimazole topical cream clotrimazole topical solution clotrimazolebetamethasone topical cream clotrimazolebetamethasone topical lotion MO; QL (90 per 8 MO; QL (45 per 8 MO; QL (10 per 8 MO MO; QL (60 per 8 MO; QL (45 per 8 MO; QL (30 per 8 MO; QL (45 per 8 MO; QL (60 per 8 econazole MO; QL (85 per 8 39

40 ketoconazole topical cream ketoconazole topical foam ketoconazole topical shampoo MO; QL (60 per 8 MO; QL (100 per 8 MO; QL (10 per 8 naftifine MO; QL (60 per 8 nyamyc MO nystatin topical cream nystatin topical ointment nystatin topical powder nystatintriamcinolone MO; QL (30 per 8 MO; QL (30 per 8 MO MO; QL (60 per 8 nystop MO oxiconazole MO TOPICAL ANTIVIRALS acyclovir topical 4 PA; MO; QL (30 per 30 DENAVIR ZOVIRAX TOPICAL CREAM (5 per 30 TOPICAL CORTICOSTEROIDS ala-cort topical cream MO alclometasone MO betamethasone dipropionate betamethasone valerate betamethasone, augmented MO MO MO clobetasol scalp MO; QL (100 per 8 clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical spray,non-aerosol clobetasol-emollient topical cream MO; QL (10 per 8 MO; QL (100 per 8 MO; QL (10 per 8 MO; QL (118 per 8 MO; QL (10 per 8 MO; QL (36 per 8 MO; QL (15 per 8 MO; QL (10 per 8 desonide 4 MO fluocinolone and shower cap fluocinolone topical cream fluocinolone topical ointment fluocinolone topical solution fluocinonide topical cream 0.1 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution MO MO MO MO MO; QL (10 per 30 MO; QL (10 per 30 MO; QL (10 per 30 MO; QL (10 per 30 fluocinonide-e MO; QL (10 per 30 40

41 halobetasol propionate topical cream halobetasol propionate topical ointment hydrocortisone butyrate topical lotion hydrocortisone topical cream 1 %,.5 % hydrocortisone topical lotion.5 % hydrocortisone topical ointment 1 %,.5 % MO MO MO MO MO MO mometasone topical MO nolix topical cream prednicarbate MO triamcinolone acetonide topical aerosol triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.05 %, 0.1 %, 0.5 % MO MO MO MO trianex MO triderm topical cream 0.1 % TOPICAL SCABICIDES / PEDICULICIDES MO lindane topical shampoo MO malathion MO permethrin topical cream MO DIAGNOSTICS / MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS acamprosate 4 MO alendronate oral tablet 40 mg ; QL (30 per 30 anagrelide MO ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG ; LA CARBAGLU ; LA cevimeline MO CHEMET 3 PA; MO CLINIMIX 4.5%/D5W SULFIT FREE d10 %-0.45 % sodium chloride d.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 10 % and 0. % nacl dextrose 10 % in water (d10w) 3 B/D PA MO MO MO 41

42 dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5%-0. % sod chloride dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride MO disulfiram MO etidronate disodium MO EXJADE 5 PA; MO; LA FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET 5 PA 5 PA; MO INCRELEX ; LA kionex (with sorbitol) MO lanthanum MO levocarnitine (with sugar) levocarnitine oral tablet MO MO LOKELMA midodrine MO NORTHERA 5 PA; MO ORFADIN ORAL CAPSULE 10 MG, MG, 5 MG ORFADIN ORAL CAPSULE 0 MG ORFADIN ORAL SUSPENSION 5 LA ; LA ; LA pilocarpine hcl oral MO PROLASTIN-C INTRAVENOUS RECON SOLN PROLASTIN-C INTRAVENOUS SOLUTION 5 LA ; LA RAVICTI riluzole MO risedronate oral tablet 30 mg sevelamer carbonate oral powder in packet sevelamer carbonate oral tablet sodium chloride 0.9 % intravenous parenteral solution sodium chloride irrigation sodium phenylbutyrate sodium polystyrene sulfonate oral powder sps (with sorbitol) oral MO; QL (30 per 30 MO MO MO MO MO THIOLA trientine 5 PA; MO VELTASSA XURIDEN SMOKING DETERRENTS bupropion hcl (smoking deter) MO CHANTIX 4

43 CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX NICOTROL 4 MO NICOTROL NS 4 MO EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal MO; QL (60 per 30 chlorhexidine gluconate mucous membrane ipratropium bromide nasal MO MO; QL (30 per 30 olopatadine nasal MO; QL (30.5 per 30 triamcinolone acetonide dental MISCELLANEOUS OTIC PREPARATIONS MO acetic acid otic (ear) MO ciprofloxacin hcl otic (ear) fluocinolone acetonide oil hydrocortisoneacetic acid MO MO MO ofloxacin otic (ear) MO OTIC STEROID / ANTIBIOTIC CIPRODEX neomycinpolymyxin-hc otic (ear) MO ENDOCRINE/DIABETES ADRENAL HORMONES cortisone MO dexamethasone intensol dexamethasone oral elixir dexamethasone oral tablet dexamethasone oral tablets,dose pack MO MO MO fludrocortisone MO hydrocortisone oral MO methylprednisolone oral tablet methylprednisolone oral tablets,dose pack B/D PA; MO MO millipred oral tablet 4 B/D PA; MO prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 10 mg/5 ml, 0 mg/5 ml (4 mg/ml), 5 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating MO MO B/D PA; MO prednisone intensol B/D PA; MO 43

44 prednisone oral solution prednisone oral tablet prednisone oral tablets,dose pack veripred 0 ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg MO 1 B/D PA; MO MO propylthiouracil MO DIABETES THERAPY acarbose oral tablet 100 mg acarbose oral tablet 5 mg acarbose oral tablet 50 mg MO; QL (90 per 30 MO; QL (360 per 30 MO; QL (180 per 30 ALCOHOL PADS BYDUREON BCISE BYDUREON PEN INJECTOR BYETTA PEN INJECTOR 10 MCG/DOSE(50 MCG/ML).4 ML BYETTA PEN INJECTOR 5 MCG/DOSE (50 MCG/ML) 1. ML 3 PA; MO; QL (4 per 8 3 PA; MO; QL (4 per 8 3 PA; MO; QL (.4 per 30 3 PA; MO; QL (1. per 30 CYCLOSET 4 MO; QL (180 per 30 FREESTYLE FREEDOM FREESTYLE FREEDOM LITE FREESTYLE INSULINX FREESTYLE INSULINX TEST STRIPS FREESTYLE LITE METER FREESTYLE LITE STRIPS 3 FREESTYLE TEST GAUZE PADS X glimepiride oral tablet 1 mg glimepiride oral tablet mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 4hr 10 mg glipizide oral tablet extended release 4hr.5 mg glipizide oral tablet extended release 4hr 5 mg glipizide-metformin oral tablet.5-50 mg ; QL (40 per 30 ; QL (10 per 30 ; QL (60 per 30 ; QL (10 per 30 ; QL (40 per 30 ; QL (60 per 30 ; QL (40 per 30 ; QL (10 per 30 ; QL (40 per 30 44

45 glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) HUMALOG JUNIOR KWIKPEN U-100 HUMALOG KWIKPEN INSULIN HUMALOG MIX INSULN U- 100 HUMALOG MIX KWIKPEN HUMALOG MIX 75-5 KWIKPEN HUMALOG MIX 75-5(U- 100)INSULN HUMALOG U-100 INSULIN HUMULIN 70/30 U-100 INSULIN HUMULIN 70/30 U-100 KWIKPEN HUMULIN N NPH INSULIN KWIKPEN HUMULIN N NPH U-100 INSULIN HUMULIN R REGULAR U-100 INSULN ; QL (10 per 30 HUMULIN R U-500 (CONC) INSULIN HUMULIN R U-500 (CONC) KWIKPEN INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML, 1 ML, 1/ ML INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 4HR 150-1,000 MG, MG, 50-1,000 MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 4HR MG INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG ; QL (60 per 30 ; QL (10 per 30 ; QL (60 per 30 ; QL (10 per 30 ; QL (90 per 30 ; QL (30 per 30 JANUMET ; QL (60 per 30 JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 100-1,000 MG, MG ; QL (30 per 30 45

46 JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 50-1,000 MG ; QL (60 per 30 JANUVIA ; QL (30 per 30 JARDIANCE ; QL (30 per 30 JENTADUETO ; QL (60 per 30 JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 4HR.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 4HR 5-1,000 MG LANTUS SOLOSTAR U-100 INSULIN LANTUS U-100 INSULIN metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 4 hr 500 mg metformin oral tablet extended release 4 hr 750 mg miglitol oral tablet 100 mg miglitol oral tablet 5 mg ; QL (60 per 30 ; QL (30 per 30 ; QL (75 per 30 ; QL (150 per 30 ; QL (90 per 30 ; QL (10 per 30 ; QL (75 per 30 MO; QL (90 per 30 MO; QL (360 per 30 miglitol oral tablet 50 mg nateglinide oral tablet 10 mg nateglinide oral tablet 60 mg NEEDLES, INSULIN DISP.,SAFETY MO; QL (180 per 30 MO; QL (90 per 30 MO; QL (180 per 30 NOVOFINE 3 OMNIPOD INSULIN MANAGEMENT OMNIPOD INSULIN REFILL ONETOUCH ULTRA BLUE TEST STRIP ONETOUCH ULTRA ONETOUCH ULTRAMINI ONETOUCH VERIO ONETOUCH VERIO IQ METER ONETOUCH VERIO SYSTEM OZEMPIC PEN INJECTOR 0.5 MG OR 0.5 MG( MG/1.5 ML) OZEMPIC PEN INJECTOR 1 MG/0.75 ML ( MG/1.5 ML) 3 PA; MO; QL (1.5 per 8 3 PA; MO; QL (3 per 8 46

47 pioglitazone ; QL (30 per 30 PRECISION PCX PLUS TEST PRECISION PCX TEST PRECISION XTRA MONITOR MO; QL (30 per 30 MO; QL (90 per 30 3 PROGLYCEM repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg repaglinide oral tablet mg pioglitazoneglimepiride pioglitazonemetformin repaglinidemetformin MO; QL (960 per 30 MO; QL (480 per 30 MO; QL (40 per 30 MO; QL (150 per 30 RIOMET ; QL (765 per 30 SYMLINPEN 10 (10.8 per 30 SYMLINPEN 60 (6 per 30 SYNJARDY ORAL TABLET 1.5-1,000 MG, MG, 5-1,000 MG SYNJARDY ORAL TABLET MG ; QL (60 per 30 ; QL (10 per 30 SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 4HR 10-1,000 MG, 1.5-1,000 MG, 5-1,000 MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 4HR 5-1,000 MG tolazamide oral tablet 50 mg tolazamide oral tablet 500 mg ; QL (60 per 30 ; QL (30 per 30 MO; QL (10 per 30 MO; QL (60 per 30 tolbutamide MO; QL (180 per 30 TOUJEO MAX U- 300 SOLOSTAR TOUJEO SOLOSTAR U-300 INSULIN TRADJENTA ; QL (30 per 30 TRULICITY 4 PA; MO; QL ( per 8 V-GO 0 V-GO 30 V-GO 40 VICTOZA 3-PAK 3 PA; MO; QL (9 per 30 MISCELLANEOUS HORMONES ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 0.5 MG/1.5 GRAM (1.6 %) 3 PA; MO; QL (150 per 30 47

48 ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (0.5 MG/1.5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (40.5 MG/.5 GRAM) 3 PA; MO; QL (37.5 per 30 3 PA; MO; QL (150 per 30 cabergoline MO calcitonin (salmon) MO calcitriol oral MO CERDELGA danazol 4 MO desmopressin nasal spray,non-aerosol MO desmopressin oral MO doxercalciferol oral MO KORLYM 5 PA; MO KUVAN 5 PA; MO methyltestosterone oral capsule miglustat ; LA MYALEPT 5 PA; MO; LA NATPARA 5 PA; MO; LA oxandrolone oral tablet 10 mg oxandrolone oral tablet.5 mg PALYNZIQ SYRINGE 10 MG/0.5 ML 5 PA; MO PA; MO 5 PA; MO; LA; QL (15 per 30 PALYNZIQ SYRINGE.5 MG/0.5 ML PALYNZIQ SYRINGE 0 MG/ML 5 PA; MO; LA; QL (4 per 30 5 PA; MO; LA; QL (60 per 30 paricalcitol oral 4 MO SAMSCA 5 PA; MO SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 MG SOMAVERT STIMATE SYNAREL testosterone cypionate testosterone enanthate testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation testosterone transdermal gel in metered-dose pump 1.5 mg/ 1.5 gram (1 %) testosterone transdermal gel in metered-dose pump 0.5 mg/1.5 gram (1.6 %) PA; MO PA; MO PA; MO; QL (10 per 30 PA; MO; QL (300 per 30 PA; MO; QL (150 per 30 48

49 testosterone transdermal gel in packet 1 % (5 mg/.5gram), 1 % (50 mg/5 gram) testosterone transdermal gel in packet 1.6 % (0.5 mg/1.5 gram) testosterone transdermal gel in packet 1.6 % (40.5 mg/.5 gram) testosterone transdermal solution in metered pump w/app THYROID HORMONES PA; MO; QL (300 per 30 PA; MO; QL (37.5 per 30 PA; MO; QL (150 per 30 PA; MO; QL (180 per 30 levothyroxine oral 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 liothyronine oral MO 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 GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS dicyclomine oral capsule MO dicyclomine oral solution dicyclomine oral tablet diphenoxylateatropine glycopyrrolate oral tablet 1 mg, mg loperamide oral capsule MO MO MO MO MO MISCELLANEOUS GASTROINTESTINAL AGENTS alosetron aprepitant B/D PA; MO balsalazide MO budesonide oral CHENODAL 5 PA; LA CHOLBAM ORAL CAPSULE 50 MG CHOLBAM ORAL CAPSULE 50 MG 5 PA; MO (10 per 30 colocort MO compro MO constulose MO CORTIFOAM CREON cromolyn oral MO CYSTADANE DIPENTUM dronabinol oral capsule 10 mg dronabinol oral capsule.5 mg, 5 mg 5 B/D PA; MO 4 B/D PA; MO 49

50 EMEND ORAL SUSPENSION FOR RECONSTITUTIO N 3 B/D PA; MO enulose MO GATTEX 30-VIAL 5 PA; MO gavilyte-c MO gavilyte-g MO gavilyte-n MO generlac MO granisetron hcl oral B/D PA; MO hydrocortisone rectal hydrocortisonepramoxine rectal cream 1-1 % lactulose oral solution 10 gram/15 ml MO MO MO LINZESS meclizine oral tablet 1.5 mg, 5 mg MO mesalamine MO metoclopramide hcl oral solution metoclopramide hcl oral tablet metoclopramide hcl oral tablet,disintegrating MO MO MOVANTIK OCALIVA 5 PA; MO; LA; QL (30 per 30 ondansetron B/D PA; MO ondansetron hcl oral solution ondansetron hcl oral tablet 4 mg ondansetron hcl oral tablet 4 mg, 8 mg peg electrolytes oral recon soln gram peg electrolytes oral recon soln gram peg-electrolyte PENTASA ORAL CAPSULE, EXTENDED RELEASE 50 MG PENTASA ORAL CAPSULE, EXTENDED RELEASE 500 MG B/D PA; MO B/D PA B/D PA; MO MO prochlorperazine MO prochlorperazine maleate oral procto-med hc MO procto-pak MO proctosol hc topical MO proctozone-hc MO RECTIV RELISTOR SOLUTION 50

51 RELISTOR SYRINGE REMICADE 5 PA; MO scopolamine base MO SUCRAID sulfasalazine MO trilyte with flavor packets MO ursodiol MO VARUBI ORAL 3 B/D PA; MO VIBERZI VIOKACE ULCER THERAPY amoxicilclarithromylansopraz MO; QL (11 per 30 cimetidine MO cimetidine hcl oral MO esomeprazole magnesium oral capsule,delayed release(dr/ec) 0 mg esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg famotidine oral suspension famotidine oral tablet 0 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) 15 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg MO; QL (30 per 30 MO MO MO; QL (30 per 30 MO 51 misoprostol MO nizatidine MO omeprazole oral capsule,delayed release(dr/ec) 10 mg, 0 mg omeprazole oral capsule,delayed release(dr/ec) 40 mg pantoprazole oral tablet,delayed release (dr/ec) 0 mg pantoprazole oral tablet,delayed release (dr/ec) 40 mg ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg ; QL (30 per 30 ; QL (30 per 30 MO sucralfate oral tablet MO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE 5 B/D PA; MO ARCALYST 5 PA; MO AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULA R PEN INJECTOR KIT (4 per 8 (4 per 8

52 AVONEX INTRAMUSCULA R SYRINGE KIT BETASERON KIT (4 per 8 (15 per 8 GRANIX 5 PA; MO INTRON A INJECTION RECON SOLN INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML LEUKINE INJECTION RECON SOLN NEULASTA SYRINGE 5 B/D PA; MO 3 B/D PA; MO 5 B/D PA; MO 5 PA; MO NEUPOGEN 5 PA; MO OMNITROPE 5 PA; MO PEGASYS PROCLICK PEN INJECTOR 180 MCG/0.5 ML PEGASYS SOLUTION PEGASYS SYRINGE ; QL ( per 8 ; QL (4 per 8 ; QL ( per 8 PLEGRIDY PEN INJECTOR 15 MCG/0.5 ML PLEGRIDY PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SYRINGE 15 MCG/0.5 ML PLEGRIDY SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 40,000 UNIT/ML REBIF (WITH ALBUMIN) REBIF REBIDOSE PEN INJECTOR MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE PEN INJECTOR 8.8MCG/0.ML- MCG/0.5ML (6) 5 (1 per 8 (1 per 180 (1 per 8 (1 per PA; MO 5 PA; MO (6 per 8 (6 per 8 (4. per 180

53 REBIF TITRATION PACK RETACRIT INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML RETACRIT INJECTION SOLUTION 40,000 UNIT/ML (4. per PA; MO 5 PA; MO SYLATRON ZARXIO 5 PA; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT )(PF) BCG VACCINE, LIVE (PF) BEXSERO BOOSTRIX TDAP DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) INTRAMUSCULA R SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE 3 B/D PA; MO 3 B/D PA; MO GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULA R SUSPENSION HAVRIX (PF) INTRAMUSCULA R SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULA R SYRINGE 70 ELISA UNIT/0.5 ML 53 HIBERIX (PF) IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULA R SUSPENSION 3 IPOL IXIARO (PF) KINRIX (PF) INTRAMUSCULA R SUSPENSION KINRIX (PF) INTRAMUSCULA R SYRINGE MENACTRA (PF) INTRAMUSCULA R SOLUTION MENVEO A-C-Y- W-135-DIP (PF) 3 M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PRIVIGEN 5 PA; MO PROQUAD (PF) QUADRACEL (PF)

54 RABAVERT (PF) RAGWITEK RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 5 MCG/0.5 ML ROTARIX 3 ROTATEQ VACCINE 3 B/D PA; MO 3 B/D PA; MO 3 B/D PA SHINGRIX (PF) TENIVAC (PF) INTRAMUSCULA R SYRINGE TETANUS,DIPHTH ERIA TOX PED(PF) TETANUS- DIPHTHERIA TOXOIDS-TD TRUMENBA TWINRIX (PF) INTRAMUSCULA R SYRINGE TYPHIM VI INTRAMUSCULA R SOLUTION 3 TYPHIM VI INTRAMUSCULA R SYRINGE VAQTA (PF) VARIVAX (PF) VARIZIG INTRAMUSCULA R SOLUTION YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol COLCRYS 4 ST; MO MITIGARE probenecid MO probenecidcolchicine MO ULORIC 3 ST; MO OSTEOPOROSIS THERAPY alendronate oral solution alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg MO; QL (186 per 30 ; QL (30 per 30 ; QL (4 per 8 FORTEO (.4 per 8 ibandronate oral MO; QL (1 per 30 PROLIA 3 PA; MO raloxifene MO 54

55 risedronate oral tablet 150 mg risedronate oral tablet 35 mg, 35 mg (1 pack), 35 mg (4 pack) risedronate oral tablet 5 mg risedronate oral tablet,delayed release (dr/ec) MO; QL (1 per 30 MO; QL (4 per 8 MO; QL (30 per 30 MO; QL (4 per 8 TYMLOS (1.56 per 30 OTHER RHEUMATOLOGICALS ACTEMRA 5 PA; MO ACTEMRA ACTPEN BENLYSTA (4 per 8 5 PA; MO CUPRIMINE DEPEN TITRATABS ENBREL MINI (8 per 8 ENBREL RECON SOLN ENBREL SYRINGE ENBREL SURECLICK (16 per 8 (8 per 8 (8 per 8 HUMIRA PEDIATRIC CROHNS START SYRINGE KIT 40 MG/0.8 ML HUMIRA PEDIATRIC CROHNS START SYRINGE KIT 40 MG/0.8 ML (6 PACK) (3 per 180 (6 per 180 HUMIRA PEN (4 per 8 HUMIRA PEN CROHNS-UC-HS START HUMIRA PEN PSOR-UVEITS- ADOL HS HUMIRA SYRINGE KIT 10 MG/0. ML, 0 MG/0.4 ML HUMIRA SYRINGE KIT 40 MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER SYRINGE KIT 80 MG/0.8 ML (6 per 180 (4 per 180 ( per 8 (4 per 8 (3 per

56 HUMIRA(CF) PEDI CROHNS STARTER SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN CROHNS-UC-HS HUMIRA(CF) PEN PSOR-UV-ADOL HS HUMIRA(CF) PEN PEN INJECTOR KIT 40 MG/0.4 ML HUMIRA(CF) SYRINGE KIT 10 MG/0.1 ML, 0 MG/0. ML HUMIRA(CF) SYRINGE KIT 40 MG/0.4 ML ( per 180 (3 per 180 (3 per 180 (4 per 8 ( per 8 (4 per 8 leflunomide MO; QL (30 per 30 ORENCIA 5 PA; MO ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT 5 PA; MO 5 PA; MO OTEZLA 5 PA; MO OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)- 0 MG (4)-30 MG (47) 5 PA; MO OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)- 0 MG (4)-30 MG(19) 56 5 PA RIDAURA OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila MO deblitane MO DEPO-PROVERA INTRAMUSCULA R SUSPENSION 400 MG/ML errin MO estradiol oral 4 PA; MO estradiol transdermal patch semiweekly estradiol transdermal patch weekly estradiol vaginal MO estradiol valerate intramuscular oil 0 mg/ml, 40 mg/ml estradiolnorethindrone acet incassia PA; MO; QL (8 per 8 PA; MO; QL (4 per 8 MO PA; MO jolivette MO lyza MO medroxyprogesteron e MENEST ORAL TABLET 0.3 MG, 0.65 MG, 1.5 MG MO 3 PA; MO

57 nora-be MO norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol oral tablet mg-mcg, 1-5 mg-mcg norlyroc progesterone micronized MO MO 4 PA; MO MO sharobel MO yuvafem MO MISCELLANEOUS OB/GYN clindamycin phosphate vaginal metronidazole vaginal miconazole-3 vaginal suppository MO MO MO terconazole MO tranexamic acid oral MO vandazole MO xulane MO ORAL CONTRACEPTIVES / RELATED AGENTS altavera (8) MO alyacen 1/35 (8) MO apri MO aranelle (8) MO aubra MO aviane MO caziant (8) MO 57 cryselle (8) MO cyclafem 1/35 (8) MO cyclafem 7/7/7 (8) MO delyla (8) desoge.estradiol/e.estradio l desogestrel-ethinyl estradiol drospirenone-ethinyl estradiol MO MO emoquette MO enpresse MO enskyce MO estarylla MO ethynodiol diac-eth estradiol falmina (8) MO fayosim MO femynor MO gianvi (8) MO introvale MO isibloom MO juleber MO kariva (8) MO kelnor 1/35 (8) MO kelnor 1-50 MO kurvelo (8) MO l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.10 mg-0 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7) MO

58 l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.15 mg-0 mcg/ 0.15 mg-5 mcg larin 1.5/30 (1) MO larin 1/0 (1) MO larin fe 1.5/30 (8) MO larin fe 1/0 (8) MO larissia MO lessina MO levonest (8) MO levonorgestrelethinyl estrad levonorg-eth estrad triphasic MO MO levora-8 MO loryna (8) MO low-ogestrel (8) MO lutera (8) MO marlissa (8) MO microgestin 1.5/30 (1) microgestin 1/0 (1) microgestin fe 1.5/30 (8) microgestin fe 1/0 (8) MO MO MO MO mili MO nikki (8) MO norethindrone ac-eth estradiol oral tablet 1-0 mg-mcg MO norgestimate-ethinyl estradiol MO nortrel 0.5/35 (8) MO nortrel 1/35 (1) MO nortrel 1/35 (8) MO nortrel 7/7/7 (8) MO ogestrel (8) MO orsythia MO pimtrea (8) MO pirmella oral tablet 1-35 mg-mcg MO portia 8 MO previfem MO quasense MO reclipsen (8) MO setlakin MO sprintec (8) MO sronyx MO syeda MO tarina fe 1/0 (8) MO tri-estarylla MO tri-legest fe MO tri-lo-estarylla MO tri-lo-sprintec MO trinessa (8) MO tri-previfem (8) MO tri-sprintec (8) MO trivora (8) MO velivet triphasic regimen (8) MO vienva MO zarah MO 58

59 zovia 1/35e (8) MO OPHTHALMOLOGY ANTIBIOTICS bacitracin ophthalmic (eye) bacitracinpolymyxin b ophthalmic (eye) ciprofloxacin hcl ophthalmic (eye) erythromycin ophthalmic (eye) MO MO MO MO gatifloxacin MO gentak ophthalmic (eye) ointment gentamicin ophthalmic (eye) drops levofloxacin ophthalmic (eye) moxifloxacin ophthalmic (eye) MO MO MO MO NATACYN neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic (eye) polymyxin b sulftrimethoprim MO MO MO MO tobramycin MO ANTIVIRALS trifluridine MO ZIRGAN 4 MO BETA-BLOCKERS betaxolol ophthalmic (eye) MO carteolol MO levobunolol ophthalmic (eye) drops 0.5 % timolol maleate ophthalmic (eye) drops timolol maleate ophthalmic (eye) drops, once daily timolol maleate ophthalmic (eye) gel forming solution MISCELLANEOUS OPHTHALMOLOGICS atropine ophthalmic (eye) drops azelastine ophthalmic (eye) MO MO MO MO MO BLEPHAMIDE 4 MO BLEPHAMIDE S.O.P. cromolyn ophthalmic (eye) 4 MO MO CYSTARAN epinastine MO olopatadine ophthalmic (eye) MO OXERVATE 5 PA; MO PHOSPHOLINE IODIDE 4 MO 59

60 pilocarpine hcl ophthalmic (eye) drops 1 %, %, 4 % sulfacetamide sodium ophthalmic (eye) sulfacetamideprednisolone MO MO MO XIIDRA ; QL (60 per 30 NON-STEROIDAL ANTI- INFLAMMATORY AGENTS diclofenac sodium ophthalmic (eye) MO flurbiprofen sodium MO ketorolac ophthalmic (eye) MO ORAL DRUGS FOR GLAUCOMA acetazolamide MO methazolamide MO OTHER GLAUCOMA DRUGS bimatoprost ophthalmic (eye) MO dorzolamide MO dorzolamide-timolol MO dorzolamide-timolol (pf) ophthalmic (eye) dropperette MO latanoprost MO STEROID-ANTIBIOTIC COMBINATIONS neomycin-polymyxin b-dexameth MO MO neomycinbacitracin-poly-hc neomycinpolymyxin-hc ophthalmic (eye) tobramycindexamethasone STEROIDS dexamethasone sodium phosphate ophthalmic (eye) MO MO MO fluorometholone MO prednisolone acetate MO prednisolone sodium phosphate ophthalmic (eye) SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % MO apraclonidine MO brimonidine MO RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS cetirizine oral solution 1 mg/ml EPINEPHRINE INJECTION AUTO- INJECTOR 0.15 MG/0.3 ML, 0.3 MG/0.3 ML (MANUFACTURE D BY MYLAN SPECIALTY) MO ; QL (4 per 30 EPIPEN -PAK ; QL (4 per 30 60

61 EPIPEN JR -PAK ; QL (4 per 30 hydroxyzine hcl oral tablet levocetirizine oral solution levocetirizine oral tablet PA; MO MO MO; QL (30 per 30 promethazine oral 4 PA; MO PULMONARY AGENTS acetylcysteine B/D PA; MO ADEMPAS 5 PA; MO; LA albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.5 mg/3 ml,.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release 1 hr ARCAPTA NEOHALER B/D PA; MO MO 4 MO 4 MO ; QL (30 per 30 ASMANEX HFA ; QL (13 per 30 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 0 MCG (30 DOSES), 0 MCG (60 DOSES) ; QL (1 per 30 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (10 DOSES) 61 ; QL ( per 30 ATROVENT HFA ; QL (5.8 per 30 budesonide inhalation B/D PA; MO CINRYZE 5 PA; MO COMBIVENT RESPIMAT ; QL (8 per 30 cromolyn inhalation B/D PA; MO DALIRESP 4 PA; MO DULERA ; QL (13 per 30 ESBRIET ORAL CAPSULE ESBRIET ORAL TABLET 67 MG ESBRIET ORAL TABLET 801 MG (70 per 30 (70 per 30 (90 per 30 FASENRA 5 PA; MO FIRAZYR 5 PA; MO flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) MO; QL (50 per 30 fluticasone nasal MO; QL (16 per 30 HAEGARDA 5 PA; MO; LA INCRUSE ELLIPTA ; QL (30 per 30

62 ipratropium bromide inhalation ipratropiumalbuterol KALYDECO ORAL GRANULES IN PACKET KALYDECO ORAL TABLET B/D PA; MO B/D PA; MO (56 per 8 (60 per 30 LETAIRIS 5 PA; MO; LA levalbuterol hcl B/D PA; MO metaproterenol MO mometasone nasal MO; QL (34 per 30 montelukast MO OFEV (60 per 30 OPSUMIT 5 PA; MO; LA ORKAMBI ORAL GRANULES IN PACKET ORKAMBI ORAL TABLET (56 per 8 (11 per 8 PERFOROMIST 3 B/D PA; MO PROAIR HFA ; QL (17 per 30 PROAIR RESPICLICK ; QL ( per 30 PULMOZYME 5 B/D PA; MO QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 80 MCG/ACTUATION SEREVENT DISKUS sildenafil (pulmonary arterial hypertension) oral SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT STRIVERDI RESPIMAT ; QL (10.6 per 30 ; QL (1. per 30 ; QL (60 per 30 PA; MO; QL (90 per 30 ; QL (4 per 30 ; QL (90 per 90 ; QL (4 per 30 ; QL (4 per 30 SYMBICORT ; QL (10. per 30 SYMDEKO (56 per 8 terbutaline oral MO THEO-4 theophylline oral solution MO 6

63 theophylline oral tablet extended release 1 hr 100 mg, 00 mg, 300 mg theophylline oral tablet extended release 4 hr TRACLEER ORAL TABLET XOLAIR RECON SOLN XOLAIR SYRINGE 150 MG/ML XOLAIR SYRINGE 75 MG/0.5 ML MO MO 5 PA; MO; LA 5 PA; MO; LA; QL (6 per 8 5 PA; MO; LA; QL (6 per 8 5 PA; MO; LA; QL (5 per 8 zafirlukast MO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS flavoxate MO MYRBETRIQ oxybutynin chloride MO tolterodine MO trospium MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin MO dutasteride MO dutasteridetamsulosin finasteride oral tablet 5 mg MO MO 63 silodosin MO tamsulosin MISCELLANEOUS UROLOGICALS bethanechol chloride MO CYSTAGON ; LA ELMIRON potassium citrate MO tadalafil oral tablet.5 mg, 5 mg PA; MO; QL (30 per 30 VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate oral capsule calcium acetate oral tablet 667 mg MO MO klor-con MO klor-con 10 MO klor-con 8 MO klor-con m10 MO klor-con m15 MO klor-con m0 MO klor-con sprinkle MO k-tab oral tablet extended release 8 meq magnesium sulfate injection solution magnesium sulfate injection syringe NORMOSOL-R IN 5 % DEXTROSE MO MO 3

64 potassium chloridd5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chloridd5-0.45%nacl intravenous parenteral solution 0 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 0 meq/l potassium chloride in water intravenous piggyback 10 meq/100 ml potassium chloride in water intravenous piggyback 0 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral liquid MO MO MO MO MO potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals potassium chloride % nacl potassium chlorided5-0.%nacl intravenous parenteral solution 0 meq/l potassium chlorided5-0.3%nacl intravenous parenteral solution 0 meq/l potassium chlorided5-0.9%nacl intravenous parenteral solution 0 meq/l potassium chlorided5-0.9%nacl intravenous parenteral solution 40 meq/l sodium chloride 0.45 % intravenous parenteral solution 64 MO MO MO sodium chloride 3 % MO sodium chloride 5 % sodium lactate intravenous MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 7 % WITH ELECTROLYTES 3 B/D PA

65 AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE- FREE) AMINOSYN-RF 5. % CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE CLINIMIX 4.5%/D10W SULF FREE CLINIMIX 4.5%- D5W SULF-FREE 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA CLINIMIX 5%- D0W(SULFITE- FREE) 3 B/D PA HEPATAMINE 8% 3 B/D PA intralipid intravenous emulsion 0 % IONOSOL-MB IN D5W ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 3 NEPHRAMINE 5.4 % NORMOSOL-R PH 7.4 PLASMA-LYTE 148 PLASMA-LYTE A 3 B/D PA B/D PA plenamine B/D PA premasol 10 % B/D PA; MO PREMASOL 6 % 3 B/D PA travasol 10 % 4 B/D PA; MO TROPHAMINE 10 % B/D PA; MO TROPHAMINE 6% 3 B/D PA VITAMINS / HEMATINICS fluoride (sodium) oral tablet prenatal vitamin oral tablet 4 MO 4 MO 65

66 Index A abacavir... 9 abacavir-lamivudine... 9 abacavir-lamivudinezidovudine... 9 ABELCET... 9 ABILIFY MAINTENA... 8 abiraterone acamprosate acarbose acebutolol acetaminophen-codeine... 5 acetazolamide acetic acid acetylcysteine acitretin ACTEMRA ACTEMRA ACTPEN ACTHIB (PF) ACTIMMUNE acyclovir... 9, 40 acyclovir sodium... 9 ADACEL(TDAP ADOLESN/ADULT)(PF) 53 adefovir... 9 ADEMPAS AFINITOR AFINITOR DISPERZ ala-cort ALBENZA albuterol sulfate alclometasone ALCOHOL PADS ALECENSA alendronate... 41, 54 alfuzosin ALINIA allopurinol alosetron ALPHAGAN P altavera (8) ALUNBRIG alyacen 1/35 (8) amantadine hcl... 9 AMBISOME... 9 amikacin amiloride amiloride-hydrochlorothiazide AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5. % amiodarone amitriptyline... 8 amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-olmesartan amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amnesteem amoxapine... 8 amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate.. 15 amphotericin b... 9 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA... 4 anagrelide anastrozole ANDROGEL... 47, 48 APOKYN... 4 apraclonidine aprepitant apri APTIOM... APTIVUS... 9 ARALAST NP aranelle (8) ARCALYST ARCAPTA NEOHALER ARIKAYCE aripiprazole... 8 ARISTADA... 8 armodafinil... 8 ASMANEX HFA ASMANEX TWISTHALER 61 aspirin-dipyridamole atazanavir... 9 atenolol atenolol-chlorthalidone atomoxetine... 8 atorvastatin atovaquone atovaquone-proguanil ATRIPLA... 9 atropine ATROVENT HFA aubra AUGMENTIN aviane AVONEX... 51, 5 AVONEX (WITH ALBUMIN) azathioprine azelaic acid azelastine... 43, 59 azithromycin aztreonam B bacitracin bacitracin-polymyxin b baclofen... 5 balsalazide BANZEL... BARACLUDE... 9 BCG VACCINE, LIVE (PF) 53 benazepril

67 benazepril-hydrochlorothiazide BENLYSTA BENZNIDAZOLE benztropine... 4 betamethasone dipropionate. 40 betamethasone valerate betamethasone, augmented BETASERON... 5 betaxolol... 33, 59 bethanechol chloride BETHKIS bexarotene BEXSERO bicalutamide BICILLIN C-R BICILLIN L-A BIKTARVY... 9 bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide BLEPHAMIDE BLEPHAMIDE S.O.P BOOSTRIX TDAP BOSULIF BRAFTOVI BRILINTA brimonidine BRIVIACT... bromocriptine... 4 budesonide... 49, 61 bumetanide buprenorphine... 5 buprenorphine hcl... 5 buprenorphine-naloxone... 7 bupropion hcl... 8, 9 bupropion hcl (smoking deter)... 4 buspirone... 9 butorphanol tartrate... 7 BYDUREON BYDUREON BCISE BYETTA C cabergoline CABOMETYX calcipotriene calcipotriene-betamethasone 38 calcitonin (salmon) calcitriol... 38, 48 calcium acetate CALQUENCE camila candesartan candesartan-hydrochlorothiazid CAPRELSA captopril captopril-hydrochlorothiazide CARBAGLU carbamazepine... carbidopa... 4 carbidopa-levodopa... 4 carbidopa-levodopaentacapone... 4 carteolol cartia xt carvedilol carvedilol phosphate caspofungin... 9 CAYSTON caziant (8) cefaclor... 1 cefadroxil... 1 cefazolin... 1 cefdinir... 1 cefepime... 1 cefixime... 1 cefotaxime... 1 cefotetan... 1 cefoxitin... 1 cefpodoxime... 1 cefprozil... 1 ceftazidime... 1 ceftriaxone... 1 cefuroxime axetil... 1 cefuroxime sodium... 1, 13 celecoxib... 7 CELONTIN... cephalexin CERDELGA cetirizine cevimeline CHANTIX... 4 CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX CHEMET CHENODAL chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorpromazine... 9 chlorthalidone CHOLBAM cholestyramine (with sugar). 36 cholestyramine light ciclopirox cilostazol CIMDUO... 9 cimetidine cimetidine hcl CINRYZE CIPRODEX ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl... 16, 43, 59 ciprofloxacin in 5 % dextrose citalopram... 9 claravis clarithromycin clindamycin hcl clindamycin in 5 % dextrose 14 clindamycin palmitate hcl clindamycin phosphate.. 14, 39, 57 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE CLINIMIX 4.5%/D10W SULF FREE CLINIMIX 4.5%/D5W SULFIT FREE CLINIMIX 4.5%-D5W SULF-FREE CLINIMIX 5%- D0W(SULFITE-FREE).. 65 clobazam... clobetasol

68 clobetasol-emollient clomipramine... 9 clonazepam... clonidine clonidine hcl... 9, 34 clopidogrel clorazepate dipotassium... 9 clotrimazole... 9, 39 clotrimazole-betamethasone. 39 clozapine... 9 COARTEM COLCRYS colesevelam colestipol... 36, 37 colistin (colistimethate na) colocort COMBIVENT RESPIMAT. 61 COMETRIQ COMPLERA... 9 compro constulose COPIKTRA CORLANOR CORTIFOAM cortisone COTELLIC CREON CRESEMBA... 9 CRIXIVAN cromolyn... 49, 59, 61 cryselle (8) CUPRIMINE cyclafem 1/35 (8) cyclafem 7/7/7 (8) cyclobenzaprine... 5 cyclophosphamide CYCLOSET cyclosporine cyclosporine modified CYSTADANE CYSTAGON CYSTARAN D d10 %-0.45 % sodium chloride d.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dalfampridine... 4 DALIRESP danazol dantrolene... 5 dapsone... 14, 39 DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin DAPTOMYCIN DARAPRIM DAURISMO deblitane DELSTRIGO delyla (8) demeclocycline DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA DESCOVY desipramine... 9 desmopressin desog-e.estradiol/e.estradiol. 57 desogestrel-ethinyl estradiol. 57 desonide desvenlafaxine succinate... 9 dexamethasone dexamethasone intensol dexamethasone sodium phosphate dextroamphetamineamphetamine... 9 dextrose 10 % and 0. % nacl dextrose 10 % in water (d10w) dextrose 5 % in water (d5w). 4 dextrose 5%-0. % sod chloride... 4 dextrose 5%-0.3 % sod.chloride... 4 dextrose with sodium chloride... 4 DIASTAT... DIASTAT ACUDIAL... diazepam... 9 diazepam intensol... 9 diclofenac potassium... 7 diclofenac sodium... 7, 38, 60 diclofenac-misoprostol... 7 dicloxacillin dicyclomine didanosine diflunisal... 7 digitek digox digoxin dihydroergotamine... 4 DILANTIN 30 MG... diltiazem hcl dilt-xr DIPENTUM diphenoxylate-atropine dipyridamole disulfiram... 4 divalproex... dofetilide donepezil... 4 DOPTELET (10 TAB PACK) DOPTELET (15 TAB PACK) dorzolamide dorzolamide-timolol dorzolamide-timolol (pf) doxazosin doxepin... 9, 38 doxercalciferol doxy doxycycline hyclate doxycycline monohydrate... 16, 17 dronabinol drospirenone-ethinyl estradiol DROXIA DULERA duloxetine... 9 DUPIXENT duramorph (pf)... 5 dutasteride dutasteride-tamsulosin

69 E e.e.s econazole EDURANT efavirenz eletriptan... 4 ELIQUIS ELMIRON EMCYT EMEND emoquette EMSAM... 9 EMTRIVA EMVERM enalapril maleate enalapril-hydrochlorothiazide ENBREL ENBREL MINI ENBREL SURECLICK endocet... 5 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone... 4 entecavir ENTRESTO enulose EPCLUSA EPIDIOLEX... epinastine EPINEPHRINE EPIPEN -PAK EPIPEN JR -PAK epitol... EPIVIR HBV eplerenone eprosartan ergoloid... 9 ergotamine-caffeine... 4 ERIVEDGE ERLEADA errin ertapenem ery-tab ERY-TAB ERYTHROCIN erythrocin (as stearate) erythromycin... 13, 59 erythromycin ethylsuccinate. 13 erythromycin with ethanol ESBRIET escitalopram oxalate... 9 esomeprazole magnesium estarylla estradiol estradiol valerate estradiol-norethindrone acet. 56 eszopiclone... 9 ethacrynic acid ethambutol ethosuximide... ethynodiol diac-eth estradiol 57 etidronate disodium... 4 etodolac... 7 EVOTAZ exemestane EXJADE... 4 ezetimibe ezetimibe-simvastatin F falmina (8) famciclovir famotidine FANAPT... 9 FARESTON FARYDAK FASENRA fayosim FAZACLO... 9 felbamate... felodipine femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized. 37 fenofibric acid fenofibric acid (choline) fenoprofen... 7 fentanyl... 6 fentanyl citrate... 5 FERRIPROX... 4 FETZIMA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE flavoxate flecainide fluconazole... 9 fluconazole in nacl (iso-osm). 9 flucytosine... 9 fludrocortisone flunisolide fluocinolone fluocinolone acetonide oil fluocinolone and shower cap 40 fluocinonide fluocinonide-e fluoride (sodium) fluorometholone fluorouracil fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen... 7 flurbiprofen sodium flutamide fluticasone fluvastatin fluvoxamine fondaparinux FORTEO fosamprenavir fosinopril fosinopril-hydrochlorothiazide FREESTYLE FREEDOM FREESTYLE FREEDOM LITE FREESTYLE INSULINX FREESTYLE INSULINX TEST STRIPS FREESTYLE LITE METER 44 FREESTYLE LITE STRIPS 44 FREESTYLE TEST furosemide FUZEON FYCOMPA... G gabapentin..., 3 69

70 galantamine... 5 GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n gemfibrozil generlac gengraf gentak gentamicin... 14, 39, 59 gentamicin in nacl (iso-osm) 14 GENVOYA GEODON gianvi (8) GILENYA... 5 GILOTRIF glatiramer... 5 glatopa... 5 GLEOSTINE glimepiride glipizide glipizide-metformin... 44, 45 GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glycopyrrolate granisetron hcl GRANIX... 5 griseofulvin microsize... 9 griseofulvin ultramicrosize... 9 guanidine H HAEGARDA halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heparin (porcine) HEPATAMINE 8% HETLIOZ HIBERIX (PF) HUMALOG JUNIOR KWIKPEN U HUMALOG KWIKPEN INSULIN HUMALOG MIX INSULN U HUMALOG MIX KWIKPEN HUMALOG MIX 75-5 KWIKPEN HUMALOG MIX 75-5(U- 100)INSULN HUMALOG U-100 INSULIN HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN CROHNS-UC- HS START HUMIRA PEN PSOR- UVEITS-ADOL HS HUMIRA(CF) HUMIRA(CF) PEDI CROHNS STARTER. 55, 56 HUMIRA(CF) PEN HUMIRA(CF) PEN CROHNS-UC-HS HUMIRA(CF) PEN PSOR- UV-ADOL HS HUMULIN 70/30 U-100 INSULIN HUMULIN 70/30 U-100 KWIKPEN HUMULIN N NPH INSULIN KWIKPEN HUMULIN N NPH U-100 INSULIN HUMULIN R REGULAR U- 100 INSULN HUMULIN R U-500 (CONC) INSULIN HUMULIN R U-500 (CONC) KWIKPEN hydralazine hydrochlorothiazide hydrocodone-acetaminophen 6 hydrocodone-ibuprofen... 6 hydrocortisone... 41, 43, 50 hydrocortisone butyrate hydrocortisone-acetic acid hydrocortisone-pramoxine hydromorphone... 6 hydromorphone (pf)... 6 hydroxychloroquine hydroxyurea hydroxyzine hcl I ibandronate IBRANCE ibu... 7 ibuprofen... 7 ibuprofen-oxycodone... 6 ICLUSIG IDHIFA imatinib... 18, 19 IMBRUVICA imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES VACCINE (PF) incassia INCRELEX... 4 INCRUSE ELLIPTA indapamide INFANRIX (DTAP) (PF) INLYTA INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U INTELENCE intralipid INTRON A... 5 introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR INVOKANA IONOSOL-MB IN D5W IPOL ipratropium bromide... 43, 6 ipratropium-albuterol... 6 irbesartan

71 irbesartan-hydrochlorothiazide IRESSA ISENTRESS ISENTRESS HD isibloom ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine itraconazole... 9 ivermectin IXIARO (PF) J JAKAFI jantoven JANUMET JANUMET XR... 45, 46 JANUVIA JARDIANCE JENTADUETO JENTADUETO XR jolivette juleber JULUCA JUXTAPID K KALETRA KALYDECO... 6 kariva (8) kelnor 1/35 (8) kelnor ketoconazole... 9, 40 ketoprofen... 8 ketorolac KHEDEZLA KINRIX (PF) kionex (with sorbitol)... 4 KISQALI KISQALI FEMARA CO- PACK klor-con klor-con klor-con klor-con m klor-con m klor-con m klor-con sprinkle KORLYM k-tab kurvelo (8) KUVAN L l norgest/e.estradiol-e.estrad 57, 58 labetalol lactulose lamivudine lamivudine-zidovudine lamotrigine... 3 LANOXIN lansoprazole lanthanum... 4 LANTUS SOLOSTAR U-100 INSULIN LANTUS U-100 INSULIN.. 46 larin 1.5/30 (1) larin 1/0 (1) larin fe 1.5/30 (8) larin fe 1/0 (8) larissia latanoprost LATUDA leflunomide LENVIMA lessina LETAIRIS... 6 letrozole leucovorin calcium LEUKERAN LEUKINE... 5 leuprolide levalbuterol hcl... 6 levetiracetam... 3 levobunolol levocarnitine... 4 levocarnitine (with sugar)... 4 levocetirizine levofloxacin... 16, 59 levofloxacin in d5w levonest (8) levonorgestrel-ethinyl estrad 58 levonorg-eth estrad triphasic 58 levora levorphanol tartrate... 6 levothyroxine levoxyl LEXIVA lidocaine lidocaine hcl lidocaine viscous lidocaine-prilocaine lindane linezolid linezolid in dextrose 5% LINZESS liothyronine lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate LOKELMA... 4 LONSURF loperamide lopinavir-ritonavir lorazepam LORBRENA lorcet (hydrocodone)... 6 lorcet hd... 6 lorcet plus... 6 loryna (8) losartan losartan-hydrochlorothiazide 34 lovastatin low-ogestrel (8) loxapine succinate LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) lutera (8) LYNPARZA LYRICA... 3 LYSODREN lyza

72 M mafenide acetate magnesium sulfate malathion maprotiline marlissa (8) MARPLAN MATULANE matzim la meclizine meclofenamate... 8 medroxyprogesterone mefenamic acid... 8 mefloquine megestrol MEKINIST MEKTOVI meloxicam... 8 memantine... 5 MENACTRA (PF) MENEST MENVEO A-C-Y-W-135-DIP (PF) mercaptopurine meropenem mesalamine MESNEX MESTINON... 5 metadate er metaproterenol... 6 metformin methadone... 6 methazolamide methenamine hippurate methimazole methotrexate sodium methotrexate sodium (pf) methoxsalen methyclothiazide methyldopa methylphenidate hcl methylprednisolone methyltestosterone metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 14, 39, 57 metronidazole in nacl (iso-os) mexiletine miconazole microgestin 1.5/30 (1) microgestin 1/0 (1) microgestin fe 1.5/30 (8) microgestin fe 1/0 (8) midodrine... 4 migergot... 4 miglitol miglustat mili millipred minocycline minoxidil mirtazapine misoprostol MITIGARE M-M-R II (PF) modafinil moderiba moderiba dose pack moexipril moexipril-hydrochlorothiazide molindone mometasone... 41, 6 mondoxyne nl montelukast... 6 morgidox morphine... 6, 7 morphine concentrate... 6 MOVANTIK moxifloxacin... 16, 59 moxifloxacin in nacl (iso-osm) MULPLETA mupirocin mupirocin calcium MYALEPT MYCAMINE... 9 mycophenolate mofetil mycophenolate sodium myorisan MYRBETRIQ N nabumetone... 8 nadolol nadolol-bendroflumethiazide 35 nafcillin naftifine naloxone... 8 naltrexone... 8 NAMZARIC... 5 naproxen... 8 naproxen sodium... 8 naratriptan... 4 NARCAN... 8 NATACYN nateglinide NATPARA NEBUPENT NEEDLES, INSULIN DISP.,SAFETY nefazodone neomycin neomycin-bacitracin-poly-hc 60 neomycin-bacitracinpolymyxin neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc. 43, 60 NEPHRAMINE 5.4 % NERLYNX... 0 NEULASTA... 5 NEUPOGEN... 5 NEUPRO... 4 nevirapine NEXAVAR... 0 niacin nicardipine NICOTROL NICOTROL NS nifedipine nikki (8) nilutamide... 0 nimodipine NINLARO... 0 nisoldipine nitro-bid nitrofurantoin

73 nitrofurantoin macrocrystal.. 17 nitrofurantoin monohyd/mcryst nitroglycerin nizatidine nolix nora-be norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol... 57, 58 norgestimate-ethinyl estradiol norlyroc NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA... 4 nortrel 0.5/35 (8) nortrel 1/35 (1) nortrel 1/35 (8) nortrel 7/7/7 (8) nortriptyline NORVIR NOVOFINE NOXAFIL... 9 NUEDEXTA... 5 NUPLAZID nyamyc nystatin... 9, 40 nystatin-triamcinolone nystop O OCALIVA octreotide acetate... 0 ODEFSEY ODOMZO... 0 OFEV... 6 ofloxacin... 16, 43, 59 ogestrel (8) olanzapine olanzapine-fluoxetine olmesartan olmesartan-amlodipinhcthiazid olmesartanhydrochlorothiazide olopatadine... 43, 59 omeprazole OMNIPOD INSULIN MANAGEMENT OMNIPOD INSULIN REFILL OMNITROPE... 5 ondansetron ondansetron hcl ONETOUCH ULTRA BLUE TEST STRIP ONETOUCH ULTRA ONETOUCH ULTRAMINI. 46 ONETOUCH VERIO ONETOUCH VERIO IQ METER ONETOUCH VERIO SYSTEM ONFI... 3 OPSUMIT... 6 ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORFADIN... 4 ORKAMBI... 6 orsythia oseltamivir OTEZLA OTEZLA STARTER oxacillin oxacillin in dextrose(iso-osm) oxandrolone oxaprozin... 8 oxcarbazepine... 3 OXERVATE oxiconazole oxybutynin chloride oxycodone... 7 oxycodone-acetaminophen... 7 oxycodone-aspirin... 7 oxymorphone... 7 OZEMPIC P pacerone paliperidone PALYNZIQ PANRETIN pantoprazole paricalcitol paromomycin paroxetine hcl paroxetine mesylate(menop.sym) PASER PAXIL PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE... 3 PEGASYS... 5 PEGASYS PROCLICK... 5 peg-electrolyte penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTAM PENTASA pentoxifylline PERFOROMIST... 6 perindopril erbumine permethrin perphenazine PERSERIS phenelzine phenobarbital... 3 phenoxybenzamine phenytoin... 3 phenytoin sodium extended.. 3 PHOSPHOLINE IODIDE PIFELTRO pilocarpine hcl... 4, 60 pimozide... 3 pimtrea (8) pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam... 8 PLASMA-LYTE PLASMA-LYTE A PLEGRIDY

74 plenamine podofilox polymyxin b sulfate polymyxin b sulf-trimethoprim POMALYST... 0 portia potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride in water.. 64 potassium chloride-0.45 % nacl potassium chloride-d5-0.%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate PRADAXA PRALUENT PEN pramipexole... 4 prasugrel pravastatin prazosin PRECISION PCX PLUS TEST PRECISION PCX TEST PRECISION XTRA MONITOR prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 43, 60 prednisone prednisone intensol premasol 10 % PREMASOL 6 % prenatal vitamin oral tablet prevalite previfem PREVYMIS PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone... 3 PRIVIGEN PROAIR HFA... 6 PROAIR RESPICLICK... 6 probenecid probenecid-colchicine procentra... 3 prochlorperazine prochlorperazine maleate oral PROCRIT... 5 procto-med hc procto-pak proctosol hc proctozone-hc profeno... 8 progesterone micronized PROGLYCEM PROLASTIN-C... 4 PROLIA PROMACTA promethazine propafenone propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) protriptyline... 3 prudoxin PULMOZYME... 6 PURIXAN... 0 pyrazinamide pyridostigmine bromide... 5 Q QUADRACEL (PF) quasense quetiapine... 3 quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate QVAR REDIHALER... 6 R RABAVERT (PF) RAGWITEK raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE... 0 rasagiline... 4 RAVICTI... 4 REBIF (WITH ALBUMIN). 5 REBIF REBIDOSE... 5 REBIF TITRATION PACK. 53 reclipsen (8) RECOMBIVAX HB (PF) RECTIV REGRANEX RELENZA DISKHALER RELISTOR... 50, 51 REMICADE repaglinide repaglinide-metformin REPATHA REPATHA PUSHTRONEX 37 REPATHA SURECLICK RESCRIPTOR RETACRIT REVLIMID... 0 REXULTI... 3 REYATAZ ribasphere ribasphere ribapak ribavirin RIDAURA rifabutin rifampin riluzole... 4 rimantadine RIOMET risedronate... 4, 55 RISPERDAL CONSTA... 3 risperidone... 3 ritonavir rivastigmine... 5 rivastigmine tartrate... 5 rizatriptan

75 ropinirole... 4 rosuvastatin ROTARIX ROTATEQ VACCINE roweepra... 3 roweepra xr... 3 ROZEREM... 3 RUBRACA... 0 RYDAPT... 0 S SABRIL... 3 SAMSCA SANDIMMUNE... 0 SANTYL SAPHRIS... 3 scopolamine base selegiline hcl... 4 selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS... 6 sertraline... 3 setlakin sevelamer carbonate... 4 sharobel SHINGRIX (PF) SIGNIFOR... 0 sildenafil (pulmonary arterial hypertension)... 6 silodosin silver sulfadiazine simvastatin sirolimus... 0 SIRTURO sodium chloride... 4 sodium chloride 0.45 % sodium chloride 0.9 %... 4 sodium chloride 3 % sodium chloride 5 % sodium lactate intravenous sodium phenylbutyrate... 4 sodium polystyrene sulfonate... 4 SOLTAMOX... 0 SOMATULINE DEPOT... 0 SOMAVERT sorine sotalol sotalol af SOTYLIZE SPIRIVA RESPIMAT... 6 SPIRIVA WITH HANDIHALER... 6 spironolactone spironolacton-hydrochlorothiaz SPORANOX... 9 sprintec (8) SPRITAM... 3 SPRYCEL... 0 sps (with sorbitol)... 4 sronyx ssd stavudine STIMATE STIOLTO RESPIMAT... 6 STIVARGA... 0 STREPTOMYCIN STRIBILD STRIVERDI RESPIMAT... 6 SUBOXONE... 8 SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne) 39 sulfacetamide-prednisolone.. 60 sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine sulindac... 8 sumatriptan... 4 sumatriptan succinate... 4 sumatriptan-naproxen... 4 SUPRAX SUTENT... 0 syeda SYLATRON SYMBICORT... 6 SYMDEKO... 6 SYMFI SYMFI LO SYMLINPEN SYMLINPEN SYMTUZA SYNAREL SYNJARDY SYNJARDY XR SYNRIBO... 0 T TABLOID... 0 tacrolimus... 0, 39 tadalafil TAFINLAR... 0 TAGRISSO... 0 TALZENNA... 0 tamoxifen... 0 tamsulosin TARCEVA... 0 TARGRETIN... 1 tarina fe 1/0 (8) TASIGNA... 1 tazarotene TAZORAC taztia xt TECFIDERA... 5 TEFLARO TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid TENIVAC (PF) tenofovir disoproxil fumarate terazosin terbinafine hcl... 9 terbutaline... 6 terconazole testosterone... 48, 49 testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine... 5 tetracycline THALOMID... 1 THEO theophylline... 6, 63 THIOLA

76 thioridazine... 3 thiothixene... 3 tiagabine... 3 TIBSOVO... 1 tigecycline timolol maleate... 35, 59 tinidazole TIVICAY tizanidine... 5 tobramycin tobramycin in 0.5 % nacl. 15 tobramycin sulfate tobramycin-dexamethasone.. 60 tolazamide tolbutamide tolcapone... 4 tolmetin... 8 tolterodine topiramate... 3 torsemide TOUJEO MAX U-300 SOLOSTAR TOUJEO SOLOSTAR U-300 INSULIN TRACLEER TRADJENTA tramadol... 8 tramadol-acetaminophen... 8 trandolapril trandolapril-verapamil tranexamic acid tranylcypromine... 3 travasol 10 % trazodone... 3 TRECATOR TRELSTAR... 1 tretinoin (chemotherapy)... 1 tretinoin topical triamcinolone acetonide. 41, 43 triamterene-hydrochlorothiazid trianex triderm trientine... 4 tri-estarylla trifluoperazine... 3 trifluridine tri-legest fe tri-lo-estarylla tri-lo-sprintec trilyte with flavor packets trimethoprim trimipramine... 3 trinessa (8) TRINTELLIX... 3 tri-previfem (8) tri-sprintec (8) TRIUMEQ trivora (8) TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA TWINRIX (PF) TYKERB... 1 TYMLOS TYPHIM VI U ULORIC unithroid UPTRAVI ursodiol V valacyclovir VALCHLOR valganciclovir valproic acid... 3 valproic acid (as sodium salt)... 3 valsartan valsartan-hydrochlorothiazide vancomycin vandazole VAQTA (PF) VARIVAX (PF) VARIZIG VARUBI VASCEPA VECAMYL velivet triphasic regimen (8) VELTASSA... 4 VEMLIDY VENCLEXTA... 1 VENCLEXTA STARTING PACK... 1 venlafaxine... 3 verapamil veripred VERZENIO... 1 V-GO V-GO V-GO VIBERZI vicodin... 7 vicodin es... 7 vicodin hp... 7 VICTOZA 3-PAK VIDEX 4 GRAM PEDIATRIC... 1 VIDEX EC... 1 vienva vigabatrin... 4 VIIBRYD... 3, 33 VIMPAT... 4 VIOKACE VIRACEPT... 1 VIRAMUNE... 1 VIREAD... 1 VITRAKVI... 1 VIVITROL... 8 VIZIMPRO... 1 voriconazole... 9 VOTRIENT... 1 VRAYLAR W warfarin X XALKORI... 1 XARELTO XATMEP... 1 XERMELO... 1 XGEVA XIFAXAN XIIDRA XOFLUZA... 1 XOLAIR XOSPATA... 1 XTANDI... 1 xulane XURIDEN

77 XYREM Y YF-VAX (PF) YONSA... 1 yuvafem Z zafirlukast zaleplon zarah ZARXIO ZEJULA... 1 ZELBORAF... 1 zenatane zidovudine... 1 ziprasidone hcl ZIRGAN ZOLINZA... 1 zolmitriptan... 4 zolpidem zonisamide... 4 ZORTRESS... 1 ZOSTAVAX (PF) zovia 1/35e (8) ZOVIRAX ZYDELIG... 1 ZYKADIA... 1 ZYPREXA RELPREVV ZYTIGA

78 This abridged formulary was updated on 0/7/019. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Member Services, at or, for TTY users, 711, 8 a.m. 8 p.m. local time, seven days a week, from October 1 March 31, and 8 a.m. 8 p.m. local time, Monday Friday, from April 1- September 30, or visit christushealthplan.org. 78