PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Transcription

1 2019 Formulary (List of Covered Drugs) PLEASE READ: TS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN TS PLAN Ally Rx (HMO SNP) This formulary was updated on March 26, For more recent information or other questions, please contact Security Health Plan Customer Service at or, for TTY users, 711, or visit We are open 7 days a week, 8 a.m. to 8 p.m., from Oct. 1-March 31; and Monday through Friday, 8 a.m. to 8 p.m., from April 1-Sept. 30. Y0117_MC C-04-19_C Effective date 4/1/2019 Updated 03/26/2019 Formulary ID , v.13

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 Security Health Plan. When it refers to plan or our plan, it means Ally Rx (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of April 1, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network and/or copayments/coinsurance may change on Jan. 1, 2020, and from time to time during the year. Security Health Plan of Wisconsin, Inc., is an HMO, MSA and D-SNP plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in Security Health Plan depends on contract renewal. This document is available in alternate formats. Call Customer Service at the number on the covers for more information.

3 What is the Ally Rx (HMO SNP) Formulary? A formulary is a list of covered drugs selected by Security Health Plan 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. Security Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Security Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. 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 Security Health Plan Formulary? Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a 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, 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 31-day supply of the drug. i

4 The enclosed formulary is current as of January 1, To get updated information about the drugs covered by Security Health Plan, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page vii. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 97. 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? Security Health Plan 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: Security Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Security Health Plan before you fill your prescriptions. If you don t get approval, Security Health Plan may not cover the drug. Quantity Limits: For certain drugs, Security Health Plan limits the amount of the drug that your Medicare Advantage plan will cover. For example, Security Health Plan provides 18 tablets per prescription for sumatriptan. This may be in addition to a standard 1-month or 3- month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page vii. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document ii

5 that explains our prior authorization restriction. 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 Security Health Plan 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 Security Health Plan s formulary? on page iii for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Security Health Plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Security Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Security Health Plan. You can ask Security Health Plan 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 Ally Rx (HMO SNP) Formulary? You can ask Security Health Plan 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 waive coverage restrictions or limits on your drug. For example, for certain drugs, Security Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Security Health Plan will only approve your request for an exception if the alternative drug is included on the plan s formulary 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 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. iii

6 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 31-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 31-day supply of medication. After your first 31-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. There are times outside of your first 90 days of new membership when the prescription drug transition process will also apply. One of the more common examples would be if you experience a change in your level of care (for example, when you are discharged from a hospital to either your home or to a long-term care facility, or if you end your long-term care facility stay and return to your home). Security Health Plan will ensure you have an effective transition of care, including your medication therapy, anytime you experience a change in your level of care. For more information For more detailed information about your Security Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Security Health Plan, 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 ( ) 24 hours a day/7 days a week. TTY users should call Or, visit iv

7 Discrimination is against the law Security Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Security Health Plan does not exclude people or treat them differently because of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status. Security Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service at (TTY: 711). If you believe that Security Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status, you can file a grievance with: Security Health Plan Attn: Grievances 1515 North Saint Joseph Avenue Marshfield, WI Phone: (TTY: 711) Fax: shp.appeals.grievance@securityhealth.org You can file a grievance in person or by mail, fax or . If you need help filing a grievance, Security Health Plan can help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC Phone: or (TDD) Complaint forms are available at Language assistance services ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). v

8 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). (Arabic) العربیة ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 117). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Deitsch (Pennsylvania Dutch) Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: (TTY: 711). ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: 711). Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). (Hindi) ध य न द : य द आप कर ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Oroomiffa (Oromo/Somalia) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711). vi

9 Large print If you require materials in large print, please call (TTY: 711). vii

10 Ally Rx (HMO SNP) Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Security Health Plan. If you have trouble finding your drug in the list, turn to the index that begins on page 97. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the column tells you if Security Health Plan has any special requirements for coverage of your drug. key: PA = Prior authorization required PA NSO = Prior authorization required on new starts only PA B vs. D = Prior authorization required for Part B vs. Part D coverage = Home infusion coverage This prescription drug may be covered under our medical benefit. For more information call Customer Service at , Monday through Sunday from 8 a.m. to 8 p.m. TTY users should call 711. LA = Limited access This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , Monday through Sunday from 8 a.m. 8 p.m. TTY users should call 711. QL = Quantity limit = Non-extended day supply (Limited to 30-day supply) viii

11 Table of Contents Analgesics... 3 Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents... 7 Antianxiety Agents... 7 Antibacterials... 8 Anticancer Agents Anticholinergic Agents Anticonvulsants Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents Contraceptives Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying

12 Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals

13 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg, mg, mg ascomp with codeine oral capsule mg astramorph-pf injection solution 0.5 mg/ml, 1 mg/ml buprenorphine hcl injection syringe 0.3 mg/ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg butalbital-aspirin-caffeine oral tablet mg butorphanol 2 mg/ml vial latex-free, sdv 2 mg/ml butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal spray,non-aerosol 10 mg/ml capacet oral capsule mg codeine sulfate oral tablet 15 mg, 30 mg, 60 mg DEMEROL (PF) INJECTION SOLUTION 100 MG/2 ML, 100 MG/ML, 25 MG/0.5 ML, 50 MG/ML, 75 MG/1.5 ML DEMEROL (PF) INJECTION SYRINGE 100 MG/ML, 50 MG/ML, 75 MG/ML DEMEROL (PF) INJECTION SYRINGE 25 MG/ML DEMEROL INJECTION SOLUTION 100 MG/ML, 50 MG/ML DILAUDID (PF) INJECTION SYRINGE 0.5 MG/0.5 ML, 1 MG/ML, 2 MG/ML, 4 MG/ML endocet oral tablet mg, mg, mg, mg QL (360 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (960 per 30 days) QL (480 per 30 days) QL (5 per 28 days) PA; ; AGE (Max 64 Years) PA; ; AGE (Max 64 Years) PA; AGE (Max 64 Years) PA; ; AGE (Max 64 Years) fentanyl citrate (pf) intravenous syringe 100 mcg/2 ml (50 mcg/ml) 3

14 fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg PA; QL (120 per 30 days); fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr fioricet oral capsule mg hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg, mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml hydromorphone 2 mg/ml carpujct latex-free,inner,suv 2 mg/ml hydromorphone 500 mg/50 ml via sdv,p/f,latex-free 10 mg/ml hydromorphone injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml hydromorphone injection syringe 0.5 mg/0.5 ml, 1 mg/ml, 4 mg/ml hydromorphone injection syringe 2 mg/ml hydromorphone oral liquid 1 mg/ml hydromorphone oral tablet 2 mg, 4 mg, 8 mg hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 32 mg, 8 mg INFUMORPH P/F INJECTION SOLUTION 10 MG/ML, 25 MG/ML levorphanol tartrate oral tablet 2 mg levorphanol tartrate oral tablet 3 mg lorcet (hydrocodone) oral tablet mg lorcet hd oral tablet mg lorcet plus oral tablet mg marten-tab oral tablet mg meperidine (pf) injection solution 100 mg/ml, 25 mg/ml, 50 mg/ml meperidine injection cartridge 10 mg/ml methadone oral concentrate 10 mg/ml methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg, 5 mg morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml, 30 mg/30 ml QL (15 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (180 per 30 days) PA; AGE (Max 64 Years) PA; ; AGE (Max 64 Years) QL (450 per 30 days) QL (900 per 30 days) QL (180 per 30 days) 4

15 morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) morphine injection solution 10 mg/ml MORPNE INJECTION SOLUTION 2 MG/ML morphine injection solution 5 mg/ml morphine injection syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml morphine intravenous solution 10 mg/ml, 4 mg/ml, 8 mg/ml morphine intravenous syringe 10 mg/ml, 2 mg/ml, 4 mg/ml, 8 mg/ml morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml) MORPNE ORAL TABLET 15 MG, 30 MG morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg morphine oral tablet extended release 200 mg nalocet oral tablet mg oxycodone oral concentrate 20 mg/ml oxycodone oral solution 5 mg/5 ml oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg oxycodone oral tablet,oral only,ext.rel.12 hr 80 mg oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin oral tablet mg OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG oxymorphone oral tablet 10 mg, 5 mg oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg phrenilin forte(with caffeine) oral capsule mg PRIALT INTRATHECAL SOLUTION 100 MCG/ML, 25 MCG/ML tencon oral tablet mg tramadol oral tablet 50 mg tramadol oral tablet extended release 24 hr 100 mg tramadol oral tablet extended release 24 hr 200 mg tramadol oral tablet extended release 24 hr 300 mg tramadol-acetaminophen oral tablet mg vicodin es oral tablet mg vicodin hp oral tablet mg QL (180 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (360 per 30 days) QL (7200 per 30 days) QL (360 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (180 per 30 days) QL (240 per 30 days) QL (90 per 30 days) QL (240 per 30 days) 5

16 vicodin oral tablet mg xylon 10 oral tablet mg zebutal oral capsule mg Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release 24 hr 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac sodium topical gel 1 % diclofenac sodium topical gel 3 % diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mgmcg, mg-mcg diflunisal oral tablet 500 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg FLECTOR TRANSDERMAL PATCH 12 HOUR 1.3 % flurbiprofen oral tablet 100 mg, 50 mg ibu oral tablet 400 mg, 600 mg, 800 mg ibuprofen oral suspension 100 mg/5 ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg, 50 mg indomethacin oral capsule, extended release 75 mg ketoprofen oral capsule 25 mg, 50 mg, 75 mg ketorolac injection cartridge 15 mg/ml ketorolac intramuscular cartridge 60 mg/2 ml ketorolac intramuscular syringe 60 mg/2 ml ketorolac oral tablet 10 mg meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5 ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg PA NSO PA NSO; QL (120 per 30 days) 6

17 naproxen sodium oral tablet, er multiphase 24 hr 375 mg, 500 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg sulindac oral tablet 150 mg, 200 mg Anesthetics Local Anesthetics lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated 5 % lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution 2 % lidocaine-prilocaine topical cream % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 mg buprenorphine hcl sublingual tablet 2 mg buprenorphine hcl sublingual tablet 8 mg buprenorphine-naloxone sublingual film 12-3 mg buprenorphine-naloxone sublingual film mg, 4-1 mg, 8-2 mg buprenorphine-naloxone sublingual tablet mg, 8-2 mg bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) disulfiram oral tablet 250 mg, 500 mg LUCEMYRA ORAL TABLET 0.18 MG naloxone injection syringe 0.4 mg/ml, 1 mg/ml naltrexone oral tablet 50 mg NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML SUBOXONE SUBLINGUAL FILM 12-3 MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG Antianxiety Agents PA NSO; QL (90 per 30 days) QL (240 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (224 per 14 days) QL (90 per 30 days) 7

18 Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg clobazam oral suspension 2.5 mg/ml clobazam oral tablet 10 mg, 20 mg clonazepam oral tablet 0.5 mg, 1 mg, 2 mg clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT 2.5 MG diazepam intensol oral concentrate 5 mg/ml diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet 10 mg, 5 mg diazepam oral tablet 2 mg diazepam rectal kit mg, 2.5 mg, mg flurazepam oral capsule 15 mg, 30 mg lorazepam oral concentrate 2 mg/ml lorazepam oral tablet 0.5 mg, 1 mg, 2 mg meprobamate oral tablet 200 mg, 400 mg midazolam (pf) injection cartridge 2 mg/2 ml (1 mg/ml), 5 mg/ml midazolam (pf) injection solution 1 mg/ml, 5 mg/ml midazolam (pf) injection syringe 2 mg/2 ml (1 mg/ml), 5 mg/ml midazolam injection solution 1 mg/ml, 5 mg/ml ONFI ORAL SUSPENSION 2.5 MG/ML ONFI ORAL TABLET 10 MG, 20 MG oxazepam oral capsule 10 mg, 15 mg, 30 mg SYMPAZAN ORAL FILM 10 MG, 20 MG SYMPAZAN ORAL FILM 5 MG temazepam oral capsule 15 mg temazepam oral capsule 30 mg Antibacterials Aminoglycosides amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml QL (120 per 30 days) QL (480 per 30 days) QL (240 per 30 days) QL (1200 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (150 per 30 days) QL (480 per 30 days) 8

19 BETHKIS INHALATION SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 120 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin injection solution 20 mg/2 ml, 40 mg/ml gentamicin sulfate (ped) (pf) injection solution 20 mg/2 ml gentamicin sulfate (pf) intravenous solution 100 mg/10 ml, 60 mg/6 ml, 80 mg/8 ml neomycin oral tablet 500 mg streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin in 5 % dextrose intravenous piggyback 300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml clindamycin palmitate hcl oral recon soln 75 mg/5 ml clindamycin phosphate injection solution 150 (mg/ml) (6 ml), 150 mg/ml clindamycin phosphate intravenous solution 600 mg/4 ml colistin (colistimethate na) injection recon soln 150 mg daptomycin intravenous recon soln 350 mg, 500 mg lincomycin injection solution 300 mg/ml linezolid 600 mg/300 ml-0.9% nacl 600 mg/300 ml linezolid in dextrose 5% intravenous piggyback 600 mg/300 ml linezolid oral suspension for reconstitution 100 mg/5 ml linezolid oral tablet 600 mg methenamine hippurate oral tablet 1 gram metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml metronidazole oral capsule 375 mg PA; LA; QL (224 per 28 days); PA; QL (224 per 28 days); PA; QL (280 per 28 days); PA; ; PA; ; PA; QL (1800 per 30 days); PA; ; 9

20 metronidazole oral tablet 250 mg, 500 mg MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin oral suspension 25 mg/5 ml polymyxin b sulfate injection recon soln 500,000 unit SIVEXTRO INTRAVENOUS RECON SOLN 200 MG SIVEXTRO ORAL TABLET 200 MG SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg TRIMPEX ORAL SOLUTION 50 MG/5 ML vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml, 500 mg/100 ml, 750 mg/150 ml vancomycin intravenous recon soln 1,000 mg, 1.25 gram, 10 gram, 5 gram, 500 mg, 750 mg VANCOMYCIN INTRAVENOUS RECON SOLN 1.5 GRAM vancomycin intravenous recon soln 250 mg vancomycin oral capsule 125 mg, 250 mg VIBATIV INTRAVENOUS RECON SOLN 750 MG XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX INTRAVENOUS PIGGYBACK 200 MG/100 ML Cephalosporins AVYCAZ INTRAVENOUS RECON SOLN 2.5 GRAM cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefepime injection recon soln 1 gram, 2 gram cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml PA; ; QL (6 per 28 days); PA; QL (6 per 28 days); QL (80 per 10 days) QL (9 per 30 days) QL (84 per 28 days) ; 10

21 cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg cefotetan injection recon soln 1 gram, 2 gram cefotetan intravenous recon soln 10 gram cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection recon soln 1 gram, 2 gram, 6 gram ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml CLAFORAN INTRAVENOUS RECON SOLN 1 GRAM, 2 GRAM FORTAZ INJECTION RECON SOLN 500 MG MAXIPIME 1 GM ADD-VANTAGE VL OUTER, LATEX-FREE 1 GRAM MAXIPIME INJECTION RECON SOLN 1 GRAM SUPRAX ORAL CAPSULE 400 MG tazicef injection recon soln 1 gram, 2 gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 400 MG, 600 MG ZERBAXA INTRAVENOUS RECON SOLN 1.5 GRAM Macrolides azithromycin intravenous recon soln 500 mg azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 250 mg (6 pack), 500 mg, 500 mg (3 pack), 600 mg clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg ; 11

22 clarithromycin oral tablet extended release 24 hr 500 mg DIFICID ORAL TABLET 200 MG ery-tab oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral tablet 250 mg, 500 mg Miscellaneous B-Lactam Antibiotics AZACTAM INJECTION RECON SOLN 1 GRAM AZACTAM-ISO-OSMOT 1 GM/50 ML 24'S,SINGLE USE 1 GRAM/50 ML aztreonam injection recon soln 1 gram, 2 gram CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML ertapenem injection recon soln 1 gram imipenem-cilastatin intravenous recon soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 gram, 500 mg Penicillins amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg ampicillin sodium intravenous recon soln 2 gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram PA; QL (20 per 10 days); PA; QL (84 per 28 days); 12

23 BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg nafcillin 1 gm/ 50 ml inj 1 gram/50 ml nafcillin injection recon soln 1 gram, 10 gram, 2 gram nafcillin intravenous recon soln 2 gram oxacillin 1 gm add-vantage vl add-vantage, inner 1 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml oxacillin injection recon soln 1 gram, 10 gram, 2 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 20 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML, 4.5 GRAM/100 ML Quinolones ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml, 400 mg/200 ml ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml levofloxacin in d5w intravenous piggyback 250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous solution 25 mg/ml levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg moxifloxacin 400 mg/250 ml bag 400 mg/250 ml moxifloxacin in nacl (iso-osm) intravenous piggyback 400 mg/250 ml moxifloxacin oral tablet 400 mg 13

24 ofloxacin oral tablet 300 mg, 400 mg Sulfonamides sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg sulfatrim oral suspension mg/5 ml Tetracyclines demeclocycline oral tablet 150 mg, 300 mg doxy-100 intravenous recon soln 100 mg doxycycline hyclate intravenous recon soln 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75 mg minocycline oral capsule 100 mg, 50 mg, 75 mg okebo oral capsule 100 mg tetracycline oral capsule 250 mg, 500 mg tigecycline intravenous recon soln 50 mg Anticancer Agents Anticancer Agents abiraterone oral tablet 250 mg ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml adrucil intravenous solution 2.5 gram/50 ml, 500 mg/10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG ALUNBRIG ORAL TABLET 180 MG, 90 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG PA NSO; QL (30 per 180 days); (23) PA NSO; QL (120 per 30 days); PA NSO; PA NSO; ; PA NSO; PA BvD; PA NSO; ; PA NSO; ; 14

25 anastrozole oral tablet 1 mg arsenic trioxide intravenous solution 1 mg/ml AVASTIN INTRAVENOUS SOLUTION 25 MG/ML azacitidine injection recon soln 100 mg BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.25 MG/ML INITIAL) bexarotene oral capsule 75 mg bicalutamide oral tablet 50 mg BICNU INTRAVENOUS RECON SOLN 100 MG bleomycin injection recon soln 15 unit, 30 unit BORTEZOMIB INTRAVENOUS RECON SOLN 3.5 MG BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 400 MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG BRAFTOVI ORAL CAPSULE 75 MG CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution 10 mg/ml carmustine intravenous recon soln 100 mg cladribine intravenous solution 10 mg/10 ml COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG X 3/DAY) COPIKTRA ORAL CAPSULE 15 MG, 25 MG COTELLIC ORAL TABLET 20 MG cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG PA BvD; PA BvD; PA NSO; QL (300 per 30 days); PA NSO; QL (120 per 30 days); PA NSO; ; PA NSO; QL (120 per 30 days); PA NSO; QL (180 per 30 days); PA NSO; ; PA NSO; QL (2 per 1 day); PA NSO; LA; ; PA NSO; LA; ; PA NSO; LA; QL (56 per 28 days); PA NSO; LA; QL (112 per 28 days); PA NSO; LA; QL (84 per 28 days); PA NSO; QL (56 per 28 days); PA NSO; LA; QL (90 per 30 days); PA BvD 15

26 CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) cytarabine injection solution 20 mg/ml DARZALEX INTRAVENOUS SOLUTION 20 MG/ML daunorubicin intravenous recon soln 20 mg daunorubicin intravenous solution 5 mg/ml DAURISMO ORAL TABLET 100 MG DAURISMO ORAL TABLET 25 MG doxorubicin intravenous recon soln 10 mg, 50 mg doxorubicin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml doxorubicin, peg-liposomal intravenous suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG epirubicin intravenous recon soln 200 mg, 50 mg epirubicin intravenous solution 200 mg/100 ml, 50 mg/25 ml ERIVEDGE ORAL CAPSULE 150 MG ERLEADA ORAL TABLET 60 MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml exemestane oral tablet 25 mg FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fluorouracil intravenous solution 1 gram/20 ml, 5 gram/100 ml, 500 mg/10 ml flutamide oral capsule 125 mg GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS RECON SOLN 150 MG, 440 MG PA NSO; QL (200 per 28 days); PA NSO; LA; QL (400 per 30 days); PA NSO; QL (28 per 28 days); PA NSO; QL (84 per 28 days); PA NSO; PA NSO; ; PA NSO; QL (120 per 30 days); ; PA NSO; QL (6 per 21 days); ; PA NSO; ; PA NSO 16

27 HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ICLUSIG ORAL TABLET 15 MG, 45 MG IDFA ORAL TABLET 100 MG, 50 MG imatinib oral tablet 100 mg, 400 mg IMBRUVICA ORAL CAPSULE 140 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG IRESSA ORAL TABLET 250 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KADCYLA INTRAVENOUS RECON SOLN 100 MG, 160 MG KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1) LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3) LENVIMA ORAL CAPSULE 14 MG/DAY(10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY(10 MG X 2-4 MG X 1) LENVIMA ORAL CAPSULE 4 MG letrozole oral tablet 2.5 mg LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 mg/0.2 ml LONSURF ORAL TABLET MG LONSURF ORAL TABLET MG LORBRENA ORAL TABLET 100 MG PA NSO; QL (21 per 28 days); PA NSO; LA; ; PA NSO; ; PA NSO; PA NSO; QL (120 per 30 days); PA NSO; ; PA NSO; ; PA BvD; PA NSO; QL (180 per 30 days); PA NSO; ; PA NSO; LA; ; PA NSO; ; PA NSO; PA NSO; PA NSO; PA NSO; PA NSO; LA; ; PA NSO; ; PA NSO; LA; ; PA NSO; LA; QL (90 per 30 days); PA NSO; ; PA NSO; QL (100 per 30 days); PA NSO; QL (80 per 30 days); PA NSO; ; 17

28 LORBRENA ORAL TABLET 25 MG LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 100 MG LYNPARZA ORAL TABLET 150 MG LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 MG/31 ML(0.16 MG/ML) FINAL MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG MEKTOVI ORAL TABLET 15 MG mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection recon soln 1 gram methotrexate sodium (pf) injection solution 25 mg/ml methotrexate sodium injection solution 25 mg/ml methotrexate sodium oral tablet 2.5 mg mitomycin intravenous recon soln 20 mg, 40 mg, 5 mg mitoxantrone intravenous concentrate 2 mg/ml MUSTARGEN INJECTION RECON SOLN 10 MG mutamycin intravenous recon soln 20 mg, 40 mg, 5 mg MYLOTARG INTRAVENOUS RECON SOLN 4.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG NEXAVAR ORAL TABLET 200 MG nilutamide oral tablet 150 mg NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG PA NSO; QL (90 per 30 days); QL (1 per 90 days) QL (1 per 112 days) QL (1 per 168 days); QL (1 per 30 days) QL (1 per 30 days); PA NSO; LA; QL (480 per 30 days); PA NSO; QL (120 per 30 days); PA NSO; QL (4 per 1 day); ; LA; PA NSO; QL (90 per 30 days); PA NSO; ; PA NSO; QL (180 per 30 days); PA BvD PA BvD; PA NSO; QL (180 per 30 days); PA NSO; QL (120 per 30 days); ; PA NSO; QL (3 per 28 days); 18

29 ODOMZO ORAL CAPSULE 200 MG OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 240 MG/24 ML, 40 MG/4 ML paclitaxel intravenous concentrate 6 mg/ml PERJETA INTRAVENOUS SOLUTION 420 MG/14 ML (30 MG/ML) POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 5 MG REVLIMID ORAL CAPSULE 15 MG, 20 MG, 25 MG REVLIMID ORAL CAPSULE 2.5 MG RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG RYDAPT ORAL CAPSULE 25 MG SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG SPRYCEL ORAL TABLET 20 MG SPRYCEL ORAL TABLET 80 MG STIVARGA ORAL TABLET 40 MG SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG TAGRISSO ORAL TABLET 40 MG, 80 MG TALZENNA ORAL CAPSULE 0.25 MG TALZENNA ORAL CAPSULE 1 MG tamoxifen oral tablet 10 mg, 20 mg TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 25 MG PA NSO; LA; ; QL (80 per 28 days); PA NSO; PA NSO; LA; QL (21 per 28 days); QL (300 per 30 days); PA NSO; LA; QL (28 per 28 days); PA NSO; LA; QL (21 per 28 days); PA NSO; LA; ; PA NSO; QL (120 per 30 days); PA NSO; PA NSO; ; PA NSO; QL (90 per 30 days); PA NSO; ; PA NSO; QL (84 per 28 days); PA NSO; QL (28 per 28 days); PA NSO; PA NSO; QL (28 per 28 days); PA NSO; QL (180 per 30 days); PA NSO; QL (120 per 30 days); PA NSO; LA; ; PA NSO; QL (90 per 30 days); PA NSO; ; PA NSO; ; PA NSO; QL (90 per 30 days); 19

30 TARGRETIN TOPICAL GEL 1 % TASIGNA ORAL CAPSULE 150 MG, 200 MG TASIGNA ORAL CAPSULE 50 MG TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TIBSOVO ORAL TABLET 250 MG toposar intravenous solution 20 mg/ml topotecan intravenous recon soln 4 mg topotecan intravenous solution 4 mg/4 ml (1 mg/ml) toremifene oral tablet 60 mg TREANDA INTRAVENOUS RECON SOLN 100 MG, 25 MG tretinoin (chemotherapy) oral capsule 10 mg TRISENOX INTRAVENOUS SOLUTION 2 MG/ML TYKERB ORAL TABLET 250 MG VELCADE INJECTION RECON SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA ORAL TABLET 50 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG vinblastine intravenous solution 1 mg/ml vincasar pfs intravenous solution 1 mg/ml, 2 mg/2 ml vincristine intravenous solution 1 mg/ml, 2 mg/2 ml vinorelbine intravenous solution 10 mg/ml, 50 mg/5 ml VITRAKVI ORAL CAPSULE 100 MG VITRAKVI ORAL CAPSULE 25 MG VITRAKVI ORAL SOLUTION 20 MG/ML VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG VOTRIENT ORAL TABLET 200 MG VYXEOS INTRAVENOUS RECON SOLN MG XALKORI ORAL CAPSULE 200 MG, 250 MG XATMEP ORAL SOLUTION 2.5 MG/ML XOSPATA ORAL TABLET 40 MG XTANDI ORAL CAPSULE 40 MG PA NSO; QL (120 per 30 days); PA NSO; QL (420 per 30 days); PA NSO; QL (20 per 21 days); PA NSO; ; ; PA NSO; PA NSO; QL (150 per 30 days); YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML) PA NSO; PA NSO; QL (120 per 30 days); PA NSO; PA NSO; QL (42 per 28 days); PA NSO; ; PA NSO; ; PA NSO; QL (180 per 30 days); PA NSO; QL (300 per 30 days); PA NSO; ; PA NSO; QL (120 per 30 days); PA BvD; ; PA NSO; ; PA BvD; PA NSO; QL (90 per 30 days); PA NSO; QL (120 per 30 days); 20

31 YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS RECON SOLN 1 MG YONSA ORAL TABLET 125 MG ZANOSAR INTRAVENOUS RECON SOLN 1 GRAM ZEJULA ORAL CAPSULE 100 MG ZELBORAF ORAL TABLET 240 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG ZYTIGA ORAL TABLET 500 MG Anticholinergic Agents Antimuscarinics/Antispasmodics chlordiazepoxide-clidinium oral capsule mg propantheline oral tablet 15 mg Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML BRIVIACT ORAL TABLET 10 MG BRIVIACT ORAL TABLET 100 MG, 25 MG, 50 MG, 75 MG carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet 200 mg carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg carbamazepine oral tablet,chewable 100 mg CELONTIN ORAL CAPSULE 300 MG DILANTIN EXTENDED ORAL CAPSULE 100 MG DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG QL (250 per 21 days); PA NSO; PA NSO; QL (120 per 30 days); ; PA NSO; PA NSO; QL (240 per 30 days); PA NSO; QL (120 per 30 days); PA NSO; ; PA NSO; QL (150 per 30 days); PA NSO; QL (120 per 30 days); PA NSO; ; QL (240 per 30 days) QL (2400 per 30 days); QL (480 per 30 days); QL (240 per 30 days); QL (600 per 30 days); QL (540 per 30 days); ; 21

32 DILANTIN ORAL CAPSULE 30 MG DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML divalproex oral capsule, delayed rel sprinkle 125 mg divalproex oral tablet extended release 24 hr 250 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 125 mg, 250 mg, 500 mg EPIDIOLEX ORAL SOLUTION 100 MG/ML epitol oral tablet 200 mg EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5 ml felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg lamotrigine oral tablets,dose pack 25 mg (35), 25 mg (42) -100 mg (7), 25 mg (84) -100 mg (14) levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml levetiracetam intravenous solution 500 mg/5 ml levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG LYRICA ORAL SOLUTION 20 MG/ML PA NSO QL (680 per 28 days) QL (270 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (900 per 30 days) 22

33 oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg PEGANONE ORAL TABLET 250 MG phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) phenobarbital oral tablet 100 mg, 97.2 mg phenobarbital oral tablet 15 mg, 16.2 mg, 30 mg, 32.4 mg phenobarbital oral tablet 60 mg, 64.8 mg phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg primidone oral tablet 250 mg, 50 mg SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG SPRITAM ORAL TABLET FOR SUSPENSION 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG tiagabine oral tablet 12 mg, 16 mg, 2 mg, 4 mg topiramate oral capsule, sprinkle 15 mg, 25 mg topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 mg, 50 mg topiramate oral tablet 100 mg, 50 mg topiramate oral tablet 200 mg topiramate oral tablet 25 mg valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml) valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid oral capsule 250 mg vigabatrin oral powder in packet 500 mg vigabatrin oral tablet 500 mg vigadrone oral powder in packet 500 mg VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG VIMPAT ORAL TABLET 150 MG VIMPAT ORAL TABLET 200 MG VIMPAT ORAL TABLET 50 MG zonisamide oral capsule 100 mg, 25 mg, 50 mg QL (1500 per 30 days) QL (90 per 30 days) QL (300 per 30 days) QL (150 per 30 days) QL (180 per 30 days); QL (90 per 30 days) QL (360 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (180 per 30 days); QL (1200 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (210 per 30 days) 23

34 Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg donepezil oral tablet 23 mg, 5 mg donepezil oral tablet,disintegrating 10 mg, 5 mg galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg galantamine oral solution 4 mg/ml galantamine oral tablet 12 mg, 4 mg, 8 mg memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, 28 mg, 7 mg memantine oral solution 2 mg/ml memantine oral tablet 10 mg memantine oral tablet 5 mg memantine oral tablets,dose pack 5-10 mg NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK 7/14/21/28 MG-10 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR MG, MG, MG, 7-10 MG rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amitriptyline-chlordiazepoxide oral tablet mg, mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg bupropion hcl oral tablet sustained-release 12 hr 100 mg, 150 mg bupropion hcl oral tablet sustained-release 12 hr 200 mg citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 20 mg citalopram oral tablet 40 mg clomipramine oral capsule 25 mg, 50 mg, 75 mg desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg QL (180 per 30 days) QL (300 per 30 days) QL (90 per 30 days) QL (98 per 30 days) QL (28 per 28 days) QL (120 per 30 days) QL (180 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (45 per 30 days) 24

35 desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 40 mg, 60 mg EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 10 mg, 5 mg escitalopram oxalate oral tablet 20 mg FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 40 MG, 80 MG ; QL (600 per 30 days) QL (45 per 30 days) QL (90 per 30 days) QL (28 per 28 days) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG QL (150 per 30 days) fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral solution 20 mg/5 ml (4 mg/ml) fluvoxamine oral capsule,extended release 24hr 100 mg, 150 mg fluvoxamine oral tablet 100 mg, 25 mg, 50 mg imipramine hcl oral tablet 10 mg, 25 mg, 50 mg imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml paroxetine hcl oral tablet 10 mg, 20 mg paroxetine hcl oral tablet 30 mg, 40 mg PAXIL ORAL SUSPENSION 10 MG/5 ML perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg phenelzine oral tablet 15 mg QL (150 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (90 per 30 days) 25

36 protriptyline oral tablet 10 mg, 5 mg sertraline oral concentrate 20 mg/ml sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg tranylcypromine oral tablet 10 mg trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg trimipramine oral capsule 100 mg, 25 mg, 50 mg TRINTELLIX ORAL TABLET 10 MG TRINTELLIX ORAL TABLET 20 MG TRINTELLIX ORAL TABLET 5 MG venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (23), 10 MG (7)-20 MG (7)-40 MG (16) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 25 mg, 50 mg ADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg alogliptin-metformin oral tablet ,000 mg, mg alogliptin-pioglitazone oral tablet mg, mg, mg, mg, mg, mg AVANDIA ORAL TABLET 2 MG, 4 MG BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET ORAL TABLET 0.8 MG QL (300 per 30 days) QL (240 per 30 days) QL (120 per 30 days) QL (45 per 30 days) QL (90 per 30 days) QL (90 per 30 days) PA; QL (6 per 28 days) PA; QL (3.4 per 28 days) PA; QL (4 per 28 days) PA; QL (4 per 28 days) PA; QL (2.4 per 30 days) PA; QL (1.2 per 30 days) QL (180 per 30 days) 26

37 GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG, MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, MG, 50-1,000 MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR MG INVOKANA ORAL TABLET 100 MG, 300 MG JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 25 MG JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG KORLYM ORAL TABLET 300 MG metformin oral tablet 1,000 mg, 500 mg, 850 mg metformin oral tablet extended release 24 hr 500 mg, 750 mg miglitol oral tablet 100 mg, 25 mg, 50 mg nateglinide oral tablet 120 mg, 60 mg OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/DOSE (2 MG/1.5 ML) pioglitazone oral tablet 15 mg, 30 mg, 45 mg pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet mg, mg QTERN ORAL TABLET 10-5 MG repaglinide oral tablet 0.5 mg, 1 mg, 2 mg SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML QL (120 per 30 days) QL (120 per 30 days); PA; QL (3 per 28 days) QL (90 per 30 days) QL (10.8 per 30 days) 27

38 SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET ,000 MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, ,000 MG, 25-1,000 MG, 5-1,000 MG TANZEUM SUBCUTANEOUS PEN INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML TRADJENTA ORAL TABLET 5 MG TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) Insulins FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) QL (10.5 per 30 days) PA; QL (4 per 28 days) PA; QL (2 per 28 days) PA; QL (9 per 30 days) 28

39 NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 UNIT- 3.6 MG /ML (3 ML) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg, 4 mg glipizide oral tablet 10 mg, 5 mg glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg glipizide-metformin oral tablet mg, mg, mg Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 mg caspofungin intravenous recon soln 50 mg, 70 mg ciclopirox topical cream 0.77 % ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % clotrimazole topical solution 1 % QL (18 per 30 days) QL (27 per 30 days) QL (15 per 30 days) ; ; 29

40 clotrimazole-betamethasone topical cream % clotrimazole-betamethasone topical lotion % econazole topical cream 1 % ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 100 MG, 50 MG fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 125 mg/5 ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg itraconazole oral capsule 100 mg itraconazole oral solution 10 mg/ml ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % miconazole-3 vaginal suppository 200 mg MYCAMINE INTRAVENOUS RECON SOLN 100 MG, 50 MG naftifine topical cream 1 %, 2 % NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7 ML NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) PA; QL (120 per 30 days) PA PA; QL (840 per 28 days); NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG PA; QL (93 per 30 days); nyamyc topical powder 100,000 unit/gram nystatin oral powder 150 million unit nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% nystop topical powder 100,000 unit/gram oxiconazole topical cream 1 % SPORANOX ORAL SOLUTION 10 MG/ML PA; 30

41 terbinafine hcl oral tablet 250 mg voriconazole intravenous solution 200 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg Antigout Agents Antigout Agents, Other allopurinol oral tablet 100 mg, 300 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg ULORIC ORAL TABLET 40 MG, 80 MG Antihistamines Antihistamines cetirizine oral solution 1 mg/ml clemastine oral tablet 2.68 mg cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg desloratadine oral tablet 5 mg hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg levocetirizine oral tablet 5 mg promethazine oral syrup 6.25 mg/5 ml Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) clindamycin phosphate vaginal cream 2 % metronidazole vaginal gel 0.75 % terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg Antimigraine Agents Antimigraine Agents AIMOVIG 70 MG/ML AUTOINJECTOR 70 MG/ML AIMOVIG AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO- INJECTOR 70 MG/ML almotriptan malate oral tablet 12.5 mg, 6.25 mg QL (90 per 365 days) PA; QL (400 per 30 days); PA; QL (120 per 30 days); QL (300 per 30 days) PA NSO; QL (2 per 28 days) PA NSO; QL (2 per 28 days) QL (12 per 30 days) 31

42 dihydroergotamine injection solution 1 mg/ml dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml) eletriptan oral tablet 20 mg, 40 mg ergotamine-caffeine oral tablet mg frovatriptan oral tablet 2.5 mg MIGERGOT RECTAL SUPPOSITORY MG naratriptan oral tablet 1 mg, 2.5 mg rizatriptan oral tablet 10 mg, 5 mg rizatriptan oral tablet,disintegrating 10 mg, 5 mg sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg QL (12 per 30 days) QL (12 per 30 days) QL (18 per 30 days) QL (18 per 30 days) QL (18 per 30 days) QL (12 per 30 days) QL (6 per 30 days) QL (18 per 30 days) sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml QL (8 per 30 days) sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 mg/0.5 ml sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml zolmitriptan oral tablet 2.5 mg, 5 mg zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 GRAM dapsone oral tablet 100 mg, 25 mg ethambutol oral tablet 100 mg, 400 mg isoniazid injection solution 100 mg/ml isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 100 mg, 300 mg PASER ORAL GRANULES DR FOR SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg rifampin intravenous recon soln 600 mg rifampin oral capsule 150 mg, 300 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG QL (8 per 30 days) QL (8 per 30 days) QL (8 per 30 days) QL (12 per 30 days) QL (12 per 30 days) QL (68 per 28 days); 32

43 TRECATOR ORAL TABLET 250 MG Antinausea Agents Antinausea Agents AKYNZEO (NETUPITANT) ORAL CAPSULE MG ANZEMET ORAL TABLET 100 MG, 50 MG aprepitant oral capsule 125 mg, 40 mg, 80 mg aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) CESAMET ORAL CAPSULE 1 MG compro rectal suppository 25 mg dronabinol oral capsule 10 mg, 2.5 mg, 5 mg granisetron hcl oral tablet 1 mg meclizine oral tablet 12.5 mg, 25 mg ondansetron hcl (pf) injection solution 4 mg/2 ml ondansetron hcl (pf) injection syringe 4 mg/2 ml ondansetron hcl intravenous solution 2 mg/ml ondansetron hcl oral solution 4 mg/5 ml ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron oral tablet,disintegrating 4 mg, 8 mg PALONOSETRON INTRAVENOUS SOLUTION 0.25 MG/2 ML palonosetron intravenous solution 0.25 mg/5 ml phenadoz rectal suppository 12.5 mg, 25 mg prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg promethazine injection solution 25 mg/ml, 50 mg/ml promethazine oral tablet 12.5 mg, 25 mg, 50 mg promethazine rectal suppository 12.5 mg, 25 mg, 50 mg promethegan rectal suppository 12.5 mg, 25 mg, 50 mg scopolamine base transdermal patch 3 day 1 mg over 3 days TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS Antiparasite Agents Antiparasite Agents albendazole oral tablet 200 mg ALBENZA ORAL TABLET 200 MG PA BvD PA BvD PA BvD PA BvD PA BvD; PA BvD; QL (120 per 30 days) PA BvD; QL (28 per 28 days) PA BvD; QL (450 per 30 days) PA BvD; PA BvD; QL (90 per 30 days) PA BvD; QL (90 per 30 days) 33

44 ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5 ml atovaquone-proguanil oral tablet mg, mg chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG EMVERM ORAL TABLET,CHEWABLE 100 MG hydroxychloroquine oral tablet 200 mg ivermectin oral tablet 3 mg KRINTAFEL ORAL TABLET 150 MG mefloquine oral tablet 250 mg NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg PENTAM INJECTION RECON SOLN 300 MG praziquantel oral tablet 600 mg PRIMAQUINE ORAL TABLET 26.3 MG quinine sulfate oral capsule 324 mg tinidazole oral tablet 250 mg, 500 mg Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 mg amantadine hcl oral solution 50 mg/5 ml amantadine hcl oral tablet 100 mg APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML benztropine oral tablet 0.5 mg, 1 mg, 2 mg bromocriptine oral capsule 5 mg bromocriptine oral tablet 2.5 mg cabergoline oral tablet 0.5 mg carbidopa oral tablet 25 mg carbidopa-levodopa oral tablet mg, mg, mg carbidopa-levodopa oral tablet extended release mg, mg carbidopa-levodopa oral tablet,disintegrating mg, mg, mg QL (180 per 30 days) QL (40 per 30 days) QL (24 per 30 days) PA; PA BvD PA; QL (42 per 7 days) QL (60 per 28 days); QL (16 per 28 days) 34

45 carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg entacapone oral tablet 200 mg NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg pramipexole oral tablet extended release 24 hr mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg rasagiline oral tablet 0.5 mg, 1 mg ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg ropinirole oral tablet extended release 24 hr 12 mg, 2 mg, 4 mg, 6 mg, 8 mg RYTARY ORAL CAPSULE, EXTENDED RELEASE MG, MG, MG, MG selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg tolcapone oral tablet 100 mg trihexyphenidyl oral elixir 0.4 mg/ml trihexyphenidyl oral tablet 2 mg, 5 mg XADAGO ORAL TABLET 100 MG, 50 MG Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG aripiprazole oral solution 1 mg/ml aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet,disintegrating 10 mg, 15 mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML QL (300 per 30 days) QL (1 per 28 days); QL (1 per 28 days); QL (900 per 30 days) ; QL (1.6 per 28 days); 35

46 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine injection solution 25 mg/ml chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 150 mg, 200 mg, 25 mg FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG FANAPT ORAL TABLET 10 MG, 12 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)-2MG(2)- 4MG(2)- 6MG(2) fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5 ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 100 mg/ml, 100 mg/ml (1 ml), 50 mg/ml haloperidol lactate intramuscular syringe 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML QL (2.4 per 28 days); QL (3.2 per 28 days); ; QL (0.75 per 28 days); QL (1 per 28 days); QL (1.5 per 28 days); QL (0.25 per 28 days) QL (0.5 per 28 days); QL (0.87 per 28 days); QL (1.31 per 28 days); INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML QL (1.75 per 28 days); 36

47 INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg molindone oral tablet 10 mg molindone oral tablet 25 mg molindone oral tablet 5 mg NUPLAZID ORAL CAPSULE 34 MG NUPLAZID ORAL TABLET 10 MG NUPLAZID ORAL TABLET 17 MG olanzapine intramuscular recon soln 10 mg olanzapine oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg olanzapine oral tablet 15 mg olanzapine oral tablet,disintegrating 10 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating 20 mg paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg pimozide oral tablet 1 mg, 2 mg quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg quetiapine oral tablet extended release 24 hr 150 mg quetiapine oral tablet extended release 24 hr 200 mg quetiapine oral tablet extended release 24 hr 300 mg, 400 mg quetiapine oral tablet extended release 24 hr 50 mg REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML QL (2.62 per 28 days); ; ; QL (240 per 30 days) QL (270 per 30 days) QL (360 per 30 days) ; ; QL (120 per 30 days); ; ; QL (90 per 30 days) QL (120 per 30 days) ; QL (2 per 28 days) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML QL (2 per 28 days); risperidone oral solution 1 mg/ml risperidone oral tablet 0.25 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet 0.5 mg QL (240 per 30 days) QL (120 per 30 days) risperidone oral tablet,disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet,disintegrating 0.5 mg QL (120 per 30 days) 37

48 SAPHRIS SUBLINGUAL TABLET 10 MG, 5 MG SAPHRIS SUBLINGUAL TABLET 2.5 MG thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG Antivirals (Systemic) Antiretrovirals abacavir oral solution 20 mg/ml abacavir oral tablet 300 mg abacavir-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML atazanavir oral capsule 150 mg, 200 mg atazanavir oral capsule 300 mg ATRIPLA ORAL TABLET MG BIKTARVY ORAL TABLET MG CIMDUO ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG CRIXIVAN ORAL CAPSULE 400 MG DELSTRIGO ORAL TABLET MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 125 mg didanosine oral capsule,delayed release(dr/ec) 200 mg didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg EDURANT ORAL TABLET 25 MG efavirenz oral capsule 200 mg ; QL (180 per 30 days); QL (540 per 30 days) ; QL (2 per 28 days) QL (1 per 28 days) QL (960 per 30 days) ; ; QL (120 per 30 days); QL (285 per 28 days); ; ; ; ; ; ; QL (360 per 30 days) QL (180 per 30 days) ; ; QL (90 per 30 days) ; QL (120 per 30 days) 38

49 efavirenz oral capsule 50 mg efavirenz oral tablet 600 mg EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG fosamprenavir oral tablet 700 mg FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG INTELENCE ORAL TABLET 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG ISENTRESS ORAL TABLET,CHEWABLE 25 MG JULUCA ORAL TABLET MG KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution 10 mg/ml lamivudine oral tablet 100 mg, 300 mg lamivudine oral tablet 150 mg lamivudine-zidovudine oral tablet mg LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution mg/5 ml nevirapine oral suspension 50 mg/5 ml nevirapine oral tablet 200 mg nevirapine oral tablet extended release 24 hr 100 mg nevirapine oral tablet extended release 24 hr 400 mg NORVIR ORAL CAPSULE 100 MG NORVIR ORAL POWDER IN PACKET 100 MG NORVIR ORAL SOLUTION 80 MG/ML QL (360 per 30 days) QL (850 per 30 days) ; QL (120 per 30 days) ; ; QL (120 per 30 days); ; QL (120 per 30 days) QL (300 per 30 days); QL (120 per 30 days); QL (300 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (720 per 30 days) ; QL (300 per 30 days) QL (150 per 30 days); QL (960 per 30 days) QL (1800 per 30 days) QL (480 per 30 days) QL (1200 per 30 days) QL (120 per 30 days) QL (360 per 30 days) QL (360 per 30 days) QL (480 per 30 days) 39

50 ODEFSEY ORAL TABLET MG PIFELTRO ORAL TABLET 100 MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG PREZISTA ORAL TABLET 75 MG PREZISTA ORAL TABLET 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG RETROVIR INTRAVENOUS SOLUTION 10 MG/ML REYATAZ ORAL POWDER IN PACKET 50 MG ritonavir oral tablet 100 mg SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 150 MG SELZENTRY ORAL TABLET 25 MG SELZENTRY ORAL TABLET 300 MG SELZENTRY ORAL TABLET 75 MG stavudine oral capsule 15 mg, 20 mg stavudine oral capsule 30 mg, 40 mg STRIBILD ORAL TABLET MG SYMFI LO ORAL TABLET MG SYMFI ORAL TABLET MG SYMTUZA ORAL TABLET MG tenofovir disoproxil fumarate oral tablet 300 mg TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VEMLIDY ORAL TABLET 25 MG VIDEX 2 GM PEDIATRIC SOLN 10 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG ; ; ; QL (360 per 30 days); QL (240 per 30 days); ; QL (480 per 30 days); ; QL (180 per 30 days) QL (360 per 30 days) QL (240 per 30 days); QL (360 per 30 days) QL (1840 per 30 days) QL (240 per 30 days); QL (120 per 30 days) QL (120 per 30 days); ; QL (120 per 30 days) ; ; ; ; ; ; ; QL (1200 per 30 days) QL (1200 per 30 days) QL (90 per 30 days) 40

51 VIRACEPT ORAL TABLET 250 MG VIRACEPT ORAL TABLET 625 MG VIRAMUNE ORAL SUSPENSION 50 MG/5 ML VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG ZERIT ORAL RECON SOLN 1 MG/ML zidovudine oral capsule 100 mg zidovudine oral syrup 10 mg/ml zidovudine oral tablet 300 mg Antivirals, Miscellaneous foscarnet intravenous solution 24 mg/ml oseltamivir oral capsule 30 mg, 45 mg, 75 mg oseltamivir oral suspension for reconstitution 6 mg/ml RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 mg XOFLUZA ORAL TABLET 20 MG, 40 MG Hcv Antivirals EPCLUSA ORAL TABLET MG HARVONI ORAL TABLET MG MAVYRET ORAL TABLET MG VOSEVI ORAL TABLET MG Interferons INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir oral capsule 200 mg QL (300 per 30 days); QL (120 per 30 days); QL (240 per 30 days); ; QL (2400 per 30 days) QL (180 per 30 days) QL (1680 per 28 days) QL (60 per 180 days) QL (4 per 180 days) PA; ; PA; QL (28 per 28 days); PA; QL (84 per 28 days); PA; ; PA NSO; PA NSO; QL (2 per 28 days); PA NSO; QL (4 per 28 days); PA NSO; QL (4 per 28 days); PA NSO; QL (4 per 28 days); 41

52 acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet 400 mg, 800 mg acyclovir sodium intravenous recon soln 500 mg acyclovir sodium intravenous solution 50 mg/ml adefovir oral tablet 10 mg BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5 mg, 1 mg famciclovir oral tablet 125 mg, 250 mg, 500 mg ganciclovir sodium intravenous recon soln 500 mg ganciclovir sodium intravenous solution 50 mg/ml ribasphere oral capsule 200 mg ribasphere oral tablet 200 mg ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg valacyclovir oral tablet 1 gram, 500 mg valganciclovir oral recon soln 50 mg/ml valganciclovir oral tablet 450 mg Blood Products/Modifiers/Volume Expanders Anticoagulants COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG ELIQUIS ORAL TABLET 2.5 MG ELIQUIS ORAL TABLET 5 MG ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS) enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml, 60 mg/0.6 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) QL (630 per 30 days); QL (90 per 30 days) QL (168 per 28 days) QL (168 per 28 days) QL (120 per 30 days) QL (74 per 30 days) QL (74 per 30 days) QL (84 per 28 days) QL (56 per 28 days) QL (44.8 per 28 days) QL (33.6 per 28 days) QL (22.4 per 28 days) QL (24 per 30 days) QL (15 per 30 days) QL (12 per 30 days) QL (18 per 30 days) 42

53 heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection syringe 5,000 unit/ml HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin, porcine (pf) injection solution 1,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 20 MG XARELTO ORAL TABLET 15 MG XARELTO ORAL TABLET 2.5 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 300 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML BERINERT INTRAVENOUS KIT 500 UNIT (10 ML) CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) FULPLA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML LEUKINE INJECTION RECON SOLN 250 MCG MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML QL (42 per 21 days) QL (51 per 30 days) PA BvD; PA BvD PA BvD PA BvD; ; ; PA; QL (1.2 per 28 days); PA; PA; QL (9.6 per 30 days); PA; QL (1.2 per 28 days); 43

54 NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML NIVESTYM SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML NIVESTYM SUBCUTANEOUS SYRINGE 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/2 ML, 40,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML PROMACTA ORAL POWDER IN PACKET 12.5 MG PROMACTA ORAL TABLET 12.5 MG, 25 MG PROMACTA ORAL TABLET 50 MG, 75 MG RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML RUCONEST INTRAVENOUS RECON SOLN 2,100 UNIT UDENYCA SUBCUTANEOUS SYRINGE 6 MG/0.6 ML ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML ZARXIO INJECTION SYRINGE 480 MCG/0.8 ML Hematologic Agents, Miscellaneous aminocaproic acid intravenous solution 250 mg/ml anagrelide oral capsule 0.5 mg, 1 mg tranexamic acid intravenous solution 1,000 mg/10 ml (100 mg/ml) tranexamic acid oral tablet 650 mg Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er multiphase 12 hr mg BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100 mg, 50 mg clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg dipyridamole oral tablet 25 mg, 50 mg, 75 mg pentoxifylline oral tablet extended release 400 mg prasugrel oral tablet 10 mg, 5 mg ZONTIVITY ORAL TABLET 2.08 MG Caloric Agents Caloric Agents PA; PA; PA; QL (7 per 30 days); PA; QL (11.2 per 30 days); PA BvD; QL (12 per 28 days) PA BvD; QL (12 per 28 days); PA BvD; QL (24 per 28 days); PA; QL (180 per 30 days); PA; ; PA; ; ; PA; QL (1.2 per 28 days); PA; QL (7 per 30 days); PA; QL (11.2 per 30 days); QL (30 per 5 days) QL (37 per 30 days) 44

55 AMINOSYN 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN 7 % WITH ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5.2 % INTRAVENOUS PARENTERAL SOLUTION 5.2 % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX 4.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 4.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; 45

56 CLINIMIX 4.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 4.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 4.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 20 % in water (d20w) intravenous parenteral solution 20 % dextrose 25 % in water (d25w) intravenous syringe dextrose 30 % in water (d30w) intravenous parenteral solution dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in ringer's intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback 5 % dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; 46

57 INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN INTRAVENOUS EMULSION % NEPHRAMINE 5.4 % INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS EMULSION 20 % PERIKABIVEN INTRAVENOUS EMULSION % PLENAMINE INTRAVENOUS PARENTERAL SOLUTION 15 % PREMASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % PA BvD; PA BvD; PA BvD; PA BvD; PA BvD; PREMASOL 6 % INTRAVENOUS PARENTERAL SOLUTION 6 % PA BvD; PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr clorpres oral tablet mg, mg, mg doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg guanfacine oral tablet 1 mg, 2 mg methyldopa oral tablet 250 mg, 500 mg methyldopa-hydrochlorothiazide oral tablet mg, mg midodrine oral tablet 10 mg, 2.5 mg, 5 mg NORTHERA ORAL CAPSULE 100 MG, 200 MG NORTHERA ORAL CAPSULE 300 MG phenoxybenzamine oral capsule 10 mg prazosin oral capsule 1 mg, 2 mg, 5 mg Angiotensin Ii Receptor Antagonists candesartan oral tablet 16 mg, 4 mg, 8 mg candesartan oral tablet 32 mg candesartan-hydrochlorothiazid oral tablet mg, mg, mg PA BvD; PA BvD; PA BvD; PA BvD; QL (4 per 28 days) QL (90 per 30 days); QL (180 per 30 days); 47

58 ENTRESTO ORAL TABLET MG, MG, MG eprosartan oral tablet 600 mg irbesartan oral tablet 150 mg, 75 mg irbesartan oral tablet 300 mg irbesartan-hydrochlorothiazide oral tablet mg, mg losartan oral tablet 100 mg, 25 mg, 50 mg losartan-hydrochlorothiazide oral tablet mg, mg, mg olmesartan oral tablet 20 mg, 40 mg, 5 mg olmesartan-amlodipin-hcthiazid oral tablet mg, mg, mg, mg, mg olmesartan-hydrochlorothiazide oral tablet mg, mg, mg telmisartan oral tablet 20 mg, 40 mg telmisartan oral tablet 80 mg telmisartan-hydrochlorothiazid oral tablet mg, mg telmisartan-hydrochlorothiazid oral tablet mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg enalapril-hydrochlorothiazide oral tablet mg, mg fosinopril oral tablet 10 mg, 20 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet mg, mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg moexipril oral tablet 15 mg, 7.5 mg moexipril-hydrochlorothiazide oral tablet mg, mg, mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg 48

59 quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg quinapril-hydrochlorothiazide oral tablet mg, mg, mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg Antiarrhythmic Agents amiodarone oral tablet 100 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 100 mg, 150 mg dofetilide oral capsule 125 mcg dofetilide oral capsule 250 mcg dofetilide oral capsule 500 mcg flecainide oral tablet 100 mg, 150 mg, 50 mg mexiletine oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 mg, 200 mg, 400 mg propafenone oral capsule,extended release 12 hr 225 mg, 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg quinidine gluconate oral tablet extended release 324 mg quinidine sulfate oral tablet 200 mg, 300 mg Beta-Adrenergic Blocking Agents acebutolol oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg atenolol-chlorthalidone oral tablet mg, mg betaxolol oral tablet 10 mg, 20 mg bisoprolol fumarate oral tablet 10 mg, 5 mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg BYSTOLIC ORAL TABLET 10 MG BYSTOLIC ORAL TABLET 2.5 MG, 5 MG BYSTOLIC ORAL TABLET 20 MG carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg carvedilol phosphate oral capsule, er multiphase 24 hr 10 mg, 20 mg, 40 mg, 80 mg labetalol oral tablet 100 mg, 200 mg, 300 mg metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg QL (240 per 30 days) QL (120 per 30 days) QL (120 per 30 days) 49

60 metoprolol ta-hydrochlorothiaz oral tablet mg, mg, mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol oral tablet 20 mg, 40 mg, 80 mg pindolol oral tablet 10 mg, 5 mg propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral tablet mg, mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol af oral tablet 120 mg, 160 mg, 80 mg sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg timolol maleate oral tablet 10 mg, 20 mg, 5 mg Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg cartia xt oral capsule,extended release 24hr 300 mg diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 24 hr 360 mg diltiazem hcl oral capsule,extended release 24 hr 420 mg diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg diltiazem hcl oral capsule,extended release 24hr 300 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg diltiazem hcl oral tablet extended release 24 hr 180 mg, 300 mg diltiazem hcl oral tablet extended release 24 hr 240 mg, 360 mg, 420 mg dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg matzim la oral tablet extended release 24 hr 180 mg, 240 mg, 300 mg, 360 mg, 420 mg taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg taztia xt oral capsule,extended release 24 hr 300 mg, 360 mg verapamil oral capsule, 24 hr er pellet ct 100 mg, 300 mg verapamil oral capsule, 24 hr er pellet ct 200 mg verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg, 360 mg 50

61 verapamil oral tablet 120 mg, 40 mg, 80 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG DEMSER ORAL CAPSULE 250 MG digitek oral tablet 125 mcg digitek oral tablet 250 mcg digox oral tablet 125 mcg digox oral tablet 250 mcg digoxin 125 mcg tablet 125 mcg digoxin injection syringe 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML digoxin oral tablet 125 mcg digoxin oral tablet 250 mcg dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml), 500 mg/40 ml (12.5 mg/ml) dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 400 mg/500 ml (800 mcg/ml), 800 mg/250 ml (3,200 mcg/ml), 800 mg/500 ml (1,600 mcg/ml) dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/10 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml) epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML hydralazine injection solution 20 mg/ml hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg LANOXIN INJECTION SOLUTION 250 MCG/ML LANOXIN ORAL TABLET MCG, 62.5 MCG milrinone in 5 % dextrose intravenous piggyback 20 mg/100 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml) milrinone intravenous solution 1 mg/ml RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1,000 MG, 500 MG SYMJEPI INJECTION SYRINGE 0.3 MG/0.3 ML PA; PA; QL (18 per 30 days); QL (120 per 30 days) 51

62 Dihydropyridines afeditab cr oral tablet extended release 30 mg, 60 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 mg amlodipine-benazepril oral capsule mg, mg amlodipine-benazepril oral capsule mg amlodipine-benazepril oral capsule 5-10 mg, 5-20 mg, 5-40 mg amlodipine-olmesartan oral tablet mg, mg, 5-20 mg, 5-40 mg amlodipine-valsartan oral tablet mg, mg, mg amlodipine-valsartan oral tablet mg amlodipine-valsartan-hcthiazid oral tablet mg, mg, mg, mg, mg felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg nicardipine oral capsule 20 mg, 30 mg nifedical xl oral tablet extended release 24hr 30 mg, 60 mg nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg nimodipine oral capsule 30 mg nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 34 mg, 40 mg, 8.5 mg nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg Diuretics amiloride oral tablet 5 mg amiloride-hydrochlorothiazide oral tablet 5-50 mg bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, 2 mg chlorothiazide oral tablet 250 mg, 500 mg chlorothiazide sodium intravenous recon soln 500 mg chlorthalidone oral tablet 25 mg, 50 mg DYRENIUM ORAL CAPSULE 100 MG, 50 MG ethacrynic acid oral tablet 25 mg furosemide injection solution 10 mg/ml furosemide injection syringe 10 mg/ml furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 mg hydrochlorothiazide oral capsule 12.5 mg 52

63 hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg, 2.5 mg, 5 mg SAMSCA ORAL TABLET 15 MG, 30 MG spironolactone oral tablet 100 mg, 25 mg, 50 mg spironolacton-hydrochlorothiaz oral tablet mg torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg triamterene-hydrochlorothiazid oral capsule mg, mg triamterene-hydrochlorothiazid oral tablet mg, mg Dyslipidemics amlodipine-atorvastatin oral tablet mg, mg, mg, mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine-atorvastatin oral tablet mg, 5-80 mg atorvastatin oral tablet 10 mg, 20 mg, 40 mg atorvastatin oral tablet 80 mg cholestyramine (with sugar) oral powder in packet 4 gram cholestyramine light oral powder 4 gram cholestyramine light packet 4 gram colesevelam oral powder in packet 3.75 gram colesevelam oral tablet 625 mg colestipol oral packet 5 gram colestipol oral tablet 1 gram ezetimibe oral tablet 10 mg ezetimibe-simvastatin oral tablet mg, mg, mg, mg fenofibrate micronized oral capsule 134 mg, 200 mg fenofibrate micronized oral capsule 67 mg fenofibrate nanocrystallized oral tablet 145 mg fenofibrate nanocrystallized oral tablet 48 mg fenofibrate oral tablet 160 mg fenofibrate oral tablet 54 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg fenofibric acid oral tablet 105 mg, 35 mg fluvastatin oral capsule 20 mg, 40 mg PA; QL (180 per 30 days) 53

64 gemfibrozil oral tablet 600 mg lovastatin oral tablet 10 mg, 20 mg, 40 mg niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg omega-3 acid ethyl esters oral capsule 1 gram PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg prevalite oral powder in packet 4 gram REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg simvastatin oral tablet 80 mg VASCEPA ORAL CAPSULE 0.5 GRAM VASCEPA ORAL CAPSULE 1 GRAM WELCHOL ORAL POWDER IN PACKET 3.75 GRAM Renin-Angiotensin-Aldosterone System Inhibitors CAROSPIR ORAL SUSPENSION 25 MG/5 ML eplerenone oral tablet 25 mg, 50 mg Vasodilators isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide dinitrate oral tablet extended release 40 mg isosorbide mononitrate oral tablet 10 mg, 20 mg isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr minoxidil oral tablet 10 mg, 2.5 mg NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr QL (120 per 30 days) PA; PA; QL (3.5 per 28 days); PA; QL (3 per 28 days); PA; QL (3 per 28 days); QL (240 per 30 days) QL (120 per 30 days) 54

65 nitroglycerin translingual spray,non-aerosol 400 mcg/spray NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg AUBAGIO ORAL TABLET 14 MG, 7 MG AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG clonidine hcl oral tablet extended release 12 hr 0.1 mg COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML dalfampridine oral tablet extended release 12 hr 10 mg dexmethylphenidate oral capsule,er biphasic mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg dextroamphetamine oral capsule, extended release 10 mg dextroamphetamine oral capsule, extended release 15 mg dextroamphetamine oral capsule, extended release 5 mg dextroamphetamine oral tablet 10 mg dextroamphetamine oral tablet 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg dextroamphetamine-amphetamine oral tablet 30 mg EXTAVIA SUBCUTANEOUS KIT 0.3 MG GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG glatiramer subcutaneous syringe 20 mg/ml glatiramer subcutaneous syringe 40 mg/ml PA; LA; PA; LA; ; PA; PA; QL (4 per 28 days); PA; QL (1 per 28 days); PA; QL (1 per 28 days); PA; QL (15 per 30 days); QL (120 per 30 days) PA; ; PA; QL (12 per 28 days); PA; ; QL (180 per 30 days) QL (120 per 30 days) QL (180 per 30 days) QL (150 per 30 days) QL (90 per 30 days) PA; QL (15 per 30 days); PA; ; PA; ; PA; QL (12 per 28 days); 55

66 glatopa subcutaneous syringe 20 mg/ml glatopa subcutaneous syringe 40 mg/ml LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml metadate er oral tablet extended release 20 mg methylphenidate hcl oral capsule, er biphasic mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er biphasic mg methylphenidate hcl oral capsule,er biphasic mg, 30 mg, 40 mg, 60 mg methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml methylphenidate hcl oral tablet 10 mg, 5 mg methylphenidate hcl oral tablet 20 mg methylphenidate hcl oral tablet extended release 10 mg methylphenidate hcl oral tablet extended release 20 mg methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet extended release 24hr 72 mg methylphenidate la 20 mg cap 20 mg methylphenidate la 40 mg cap 40 mg NUEDEXTA ORAL CAPSULE MG PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML RADICAVA INTRAVENOUS PIGGYBACK 30 MG/100 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) PA; ; PA; QL (12 per 28 days); ; QL (90 per 30 days) QL (180 per 30 days) QL (90 per 30 days) PA; PA; LA; QL (1 per 28 days); PA; LA; QL (2 per 365 days); PA; LA; QL (1 per 28 days); PA; QL (2 per 365 days); ; PA; QL (6 per 28 days); PA; QL (6 per 28 days); PA; QL (4.2 per 28 days); 56

67 REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) riluzole oral tablet 50 mg SAVELLA ORAL TABLET 100 MG, 12.5 MG, 50 MG SAVELLA ORAL TABLET 25 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)- 50 MG(42) TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG tetrabenazine oral tablet 12.5 mg tetrabenazine oral tablet 25 mg VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG zenzedi oral tablet 10 mg zenzedi oral tablet 5 mg Contraceptives Contraceptives altavera (28) oral tablet mg alyacen 1/35 (28) oral tablet 1-35 mg-mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg amethia lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) amethyst (28) oral tablet mcg (28) apri oral tablet mg aranelle (28) oral tablet 0.5/1/ mg-mcg ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) aubra oral tablet mg-mcg aviane oral tablet mg-mcg azurette (28) oral tablet mgx21 /0.01 mg x 5 balziva (28) oral tablet mg-mcg bekyree (28) oral tablet mgx21 /0.01 mg x 5 blisovi 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) PA; QL (4.2 per 28 days); QL (90 per 30 days) PA; LA; ; PA; QL (240 per 30 days); PA; QL (120 per 30 days); QL (180 per 30 days) QL (150 per 30 days) QL (91 per 90 days) QL (91 per 90 days) blisovi fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) 57

68 blisovi fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) brevicon (28) oral tablet mg-mcg briellyn oral tablet mg-mcg camila oral tablet 0.35 mg camrese lo oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) caziant (28) oral tablet 0.1/.125/ mg-mcg chateal (28) oral tablet mg cryselle (28) oral tablet mg-mcg cyclafem 1/35 (28) oral tablet 1-35 mg-mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg cyred 28 day tablet outer mg cyred eq oral tablet mg dasetta 1/35 (28) oral tablet 1-35 mg-mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg daysee oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) deblitane oral tablet 0.35 mg delyla (28) oral tablet mg-mcg desog-e.estradiol/e.estradiol oral tablet mgx21 /0.01 mg x 5 desogestrel-ethinyl estradiol oral tablet mg drospirenone-e.estradiol-lm.fa oral tablet mg (24) (4), mg (21) (7) drospirenone-ethinyl estradiol oral tablet mg, mg elinest oral tablet mg-mcg emoquette oral tablet mg enpresse oral tablet (6)/75-40 (5)/125-30(10) enskyce oral tablet mg errin oral tablet 0.35 mg estarylla oral tablet mg-mcg ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-mcg falmina (28) oral tablet mg-mcg fayosim oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg femynor oral tablet mg-mcg gianvi (28) oral tablet mg QL (91 per 90 days) 58

69 gildess 1.5/30 (21) oral tablet mg-mcg gildess 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) hailey 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) heather oral tablet 0.35 mg incassia oral tablet 0.35 mg introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) isibloom oral tablet mg jasmiel (28) oral tablet mg jencycla oral tablet 0.35 mg jolessa oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) jolivette oral tablet 0.35 mg juleber oral tablet mg junel 1.5/30 (21) oral tablet mg-mcg junel 1/20 (21) oral tablet 1-20 mg-mcg junel fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) junel fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) junel fe 24 oral tablet 1 mg-20 mcg (24)/75 mg (4) kaitlib fe oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) kariva (28) oral tablet mgx21 /0.01 mg x 5 kelnor 1/35 (28) oral tablet 1-35 mg-mcg kelnor 1-50 oral tablet 1-50 mg-mcg kimidess (28) oral tablet mgx21 /0.01 mg x 5 kurvelo (28) oral tablet mg l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg- 20 mcg (84)/10 mcg (7) l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg- 20 mcg/ 0.15 mg-25 mcg, 0.15 mg-30 mcg (84)/10 mcg (7) larin 1.5/30 (21) oral tablet mg-mcg larin 1/20 (21) oral tablet 1-20 mg-mcg larin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) larin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) larin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) larissia oral tablet mg-mcg layolis fe oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) leena 28 oral tablet 0.5/1/ mg-mcg lessina oral tablet mg-mcg QL (91 per 30 days) QL (91 per 90 days) QL (91 per 90 days) 59

70 levonest (28) oral tablet (6)/75-40 (5)/125-30(10) levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg, mcg (28) levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg- 30 mcg (91) levonorg-eth estrad triphasic oral tablet (6)/75-40 (5)/125-30(10) levora-28 oral tablet mg lillow (28) oral tablet mg LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG (24)/10 MCG (2) lomedia 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) loryna (28) oral tablet mg low-ogestrel (28) oral tablet mg-mcg lutera (28) oral tablet mg-mcg lyza oral tablet 0.35 mg marlissa (28) oral tablet mg melodetta 24 fe oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4) mibelas 24 fe oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4) microgestin 1.5/30 (21) oral tablet mg-mcg microgestin 1/20 (21) oral tablet 1-20 mg-mcg microgestin 24 fe oral tablet 1 mg-20 mcg (24)/75 mg (4) microgestin fe 1.5/30 (28) oral tablet 1.5 mg-30 mcg (21)/75 mg (7) microgestin fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) mili oral tablet mg-mcg mono-linyah oral tablet mg-mcg mononessa (28) oral tablet mg-mcg myzilra oral tablet (6)/75-40 (5)/125-30(10) NATAZIA ORAL TABLET 3 MG/2 MG-2 MG/ 2 MG-3 MG/1 MG necon 0.5/35 (28) oral tablet mg-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg nikki (28) oral tablet mg nora-be oral tablet 0.35 mg noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7), 0.8mg-25mcg(24) and 75 mg (4) norethindrone (contraceptive) oral tablet 0.35 mg norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 60

71 norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4) norethindrone-e.estradiol-iron oral tablet,chewable 1 mg-20 mcg(24) /75 mg (4) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28), mg-mcg norlyda oral tablet 0.35 mg norlyroc oral tablet 0.35 mg nortrel 0.5/35 (28) oral tablet mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg (21) nortrel 1/35 (28) oral tablet 1-35 mg-mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1 mg- 35 mcg ocella oral tablet mg ogestrel (28) oral tablet mg-mcg orsythia oral tablet mg-mcg philith oral tablet mg-mcg pimtrea (28) oral tablet mgx21 /0.01 mg x 5 pirmella oral tablet 0.5/0.75/1 mg- 35 mcg, 1-35 mg-mcg portia 28 oral tablet mg previfem oral tablet mg-mcg quasense oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) rajani oral tablet mg (24) (4) reclipsen (28) oral tablet mg rivelsa oral tablets,dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg setlakin oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) sharobel oral tablet 0.35 mg sprintec (28) oral tablet mg-mcg sronyx oral tablet mg-mcg syeda oral tablet mg tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7) tilia fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri femynor oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-estarylla oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9) tri-linyah oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg QL (91 per 90 days) 61

72 tri-lo-marzia oral tablet 0.18/0.215/0.25 mg-25 mcg tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg tri-mili oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg tri-previfem (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/0.25 mg-35 mcg (28) trivora (28) oral tablet (6)/75-40 (5)/125-30(10) tri-vylibra lo oral tablet 0.18/0.215/0.25 mg-25 mcg tri-vylibra oral tablet 0.18/0.215/0.25 mg-35 mcg (28) tulana oral tablet 0.35 mg tydemy oral tablet mg (21) (7) velivet triphasic regimen (28) oral tablet 0.1/.125/ mg-mcg vestura (28) oral tablet mg vienva oral tablet mg-mcg viorele (28) oral tablet mgx21 /0.01 mg x 5 vyfemla (28) oral tablet mg-mcg vylibra oral tablet mg-mcg wera (28) oral tablet mg-mcg wymzya fe oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7) xulane transdermal patch weekly mcg/24 hr zarah oral tablet mg zenchent (28) oral tablet mg-mcg zovia 1/35e (28) oral tablet 1-35 mg-mcg Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 mg chlorhexidine gluconate mucous membrane mouthwash 0.12 % denta 5000 plus dental cream 1.1 % dentagel dental gel 1.1 % oralone dental paste 0.1 % paroex oral rinse mucous membrane mouthwash 0.12 % periogard mucous membrane mouthwash 0.12 % pilocarpine hcl oral tablet 5 mg, 7.5 mg sf 5000 plus dental cream 1.1 % QL (3 per 28 days) triamcinolone acetonide dental paste 0.1 % 62

73 Dermatological Agents Dermatological Agents, Other acitretin oral capsule 10 mg, 17.5 mg, 25 mg acyclovir topical ointment 5 % ALCOHOL PADS TOPICAL PADS, MEDICATED ammonium lactate topical cream 12 % ammonium lactate topical lotion 12 % amnesteem oral capsule 10 mg, 20 mg, 40 mg azelaic acid topical gel 15 % AZELEX TOPICAL CREAM 20 % calcipotriene scalp solution % calcipotriene topical cream % calcipotriene topical ointment % calcitrene topical ointment % calcitriol topical ointment 3 mcg/gram claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML dapsone topical gel 5 % DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML FINACEA TOPICAL FOAM 15 % FINACEA TOPICAL GEL 15 % fluorouracil topical cream 0.5 %, 5 % fluorouracil topical solution 2 %, 5 % imiquimod topical cream in metered-dose pump 3.75 % imiquimod topical cream in packet 5 % isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg mafenide acetate topical packet 50 gram methoxsalen oral capsule,liqd-filled,rapid rel 10 mg MIRVASO TOPICAL GEL WITH PUMP 0.33 % myorisan oral capsule 10 mg, 20 mg, 30 mg, 40 mg PANRETIN TOPICAL GEL 0.1 % PICATO TOPICAL GEL % PICATO TOPICAL GEL 0.05 % QL (120 per 30 days) QL (120 per 30 days) PA; LA; QL (2 per 28 days); PA; LA; QL (2 per 28 days); QL (28 per 28 days) QL (12 per 30 days) QL (3 per 30 days) QL (2 per 30 days) 63

74 podofilox topical solution 0.5 % REGRANEX TOPICAL GEL 0.01 % SANTYL TOPICAL OINTMENT 250 UNIT/GRAM SILIQ SUBCUTANEOUS SYRINGE 210 MG/1.5 ML SULFAMYLON TOPICAL CREAM 85 MG/G SULFAMYLON TOPICAL PACKET 50 GRAM TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % VALCHLOR TOPICAL GEL % zenatane oral capsule 10 mg, 20 mg, 30 mg, 40 mg ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 2.5 % PA; PA; PA; LA; PA; LA; QL (60 per 28 days); QL (7.5 per 28 days) ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 3.75 % QL (28 per 28 days) Dermatological Antibacterials BACTROBAN NASAL NASAL OINTMENT 2 % clindamycin phosphate topical foam 1 % clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % clindamycin phosphate topical swab 1 % clindamycin-benzoyl peroxide topical gel 1-5 %, 1.2 %(1 % base) -5 % CORTISPORIN TOPICAL CREAM , MG/G-UNIT/G-% CORTISPORIN TOPICAL OINTMENT 1 % ery pads topical swab 2 % erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 % erythromycin-benzoyl peroxide topical gel 3-5 % gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, 1 % metronidazole topical lotion 0.75 % mupirocin calcium topical cream 2 % mupirocin topical ointment 2 % 64

75 neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml neuac topical gel 1.2 %(1 % base) -5 % rosadan topical cream 0.75 % selenium sulfide topical lotion 2.5 % silver sulfadiazine topical cream 1 % ssd topical cream 1 % sulfacetamide sodium (acne) topical suspension 10 % Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 %, 2.5 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % ANALPRAM-HC RECTAL CREAM 1-1 % ANALPRAM-HC TOPICAL LOTION % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0.1 % betamethasone valerate topical lotion 0.1 % betamethasone valerate topical ointment 0.1 % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % clobetasol scalp solution 0.05 % clobetasol topical cream 0.05 % clobetasol topical foam 0.05 % clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % clobetasol topical ointment 0.05 % clobetasol topical shampoo 0.05 % clobetasol topical spray,non-aerosol 0.05 % clobetasol-emollient topical cream 0.05 % clobetasol-emollient topical foam 0.05 % CORDRAN TAPE LARGE ROLL TOPICAL TAPE 4 MCG/CM2 cormax scalp solution 0.05 % desonide topical cream 0.05 % 65

76 desonide topical lotion 0.05 % desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.25 % desoximetasone topical gel 0.05 % desoximetasone topical ointment 0.05 %, 0.25 % ELIDEL TOPICAL CREAM 1 % fluocinolone 0.01% body oil 0.01 % fluocinolone and shower cap scalp oil 0.01 % fluocinolone topical cream 0.01 %, % fluocinolone topical ointment % fluocinolone topical solution 0.01 % fluocinonide topical cream 0.05 %, 0.1 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluticasone propionate topical cream 0.05 % fluticasone propionate topical ointment % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocort buty 0.1% lipo cream 0.1 % hydrocortisone butyrate topical cream 0.1 % hydrocortisone butyrate topical lotion 0.1 % hydrocortisone butyrate topical ointment 0.1 % hydrocortisone butyrate topical solution 0.1 % hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % hydrocortisone-pramoxine rectal cream 1-1 % mometasone topical cream 0.1 % mometasone topical ointment 0.1 % mometasone topical solution 0.1 % pimecrolimus topical cream 1 % PRAMOSONE TOPICAL CREAM 1-1 % 66

77 PRAMOSONE TOPICAL LOTION 1-1 %, % prednicarbate topical cream 0.1 % prednicarbate topical ointment 0.1 % procto-med hc topical cream with perineal applicator 2.5 % procto-pak topical cream with perineal applicator 1 % proctosol hc topical cream with perineal applicator 2.5 % proctozone-hc topical cream with perineal applicator 2.5 % tacrolimus topical ointment 0.03 %, 0.1 % triamcinolone acetonide topical cream %, 0.1 %, 0.5 % triamcinolone acetonide topical lotion %, 0.1 % triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % triderm topical cream 0.1 %, 0.5 % tridesilon topical cream 0.05 % Dermatological Retinoids adapalene 0.3% gel pump 0.3 % adapalene topical cream 0.1 % adapalene topical gel 0.1 %, 0.3 % avita topical cream % avita topical gel % tazarotene topical cream 0.1 % TAZORAC TOPICAL CREAM 0.05 % TAZORAC TOPICAL GEL 0.05 %, 0.1 % tretinoin topical cream %, 0.05 %, 0.1 % tretinoin topical gel 0.01 %, % Scabicides And Pediculicides lindane topical shampoo 1 % malathion topical lotion 0.5 % permethrin topical cream 5 % spinosad topical suspension 0.9 % Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 1/2" BD UF NANO PEN NEEDLE 4MMX32G 32 GAUGE X 5/32" BD VEO INS 0.3 ML 6MMX31G (1/2) 0.3 ML 31 GAUGE X 15/64" BD VEO INS SYRING 1 ML 6MMX31G 1 ML 31 GAUGE X 15/64" PA PA PA PA PA PA PA PA PA PA 67

78 BD VEO INS SYRN 0.5 ML 6MMX31G 1/2 ML 31 GAUGE X 15/64" GAUZE PAD TOPICAL BANDAGE 2 X 2 " INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.3 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2" SURE COMFORT 0.5 ML SYRINGE 0.5 ML 29 GAUGE X 1/2" Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5 ML CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELELYSO INTRAVENOUS RECON SOLN 200 UNIT FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL POWDER IN PACKET 100 MG, 500 MG KUVAN ORAL TABLET,SOLUBLE 100 MG LUMIZYME INTRAVENOUS RECON SOLN 50 MG miglustat oral capsule 100 mg NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500-61,500 UNIT, 16,800-56,800-98,400 UNIT, 2,600-6,200-10,850 UNIT, 21,000-54,700-83,900 UNIT, 4,200-14,200-24,600 UNIT PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500-60,500 UNIT, 24,000-86,250-90,750 UNIT, 4,000-14,375-15,125 UNIT, 8,000-28,750-30,250 UNIT PULMOZYME INHALATION SOLUTION 1 MG/ML ; ; ; ; ; ; PA; PA; ; QL (90 per 30 days); ; STRENSIQ 28 MG/0.7 ML VIAL OUTER, L/F, P/F, SUV 40 MG/ML STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML PA; VIOKACE ORAL TABLET 10,440-39,150-39,150 UNIT, 20,880-78,300-78,300 UNIT VPRIV INTRAVENOUS RECON SOLN 400 UNIT PA; QL (150 per 30 days); ; 68

79 ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000-42,000 UNIT, 10,000-34,000-55,000 UNIT, 15,000-47,000-63,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-63,000-84,000 UNIT, 25,000-79, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-14,000-UNIT, 3,000-10,000-16,000 UNIT, 40, , ,000 UNIT, 5,000-17,000-27,000 UNIT, 5,000-17,000-24,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous apraclonidine ophthalmic (eye) drops 0.5 % atropine ophthalmic (eye) drops 1 % azelastine nasal aerosol,spray 137 mcg (0.1 %) azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg) azelastine ophthalmic (eye) drops 0.05 % BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % cromolyn ophthalmic (eye) drops 4 % cyclopentolate ophthalmic (eye) drops 0.5 %, 1 %, 2 % DYMISTA NASAL SPRAY,NON-AEROSOL MCG/SPRAY epinastine ophthalmic (eye) drops 0.05 % ipratropium bromide nasal spray,non-aerosol 0.03 % ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06 %) LACRISERT OPHTHALMIC (EYE) INSERT 5 MG LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 % naphazoline ophthalmic (eye) drops 0.1 % olopatadine nasal spray,non-aerosol 0.6 % olopatadine ophthalmic (eye) drops 0.1 %, 0.2 % proparacaine ophthalmic (eye) drops 0.5 % tropicamide ophthalmic (eye) drops 0.5 %, 1 % Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (ear) solution 2 % AZASITE OPHTHALMIC (EYE) DROPS 1 % bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment ,000 unit/gram BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % bleph-10 ophthalmic (eye) drops 10 % QL (30 per 25 days) QL (30 per 25 days) QL (45 per 30 days) QL (120 per 30 days) QL (30.5 per 30 days) BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION % 69

80 BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT % CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % CIPRO HC OTIC (EAR) DROPS,SUSPENSION % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic (eye) drops 0.3 % COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION MG/ML erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) gatifloxacin ophthalmic (eye) drops 0.5 % gentak ophthalmic (eye) ointment 0.3 % (3 mg/gram) gentamicin ophthalmic (eye) drops 0.3 % hydrocortisone-acetic acid otic (ear) drops 1-2 % levofloxacin ophthalmic (eye) drops 0.5 % MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg- 10,000 unit-0.025mg/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension , mg-unit-mg/ml neomycin-polymyxin-hc otic (ear) drops,suspension ,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution ,000-1 mg/ml-unit/ml- % neo-polycin hc ophthalmic (eye) ointment ,000 mg-unit/g- 1% neo-polycin ophthalmic (eye) ointment ,000 mg-unit-unit/g ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin otic (ear) drops 0.3 % polycin ophthalmic (eye) ointment ,000 unit/gram QL (2.5 per 25 days) 70

81 polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml sulfacetamide sodium ophthalmic (eye) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC (EYE) OINTMENT % TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION % tobramycin ophthalmic (eye) drops 0.3 % tobramycin-dexamethasone ophthalmic (eye) drops,suspension % TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % trifluridine ophthalmic (eye) drops 1 % ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 0.45 % ALOCRIL OPHTHALMIC (EYE) DROPS 2 % ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % bromfenac ophthalmic (eye) drops 0.09 % dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluocinolone acetonide oil otic (ear) drops 0.01 % fluorometholone ophthalmic (eye) drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops 0.03 % fluticasone propionate nasal spray,suspension 50 mcg/actuation FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 % INVELTYS OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % QL (5 per 30 days) QL (50 per 30 days) QL (16 per 30 days) 71

82 LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % mometasone nasal spray,non-aerosol 50 mcg/actuation NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 % prednisolone acetate ophthalmic (eye) drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION, 80 MCG/ACTUATION RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral combo pack mg CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 mg/5 ml cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg, 40 mg famotidine oral suspension 40 mg/5 ml (8 mg/ml) famotidine oral tablet 20 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) 15 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg lansoprazole oral tablet,disintegrat, delay rel 15 mg lansoprazole oral tablet,disintegrat, delay rel 30 mg misoprostol oral tablet 100 mcg, 200 mcg nizatidine oral capsule 150 mg, 300 mg nizatidine oral solution 150 mg/10 ml omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg, 40 mg pantoprazole oral tablet,delayed release (dr/ec) 20 mg, 40 mg rabeprazole oral tablet,delayed release (dr/ec) 20 mg ranitidine hcl injection solution 50 mg/2 ml (25 mg/ml) ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg, 300 mg sucralfate oral tablet 1 gram Gastrointestinal Agents, Other QL (34 per 30 days) 72

83 AMITIZA ORAL CAPSULE 24 MCG, 8 MCG CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG CHOLBAM ORAL CAPSULE 250 MG, 50 MG constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 mg/5 ml dicyclomine oral capsule 10 mg dicyclomine oral solution 10 mg/5 ml dicyclomine oral tablet 20 mg diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg enulose oral solution 10 gram/15 ml GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG generlac oral solution 10 gram/15 ml glycopyrrolate oral tablet 1 mg, 2 mg kionex (with sorbitol) oral suspension gram/60 ml lactulose oral packet 10 gram lactulose oral solution 10 gram/15 ml LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG loperamide oral capsule 2 mg methscopolamine oral tablet 2.5 mg, 5 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl injection syringe 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg RAVICTI ORAL LIQUID 1.1 GRAM/ML RELISTOR ORAL TABLET 150 MG RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 8 MG/0.4 ML sod polystyren sulf 15 g/60 ml sorbitol free 15 gram/60 ml sodium phenylbutyrate oral powder 0.94 gram/gram sodium polystyrene sulfonate oral powder sps (with sorbitol) oral suspension gram/60 ml TRULANCE ORAL TABLET 3 MG ursodiol oral capsule 300 mg ursodiol oral tablet 250 mg, 500 mg PA; PA; PA; PA; QL (90 per 30 days); QL (18 per 30 days); QL (18 per 30 days); QL (12 per 30 days); 73

84 VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM VIBERZI ORAL TABLET 100 MG, 75 MG Laxatives COLYTE WITH FLAVOR PACKS ORAL RECON SOLN GRAM, GRAM gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 420 gram GOLYTELY ORAL POWDER IN PACKET GRAM GOLYTELY ORAL RECON SOLN GRAM peg 3350-electrolytes oral recon soln gram, gram peg-electrolyte soln oral recon soln 420 gram polyethylene glycol 3350 oral powder 17 gram/dose SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM trilyte with flavor packets oral recon soln 420 gram Phosphate Binders calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg eliphos oral tablet 667 mg lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML sevelamer carbonate oral powder in packet 0.8 gram, 2.4 gram sevelamer carbonate oral tablet 800 mg sevelamer hcl oral tablet 400 mg, 800 mg VELPHORO ORAL TABLET,CHEWABLE 500 MG Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg darifenacin oral tablet extended release 24 hr 15 mg, 7.5 mg flavoxate oral tablet 100 mg MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg ; 74

85 oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 24hr 5 mg tolterodine oral capsule,extended release 24hr 2 mg, 4 mg tolterodine oral tablet 1 mg, 2 mg TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG, 8 MG trospium oral capsule,extended release 24hr 60 mg trospium oral tablet 20 mg VESICARE ORAL TABLET 10 MG, 5 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 24 hr 10 mg dutasteride oral capsule 0.5 mg dutasteride-tamsulosin oral capsule, er multiphase 24 hr mg finasteride oral tablet 5 mg RAPAFLO ORAL CAPSULE 4 MG, 8 MG silodosin oral capsule 4 mg, 8 mg tamsulosin oral capsule 0.4 mg terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln 2 gram, 500 mg DEPEN TITRATABS ORAL TABLET 250 MG EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG JADENU ORAL TABLET 180 MG, 360 MG, 90 MG JADENU SPRINKLE ORAL GRANULES IN PACKET 180 MG, 360 MG, 90 MG trientine oral capsule 250 mg Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANADROL-50 ORAL TABLET 50 MG ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR ANDRODERM TRANSDERMAL PATCH 24 HOUR 4 MG/24 HR PA; LA; PA; PA; PA; PA; PA NSO; PA NSO; 75

86 ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) danazol oral capsule 100 mg, 200 mg, 50 mg DEPO-TESTOSTERONE INTRAMUSCULAR OIL 200 MG/ML oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg testosterone cyp 200 mg/ml sdv, latex-free 200 mg/ml testosterone cypionate intramuscular oil 100 mg/ml testosterone cypionate intramuscular oil 200 mg/ml testosterone enanthate intramuscular oil 200 mg/ml testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) testosterone transdermal gel in metered-dose pump mg/1.25 gram (1.62 %) testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram) testosterone transdermal gel in packet 1.62 % (20.25 mg/1.25 gram) testosterone transdermal gel in packet 1.62 % (40.5 mg/2.5 gram) Estrogens And Antiestrogens ALORA TRANSDERMAL PATCH SEMIWEEKLY MG/24 HR, 0.05 MG/24 HR, MG/24 HR, 0.1 MG/24 HR amabelz oral tablet mg, mg BIJUVA ORAL CAPSULE MG CLIMARA PRO TRANSDERMAL PATCH WEEKLY MG/24 HR DUAVEE ORAL TABLET MG estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly mg/24 hr estradiol transdermal patch semiweekly mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol vaginal cream 0.01 % (0.1 mg/gram) estradiol vaginal tablet 10 mcg PA NSO; QL (150 per 30 days) PA NSO; QL (112.5 per 30 days) PA NSO; QL (150 per 30 days) PA NSO ; QL (180 per 30 days) PA NSO PA NSO PA NSO; QL (4.5 per 30 days) PA NSO; QL (300 per 30 days) PA NSO; QL (150 per 30 days) PA NSO; QL (300 per 30 days) PA NSO; QL (37.5 per 30 days) PA NSO; QL (150 per 30 days) QL (8 per 28 days) QL (8 per 28 days) QL (4 per 28 days) 76

87 estradiol-norethindrone acet oral tablet mg, mg ESTRING VAGINAL RING 2 MG (7.5 MCG /24 HOUR) estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg fyavolv oral tablet mg-mcg, 1-5 mg-mcg IMVEXXY MAINTENANCE PACK VAGINAL INSERT 10 MCG, 4 MCG IMVEXXY STARTER PACK VAGINAL INSERT, DOSE PACK 10 MCG, 4 MCG jinteli oral tablet 1-5 mg-mcg lopreeza oral tablet mg, mg MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG, 2.5 MG mimvey lo oral tablet mg mimvey oral tablet mg norethindrone ac-eth estradiol oral tablet mg-mcg, 1-5 mg-mcg PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET MG (14)/ 0.625MG-5MG(14) PREMPRO ORAL TABLET MG, MG, MG, MG raloxifene oral tablet 60 mg yuvafem vaginal tablet 10 mcg Glucocorticoids/Mineralocorticoids cortisone oral tablet 25 mg deltasone oral tablet 20 mg DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML dexamethasone oral elixir 0.5 mg/5 ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg dexamethasone sodium phos (pf) injection solution 10 mg/ml dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml dexamethasone sodium phosphate injection syringe 4 mg/ml EMFLAZA ORAL SUSPENSION MG/ML EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG fludrocortisone oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 20 mg, 5 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml QL (1 per 90 days) PA BvD PA BvD PA BvD PA; PA; 77

88 methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg methylprednisolone oral tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous recon soln 1,000 mg prednisolone 15 mg/5 ml soln a/f, d/f 15 mg/5 ml (3 mg/ml) prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone oral solution 5 mg/5 ml prednisone oral tablet 1 mg, 2.5 mg, 20 mg, 5 mg, 50 mg prednisone oral tablet 10 mg SOLU-CORTEF (PF) INJECTION RECON SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250 MG/2 ML, 500 MG/4 ML SOLU-MEDROL (PF) INJECTION RECON SOLN 125 MG/2 ML, 40 MG/ML SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 1,000 MG/8 ML, 500 MG/4 ML SOLU-MEDROL INTRAVENOUS RECON SOLN 2 GRAM triamcinolone acetonide injection suspension 40 mg/ml Pituitary desmopressin 10 mcg/0.1 ml spr 10 mcg/spray (0.1 ml) desmopressin injection solution 4 mcg/ml desmopressin nasal solution 0.1 mg/ml (refrigerate) desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1 mg, 0.2 mg EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA; LA; ; PA; PA; PA PA PA; PA; 78

89 SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 30 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON SOLN 25 MG, 30 MG STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML) Progestins DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE 104 MG/0.65 ML medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml norethindrone acetate oral tablet 5 mg progesterone micronized oral capsule 100 mg, 200 mg Thyroid And Antithyroid Agents levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg methimazole oral tablet 10 mg, 5 mg propylthiouracil oral tablet 50 mg SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG THYROLAR-1 ORAL TABLET MCG THYROLAR-1/2 ORAL TABLET MCG THYROLAR-1/4 ORAL TABLET MCG THYROLAR-2 ORAL TABLET MCG THYROLAR-3 ORAL TABLET MCG Immunological Agents Immunological Agents PA; ; PA NSO; ; ; QL (0.65 per 90 days) 79

90 ACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG/0.9 ML ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML ATGAM INTRAVENOUS SOLUTION 50 MG/ML azathioprine oral tablet 50 mg azathioprine sodium injection recon soln 100 mg BIVIGAM INTRAVENOUS SOLUTION 10 % CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2) cyclosporine intravenous solution 250 mg/5 ml cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg cyclosporine modified oral solution 100 mg/ml cyclosporine oral capsule 100 mg, 25 mg CYTOGAM INTRAVENOUS SOLUTION 50 MG/ML ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION % RANGE GAMASTAN S-D VIAL P/F, L/F, OUTER, SDV % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM PA; ; PA; ; PA BvD PA BvD PA BvD; ; PA BvD; ; PA; PA; PA BvD; PA BvD PA BvD PA BvD ; PA; QL (8 per 28 days); PA; QL (4.08 per 28 days); PA; QL (8 per 28 days); PA; QL (8 per 28 days); PA BvD PA BvD; ; ; PA BvD; ; PA BvD; ; PA BvD; ; GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML PA BvD; ; (10 %), 5 GRAM/50 ML (10 %) GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % PA BvD; ; 80

91 GAMMAPLEX INTRAVENOUS SOLUTION 10 %, 10 % (100 ML), 10 % (200 ML) GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %) GAMUNEX-C INJECTION SOLUTION 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 40 GRAM/400 ML (10 %), 5 GRAM/50 ML (10 %) gengraf oral capsule 100 mg, 25 mg, 50 mg gengraf oral solution 100 mg/ml HEPAGAM B INJECTION SOLUTION >312 UNIT/ML, GREATR THAN 312 UNIT/ML (5 ML) ZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML, 40 MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 20 MG/0.2 ML HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML HYPERHEP B S/D INTRAMUSCULAR SOLUTION 220 UNIT/ML, 220 UNIT/ML (5 ML) HYPERHEP B S/D INTRAMUSCULAR SYRINGE 220 UNIT/ML PA BvD; ; PA BvD; ; ; PA BvD PA BvD ; PA; QL (6 per 28 days); PA; QL (6 per 28 days); PA; QL (6 per 28 days); PA; QL (6 per 28 days); PA; QL (2 per 28 days); PA; QL (6 per 28 days); PA; QL (3 per 28 days); PA; QL (2 per 28 days); PA; QL (3 per 28 days); PA; QL (3 per 28 days); PA; QL (6 per 28 days); PA; QL (2 per 28 days); PA; QL (6 per 28 days); 81

92 HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE 110 UNIT/0.5 ML HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %), 2.5 GRAM /25 ML (10 %), 20 GRAM /200 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 150 MG/ML ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML INFLECTRA INTRAVENOUS RECON SOLN 100 MG KEDRAB (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10 mg, 20 mg mycophenolate mofetil hcl intravenous recon soln 500 mg mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral suspension for reconstitution 200 mg/ml mycophenolate mofetil oral tablet 500 mg mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg NABI-HB INTRAMUSCULAR SOLUTION GREATER THAN 1,560 UNIT/5 ML, GREATR THAN 312 UNIT/ML NULOJIX INTRAVENOUS RECON SOLN 250 MG OCTAGAM INTRAVENOUS SOLUTION 10 %, 5 % ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) PRIVIGEN INTRAVENOUS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION 1 MG/ML REMICADE INTRAVENOUS RECON SOLN 100 MG ; PA; PA; ; PA; PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD; QL (20 per 30 days); PA BvD; ; PA; PA; PA; PA; PA BvD; ; PA BvD PA BvD ; RHOPHYLAC INJECTION SYRINGE 1,500 UNIT (300 MCG)/2 ML ; RIDAURA ORAL CAPSULE 3 MG SANDIMMUNE ORAL SOLUTION 100 MG/ML SIMPONI ARIA INTRAVENOUS SOLUTION 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML, 50 MG/0.5 ML PA BvD PA; ; PA; QL (1 per 30 days); 82

93 SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML sirolimus oral solution 1 mg/ml sirolimus oral tablet 0.5 mg, 1 mg, 2 mg STELARA INTRAVENOUS SOLUTION 130 MG/26 ML STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg THYMOGLOBULIN INTRAVENOUS RECON SOLN 25 MG TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML WINRHO SDF INJECTION SOLUTION 1,500 UNIT (300 MCG)/1.3 ML, UNIT(3000 MCG)/13 ML, 2,500 UNIT (500 MCG)/2.2 ML, 5,000 UNIT(1000 MCG)/4.4 ML XELJANZ ORAL TABLET 10 MG, 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG ZORTRESS ORAL TABLET 0.25 MG, 0.75 MG, 1 MG ZORTRESS ORAL TABLET 0.5 MG Vaccines ACTB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF- MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF- MCG-LF/0.5ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML PA; PA; QL (1 per 30 days); PA BvD PA BvD ; PA; PA; PA BvD ; PA; ; ; PA; ; PA; ; PA BvD; PA BvD; QL (120 per 30 days) PA BvD PA BvD PA BvD 83

94 GARDASIL (PF) INTRAMUSCULAR SYRINGE MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML BERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX B (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML QL (1.5 per 365 days) QL (1.5 per 365 days) 84

95 RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML SNGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCG/ML TYPM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5 mg, 1 mg balsalazide oral capsule 750 mg PA BvD PA BvD QL (2 per 365 days); AGE (Min 50 Years) QL (1 per 365 days); AGE (Min 49 Years) ; 85

96 budesonide oral capsule,delayed,extend.release 3 mg budesonide oral tablet,delayed and ext.release 9 mg CANASA RECTAL SUPPOSITORY 1,000 MG colocort rectal enema 100 mg/60 ml DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 400 MG GIAZO ORAL TABLET 1.1 GRAM hydrocortisone rectal enema 100 mg/60 ml mesalamine oral tablet,delayed release (dr/ec) 1.2 gram, 800 mg mesalamine rectal enema 4 gram/60 ml mesalamine rectal suppository 1,000 mg PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG PENTASA ORAL CAPSULE, EXTENDED RELEASE 500 MG sulfasalazine oral tablet 500 mg sulfasalazine oral tablet,delayed release (dr/ec) 500 mg Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.25 % LACTATED RINGERS IRRIGATION SOLUTION PHYSIOSOL IRRIGATION IRRIGATION SOLUTION MEQ/L ringer's irrigation solution sodium chloride irrigation solution 0.9 % water for irrigation, sterile irrigation solution Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 mg/75 ml alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg, 70 mg calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml cinacalcet oral tablet 30 mg, 90 mg cinacalcet oral tablet 60 mg doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg etidronate disodium oral tablet 200 mg, 400 mg QL (150 per 30 days) QL (300 per 30 days) QL (4 per 28 days) QL (3.7 per 28 days) PA BvD; QL (120 per 30 days) PA BvD; QL (90 per 30 days) 86

97 FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE MCG/2.4 ML ibandronate oral tablet 150 mg MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous recon soln 30 mg, 90 mg pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml) paricalcitol hemodialysis port injection solution 2 mcg/ml PARICALCITOL HEMODIALYSIS PORT INJECTION SOLUTION 5 MCG/ML paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML RAYALDEE ORAL CAPSULE,EXTENDED RELEASE 24 HR 30 MCG risedronate oral tablet 150 mg risedronate oral tablet 30 mg, 5 mg risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack) risedronate oral tablet,delayed release (dr/ec) 35 mg SENSIPAR ORAL TABLET 30 MG, 90 MG SENSIPAR ORAL TABLET 60 MG TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7 ML (70 MG/ML) zoledronic acid intravenous recon soln 4 mg zoledronic acid intravenous solution 4 mg/5 ml zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml zoledronic ac-mannitol-0.9nacl intravenous piggyback 4 mg/100 ml ZOMETA INTRAVENOUS PIGGYBACK 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML BENLYSTA INTRAVENOUS RECON SOLN 120 MG BENLYSTA INTRAVENOUS RECON SOLN 400 MG BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML PA NSO; QL (2.4 per 28 days) QL (1 per 28 days) QL (2 per 28 days); PA; QL (2 per 365 days) QL (1 per 30 days) QL (4 per 28 days) QL (4 per 28 days) PA BvD; QL (120 per 30 days); PA BvD; QL (90 per 30 days); PA NSO; QL (1.56 per 30 days) PA; QL (1.7 per 28 days); ; QL (15 per 21 days) ; QL (15 per 21 days) ; QL (100 per 365 days) ; QL (20 per 28 days); ; QL (6 per 28 days); QL (4 per 28 days); 87

98 BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML ELMIRON ORAL CAPSULE 100 MG ENTYVIO INTRAVENOUS RECON SOLN 300 MG ergoloid oral tablet 1 mg EXONDYS 51 INTRAVENOUS SOLUTION 50 MG/ML hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg, 500 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg levocarnitine (with sugar) oral solution 100 mg/ml levocarnitine oral tablet 330 mg levoleucovorin calcium intravenous solution 10 mg/ml mesna intravenous solution 100 mg/ml MESNEX ORAL TABLET 400 MG METHERGINE ORAL TABLET 0.2 MG methylergonovine oral tablet 0.2 mg MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.) PROGLYCEM ORAL SUSPENSION 50 MG/ML pyridostigmine bromide oral tablet 60 mg pyridostigmine bromide oral tablet extended release 180 mg RENFLEXIS INTRAVENOUS RECON SOLN 100 MG SIMULECT INTRAVENOUS RECON SOLN 10 MG, 20 MG SOLIRIS INTRAVENOUS SOLUTION 300 MG/30 ML THALOMID ORAL CAPSULE 100 MG THALOMID ORAL CAPSULE 150 MG, 200 MG THALOMID ORAL CAPSULE 50 MG TYBOST ORAL TABLET 150 MG Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 125 mg, 250 mg ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % betaxolol ophthalmic (eye) drops 0.5 % BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % QL (4 per 28 days); ; ; PA; ; ; ; ; PA NSO; QL (90 per 30 days); PA NSO; ; PA NSO; ; 88

99 bimatoprost ophthalmic (eye) drops 0.03 % brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % carteolol ophthalmic (eye) drops 1 % COMBIGAN OPHTHALMIC (EYE) DROPS % COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE % COSOPT OPHTHALMIC (EYE) DROPS MG/ML dorzolamide ophthalmic (eye) drops 2 % dorzolamide-timolol (pf) ophthalmic (eye) dropperette % dorzolamide-timolol ophthalmic (eye) drops mg/ml latanoprost ophthalmic (eye) drops % levobunolol ophthalmic (eye) drops 0.5 % LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % methazolamide oral tablet 25 mg, 50 mg metipranolol ophthalmic (eye) drops 0.3 % PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS % pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % RHOPRESSA OPHTHALMIC (EYE) DROPS 0.02 % SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION % timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % timolol maleate ophthalmic (eye) drops, once daily 0.5 % timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) DROPS % travoprost (benzalkonium) ophthalmic (eye) drops % XELPROS OPHTHALMIC (EYE) DROPS, EMULSION % Replacement Preparations Replacement Preparations d10 %-0.45 % sodium chloride intravenous parenteral solution d2.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 10 % and 0.2 % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution % QL (10 per 30 days) QL (10 per 30 days) QL (10 per 30 days) QL (5 per 25 days) QL (2.5 per 25 days) QL (2.5 per 25 days) KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ 89

100 KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq klor-con m20 oral tablet,er particles/crystals 20 meq KLOR-CON ORAL PACKET 20 MEQ klor-con sprinkle oral capsule, extended release 10 meq, 8 meq K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ LACTATED RINGERS INTRAVENOUS PARENTERAL SOLUTION magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in water intravenous piggyback 10 meq/100 ml, 10 meq/50 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride intravenous solution 2 meq/ml (20 ml) potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral packet 20 meq potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l 90

101 potassium chloride-d5-0.2%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 mg), 15 meq, 5 meq (540 mg) ringer's intravenous parenteral solution sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.45 % intravenous piggyback 0.45 % sodium chloride 0.9 % intravenous parenteral solution sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 113 MCG/ACTUATION, 232 MCG/ACTUATION, 55 MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml FLOVENT 100 MCG DISKUS 100 MCG/ACTUATION FLOVENT 250 MCG DISKUS 250 MCG/ACTUATION QL (12 per 30 days) PA BvD QL (240 per 30 days) 91

102 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION fluticasone propion-salmeterol inhalation aerosol powdr breath activated mcg/actuation, mcg/actuation, mcg/actuation QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION SYMBICORT MCG INHALER 60 INHALATIONS MCG/ACTUATION SYMBICORT MCG INHALER 60 INHALATIONS MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION Antileukotrienes montelukast oral tablet 10 mg montelukast oral tablet,chewable 4 mg, 5 mg zafirlukast oral tablet 10 mg, 20 mg zileuton oral tablet, er multiphase 12 hr 600 mg ZYFLO ORAL TABLET 600 MG Bronchodilators albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg aminophylline intravenous solution 250 mg/10 ml, 500 mg/20 ml ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION QL (240 per 30 days) QL (24 per 30 days) QL (12 per 30 days) QL (13.8 per 30 days) QL (10.2 per 30 days) PA BvD QL (25.8 per 30 days) 92

103 BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml levalbuterol tartrate inhalation hfa aerosol inhaler 45 mcg/actuation metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION 20 MCG/2 ML SEREVENT DISKUS 50 MCG 50 MCG/DOSE SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION PA BvD; QL (120 per 30 days) QL (4 per 20 days) PA BvD PA BvD PA BvD PA BvD; QL (120 per 30 days) QL (4 per 28 days) SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION QL (4 per 28 days) SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 24 hr 400 mg, 600 mg TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG VENTOLIN HFA 90 MCG INHALER 60 ACTUATIONS 90 MCG/ACTUATION VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION YUPELRI INHALATION SOLUTION FOR NEBULIZATION 175 MCG/3 ML QL (4 per 28 days) QL (36 per 30 days) PA BvD; QL (90 per 30 days) 93

104 Respiratory Tract Agents, Other acetylcysteine intravenous solution 200 mg/ml (20 %) acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG CINQAIR INTRAVENOUS SOLUTION 10 MG/ML cromolyn inhalation solution for nebulization 20 mg/2 ml DALIRESP ORAL TABLET 250 MCG, 500 MCG ESBRIET ORAL CAPSULE 267 MG ESBRIET ORAL TABLET 267 MG, 801 MG FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %) KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG NUCALA SUBCUTANEOUS RECON SOLN 100 MG OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL GRANULES IN PACKET MG, MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG SYMDEKO ORAL TABLETS, SEQUENTIAL MG (D)/ 150 MG (N) XOLAIR SUBCUTANEOUS RECON SOLN 150 MG XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10 mg, 20 mg carisoprodol oral tablet 250 mg, 350 mg chlorzoxazone oral tablet 250 mg, 500 mg cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene oral capsule 100 mg, 25 mg, 50 mg metaxall oral tablet 800 mg metaxalone oral tablet 400 mg, 800 mg methocarbamol oral tablet 500 mg, 750 mg orphenadrine citrate oral tablet extended release 100 mg PA BvD ; ; PA BvD PA; QL (270 per 30 days); PA; ; PA; QL (56 per 28 days); PA; ; PA; ; PA; QL (56 per 28 days); PA; LA; QL (112 per 28 days); ; PA; ; QL (6 per 28 days); QL (4 per 28 days); QL (2 per 28 days); ; PA; AGE (Max 64 Years) PA; AGE (Max 64 Years) PA; AGE (Max 64 Years) PA; AGE (Max 64 Years) 94

105 tizanidine oral tablet 2 mg, 4 mg Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150 mg, 200 mg, 250 mg armodafinil oral tablet 50 mg BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG eszopiclone oral tablet 1 mg, 2 mg, 3 mg HETLIOZ ORAL CAPSULE 20 MG modafinil oral tablet 100 mg modafinil oral tablet 200 mg ROZEREM ORAL TABLET 8 MG XYREM ORAL SOLUTION 500 MG/ML zaleplon oral capsule 10 mg, 5 mg zolpidem oral tablet 10 mg zolpidem oral tablet 5 mg zolpidem oral tablet,ext release multiphase 12.5 mg zolpidem oral tablet,ext release multiphase 6.25 mg Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 20 MG ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG alyq oral tablet 20 mg CIALIS ORAL TABLET 2.5 MG, 5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg LETAIRIS ORAL TABLET 10 MG, 5 MG OPSUMIT ORAL TABLET 10 MG ORENITRAM ORAL TABLET EXTENDED RELEASE MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML REVATIO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML sildenafil (antihypertensive) oral tablet 20 mg tadalafil (antihypertensive) oral tablet 20 mg tadalafil oral tablet 2.5 mg, 5 mg PA; PA; PA; ; PA; QL (90 per 30 days) PA; PA; LA; QL (540 per 30 days); PA; ; PA; QL (90 per 30 days); PA; PA ; ; PA; ; PA PA; ; PA; QL (180 per 30 days); PA; QL (90 per 30 days) PA; PA; 95

106 TRACLEER ORAL TABLET 125 MG, 62.5 MG UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 800 MCG UPTRAVI ORAL TABLET 200 MCG, 400 MCG, 600 MCG UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60) VELETRI INTRAVENOUS RECON SOLN 0.5 MG, 1.5 MG VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 20 MCG/ML Vitamins And Minerals Vitamins And Minerals FLUORIDE (SODIUM) ORAL TABLET 1 MG (2.2 MG SOD. FLUORIDE) LUDENT FLUORIDE 1 MG TAB CHEW D/F, S/F, CHEWABLE (OTC) 1 MG (2.2 MG SOD. FLUORIDE) pnv prenatal plus multivit tab s/f, gluten-free 27 mg iron- 1 mg prenatal vitamin plus low iron oral tablet 27 mg iron- 1 mg LA; ; PA; ; PA; PA; ; PA BvD; QL (270 per 30 days); 96

107 INDEX A abacavir abacavir-lamivudine abacavir-lamivudine-zidovudine ABELCET ABILIFY MAINTENA abiraterone ABRAXANE acamprosate... 7 acarbose acebutolol acetaminophen-codeine... 3 acetazolamide acetic acid... 69, 86 acetylcysteine acitretin ACTEMRA ACTEMRA ACTPEN ACTB (PF) ACTIMMUNE ACUVAIL (PF) acyclovir... 41, 62 acyclovir sodium... 41, 42 ADACEL(TDAP ADOLESN/ADULT)(PF).. 83 ADAGEN adapalene ADCIRCA adefovir ADEMPAS ADLYXIN adriamycin adrucil ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR AFINITOR DISPERZ AIMOVIG AUTOINJECTOR31 AIMOVIG AUTOINJECTOR (2 PACK) AKYNZEO (NETUPITANT) 33 ala-cort albendazole ALBENZA albuterol sulfate alclometasone ALCOHOL PADS ALDURAZYME ALECENSA alendronate alfuzosin ALIMTA ALINIA... 33, 34 ALIQOPA allopurinol almotriptan malate ALOCRIL alogliptin alogliptin-metformin alogliptin-pioglitazone ALORA alosetron ALPHAGAN P alprazolam... 7 ALREX altavera (28) ALUNBRIG alyacen 1/35 (28) alyacen 7/7/7 (28) alyq amabelz amantadine hcl AMBISOME amethia amethia lo amethyst (28) amikacin... 8 amiloride amiloride-hydrochlorothiazide52 aminocaproic acid aminophylline AMINOSYN 10 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amitriptyline-chlordiazepoxide amlodipine amlodipine-atorvastatin amlodipine-benazepril... 51, 52 amlodipine-olmesartan amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amnesteem amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphotericin b ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA ANADROL anagrelide ANALPRAM-HC anastrozole ANDRODERM ANDROGEL ANORO ELLIPTA ANZEMET APOKYN apraclonidine aprepitant apri APTIOM APTIVUS ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) ARCAPTA NEOHALER aripiprazole ARISTADA armodafinil

108 ARMONAIR RESPICLICK.. 91 ARNUITY ELLIPTA arsenic trioxide ascomp with codeine... 3 ashlyna aspirin-dipyridamole ASSURE ID INSULIN SAFETY astramorph-pf... 3 atazanavir atenolol atenolol-chlorthalidone ATGAM atomoxetine atorvastatin atovaquone atovaquone-proguanil ATRIPLA atropine ATROVENT HFA AUBAGIO aubra AUSTEDO AVANDIA AVASTIN aviane avita AVONEX AVONEX (WITH ALBUMIN) AVYCAZ azacitidine AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) AZASITE azathioprine azathioprine sodium azelaic acid azelastine AZELEX azithromycin AZOPT aztreonam azurette (28) B baciim... 9 bacitracin... 9, 69 bacitracin-polymyxin b baclofen BACTROBAN NASAL balsalazide balziva (28) BANZEL BARACLUDE BAVENCIO BCG VACCINE, LIVE (PF).. 83 BD ULTRA-FINE NANO PEN NEEDLE BD VEO INSULIN SYR HALF UNIT BD VEO INSULIN SYRINGE UF bekyree (28) BELEODAQ BELSOMRA benazepril benazepril-hydrochlorothiazide BENLYSTA... 87, 88 benztropine BEPREVE BERINERT BESIVANCE BESPONSA betamethasone dipropionate betamethasone valerate betamethasone, augmented BETASERON betaxolol... 49, 88 bethanechol chloride BETHKIS... 8 BETOPTIC S bexarotene BEXSERO bicalutamide BICILLIN L-A BICNU BIJUVA BIKTARVY bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM bleomycin bleph BLEPHAMIDE BLEPHAMIDE S.O.P blisovi 24 fe blisovi fe 1.5/30 (28) blisovi fe 1/20 (28) BOOSTRIX TDAP BORTEZOMIB BOSULIF BRAFTOVI BREO ELLIPTA brevicon (28) briellyn BRILINTA brimonidine BRIVIACT bromfenac bromocriptine BROVANA budesonide... 86, 91 bumetanide buprenorphine... 3 buprenorphine hcl... 3, 7 buprenorphine-naloxone... 7 bupropion hcl bupropion hcl (smoking deter). 7 buspirone... 7 butalbital compound w/codeine 3 butalbital-acetaminop-caf-cod.. 3 butalbital-acetaminophen... 3 butalbital-acetaminophen-caff.. 3 butalbital-aspirin-caffeine... 3 butorphanol tartrate... 3 BYDUREON BYDUREON BCISE BYETTA BYSTOLIC C cabergoline CABOMETYX calcipotriene calcitonin (salmon) calcitrene calcitriol... 63, 86 calcium acetate CALQUENCE camila camrese camrese lo CANASA candesartan candesartan-hydrochlorothiazid capacet... 3 CAPASTAT CAPRELSA captopril

109 captopril-hydrochlorothiazide 48 CARAFATE CARBAGLU carbamazepine carbidopa carbidopa-levodopa carbidopa-levodopa-entacapone carboplatin CARIMUNE NF NANOFILTERED carisoprodol carmustine CAROSPIR carteolol cartia xt carvedilol carvedilol phosphate caspofungin CAYSTON caziant (28) cefaclor cefadroxil cefazolin cefazolin in dextrose (iso-os). 10 cefdinir cefepime cefixime cefotaxime cefotetan cefoxitin cefpodoxime cefprozil ceftazidime ceftriaxone cefuroxime axetil cefuroxime sodium celecoxib... 6 CELONTIN cephalexin CEREZYME CESAMET cetirizine cevimeline CHANTIX... 7 CHANTIX CONTINUING MONTH BOX... 7 CHANTIX STARTING MONTH BOX... 7 chateal (28) chloramphenicol sod succinate. 9 chlordiazepoxide hcl... 7 chlordiazepoxide-clidinium chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone chlorzoxazone CHOLBAM cholestyramine (with sugar) cholestyramine light CIALIS ciclopirox cilostazol CILOXAN CIMDUO cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST cinacalcet CINQAIR CINRYZE CIPRO HC CIPRODEX ciprofloxacin ciprofloxacin hcl... 13, 70 ciprofloxacin in 5 % dextrose. 13 citalopram cladribine CLAFORAN claravis clarithromycin clemastine CLIMARA PRO clindamycin hcl... 9 clindamycin in 5 % dextrose... 9 clindamycin palmitate hcl... 9 clindamycin phosphate. 9, 31, 64 clindamycin-benzoyl peroxide64 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobazam... 8 clobetasol clobetasol-emollient clomipramine clonazepam... 8 clonidine clonidine hcl... 47, 55 clopidogrel clorazepate dipotassium... 8 clorpres clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 3 colchicine colesevelam colestipol colistin (colistimethate na)... 9 colocort COLY-MYCIN S COLYTE WITH FLAVOR PACKS COMBIGAN COMBIVENT RESPIMAT COMETRIQ

110 COMPLERA compro constulose COPAXONE COPIKTRA CORDRAN TAPE LARGE ROLL CORLANOR cormax cortisone CORTISPORIN COSENTYX (2 SYRINGES) 63 COSENTYX PEN (2 PENS).. 63 COSOPT COSOPT (PF) COTELLIC COUMADIN CREON CRIXIVAN cromolyn... 69, 73, 94 cryselle (28) cyclafem 1/35 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET cyclosporine cyclosporine modified cyproheptadine CYRAMZA cyred cyred eq cytarabine cytarabine (pf) CYTOGAM D d10 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 89 dalfampridine DALIRESP danazol dantrolene dapsone... 32, 63 DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin... 9 DARAPRIM darifenacin DARZALEX dasetta 1/35 (28) dasetta 7/7/7 (28) daunorubicin DAURISMO daysee deblitane deferoxamine DELSTRIGO deltasone delyla (28) DELZICOL demeclocycline DEMEROL... 3 DEMEROL (PF)... 3 DEMSER denta 5000 plus dentagel DEPEN TITRATABS DEPO-MEDROL DEPO-SUBQ PROVERA DEPO-TESTOSTERONE DESCOVY desipramine desloratadine desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone... 65, 66 desvenlafaxine succinate dexamethasone dexamethasone sodium phos (pf) dexamethasone sodium phosphate... 71, 77 dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0.2 % nacl 89 dextrose 10 % in water (d10w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in ringer's dextrose 5 % in water (d5w) dextrose 5 %-lactated ringers. 89 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride 89 DIASTAT... 8 DIASTAT ACUDIAL... 8 diazepam... 8 diazepam intensol... 8 diclofenac potassium... 6 diclofenac sodium... 6, 71 diclofenac-misoprostol... 6 dicloxacillin dicyclomine didanosine DIFICID diflunisal... 6 digitek digox digoxin DIGOXIN dihydroergotamine... 31, 32 DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN DILAUDID (PF)... 3 diltiazem hcl dilt-xr diphenoxylate-atropine dipyridamole disopyramide phosphate disulfiram... 7 divalproex... 21, 22 dobutamine dobutamine in d5w dofetilide donepezil... 23,

111 dopamine dopamine in 5 % dextrose dorzolamide dorzolamide-timolol dorzolamide-timolol (pf) doxazosin doxepin doxercalciferol doxorubicin doxorubicin, peg-liposomal doxy doxycycline hyclate doxycycline monohydrate dronabinol drospirenone-e.estradiol-lm.fa 58 drospirenone-ethinyl estradiol 58 DROXIA DUAVEE duloxetine DUPIXENT DUREZOL dutasteride dutasteride-tamsulosin DYMISTA DYRENIUM E econazole EDURANT efavirenz EGRIFTA ELAPRASE ELELYSO eletriptan ELIDEL elinest eliphos ELIQUIS ELMIRON EMCYT EMFLAZA emoquette EMPLICITI EMSAM EMTRIVA... 38, 39 EMVERM enalapril maleate enalapril-hydrochlorothiazide 48 ENBREL ENBREL SURECLICK endocet... 3 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone entecavir ENTRESTO ENTYVIO enulose ENVARSUS XR EPCLUSA EPIDIOLEX epinastine epinephrine epirubicin epitol EPIVIR HBV eplerenone epoprostenol (glycine) eprosartan EPZICOM EQUETRO ERAXIS(WATER DILUENT) ergoloid ergotamine-caffeine ERIVEDGE ERLEADA errin ertapenem ery pads ery-tab ERY-TAB ERYTHROCIN erythromycin... 12, 70 erythromycin ethylsuccinate erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate esomeprazole magnesium estarylla estradiol estradiol-norethindrone acet ESTRING estropipate eszopiclone ethacrynic acid ethambutol ethosuximide ethynodiol diac-eth estradiol.. 58 etidronate disodium etodolac... 6 ETOPOPHOS etoposide EVOTAZ exemestane EXJADE EXONDYS EXTAVIA ezetimibe ezetimibe-simvastatin F FABRAZYME falmina (28) famciclovir famotidine FANAPT FARESTON FARYDAK FASENRA FASLODEX fayosim felbamate felodipine femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fentanyl... 4 fentanyl citrate... 3 fentanyl citrate (pf)... 3 FERRIPROX FETZIMA FIASP FLEXTOUCH U-100 INSULIN FIASP U-100 INSULIN FINACEA finasteride fioricet... 4 FIRAZYR FIRMAGON KIT W DILUENT SYRINGE FLAREX flavoxate FLEBOGAMMA DIF flecainide FLECTOR

112 FLOVENT DISKUS... 91, 92 FLOVENT HFA fluconazole fluconazole in nacl (iso-osm). 30 flucytosine fludrocortisone flunisolide fluocinolone fluocinolone acetonide oil fluocinolone and shower cap.. 66 fluocinonide fluocinonide-e FLUORIDE (SODIUM) fluorometholone fluorouracil... 16, 63 fluoxetine fluphenazine decanoate fluphenazine hcl flurazepam... 8 flurbiprofen... 6 flurbiprofen sodium flutamide fluticasone propionate... 66, 71 fluticasone propion-salmeterol fluvastatin fluvoxamine FML FORTE FML S.O.P fondaparinux FORTAZ FORTEO fosamprenavir foscarnet fosinopril fosinopril-hydrochlorothiazide fosphenytoin FREAMINE HBC 6.9 % FREAMINE III 10 % frovatriptan FULPLA furosemide FUZEON fyavolv FYCOMPA G gabapentin galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S-D (IGA < 1 MCG/ML) GAMMAKED GAMMAPLEX GAMMAPLEX (WITH SORBITOL) GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n gemfibrozil generlac gengraf gentak gentamicin... 9, 64, 70 gentamicin in nacl (iso-osm)... 8 gentamicin sulfate (ped) (pf)... 9 gentamicin sulfate (pf)... 9 GENVOYA GEODON gianvi (28) GIAZO gildess 1.5/30 (21) gildess 24 fe GILENYA GILOTRIF GLASSIA glatiramer glatopa GLEOSTINE glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glycopyrrolate GLYXAMBI GOLYTELY granisetron hcl GRANIX griseofulvin microsize griseofulvin ultramicrosize guanfacine H hailey 24 fe halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heather HEPAGAM B heparin (porcine)... 42, 43 heparin (porcine) in 5 % dex.. 42 heparin (porcine) in nacl (pf).. 42 HEPARIN(PORCINE) IN 0.45% NACL heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN BERIX (PF) ZENTRA HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN CROHNS-UC- HS START HUMIRA PEN PSOR-UVEITS- ADOL HS HUMIRA(CF) HUMIRA(CF) PEDI CROHNS STARTER HUMIRA(CF) PEN HUMIRA(CF) PEN CROHNS- UC-HS HUMIRA(CF) PEN PSOR-UV- ADOL HS hydralazine hydrochlorothiazide hydrocodone-acetaminophen... 4 hydrocodone-ibuprofen... 4 hydrocortisone... 66, 77, 86 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-pramoxine hydromorphone... 4 hydromorphone (pf)

113 hydroxychloroquine hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERHEP B S/D HYPERHEP B S-D NEONATAL HYQVIA I ibandronate IBRANCE ibu... 6 ibuprofen... 6 ICLUSIG IDFA ILARIS (PF) ILEVRO imatinib IMBRUVICA IMFINZI imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES VACCINE (PF) IMVEXXY MAINTENANCE PACK IMVEXXY STARTER PACK incassia INCRELEX INCRUSE ELLIPTA indapamide indomethacin... 6 INFANRIX (DTAP) (PF) INFLECTRA INFUMORPH P/F... 4 INLYTA INSULIN SYRINGE-NEEDLE U INTELENCE INTRALIPID INTRON A introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVELTYS INVIRASE INVOKAMET INVOKAMET XR INVOKANA IPOL ipratropium bromide... 69, 93 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRESSA ISENTRESS ISENTRESS HD isibloom isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin itraconazole ivermectin IXIARO (PF) J JADENU JADENU SPRINKLE JAKAFI jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jasmiel (28) jencycla JENTADUETO JENTADUETO XR jinteli jolessa jolivette juleber JULUCA junel 1.5/30 (21) junel 1/20 (21) junel fe 1.5/30 (28) junel fe 1/20 (28) junel fe K KABIVEN KADCYLA kaitlib fe KALETRA KALYDECO kariva (28) KEDRAB (PF) kelnor 1/35 (28) kelnor ketoconazole ketoprofen... 6 ketorolac... 6, 71 KEYTRUDA kimidess (28) KINERET KINRIX (PF) kionex (with sorbitol) KISQALI KISQALI FEMARA CO-PACK KLOR-CON KLOR-CON KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle KORLYM KRINTAFEL KRYSTEXXA K-TAB kurvelo (28) KUVAN L l norgest/e.estradiol-e.estrad labetalol LACRISERT LACTATED RINGERS... 86, 90 lactulose lamivudine lamivudine-zidovudine lamotrigine LANOXIN lansoprazole lanthanum LANTUS SOLOSTAR U-100 INSULIN LANTUS U-100 INSULIN larin 1.5/30 (21) larin 1/20 (21) larin 24 fe larin fe 1.5/30 (28) larin fe 1/20 (28) larissia LARTRUVO LASTACAFT latanoprost LATUDA... 36, 37 layolis fe

114 leena leflunomide LEMTRADA LENVIMA lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levalbuterol hcl levalbuterol tartrate LEVEMIR FLEXTOUCH U- 100 INSULN LEVEMIR U-100 INSULIN.. 28 levetiracetam levetiracetam in nacl (iso-os). 22 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 13, 70 levofloxacin in d5w levoleucovorin calcium levonest (28) levonorgestrel-ethinyl estrad.. 59 levonorg-eth estrad triphasic.. 60 levora levorphanol tartrate... 4 levothyroxine LEVOXYL LEXIVA lidocaine... 7 lidocaine hcl... 7 lidocaine viscous... 7 lidocaine-prilocaine... 7 lillow (28) lincomycin... 9 lindane linezolid... 9 linezolid in dextrose 5%... 9 linezolid-0.9% sodium chloride 9 LINZESS liothyronine lisinopril lisinopril-hydrochlorothiazide 48 lithium carbonate... 55, 56 lithium citrate LO LOESTRIN FE lomedia 24 fe LONSURF loperamide lopinavir-ritonavir lopreeza lorazepam... 8 LORBRENA lorcet (hydrocodone)... 4 lorcet hd... 4 lorcet plus... 4 loryna (28) losartan losartan-hydrochlorothiazide.. 48 LOTEMAX... 71, 72 lovastatin low-ogestrel (28) loxapine succinate LUCEMYRA... 7 LUDENT FLUORIDE LUMIGAN LUMIZYME LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) lutera (28) LYNPARZA LYRICA LYSODREN lyza M mafenide acetate magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion maprotiline marlissa (28) MARPLAN MARQIBO marten-tab... 4 MATULANE matzim la MAVYRET MAXIDEX MAXIPIME meclizine medroxyprogesterone mefloquine megestrol... 18, 79 MEKINIST MEKTOVI melodetta 24 fe meloxicam... 6 memantine MENACTRA (PF) MENEST MENVEO A-C-Y-W-135-DIP (PF) meperidine... 4 meperidine (pf)... 4 meprobamate... 8 mercaptopurine meropenem mesalamine mesna MESNEX metadate er metaproterenol metaxall metaxalone metformin methadone... 4 methazolamide methenamine hippurate... 9 METHERGINE methimazole methocarbamol methotrexate sodium methotrexate sodium (pf) methoxsalen methscopolamine methyclothiazide methyldopa methyldopa-hydrochlorothiazide methylergonovine methylphenidate hcl methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 9, 31,

115 metronidazole in nacl (iso-os).. 9 mexiletine MIACALCIN mibelas 24 fe miconazole microgestin 1.5/30 (21) microgestin 1/20 (21) microgestin 24 fe microgestin fe 1.5/30 (28) microgestin fe 1/20 (28) midazolam... 8 midazolam (pf)... 8 midodrine MIGERGOT miglitol miglustat mili milrinone milrinone in 5 % dextrose mimvey mimvey lo minitran minocycline minoxidil mirtazapine MIRVASO misoprostol mitomycin mitoxantrone M-M-R II (PF) modafinil moexipril moexipril-hydrochlorothiazide molindone mometasone... 66, 72 mono-linyah mononessa (28) montelukast MONUROL... 9 morphine... 4, 5 MORPNE... 4, 5 morphine (pf)... 4 morphine concentrate... 4 MOXEZA moxifloxacin... 13, 70 moxifloxacin in nacl (iso-osm) moxifloxacin-sod.ace,sul-water MOZOBIL MULTAQ mupirocin mupirocin calcium MUSTARGEN mutamycin MYALEPT MYCAMINE mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYLOTARG myorisan MYRBETRIQ myzilra N NABI-HB nabumetone... 6 nadolol nafcillin... 12, 13 nafcillin in dextrose iso-osm.. 12 naftifine NAGLAZYME nalocet... 5 naloxone... 7 naltrexone... 7 NAMZARIC naphazoline naproxen... 6 naproxen sodium... 6 naratriptan NARCAN... 7 NATACYN NATAZIA nateglinide NATPARA NEBUPENT necon 0.5/35 (28) necon 7/7/7 (28) nefazodone neomycin... 9 neomycin-bacitracin-poly-hc.. 70 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin neo-polycin hc NEPHRAMINE 5.4 % NERLYNX neuac NEULASTA NEUPOGEN NEUPRO NEVANAC nevirapine NEXAVAR niacin nicardipine NICOTROL... 7 NICOTROL NS... 7 nifedical xl nifedipine nikki (28) nilutamide nimodipine NINLARO nisoldipine NITRO-BID nitrofurantoin nitrofurantoin macrocrystal... 9 nitrofurantoin monohyd/m-cryst... 9 nitroglycerin NITROSTAT NIVESTYM nizatidine nora-be NORDITROPIN FLEXPRO.. 78 noreth-ethinyl estradiol-iron norethindrone (contraceptive) 60 norethindrone acetate norethindrone ac-eth estradiol... 60, 77 norethindrone-e.estradiol-iron 60 norgestimate-ethinyl estradiol 60 norlyda norlyroc NORTHERA nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR NOVOLIN 70/30 U-100 INSULIN NOVOLIN FLEXPEN U

116 NOVOLIN N NPH U-100 INSULIN NOVOLIN R REGULAR U- 100 INSULN NOVOLOG FLEXPEN U-100 INSULIN NOVOLOG MIX U-100 INSULN NOVOLOG MIX 70-30FLEXPEN U NOVOLOG PENFILL U-100 INSULIN NOVOLOG U-100 INSULIN ASPART NOXAFIL NUCALA NUEDEXTA NULOJIX NUPLAZID NUTRILIPID nyamyc nystatin nystatin-triamcinolone nystop O ocella OCTAGAM octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin... 13, 70 ogestrel (28) okebo olanzapine olmesartan olmesartan-amlodipin-hcthiazid olmesartan-hydrochlorothiazide olopatadine omega-3 acid ethyl esters omeprazole OMNITROPE ondansetron ondansetron hcl ondansetron hcl (pf) ONFI... 8 OPDIVO OPSUMIT oralone ORENCIA ORENCIA CLICKJECT ORENITRAM ORKAMBI orphenadrine citrate orsythia oseltamivir OTEZLA OTEZLA STARTER oxacillin oxacillin in dextrose(iso-osm) 13 oxandrolone oxaprozin... 6 oxazepam... 8 oxcarbazepine oxiconazole oxybutynin chloride... 74, 75 oxycodone... 5 oxycodone-acetaminophen... 5 oxycodone-aspirin... 5 OXYCONTIN... 5 oxymorphone... 5 OZEMPIC P pacerone paclitaxel paliperidone palonosetron PALONOSETRON pamidronate PANCREAZE PANRETIN pantoprazole paricalcitol PARICALCITOL paroex oral rinse paromomycin paroxetine hcl PASER PAXIL PEDIARIX (PF) PEDVAX B (PF) peg 3350-electrolytes PEGANONE PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEGINTRON REDIPEN PEN NEEDLE, DIABETIC penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTACEL (PF) PENTACEL DTAP-IPV COMPNT (PF) PENTAM PENTASA pentoxifylline PERFOROMIST PERIKABIVEN perindopril erbumine periogard PERJETA permethrin perphenazine perphenazine-amitriptyline PERTZYE pfizerpen-g phenadoz phenelzine phenobarbital phenoxybenzamine phenytoin phenytoin sodium extended philith PHOSLYRA PHOSPHOLINE IODIDE phrenilin forte(with caffeine)... 5 PHYSIOSOL IRRIGATION.. 86 PICATO PIFELTRO pilocarpine hcl... 62, 89 pimecrolimus pimozide pimtrea (28) pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella piroxicam... 6 PLEGRIDY PLENAMINE podofilox polycin polyethylene glycol polymyxin b sulfate polymyxin b sulf-trimethoprim

117 POMALYST portia potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex 90 potassium chloride in lr-d potassium chloride in water potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate PRALUENT PEN pramipexole PRAMOSONE prasugrel pravastatin praziquantel prazosin PRED MILD prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate... 72, 78 prednisone PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal plus (calcium carb) prenatal vitamin plus low iron 96 prevalite previfem PREZCOBIX PREZISTA PRIALT... 5 PRIFTIN PRIMAQUINE primidone PRIVIGEN probenecid probenecid-colchicine prochlorperazine prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLEUKIN PROLIA PROMACTA promethazine... 31, 33 promethegan propafenone propantheline proparacaine propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSOL 20 % protriptyline PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide Q QNASL QTERN QUADRACEL (PF) quasense quetiapine quinapril quinapril-hydrochlorothiazide 48 quinidine gluconate quinidine sulfate quinine sulfate QVAR QVAR REDIHALER R RABAVERT (PF) rabeprazole RADICAVA rajani raloxifene ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE rasagiline RAVICTI RAYALDEE REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK reclipsen (28) RECOMBIVAX HB (PF) REGRANEX RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENFLEXIS repaglinide REPATHA PUSHTRONEX.. 54 REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR RESTASIS RETACRIT RETROVIR REVATIO REVLIMID REXULTI REYATAZ RHOPHYLAC RHOPRESSA ribasphere ribavirin RIDAURA rifabutin rifampin RIFATER riluzole rimantadine ringer's... 86, 91 risedronate RISPERDAL CONSTA risperidone ritonavir RITUXAN rivastigmine rivastigmine tartrate rivelsa rizatriptan ropinirole rosadan

118 rosuvastatin ROTARIX ROTATEQ VACCINE ROZEREM RUBRACA RUCONEST RYDAPT RYTARY S SABRIL SAMSCA SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS SAVELLA... 56, 57 scopolamine base selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS sertraline... 25, 26 setlakin sevelamer carbonate sevelamer hcl sf 5000 plus sharobel SNGRIX (PF) SIGNIFOR sildenafil (antihypertensive) SILIQ silodosin silver sulfadiazine SIMBRINZA SIMPONI... 82, 83 SIMPONI ARIA SIMULECT simvastatin sirolimus SIRTURO SIVEXTRO sodium chloride... 86, 91 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate. 73 SOLIQUA 100/ SOLIRIS SOLTAMOX SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF) SOMATULINE DEPOT SOMAVERT sorine sotalol sotalol af spinosad SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX sprintec (28) SPRITAM SPRYCEL sps (with sorbitol) sronyx ssd stavudine STELARA STIMATE STIOLTO RESPIMAT STIVARGA STRENSIQ streptomycin... 9 STRIBILD STRIVERDI RESPIMAT SUBOXONE... 7 sucralfate sulfacetamide sodium sulfacetamide sodium (acne).. 65 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim... 13, 14 SULFAMYLON sulfasalazine sulfatrim sulindac... 6 sumatriptan sumatriptan succinate SUPRAX SUPREP BOWEL PREP KIT 74 SURE COMFORT INS. SYR. U SUTENT syeda SYLATRON SYLVANT SYMBICORT SYMDEKO SYMFI SYMFI LO SYMJEPI SYMLINPEN SYMLINPEN SYMPAZAN... 8 SYMTUZA SYNERCID SYNJARDY SYNJARDY XR SYNRIBO SYNTHROID T TABLOID tacrolimus... 67, 83 tadalafil tadalafil (antihypertensive) TAFINLAR TAGRISSO TALTZ AUTOINJECTOR TALTZ SYRINGE TALZENNA tamoxifen tamsulosin TANZEUM TARCEVA TARGRETIN tarina fe 1/20 (28) TASIGNA tazarotene tazicef TAZORAC taztia xt TECENTRIQ TECFIDERA TEFLARO telmisartan telmisartan-hydrochlorothiazid temazepam... 8 tencon... 5 TENIVAC (PF) tenofovir disoproxil fumarate

119 terazosin terbinafine hcl terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline THALOMID theophylline thioridazine thiothixene THYMOGLOBULIN THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine TIBSOVO TICE BCG tigecycline tilia fe timolol maleate... 50, 89 tinidazole TIVICAY tizanidine TOBI PODHALER... 9 TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl... 9 tobramycin in 0.9 % nacl... 9 tobramycin sulfate... 9 tobramycin-dexamethasone TOBREX TOLAK tolcapone tolterodine topiramate toposar topotecan toremifene torsemide TOUJEO MAX U-300 SOLOSTAR TOUJEO SOLOSTAR U-300 INSULIN TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol... 5 tramadol-acetaminophen... 5 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travoprost (benzalkonium) trazodone TREANDA TRECATOR TRELEGY ELLIPTA TRESIBA FLEXTOUCH U TRESIBA FLEXTOUCH U TRESIBA U-100 INSULIN tretinoin tretinoin (chemotherapy) tri femynor triamcinolone acetonide.. 62, 67, 78 triamterene-hydrochlorothiazid triderm tridesilon trientine tri-estarylla trifluoperazine trifluridine trihexyphenidyl tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte with flavor packets trimethoprim tri-mili trimipramine TRIMPEX trinessa (28) trinessa lo TRINTELLIX tri-previfem (28) TRISENOX tri-sprintec (28) TRIUMEQ trivora (28) tri-vylibra tri-vylibra lo TROPHAMINE 10 % TROPHAMINE 6% tropicamide trospium TRULANCE TRULICITY TRUMENBA TRUVADA tulana TWINRIX (PF) TYBOST tydemy TYKERB TYMLOS TYPM VI TYSABRI U UDENYCA ULORIC UPTRAVI ursodiol V valacyclovir VALCHLOR valganciclovir valproate sodium valproic acid valproic acid (as sodium salt). 23 valsartan valsartan-hydrochlorothiazide 48 vancomycin VANCOMYCIN vancomycin in dextrose 5 % VAQTA (PF) VARIVAX (PF) VASCEPA VELCADE VELETRI velivet triphasic regimen (28). 62 VELPHORO VELTASSA VEMLIDY VENCLEXTA

120 VENCLEXTA STARTING PACK venlafaxine VENTAVIS VENTOLIN HFA verapamil VERSACLOZ VERZENIO VESICARE vestura (28) VIBATIV VIBERZI vicodin... 5 vicodin es... 5 vicodin hp... 5 VICTOZA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC vienva vigabatrin vigadrone VIIBRYD VIMPAT vinblastine vincasar pfs vincristine vinorelbine VIOKACE viorele (28) VIRACEPT VIRAMUNE VIREAD VITRAKVI VIZIMPRO voriconazole... 30, 31 VOSEVI VOTRIENT VPRIV VRAYLAR vyfemla (28) vylibra VYVANSE VYXEOS W warfarin water for irrigation, sterile WELCHOL wera (28) WINRHO SDF wymzya fe X XADAGO XALKORI XARELTO XATMEP XELJANZ XELJANZ XR XELPROS XGEVA XIFAXAN XIIDRA XOFLUZA XOLAIR XOSPATA XTANDI xulane XULTOPHY 100/ xylon XYREM Y YERVOY YF-VAX (PF) YONDELIS YONSA YUPELRI yuvafem Z zafirlukast zaleplon ZANOSAR zarah ZARXIO zebutal... 5 ZEJULA ZELBORAF ZEMAIRA zenatane zenchent (28) ZENPEP zenzedi ZERBAXA ZERIT zidovudine zileuton ziprasidone hcl ZIRGAN zoledronic acid zoledronic acid-mannitol-water zoledronic ac-mannitol-0.9nacl ZOLINZA zolmitriptan zolpidem ZOMETA zonisamide ZONTIVITY ZORTRESS ZOSTAVAX (PF) ZOSYN IN DEXTROSE (ISO- OSM) zovia 1/35e (28) ZYCLARA ZYDELIG ZYFLO ZYKADIA ZYLET ZYPREXA RELPREVV ZYTIGA ZYVOX

121 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI TTY: 711 Fax a.m. 8 p.m., 7 days a week This formulary was updated on March 26, For more recent information or other questions please contact Security Health Plan Customer Service at or, for TTY users, 711, or visit We are open 7 days a week, 8 a.m. to 8 p.m., from Oct. 1-March 31; and Monday through Friday, 8 a.m. to 8 p.m., from April 1-Sept Security Health Plan of Wisconsin, Inc.