Stanford Health Care Advantage 2019 Formulary List of Covered Drugs

Transcription

1 Stanford Health Care Advantage 019 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN , 11 This formulary was updated on 0/01/019. For more recent information or other questions, please contact Stanford Health Care Advantage Member Care Services, at or, for TTY users, 711, 8 am to 8 pm, seven days a week (except Thanksgiving and Christmas) from October 1 through March 1 and Monday through Friday (except holidays) from April 1 through September 0, or visit StanfordHealthCareAdvantage.org.

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13 Table of Contents Analgesics... Anesthetics... 7 Anti-Addiction/Substance Abuse Treatment Agents...7 Antianxiety Agents...8 Antibacterials Anticancer Agents Anticholinergic Agents... 7 Anticonvulsants...7 Antidementia Agents...1 Antidepressants... 1 Antidiabetic Agents... Antifungals...8 Antigout Agents... 9 Antihistamines...9 Anti-Infectives (Skin And Mucous Membrane)...0 Antimigraine Agents...0 Antimycobacterials...1 Antinausea Agents...1 Antiparasite Agents... Antiparkinsonian Agents... Antipsychotic Agents...5 Antivirals (Systemic)...50 Blood Products/Modifiers/Volume Expanders Caloric Agents...59 Cardiovascular Agents... 6 Central Nervous System Agents... 7 Contraceptives...75 Dental And Oral Agents...81 Dermatological Agents...81 Devices Enzyme Replacement/Modifiers...86 Eye, Ear, Nose, Throat Agents...88 Gastrointestinal Agents Genitourinary Agents...9 Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying

14 Immunological Agents...10 Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents...11 Miscellaneous Therapeutic Agents...11 Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants... 1 Sleep Disorder Agents... 1 Vasodilating Agents...1 Vitamins And Minerals...15

15 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml 1 GC; QL (700 per 0 days) acetaminophen-codeine oral tablet QL (60 per 0 days) acetaminophen-codeine oral tablet 00-0 (Tylenol-Codeine #) QL (60 per 0 days) acetaminophen-codeine oral tablet (Tylenol-Codeine #) QL (180 per 0 days) buprenorphine hcl injection solution 0. (Buprenex) /ml buprenorphine hcl injection syringe 0. /ml butalbital-acetaminophen-caff oral tablet (Esgic) QL (180 per 0 days) butalbital-aspirin-caffeine oral capsule (Fiorinal) QL (180 per 0 days) butalbital-aspirin-caffeine oral tablet 50- QL (180 per 0 days) 5-0 codeine sulfate oral tablet 15, 0, QL (180 per 0 days) 60 endocet oral tablet 10-5 QL (180 per 0 days) endocet oral tablet.5-5, 5-5 QL (60 per 0 days) endocet oral tablet QL (0 per 0 days) fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution /15 ml hydrocodone-acetaminophen oral tablet 10-5 hydrocodone-acetaminophen oral tablet.5-5 hydrocodone-acetaminophen oral tablet 5-5 hydrocodone-acetaminophen oral tablet (Actiq) ; QL (10 per 0 days) (Duragesic) QL (10 per 0 days) QL (700 per 0 days) (Lorcet HD) QL (180 per 0 days) (Verdrocet) QL (0 per 0 days) (Lorcet (hydrocodone)) QL (0 per 0 days) (Lorcet Plus) QL (180 per 0 days)

16 hydrocodone-ibuprofen oral tablet 7.5- QL (150 per 0 days) 00 hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 0 days) hydromorphone oral tablet,, 8 (Dilaudid) QL (180 per 0 days) HYSINGLA ER ORAL QL (0 per 0 days) TABLET,ORAL ONLY,EXT.REL. HR 100 MG, 10 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 ; QL (0 per 0 days) MCG/SPRAY, 00 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-5 QL (0 per 0 days) lorcet hd oral tablet 10-5 QL (180 per 0 days) lorcet plus oral tablet QL (180 per 0 days) methadone injection solution 10 /ml methadone oral solution 10 /5 ml QL (600 per 0 days) methadone oral solution 5 /5 ml QL (100 per 0 days) methadone oral tablet 10 (Dolophine) QL (10 per 0 days) methadone oral tablet 5 (Dolophine) QL (180 per 0 days) methadose oral tablet,soluble 0 QL (0 per 0 days) morphine 10 /ml isecure syrg l/f, p/f, suv, inner 10 /ml morphine concentrate oral solution 100 QL (180 per 0 days) /5 ml (0 /ml) morphine injection syringe 10 /ml morphine intravenous solution 10 /ml morphine oral solution 10 /5 ml QL (700 per 0 days) morphine oral solution 0 /5 ml ( QL (00 per 0 days) /ml) MORPHINE ORAL TABLET 15 MG QL (180 per 0 days) MORPHINE ORAL TABLET 0 MG QL (10 per 0 days) morphine oral tablet extended release 100 (MS Contin) QL (60 per 0 days), 00, 60 morphine oral tablet extended release 15, 0 (MS Contin) QL (90 per 0 days)

17 NUCYNTA ER ORAL TABLET QL (60 per 0 days) EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, QL (181 per 0 days) 50 MG, 75 MG oxycodone oral solution 5 /5 ml QL (100 per 0 days) oxycodone oral tablet 10 QL (180 per 0 days) oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 days) oxycodone oral tablet 0 QL (10 per 0 days) oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 days) oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 0 days) hr 10, 15, 0, 0, 0, 60, 80 oxycodone-acetaminophen oral solution QL (1800 per 0 days) 5-5 /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (180 per 0 days) 5 oxycodone-acetaminophen oral tablet (Endocet) QL (60 per 0 days).5-5, 5-5 oxycodone-acetaminophen oral tablet (Endocet) QL (0 per 0 days) oxycodone-aspirin oral tablet QL (60 per 0 days) OXYCONTIN ORAL QL (60 per 0 days) TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 00 MG/1.5 ML tramadol oral tablet 50 (Ultram) 1 GC; QL (0 per 0 days) tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (0 per 0 days) 5 XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 1HR TMPRR 1.5 MG, 18 MG, 9 MG QL (60 per 0 days) 5

18 XTAMPZA ER ORAL QL (10 per 0 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG XTAMPZA ER ORAL QL (0 per 0 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 6 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (100 MG/ML) celecoxib oral capsule 100, 00, (Celebrex) QL (60 per 0 days) 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops 1.5 % QL (00 per 0 days) diclofenac sodium topical gel % (Solaraze) PA; QL (100 per 8 days) etodolac oral capsule 00, 00 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 FLECTOR TRANSDERMAL PA PATCH 1 HOUR 1. % flurbiprofen oral tablet 100, 50 ibu oral tablet 00, 600, GC ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 00, 600, (IBU) 1 GC 800 indomethacin oral capsule 5 1 GC; QL (0 per 0 days) indomethacin oral capsule 50 1 GC; QL (10 per 0 days) indomethacin sodium intravenous recon soln 1 ketorolac oral tablet 10 QL (0 per 0 days) mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) 1 GC 6

19 nabumetone oral tablet 500, 750 naproxen oral tablet 50, 75 1 GC naproxen oral tablet 500 (Naprosyn) 1 GC naproxen oral tablet,delayed release (dr/ec) 75, 500 (EC-Naprosyn) PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 0 MG/GRAM /ACTUATION( %) ; QL ( per 8 days) sulindac oral tablet 150, 00 VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in QL (0 per 0 days) applicator % lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %), 15 /ml (1.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 0 /ml ( %) lidocaine hcl injection solution 10 /ml (1 %), 0 /ml ( %), 5 /ml (0.5 %) (Xylocaine) lidocaine hcl mucous membrane jelly % QL (0 per 0 days) lidocaine hcl mucous membrane solution % (0 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 0 days) lidocaine topical ointment 5 % PA; QL (90 per 0 days) lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl sublingual tablet, 8 PA; QL (0 per 0 days) QL (90 per 0 days) 7

20 buprenorphine-naloxone sublingual tablet QL (90 per 0 days) -0.5, 8- bupropion hcl (smoking deter) oral tablet (Zyban) extended release 1 hr 150 CHANTIX CONTINUING MONTH QL (6 per 65 days) BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (6 per 65 days) MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG () QL (106 per 65 days) disulfiram oral tablet 50, 500 (Antabuse) LUCEMYRA ORAL TABLET 0.18 MG ; QL (8 per 1 days) naloxone injection solution 0. /ml naloxone injection syringe 0. /ml, 1 /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- QL ( per 0 days) AEROSOL MG/ACTUATION NICOTROL INHALATION QL (1008 per 90 days) CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM QL (60 per 0 days) 1- MG, 8- MG SUBOXONE SUBLINGUAL FILM - QL (0 per 0 days) 0.5 MG, -1 MG ZUBSOLV SUBLINGUAL TABLET QL (0 per 0 days) MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG QL (60 per 0 days) Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 GC; QL (10 per 0 days) alprazolam oral tablet (Xanax) 1 GC; QL (150 per 0 buspirone oral tablet 10, 15, 0, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 5, 5 days) 1 GC; QL (10 per 0 days) 8

21 clobazam oral suspension.5 /ml (Onfi) PA NSO; QL (80 per 0 days) clobazam oral tablet 10, 0 (Onfi) PA NSO; QL (60 per 0 days) clonazepam oral tablet 0.5, 1 (Klonopin) 1 GC; QL (90 per 0 days) clonazepam oral tablet (Klonopin) 1 GC; QL (00 per 0 days) clonazepam oral tablet,disintegrating QL (90 per 0 days) 0.15, 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 days) clorazepate dipotassium oral tablet 15 QL (180 per 0 days),.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (180 per 0 days) DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG diazepam injection solution 5 /ml QL (10 per 8 days) diazepam injection syringe 5 /ml QL (10 per 8 days) diazepam intensol oral concentrate 5 QL (100 per 0 days) /ml diazepam oral solution 5 /5 ml (1 QL (100 per 0 days) /ml) diazepam oral tablet 10,, 5 (Valium) 1 GC; QL (10 per 0 days) diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml (Ativan) 1 GC; QL ( per 0 days) lorazepam injection solution /ml (Ativan) QL ( per 0 days) lorazepam injection syringe /ml, QL ( per 0 days) /ml lorazepam oral tablet 0.5, 1 (Ativan) 1 GC; QL (90 per 0 days) lorazepam oral tablet (Ativan) 1 GC; QL (150 per 0 days) ONFI ORAL SUSPENSION.5 MG/ML 5 PA NSO; NM; NDS; QL (80 per 0 days) 9

22 ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) temazepam oral capsule 15, 0 (Restoril) QL (0 per 0 days) Antibacterials Aminoglycosides BETHKIS INHALATION 5 PA BvD; NM; NDS SOLUTION FOR NEBULIZATION 00 MG/ ML gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 10 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 0 / ml, 0 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml, 60 /6 ml, 80 /8 ml neomycin oral tablet GC streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 0 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150, 00, 75 ; QL ( per 8 days) (Tobi) 5 PA BvD; NM; NDS (BACiiM) (Cleocin HCl) 10

23 clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution 150 /ml clindamycin phosphate intravenous solution 600 / ml colistin (colistimethate na) injection recon soln 150 daptomycin intravenous recon soln 50 daptomycin intravenous recon soln 500 FIRVANQ ORAL RECON SOLN 5 MG/ML, 50 MG/ML linezolid 600 /00 ml-0.9% nacl 600 /00 ml linezolid in dextrose 5% intravenous piggyback 600 /00 ml linezolid oral suspension for reconstitution 100 /5 ml (Cleocin) (Cleocin) (Coly-Mycin M Parenteral) 5 PA BvD; NM; NDS (Cubicin) (Zyvox) (Zyvox) linezolid oral tablet 600 (Zyvox) methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 /100 ml (Metro I.V.) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule (Macrodantin) QL (10 per 0 days) 100, 5, 50 nitrofurantoin monohyd/m-cryst oral (Macrobid) QL (60 per 0 days) capsule 100 polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet GC vancomycin intravenous recon soln 1,000, 1.5 gram, 10 gram, 50, 5 gram, 500, 750 PA BvD 11

24 vancomycin oral capsule 15 (Vancocin) vancomycin oral capsule 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG ; QL (9 per 0 days) XIFAXAN ORAL TABLET 550 MG Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 00 (Spectracef) cefepime injection recon soln 1 gram, (Maxipime) gram cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln 10 gram, (Claforan) gram cefoxitin intravenous recon soln 1 gram, 10 gram, gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln 1 gram (Fortaz) ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftibuten oral capsule 00 1

25 ceftibuten oral suspension for reconstitution 180 /5 ml ceftriaxone injection recon soln 1 gram, 10 gram, gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) 1 GC cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml SUPRAX ORAL CAPSULE 00 MG tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 1 GC pack), 500 ( pack) azithromycin oral tablet 50, 500 (Zithromax) 1 GC azithromycin oral tablet 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 DIFICID ORAL TABLET 00 MG 5 ST; NM; NDS; QL (0 per 10 days) erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram (Azactam) 1

26 CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 NM; LA; NDS ertapenem injection recon soln 1 gram (Invanz) imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, GC amoxicillin oral suspension for 1 GC reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, GC amoxicillin oral tablet,chewable 15, 1 GC 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, GC ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, gram (Unasyn) 1

27 BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin 1 gm/ 50 ml inj 1 gram/50 ml nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram nafcillin injection recon soln gram nafcillin intravenous recon soln gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin injection recon soln 1 gram, 10 gram, gram penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 1 GC 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous (Zosyn) PA BvD recon soln.5 gram,.75 gram,.5 gram, 0.5 gram Quinolones BAXDELA ORAL TABLET 50 MG ; QL (8 per 1 days) ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 GC ciprofloxacin hcl oral tablet GC ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 00 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 00 /0 ml 15

28 ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50 1 GC levofloxacin oral tablet 500, 750 (Levaquin) 1 GC moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 00, 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 GC tablet sulfatrim oral suspension 00-0 /5 ml Tetracyclines doxy-100 intravenous recon soln 100 doxycycline hyclate intravenous recon (Doxy-100) soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline monohydrate oral capsule (Mondoxyne NL) 100, 50 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 50 minocycline oral capsule 100, 75 16

29 minocycline oral capsule 50 (Minocin) mondoxyne nl oral capsule 100, 50 okebo oral capsule 100 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 /5 PA BvD ml, /ml, 0 /10 ml, 50 /5 ml adrucil intravenous solution.5 gram/50 PA BvD ml, 500 /10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 5 PA NSO; NM; NDS; QL (11 per 8 days) MG, 5 MG AFINITOR ORAL TABLET 10 MG 5 PA NSO; NM; NDS; QL (56 per 8 days) AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; NM; NDS; QL (8 per 8 days) ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG 5 PA NSO; NM; NDS; QL ( per 8 days) ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) ALUNBRIG ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG () 5 PA NSO; NM; NDS; QL (0 per 0 days) anastrozole oral tablet 1 (Arimidex) 1 GC arsenic trioxide intravenous solution 1 /ml AVASTIN INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 5 MG/ML azacitidine injection recon soln 100 (Vidaza) 17

30 BAVENCIO INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 500 MG BENDEKA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 5 PA NSO; NM; NDS; QL (0 per 0 days) bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 15 unit, 0 PA BvD unit BLINCYTO INTRAVENOUS KIT 5 5 PA NSO; NM; NDS MCG BORTEZOMIB INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN.5 MG BOSULIF ORAL TABLET 100 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) BOSULIF ORAL TABLET 00 MG, 500 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) BRAFTOVI ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) BRAFTOVI ORAL CAPSULE 75 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) CABOMETYX ORAL TABLET 0 MG, 60 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) CABOMETYX ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) CAPRELSA ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) clofarabine intravenous solution 0 /0 (Clolar) ml 18

31 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), 10 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COPIKTRA ORAL CAPSULE 15 MG, 5 MG 5 PA NSO; NM; NDS; QL (11 per 8 days) 5 PA NSO; NM; NDS; QL (56 per 8 days) COTELLIC ORAL TABLET 0 MG 5 PA NSO; NM; LA; NDS; QL (6 per 8 days) cyclophosphamide intravenous recon soln 5 PA BvD; NM; NDS 1 gram, gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 10 MG/ML DARZALEX INTRAVENOUS SOLUTION 0 MG/ML 5 PA NSO; NM; LA; NDS DAURISMO ORAL TABLET 100 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) DAURISMO ORAL TABLET 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) decitabine intravenous recon soln 50 (Dacogen) doxorubicin intravenous solution 10 /5 (Adriamycin) PA BvD ml, /ml, 0 /10 ml, 50 /5 ml doxorubicin, peg-liposomal intravenous (Doxil) 5 PA BvD; NM; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE.5 MG ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 5 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS RECON SOLN 00 MG, 00 MG 5 PA NSO; NM; NDS 19

32 ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) ERLEADA ORAL TABLET 60 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 5 PA NSO; NM; NDS MG, 15 MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/100 ml, 500 /10 ml flutamide oral capsule 15 GAZYVA INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 1,000 MG/0 ML GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) GLEOSTINE ORAL CAPSULE 10 MG, 0 MG, 5 MG GLEOSTINE ORAL CAPSULE 100 MG HERCEPTIN INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 150 MG, 0 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG 5 PA NSO; NM; NDS; QL (1 per 8 days) ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) ICLUSIG ORAL TABLET 5 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) ifosfamide intravenous recon soln 1 gram (Ifex) PA BvD 0

33 ifosfamide intravenous solution 1 gram/0 PA BvD ml, gram/60 ml ifosfamide-mesna intravenous kit PA BvD; NM; NDS gram,,000-1,000 imatinib oral tablet 100 (Gleevec) 5 PA NSO; NM; NDS; QL (90 per 0 days) imatinib oral tablet 00 (Gleevec) 5 PA NSO; NM; NDS; QL (60 per 0 days) IMBRUVICA ORAL CAPSULE 10 MG, 70 MG 5 PA NSO; NM; NDS; QL (8 per 8 days) IMBRUVICA ORAL TABLET 10 MG, 80 MG, 0 MG, 560 MG 5 PA NSO; NM; NDS; QL (8 per 8 days) IMFINZI INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 50 MG/ML IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML 5 PA NSO; NM; NDS; QL ( per 65 days) IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML 5 PA NSO; NM; NDS; QL (8 per 8 days) INLYTA ORAL TABLET 1 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) INLYTA ORAL TABLET 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) IRESSA ORAL TABLET 50 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 5 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML 5 PA NSO; NM; NDS; QL (8 per 1 days) KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X )-.5 MG 5 PA NSO; NM; NDS; QL (9 per 8 days) 5 PA NSO; NM; NDS; QL (70 per 8 days) 5 PA NSO; NM; NDS; QL (91 per 8 days) 1

34 KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1) 5 PA NSO; NM; NDS; QL (1 per 8 days) KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) 5 PA NSO; NM; NDS; QL ( per 8 days) KISQALI ORAL TABLET 600 MG/DAY (00 MG X ) 5 PA NSO; NM; NDS; QL (6 per 8 days) KYPROLIS INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 10 MG, 0 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML 5 PA NSO; NM; LA; NDS LENVIMA ORAL CAPSULE 10 5 PA NSO; NM; NDS MG/DAY (10 MG X 1), 1 MG/DAY ( MG X ), 1 MG/DAY(10 MG X 1- MG X 1), 18 MG/DAY (10 MG X 1- MG X), 0 MG/DAY (10 MG X ), MG/DAY(10 MG X - MG X 1), MG, 8 MG/DAY ( MG X ) letrozole oral tablet.5 (Femara) 1 GC LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit 1 /0. ml LIBTAYO INTRAVENOUS SOLUTION 50 MG/7 ML (50 5 PA NSO; NM; NDS; QL (7 per 1 days) MG/ML) LONSURF ORAL TABLET MG 5 PA NSO; NM; NDS; QL (100 per 8 days) LONSURF ORAL TABLET MG 5 PA NSO; NM; NDS; QL (80 per 8 days) LORBRENA ORAL TABLET 100 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) LORBRENA ORAL TABLET 5 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) LUMOXITI INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 1 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG

35 LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (8 per 8 days) LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 0 MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) MEKINIST ORAL TABLET MG 5 PA NSO; NM; NDS; QL (0 per 0 days) MEKTOVI ORAL TABLET 15 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon PA BvD soln 1 gram methotrexate sodium (pf) injection PA BvD solution 5 /ml methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST mitoxantrone intravenous concentrate /ml MYLOTARG INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) nilutamide oral tablet 150 (Nilandron) NINLARO ORAL CAPSULE. MG, MG, MG 5 PA NSO; NM; NDS; QL ( per 8 days)

36 ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; NM; LA; NDS ONCASPAR INJECTION 5 PA NSO; NM; NDS SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS 5 PA BvD; NM; NDS DISPERSION. MG/ML OPDIVO INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 100 MG/10 ML, 0 MG/ ML, 0 MG/ ML POMALYST ORAL CAPSULE 1 MG, MG, MG, MG 5 PA NSO; NM; NDS; QL (1 per 8 days) PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 5 PA NSO; NM; NDS; QL (100 per 1 days) MG/ML) POTELIGEO INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION MG/ML PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS SOLUTION 100 MG/11.7 ML (10 MG/ML), 1600 MG/1. ML (10 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML RUBRACA ORAL TABLET 00 MG, 50 MG, 00 MG 5 PA NSO; NM; LA; NDS; QL (8 per 8 days) 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS 5 PA NSO; NM; NDS; QL (10 per 0 days) RYDAPT ORAL CAPSULE 5 MG 5 PA NSO; NM; NDS; QL ( per 8 days) SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 10 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) STIVARGA ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (8 per 8 days)

37 SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 7.5 MG, 50 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) SYLVANT INTRAVENOUS RECON 5 PA NSO; NM; NDS SOLN 100 MG, 00 MG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG 5 PA NSO; NM; NDS; QL (8 per 8 days) TABLOID ORAL TABLET 0 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) TAGRISSO ORAL TABLET 0 MG, 80 MG 5 PA NSO; NM; LA; NDS; QL (0 per 0 days) TALZENNA ORAL CAPSULE 0.5 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) TALZENNA ORAL CAPSULE 1 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) tamoxifen oral tablet 10, 0 TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) TARCEVA ORAL TABLET 150 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) TARGRETIN TOPICAL GEL 1 % 5 PA NSO; NM; NDS; QL (60 per 8 days) TASIGNA ORAL CAPSULE 150 MG, 00 MG 5 PA NSO; NM; NDS; QL (11 per 8 days) TASIGNA ORAL CAPSULE 50 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) TECENTRIQ INTRAVENOUS SOLUTION 1,00 MG/0 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG 5 PA NSO; NM; NDS; QL (0 per 1 days) 5 PA NSO; NM; NDS thiotepa injection recon soln 15 (Tepadina) TIBSOVO ORAL TABLET 50 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) toposar intravenous solution 0 /ml TREANDA INTRAVENOUS RECON SOLN 100 MG, 5 MG TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.5 MG ; QL (1 per 8 days) 5

38 TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 MG TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.75 MG tretinoin (chemotherapy) oral capsule 10 ; QL (1 per 168 days) TYKERB ORAL TABLET 50 MG UNITUXIN INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 0 MG/ML VELCADE INJECTION RECON 5 PA NSO; NM; NDS SOLN.5 MG VENCLEXTA ORAL TABLET 10 MG PA NSO; LA; QL (60 per 0 days) VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; NM; LA; NDS; QL (180 per 0 days) VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (0 per 0 days) VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG vinorelbine intravenous solution 10 /ml, 50 /5 ml VITRAKVI ORAL CAPSULE 100 MG 5 PA NSO; NM; LA; NDS; QL ( per 8 days) 5 PA NSO; NM; NDS; QL (56 per 8 days) (Navelbine) 5 PA NSO; NM; NDS; QL (60 per 0 days) VITRAKVI ORAL CAPSULE 5 MG 5 PA NSO; NM; NDS; QL (180 per 0 days) VITRAKVI ORAL SOLUTION 0 MG/ML 5 PA NSO; NM; NDS; QL (00 per 0 days) VIZIMPRO ORAL TABLET 15 MG, 0 MG, 5 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) VYXEOS INTRAVENOUS RECON SOLN -100 MG 5 PA BvD; NM; NDS 6

39 XALKORI ORAL CAPSULE 00 MG, 50 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) XATMEP ORAL SOLUTION.5 PA BvD; ST MG/ML XOSPATA ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) XTANDI ORAL CAPSULE 0 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) YERVOY INTRAVENOUS 5 PA NSO; NM; NDS SOLUTION 00 MG/0 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS 5 PA NSO; NM; NDS RECON SOLN 1 MG YONSA ORAL TABLET 15 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) ZELBORAF ORAL TABLET 0 MG 5 PA NSO; NM; NDS; QL (0 per 0 days) ZOLADEX SUBCUTANEOUS QL (1 per 8 days) IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS QL (1 per 8 days) IMPLANT.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NM; NDS; QL (90 per 0 days) ZYTIGA ORAL TABLET 50 MG, 500 MG 5 PA NSO; NM; NDS; QL (10 per 0 days) Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0.1 /ml propantheline oral tablet 15 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 5 ST; NM; NDS 00 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 0 MG/ML 5 ST; NM; NDS 7

40 BANZEL ORAL TABLET 00 MG, 5 ST; NM; NDS 00 MG BRIVIACT INTRAVENOUS QL (80 per 0 days) SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML ; QL (600 per 0 days) BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG ; QL (60 per 0 days) carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr 100, 00, 00 carbamazepine oral tablet,chewable 100 CELONTIN ORAL CAPSULE 00 MG DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, delayed rel sprinkle 15 (Depakote Sprinkles) divalproex oral tablet extended release (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 15, 50, 500 (Depakote) EPIDIOLEX ORAL SOLUTION PA NSO; NM; NDS MG/ML epitol oral tablet 00 ethosuximide oral capsule 50 (Zarontin) ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 00, 600 (Felbatol) fosphenytoin injection solution 100 pe/ ml, 500 pe/10 ml (Cerebyx) FYCOMPA ORAL SUSPENSION 0.5 ST MG/ML FYCOMPA ORAL TABLET 10 MG, 5 ST; NM; NDS 1 MG, MG, 6 MG, 8 MG FYCOMPA ORAL TABLET MG ST 8

41 gabapentin oral capsule 100, 00, (Neurontin) 1 GC 00 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) lamotrigine oral tablet 100, 150, (Lamictal) 1 GC 00, 5 lamotrigine oral tablet, chewable (Lamictal) dispersible 5, 5 levetiracetam intravenous solution 500 (Keppra) /5 ml levetiracetam oral solution 100 /ml (Keppra) levetiracetam oral tablet 1,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release (Keppra XR) hr 500, 750 LYRICA ORAL CAPSULE 100 MG, QL (90 per 0 days) 150 MG, 00 MG, 5 MG, 5 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 QL (900 per 0 days) MG/ML oxcarbazepine oral suspension 00 /5 (Trileptal) ml (60 /ml) oxcarbazepine oral tablet 150, 00 (Trileptal), 600 OXTELLAR XR ORAL TABLET ST EXTENDED RELEASE HR 150 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml ( /ml) phenobarbital oral tablet 100, 15, 16., 0,., 60, 6.8, 97. phenytoin oral suspension 15 /5 ml (Dilantin-15) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 100 phenytoin sodium extended oral capsule 00, 00 (Phenytek) 9

42 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml primidone oral tablet 50, 50 (Mysoline) ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 0 days) SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 50 MG, 500 MG, 750 ST; QL (10 per 0 days) MG subvenite oral tablet 100, 150, 00, 5 1 GC tiagabine oral tablet 1, 16,, (Gabitril) topiramate oral capsule, sprinkle 15, (Topamax) 5 topiramate oral capsule,sprinkle,er hr (Qudexy XR) 100, 150, 00, 5, 50 topiramate oral tablet 100, 00, 5, 50 (Topamax) 1 GC TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE HR 00 MG valproate sodium intravenous solution 500 /5 ml (100 /ml) valproic acid (as sodium salt) oral solution 50 /5 ml (Depacon) (Depakene) 5 ST; NM; NDS; QL (60 per 0 days) valproic acid oral capsule 50 (Depakene) vigabatrin oral powder in packet 500 (Sabril) vigabatrin oral tablet 500 (Sabril) vigadrone oral powder in packet 500 VIMPAT INTRAVENOUS ST; QL (00 per 5 days) SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 10 MG/ML ST; QL (100 per 0 days) VIMPAT ORAL TABLET 100 MG, ST; QL (60 per 0 days) 150 MG, 00 MG, 50 MG zonisamide oral capsule 100, 5 (Zonegran) 0

43 zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 10, 5 (Aricept) 1 GC; QL (0 per 0 days) donepezil oral tablet,disintegrating 10 QL (0 per 0 days), 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (0 per 0 days) hr 16,, 8 galantamine oral solution /ml QL (00 per 0 days) galantamine oral tablet 1,, 8 (Razadyne) QL (60 per 0 days) memantine oral capsule,sprinkle,er hr (Namenda XR) QL (0 per 0 days) 1, 1, 8, 7 memantine oral solution /ml QL (60 per 0 days) memantine oral tablet 10, 5 (Namenda) QL (60 per 0 days) NAMZARIC ORAL QL (56 per 65 days) CAP,SPRINKLE,ER HR DOSE PACK 7/1/1/8 MG-10 MG NAMZARIC ORAL QL (0 per 0 days) CAPSULE,SPRINKLE,ER HR 1-10 MG, 1-10 MG, 8-10 MG, 7-10 MG rivastigmine tartrate oral capsule 1.5, QL (60 per 0 days),.5, 6 rivastigmine transdermal patch hour (Exelon) QL (0 per 0 days) 1. / hour,.6 / hr, 9.5 / hr Antidepressants Antidepressants amitriptyline oral tablet 10, 100, 150, 5, 50, 75 amoxapine oral tablet 100, 150, 5, 50 bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release (Wellbutrin XL) hr 150, 00 bupropion hcl oral tablet sustainedrelease 1 hr 100, 150, 00 (Wellbutrin SR) citalopram oral solution 10 /5 ml QL (600 per 0 days) 1

44 citalopram oral tablet 10, 0, 0 (Celexa) 1 GC; QL (0 per 0 days) clomipramine oral capsule 5, 50, (Anafranil) 75 desipramine oral tablet 10, 5 (Norpramin) desipramine oral tablet 100, 150, 50, 75 desvenlafaxine succinate oral tablet (Pristiq) QL (0 per 0 days) extended release hr 100, 5, 50 doxepin oral capsule 10, 100, 150, 5, 50, 75 doxepin oral concentrate 10 /ml duloxetine oral capsule,delayed (Cymbalta) QL (60 per 0 days) release(dr/ec) 0, 60 duloxetine oral capsule,delayed (Cymbalta) QL (0 per 0 days) release(dr/ec) 0 EMSAM TRANSDERMAL PATCH HOUR 1 MG/ HR, 6 MG/ ; QL (0 per 0 days) HR, 9 MG/ HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, (Lexapro) 1 GC 0, 5 FETZIMA ORAL CAPSULE,EXT QL (56 per 65 days) REL HR DOSE PACK 0 MG ()- 0 MG (6) FETZIMA ORAL QL (0 per 0 days) CAPSULE,EXTENDED RELEASE HR 10 MG, 0 MG, 0 MG, 80 MG fluoxetine oral capsule 10, 0, 0 (Prozac) 1 GC fluoxetine oral solution 0 /5 ml ( /ml) fluvoxamine oral tablet 100, 5, 50 imipramine hcl oral tablet 10, 5, (Tofranil) 50 maprotiline oral tablet 5, 50, 75 MARPLAN ORAL TABLET 10 MG

45 mirtazapine oral tablet 15, 0 (Remeron) mirtazapine oral tablet 5, 7.5 mirtazapine oral tablet,disintegrating 15 (Remeron SolTab), 0, 5 nefazodone oral tablet 100, 150, 00, 50, 50 nortriptyline oral capsule 10, 5, (Pamelor) 1 GC 50, 75 nortriptyline oral solution 10 /5 ml paroxetine hcl oral tablet 10, 0, (Paxil) 1 GC 0, 0 PAXIL ORAL SUSPENSION 10 MG/5 ML perphenazine-amitriptyline oral tablet - 10, -5, -10, -5, -50 phenelzine oral tablet 15 (Nardil) protriptyline oral tablet 10, 5 sertraline oral concentrate 0 /ml (Zoloft) sertraline oral tablet 100, 5, 50 (Zoloft) 1 GC tranylcypromine oral tablet 10 (Parnate) trazodone oral tablet 100, 150, 50 1 GC trazodone oral tablet 00 trimipramine oral capsule 100, 5, (Surmontil) 50 TRINTELLIX ORAL TABLET 10 ST; QL (0 per 0 days) MG, 0 MG, 5 MG venlafaxine oral capsule,extended release (Effexor XR) QL (0 per 0 days) hr 150 venlafaxine oral capsule,extended release (Effexor XR) QL (90 per 0 days) hr 7.5, 75 venlafaxine oral tablet 100, 5, 7.5, 50, 75 VIIBRYD ORAL TABLET 10 MG, 0 ST; QL (0 per 0 days) MG, 0 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG () ST; QL (0 per 180 days)

46 Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100, 5, 50 (Precose) QL (90 per 0 days) GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLYXAMBI ORAL TABLET 10-5 ST; QL (0 per 0 days) MG, 5-5 MG INVOKAMET ORAL TABLET 150- ST; QL (60 per 0 days) 1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG ST; QL (10 per 0 days) INVOKAMET XR ORAL TABLET, ST; QL (60 per 0 days) IR - ER, BIPHASIC HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 ST; QL (60 per 0 days) MG INVOKANA ORAL TABLET 00 ST; QL (0 per 0 days) MG JANUMET ORAL TABLET 50-1,000 QL (60 per 0 days) MG, MG JANUMET XR ORAL TABLET, ER QL (0 per 0 days) MULTIPHASE HR 100-1,000 MG JANUMET XR ORAL TABLET, ER QL (60 per 0 days) MULTIPHASE HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, QL (0 per 0 days) 5 MG, 50 MG JARDIANCE ORAL TABLET 10 ST; QL (0 per 0 days) MG, 5 MG JENTADUETO ORAL TABLET.5- QL (60 per 0 days) 1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, QL (60 per 0 days) IR - ER, BIPHASIC HR.5-1,000 MG JENTADUETO XR ORAL TABLET, QL (0 per 0 days) IR - ER, BIPHASIC HR 5-1,000 MG KORLYM ORAL TABLET 00 MG ; QL (11 per 8 days)

47 metformin oral tablet 1,000 (Glucophage) 6 GC; QL (75 per 0 days) metformin oral tablet 500 (Glucophage) 6 GC; QL (150 per 0 days) metformin oral tablet 850 (Glucophage) 6 GC; QL (90 per 0 days) metformin oral tablet extended release hr 500 (Glucophage XR) 6 GC; QL (10 per 0 days) metformin oral tablet extended release hr 750 (Glucophage XR) 6 GC; QL (60 per 0 days) OZEMPIC SUBCUTANEOUS PEN QL ( per 8 days) INJECTOR 0.5 MG OR 0.5 MG( MG/1.5 ML), 1 MG/0.75 ML ( MG/1.5 ML) pioglitazone oral tablet 15, 0, 5 (Actos) 6 GC; QL (0 per 0 days) repaglinide oral tablet 0.5 QL (0 per 0 days) repaglinide oral tablet 1, (Prandin) QL (0 per 0 days) SYMLINPEN 10 SUBCUTANEOUS PEN INJECTOR,700 MCG/.7 ML ; QL (10.8 per 8 days) SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML ; QL (10.8 per 8 days) SYNJARDY ORAL TABLET 1.5- ST; QL (60 per 0 days) 1,000 MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR ST; QL (0 per 0 days) - ER, BIPHASIC HR 10-1,000 MG, 5-1,000 MG SYNJARDY XR ORAL TABLET, IR ST; QL (60 per 0 days) - ER, BIPHASIC HR 1.5-1,000 MG, 5-1,000 MG TRADJENTA ORAL TABLET 5 MG QL (0 per 0 days) TRULICITY SUBCUTANEOUS PEN QL ( per 8 days) 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/ ML) QL (9 per 0 days) 5

48 Insulins FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML ( ML) LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/0 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-0) NOVOLIN 70-0 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) 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 70-0 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-0) NOVOLOG MIX 70-0FLEXPEN U- 100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) QL (0 per 8 days) QL (0 per 8 days) QL (0 per 8 days) QL ( per 8 days) QL (0 per 8 days) QL (0 per 8 days) QL (0 per 8 days) QL (0 per 8 days) QL (0 per 8 days) QL (0 per 8 days) QL (0 per 8 days) QL (0 per 8 days) QL (0 per 8 days) 6

49 NOVOLOG PENFILL U-100 QL (0 per 8 days) INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN QL (0 per 8 days) ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML SOLIQUA 100/ SUBCUTANEOUS ST; QL (0 per 0 days) INSULIN PEN 100 UNIT- MCG/ML TOUJEO MAX U-00 SOLOSTAR QL (18 per 8 days) SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) TOUJEO SOLOSTAR U-00 QL (1.5 per 8 days) INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) XULTOPHY 100/.6 ST; QL (15 per 8 days) SUBCUTANEOUS INSULIN PEN 100 UNIT-.6 MG /ML ( ML) Sulfonylureas glimepiride oral tablet 1, (Amaryl) 6 GC; QL (0 per 0 days) glimepiride oral tablet (Amaryl) 6 GC; QL (60 per 0 days) glipizide oral tablet 10 (Glucotrol) 6 GC; QL (10 per 0 days) glipizide oral tablet 5 (Glucotrol) 6 GC; QL (60 per 0 days) glipizide oral tablet extended release hr (Glucotrol XL) QL (60 per 0 days) 10 glipizide oral tablet extended release hr (Glucotrol XL) QL (0 per 0 days).5, 5 glipizide-metformin oral tablet.5-50 QL (0 per 0 days) glipizide-metformin oral tablet.5-500, QL (10 per 0 days) glyburide micronized oral tablet 1.5, (Glynase), 6 glyburide oral tablet 1.5,.5, 5 7

50 glyburide-metformin oral tablet GC,.5-500, tolazamide oral tablet 50 QL (10 per 0 days) tolazamide oral tablet 500 QL (60 per 0 days) Antifungals Antifungals ABELCET INTRAVENOUS 5 PA BvD; NM; NDS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS 5 PA BvD; NM; NDS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 PA BvD caspofungin intravenous recon soln 50 (Cancidas), 70 ciclopirox topical cream 0.77 % (Ciclodan) ciclopirox topical solution 8 % (Ciclodan) clotrimazole mucous membrane troche 10 clotrimazole topical cream 1 % (Antifungal (clotrimazole)) clotrimazole-betamethasone topical (Lotrisone) cream % econazole topical cream 1 % fluconazole in nacl (iso-osm) intravenous PA BvD piggyback 100 /50 ml, 00 /100 ml, 00 /00 ml fluconazole oral suspension for (Diflucan) reconstitution 10 /ml, 0 /ml fluconazole oral tablet 100, 150, (Diflucan) 00, 50 flucytosine oral capsule 50, 500 (Ancobon) griseofulvin microsize oral suspension 15 /5 ml griseofulvin microsize oral tablet 500 itraconazole oral capsule 100 (Sporanox) ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical shampoo % (Nizoral) miconazole- vaginal suppository 00 8

51 NOXAFIL ORAL SUSPENSION 00 MG/5 ML (0 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram 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 (Nyamyc) unit/gram nystop topical powder 100,000 unit/gram terbinafine hcl oral tablet 50 1 GC voriconazole intravenous solution 00 (Vfend IV) 5 PA BvD; NM; NDS voriconazole oral suspension for (Vfend) reconstitution 00 /5 ml (0 /ml) voriconazole oral tablet 00, 50 (Vfend) Antigout Agents Antigout Agents, Other allopurinol oral tablet 100, 00 (Zyloprim) 1 GC colchicine oral tablet 0.6 (Colcrys) probenecid oral tablet 500 probenecid-colchicine oral tablet ULORIC ORAL TABLET 0 MG, 80 QL (0 per 0 days) MG Antihistamines Antihistamines cyproheptadine oral syrup /5 ml diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl injection syringe 50 /ml diphenhydramine hcl oral elixir 1.5 /5 (Children's Allergy 1 GC ml (diphenhyd)) hydroxyzine hcl intramuscular solution 5 /ml, 50 /ml 9

52 hydroxyzine hcl oral solution 10 /5 ml hydroxyzine hcl oral tablet 10, 5, 50 1 GC levocetirizine oral solution.5 /5 ml (Xyzal) levocetirizine oral tablet 5 (HR Allergy Relief) 1 GC promethazine oral syrup 6.5 /5 ml 1 GC promethazine-phenylephrine oral syrup (Promethazine VC) /5 ml Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) clindamycin phosphate vaginal cream % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0. %, 0.8 % terconazole vaginal suppository 80 Antimigraine Agents Antimigraine Agents AIMOVIG (70 MG/ML) 10 MG PA; QL ( per 0 days) DOSE - AUTOINJECTORS 70 MG/ML AIMOVIG 70 MG/ML PA; QL (1 per 0 days) AUTOINJECTOR 70 MG/ML AIMOVIG AUTOINJECTOR ( PA; QL (1 per 0 days) PACK) SUBCUTANEOUS AUTO- INJECTOR 70 MG/ML AJOVY SUBCUTANEOUS SYRINGE 5 MG/1.5 ML PA; QL (1.5 per 0 days) dihydroergotamine injection solution 1 /ml (D.H.E.5) ; QL ( per 8 days) dihydroergotamine nasal spray,nonaerosol 0.5 /pump act. ( /ml) (Migranal) ; QL (8 per 8 days) EMGALITY PEN SUBCUTANEOUS PA; QL ( per 0 days) PEN INJECTOR 10 MG/ML EMGALITY SYRINGE PA; QL ( per 0 days) SUBCUTANEOUS SYRINGE 10 MG/ML ERGOMAR SUBLINGUAL TABLET QL (0 per 8 days) MG rizatriptan oral tablet 10 (Maxalt) QL (18 per 8 days) 0

53 rizatriptan oral tablet 5 QL (18 per 8 days) rizatriptan oral tablet,disintegrating 10 (Maxalt-MLT) QL (18 per 8 days), 5 sumatriptan nasal spray,non-aerosol 0 (Imitrex) QL (1 per 8 days) /actuation, 5 /actuation sumatriptan succinate oral tablet 100, 5, 50 (Imitrex) 1 GC; QL (18 per 8 days) sumatriptan succinate subcutaneous (Imitrex STATdose QL ( per 8 days) cartridge /0.5 ml, 6 /0.5 ml Refill) sumatriptan succinate subcutaneous pen (Imitrex STATdose QL ( per 8 days) injector /0.5 ml, 6 /0.5 ml Pen) sumatriptan succinate subcutaneous (Imitrex) QL ( per 8 days) solution 6 /0.5 ml sumatriptan succinate subcutaneous QL ( per 8 days) syringe 6 /0.5 ml Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON SOLN 1 GRAM dapsone oral tablet 100, 5 ethambutol oral tablet 100 ethambutol oral tablet 00 (Myambutol) isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, 00 1 GC PASER ORAL GRANULES DR FOR SUSP IN PACKET GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 (Mycobutin) rifampin intravenous recon soln 600 (Rifadin) rifampin oral capsule 150, 00 (Rifadin) SIRTURO ORAL TABLET 100 MG ; QL (188 per 168 days) TRECATOR ORAL TABLET 50 MG Antinausea Agents Antinausea Agents AKYNZEO (FOSNETUPITANT) INTRAVENOUS RECON SOLN MG 1

54 AKYNZEO (NETUPITANT) ORAL PA BvD CAPSULE MG aprepitant oral capsule 15 (Emend) PA BvD; QL ( per 8 days) aprepitant oral capsule 0 (Emend) PA BvD; QL (1 per 8 days) aprepitant oral capsule 80 (Emend) PA BvD; QL ( per 8 days) aprepitant oral capsule,dose pack 15 (1)- 80 () (Emend) PA BvD; QL (6 per 8 days) CINVANTI INTRAVENOUS QL (6 per 8 days) EMULSION 7. MG/ML compro rectal suppository 5 dimenhydrinate injection solution 50 /ml dronabinol oral capsule 10,.5, 5 (Marinol) PA EMEND (FOSAPREPITANT) QL ( per 8 days) INTRAVENOUS RECON SOLN 150 MG EMEND ORAL SUSPENSION FOR RECONSTITUTION 15 MG (5 MG/ PA BvD; QL (6 per 8 days) ML FINAL CONC.) granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution 1 /ml, 1 /ml (1 ml) granisetron hcl oral tablet 1 PA BvD meclizine oral tablet 1.5 meclizine oral tablet 5 (Dramamine Less Drowsy) ondansetron hcl (pf) injection solution 1 GC / ml ondansetron hcl (pf) injection syringe 1 GC / ml ondansetron hcl intravenous solution 1 GC /ml ondansetron hcl oral tablet PA BvD ondansetron hcl oral tablet, 8 (Zofran) PA BvD ondansetron oral tablet,disintegrating, 8 PA BvD