OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY

Transcription

1 OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY 09 OPTIMAFIT INDIVIDUAL AND FAMILY PLANS (April - June 09) Revised: /7/09 NOTE: Formulary Status means Affordable Care () drugs are covered at 00%.

2 Table of Contents Analgesics - Drugs for Pain... Analgesics - Drugs for Pain and Inflammation...7 Anesthetics...9 Anti-Addiction / Substance Abuse Treatment Agents...0 Antibacterials... Anticoagulants...6 Anticonvulsants - Drugs for Seizures...7 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia... Antidepressants... Antiemetics - Drugs for Nausea and Vomiting...5 Antifungals...6 Antigout Agents...8 Antimigraine Agents...8 Antimyasthenic Agents...9 Antimycobacterials...9 Antineoplastics - Drugs for Cancer...0 Antiparasitics... Antiparkinson Agents...5 Antiplatelets...6 Antipsychotics - Drugs for Mood Disorders...6 Antivirals... 0 Anxiolytics - Drugs for Anxiety... Bipolar Agents - Drugs for Mood Disorders...5 Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders...5 Cardiovascular Agents - Drugs for Heart and Circulation Conditions...7 Central Nervous System Agents - Drugs for Attention Deficit Disorder...55 Central Nervous System Agents - Drugs for Multiple Sclerosis...59 Central Nervous System Agents - Miscellaneous...60 Dental and Oral Agents - Drugs for Mouth and Throat Conditions...6 Dermatological Agents - Drugs for Skin Conditions...6 Diabetes - Antidiabetic Agents...69 Diabetes - Glycemic Agents...7 Diabetes - Insulins...7 Electrolytes / Minerals / Metals / Vitamins...7 Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer...8 Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions...8

3 Genetic or Enzyme Disorder: Drugs for Replacement, Modifiers, Treatment...85 Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions...86 Genitourinary Agents - Drugs for Prostate Conditions...88 Hormonal Agents - Adrenal...89 Hormonal Agents - Men's Health...9 Hormonal Agents - Osteoporosis...9 Hormonal Agents - Parathyroid...9 Hormonal Agents - Pituitary...9 Hormonal Agents - Prostaglandins...95 Hormonal Agents - Sex Hormones and Birth Control...95 Hormonal Agents - Thyroid...0 Immunological Agents - Drugs for Immune System Stimulation or Suppression...0 Immunological Agents - Drugs for Vaccination...06 Inflammatory Bowel Disease Agents...07 Metabolic Bone Disease Agents - Drugs for Osteoporosis...08 Miscellaneous Therapeutic Agents...09 Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation... Ophthalmic Agents - Drugs for Glaucoma... Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions... Otic Agents - Drugs for Ear Conditions...5 Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold...6 Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions...8 Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis... Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension... Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm... Sleep Disorder Agents...

4 Analgesics - Drugs for Pain ABSTRAL SUBLINGUAL TABLET SUBLINGUAL 00 MCG, 00 MCG, 00 MCG, 00 MCG, 600 PA; QL ( EA per day) MCG, 800 MCG acetaminophen-codeine # oral tablet 00-5 QL (0 EA per day) acetaminophen-codeine # oral tablet 00-0 QL (0 EA per day) acetaminophen-codeine # oral tablet QL (0 EA per day) acetaminophen-codeine oral solution 0- /5ml QL (50 ML per day) acetaminophen-codeine oral tablet 00-5, QL (0 EA per day) ALLZITAL ORAL TABLET 5-5 MG ST; QL ( EA per day) apap-caff-dihydrocodeine oral capsule PA; QL (0 EA per day) ascomp-codeine oral capsule QL (6 EA per day) BELBUCA BUCCAL FILM 50 MCG, 00 MCG, 50 MCG, 600 MCG, 75 MCG, 750 MCG, 900 PA; QL ( EA per day) MCG butalbital-acetaminophen oral tablet 50-5 QL (6 EA per day) butalbital-apap oral tablet 50-5 QL (6 EA per day) butalbital-apap-caff-cod oral capsule , QL (6 EA per day) butalbital-apap-caffeine oral capsule , QL (6 EA per day) butalbital-apap-caffeine oral tablet QL (6 EA per day) butalbital-asa-caff-codeine oral capsule QL (6 EA per day) butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet butorphanol tartrate nasal solution 0 /ml PA; QL ( ML per day) carisoprodol-aspirin-codeine oral tablet codeine sulfate oral tablet 0 QL ( EA per day) codeine sulfate oral tablet 60 QL (6 EA per day) duraxin oral capsule EMBEDA ORAL CAPSULE EXTENDED RELEASE 00- MG, 80-. MG QL ( EA per day) EMBEDA ORAL CAPSULE EXTENDED RELEASE MG, 0-. MG, 50- MG, 60-. MG QL ( EA per day)

5 endocet oral tablet 0-5 QL (6 EA per day) endocet oral tablet.5-5, 5-5 QL ( EA per day) endocet oral tablet QL (8 EA per day) esgic oral capsule QL (6 EA per day) fentanyl citrate buccal lozenge on a handle 00 mcg, 600 mcg, 00 mcg, 00 mcg, 600 mcg, PA; QL ( EA per day) 800 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 7.5 mcg/hr, 50 mcg/hr, QL (0 EA per 0 days) 6.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr FENTORA BUCCAL TABLET 00 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG PA; QL ( EA per day) hydrocodone-acetaminophen oral solution 0-5 /5ml QL (5 ML per day) hydrocodone-acetaminophen oral solution.5-08 /5ml, 5-7 /0ml, /5ml QL (80 ML per day) hydrocodone-acetaminophen oral tablet 0-00, QL (6 EA per day) hydrocodone-acetaminophen oral tablet 0-5 QL (9 EA per day) hydrocodone-acetaminophen oral tablet.5-5 QL ( EA per day) hydrocodone-acetaminophen oral tablet 5-00 QL (8 EA per day) hydrocodone-acetaminophen oral tablet 5-5, QL ( EA per day) hydrocodone-ibuprofen oral tablet 0-00 QL (5 EA per day) hydrocodone-ibuprofen oral tablet 5-00, QL (5 EA per day) hydromorphone hcl er oral tablet er hour abuse-deterrent, 6,, 8 PA; QL ( EA per day) hydromorphone hcl oral liquid /ml QL ( ML per day) hydromorphone hcl oral tablet QL ( EA per day) hydromorphone hcl oral tablet QL (5 EA per day) hydromorphone hcl oral tablet 8 QL ( EA per day) hydromorphone hcl rectal suppository QL ( EA per day) HYSINGLA ER ORAL TABLET ER HOUR ABUSE-DETERRENT 00 MG, 0 MG, 0 MG, PA; QL ( EA per day) 0 MG, 0 MG, 60 MG, 80 MG KADIAN ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG QL ( EA per day) LAZANDA NASAL SOLUTION 00 MCG/ACT, 00 MCG/ACT, 00 MCG/ACT PA; QL ( EA per day)

6 lorcet hd oral tablet 0-5 QL (9 EA per day) lorcet oral tablet 5-5 QL ( EA per day) lorcet plus oral tablet QL ( EA per day) MEDROX-RX EXTERNAL OINTMENT % meperidine hcl oral solution 50 /5ml QL (90 ML per day) meperidine hcl oral tablet 00 QL (9 EA per day) meperidine hcl oral tablet 50 QL (8 EA per day) methadone hcl intensol oral concentrate 0 /ml QL ( ML per day) methadone hcl oral concentrate 0 /ml QL ( ML per day) methadone hcl oral solution 0 /5ml QL (5 ML per day) methadone hcl oral solution 5 /5ml QL (0 ML per day) methadone hcl oral tablet 0, 5 QL (6 EA per day) methadone hcl oral tablet soluble 0 methadose oral concentrate 0 /ml QL ( ML per day) methadose oral tablet soluble 0 methadose sugar-free oral concentrate 0 /ml QL ( ML per day) morphine sulfate (concentrate) oral solution 00 /5ml, 0 /ml QL ( ML per day) morphine sulfate er beads oral capsule extended release hour 0, 0, 5, 60, QL ( EA per day) 75, 90 morphine sulfate er oral capsule extended release hour 0, 0, 50 QL ( EA per day) morphine sulfate er oral capsule extended release hour 00, 60, 80 QL ( EA per day) morphine sulfate er oral capsule extended release hour 0 QL ( EA per day) morphine sulfate er oral capsule extended release hour 0 QL ( EA per day) morphine sulfate er oral tablet extended release 00, 00, 60 QL ( EA per day) morphine sulfate er oral tablet extended release 5, 0 QL ( EA per day) morphine sulfate oral solution 0 /5ml QL (0 ML per day) morphine sulfate oral solution 0 /5ml QL ( ML per day) morphine sulfate oral tablet 5 QL (6 EA per day) morphine sulfate oral tablet 0 QL ( EA per day) morphine sulfate rectal suppository 0, 5 QL (6 EA per day) morphine sulfate rectal suppository 0 QL ( EA per day) 5

7 morphine sulfate rectal suppository 0 QL ( EA per day) NUCYNTA ER ORAL TABLET EXTENDED RELEASE HOUR 00 MG, 50 MG, 00 MG, PA; QL ( EA per day) 50 MG, 50 MG NUCYNTA ORAL TABLET 00 MG PA; QL ( EA per day) NUCYNTA ORAL TABLET 50 MG PA; QL ( EA per day) NUCYNTA ORAL TABLET 75 MG PA; QL ( EA per day) OXAYDO ORAL TABLET ABUSE-DETERRENT 5 MG PA; QL ( EA per day) OXAYDO ORAL TABLET ABUSE-DETERRENT 7.5 MG PA; QL (8 EA per day) OXYCODONE HCL ER ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG, 5 MG PA; QL ( EA per day) OXYCODONE HCL ER ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG PA; QL ( EA per day) OXYCODONE HCL ER ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG, 60 MG, 80 PA; QL ( EA per day) MG OXYCODONE HCL ER ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG PA; QL ( EA per day) oxycodone hcl oral capsule 5 QL (6 EA per day) oxycodone hcl oral concentrate 00 /5ml QL ( ML per day) oxycodone hcl oral solution 5 /5ml QL (0 ML per day) oxycodone hcl oral tablet 0, 5 QL (6 EA per day) oxycodone hcl oral tablet 5 QL ( EA per day) oxycodone hcl oral tablet 0 QL ( EA per day) oxycodone hcl oral tablet 0 QL ( EA per day) oxycodone-acetaminophen oral tablet 0-5 QL (6 EA per day) oxycodone-acetaminophen oral tablet.5-5, 5-5 QL ( EA per day) oxycodone-acetaminophen oral tablet QL (8 EA per day) oxycodone-aspirin oral tablet QL ( EA per day) oxycodone-ibuprofen oral tablet 5-00 QL ( EA per day) OXYCONTIN ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG, 5 MG PA; QL ( EA per day) OXYCONTIN ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG PA; QL ( EA per day) OXYCONTIN ORAL TABLET ER HOUR ABUSE-DETERRENT 0 MG, 0 MG, 60 MG PA; QL ( EA per day) OXYCONTIN ORAL TABLET ER HOUR ABUSE-DETERRENT 80 MG PA; QL ( EA per day) 6

8 oxymorphone hcl er oral tablet extended release hour 0, 5, 0, 0, 0, 5 PA; QL ( EA per day), 7.5 oxymorphone hcl oral tablet 0 PA; QL ( EA per day) oxymorphone hcl oral tablet 5 PA; QL (6 EA per day) pentazocine-naloxone hcl oral tablet QL ( EA per day) phrenilin forte oral capsule QL (6 EA per day) PRIMLEV ORAL TABLET 0-00 MG QL (6 EA per day) PRIMLEV ORAL TABLET 5-00 MG QL ( EA per day) PRIMLEV ORAL TABLET MG QL (8 EA per day) SUBSYS SUBLINGUAL LIQUID 00 MCG, 00 (600 X ) MCG, 600 (800 X ) MCG, 00 MCG, PA; QL ( EA per day) 00 MCG, 600 MCG, 800 MCG tencon oral tablet 50-5 QL (6 EA per day) tramadol hcl er (biphasic) oral tablet extended release hour 00, 00, 00 QL ( EA per day) tramadol hcl er oral tablet extended release hour 00, 00, 00 QL ( EA per day) tramadol hcl oral tablet 50 QL (8 EA per day) tramadol-acetaminophen oral tablet QL (8 EA per day) VANATOL LQ ORAL SOLUTION MG/5ML QL (90 ML per day) VANATOL S ORAL SOLUTION MG/5ML QL (90 ML per day) verdrocet oral tablet.5-5 QL ( EA per day) vicodin es oral tablet QL (6 EA per day) vicodin hp oral tablet 0-00 QL (6 EA per day) vicodin oral tablet 5-00 QL (8 EA per day) zebutal oral capsule QL (6 EA per day) Analgesics - Drugs for Pain and Inflammation aspirin adult oral tablet 5 aspirin oral tablet 5 aspirin oral tablet delayed release 5 bayer aspirin oral tablet 5 CAMBIA ORAL PACKET 50 MG ST; QL (9 EA per 0 days) CELEBREX ORAL CAPSULE 00 MG QL ( EA per day) CELEBREX ORAL CAPSULE 00 MG QL ( EA per day) CELEBREX ORAL CAPSULE 00 MG QL ( EA per day) CELEBREX ORAL CAPSULE 50 MG QL (8 EA per day) celecoxib oral capsule 00 QL ( EA per day) 7

9 celecoxib oral capsule 00 QL ( EA per day) celecoxib oral capsule 00 QL ( EA per day) celecoxib oral capsule 50 QL (8 EA per day) choline-mag trisalicylate oral liquid 500 /5ml diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release hour 00 diclofenac sodium oral tablet delayed release 5, 50, 75 diclofenac sodium transdermal gel % diclofenac sodium transdermal solution.5 % diclofenac-misoprostol oral tablet delayed release 50-0., diflunisal oral tablet 500 etodolac er oral tablet extended release hour 00, 500, 600 etodolac oral capsule 00, 00 etodolac oral tablet 00, 500 fenoprofen calcium oral capsule 00 fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 00, 50 ibu oral tablet 600, 800 ibuprofen oral tablet 00, 600, 800 INDOCIN ORAL SUSPENSION 5 MG/5ML INDOCIN RECTAL SUPPOSITORY 50 MG indomethacin er oral capsule extended release 75 indomethacin oral capsule 5, 50 inflammacin combination therapy pack 75 & % ketoprofen er oral capsule extended release hour 00 ketoprofen oral capsule 5 ketorolac tromethamine oral tablet 0 QL (0 EA per day) klofensaid ii transdermal solution.5 % LEXIXRYL TRANSDERMAL THERAPY PACK.5 % meclofenamate sodium oral capsule 00, 50 medique aspirin oral tablet 5 8

10 mefenamic acid oral capsule 50 meloxicam oral tablet 5, 7.5 nabumetone oral tablet 500, 750 NAPROSYN ORAL SUSPENSION 5 MG/5ML QL (60 ML per day) NAPROXEN COMFORT PAC COMBINATION KIT 500 MG naproxen dr oral tablet delayed release 75 QL (.67 EA per day) naproxen dr oral tablet delayed release 500 QL ( EA per day) naproxen oral suspension 5 /5ml QL (60 ML per day) naproxen oral tablet 50 QL (6 EA per day) naproxen oral tablet 75 QL ( EA per day) naproxen oral tablet 500 QL ( EA per day) naproxen sodium er oral tablet extended release hour 75, 500 naproxen sodium oral tablet 75, 550 nudiclo tabpak combination therapy pack 75 & % oxaprozin oral tablet 600 QL ( EA per day) piroxicam oral capsule 0, 0 previdolrx plus analgesic combination therapy pack 75 & % salsalate oral tablet 500, 750 sulindac oral tablet 50, 00 tolmetin sodium oral capsule 00 tolmetin sodium oral tablet 00, 600 xenaflamm combination therapy pack 75 & % XRYLIX TRANSDERMAL THERAPY PACK.5 % Anesthetics ACCUCAINE COMBINATION KIT % ethyl chloride external aerosol lidocaine external ointment 5 % lidocaine external patch 5 % QL ( EA per day) lidocaine hcl external cream %,.88 % lidocaine hcl external lotion % lidocaine hcl external solution % lidocaine-prilocaine external cream.5-.5 % 9

11 LIDOCAINE-TETRINE EXTERNAL CREAM 7-7 % lido-k external lotion % lidopin external cream % LIDOPIN EXTERNAL CREAM.5 % LIDORX EXTERNAL GEL % LIDOZION EXTERNAL LOTION % premium lidocaine external ointment 5 % relador pak external kit.5-.5 % relador pak plus external kit.5-.5 % SYNERA EXTERNAL PATCH MG SYNVEXIA TC EXTERNAL CREAM - % Anti-Addiction / Substance Abuse Treatment Agents acamprosate calcium oral tablet delayed release buprenorphine hcl sublingual tablet sublingual QL ( EA per day) buprenorphine hcl sublingual tablet sublingual 8 QL ( EA per day) buprenorphine hcl-naloxone hcl sublingual tablet sublingual -0.5 QL ( EA per day) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8- QL ( EA per day) bupropion hcl er (smoking det) oral tablet extended release hour 50 QL (8 EA per 65 days) CHANTIX CONTINUING MONTH PAK ORAL TABLET MG QL (8 EA per 65 days) CHANTIX ORAL TABLET 0.5 MG, MG QL (8 EA per 65 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X & MG X QL (8 EA per 65 days) disulfiram oral tablet 50, 500 EVZIO INJECTION SOLUTION AUTO- INJECTOR MG/0.ML PA; QL (.6 ML per 0 days) naloxone hcl injection solution 0. /ml, /0ml naloxone hcl injection solution cartridge 0. /ml naloxone hcl injection solution prefilled syringe /ml naltrexone hcl oral tablet 50 0

12 NARCAN NASAL LIQUID MG/0.ML nicotine polacrilex mouth/throat gum, QL (8 EA per 65 days) nicotine polacrilex mouth/throat lozenge QL (8 EA per 65 days) nicotine step transdermal patch hour /hr QL (8 EA per 65 days) nicotine step transdermal patch hour /hr QL (8 EA per 65 days) nicotine step transdermal patch hour 7 /hr QL (8 EA per 65 days) NICOTROL INHALATION INHALER 0 MG QL (8 EA per 65 days) NICOTROL NS NASAL SOLUTION 0 MG/ML QL (8 ML per 65 days) SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 00 MG/0.5ML, 00 QL ( ML per 0 days) MG/.5ML SUBOXONE SUBLINGUAL FILM - MG QL ( EA per day) SUBOXONE SUBLINGUAL FILM -0.5 MG QL ( EA per day) SUBOXONE SUBLINGUAL FILM - MG QL ( EA per day) SUBOXONE SUBLINGUAL FILM 8- MG QL ( EA per day) VIVITROL INTRAMUSCULAR SUSPENSION RECONSTITUTED 80 MG Antibacterials ALTABAX EXTERNAL OINTMENT % amikacin sulfate injection solution gm/ml, 500 /ml amoxicillin oral capsule 50, 500 amoxicillin oral suspension reconstituted 5 /5ml, 00 /5ml, 50 /5ml, 00 /5ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 5, 50 amoxicillin-potassium clavulanate er oral tablet extended release hour amoxicillin-potassium clavulanate oral suspension reconstituted /5ml, /5ml, /5ml, /5ml amoxicillin-potassium clavulanate oral tablet 50-5, 500-5, amoxicillin-potassium clavulanate oral tablet chewable , ampicillin oral capsule 500 AVIDOXY DK COMBINATION KIT 00 MG avidoxy oral tablet 00

13 azithromycin oral packet gm azithromycin oral suspension reconstituted 00 /5ml, 00 /5ml azithromycin oral tablet 50, 500, 600 benzalkonium chloride external solution 50 % cefaclor er oral tablet extended release hour 500 cefaclor oral capsule 50, 500 cefaclor oral suspension reconstituted 5 /5ml, 50 /5ml, 75 /5ml cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 50 /5ml, 500 /5ml cefadroxil oral tablet gm cefdinir oral capsule 00 cefdinir oral suspension reconstituted 5 /5ml, 50 /5ml cefditoren pivoxil oral tablet 00, 00 cefixime oral suspension reconstituted 00 /5ml, 00 /5ml cefpodoxime proxetil oral suspension reconstituted 00 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 00, 00 cefprozil oral suspension reconstituted 5 /5ml, 50 /5ml cefprozil oral tablet 50, 500 ceftriaxone sodium injection solution reconstituted 00 gm cefuroxime axetil oral tablet 50, 500 CENTANY AT EXTERNAL KIT % cephalexin oral capsule 50, 500 cephalexin oral capsule 750 cephalexin oral suspension reconstituted 5 /5ml, 50 /5ml cephalexin oral tablet 50, 500 ciprofloxacin hcl oral tablet 00, 50, 500, 750 ciprofloxacin oral suspension reconstituted 500 /5ml (0%) ciprofloxacin-ciproflox hcl er oral tablet extended release hour 000, 500

14 clarithromycin er oral tablet extended release hour 500 clarithromycin oral suspension reconstituted 5 /5ml, 50 /5ml clarithromycin oral tablet 50, 500 CLEOCIN VAGINAL SUPPOSITORY 00 MG clindamycin hcl oral capsule 50, 00, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate vaginal cream % demeclocycline hcl oral tablet 50, 00 dicloxacillin sodium oral capsule 50, 500 DIFICID ORAL TABLET 00 MG PA doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00, 0 doxycycline hyclate oral tablet delayed release 00, 50, 75 ST doxycycline monohydrate oral capsule 00, 50 doxycycline monohydrate oral capsule 50, 75 doxycycline monohydrate oral suspension reconstituted 5 /5ml doxycycline monohydrate oral tablet 00, 50, 50, 75 e.e.s. 00 oral tablet 00 ERYPED 00 ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ERY-TAB ORAL TABLET DELAYED RELEASE 50 MG, MG, 500 MG ERYTHROCIN STEARATE ORAL TABLET 50 MG erythromycin base oral capsule delayed release particles 50 erythromycin base oral tablet 50, 500 erythromycin ethylsuccinate oral suspension reconstituted 00 /5ml AL (Max 7 Years) erythromycin ethylsuccinate oral tablet 00 FIRST-VANCOMYCIN 5 ORAL SOLUTION 5 MG/ML

15 FIRST-VANCOMYCIN 50 ORAL SOLUTION 50 MG/ML FIRVANQ ORAL SOLUTION RECONSTITUTED 50 MG/ML gentamicin sulfate external cream 0. % gentamicin sulfate external ointment 0. % hydrogen peroxide solution 0 % IODOFLEX EXTERNAL PAD 0.9 % IODOSORB EXTERNAL GEL 0.9 % levofloxacin oral solution 5 /ml levofloxacin oral tablet 50, 500, 750 linezolid oral suspension reconstituted 00 /5ml linezolid oral tablet 600 lugols external solution methenamine hippurate oral tablet gm methenamine mandelate oral tablet 0.5 gm, gm metronidazole oral capsule 75 metronidazole oral tablet 50, 500 metronidazole vaginal gel 0.75 % MINOCIN ORAL CAPSULE 50 MG minocycline hcl er oral tablet extended release hour 5, 65 ST minocycline hcl er oral tablet extended release hour 5, 5, 90 minocycline hcl oral capsule 00, 50 minocycline hcl oral capsule 75 minocycline hcl oral tablet 00, 50, 75 mondoxyne nl oral capsule 00, 50 mondoxyne nl oral capsule 75 MONUROL ORAL PACKET GM MORGIDOX COMBINATION KIT X 00 MG, X 00 MG morgidox oral capsule 00, 50 moxifloxacin hcl oral tablet 00 mupirocin calcium external cream % mupirocin external ointment % neomycin sulfate oral tablet 500

16 nitrofurantoin macrocrystal oral capsule 00, 50 nitrofurantoin macrocrystal oral capsule 5 nitrofurantoin monohydrate macrocrystals oral capsule 00 nitrofurantoin oral suspension 5 /5ml NUTRIDOX ORAL KIT 75 MG ofloxacin oral tablet 00, 00 okebo oral capsule 75 paromomycin sulfate oral capsule 50 penicillin v potassium oral solution reconstituted 5 /5ml, 50 /5ml penicillin v potassium oral tablet 50, 500 PRIMSOL ORAL SOLUTION 50 MG/5ML silver nitrate external ointment 0 % silver nitrate external solution 0.5 %, 0 %, 5 %, 50 % silver sulfadiazine external cream % SIVEXTRO ORAL TABLET 00 MG soloxide oral tablet delayed release 50 ST ssd external cream % sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim oral suspension 00-0 /5ml sulfamethoxazole-trimethoprim oral tablet 00-80, SULFAMYLON EXTERNAL CREAM 85 MG/GM sulfatrim pediatric oral suspension 00-0 /5ml SUPRAX ORAL CAPSULE 00 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 00 MG/5ML, 00 MG/5ML, 500 MG/5ML SUPRAX ORAL TABLET CHEWABLE 00 MG, 00 MG tetracycline hcl oral capsule 50, 500 tinidazole oral tablet 50, 500 trimethoprim oral tablet 00 vancomycin hcl oral capsule 5, 50 5

17 VANCOMYCIN+SYRSPEND SF PH ORAL SUSPENSION 50 MG/ML vandazole vaginal gel 0.75 % XIFAXAN ORAL TABLET 00 MG, 550 MG PA; QL ( EA per 0 days) ZYVOX ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ST ZYVOX ORAL TABLET 600 MG ST Anticoagulants ELIQUIS ORAL TABLET.5 MG, 5 MG ELIQUIS STARTER PACK ORAL TABLET 5 MG enoxaparin sodium injection solution 00 /ml enoxaparin sodium subcutaneous solution 00 /ml, 0 /0.8ml, 50 /ml, 0 /0.ml, 0 /0.ml, 60 /0.6ml, 80 /0.8ml fondaparinux sodium subcutaneous solution 0 /0.8ml,.5 /0.5ml, 5 /0.ml, 7.5 /0.6ml FRAGMIN SUBCUTANEOUS SOLUTION 0000 UNIT/ML, 500 UNIT/0.5ML, 5000 UNIT/0.6ML, 8000 UNT/0.7ML, 500 UNIT/0.ML, 5000 UNIT/0.ML, 7500 UNIT/0.ML, UNIT/.8ML heparin (porcine) in d5w intravenous solution 0-5 unit/ml-%, 50-5 unit/ml-% heparin (porcine) in nacl injection solution unit/ml-%, -0.9 unit/ml-%, unit/ml- % heparin sod (porcine) in d5w intravenous solution 00 unit/ml heparin sodium (porcine) injection solution 000 unit/ml, 0000 unit/ml, 0000 unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml jantoven oral tablet, 0,,.5,,, 5, 6, 7.5 SAVAYSA ORAL TABLET 5 MG, 0 MG, 60 MG PA warfarin sodium oral tablet, 0,,.5,,, 5, 6, 7.5 XARELTO ORAL TABLET 0 MG, 5 MG,.5 MG, 0 MG XARELTO STARTER PACK ORAL TABLET THERAPY PACK 5 & 0 MG 6

18 Anticonvulsants - Drugs for Seizures APTIOM ORAL TABLET 00 MG, 00 MG, 600 MG, 800 MG ST BANZEL ORAL SUSPENSION 0 MG/ML BANZEL ORAL TABLET 00 MG, 00 MG BRIVIACT ORAL SOLUTION 0 MG/ML ST BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG ST carbamazepine er oral capsule extended release hour 00, 00, 00 carbamazepine er oral tablet extended release hour 00, 00, 00 carbamazepine oral suspension 00 /5ml carbamazepine oral tablet 00 carbamazepine oral tablet chewable 00 CARBATROL ORAL CAPSULE EXTENDED RELEASE HOUR 00 MG, 00 MG, 00 MG ST CELONTIN ORAL CAPSULE 00 MG clobazam oral suspension.5 /ml ST clobazam oral tablet 0, 0 ST DEPAKENE ORAL CAPSULE 50 MG ST DEPAKOTE ER ORAL TABLET EXTENDED RELEASE HOUR 50 MG, 500 MG ST DEPAKOTE ORAL TABLET DELAYED RELEASE 5 MG, 50 MG, 500 MG ST DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE 5 MG ST DIASTAT ACUDIAL RECTAL GEL 0 MG, 0 MG DIASTAT PEDIATRIC RECTAL GEL.5 MG diazepam rectal gel 0,.5, 0 DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG ST DILANTIN ORAL CAPSULE 00 MG ST DILANTIN ORAL CAPSULE 0 MG DILANTIN ORAL SUSPENSION 5 MG/5ML ST divalproex sodium er oral tablet extended release hour 50, 500 divalproex sodium oral capsule delayed release sprinkle 5 7

19 divalproex sodium oral tablet delayed release 5, 50, 500 EPIDIOLEX ORAL SOLUTION 00 MG/ML PA epitol oral tablet 00 ethosuximide oral capsule 50 ethosuximide oral solution 50 /5ml felbamate oral suspension 600 /5ml felbamate oral tablet 00, 600 FELBATOL ORAL SUSPENSION 600 MG/5ML ST FELBATOL ORAL TABLET 00 MG, 600 MG ST FYCOMPA ORAL SUSPENSION 0.5 MG/ML ST FYCOMPA ORAL TABLET 0 MG, MG, MG, MG, 6 MG, 8 MG ST gabapentin oral capsule 00, 00, 00 gabapentin oral solution 50 /5ml, 00 /6ml gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET MG, MG ST KEPPRA ORAL SOLUTION 00 MG/ML ST KEPPRA ORAL TABLET 000 MG, 50 MG, 500 MG, 750 MG ST KEPPRA XR ORAL TABLET EXTENDED RELEASE HOUR 500 MG, 750 MG ST LAMICTAL ODT ORAL KIT 5 & 50 & 00 MG, 5 ()-50 (7) MG, 50 ()-00() MG ST LAMICTAL ODT ORAL TABLET DISPERSIBLE 00 MG, 00 MG, 5 MG, 50 MG ST LAMICTAL ORAL TABLET 00 MG, 50 MG, 00 MG, 5 MG ST LAMICTAL ORAL TABLET CHEWABLE 5 MG, 5 MG ST LAMICTAL XR ORAL KIT 5 & 50 & 00 MG, 5 ()-50 (7) MG, 50 & 00 & 00 MG LAMICTAL XR ORAL TABLET EXTENDED RELEASE HOUR 00 MG, 00 MG, 5 MG, ST 50 MG, 00 MG, 50 MG lamotrigine er oral tablet extended release hour 00, 00, 5, 50, 00, 50 lamotrigine oral tablet 00, 50, 00, 5 lamotrigine oral tablet chewable 5, 5 8

20 lamotrigine oral tablet dispersible 00, 00, 5, 50 lamotrigine starter kit-blue oral kit 5 (5) lamotrigine starter kit-green oral kit 5 (8)- 00() lamotrigine starter kit-orange oral kit 5 ()-00 (7) levetiracetam er oral tablet extended release hour 500, 750 levetiracetam oral solution 00 /ml levetiracetam oral tablet 000, 50, 500, 750 MYSOLINE ORAL TABLET 50 MG, 50 MG ST NEURONTIN ORAL CAPSULE 00 MG, 00 MG, 00 MG ST NEURONTIN ORAL SOLUTION 50 MG/5ML ST NEURONTIN ORAL TABLET 600 MG, 800 MG ST oxcarbazepine oral suspension 00 /5ml oxcarbazepine oral tablet 50, 00, 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE HOUR 50 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5ml phenobarbital oral solution 0 /5ml phenobarbital oral tablet 00, 5, 6., 0,., 60, 6.8, 97. PHENYTEK ORAL CAPSULE 00 MG, 00 MG ST phenytoin infatabs oral tablet chewable 50 phenytoin oral suspension 5 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 00, 00, 00 primidone oral tablet 50, 50 roweepra oral tablet 000, 500, 750 roweepra xr oral tablet extended release hour 500, 750 SABRIL ORAL PACKET 500 MG SABRIL ORAL TABLET 500 MG subvenite oral tablet 00, 50, 00, 5 9

21 subvenite starter kit-blue oral kit 5 (5) subvenite starter kit-green oral kit 5 (8)- 00() subvenite starter kit-orange oral kit 5 ()-00 (7) TEGRETOL ORAL SUSPENSION 00 MG/5ML ST TEGRETOL ORAL TABLET 00 MG ST TEGRETOL-XR ORAL TABLET EXTENDED RELEASE HOUR 00 MG, 00 MG, 00 MG ST tiagabine hcl oral tablet, TOPAMAX ORAL TABLET 00 MG, 00 MG, 5 MG, 50 MG ST TOPAMAX SPRINKLE ORAL CAPSULE SPRINKLE 5 MG, 5 MG topiramate er oral capsule er hour sprinkle 00 PA; QL ( EA per day) topiramate er oral capsule er hour sprinkle 50 PA; QL (.66 EA per day) topiramate er oral capsule er hour sprinkle 00 PA; QL ( EA per day) topiramate er oral capsule er hour sprinkle 5 PA; QL (6 EA per day) topiramate er oral capsule er hour sprinkle 50 PA; QL (8 EA per day) topiramate oral capsule sprinkle 5, 5 topiramate oral tablet 00, 00, 5, 50 TRILEPTAL ORAL SUSPENSION 00 MG/5ML ST TRILEPTAL ORAL TABLET 50 MG, 00 MG, 600 MG ST valproate sodium oral solution 50 /5ml valproic acid oral capsule 50 valproic acid oral solution 50 /5ml vigabatrin oral packet 500 vigabatrin oral tablet 500 vigadrone oral packet 500 VIMPAT ORAL SOLUTION 0 MG/ML ST VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG ST ZARONTIN ORAL CAPSULE 50 MG ST ZARONTIN ORAL SOLUTION 50 MG/5ML ST 0

22 ZONEGRAN ORAL CAPSULE 00 MG, 5 MG ST zonisamide oral capsule 00, 5, 50 Antidementia Agents - Drugs for Alzheimer's Disease and Dementia donepezil hcl oral tablet 0, 5 donepezil hcl oral tablet donepezil hcl oral tablet dispersible 0, 5 galantamine hydrobromide er oral capsule extended release hour 6,, 8 galantamine hydrobromide oral solution /ml galantamine hydrobromide oral tablet,, 8 memantine hcl er oral capsule extended release hour,, 8, 7 memantine hcl oral solution /ml memantine hcl oral tablet 0, 5 (8)-0 (), 5 NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE HOUR 7 & ST & &8 MG NAMZARIC ORAL CAPSULE ER HOUR THERAPY PACK 7 & & &8-0 MG NAMZARIC ORAL CAPSULE EXTENDED RELEASE HOUR -0 MG, -0 MG, 8-0 MG, 7-0 MG rivastigmine tartrate oral capsule.5,,.5, 6 rivastigmine transdermal patch hour. /hr,.6 /hr, 9.5 /hr Antidepressants amitriptyline hcl oral tablet 0, 00, 50, 5, 50, 75 amoxapine oral tablet 00, 50, 5, 50 APLENZIN ORAL TABLET EXTENDED RELEASE HOUR 7 MG, 8 MG, 5 MG bupropion hcl er (sr) oral tablet extended release hour 00 bupropion hcl er (sr) oral tablet extended release hour 50 bupropion hcl er (sr) oral tablet extended release hour 00 QL (.5 EA per day) QL ( EA per day) QL (.5 EA per day)

23 bupropion hcl er (xl) oral tablet extended release hour 50 QL ( EA per day) bupropion hcl er (xl) oral tablet extended release hour 00 QL (.5 EA per day) bupropion hcl oral tablet 00 QL (.5 EA per day) bupropion hcl oral tablet 75 QL (6 EA per day) chlordiazepoxide-amitriptyline oral tablet 0-5, 5-.5 citalopram hydrobromide oral solution 0 /5ml QL (0 ML per day) citalopram hydrobromide oral tablet 0 QL ( EA per day) citalopram hydrobromide oral tablet 0 QL ( EA per day) citalopram hydrobromide oral tablet 0 QL ( EA per day) clomipramine hcl oral capsule 5, 50, 75 desipramine hcl oral tablet 0, 00, 50, 5, 50, 75 DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE HOUR 00 MG QL ( EA per day) DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE HOUR 50 MG QL ( EA per day) desvenlafaxine succinate er oral tablet extended release hour 00 ST; QL ( EA per day) desvenlafaxine succinate er oral tablet extended release hour 5 ST; QL ( EA per day) desvenlafaxine succinate er oral tablet extended release hour 50 ST; QL ( EA per day) doxepin hcl oral capsule 0, 00, 50, 5, 50, 75 doxepin hcl oral concentrate 0 /ml duloxetine hcl oral capsule delayed release particles 0 QL (6 EA per day) duloxetine hcl oral capsule delayed release particles 0 QL ( EA per day) duloxetine hcl oral capsule delayed release particles 0 duloxetine hcl oral capsule delayed release particles 60 QL ( EA per day) EMSAM TRANSDERMAL PATCH HOUR MG/HR, 6 MG/HR, 9 MG/HR escitalopram oxalate oral solution 5 /5ml QL (0 ML per day) escitalopram oxalate oral tablet 0 QL ( EA per day) escitalopram oxalate oral tablet 0 QL ( EA per day) escitalopram oxalate oral tablet 5 QL ( EA per day)

24 FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG ST; QL ( EA per day) FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG ST; QL (6 EA per day) FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG ST; QL ( EA per day) FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 80 MG ST; QL (.5 EA per day) FETZIMA TITRATION ORAL CAPSULE ER HOUR THERAPY PACK 0 & 0 MG ST; QL ( EA per 0 days) fluoxetine hcl (pmdd) oral capsule 0 QL (8 EA per day) fluoxetine hcl (pmdd) oral capsule 0 QL ( EA per day) fluoxetine hcl (pmdd) oral tablet 0 QL (8 EA per day) fluoxetine hcl (pmdd) oral tablet 0 QL ( EA per day) fluoxetine hcl oral capsule 0 QL (8 EA per day) fluoxetine hcl oral capsule 0 QL ( EA per day) fluoxetine hcl oral capsule 0 QL ( EA per day) fluoxetine hcl oral capsule delayed release 90 QL ( EA per day) fluoxetine hcl oral solution 0 /5ml QL (0 ML per day) fluoxetine hcl oral tablet 0 QL (8 EA per day) fluoxetine hcl oral tablet 0 QL ( EA per day) fluoxetine hcl oral tablet 60 QL (. EA per day) fluvoxamine maleate er oral capsule extended release hour 00 QL ( EA per day) fluvoxamine maleate er oral capsule extended release hour 50 QL ( EA per day) fluvoxamine maleate oral tablet 00 QL ( EA per day) fluvoxamine maleate oral tablet 5 QL ( EA per day) fluvoxamine maleate oral tablet 50 QL (6 EA per day) imipramine hcl oral tablet 0, 5, 50 imipramine pamoate oral capsule 00, 5, 50 imipramine pamoate oral capsule 75 KHEDEZLA ORAL TABLET EXTENDED RELEASE HOUR 00 MG QL ( EA per day) KHEDEZLA ORAL TABLET EXTENDED RELEASE HOUR 50 MG QL ( EA per day) maprotiline hcl oral tablet 5, 50, 75 MARPLAN ORAL TABLET 0 MG mirtazapine oral tablet 5 QL ( EA per day) mirtazapine oral tablet 0 QL ( EA per day)

25 mirtazapine oral tablet 5 QL (. EA per day) mirtazapine oral tablet 7.5 QL (8 EA per day) mirtazapine oral tablet dispersible 5 QL ( EA per day) mirtazapine oral tablet dispersible 0 QL ( EA per day) mirtazapine oral tablet dispersible 5 QL (. EA per day) NARDIL ORAL TABLET 5 MG ST nefazodone hcl oral tablet 00, 50, 00, 50, 50 nortriptyline hcl oral capsule 0, 5, 50, 75 nortriptyline hcl oral solution 0 /5ml olanzapine-fluoxetine hcl oral capsule -5, -50, -5, 6-5, 6-50 paroxetine hcl er oral tablet extended release hour.5 QL (5 EA per day) paroxetine hcl er oral tablet extended release hour 5 QL (.5 EA per day) paroxetine hcl er oral tablet extended release hour 7.5 QL (.67 EA per day) paroxetine hcl oral tablet 0 QL (6 EA per day) paroxetine hcl oral tablet 0 QL ( EA per day) paroxetine hcl oral tablet 0 QL ( EA per day) paroxetine hcl oral tablet 0 QL (.5 EA per day) perphenazine-amitriptyline oral tablet -0, - 5, -0, -5, -50 PEXEVA ORAL TABLET 0 MG, 0 MG, 0 MG, 0 MG phenelzine sulfate oral tablet 5 PRISTIQ ORAL TABLET EXTENDED RELEASE HOUR 00 MG ST; QL ( EA per day) PRISTIQ ORAL TABLET EXTENDED RELEASE HOUR 5 MG ST; QL ( EA per day) PRISTIQ ORAL TABLET EXTENDED RELEASE HOUR 50 MG ST; QL ( EA per day) protriptyline hcl oral tablet 0, 5 sertraline hcl oral concentrate 0 /ml QL (0 ML per day) sertraline hcl oral tablet 00 QL ( EA per day) sertraline hcl oral tablet 5 QL (8 EA per day) sertraline hcl oral tablet 50 QL ( EA per day) tranylcypromine sulfate oral tablet 0 trazodone hcl oral tablet 00 QL (6 EA per day)

26 trazodone hcl oral tablet 50 QL ( EA per day) trazodone hcl oral tablet 00 QL ( EA per day) trazodone hcl oral tablet 50 QL ( EA per day) trimipramine maleate oral capsule 00, 5, 50 TRINTELLIX ORAL TABLET 0 MG ST; QL ( EA per day) TRINTELLIX ORAL TABLET 0 MG ST; QL ( EA per day) TRINTELLIX ORAL TABLET 5 MG ST; QL ( EA per day) venlafaxine hcl er oral capsule extended release hour 50 QL ( EA per day) venlafaxine hcl er oral capsule extended release hour 7.5 QL ( EA per day) venlafaxine hcl er oral capsule extended release hour 75 QL (6 EA per day) venlafaxine hcl er oral tablet extended release hour 50 QL ( EA per day) venlafaxine hcl er oral tablet extended release hour 5 QL ( EA per day) venlafaxine hcl er oral tablet extended release hour 7.5 QL ( EA per day) venlafaxine hcl er oral tablet extended release hour 75 QL (6 EA per day) venlafaxine hcl oral tablet 00 QL (.5 EA per day) venlafaxine hcl oral tablet 5 QL (8 EA per day) venlafaxine hcl oral tablet 7.5 QL ( EA per day) venlafaxine hcl oral tablet 50 QL (9 EA per day) venlafaxine hcl oral tablet 75 QL (6 EA per day) VIIBRYD ORAL TABLET 0 MG ST; QL ( EA per day) VIIBRYD ORAL TABLET 0 MG ST; QL ( EA per day) VIIBRYD ORAL TABLET 0 MG ST; QL ( EA per day) VIIBRYD STARTER PACK ORAL KIT 0 & 0 MG ST; QL ( EA per 0 days) Antiemetics - Drugs for Nausea and Vomiting AKYNZEO ORAL CAPSULE MG QL ( EA per 8 days) ANZEMET ORAL TABLET 00 MG, 50 MG QL (0 EA per day) aprepitant oral capsule 5, 0, 80 QL ( EA per day) aprepitant oral capsule 80 & 5 QL ( EA per day) CESAMET ORAL CAPSULE MG compro rectal suppository 5 dronabinol oral capsule 0,.5, 5 granisetron hcl oral tablet QL (5 EA per day) 5

27 meclizine hcl oral tablet 5 metoclopramide hcl oral solution 0 /0ml, 5 /5ml metoclopramide hcl oral tablet 0, 5 metoclopramide hcl oral tablet dispersible 0, 5 ST ondansetron hcl oral solution /5ml ondansetron hcl oral tablet,, 8 ondansetron odt oral tablet dispersible, 8 perphenazine oral tablet 6 QL ( EA per day) perphenazine oral tablet QL ( EA per day) perphenazine oral tablet QL (6 EA per day) perphenazine oral tablet 8 QL (8 EA per day) prochlorperazine maleate oral tablet 0, 5 prochlorperazine rectal suppository 5 SYNDROS ORAL SOLUTION 5 MG/ML PA trimethobenzamide hcl oral capsule 00 VARUBI ORAL TABLET 90 MG QL ( EA per 8 days) Antifungals AVC VAGINAL VAGINAL CREAM 5 % BIO-STATIN ORAL CAPSULE UNIT, UNIT bio-statin oral powder ciclodan external solution 8 % ciclopirox external gel 0.77 % ciclopirox external shampoo % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % clotrimazole mouth/throat lozenge 0 clotrimazole mouth/throat troche 0 CRESEMBA ORAL CAPSULE 86 MG econazole nitrate external cream % ERTACZO EXTERNAL CREAM % ST EXELDERM EXTERNAL CREAM % ST EXELDERM EXTERNAL SOLUTION % ST exoderm external lotion 5- % 6

28 fluconazole oral suspension reconstituted 0 /ml, 0 /ml fluconazole oral tablet 00, 50, 00, 50 flucytosine oral capsule 50, 500 griseofulvin microsize oral suspension 5 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 5, 50 GYNAZOLE- VAGINAL CREAM % itraconazole oral capsule 00 itraconazole oral solution 0 /ml JUBLIA EXTERNAL SOLUTION 0 % PA KERYDIN EXTERNAL SOLUTION 5 % PA ketoconazole external cream % ketoconazole external foam % ketoconazole external shampoo % ketoconazole oral tablet 00 LOPROX EXTERNAL KIT 0.77 % LULICONAZOLE EXTERNAL CREAM % ST LUZU EXTERNAL CREAM % ST MENTAX EXTERNAL CREAM % miconazole vaginal suppository 00 naftifine hcl external cream %, % NAFTIN EXTERNAL GEL %, % ST NOXAFIL ORAL SUSPENSION 0 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 00 MG nyamyc external powder unit/gm nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystatin mouth/throat suspension unit/ml nystatin oral tablet unit nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% 7

29 nystop external powder unit/gm oxiconazole nitrate external cream % OXISTAT EXTERNAL LOTION % ST PENLAC EXTERNAL SOLUTION 8 % terbinafine hcl oral tablet 50 terconazole vaginal cream 0. %, 0.8 % terconazole vaginal suppository 80 voriconazole oral suspension reconstituted 0 /ml voriconazole oral tablet 00, 50 XOLEGEL COREPAK EXTERNAL KIT & % Antigout Agents allopurinol oral tablet 00, 00 COLCHICINE ORAL CAPSULE 0.6 MG COLCHICINE ORAL TABLET 0.6 MG colchicine-probenecid oral tablet probenecid oral tablet 500 ULORIC ORAL TABLET 0 MG, 80 MG ST Antimigraine Agents AIMOVIG 0 DOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR 70 MG/ML PA; QL ( ML per 0 days) AIMOVIG SUBCUTANEOUS SOLUTION AUTO- INJECTOR 70 MG/ML PA; QL ( ML per 0 days) AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 5 MG/.5ML PA; QL (.5 ML per 0 days) almotriptan malate oral tablet.5, 6.5 QL ( EA per 0 days) dihydroergotamine mesylate injection solution /ml dihydroergotamine mesylate nasal solution /ml QL (8 ML per 0 days) eletriptan hydrobromide oral tablet 0, 0 QL ( EA per 0 days) EMGALITY SUBCUTANEOUS SOLUTION AUTO-INJECTOR 0 MG/ML PA ERGOMAR SUBLINGUAL TABLET SUBLINGUAL MG QL (0 EA per 8 days) ergotamine-caffeine oral tablet -00 FROVA ORAL TABLET.5 MG QL ( EA per 0 days) frovatriptan succinate oral tablet.5 QL ( EA per 0 days) 8

30 IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO- QL (8 ML per 0 days) INJECTOR 6 MG/0.5ML MIGERGOT RECTAL SUPPOSITORY -00 MG naratriptan hcl oral tablet,.5 QL (9 EA per 0 days) RELPAX ORAL TABLET 0 MG, 0 MG QL ( EA per 0 days) rizatriptan benzoate oral tablet 0, 5 QL ( EA per 0 days) rizatriptan benzoate oral tablet dispersible 0, 5 QL ( EA per 0 days) sumatriptan nasal solution 0 /act QL (6 EA per 0 days) sumatriptan nasal solution 5 /act QL ( EA per 0 days) sumatriptan succinate oral tablet 00 QL (9 EA per 0 days) sumatriptan succinate oral tablet 5, 50 QL (8 EA per 0 days) sumatriptan succinate refill subcutaneous solution cartridge /0.5ml, 6 /0.5ml QL (8 ML per 0 days) sumatriptan succinate subcutaneous solution 6 /0.5ml QL (8 ML per 0 days) sumatriptan succinate subcutaneous solution auto-injector /0.5ml, 6 /0.5ml QL (8 ML per 0 days) sumatriptan succinate subcutaneous solution prefilled syringe 6 /0.5ml QL (8 ML per 0 days) sumatriptan-naproxen sodium oral tablet TREXIMET ORAL TABLET MG ST zolmitriptan oral tablet.5, 5 QL ( EA per 0 days) zolmitriptan oral tablet dispersible.5, 5 QL ( EA per 0 days) ZOMIG NASAL SOLUTION 5 MG ST; QL ( EA per 0 days) Antimyasthenic Agents GUANIDINE HCL ORAL TABLET 5 MG pyridostigmine bromide er oral tablet extended release 80 pyridostigmine bromide oral tablet 60 Antimycobacterials cycloserine oral capsule 50 dapsone oral tablet 00, 5 ethambutol hcl oral tablet 00, 00 isoniazid oral syrup 50 /5ml isoniazid oral tablet 00, 00 PASER ORAL PACKET GM PRIFTIN ORAL TABLET 50 MG 9

31 pyrazinamide oral tablet 500 rifabutin oral capsule 50 RIFAMATE ORAL CAPSULE MG rifampin oral capsule 50, 00 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG ST TRECATOR ORAL TABLET 50 MG Antineoplastics - Drugs for Cancer abiraterone acetate oral tablet 50 AFINITOR DISPERZ ORAL TABLET SOLUBLE MG, MG, 5 MG AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG anastrozole oral tablet bexarotene oral capsule 75 bicalutamide oral tablet 50 BOSULIF ORAL TABLET 00 MG, 00 MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG, 75 MG CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG QL ( EA per day) CALQUENCE ORAL CAPSULE 00 MG capecitabine oral tablet 50, 500 CAPRELSA ORAL TABLET 00 MG, 00 MG COMETRIQ (00 MG DAILY DOSE) ORAL KIT X 80 & X 0 MG QL (56 EA per 0 days) COMETRIQ (0 MG DAILY DOSE) ORAL KIT X 80 & X 0 MG QL ( EA per 0 days) COMETRIQ (60 MG DAILY DOSE) ORAL KIT 0 MG QL (8 EA per 0 days) COPIKTRA ORAL CAPSULE 5 MG, 5 MG COTELLIC ORAL TABLET 0 MG cyclophosphamide oral capsule 5 cyclophosphamide oral capsule 50 DAURISMO ORAL TABLET 00 MG, 5 MG DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG EMCYT ORAL CAPSULE 0 MG 0

32 ERIVEDGE ORAL CAPSULE 50 MG ERLEADA ORAL TABLET 60 MG PA etoposide oral capsule 50 exemestane oral tablet 5 FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 0 MG flutamide oral capsule 5 GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG GLEEVEC ORAL TABLET 00 MG GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 0 MG HYCAMTIN ORAL CAPSULE 0.5 MG, MG hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG PA ICLUSIG ORAL TABLET 5 MG, 5 MG PA imatinib mesylate oral tablet 00, 00 IMBRUVICA ORAL CAPSULE 0 MG, 70 MG IMBRUVICA ORAL TABLET 0 MG, 80 MG, 0 MG, 560 MG INLYTA ORAL TABLET MG, 5 MG IRESSA ORAL TABLET 50 MG PA JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG KISQALI 00 DOSE ORAL TABLET 00 MG PA KISQALI 00 DOSE ORAL TABLET 00 MG PA KISQALI 600 DOSE ORAL TABLET 00 MG PA LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK () MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 & MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 & () MG LENVIMA 0 MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 () MG LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK 0 () & MG

33 LENVIMA MG DAILY DOSE ORAL CAPSULE THERAPY PACK MG LENVIMA 8 MG DAILY DOSE ORAL CAPSULE THERAPY PACK () MG letrozole oral tablet.5 leucovorin calcium oral tablet 0, 5, 5, 5 LEUKERAN ORAL TABLET MG LONSURF ORAL TABLET 5-6. MG, MG LORBRENA ORAL TABLET 00 MG, 5 MG LYNPARZA ORAL TABLET 00 MG, 50 MG LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG MEKINIST ORAL TABLET 0.5 MG, MG MEKTOVI ORAL TABLET 5 MG melphalan oral tablet mercaptopurine oral tablet 50 MESNEX ORAL TABLET 00 MG MYLERAN ORAL TABLET MG NEXAVAR ORAL TABLET 00 MG PA NILANDRON ORAL TABLET 50 MG nilutamide oral tablet 50 NINLARO ORAL CAPSULE. MG, MG, MG ODOMZO ORAL CAPSULE 00 MG ONIVYDE INTRAVENOUS INJECTABLE MG/0ML PANRETIN EXTERNAL GEL 0. % POMALYST ORAL CAPSULE MG, MG, MG, MG PA PURIXAN ORAL SUSPENSION 000 MG/00ML REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG PA RUBR ORAL TABLET 00 MG, 50 MG, 00 MG PA; QL ( EA per day) SOLTAMOX ORAL SOLUTION 0 MG/5ML SPRYCEL ORAL TABLET 00 MG, 0 MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 0 MG PA

34 SUTENT ORAL CAPSULE.5 MG, 5 MG, 7.5 MG, 50 MG PA SYLATRON SUBCUTANEOUS KIT 00 MCG, 00 MCG, 600 MCG TABLOID ORAL TABLET 0 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 0 MG, 80 MG PA TALZENNA ORAL CAPSULE 0.5 MG, MG tamoxifen citrate oral tablet 0, 0 TARCEVA ORAL TABLET 00 MG, 50 MG, 5 MG TARGRETIN EXTERNAL GEL % TASIGNA ORAL CAPSULE 50 MG, 00 MG, 50 MG temozolomide oral capsule 00, 0, 80, 0, 50, 5 THALOMID ORAL CAPSULE 00 MG, 50 MG, 00 MG, 50 MG TIBSOVO ORAL TABLET 50 MG tretinoin oral capsule 0 TYKERB ORAL TABLET 50 MG PA VALCHLOR EXTERNAL GEL 0.06 % VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG PA VENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK 0 & 50 & 00 MG PA VERZENIO ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG PA VITRAKVI ORAL CAPSULE 00 MG, 5 MG VITRAKVI ORAL SOLUTION 0 MG/ML VIZIMPRO ORAL TABLET 5 MG, 0 MG, 5 MG VOTRIENT ORAL TABLET 00 MG XALKORI ORAL CAPSULE 00 MG, 50 MG PA XOSPATA ORAL TABLET 0 MG XTANDI ORAL CAPSULE 0 MG YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED MG YONSA ORAL TABLET 5 MG ZEJULA ORAL CAPSULE 00 MG PA

35 ZELBORAF ORAL TABLET 0 MG PA ZOLINZA ORAL CAPSULE 00 MG ZYDELIG ORAL TABLET 00 MG, 50 MG ZYKADIA ORAL CAPSULE 50 MG PA ZYTIGA ORAL TABLET 500 MG Antiparasitics albendazole oral tablet 00 PA ALINIA ORAL SUSPENSION RECONSTITUTED 00 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5ml atovaquone-proguanil hcl oral tablet 50-00, BILTRICIDE ORAL TABLET 600 MG chloroquine phosphate oral tablet 50, 500 COARTEM ORAL TABLET 0-0 MG crotan external lotion 0 % DARAPRIM ORAL TABLET 5 MG PA EMVERM ORAL TABLET CHEWABLE 00 MG ST EURAX EXTERNAL CREAM 0 % ST hydroxychloroquine sulfate oral tablet 00 IMPAVIDO ORAL CAPSULE 50 MG ivermectin oral tablet lindane external shampoo % ST malathion external lotion 0.5 % mefloquine hcl oral tablet 50 NEBUPENT INHALATION SOLUTION RECONSTITUTED 00 MG permethrin external cream 5 % pinworm medicine oral suspension (50 base) /ml praziquantel oral tablet 600 primaquine phosphate oral tablet 6. quinine sulfate oral capsule SKLICE EXTERNAL LOTION 0.5 % PA spinosad external suspension 0.9 % STROMECTOL ORAL TABLET MG ST

36 ULESFIA EXTERNAL LOTION 5 % PA Antiparkinson Agents amantadine hcl oral capsule 00 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 00 APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 0 MG/ML benztropine mesylate oral tablet 0.5,, bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet.5 carbidopa oral tablet 5 carbidopa-levodopa er oral tablet extended release 5-00, carbidopa-levodopa oral tablet 0-00, 5-00, 5-50 carbidopa-levodopa oral tablet dispersible 0-00, 5-00, 5-50 carbidopa-levodopa-entacapone oral tablet , , , , , entacapone oral tablet 00 LODOSYN ORAL TABLET 5 MG ST pramipexole dihydrochloride er oral tablet extended release hour 0.75, 0.75,.5,.5,,.75,.5 pramipexole dihydrochloride oral tablet 0.5, 0.5, 0.5, 0.75,,.5 rasagiline mesylate oral tablet 0.5, ropinirole hcl er oral tablet extended release hour,,, 6, 8 ropinirole hcl oral tablet 0.5, 0.5,,,,, 5 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 TASMAR ORAL TABLET 00 MG ST tolcapone oral tablet 00 trihexyphenidyl hcl oral elixir 0. /ml trihexyphenidyl hcl oral tablet, 5 XADAGO ORAL TABLET 00 MG, 50 MG ST 5

37 ZELAPAR ORAL TABLET DISPERSIBLE.5 MG Antiplatelets AGGRENOX ORAL CAPSULE EXTENDED RELEASE HOUR 5-00 MG aspirin-dipyridamole er oral capsule extended release hour 5-00 BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 00, 50 clopidogrel bisulfate oral tablet 00, 75 ST dipyridamole oral tablet 5, 50, 75 DURLAZA ORAL CAPSULE EXTENDED RELEASE HOUR 6.5 MG prasugrel hcl oral tablet 0, 5 ZONTIVITY ORAL TABLET.08 MG PA Antipsychotics - Drugs for Mood Disorders ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE 00 MG, 00 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER 00 MG, 00 MG aripiprazole oral solution /ml QL (0 ML per day) aripiprazole oral tablet 0 QL ( EA per day) aripiprazole oral tablet 5 QL ( EA per day) aripiprazole oral tablet QL (5 EA per day) aripiprazole oral tablet 0 QL (.5 EA per day) aripiprazole oral tablet 0 QL ( EA per day) aripiprazole oral tablet 5 QL (6 EA per day) aripiprazole oral tablet dispersible 0 QL ( EA per day) aripiprazole oral tablet dispersible 5 QL ( EA per day) ARISTADA INITIO INTRAMUSCULAR PREFILLED SYRINGE 675 MG/.ML ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 06 MG/.9ML, MG/.6ML, 66 MG/.ML, 88 MG/.ML chlorpromazine hcl oral tablet 0 QL (80 EA per day) chlorpromazine hcl oral tablet 00 QL (8 EA per day) chlorpromazine hcl oral tablet 00 QL ( EA per day) chlorpromazine hcl oral tablet 5 QL ( EA per day) chlorpromazine hcl oral tablet 50 QL (6 EA per day) clozapine oral tablet 00 QL (9 EA per day) 6

38 clozapine oral tablet 00 QL (.5 EA per day) clozapine oral tablet 5 QL (6 EA per day) clozapine oral tablet 50 QL (8 EA per day) clozapine oral tablet dispersible 00 QL (9 EA per day) clozapine oral tablet dispersible.5 QL (7 EA per day) clozapine oral tablet dispersible 50 QL (6 EA per day) clozapine oral tablet dispersible 00 QL (.5 EA per day) clozapine oral tablet dispersible 5 QL (6 EA per day) FANAPT ORAL TABLET MG ST; QL ( EA per day) FANAPT ORAL TABLET 0 MG ST; QL (. EA per day) FANAPT ORAL TABLET MG ST; QL ( EA per day) FANAPT ORAL TABLET MG ST; QL ( EA per day) FANAPT ORAL TABLET MG ST; QL (6 EA per day) FANAPT ORAL TABLET 6 MG ST; QL ( EA per day) FANAPT ORAL TABLET 8 MG ST; QL ( EA per day) FANAPT TITRATION PACK ORAL TABLET & & & 6 MG ST; QL ( EA per 0 days) fluphenazine decanoate injection solution 5 /ml fluphenazine hcl injection solution.5 /ml fluphenazine hcl oral concentrate 5 /ml QL (8 ML per day) fluphenazine hcl oral elixir.5 /5ml QL (80 ML per day) fluphenazine hcl oral tablet QL (0 EA per day) fluphenazine hcl oral tablet 0 QL ( EA per day) fluphenazine hcl oral tablet.5 QL (6 EA per day) fluphenazine hcl oral tablet 5 QL (8 EA per day) haloperidol decanoate intramuscular solution 00 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate /ml QL (5 ML per day) haloperidol oral tablet 0.5 QL (60 EA per day) haloperidol oral tablet QL (0 EA per day) haloperidol oral tablet 0 QL ( EA per day) haloperidol oral tablet QL (5 EA per day) haloperidol oral tablet 0 QL (.5 EA per day) haloperidol oral tablet 5 QL (6 EA per day) INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 7 MG/0.75ML, 56 MG/ML, MG/.5ML, 9 MG/0.5ML, 78 MG/0.5ML 7