2017 COMPREHENSIVE FORMULARY

Transcription

1 017 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) PRESCRIPTION DRUG PLANS Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 09/01/016. For more recent information or other questions, please contact WellCare at the telephone number listed on the inside front and back covers of this formulary or visit WELLCARE PRESCRIPTION INSURANCE, INC. WellCare Classic (PDP) Plan in the following states: AZ, CA, CO, FL, IA, IL, KS, MN, MT, NC, ND, NE, NJ, NM, NV, SC, SD, TX, VA, WY HPMS Approved Formulary File Submission ID: 1791 Version Number: 8 Y0070_NA06_WCM_FOR_ENG_FINAL_01 CMS Approved WellCare 016 NA_06_16 PD7V01FOR777E_0616

2 We re always just a phone call away! If you re ready to enroll or have enrollment questions, call a.m. to 8 p.m., 7 days a week. If you re already a member, call the number listed below. Prescription Plans: WellCare Classic (PDP) WellCare Extra (PDP) TTY Hours of operation are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 1, representatives are available Monday Sunday, 8 a.m. to 8 p.m., or visit us anytime at

3 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us or our, it means WellCare. When it refers to plan or our plan, it means 017 WellCare. This document includes a list of the drugs (formulary) for our plan which is current as of 09/01/016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may change on January 1, 018, and from time to time during the year. WHAT IS THE WELLCARE CLASSIC (PDP) COMPREHENSIVE FORMULARY? A formulary is a list of covered drugs. WellCare selects the drugs by working with a team of health care providers. The list contains the prescription medications we believe are a necessary part of a quality treatment program. WellCare will generally cover the drugs listed in our formulary as long as: 1. the drug is medically necessary,. the prescription is filled at a WellCare network pharmacy, and. other plan rules are followed. For more information on how to fill your prescriptions, please see your Evidence of Coverage. CAN THE FORMULARY (DRUG LIST) CHANGE? In general, if you are taking a drug on our 017 formulary that was covered at the beginning of the year, we will not stop or reduce coverage of the drug during the 017 coverage year. However, there are some cases when we may stop or reduce coverage. These are: when a new, less expensive generic drug becomes available or when new negative information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. For those members, it will remain available at the same cost share for the remainder of the coverage year. We think it s important that you can continue to get the formulary drugs that were available when you chose our plan for the remainder of the coverage year. The only exceptions are for cases in which you can save additional money or we can ensure your safety. When we make certain changes to our formulary, we must notify the members who will be affected by the changes. This includes if we: remove drugs from our formulary; add restrictions on a drug such as prior authorization, quantity limits and/or step therapy; 017 Comprehensive Formulary I PD7V01FOR777E_0616

4 move a drug to a higher cost-sharing tier. If we make any of these changes, we must notify affected members at least 60 days before the change goes into effect. We will also notify the member at the time he or she asks for a refill of the drug. In that case, the member will receive a 60-day supply of the drug. If the Food and Administration announces that a drug on our formulary is unsafe, or a drug manufacturer removes a drug from the market, we will immediately remove the drug from our formulary and notify members who take the drug. The enclosed formulary is current as of 09/01/016. To get updated information about the drugs covered by WellCare, please visit our website at or call Customer Service at the telephone number listed for your state/plan on the inside front and back cover pages of this formulary. Every month, our printed comprehensive formulary will be updated. Please contact Customer Service or visit our website at for more information. HOW DO I USE THE FORMULARY? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 8. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. WHAT ARE GENERIC DRUGS? WellCare covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. ARE THERE ANY RESTRICTIONS ON MY COVERAGE? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: 017 Comprehensive Formulary II

5 Prior Authorization: WellCare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, WellCare provides 18 tablets for 0 days per prescription for rizatriptan 5mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, WellCare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at We have posted online documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask WellCare to make an exception to these restrictions or limits, or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the WellCare formulary? on page IV for information about how to request an exception. WHAT IF MY DRUG IS NOT ON THE FORMULARY? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. You can contact Customer Service at the telephone number listed for your state/plan on the inside front and back covers of this formulary. If you learn that WellCare does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by WellCare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by WellCare. You can ask WellCare to make an exception and cover your drug. See below for information about how to request an exception. WHICH VACCINES DO WE COVER? Your prescription benefit may cover many vaccines. For details, see the Immunological Agents section. The cost for vaccines varies, depending on the facility where you receive them. For best coverage, use a network pharmacy. All commercially available vaccines are covered under Part D, except for those that are covered under Medicare Part B, such as influenza or pneumococcal vaccines. 017 Comprehensive Formulary III

6 HOW DO I REQUEST AN EXCEPTION TO THE WELLCARE CLASSIC (PDP) FORMULARY? You can ask WellCare to make an exception to our coverage rules. There are several types of formulary exceptions that you can ask us to make. Initial Coverage Decision Exception You can ask us to cover your drug even if it is not on our formulary. If your request is approved, the drug will be covered at a pre-determined cost-sharing level. You would not be able to ask us to provide the drug at a lower cost-sharing level. Utilization Restriction Exception You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the amount of the drug that we cover is limited. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. ing Exception You can ask us to cover a formulary drug at a lower cost-sharing level if the drug is not on the preferred generic, preferred brand or specialty tier. If approved, this would lower the amount you must pay for your drug. Generally, WellCare will only approve your request for an exception if: the alternative drugs included on the plan s formulary would not be as effective in treating your condition; the lower cost-sharing drug would not be as effective in treating your condition; the additional utilization restrictions would not be as effective in treating your condition and/or; the alternative drugs would cause you to have adverse medical effects. You should contact us to ask us for a formulary exception for an initial coverage decision, a tiering exception or a utilization restriction exception. When you request any of these exceptions, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescribing physician s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request for a fast review is granted, we must give you a decision no later than hours after we get your prescriber s or prescribing physician s supporting statement. WHAT DO I DO BEFORE I CAN TALK TO MY DOCTOR ABOUT CHANGING MY DRUGS OR REQUESTING AN EXCEPTION? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover, or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover 017 Comprehensive Formulary IV

7 your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 9-day transition supply that meets the dispensing instructions (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 9 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 9 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer days) while you seek a formulary exception. If you experience a level of care change (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can call our Provider Service Center and request a one-time override. This one-time override will be up to a 1-day supply (unless you have a prescription written for fewer days). FOR MORE INFORMATION For more details about your WellCare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about WellCare, please contact us. Our contact information, along with the date we last updated the formulary, is on the inside front and back covers of this document. Or visit If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day, 7 days a week. TTY users should call Or visit WELLCARE FORMULARY The comprehensive formulary that begins on page 1 provides coverage information about the drugs covered by WellCare. If you have trouble finding your drug in the list, turn to the Index that begins on page 8. The first column of the chart lists the drug name. Brand-name drugs are UPPERCASE (e.g., COUMADIN) and generic drugs are listed in lowercase italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if WellCare has any special requirements for coverage of your drug. 017 Comprehensive Formulary V

8 NM means the drug is not available via your monthly mail service benefit. This is noted in the Requirements/Limits column of your formulary. You may be able to receive more than one month s supply of most of the drugs on your formulary via mail service at a reduced cost share. Please see Chapter of your Evidence of Coverage for more information.** PA stands for Prior Authorization: Please see page III for details. B/D stands for Covered under Medicare B or D: This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from WellCare to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, WellCare may not cover this drug. QL stands for Quantity Limits: Please see page III for details. LA stands for Limited Access medication. This medication may be available from certain other pharmacies. For more information, please refer to the Specialty Pharmacy section of your Pharmacy Directory or contact Customer Service at the telephone number listed for your state/plan on the inside front and back cover pages of this formulary. ST stands for Step Therapy: Please see page III for details. ^ = may be available for up to a 0-day supply only. ** You have the choice to sign up for automated mail service delivery. You can get prescription drugs shipped to your home through our network mail service delivery program. You should expect to receive your prescription drugs within 7 10 business days from the time that the mail service pharmacy receives the order. If you do not receive your prescription drugs within this time, please contact us at the telephone number listed on the inside front and back covers of this formulary or visit DRUG TIER CO-PAYMENT/COINSURANCE AMOUNTS The WellCare formulary is divided into five tiers. 1: Preferred Generic s that are available at the lowest cost share for this plan. : Generic s that WellCare offers at a higher cost to you than preferred generics. : Preferred Brand s that WellCare may be able to offer at a lower cost to you than non-preferred brand drugs. : Non-Preferred s that WellCare offers at a higher cost to you than preferred brands. 5: Specialty Some injectables and other high-cost drugs. ^ Indicates specialty drugs are available for up to a 0-day supply only. Brand drugs may be available in s, and 5. Generic drugs are available in all s. Consult your Evidence of Coverage or Summary of Benefits for your applicable co-pays/ coinsurance and deductible amounts. 017 Comprehensive Formulary VI

9 HOW TO READ FORMULARY LISTINGS: Requirements/Limits CENTRAL NERVOUS SYSTEM ANTICONVULSANTS BANZEL TAB 00MG BANZEL TAB 00MG carbamazepine cap sr 1hr 100 mg carbamazepine cap sr 1hr 00 mg Therapeutic Class PA PA Therapeutic Category of ^ = may be available for up to a 0-day supply only Name of UPPERCASE = Brand s lowercase italics = Generic s Find your drug quickly in the Index at the back of the book. Requirements/Limits Codes: LA = Limited Access NM = Not Available by Mail Service PA = Prior Authorization B/D = Covered under Medicare B or D QL = Quantity Limits ST = Step Therapy 017 Comprehensive Formulary VII

10 ANALGESICS GOUT allopurinol oral tablet 100 mg, 00 mg 1 colchicine-probenecid oral tablet mg COLCRYS ORAL TABLET 0.6 MG QL (10 EA per 0 days) probenecid oral tablet 500 mg ULORIC ORAL TABLET 0 MG, 80 MG ST NSAIDS celecoxib oral capsule 100 mg QL (10 EA per 0 days) celecoxib oral capsule 00 mg QL (60 EA per 0 days) celecoxib oral capsule 00 mg QL (0 EA per 0 days) celecoxib oral capsule 50 mg QL (0 EA per 0 days) diclofenac potassium oral tablet 50 mg QL (10 EA per 0 days) diclofenac sodium er oral tablet extended release hr* 100 mg diclofenac sodium oral tablet delayed release 5 mg, 50 mg, 75 mg diflunisal oral tablet 500 mg etodolac er oral tablet extended release hr* 00 mg, 500 mg, 600 mg etodolac oral capsule 00 mg, 00 mg etodolac oral tablet 00 mg, 500 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 00 mg, 600 mg, 800 mg ketoprofen oral capsule 50 mg, 75 mg meloxicam oral tablet 15 mg, 7.5 mg 1 nabumetone oral tablet 500 mg, 750 mg naproxen dr oral tablet delayed release 75 mg, 500 mg naproxen oral suspension 15 mg/5ml naproxen oral tablet 50 mg, 75 mg, 500 mg 1 naproxen sodium oral tablet 75 mg, 550 mg 1

11 sulindac oral tablet 150 mg, 00 mg OPIOID ANALGESICS, CII DURAMORPH INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML B/D endocet oral tablet 10-5 mg, 5-5 mg, mg QL (60 EA per 0 days) fentanyl citrate buccal lollipop 100 mcg, 1600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg PA; QL (10 EA per 0 days) fentanyl transdermal patch 7 hr 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr QL (10 EA per 0 days) FENTORA BUCCAL TABLET 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG PA; QL (10 EA per 0 days) hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet 10-5 mg, 5-5 mg, mg QL (500 ML per 0 days) QL (60 EA per 0 days) hydrocodone-ibuprofen oral tablet mg QL (150 EA per 0 days) hydromorphone hcl oral liquid 1 mg/ml hydromorphone hcl oral tablet mg, mg, 8 mg QL (70 EA per 0 days) hydromorphone hcl pf injection solution 10 mg/ml, 50 mg/5ml, 500 mg/50ml B/D lorcet oral tablet 5-5 mg QL (60 EA per 0 days) lorcet plus oral tablet mg QL (60 EA per 0 days) lortab oral tablet 10-5 mg, 5-5 mg, mg QL (60 EA per 0 days) methadone hcl intensol oral concentrate 10 mg/ml QL (10 ML per 0 days) methadone hcl oral solution 10 mg/5ml, 5 mg/5ml QL (600 ML per 0 days) methadone hcl oral tablet 10 mg, 5 mg QL (0 EA per 0 days) MORPHINE SULFATE (CONCENTRATE) ORAL SOLUTION 100 MG/5ML morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml MORPHINE SULFATE (PF) INTRAVENOUS* SOLUTION 10 MG/ML, 15 MG/ML, MG/ML, MG/ML, 8 MG/ML B/D B/D morphine sulfate er oral tablet extendedrelease* 100 QL (90 EA per 0 days) mg, 15 mg, 0 mg, 60 mg

12 morphine sulfate er oral tablet extendedrelease* 00 mg QL (60 EA per 0 days) MORPHINE SULFATE INTRAVENOUS* SOLUTION 1 MG/ML, 150 MG/0ML MORPHINE SULFATE ORAL SOLUTION 10 MG/5ML, 0 MG/5ML B/D MORPHINE SULFATE ORAL TABLET 15 MG, 0 MG QL (180 EA per 0 days) OPANA ER ORAL 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 5 MG, 7.5 MG QL (10 EA per 0 days) oxycodone hcl oral capsule 5 mg QL (180 EA per 0 days) OXYCODONE HCL ORAL SOLUTION 5 MG/5ML oxycodone hcl oral tablet 10 mg, 15 mg, 0 mg, 0 mg, 5 mg QL (180 EA per 0 days) oxycodone-acetaminophen oral solution 5-5 mg/5ml QL (1800 ML per 0 days) oxycodone-acetaminophen oral tablet 10-5 mg,.5-5 mg, 5-5 mg, mg QL (60 EA per 0 days) roxicet oral solution 5-5 mg/5ml QL (1800 ML per 0 days) roxicet oral tablet 5-5 mg QL (60 EA per 0 days) OPIOID ANALGESICS acetaminophen-codeine # oral tablet mg QL (00 EA per 0 days) acetaminophen-codeine # oral tablet 00-0 mg QL (00 EA per 0 days) acetaminophen-codeine # oral tablet mg QL (00 EA per 0 days) acetaminophen-codeine oral solution 10-1 mg/5ml QL (5000 ML per 0 days) nalbuphine hcl injection solution 10 mg/ml, 0 mg/ml tramadol hcl oral tablet 50 mg QL (0 EA per 0 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (pf) injection solution 0.5 %, 1 % B/D lidocaine hcl injection solution 0.5 %, 1 %, 1.5 %, % B/D ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate injection solution 1 gm/ml, 500 mg/ml

13 gentamicin in saline intravenous* solution mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-%, mg/ml-%, -0.9 mg/ml-% gentamicin sulfate injection solution 10 mg/ml, 0 mg/ml gentamicin sulfate intravenous* solution 10 mg/ml neomycin sulfate oral tablet 500 mg paromomycin sulfate oral capsule 50 mg streptomycin sulfate intramuscular* solution reconstituted 1 gm sulfadiazine oral tablet 500 mg tobramycin inhalation nebulization solution 00 mg/5ml PA tobramycin sulfate injection solution 1. gm/0ml, 10 mg/ml, gm/50ml, 80 mg/ml tobramycin sulfate injection solution reconstituted 1. gm ANTIFUNGALS ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML B/D AMBISOME INTRAVENOUS* SUSPENSION RECONSTITUTED 50 MG B/D amphotericin b injection solution reconstituted 50 mg B/D CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG, 70 MG fluconazole in dextrose intravenous* solution 00 mg/100ml, 00 mg/00ml fluconazole in sodium chloride intravenous* solution mg/50ml-%, mg/100ml-%, mg/00ml-% fluconazole oral suspension reconstituted 10 mg/ml, 0 mg/ml fluconazole oral tablet 100 mg, 150 mg, 00 mg, 50 mg flucytosine oral capsule 50 mg, 500 mg griseofulvin microsize oral suspension 15 mg/5ml

14 griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 15 mg, 50 mg itraconazole oral capsule 100 mg PA ketoconazole oral tablet 00 mg PA MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 50 MG NOXAFIL ORAL SUSPENSION 0 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin oral tablet unit terbinafine hcl oral tablet 50 mg QL (90 EA per 65 days) voriconazole intravenous* solution reconstituted 00 mg voriconazole oral suspension reconstituted 0 mg/ml voriconazole oral tablet 00 mg, 50 mg ANTI-INFECTIVES - MISCELLANEOUS ALBENZA ORAL TABLET 00 MG ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 mg/5ml aztreonam injection solution reconstituted 1 gm, gm BILTRICIDE ORAL TABLET 600 MG CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG clindamycin hcl oral capsule 150 mg, 00 mg, 75 mg clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml clindamycin phosphate in d5w intravenous* solution 00 mg/50ml, 600 mg/50ml, 900 mg/50ml clindamycin phosphate injection solution 00 mg/ml, 600 mg/ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml clindamycin phosphate intravenous* solution 150 mg/ml, 900 mg/6ml PA; LA 5

15 colistimethate sodium injection solution reconstituted 150 mg CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG dapsone oral tablet 100 mg, 5 mg imipenem-cilastatin intravenous* solution reconstituted 50 mg, 500 mg INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM INVANZ INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM ivermectin oral tablet mg linezolid intravenous* solution 600 mg/00ml LINEZOLID ORAL SUSPENSION RECONSTITUTED 100 MG/5ML LINEZOLID ORAL TABLET 600 MG meropenem intravenous* solution reconstituted 1 gm, 500 mg methenamine hippurate oral tablet 1 gm metronidazole in nacl intravenous* solution mg/100ml-% metronidazole oral tablet 50 mg, 500 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 00 MG B/D nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg PA nitrofurantoin monohyd macro oral capsule 100 mg PA PENTAM INJECTION SOLUTION RECONSTITUTED 00 MG SIVEXTRO INTRAVENOUS* SOLUTION RECONSTITUTED 00 MG SIVEXTRO ORAL TABLET 00 MG sulfamethoxazole-trimethoprim intravenous* solution mg/5ml sulfamethoxazole-trimethoprim oral suspension 00-0 mg/5ml 6

16 sulfamethoxazole-trimethoprim oral tablet mg, mg SYNERCID INTRAVENOUS* SOLUTION RECONSTITUTED MG trimethoprim oral tablet 100 mg TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG vancomycin hcl intravenous* solution reconstituted 10 gm, 1000 mg, 500 mg, 5000 mg, 750 mg vancomycin hcl oral capsule 15 mg, 50 mg ANTIMALARIALS atovaquone-proguanil hcl oral tablet mg, mg chloroquine phosphate oral tablet 50 mg, 500 mg COARTEM ORAL TABLET 0-10 MG mefloquine hcl oral tablet 50 mg PRIMAQUINE PHOSPHATE ORAL TABLET 6. MG quinine sulfate oral capsule mg PA ANTIRETROVIRAL AGENTS abacavir sulfate oral tablet 00 mg APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION 100 MG/ML CRIXIVAN ORAL CAPSULE 00 MG, 00 MG didanosine oral capsule delayed release 15 mg, 00 mg, 50 mg, 00 mg EDURANT ORAL TABLET 5 MG EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLUTION 10 MG/ML FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ORAL CAPSULE 00 MG 7

17 INVIRASE ORAL TABLET 500 MG ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 00 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG ISENTRESS ORAL TABLET CHEWABLE 5 MG lamivudine oral solution 10 mg/ml lamivudine oral tablet 150 mg, 00 mg LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG nevirapine er oral tablet extended release hr* 100 mg, 00 mg NEVIRAPINE ORAL SUSPENSION 50 MG/5ML nevirapine oral tablet 00 mg NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG RESCRIPTOR ORAL TABLET 100 MG, 00 MG RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 00 MG, 00 MG REYATAZ ORAL PACKET 50 MG SELZENTRY ORAL TABLET 150 MG, 00 MG stavudine oral capsule 15 mg, 0 mg, 0 mg, 0 mg stavudine oral solution reconstituted 1 mg/ml SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET 600 MG TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 5 MG, 50 MG 8

18 TYBOST ORAL TABLET 150 MG VIDEX ORAL SOLUTION RECONSTITUTED GM, GM VIRACEPT ORAL TABLET 50 MG, 65 MG VIREAD ORAL POWDER 0 MG/GM VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG, 00 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZIAGEN ORAL SOLUTION 0 MG/ML zidovudine oral capsule 100 mg zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 00 mg ANTIRETROVIRAL COMBINATION AGENTS abacavir-lamivudine-zidovudine oral tablet mg ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG DESCOVY ORAL TABLET 00-5 MG EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG GENVOYA ORAL TABLET MG KALETRA ORAL SOLUTION MG/5ML KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine-zidovudine oral tablet mg ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG STRIBILD ORAL TABLET MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG QL (60 EA per 0 days) TRUVADA ORAL TABLET 1-00 MG, MG, MG QL (0 EA per 0 days) 9

19 ANTITUBERCULAR AGENTS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM cycloserine oral capsule 50 mg ethambutol hcl oral tablet 100 mg, 00 mg isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 00 mg paser oral packet gm PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg rifampin intravenous* solution reconstituted 600 mg rifampin oral capsule 150 mg, 00 mg RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG PA; LA TRECATOR ORAL TABLET 50 MG ANTIVIRALS acyclovir oral capsule 00 mg acyclovir oral suspension 00 mg/5ml acyclovir oral tablet 00 mg, 800 mg acyclovir sodium intravenous* solution 50 mg/ml B/D acyclovir sodium intravenous* solution reconstituted 500 mg adefovir dipivoxil oral tablet 10 mg BARACLUDE ORAL SOLUTION 0.05 MG/ML B/D DAKLINZA ORAL TABLET 0 MG, 60 MG, 90 MG PA entecavir oral tablet 0.5 mg, 1 mg EPIVIR HBV ORAL SOLUTION 5 MG/ML famciclovir oral tablet 15 mg, 50 mg, 500 mg ganciclovir sodium intravenous* solution reconstituted 500 mg lamivudine oral tablet 100 mg B/D 10

20 moderiba oral tablet 00 mg PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 15 MCG/0.5ML, 180 MCG/0.5ML PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML, 180 MCG/ML RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER PA PA ribasphere oral capsule 00 mg ribasphere oral tablet 00 mg ribavirin oral capsule 00 mg ribavirin oral tablet 00 mg rimantadine hcl oral tablet 100 mg SOVALDI ORAL TABLET 00 MG PA TAMIFLU ORAL CAPSULE 0 MG, 5 MG, 75 MG TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML TYZEKA ORAL TABLET 600 MG valacyclovir hcl oral tablet 1 gm, 500 mg VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML valganciclovir hcl oral tablet 50 mg CEPHALOSPORINS cefaclor oral capsule 50 mg, 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 50 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 0 gm, 500 mg cefazolin sodium intravenous* solution 1-5 gm-% cefazolin sodium intravenous* solution reconstituted 1 gm CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS* SOLUTION - GM/100ML-% cefdinir oral capsule 00 mg 11

21 cefdinir oral suspension reconstituted 15 mg/5ml, 50 mg/5ml cefepime hcl injection solution reconstituted 1 gm, gm cefixime oral suspension reconstituted 100 mg/5ml, 00 mg/5ml cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous* solution reconstituted 1 gm, gm cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 00 mg ceftazidime injection solution reconstituted 1 gm, gm, 6 gm ceftriaxone sodium injection solution reconstituted 1 gm, gm, 50 mg, 500 mg ceftriaxone sodium intravenous* solution reconstituted 1 gm, 10 gm, gm cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg cefuroxime sodium intravenous* solution reconstituted 1.5 gm, 7.5 gm cephalexin oral capsule 50 mg, 500 mg cephalexin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml SUPRAX ORAL CAPSULE 00 MG SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML suprax oral tablet chewable 100 mg, 00 mg tazicef injection solution reconstituted 1 gm, gm, 6 gm tazicef intravenous* solution reconstituted 1 gm, gm TEFLARO INTRAVENOUS* SOLUTION RECONSTITUTED 00 MG, 600 MG 1

22 ERYTHROMYCINS/MACROLIDES azithromycin intravenous* solution reconstituted 500 mg AZITHROMYCIN ORAL PACKET 1 GM azithromycin oral suspension reconstituted 100 mg/5ml, 00 mg/5ml azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 600 mg clarithromycin er oral tablet extended release hr* 500 mg clarithromycin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml clarithromycin oral tablet 50 mg, 500 mg e.e.s. 00 oral tablet 00 mg ery-tab oral tablet delayed release 50 mg, mg, 500 mg erythrocin lactobionate intravenous* solution reconstituted 500 mg erythrocin stearate oral tablet 50 mg erythromycin base oral capsule delayed release particles 50 mg erythromycin base oral tablet 50 mg, 500 mg erythromycin ethylsuccinate oral tablet 00 mg FLUOROQUINOLONES ciprofloxacin hcl oral tablet 100 mg, 50 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous* solution 00 mg/100ml, 00 mg/00ml ciprofloxacin intravenous* solution 00 mg/0ml, 00 mg/0ml levofloxacin in d5w intravenous* solution 50 mg/50ml, 500 mg/100ml, 750 mg/150ml levofloxacin intravenous* solution 5 mg/ml levofloxacin oral solution 5 mg/ml levofloxacin oral tablet 50 mg, 500 mg, 750 mg 1

23 PENICILLINS amoxicillin oral capsule 50 mg, 500 mg amoxicillin oral suspension reconstituted 15 mg/5ml, 00 mg/5ml, 50 mg/5ml, 00 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 15 mg, 50 mg amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 50 mg, 500 mg ampicillin oral suspension reconstituted 15 mg/5ml, 50 mg/5ml ampicillin sodium injection solution reconstituted 1 gm, 15 mg, gm, 50 mg, 500 mg ampicillin sodium intravenous* solution reconstituted 1 gm, 10 gm, gm ampicillin-sulbactam sodium injection solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, (-1) gm ampicillin-sulbactam sodium intravenous* solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm, (-1) gm BICILLIN L-A INTRAMUSCULAR* SUSPENSION UNIT/ML, UNIT/ML, UNIT/ML dicloxacillin sodium oral capsule 50 mg, 500 mg nafcillin sodium injection solution reconstituted 1 gm, 10 gm, gm nafcillin sodium intravenous* solution reconstituted 1 gm, gm PENICILLIN G POT IN DEXTROSE INTRAVENOUS* SOLUTION 0000 UNIT/ML, UNIT/ML 1

24 penicillin g potassium injection solution reconstituted unit, unit penicillin g procaine intramuscular* suspension unit/ml penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 15 mg/5ml, 50 mg/5ml penicillin v potassium oral tablet 50 mg, 500 mg piperacillin sod-tazobactam so intravenous* solution reconstituted.5 (-0.5) gm,.75 (-0.75) gm,.5 (-0.5) gm, 0.5 (6-.5) gm TETRACYCLINES doxy 100 intravenous* solution reconstituted 100 mg doxycycline hyclate intravenous* solution reconstituted 100 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BENDEKA INTRAVENOUS* SOLUTION 100 MG/ML B/D CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG B/D dacarbazine intravenous* solution reconstituted 100 mg, 00 mg B/D EMCYT ORAL CAPSULE 10 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG, 5 MG HEXALEN ORAL CAPSULE 50 MG LEUKERAN ORAL TABLET MG 15

25 ANTIBIOTICS bleomycin sulfate injection solution reconstituted 15 unit, 0 unit B/D mitomycin intravenous* solution reconstituted 0 mg, 0 mg, 5 mg ANTIMETABOLITES B/D adrucil intravenous* solution.5 gm/50ml, 5 gm/100ml, 500 mg/10ml B/D ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 500 MG B/D azacitidine injection suspension reconstituted 100 mg B/D fluorouracil intravenous* solution 1 gm/0ml,.5 gm/50ml, 5 gm/100ml, 500 mg/10ml B/D mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection solution 1 gm/0ml, 100 mg/ml, 00 mg/8ml, 50 mg/10ml, 50 mg/ml B/D methotrexate sodium injection solution 50 mg/10ml B/D METHOTREXATE SODIUM INJECTION SOLUTION 50 MG/ML methotrexate sodium injection solution reconstituted 1 gm B/D B/D NIPENT INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG B/D PURIXAN ORAL SUSPENSION 000 MG/100ML TABLOID ORAL TABLET 0 MG ANTIMITOTIC, TAXOIDS ABRAXANE INTRAVENOUS* SUSPENSION RECONSTITUTED 100 MG DOCEFREZ INTRAVENOUS* SOLUTION RECONSTITUTED 0 MG B/D B/D docetaxel intravenous* concentrate 10 mg/7ml B/D DOCETAXEL INTRAVENOUS* CONCENTRATE 160 MG/8ML, 0 MG/ML, 80 MG/ML B/D 16

26 DOCETAXEL INTRAVENOUS* SOLUTION 160 MG/16ML, 0 MG/ML, 00 MG/0ML, 80 MG/8ML BIOLOGIC RESPONSE MODIFIERS AVASTIN INTRAVENOUS* SOLUTION 100 MG/ML, 00 MG/16ML BELEODAQ INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG B/D PA; LA PA ERIVEDGE ORAL CAPSULE 150 MG PA; LA FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG PA; LA HERCEPTIN INTRAVENOUS* SOLUTION RECONSTITUTED 0 MG PA IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG PA; LA KEYTRUDA INTRAVENOUS* SOLUTION 100 MG/ML PA KEYTRUDA INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG PA LYNPARZA ORAL CAPSULE 50 MG PA; LA NINLARO ORAL CAPSULE. MG, MG, MG PA RITUXAN INTRAVENOUS* SOLUTION 100 MG/10ML, 500 MG/50ML PA; LA TECENTRIQ INTRAVENOUS* SOLUTION 100 MG/0ML PA; LA VELCADE INJECTION SOLUTION RECONSTITUTED.5 MG PA VENCLEXTA ORAL TABLET 10 MG, 50 MG PA; LA VENCLEXTA ORAL TABLET 100 MG PA; LA VENCLEXTA STARTING PACK ORAL 10 & 50 & 100 MG PA; LA YERVOY INTRAVENOUS* SOLUTION 00 MG/0ML, 50 MG/10ML PA ZOLINZA ORAL CAPSULE 100 MG PA HORMONAL ANTINEOPLASTIC AGENTS anastrozole oral tablet 1 mg bicalutamide oral tablet 50 mg exemestane oral tablet 5 mg FARESTON ORAL TABLET 60 MG 17

27 FASLODEX INTRAMUSCULAR* SOLUTION 50 MG/5ML B/D flutamide oral capsule 15 mg hydroxyprogesterone caproate intramuscular* solution 1.5 gm/5ml letrozole oral tablet.5 mg B/D leuprolide acetate injection kit 1 mg/0.ml PA LUPRON DEPOT INTRAMUSCULAR* KIT 11.5 MG,.75 MG LYSODREN ORAL TABLET 500 MG megestrol acetate oral suspension 0 mg/ml PA MEGESTROL ACETATE ORAL SUSPENSION 65 MG/5ML PA megestrol acetate oral tablet 0 mg, 0 mg PA NILANDRON ORAL TABLET 150 MG SOLTAMOX ORAL SOLUTION 10 MG/5ML tamoxifen citrate oral tablet 10 mg, 0 mg 1 TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.5 MG,.75 MG XTANDI ORAL CAPSULE 0 MG PA; LA ZYTIGA ORAL TABLET 50 MG PA; LA KINASE INHIBITORS AFINITOR DISPERZ ORAL TABLET SOLUBLE MG, MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 MG, 5 MG, 7.5 MG PA ALECENSA ORAL CAPSULE 150 MG PA; LA BOSULIF ORAL TABLET 100 MG, 500 MG PA CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG PA; LA CAPRELSA ORAL TABLET 100 MG, 00 MG PA; LA COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 0 MG COMETRIQ (10 MG DAILY DOSE) ORAL KIT 1 X 80 & X 0 MG PA PA PA PA; LA PA; LA COMETRIQ (60 MG DAILY DOSE) ORAL KIT 0 MG PA; LA COTELLIC ORAL TABLET 0 MG PA; LA 18

28 GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG PA; LA ICLUSIG ORAL TABLET 15 MG, 5 MG PA; LA imatinib mesylate oral tablet 100 mg PA; QL (90 EA per 0 days) imatinib mesylate oral tablet 00 mg PA; QL (60 EA per 0 days) IMBRUVICA ORAL CAPSULE 10 MG PA; LA INLYTA ORAL TABLET 1 MG, 5 MG PA; LA IRESSA ORAL TABLET 50 MG PA; LA JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG PA; LA LENVIMA 10 MG DAILY DOSE ORAL 10 MG PA; LA LENVIMA 1 MG DAILY DOSE ORAL 10 & MG PA; LA LENVIMA 18 MG DAILY DOSE ORAL 10 & () MG PA; LA LENVIMA 0 MG DAILY DOSE ORAL 10 () MG PA; LA LENVIMA MG DAILY DOSE ORAL 10 () & MG PA; LA LENVIMA 8 MG DAILY DOSE ORAL () MG PA; LA MEKINIST ORAL TABLET 0.5 MG, MG PA; LA NEXAVAR ORAL TABLET 00 MG PA; LA SPRYCEL ORAL TABLET 100 MG, 10 MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 0 MG PA; LA SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 7.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA; LA TAGRISSO ORAL TABLET 0 MG, 80 MG PA; LA TARCEVA ORAL TABLET 100 MG, 150 MG, 5 MG PA; LA TASIGNA ORAL CAPSULE 150 MG, 00 MG PA TYKERB ORAL TABLET 50 MG PA; LA VOTRIENT ORAL TABLET 00 MG PA; LA XALKORI ORAL CAPSULE 00 MG, 50 MG PA; LA ZELBORAF ORAL TABLET 0 MG PA; LA ZYDELIG ORAL TABLET 100 MG, 150 MG PA; LA ZYKADIA ORAL CAPSULE 150 MG PA; LA 19 PA PA

29 MISCELLANEOUS bexarotene oral capsule 75 mg PA DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG hydroxyurea oral capsule 500 mg LONSURF ORAL TABLET MG, MG PA MATULANE ORAL CAPSULE 50 MG LA mitoxantrone hcl intravenous* concentrate 0 mg/10ml, 5 mg/1.5ml, 0 mg/15ml B/D ODOMZO ORAL CAPSULE 00 MG PA; LA SYLATRON SUBCUTANEOUS* KIT 00 MCG, 00 MCG, 600 MCG SYNRIBO SUBCUTANEOUS* SOLUTION RECONSTITUTED.5 MG PA PA tretinoin oral capsule 10 mg TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML B/D PLATINUM-BASED AGENTS carboplatin intravenous* solution 150 mg/15ml, 50 mg/5ml, 50 mg/5ml, 600 mg/60ml cisplatin intravenous* solution 100 mg/100ml, 00 mg/00ml, 50 mg/50ml PROTECTIVE AGENTS B/D B/D amifostine intravenous* solution reconstituted 500 mg B/D dexrazoxane intravenous* solution reconstituted 500 mg B/D ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG FUSILEV INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG B/D B/D leucovorin calcium injection solution reconstituted 100 mg, 00 mg, 50 mg, 50 mg, 500 mg leucovorin calcium oral tablet 10 mg, 15 mg, 5 mg, 5 mg B/D levoleucovorin calcium intravenous* solution 175 mg/17.5ml B/D 0

30 levoleucovorin calcium pf intravenous* solution 50 mg/5ml B/D mesna intravenous* solution 100 mg/ml B/D MESNEX ORAL TABLET 00 MG TOPOISOMERASE INHIBITORS etoposide intravenous* solution 100 mg/5ml, 500 mg/5ml B/D toposar intravenous* solution 1 gm/50ml, 100 mg/5ml B/D TOPOTECAN HCL INTRAVENOUS* SOLUTION MG/ML B/D topotecan hcl intravenous* solution reconstituted mg B/D CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besy-benazepril hcl oral capsule 10-0 mg, 10-0 mg,.5-10 mg, 5-10 mg, 5-0 mg, 5-0 mg benazepril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg, mg captopril-hydrochlorothiazide oral tablet 5-15 mg, 5-5 mg, mg, 50-5 mg enalapril-hydrochlorothiazide oral tablet 10-5 mg, mg fosinopril sodium-hctz oral tablet mg, mg lisinopril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg moexipril-hydrochlorothiazide oral tablet mg, 15-5 mg, mg quinapril-hydrochlorothiazide oral tablet mg, mg, 0-5 mg ACE INHIBITORS benazepril hcl oral tablet 10 mg, 0 mg, 0 mg, 5 mg 1 captopril oral tablet 100 mg, 1.5 mg, 5 mg, 50 mg 1 enalapril maleate oral tablet 10 mg,.5 mg, 0 mg, 5 mg fosinopril sodium oral tablet 10 mg, 0 mg, 0 mg 1 1

31 lisinopril oral tablet 10 mg,.5 mg, 0 mg, 0 mg, 0 mg, 5 mg 1 moexipril hcl oral tablet 15 mg, 7.5 mg perindopril erbumine oral tablet mg, mg, 8 mg quinapril hcl oral tablet 10 mg, 0 mg, 0 mg, 5 mg 1 ramipril oral capsule 1.5 mg, 10 mg,.5 mg, 5 mg 1 trandolapril oral tablet 1 mg, mg, mg ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone oral tablet 5 mg, 50 mg spironolactone oral tablet 100 mg, 5 mg, 50 mg 1 ALPHA BLOCKERS doxazosin mesylate oral tablet 1 mg, mg, mg, 8 mg prazosin hcl oral capsule 1 mg, mg, 5 mg terazosin hcl oral capsule 1 mg, 10 mg, mg, 5 mg 1 ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan oral tablet mg, 10-0 mg, mg, 5-0 mg amlodipine-valsartan-hctz oral tablet mg, mg, mg, mg, mg ENTRESTO ORAL TABLET -6 MG, 9-51 MG, MG irbesartan-hydrochlorothiazide oral tablet mg, mg losartan potassium-hctz oral tablet mg, mg, mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, 0-5 mg, mg ANGIOTENSIN II RECEPTOR ANTAGONISTS PA 1 irbesartan oral tablet 150 mg, 00 mg, 75 mg losartan potassium oral tablet 100 mg, 5 mg, 50 mg 1 valsartan oral tablet 160 mg, 0 mg, 0 mg, 80 mg

32 ANTIARRHYTHMICS amiodarone hcl intravenous* solution 150 mg/ml, 50 mg/9ml, 900 mg/18ml amiodarone hcl oral tablet 100 mg, 00 mg amiodarone hcl oral tablet 00 mg disopyramide phosphate oral capsule 100 mg, 150 mg PA DOFETILIDE ORAL CAPSULE 15 MCG, 50 MCG, 500 MCG flecainide acetate oral tablet 100 mg, 150 mg, 50 mg mexiletine hcl oral capsule 150 mg, 00 mg, 50 mg MULTAQ ORAL TABLET 00 MG NORPACE CR ORAL CAPSULE EXTENDED RELEASE 1 HOUR 100 MG, 150 MG pacerone oral tablet 100 mg, 00 mg pacerone oral tablet 00 mg propafenone hcl er oral capsule extended release 1 hour 5 mg, 5 mg, 5 mg propafenone hcl oral tablet 150 mg, 5 mg, 00 mg quinidine gluconate er oral tablet extendedrelease* mg quinidine sulfate oral tablet 00 mg, 00 mg sorine oral tablet 10 mg, 160 mg, 0 mg, 80 mg sotalol hcl (af) oral tablet 10 mg, 160 mg, 80 mg sotalol hcl oral tablet 10 mg, 160 mg, 0 mg, 80 mg ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 10 mg, 0 mg, 0 mg, 80 mg lovastatin oral tablet 10 mg, 0 mg, 0 mg 1 pravastatin sodium oral tablet 10 mg, 0 mg, 0 mg, 80 mg rosuvastatin calcium oral tablet 10 mg, 0 mg, 0 mg, 5 mg simvastatin oral tablet 10 mg, 0 mg, 0 mg, 5 mg 1 PA 1 1 QL (0 EA per 0 days)

33 simvastatin oral tablet 80 mg 1 QL (0 EA per 0 days) ANTILIPEMICS, MISCELLANEOUS cholestyramine light oral packet gm cholestyramine oral packet gm cholestyramine oral powder gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral packet 5 gm colestipol hcl oral tablet 1 gm fenofibrate micronized oral capsule 1 mg, 00 mg, 67 mg fenofibrate oral tablet 15 mg, 160 mg, 8 mg, 5 mg gemfibrozil oral tablet 600 mg JUXTAPID ORAL CAPSULE 10 MG, 0 MG, 0 MG, 0 MG, 5 MG, 60 MG KYNAMRO SUBCUTANEOUS* 00 MG/ML PA niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000 mg, 750 mg niacin er (antihyperlipidemic) oral tablet extendedrelease* 500 mg niacor oral tablet 500 mg omega--acid ethyl esters oral capsule 1 gm PRALUENT SUBCUTANEOUS* 150 MG/ML, 75 MG/ML PA prevalite oral packet gm prevalite oral powder gm/dose VASCEPA ORAL CAPSULE 1 GM WELCHOL ORAL PACKET.75 GM WELCHOL ORAL TABLET 65 MG ZETIA ORAL TABLET 10 MG BETA-BLOCKER/DIURETIC COMBINATIONS atenolol-chlorthalidone oral tablet mg, 50-5 mg PA; LA QL (90 EA per 0 days) bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg

34 metoprolol-hydrochlorothiazide oral tablet mg, mg, 50-5 mg BETA-BLOCKERS acebutolol hcl oral capsule 00 mg, 00 mg atenolol oral tablet 100 mg, 5 mg, 50 mg 1 bisoprolol fumarate oral tablet 10 mg, 5 mg BYSTOLIC ORAL TABLET 10 MG,.5 MG, 0 MG, 5 MG carvedilol oral tablet 1.5 mg, 5 mg,.15 mg, 6.5 mg 1 labetalol hcl oral tablet 100 mg, 00 mg, 00 mg metoprolol succinate er oral tablet extended release hr* 100 mg, 00 mg, 5 mg, 50 mg metoprolol tartrate intravenous* solution 1 mg/ml, 5 mg/5ml metoprolol tartrate oral tablet 100 mg, 5 mg, 50 mg 1 nadolol oral tablet 0 mg, 0 mg, 80 mg pindolol oral tablet 10 mg, 5 mg propranolol hcl er oral capsule extended release hour 10 mg, 160 mg, 60 mg, 80 mg propranolol hcl intravenous* solution 1 mg/ml propranolol hcl oral solution 0 mg/5ml, 0 mg/5ml propranolol hcl oral tablet 10 mg, 0 mg, 0 mg, 60 mg, 80 mg timolol maleate oral tablet 10 mg, 0 mg, 5 mg CALCIUM CHANNEL BLOCKERS afeditab cr oral tablet extended release hr* 0 mg, 60 mg amlodipine besylate oral tablet 10 mg,.5 mg, 5 mg 1 cartia xt oral capsule extended release hour 10 mg, 180 mg, 0 mg, 00 mg diltiazem hcl er beads oral capsule extended release hour 10 mg, 180 mg, 0 mg, 00 mg, 60 mg, 0 mg 5

35 diltiazem hcl er coated beads oral capsule extended release hour 10 mg, 180 mg, 0 mg, 00 mg, 60 mg diltiazem hcl er oral capsule extended release 1 hour 10 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release hour 10 mg, 0 mg diltiazem hcl intravenous* solution 15 mg/5ml, 5 mg/5ml, 50 mg/10ml diltiazem hcl oral tablet 10 mg, 0 mg, 60 mg, 90 mg dilt-xr oral capsule extended release hour 10 mg, 180 mg, 0 mg felodipine er oral tablet extended release hr* 10 mg,.5 mg, 5 mg nicardipine hcl oral capsule 0 mg, 0 mg nifedical xl oral tablet extended release hr* 0 mg, 60 mg nifedipine er oral tablet extended release hr* 0 mg, 60 mg, 90 mg nifedipine er osmotic release oral tablet extended release hr* 0 mg, 60 mg, 90 mg nimodipine oral capsule 0 mg NYMALIZE ORAL SOLUTION 60 MG/0ML taztia xt oral capsule extended release hour 10 mg, 180 mg, 0 mg, 00 mg, 60 mg verapamil hcl er oral capsule extended release hour 100 mg, 10 mg, 180 mg, 00 mg, 0 mg, 00 mg VERAPAMIL HCL ER ORAL CAPSULE EXTENDED RELEASE HOUR 60 MG verapamil hcl er oral tablet extendedrelease* 10 mg, 180 mg, 0 mg verapamil hcl intravenous* solution.5 mg/ml verapamil hcl oral tablet 10 mg, 0 mg, 80 mg 1 6

36 DIGITALIS GLYCOSIDES digitek oral tablet 15 mcg QL (0 EA per 0 days) digitek oral tablet 50 mcg PA digox oral tablet 15 mcg QL (0 EA per 0 days) digox oral tablet 50 mcg PA digoxin injection solution 0.5 mg/ml DIGOXIN ORAL SOLUTION 0.05 MG/ML PA digoxin oral tablet 15 mcg QL (0 EA per 0 days) digoxin oral tablet 50 mcg PA DIURETICS acetazolamide er oral capsule extended release 1 hour 500 mg acetazolamide oral tablet 15 mg, 50 mg amiloride hcl oral tablet 5 mg amiloride-hydrochlorothiazide oral tablet 5-50 mg bumetanide injection solution 0.5 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, mg chlorothiazide oral tablet 50 mg, 500 mg chlorthalidone oral tablet 5 mg, 50 mg FUROSEMIDE INJECTION SOLUTION 10 MG/ML furosemide injection solution 10 mg/ml (ml syringe) furosemide oral solution 10 mg/ml, 8 mg/ml furosemide oral tablet 0 mg, 0 mg, 80 mg 1 hydrochlorothiazide oral capsule 1.5 mg 1 hydrochlorothiazide oral tablet 1.5 mg, 5 mg, 50 mg 1 indapamide oral tablet 1.5 mg,.5 mg methazolamide oral tablet 5 mg, 50 mg metolazone oral tablet 10 mg,.5 mg, 5 mg spironolactone-hctz oral tablet 5-5 mg torsemide oral tablet 10 mg, 100 mg, 0 mg, 5 mg triamterene-hctz oral capsule mg 1 7

37 triamterene-hctz oral tablet mg, mg 1 MISCELLANEOUS clonidine hcl oral tablet 0.1 mg, 0. mg, 0. mg 1 clonidine hcl transdermal patch weekly 0.1 mg/hr, 0. mg/hr, 0. mg/hr DEMSER ORAL CAPSULE 50 MG hydralazine hcl injection solution 0 mg/ml hydralazine hcl oral tablet 10 mg, 100 mg, 5 mg, 50 mg midodrine hcl oral tablet 10 mg,.5 mg, 5 mg minoxidil oral tablet 10 mg,.5 mg NORTHERA ORAL CAPSULE 100 MG, 00 MG, 00 MG PA; LA RANEXA ORAL TABLET EXTENDED RELEASE 1 HR* 1000 MG, 500 MG NITRATES isosorbide dinitrate er oral tablet extendedrelease* 0 mg isosorbide dinitrate oral tablet 10 mg, 0 mg, 0 mg, 5 mg isosorbide mononitrate er oral tablet extended release hr* 10 mg, 0 mg, 60 mg isosorbide mononitrate oral tablet 10 mg, 0 mg minitran transdermal patch hr 0.1 mg/hr, 0. mg/hr, 0. mg/hr, 0.6 mg/hr nitro-bid transdermal ointment % nitroglycerin transdermal patch hr 0.1 mg/hr, 0. mg/hr, 0. mg/hr, 0.6 mg/hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0. MG, 0. MG, 0.6 MG PULMONARY ARTERIAL HYPERTENSION ADCIRCA ORAL TABLET 0 MG PA ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, MG,.5 MG PA; LA; QL (90 EA per 0 days) 8

38 LETAIRIS ORAL TABLET 10 MG, 5 MG PA; LA; QL (0 EA per 0 days) OPSUMIT ORAL TABLET 10 MG PA; LA REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML,.5 MG/ML, 5 MG/ML REVATIO ORAL SUSPENSION RECONSTITUTED 10 MG/ML PA; LA PA; QL ( ML per 0 days) sildenafil citrate oral tablet 0 mg PA; QL (90 EA per 0 days) UPTRAVI ORAL 00 & 800 MCG PA; LA UPTRAVI ORAL TABLET 1000 MCG PA; LA; QL (90 EA per 0 days) UPTRAVI ORAL TABLET 100 MCG, 100 MCG, 1600 MCG PA; LA; QL (60 EA per 0 days) UPTRAVI ORAL TABLET 00 MCG PA; LA; QL (80 EA per 0 days) UPTRAVI ORAL TABLET 00 MCG PA; LA; QL (0 EA per 0 days) UPTRAVI ORAL TABLET 600 MCG PA; LA; QL (150 EA per 0 days) UPTRAVI ORAL TABLET 800 MCG PA; LA; QL (10 EA per 0 days) VENTAVIS INHALATION SOLUTION 10 MCG/ML, 0 MCG/ML CENTRAL NERVOUS SYSTEM ANTIANXIETY PA alprazolam oral tablet 0.5 mg QL (80 EA per 0 days) alprazolam oral tablet 0.5 mg QL (0 EA per 0 days) alprazolam oral tablet 1 mg QL (10 EA per 0 days) alprazolam oral tablet mg QL (150 EA per 0 days) buspirone hcl oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg fluvoxamine maleate oral tablet 100 mg fluvoxamine maleate oral tablet 5 mg, 50 mg QL (5 EA per 0 days) lorazepam injection solution mg/ml, mg/ml lorazepam intensol oral concentrate mg/ml QL (150 ML per 0 days) lorazepam oral tablet 0.5 mg, 1 mg, mg QL (150 EA per 0 days) ANTICONVULSANTS APTIOM ORAL TABLET 00 MG QL (180 EA per 0 days) APTIOM ORAL TABLET 00 MG QL (90 EA per 0 days) 9

39 APTIOM ORAL TABLET 600 MG QL (60 EA per 0 days) APTIOM ORAL TABLET 800 MG QL (0 EA per 0 days) BANZEL ORAL SUSPENSION 0 MG/ML PA BANZEL ORAL TABLET 00 MG, 00 MG PA BRIVIACT INTRAVENOUS* SOLUTION 50 MG/5ML PA BRIVIACT ORAL SOLUTION 10 MG/ML PA BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG carbamazepine er oral capsule extended release 1 hour 100 mg, 00 mg, 00 mg carbamazepine er oral tablet extended release 1 hr* 100 mg, 00 mg, 00 mg carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 00 mg carbamazepine oral tablet chewable 100 mg CELONTIN ORAL CAPSULE 00 MG clonazepam oral tablet 0.5 mg QL (0 EA per 0 days) clonazepam oral tablet 1 mg QL (10 EA per 0 days) clonazepam oral tablet mg QL (00 EA per 0 days) clonazepam oral tablet dispersible 0.15 mg QL (960 EA per 0 days) clonazepam oral tablet dispersible 0.5 mg QL (80 EA per 0 days) clonazepam oral tablet dispersible 0.5 mg QL (0 EA per 0 days) clonazepam oral tablet dispersible 1 mg QL (10 EA per 0 days) clonazepam oral tablet dispersible mg QL (00 EA per 0 days) clorazepate dipotassium oral tablet 15 mg PA; QL (180 EA per 0 days) clorazepate dipotassium oral tablet.75 mg, 7.5 mg PA; QL (10 EA per 0 days) DIAZEPAM GEL 10 MG,.5 MG, 0 MG diazepam injection solution 5 mg/ml diazepam intensol oral concentrate 5 mg/ml PA; QL (0 ML per 0 days) diazepam oral solution 1 mg/ml PA; QL (100 ML per 0 days) diazepam oral tablet 10 mg, mg, 5 mg PA; QL (10 EA per 0 days) dilantin infatabs oral tablet chewable 50 mg 0 PA

40 dilantin oral capsule 100 mg, 0 mg DILANTIN ORAL SUSPENSION 15 MG/5ML divalproex sodium er oral tablet extended release hr* 50 mg, 500 mg divalproex sodium oral 15 mg divalproex sodium oral tablet delayed release 15 mg, 50 mg, 500 mg epitol oral tablet 00 mg ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5ml felbamate oral suspension 600 mg/5ml felbamate oral tablet 00 mg, 600 mg FYCOMPA ORAL SUSPENSION 0.5 MG/ML PA; QL (70 ML per 0 days) FYCOMPA ORAL TABLET 10 MG, 1 MG, 8 MG PA; QL (0 EA per 0 days) FYCOMPA ORAL TABLET MG PA; QL (180 EA per 0 days) FYCOMPA ORAL TABLET MG PA; QL (90 EA per 0 days) FYCOMPA ORAL TABLET 6 MG PA; QL (60 EA per 0 days) gabapentin oral capsule 100 mg QL (1080 EA per 0 days) gabapentin oral capsule 00 mg QL (60 EA per 0 days) gabapentin oral capsule 00 mg QL (70 EA per 0 days) gabapentin oral solution 50 mg/5ml QL (160 ML per 0 days) gabapentin oral tablet 600 mg QL (180 EA per 0 days) gabapentin oral tablet 800 mg QL (10 EA per 0 days) lamotrigine oral tablet 100 mg, 150 mg, 00 mg, 5 mg lamotrigine oral tablet chewable 5 mg, 5 mg LEVETIRACETAM IN NACL INTRAVENOUS* SOLUTION 1000 MG/100ML, 1500 MG/100ML, 500 MG/100ML levetiracetam intravenous* solution 500 mg/5ml levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 50 mg, 500 mg, 750 mg 1

41 LYRICA ORAL CAPSULE 100 MG, 150 MG, 5 MG, 50 MG, 75 MG QL (10 EA per 0 days) LYRICA ORAL CAPSULE 00 MG QL (90 EA per 0 days) LYRICA ORAL CAPSULE 5 MG, 00 MG QL (60 EA per 0 days) LYRICA ORAL SOLUTION 0 MG/ML QL (96 ML per 0 days) ONFI ORAL SUSPENSION.5 MG/ML PA ONFI ORAL TABLET 10 MG PA ONFI ORAL TABLET 0 MG PA oxcarbazepine oral suspension 00 mg/5ml oxcarbazepine oral tablet 150 mg, 00 mg, 600 mg PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 mg/5ml PA phenobarbital oral tablet 100 mg, 15 mg, 16. mg, 0 mg,. mg, 60 mg, 6.8 mg, 97. mg PA phenobarbital sodium injection solution 10 mg/ml PA PHENOBARBITAL SODIUM INJECTION SOLUTION 65 MG/ML phenytek oral capsule 00 mg, 00 mg phenytoin oral suspension 15 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium extended oral capsule 100 mg, 00 mg, 00 mg phenytoin sodium injection solution 50 mg/ml PA POTIGA ORAL TABLET 00 MG QL (180 EA per 0 days) POTIGA ORAL TABLET 00 MG, 00 MG QL (90 EA per 0 days) POTIGA ORAL TABLET 50 MG primidone oral tablet 50 mg, 50 mg roweepra oral tablet 500 mg SABRIL ORAL PACKET 500 MG PA; LA; QL (180 EA per 0 days) SABRIL ORAL TABLET 500 MG PA; LA; QL (180 EA per 0 days) SPRITAM ORAL 1000 MG, 50 MG, 500 MG, 750 MG TEGRETOL ORAL SUSPENSION 100 MG/5ML

42 TEGRETOL ORAL TABLET 00 MG TEGRETOL-XR ORAL TABLET EXTENDED RELEASE 1 HR* 100 MG, 00 MG, 00 MG tiagabine hcl oral tablet mg, mg topiramate oral capsule sprinkle 15 mg, 5 mg topiramate oral tablet 100 mg, 00 mg, 5 mg, 50 mg valproate sodium intravenous* solution 500 mg/5ml valproic acid oral capsule 50 mg valproic acid oral syrup 50 mg/5ml VIMPAT INTRAVENOUS* SOLUTION 00 MG/0ML VIMPAT ORAL SOLUTION 10 MG/ML QL (100 ML per 0 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 00 MG QL (60 EA per 0 days) VIMPAT ORAL TABLET 50 MG QL (180 EA per 0 days) zonisamide oral capsule 100 mg, 5 mg, 50 mg ANTIDEMENTIA donepezil hcl oral tablet 10 mg donepezil hcl oral tablet 5 mg QL (60 EA per 0 days) donepezil hcl oral tablet dispersible 10 mg donepezil hcl oral tablet dispersible 5 mg QL (60 EA per 0 days) galantamine hydrobromide er oral capsule extended release hour 16 mg, 8 mg galantamine hydrobromide er oral capsule extended release hour mg galantamine hydrobromide oral solution mg/ml galantamine hydrobromide oral tablet 1 mg QL (0 EA per 0 days) galantamine hydrobromide oral tablet mg QL (180 EA per 0 days) galantamine hydrobromide oral tablet 8 mg QL (90 EA per 0 days) memantine hcl oral solution mg/ml PA MEMANTINE HCL ORAL TABLET 10 MG PA memantine hcl oral tablet 5 mg PA NAMENDA XR ORAL CAPSULE EXTENDED RELEASE HOUR 1 MG, 1 MG, 8 MG, 7 MG PA

43 NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE HOUR 7 & 1 & 1 NAMZARIC ORAL CAPSULE EXTENDED RELEASE HOUR 1-10 MG, 8-10 MG rivastigmine tartrate oral capsule 1.5 mg, mg,.5 mg, 6 mg rivastigmine transdermal patch hr 1. mg/hr,.6 mg/hr, 9.5 mg/hr ANTIDEPRESSANTS amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg PA QL (0 EA per 0 days) PA amoxapine oral tablet 100 mg, 150 mg, 5 mg, 50 mg bupropion hcl er (sr) oral tablet extended release 1 hr* 100 mg, 150 mg, 00 mg bupropion hcl er (xl) oral tablet extended release hr* 150 mg bupropion hcl er (xl) oral tablet extended release hr* 00 mg QL (90 EA per 0 days) QL (0 EA per 0 days) bupropion hcl oral tablet 100 mg, 75 mg citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg, 0 mg, 0 mg 1 clomipramine hcl oral capsule 5 mg, 50 mg, 75 mg PA desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 5 mg, 50 mg, 75 mg PA doxepin hcl oral concentrate 10 mg/ml PA duloxetine hcl oral capsule delayed release particles 0 mg duloxetine hcl oral capsule delayed release particles 0 mg duloxetine hcl oral capsule delayed release particles 60 mg QL (180 EA per 0 days) QL (10 EA per 0 days) QL (60 EA per 0 days)

44 EMSAM TRANSDERMAL PATCH HR 1 MG/HR, 6 MG/HR, 9 MG/HR PA; QL (0 EA per 0 days) escitalopram oxalate oral solution 5 mg/5ml QL (600 ML per 0 days) escitalopram oxalate oral tablet 10 mg, 5 mg QL (5 EA per 0 days) escitalopram oxalate oral tablet 0 mg QL (60 EA per 0 days) FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 10 MG, 80 MG FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG FETZIMA ORAL CAPSULE EXTENDED RELEASE HOUR 0 MG FETZIMA TITRATION ORAL 0 & 0 MG QL (0 EA per 0 days) QL (180 EA per 0 days) QL (90 EA per 0 days) fluoxetine hcl oral capsule 10 mg 1 QL (0 EA per 0 days) fluoxetine hcl oral capsule 0 mg 1 QL (10 EA per 0 days) fluoxetine hcl oral capsule 0 mg 1 fluoxetine hcl oral solution 0 mg/5ml fluoxetine hcl oral tablet 10 mg QL (5 EA per 0 days) fluoxetine hcl oral tablet 0 mg imipramine hcl oral tablet 10 mg, 5 mg, 50 mg PA maprotiline hcl oral tablet 5 mg, 50 mg, 75 mg MARPLAN ORAL TABLET 10 MG QL (180 EA per 0 days) mirtazapine oral tablet 15 mg, 7.5 mg QL (5 EA per 0 days) mirtazapine oral tablet 0 mg, 5 mg mirtazapine oral tablet dispersible 15 mg QL (0 EA per 0 days) mirtazapine oral tablet dispersible 0 mg, 5 mg nefazodone hcl oral tablet 100 mg, 150 mg, 00 mg, 50 mg, 50 mg nortriptyline hcl oral capsule 10 mg, 5 mg, 50 mg, 75 mg nortriptyline hcl oral solution 10 mg/5ml paroxetine hcl oral tablet 10 mg, 0 mg, 0 mg 1 QL (5 EA per 0 days) paroxetine hcl oral tablet 0 mg 1 QL (60 EA per 0 days) PAXIL ORAL SUSPENSION 10 MG/5ML QL (900 ML per 0 days) 5

45 phenelzine sulfate oral tablet 15 mg PRISTIQ ORAL TABLET EXTENDED RELEASE HR* 100 MG, 5 MG, 50 MG protriptyline hcl oral tablet 10 mg, 5 mg sertraline hcl oral concentrate 0 mg/ml sertraline hcl oral tablet 100 mg 1 QL (0 EA per 0 days) sertraline hcl oral tablet 5 mg, 50 mg 1 QL (5 EA per 0 days) tranylcypromine sulfate oral tablet 10 mg trazodone hcl oral tablet 100 mg, 150 mg, 50 mg trimipramine maleate oral capsule 100 mg PA; QL (60 EA per 0 days) trimipramine maleate oral capsule 5 mg PA; QL (0 EA per 0 days) trimipramine maleate oral capsule 50 mg PA; QL (10 EA per 0 days) TRINTELLIX ORAL TABLET 10 MG QL (60 EA per 0 days) TRINTELLIX ORAL TABLET 0 MG QL (0 EA per 0 days) TRINTELLIX ORAL TABLET 5 MG QL (10 EA per 0 days) venlafaxine hcl er oral capsule extended release hour 150 mg, 7.5 mg, 75 mg venlafaxine hcl oral tablet 100 mg, 5 mg, 7.5 mg, 50 mg, 75 mg VIIBRYD ORAL TABLET 10 MG, 0 MG, 0 MG QL (0 EA per 0 days) VIIBRYD STARTER PACK ORAL KIT 10 & 0 MG ANTIPARKINSONIAN AGENTS amantadine hcl oral capsule 100 mg QL (10 EA per 0 days) amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 100 mg APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML PA; LA AZILECT ORAL TABLET 0.5 MG, 1 MG BENZTROPINE MESYLATE INJECTION SOLUTION 1 MG/ML benztropine mesylate oral tablet 0.5 mg, 1 mg, mg PA bromocriptine mesylate oral capsule 5 mg bromocriptine mesylate oral tablet.5 mg 6

46 carbidopa-levodopa er oral tablet extendedrelease* mg, mg carbidopa-levodopa oral tablet mg, mg, 5-50 mg carbidopa-levodopa oral tablet dispersible mg, mg, 5-50 mg ENTACAPONE ORAL TABLET 00 MG NEUPRO TRANSDERMAL PATCH HR 1 MG/HR, MG/HR, MG/HR, MG/HR, 6 MG/HR, 8 MG/HR pramipexole dihydrochloride oral tablet 0.15 mg, 0.5 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl oral tablet 0.5 mg, 0.5 mg, 1 mg, mg, mg, mg, 5 mg selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg ANTIPSYCHOTICS ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 00 MG, 00 MG (1.5ML SYRINGE), 00 MG QL (1 EA per 8 days) aripiprazole oral solution 1 mg/ml QL (900 ML per 0 days) aripiprazole oral tablet 10 mg, 15 mg, mg, 0 mg, 0 mg, 5 mg QL (0 EA per 0 days) aripiprazole oral tablet dispersible 10 mg, 15 mg QL (60 EA per 0 days) chlorpromazine hcl injection solution 5 mg/ml, 50 mg/ml chlorpromazine hcl oral tablet 10 mg, 100 mg, 00 mg, 5 mg, 50 mg clozapine oral tablet 100 mg QL (70 EA per 0 days) clozapine oral tablet 00 mg QL (15 EA per 0 days) clozapine oral tablet 5 mg, 50 mg CLOZAPINE ORAL TABLET DISPERSIBLE 100 MG PA; QL (70 EA per 0 days) CLOZAPINE ORAL TABLET DISPERSIBLE 1.5 MG, 5 MG PA 7

47 CLOZAPINE ORAL TABLET DISPERSIBLE 150 MG PA; QL (180 EA per 0 days) CLOZAPINE ORAL TABLET DISPERSIBLE 00 MG PA; QL (15 EA per 0 days) FANAPT ORAL TABLET 1 MG, 10 MG, 1 MG, MG, MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET 1 & & & 6 MG fluphenazine decanoate injection solution 5 mg/ml fluphenazine hcl injection solution.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir.5 mg/5ml fluphenazine hcl oral tablet 1 mg, 10 mg,.5 mg, 5 mg GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 0 MG haloperidol decanoate intramuscular* solution 100 mg/ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate mg/ml haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, mg, 0 mg, 5 mg INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION MG/1.5ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 9 MG/0.5ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 7 MG/0.875ML INVEGA TRINZA INTRAMUSCULAR* SUSPENSION 10 MG/1.15ML QL (60 EA per 0 days) QL (6 EA per days) QL (0.75 ML per 8 days) QL (1 ML per 8 days) QL (1.5 ML per 8 days) QL (0.5 ML per 8 days) QL (0.5 ML per 8 days) QL (0.875 ML per 90 days) QL (1.15 ML per 90 days) 8

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

49 risperidone oral tablet 0.5 mg, 0.5 mg QL (90 EA per 0 days) risperidone oral tablet 1 mg, mg, mg QL (60 EA per 0 days) risperidone oral tablet mg QL (10 EA per 0 days) risperidone oral tablet dispersible 0.5 mg, 0.5 mg QL (90 EA per 0 days) risperidone oral tablet dispersible 1 mg, mg, mg QL (60 EA per 0 days) risperidone oral tablet dispersible mg QL (10 EA per 0 days) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG QL (60 EA per 0 days) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL.5 MG QL (0 EA per 0 days) SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG QL (10 EA per 0 days) SEROQUEL XR ORAL TABLET EXTENDED RELEASE HR* 150 MG, 00 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE HR* 00 MG, 00 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE HR* 50 MG thioridazine hcl oral tablet 10 mg, 100 mg, 5 mg, 50 mg QL (0 EA per 0 days) QL (60 EA per 0 days) QL (10 EA per 0 days) PA thiothixene oral capsule 1 mg, 10 mg, mg, 5 mg trifluoperazine hcl oral tablet 1 mg, 10 mg, mg, 5 mg VERSACLOZ ORAL SUSPENSION 50 MG/ML PA; QL (600 ML per 0 days) VRAYLAR ORAL 1.5 & MG VRAYLAR ORAL CAPSULE 1.5 MG QL (10 EA per 0 days) VRAYLAR ORAL CAPSULE MG QL (60 EA per 0 days) VRAYLAR ORAL CAPSULE.5 MG, 6 MG QL (0 EA per 0 days) ziprasidone hcl oral capsule 0 mg, 0 mg QL (60 EA per 0 days) ziprasidone hcl oral capsule 60 mg, 80 mg QL (90 EA per 0 days) ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION RECONSTITUTED 10 MG, 00 MG ZYPREXA RELPREVV INTRAMUSCULAR* SUSPENSION RECONSTITUTED 05 MG ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphet er oral capsule extended release hour 10 mg, 5 mg PA; QL ( EA per 8 days) PA; QL (1 EA per 8 days) QL (90 EA per 0 days) 0

50 amphetamine-dextroamphet er oral capsule extended release hour 15 mg, 0 mg, 5 mg, 0 mg QL (0 EA per 0 days) amphetamine-dextroamphetamine oral tablet 10 mg QL (180 EA per 0 days) amphetamine-dextroamphetamine oral tablet 1.5 mg QL (1 EA per 0 days) amphetamine-dextroamphetamine oral tablet 15 mg QL (10 EA per 0 days) amphetamine-dextroamphetamine oral tablet 0 mg QL (90 EA per 0 days) amphetamine-dextroamphetamine oral tablet 0 mg QL (60 EA per 0 days) amphetamine-dextroamphetamine oral tablet 5 mg QL (60 EA per 0 days) amphetamine-dextroamphetamine oral tablet 7.5 mg QL (0 EA per 0 days) guanfacine hcl er oral tablet extended release hr* 1 mg, mg, mg, mg PA metadate er oral tablet extendedrelease* 0 mg QL (90 EA per 0 days) methylphenidate hcl er oral tablet extendedrelease* 10 mg, 0 mg QL (90 EA per 0 days) methylphenidate hcl oral solution 10 mg/5ml QL (900 ML per 0 days) methylphenidate hcl oral solution 5 mg/5ml QL (1800 ML per 0 days) methylphenidate hcl oral tablet 10 mg, 5 mg QL (180 EA per 0 days) methylphenidate hcl oral tablet 0 mg QL (90 EA per 0 days) STRATTERA ORAL CAPSULE 10 MG, 18 MG, 5 MG QL (10 EA per 0 days) STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG QL (0 EA per 0 days) STRATTERA ORAL CAPSULE 0 MG QL (60 EA per 0 days) HYPNOTICS HETLIOZ ORAL CAPSULE 0 MG PA; LA SILENOR ORAL TABLET MG QL (60 EA per 0 days) SILENOR ORAL TABLET 6 MG QL (0 EA per 0 days) temazepam oral capsule 15 mg PA; QL (60 EA per 0 days) temazepam oral capsule 7.5 mg PA; QL (0 EA per 0 days) zolpidem tartrate oral tablet 10 mg, 5 mg PA; QL (0 EA per 0 days) MIGRAINE cafergot oral tablet mg dihydroergotamine mesylate injection solution 1 mg/ml migergot suppository -100 mg 1

51 rizatriptan benzoate oral tablet 10 mg, 5 mg QL (18 EA per 0 days) SUMATRIPTAN NASAL SOLUTION 0 MG/ACT QL (1 EA per 0 days) SUMATRIPTAN NASAL SOLUTION 5 MG/ACT QL ( EA per 0 days) sumatriptan succinate oral tablet 100 mg, 5 mg, 50 mg SUMATRIPTAN SUCCINATE REFILL SUBCUTANEOUS* MG/0.5ML SUMATRIPTAN SUCCINATE REFILL SUBCUTANEOUS* 6 MG/0.5ML SUMATRIPTAN SUCCINATE SUBCUTANEOUS* MG/0.5ML QL (1 EA per 0 days) QL (9 ML per 0 days) QL (6 ML per 0 days) QL (9 ML per 0 days) sumatriptan succinate subcutaneous* 6 mg/0.5ml QL (6 ML per 0 days) sumatriptan succinate subcutaneous* solution 6 mg/0.5ml MISCELLANEOUS lithium carbonate er oral tablet extendedrelease* 00 mg, 50 mg lithium carbonate oral capsule 150 mg, 00 mg, 600 mg QL (6 ML per 0 days) lithium carbonate oral tablet 00 mg LITHIUM ORAL SOLUTION 8 MEQ/5ML NUEDEXTA ORAL CAPSULE 0-10 MG PA pyridostigmine bromide oral tablet 60 mg riluzole oral tablet 50 mg TETRABENAZINE ORAL TABLET 1.5 MG PA; QL (0 EA per 0 days) TETRABENAZINE ORAL TABLET 5 MG PA; QL (10 EA per 0 days) MULTIPLE SCLEROSIS AGENTS AMPYRA ORAL TABLET EXTENDED RELEASE 1 HR* 10 MG PA; LA BETASERON SUBCUTANEOUS* KIT 0. MG PA; QL (1 EA per 8 days) COPAXONE SUBCUTANEOUS* 0 MG/ML PA; QL (1 ML per 8 days) GILENYA ORAL CAPSULE 0.5 MG PA; QL (8 EA per 8 days) glatopa subcutaneous* 0 mg/ml PA; QL (0 ML per 0 days)

52 TYSABRI INTRAVENOUS* CONCENTRATE 00 MG/15ML PA; LA MUSCULOSKELETAL THERAPY AGENTS baclofen oral tablet 10 mg, 0 mg cyclobenzaprine hcl oral tablet 10 mg, 5 mg PA dantrolene sodium oral capsule 100 mg, 5 mg, 50 mg tizanidine hcl oral tablet mg, mg NARCOLEPSY/CATAPLEXY armodafinil oral tablet 150 mg PA; QL (60 EA per 0 days) ARMODAFINIL ORAL TABLET 00 MG PA; QL (0 EA per 0 days) armodafinil oral tablet 50 mg PA; QL (0 EA per 0 days) armodafinil oral tablet 50 mg PA; QL (150 EA per 0 days) XYREM ORAL SOLUTION 500 MG/ML PA; LA; QL (50 ML per 0 days) PSYCHOTHERAPEUTIC-MISC acamprosate calcium oral tablet delayed release mg buprenorphine hcl sublingual tablet sublingual mg, 8 mg buprenorphine hcl-naloxone hcl sublingual tablet sublingual -0.5 mg, 8- mg buproban oral tablet extended release 1 hr* 150 mg bupropion hcl er (smoking det) oral tablet extended release 1 hr* 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X disulfiram oral tablet 50 mg, 500 mg naloxone hcl injection solution 0. mg/ml, 1 mg/ml naltrexone hcl oral tablet 50 mg NICOTROL INHALATION INHALER 10 MG NICOTROL NS NASAL SOLUTION 10 MG/ML PA PA; QL (10 EA per 0 days) SUBOXONE SUBLINGUAL FILM 1- MG PA; QL (60 EA per 0 days)

53 SUBOXONE SUBLINGUAL FILM -0.5 MG, -1 MG, 8- MG CORTICOSTEROIDS - TOPICAL CORTICOSTEROIDS - TOPICAL PA; QL (10 EA per 0 days) clobetasol propionate emulsion external foam 0.05 % ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 ORAL TABLET 50 MG PA ANDRODERM TRANSDERMAL PATCH HR MG/HR, MG/HR PA; QL (0 EA per 0 days) AXIRON TRANSDERMAL SOLUTION 0 MG/ACT PA; QL (0 ML per 0 days) oxandrolone oral tablet 10 mg,.5 mg PA testosterone cypionate intramuscular* solution 100 mg/ml, 00 mg/ml testosterone enanthate intramuscular* solution 00 mg/ml ANTIDIABETICS, INJECTABLE ASSURE ID INSULIN SAFETY SYR 9G X 1/" 1 ML BYDUREON SUBCUTANEOUS* MG QL ( EA per 8 days) BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.0ML QL (. ML per 0 days) BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.0ML QL (1. ML per 0 days) COMFORT ASSIST INSULIN SYRINGE 9G X 1/" 1 ML CVS GAUZE STERILE PAD "X" EXEL COMFORT POINT PEN NEEDLE 9G X 1MM GLOBAL ALCOHOL PREP EASE PAD 70 % HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML HUMULIN R U-500 KWIKPEN SUBCUTANEOUS* 500 UNIT/ML B/D LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML

54 NOVOLIN 70/0 SUBCUTANEOUS* SUSPENSION (70-0) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS* 100 UNIT/ML NOVOLOG MIX 70/0 FLEXPEN SUBCUTANEOUS* (70-0) 100 UNIT/ML NOVOLOG MIX 70/0 SUBCUTANEOUS* SUSPENSION (70-0) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS* 100 UNIT/ML NOVOLOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML PREFERRED PLUS INSULIN SYRINGE 8G X 1/" 0.5 ML RELI-ON INSULIN SYRINGE 9G 0. ML SYMLINPEN 10 SUBCUTANEOUS* 700 MCG/.7ML PA; QL (10.8 ML per 0 days) SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML PA; QL (1 ML per 0 days) TOUJEO SOLOSTAR SUBCUTANEOUS* 00 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML, 00 UNIT/ML TRULICITY SUBCUTANEOUS* 0.75 MG/0.5ML, 1.5 MG/0.5ML QL ( ML per 8 days) VICTOZA SUBCUTANEOUS* 18 MG/ML QL (9 ML per 0 days) ANTIDIABETICS, ORAL acarbose oral tablet 100 mg, 5 mg, 50 mg FARXIGA ORAL TABLET 10 MG QL (0 EA per 0 days) FARXIGA ORAL TABLET 5 MG QL (60 EA per 0 days) glimepiride oral tablet 1 mg 1 QL (0 EA per 0 days) glimepiride oral tablet mg 1 QL (10 EA per 0 days) glimepiride oral tablet mg 1 QL (60 EA per 0 days) glipizide er oral tablet extended release hr* 10 mg QL (60 EA per 0 days) glipizide er oral tablet extended release hr*.5 mg QL (0 EA per 0 days) glipizide er oral tablet extended release hr* 5 mg QL (10 EA per 0 days) glipizide oral tablet 10 mg 1 QL (10 EA per 0 days) 5

55 glipizide oral tablet 5 mg 1 QL (0 EA per 0 days) glipizide xl oral tablet extended release hr*.5 mg QL (0 EA per 0 days) glipizide xl oral tablet extended release hr* 5 mg QL (10 EA per 0 days) glipizide-metformin hcl oral tablet.5-50 mg QL (0 EA per 0 days) glipizide-metformin hcl oral tablet mg, mg INVOKAMET ORAL TABLET MG, MG, MG QL (10 EA per 0 days) QL (60 EA per 0 days) INVOKAMET ORAL TABLET MG QL (10 EA per 0 days) INVOKANA ORAL TABLET 100 MG QL (90 EA per 0 days) INVOKANA ORAL TABLET 00 MG QL (0 EA per 0 days) JANUMET ORAL TABLET MG, MG QL (60 EA per 0 days) JANUMET XR ORAL TABLET EXTENDED RELEASE HR* MG JANUMET XR ORAL TABLET EXTENDED RELEASE HR* MG, MG QL (0 EA per 0 days) QL (60 EA per 0 days) JANUVIA ORAL TABLET 100 MG, 5 MG, 50 MG QL (0 EA per 0 days) metformin hcl er oral tablet extended release hr* 500 mg metformin hcl er oral tablet extended release hr* 750 mg 1 QL (10 EA per 0 days) 1 QL (60 EA per 0 days) metformin hcl oral tablet 1000 mg 1 QL (75 EA per 0 days) metformin hcl oral tablet 500 mg 1 QL (150 EA per 0 days) metformin hcl oral tablet 850 mg 1 QL (90 EA per 0 days) nateglinide oral tablet 10 mg, 60 mg QL (90 EA per 0 days) pioglitazone hcl oral tablet 15 mg, 0 mg, 5 mg QL (0 EA per 0 days) repaglinide oral tablet 0.5 mg, 1 mg 1 QL (10 EA per 0 days) repaglinide oral tablet mg 1 QL (0 EA per 0 days) XIGDUO XR ORAL TABLET EXTENDED RELEASE HR* MG, MG XIGDUO XR ORAL TABLET EXTENDED RELEASE HR* MG, MG QL (0 EA per 0 days) QL (60 EA per 0 days) 6

56 BISPHOSPHONATES alendronate sodium oral tablet 10 mg, 0 mg, 5 mg 1 alendronate sodium oral tablet 5 mg, 70 mg 1 QL ( EA per 8 days) ibandronate sodium oral tablet 150 mg B/D; QL (1 EA per 0 days) pamidronate disodium intravenous* solution 0 mg/10ml, 6 mg/ml, 90 mg/10ml pamidronate disodium intravenous* solution reconstituted 0 mg, 90 mg B/D B/D zoledronic acid intravenous* concentrate mg/5ml B/D zoledronic acid intravenous* solution 5 mg/100ml B/D zoledronic acid intravenous* solution reconstituted mg B/D CALCIUM RECEPTOR AGONISTS SENSIPAR ORAL TABLET 0 MG QL (10 EA per 0 days) SENSIPAR ORAL TABLET 60 MG QL (60 EA per 0 days) SENSIPAR ORAL TABLET 90 MG QL (10 EA per 0 days) CHELATING AGENTS CHEMET ORAL CAPSULE 100 MG DEPEN TITRATABS ORAL TABLET 50 MG EXJADE ORAL TABLET SOLUBLE 15 MG, 50 MG, 500 MG PA; LA FERRIPROX ORAL SOLUTION 100 MG/ML PA; LA FERRIPROX ORAL TABLET 500 MG PA; LA kionex oral powder kionex oral suspension 15 gm/60ml sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 15 gm/60ml sps oral suspension 15 gm/60ml SYPRINE ORAL CAPSULE 50 MG CONTRACEPTIVES altavera oral tablet mg-mcg apri oral tablet mg-mcg 7

57 aranelle oral tablet 0.5/1/0.5-5 mg-mcg aubra oral tablet mg-mcg aviane oral tablet mg-mcg balziva oral tablet 0.-5 mg-mcg bekyree oral tablet /0.01 mg (1/5) blisovi fe 1.5/0 oral tablet mg-mcg blisovi fe 1/0 oral tablet 1-0 mg-mcg briellyn oral tablet 0.-5 mg-mcg camila oral tablet 0.5 mg cryselle-8 oral tablet 0.-0 mg-mcg cyclafem 1/5 oral tablet 1-5 mg-mcg cyclafem 7/7/7 oral tablet 0.5/0.75/1-5 mg-mcg cyred oral tablet mg-mcg deblitane oral tablet 0.5 mg delyla oral tablet mg-mcg desogestrel-ethinyl estradiol oral tablet /0.01 mg (1/5) drospirenone-ethinyl estradiol oral tablet -0.0 mg, -0.0 mg ELLA ORAL TABLET 0 MG emoquette oral tablet mg-mcg enpresse-8 oral tablet errin oral tablet 0.5 mg estarylla oral tablet mg-mcg falmina oral tablet mg-mcg GIANVI ORAL TABLET -0.0 MG gildagia oral tablet 0.-5 mg-mcg gildess 1.5/0 oral tablet mg-mcg heather oral tablet 0.5 mg introvale oral tablet mg JOLESSA ORAL TABLET MG JOLIVETTE ORAL TABLET 0.5 MG 8

58 juleber oral tablet mg-mcg junel 1.5/0 oral tablet mg-mcg junel 1/0 oral tablet 1-0 mg-mcg junel fe 1.5/0 oral tablet mg-mcg junel fe 1/0 oral tablet 1-0 mg-mcg kariva oral tablet /0.01 mg (1/5) kelnor 1/5 oral tablet 1-5 mg-mcg kimidess oral tablet /0.01 mg (1/5) larin 1.5/0 oral tablet mg-mcg larin 1/0 oral tablet 1-0 mg-mcg larin fe 1.5/0 oral tablet mg-mcg larin fe 1/0 oral tablet 1-0 mg-mcg LEENA ORAL TABLET 0.5/1/0.5-5 MG-MCG lessina oral tablet mg-mcg levonest oral tablet levonorgest-eth estrad 91-day oral tablet mg levonorgestrel oral tablet 1.5 mg levonorgestrel-ethinyl estrad oral tablet mg-mcg levonorg-eth estrad triphasic oral tablet levora 0.15/0 (8) oral tablet mg-mcg loryna oral tablet -0.0 mg low-ogestrel oral tablet 0.-0 mg-mcg lutera oral tablet mg-mcg lyza oral tablet 0.5 mg marlissa oral tablet mg-mcg medroxyprogesterone acetate intramuscular* suspension 150 mg/ml MICROGESTIN 1.5/0 ORAL TABLET MG-MCG MICROGESTIN 1/0 ORAL TABLET 1-0 MG-MCG MICROGESTIN FE 1.5/0 ORAL TABLET MG-MCG MICROGESTIN FE 1/0 ORAL TABLET 1-0 MG-MCG 9

59 mono-linyah oral tablet mg-mcg MONONESSA ORAL TABLET MG-MCG myzilra oral tablet necon 0.5/5 (8) oral tablet mg-mcg necon 1/5 (8) oral tablet 1-5 mg-mcg NECON 1/50 (8) ORAL TABLET 1-50 MG-MCG NECON 7/7/7 ORAL TABLET 0.5/0.75/1-5 MG-MCG nikki oral tablet -0.0 mg NORA-BE ORAL TABLET 0.5 MG norethindrone oral tablet 0.5 mg norgestimate-eth estradiol oral tablet mg-mcg norgestim-eth estrad triphasic oral tablet 0.18/0.15/0.5 mg-5 mcg, 0.18/0.15/0.5 mg-5 mcg norlyroc oral tablet 0.5 mg nortrel 0.5/5 (8) oral tablet mg-mcg nortrel 1/5 (1) oral tablet 1-5 mg-mcg nortrel 1/5 (8) oral tablet 1-5 mg-mcg nortrel 7/7/7 oral tablet 0.5/0.75/1-5 mg-mcg NUVARING VAGINAL RING MG/HR OCELLA ORAL TABLET -0.0 MG orsythia oral tablet mg-mcg philith oral tablet 0.-5 mg-mcg pimtrea oral tablet /0.01 mg (1/5) pirmella 1/5 oral tablet 1-5 mg-mcg portia-8 oral tablet mg-mcg previfem oral tablet mg-mcg quasense oral tablet mg reclipsen oral tablet mg-mcg setlakin oral tablet mg sharobel oral tablet 0.5 mg sprintec 8 oral tablet mg-mcg 50

60 sronyx oral tablet mg-mcg syeda oral tablet -0.0 mg tarina fe 1/0 oral tablet 1-0 mg-mcg tri-legest fe oral tablet 1-0/1-0/1-5 mg-mcg tri-lo-estarylla oral tablet 0.18/0.15/0.5 mg-5 mcg tri-lo-marzia oral tablet 0.18/0.15/0.5 mg-5 mcg tri-lo-sprintec oral tablet 0.18/0.15/0.5 mg-5 mcg TRINESSA (8) ORAL TABLET 0.18/0.15/0.5 MG-5 MCG TRINESSA LO ORAL TABLET 0.18/0.15/0.5 MG-5 MCG tri-previfem oral tablet 0.18/0.15/0.5 mg-5 mcg tri-sprintec oral tablet 0.18/0.15/0.5 mg-5 mcg trivora (8) oral tablet velivet oral tablet 0.1/0.15/ mg vestura oral tablet -0.0 mg vienva oral tablet mg-mcg viorele oral tablet /0.01 mg (1/5) vyfemla oral tablet 0.-5 mg-mcg xulane transdermal patch weekly mcg/hr zarah oral tablet -0.0 mg zenchent oral tablet 0.-5 mg-mcg zovia 1/5e (8) oral tablet 1-5 mg-mcg zovia 1/50e (8) oral tablet 1-50 mg-mcg ENDOMETRIOSIS danazol oral capsule 100 mg, 00 mg, 50 mg SYNAREL NASAL SOLUTION MG/ML ENZYME REPLACEMENTS ADAGEN INTRAMUSCULAR* SOLUTION 50 UNIT/ML PA; LA ALDURAZYME INTRAVENOUS* SOLUTION.9 MG/5ML PA; LA BUPHENYL ORAL TABLET 500 MG PA; LA CARBAGLU ORAL TABLET 00 MG PA; LA 51

61 CERDELGA ORAL CAPSULE 8 MG PA CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 00 UNIT CYSTADANE ORAL POWDER LA PA; LA CYSTAGON ORAL CAPSULE 150 MG, 50 MG PA; LA FABRAZYME INTRAVENOUS* SOLUTION RECONSTITUTED 5 MG, 5 MG PA; LA KUVAN ORAL PACKET 100 MG, 500 MG PA; LA KUVAN ORAL TABLET SOLUBLE 100 MG PA; LA levocarnitine intravenous* solution 00 mg/ml B/D levocarnitine oral solution 1 gm/10ml B/D levocarnitine oral tablet 0 mg B/D LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG PA; LA NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML PA; LA ORFADIN ORAL CAPSULE 10 MG, MG, 5 MG PA; LA ORFADIN ORAL SUSPENSION MG/ML PA; LA RAVICTI ORAL LIQUID 1.1 GM/ML PA ZAVESCA ORAL CAPSULE 100 MG PA; LA ESTROGENS DELESTROGEN INTRAMUSCULAR* OIL 10 MG/ML estrace vaginal cream 0.1 mg/gm estradiol oral tablet 0.5 mg, 1 mg, mg PA estradiol transdermal patch weekly 0.05 mg/hr, mg/hr, 0.05 mg/hr, 0.06 mg/hr, mg/hr, 0.1 mg/hr estradiol valerate intramuscular* oil 0 mg/ml, 0 mg/ml PA fyavolv oral tablet 1-5 mg-mcg PA jinteli oral tablet 1-5 mg-mcg PA norethindrone-eth estradiol oral tablet 1-5 mg-mcg PA VAGIFEM VAGINAL TABLET 10 MCG 5

62 GLUCOCORTICOIDS a-hydrocort injection solution reconstituted 100 mg cortisone acetate oral tablet 5 mg dexamethasone intensol oral concentrate 1 mg/ml dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral solution 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, mg, mg, 6 mg dexamethasone sod phosphate pf injection solution 10 mg/ml dexamethasone sodium phosphate injection solution 10 mg/ml, 100 mg/10ml, 10 mg/0ml, 0 mg/5ml, mg/ml fludrocortisone acetate oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 0 mg, 5 mg methylprednisolone acetate injection suspension 0 mg/ml, 80 mg/ml methylprednisolone oral mg methylprednisolone oral tablet 16 mg, mg, mg, 8 mg methylprednisolone sodium succ injection solution reconstituted 1000 mg, 15 mg, 0 mg prednisolone oral solution 15 mg/5ml prednisolone sodium phosphate oral solution 15 mg/5ml prednisolone sodium phosphate oral solution 5 mg/5ml, 6.7 (5 base) mg/5ml prednisone intensol oral concentrate 5 mg/ml prednisone oral 10 mg (1), 10 mg (8), 5 mg (1), 5 mg (8) prednisone oral solution 5 mg/5ml prednisone oral tablet 1 mg, 10 mg,.5 mg, 0 mg, 5 mg, 50 mg 1 SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 50 MG 5

63 GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML HUMAN GROWTH HORMONES NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 0 MG/ML, 5 MG/1.5ML MISCELLANEOUS PA cabergoline oral tablet 0.5 mg calcitonin (salmon) nasal solution 00 unit/act B/D FORTICAL NASAL SOLUTION 00 UNIT/ACT B/D INCRELEX SUBCUTANEOUS* SOLUTION 0 MG/ML PA; LA KORLYM ORAL TABLET 00 MG PA; LA MIACALCIN INJECTION SOLUTION 00 UNIT/ML B/D octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml PA octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml PA PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML QL (1 ML per 180 days) raloxifene hcl oral tablet 60 mg SIGNIFOR SUBCUTANEOUS* SOLUTION 0. MG/ML, 0.6 MG/ML, 0.9 MG/ML SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION 10 MG/0.5ML, 60 MG/0.ML, 90 MG/0.ML SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 15 MG, 0 MG, 5 MG, 0 MG PA; LA PA PA; LA XGEVA SUBCUTANEOUS* SOLUTION 10 MG/1.7ML PA PARATHYROID HORMONES FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/.ML PA; QL (. ML per 8 days) NATPARA SUBCUTANEOUS* 100 MCG, 5 MCG, 50 MCG, 75 MCG PA 5

64 PHOSPHATE BINDER AGENTS AURYXIA ORAL TABLET 10 MG calcium acetate (phos binder) oral capsule 667 mg calcium acetate (phos binder) oral tablet 667 mg RENVELA ORAL PACKET 0.8 GM,. GM RENVELA ORAL TABLET 800 MG PROGESTINS medroxyprogesterone acetate oral tablet 10 mg,.5 mg, 5 mg norethindrone acetate oral tablet 5 mg THYROID AGENTS levothyroxine sodium oral tablet 100 mcg, 11 mcg, 15 mcg, 17 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 00 mcg, 50 mcg, 75 mcg, 88 mcg levoxyl oral tablet 100 mcg, 11 mcg, 15 mcg, 17 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine sodium oral tablet 5 mcg, 5 mcg, 50 mcg methimazole oral tablet 10 mg, 5 mg propylthiouracil oral tablet 50 mg SYNTHROID ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 17 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 00 MCG, 50 MCG, 75 MCG, 88 MCG unithroid oral tablet 100 mcg, 11 mcg, 15 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 00 mcg, 50 mcg, 75 mcg, 88 mcg VASOPRESSINS DESMOPRESSIN ACE RHINAL TUBE NASAL SOLUTION 0.01 % desmopressin ace spray refrig nasal solution 0.01 % desmopressin acetate injection solution mcg/ml desmopressin acetate oral tablet 0.1 mg, 0. mg desmopressin acetate spray nasal solution 0.01 % 55

65 STIMATE NASAL SOLUTION 1.5 MG/ML GASTROINTESTINAL ANTIEMETICS compro suppository 5 mg dronabinol oral capsule 10 mg,.5 mg, 5 mg B/D; QL (60 EA per 0 days) EMEND ORAL CAPSULE 15 MG, 0 MG, 80 & 15 MG, 80 MG granisetron hcl intravenous* solution 0.1 mg/ml, 1 mg/ml, mg/ml B/D granisetron hcl oral tablet 1 mg B/D meclizine hcl oral tablet 1.5 mg, 5 mg metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 10 mg, 5 mg ondansetron hcl injection solution mg/ml, mg/ml (ml syringe), 0 mg/0ml ondansetron hcl oral solution mg/5ml ondansetron hcl oral tablet mg, mg, 8 mg ondansetron oral tablet dispersible mg, 8 mg phenadoz suppository 1.5 mg, 5 mg PA phenergan suppository 1.5 mg, 5 mg, 50 mg PA prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine suppository 5 mg promethazine hcl injection solution 5 mg/ml, 50 mg/ml PA promethazine hcl oral syrup 6.5 mg/5ml PA promethazine hcl oral tablet 1.5 mg, 5 mg, 50 mg PA promethazine hcl suppository 1.5 mg, 5 mg, 50 mg PA promethegan suppository 1.5 mg, 5 mg, 50 mg PA TRANSDERM-SCOP (1.5 MG) TRANSDERMAL PATCH 7 HR 1 MG/DAYS PA; QL (10 EA per 0 days) 56

66 ANTISPASMODICS dicyclomine hcl oral capsule 10 mg dicyclomine hcl oral solution 10 mg/5ml dicyclomine hcl oral tablet 0 mg glycopyrrolate injection solution mg/0ml glycopyrrolate oral tablet 1 mg, mg H-RECEPTOR ANTAGONISTS famotidine intravenous* solution 0 mg/ml, 00 mg/0ml, 0 mg/ml famotidine oral tablet 0 mg, 0 mg famotidine premixed intravenous* solution mg/50ml-% ranitidine hcl injection solution 150 mg/6ml, 50 mg/ml ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg, 00 mg 1 INFLAMMATORY BOWEL DISEASE APRISO ORAL CAPSULE EXTENDED RELEASE HOUR 0.75 GM ASACOL HD ORAL TABLET DELAYED RELEASE 800 MG balsalazide disodium oral capsule 750 mg budesonide oral capsule delayed release particles mg CANASA SUPPOSITORY 1000 MG colocort enema 100 mg/60ml DELZICOL ORAL CAPSULE DELAYED RELEASE 00 MG DIPENTUM ORAL CAPSULE 50 MG HYDROCORTISONE ENEMA 100 MG/60ML mesalamine enema gm mesalamine-cleanser kit gm sulfasalazine oral tablet 500 mg sulfasalazine oral tablet delayed release 500 mg LAXATIVES constulose oral solution 10 gm/15ml 57

67 enulose oral solution 10 gm/15ml gavilyte-c oral solution reconstituted 0 gm gavilyte-g oral solution reconstituted 6 gm gavilyte-h oral kit 5-10 mg-gm gavilyte-n with flavor pack oral solution reconstituted 0 gm generlac oral solution 10 gm/15ml GOLYTELY ORAL SOLUTION RECONSTITUTED 7.1 GM, 6 GM lactulose encephalopathy oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM NULYTELY WITH FLAVOR PACKS ORAL SOLUTION RECONSTITUTED 0 GM peg 50/electrolytes oral solution reconstituted 0 gm peg 50-kcl-na bicarb-nacl oral solution reconstituted 0 gm peg-50/electrolytes oral solution reconstituted 6 gm polyethylene glycol 50 oral packet polyethylene glycol 50 oral powder SUPREP BOWEL PREP ORAL SOLUTION trilyte oral solution reconstituted 0 gm MISCELLANEOUS alosetron hcl oral tablet 0.5 mg, 1 mg PA AMITIZA ORAL CAPSULE MCG, 8 MCG QL (60 EA per 0 days) CARAFATE ORAL SUSPENSION 1 GM/10ML cromolyn sodium oral concentrate 100 mg/5ml diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg GATTEX SUBCUTANEOUS* KIT 5 MG PA; LA LINZESS ORAL CAPSULE 15 MCG QL (60 EA per 0 days) 58

68 LINZESS ORAL CAPSULE 90 MCG QL (0 EA per 0 days) loperamide hcl oral capsule mg misoprostol oral tablet 100 mcg, 00 mcg MOVANTIK ORAL TABLET 1.5 MG QL (60 EA per 0 days) MOVANTIK ORAL TABLET 5 MG QL (0 EA per 0 days) RELISTOR SUBCUTANEOUS* SOLUTION 1 MG/0.6ML, 1 MG/0.6ML (0.6ML SYRINGE), 8 MG/0.ML PA sucralfate oral tablet 1 gm ursodiol oral capsule 00 mg ursodiol oral tablet 50 mg, 500 mg XIFAXAN ORAL TABLET 550 MG PA PANCREATIC ENZYMES CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 1000 UNIT, 000 UNIT, UNIT, 6000 UNIT, 6000 UNIT ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, 0000 UNIT, 5000 UNIT, UNIT, 0000 UNIT, 5000 UNIT PROTON PUMP INHIBITORS DEXILANT ORAL CAPSULE DELAYED RELEASE 0 MG, 60 MG esomeprazole magnesium oral capsule delayed release 0 mg, 0 mg esomeprazole sodium intravenous* solution reconstituted 0 mg, 0 mg NEXIUM ORAL PACKET 10 MG,.5 MG, 0 MG, 0 MG, 5 MG omeprazole oral capsule delayed release 10 mg, 0 mg, 0 mg pantoprazole sodium oral tablet delayed release 0 mg, 0 mg 1 59

69 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl er oral tablet extended release hr* 10 mg QL (0 EA per 0 days) dutasteride oral capsule 0.5 mg QL (0 EA per 0 days) dutasteride-tamsulosin hcl oral capsule mg QL (0 EA per 0 days) finasteride oral tablet 5 mg tamsulosin hcl oral capsule 0. mg MISCELLANEOUS bethanechol chloride oral tablet 10 mg, 5 mg, 5 mg, 50 mg ELMIRON ORAL CAPSULE 100 MG POTASSIUM CITRATE ER ORAL TABLET EXTENDEDRELEASE* 10 MEQ (1080 MG), 5 MEQ (50 MG) URINARY ANTISPASMODICS MYRBETRIQ ORAL TABLET EXTENDED RELEASE HR* 5 MG MYRBETRIQ ORAL TABLET EXTENDED RELEASE HR* 50 MG oxybutynin chloride er oral tablet extended release hr* 10 mg, 15 mg oxybutynin chloride er oral tablet extended release hr* 5 mg QL (60 EA per 0 days) QL (0 EA per 0 days) QL (60 EA per 0 days) QL (0 EA per 0 days) oxybutynin chloride oral syrup 5 mg/5ml oxybutynin chloride oral tablet 5 mg tolterodine tartrate er oral capsule extended release hour mg, mg QL (0 EA per 0 days) tolterodine tartrate oral tablet 1 mg, mg TOVIAZ ORAL TABLET EXTENDED RELEASE HR* MG, 8 MG QL (0 EA per 0 days) VESICARE ORAL TABLET 10 MG, 5 MG QL (0 EA per 0 days) 60

70 VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal cream % metronidazole vaginal gel 0.75 % terconazole vaginal cream 0. %, 0.8 % terconazole vaginal suppository 80 mg VANDAZOLE VAGINAL GEL 0.75 % ZAZOLE VAGINAL CREAM 0.8 % HEMATOLOGIC ANTICOAGULANTS COUMADIN ORAL TABLET 1 MG, 10 MG, MG,.5 MG, MG, MG, 5 MG, 6 MG, 7.5 MG enoxaparin sodium injection solution 00 mg/ml enoxaparin sodium subcutaneous* solution 100 mg/ml, 10 mg/0.8ml, 150 mg/ml, 0 mg/0.ml, 0 mg/0.ml, 60 mg/0.6ml, 80 mg/0.8ml fondaparinux sodium subcutaneous* solution 10 mg/0.8ml, 5 mg/0.ml, 7.5 mg/0.6ml fondaparinux sodium subcutaneous* solution.5 mg/0.5ml HEPARIN (PORCINE) IN D5W INTRAVENOUS* SOLUTION 0-5 UNIT/ML-%, 50-5 UNIT/ML-% HEPARIN (PORCINE) IN NACL INJECTION SOLUTION UNIT/ML-%, UNIT/ML-% HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS* SOLUTION 100 UNIT/ML heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, 0000 unit/ml, 5000 unit/ml HEPARIN SODIUM (PORCINE) INJECTION SOLUTION 500 UNIT/ML HEPARIN SODIUM (PORCINE) INTRAVENOUS* SOLUTION 000 UNIT/ML jantoven oral tablet 1 mg, 10 mg, mg,.5 mg, mg, mg, 5 mg, 6 mg, 7.5 mg PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG B/D B/D B/D 1 61

71 warfarin sodium oral tablet 1 mg, 10 mg, mg,.5 mg, mg, mg, 5 mg, 6 mg, 7.5 mg 1 XARELTO ORAL TABLET 10 MG, 15 MG, 0 MG XARELTO STARTER PACK ORAL 15 & 0 MG HEMATOPOIETIC GROWTH FACTORS GRANIX SUBCUTANEOUS* 00 MCG/0.5ML, 80 MCG/0.8ML LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED 50 MCG PA PA MOZOBIL SUBCUTANEOUS* SOLUTION MG/1.ML PA NEUPOGEN INJECTION 00 MCG/0.5ML, 80 MCG/0.8ML NEUPOGEN INJECTION SOLUTION 00 MCG/ML, 80 MCG/1.6ML PA PA PROCRIT INJECTION SOLUTION UNIT/ML, 000 UNIT/ML, 000 UNIT/ML, 000 UNIT/ML PA PROCRIT INJECTION SOLUTION 0000 UNIT/ML, 0000 UNIT/ML MISCELLANEOUS PA anagrelide hcl oral capsule 0.5 mg, 1 mg cilostazol oral tablet 100 mg, 50 mg CINRYZE INTRAVENOUS* SOLUTION RECONSTITUTED 500 UNIT PA; LA FIRAZYR SUBCUTANEOUS* SOLUTION 0 MG/ML PA pentoxifylline er oral tablet extendedrelease* 00 mg PROMACTA ORAL TABLET 1.5 MG PA; LA; QL (60 EA per 0 days) PROMACTA ORAL TABLET 5 MG PA; LA; QL (180 EA per 0 days) PROMACTA ORAL TABLET 50 MG PA; LA; QL (90 EA per 0 days) PROMACTA ORAL TABLET 75 MG PA; LA; QL (60 EA per 0 days) tranexamic acid intravenous* solution 1000 mg/10ml tranexamic acid oral tablet 650 mg 6

72 PLATELET AGGREGATION INHIBITORS ASPIRIN-DIPYRIDAMOLE ER ORAL CAPSULE EXTENDED RELEASE 1 HOUR 5-00 MG BRILINTA ORAL TABLET 60 MG, 90 MG clopidogrel bisulfate oral tablet 75 mg 1 EFFIENT ORAL TABLET 10 MG, 5 MG ZONTIVITY ORAL TABLET.08 MG IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS* 0 MG/0.8ML, 0 MG/0.8ML (6 PACK) PA HUMIRA PEN SUBCUTANEOUS* 0 MG/0.8ML PA; QL (6 EA per 8 days) HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* 0 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* 0 MG/0.8ML PA PA HUMIRA SUBCUTANEOUS* 10 MG/0.ML, 0 MG/0.ML PA; QL ( EA per 8 days) HUMIRA SUBCUTANEOUS* 0 MG/0.8ML PA; QL (6 EA per 8 days) hydroxychloroquine sulfate oral tablet 00 mg leflunomide oral tablet 10 mg, 0 mg methotrexate oral tablet.5 mg REMICADE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG PA XELJANZ ORAL TABLET 5 MG PA; QL (60 EA per 0 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE HR* 11 MG IMMUNOGLOBULINS BIVIGAM INTRAVENOUS* SOLUTION 10 GM/100ML, 5 GM/50ML CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM, 6 GM PA; QL (0 EA per 0 days) PA PA 6

73 FLEBOGAMMA DIF INTRAVENOUS* SOLUTION 0.5 GM/10ML, 10 GM/100ML, 10 GM/00ML,.5 GM/50ML, 0 GM/00ML, 0 GM/00ML, 5 GM/100ML, 5 GM/50ML PA GAMASTAN S/D INTRAMUSCULAR* INJECTABLE B/D GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML,.5 GM/5ML, 0 GM/00ML, 0 GM/00ML, 5 GM/50ML GAMMAGARD S/D LESS IGA INTRAVENOUS* SOLUTION RECONSTITUTED 10 GM, 5 GM GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML,.5 GM/5ML, 0 GM/00ML, 5 GM/50ML GAMMAPLEX INTRAVENOUS* SOLUTION 10 GM/00ML, 5 GM/100ML GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10 GM/100ML,.5 GM/5ML, 0 GM/00ML, 0 GM/00ML, 5 GM/50ML OCTAGAM INTRAVENOUS* SOLUTION 1 GM/0ML, 10 GM/00ML, GM/0ML,.5 GM/50ML, 5 GM/500ML, 5 GM/100ML PRIVIGEN INTRAVENOUS* SOLUTION 10 GM/100ML, 0 GM/00ML, 0 GM/00ML, 5 GM/50ML IMMUNOMODULATORS ACTIMMUNE SUBCUTANEOUS* SOLUTION UNIT/0.5ML ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED 0 MG INTRON A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT, UNIT PA PA PA PA PA PA PA PA; LA PA B/D B/D POMALYST ORAL CAPSULE 1 MG, MG, MG, MG PA; LA REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG PA; LA 6

74 THALOMID ORAL CAPSULE 100 MG, 150 MG, 00 MG, 50 MG IMMUNOSUPPRESSANTS PA azathioprine oral tablet 50 mg B/D azathioprine sodium injection solution reconstituted 100 mg B/D BENLYSTA INTRAVENOUS* SOLUTION RECONSTITUTED 10 MG, 00 MG PA cyclosporine modified oral capsule 100 mg, 5 mg, 50 mg B/D cyclosporine modified oral solution 100 mg/ml B/D cyclosporine oral capsule 100 mg, 5 mg B/D gengraf oral capsule 100 mg, 5 mg B/D gengraf oral solution 100 mg/ml B/D mycophenolate mofetil oral capsule 50 mg B/D mycophenolate mofetil oral suspension reconstituted 00 mg/ml B/D mycophenolate mofetil oral tablet 500 mg B/D mycophenolic acid oral tablet delayed release 180 mg, 60 mg B/D NEORAL ORAL CAPSULE 100 MG, 5 MG B/D NEORAL ORAL SOLUTION 100 MG/ML B/D NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG B/D PROGRAF ORAL CAPSULE 0.5 MG, 1 MG B/D PROGRAF ORAL CAPSULE 5 MG B/D RAPAMUNE ORAL SOLUTION 1 MG/ML B/D SANDIMMUNE ORAL SOLUTION 100 MG/ML B/D sirolimus oral tablet 0.5 mg B/D SIROLIMUS ORAL TABLET 1 MG B/D sirolimus oral tablet mg B/D tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg B/D ZORTRESS ORAL TABLET 0.5 MG B/D 65

75 ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG B/D VACCINES ACTHIB INTRAMUSCULAR* SOLUTION RECONSTITUTED NM ADACEL INTRAMUSCULAR* SUSPENSION LF-MCG/0.5 NM BCG VACCINE INJECTION INJECTABLE NM BEXSERO INTRAMUSCULAR* NM BOOSTRIX INTRAMUSCULAR* SUSPENSION , (0.5ML SYRINGE) NM CERVARIX INTRAMUSCULAR* SUSPENSION NM DAPTACEL INTRAMUSCULAR* SUSPENSION NM DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR* SUSPENSION 5-5 LFU/0.5ML ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 10 MCG/0.5ML (0.5ML SYRINGE), 0 MCG/ML B/D; NM B/D; NM GARDASIL 9 INTRAMUSCULAR* NM GARDASIL 9 INTRAMUSCULAR* SUSPENSION NM GARDASIL INTRAMUSCULAR* SUSPENSION, (0.5ML SYRINGE) HAVRIX INTRAMUSCULAR* SUSPENSION 10 EL U/ML, 70 EL U/0.5ML NM NM HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG NM IMOVAX RABIES INTRAMUSCULAR* INJECTABLE.5 UNIT/ML NM INFANRIX INTRAMUSCULAR* SUSPENSION NM IPOL INJECTION INJECTABLE NM IXIARO INTRAMUSCULAR* SUSPENSION NM KINRIX INTRAMUSCULAR* SUSPENSION NM MENACTRA INTRAMUSCULAR* INJECTABLE NM MENHIBRIX INTRAMUSCULAR* SOLUTION RECONSTITUTED MCG NM MENOMUNE SUBCUTANEOUS* INJECTABLE NM MENVEO INTRAMUSCULAR* SOLUTION RECONSTITUTED NM 66

76 M-M-R II SUBCUTANEOUS* INJECTABLE NM PEDIARIX INTRAMUSCULAR* SUSPENSION NM PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5 MCG/0.5ML PENTACEL INTRAMUSCULAR* SUSPENSION RECONSTITUTED NM NM PROQUAD SUBCUTANEOUS* INJECTABLE NM QUADRACEL INTRAMUSCULAR* SUSPENSION NM RABAVERT INTRAMUSCULAR* SUSPENSION RECONSTITUTED RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 10 MCG/ML (1ML SYRINGE), 0 MCG/ML, 5 MCG/0.5ML NM B/D; NM ROTARIX ORAL SUSPENSION RECONSTITUTED NM ROTATEQ ORAL SOLUTION NM SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/0.5ML NM TENIVAC INTRAMUSCULAR* INJECTABLE 5- LFU B/D; NM TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR* SUSPENSION - LF/0.5ML B/D; NM TRUMENBA INTRAMUSCULAR* NM TWINRIX INTRAMUSCULAR* SUSPENSION 70-0 NM TYPHIM VI INTRAMUSCULAR* SOLUTION 5 MCG/0.5ML, 5 MCG/0.5ML (0.5ML SYRINGE) VAQTA INTRAMUSCULAR* SUSPENSION 5 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS* INJECTABLE 150 PFU/0.5ML NM NM NM YF-VAX SUBCUTANEOUS* INJECTABLE NM ZOSTAVAX SUBCUTANEOUS* SOLUTION RECONSTITUTED 1900 UNT/0.65ML NUTRITIONAL/SUPPLEMENTS ELECTROLYTES NM; QL (1 EA per 999 days) klor-con 10 oral tablet extendedrelease* 10 meq 67

77 klor-con m10 oral tablet extendedrelease* 10 meq klor-con m15 oral tablet extendedrelease* 15 meq klor-con m0 oral tablet extendedrelease* 0 meq klor-con oral packet 0 meq klor-con oral tablet extendedrelease* 8 meq klor-con sprinkle oral capsule extended release* 10 meq, 8 meq MAGNESIUM SULFATE IN D5W INTRAVENOUS* SOLUTION 10-5 MG/ML-%, 0-5 MG/ML-% MAGNESIUM SULFATE INJECTION SOLUTION 50 % magnesium sulfate injection solution 50 % (10ml syringe) MAGNESIUM SULFATE INTRAVENOUS* SOLUTION GM/50ML, 0 GM/500ML, GM/100ML, GM/50ML, 0 GM/1000ML potassium chloride crys er oral tablet extendedrelease* 10 meq, 0 meq potassium chloride er oral capsule extended release* 10 meq, 8 meq potassium chloride er oral tablet extendedrelease* 10 meq, 0 meq potassium chloride er oral tablet extendedrelease* 8 meq POTASSIUM CHLORIDE ORAL SOLUTION 0 MEQ/15ML (10%), 0 MEQ/15ML (0%) SODIUM CHLORIDE INJECTION SOLUTION.5 MEQ/ML sodium fluoride oral tablet. (1 f) mg TPN ELECTROLYTES INTRAVENOUS* SOLUTION B/D IV NUTRITION AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 7 %, 8.5 % AMINOSYN II/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 % B/D B/D AMINOSYN INTRAVENOUS* SOLUTION 10 %, 8.5 % B/D 68

78 AMINOSYN M INTRAVENOUS* SOLUTION.5 % B/D AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 7 %, 8.5 % B/D AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 % B/D AMINOSYN-PF INTRAVENOUS* SOLUTION 10 %, 7 % B/D AMINOSYN-RF INTRAVENOUS* SOLUTION 5. % B/D CLINIMIX/DEXTROSE (.75/5) INTRAVENOUS* SOLUTION.75 % CLINIMIX/DEXTROSE (.5/10) INTRAVENOUS* SOLUTION.5 % CLINIMIX/DEXTROSE (.5/0) INTRAVENOUS* SOLUTION.5 % CLINIMIX/DEXTROSE (.5/5) INTRAVENOUS* SOLUTION.5 % CLINIMIX/DEXTROSE (.5/5) INTRAVENOUS* SOLUTION.5 % CLINIMIX/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5 % CLINIMIX/DEXTROSE (5/0) INTRAVENOUS* SOLUTION 5 % CLINIMIX/DEXTROSE (5/5) INTRAVENOUS* SOLUTION 5 % B/D B/D B/D B/D B/D B/D B/D B/D FREAMINE HBC INTRAVENOUS* SOLUTION 6.9 % B/D FREAMINE III INTRAVENOUS* SOLUTION 10 % B/D HEPATAMINE INTRAVENOUS* SOLUTION 8 % B/D INTRALIPID INTRAVENOUS* EMULSION 0 %, 0 % B/D NEPHRAMINE INTRAVENOUS* SOLUTION 5. % B/D NUTRILIPID INTRAVENOUS* EMULSION 0 % B/D premasol intravenous* solution 10 %, 6 % B/D PROCALAMINE INTRAVENOUS* SOLUTION % B/D PROSOL INTRAVENOUS* SOLUTION 0 % B/D TRAVASOL INTRAVENOUS* SOLUTION 10 % B/D TROPHAMINE INTRAVENOUS* SOLUTION 10 % B/D 69

79 IV REPLACEMENT SOLUTIONS DEXTROSE 5%/ELECTROLYTE #8 INTRAVENOUS* SOLUTION DEXTROSE IN LACTATED RINGERS INTRAVENOUS* SOLUTION 5 % DEXTROSE INTRAVENOUS* SOLUTION 10 %, 5 %, 50 %, 70 % DEXTROSE-NACL INTRAVENOUS* SOLUTION %, %, %, 5-0. %, %, 5-0. %, 5-0. %, %, % ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION ISOLYTE-S INTRAVENOUS* SOLUTION KCL IN DEXTROSE-NACL INTRAVENOUS* SOLUTION MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-% LACTATED RINGERS INTRAVENOUS* SOLUTION NORMOSOL-M IN D5W INTRAVENOUS* SOLUTION NORMOSOL-R IN D5W INTRAVENOUS* SOLUTION NORMOSOL-R PH 7. INTRAVENOUS* SOLUTION PLASMA-LYTE 18 INTRAVENOUS* SOLUTION PLASMA-LYTE A INTRAVENOUS* SOLUTION PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION POTASSIUM CHLORIDE IN DEXTROSE INTRAVENOUS* SOLUTION 0-5 MEQ/L-%, 0-5 MEQ/L-% potassium chloride in nacl intravenous* solution meq/l-% POTASSIUM CHLORIDE IN NACL INTRAVENOUS* SOLUTION MEQ/L-%, MEQ/L-% POTASSIUM CHLORIDE INTRAVENOUS* SOLUTION 0. MEQ/ML, 10 MEQ/100ML, 10 MEQ/50ML, 0 MEQ/100ML, 0 MEQ/100ML 70

80 potassium chloride intravenous* solution meq/ml RINGERS INTRAVENOUS* SOLUTION SODIUM CHLORIDE INTRAVENOUS* SOLUTION 0.5 %, 0.9 %, %, 5 % VITAMINS calcitriol intravenous* solution 1 mcg/ml B/D calcitriol oral capsule 0.5 mcg, 0.5 mcg B/D calcitriol oral solution 1 mcg/ml B/D paricalcitol oral capsule 1 mcg, mcg, mcg B/D prenatal oral tablet 7-1 mg OPHTHALMIC ANTIALLERGICS azelastine hcl ophthalmic solution 0.05 % BEPREVE OPHTHALMIC SOLUTION 1.5 % cromolyn sodium ophthalmic solution % LASTACAFT OPHTHALMIC SOLUTION 0.5 % PATADAY OPHTHALMIC SOLUTION 0. % PAZEO OPHTHALMIC SOLUTION 0.7 % ANTIGLAUCOMA ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % AZOPT OPHTHALMIC SUSPENSION 1 % betaxolol hcl ophthalmic solution 0.5 % BETOPTIC-S OPHTHALMIC SUSPENSION 0.5 % BRIMONIDINE TARTRATE OPHTHALMIC SOLUTION 0.15 % brimonidine tartrate ophthalmic solution 0. % carteolol hcl ophthalmic solution 1 % COMBIGAN OPHTHALMIC SOLUTION % dorzolamide hcl ophthalmic solution % dorzolamide hcl-timolol mal ophthalmic solution.-6.8 mg/ml ISTALOL OPHTHALMIC SOLUTION 0.5 % 71

81 latanoprost ophthalmic solution % levobunolol hcl ophthalmic solution 0.5 % LUMIGAN OPHTHALMIC SOLUTION 0.01 % metipranolol ophthalmic solution 0. % PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED 0.15 % PILOCARPINE HCL OPHTHALMIC SOLUTION 1 %, %, % SIMBRINZA OPHTHALMIC SUSPENSION 1-0. % TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLUTION 0.5 %, 0.5 % timolol maleate ophthalmic solution 0.5 %, 0.5 % TRAVATAN Z OPHTHALMIC SOLUTION 0.00 % ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % blephamide s.o.p. ophthalmic ointment % neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension sulfacetamide-prednisolone ophthalmic solution % TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX ST OPHTHALMIC SUSPENSION % tobramycin-dexamethasone ophthalmic suspension % ZYLET OPHTHALMIC SUSPENSION % ANTI-INFECTIVES bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm BESIVANCE OPHTHALMIC SUSPENSION 0.6 % 7

82 CILOXAN OPHTHALMIC OINTMENT 0. % ciprofloxacin hcl ophthalmic solution 0. % erythromycin ophthalmic ointment 5 mg/gm gatifloxacin ophthalmic solution 0.5 % gentak ophthalmic ointment 0. % gentamicin sulfate ophthalmic ointment 0. % gentamicin sulfate ophthalmic solution 0. % ilotycin ophthalmic ointment 5 mg/gm MOXEZA OPHTHALMIC SOLUTION 0.5 % NATACYN OPHTHALMIC SUSPENSION 5 % neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution 0. % polymyxin b-trimethoprim ophthalmic solution unit/ml-% sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide sodium ophthalmic solution 10 % tobramycin ophthalmic solution 0. % trifluridine ophthalmic solution 1 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % ANTI-INFLAMMATORIES ALREX OPHTHALMIC SUSPENSION 0. % bromfenac sodium (once-daily) ophthalmic solution 0.09 % bromfenac sodium ophthalmic solution 0.09 % dexamethasone sodium phosphate ophthalmic solution 0.1 % diclofenac sodium ophthalmic solution 0.1 % DUREZOL OPHTHALMIC EMULSION 0.05 % 7

83 FLUOROMETHOLONE OPHTHALMIC SUSPENSION 0.1 % flurbiprofen sodium ophthalmic solution 0.0 % ILEVRO OPHTHALMIC SUSPENSION 0. % ketorolac tromethamine ophthalmic solution 0. %, 0.5 % LOTEMAX OPHTHALMIC GEL 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % LOTEMAX OPHTHALMIC SUSPENSION 0.5 % prednisolone acetate ophthalmic suspension 1 % prednisolone sodium phosphate ophthalmic solution 1 % MISCELLANEOUS CYSTARAN OPHTHALMIC SOLUTION 0. % PA; LA naphazoline hcl ophthalmic solution 0.1 % PROLENSA OPHTHALMIC SOLUTION 0.07 % proparacaine hcl ophthalmic solution 0.5 % RESTASIS OPHTHALMIC EMULSION 0.05 % QL (6 EA per 0 days) RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION MCG/ACT ipratropium-albuterol inhalation solution () mg/ml ANTICHOLINERGICS ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 6.5 MCG/INH QL (60 EA per 0 days) QL (8 GM per 0 days) B/D QL (5.8 GM per 0 days) QL (0 EA per 0 days) ipratropium bromide inhalation solution 0.0 % B/D ipratropium bromide nasal solution 0.0 %, 0.06 % 7

84 ANTIHISTAMINES azelastine hcl nasal solution 0.1 %, 0.15 % cetirizine hcl oral syrup 1 mg/ml cyproheptadine hcl oral syrup mg/5ml PA cyproheptadine hcl oral tablet mg PA diphenhydramine hcl injection solution 50 mg/ml hydroxyzine hcl intramuscular* solution 5 mg/ml, 50 mg/ml PA hydroxyzine hcl oral syrup 10 mg/5ml PA hydroxyzine hcl oral tablet 10 mg, 5 mg, 50 mg PA hydroxyzine pamoate oral capsule 100 mg, 5 mg, 50 mg levocetirizine dihydrochloride oral solution.5 mg/5ml levocetirizine dihydrochloride oral tablet 5 mg BETA AGONISTS albuterol sulfate inhalation nebulization solution (.5 mg/ml) 0.08%, (5 mg/ml) 0.5%, 0.6 mg/ml, 1.5 mg/ml albuterol sulfate oral syrup mg/5ml albuterol sulfate oral tablet mg, mg SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 mg/ml terbutaline sulfate oral tablet.5 mg, 5 mg VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT PA B/D QL (60 EA per 0 days) QL (6 GM per 0 days) XOPENEX HFA INHALATION AEROSOL 5 MCG/ACT QL (0 GM per 0 days) LEUKOTRIENE MODULATORS montelukast sodium oral packet mg montelukast sodium oral tablet 10 mg montelukast sodium oral tablet chewable mg, 5 mg zafirlukast oral tablet 10 mg, 0 mg 75

85 MAST CELL STABILIZERS cromolyn sodium inhalation nebulization solution 0 mg/ml MISCELLANEOUS B/D acetylcysteine inhalation solution 10 %, 0 % B/D ARALAST NP INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG, 500 MG PA; LA DALIRESP ORAL TABLET 500 MCG EPIPEN -PAK INJECTION 0. MG/0.ML EPIPEN JR -PAK INJECTION 0.15 MG/0.ML ESBRIET ORAL CAPSULE 67 MG PA KALYDECO ORAL PACKET 50 MG, 75 MG PA KALYDECO ORAL TABLET 150 MG PA OFEV ORAL CAPSULE 100 MG, 150 MG PA ORKAMBI ORAL TABLET MG PA PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG PA; LA PULMOZYME INHALATION SOLUTION 1 MG/ML PA XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG ZEMAIRA INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG NASAL STEROIDS PA; LA PA; LA flunisolide nasal solution 5 mcg/act (0.05%) QL (50 ML per 0 days) fluticasone propionate nasal suspension 50 mcg/act QL (16 GM per 0 days) STEROID INHALANTS ARNUITY ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/ACT, 00 MCG/ACT budesonide inhalation suspension 0.5 mg/ml, 0.5 mg/ml FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 50 MCG/BLIST QL (0 EA per 0 days) B/D QL (10 EA per 0 days) 76

86 FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 0 MCG/ACT QL (0 EA per 0 days) QL ( GM per 0 days) FLOVENT HFA INHALATION AEROSOL MCG/ACT QL (1. GM per 0 days) PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, 0-1 MCG/ACT, 5-1 MCG/ACT BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/INH, 00-5 MCG/INH SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT XANTHINES QL ( EA per 0 days) QL (60 EA per 0 days) QL (1 GM per 0 days) QL (60 EA per 0 days) QL (10. GM per 0 days) aminophylline intravenous* solution 5 mg/ml theophylline er oral tablet extended release 1 hr* 100 mg, 00 mg, 00 mg, 50 mg theophylline er oral tablet extended release hr* 00 mg, 600 mg TOPICAL DERMATOLOGY, ACNE AVITA EXTERNAL CREAM 0.05 % PA AVITA EXTERNAL GEL 0.05 % PA claravis oral capsule 10 mg, 0 mg, 0 mg, 0 mg PA clindamax external gel 1 % clindamycin phosphate external gel 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % erythromycin external gel % 77

87 erythromycin external solution % myorisan oral capsule 10 mg, 0 mg, 0 mg, 0 mg PA sulfacetamide sodium external suspension 10 % tretinoin external cream 0.05 %, 0.05 %, 0.1 % PA TRETINOIN EXTERNAL GEL 0.01 % PA tretinoin external gel 0.05 % PA zenatane oral capsule 10 mg, 0 mg, 0 mg, 0 mg PA DERMATOLOGY, ANTIBIOTICS gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % mupirocin calcium external cream % mupirocin external ointment % silver sulfadiazine external cream 1 % ssd external cream 1 % SULFAMYLON EXTERNAL CREAM 85 MG/GM SULFAMYLON EXTERNAL PACKET 5 % DERMATOLOGY, ANTIFUNGALS ciclopirox external gel 0.77 % ciclopirox external shampoo 1 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % clotrimazole external cream 1 % clotrimazole external solution 1 % ketoconazole external cream % nyamyc external powder unit/gm nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystop external powder unit/gm DERMATOLOGY, ANTIPRURITIC DOXEPIN HCL EXTERNAL CREAM 5 % 78

88 procto-med hc cream.5 % procto-pak cream 1 % proctosol hc cream.5 % proctozone-hc cream.5 % DERMATOLOGY, ANTIPSORIATICS 8-MOP ORAL CAPSULE 10 MG acitretin oral capsule 10 mg, 17.5 mg, 5 mg PA calcipotriene external cream % calcipotriene external solution % TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole external shampoo % selenium sulfide external lotion.5 % DERMATOLOGY, CORTICOSTEROIDS ala cort external cream 1 % alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external gel 0.05 % betamethasone dipropionate aug external lotion 0.05 % BETAMETHASONE DIPROPIONATE AUG EXTERNAL OINTMENT 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external lotion 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % clobetasol propionate external foam 0.05 % clobetasol propionate external lotion 0.05 % clobetasol propionate external shampoo 0.05 % 79

89 desonide external cream 0.05 % desonide external ointment 0.05 % fluocinolone acetonide external solution 0.01 % fluocinonide external cream 0.05 % fluocinonide external gel 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % fluticasone propionate external cream 0.05 % fluticasone propionate external ointment % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % hydrocortisone butyrate external cream 0.1 % hydrocortisone butyrate external ointment 0.1 % hydrocortisone butyrate external solution 0.1 % hydrocortisone external cream 1 %,.5 % hydrocortisone external lotion.5 % hydrocortisone external ointment 1 %,.5 % mometasone furoate external cream 0.1 % mometasone furoate external ointment 0.1 % mometasone furoate external solution 0.1 % triamcinolone acetonide external cream 0.05 %, 0.1 %, 0.5 % triamcinolone acetonide external lotion 0.05 %, 0.1 % triamcinolone acetonide external ointment 0.05 %, 0.1 %, 0.5 % triderm external cream 0.1 % DERMATOLOGY, LOCAL ANESTHETICS lidocaine external ointment 5 % PA lidocaine external patch 5 % PA; QL ( EA per 1 day) lidocaine hcl external gel %, % (10ml applicator), % (5ml applicator) PA lidocaine hcl external solution % PA 80

90 lidocaine-prilocaine external cream.5-.5 % PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate external cream 1 % ammonium lactate external lotion 1 % diclofenac sodium transdermal gel 1 % fluorouracil external cream 5 % fluorouracil external solution %, 5 % imiquimod external cream 5 % metronidazole external cream 0.75 % metronidazole external gel 0.75 % PANRETIN EXTERNAL GEL 0.1 % podofilox external solution 0.5 % rosadan external cream 0.75 % tacrolimus external ointment 0.0 %, 0.1 % TARGRETIN EXTERNAL GEL 1 % PA VALCHLOR EXTERNAL GEL % PA; LA DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX EXTERNAL CREAM 10 % EURAX EXTERNAL LOTION 10 % malathion external lotion 0.5 % permethrin external cream 5 % DERMATOLOGY, WOUND CARE AGENTS acetic acid irrigation solution 0.5 % REGRANEX EXTERNAL GEL 0.01 % PA SANTYL EXTERNAL OINTMENT 50 UNIT/GM sodium chloride irrigation solution 0.9 % sterile water for irrigation irrigation solution MOUTH/THROAT/DENTAL AGENTS chlorhexidine gluconate mouth/throat solution 0.1 % clotrimazole mouth/throat troche 10 mg 81

91 lidocaine viscous mouth/throat solution % nystatin mouth/throat suspension unit/ml paroex mouth/throat solution 0.1 % periogard mouth/throat solution 0.1 % PILOCARPINE HCL ORAL TABLET 5 MG pilocarpine hcl oral tablet 7.5 mg triamcinolone acetonide mouth/throat paste 0.1 % OTIC acetic acid otic solution % acetic acid-aluminum acetate otic solution % CIPRODEX OTIC SUSPENSION % fluocinolone acetonide otic oil 0.01 % neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension ofloxacin otic solution 0. % 8

92 Index of s 8-MOP abacavir sulfate... 7 abacavir-lamivudine-zidovudine... 9 ABELCET... ABILIFY MAINTENA... 7 ABRAXANE acamprosate calcium... acarbose... 5 acebutolol hcl... 5 acetaminophen-codeine... acetaminophen-codeine #... acetaminophen-codeine #... acetaminophen-codeine #... acetazolamide... 7 acetazolamide er... 7 acetic acid... 81, 8 acetic acid-aluminum acetate... 8 acetylcysteine acitretin ACTHIB ACTIMMUNE... 6 acyclovir acyclovir sodium ADACEL ADAGEN ADCIRCA... 8 adefovir dipivoxil ADEMPAS... 8 adrucil ADVAIR DISKUS ADVAIR HFA afeditab cr... 5 AFINITOR AFINITOR DISPERZ a-hydrocort... 5 ala cort ALBENZA... 5 albuterol sulfate alclometasone dipropionate ALDURAZYME ALECENSA alendronate sodium... 7 alfuzosin hcl er ALIMTA ALINIA... 5 allopurinol... 1 alosetron hcl ALPHAGAN P alprazolam... 9 ALREX... 7 altavera... 7 amantadine hcl... 6 AMBISOME... amifostine... 0 amikacin sulfate... amiloride hcl... 7 amiloride-hydrochlorothiazide... 7 aminophylline AMINOSYN AMINOSYN II AMINOSYN II/ELECTROLYTES AMINOSYN M AMINOSYN/ELECTROLYTES AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl... AMITIZA amitriptyline hcl... amlodipine besy-benazepril hcl... 1 amlodipine besylate... 5 amlodipine besylate-valsartan... amlodipine-valsartan-hctz... ammonium lactate amoxapine... amoxicillin... 1 amoxicillin-pot clavulanate... 1 amphetamine-dextroamphet er... 0, 1 amphetamine-dextroamphetami ne... 1 amphotericin b... ampicillin... 1 ampicillin sodium... 1 ampicillin-sulbactam sodium AMPYRA... ANADROL anagrelide hcl... 6 anastrozole ANDRODERM... ANORO ELLIPTA... 7 APOKYN... 6 apri... 7 APRISO APTIOM... 9, 0 APTIVUS... 7 ARALAST NP aranelle... 8 ARCALYST... 6 aripiprazole... 7 armodafinil... ARMODAFINIL... ARNUITY ELLIPTA ASACOL HD ASPIRIN-DIPYRIDAMOLE ER... 6 ASSURE ID INSULIN SAFETY SYR... atenolol... 5 atenolol-chlorthalidone... atorvastatin calcium... atovaquone... 5 atovaquone-proguanil hcl... 7 ATRIPLA... 9 ATROVENT HFA... 7 aubra... 8 AURYXIA AVASTIN aviane... 8 AVITA AXIRON... azacitidine azathioprine azathioprine sodium azelastine hcl... 71, 75 AZILECT... 6 azithromycin... 1 AZITHROMYCIN... 1 AZOPT aztreonam... 5 bacitracin... 7 bacitracin-polymyxin b... 7

93 bacitra-neomycin-polymyxin-hc... 7 baclofen... balsalazide disodium balziva... 8 BANZEL... 0 BARACLUDE BCG VACCINE bekyree... 8 BELEODAQ benazepril hcl... 1 benazepril-hydrochlorothiazide... 1 BENDEKA BENLYSTA BENZTROPINE MESYLATE... 6 benztropine mesylate... 6 BEPREVE BESIVANCE... 7 betamethasone dipropionate betamethasone dipropionate aug BETAMETHASONE DIPROPIONATE AUG betamethasone valerate BETASERON... betaxolol hcl bethanechol chloride BETOPTIC-S bexarotene... 0 BEXSERO bicalutamide BICILLIN L-A... 1 BILTRICIDE... 5 bisoprolol fumarate... 5 bisoprolol-hydrochlorothiazide... BIVIGAM... 6 bleomycin sulfate blephamide s.o.p blisovi fe 1.5/ blisovi fe 1/ BOOSTRIX BOSULIF BREO ELLIPTA briellyn... 8 BRILINTA... 6 BRIMONIDINE TARTRATE brimonidine tartrate BRIVIACT... 0 bromfenac sodium... 7 bromfenac sodium (once-daily)... 7 bromocriptine mesylate... 6 budesonide... 57, 76 bumetanide... 7 BUPHENYL buprenorphine hcl... buprenorphine hcl-naloxone hcl... buproban... bupropion hcl... bupropion hcl er (smoking det)... bupropion hcl er (sr)... bupropion hcl er (xl)... buspirone hcl... 9 BYDUREON... BYETTA 10 MCG PEN... BYETTA 5 MCG PEN... BYSTOLIC... 5 cabergoline... 5 CABOMETYX cafergot... 1 calcipotriene calcitonin (salmon)... 5 calcitriol calcium acetate (phos binder) camila... 8 CANASA CANCIDAS... CAPASTAT SULFATE CAPRELSA captopril... 1 captopril-hydrochlorothiazide... 1 CARAFATE CARBAGLU carbamazepine... 0 carbamazepine er... 0 carbidopa-levodopa... 7 carbidopa-levodopa er... 7 carboplatin... 0 CARIMUNE NF... 6 carteolol hcl cartia xt... 5 carvedilol... 5 CAYSTON... 5 cefaclor cefadroxil cefazolin sodium CEFAZOLIN SODIUM-DEXTROSE cefdinir... 11, 1 cefepime hcl... 1 cefixime... 1 cefoxitin sodium... 1 cefpodoxime proxetil... 1 ceftazidime... 1 ceftriaxone sodium... 1 cefuroxime axetil... 1 cefuroxime sodium... 1 celecoxib... 1 CELONTIN... 0 cephalexin... 1 CERDELGA... 5 CEREZYME... 5 CERVARIX cetirizine hcl CHANTIX... CHANTIX CONTINUING MONTH PAK... CHANTIX STARTING MONTH PAK... CHEMET... 7 chlorhexidine gluconate chloroquine phosphate... 7 chlorothiazide... 7 chlorpromazine hcl... 7 chlorthalidone... 7 cholestyramine... cholestyramine light... ciclopirox ciclopirox olamine cilostazol... 6 CILOXAN... 7 CINRYZE... 6 CIPRODEX... 8 ciprofloxacin... 1 ciprofloxacin hcl... 1, 7 ciprofloxacin in d5w... 1 cisplatin... 0 citalopram hydrobromide...

94 claravis clarithromycin... 1 clarithromycin er... 1 clindamax clindamycin hcl... 5 clindamycin palmitate hcl... 5 clindamycin phosphate... 5, 61, 77 clindamycin phosphate in d5w... 5 CLINIMIX/DEXTROSE (.75/5) CLINIMIX/DEXTROSE (.5/10) CLINIMIX/DEXTROSE (.5/0) CLINIMIX/DEXTROSE (.5/5) CLINIMIX/DEXTROSE (.5/5) CLINIMIX/DEXTROSE (5/15) CLINIMIX/DEXTROSE (5/0) CLINIMIX/DEXTROSE (5/5) clobetasol propionate clobetasol propionate emulsion... clomipramine hcl... clonazepam... 0 clonidine hcl... 8 clopidogrel bisulfate... 6 clorazepate dipotassium... 0 clotrimazole... 78, 81 clozapine... 7 CLOZAPINE... 7, 8 COARTEM... 7 colchicine-probenecid... 1 COLCRYS... 1 colestipol hcl... colistimethate sodium... 6 colocort COMBIGAN COMBIVENT RESPIMAT... 7 COMETRIQ (100 MG DAILY DOSE) COMETRIQ (10 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) COMFORT ASSIST INSULIN SYRINGE... COMPLERA... 9 compro constulose COPAXONE... cortisone acetate... 5 COTELLIC COUMADIN CREON CRIXIVAN... 7 cromolyn sodium... 58, 71, 76 cryselle CUBICIN... 6 CVS GAUZE STERILE... cyclafem 1/ cyclafem 7/7/ cyclobenzaprine hcl... CYCLOPHOSPHAMIDE cycloserine cyclosporine cyclosporine modified cyproheptadine hcl cyred... 8 CYSTADANE... 5 CYSTAGON... 5 CYSTARAN... 7 dacarbazine DAKLINZA DALIRESP danazol dantrolene sodium... dapsone... 6 DAPTACEL deblitane... 8 DELESTROGEN... 5 delyla... 8 DELZICOL DEMSER... 8 DEPEN TITRATABS... 7 DESCOVY... 9 desipramine hcl... DESMOPRESSIN ACE RHINAL TUBE desmopressin ace spray refrig desmopressin acetate desmopressin acetate spray desogestrel-ethinyl estradiol... 8 desonide dexamethasone... 5 dexamethasone intensol... 5 dexamethasone sod phosphate pf... 5 dexamethasone sodium phosphate... 5, 7 DEXILANT dexrazoxane... 0 DEXTROSE DEXTROSE 5%/ELECTROLYTE # DEXTROSE IN LACTATED RINGERS DEXTROSE-NACL DIAZEPAM... 0 diazepam... 0 diazepam intensol... 0 diclofenac potassium... 1 diclofenac sodium... 1, 7, 81 diclofenac sodium er... 1 dicloxacillin sodium... 1 dicyclomine hcl didanosine... 7 diflunisal... 1 digitek... 7 digox... 7 digoxin... 7 DIGOXIN... 7 dihydroergotamine mesylate... 1 dilantin... 1 DILANTIN... 1 dilantin infatabs... 0 diltiazem hcl... 6 diltiazem hcl er... 6 diltiazem hcl er beads... 5 diltiazem hcl er coated beads... 6 dilt-xr... 6 DIPENTUM diphenhydramine hcl diphenoxylate-atropine DIPHTHERIA-TETANUS TOXOIDS DT disopyramide phosphate... disulfiram... divalproex sodium... 1

95 divalproex sodium er... 1 DOCEFREZ docetaxel DOCETAXEL... 16, 17 DOFETILIDE... donepezil hcl... dorzolamide hcl dorzolamide hcl-timolol mal doxazosin mesylate... doxepin hcl... DOXEPIN HCL doxy doxycycline hyclate doxycycline monohydrate dronabinol drospirenone-ethinyl estradiol... 8 DROXIA... 0 duloxetine hcl... DURAMORPH... DUREZOL... 7 dutasteride dutasteride-tamsulosin hcl e.e.s EDURANT... 7 EFFIENT... 6 ELITEK... 0 ELLA... 8 ELMIRON EMCYT EMEND emoquette... 8 EMSAM... 5 EMTRIVA... 7 enalapril maleate... 1 enalapril-hydrochlorothiazide... 1 endocet... ENGERIX-B enoxaparin sodium enpresse ENTACAPONE... 7 entecavir ENTRESTO... enulose EPIPEN -PAK EPIPEN JR -PAK epitol... 1 EPIVIR HBV eplerenone... EPZICOM... 9 ERIVEDGE errin... 8 ery-tab... 1 erythrocin lactobionate... 1 erythrocin stearate... 1 erythromycin... 7, 77, 78 erythromycin base... 1 erythromycin ethylsuccinate... 1 ESBRIET escitalopram oxalate... 5 esomeprazole magnesium esomeprazole sodium estarylla... 8 estrace... 5 estradiol... 5 estradiol valerate... 5 ethambutol hcl ethosuximide... 1 etodolac... 1 etodolac er... 1 etoposide... 1 EURAX EVOTAZ... 9 EXEL COMFORT POINT PEN NEEDLE... exemestane EXJADE... 7 FABRAZYME... 5 falmina... 8 famciclovir famotidine famotidine premixed FANAPT... 8 FANAPT TITRATION PACK... 8 FARESTON FARXIGA... 5 FARYDAK FASLODEX felbamate... 1 felodipine er... 6 fenofibrate... fenofibrate micronized... fentanyl... fentanyl citrate... FENTORA FERRIPROX... 7 FETZIMA... 5 FETZIMA TITRATION... 5 finasteride FIRAZYR... 6 FLEBOGAMMA DIF... 6 flecainide acetate... FLOVENT DISKUS... 76, 77 FLOVENT HFA fluconazole... fluconazole in dextrose... fluconazole in sodium chloride... flucytosine... fludrocortisone acetate... 5 flunisolide fluocinolone acetonide... 80, 8 fluocinonide fluocinonide-e FLUOROMETHOLONE... 7 fluorouracil... 16, 81 fluoxetine hcl... 5 fluphenazine decanoate... 8 fluphenazine hcl... 8 flurbiprofen... 1 flurbiprofen sodium... 7 flutamide fluticasone propionate... 76, 80 fluvoxamine maleate... 9 fondaparinux sodium FORTEO... 5 FORTICAL... 5 fosinopril sodium... 1 fosinopril sodium-hctz... 1 FREAMINE HBC FREAMINE III FUROSEMIDE... 7 furosemide... 7 FUSILEV... 0 FUZEON... 7 fyavolv... 5 FYCOMPA... 1 gabapentin... 1 galantamine hydrobromide... galantamine hydrobromide er... GAMASTAN S/D... 6 GAMMAGARD... 6

96 GAMMAGARD S/D LESS IGA... 6 GAMMAKED... 6 GAMMAPLEX... 6 GAMUNEX-C... 6 ganciclovir sodium GARDASIL GARDASIL gatifloxacin... 7 GATTEX gavilyte-c gavilyte-g gavilyte-h gavilyte-n with flavor pack gemfibrozil... generlac gengraf gentak... 7 gentamicin in saline... gentamicin sulfate..., 7, 78 GENVOYA... 9 GEODON... 8 GIANVI... 8 gildagia... 8 gildess 1.5/ GILENYA... GILOTRIF glatopa... GLEOSTINE glimepiride... 5 glipizide... 5, 6 glipizide er... 5 glipizide xl... 6 glipizide-metformin hcl... 6 GLOBAL ALCOHOL PREP EASE... GLUCAGEN HYPOKIT... 5 GLUCAGON EMERGENCY... 5 glycopyrrolate GOLYTELY granisetron hcl GRANIX... 6 griseofulvin microsize..., 5 griseofulvin ultramicrosize... 5 guanfacine hcl er... 1 halobetasol propionate haloperidol... 8 haloperidol decanoate... 8 haloperidol lactate... 8 HAVRIX heather... 8 HEPARIN (PORCINE) IN D5W HEPARIN (PORCINE) IN NACL HEPARIN SOD (PORCINE) IN D5W heparin sodium (porcine) HEPARIN SODIUM (PORCINE) HEPATAMINE HERCEPTIN HETLIOZ... 1 HEXALEN HIBERIX HUMIRA... 6 HUMIRA PEDIATRIC CROHNS START... 6 HUMIRA PEN... 6 HUMIRA PEN-CROHNS STARTER... 6 HUMIRA PEN-PSORIASIS STARTER... 6 HUMULIN R U-500 (CONCENTRATED)... HUMULIN R U-500 KWIKPEN... hydralazine hcl... 8 hydrochlorothiazide... 7 hydrocodone-acetaminophen... hydrocodone-ibuprofen... hydrocortisone... 5, 80 HYDROCORTISONE hydrocortisone butyrate hydromorphone hcl... hydromorphone hcl pf... hydroxychloroquine sulfate... 6 hydroxyprogesterone caproate hydroxyurea... 0 hydroxyzine hcl hydroxyzine pamoate ibandronate sodium... 7 IBRANCE ibuprofen... 1 ICLUSIG ILEVRO... 7 ilotycin... 7 imatinib mesylate IMBRUVICA imipenem-cilastatin imipramine hcl... 5 imiquimod IMOVAX RABIES INCRELEX... 5 INCRUSE ELLIPTA... 7 indapamide... 7 INFANRIX INLYTA INTELENCE... 7 INTRALIPID INTRON A... 6 introvale... 8 INVANZ... 6 INVEGA SUSTENNA... 8 INVEGA TRINZA... 8, 9 INVIRASE... 7, 8 INVOKAMET... 6 INVOKANA... 6 IPOL ipratropium bromide... 7 ipratropium-albuterol... 7 irbesartan... irbesartan-hydrochlorothiazide... IRESSA ISENTRESS... 8 ISOLYTE-P IN D5W ISOLYTE-S isoniazid isosorbide dinitrate... 8 isosorbide dinitrate er... 8 isosorbide mononitrate... 8 isosorbide mononitrate er... 8 ISTALOL itraconazole... 5 ivermectin... 6 IXIARO JAKAFI jantoven JANUMET... 6 JANUMET XR... 6 JANUVIA... 6 jinteli... 5 JOLESSA... 8 JOLIVETTE... 8 juleber... 9 junel 1.5/ junel 1/0... 9

97 junel fe 1.5/ junel fe 1/ JUXTAPID... KALETRA... 9 KALYDECO kariva... 9 KCL IN DEXTROSE-NACL kelnor 1/ ketoconazole... 5, 78, 79 ketoprofen... 1 ketorolac tromethamine... 7 KEYTRUDA kimidess... 9 KINRIX kionex... 7 klor-con klor-con klor-con m klor-con m klor-con m klor-con sprinkle KORLYM... 5 KUVAN... 5 KYNAMRO... labetalol hcl... 5 LACTATED RINGERS lactulose lactulose encephalopathy lamivudine... 8, 10 lamivudine-zidovudine... 9 lamotrigine... 1 LANTUS... LANTUS SOLOSTAR... larin 1.5/ larin 1/ larin fe 1.5/ larin fe 1/ LASTACAFT latanoprost... 7 LATUDA... 9 LEENA... 9 leflunomide... 6 LENVIMA 10 MG DAILY DOSE LENVIMA 1 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 0 MG DAILY DOSE LENVIMA MG DAILY DOSE LENVIMA 8 MG DAILY DOSE lessina... 9 LETAIRIS... 9 letrozole leucovorin calcium... 0 LEUKERAN LEUKINE... 6 leuprolide acetate LEVEMIR... LEVEMIR FLEXTOUCH... levetiracetam... 1 LEVETIRACETAM IN NACL... 1 levobunolol hcl... 7 levocarnitine... 5 levocetirizine dihydrochloride levofloxacin... 1 levofloxacin in d5w... 1 levoleucovorin calcium... 0 levoleucovorin calcium pf... 1 levonest... 9 levonorgest-eth estrad 91-day... 9 levonorgestrel... 9 levonorgestrel-ethinyl estrad... 9 levonorg-eth estrad triphasic... 9 levora 0.15/0 (8)... 9 levothyroxine sodium levoxyl LEXIVA... 8 lidocaine lidocaine hcl..., 80 lidocaine hcl (pf)... lidocaine viscous... 8 lidocaine-prilocaine linezolid... 6 LINEZOLID... 6 LINZESS... 58, 59 liothyronine sodium lisinopril... lisinopril-hydrochlorothiazide... 1 LITHIUM lithium carbonate... lithium carbonate er... LONSURF... 0 loperamide hcl lorazepam... 9 lorazepam intensol... 9 lorcet... lorcet plus... lortab... loryna... 9 losartan potassium... losartan potassium-hctz... LOTEMAX... 7 lovastatin... low-ogestrel... 9 loxapine succinate... 9 LUMIGAN... 7 LUMIZYME... 5 LUPRON DEPOT lutera... 9 LYNPARZA LYRICA... LYSODREN lyza... 9 MAGNESIUM SULFATE magnesium sulfate MAGNESIUM SULFATE IN D5W malathion maprotiline hcl... 5 marlissa... 9 MARPLAN... 5 MATULANE... 0 meclizine hcl medroxyprogesterone acetate... 9, 55 mefloquine hcl... 7 megestrol acetate MEGESTROL ACETATE MEKINIST meloxicam... 1 memantine hcl... MEMANTINE HCL... MENACTRA MENHIBRIX MENOMUNE MENVEO mercaptopurine... 16

98 meropenem... 6 mesalamine mesalamine-cleanser mesna... 1 MESNEX... 1 metadate er... 1 metformin hcl... 6 metformin hcl er... 6 methadone hcl... methadone hcl intensol... methazolamide... 7 methenamine hippurate... 6 methimazole methotrexate... 6 methotrexate sodium METHOTREXATE SODIUM methotrexate sodium (pf) methylphenidate hcl... 1 methylphenidate hcl er... 1 methylprednisolone... 5 methylprednisolone acetate... 5 methylprednisolone sodium succ... 5 metipranolol... 7 metoclopramide hcl metolazone... 7 metoprolol succinate er... 5 metoprolol tartrate... 5 metoprolol-hydrochlorothiazide... 5 metronidazole... 6, 61, 81 metronidazole in nacl... 6 mexiletine hcl... MIACALCIN... 5 MICROGESTIN 1.5/ MICROGESTIN 1/ MICROGESTIN FE 1.5/ MICROGESTIN FE 1/ midodrine hcl... 8 migergot... 1 minitran... 8 minocycline hcl minoxidil... 8 mirtazapine... 5 misoprostol mitomycin mitoxantrone hcl... 0 M-M-R II moderiba moexipril hcl... moexipril-hydrochlorothiazide... 1 molindone hcl... 9 mometasone furoate mono-linyah MONONESSA montelukast sodium MORPHINE SULFATE... MORPHINE SULFATE (CONCENTRATE)... morphine sulfate (pf)... MORPHINE SULFATE (PF)... morphine sulfate er..., MOVANTIK MOVIPREP MOXEZA... 7 MOZOBIL... 6 MULTAQ... mupirocin mupirocin calcium MYCAMINE... 5 mycophenolate mofetil mycophenolic acid myorisan MYRBETRIQ myzilra nabumetone... 1 nadolol... 5 nafcillin sodium... 1 NAGLAZYME... 5 nalbuphine hcl... naloxone hcl... naltrexone hcl... NAMENDA XR... NAMENDA XR TITRATION PACK... NAMZARIC... naphazoline hcl... 7 naproxen... 1 naproxen dr... 1 naproxen sodium... 1 NATACYN... 7 nateglinide... 6 NATPARA... 5 NEBUPENT... 6 necon 0.5/5 (8) necon 1/5 (8) NECON 1/50 (8) NECON 7/7/ nefazodone hcl... 5 neomycin sulfate... neomycin-bacitracin zn-polymyx... 7 neomycin-polymyxin-dexameth... 7 neomycin-polymyxin-gramicidin... 7 neomycin-polymyxin-hc... 8 NEORAL NEPHRAMINE NEUPOGEN... 6 NEUPRO... 7 NEVIRAPINE... 8 nevirapine... 8 nevirapine er... 8 NEXAVAR NEXIUM niacin er (antihyperlipidemic)... niacor... nicardipine hcl... 6 NICOTROL... NICOTROL NS... nifedical xl... 6 nifedipine er... 6 nifedipine er osmotic release... 6 nikki NILANDRON nimodipine... 6 NINLARO NIPENT nitro-bid... 8 nitrofurantoin macrocrystal... 6 nitrofurantoin monohyd macro... 6 nitroglycerin... 8 NITROSTAT... 8 NORA-BE NORDITROPIN FLEXPRO... 5 norethindrone norethindrone acetate norethindrone-eth estradiol... 5 norgestimate-eth estradiol... 50

99 norgestim-eth estrad triphasic norlyroc NORMOSOL-M IN D5W NORMOSOL-R IN D5W NORMOSOL-R PH NORPACE CR... NORTHERA... 8 nortrel 0.5/5 (8) nortrel 1/5 (1) nortrel 1/5 (8) nortrel 7/7/ nortriptyline hcl... 5 NORVIR... 8 NOVOLIN 70/ NOVOLIN N... 5 NOVOLIN R... 5 NOVOLOG... 5 NOVOLOG FLEXPEN... 5 NOVOLOG MIX 70/ NOVOLOG MIX 70/0 FLEXPEN... 5 NOVOLOG PENFILL... 5 NOXAFIL... 5 NUEDEXTA... NULOJIX NULYTELY WITH FLAVOR PACKS NUPLAZID... 9 NUTRILIPID NUVARING nyamyc NYMALIZE... 6 nystatin... 5, 78, 8 nystop OCELLA OCTAGAM... 6 octreotide acetate... 5 ODEFSEY... 9 ODOMZO... 0 OFEV ofloxacin... 7, 8 olanzapine... 9 omega--acid ethyl esters... omeprazole ondansetron ondansetron hcl ONFI... OPANA ER... OPSUMIT... 9 ORFADIN... 5 ORKAMBI orsythia oxandrolone... oxcarbazepine... oxybutynin chloride oxybutynin chloride er oxycodone hcl... OXYCODONE HCL... oxycodone-acetaminophen... pacerone... paliperidone er... 9 pamidronate disodium... 7 PANRETIN pantoprazole sodium paricalcitol paroex... 8 paromomycin sulfate... paroxetine hcl... 5 paser PATADAY PAXIL... 5 PAZEO PEDIARIX PEDVAX HIB peg 50/electrolytes peg 50-kcl-na bicarb-nacl peg-50/electrolytes PEGANONE... PEGASYS PEGASYS PROCLICK PENICILLIN G POT IN DEXTROSE... 1 penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTACEL PENTAM... 6 pentoxifylline er... 6 perindopril erbumine... periogard... 8 permethrin perphenazine... 9 phenadoz phenelzine sulfate... 6 phenergan phenobarbital... phenobarbital sodium... PHENOBARBITAL SODIUM... phenytek... phenytoin... phenytoin sodium... phenytoin sodium extended... philith PHOSPHOLINE IODIDE... 7 PILOCARPINE HCL... 7, 8 pilocarpine hcl... 8 pimozide... 9 pimtrea pindolol... 5 pioglitazone hcl... 6 piperacillin sod-tazobactam so pirmella 1/ PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN D5W podofilox polyethylene glycol polymyxin b-trimethoprim... 7 POMALYST... 6 portia POTASSIUM CHLORIDE... 68, 70 potassium chloride potassium chloride crys er potassium chloride er POTASSIUM CHLORIDE IN DEXTROSE potassium chloride in nacl POTASSIUM CHLORIDE IN NACL POTASSIUM CITRATE ER POTIGA... PRADAXA PRALUENT... pramipexole dihydrochloride... 7 pravastatin sodium... prazosin hcl... prednisolone... 5 prednisolone acetate... 7 prednisolone sodium phosphate... 5, 7

100 prednisone... 5 prednisone intensol... 5 PREFERRED PLUS INSULIN SYRINGE... 5 premasol prenatal prevalite... previfem PREZCOBIX... 9 PREZISTA... 8 PRIFTIN PRIMAQUINE PHOSPHATE... 7 primidone... PRISTIQ... 6 PRIVIGEN... 6 probenecid... 1 PROCALAMINE prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT... 6 procto-med hc procto-pak proctosol hc proctozone-hc PROGLYCEM... 5 PROGRAF PROLASTIN-C PROLENSA... 7 PROLIA... 5 PROMACTA... 6 promethazine hcl promethegan propafenone hcl... propafenone hcl er... proparacaine hcl... 7 propranolol hcl... 5 propranolol hcl er... 5 propylthiouracil PROQUAD PROSOL protriptyline hcl... 6 PULMICORT FLEXHALER PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide... QUADRACEL quasense quetiapine fumarate... 9 quinapril hcl... quinapril-hydrochlorothiazide... 1 quinidine gluconate er... quinidine sulfate... quinine sulfate... 7 RABAVERT raloxifene hcl... 5 ramipril... RANEXA... 8 ranitidine hcl RAPAMUNE RAVICTI... 5 reclipsen RECOMBIVAX HB REGRANEX RELENZA DISKHALER RELI-ON INSULIN SYRINGE... 5 RELISTOR REMICADE... 6 REMODULIN... 9 RENVELA repaglinide... 6 RESCRIPTOR... 8 RESTASIS... 7 RETROVIR... 8 REVATIO... 9 REVLIMID... 6 REXULTI... 9 REYATAZ... 8 ribasphere ribavirin rifabutin rifampin RIFATER riluzole... rimantadine hcl RINGERS RISPERDAL CONSTA... 9 risperidone... 9, 0 RITUXAN rivastigmine... rivastigmine tartrate... rizatriptan benzoate... ropinirole hcl... 7 rosadan rosuvastatin calcium... ROTARIX ROTATEQ roweepra... roxicet... SABRIL... SANDIMMUNE SANTYL SAPHRIS... 0 selegiline hcl... 7 selenium sulfide SELZENTRY... 8 SENSIPAR... 7 SEREVENT DISKUS SEROQUEL XR... 0 sertraline hcl... 6 setlakin sharobel SIGNIFOR... 5 sildenafil citrate... 9 SILENOR... 1 silver sulfadiazine SIMBRINZA... 7 simvastatin..., sirolimus SIROLIMUS SIRTURO SIVEXTRO... 6 SODIUM CHLORIDE... 68, 71 sodium chloride sodium fluoride sodium polystyrene sulfonate... 7 SOLTAMOX SOLU-CORTEF... 5 SOMATULINE DEPOT... 5 SOMAVERT... 5 sorine... sotalol hcl... sotalol hcl (af)... SOVALDI spironolactone... spironolactone-hctz... 7 sprintec SPRITAM... SPRYCEL sps... 7 sronyx... 51

101 ssd stavudine... 8 sterile water for irrigation STIMATE STIVARGA STRATTERA... 1 streptomycin sulfate... STRIBILD... 9 SUBOXONE..., sucralfate sulfacetamide sodium... 7, 78 sulfacetamide-prednisolone... 7 sulfadiazine... sulfamethoxazole-trimethoprim... 6, 7 SULFAMYLON sulfasalazine sulindac... SUMATRIPTAN... sumatriptan succinate... SUMATRIPTAN SUCCINATE... SUMATRIPTAN SUCCINATE REFILL... SUPRAX... 1 suprax... 1 SUPREP BOWEL PREP SUSTIVA... 8 SUTENT syeda SYLATRON... 0 SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID... 7 SYNRIBO... 0 SYNTHROID SYPRINE... 7 TABLOID tacrolimus... 65, 81 TAFINLAR TAGRISSO TAMIFLU tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN tarina fe 1/ TASIGNA tazicef... 1 TAZORAC taztia xt... 6 TECENTRIQ TEFLARO... 1 TEGRETOL..., TEGRETOL-XR... temazepam... 1 TENIVAC terazosin hcl... terbinafine hcl... 5 terbutaline sulfate terconazole testosterone cypionate... testosterone enanthate... TETANUS-DIPHTHERIA TOXOIDS TD TETRABENAZINE... THALOMID theophylline er thioridazine hcl... 0 thiothixene... 0 tiagabine hcl... timolol maleate... 5, 7 TIMOLOL MALEATE... 7 TIVICAY... 8 tizanidine hcl... TOBRADEX... 7 TOBRADEX ST... 7 tobramycin..., 7 tobramycin sulfate... tobramycin-dexamethasone... 7 tolterodine tartrate tolterodine tartrate er topiramate... toposar... 1 TOPOTECAN HCL... 1 topotecan hcl... 1 torsemide... 7 TOUJEO SOLOSTAR... 5 TOVIAZ TPN ELECTROLYTES tramadol hcl... trandolapril... tranexamic acid TRANSDERM-SCOP (1.5 MG) tranylcypromine sulfate... 6 TRAVASOL TRAVATAN Z... 7 trazodone hcl... 6 TRECATOR TRELSTAR MIXJECT TRESIBA FLEXTOUCH... 5 tretinoin... 0, 78 TRETINOIN triamcinolone acetonide... 80, 8 triamterene-hctz... 7, 8 triderm trifluoperazine hcl... 0 trifluridine... 7 tri-legest fe tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte trimethoprim... 7 trimipramine maleate... 6 TRINESSA (8) TRINESSA LO TRINTELLIX... 6 tri-previfem TRISENOX... 0 tri-sprintec TRIUMEQ... 9 trivora (8) TROPHAMINE TRULICITY... 5 TRUMENBA TRUVADA... 9 TWINRIX TYBOST... 9 TYGACIL... 7 TYKERB TYPHIM VI TYSABRI... TYZEKA ULORIC... 1 unithroid UPTRAVI... 9 ursodiol VAGIFEM... 5 valacyclovir hcl... 11

102 VALCHLOR VALCYTE valganciclovir hcl valproate sodium... valproic acid... valsartan... valsartan-hydrochlorothiazide... vancomycin hcl... 7 VANDAZOLE VAQTA VARIVAX VASCEPA... VELCADE velivet VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl... 6 venlafaxine hcl er... 6 VENTAVIS... 9 VENTOLIN HFA verapamil hcl... 6 verapamil hcl er... 6 VERAPAMIL HCL ER... 6 VERSACLOZ... 0 VESICARE vestura VICTOZA... 5 VIDEX... 9 vienva VIGAMOX... 7 VIIBRYD... 6 VIIBRYD STARTER PACK... 6 VIMPAT... viorele VIRACEPT... 9 VIREAD... 9 VITEKTA... 9 voriconazole... 5 VOTRIENT VRAYLAR... 0 vyfemla warfarin sodium... 6 WELCHOL... XALKORI XARELTO... 6 XARELTO STARTER PACK... 6 XELJANZ... 6 XELJANZ XR... 6 XGEVA... 5 XIFAXAN XIGDUO XR... 6 XOLAIR XOPENEX HFA XTANDI xulane XYREM... YERVOY YF-VAX zafirlukast zarah ZAVESCA... 5 ZAZOLE ZELBORAF ZEMAIRA zenatane zenchent ZENPEP ZETIA... ZIAGEN... 9 zidovudine... 9 ziprasidone hcl... 0 ZIRGAN... 7 zoledronic acid... 7 ZOLINZA zolpidem tartrate... 1 zonisamide... ZONTIVITY... 6 ZORTRESS... 65, 66 ZOSTAVAX zovia 1/5e (8) zovia 1/50e (8) ZYDELIG ZYKADIA ZYLET... 7 ZYPREXA RELPREVV... 0 ZYTIGA

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

104 Y0070_NA08_WCM_INS_ENG_NA_07_16_PDP_FINAL We re always just a phone call away! If you re ready to enroll or have enrollment questions, call a.m. to 8 p.m., 7 days a week. If you re already a member, call the number listed below. Prescription Plans: WellCare Classic (PDP) WellCare Extra (PDP) TTY Hours of operation are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 1, representatives are available Monday Sunday, 8 a.m. to 8 p.m., or visit us anytime at

105 WellCare (PDP) is a Medicare-approved Part D sponsor. Enrollment in WellCare (PDP) depends on contract renewal. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Benefits, premiums and/or co-payments/ coinsurance may change on January 1 of each year. This formulary was updated on 09/01/016. For more recent information or other questions, please contact WellCare at the telephone number listed on the inside front and back covers of this formulary or visit P.O. Box 189 Tampa, FL