Stanford Health Care Advantage 2017 Abridged Formulary Partial List of Covered Drugs

Transcription

1 Stanford Health Care Advantage 2017 Abridged Formulary Partial List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN , 6 This abridged formulary was updated on 02/01/2017. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact Member Care Services, at or, for TTY users, 711, 8 am to 8 pm (seven days a week from October 1 through February 14 and Monday through Friday from February 15 through September 0) or visit StanfordHealthCareAdvantage.org.

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11 Table of Contents Analgesics... Anesthetics... 6 Anti-Addiction/Substance Abuse Treatment Agents... 6 Antianxiety Agents... 7 Antibacterials... 8 Anticancer Agents Anticholinergic Agents... 1 Anticonvulsants... 1 Antidementia Agents Antidepressants Antidiabetic Agents Antifungals Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic)... 2 Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents Central Nervous System Agents... Contraceptives... 4 Dental And Oral Agents... 6 Dermatological Agents... 7 Devices... 9 Enzyme Replacement/Modifiers... 9 Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents

12 Miscellaneous Therapeutic Agents... 5 Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals

13 Analgesics Analgesics, Miscellaneous acetaminophen-codeine /5 ml solution /5 ml (Acetaminophen with Codeine) 2 GC; QL (2700 per 0 acetaminophen-codeine oral solution 00-0 /12.5 ml (Acetaminophen with Codeine) 2 GC; QL (2700 per 0 acetaminophen-codeine oral tablet (Tylenol-Codeine 2 GC; QL (60 per 0, 00-0 No.) acetaminophen-codeine oral tablet (Tylenol-Codeine 2 GC; QL (180 per 0 No.) butalbital-acetaminophen-caff oral capsule (Esgic) 2 GC; QL (180 per 0 butalbital-acetaminophen-caff oral tablet (Esgic) 2 GC; QL (180 per 0 endocet oral tablet (Xolox) 2 GC; QL (240 per 0 endocet oral tablet 5-25 (Xolox) 2 GC; QL (60 per 0 endocet oral tablet (Xolox) 2 GC; QL (00 per 0 hydrocodone-acetaminophen oral solution /15 ml (Hycet) 2 GC; QL (2700 per 0 hydrocodone-acetaminophen oral tablet 10-00, 5-00, (Norco) 2 GC; QL (90 per 0 hydrocodone-acetaminophen oral tablet 10-25, , 5-25, lorcet (hydrocodone) oral tablet 5-25 (Norco) 2 GC; QL (60 per 0 (Norco) 2 GC; QL (60 per 0 lorcet plus oral tablet (Norco) 2 GC; QL (60 per 0 morphine 10 /ml carpuject outer,p/f,latex-free 10 /ml morphine 2 /ml carpuject outer, latex-f, p/f 2 /ml (Morphine Sulfate) 2 GC (Morphine Sulfate) 2 GC

14 morphine 4 /ml syringe p/f, latex-free (Morphine Sulfate) 2 GC 4 /ml morphine 8 /ml syringe 8 /ml (Morphine Sulfate) 2 GC morphine concentrate oral solution 100 /5 ml (20 /ml) (Morphine Sulfate) 2 GC; QL (180 per 0 morphine intravenous syringe 10 /ml, 2 (Morphine Sulfate) 2 GC /ml, 4 /ml, 8 /ml morphine oral solution 10 /5 ml (Morphine Sulfate) 2 GC; QL (700 per 0 morphine oral solution 20 /5 ml (4 /ml) (Morphine Sulfate) 2 GC; QL (00 per 0 MORPHINE ORAL TABLET 15 MG 4 QL (180 per 0 MORPHINE ORAL TABLET 0 MG 4 QL (120 per 0 morphine oral tablet extended release 100 (MS Contin) 2 GC; QL (60 per 0, 200, 60 morphine oral tablet extended release 15 (MS Contin) 2 GC; QL (180 per 0 morphine oral tablet extended release 0 (MS Contin) 2 GC; QL (120 per 0 oxycodone oral capsule 5 (Oxycodone HCl) 2 GC; QL (180 per 0 oxycodone oral concentrate 20 /ml (Oxycodone HCl) 2 GC; QL (120 per 0 oxycodone oral solution 5 /5 ml (Oxycodone HCl) 2 GC; QL (100 per 0 oxycodone oral tablet 10, 5 (Roxicodone) 2 GC; QL (180 per 0 oxycodone oral tablet 15, 20, 0 (Roxicodone) 2 GC; QL (120 per 0 oxycodone-acetaminophen oral solution 5-25 /5 ml (Oxycodone HCl/Acetaminophen) 2 GC; QL (1800 per 0 oxycodone-acetaminophen oral tablet (Xolox) 2 GC; QL (240 per 0 oxycodone-acetaminophen oral tablet , 5-25 (Xolox) 2 GC; QL (60 per 0 4

15 oxycodone-acetaminophen oral tablet (Xolox) 2 GC; QL (00 per 0 OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 0 MG, 40 MG, 60 MG OXYCONTIN ORAL QL (120 per 0 TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG tramadol oral tablet 50 (Ultram) 2 GC; QL (240 per 0 vicodin es oral tablet (Norco) 2 GC; QL (90 per 0 vicodin hp oral tablet (Norco) 2 GC; QL (90 per 0 vicodin oral tablet 5-00 (Norco) 2 GC; QL (90 per 0 XARTEMIS XR ORAL TAB,ORAL QL (00 per 0 ONLY,IR - ER, BIPHASE MG zebutal oral capsule (Esgic) 2 GC; QL (180 per 0 Nonsteroidal Anti-Inflammatory Agents diclofenac sodium oral tablet extended (Voltaren-XR) 2 GC release 24 hr 100 diclofenac sodium oral tablet,delayed (Diclofenac Sodium) 2 GC release (dr/ec) 25, 50, 75 ibuprofen oral suspension 100 /5 ml (Ibuprofen) 2 GC ibuprofen oral tablet 400, 600, (Ibuprofen) 1 GC 800 indomethacin oral capsule 25 (Indomethacin) 1 GC; QL (240 per 0 indomethacin oral capsule 50 (Indomethacin) 1 GC; QL (120 per 0 indomethacin oral capsule, extended release 75 (Indomethacin) 2 GC; QL (60 per 0 meloxicam oral suspension 7.5 /5 ml (Mobic) 2 GC 5

16 meloxicam oral tablet 15, 7.5 (Mobic) 1 GC nabumetone oral tablet 500, 750 (Nabumetone) 2 GC naproxen oral suspension 125 /5 ml (Naprosyn) 2 GC naproxen oral tablet 250, 75, 500 (Naprosyn) 1 GC naproxen oral tablet,delayed release (Ec-Naprosyn) 2 GC (dr/ec) 75, 500 VOLTAREN TOPICAL GEL 1 % 2 GC Anesthetics Local Anesthetics lidocaine 2% viscous soln 2 % (Pre-Attached Lta Kit) 2 GC lidocaine hcl injection solution 20 /ml (Xylocaine) 2 GC (2 %) lidocaine hcl mucous membrane jelly 2 % (Lidocaine HCl) 2 GC lidocaine hcl mucous membrane solution (Pre-Attached Lta Kit) 2 GC 2 %, 4 % (40 /ml) lidocaine topical adhesive (Lidoderm) 2 PA; GC patch,medicated 5 % lidocaine topical ointment 5 % (Lidocaine) 2 GC Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents BUNAVAIL BUCCAL FILM MG PA; QL (0 per 0 BUNAVAIL BUCCAL FILM MG, 6.-1 MG PA; QL (60 per 0 buprenorphine hcl sublingual tablet 2, 8 (Buprenorphine HCl) 2 PA; GC; QL (90 per 0 buprenorphine-naloxone sublingual tablet 2-0.5, 8-2 (Buprenorphine HCl/Naloxone HCl) 2 PA; GC; QL (90 per 0 CHANTIX ORAL TABLET 0.5 MG, 1 QL (168 per 84 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) QL (5 per 28 6

17 SUBOXONE SUBLINGUAL FILM 12- MG, 8-2 MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25, 0.5, 1 4 PA; QL (60 per 0 4 PA; QL (0 per 0 PA; QL (0 per 0 PA; QL (60 per 0 (Xanax) 1 GC; QL (120 per 0 alprazolam oral tablet 2 (Xanax) 1 GC; QL (150 per 0 (Xanax XR) 2 GC; QL (120 per 0 (Xanax XR) 2 GC; QL (90 per 0 alprazolam oral tablet extended release 24 hr 0.5, 1, 2 alprazolam oral tablet extended release 24 hr clonazepam oral tablet 0.5, 1 (Klonopin) 1 GC; QL (90 per 0 clonazepam oral tablet 2 (Klonopin) 1 GC; QL (00 per 0 clonazepam oral tablet,disintegrating 0.125, 0.25, 0.5, 1 (Clonazepam) 2 GC; QL (90 per 0 clonazepam oral tablet,disintegrating 2 (Clonazepam) 2 GC; QL (00 per 0 lorazepam 2 /ml oral concent 2 /ml (Lorazepam) 2 GC; QL (150 per 0 lorazepam intensol oral concentrate 2 /ml (Lorazepam) 2 GC; QL (150 per 0 lorazepam oral tablet 0.5, 1 (Ativan) 1 GC; QL (90 per 0 lorazepam oral tablet 2 (Ativan) 1 GC; QL (150 per 0 7

18 Antibacterials Aminoglycosides gentamicin injection solution 40 /ml (Gentamicin Sulfate) 2 GC neomycin oral tablet 500 (Neomycin Sulfate) 2 GC Antibacterials, Miscellaneous clindamycin hcl oral capsule 150, 00 (Cleocin HCl) 2 GC, 75 metronidazole oral capsule 75 (Flagyl) 2 GC metronidazole oral tablet 250, 500 (Flagyl) 2 GC nitrofurantoin macrocrystal oral capsule 100, 25, 50 (Macrodantin/Macrobi d) 2 GC; QL (120 per 0 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) 2 GC; QL (60 per 0 trimethoprim oral tablet 100 (Trimethoprim) 2 GC XIFAXAN ORAL TABLET 200 MG 5 PA; NDS; QL (9 per 0 XIFAXAN ORAL TABLET 550 MG 5 PA; NDS Cephalosporins cefadroxil oral capsule 500 (Cefadroxil) 2 GC cefadroxil oral suspension for (Cefadroxil) 2 GC reconstitution 250 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram (Cefadroxil) 2 GC cefdinir oral capsule 00 (Cefdinir) 2 GC cefdinir oral suspension for reconstitution (Cefdinir) 2 GC 125 /5 ml, 250 /5 ml cefprozil oral suspension for (Cefprozil) 2 GC reconstitution 125 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 (Cefprozil) 2 GC cefuroxime axetil oral tablet 250, 500 (Ceftin) 2 GC cephalexin oral capsule 250, 500 (Keflex) 1 GC cephalexin oral capsule 750 (Keflex) 2 GC cephalexin oral suspension for (Cephalexin) 1 GC reconstitution 125 /5 ml, 250 /5 ml cephalexin oral tablet 250, 500 (Cephalexin) 1 GC 8

19 Macrolides azithromycin intravenous recon soln 500 (Zithromax) 2 GC azithromycin oral packet 1 gram (Zithromax) 2 GC azithromycin oral suspension for (Zithromax) 2 GC reconstitution 100 /5 ml, 200 /5 ml azithromycin oral tablet 250, 250 (Zithromax) 2 GC (6 pack), 500, 600 clarithromycin oral suspension for (Biaxin) 2 GC reconstitution 125 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 (Biaxin) 2 GC clarithromycin oral tablet extended (Clarithromycin) 2 GC release 24 hr 500 Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION 5 LA; NDS SOLUTION FOR NEBULIZATION 75 MG/ML INVANZ INJECTION RECON SOLN 4 1 GRAM Penicillins amoxicillin oral capsule 250, 500 (Amoxicillin) 1 GC amoxicillin oral suspension for (Amoxicillin) 1 GC reconstitution 125 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 (Amoxicillin) 1 GC amoxicillin oral tablet,chewable 125, (Amoxicillin) 1 GC 250 amoxicillin-pot clavulanate oral (Augmentin) 2 GC suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) 2 GC , , amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, (Augmentin XR) 2 GC 9

20 amoxicillin-pot clavulanate oral (Amoxicillin/Potassium 2 GC tablet,chewable , Clav) dicloxacillin oral capsule 250, 500 (Dicloxacillin Sodium) 2 GC penicillin v potassium oral recon soln 125 (Penicillin V 2 GC /5 ml, 250 /5 ml Potassium) penicillin v potassium oral tablet 250, (Penicillin V 2 GC 500 Potassium) Quinolones ciprofloxacin (mixture) oral tablet, er (Cipro XR) 2 GC multiphase 24 hr 1,000, 500 ciprofloxacin hcl oral tablet 100, 250 (Cipro) 1 GC, 500, 750 levofloxacin intravenous solution 25 (Levofloxacin) 2 GC /ml levofloxacin oral solution 250 /10 ml (Levofloxacin) 2 GC levofloxacin oral tablet 250, 500, (Levaquin) 1 GC 750 Sulfonamides sulfamethoxazole-trimethoprim (Sulfamethoxazole/Tri 2 GC intravenous solution /5 ml methoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tri 2 GC suspension /5 ml methoprim) sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet , sulfasalazine oral tablet 500 (Azulfidine) 2 GC sulfasalazine oral tablet,delayed release (Azulfidine) 2 GC (dr/ec) 500 Tetracyclines doxy-100 intravenous recon soln 100 (Doxycycline Hyclate) 2 GC doxycycline hyclate intravenous recon (Doxycycline Hyclate) 2 GC soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 2 GC 50 doxycycline hyclate oral tablet 100, 20 (Doryx) 2 GC 10

21 doxycycline hyclate oral tablet,delayed release (dr/ec) 100, 150, 200, 50, 75 minocycline oral capsule 100, 50, 75 minocycline oral tablet 100, 50, 75 minocycline oral tablet extended release 24 hr 15, 45, 90 Anticancer Agents Anticancer Agents AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, MG, 5 MG (Doryx) 2 GC (Minocin) 2 GC (Minocycline HCl) 2 GC (Minocycline HCl) 2 GC 5 PA NSO; NDS; QL (112 per 28 AFINITOR ORAL TABLET 10 MG 5 PA NSO; NDS; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 5 PA NSO; NDS; QL (28 per 28 anastrozole oral tablet 1 (Arimidex) 2 GC bicalutamide oral tablet 50 (Casodex) 2 GC DROXIA ORAL CAPSULE 200 MG, 00 MG, 400 MG ELIGARD ( MONTH) 4 QL (1 per 84 SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD (4 MONTH) 4 QL (1 per 112 SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) 4 QL (1 per 168 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS 4 SYRINGE 7.5 MG (1 MONTH) exemestane oral tablet 25 (Aromasin) 2 GC flutamide oral capsule 125 (Flutamide) 2 GC hydroxyurea oral capsule 500 (Hydrea) 2 GC JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG 5 PA NSO; NDS; QL (60 per 0 11

22 letrozole oral tablet 2.5 (Femara) 2 GC LEUKERAN ORAL TABLET 2 MG 4 leuprolide subcutaneous kit 1 /0.2 ml (Leuprolide Acetate) 2 GC LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG 5 NDS; QL (1 per 84 5 NDS; QL (1 per 84 5 NDS; QL (1 per NDS LYSODREN ORAL TABLET 500 MG 5 NDS megestrol oral tablet 20, 40 (Megestrol Acetate) 2 GC mercaptopurine oral tablet 50 (Mercaptopurine) 2 GC methotrexate sodium oral tablet 2.5 (Methotrexate Sodium) 2 PA BvD; ST ; GC NEXAVAR ORAL TABLET 200 MG 5 PA NSO; NDS; QL (120 per 0 POMALYST ORAL CAPSULE 1 MG, 2 MG, MG, 4 MG 5 PA NSO; NDS; QL (21 per 28 PURIXAN ORAL SUSPENSION 20 5 NDS MG/ML REVLIMID ORAL CAPSULE 10 5 PA NSO; LA; NDS MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG SOLTAMOX ORAL SOLUTION 10 4 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NDS; QL (0 per 0 SPRYCEL ORAL TABLET 20 MG 5 PA NSO; NDS; QL (60 per 0 SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 7.5 MG, 50 MG 5 PA NSO; NDS; QL (0 per 0 12

23 tamoxifen oral tablet 10, 20 (Tamoxifen Citrate) 2 GC TARCEVA ORAL TABLET 100 MG, 25 MG 5 PA NSO; NDS; QL (60 per 0 TARCEVA ORAL TABLET 150 MG 5 PA NSO; NDS; QL (90 per 0 TASIGNA ORAL CAPSULE 150 MG, 200 MG 5 PA NSO; NDS; QL (112 per 28 tretinoin (chemotherapy) oral capsule 10 (Tretinoin) 5 NDS TREXALL ORAL TABLET 10 MG, 4 PA BvD; ST 15 MG, 5 MG, 7.5 MG TYKERB ORAL TABLET 250 MG 5 NDS VOTRIENT ORAL TABLET 200 MG 5 PA NSO; NDS; QL (120 per 0 XALKORI ORAL CAPSULE 200 MG, 250 MG 5 PA NSO; NDS; QL (60 per 0 XTANDI ORAL CAPSULE 40 MG 5 PA NSO; NDS; QL (120 per 0 ZELBORAF ORAL TABLET 240 MG 5 PA NSO; NDS; QL (240 per 0 ZYTIGA ORAL TABLET 250 MG 5 PA NSO; NDS; QL (120 per 0 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0.1 (Atropine Sulfate) 2 GC /ml propantheline oral tablet 15 (Propantheline 2 GC Bromide) Anticonvulsants Anticonvulsants carbamazepine oral capsule, er (Carbatrol) 2 GC multiphase 12 hr 100, 200, 00 carbamazepine oral suspension 100 /5 (Tegretol) 2 GC ml carbamazepine oral tablet 200 (Tegretol) 2 GC 1

24 carbamazepine oral tablet extended (Tegretol XR) 2 GC release 12 hr 100, 200, 400 carbamazepine oral tablet,chewable 100 (Carbamazepine) 2 GC DILANTIN ORAL CAPSULE 0 MG 2 GC divalproex oral capsule, sprinkle 125 (Depakote Sprinkle) 2 GC divalproex oral tablet extended release 24 (Depakote ER) 2 GC hr 250, 500 divalproex oral tablet,delayed release (Depakote) 2 GC (dr/ec) 125, 250, 500 epitol oral tablet 200 (Tegretol) 2 GC gabapentin oral capsule 100, 00, (Neurontin) 2 GC 400 gabapentin oral solution 250 /5 ml (Neurontin) 2 GC gabapentin oral tablet 600, 800 (Neurontin) 2 GC GRALISE 0-DAY STARTER PACK 4 ST; QL (78 per 0 ORAL TABLET EXTENDED RELEASE 24 HR 00 MG (9)- 600 MG (69) GRALISE ORAL TABLET 4 ST; QL (90 per 0 EXTENDED RELEASE 24 HR 00 MG, 600 MG lamotrigine oral tablet 100, 150, (Lamictal) 2 GC 200, 25 lamotrigine oral tablet extended release (Lamictal XR) 2 GC 24hr 100, 200, 25, 250, 00, 50 lamotrigine oral tablet, chewable (Lamictal) 2 GC dispersible 25, 5 lamotrigine oral tablet,disintegrating 100 (Lamictal Odt) 2 GC, 200, 25, 50 levetiracetam intravenous solution 500 (Keppra) 2 GC /5 ml levetiracetam oral solution 100 /ml (Keppra) 2 GC levetiracetam oral tablet 1,000, 250, 500, 750 (Roweepra) 2 GC 14

25 levetiracetam oral tablet extended release 24 hr 500, 750 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML phenytoin sodium extended oral capsule 100, 200, 00 ROWEEPRA ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG topiramate oral capsule, sprinkle 15, 25 topiramate oral capsule,sprinkle,er 24hr 100, 150, 200, 25, 50 topiramate oral tablet 100, 200, 25, 50 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG (Keppra XR) 2 GC (Dilantin) 2 GC QL (90 per 0 QL (900 per 0 2 GC (Topamax) 2 GC (Qudexy XR) 2 GC (Topamax) 2 GC 4 ST ; QL (60 per 0 4 ST ; QL (120 per 0 Antidementia Agents Antidementia Agents donepezil oral tablet 10, 2, 5 (Aricept) 2 GC; QL (0 per 0 donepezil oral tablet,disintegrating 10, 5 (Donepezil HCl) 2 GC; QL (0 per 0 memantine oral solution 2 /ml (Namenda) 2 GC; QL (60 per 0 memantine oral tablet 10, 5 (Namenda) 2 GC; QL (60 per

26 memantine oral tablets,dose pack 5-10 NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 14 MG, 21 MG, 28 MG, 7 MG Antidepressants Antidepressants amitriptyline oral tablet 10, 100, 150, 25, 50, 75 (Namenda) 2 GC; QL (49 per 28 QL (28 per 28 (Amitriptyline HCl) 2 GC QL (0 per 0 bupropion hcl oral tablet 100, 75 (Wellbutrin) 2 GC bupropion hcl oral tablet extended release 100, 150, 200 (Wellbutrin SR) 2 GC bupropion hcl oral tablet extended release (Wellbutrin XL) 2 GC 24 hr 150, 00 citalopram oral solution 10 /5 ml (Citalopram Hydrobromide) 2 GC; QL (600 per 0 citalopram oral tablet 10, 20, 40 (Celexa) 1 GC; QL (0 per 0 escitalopram oxalate oral solution 5 /5 (Lexapro) 2 GC ml escitalopram oxalate oral tablet 10, (Lexapro) 1 GC 20, 5 fluoxetine oral capsule 10, 20, 40 (Prozac) 1 GC fluoxetine oral capsule,delayed (Prozac Weekly) 2 GC release(dr/ec) 90 fluoxetine oral solution 20 /5 ml (4 (Fluoxetine HCl) 2 GC /ml) fluoxetine oral tablet 10, 20 (Fluoxetine HCl) 2 GC FLUOXETINE ORAL TABLET 60 4 MG paroxetine hcl oral tablet 10, 20, 40 (Paxil) 1 GC 16

27 paroxetine hcl oral tablet 0 (Paxil) 2 GC paroxetine hcl oral tablet extended (Paxil CR) 2 GC release 24 hr 12.5, 25, 7.5 PAXIL ORAL SUSPENSION 10 4 MG/5 ML sertraline oral concentrate 20 /ml (Zoloft) 2 GC sertraline oral tablet 100, 25, 50 (Zoloft) 1 GC trazodone oral tablet 100, 150, (Trazodone HCl) 1 GC 00, 50 venlafaxine oral capsule,extended release (Effexor XR) 2 GC 24hr 150, 7.5, 75 venlafaxine oral tablet 100, 25, (Venlafaxine HCl) 2 GC 7.5, 50, 75 venlafaxine oral tablet extended release (Venlafaxine HCl) 2 GC 24hr 150, 7.5, 75 venlafaxine oral tablet extended release (Venlafaxine HCl) 4 24hr 225 Antidiabetic Agents Antidiabetic Agents, Miscellaneous JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG metformin oral tablet 1,000 (Glucophage) 1 GC; QL (75 per 0 metformin oral tablet 500 (Glucophage) 1 GC; QL (150 per 0 metformin oral tablet 850 (Glucophage) 1 GC; QL (90 per 0 metformin oral tablet extended release 24 hr 500 (Glucophage XR) 2 GC; QL (120 per 0 17

28 metformin oral tablet extended release 24 hr 750 metformin oral tablet extended release 24hr 1,000 ONGLYZA ORAL TABLET 2.5 MG, 5 MG pioglitazone oral tablet 15, 0, 45 TRADJENTA ORAL TABLET 5 MG VICTOZA (Glucophage XR) 2 GC; QL (90 per 0 (Fortamet) 2 ST; GC; QL (60 per 0 4 QL (0 per 0 (Actos) 1 GC; QL (0 per 0 Insulins HUMALOG KWIKPEN QL (0 per 28 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML ( ML) HUMALOG SUBCUTANEOUS QL (0 per 28 CARTRIDGE 100 UNIT/ML HUMALOG SUBCUTANEOUS QL (40 per 28 SOLUTION 100 UNIT/ML LANTUS SOLOSTAR QL (0 per 28 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LANTUS SUBCUTANEOUS QL (40 per 28 SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) Sulfonylureas glimepiride oral tablet 1, 2 (Amaryl) 1 GC; QL (0 per 0 glimepiride oral tablet 4 (Amaryl) 1 GC; QL (60 per 0 glipizide oral tablet 10 (Glucotrol) 1 GC; QL (120 per 0 glipizide oral tablet 5 (Glucotrol) 1 GC; QL (60 per 0 glipizide oral tablet extended release 24hr 10 (Glucotrol XL) 2 GC; QL (60 per 0 18

29 glipizide oral tablet extended release 24hr 2.5, 5 Antifungals Antifungals clotrimazole mucous membrane troche 10 (Glucotrol XL) 2 GC; QL (0 per 0 (Clotrimazole) 2 GC clotrimazole topical cream 1 % (Clotrimazole) 2 GC clotrimazole topical solution 1 % (Clotrimazole) 2 GC clotrimazole-betamethasone topical (Lotrisone) 2 GC cream % clotrimazole-betamethasone topical (Clotrimazole/Betamet 2 GC lotion % hasone Dip) fluconazole oral suspension for (Diflucan) 2 GC reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 150, (Diflucan) 2 GC 200, 50 ketoconazole oral tablet 200 (Ketoconazole) 2 GC ketoconazole topical cream 2 % (Ketoconazole) 2 GC ketoconazole topical shampoo 2 % (Nizoral) 2 GC nyamyc topical powder 100,000 (Nystatin) 2 GC unit/gram nystatin oral suspension 100,000 unit/ml (Nystatin) 2 GC nystatin oral tablet 500,000 unit (Nystatin) 2 GC nystatin topical cream 100,000 unit/gram (Nystatin) 2 GC nystatin topical ointment 100,000 (Nystatin) 2 GC unit/gram nystatin topical powder 100,000 (Nystatin) 2 GC unit/gram nystop topical powder 100,000 unit/gram (Nystatin) 2 GC terbinafine hcl oral tablet 250 (Lamisil) 1 GC Antigout Agents Antigout Agents, Other allopurinol oral tablet 100, 00 (Zyloprim) 2 GC COLCRYS ORAL TABLET 0.6 MG 2 GC 19

30 Antihistamines Antihistamines hydroxyzine hcl intramuscular solution (Hydroxyzine HCl) 2 GC 25 /ml, 50 /ml hydroxyzine hcl oral solution 10 /5 ml (Hydroxyzine HCl) 2 GC hydroxyzine hcl oral tablet 10, 25, (Hydroxyzine HCl) 2 GC 50 levocetirizine oral solution 2.5 /5 ml (Xyzal) 2 GC levocetirizine oral tablet 5 (Xyzal) 2 GC Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) metronidazole vaginal gel 0.75 % (Metrogel-Vaginal) 2 GC terconazole vaginal cream 0.4 %, 0.8 % (Terazol 7) 2 GC terconazole vaginal suppository 80 (Terconazole) 2 GC Antimigraine Agents Antimigraine Agents rizatriptan oral tablet 10, 5 (Maxalt) 2 GC; QL (18 per 28 rizatriptan oral tablet,disintegrating 10, 5 (Maxalt Mlt) 2 GC; QL (18 per 28 sumatriptan 4 /0.5 ml inject latex-free (Imitrex) 2 GC; QL (4 per 28 4 /0.5 ml sumatriptan succinate oral tablet 100, 25, 50 (Imitrex) 2 GC; QL (18 per 28 sumatriptan succinate subcutaneous (Imitrex) 2 GC; QL (4 per 28 cartridge 4 /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous pen (Imitrex) 2 GC; QL (4 per 28 injector 6 /0.5 ml sumatriptan succinate subcutaneous solution 6 /0.5 ml (Imitrex) 2 GC; QL (4 per 28 sumatriptan succinate subcutaneous syringe 6 /0.5 ml (Sumatriptan Succinate) 2 GC; QL (4 per 28 20

31 Antimycobacterials Antimycobacterials dapsone oral tablet 100, 25 (Dapsone) 2 GC isoniazid oral solution 50 /5 ml (Isoniazid) 2 GC isoniazid oral tablet 100, 00 (Isoniazid) 1 GC rifampin intravenous recon soln 600 (Rifadin) 2 GC rifampin oral capsule 150, 00 (Rifadin) 2 GC Antinausea Agents Antinausea Agents meclizine oral tablet 12.5, 25 (Meclizine HCl) 2 GC ondansetron oral tablet,disintegrating 4 (Zofran Odt) 2 PA BvD; GC, 8 phenadoz rectal suppository 12.5 (Phenergan) 2 GC prochlorperazine maleate oral tablet 10 (Compazine) 1 GC, 5 promethazine oral tablet 12.5, 25, (Promethazine HCl) 2 GC 50 promethazine rectal suppository 12.5, (Phenergan) 2 GC 25, 50 promethegan rectal suppository 25, (Phenergan) 2 GC 50 Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 200 MG 5 NDS atovaquone-proguanil oral tablet (Malarone) 2 GC, hydroxychloroquine oral tablet 200 (Plaquenil) 2 GC mefloquine oral tablet 250 (Mefloquine HCl) 2 GC Antiparkinsonian Agents Antiparkinsonian Agents benztropine injection solution 2 /2 ml (Cogentin) 2 GC benztropine oral tablet 0.5, 1, 2 (Benztropine Mesylate) 2 GC carbidopa-levodopa oral tablet , , (Sinemet CR) 2 GC 21

32 carbidopa-levodopa oral tablet extended (Sinemet CR) 2 GC release , carbidopa-levodopa oral (Carbidopa/Levodopa) 2 GC tablet,disintegrating , , COGENTIN INJECTION 4 SOLUTION 2 MG/2 ML pramipexole oral tablet 0.125, 0.25 (Mirapex) 2 GC, 0.5, 0.75, 1, 1.5 ropinirole oral tablet 0.25, 0.5, 1 (Requip) 2 GC, 2,, 4, 5 ropinirole oral tablet extended release 24 (Requip XL) 2 GC hr 12, 2, 4, 6, 8 Antipsychotic Agents Antipsychotic Agents clozapine oral tablet 100 (Clozaril) 2 GC; QL (270 per 0 clozapine oral tablet 200 (Clozaril) 2 GC; QL (15 per 0 clozapine oral tablet 25, 50 (Clozaril) 2 GC; QL (90 per 0 clozapine oral tablet,disintegrating 100 (Fazaclo) 2 ST ; GC, 12.5, 150, 200, 25 haloperidol oral tablet 0.5, 1, 10 (Haloperidol) 2 GC, 2, 20, 5 LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG 5 NDS; QL (0 per 0 olanzapine intramuscular recon soln 10 (Zyprexa) 2 GC; QL (0 per 0 olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 (Zyprexa) 2 GC; QL (0 per 0 olanzapine oral tablet,disintegrating 10, 15, 20, 5 (Zyprexa Zydis) 2 GC; QL (0 per 0 perphenazine oral tablet 16, 2, 4, 8 (Perphenazine) 2 GC 22

33 quetiapine oral tablet 100, 200, 25, 00, 400, 50 (Seroquel) 2 GC; QL (90 per 0 risperidone oral solution 1 /ml (Risperdal) 2 GC; QL (480 per 0 risperidone oral tablet 0.25, 0.5, 1, 2,, 4 (Risperdal) 2 GC; QL (60 per 0 risperidone oral tablet,disintegrating 0.25, 0.5, 1, 2 (Risperdal M-Tab) 2 GC; QL (60 per 0 risperidone oral tablet,disintegrating, 4 (Risperdal M-Tab) 2 GC; QL (120 per 0 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 00 MG, 50 MG 4 ST ; QL (60 per 0 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG VERSACLOZ ORAL SUSPENSION 50 MG/ML ziprasidone hcl oral capsule 20, 40, 60, 80 Antivirals (Systemic) Antiretrovirals ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EPZICOM ORAL TABLET MG ISENTRESS ORAL POWDER IN PACKET 100 MG 4 ST ; QL (0 per 0 5 ST ; NDS; QL (60 per 0 5 ST ; NDS; QL (540 per 0 (Geodon) 2 GC; QL (60 per 0 5 NDS 5 NDS 5 NDS ISENTRESS ORAL TABLET 400 MG 5 NDS ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG 2

34 NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZISTA ORAL SUSPENSION MG/ML PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 5 NDS 800 MG REYATAZ ORAL CAPSULE NDS MG, 200 MG, 00 MG REYATAZ ORAL POWDER IN 5 NDS PACKET 50 MG STRIBILD ORAL TABLET 5 NDS MG TRUVADA ORAL TABLET NDS MG, MG, MG, MG VIREAD ORAL POWDER 40 5 NDS MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 5 NDS 200 MG, 250 MG, 00 MG Antivirals, Miscellaneous SYNAGIS INTRAMUSCULAR 5 PA; NDS SOLUTION 50 MG/0.5 ML TAMIFLU ORAL CAPSULE 0 MG QL (84 per 180 TAMIFLU ORAL CAPSULE 45 MG QL (48 per 180 TAMIFLU ORAL CAPSULE 75 MG QL (42 per 180 TAMIFLU ORAL SUSPENSION QL (540 per 180 FOR RECONSTITUTION 6 MG/ML Hcv Antivirals OLYSIO ORAL CAPSULE 150 MG 5 PA; NDS; QL (28 per 28 SOVALDI ORAL TABLET 400 MG 5 PA; NDS; QL (28 per 28 24

35 Interferons INTRON A INJECTION RECON 5 PA NSO; NDS SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 5 PA NSO; NDS 6 MILLION UNIT/ML PEGASYS PROCLICK 5 NDS SUBCUTANEOUS PEN INJECTOR 15 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS 5 NDS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS 5 NDS SYRINGE 180 MCG/0.5 ML Nucleosides And Nucleotides acyclovir oral capsule 200 (Zovirax) 2 GC acyclovir oral suspension 200 /5 ml (Zovirax) 2 GC acyclovir oral tablet 400, 800 (Zovirax) 2 GC famciclovir oral tablet 125, 250, (Famvir) 2 GC 500 valacyclovir oral tablet 1 gram, 500 (Valtrex) 2 GC Blood Products/Modifiers/Volume Expanders Anticoagulants enoxaparin subcutaneous solution 00 (Lovenox) 2 GC / ml enoxaparin subcutaneous syringe 100 (Lovenox) 2 GC /ml, 120 /0.8 ml, 150 /ml, 0 /0. ml, 40 /0.4 ml, 60 /0.6 ml, 80 /0.8 ml jantoven oral tablet 1, 10, 2, (Coumadin) 1 GC 2.5,, 4, 5, 6, 7.5 warfarin oral tablet 1, 10, 2, (Coumadin) 1 GC 2.5,, 4, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG 25

36 XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Blood Formation Modifiers EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML PA; QL (12 per 28 EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, PA; QL (12 per 28 20,000 UNIT/ML,,000 UNIT/ML, 4,000 UNIT/ML NEULASTA SUBCUTANEOUS 5 NDS SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION 5 NDS SOLUTION 00 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 5 NDS 00 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, PA; QL (12 per 28,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML 5 PA; NDS; QL (12 per 28 PROCRIT INJECTION SOLUTION 40,000 UNIT/ML 5 PA; NDS; QL (6 per 28 Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5, 1 (Agrylin) 2 GC tranexamic acid intravenous solution (Tranexamic Acid) 2 GC 1,000 /10 ml (100 /ml) tranexamic acid oral tablet 650 (Lysteda) 2 GC; QL (0 per 0 Platelet-Aggregation Inhibitors clopidogrel oral tablet 00 (Plavix) 2 GC clopidogrel oral tablet 75 (Plavix) 1 GC EFFIENT ORAL TABLET 10 MG, 5 MG QL (0 per 0 26

37 Caloric Agents Caloric Agents AMINO ACIDS 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 4.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % dextrose 5 % in water (d5w) intravenous parenteral solution INTRALIPID INTRAVENOUS EMULSION 20 %, 0 % NUTRILIPID INTRAVENOUS EMULSION 20 % PROSOL 20 % INTRAVENOUS PARENTERAL SOLUTION TRAVASOL 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1, 0.2, 0. (Dextrose 5 % in Water) 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 2 GC 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD (Catapres) 1 GC 27

38 doxazosin oral tablet 1, 2, 4, 8 (Cardura) 2 GC Angiotensin Ii Receptor Antagonists BENICAR ORAL TABLET 20 MG, 40 2 GC MG, 5 MG irbesartan oral tablet 150, 00, 75 (Avapro) 1 GC losartan oral tablet 100, 25, 50 (Cozaar) 1 GC losartan-hydrochlorothiazide oral tablet (Hyzaar) 1 GC , , valsartan-hydrochlorothiazide oral tablet (Diovan HCT) 2 GC , , , 20-25, Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10, 20, 40 (Lotensin) 1 GC, 5 enalapril maleate oral tablet 10, 2.5 (Vasotec) 2 GC, 20, 5 lisinopril oral tablet 10, 2.5, 20 (Zestril) 1 GC, 0, 40, 5 lisinopril-hydrochlorothiazide oral tablet (Zestoretic) 1 GC , , ramipril oral capsule 1.25, 10, 2.5 (Altace) 1 GC, 5 Antiarrhythmic Agents amiodarone intravenous solution 50 (Amiodarone HCl) 2 GC /ml amiodarone oral tablet 200, 400 (Cordarone) 2 GC flecainide oral tablet 100, 150, 50 (Tambocor) 2 GC pacerone oral tablet 100, 200, 400 (Cordarone) 2 GC propafenone oral capsule,extended release 12 hr 225, 25, 425 (Rythmol SR) 2 GC 28

39 propafenone oral tablet 150, 225, (Rythmol) 2 GC 00 Beta-Adrenergic Blocking Agents atenolol oral tablet 100, 25, 50 (Tenormin) 1 GC carvedilol oral tablet 12.5, 25, (Coreg) 1 GC.125, 6.25 metoprolol succinate oral tablet extended release 24 hr 100, 200, 25, 50 (Toprol XL) 2 GC metoprolol tartrate intravenous solution 5 (Metoprolol Tartrate) 2 GC /5 ml metoprolol tartrate intravenous syringe 5 /5 ml (Metoprolol Tartrate) 2 GC metoprolol tartrate oral tablet 100, 25 (Lopressor) 1 GC, 50 propranolol intravenous solution 1 /ml (Propranolol HCl) 2 GC propranolol oral capsule,extended release (Inderal LA) 2 GC 24 hr 120, 160, 60, 80 propranolol oral solution 20 /5 ml (4 (Propranolol HCl) 2 GC /ml), 40 /5 ml (8 /ml) propranolol oral tablet 10, 20, 40 (Propranolol HCl) 2 GC, 60, 80 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release (Cardizem CD) 2 GC 24hr 120, 180, 240, 00 diltiazem 24hr er 180 cap 180 (Cardizem CD) 2 GC diltiazem 24hr er 60 cap 60 (Cardizem CD) 2 GC diltiazem hcl intravenous recon soln 100 (Cardizem CD) 2 GC diltiazem hcl intravenous solution 5 (Cardizem CD) 2 GC /ml diltiazem hcl oral capsule, extended (Cardizem CD) 2 GC release 180, 60, 420 diltiazem hcl oral capsule,extended release 12 hr 120, 60, 90 (Cardizem CD) 2 GC 29

40 diltiazem hcl oral capsule,extended (Cardizem CD) 2 GC release 24hr 120, 240, 00 diltiazem hcl oral tablet 120, 0, (Cardizem CD) 1 GC 60, 90 dilt-xr oral capsule,ext release (Cardizem CD) 2 GC degradable 120, 180, 240 matzim la oral tablet extended release 24 (Cardizem CD) 2 GC hr 180, 240, 00, 60, 420 taztia xt oral capsule, extended release (Cardizem CD) 2 GC 120, 180, 240, 00, 60 verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) 2 GC 100, 200, 00 verapamil oral capsule,ext rel. pellets 24 (Verelan) 2 GC hr 120, 180, 240, 60 verapamil oral tablet 120, 40, 80 (Calan) 1 GC verapamil oral tablet extended release (Calan SR) 2 GC 120, 180, 240 Cardiovascular Agents, Miscellaneous epinephrine injection auto-injector 0.15 (Epipen 2-Pak) 2 GC /0.15 ml, 0. /0. ml EPIPEN 2-PAK INJECTION QL (4 per 0 AUTO-INJECTOR 0. MG/0. ML EPIPEN JR 2-PAK INJECTION QL (4 per 0 AUTO-INJECTOR 0.15 MG/0. ML hydralazine injection solution 20 /ml (Hydralazine HCl) 2 GC hydralazine oral tablet 10, 100, 25 (Hydralazine HCl) 2 GC, 50 Dihydropyridines afeditab cr oral tablet extended release (Adalat CC) 2 GC 0, 60 amlodipine oral tablet 10, 2.5, 5 (Norvasc) 1 GC 0

41 amlodipine-benazepril oral capsule (Lotrel) 2 GC, 10-40, , 5-10, 5-20, 5-40 nifedical xl oral tablet extended release (Procardia XL) 2 GC 24hr 0, 60 nifedipine er 0 tablet f/c 0 (Adalat CC) 2 GC nifedipine er 60 tablet f/c 60 (Adalat CC) 2 GC nifedipine oral tablet extended release (Adalat CC) 2 GC 24hr 0, 60 nifedipine oral tablet extended release (Procardia XL) 2 GC 24hr 90 Diuretics furosemide injection solution 10 /ml (Furosemide) 2 GC furosemide injection syringe 10 /ml (Furosemide) 2 GC furosemide oral solution 10 /ml, 40 (Furosemide) 2 GC /5 ml (8 /ml) furosemide oral tablet 20, 40, 80 (Lasix) 1 GC hydrochlorothiazide oral capsule 12.5 (Microzide) 1 GC hydrochlorothiazide oral tablet 12.5, (Hydrochlorothiazide) 1 GC 25, 50 spironolactone oral tablet 100, 25, (Aldactone) 2 GC 50 triamterene-hydrochlorothiazid oral (Dyazide) 2 GC capsule , triamterene-hydrochlorothiazid oral (Maxzide) 1 GC tablet , Dyslipidemics ALTOPREV ORAL TABLET 4 EXTENDED RELEASE 24 HR 20 MG, 40 MG atorvastatin oral tablet 10, 20, 40 (Lipitor) 1 GC, 80 fenofibrate oral tablet 120, 160, (Lofibra) 2 GC 40, 54 gemfibrozil oral tablet 600 (Lopid) 1 GC 1

42 lovastatin oral tablet 10, 20, 40 (Lovastatin) 1 GC pravastatin oral tablet 10, 20, 40 (Pravachol) 1 GC, 80 simvastatin oral tablet 10, 20, 40 (Zocor) 1 GC, 5 simvastatin oral tablet 80 (Zocor) 1 GC; QL (0 per 0 ZETIA ORAL TABLET 10 MG 2 GC Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 25, 50 (Inspra) 2 GC TEKTURNA ORAL TABLET 150 ST MG, 00 MG Vasodilators isosorbide mononitrate oral tablet 10, (Isosorbide 2 GC 20 Mononitrate) isosorbide mononitrate oral tablet (Imdur) 2 GC extended release 24 hr 120, 0, 60 minitran transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.6 /hr (Nitro-Dur) 2 GC; QL (0 per 0 minitran transdermal patch 24 hour 0.4 /hr (Nitro-Dur) 2 GC; QL (60 per 0 NITRO-BID TRANSDERMAL 2 GC OINTMENT 2 % nitroglycerin intravenous solution 50 (Nitroglycerin) 2 GC /10 ml (5 /ml) nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.2 /hr, 0.6 /hr (Nitro-Dur) 2 GC; QL (0 per 0 nitroglycerin transdermal patch 24 hour 0.4 /hr (Nitro-Dur) 2 GC; QL (60 per 0 NITROSTAT SUBLINGUAL TABLET 0. MG, 0.4 MG, 0.6 MG 2

43 Central Nervous System Agents Central Nervous System Agents COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML, 40 MG/ML dextroamphetamine oral capsule, extended release 10, 15, 5 dextroamphetamine oral tablet 10, 5 dextroamphetamine-amphetamine oral capsule,extended release 24hr 10, 15, 5 dextroamphetamine-amphetamine oral capsule,extended release 24hr 20, 25, 0 dextroamphetamine-amphetamine oral tablet 10, 12.5, 15, 20, 0, 5, 7.5 lithium carbonate oral capsule 150, 00, PA; NDS (Dexedrine) 2 GC; QL (120 per 0 (Dexedrine) 2 GC; QL (180 per 0 (Adderall XR) 2 GC; QL (0 per 0 (Adderall XR) 2 GC; QL (60 per 0 (Adderall) 2 GC; QL (60 per 0 (Lithium Carbonate) 1 GC lithium carbonate oral tablet 00 (Lithobid) 2 GC lithium carbonate oral tablet extended (Lithobid) 2 GC release 00, 450 methylphenidate cd 20 cap 20 (Metadate Cd) 2 GC; QL (0 per 0 methylphenidate cd 40 cap 40 (Metadate Cd) 2 GC; QL (0 per 0 methylphenidate oral capsule, er biphasic , 50, 60 (Metadate Cd) 2 GC; QL (0 per 0 methylphenidate oral capsule, er biphasic (Metadate Cd) 2 GC; QL (60 per 0 methylphenidate oral capsule,er biphasic , 40 (Metadate Cd) 2 GC; QL (0 per 0 methylphenidate oral solution 10 /5 ml, 5 /5 ml (Methylin) 2 GC; QL (900 per 0 methylphenidate oral tablet 10, 20, 5 (Ritalin) 2 GC; QL (90 per 0

44 methylphenidate oral tablet extended release 10, 20 methylphenidate oral tablet extended release 24hr 18, 27, 54 methylphenidate oral tablet extended release 24hr 6 STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG (Methylphenidate HCl) 2 GC; QL (90 per 0 (Concerta) 2 GC; QL (0 per 0 (Concerta) 2 GC; QL (60 per 0 Contraceptives Contraceptives aubra oral tablet mcg (Amethyst) 2 GC aviane oral tablet mcg (Amethyst) 2 GC blisovi 24 fe oral tablet 1-20 mcg (Loestrin Fe) 2 GC (24)/75 (4) blisovi fe 1.5/0 (28) oral tablet 1.5 (Loestrin Fe) 2 GC -0 mcg (21)/75 (7) blisovi fe 1/20 (28) oral tablet 1-20 (Loestrin Fe) 2 GC mcg (21)/75 (7) delyla (28) oral tablet mcg (Amethyst) 2 GC drospirenone-ethinyl estradiol oral tablet (Yaz) 2 GC -0.02, -0.0 enpresse oral tablet 50-0 (6)/75-40 (Amethyst) 2 GC (5)/125-0(10) falmina (28) oral tablet mcg (Amethyst) 2 GC gianvi (28) oral tablet (Yaz) 2 GC gildess 24 fe oral tablet 1-20 mcg (Loestrin Fe) 2 GC (24)/75 (4) introvale oral tablets,dose pack, month mcg (Levonorgestrel-Ethin Estradiol) 2 GC; QL (91 per 84 junel fe 1.5/0 (28) oral tablet (Loestrin Fe) 2 GC mcg (21)/75 (7) junel fe 1/20 (28) oral tablet 1-20 (Loestrin Fe) 2 GC mcg (21)/75 (7) junel fe 24 oral tablet 1-20 mcg (24)/75 (4) (Loestrin Fe) 2 GC 4

45 larin fe 1.5/0 (28) oral tablet (Loestrin Fe) 2 GC mcg (21)/75 (7) larin fe 1/20 (28) oral tablet 1-20 (Loestrin Fe) 2 GC mcg (21)/75 (7) lessina oral tablet mcg (Amethyst) 2 GC levonest (28) oral tablet 50-0 (6)/75-40 (Amethyst) 2 GC (5)/125-0(10) levonor-eth estrad outer (Amethyst) 2 GC; QL (91 per 84 levonorgestrel-ethinyl estrad oral tablet (Amethyst) 2 GC mcg levonorgestrel-ethinyl estrad oral tablets,dose pack, month (Amethyst) 2 GC; QL (91 per 84 mcg levonorg-eth estrad triphasic oral tablet 50-0 (6)/75-40 (5)/125-0(10) (Amethyst) 2 GC; QL (91 per 84 levora-28 oral tablet (Amethyst) 2 GC lomedia 24 fe oral tablet 1-20 mcg (Loestrin Fe) 2 GC (24)/75 (4) loryna (28) oral tablet (Yaz) 2 GC lutera (28) oral tablet mcg (Amethyst) 2 GC marlissa oral tablet (Amethyst) 2 GC microgestin fe 1.5/0 (28) oral tablet 1.5 (Loestrin Fe) 2 GC -0 mcg (21)/75 (7) microgestin fe 1/20 (28) oral tablet 1 (Loestrin Fe) 2 GC -20 mcg (21)/75 (7) mononessa (28) oral tablet (Ortho-Cyclen) 2 GC -mcg nikki (28) oral tablet (Yaz) 2 GC norethindrone-e.estradiol-iron oral tablet (Loestrin Fe) 2 GC 1-20 mcg (24)/75 (4) norg-ee /0.05 x28 day (Ortho-Cyclen) 2 GC regimen 0.18/0.215/ mcg (28) norgestimate-ethinyl estradiol oral tablet (Ortho-Cyclen) 2 GC 0.18/0.215/ mcg ocella oral tablet -0.0 (Yaz) 2 GC 5

46 orsythia oral tablet mcg (Amethyst) 2 GC portia oral tablet (Amethyst) 2 GC previfem oral tablet mcg (Ortho-Cyclen) 2 GC quasense oral tablets,dose pack, month mcg (Levonorgestrel-Ethin Estradiol) 2 GC; QL (91 per 84 setlakin oral tablets,dose pack, month mcg (Levonorgestrel-Ethin Estradiol) 2 GC; QL (91 per 84 sprintec (28) oral tablet mcg (Ortho-Cyclen) 2 GC sronyx oral tablet mcg (Amethyst) 2 GC tarina fe 1/20 (28) oral tablet 1-20 (Loestrin Fe) 2 GC mcg (21)/75 (7) tri-legest fe oral tablet 1-20(5)/1-0(7) /1-5mcg (9) (Loestrin Fe) 2 GC tri-lo-estarylla oral tablet 0.18/0.215/0.25 (Ortho-Cyclen) 2 GC -25 mcg tri-lo-sprintec oral tablet 0.18/0.215/0.25 (Ortho-Cyclen) 2 GC -25 mcg trinessa (28) oral tablet 0.18/0.215/0.25 (Ortho-Cyclen) 2 GC -5 mcg (28) tri-previfem (28) oral tablet (Ortho-Cyclen) 2 GC 0.18/0.215/ mcg (28) tri-sprintec (28) oral tablet (Ortho-Cyclen) 2 GC 0.18/0.215/ mcg (28) trivora (28) oral tablet 50-0 (6)/75-40 (Amethyst) 2 GC (5)/125-0(10) vestura (28) oral tablet (Yaz) 2 GC vienva oral tablet mcg (Amethyst) 2 GC Dental And Oral Agents Dental And Oral Agents chlorhexidine gluconate mucous (Peridex) 2 GC membrane mouthwash 0.12 % periogard mucous membrane mouthwash 0.12 % (Peridex) 2 GC triamcinolone acetonide dental paste 0.1 % (Triamcinolone Acetonide) 2 GC 6

47 Dermatological Agents Dermatological Agents, Other acyclovir topical ointment 5 % (Zovirax) 2 GC; QL (5 per 4 ammonium lactate topical cream 12 % (Ammonium Lactate) 2 GC ammonium lactate topical lotion 12 % (Ammonium Lactate) 2 GC calcipotriene scalp solution % (Calcipotriene) 2 GC calcipotriene topical cream % (Dovonex) 2 GC calcipotriene topical ointment % (Calcipotriene) 2 GC fluorouracil topical cream 0.5 % (Carac) 5 NDS fluorouracil topical cream 5 % (Carac) 2 GC fluorouracil topical solution 2 %, 5 % (Fluorouracil) 2 GC imiquimod topical cream in packet 5 % (Aldara) 2 PA NSO; GC; QL (24 per 0 SANTYL TOPICAL OINTMENT UNIT/GRAM TOLAK TOPICAL CREAM 4 % 4 ZOVIRAX TOPICAL CREAM 5 % 5 NDS; QL (5 per 4 Dermatological Antibacterials clindamycin phosphate topical foam 1 % (Evoclin) 2 GC clindamycin phosphate topical gel 1 % (Cleocin T) 2 GC clindamycin phosphate topical lotion 1 % (Cleocin T) 2 GC clindamycin phosphate topical solution 1 (Cleocin T) 2 GC % clindamycin phosphate topical swab 1 % (Cleocin T) 2 GC metronidazole topical cream 0.75 % (Metrocream) 2 GC metronidazole topical gel 0.75 %, 1 % (Rosadan) 2 GC metronidazole topical lotion 0.75 % (Metrolotion) 2 GC silver sulfadiazine topical cream 1 % (Silvadene) 2 GC ssd topical cream 1 % (Silvadene) 2 GC Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 % (Anusol-HC) 2 GC ala-scalp topical lotion 2 % (Scalacort) 2 GC clobetasol 0.05% cream 0.05 % (Temovate) 2 GC 7

48 clobetasol scalp solution 0.05 % (Clobetasol 2 GC Propionate) clobetasol topical foam 0.05 % (Olux) 2 GC clobetasol topical gel 0.05 % (Clobetasol 2 GC Propionate) clobetasol topical lotion 0.05 % (Clobex) 2 GC clobetasol topical ointment 0.05 % (Temovate) 2 GC clobetasol topical shampoo 0.05 % (Clobex) 2 GC clobetasol-emollient topical cream 0.05 % (Temovate) 2 GC cormax scalp solution 0.05 % (Clobetasol 2 GC Propionate) desonide topical cream 0.05 % (Desowen) 2 GC desonide topical lotion 0.05 % (Desowen) 2 GC desonide topical ointment 0.05 % (Desonide) 2 GC fluocinonide 0.05% cream 0.05 % (Vanos) 2 GC fluocinonide topical gel 0.05 % (Fluocinonide) 2 GC fluocinonide topical ointment 0.05 % (Fluocinonide) 2 GC fluocinonide topical solution 0.05 % (Fluocinonide) 2 GC fluocinonide-e topical cream 0.05 % (Vanos) 2 GC hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) 1 GC hydrocortisone topical lotion 2.5 % (Scalacort) 2 GC hydrocortisone topical ointment 1 %, 2.5 (Hydrocortisone) 1 GC % procto-med hc topical cream with (Hydrocortisone) 2 GC perineal applicator 2.5 % procto-pak topical cream with perineal (Hydrocortisone) 2 GC applicator 1 % proctosol hc rectal cream 2.5 % (Hydrocortisone) 2 GC proctosol-hc 2.5% cream 2.5 % (Hydrocortisone) 2 GC proctozone-hc topical cream with perineal (Hydrocortisone) 2 GC applicator 2.5 % triamcinolone acetonide topical cream (Triamcinolone 1 GC %, 0.1 %, 0.5 % Acetonide) triamcinolone acetonide topical lotion %, 0.1 % (Triamcinolone Acetonide) 2 GC 8

49 triamcinolone acetonide topical ointment (Triamcinolone 1 GC %, 0.1 %, 0.5 % Acetonide) trianex topical ointment 0.05 % (Triamcinolone 2 GC Acetonide) Dermatological Retinoids adapalene topical cream 0.1 % (Differin) 2 GC adapalene topical gel 0.1 % (Differin) 2 GC tretinoin topical cream %, 0.05 %, (Retin-A) 2 PA; GC 0.1 % tretinoin topical gel 0.01 %, %, (Retin-A) 2 PA; GC 0.05 % Scabicides And Pediculicides malathion topical lotion 0.5 % (Ovide) 2 GC permethrin topical cream 5 % (Elimite) 2 GC Devices Devices BD INSULIN SYR 0.5 ML 1GX5/16" 2 GC 0.5 ML 1 GAUGE X 5/16 BD INSULIN SYR 1 ML 1GX5/16" 1 2 GC ML 1 GAUGE X 5/16 INSULIN SYRINGE-NEEDLE U GC SYRINGE 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-8,000-60,000 UNIT, 24,000-76, ,000 UNIT,,000-9,500-15,000 UNIT, 6, , ,000 UNIT, 6,000-19,000-0,000 UNIT KUVAN ORAL TABLET,SOLUBLE 5 NDS 100 MG ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG 5 NDS 9

50 ORFADIN ORAL SUSPENSION 4 5 NDS MG/ML PERTZYE ORAL 5 NDS CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500-60,500 UNIT PERTZYE ORAL 4 CAPSULE,DELAYED RELEASE(DR/EC) 8,000-28,750-0,250 UNIT PULMOZYME INHALATION 5 PA BvD; NDS SOLUTION 1 MG/ML ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-4,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68, ,000 UNIT, 25,000-85,000-16,000 UNIT,,000-10,000-16,000 UNIT, 40,000-16, ,000 UNIT, 5,000-17,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous azelastine nasal aerosol,spray 17 mcg (0.1 %) (Astepro) 2 GC; QL (0 per 25 azelastine nasal spray,non-aerosol 0.15 % (Astepro) 2 GC; QL (0 per 25 (205.5 mcg) azelastine ophthalmic drops 0.05 % (Azelastine HCl) 2 GC ipratropium bromide nasal spray,non-aerosol 0.0 % (Atrovent) 2 GC; QL (0 per 28 ipratropium bromide nasal spray,non-aerosol 0.06 % (Atrovent) 2 GC; QL (15 per 10 olopatadine nasal spray,non-aerosol 0.6 % (Patanase) 2 GC; QL (0.5 per 0 olopatadine ophthalmic drops 0.1 % (Patanol) 2 GC 40

51 PATADAY OPHTHALMIC DROPS 4 ST 0.2 % Eye, Ear, Nose, Throat Anti-Infectives Agents erythromycin ophthalmic ointment 5 (Ilotycin) 2 GC /gram (0.5 %) gentak ophthalmic ointment 0. % ( (Garamycin) 2 GC /gram) gentamicin ophthalmic drops 0. % (Garamycin) 2 GC gentamicin ophthalmic ointment 0. % ( (Garamycin) 2 GC /gram) MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 % neomycin-polymyxin b-dexameth (Maxitrol) 2 GC ophthalmic drops,suspension.5/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth (Maxitrol) 2 GC ophthalmic ointment.5 /g-10,000 unit/g-0.1 % neomycin-polymyxin-hc ophthalmic drops,suspension.5-10, unit-/ml (Neomycin/Polymyxin B Sulf/HC) 2 GC neomycin-polymyxin-hc otic drops,suspension.5-10,000-1 /ml-unit/ml-% neomycin-polymyxin-hc otic solution.5-10,000-1 /ml-unit/ml-% (Neomycin/Polymyxin B Sulf/HC) 2 GC (Neomycin/Polymyxin 2 GC B Sulf/HC) ofloxacin ophthalmic drops 0. % (Floxin) 2 GC ofloxacin otic drops 0. % (Floxin) 2 GC TOBRADEX OPHTHALMIC 4 OINTMENT % TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION % tobramycin-dexamethasone ophthalmic (Tobradex) 2 GC drops,suspension % VIGAMOX OPHTHALMIC DROPS 0.5 % 41

52 Eye, Ear, Nose, Throat Anti-Inflammatory Agents fluticasone nasal spray,suspension 50 (Fluticasone 1 GC mcg/actuation Propionate) ketorolac ophthalmic drops 0.4 %, 0.5 % (Acular) 2 GC prednisolone acetate ophthalmic (Omnipred) 2 GC drops,suspension 1 % RESTASIS OPHTHALMIC QL (60 per 0 DROPPERETTE 0.05 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants famotidine (pf) intravenous solution 20 (Famotidine) 2 GC /2 ml famotidine 40 /4 ml vial 25's,outer 10 (Famotidine) 2 GC /ml famotidine oral suspension 40 /5 ml (8 (Pepcid) 2 GC /ml) famotidine oral tablet 20, 40 (Pepcid) 1 GC omeprazole oral capsule,delayed (Prilosec) 1 GC release(dr/ec) 10, 20, 40 pantoprazole intravenous recon soln 40 (Protonix IV) 2 GC pantoprazole oral tablet,delayed release (Protonix) 1 GC (dr/ec) 20, 40 ranitidine hcl 50 /2 ml vial sdv 50 /2 (Ranitidine HCl) 2 GC ml (25 /ml) ranitidine hcl injection solution 25 /ml (Ranitidine HCl) 2 GC ranitidine hcl oral capsule 150, 00 (Ranitidine HCl) 2 GC ranitidine hcl oral syrup 15 /ml (Ranitidine HCl) 2 GC ranitidine hcl oral tablet 150, 00 (Zantac) 1 GC Gastrointestinal Agents, Other constulose oral solution 10 gram/15 ml (Lactulose) 2 GC dicyclomine oral capsule 10 (Bentyl) 2 GC dicyclomine oral solution 10 /5 ml (Dicyclomine HCl) 2 GC 42

53 dicyclomine oral tablet 20 (Bentyl) 2 GC diphenoxylate-atropine oral liquid (Diphenoxylate 2 GC /5 ml HCl/Atropine) diphenoxylate-atropine oral tablet (Lomotil) 2 GC enulose oral solution 10 gram/15 ml (Lactulose) 2 GC generlac oral solution 10 gram/15 ml (Lactulose) 2 GC lactulose oral solution 10 gram/15 ml (Lactulose) 2 GC loperamide oral capsule 2 (Loperamide HCl) 2 GC metoclopramide hcl injection solution 5 (Metoclopramide HCl) 2 GC /ml metoclopramide hcl oral solution 5 /5 (Metoclopramide HCl) 2 GC ml metoclopramide hcl oral tablet 10, 5 (Reglan) 1 GC ursodiol oral capsule 00 (Actigall) 2 GC ursodiol oral tablet 250, 500 (Urso) 2 GC Laxatives gavilyte-c oral recon soln (Golytely) 2 GC gram gavilyte-g oral recon soln (Golytely) 2 GC gram peg 50-electrolytes oral recon soln (Golytely) 2 GC gram polyethylene glycol 50 oral powder 17 (Gavilyte-N) 2 GC gram/dose Phosphate Binders calcium acetate oral capsule 667 (Phoslo) 2 GC eliphos oral tablet 667 (Calcium Acetate) 2 GC PHOSLYRA ORAL SOLUTION MG (169 MG CALCIUM)/5 ML RENVELA ORAL POWDER IN PACKET 0.8 GRAM, 2.4 GRAM RENVELA ORAL TABLET 800 MG 4