Medi-Cal Formulary 2016

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1 Medi-Cal ormulary 2016

2 IEHP Medi-Cal 2016 ormulary Table of Contents Analgesics... 2 Anesthetics... 3 Antiarthritics... 3 Antiasthmatics... 4 Antibiotics... 6 Anticoagulants Antifungals Antihistamine and Decongestant Combination Antihistamines Antihyperglycemics Antiinfectives/Miscellaneous Antineoplastics Antiparkinson Drugs Antiplatelet Drugs Antivirals Autonomic Drugs Blood Cardiac Drugs Cardiovascular Central Nervous System (CNS) Drugs Contraceptives Cough/Cold Preparations Diagnostic Diuretics Eye, Ear, Nose, and Throat (EENT) Preps Electrolyte/Caloric/H2O Gastrointestinal Hormones Immunosuppressant Miscellaneous Medical Supplies, Devices, Non-Drug Muscle Relaxants Pre-Natal Vitamins Psychotherapeutic Drugs Sedative/Hypnotics Skin Preps Smoking Deterrents Thyroid Preps Unclassified Drug Products Vitamins Index

3 IEHP Medi-Cal 2016 ormulary List of Covered Drugs lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs CURRENT AS O 1/01/2016 Tier C1= Code 1 = ormulary NC= Not Covered N= Non-ormulary Requirements/Limits PA= Prior Authorization = Quantity Limit ST= Step Therapy Drug Name Analgesics acetaminophen oral drops, suspension 80 mg/0.8 ml acetaminophen oral elixir 160 mg/5 ml acetaminophen oral liquid 160 mg/5 ml acetaminophen oral solution 160 mg/5 ml (5 ml) acetaminophen oral suspension 160 mg/5 ml acetaminophen oral tablet 325 mg acetaminophen oral tablet 500 mg acetaminophen rectal suppository 120 mg acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg, mg, mg ASPIRIN LOW-STRENGTH ORAL TABLET,CHEWABLE 81 MG aspirin oral tablet 325 mg aspirin oral tablet, delayed release (dr/ec) 325 mg, 81 mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg CAERGOT ORAL TABLET MG CAPITAL WITH CODEINE ORAL SUSPENSION MG/5 ML CHILDREN'S NON-ASPIRIN ORAL TABLET,CHEWABLE 80 MG choline, magnesium salicylate oral liquid 500 mg/5 ml diclofenac potassium oral tablet 50 mg ENDODAN ORAL TABLET MG 2

4 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr EVERALL RECTAL SUPPOSITORY 325 MG, 80 MG hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg infant's non-aspirin oral drops 100 mg/ml isometh-dichloral-acetaminophn oral capsule mg KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 200 MG ketorolac oral tablet 10 mg MIGERGOT RECTAL SUPPOSITORY MG MIGRAINE ORMULA ORAL TABLET MG morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule, extend. release pellets 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 10 mg/5 ml, 20 mg/5 ml morphine oral tablet 15 mg, 30 mg morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg naratriptan oral tablet 1 mg, 2.5 mg non-aspirin jr strength oral tablet, chewable 160 mg oxycodone-acetaminophen oral tablet mg, mg, mg Q-PAP ORAL DROPS 80 MG/0.8 ML rizatriptan oral tablet 10 mg, 5 mg sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg tramadol oral tablet 50 mg Anesthetics BUCALSEP MUCOUS MEMBRANE SOLUTION lidocaine topical adhesive patch, medicated 5 %(700 mg/patch) LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 % phenazopyridine oral tablet 100 mg, 200 mg Antiarthritics 3

5 allopurinol oral tablet 100 mg, 300 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg colchicine-probenecid oral tablet mg diclofenac sodium oral tablet extended release 24 hr 100 mg diclofenac sodium oral tablet, delayed release (dr/ec) 25 mg, 50 mg, 75 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg ibuprofen oral capsule 200 mg ibuprofen oral suspension 100 mg/5 ml ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg, 50 mg leflunomide oral tablet 10 mg, 20 mg meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5 ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 220 mg, 275 mg, 550 mg piroxicam oral capsule 10 mg, 20 mg probenecid oral tablet 500 mg RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 MG RIDAURA ORAL CAPSULE 3 MG salsalate oral tablet 500 mg, 750 mg sulindac oral tablet 150 mg, 200 mg Antiasthmatics acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg 4

6 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) ATROVENT HA INHALATION HA AEROSOL INHALER 17 MCG/ACTUATION budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION cromolyn inhalation solution for nebulization 20 mg/2 ml cromolyn nasal spray, non-aerosol 5.2 mg/spray (4 %) LOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION LOVENT HA INHALATION HA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg montelukast oral tablet 10 mg montelukast oral tablet, chewable 4 mg, 5 mg PULMICORT LEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE terbutaline oral tablet 2.5 mg, 5 mg THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG, 200 MG, 300 MG, 400 MG theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 400 mg TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION 5

7 VENTOLIN HA INHALATION HA AEROSOL INHALER 90 MCG/ACTUATION Antibiotics amoxicillin oral capsule 250 mg amoxicillin oral capsule 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet, chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet, chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 600 mg azithromycin oral tablet 500 mg bacitracin topical ointment 500 unit/gram bacitracin zinc topical ointment 500 unit/gram bacitracin-polymyxin b ophthalmic ointment ,000 unit/gram bacitracin-polymyxin b topical ointment ,000 unit/gram bacitracin-polymyxin b topical packet ,000 unit/gram BACTROBAN NASAL NASAL OINTMENT 2 % BENZAMYCINPAK TOPICAL GEL 3-5 % BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % cefaclor oral tablet extended release 12 hr 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml 6 C1 C1 C1

8 cefixime oral suspension for reconstitution 100 mg/5 ml ceftibuten oral capsule 400 mg ceftibuten oral suspension for reconstitution 180 mg/5 ml cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml CILOXAN OPHTHALMIC OINTMENT 0.3 % CIPRO HC OTIC DROPS,SUSPENSION % CIPRODEX OTIC DROPS,SUSPENSION % ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg ciprofloxacin hcl ophthalmic drops 0.3 % ciprofloxacin hcl oral tablet 100 mg ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg ciprofloxacin oral suspension, microcapsule recon 250 mg/5 ml, 500 mg/5 ml clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg clarithromycin oral tablet extended release 24 hr 500 mg clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral recon soln 75 mg/5 ml clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % clindamycin phosphate vaginal cream 2 % CORTISPORIN TOPICAL OINTMENT 1 % cycloserine oral capsule 250 mg dapsone oral tablet 100 mg, 25 mg dicloxacillin oral capsule 250 mg, 500 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg E.E.S. 400 ORAL TABLET 400 MG E.E.S. GRANULES ORAL SUSPENSION OR RECONSTITUTION 200 MG/5 ML 7 C1 C1 C1

9 ERYPED 400 ORAL SUSPENSION OR RECONSTITUTION 400 MG/5 ML ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG ery-tab oral tablet, delayed release (dr/ec) 500 mg erythromycin ophthalmic ointment 5 mg/gram (0.5 %) erythromycin oral capsule, delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg erythromycin stearate oral tablet 250 mg erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % erythromycin-benzoyl peroxide topical gel 3-5 % ethambutol oral tablet 100 mg, 400 mg GENTAK OPHTHALMIC OINTMENT 0.3 % (3 MG/GRAM) gentamicin ophthalmic drops 0.3 % gentamicin topical cream 0.1 % isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 100 mg, 300 mg levofloxacin ophthalmic drops 0.5 % levofloxacin oral tablet 250 mg, 500 mg, 750 mg methenamine mandelate oral tablet 0.5 g, 1 gram metronidazole oral tablet 250 mg, 500 mg metronidazole vaginal gel 0.75 % minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg mupirocin calcium topical cream 2 % mupirocin topical ointment 2 % neomycin oral tablet 500 mg neomycin-bacitracin-polymyxin ophthalmic ointment ,000 mg-unitunit/g neomycin-polymyxin b-dexameth ophthalmic drops, suspension 3.5mg/ml- 10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic ointment 3.5 mg/g-10,000 unit/g- 0.1 % 8

10 neomycin-polymyxin-gramicidin ophthalmic drops 1.75 mg-10,000 unit mg/ml neomycin-polymyxin-hc ophthalmic drops, suspension , mg-unitmg/ml neomycin-polymyxin-hc otic drops, suspension ,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic solution ,000-1 mg/ml-unit/ml-% nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin macrocrystal oral capsule 25 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin oral suspension 25 mg/5 ml ofloxacin ophthalmic drops 0.3 % ofloxacin otic drops 0.3 % PCE ORAL TABLET, PARTICLES/CRYSTALS 333 MG PCE ORAL TABLET, PARTICLES/CRYSTALS 500 MG penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg polymyxin b sulf-trimethoprim ophthalmic drops 10,000 unit- 1 mg/ml PRIMSOL ORAL SOLUTION 50 MG/5 ML pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg RIAMATE ORAL CAPSULE MG rifampin oral capsule 150 mg, 300 mg silver sulfadiazine topical cream 1 % sulfacetamide sodium ophthalmic drops 10 % sulfacetamide sodium ophthalmic ointment 10 % sulfacetamide-prednisolone ophthalmic drops 10 %-0.23 % (0.25 %) sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg tetracycline oral capsule 250 mg, 500 mg TOBRADEX OPHTHALMIC OINTMENT % tobramycin ophthalmic drops 0.3 % tobramycin-dexamethasone ophthalmic drops, suspension % 9 C1

11 TOBREX OPHTHALMIC OINTMENT 0.3 % trimethoprim oral tablet 100 mg TRIPLE ANTIBIOTIC (PRAM) EXTRA TOPICAL OINTMENT ,000 MG-UNIT-UNIT/G TRIPLE ANTIBIOTIC TOPICAL OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM VIGAMOX OPHTHALMIC DROPS 0.5 % Anticoagulants ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Antifungals 3 DAY VAGINAL VAGINAL CREAM 200 MG/5 GRAM (4 %) ATHLETE'S OOT (TERBINAINE) TOPICAL CREAM 1 % clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % clotrimazole topical solution 1 % clotrimazole vaginal cream 1 % clotrimazole-betamethasone topical cream % clotrimazole-betamethasone topical lotion % econazole topical cream 1 % fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 125 mg/5 ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % 10 C1 C1 C1

12 MEDI-IRST ANTI-UNGAL TOPICAL PACKET 1 % miconazole nitrate topical cream 2 % miconazole nitrate vaginal comb pack, prefill appl & cream 4 % (200 mg)- 2% (9 gram) miconazole nitrate vaginal cream 2 % miconazole nitrate vaginal suppository 100 mg MICONAZOLE-3 VAGINAL KIT 200 MG- 2 % (9 GRAM) MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG NATACYN OPHTHALMIC DROPS,SUSPENSION 5 % nystatin oral powder 150 million unit nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM terbinafine hcl oral tablet 250 mg terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg tolnaftate topical solution 1 % Antihistamine and Decongestant Combination ALAVERT D-12 ALLERGY-SINUS ORAL TABLET EXTENDED RELEASE 12 HR MG cetirizine-pseudoephedrine oral tablet extended release 12 hr mg DIMETAPP COLD-ALLERGY (PE) ORAL SOLUTION MG/5 ML LOHIST - D ORAL LIQUID 2-30 MG/5 ML LORATADINE-D ORAL TABLET EXTENDED RELEASE 24 HR MG PROMETHAZINE VC ORAL SYRUP MG/5 ML RITIED ORAL SYRUP MG/5 ML RYNEX PSE ORAL LIQUID 1-15 MG/5 ML WAL-ACT D COLD & ALLERGY ORAL TABLET MG 11

13 WAL-PHED ORAL TABLET 4-60 MG Antihistamines ALLER-CHLOR ORAL SYRUP 2 MG/5 ML BENADRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML cetirizine oral solution 1 mg/ml cetirizine oral tablet 10 mg, 5 mg cetirizine oral tablet, chewable 10 mg, 5 mg CHILDREN'S CLARITIN ORAL TABLET,CHEWABLE 5 MG CHILDREN'S WAL-DRYL ALLERGY ORAL PREILLED SPOON 12.5 MG/5 ML chlorpheniramine maleate oral tablet 4 mg chlorpheniramine maleate oral tablet extended release 12 mg cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg diphenhydramine hcl oral capsule 25 mg, 50 mg diphenhydramine hcl oral elixir 12.5 mg/5 ml diphenhydramine hcl oral syrup 12.5 mg/5 ml diphenhydramine hcl oral tablet 25 mg hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg loratadine oral solution 5 mg/5 ml loratadine oral tablet 10 mg loratadine oral tablet, disintegrating 10 mg PATANOL OPHTHALMIC DROPS 0.1 % promethazine oral syrup 6.25 mg/5 ml promethazine oral tablet 12.5 mg, 25 mg, 50 mg ZADITOR OPHTHALMIC DROPS % (0.035 %) Antihyperglycemics acarbose oral tablet 100 mg, 25 mg, 50 mg APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML APIDRA SUBCUTANEOUS SOLUTION 100 UNIT/ML glimepiride oral tablet 1 mg, 2 mg, 4 mg 12 C1

14 glipizide oral tablet 10 mg, 5 mg glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg glipizide-metformin oral tablet mg, mg, mg glyburide oral tablet 1.25 mg, 5 mg glyburide oral tablet 2.5 mg glyburide-metformin oral tablet mg, mg, mg HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG, MG ST; INVOKANA ORAL TABLET 100 MG, 300 MG ST; JANUMET ORAL TABLET 50-1,000 MG, MG ST; JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, MG ST; JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG ST; 13

15 LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML metformin oral tablet 1,000 mg, 500 mg, 850 mg metformin oral tablet extended release 24 hr 500 mg, 750 mg NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG LEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX LEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG MIX SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG PENILL SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML pioglitazone oral tablet 15 mg, 30 mg, 45 mg Antiinfectives/Miscellaneous atovaquone oral suspension 750 mg/5 ml chloroquine phosphate oral tablet 250 mg, 500 mg hydroxychloroquine oral tablet 200 mg NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg primaquine oral tablet 26.3 mg REESE'S PINWORM MEDICINE ORAL SUSPENSION 50 MG/ML Antineoplastics anastrozole oral tablet 1 mg etoposide oral capsule 50 mg LUOROPLEX TOPICAL CREAM 1 % fluorouracil topical cream 5 % flutamide oral capsule 125 mg hydroxyurea oral capsule 500 mg ifosfamide intravenous solution 3 gram/60 ml LEUKERAN ORAL TABLET 2 MG 14 C1

16 LOMUSTINE ORAL CAPSULE 10 MG, 100 MG MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg mercaptopurine oral tablet 50 mg methotrexate sodium oral tablet 2.5 mg MYLERAN ORAL TABLET 2 MG TABLOID ORAL TABLET 40 MG tamoxifen oral tablet 10 mg tamoxifen oral tablet 20 mg tretinoin (chemotherapy) oral capsule 10 mg Antiparkinson Drugs bromocriptine oral capsule 5 mg C1 bromocriptine oral tablet 2.5 mg C1 carbidopa-levodopa oral tablet mg, mg, mg carbidopa-levodopa oral tablet extended release mg pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg Antiplatelet Drugs aspirin-dipyridamole oral capsule, er multiphase 12 hr mg cilostazol oral tablet 100 mg, 50 mg clopidogrel oral tablet 75 mg Antivirals ABREVA TOPICAL CREAM 10 % acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet 400 mg, 800 mg famciclovir oral tablet 125 mg, 250 mg, 500 mg TAMILU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMILU ORAL SUSPENSION OR RECONSTITUTION 6 MG/ML trifluridine ophthalmic drops 1 % 15

17 valacyclovir oral tablet 1 gram, 500 mg Autonomic Drugs ADRENALIN INJECTION SOLUTION 1 MG/ML (1:1,000) (1ML) AMPHETAMINE SALT COMBO ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 7.5 MG bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule, extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg dextroamphetamine-amphetamine oral tablet 5 mg donepezil oral tablet 10 mg, 5 mg donepezil oral tablet, disintegrating 10 mg, 5 mg epinephrine injection auto-injector 0.15 mg/0.15 ml (1:1,000), 0.3 mg/0.3 ml (1:1,000) epinephrine injection syringe 0.1 mg/ml (1:10,000) EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML (1:2,000) MESTINON ORAL SYRUP 60 MG/5 ML MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG midodrine oral tablet 10 mg, 2.5 mg, 5 mg pyridostigmine bromide oral tablet 60 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg Blood pentoxifylline oral tablet extended release 400 mg Cardiac Drugs amiodarone oral tablet 200 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 mg digoxin oral solution 50 mcg/ml digoxin oral tablet 125 mcg, 250 mcg DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 40 MG diltiazem hcl oral capsule, extended release 360 mg, 420 mg diltiazem hcl oral capsule, extended release 12 hr 120 mg 16

18 diltiazem hcl oral capsule, extended release 12 hr 60 mg, 90 mg diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg DILT-XR ORAL CAPSULE,EXT RELEASE DEGRADABLE 120 MG, 180 MG, 240 MG felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg ISORDIL ORAL TABLET 40 MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide dinitrate oral tablet extended release 40 mg isosorbide mononitrate oral tablet 10 mg, 20 mg isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg mexiletine oral capsule 150 mg, 200 mg, 250 mg nifedipine oral capsule 10 mg, 20 mg nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg NITRO-BID TRANSDERMAL OINTMENT 2 % NITROSTAT SUBLINGUAL TABLET 0.3 MG, 0.4 MG, 0.6 MG propafenone oral capsule, extended release 12 hr 225 mg propafenone oral capsule, extended release 12 hr 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg quinidine gluconate oral tablet extended release 324 mg TAZTIA XT ORAL CAPSULE, EXTENDED RELEASE 120 MG, 180 MG, 240 MG, 300 MG verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg verapamil oral capsule, ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg verapamil oral tablet 120 mg, 40 mg, 80 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg Cardiovascular amlodipine-benazepril oral capsule mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg atenolol oral tablet 100 mg, 25 mg, 50 mg atenolol-chlorthalidone oral tablet mg, mg 17

19 atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg cholestyramine (with sugar) oral powder in packet 4 gram CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr doxazosin oral tablet 1 mg, 2 mg, 4 mg doxazosin oral tablet 8 mg enalapril maleate oral tablet 10 mg, 20 mg, 5 mg enalapril maleate oral tablet 2.5 mg fenofibrate micronized oral capsule 134 mg fenofibrate micronized oral capsule 200 mg, 67 mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg fenofibrate oral tablet 160 mg, 54 mg fenofibric acid (choline) oral capsule, delayed release(dr/ec) 135 mg, 45 mg gemfibrozil oral tablet 600 mg guanfacine oral tablet 1 mg, 2 mg hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg irbesartan oral tablet 150 mg, 300 mg, 75 mg labetalol intravenous solution 5 mg/ml labetalol oral tablet 100 mg, 200 mg, 300 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg losartan oral tablet 100 mg, 25 mg, 50 mg losartan-hydrochlorothiazide oral tablet mg, mg, mg lovastatin oral tablet 10 mg, 20 mg, 40 mg methyldopa oral tablet 250 mg, 500 mg methyldopa-hydrochlorothiazide oral tablet mg, mg 18

20 metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg NIACOR ORAL TABLET 500 MG pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg prazosin oral capsule 1 mg, 2 mg, 5 mg propranolol oral capsule, extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml, 40 mg/5 ml propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg simvastatin oral tablet 10 mg, 40 mg, 5 mg, 80 mg simvastatin oral tablet 20 mg sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg Central Nervous System (CNS) Drugs carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet 200 mg carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg carbamazepine oral tablet, chewable 100 mg clonazepam oral tablet 0.5 mg, 1 mg, 2 mg diazepam rectal kit mg, 2.5 mg, mg DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, sprinkle 125 mg divalproex oral tablet extended release 24 hr 250 mg, 500 mg divalproex oral tablet, delayed release (dr/ec) 125 mg divalproex oral tablet, delayed release (dr/ec) 250 mg, 500 mg ethosuximide oral capsule 250 mg 19

21 ethosuximide oral solution 250 mg/5 ml gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral tablet 600 mg, 800 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg oxcarbazepine oral suspension 300 mg/5 ml oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet, chewable 50 mg phenytoin sodium extended oral capsule 100 mg primidone oral tablet 250 mg, 50 mg TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG topiramate oral capsule, sprinkle 15 mg, 25 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid oral capsule 250 mg zonisamide oral capsule 100 mg, 25 mg, 50 mg Contraceptives AZURETTE (28) ORAL TABLET MGX21 /0.01 MG X 5 BALZIVA (28) ORAL TABLET MG-MCG CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) CAZIANT (28) ORAL TABLET 0.1/.125/ MG-MCG CONCEPTROL VAGINAL GEL 4 % CONDOMS-PREM LUBRICATED DEVICE DESOGESTREL-ETHINYL ESTRADIOL ORAL TABLET MG ELLA ORAL TABLET 30 MG ALLBACK SOLO ORAL TABLET 1.5 MG fc2 female condom 20

22 GIANVI (28) ORAL TABLET MG GYNOL II VAGINAL GEL 3 % JUNEL E 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) JUNEL E 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) l norgest/e.estradiol-e. estrad oral tablets, dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) LEENA 28 ORAL TABLET 0.5/1/ MG-MCG LEVORA-28 ORAL TABLET MG LOW-OGESTREL (28) ORAL TABLET MG-MCG medroxyprogesterone intramuscular suspension 150 mg/ml MICROGESTIN 1.5/30 (21) ORAL TABLET MG-MCG MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG MONONESSA (28) ORAL TABLET MG-MCG MY WAY ORAL TABLET 1.5 MG NECON 0.5/35 (28) ORAL TABLET MG-MCG NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG NECON 10/11 (28) ORAL TABLET /1-35 MG-MCG/MG-MCG NECON 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG norethindrone (contraceptive) oral tablet 0.35 mg NUVARING VAGINAL RING MG/24 HR OCELLA ORAL TABLET MG OGESTREL (28) ORAL TABLET MG-MCG QUASENSE ORAL TABLETS,DOSE PACK,3 MONTH MG- MCG SRONYX ORAL TABLET MG-MCG TILIA E ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) TRIVORA (28) ORAL TABLET (6)/75-40 (5)/125-30(10) VAGINAL CONTRACEPTIVE ILM VAGINAL ILM 28 % VAGINAL CONTRACEPTIVE OAM VAGINAL OAM 12.5 % 21

23 ZENCHENT E ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7) ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG Cough/Cold Preparations ADULT ROBITUSSIN PEAK COLD M-S ORAL LIQUID MG/5 ML allergy relief(chlorphen-acet) oral tablet mg benzonatate oral capsule 100 mg, 200 mg BIO-S-PRES DX ORAL DROPS MG/ML BROMED DM ORAL SYRUP MG/5 ML BROTAPP DM ORAL ELIXIR MG/5 ML CHILD MUCINEX STUY NOSE-COLD ORAL LIQUID MG/5 ML DIABETIC TUSSIN MAX ST ORAL LIQUID MG/5 ML DIMETAPP DM COLD-COUGH (PE) ORAL SOLUTION MG/5 ML EXPECTORANT ORAL LIQUID 100 MG/5 ML GUAIENESIN AC ORAL LIQUID MG/5 ML guaifenesin oral tablet extended release 12hr 600 mg hydrocodone-homatropine oral syrup mg/5 ml MUCINEX COUGH MINI-MELTS ORAL GRANULES IN PACKET MG MUCINEX D MAXIMUM STRENGTH ORAL TABLET EXTENDED RELEASE 12 HR 120-1,200 MG MUCINEX D ORAL TABLET EXTENDED RELEASE 12 HR MG MUCINEX DM ORAL TABLET, ER MULTIPHASE 12 HR 60-1,200 MG MUCINEX ORAL TABLET EXTENDED RELEASE 12HR 1,200 MG mucus dm oral tablet extended release 12 hr mg mucus relief cough oral liquid mg/5 ml NEO-TUSS ORAL LIQUID MG/5 ML nohist-dm oral liquid mg/5 ml PEDIA RELIE COUGH-COLD ORAL LIQUID MG/5 ML PROMETHAZINE VC-CODEINE ORAL SYRUP MG/5 ML 22

24 promethazine-codeine oral syrup mg/5 ml promethazine-dm oral syrup mg/5 ml pseudoephedrine hcl oral tablet 30 mg, 60 mg pseudoephedrine hcl oral tablet extended release 120 mg ROBITUSSIN PEDIATRIC ORAL SYRUP 7.5 MG/5 ML SCOT-TUSSIN DM ORAL LIQUID 2-15 MG/5 ML SCOT-TUSSIN SENIOR ORAL LIQUID MG/5 ML SUPHEDRIN ORAL LIQUID 15 MG/5 ML TUSSIN DM ORAL LIQUID MG/5 ML TUSSIN DM ORAL SYRUP MG/5 ML Diagnostic CHEMSTRIP K STRIP KETO-DIASTIX STRIP MULTISTIX 10 SG STRIP Diuretics acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 125 mg, 250 mg ALDACTAZIDE ORAL TABLET MG bumetanide oral tablet 0.5 mg, 1 mg, 2 mg chlorothiazide oral tablet 250 mg, 500 mg chlorthalidone oral tablet 25 mg, 50 mg DIURIL ORAL SUSPENSION 250 MG/5 ML DYRENIUM ORAL CAPSULE 50 MG EDECRIN ORAL TABLET 25 MG furosemide oral solution 10 mg/ml, 40 mg/5 ml furosemide oral tablet 20 mg, 40 mg, 80 mg hydrochlorothiazide oral capsule 12.5 mg hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg spironolacton-hydrochlorothiaz oral tablet mg triamterene-hydrochlorothiazid oral capsule mg 23

25 triamterene-hydrochlorothiazid oral tablet mg, mg Eye, Ear, Nose, and Throat (EENT) Preps acetic acid otic solution 2 % acetic acid-aluminum acetate otic drops 2 % allergy eye (naphazoline-phen) ophthalmic drops % ALOMIDE OPHTHALMIC DROPS 0.1 % apraclonidine ophthalmic drops 0.5 % ARTIICIAL TEARS OPHTHALMIC DROPS, % atropine ophthalmic drops 1 % atropine ophthalmic ointment 1 % AYR SALINE NASAL DROPS 0.65 % azelastine nasal aerosol, spray 137 mcg (0.1 %) AZOPT OPHTHALMIC DROPS,SUSPENSION 1 % betaxolol ophthalmic drops 0.5 % BETIMOL OPHTHALMIC DROPS 0.25 %, 0.5 % BETOPTIC S OPHTHALMIC DROPS,SUSPENSION 0.25 % brimonidine ophthalmic drops 0.15 %, 0.2 % carbamoxide ear drops otic drops 6.5 % cromolyn ophthalmic drops 4 % CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate ophthalmic drops 1 %, 2 % dexamethasone sodium phosphate ophthalmic drops 0.1 % diclofenac sodium ophthalmic drops 0.1 % dorzolamide ophthalmic drops 2 % dorzolamide-timolol ophthalmic drops mg/ml EYE ALLERGY RELIE OPHTHALMIC DROPS % LAREX OPHTHALMIC DROPS,SUSPENSION 0.1 % flunisolide nasal spray, non-aerosol 25 mcg (0.025 %) fluorometholone ophthalmic drops, suspension 0.1 % fluticasone nasal spray, suspension 50 mcg/actuation ML ORTE OPHTHALMIC DROPS,SUSPENSION 0.25 % for sty relief ophthalmic ointment 24

26 GENTEAL MILD OPHTHALMIC DROPS 0.2 % HOMATROPAIRE OPHTHALMIC DROPS 5 % ISOPTO TEARS OPHTHALMIC DROPS 0.5 % ketorolac ophthalmic drops 0.4 %, 0.5 % latanoprost ophthalmic drops % levobunolol ophthalmic drops 0.5 % lubricant eye drops (glyc-pg) ophthalmic drops % lubricant eye drops ophthalmic drops 0.5 % LUBRICANT EYE OPHTHALMIC OINTMENT % MAXIDEX OPHTHALMIC DROPS,SUSPENSION 0.1 % metipranolol ophthalmic drops 0.3 % MURO 128 OPHTHALMIC DROPS 2 % naphazoline ophthalmic drops 0.1 % NASAL SPRAY EXTRA MOISTURIZING NASAL SPRAY,NON- AEROSOL 0.05 % NATURAL BALANCE OPHTHALMIC DROPS 0.4 % PHENYLEPHRINE HCL OPHTHALMIC DROPS 2.5 % PHOSPHOLINE IODIDE OPHTHALMIC DROPS % pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % polyvinyl alcohol ophthalmic drops 1.4 % PRED MILD OPHTHALMIC DROPS,SUSPENSION 0.12 % prednisolone acetate ophthalmic drops, suspension 1 % prednisolone sodium phosphate ophthalmic drops 1 % proparacaine ophthalmic drops 0.5 % PURE & GENTLE EYE OPHTHALMIC DROPS 0.3 % RERESH LACRI-LUBE OPHTHALMIC OINTMENT % RERESH P.M. OPHTHALMIC OINTMENT % saline nasal nasal aerosol, spray 0.65 % sodium chloride ophthalmic drops 5 % sodium chloride ophthalmic ointment 5 % SYSTANE NIGHTTIME OPHTHALMIC OINTMENT 94-3 % TEARS NATURALE ORTE OPHTHALMIC DROPS % timolol maleate ophthalmic drops 0.25 %, 0.5 % 25

27 timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC DROPS % travoprost (benzalkonium) ophthalmic drops % tropicamide ophthalmic drops 0.5 %, 1 % Electrolyte/Caloric/H2O CALCIUM 600 ORAL TABLET 600 MG (1,500 MG) calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg calcium carbonate oral tablet 500 mg calcium (1,250 mg), 650 mg calcium (1,625 mg) calcium gluconate oral tablet 45 mg (500 mg), 60 mg (650 mg) calcium lactate oral tablet 84 mg (648 mg) CHELATED ZINC ORAL TABLET 50 MG EER-K ORAL TABLET, EERVESCENT 10 MEQ, 20 MEQ, 25 MEQ ferrous sulfate oral drops 15 mg iron (75 mg)/ml ferrous sulfate oral liquid 300 mg (60 mg iron)/5 ml ferrous sulfate oral solution 220 mg (44 mg iron)/5 ml ferrous sulfate oral tablet, delayed release (dr/ec) 324 mg (65 mg iron), 325 mg (65 mg iron) ERROUSUL ORAL TABLET 325 MG (65 MG IRON) LUOR-A-DAY ORAL DROPS 2.5 MG LUORIDE (5.56 MG)/ML LUORITAB ORAL TABLET,CHEWABLE 1 MG LUORIDE (2.2 MG) GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG glucose oral tablet, chewable 4 gram magnesium oxide oral tablet 250 mg, 400 mg, 420 mg, 500 mg PEDIATRIC ELECTROLYTE ORAL SOLUTION potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral tablet extended release 10 meq, 8 meq potassium chloride oral tablet, er particles/crystals 10 meq, 20 meq RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL TABLET 800 MG 26

28 sf 5000 plus dental cream 1.1 % sodium chloride 0.9 % intravenous parenteral solution 0.9 % sodium fluoride oral drops 0.5 mg fluoride (1.1 mg)/ml sodium fluoride oral tablet, chewable 0.25 mg fluorid (0.55 mg), 0.5 mg fluoride (1.1 mg) SSKI ORAL SOLUTION 1 GRAM/ML zinc gluconate oral tablet 50 mg Gastrointestinal ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION MG/5 ML ANTACID MAXIMUM STRENGTH ORAL SUSPENSION MG/5 ML ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML ANUSOL-HC RECTAL CREAM 2.5 % balsalazide oral capsule 750 mg bisacodyl oral tablet, delayed release (dr/ec) 5 mg BISMUTH MAXIMUM STRENGTH ORAL SUSPENSION 525 MG/15 ML CARAATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 mg/5 ml cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg CITRUCEL ORAL TABLET 500 MG CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT dicyclomine oral capsule 10 mg dicyclomine oral solution 10 mg/5 ml dicyclomine oral tablet 20 mg diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg docusate sodium oral capsule 100 mg docusate sodium oral liquid 50 mg/5 ml docusate sodium oral syrup 60 mg/15 ml docusate sodium oral tablet 100 mg 27

29 DONNATAL ORAL ELIXIR MG/5 ML DONNATAL ORAL TABLET MG enema rectal enema 19-7 gram/118 ml ENULOSE ORAL SOLUTION 10 GRAM/15 ML famotidine oral suspension 40 mg/5 ml famotidine oral tablet 10 mg famotidine oral tablet 20 mg, 40 mg fiber (calcium polycarbophil) oral tablet 625 mg fiber (psyllium husk/sugar) oral powder 3.4 gram/12 gram GAVILYTE-G ORAL RECON SOLN GRAM glycerin (adult) rectal suppository glycerin (child) rectal suppository hydrocortisone acetate rectal suppository 25 mg, 30 mg konsyl (sugar) oral powder in packet 3.4 gram lactulose oral solution 10 gram/15 ml lansoprazole oral capsule, delayed release(dr/ec) 15 mg lansoprazole oral capsule, delayed release(dr/ec) 30 mg LAXATIVE ORAL TABLET 5 MG loperamide oral capsule 2 mg LOPERAMIDE ORAL TABLET 2 MG magnesium citrate oral solution meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet, chewable 25 mg METAMUCIL ORAL CAPSULE 0.52 GRAM metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg MILK O MAGNESIA CONCENTRATED ORAL SUSPENSION 2,400 MG/10 ML MILK O MAGNESIA ORAL SUSPENSION 400 MG/5 ML MINTOX PLUS ORAL TABLET,CHEWABLE MG misoprostol oral tablet 100 mcg, 200 mcg NATURAL IBER LAXATIVE THERAPY ORAL POWDER natural psyllium fiber oral powder 3.4 gram/5.8 gram 28 C1

30 NEXIUM 24HR ORAL CAPSULE,DELAYED RELEASE(DR/EC) 22.3 MG NUTRISOURCE IBER ORAL POWDER omeprazole oral capsule, delayed release(dr/ec) 10 mg, 20 mg omeprazole oral capsule, delayed release(dr/ec) 40 mg omeprazole oral tablet, delayed release (dr/ec) 20 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron oral tablet, disintegrating 4 mg, 8 mg PANCRELIPASE 5000 ORAL CAPSULE,DELAYED RELEASE(DR/EC) 5,000-17,000-27,000 UNIT pantoprazole oral tablet, delayed release (dr/ec) 20 mg, 40 mg PEDIA-LAX STOOL SOTENER ORAL SYRUP 50 MG/15 ML PEDIATRIC ENEMA RECTAL ENEMA GRAM/59 ML peg 3350-electrolytes oral recon soln gram pink bismuth oral suspension 262 mg/15 ml PINK BISMUTH ORAL TABLET 262 MG PINK BISMUTH ORAL TABLET,CHEWABLE 262 MG polyethylene glycol 3350 oral powder 17 gram/dose PREVACID 24HR ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15 MG PRILOSEC OTC ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg PROCTOOAM HC RECTAL OAM 1-1 % PROCTO-PAK RECTAL CREAM 1 % promethazine rectal suppository 12.5 mg, 25 mg PROMETHEGAN RECTAL SUPPOSITORY 50 MG rabeprazole oral tablet, delayed release (dr/ec) 20 mg ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg, 300 mg ranitidine hcl oral tablet 75 mg SENNA LAX ORAL TABLET 8.6 MG SENNA ORAL SYRUP 8.8 MG/5 ML 29

31 SENNA PLUS ORAL TABLET MG SIMETHICONE ORAL DROPS,SUSPENSION 40 MG/0.6 ML simethicone oral tablet, chewable 80 mg sodium bicarbonate oral tablet 325 mg, 650 mg stool softener oral capsule 50 mg sucralfate oral tablet 1 gram sulfasalazine oral tablet 500 mg sulfasalazine oral tablet, delayed release (dr/ec) 500 mg TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY 1.5 MG (1 MG OVER 3 DAYS) TRILYTE WITH LAVOR PACKETS ORAL RECON SOLN 420 GRAM trimethobenzamide oral capsule 300 mg ursodiol oral capsule 300 mg ursodiol oral tablet 250 mg Hormones calcitonin (salmon) nasal spray, non-aerosol 200 unit/actuation DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML desmopressin oral tablet 0.1 mg, 0.2 mg DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML dexamethasone oral elixir 0.5 mg/5 ml dexamethasone oral solution 0.5 mg/5 ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5 mg, 1 mg, 2 mg estradiol transdermal patch semiweekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estradiol transdermal patch weekly mg/24 hr, mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, mg/24 hr, 0.1 mg/24 hr estrogens-methyltestosterone oral tablet mg, mg fludrocortisone oral tablet 0.1 mg hydrocortisone oral tablet 10 mg, 20 mg, 5 mg hydrocortisone rectal enema 100 mg/60 ml JINTELI ORAL TABLET 1-5 MG-MCG 30 C1

32 medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg MENEST ORAL TABLET 0.3 MG, MG MENEST ORAL TABLET 1.25 MG, 2.5 MG methylergonovine oral tablet 0.2 mg methylprednisolone oral tablet 4 mg methylprednisolone oral tablets, dose pack 4 mg MILLIPRED DP ORAL TABLETS,DOSE PACK 5 MG (21 TABS) MILLIPRED ORAL TABLET 5 MG prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 mg/5 ml prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg prednisone oral tablets, dose pack 10 mg, 5 mg PREMARIN ORAL TABLET 0.3 MG, MG, 0.9 MG, 1.25 MG PREMARIN ORAL TABLET 0.45 MG PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET MG (14)/ 0.625MG-5MG(14) PREMPRO ORAL TABLET MG, MG, MG, MG Immunosuppressant azathioprine oral tablet 50 mg mycophenolate mofetil oral capsule 250 mg mycophenolate mofetil oral tablet 500 mg Miscellaneous Medical Supplies, Devices, Non-Drug AEROCHAMBER PLUS LOW-VU SPACER bd insulin pen needle uf orig needle 29 gauge x 1/2" bd insulin pen needle uf short needle 31 gauge x 5/16" peak air peak flow meter device Muscle Relaxants baclofen oral tablet 10 mg, 20 mg carisoprodol oral tablet 350 mg 31

33 carisoprodol-aspirin oral tablet mg cyclobenzaprine oral tablet 10 mg, 5 mg methocarbamol oral tablet 500 mg, 750 mg tizanidine oral tablet 2 mg, 4 mg Pre-Natal Vitamins O-CAL A ORAL TABLET 66-1 MG pnv 29-1 oral tablet 29 mg iron- 1 mg PRENATAL LOW IRON ORAL TABLET 27-1 MG PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 27 MG IRON- 1 MG PRENATAL VITAMIN ORAL TABLET, MG PRENATAL VITAMIN WITH MINERALS ORAL TABLET MG PRETAB ORAL TABLET 29-1 MG Psychotherapeutic Drugs ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg, 3 mg amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg buspirone oral tablet 10 mg, 15 mg, 5 mg, 7.5 mg buspirone oral tablet 30 mg citalopram oral solution 10 mg/5 ml citalopram oral tablet 10 mg, 20 mg, 40 mg clonidine hcl oral tablet extended release 12 hr 0.1 mg desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg dexmethylphenidate oral capsule, er biphasic mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML diazepam oral solution 5 mg/5 ml diazepam oral tablet 10 mg, 2 mg, 5 mg 32

34 doxepin oral capsule 10 mg, 25 mg, 50 mg doxepin oral capsule 100 mg, 150 mg, 75 mg duloxetine oral capsule, delayed release(dr/ec) 20 mg, 30 mg, 60 mg escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg fluoxetine oral capsule 10 mg, 20 mg, 40 mg fluoxetine oral solution 20 mg/5 ml fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg OCALIN XR ORAL CAPSULE,ER BIPHASIC MG, 35 MG imipramine hcl oral tablet 10 mg, 25 mg, 50 mg lorazepam oral tablet 0.5 mg, 1 mg, 2 mg methylphenidate oral tablet 10 mg, 20 mg, 5 mg methylphenidate oral tablet extended release 10 mg methylphenidate oral tablet extended release 20 mg methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet, disintegrating 15 mg, 30 mg mirtazapine oral tablet, disintegrating 45 mg nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg sertraline oral concentrate 20 mg/ml sertraline oral tablet 100 mg, 25 mg, 50 mg STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg venlafaxine oral capsule, extended release 24hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release 24hr 150 mg, 225 mg, 37.5 mg, 75 mg Sedative/Hypnotics NIGHTTIME SLEEP AID (DIPHEN) ORAL TABLET 25 MG phenobarbital oral elixir 20 mg/5 ml 33

35 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg triazolam oral tablet mg, 0.25 mg zolpidem oral tablet 10 mg, 5 mg Skin Preps ACNE TREATMENT (BENZOYL PEROX) TOPICAL CREAM 10 % ALCOHOL PREP PADS TOPICAL PADS, MEDICATED AMLACTIN TOPICAL CREAM ammonium lactate topical lotion 12 % benzoyl peroxide topical cleanser 10 %, 5 % benzoyl peroxide topical gel 10 %, 2.5 %, 5 % benzoyl peroxide topical lotion 10 % BETA-HC TOPICAL LOTION 1 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0.1 % betamethasone valerate topical ointment 0.1 % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical ointment 0.05 % calamine topical lotion calamine-zinc oxide topical lotion 8-8 % clobetasol topical foam 0.05 % clobetasol topical gel 0.05 % clobetasol topical ointment 0.05 % clobetasol topical solution 0.05 % clobetasol-emollient topical cream 0.05 % CONDYLOX TOPICAL GEL 0.5 % CORN-CALLUS REMOVER TOPICAL LIQUID DESITIN TOPICAL CREAM 13 % desonide topical cream 0.05 % desonide topical lotion 0.05 % 34

36 desonide topical ointment 0.05 % DRITHOCREME HP TOPICAL CREAM 1 % EURAX TOPICAL CREAM 10 % EURAX TOPICAL LOTION 10 % LANDERS BUTTOCKS TOPICAL OINTMENT fluocinolone topical cream 0.01 %, % fluocinolone topical ointment % fluocinolone topical solution 0.01 % fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % LUOCINONIDE-E TOPICAL CREAM 0.05 % fluticasone topical cream 0.05 % fluticasone topical ointment % HIBICLENS TOPICAL LIQUID 4 % hydrocortisone acetate topical cream 0.5 % HYDROCORTISONE ACETATE TOPICAL CREAM 1 % hydrocortisone acetate topical ointment 1 % HYDROCORTISONE TOPICAL CREAM 1 % hydrocortisone topical cream 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 0.5 %, 1 % hydrocortisone topical ointment 2.5 % imiquimod topical cream in packet 5 % LICE KILLING TOPICAL SHAMPOO % LICE TREATMENT (RESMETHRIN) TOPICAL KIT % malathion topical lotion 0.5 % metronidazole topical cream 0.75 % metronidazole topical gel 0.75 % metronidazole topical lotion 0.75 % mometasone topical cream 0.1 % 35

37 mometasone topical ointment 0.1 % mometasone topical solution 0.1 % neomycin-polymyxin b gu irrigation solution 40 mg-200,000 unit/ml permethrin topical cream 5 % permethrin topical liquid 1 % podofilox topical solution 0.5 % povidone-iodine topical solution 10 % povidone-iodine topical swab 10 % prednicarbate topical cream 0.1 % prednicarbate topical ointment 0.1 % PYRETHRIN LICE TREATMENT M TOPICAL LIQUID % RID COMPLETE LICE ELIM KIT TOPICAL KIT % SCALPICIN ANTI-ITCH TOPICAL SOLUTION 1 % selenium sulfide topical shampoo 2.25 % selenium sulfide topical suspension 2.5 % SELSUN BLUE TOPICAL SUSPENSION 1 % SELSUN BLUE WITH MENTHOL TOPICAL SUSPENSION 1 % STERILE SALINE IRRIGATION SOLUTION 0.9 % tretinoin (emollient) topical cream 0.05 % C1 tretinoin topical cream %, 0.05 %, 0.1 % C1 tretinoin topical gel 0.01 %, % C1 triamcinolone acetonide topical cream %, 0.1 %, 0.5 % triamcinolone acetonide topical lotion %, 0.1 % triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % trianex topical ointment 0.05 % ULESIA TOPICAL LOTION 5 % urea topical lotion 10 % VOLTAREN TOPICAL GEL 1 % wart remover topical gel 17 % WART REMOVER TOPICAL LIQUID, 17 % zinc oxide topical ointment, 40 % zinc oxide topical paste 25 % 36

38 Smoking Deterrents buproban oral tablet extended release 150 mg CHANTIX CONTINUING MONTH PAK ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG CHANTIX STARTING MONTH PAK ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42) nicotine (polacrilex) buccal gum 2 mg, 4 mg nicotine (polacrilex) buccal lozenge 2 mg, 4 mg nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr nicotine transdermal patch, td daily, sequential mg/24 hr NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML Thyroid Preps ARMOUR THYROID ORAL TABLET 120 MG, 30 MG, 60 MG ARMOUR THYROID ORAL TABLET 15 MG, 180 MG, 240 MG, 300 MG, 90 MG levothyroxine oral tablet 100 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg levothyroxine oral tablet 112 mcg, 137 mcg, 300 mcg, 88 mcg liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg methimazole oral tablet 10 mg, 5 mg propylthiouracil oral tablet 50 mg Unclassified Drug Products alendronate oral tablet 10 mg, 40 mg alendronate oral tablet 35 mg, 70 mg CARNITOR SUGAR-REE ORAL SOLUTION 100 MG/ML chlorhexidine gluconate mucous membrane mouthwash 0.12 % disulfiram oral tablet 250 mg, 500 mg finasteride oral tablet 5 mg leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg levocarnitine oral tablet 330 mg megestrol oral suspension 400 mg/10 ml (40 mg/ml) ORALONE DENTAL PASTE 0.1 % 37

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