Medicaid-Approved Preferred Drug List

Transcription

1 Hoosier Healthwise Medicaid-Approved Preferred Drug List Effective August 1, 2017 Legend In each class, drugs are listed alphabetically by either brand name or generic name. Brand name drug: Uppercase in bold type Generic drug: Lowercase in plain type : Age Limit Restrictions DO: Dose Optimization Program GR: Gender Restriction : Over the counter medication available with a prescription. (Prescribers please indicate on the prescription) PA: Prior authorization is required. Prior authorization is the process of obtaining approval of benefits before certain prescriptions are filled. : Quantity limits; certain prescription medications have specific quantity limits per prescription or per month. SP: Specialty Pharmacy ST: Step therapy is required. You may need to use one medication before benefits for the use of another medication can be authorized.

2 lowercase = Generic drugs UPPERCASE BOLD = Brand name drugs Reference Drug Reference Reference TERNATIVE THERAPY TERNATIVE THERAPY - ANTIARTHRITICS GLUCOTEN OR TABLET TERNATIVE THERAPY - ANTIOXIDANT eye health plus lutein oral tablet healthy eyes supervision oral capsule ICAPS AREDS OR CAPSULE ICAPS AREDS OR TABLET,DELAYED RELEASE (DR/EC) i-vite oral tablet i-vite protect oral tablet MULTI-BETIC OR TABLET OCUVITE LUTEIN AND ZEAXANTHIN OR CAPSULE OCUVITE OR CAPSULE PRESERVISION AREDS 2 OR CAPSULE PRESERVISION AREDS OR CAPSULE PRESERVISION AREDS OR TABLET SAVISION OR TABLET vision-vite + zinc oral tablet TERNATIVE THERAPY - UNCLASSIFIED cranberry urinary comfort oral capsule kelp-lecithin-b6 oral tablet lecithin-kelp-b6 ( ) oral tablet lecithin-kelp-b6 (400-20) oral tablet lecithin-kelp-b6 oral capsule mg-plus-protein oral tablet 1

3 SEDATIVE-HYPNOTICS, NON- BARBITURATES TRYPTOPHAN OR CAPSULE TRYPTOPHAN OR TABLET ANGESIC, ANTI-INFLAMMATORY OR ANTIPYRETIC ANGESIC/ANTIPYRETICS, SICYLATES added strength headache relief oral tablet added strength pain reliever oral tablet adult low dose aspirin oral tablet,delayed release (dr/ec) antacid and pain relief oral tablet, effervescent aspir-81 oral tablet,delayed release (dr/ec) aspirin childrens oral tablet,chewable aspirin low dose oral tablet,delayed release (dr/ec) aspirin oral tablet Bayer Aspirin aspirin oral tablet,chewable Children's Aspirin aspirin oral tablet,delayed release (dr/ec) aspirin rectal suppository aspirin, buffered oral tablet Bufferin aspir-low oral tablet,delayed release (dr/ec) aspir-trin oral tablet,delayed release (dr/ec) back and body pain reliever oral tablet bayer advanced oral tablet bayer aspirin oral tablet bufferin oral tablet butalbital-aspirin-caffeine oral capsule child aspirin oral tablet,chewable children's aspirin oral tablet,chewable choline,magnesium salicylate oral liquid diflunisal oral tablet e.c. prin oral tablet,delayed release (dr/ec) ecotrin low strength oral tablet,delayed release (dr/ec) ecotrin oral tablet,delayed release (dr/ec) efferves pain relief antacid oral tablet, effervescent enteric coated aspirin oral tablet,delayed release (dr/ec) Fiorinal 2

4 headache relief (asa-acet-caf) oral tablet lite coat aspirin oral tablet lo-dose aspirin oral tablet,delayed release (dr/ec) migraine formula oral tablet migraine relief oral tablet pain relief (acetamin-asp-caf) oral tablet pain reliever (acetam-aspirin) oral tablet pain reliever plus oral tablet pain-off oral tablet pamprin max oral tablet salsalate oral tablet super pain relief oral tablet tri-buffered aspirin oral tablet ANGESICS, NARCOTICS Disalcid acetaminophen-codeine oral solution 120 mg- 12 mg /5 ml (5 ml), mg/5 ml acetaminophen-codeine oral solution 240 mg- 24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg acetaminophen-codeine oral tablet mg Tylenol-Codeine #3 acetaminophen-codeine oral tablet mg Tylenol-Codeine #4 ascomp with codeine oral capsule aspirin-caffeine-dihydrocodein oral capsule butalbital compound w/codeine oral capsule butalbital compound-codeine oral capsule butalbital-acetaminop-caf-cod oral capsule butorphanol tartrate nasal spray,non-aerosol codeine sulfate oral tablet 15 mg, 30 mg, 60 mg Synalgos-DC codeine-butalbital-asa-caff oral capsule Fiorinal-Codeine #3 diskets oral tablet,soluble endocet oral tablet endodan oral tablet PA; fentanyl citrate buccal lozenge on a handle Actiq PA; fentanyl transdermal patch 72 hour Duragesic PA; hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/7.5ml(7.5ml) hydrocodone-acetaminophen oral solution mg/15 ml Hycet 3

5 hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg, mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-acetaminophen oral tablet mg hydrocodone-ibuprofen oral tablet Xodol 10/300 Norco Verdrocet Vicodin Xodol 7.5/300 Lorcet Plus hydromorphone oral liquid Dilaudid hydromorphone oral tablet 2 mg, 4 mg, 8 mg Dilaudid hydromorphone rectal suppository meperidine oral solution meperidine oral tablet 100 mg Demerol meperidine oral tablet 50 mg methadone intensol oral concentrate PA; methadone oral concentrate Methadose PA; methadone oral solution 10 mg/5 ml, 5 mg/5 ml PA; methadone oral tablet 10 mg, 5 mg Dolophine PA; methadone oral tablet,soluble Diskets PA; methadose oral concentrate methadose oral tablet,soluble morphine concentrate oral solution morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml) morphine oral tablet morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg morphine rectal suppository oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 20 mg MS Contin oxycodone oral tablet 15 mg, 30 mg, 5 mg Roxicodone oxycodone-acetaminophen oral tablet Percocet oxycodone-aspirin oral tablet pentazocine-naloxone oral tablet 4 PA; PA; PA;

6 tramadol oral tablet Ultram tramadol-acetaminophen oral tablet Ultracet vicodin es oral tablet vicodin hp oral tablet vicodin oral tablet zamicet oral solution ANGESICS, NON-NARCOTIC 8 hour pain reliever oral tablet extended release acephen rectal suppository acetaminophen extra strength oral tablet acetaminophen oral drops,suspension Mapap (acetaminophen) acetaminophen oral elixir Non-Aspirin acetaminophen oral liquid Little Remedies Fever and Pain acetaminophen oral solution Mapap (acetaminophen) acetaminophen oral suspension Non-Aspirin acetaminophen oral tablet Tylenol acetaminophen oral tablet extended release Arthritis Pain Reliever acetaminophen oral tablet,chewable Children's Acetaminophen acetaminophen oral tablet,disintegrating Children's Pain Reliever acetaminophen pain relief oral tablet acetaminophen rectal suppository Feverall arthritis pain relief (acetam) oral tablet extended release arthritis pain reliever oral tablet extended release athenol oral tablet betatemp oral suspension butalbital-acetaminophen oral tablet Marten-Tab butalbital-acetaminophen-caff oral capsule Capacet butalbital-acetaminophen-caff oral tablet Esgic capacet oral capsule child pain rel-fever reducer rectal suppository children's acetaminophen oral suspension children's acetaminophen oral tablet,chewable children's acetaminophen oral tablet,disintegrating children's easy-melts oral tablet,disintegrating children's fever reducing rectal suppository children's mapap oral tablet,disintegrating 5

7 children's non-aspirin oral suspension children's non-aspirin oral tablet,chewable children's non-aspirin pain oral tablet,chewable children's pain relief oral suspension children's pain reliever oral suspension children's pain reliever oral tablet,disintegrating children's pain-fever relief oral liquid children's pain-fever relief oral suspension children's pain-fever relief oral tablet,chewable children's pain-fever relief oral tablet,disintegrating children's q-pap oral suspension children's silapap oral liquid children's tactinal oral tablet,chewable ed-apap oral liquid fever reducer an pain reliever oral suspension fever reducer rectal suppository feverall rectal suppository infant fever reducer-pain relf oral suspension infant pain reliever oral suspension infant's non-aspirin oral drops infant's non-aspirin oral drops,suspension infants' pain and fever oral suspension infant's pain relief oral drops,suspension infants' pain relief oral suspension infant's pain relief oral suspension infant's pain reliever oral drops,suspension jr. acetaminophen oral tablet,disintegrating jr. str non-aspirin pain oral tablet,disintegrating jr. strength pain reliever oral tablet,disintegrating junior mapap oral tablet,disintegrating little remedies fever and pain oral liquid mapap (acetaminophen) oral capsule mapap (acetaminophen) oral drops,suspension mapap (acetaminophen) oral liquid mapap (acetaminophen) oral suspension mapap (acetaminophen) oral tablet 6

8 mapap (acetaminophen) oral tablet,chewable mapap arthritis pain oral tablet extended release mapap extra strength oral tablet marten-tab oral tablet masophen oral tablet non-aspirin childrens oral drops non-aspirin children's oral tablet,chewable non-aspirin extra strength oral liquid non-aspirin extra strength oral tablet non-aspirin infants oral drops,suspension non-aspirin jr strength oral tablet,chewable non-aspirin oral elixir non-aspirin oral suspension non-aspirin oral tablet non-aspirin oral tablet,chewable non-aspirin pain relief oral tablet nortemp oral drops nortemp oral suspension pain and fever oral tablet pain relief adult oral liquid pain relief extra strength oral tablet pain relief oral liquid pain relief oral tablet pain relief oral tablet extended release pain relief regular strength oral tablet pain reliever extra strength oral tablet pain reliever jr strength oral tablet,chewable pain reliever oral capsule pain reliever oral tablet pediacare fever reducer oral suspension pharbetol oral tablet pms maximum strength oral tablet pre-menstrual relief oral tablet premsyn pms oral tablet q-pap extra strength oral tablet q-pap oral drops q-pap oral liquid q-pap oral tablet tactinal extra strength oral tablet 7

9 tactinal oral tablet tencon oral tablet tylophen oral capsule ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT HUMIRA SUBCUTANEOUS SYRINGE KIT ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR PA; PA; PA; PA; PA; PA; PA; PA; leflunomide oral tablet RIDAURA OR CAPSULE CHELATING AGENTS Arava CUPRIMINE OR CAPSULE DEPEN TITRATABS OR TABLET minocycline oral capsule minocycline oral tablet Minocin sulfasalazine oral tablet Sulfazine sulfasalazine oral tablet,delayed release (dr/ec) sulfazine oral tablet IMMUNOSUPRESSANTS Azulfidine EN-tabs azathioprine oral tablet cyclosporine modified oral capsule cyclosporine modified oral solution cyclosporine oral capsule gengraf oral capsule gengraf oral solution mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution Imuran Gengraf Gengraf Sandimmune CellCept CellCept 8

10 mycophenolate mofetil oral tablet SANDIMMUNE OR SOLUTION NSAIDS CellCept advil oral tablet advil oral tablet,chewable all day pain relief oral tablet all day relief oral tablet child ibuprofen oral suspension children's advil oral suspension children's ibuprofen oral suspension children's profen ib oral suspension diclofenac potassium oral tablet diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr fenoprofen oral tablet flanax (naproxen) oral tablet flurbiprofen oral tablet ibu-drops oral drops,suspension ibuprofen ib oral tablet ibuprofen ib oral tablet,chewable ibuprofen jr strength oral tablet,chewable Voltaren-XR Lodine ibuprofen oral capsule Advil Liqui-Gel ibuprofen oral drops,suspension Infant's Motrin ibuprofen oral suspension Children's Profen IB ibuprofen oral tablet 100 mg Advil ibuprofen oral tablet 200 mg I-Prin ibuprofen oral tablet 400 mg, 600 mg, 800 mg ibuprofen pm oral tablet ibuprofen-diphenhydramine cit oral tablet Advil PM indomethacin oral capsule indomethacin oral capsule, extended release infants ibu-drops oral drops,suspension infant's ibuprofen oral drops,suspension infants profenib oral drops,suspension i-prin oral tablet 9

11 ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr ketorolac oral tablet meclofenamate oral capsule mediproxen oral tablet meloxicam oral suspension meloxicam oral tablet Mobic motrin pm oral tablet nabumetone oral tablet naproxen oral suspension Naprosyn naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) EC-Naprosyn naproxen sodium oral capsule Aleve naproxen sodium oral tablet 220 mg Aleve naproxen sodium oral tablet 275 mg naproxen sodium oral tablet 550 mg Anaprox DS PA oxaprozin oral tablet Daypro piroxicam oral capsule Feldene provil oral tablet sulindac oral tablet tolmetin oral capsule tolmetin oral tablet wal-profen oral capsule wal-profen oral tablet wal-proxen oral tablet PLASMOCIDES hydroxychloroquine oral tablet ANESTHETICS TOPIC ANESTHETICS Plaquenil lidocaine hcl laryngotracheal solution LTA Pre-Attached lidocaine topical ointment ANORECT PREPARATIONS HEMORRHOID PREPARATIONS anu-med rectal suppository hemorrhoid rectal ointment hemorrhoidal (phenyleph-cocoa) rectal suppository hemorrhoidal rectal ointment hemorrhoidal suppository rectal suppository 10

12 hydrocortisone topical cream with perineal applicator proctosol hc topical cream with perineal applicator proctozone-hc topical cream with perineal applicator ANTIDOTES AND OTHER REVERS AGENTS ANTIDOTE - ACETAMINOPHEN POISONING acetylcysteine solution BENZODIAZEPINE REVERS AGENTS - BENZODIAZEPINE ANTAGONISTS flumazenil intravenous solution CHELATING AGENTS CUPRIMINE OR CAPSULE DEPEN TITRATABS OR TABLET SYPRINE OR CAPSULE NARCOTIC ANTAGONISTS naloxone injection solution naloxone injection syringe naltrexone oral tablet NARCAN NAS SPRAY,NON-AEROSOL ANTI-INFECTIVE AGENTS ABSORBABLE SULFONAMIDES sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet trimethoprim oral tablet AMEBICIDES paromomycin oral capsule AMINOGLYCOSIDES neomycin oral tablet ANAEROBIC ANTIPROTOZO ANTIBACTERI AGENTS metronidazole oral capsule metronidazole oral tablet tinidazole oral tablet ANTHELMINTICS BENZA OR TABLET Proctozone-HC Revia Sulfatrim Bactrim Flagyl Flagyl 11

13 BILTRICIDE OR TABLET ivermectin oral tablet pin-x oral suspension pin-x oral tablet,chewable reese's pinworm medicine oral suspension ANTIFUNG ANTIBIOTICS Stromectol fluconazole oral suspension for reconstitution fluconazole oral tablet flucytosine oral capsule griseofulvin microsize oral suspension griseofulvin ultramicrosize oral tablet Diflucan Diflucan Ancobon Gris-PEG (ultramicrosize) itraconazole oral capsule Sporanox Pulsepak PA ketoconazole oral tablet nystatin oral powder nystatin oral tablet terbinafine hcl oral tablet voriconazole oral suspension for reconstitution Lamisil Vfend voriconazole oral tablet Vfend PA ANTIMYCOBACTERIUM AGENTS PA ethambutol oral tablet isoniazid oral solution isoniazid oral tablet PRIFTIN OR TABLET pyrazinamide oral tablet rifabutin oral capsule rifampin oral capsule RIFATER OR TABLET sulfadiazine oral tablet ANTIVIRS, GENER Myambutol Mycobutin Rifadin acyclovir oral capsule acyclovir oral suspension acyclovir oral tablet famciclovir oral tablet Zovirax Zovirax Zovirax oseltamivir oral capsule 30 mg, 45 mg, 75 mg Tamiflu RELENZA DISKHER INHATION BLISTER WITH DEVICE rimantadine oral tablet TAMIFLU OR SUSPENSION FOR RECONSTITUTION Flumadine 12

14 valacyclovir oral tablet valganciclovir oral recon soln valganciclovir oral tablet ANTIVIRS, HIV SPECIFIC abacavir oral tablet abacavir-lamivudine oral tablet abacavir-lamivudine-zidovudine oral tablet APTIVUS OR CAPSULE APTIVUS OR SOLUTION CRIXIVAN OR CAPSULE DESCOVY OR TABLET didanosine oral capsule,delayed release(dr/ec) EDURANT OR TABLET EMTRIVA OR CAPSULE EMTRIVA OR SOLUTION EVOTAZ OR TABLET FUZEON SUBCUTANEOUS RECON SOLN GENVOYA OR TABLET INTELENCE OR TABLET ISENTRESS HD OR TABLET ISENTRESS OR POWDER IN PACKET ISENTRESS OR TABLET ISENTRESS OR TABLET,CHEWABLE KETRA OR TABLET lamivudine oral solution lamivudine oral tablet lamivudine-zidovudine oral tablet lopinavir-ritonavir oral solution nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR OR CAPSULE NORVIR OR SOLUTION NORVIR OR TABLET PREZCOBIX OR TABLET PREZISTA OR SUSPENSION PREZISTA OR TABLET RESCRIPTOR OR TABLET Valtrex Valcyte Valcyte Ziagen Epzicom Trizivir Videx EC Epivir Epivir Combivir Kaletra Viramune Viramune Viramune XR PA 13

15 RESCRIPTOR OR TABLET, DISPERSIBLE REYATAZ OR CAPSULE SELZENTRY OR SOLUTION SELZENTRY OR TABLET stavudine oral capsule stavudine oral recon soln STRIBILD OR TABLET TIVICAY OR TABLET TRIUMEQ OR TABLET TRUVADA OR TABLET VIRACEPT OR TABLET VIREAD OR TABLET VITEKTA OR TABLET ZIAGEN OR SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet CEPHOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution cefaclor oral tablet extended release 12 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution cefadroxil oral tablet cefdinir oral capsule cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet CEFTIN OR SUSPENSION FOR RECONSTITUTION cefuroxime axetil oral suspension for reconstitution cefuroxime axetil oral tablet 250 mg cefuroxime axetil oral tablet 500 mg cephalexin oral capsule cephalexin oral suspension for reconstitution 14 Zerit Zerit Retrovir Retrovir Ceftin Keflex PA;

16 cephalexin oral tablet CHEMOTHERAPEUTICS, ANTIBACTERI, MISCELLANEOUS dapsone oral tablet HEPATITIS B TREATMENT AGENTS adefovir oral tablet Hepsera PA BARACLUDE OR SOLUTION entecavir oral tablet Baraclude PA EPIVIR HBV OR SOLUTION PA PA; lamivudine oral tablet Epivir HBV PA; LINCOSAMIDES clindamycin hcl oral capsule clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln MACROLIDES Cleocin HCl Cleocin Pediatric azithromycin oral packet Zithromax azithromycin oral suspension for reconstitution 100 mg/5 ml azithromycin oral suspension for reconstitution 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg, 600 mg clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr e.e.s. 400 oral tablet ery-tab oral tablet,delayed release (dr/ec) erythrocin (as stearate) oral tablet Zithromax Zithromax Zithromax erythromycin ethylsuccinate oral tablet E.E.S. 400 erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet erythromycin stearate oral tablet PENICILLINS Erythrocin (as stearate) amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15

17 amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule ampicillin oral suspension for reconstitution dicloxacillin oral capsule penicillin v potassium oral recon soln penicillin v potassium oral tablet PLASMOCIDES atovaquone-proguanil oral tablet chloroquine phosphate oral tablet hydroxychloroquine oral tablet mefloquine oral tablet PRIMAQUINE OR TABLET QUINOLONES Augmentin ES-600 Augmentin Augmentin Augmentin XR Malarone Pediatric Plaquenil ciprofloxacin hcl oral tablet levofloxacin oral solution levofloxacin oral tablet Levaquin ofloxacin oral tablet TETRACYCLINES demeclocycline oral tablet doxycycline monohydrate oral capsule Monodox PA doxycycline monohydrate oral suspension for reconstitution minocycline oral capsule minocycline oral tablet tetracycline oral capsule VANCOMYCIN AND DERIVATIVES Vibramycin Minocin linezolid oral suspension for reconstitution Zyvox PA; linezolid oral tablet Zyvox PA; vancomycin oral capsule Vancocin PA PA 16

18 ANTINEOPLASTICS ANTINEOPLASTIC - ANTIANDROGENIC AGENTS bicalutamide oral tablet flutamide oral capsule ANTINEOPLASTIC/IMMUNOSUPPRESS ANT DRUGS Casodex anastrozole oral tablet Arimidex DEPO-PROVERA INTRAMUSCULAR SOLUTION EMCYT OR CAPSULE exemestane oral tablet Aromasin HEXEN OR CAPSULE hydroxyurea oral capsule Hydrea imatinib oral tablet 100 mg, 400 mg Gleevec PA; IRESSA OR TABLET letrozole oral tablet Femara leucovorin calcium oral tablet megestrol oral tablet MESNEX OR TABLET MYLERAN OR TABLET tamoxifen oral tablet tretinoin (chemotherapy) oral capsule ANTISEPTICS AND DISINFECTANTS ANTISEPTICS, GENER alcohol pads topical pads, medicated alcohol prep pads topical pads, medicated alcohol prep swabs topical pads, medicated PA PA PA; PA alcohol swabs topical pads, medicated IV Prep Wipes alcohol wipes topical pads, medicated alcoh-wipe towelette antiseptic skin clnsr(chlorhe) topical liquid betasept surgical scrub topical liquid chlorhexidine gluconate topical liquid Hand Wash curity alcohol swabs topical pads, medicated easy touch alcohol prep pads topical pads, medicated hibiclens topical liquid hydrogen peroxide solution 17

19 sure comfort alcohol prep pads topical pads, medicated webcol topical pads, medicated BIOLOGICS IMMUNE GLOBULINS GAMUNEX-C INJECTION SOLUTION OCTAGAM INTRAVENOUS SOLUTION IMMUNOLOGICS VACCINES ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE AFLURIA (PF) INTRAMUSCULAR SYRINGE AFLURIA INTRAMUSCULAR SUSPENSION AFLURIA QUAD (PF) INTRAMUSCULAR SYRINGE CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION EZ FLU (AFLURIA) (PF) INTRAMUSCULAR SYRINGE KIT EZ FLU (FLUVIRIN) (PF) INTRAMUSCULAR SYRINGE KIT EZ FLU16-17(FLUZON QD PED)(PF) INTRAMUSCULAR SYRINGE KIT FLUAD (65 YR UP)(PF) INTRAMUSCULAR SYRINGE FLUARIX QUAD (PF) INTRAMUSCULAR SYRINGE FLUBLOK (PF) INTRAMUSCULAR SOLUTION FLUCELVAX QUAD (PF) INTRAMUSCULAR SYRINGE FLULAV QUAD (PF) INTRAMUSCULAR SYRINGE FLULAV QUAD INTRAMUSCULAR SUSPENSION FLUVIRIN (PF) INTRAMUSCULAR SYRINGE FLUVIRIN INTRAMUSCULAR SUSPENSION 18

20 FLUZONE HIGH-DOSE (PF) INTRAMUSCULAR SYRINGE FLUZONE INTRADERM QUAD INTRADERM SYRINGE FLUZONE QUAD (PF) INTRAMUSCULAR SUSPENSION FLUZONE QUAD (PF) INTRAMUSCULAR SYRINGE FLUZONE QUAD INTRAMUSCULAR SUSPENSION FLUZONE QUAD PEDI (PF) INTRAMUSCULAR SYRINGE GARDASIL (PF) INTRAMUSCULAR SUSPENSION GARDASIL (PF) INTRAMUSCULAR SYRINGE GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE KINRIX (PF) INTRAMUSCULAR SUSPENSION KINRIX (PF) INTRAMUSCULAR SYRINGE QUADRACEL (PF) INTRAMUSCULAR SUSPENSION SYNAGIS INTRAMUSCULAR SOLUTION TENIVAC (PF) INTRAMUSCULAR SUSPENSION TENIVAC (PF) INTRAMUSCULAR SYRINGE TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION VACCINE BACTERI - GRAM NEGATIVE BACILLI (NON-ENTERIC) ACTHIB (PF) INTRAMUSCULAR RECON SOLN PA 19

21 VACCINE BACTERI - GRAM NEGATIVE COCCI AND BACILLI MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN VACCINE BACTERI - GRAM NEGATIVE COCCI MENACTRA (PF) INTRAMUSCULAR SOLUTION MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT VACCINE BACTERI - GRAM POSITIVE COCCI PNEUMOVAX 23 INJECTION SOLUTION PNEUMOVAX 23 INJECTION SYRINGE PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE VACCINE BACTERI - MENINGOCOCC GROUP B VACCINES BEXSERO INTRAMUSCULAR SYRINGE TRUMENBA INTRAMUSCULAR SYRINGE VACCINE MIXED COMBINATIONS (BACTERI AND VIR) PENTACEL (PF) INTRAMUSCULAR KIT CARDIOVASCULAR THERAPY AGENTS HYPOTENSIVES, SYMPATHOLYTIC methyldopa-hydrochlorothiazide oral tablet ACE INHIBITOR/CCIUM CHANNEL BLOCK COMBINATION amlodipine-benazepril oral capsule ADRENERGIC VASOPRESSOR midodrine oral tablet DOSTERONE RECEPTOR ANTAGONISTS spironolactone oral tablet Aldactone 20

22 PHA/BETA-ADRENERGIC BLOCKING AGENTS carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg labetalol oral tablet PHA-ADRENERGIC BLOCKING AGENTS Coreg doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg Cardura prazosin oral capsule terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg ANAPHYLAXIS THERAPY AGENTS Minipress epinephrine injection auto-injector Adrenaclick epinephrine injection solution ANTIARRHYTHMICS amiodarone oral tablet disopyramide phosphate oral capsule flecainide oral tablet mexiletine oral capsule pacerone oral tablet propafenone oral capsule,extended release 12 hr propafenone oral tablet quinidine gluconate oral tablet extended release quinidine sulfate oral tablet sorine oral tablet sotalol af oral tablet sotalol oral tablet Adrenalin Pacerone Norpace Rythmol SR Sorine verapamil oral tablet 120 mg, 80 mg Calan verapamil oral tablet 40 mg BETA-ADRENERGIC BLOCKING AGENTS acebutolol oral capsule atenolol oral tablet betaxolol oral tablet bisoprolol fumarate oral tablet HEMANGEOL OR SOLUTION INDER XL OR CAPSULE,EXTENDED RELEASE 24HR Tenormin PA 21

23 INNOPRAN XL OR CAPSULE,EXTENDED RELEASE 24HR metoprolol succinate oral tablet extended release 24 hr metoprolol tartrate oral tablet nadolol oral tablet pindolol oral tablet propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet sorine oral tablet sotalol af oral tablet sotalol oral tablet timolol maleate oral tablet CCIUM CHANNEL BLOCKING AGENTS Toprol XL Lopressor Corgard Inderal LA Sorine PA afeditab cr oral tablet extended release 30 mg afeditab cr oral tablet extended release 60 mg amlodipine oral tablet 10 mg Norvasc DO; amlodipine oral tablet 2.5 mg, 5 mg Norvasc DO; cartia xt oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg cartia xt oral capsule,extended release 24hr 300 mg diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg diltiazem hcl oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg diltiazem hcl oral capsule,extended release 24hr 240 mg diltiazem hcl oral capsule,extended release 24hr 300 mg diltiazem hcl oral capsule,extended release 24hr 360 mg DILT-XR DILT-XR Tiazac Tiazac Cartia XT Cardizem CD Cartia XT Cardizem CD DO; DO; DO; DO; DO; 22

24 diltiazem hcl oral tablet Cardizem diltiazem hcl oral tablet extended release 24 hr 180 mg, 240 mg diltiazem hcl oral tablet extended release 24 hr 300 mg, 360 mg, 420 mg dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg dilt-xr oral capsule,ext.rel 24h degradable 240 mg felodipine oral tablet extended release 24 hr 10 mg felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg isradipine oral capsule 2.5 mg, 5 mg matzim la oral tablet extended release 24 hr 180 mg, 240 mg matzim la oral tablet extended release 24 hr 300 mg, 360 mg, 420 mg nicardipine oral capsule 20 mg, 30 mg nifedipine oral capsule nifedipine oral tablet extended release 24hr 30 mg nifedipine oral tablet extended release 24hr 60 mg, 90 mg Matzim LA Matzim LA Procardia XL Procardia XL DO; DO; DO; DO; DO; nifedipine oral tablet extended release 30 mg Afeditab CR DO; nifedipine oral tablet extended release 60 mg Afeditab CR nifedipine oral tablet extended release 90 mg Adalat CC taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg taztia xt oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg DO; verapamil oral capsule, 24 hr er pellet ct Verelan PM DO; verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg Verelan Verelan verapamil oral tablet 120 mg, 80 mg Calan verapamil oral tablet 40 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg DIGITIS GLYCOSIDES digox oral tablet digoxin oral solution Calan SR DO; 23

25 digoxin oral tablet LANOXIN OR TABLET DIURETIC - CARBONIC ANHYDRASE INHIBITORS Digox acetazolamide oral capsule, extended release Diamox Sequels acetazolamide oral tablet methazolamide oral tablet HYPOTENSIVES, ACE INHIBITORS, COMBINATIONS benazepril oral tablet benazepril-hydrochlorothiazide oral tablet captopril oral tablet captopril-hydrochlorothiazide oral tablet Neptazane enalapril maleate oral tablet Vasotec enalapril-hydrochlorothiazide oral tablet fosinopril oral tablet fosinopril-hydrochlorothiazide oral tablet lisinopril oral tablet 10 mg Prinivil DO; lisinopril oral tablet 2.5 mg, 20 mg, 5 mg Zestril DO; lisinopril oral tablet 30 mg, 40 mg Zestril lisinopril-hydrochlorothiazide oral tablet mg lisinopril-hydrochlorothiazide oral tablet mg, mg moexipril oral tablet moexipril-hydrochlorothiazide oral tablet perindopril erbumine oral tablet Zestoretic Zestoretic quinapril oral tablet Accupril quinapril-hydrochlorothiazide oral tablet Accuretic ramipril oral capsule Altace trandolapril oral tablet HYPOTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg candesartan-hydrochlorothiazid oral tablet mg, mg, mg Atacand Atacand HCT DO; irbesartan oral tablet 150 mg, 75 mg Avapro DO; irbesartan oral tablet 300 mg Avapro irbesartan-hydrochlorothiazide oral tablet mg, mg Avalide 24

26 losartan oral tablet 100 mg, 25 mg, 50 mg Cozaar losartan-hydrochlorothiazide oral tablet mg, mg losartan-hydrochlorothiazide oral tablet mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet mg, mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg HYPOTENSIVES, MISCELLANEOUS Hyzaar Hyzaar Diovan Diovan HCT Diovan HCT DO; DO; atenolol-chlorthalidone oral tablet Tenoretic 100 bisoprolol-hydrochlorothiazide oral tablet metoprolol ta-hydrochlorothiaz oral tablet mg, mg metoprolol ta-hydrochlorothiaz oral tablet mg nadolol-bendroflumethiazide oral tablet propranolol-hydrochlorothiazid oral tablet HYPOTENSIVES, SYMPATHOLYTIC Ziac Lopressor HCT Corzide clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly guanfacine oral tablet methyldopa oral tablet HYPOTENSIVES, VASODILATORS hydralazine oral tablet minoxidil oral tablet LIPOTROPICS Catapres Catapres-TTS-1 DO; DO; atorvastatin oral tablet 10 mg, 20 mg, 40 mg Lipitor DO; atorvastatin oral tablet 80 mg Lipitor cholestyramine (with sugar) oral powder cholestyramine (with sugar) oral powder in packet cholestyramine light oral powder cholestyramine light oral powder in packet colestipol oral granules colestipol oral packet colestipol oral tablet fenofibrate micronized oral capsule Questran Questran Colestid Flavored Colestid Colestid fenofibrate nanocrystallized oral tablet Tricor 25

27 fenofibrate oral tablet fenofibric acid (choline) oral capsule,delayed release(dr/ec) Trilipix fenofibric acid oral tablet Fibricor fish oil concentrate oral capsule fish oil oral capsule fish oil oral capsule,delayed release(dr/ec) gemfibrozil oral tablet inositol oral tablet lecithin oral capsule lecithin, soy oral capsule lovastatin oral tablet 10 mg, 20 mg lovastatin oral tablet 40 mg maxepa oral capsule Lopid DO; niacin oral tablet Niacor NIACOR OR TABLET omega-3 fatty acids oral capsule Super Omega-3 pravastatin oral tablet 10 mg DO; pravastatin oral tablet 20 mg, 40 mg Pravachol DO; pravastatin oral tablet 80 mg Pravachol prevalite oral powder prevalite oral powder in packet simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Zocor DO; simvastatin oral tablet 80 mg Zocor PA; super omega-3 oral capsule super twin epa-dha oral capsule vitamin e oral capsule LOOP DIURETICS bumetanide oral tablet furosemide oral solution furosemide oral tablet torsemide oral tablet PCSK-9 INHIBITORS Lasix Demadex REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR REPATHA SYRINGE SUBCUTANEOUS SYRINGE PA; PA; PA; 26

28 PERIPHER VASODILATORS, SINGLE AGENTS isoxsuprine oral tablet POTASSIUM SPARING DIURETICS amiloride oral tablet amiloride-hydrochlorothiazide oral tablet spironolactone oral tablet spironolacton-hydrochlorothiaz oral tablet triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet PULMONARY ARTERI HYPERTENSION Aldactone Aldactazide Maxzide-25mg LETAIRIS OR TABLET RESERPINE AND DERIVATIVES PA reserpine oral tablet THIAZIDE AND RELATED DIURETICS chlorothiazide oral tablet chlorthalidone oral tablet hydrochlorothiazide oral capsule Microzide hydrochlorothiazide oral tablet 12.5 mg hydrochlorothiazide oral tablet 25 mg, 50 mg indapamide oral tablet metolazone oral tablet VASODILATING DRUGS ADCIRCA OR TABLET PA sildenafil oral tablet Revatio PA; VASODILATORS, CORONARY isosorbide dinitrate oral tablet isosorbide dinitrate oral tablet extended release isosorbide mononitrate oral tablet isosorbide mononitrate oral tablet extended release 24 hr nitro-bid transdermal ointment NITRO-DUR TRANSDERM PATCH 24 HOUR nitroglycerin oral capsule, extended release nitroglycerin sublingual tablet nitroglycerin transdermal patch 24 hour nitro-time oral capsule, extended release ISOCHRON Nitro-Time Nitrostat Nitro-Dur 27

29 CENTR NERVOUS SYSTEM AGENTS PHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS mirtazapine oral tablet Remeron DO; mirtazapine oral tablet,disintegrating Remeron SolTab DO; ANTI-ANXIETY DRUGS alprazolam intensol oral concentrate alprazolam oral tablet Xanax DO; alprazolam oral tablet extended release 24 hr Xanax XR DO; alprazolam oral tablet,disintegrating buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg chlordiazepoxide hcl oral capsule clonazepam oral tablet Klonopin clonazepam oral tablet,disintegrating clorazepate dipotassium oral tablet diazepam intensol oral concentrate DO; DO; DO; DO; DO; diazepam oral concentrate Diazepam Intensol DO; diazepam oral solution diazepam oral tablet Valium DO; hydroxyzine hcl oral solution hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule lorazepam intensol oral concentrate lorazepam oral concentrate Lorazepam Intensol lorazepam oral tablet Ativan meprobamate oral tablet oxazepam oral capsule ANTICONVULSANTS carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg Carbatrol DO; DO; DO; carbamazepine oral suspension Tegretol DO; carbamazepine oral tablet Tegretol DO; carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable Tegretol XR clonazepam oral tablet Klonopin clonazepam oral tablet,disintegrating diazepam rectal kit Diastat 28 DO; DO;

30 DILANTIN KAPSE OR CAPSULE DILANTIN OR CAPSULE divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol oral tablet EQUETRO OR CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG ethosuximide oral capsule ethosuximide oral solution felbamate oral suspension felbamate oral tablet Depakote Sprinkles Depakote ER Depakote Zarontin Zarontin Felbatol Felbatol DO; PA; gabapentin oral capsule 100 mg Neurontin DO; gabapentin oral capsule 300 mg, 400 mg Neurontin gabapentin oral solution Neurontin gabapentin oral tablet 600 mg, 800 mg Neurontin LAMICT STARTER (BLUE) KIT OR TABLETS,DOSE PACK LAMICT STARTER (GREEN) KIT OR TABLETS,DOSE PACK LAMICT STARTER (ORANGE) KIT OR TABLETS,DOSE PACK LAMICT XR STARTER (BLUE) OR TABLET EXTENDED REL,DOSE PACK LAMICT XR STARTER (GREEN) OR TABLET EXTENDED REL,DOSE PACK LAMICT XR STARTER (ORANGE) OR TABLET EXTENDED REL,DOSE PACK lamotrigine oral tablet Lamictal lamotrigine oral tablet disintegrating, dose pk lamotrigine oral tablet extended release 24hr 100 mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg lamotrigine oral tablets,dose pack levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg Lamictal ODT Starter (Blue) Lamictal XR Lamictal Lamictal ODT Lamictal Starter (Blue) Kit Keppra Roweepra Keppra XR 29

31 LYRICA OR CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA OR SOLUTION ONFI OR SUSPENSION ONFI OR TABLET 10 MG, 20 MG oxcarbazepine oral suspension Trileptal DO; oxcarbazepine oral tablet 150 mg, 300 mg Trileptal oxcarbazepine oral tablet 600 mg Trileptal DO; OXTELLAR XR OR TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE OR TABLET phenobarbital oral elixir phenobarbital oral tablet 100 mg, 15 mg, 60 mg phenobarbital oral tablet 16.2 mg, 30 mg, 32.4 mg, 64.8 mg, 97.2 mg phenytoin oral suspension phenytoin oral tablet,chewable phenytoin sodium extended oral capsule primidone oral tablet QUDEXY XR OR CAPSULE,SPRINKLE,ER 24HR 100 MG, 150 MG, 200 MG, 25 MG, 50 MG ROWEEPRA OR TABLET SPRITAM OR TABLET FOR SUSPENSION tiagabine oral tablet Dilantin-125 Dilantin Infatabs Phenytek Mysoline Gabitril topiramate oral capsule, sprinkle Topamax topiramate oral capsule,sprinkle,er 24hr 100 mg, 150 mg, 200 mg, 25 mg, 50 mg Qudexy XR topiramate oral tablet Topamax TROKENDI XR OR CAPSULE,EXTENDED RELEASE 24HR valproic acid (as sodium salt) oral solution valproic acid (as sodium salt) oral syringe Depakene valproic acid oral capsule Depakene DO; zonisamide oral capsule ANTIMANIA DRUGS lithium carbonate oral capsule lithium carbonate oral tablet Zonegran lithium carbonate oral tablet extended release Lithobid 30

32 lithium citrate oral solution ANTIMIGRAINE PREPARATIONS divalproex oral tablet extended release 24 hr ergotamine-caffeine oral tablet isometh-dichloral-acetaminophn oral capsule migergot rectal suppository Depakote ER Cafergot Nodolor naratriptan oral tablet Amerge nodolor oral capsule sumatriptan nasal spray,non-aerosol Imitrex PA; sumatriptan succinate oral tablet Imitrex sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml Imitrex STATdose Kit Refill Imitrex STATdose Pen Alsuma PA; PA; PA; sumatriptan succinate subcutaneous solution Imitrex PA; sumatriptan succinate subcutaneous syringe ANTIPARKINSONISM DRUGS, ANTICHOLINERGIC benztropine oral tablet trihexyphenidyl oral elixir trihexyphenidyl oral tablet ANTIPARKINSONISM DRUGS, OTHER amantadine hcl oral capsule amantadine hcl oral solution amantadine hcl oral tablet bromocriptine oral capsule bromocriptine oral tablet carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating Parlodel Parlodel Sinemet Sinemet CR carbidopa-levodopa-entacapone oral tablet Stalevo 50 entacapone oral tablet pramipexole oral tablet ropinirole oral tablet selegiline hcl oral capsule selegiline hcl oral tablet Comtan Mirapex Requip Eldepryl PA; 31

33 ANTIPSYCHOTICS, ATYPIC DOPAMINE, AND SEROTONIN ANTAGONISTS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING aripiprazole oral solution PA; ; PA; ; aripiprazole oral tablet 10 mg, 2 mg, 5 mg Abilify DO; aripiprazole oral tablet 15 mg, 20 mg, 30 mg Abilify aripiprazole oral tablet,disintegrating ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING PA; PA; ; clozapine oral tablet 100 mg, 25 mg Clozaril ; clozapine oral tablet 200 mg, 50 mg ; clozapine oral tablet,disintegrating 100 mg FazaClo ; clozapine oral tablet,disintegrating 12.5 mg, 25 mg clozapine oral tablet,disintegrating 150 mg, 200 mg FANAPT OR TABLET 1 MG, 2 MG, 4 MG FANAPT OR TABLET 10 MG, 12 MG, 6 MG, 8 MG FANAPT OR TABLETS,DOSE PACK FAZACLO OR TABLET,DISINTEGRATING 150 MG, 200 MG GEODON INTRAMUSCULAR RECON SOLN INVEGA SUSTENNA INTRAMUSCULAR SYRINGE INVEGA TRINZA INTRAMUSCULAR SYRINGE LATUDA OR TABLET 120 MG, 80 MG LATUDA OR TABLET 20 MG, 40 MG LATUDA OR TABLET 60 MG NUPLAZID OR TABLET olanzapine intramuscular recon soln FazaClo FazaClo Zyprexa DO; ; DO; ; ; ; PA; ; PA; ; DO; ; olanzapine oral tablet 10 mg, 15 mg, 20 mg Zyprexa ; olanzapine oral tablet 2.5 mg, 5 mg, 7.5 mg Zyprexa DO; ; olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg Zyprexa Zydis olanzapine oral tablet,disintegrating 5 mg Zyprexa Zydis DO; 32

34 paliperidone oral tablet extended release 24hr 1.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg, 9 mg Invega Invega Invega DO; ; ; quetiapine oral tablet 100 mg, 25 mg, 50 mg Seroquel DO; ; quetiapine oral tablet 200 mg, 300 mg, 400 mg quetiapine oral tablet extended release 24 hr 150 mg, 50 mg quetiapine oral tablet extended release 24 hr 200 mg quetiapine oral tablet extended release 24 hr 300 mg, 400 mg REXULTI OR TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG RISPERD CONSTA INTRAMUSCULAR SYRINGE risperidone oral solution risperidone oral syringe risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg Seroquel Seroquel XR Seroquel XR Seroquel XR Risperdal Risperdal risperidone oral tablet 3 mg, 4 mg Risperdal risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SUBLINGU TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGU TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGU TABLET 5 MG SEROQUEL XR OR TABLET, EXT REL 24HR DOSE PACK VERSACLOZ OR SUSPENSION VRAYLAR OR CAPSULE VRAYLAR OR CAPSULE,DOSE PACK Risperdal M-TAB Risperdal M-TAB ; DO; ; PA; ; DO; DO; DO; ziprasidone hcl oral capsule 20 mg, 40 mg Geodon DO; ; ziprasidone hcl oral capsule 60 mg, 80 mg Geodon ; ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION PA; 33

35 ANTIPSYCHOTICS, TYPIC ADASUVE INHATION AEROSOL POWDR BREATH ACTIVATED chlorpromazine injection solution chlorpromazine oral tablet 10 mg, 25 mg, 50 mg chlorpromazine oral tablet 100 mg, 200 mg fluphenazine decanoate injection solution fluphenazine hcl injection solution fluphenazine hcl oral concentrate fluphenazine hcl oral elixir fluphenazine hcl oral tablet 1 mg fluphenazine hcl oral tablet 10 mg fluphenazine hcl oral tablet 2.5 mg fluphenazine hcl oral tablet 5 mg HDOL DECANOATE INTRAMUSCULAR SOLUTION HDOL INJECTION SOLUTION haloperidol decanoate intramuscular solution 100 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate injection solution haloperidol lactate oral concentrate haloperidol oral tablet 0.5 mg, 1 mg, 2 mg haloperidol oral tablet 10 mg, 20 mg, 5 mg loxapine succinate oral capsule 10 mg, 25 mg, 5 mg loxapine succinate oral capsule 50 mg molindone oral tablet perphenazine oral tablet 16 mg perphenazine oral tablet 2 mg perphenazine oral tablet 4 mg, 8 mg Haldol Decanoate Haldol Decanoate Haldol DO; PA; DO; ; PA; ; DO; ; ; ; DO; DO; ; ; DO; ; ; pimozide oral tablet 1 mg, 2 mg Orap DO; ; prochlorperazine maleate oral tablet thioridazine oral tablet 10 mg, 25 mg thioridazine oral tablet 100 mg, 50 mg thiothixene oral capsule 1 mg, 2 mg, 5 mg thiothixene oral capsule 10 mg trifluoperazine oral tablet 1 mg, 2 mg trifluoperazine oral tablet 10 mg, 5 mg 34 Compazine DO; DO; ; ; DO;

36 ATTENTION DEFICIT - HYPERACTIVITY (ADHD)/NARCOLEPSY ADZENYS XR-ODT OR TABLET,DISINTEG ER BIPHASE 24H APTENSIO XR OR CAP,ER SPRINKLE,BIPHASIC armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 80 mg Nuvigil Strattera atomoxetine oral capsule 60 mg Strattera caffeine citrate oral solution clonidine hcl oral tablet extended release 12 hr DAYTRANA TRANSDERM PATCH 24 HOUR 10 MG/9 HR, 15 MG/9 HR DAYTRANA TRANSDERM PATCH 24 HOUR 20 MG/9 HR, 30 MG/9 HR dexedrine oral tablet 10 mg dexedrine oral tablet 5 mg dexmethylphenidate oral capsule,er biphasic mg, 15 mg, 20 mg, 5 mg dexmethylphenidate oral capsule,er biphasic mg, 30 mg, 35 mg, 40 mg Kapvay Focalin XR Focalin XR dexmethylphenidate oral tablet 10 mg Focalin DO; DO; DO; dexmethylphenidate oral tablet 2.5 mg, 5 mg Focalin DO; dextroamphetamine oral capsule, extended release 10 mg, 15 mg dextroamphetamine oral capsule, extended release 5 mg Dexedrine Spansule Dexedrine Spansule dextroamphetamine oral solution ProCentra dextroamphetamine oral tablet 10 mg Zenzedi DO; dextroamphetamine oral tablet 5 mg Zenzedi DO; dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg dextroamphetamine-amphetamine oral tablet 20 mg, 30 mg Adderall XR Adderall XR Adderall Adderall DO; DO; 35

37 DYANAVEL XR OR SUSPEN, IR - ER, BIPHASIC 24HR EVEKEO OR TABLET 10 MG, 5 MG guanfacine oral tablet extended release 24 hr Intuniv ER metadate er oral tablet extended release methamphetamine oral tablet Desoxyn methylphenidate hcl oral capsule, er biphasic mg, 20 mg, 30 mg methylphenidate hcl oral capsule, er biphasic mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er biphasic mg methylphenidate hcl oral capsule,er biphasic mg, 40 mg methylphenidate hcl oral capsule,er biphasic mg methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml Ritalin LA Ritalin LA Methylin DO; DO; methylphenidate hcl oral tablet 10 mg, 5 mg Ritalin DO; methylphenidate hcl oral tablet 20 mg Ritalin methylphenidate hcl oral tablet extended release 10 mg methylphenidate hcl oral tablet extended release 20 mg methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg methylphenidate hcl oral tablet extended release 24hr 36 mg, 54 mg methylphenidate hcl oral tablet,chewable 10 mg methylphenidate hcl oral tablet,chewable 2.5 mg, 5 mg Metadate ER Concerta Concerta DO; DO; DO; modafinil oral tablet 100 mg Provigil DO; modafinil oral tablet 200 mg Provigil procentra oral solution QUILLICHEW ER OR TABLET,CHEW,IR- ER.BIPHASIC24HR 20 MG QUILLICHEW ER OR TABLET,CHEW,IR- ER.BIPHASIC24HR 30 MG, 40 MG QUILLIVANT XR OR SUSPENSION,EXT REL 24HR,RECON RITIN LA OR CAPSULE,ER BIPHASIC DO; 36

38 VYVANSE OR CAPSULE 10 MG, 20 MG, 30 MG VYVANSE OR CAPSULE 40 MG, 50 MG, 60 MG, 70 MG VYVANSE OR TABLET,CHEWABLE 10 MG VYVANSE OR TABLET,CHEWABLE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG XYREM OR SOLUTION zenzedi oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 7.5 mg zenzedi oral tablet 2.5 mg, 5 mg BENZODIAZEPINES DO; DO; amitriptyline-chlordiazepoxide oral tablet diazepam intensol oral concentrate DO; diazepam oral concentrate Diazepam Intensol DO; diazepam oral solution diazepam oral tablet Valium DO; diazepam rectal kit Diastat lorazepam intensol oral concentrate lorazepam oral concentrate Lorazepam Intensol lorazepam oral tablet Ativan ONFI OR SUSPENSION ONFI OR TABLET 10 MG, 20 MG FIBROMYGIA AGENTS - GABA ANOGS LYRICA OR CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA OR SOLUTION MAO INHIBITORS EMSAM TRANSDERM PATCH 24 HOUR 12 MG/24 HR, 9 MG/24 HR EMSAM TRANSDERM PATCH 24 HOUR 6 MG/24 HR MARPLAN OR TABLET PA; PA; DO; phenelzine oral tablet Nardil DO; tranylcypromine oral tablet Parnate DO; MOVEMENT DISORDER DRUG THERAPY HORIZANT OR TABLET EXTENDED RELEASE PA; 37

39 NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIBITORS (NDRIS) APLENZIN OR TABLET EXTENDED RELEASE 24 HR 174 MG APLENZIN OR TABLET EXTENDED RELEASE 24 HR 348 MG, 522 MG bupropion hcl oral tablet 100 mg bupropion hcl oral tablet 75 mg bupropion hcl oral tablet extended release 12 hr 100 mg bupropion hcl oral tablet extended release 12 hr 150 mg, 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg FORFIVO XL OR TABLET EXTENDED RELEASE 24 HR POSTHERPETIC NEURGIA AGENTS GRISE 30-DAY STARTER PACK OR TABLET EXTENDED RELEASE 24 HR GRISE OR TABLET EXTENDED RELEASE 24 HR 300 MG GRISE OR TABLET EXTENDED RELEASE 24 HR 600 MG PSEUDOBULBAR AFFECT (PBA) AGENTS, NMDA ANTAGONISTS TYPE NUEDEXTA OR CAPSULE SEDATIVE-HYPNOTIC - ANTIHISTAMINES Wellbutrin SR Wellbutrin SR Wellbutrin XL Wellbutrin XL DO; DO; DO; DO; PA; PA; DO; PA; PA alka-seltzer plus allergy oral tablet diphenhydramine hcl oral capsule 25 mg Pharbedryl ; diphenhydramine hcl oral capsule 50 mg Pharbedryl diphenhydramine hcl oral tablet Banophen nightime sleep oral capsule nighttime sleep aid (diphen) oral capsule nighttime sleep aid (diphen) oral tablet ormir oral capsule rest simply nighttime sleep oral tablet restfully sleep oral tablet sleep aid (diphenhydramine) oral capsule sleep aid (diphenhydramine) oral liquid 38

40 sleep aid (diphenhydramine) oral tablet sleep aid (doxylamine) oral tablet sleep aid max str (diphenhydr) oral capsule sleep ii oral tablet sleep oral tablet sleep tablet (diphenhydramine) oral tablet SLEEP TIME OR LIQUID sleep-tabs oral tablet ultra sleep (doxylamine succ) oral tablet unisom sleepgels oral capsule unisom sleepmelts oral tablet,disintegrating W-SLEEP Z OR CAPSULE W-SLEEP Z OR LIQUID W-SLEEP Z OR TABLET,DISINTEGRATING wal-som (diphenhydramine) oral capsule wal-som (diphenhydramine) oral tablet,disintegrating wal-som (doxylamine) oral tablet Z-SLEEP OR CAPSULE Z-SLEEP OR LIQUID ZZZQUIL OR CAPSULE ZZZQUIL OR LIQUID SEDATIVE-HYPNOTICS, BARBITURATES BUTISOL OR TABLET phenobarbital oral elixir phenobarbital oral tablet 100 mg, 15 mg, 60 mg phenobarbital oral tablet 16.2 mg, 30 mg, 32.4 mg, 64.8 mg, 97.2 mg seconal sodium oral capsule SEDATIVE-HYPNOTICS, NON- BARBITURATES DO; BELSOMRA OR TABLET PA; DOR OR TABLET DO; EDLUAR SUBLINGU TABLET PA; DO; estazolam oral tablet DO; eszopiclone oral tablet Lunesta PA; DO; flurazepam oral capsule DO; HETLIOZ OR CAPSULE PA; 39