2015 Comprehensive Formulary (List of Covered Drugs)

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1 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on 03/01/2015. For more recent information or other questions, please contact WellCare/ Ohana at the telephone number listed on the inside front and back covers of this formulary or visit or WellCare/ Ohana Plans WellCare Choice (HMO-POS) WellCare Dividend (HMO/HMO-POS) WellCare Essential (HMO/HMO-POS) WellCare Value (HMO/HMO-POS) WellCare Emerald Value (HMO) WellCare Gold Essential (HMO) Ohana Value (HMO-POS) Ohana Choice (HMO-POS) excluding Connecticut and New York HPMS Approved Formulary File Submission ID: Version Number: 10 Y0070_NA026578_WCM_FOR_ENG_FINAL_03 CMS Approved NA5V03FOR59890E 0315 WellCare 2015 NA_03_15

2 We re always just a phone call away! If you re ready to enroll or have enrollment questions, call , 8 a.m. to 8 p.m., 7 days a week. If you re already a member, call the number for your state/plan listed below. Arkansas: Florida: Georgia: Hawai i: Illinois: Kentucky: Louisiana: Mississippi: New Jersey: South Carolina: Tennessee: Texas: WellCare Emerald Value (HMO) WellCare Choice, Dividend, Essential, Value (HMO/HMO-POS) WellCare Value (HMO) Ohana Choice or Value (HMO-POS) WellCare Value (HMO-POS) WellCare Value (HMO-POS) WellCare Value (HMO) WellCare Value or Gold Essential (HMO/HMO-POS) WellCare Value (HMO) WellCare Emerald Value (HMO) WellCare Dividend or Emerald Value (HMO/HMO-POS) WellCare Dividend or Value (HMO/HMO-POS) Hours of operation are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are available Monday Sunday, 8 a.m. to 8 p.m., or visit us anytime at or Nurse Advice Line (24 hours, 7 days a week) TTY for all of the above NA5V03FOR59890E 0315

3 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us or our, it means WellCare/ Ohana. When it refers to plan or our plan, it means WellCare/ Ohana. This document includes a list of the drugs (formulary) for our plan which is current as of 03/01/2015. For an updated formulary, please contact us. Our contact information along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may change on January 1, 2016, and from time to time during the year. What is the WellCare Choice (HMO-POS), WellCare Dividend (HMO/HMO- POS), WellCare Essential (HMO/HMO-POS), WellCare Value (HMO/HMO-POS), WellCare Emerald Value (HMO), WellCare Gold Essential (HMO), Ohana Value (HMO-POS), and Ohana Choice (HMO-POS) comprehensive formulary? A formulary is a list of covered drugs. WellCare/ Ohana selects the drugs by working with a team of health care providers. The list contains the prescription medications we believe are a necessary part of a quality treatment program. WellCare/ Ohana will generally cover the drugs listed in our formulary as long as: 1. the drug is medically necessary, 2. the prescription is filled at a/an WellCare/ Ohana network pharmacy, and 3. other plan rules are followed. For more information on how to fill your prescriptions, please see your Evidence of Coverage. Can the formulary (drug list) change? In general, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not stop or reduce coverage of the drug during the 2015 coverage year. However, there are some cases when we may stop or reduce coverage. These are: when a new, less expensive generic drug becomes available or when new negative information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. For those members, it will remain available at the same cost share for the remainder of the coverage year. We think it s important that you can continue to get the formulary drugs that were available when you chose our plan for the remainder of the coverage year. The only exceptions are for cases in which you can save additional money or we can ensure your safety. When we make certain changes to our formulary, we must notify the members who will be affected by the changes. This includes if we: remove drugs from our formulary; 2015 Comprehensive Formulary I NA5V03FOR59890E 0315

4 add restrictions on a drug such as prior authorization, quantity limits and/or step therapy; move a drug to a higher cost-sharing tier. If we make any of these changes, we must notify affected members at least 60 days before the change goes into effect. We will also notify the member at the time he or she asks for a refill of the drug. In that case, the member will receive a 60-day supply of the drug. If the Food and Drug Administration announces that a drug on our formulary is unsafe, or a drug manufacturer removes a drug from the market, we will immediately remove the drug from our formulary and notify members who take the drug. The enclosed formulary is current as of 03/01/2015. To get updated information about the drugs covered by WellCare/ Ohana, please visit our website at or or call Customer Service at the telephone number listed for your state/plan on the inside front and back cover pages of this formulary. Every month, we update our printed formulary with a monthly addendum. Please contact Customer Service or visit our website at or for more information. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 85. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? WellCare/ Ohana covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: 2015 Comprehensive Formulary II

5 Prior Authorization: WellCare/ Ohana requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, WellCare/ Ohana provides 9 tablets for 30 days per prescription for sumatriptan 25mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, WellCare/ Ohana requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website at or We have posted online documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask WellCare/ Ohana to make an exception to these restrictions or limits, or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the WellCare/ Ohana formulary? on page IV for information about how to request an exception. What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. You can contact Customer Service at the telephone number listed for your state/plan on the inside front and back covers of this formulary. If you learn that WellCare/ Ohana does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by WellCare/ Ohana. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by WellCare/ Ohana. You can ask WellCare/ Ohana to make an exception and cover your drug. See below for information about how to request an exception. Which vaccines do we cover? Your prescription benefit may cover many vaccines. For details, see the Immunological Agents section. The cost for vaccines varies, depending on the facility where you receive them. For best coverage, use a network pharmacy. All commercially available vaccines are covered under Part D, except for those that are covered under Medicare Part B, such as influenza or pneumococcal vaccines Comprehensive Formulary III

6 How do I request an exception to the WellCare Choice (HMO-POS), WellCare Dividend (HMO/HMO-POS), WellCare Essential (HMO/HMO-POS), WellCare Value (HMO/HMO-POS), WellCare Emerald Value (HMO), WellCare Gold Essential (HMO), Ohana Value (HMO-POS), and Ohana Choice (HMO-POS) formulary? You can ask WellCare/ Ohana to make an exception to our coverage rules. There are several types of formulary exceptions that you can ask us to make. Initial Coverage Decision Exception You can ask us to cover your drug even if it is not on our formulary. If your request is approved, the drug will be covered at a pre-determined cost-sharing level. You would not be able to ask us to provide the drug at a lower cost-sharing level. Utilization Restriction Exception You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the amount of the drug that we cover is limited. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Tiering Exception You can ask us to cover a formulary drug at a lower cost-sharing level (if the drug is not on the specialty tier). If approved, this would lower the amount you must pay for your drug. Generally, WellCare/ Ohana will only approve your request for an exception if: the alternative drugs included on the plan s formulary would not be as effective in treating your condition; the lower cost-sharing drug would not be as effective in treating your condition; the additional utilization restrictions would not be as effective in treating your condition and/or; the alternative drugs would cause you to have adverse medical effects. You should contact us to ask us for a formulary exception for an initial coverage decision, a tiering exception or a utilization restriction exception. When you request any of these exceptions, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request for a fast review is granted, we must give you a decision no later than 24 hours after we get your prescriber s or prescribing physician s supporting statement. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover, or request a formulary exception so that we will cover the drug you take Comprehensive Formulary IV

7 While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply that meets the dispensing instructions (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 30-day emergency supply of that drug (unless you have a prescription for fewer days) while you seek a formulary exception. If you experience a level of care change (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can call our Provider Service Center and request a one-time override. This one-time override will be up to a 30-day supply (unless you have a prescription written for fewer days). For more information For more details about your WellCare/ Ohana prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about WellCare/ Ohana, please contact us. Our contact information is on the inside front and back covers of this document. Or visit or If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day, 7 days a week. TTY users should call Or, visit WellCare/ Ohana formulary The comprehensive formulary that begins on page 1 provides coverage information about the drugs covered by WellCare/ Ohana. If you have trouble finding your drug in the list, turn to the Index that begins on page 85. The first column of the chart lists the drug name. Brand-name drugs are BOLD and UPPERCASE (e.g., COUMADIN) and generic drugs are listed in lowercase italics (e.g., simvastatin). The information in the Requirements/Limits column tells you if WellCare/ Ohana has any special requirements for coverage of your drug. MS means the drug is available by Mail Service (otherwise known as mail-order). Please see Chapter 5 of your Evidence of Coverage for more information.** PA stands for Prior Authorization: Please see page III for details Comprehensive Formulary V

8 PA-BvsD stands for Prior Authorization Restriction for Part B vs. Part D Determination: This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from WellCare/ Ohana to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, WellCare/ Ohana may not cover this drug. PA-NS stands for Prior Authorization Restriction for New Starts: This type of prior authorization restriction will impact new starts to the drug. Members taking this medication at the time of enrollment will not be required to meet prerequisites for prior authorization. QL stands for Quantity Limits: Please see page III for details. LA stands for Limited Access medication. This medication may be available from certain other pharmacies. For more information, please refer to the Specialty Pharmacy section of your Pharmacy Directory or contact Customer Service at the telephone number listed for your state/plan on the inside front and back cover pages of this formulary. ST stands for Step Therapy: Please see page III for details. ST-NS stands for Step Therapy Restriction for New Starts: This type of step therapy restriction will impact new starts to the drug. Members taking this medication at the time of enrollment will not be required to meet prerequisites for step therapy. * = Drug may be available for up to a 30-day supply only. ** You can get prescription drugs shipped to your home through our network mail-service delivery program. You should expect to receive your prescription drugs within 7 10 business days from the time that the mail-service pharmacy receives the order. If you do not receive your prescription drugs within this time, please contact us at the telephone number listed on the inside front and back covers of this formulary or visit or Drug tier co-payment/coinsurance amounts The WellCare/ Ohana formulary is divided into five tiers. Tier 1: Preferred Generic Drugs Drugs that are available at the lowest cost share for this plan. Tier 2: Non-Preferred Generic Drugs Drugs that WellCare/ Ohana offers at a higher cost to you than preferred generics. Tier 3: Preferred Brand Drugs Drugs that WellCare/ Ohana may be able to offer at a lower cost to you than non-preferred brand drugs. Tier 4: Non-Preferred Brand Drugs Drugs that WellCare/ Ohana offers at a higher cost to you than preferred brands. Tier 5: Specialty Drugs Some injectables and other high-cost drugs. * Indicates specialty drugs are available for up to a 30-day supply only. Brand drugs may be available in Tiers 3, 4 and 5. Generic drugs are available in Tiers 1, 2 and 5. Consult your Evidence of Coverage or Summary of Benefits for your applicable co-pays/ coinsurance and deductible amounts Comprehensive Formulary VI

9 How to read formulary listings: NAME Anticonvulsants REQUIREMENTS/LIMITS Therapeutic Category Anticonvulsants, Other Therapeutic Class phenobarbital elixir 2 PA-NS; MS phenobarbital tablet 2 PA-NS; MS POTIGA TABLET 50MG, 200MG, 300MG 5* PA-NS; MS* POTIGA TABLET 400MG 4 PA-NS; MS Tier of Drug * = Drug may be available for up to a 30-day supply only Name of Drug BOLD UPPERCASE = Brand Drugs lowercase italics = Generic Drugs Find your drug quickly in the Index at the back of the book. Requirements/Limits Codes: LA = Limited Access MS = Mail-Service Available PA = Prior Authorization PA-BvsD = Prior Authorization Part B vs. Part D Only PA-NS = Prior Authorization Restriction for New Starts QL = Quantity Limits ST = Step Therapy ST-NS = Step Therapy Restriction for New Starts 2015 Comprehensive Formulary VII

10 NAME Analgesics Analgesics acetaminophen-codeine oral solution mg/5ml ; QL (4500 ML per 30 days) acetaminophen-codeine #2 oral tablet mg ; QL (360 EA per 30 days) acetaminophen-codeine #3 oral tablet mg ; QL (360 EA per 30 days) acetaminophen-codeine #4 oral tablet mg ; QL (180 EA per 30 days) butalbital-acetaminophen oral tablet mg 2 PA; MS; QL (180 EA per 30 days) butalbital-apap-caff-cod oral capsule mg 2 PA; MS; QL (180 EA per 30 days) butalbital-apap-caffeine oral capsule mg 2 PA; MS; QL (180 EA per 30 days) butalbital-apap-caffeine oral tablet mg 2 PA; MS; QL (180 EA per 30 days) butalbital-aspirin-caffeine oral capsule mg 2 PA; MS; QL (180 EA per 30 days) endocet oral tablet mg, mg, mg ; QL (360 EA per 30 days) hydrocodone-acetaminophen oral solution mg/15ml hydrocodone-acetaminophen oral tablet mg, mg, mg ; QL (3600 ML per 30 days) ; QL (360 EA per 30 days) hydrocodone-ibuprofen oral tablet mg ; QL (150 EA per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg, mg ; QL (360 EA per 30 days) roxicet oral tablet mg ; QL (360 EA per 30 days) tramadol-acetaminophen oral tablet mg ; QL (300 EA per 30 days) Nonsteroidal Anti-Inflammatory Drugs diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet delayed release 25 mg, 50 mg diclofenac sodium oral tablet delayed release 75 mg ; QL (60 EA per 30 days) diclofenac sodium er oral tablet extended release 24 hr* 100 mg diflunisal oral tablet 500 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg ; QL (60 EA per 30 days) 1

11 NAME etodolac er oral tablet extended release 24 hr* 400 mg, 500 mg, 600 mg fenoprofen calcium oral tablet 600 mg flurbiprofen oral tablet 100 mg, 50 mg ibuprofen oral suspension 100 mg/5ml ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MS indomethacin oral capsule 25 mg, 50 mg 2 ST; MS ketoprofen oral capsule 50 mg, 75 mg ketoprofen er oral capsule extended release 24 hour 200 mg meloxicam oral suspension 7.5 mg/5ml ; QL (30 EA per 30 days) meloxicam oral tablet 15 mg 1 MS; QL (30 EA per 30 days) meloxicam oral tablet 7.5 mg 1 MS; QL (60 EA per 30 days) nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen dr oral tablet delayed release 375 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 mg oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg sulindac oral tablet 150 mg, 200 mg Opioid Analgesics, Long-Acting duramorph injection solution 0.5 mg/ml, 1 mg/ml fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr methadone hcl injection solution 10 mg/ml methadone hcl oral solution 10 mg/5ml, 5 mg/5ml ; QL (20 EA per 30 days) methadone hcl oral tablet 10 mg, 5 mg 1 MS; QL (240 EA per 30 days) morphine sulfate injection solution 2 mg/ml morphine sulfate oral solution 10 mg/5ml, 20 mg/5ml morphine sulfate oral tablet 15 mg, 30 mg ; QL (240 EA per 30 days) morphine sulfate (concentrate) oral solution 20 mg/ml 2

12 NAME morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml morphine sulfate (pf) intravenous* solution 8 mg/ml morphine sulfate er oral tablet extendedrelease* 100 mg, 15 mg, 200 mg, 30 mg, 60 mg OPANA ER ORAL 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG oxymorphone hcl er oral tablet extended release 12 hr* 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg Opioid Analgesics, Short-Acting ; QL (240 EA per 30 days) 4 MS; QL (60 EA per 30 days) ; QL (60 EA per 30 days) codeine sulfate oral tablet 15 mg, 30 mg ; QL (360 EA per 30 days) codeine sulfate oral tablet 60 mg ; QL (180 EA per 30 days) fentanyl citrate buccal lollipop 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg 5* PA; MS; QL (120 EA per 30 days) hydromorphone hcl oral tablet 2 mg, 4 mg, 8 mg ; QL (240 EA per 30 days) hydromorphone hcl pf injection solution 1 mg/ml, 4 mg/ml, 500 mg/50ml LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 MCG/ACT morphine sulfate (pf) intravenous* solution 2 mg/ml, 4 mg/ml 5* PA; MS oxycodone hcl oral concentrate 20 mg/ml oxycodone hcl oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg ; QL (240 EA per 30 days) tramadol hcl oral tablet 50 mg 1 MS; QL (240 EA per 30 days) Anesthetics Local Anesthetics lidocaine external ointment 5 % lidocaine hcl external 2 % lidocaine hcl external solution 4 % 1 MS lidocaine hcl injection solution 2 % lidocaine hcl (cardiac) intravenous* solution 20 mg/ml lidocaine hcl (pf) injection solution 0.5 %, 1 % 3

13 NAME lidocaine viscous mouth/throat solution 2 % 1 MS lidocaine-prilocaine external cream % ; QL (60 GM per 30 days) LIDODERM EXTERNAL PATCH 5 % 3 MS; QL (90 EA per 30 days) Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/ Anti-Craving acamprosate calcium oral tablet delayed release 333 mg disulfiram oral tablet 250 mg, 500 mg naltrexone hcl oral tablet 50 mg Opioid Dependence Treatments buprenorphine hcl injection solution 0.3 mg/ml 2 PA-BvsD; MS buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG Opioid Reversal Agents 2 PA; MS 4 PA; MS naloxone hcl injection solution 1 mg/ml 1 MS Smoking Cessation Agents CHANTIX ORAL TABLET 0.5 MG, 1 MG 4 MS; QL (340 EA per 365 days) CHANTIX STARTING MONTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 4 MS; QL (106 EA per 365 days) NICOTROL NS NASAL SOLUTION 10 MG/ML 3 MS Antibacterials Aminoglycosides amikacin sulfate injection solution 500 mg/2ml gentak ophthalmic ointment 0.3 % gentamicin in saline intravenous* solution mg/ml-%, mg/ml-%, mg/ml-% gentamicin sulfate external cream 0.1 % 1 MS gentamicin sulfate external ointment 0.1 % 1 MS gentamicin sulfate injection solution 40 mg/ml gentamicin sulfate intravenous* solution 10 mg/ml 4

14 NAME gentamicin sulfate ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic solution 0.3 % neomycin sulfate oral tablet 500 mg neomycin-polymyxin b gu irrigation solution paromomycin sulfate oral capsule 250 mg streptomycin sulfate intramuscular* solution reconstituted 1 gm TOBI PODHALER INHALATION CAPSULE 28 MG 5* PA; MS; QL (28 EA per 56 days) tobramycin inhalation nebulization solution 300 mg/5ml 5* PA; MS tobramycin ophthalmic solution 0.3 % tobramycin sulfate injection solution 10 mg/ml, 80 mg/2ml tobramycin sulfate injection solution reconstituted 1.2 gm Antibacterials colistimethate sodium injection solution reconstituted 150 mg SYNERCID INTRAVENOUS* SOLUTION RECONSTITUTED MG Antibacterials, Other 2 PA-BvsD; MS 5* PA; MS acetic acid otic solution 2 % alcohol pads pad 70 % 1 MS baciim intramuscular* solution reconstituted unit bacitracin intramuscular* solution reconstituted unit bacitracin ophthalmic ointment 500 unit/gm chloramphenicol sod succinate intravenous* solution reconstituted 1 gm clindacin pac external kit 1 % clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg 1 MS clindamycin phosphate external 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % 5

15 NAME clindamycin phosphate external swab 1 % clindamycin phosphate intravenous* solution 600 mg/4ml clindamycin phosphate vaginal cream 2 % clindamycin phosphate in d5w intravenous* solution 300 mg/50ml, 600 mg/50ml, 900 mg/50ml CUBICIN INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG 5* PA; MS methenamine hippurate oral tablet 1 gm metronidazole external 0.75 % metronidazole external cream 0.75 % metronidazole external lotion 0.75 % metronidazole oral tablet 250 mg, 500 mg metronidazole vaginal 0.75 % metronidazole in nacl intravenous* solution mg/100ml-% mupirocin external ointment 2 % mupirocin calcium external cream 2 % nitrofurantoin macrocrystal oral capsule 50 mg 2 PA; MS; QL (90 EA per 365 days) nitrofurantoin monohyd macro oral capsule 100 mg 2 PA; MS; QL (90 EA per 365 days) sivextro oral tablet 200 mg 5* PA; MS trimethoprim oral tablet 100 mg TYGACIL INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG vancomycin hcl intravenous* solution reconstituted 10 gm, 1000 mg, 500 mg, 5000 mg, 750 mg 5* PA; MS vancomycin hcl oral capsule 125 mg, 250 mg 5* PA; MS vandazole vaginal 0.75 % XIFAXAN ORAL TABLET 200 MG, 550 MG 5* ST; MS ZYVOX INTRAVENOUS* SOLUTION 2 MG/ML 5* PA; MS ZYVOX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 5* PA; MS ZYVOX ORAL TABLET 600 MG 5* PA; MS; QL (60 EA per 30 days) 6

16 NAME Beta-Lactam, Cephalosporins cefaclor oral capsule 250 mg, 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension reconstituted 250 mg/5ml, 500 mg/5ml cefadroxil oral tablet 1 gm cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg cefazolin sodium intravenous* solution 1-5 gm-% cefdinir oral capsule 300 mg cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefepime hcl injection solution reconstituted 1 gm, 2 gm cefotaxime sodium injection solution reconstituted 1 gm, 10 gm, 2 gm, 500 mg cefoxitin sodium injection solution reconstituted 10 gm cefoxitin sodium intravenous* solution reconstituted 1 gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml, 50 mg/5ml cefpodoxime proxetil oral tablet 100 mg, 200 mg cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cefprozil oral tablet 250 mg, 500 mg ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm ceftazidime and dextrose intravenous* solution reconstituted 1 gm/50ml, 2 gm/50ml ceftriaxone sodium injection solution reconstituted 250 mg, 500 mg ceftriaxone sodium intravenous* solution reconstituted 1 gm, 10 gm, 2 gm cefuroxime axetil oral suspension reconstituted 125 mg/5ml 7

17 NAME cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 mg cephalexin oral capsule 250 mg, 500 mg 1 MS cephalexin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml cephalexin oral tablet 250 mg, 500 mg SUPRAX ORAL CAPSULE 400 MG 4 MS SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML, 500 MG/5ML 4 MS SUPRAX ORAL TABLET 400 MG 4 MS SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG 4 MS TEFLARO INTRAVENOUS* SOLUTION RECONSTITUTED 400 MG, 600 MG Beta-Lactam, Other 4 PA; MS aztreonam injection solution reconstituted 1 gm DORIBAX INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG imipenem-cilastatin intravenous* solution reconstituted 250 mg, 500 mg 4 PA; MS INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM 4 MS meropenem intravenous* solution reconstituted 1 gm, 500 mg Beta-Lactam, Penicillins amoxicillin oral capsule 250 mg, 500 mg 1 MS amoxicillin oral suspension reconstituted 125 mg/5ml, 200 mg/5ml, 250 mg/5ml, 400 mg/5ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension reconstituted mg/5ml, mg/5ml, mg/5ml, mg/5ml amoxicillin-pot clavulanate oral tablet mg, mg, mg 8

18 NAME amoxicillin-pot clavulanate oral tablet chewable mg, mg ampicillin oral capsule 250 mg, 500 mg 1 MS ampicillin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg ampicillin-sulbactam sodium injection solution reconstituted 3 (2-1) gm ampicillin-sulbactam sodium intravenous* solution reconstituted 15 (10-5) gm bactocill in dextrose intravenous* solution 2 gm/50ml 5* MS BICILLIN C-R INTRAMUSCULAR* SUSPENSION UNIT/2ML BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION UNIT/2ML BICILLIN L-A INTRAMUSCULAR* SUSPENSION UNIT/2ML, UNIT/4ML, UNIT/ML 3 MS 3 MS 3 MS dicloxacillin sodium oral capsule 250 mg, 500 mg oxacillin sodium injection solution reconstituted 10 gm 5* MS oxacillin sodium injection solution reconstituted 2 gm penicillin g potassium injection solution reconstituted unit, unit PENICILLIN G PROCAINE INTRAMUSCULAR* SUSPENSION UNIT/ML penicillin v potassium oral solution reconstituted 125 mg/5ml, 250 mg/5ml 3 MS 1 MS penicillin v potassium oral tablet 250 mg, 500 mg 1 MS piperacillin sod-tazobactam so intravenous* solution reconstituted gm, gm, gm, gm TIMENTIN INTRAVENOUS* SOLUTION RECONSTITUTED 3.1 GM 3 MS 9

19 NAME Macrolides azithromycin intravenous* solution reconstituted 500 mg azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 mg/5ml, 200 mg/5ml azithromycin oral tablet 250 mg, 500 mg, 600 mg clarithromycin oral suspension reconstituted 125 mg/5ml, 250 mg/5ml clarithromycin oral tablet 250 mg, 500 mg clarithromycin er oral tablet extended release 24 hr* 500 mg DIFICID ORAL TABLET 200 MG 5* PA; MS e.e.s. 400 oral tablet 400 mg E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML 4 MS e.s.p. oral suspension reconstituted mg/5ml ery-tab oral tablet delayed release 250 mg, 333 mg, 500 mg ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML erythrocin lactobionate intravenous* solution reconstituted 500 mg 4 MS erythrocin stearate oral tablet 250 mg erythromycin external 2 % erythromycin external solution 2 % erythromycin ophthalmic ointment 5 mg/gm erythromycin base oral tablet 250 mg, 500 mg erythromycin ethylsuccinate oral tablet 400 mg ilotycin ophthalmic ointment 5 mg/gm Quinolones BESIVANCE OPHTHALMIC SUSPENSION 0.6 % 4 MS ciprofloxacin intravenous* solution 400 mg/40ml ciprofloxacin hcl ophthalmic solution 0.3 % 10

20 NAME ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin in d5w intravenous* solution 200 mg/100ml 1 MS gatifloxacin ophthalmic solution 0.5 % levofloxacin intravenous* solution 25 mg/ml levofloxacin oral solution 25 mg/ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg levofloxacin in d5w intravenous* solution 250 mg/50ml, 500 mg/100ml, 750 mg/150ml MOXEZA OPHTHALMIC SOLUTION 0.5 % 4 MS ofloxacin ophthalmic solution 0.3 % ofloxacin oral tablet 200 mg, 300 mg, 400 mg ofloxacin otic solution 0.3 % VIGAMOX OPHTHALMIC SOLUTION 0.5 % 4 MS Sulfonamides silver sulfadiazine external cream 1 % ssd external cream 1 % sulfacetamide sodium external suspension 10 % sulfacetamide sodium ophthalmic ointment 10 % 1 MS sulfacetamide sodium ophthalmic solution 10 % sulfadiazine oral tablet 500 mg sulfamethoxazole-tmp ds oral tablet mg sulfamethoxazole-trimethoprim intravenous* solution mg/5ml sulfamethoxazole-trimethoprim oral suspension mg/5ml sulfamethoxazole-trimethoprim oral tablet mg Tetracyclines demeclocycline hcl oral tablet 150 mg, 300 mg doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg, 20 mg 11

21 NAME doxycycline hyclate oral tablet delayed release 100 mg, 150 mg, 75 mg doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg minocycline hcl oral capsule 100 mg, 50 mg, 75 mg tetracycline hcl oral capsule 250 mg, 500 mg 1 MS Anticonvulsants Anticonvulsants, Other diazepam 10 mg, 2.5 mg, 20 mg levetiracetam intravenous* solution 500 mg/5ml levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg levetiracetam in nacl intravenous* solution 1000 mg/100ml, 1500 mg/100ml, 500 mg/100ml POTIGA ORAL TABLET 200 MG, 300 MG, 50 MG 5* PA-NS; MS POTIGA ORAL TABLET 400 MG 4 PA-NS; MS Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 300 MG 3 MS ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5ml LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG 4 MS; QL (90 EA per 30 days) LYRICA ORAL CAPSULE 225 MG, 300 MG 4 MS; QL (60 EA per 30 days) LYRICA ORAL SOLUTION 20 MG/ML 4 MS; QL (900 ML per 30 days) zonisamide oral capsule 100 mg, 25 mg, 50 mg Gamma-Aminobutyric Acid (Gaba) Augmenting Agents divalproex sodium oral capsule sprinkle 125 mg divalproex sodium oral tablet delayed release 125 mg, 250 mg, 500 mg divalproex sodium er oral tablet extended release 24 hr* 250 mg, 500 mg 12

22 NAME gabapentin oral capsule 100 mg, 300 mg ; QL (360 EA per 30 days) gabapentin oral capsule 400 mg ; QL (270 EA per 30 days) gabapentin oral solution 250 mg/5ml gabapentin oral tablet 600 mg ; QL (180 EA per 30 days) gabapentin oral tablet 800 mg ; QL (135 EA per 30 days) GABITRIL ORAL TABLET 12 MG, 16 MG 4 MS GRALISE ORAL TABLET 300 MG, 600 MG 4 ST-NS; MS GRALISE STARTER ORAL 300 & 600 MG 4 ST-NS; MS ONFI ORAL SUSPENSION 2.5 MG/ML 4 MS ONFI ORAL TABLET 10 MG 4 MS ONFI ORAL TABLET 20 MG 5* MS phenobarbital oral elixir 20 mg/5ml 2 PA-NS; MS phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg 2 PA-NS; MS primidone oral tablet 250 mg, 50 mg SABRIL ORAL PACKET 500 MG 5* PA-NS; LA; QL (180 EA per 30 days) SABRIL ORAL TABLET 500 MG 5* PA-NS; LA; QL (180 EA per 30 days) tiagabine hcl oral tablet 2 mg, 4 mg valproate sodium intravenous* solution 500 mg/5ml valproic acid oral capsule 250 mg valproic acid oral syrup 250 mg/5ml Glutamate Reducing Agents felbamate oral suspension 600 mg/5ml 5* MS felbamate oral tablet 400 mg felbamate oral tablet 600 mg 5* MS FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG 4 PA-NS; MS lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet chewable 25 mg, 5 mg topiramate oral capsule sprinkle 15 mg, 25 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 MS 13

23 NAME TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MG TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MG Sodium Channel Agents 4 PA-NS; MS; QL (60 EA per 30 days) 5* PA-NS; MS; QL (60 EA per 30 days) APTIOM ORAL TABLET 200 MG 4 PA-NS; MS; QL (30 EA per 30 days) APTIOM ORAL TABLET 400 MG, 800 MG 5* PA-NS; MS; QL (30 EA per 30 days) APTIOM ORAL TABLET 600 MG 5* PA-NS; MS; QL (60 EA per 30 days) BANZEL ORAL SUSPENSION 40 MG/ML 5* PA-NS; MS BANZEL ORAL TABLET 200 MG 4 PA-NS; MS; QL (240 EA per 30 days) BANZEL ORAL TABLET 400 MG 5* PA-NS; MS; QL (240 EA per 30 days) carbamazepine oral suspension 100 mg/5ml carbamazepine oral tablet 200 mg carbamazepine oral tablet chewable 100 mg DILANTIN ORAL CAPSULE 30 MG 3 MS DILANTIN INFATABS ORAL TABLET CHEWABLE 50 MG 3 MS epitol oral tablet 200 mg fosphenytoin sodium injection solution 100 mg pe/2ml oxcarbazepine oral suspension 300 mg/5ml oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg PEGANONE ORAL TABLET 250 MG 4 MS phenytoin oral suspension 125 mg/5ml phenytoin oral tablet chewable 50 mg phenytoin sodium injection solution 50 mg/ml phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg VIMPAT INTRAVENOUS* SOLUTION 200 MG/20ML 4 MS VIMPAT ORAL SOLUTION 10 MG/ML 4 MS VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 4 MS 14

24 NAME Antidementia Agents Antidementia Agents, Other ergoloid mesylates oral tablet 1 mg 2 PA; MS Cholinesterase Inhibitors donepezil hcl oral tablet 10 mg, 5 mg 1 MS donepezil hcl oral tablet dispersible 10 mg, 5 mg EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR 3 MS; QL (30 EA per 30 days) galantamine hydrobromide oral solution 4 mg/ml ; QL (180 ML per 30 days) galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg galantamine hydrobromide er oral capsule extended release 24 hour 16 mg, 24 mg, 8 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg N-Methyl-D-Aspartate (Nmda) Receptor Antagonist ; QL (60 EA per 30 days) ; QL (30 EA per 30 days) NAMENDA ORAL SOLUTION 10 MG/5ML 3 PA; MS NAMENDA ORAL TABLET 10 MG, 5 MG 3 PA; MS; QL (60 EA per 30 days) NAMENDA TITRATION PAK ORAL TABLET 5 (28)-10 (21) MG NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG Antidepressants Antidepressants, Other 3 PA; MS 3 PA; MS; QL (30 EA per 30 days) 3 PA; MS buproban oral tablet extended release 12 hr* 150 mg ; QL (60 EA per 30 days) bupropion hcl oral tablet 100 mg, 75 mg bupropion hcl er (sr) oral tablet extended release 12 hr* 100 mg, 150 mg, 200 mg bupropion hcl er (xl) oral tablet extended release 24 hr* 150 mg, 300 mg ; QL (60 EA per 30 days) ; QL (30 EA per 30 days) maprotiline hcl oral tablet 25 mg, 50 mg, 75 mg 15

25 NAME mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg trazodone hcl oral tablet 100 mg, 150 mg, 50 mg 1 MS trazodone hcl oral tablet 300 mg VIIBRYD ORAL KIT 10 & 20 & 40 MG 4 ST-NS; MS; QL (30 EA per 30 days) Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR MARPLAN ORAL TABLET 10 MG 4 MS phenelzine sulfate oral tablet 15 mg tranylcypromine sulfate oral tablet 10 mg Ssris/ Snris 5* PA-NS; MS; QL (30 EA per 30 days) BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG 4 PA-NS; MS; QL (30 EA per 30 days) citalopram hydrobromide oral solution 10 mg/5ml citalopram hydrobromide oral tablet 10 mg, 20 mg 1 MS; QL (60 EA per 30 days) citalopram hydrobromide oral tablet 40 mg 1 MS; QL (30 EA per 30 days) duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60 mg escitalopram oxalate oral solution 5 mg/5ml ; QL (60 EA per 30 days) escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg ; QL (30 EA per 30 days) FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG 4 PA-NS; MS; QL (30 EA per 30 days) FETZIMA TITRATION ORAL 20 & 40 MG 4 PA-NS; MS; QL (30 EA per 30 days) fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg 1 MS fluoxetine hcl oral solution 20 mg/5ml fluoxetine hcl oral tablet 10 mg 1 MS fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg ; QL (60 EA per 30 days) PAXIL ORAL SUSPENSION 10 MG/5ML 4 MS 16

26 NAME PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 50 MG sertraline hcl oral concentrate 20 mg/ml sertraline hcl oral tablet 100 mg, 25 mg, 50 mg 1 MS venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg venlafaxine hcl er oral capsule extended release 24 hour 150 mg, 37.5 mg, 75 mg venlafaxine hcl er oral tablet extended release 24 hr* 150 mg, 37.5 mg, 75 mg 4 PA-NS; MS; QL (30 EA per 30 days) ; QL (30 EA per 30 days) ; QL (30 EA per 30 days) VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG 4 ST-NS; MS; QL (30 EA per 30 days) Tricyclics amitriptyline hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 2 PA-NS; MS amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg clomipramine hcl oral capsule 25 mg, 50 mg, 75 mg 2 PA-NS; MS desipramine hcl oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg doxepin hcl oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 2 PA-NS; MS doxepin hcl oral concentrate 10 mg/ml 2 PA-NS; MS imipramine hcl oral tablet 10 mg, 25 mg, 50 mg 2 PA-NS; MS imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg nortriptyline hcl oral capsule 10 mg, 25 mg, 50 mg, 75 mg 2 PA-NS; MS nortriptyline hcl oral solution 10 mg/5ml protriptyline hcl oral tablet 10 mg, 5 mg SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG 4 PA-NS; MS Antiemetics Antiemetics, Other compro suppository 25 mg 17

27 NAME hydroxyzine hcl intramuscular* solution 25 mg/ml, 50 mg/ml 2 PA; MS meclizine hcl oral tablet 12.5 mg, 25 mg phenadoz suppository 12.5 mg, 25 mg 2 PA; MS phenergan suppository 12.5 mg, 25 mg, 50 mg 2 PA; MS prochlorperazine suppository 25 mg promethazine hcl injection solution 25 mg/ml, 50 mg/ml 2 PA; MS promethazine hcl oral syrup 6.25 mg/5ml 2 PA; MS promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg 2 PA; MS promethazine hcl suppository 12.5 mg, 25 mg, 50 mg 2 PA; MS promethegan suppository 25 mg, 50 mg 2 PA; MS Emetogenic Therapy Adjuncts dronabinol oral capsule 10 mg 5* PA; MS; QL (60 EA per 30 days) dronabinol oral capsule 2.5 mg, 5 mg 2 PA; MS; QL (60 EA per 30 days) EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG, 80 MG granisetron hcl intravenous* solution 0.1 mg/ml, 1 mg/ml 4 PA-BvsD; MS 2 PA; MS; QL (10 ML per 30 days) granisetron hcl oral tablet 1 mg 2 PA; MS; QL (60 EA per 30 days) ondansetron oral tablet dispersible 4 mg, 8 mg 1 MS ondansetron hcl injection solution 4 mg/2ml ondansetron hcl oral solution 4 mg/5ml 2 PA; MS ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg 1 MS Antifungals Antifungals ABELCET INTRAVENOUS* SUSPENSION 5 MG/ML 5* PA; MS AMBISOME INTRAVENOUS* SUSPENSION RECONSTITUTED 50 MG 5* PA; MS amphotericin b injection solution reconstituted 50 mg 2 PA-BvsD; MS CANCIDAS INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG, 70 MG 5* PA; MS ciclopirox external 0.77 % 18

28 NAME ciclopirox external shampoo 1 % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % clotrimazole external cream 1 % clotrimazole external solution 1 % clotrimazole mouth/throat troche 10 mg econazole nitrate external cream 1 % fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg 1 MS fluconazole in dextrose intravenous* solution 200 mg/100ml, 400 mg/200ml fluconazole in sodium chloride intravenous* solution mg/50ml-% flucytosine oral capsule 250 mg, 500 mg 5* MS griseofulvin microsize oral suspension 125 mg/5ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg itraconazole oral capsule 100 mg 2 PA; MS ketoconazole external cream 2 % ketoconazole external shampoo 2 % ketoconazole oral tablet 200 mg 2 PA; MS MYCAMINE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 50 MG 5* PA; MS NAFTIN EXTERNAL 1 %, 2 % 3 MS NAFTIN EXTERNAL CREAM 1 %, 2 % 3 MS NATACYN OPHTHALMIC SUSPENSION 5 % 3 MS NOXAFIL ORAL SUSPENSION 40 MG/ML 5* PA; MS nyamyc external powder unit/gm nystatin external cream unit/gm nystatin external ointment unit/gm 19

29 NAME nystatin external powder unit/gm nystatin mouth/throat suspension unit/ml nystatin oral tablet unit nystop external powder unit/gm pedi-dri external powder unit/gm terbinafine hcl oral tablet 250 mg terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg voriconazole intravenous* solution reconstituted 200 mg 2 PA; MS voriconazole oral tablet 200 mg 5* PA; MS; QL (60 EA per 30 days) voriconazole oral tablet 50 mg 5* PA; MS; QL (180 EA per 30 days) zazole vaginal cream 0.4 %, 0.8 % ZOLINZA ORAL CAPSULE 100 MG 5* PA-NS; MS; QL (120 EA per 30 days) Antigout Agents Antigout Agents allopurinol oral tablet 100 mg, 300 mg 1 MS colchicine-probenecid oral tablet mg COLCRYS ORAL TABLET 0.6 MG 3 MS probenecid oral tablet 500 mg ULORIC ORAL TABLET 40 MG, 80 MG 4 ST; MS Antimigraine Agents Ergot Alkaloids dihydroergotamine mesylate injection solution 1 mg/ml MIGERGOT SUPPOSITORY MG 4 MS MIGRANAL NASAL SOLUTION 4 MG/ML 4 MS Serotonin (5-Ht) 1B/1D Receptor Agonists naratriptan hcl oral tablet 1 mg, 2.5 mg ; QL (9 EA per 30 days) sumatriptan nasal solution 20 mg/act, 5 mg/act ; QL (12 EA per 30 days) sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous* 6 mg/0.5ml ; QL (8 ML per 30 days) 20

30 NAME sumatriptan succinate subcutaneous* solution 6 mg/0.5ml Antimyasthenic Agents Parasympathomimetics ; QL (8 ML per 30 days) guanidine hcl oral tablet 125 mg MESTINON ORAL SYRUP 60 MG/5ML 3 MS MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG 3 MS pyridostigmine bromide oral tablet 60 mg Antimycobacterials Antimycobacterials, Other DAPSONE ORAL TABLET 100 MG, 25 MG 3 MS rifabutin oral capsule 150 mg Antituberculars CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM 4 MS ethambutol hcl oral tablet 100 mg, 400 mg isoniazid oral syrup 50 mg/5ml isoniazid oral tablet 100 mg, 300 mg 1 MS PASER ORAL PACKET 4 GM 4 MS PRIFTIN ORAL TABLET 150 MG 4 MS pyrazinamide oral tablet 500 mg rifampin intravenous* solution reconstituted 600 mg rifampin oral capsule 150 mg, 300 mg TRECATOR ORAL TABLET 250 MG 4 MS Antineoplastics Alkylating Agents cyclophosphamide injection solution reconstituted 1 gm, 2 gm, 500 mg 2 PA-BvsD; MS cyclophosphamide oral capsule 25 mg, 50 mg 2 PA-BvsD; MS cyclophosphamide oral tablet 25 mg, 50 mg 2 PA-BvsD; MS HEXALEN ORAL CAPSULE 50 MG 5* PA-NS; MS 21

31 NAME LEUKERAN ORAL TABLET 2 MG 3 MS lomustine oral capsule 10 mg, 100 mg, 40 mg MATULANE ORAL CAPSULE 50 MG 5* LA VALCHLOR EXTERNAL % 5* PA-NS; MS Antiandrogens bicalutamide oral tablet 50 mg flutamide oral capsule 125 mg NILANDRON ORAL TABLET 150 MG 5* MS XTANDI ORAL CAPSULE 40 MG 5* PA-NS; LA; QL (120 EA per 30 days) ZYTIGA ORAL TABLET 250 MG 5* PA-NS; LA; QL (120 EA per 30 days) Antiangiogenic Agents POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG 5* PA-NS; LA REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG Antiestrogens/Modifiers 5* PA-NS; LA 5* PA-NS; MS EMCYT ORAL CAPSULE 140 MG 4 PA-NS; MS FARESTON ORAL TABLET 60 MG 5* MS; QL (30 EA per 30 days) SOLTAMOX ORAL SOLUTION 10 MG/5ML 4 MS tamoxifen citrate oral tablet 10 mg, 20 mg Antimetabolites DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG 3 MS hydroxyurea oral capsule 500 mg TABLOID ORAL TABLET 40 MG 4 PA-NS; MS Antineoplastics ALIMTA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 500 MG 5* PA-BvsD; MS AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML 5* PA-BvsD; LA azacitidine injection suspension reconstituted 100 mg 5* PA-BvsD; MS bleomycin sulfate injection solution reconstituted 15 unit, 30 unit 2 PA-BvsD; MS 22

32 NAME BLINCYTO INTRAVENOUS* SOLUTION RECONSTITUTED 35 MCG ELITEK INTRAVENOUS* SOLUTION RECONSTITUTED 1.5 MG, 7.5 MG 5* PA-BvsD; MS 5* PA-BvsD; MS FASLODEX INTRAMUSCULAR* SOLUTION 250 MG/5ML ifosfamide intravenous* solution reconstituted 1 gm IXEMPRA KIT INTRAVENOUS* SOLUTION RECONSTITUTED 15 MG, 45 MG 5* PA-BvsD; MS; QL (10 ML per 28 days) 5* PA-BvsD; MS mesna intravenous* solution 100 mg/ml MESNEX ORAL TABLET 400 MG 5* MS PROLEUKIN INTRAVENOUS* SOLUTION RECONSTITUTED UNIT 5* PA-BvsD; MS TREANDA INTRAVENOUS* SOLUTION 45 MG/0.5ML 5* PA-BvsD; MS TREANDA INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG, 25 MG 5* PA-BvsD; MS TRISENOX INTRAVENOUS* SOLUTION 10 MG/10ML 5* PA-BvsD; MS VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG Antineoplastics, Other 5* PA-BvsD; MS amifostine intravenous* solution reconstituted 500 mg 5* PA-BvsD; MS leucovorin calcium injection solution reconstituted 100 mg, 200 mg, 350 mg, 50 mg, 500 mg leucovorin calcium intravenous* solution 10 mg/ml leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg LYNPARZA ORAL CAPSULE 50 MG 5* PA-NS; MS REVLIMID ORAL CAPSULE 2.5 MG, 20 MG 5* PA-NS; LA SYNRIBO SUBCUTANEOUS* SOLUTION RECONSTITUTED 3.5 MG Aromatase Inhibitors, 3Rd Generation 5* PA-NS; MS anastrozole oral tablet 1 mg ; QL (30 EA per 30 days) exemestane oral tablet 25 mg 23

33 NAME letrozole oral tablet 2.5 mg Molecular Target Inhibitors AFINITOR ORAL TABLET 10 MG, 5 MG, 7.5 MG 5* PA-NS; MS; QL (30 EA per 30 days) BOSULIF ORAL TABLET 100 MG, 500 MG 5* PA-NS; MS CAPRELSA ORAL TABLET 100 MG 5* PA-NS; LA; QL (60 EA per 30 days) CAPRELSA ORAL TABLET 300 MG 5* PA-NS; LA; QL (30 EA per 30 days) COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG 5* PA-NS; LA 5* PA-NS; LA COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG 5* PA-NS; LA ERIVEDGE ORAL CAPSULE 150 MG 5* PA-NS; LA; QL (30 EA per 30 days) GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG 5* PA-NS; LA; QL (30 EA per 30 days) GLEEVEC ORAL TABLET 100 MG 5* PA-NS; MS; QL (180 EA per 30 days) GLEEVEC ORAL TABLET 400 MG 5* PA-NS; MS; QL (60 EA per 30 days) ICLUSIG ORAL TABLET 15 MG, 45 MG 5* PA-NS; MS IMBRUVICA ORAL CAPSULE 140 MG 5* PA-NS; LA INLYTA ORAL TABLET 1 MG, 5 MG 5* PA-NS; LA JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG 5* PA-NS; LA MEKINIST ORAL TABLET 0.5 MG, 2 MG 5* PA-NS; LA NEXAVAR ORAL TABLET 200 MG 5* PA-NS; LA; QL (120 EA per 30 days) SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG 5* PA-NS; LA SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5* PA-NS; LA 5* PA-NS; MS; QL (30 EA per 30 days) 5* PA-NS; MS; QL (30 EA per 30 days) TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG 5* PA-NS; LA; QL (30 EA per 30 days) TASIGNA ORAL CAPSULE 150 MG, 200 MG 5* PA-NS; MS; QL (120 EA per 30 days) TYKERB ORAL TABLET 250 MG 5* PA-NS; LA; QL (180 EA per 30 days) VOTRIENT ORAL TABLET 200 MG 5* PA-NS; LA; QL (120 EA per 30 days) 24

34 NAME XALKORI ORAL CAPSULE 200 MG, 250 MG 5* PA-NS; LA; QL (60 EA per 30 days) ZELBORAF ORAL TABLET 240 MG 5* PA-NS; LA; QL (240 EA per 30 days) ZYDELIG ORAL TABLET 100 MG, 150 MG 5* PA-NS; LA; QL (60 EA per 30 days) ZYKADIA ORAL CAPSULE 150 MG 5* PA-NS; MS; QL (150 EA per 30 days) Monoclonal Antibodies ARZERRA INTRAVENOUS* CONCENTRATE 100 MG/5ML 5* PA-BvsD; MS RITUXAN INTRAVENOUS* CONCENTRATE 10 MG/ML 5* PA-NS; LA Retinoids avita external % avita external cream % PANRETIN EXTERNAL 0.1 % 5* MS TARGRETIN EXTERNAL 1 % 5* PA-NS; MS TARGRETIN ORAL CAPSULE 75 MG 5* PA-NS; MS tretinoin external 0.01 %, % tretinoin external cream %, 0.05 %, 0.1 % tretinoin oral capsule 10 mg 5* MS Antiparasitics Anthelmintics ALBENZA ORAL TABLET 200 MG 4 MS ivermectin oral tablet 3 mg STROMECTOL ORAL TABLET 3 MG 3 MS Antiprotozoals ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML 4 MS ALINIA ORAL TABLET 500 MG 4 MS atovaquone oral suspension 750 mg/5ml 5* MS atovaquone-proguanil hcl oral tablet mg chloroquine phosphate oral tablet 250 mg, 500 mg COARTEM ORAL TABLET MG 4 MS DARAPRIM ORAL TABLET 25 MG 3 MS hydroxychloroquine sulfate oral tablet 200 mg 25

35 NAME mefloquine hcl oral tablet 250 mg NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG 4 PA-BvsD; MS 4 PA; MS primaquine phosphate oral tablet 26.3 mg quinine sulfate oral capsule 324 mg 2 PA; MS; QL (42 EA per 30 days) Pediculicides/ Scabicides malathion external lotion 0.5 % permethrin external cream 5 % Antiparkinson Agents Anticholinergics benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg 2 PA; MS trihexyphenidyl hcl oral elixir 0.4 mg/ml 2 PA; MS trihexyphenidyl hcl oral tablet 2 mg, 5 mg 2 PA; MS Antiparkinson Agents carbidopa oral tablet 25 mg Antiparkinson Agents, Other entacapone oral tablet 200 mg TASMAR ORAL TABLET 100 MG 5* MS Dopamine Agonists APOKYN SUBCUTANEOUS* SOLUTION 10 MG/ML 5* PA; MS; QL (90 ML per 30 days) bromocriptine mesylate oral capsule 5 mg bromocriptine mesylate oral tablet 2.5 mg NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR pramipexole dihydrochloride oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg 4 ST; MS; QL (30 EA per 30 days) 26

36 NAME Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa-levodopa oral tablet mg, mg, mg carbidopa-levodopa er oral tablet extendedrelease* mg, mg Monoamine Oxidase B (Mao-B) Inhibitors AZILECT ORAL TABLET 0.5 MG, 1 MG 4 MS selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG 5* MS Antipsychotics 1St Generation/ Typical chlorpromazine hcl injection solution 25 mg/ml chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg fluphenazine decanoate injection solution 25 mg/ml fluphenazine hcl injection solution 2.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir 2.5 mg/5ml fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg HALDOL DECANOATE INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/ML haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg haloperidol decanoate intramuscular* solution 100 mg/ml, 50 mg/ml 3 MS haloperidol lactate injection solution 5 mg/ml haloperidol lactate oral concentrate 2 mg/ml loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg ORAP ORAL TABLET 1 MG, 2 MG 3 MS perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg 27

37 NAME prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 10 mg, 5 mg thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg 2Nd Generation/ Atypical ABILIFY INTRAMUSCULAR* SOLUTION 9.75 MG/1.3ML 4 PA-NS; MS ABILIFY ORAL SOLUTION 1 MG/ML 4 MS; QL (1050 ML per 30 days) ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG ABILIFY DISCMELT ORAL TABLET DISPERSIBLE 10 MG ABILIFY DISCMELT ORAL TABLET DISPERSIBLE 15 MG ABILIFY MAINTENA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 300 MG, 400 MG 4 MS; QL (30 EA per 30 days) 5* PA-NS; MS; QL (90 EA per 30 days) 5* PA-NS; MS; QL (60 EA per 30 days) 5* PA-NS; MS; QL (1 EA per 26 days) FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG, 6 MG 4 PA-NS; MS; QL (60 EA per 30 days) FANAPT ORAL TABLET 10 MG, 12 MG, 8 MG 5* PA-NS; MS; QL (60 EA per 30 days) FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG GEODON INTRAMUSCULAR* SOLUTION RECONSTITUTED 20 MG INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 24 HR* 6 MG INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 78 MG/0.5ML INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 39 MG/0.25ML 4 PA-NS; MS 4 MS; QL (12 EA per 30 days) 5* PA-NS; MS; QL (30 EA per 30 days) 5* PA-NS; MS; QL (60 EA per 30 days) 5* MS 4 MS 28

38 NAME LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG 4 ST-NS; MS olanzapine intramuscular* solution reconstituted 10 mg olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg ; QL (30 EA per 30 days) olanzapine oral tablet dispersible 10 mg, 5 mg 2 PA-NS; MS; QL (30 EA per 30 days) olanzapine oral tablet dispersible 15 mg, 20 mg 5* PA-NS; MS; QL (30 EA per 30 days) quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg, 50 mg RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 12.5 MG, 25 MG RISPERDAL CONSTA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 37.5 MG, 50 MG ; QL (90 EA per 30 days) 4 MS; QL (4 EA per 28 days) 5* MS; QL (4 EA per 28 days) risperidone oral solution 1 mg/ml ; QL (270 ML per 30 days) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR* 300 MG, 400 MG, 50 MG ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg Treatment-Resistant ; QL (120 EA per 30 days) ; QL (120 EA per 30 days) 4 ST-NS; MS; QL (60 EA per 30 days) 4 MS; QL (30 EA per 30 days) 4 MS; QL (60 EA per 30 days) ; QL (60 EA per 30 days) clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg clozapine oral tablet dispersible 100 mg, 12.5 mg, 25 mg 2 PA-NS; MS FAZACLO ORAL TABLET DISPERSIBLE 12.5 MG 4 PA-NS; MS VERSACLOZ ORAL SUSPENSION 50 MG/ML 4 PA-NS; MS 29

39 NAME Antispasticity Agents Antispasticity Agents baclofen oral tablet 10 mg, 20 mg 1 MS tizanidine hcl oral tablet 2 mg, 4 mg Antivirals Anti-Cytomegalovirus (Cmv) Agents foscarnet sodium intravenous* solution 24 mg/ml 2 PA; MS ganciclovir sodium intravenous* solution reconstituted 500 mg VALCYTE ORAL SOLUTION RECONSTITUTED 50 MG/ML 2 PA; MS 5* MS VALCYTE ORAL TABLET 450 MG 5* MS valganciclovir hcl oral tablet 450 mg 5* MS ZIRGAN OPHTHALMIC 0.15 % 4 MS Anti-Hepatitis B (Hbv) Agents adefovir dipivoxil oral tablet 10 mg 5* MS; QL (30 EA per 30 days) BARACLUDE ORAL SOLUTION 0.05 MG/ML 4 MS BARACLUDE ORAL TABLET 0.5 MG, 1 MG 5* MS; QL (30 EA per 30 days) entecavir oral tablet 0.5 mg, 1 mg 5* MS; QL (30 EA per 30 days) EPIVIR HBV ORAL SOLUTION 5 MG/ML 4 MS INTRON A INJECTION SOLUTION RECONSTITUTED UNIT, UNIT INTRON-A INJECTION SOLUTION UNIT/ML, UNIT/ML INTRON-A INJECTION SOLUTION RECONSTITUTED UNIT 5* PA-NS; MS 5* PA-NS; MS 5* PA-NS; MS lamivudine oral tablet 100 mg TYZEKA ORAL TABLET 600 MG 5* PA; MS VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM Anti-Hepatitis C (Hcv) Agents 5* PA-BvsD; MS HARVONI ORAL TABLET MG 5* PA; MS; QL (28 EA per 28 days) 30

40 NAME OLYSIO ORAL CAPSULE 150 MG 5* PA; MS; QL (28 EA per 28 days) PEG-INTRON SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML PEG-INTRON REDIPEN SUBCUTANEOUS* KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML 5* PA; MS 5* PA; MS ribasphere oral tablet 200 mg RIBASPHERE RIBAPAK ORAL TABLET 400 & 600 MG, 400 MG, 600 MG 5* MS ribavirin oral tablet 200 mg SOVALDI ORAL TABLET 400 MG 5* PA; MS; QL (28 EA per 28 days) SYLATRON SUBCUTANEOUS* KIT 296 MCG, 4 X 296 MCG, 4 X 444 MCG, 444 MCG, 888 MCG 5* PA-NS; MS VICTRELIS ORAL CAPSULE 200 MG 5* PA; MS; QL (336 EA per 28 days) Antiherpetic Agents acyclovir external ointment 5 % acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5ml acyclovir oral tablet 400 mg, 800 mg acyclovir sodium intravenous* solution 50 mg/ml 2 PA-BvsD; MS DENAVIR EXTERNAL CREAM 1 % 3 MS famciclovir oral tablet 125 mg, 250 mg, 500 mg trifluridine ophthalmic solution 1 % valacyclovir hcl oral tablet 1 gm, 500 mg ZOVIRAX EXTERNAL CREAM 5 % 4 MS Anti-Hiv Agents, Integrase Inhibitors (Insti) ISENTRESS ORAL PACKET 100 MG 4 MS ISENTRESS ORAL TABLET 400 MG 5* MS; QL (60 EA per 30 days) ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG 3 MS STRIBILD ORAL TABLET MG 5* MS; QL (30 EA per 30 days) TIVICAY ORAL TABLET 50 MG 5* MS; QL (60 EA per 30 days) 31

41 NAME Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Nnrti) COMPLERA ORAL TABLET MG 5* MS EDURANT ORAL TABLET 25 MG 5* MS; QL (30 EA per 30 days) INTELENCE ORAL TABLET 100 MG 5* MS; QL (120 EA per 30 days) INTELENCE ORAL TABLET 200 MG 5* MS; QL (60 EA per 30 days) INTELENCE ORAL TABLET 25 MG 4 MS; QL (120 EA per 30 days) nevirapine oral suspension 50 mg/5ml nevirapine oral tablet 200 mg nevirapine er oral tablet extended release 24 hr* 400 mg RESCRIPTOR ORAL TABLET 100 MG, 200 MG 3 MS SUSTIVA ORAL CAPSULE 200 MG 5* MS SUSTIVA ORAL CAPSULE 50 MG 4 MS SUSTIVA ORAL TABLET 600 MG 5* MS VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR* 400 MG Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors 4 MS 5* MS TRIUMEQ ORAL TABLET MG 5* MS; QL (30 EA per 30 days) Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti) abacavir sulfate oral tablet 300 mg abacavir-lamivudine-zidovudine oral tablet mg 5* MS; QL (60 EA per 30 days) ATRIPLA ORAL TABLET MG 5* MS; QL (30 EA per 30 days) didanosine oral capsule delayed release 125 mg, 200 mg, 250 mg, 400 mg EMTRIVA ORAL CAPSULE 200 MG 3 MS EMTRIVA ORAL SOLUTION 10 MG/ML 3 MS EPIVIR ORAL SOLUTION 10 MG/ML 4 MS 32

42 NAME EPZICOM ORAL TABLET MG 5* MS lamivudine oral tablet 150 mg, 300 mg lamivudine-zidovudine oral tablet mg 5* MS RETROVIR INTRAVENOUS* SOLUTION 10 MG/ML 4 MS stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg stavudine oral solution reconstituted 1 mg/ml TRUVADA ORAL TABLET MG 5* MS; QL (30 EA per 30 days) VIDEX ORAL SOLUTION RECONSTITUTED 2 GM 4 MS VIREAD ORAL POWDER 40 MG/GM 5* MS VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG 5* MS ZIAGEN ORAL SOLUTION 20 MG/ML 4 MS zidovudine oral capsule 100 mg zidovudine oral syrup 50 mg/5ml zidovudine oral tablet 300 mg Anti-Hiv Agents, Other FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG 5* MS; QL (60 EA per 30 days) SELZENTRY ORAL TABLET 150 MG, 300 MG 5* MS; QL (120 EA per 30 days) TYBOST ORAL TABLET 150 MG 4 MS; QL (30 EA per 30 days) Anti-Hiv Agents, Protease Inhibitors APTIVUS ORAL CAPSULE 250 MG 5* MS; QL (120 EA per 30 days) APTIVUS ORAL SOLUTION 100 MG/ML 5* MS; QL (300 ML per 30 days) CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 3 MS INVIRASE ORAL CAPSULE 200 MG 5* MS INVIRASE ORAL TABLET 500 MG 5* MS KALETRA ORAL SOLUTION MG/5ML 5* MS KALETRA ORAL TABLET MG 4 MS KALETRA ORAL TABLET MG 5* MS LEXIVA ORAL SUSPENSION 50 MG/ML 4 MS LEXIVA ORAL TABLET 700 MG 5* MS NORVIR ORAL CAPSULE 100 MG 4 MS 33

43 NAME NORVIR ORAL SOLUTION 80 MG/ML 4 MS NORVIR ORAL TABLET 100 MG 4 MS PREZISTA ORAL SUSPENSION 100 MG/ML 5* MS; QL (360 ML per 30 days) PREZISTA ORAL TABLET 150 MG 4 MS PREZISTA ORAL TABLET 600 MG, 800 MG 5* MS; QL (60 EA per 30 days) PREZISTA ORAL TABLET 75 MG 3 MS; QL (60 EA per 30 days) REYATAZ ORAL CAPSULE 150 MG, 200 MG 3 MS; QL (60 EA per 30 days) REYATAZ ORAL CAPSULE 300 MG 3 MS; QL (30 EA per 30 days) REYATAZ ORAL PACKET 50 MG 3 MS VIRACEPT ORAL TABLET 250 MG, 625 MG 5* MS Anti-Influenza Agents amantadine hcl oral capsule 100 mg amantadine hcl oral syrup 50 mg/5ml amantadine hcl oral tablet 100 mg RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER 3 MS; QL (120 EA per 365 days) rimantadine hcl oral tablet 100 mg TAMIFLU ORAL CAPSULE 30 MG 3 MS; QL (112 EA per 365 days) TAMIFLU ORAL CAPSULE 45 MG, 75 MG 3 MS; QL (56 EA per 365 days) TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML Anxiolytics Anxiolytics, Other buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg 3 MS; QL (720 ML per 365 days) meprobamate oral tablet 200 mg, 400 mg 2 ST-NS; MS oxazepam oral capsule 10 mg, 15 mg, 30 mg ; QL (120 EA per 30 days) triazolam oral tablet mg ; QL (30 EA per 30 days) triazolam oral tablet 0.25 mg ; QL (60 EA per 30 days) Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg 1 MS clonazepam oral tablet 0.5 mg 1 MS; QL (90 EA per 30 days) 34

44 NAME clonazepam oral tablet 1 mg 1 MS; QL (120 EA per 30 days) clonazepam oral tablet 2 mg 1 MS; QL (300 EA per 30 days) clonazepam oral tablet dispersible mg, 0.25 mg ; QL (60 EA per 30 days) clonazepam oral tablet dispersible 0.5 mg ; QL (90 EA per 30 days) clonazepam oral tablet dispersible 1 mg ; QL (120 EA per 30 days) clonazepam oral tablet dispersible 2 mg ; QL (300 EA per 30 days) clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg diazepam oral solution 1 mg/ml diazepam oral tablet 10 mg, 2 mg, 5 mg 1 MS; QL (120 EA per 30 days) diazepam intensol oral concentrate 5 mg/ml lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1 MS; QL (90 EA per 30 days) Bipolar Agents Mood Stabilizers carbamazepine er oral capsule extended release 12 hour 100 mg, 200 mg, 300 mg lithium oral solution 8 meq/5ml lithium carbonate oral capsule 150 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate er oral tablet extendedrelease* 300 mg, 450 mg Blood Glucose Regulators Antidiabetic Agents acarbose oral tablet 100 mg, 25 mg, 50 mg BYDUREON SUBCUTANEOUS* 2 MG 4 MS BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED 2 MG BYETTA 10 MCG PEN SUBCUTANEOUS* 10 MCG/0.04ML 4 MS 4 MS BYETTA 5 MCG PEN SUBCUTANEOUS* 5 MCG/0.02ML 4 MS CYCLOSET ORAL TABLET 0.8 MG 4 PA; MS 35

45 NAME glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 MS; QL (60 EA per 30 days) glipizide oral tablet 10 mg, 5 mg 1 MS; QL (120 EA per 30 days) glipizide er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg ; QL (60 EA per 30 days) glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 2 ST; MS; QL (120 EA per 30 days) glyburide micronized oral tablet 1.5 mg, 3 mg, 6 mg 2 ST; MS; QL (60 EA per 30 days) INVOKAMET ORAL TABLET MG, MG, MG, MG 4 ST; MS INVOKANA ORAL TABLET 100 MG, 300 MG 4 ST; MS JANUVIA ORAL TABLET 100 MG 4 MS; QL (30 EA per 30 days) JANUVIA ORAL TABLET 25 MG, 50 MG 4 MS; QL (60 EA per 30 days) JARDIANCE ORAL TABLET 10 MG, 25 MG 4 ST; MS metformin hcl oral tablet 1000 mg 1 MS; QL (75 EA per 30 days) metformin hcl oral tablet 500 mg 1 MS; QL (150 EA per 30 days) metformin hcl oral tablet 850 mg 1 MS; QL (90 EA per 30 days) metformin hcl er oral tablet extended release 24 hr* 500 mg metformin hcl er oral tablet extended release 24 hr* 750 mg metformin hcl er (osm) oral tablet extended release 24 hr* 500 mg nateglinide oral tablet 120 mg, 60 mg ; QL (120 EA per 30 days) ; QL (75 EA per 30 days) ; QL (120 EA per 30 days) ONGLYZA ORAL TABLET 2.5 MG, 5 MG 4 MS; QL (30 EA per 30 days) pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg ; QL (30 EA per 30 days) repaglinide oral tablet 0.5 mg, 1 mg, 2 mg SYMLINPEN 120 SUBCUTANEOUS* 2700 MCG/2.7ML 5* PA; MS SYMLINPEN 60 SUBCUTANEOUS* 1500 MCG/1.5ML 4 PA; MS tolazamide oral tablet 250 mg, 500 mg ; QL (60 EA per 30 days) tolbutamide oral tablet 500 mg ; QL (180 EA per 30 days) Blood Glucose Regulators glipizide-metformin hcl oral tablet mg, mg, mg ; QL (120 EA per 30 days) 36

46 NAME glyburide-metformin oral tablet mg, mg, mg 2 ST; MS; QL (120 EA per 30 days) JANUMET ORAL TABLET MG, MG 4 MS; QL (60 EA per 30 days) JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* MG, MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* MG KOMBIGLYZE XR ORAL TABLET EXTENDED RELEASE 24 HR* MG, MG metformin hcl er (osm) oral tablet extended release 24 hr* 1000 mg pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg pioglitazone hcl-metformin hcl oral tablet mg, mg PRANDIMET ORAL TABLET MG, MG 4 MS Glycemic Agents GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG 4 MS; QL (30 EA per 30 days) 4 MS; QL (60 EA per 30 days) 4 MS; QL (60 EA per 30 days) 4 MS; QL (30 EA per 30 days) ; QL (60 EA per 30 days) ; QL (30 EA per 30 days) ; QL (90 EA per 30 days) 3 MS; QL (4 EA per 30 days) GLUCAGON EMERGENCY INJECTION KIT 1 MG 3 MS; QL (4 EA per 30 days) KORLYM ORAL TABLET 300 MG 5* PA; MS; QL (120 EA per 30 days) PROGLYCEM ORAL SUSPENSION 50 MG/ML 4 MS Insulins ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML 3 MS BD INSULIN SYRINGE U ML 3 MS CURITY GAUZE PAD 2"X2" 3 MS EXEL PEN NEEDLES 1/3" 31G X 8 MM 3 MS GNP ULTRA COM INSULIN SYRINGE 31G X 5/16" 0.3 ML 3 MS HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3 MS; QL (60 ML per 30 days) HUMALOG KWIKPEN SUBCUTANEOUS* 100 UNIT/ML 3 MS; QL (60 ML per 30 days) 37

47 NAME HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS* (50-50) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* (75-25) 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML HUMULIN 70/30 PEN SUBCUTANEOUS* (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML 3 MS; QL (60 ML per 30 days) 3 MS; QL (60 ML per 30 days) 3 MS; QL (60 ML per 30 days) 3 MS; QL (60 ML per 30 days) 3 MS; QL (60 ML per 30 days) 3 MS; QL (60 ML per 30 days) 3 MS; QL (60 ML per 30 days) HUMULIN N PEN SUBCUTANEOUS* 100 UNIT/ML 3 MS; QL (60 ML per 30 days) HUMULIN R INJECTION SOLUTION 100 UNIT/ML 3 MS; QL (60 ML per 30 days) HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML 5* PA-BvsD; MS; QL (40 ML per 30 days) LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3 MS; QL (60 ML per 30 days) LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML 3 MS; QL (60 ML per 30 days) LEVEMIR SUBCUTANEOUS* SOLUTION 100 UNIT/ML 3 MS; QL (60 ML per 30 days) LEVEMIR FLEXTOUCH SUBCUTANEOUS* 100 UNIT/ML 3 MS; QL (60 ML per 30 days) RELION INSULIN SYRINGE 29G X 1/2" 0.5 ML 3 MS V-GO 20 KIT 4 MS V-GO 30 KIT 4 MS V-GO 40 KIT 4 MS Blood Products/ Modifiers/ Volume Expanders Anticoagulants COUMADIN INTRAVENOUS* SOLUTION RECONSTITUTED 5 MG COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG 3 MS 3 MS ELIQUIS ORAL TABLET 2.5 MG, 5 MG 4 MS 38

48 NAME enoxaparin sodium injection solution 300 mg/3ml ; QL (24 ML per 30 days) enoxaparin sodium subcutaneous* solution 100 mg/ml, 150 mg/ml enoxaparin sodium subcutaneous* solution 120 mg/0.8ml enoxaparin sodium subcutaneous* solution 30 mg/0.3ml, 40 mg/0.4ml 5* MS; QL (28 ML per 30 days) 5* MS; QL (22.4 ML per 30 days) ; QL (8.4 ML per 30 days) enoxaparin sodium subcutaneous* solution 60 mg/0.6ml ; QL (16.8 ML per 30 days) enoxaparin sodium subcutaneous* solution 80 mg/0.8ml ; QL (22.4 ML per 30 days) fondaparinux sodium subcutaneous* solution 10 mg/0.8ml fondaparinux sodium subcutaneous* solution 2.5 mg/0.5ml fondaparinux sodium subcutaneous* solution 5 mg/0.4ml fondaparinux sodium subcutaneous* solution 7.5 mg/0.6ml heparin (porcine) in d5w intravenous* solution 40-5 unit/ml-%, 50-5 unit/ml-% heparin (porcine) in nacl injection solution unit/ml-% heparin sod (porcine) in d5w intravenous* solution 100 unit/ml heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 2500 unit/ml, 5000 unit/ml heparin sodium (porcine) intravenous* solution 2000 unit/ml jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg 5* MS; QL (11.2 ML per 30 days) ; QL (16 ML per 30 days) 5* MS; QL (5.6 ML per 30 days) 5* MS; QL (8.4 ML per 30 days) 1 MS PRADAXA ORAL CAPSULE 150 MG, 75 MG 4 MS; QL (60 EA per 30 days) warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg 1 MS 39

49 NAME Blood Formation Modifiers anagrelide hcl oral capsule 0.5 mg, 1 mg LEUKINE INTRAVENOUS* SOLUTION RECONSTITUTED 250 MCG 5* PA; MS MOZOBIL SUBCUTANEOUS* SOLUTION 24 MG/1.2ML 5* PA; MS; QL (9.6 ML per 1 day) NEUMEGA SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML PROCRIT INJECTION SOLUTION UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION UNIT/ML, UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG Coagulants 5* PA; MS 5* PA; MS 3 PA; MS 5* PA; MS 5* PA; LA; QL (60 EA per 30 days) tranexamic acid intravenous* solution 100 mg/ml tranexamic acid oral tablet 650 mg Platelet Modifying Agents AGGRENOX ORAL CAPSULE EXTENDED RELEASE 12 HOUR MG 4 MS BRILINTA ORAL TABLET 90 MG 3 MS cilostazol oral tablet 100 mg, 50 mg clopidogrel bisulfate oral tablet 300 mg ; QL (1 EA per 30 days) clopidogrel bisulfate oral tablet 75 mg 1 MS; QL (30 EA per 30 days) dipyridamole oral tablet 25 mg, 50 mg, 75 mg 2 PA; MS EFFIENT ORAL TABLET 10 MG, 5 MG 3 MS ticlopidine hcl oral tablet 250 mg Cardiovascular Agents Alpha-Adrenergic Agonists clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg 1 MS guanfacine hcl oral tablet 1 mg, 2 mg 2 PA; MS methyldopa oral tablet 250 mg, 500 mg 2 PA; MS 40

50 NAME midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg Alpha-Adrenergic Blocking Agents prazosin hcl oral capsule 1 mg, 2 mg, 5 mg terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg 1 MS Angiotensin Ii Receptor Antagonists DIOVAN ORAL TABLET 160 MG, 40 MG, 80 MG 4 MS; QL (60 EA per 30 days) DIOVAN ORAL TABLET 320 MG 4 MS; QL (30 EA per 30 days) EDARBI ORAL TABLET 40 MG, 80 MG 4 MS; QL (30 EA per 30 days) losartan potassium oral tablet 100 mg 1 MS; QL (30 EA per 30 days) losartan potassium oral tablet 25 mg, 50 mg 1 MS; QL (60 EA per 30 days) telmisartan oral tablet 20 mg, 40 mg, 80 mg ; QL (30 EA per 30 days) Angiotensin-Converting Enzyme (Ace) Inhibitors benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 MS captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg 1 MS enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg 1 MS fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg 1 MS lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg 1 MS moexipril hcl oral tablet 15 mg, 7.5 mg perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg trandolapril oral tablet 1 mg, 2 mg, 4 mg 1 MS Antiarrhythmics amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg disopyramide phosphate oral capsule 100 mg, 150 mg flecainide acetate oral tablet 100 mg, 150 mg, 50 mg mexiletine hcl oral capsule 150 mg, 200 mg, 250 mg MULTAQ ORAL TABLET 400 MG 4 MS NORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR 100 MG, 150 MG 4 PA; MS 41

51 NAME pacerone oral tablet 100 mg, 200 mg, 400 mg procainamide hcl injection solution 100 mg/ml, 500 mg/ml 1 MS propafenone hcl oral tablet 150 mg, 225 mg, 300 mg quinidine gluconate er oral tablet extendedrelease* 324 mg quinidine sulfate oral tablet 200 mg, 300 mg quinidine sulfate er oral tablet extendedrelease* 300 mg sorine oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol hcl (af) oral tablet 120 mg, 160 mg, 80 mg TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500 MCG Beta-Adrenergic Blocking Agents 4 MS acebutolol hcl oral capsule 200 mg, 400 mg atenolol oral tablet 100 mg, 25 mg, 50 mg 1 MS betaxolol hcl oral tablet 10 mg, 20 mg bisoprolol fumarate oral tablet 10 mg, 5 mg BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg COREG CR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 20 MG, 40 MG, 80 MG 4 MS 1 MS 3 MS; QL (30 EA per 30 days) labetalol hcl intravenous* solution 5 mg/ml labetalol hcl oral tablet 100 mg, 200 mg, 300 mg metoprolol succinate er oral tablet extended release 24 hr* 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate intravenous* solution 1 mg/ml metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg 1 MS nadolol oral tablet 20 mg, 40 mg, 80 mg pindolol oral tablet 10 mg, 5 mg propranolol hcl intravenous* solution 1 mg/ml 42

52 NAME propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg propranolol hcl er oral capsule extended release 24 hour 120 mg, 160 mg, 60 mg, 80 mg 1 MS timolol maleate oral tablet 10 mg, 20 mg, 5 mg Calcium Channel Blocking Agents afeditab cr oral tablet extended release 24 hr* 30 mg, 60 mg amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg 1 MS cartia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg ; QL (60 EA per 30 days) diltiazem hcl intravenous* solution 50 mg/10ml diltiazem hcl intravenous* solution reconstituted 100 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg diltiazem hcl er oral capsule extended release 12 hour 120 mg, 60 mg, 90 mg diltiazem hcl er beads oral capsule extended release 24 hour 180 mg, 360 mg, 420 mg diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 240 mg, 300 mg felodipine er oral tablet extended release 24 hr* 10 mg, 2.5 mg, 5 mg matzim la oral tablet extended release 24 hr* 180 mg, 240 mg, 300 mg, 360 mg, 420 mg ; QL (30 EA per 30 days) nicardipine hcl oral capsule 20 mg, 30 mg nifedical xl oral tablet extended release 24 hr* 30 mg, 60 mg nifedipine oral capsule 10 mg, 20 mg 2 PA; MS nifedipine er osmotic oral tablet extended release 24 hr* 30 mg, 60 mg, 90 mg nimodipine oral capsule 30 mg ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) 43

53 NAME taztia xt oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg verapamil hcl oral tablet 120 mg, 40 mg, 80 mg 1 MS verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg, 360 mg verapamil hcl er oral tablet extendedrelease* 120 mg, 180 mg, 240 mg Cardiovascular Agents amiloride-hydrochlorothiazide oral tablet 5-50 mg amlodipine besy-benazepril hcl oral capsule mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg amlodipine besylate-valsartan oral tablet mg, mg, mg, mg amlodipine-valsartan-hctz oral tablet mg, mg, mg, mg, mg atenolol-chlorthalidone oral tablet mg, mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg captopril-hydrochlorothiazide oral tablet mg, mg, mg, mg ; QL (30 EA per 30 days) 1 MS 1 MS 1 MS clorpres oral tablet mg, mg, mg DEMSER ORAL CAPSULE 250 MG 4 MS; QL (480 EA per 30 days) EDARBYCLOR ORAL TABLET MG, MG 4 MS; QL (30 EA per 30 days) enalapril-hydrochlorothiazide oral tablet mg, mg EXFORGE ORAL TABLET MG, MG, MG, MG 4 MS EXFORGE HCT ORAL TABLET MG, MG, MG, MG, MG 4 MS 44

54 NAME fosinopril sodium-hctz oral tablet mg, mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg losartan potassium-hctz oral tablet mg, mg 1 MS 1 MS; QL (30 EA per 30 days) losartan potassium-hctz oral tablet mg 1 MS; QL (60 EA per 30 days) methyldopa-hydrochlorothiazide oral tablet mg, mg metoprolol-hydrochlorothiazide oral tablet mg, mg, mg moexipril-hydrochlorothiazide oral tablet mg, mg, mg 2 PA; MS propranolol-hctz oral tablet mg, mg quinapril-hydrochlorothiazide oral tablet mg, mg, mg reserpine oral tablet 0.1 mg, 0.25 mg spironolactone-hctz oral tablet mg TEKTURNA HCT ORAL TABLET MG, MG, MG, MG telmisartan-amlodipine oral tablet mg, 40-5 mg, mg, 80-5 mg telmisartan-hctz oral tablet mg, mg, mg 4 MS; QL (30 EA per 30 days) ; QL (30 EA per 30 days) ; QL (30 EA per 30 days) triamterene-hctz oral capsule mg triamterene-hctz oral tablet mg, mg valsartan-hydrochlorothiazide oral tablet mg, mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg Cardiovascular Agents, Other ; QL (60 EA per 30 days) ; QL (30 EA per 30 days) digitek oral tablet 125 mcg 1 MS; QL (30 EA per 30 days) digitek oral tablet 250 mcg 1 PA; MS; QL (30 EA per 30 days) digoxin injection solution 0.25 mg/ml 45

55 NAME digoxin oral solution 0.05 mg/ml digoxin oral tablet mg 1 MS; QL (30 EA per 30 days) digoxin oral tablet 250 mcg 1 PA; MS; QL (30 EA per 30 days) LANOXIN INJECTION SOLUTION 0.25 MG/ML 3 MS LANOXIN ORAL TABLET MG 3 MS LANOXIN ORAL TABLET MG 3 MS; QL (30 EA per 30 days) LANOXIN ORAL TABLET 0.25 MG, MCG 3 PA; MS; QL (30 EA per 30 days) LANOXIN PEDIATRIC INJECTION SOLUTION 0.1 MG/ML 3 MS pentoxifylline er oral tablet extendedrelease* 400 mg RANEXA ORAL TABLET EXTENDED RELEASE 12 HR* 1000 MG, 500 MG 4 MS; QL (60 EA per 30 days) TEKTURNA ORAL TABLET 150 MG, 300 MG 4 MS; QL (30 EA per 30 days) Diuretics, Carbonic Anhydrase Inhibitors acetazolamide oral tablet 125 mg, 250 mg acetazolamide er oral capsule extended release 12 hour 500 mg acetazolamide sodium injection solution reconstituted 500 mg methazolamide oral tablet 25 mg, 50 mg Diuretics, Loop bumetanide injection solution 0.25 mg/ml bumetanide oral tablet 0.5 mg, 1 mg, 2 mg furosemide injection solution 10 mg/ml furosemide oral solution 10 mg/ml, 8 mg/ml furosemide oral tablet 20 mg, 40 mg, 80 mg 1 MS torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg Diuretics, Potassium-Sparing amiloride hcl oral tablet 5 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg Diuretics, Thiazide chlorothiazide oral tablet 250 mg, 500 mg 1 MS 46

56 NAME chlorothiazide sodium intravenous* solution reconstituted 500 mg chlorthalidone oral tablet 25 mg, 50 mg hydrochlorothiazide oral capsule 12.5 mg 1 MS hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg 1 MS indapamide oral tablet 1.25 mg, 2.5 mg 1 MS methyclothiazide oral tablet 5 mg metolazone oral tablet 10 mg, 2.5 mg, 5 mg Dyslipidemics, Fibric Acid Derivatives fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg gemfibrozil oral tablet 600 mg Dyslipidemics, Hmg Coa Reductase Inhibitors atorvastatin calcium oral tablet 10 mg, 20 mg, 40 mg 1 MS; QL (45 EA per 30 days) atorvastatin calcium oral tablet 80 mg 1 MS; QL (30 EA per 30 days) CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG 4 MS; QL (30 EA per 30 days) LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG 4 MS lovastatin oral tablet 10 mg, 20 mg, 40 mg pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg 1 MS; QL (45 EA per 30 days) pravastatin sodium oral tablet 80 mg 1 MS; QL (30 EA per 30 days) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 MS; QL (45 EA per 30 days) simvastatin oral tablet 80 mg 1 MS; QL (30 EA per 30 days) Dyslipidemics, Other cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral tablet 1 gm JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG 5* PA; LA 47

57 NAME niacin er (antihyperlipidemic) oral tablet extendedrelease* 1000 mg, 500 mg, 750 mg NIACOR ORAL TABLET 500 MG 3 MS omega-3-acid ethyl esters oral capsule 1 gm prevalite oral powder 4 gm/dose VASCEPA ORAL CAPSULE 1 GM 4 MS WELCHOL ORAL PACKET 3.75 GM 4 MS WELCHOL ORAL TABLET 625 MG 4 MS ZETIA ORAL TABLET 10 MG 4 MS; QL (30 EA per 30 days) Vasodilators, Direct-Acting Arterial hydralazine hcl injection solution 20 mg/ml hydralazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg Vasodilators, Direct-Acting Arterial/ Venous isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide dinitrate er oral tablet extendedrelease* 40 mg isosorbide mononitrate oral tablet 10 mg, 20 mg isosorbide mononitrate er oral tablet extended release 24 hr* 120 mg, 30 mg, 60 mg minitran transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr NITRO-BID TRANSDERMAL OINTMENT 2 % 3 MS nitroglycerin intravenous* solution 5 mg/ml 1 MS nitroglycerin transdermal patch 24 hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG 3 MS 48

58 NAME Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg 2 PA; MS; QL (60 EA per 30 days) dexedrine oral tablet 10 mg, 5 mg 2 PA; MS dextroamphetamine sulfate oral tablet 10 mg, 5 mg 2 PA; MS dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines clonidine hcl er oral tablet extended release 12 hr* 0.1 mg 2 PA; MS 2 PA; MS dexmethylphenidate hcl oral tablet 10 mg, 2.5 mg, 5 mg ; QL (120 EA per 30 days) metadate er oral tablet extendedrelease* 20 mg ; QL (90 EA per 30 days) methylphenidate hcl oral solution 5 mg/5ml ; QL (2160 ML per 30 days) methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg ; QL (90 EA per 30 days) methylphenidate hcl er oral tablet extendedrelease* 20 mg STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG ; QL (90 EA per 30 days) 4 PA; MS; QL (60 EA per 30 days) STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG 4 PA; MS; QL (30 EA per 30 days) Central Nervous System, Other estazolam oral tablet 1 mg, 2 mg NUEDEXTA ORAL CAPSULE MG 3 PA; MS riluzole oral tablet 50 mg 5* MS XENAZINE ORAL TABLET 12.5 MG 5* PA; LA; QL (210 EA per 30 days) XENAZINE ORAL TABLET 25 MG 5* PA; LA; QL (120 EA per 30 days) Fibromyalgia Agents SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG 3 MS SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG 3 MS 49

59 NAME Multiple Sclerosis Agents AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR* 10 MG 5* PA; LA; QL (60 EA per 30 days) AUBAGIO ORAL TABLET 14 MG, 7 MG 5* PA; LA; QL (30 EA per 30 days) COPAXONE SUBCUTANEOUS* 40 MG/ML 5* PA; MS; QL (12 ML per 28 days) COPAXONE SUBCUTANEOUS* KIT 20 MG/ML 5* PA; MS; QL (30 ML per 30 days) EXTAVIA SUBCUTANEOUS* KIT 0.3 MG 5* PA; MS GILENYA ORAL CAPSULE 0.5 MG 5* PA; MS; QL (30 EA per 30 days) mitoxantrone hcl intravenous* concentrate 25 mg/12.5ml REBIF SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML REBIF REBIDOSE SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG REBIF TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG 5* PA; MS; QL (6 ML per 28 days) 5* PA; MS; QL (6 ML per 28 days) 5* PA; MS; QL (4.2 ML per 28 days) 5* PA; MS; QL (4.2 ML per 28 days) TECFIDERA ORAL 120 & 240 MG 5* PA; MS TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG TYSABRI INTRAVENOUS* CONCENTRATE 300 MG/15ML Dental And Oral Agents Dental And Oral Agents 5* PA; MS 5* PA; LA chlorhexidine gluconate mouth/throat solution 0.12 % 1 MS periogard mouth/throat solution 0.12 % 1 MS pilocarpine hcl oral tablet 5 mg, 7.5 mg triamcinolone acetonide mouth/throat paste 0.1 % Dermatological Agents Dermatological Agents 8-MOP ORAL CAPSULE 10 MG 5* MS acitretin oral capsule 10 mg, 17.5 mg, 25 mg 5* MS; QL (60 EA per 30 days) 50

60 NAME ammonium lactate external cream 12 % ammonium lactate external lotion 12 % amnesteem oral capsule 10 mg, 20 mg, 40 mg AZELEX EXTERNAL CREAM 20 % 3 MS benzoyl peroxide-erythromycin external 5-3 % betamethasone dipropionate external lotion 0.05 % calcipotriene external cream % calcipotriene external ointment % calcipotriene external solution % CARAC EXTERNAL CREAM 0.5 % 4 MS claravis oral capsule 10 mg, 20 mg, 30 mg, 40 mg clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % CONDYLOX EXTERNAL 0.5 % 4 MS ELIDEL EXTERNAL CREAM 1 % 4 PA; MS FINACEA EXTERNAL 15 % 3 MS FLUOROURACIL EXTERNAL CREAM 0.5 % 4 MS fluorouracil external cream 5 % fluorouracil external solution 2 %, 5 % imiquimod external cream 5 % 2 PA-NS; MS methoxsalen rapid oral capsule 10 mg 5* PA; MS myorisan oral capsule 10 mg, 20 mg, 40 mg nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% podofilox external solution 0.5 % prednicarbate external cream 0.1 % REGRANEX EXTERNAL 0.01 % 4 PA; MS SANTYL EXTERNAL OINTMENT 250 UNIT/GM 4 MS selenium sulfide external lotion 2.5 % TAZORAC EXTERNAL 0.05 %, 0.1 % 4 MS 51

61 NAME TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % 4 MS VOLTAREN TRANSDERMAL 1 % 3 MS zenatane oral capsule 10 mg, 20 mg, 40 mg Enzyme Replacement/ Modifiers Enzyme Replacement/ Modifiers ADAGEN INTRAMUSCULAR* SOLUTION 250 UNIT/ML 5* PA-BvsD; LA ALDURAZYME INTRAVENOUS* SOLUTION 2.9 MG/5ML 5* PA-BvsD; LA CEREZYME INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT CREON ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, 6000 UNIT 5* PA; LA 4 MS CYSTADANE ORAL POWDER 5* LA CYSTAGON ORAL CAPSULE 150 MG, 50 MG 3 PA; LA ELAPRASE INTRAVENOUS* SOLUTION 6 MG/3ML 5* PA-BvsD; LA FABRAZYME INTRAVENOUS* SOLUTION RECONSTITUTED 35 MG, 5 MG 5* PA-BvsD; LA KUVAN ORAL TABLET SOLUBLE 100 MG 5* PA; LA MYOZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG 5* PA-BvsD; LA NAGLAZYME INTRAVENOUS* SOLUTION 1 MG/ML 5* PA-BvsD; LA ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG 5* PA; LA PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, 8000 UNIT 4 MS SUCRAID ORAL SOLUTION 8500 UNIT/ML 5* LA VPRIV INTRAVENOUS* SOLUTION RECONSTITUTED 400 UNIT 5* PA; MS ZAVESCA ORAL CAPSULE 100 MG 5* PA; LA; QL (90 EA per 30 days) ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, 5000 UNIT 4 MS 52

62 NAME Gastrointestinal Agents Antispasmodics, Gastrointestinal atropine sulfate injection solution 0.05 mg/ml, 0.1 mg/ml dicyclomine hcl oral capsule 10 mg dicyclomine hcl oral solution 10 mg/5ml dicyclomine hcl oral tablet 20 mg glycopyrrolate injection solution 4 mg/20ml glycopyrrolate oral tablet 1 mg, 2 mg methscopolamine bromide oral tablet 2.5 mg, 5 mg propantheline bromide oral tablet 15 mg TRANSDERM-SCOP TRANSDERMAL PATCH 72 HR 1.5 MG Gastrointestinal Agents, Other 4 MS; QL (10 EA per 30 days) diphenoxylate-atropine oral liquid mg/5ml diphenoxylate-atropine oral tablet mg loperamide hcl oral capsule 2 mg 1 MS metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl oral solution 5 mg/5ml metoclopramide hcl oral tablet 10 mg, 5 mg 1 MS proctosol hc cream 2.5 % 1 MS RELISTOR SUBCUTANEOUS* KIT 12 MG/0.6ML 4 PA; MS RELISTOR SUBCUTANEOUS* SOLUTION 8 MG/0.4ML 4 PA; MS ursodiol oral capsule 300 mg Histamine2 (H2) Receptor Antagonists cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg cimetidine hcl oral solution 300 mg/5ml famotidine intravenous* solution 20 mg/2ml 1 MS famotidine oral suspension reconstituted 40 mg/5ml famotidine oral tablet 20 mg, 40 mg 1 MS famotidine premixed intravenous* solution mg/50ml-% 1 MS 53

63 NAME ranitidine hcl injection solution 150 mg/6ml, 50 mg/2ml ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg, 300 mg 1 MS Irritable Bowel Syndrome Agents AMITIZA ORAL CAPSULE 24 MCG, 8 MCG 3 MS budesonide er oral capsule extended release 24 hour 3 mg 5* MS LOTRONEX ORAL TABLET 0.5 MG, 1 MG 5* PA; MS; QL (60 EA per 30 days) Laxatives constulose oral solution 10 gm/15ml enulose oral solution 10 gm/15ml gavilyte-c oral solution reconstituted 240 gm 1 MS gavilyte-g oral solution reconstituted 236 gm 1 MS gavilyte-n with flavor pack oral solution reconstituted 420 gm 1 MS generlac oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml MOVIPREP ORAL SOLUTION RECONSTITUTED 100 GM 4 MS peg 3350/electrolytes oral solution reconstituted 240 gm peg-3350/electrolytes oral solution reconstituted 236 gm 1 MS 1 MS polyethylene glycol 3350 oral powder trilyte oral solution reconstituted 420 gm 1 MS Protectants CARAFATE ORAL SUSPENSION 1 GM/10ML 4 MS misoprostol oral tablet 100 mcg, 200 mcg sucralfate oral tablet 1 gm Proton Pump Inhibitors DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MG 4 MS; QL (30 EA per 30 days) 54

64 NAME esomeprazole sodium intravenous* solution reconstituted 20 mg, 40 mg NEXIUM ORAL CAPSULE DELAYED RELEASE 20 MG, 40 MG NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40 MG, 5 MG omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg pantoprazole sodium intravenous* solution reconstituted 40 mg pantoprazole sodium oral tablet delayed release 20 mg, 40 mg Genitourinary Agents Antispasmodics, Urinary 4 MS 4 MS 1 MS oxybutynin chloride oral syrup 5 mg/5ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride er oral tablet extended release 24 hr* 10 mg, 15 mg, 5 mg trospium chloride oral tablet 20 mg VESICARE ORAL TABLET 10 MG, 5 MG 3 MS Benign Prostatic Hypertrophy Agents alfuzosin hcl er oral tablet extended release 24 hr* 10 mg AVODART ORAL CAPSULE 0.5 MG 3 MS; QL (30 EA per 30 days) CIALIS ORAL TABLET 2.5 MG, 5 MG 4 PA; MS; QL (30 EA per 30 days) doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg 1 MS finasteride oral tablet 5 mg JALYN ORAL CAPSULE MG 3 MS; QL (30 EA per 30 days) RAPAFLO ORAL CAPSULE 4 MG, 8 MG 4 MS; QL (30 EA per 30 days) tamsulosin hcl oral capsule 0.4 mg Genitourinary Agents, Other bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg 55

65 NAME CUPRIMINE ORAL CAPSULE 250 MG 4 MS ELMIRON ORAL CAPSULE 100 MG 4 PA; MS potassium citrate er oral tablet extendedrelease* 10 meq (1080 mg), 15 meq (1620 mg), 5 meq (540 mg) Phosphate Binders calcium acetate oral capsule 667 mg eliphos oral tablet 667 mg FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500 MG, 750 MG 4 MS RENVELA ORAL PACKET 0.8 GM, 2.4 GM 4 MS RENVELA ORAL TABLET 800 MG 4 MS Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ala cort external cream 1 % 1 MS alclometasone dipropionate external cream 0.05 % alclometasone dipropionate external ointment 0.05 % amcinonide external cream 0.1 % amcinonide external lotion 0.1 % amcinonide external ointment 0.1 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone dipropionate aug external 0.05 % betamethasone dipropionate aug external cream 0.05 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate aug external ointment 0.05 % betamethasone valerate external cream 0.1 % betamethasone valerate external foam 0.12 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % 56

66 NAME clobetasol propionate external 0.05 % clobetasol propionate external cream 0.05 % clobetasol propionate external foam 0.05 % clobetasol propionate external lotion 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external shampoo 0.05 % clobetasol propionate external solution 0.05 % clobetasol propionate e external cream 0.05 % clocortolone pivalate pump external cream 0.1 % clodan external shampoo 0.05 % CLODERM PUMP EXTERNAL CREAM 0.1 % 4 MS cortisone acetate oral tablet 25 mg desonide external cream 0.05 % desonide external lotion 0.05 % desonide external ointment 0.05 % desoximetasone external 0.05 % desoximetasone external cream 0.05 %, 0.25 % desoximetasone external ointment 0.05 %, 0.25 % dexamethasone oral elixir 0.5 mg/5ml dexamethasone oral solution 0.5 mg/5ml dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg 1 MS dexamethasone intensol oral concentrate 1 mg/ml dexamethasone sod phosphate pf injection solution 10 mg/ml dexamethasone sodium phosphate injection solution 10 mg/ml, 120 mg/30ml fludrocortisone acetate oral tablet 0.1 mg fluocinolone acetonide external cream 0.01 %, % fluocinolone acetonide external ointment % fluocinolone acetonide external solution 0.01 % fluocinolone acetonide otic oil 0.01 % 57

67 NAME fluocinolone acetonide body external oil 0.01 % fluocinonide external 0.05 % fluocinonide external cream 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % fluticasone propionate external cream 0.05 % fluticasone propionate external ointment % halobetasol propionate external ointment 0.05 % hydrocortisone external cream 1 %, 2.5 % 1 MS hydrocortisone external lotion 2.5 % hydrocortisone external ointment 1 %, 2.5 % 1 MS hydrocortisone oral tablet 10 mg, 20 mg, 5 mg hydrocortisone butyrate external ointment 0.1 % hydrocortisone butyrate external solution 0.1 % hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % lokara external lotion 0.05 % MEDROL ORAL TABLET 2 MG 4 MS methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg methylprednisolone (pak) oral tablet 4 mg methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg millipred oral tablet 5 mg mometasone furoate external cream 0.1 % mometasone furoate external ointment 0.1 % mometasone furoate external solution 0.1 % prednicarbate external ointment 0.1 % prednisolone oral solution 15 mg/5ml 58

68 NAME prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml prednisone oral solution 5 mg/5ml prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg 1 MS prednisone intensol oral concentrate 5 mg/ml proctozone-hc cream 2.5 % 1 MS triamcinolone acetonide external cream %, 0.1 %, 0.5 % triamcinolone acetonide external lotion %, 0.1 % triamcinolone acetonide external ointment %, 0.1 %, 0.5 % triderm external cream 0.1 % Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) chorionic gonadotropin intramuscular* solution reconstituted unit 2 PA-BvsD; MS desmopressin ace rhinal tube nasal solution 0.01 % ; QL (15 ML per 30 days) desmopressin ace spray refrig nasal solution 0.01 % ; QL (15 ML per 30 days) desmopressin acetate injection solution 4 mcg/ml desmopressin acetate oral tablet 0.1 mg, 0.2 mg desmopressin acetate spray nasal solution 0.01 % ; QL (15 ML per 30 days) EGRIFTA SUBCUTANEOUS* SOLUTION RECONSTITUTED 2 MG GENOTROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED 12 MG GENOTROPIN MINIQUICK SUBCUTANEOUS* SOLUTION RECONSTITUTED 0.4 MG, 0.8 MG HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 MG, 5 MG, 6 MG 5* PA; LA; QL (30 EA per 30 days) 5* PA; LA 5* PA; LA 5* PA; LA INCRELEX SUBCUTANEOUS* SOLUTION 40 MG/4ML 5* PA; LA 59

69 NAME NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 10 MG/1.5ML NORDITROPIN FLEXPRO SUBCUTANEOUS* SOLUTION 15 MG/1.5ML, 5 MG/1.5ML NORDITROPIN NORDIFLEX PEN SUBCUTANEOUS* SOLUTION 30 MG/3ML NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS* SOLUTION 5 MG/2ML NUTROPIN AQ PEN SUBCUTANEOUS* SOLUTION 20 MG/2ML OMNITROPE SUBCUTANEOUS* SOLUTION 10 MG/1.5ML, 5 MG/1.5ML OMNITROPE SUBCUTANEOUS* SOLUTION RECONSTITUTED 5.8 MG 5* PA; LA 5* PA; MS 5* PA; MS 5* PA; LA 5* PA; MS 5* PA; LA 5* PA; LA SAIZEN INJECTION SOLUTION RECONSTITUTED 5 MG 5* PA; LA Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Anabolic Steroids ANADROL-50 ORAL TABLET 50 MG 5* PA; MS oxandrolone oral tablet 10 mg 5* PA; MS; QL (60 EA per 30 days) oxandrolone oral tablet 2.5 mg 2 PA; MS; QL (120 EA per 30 days) Androgens androxy oral tablet 10 mg danazol oral capsule 100 mg, 200 mg, 50 mg TESTIM TRANSDERMAL 50 MG/5GM 3 PA; MS testosterone cypionate intramuscular* solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular* solution 200 mg/ml Estrogens DUAVEE ORAL TABLET MG 3 MS ESTRACE VAGINAL CREAM 0.1 MG/GM 4 MS estradiol oral tablet 0.5 mg, 1 mg, 2 mg 2 PA; MS 60

70 NAME estradiol transdermal patch weekly mg/24hr, mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, mg/24hr, 0.1 mg/24hr 2 PA; MS estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 2 PA; MS marlissa oral tablet mg-mcg MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG, 2.5 MG PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, 1.25 MG 4 MS 3 MS 3 MS; QL (30 EA per 30 days) PREMARIN VAGINAL CREAM MG/GM 3 MS VIVELLE-DOT TRANSDERMAL PATCH BIWEEKLY MG/24HR, MG/24HR, 0.05 MG/24HR, MG/24HR, 0.1 MG/24HR Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) 3 MS amethia oral tablet &0.01 mg amethyst oral tablet mcg apri oral tablet mg-mcg aranelle oral tablet 0.5/1/ mg-mcg aubra oral tablet mg-mcg aviane oral tablet mg-mcg balziva oral tablet mg-mcg briellyn oral tablet mg-mcg COMBIPATCH TRANSDERMAL PATCH BIWEEKLY MG/DAY, MG/DAY 4 MS cryselle-28 oral tablet mg-mcg cyclafem 1/35 oral tablet 1-35 mg-mcg cyclafem 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg delyla oral tablet mg-mcg desogestrel-ethinyl estradiol oral tablet /0.01 mg (21/5) 61

71 NAME drospirenone-ethinyl estradiol oral tablet mg emoquette oral tablet mg-mcg enpresse-28 oral tablet estradiol-norethindrone acet oral tablet mg, mg 2 PA; MS falmina oral tablet mg-mcg gianvi oral tablet mg gildagia oral tablet mg-mcg gildess 1.5/30 oral tablet mg-mcg introvale oral tablet mg jinteli oral tablet 1-5 mg-mcg junel 1.5/30 oral tablet mg-mcg junel 1/20 oral tablet 1-20 mg-mcg junel fe 1.5/30 oral tablet mg-mcg junel fe 1/20 oral tablet 1-20 mg-mcg kariva oral tablet /0.01 mg (21/5) kelnor 1/35 oral tablet 1-35 mg-mcg larin 1.5/30 oral tablet mg-mcg larin 1/20 oral tablet 1-20 mg-mcg larin fe 1.5/30 oral tablet mg-mcg larin fe 1/20 oral tablet 1-20 mg-mcg leena oral tablet 0.5/1/ mg-mcg lessina oral tablet mg-mcg levonest oral tablet levonorgest-eth estrad 91-day oral tablet mg levora 0.15/30 (28) oral tablet mg-mcg loryna oral tablet mg low-ogestrel oral tablet mg-mcg lutera oral tablet mg-mcg microgestin 1.5/30 oral tablet mg-mcg microgestin 1/20 oral tablet 1-20 mg-mcg 62

72 NAME microgestin fe 1.5/30 oral tablet mg-mcg microgestin fe 1/20 oral tablet 1-20 mg-mcg mimvey lo oral tablet mg mononessa oral tablet mg-mcg 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 35 mcg necon 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg nikki oral tablet mg nora-be oral tablet 0.35 mg nortrel 0.5/35 (28) oral tablet mg-mcg nortrel 1/35 (21) oral tablet 1-35 mg-mcg nortrel 1/35 (28) oral tablet 1-35 mg-mcg nortrel 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg ocella oral tablet mg ogestrel oral tablet mg-mcg orsythia oral tablet mg-mcg pimtrea oral tablet /0.01 mg (21/5) pirmella 1/35 oral tablet 1-35 mg-mcg portia-28 oral tablet mg-mcg prefest oral tablet 1/ mg (15/15) PREMPHASE ORAL TABLET MG 3 MS PREMPRO ORAL TABLET MG, MG, MG, MG 3 MS previfem oral tablet mg-mcg quasense oral tablet mg reclipsen oral tablet mg-mcg sprintec 28 oral tablet mg-mcg sronyx oral tablet mg-mcg tarina fe 1/20 oral tablet 1-20 mg-mcg 63

73 NAME tri-legest fe oral tablet 1-20/1-30/1-35 mg-mcg tri-previfem oral tablet 0.18/0.215/0.25 mg-35 mcg tri-sprintec oral tablet 0.18/0.215/0.25 mg-35 mcg trinessa (28) oral tablet 0.18/0.215/0.25 mg-35 mcg trivora (28) oral tablet velivet oral tablet 0.1/0.125/ mg vestura oral tablet mg vyfemla oral tablet mg-mcg wymzya fe oral tablet chewable mg-mcg zenchent oral tablet mg-mcg zenchent fe oral tablet chewable mg-mcg zovia 1/35e (28) oral tablet 1-35 mg-mcg zovia 1/50e (28) oral tablet 1-50 mg-mcg Progesterone Agonists/ Antagonists ELLA ORAL TABLET 30 MG 3 MS; QL (1 EA per 30 days) Progestins camila oral tablet 0.35 mg deblitane oral tablet 0.35 mg errin oral tablet 0.35 mg jolivette oral tablet 0.35 mg lyza oral tablet 0.35 mg medroxyprogesterone acetate intramuscular* suspension 150 mg/ml medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg 1 MS megestrol acetate oral suspension 40 mg/ml megestrol acetate oral tablet 20 mg, 40 mg norethindrone oral tablet 0.35 mg norethindrone acetate oral tablet 5 mg norlyroc oral tablet 0.35 mg sharobel oral tablet 0.35 mg 64

74 NAME Selective Estrogen Receptor Modifying Agents raloxifene hcl oral tablet 60 mg ; QL (30 EA per 30 days) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG levothyroxine sodium intravenous* solution reconstituted 100 mcg levothyroxine sodium intravenous* solution reconstituted 200 mcg, 500 mcg levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg 3 MS 5* MS 1 MS 1 MS liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg NATURE-THROID ORAL TABLET MG, 130 MG, MG, MG, MG, 195 MG, 260 MG, 32.5 MG, 325 MG, MG, 65 MG, MG, 97.5 MG 3 MS np thyroid oral tablet 30 mg, 60 mg, 90 mg SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG 3 MS THYROLAR-1 ORAL TABLET 60 ( ) MG (MCG) 3 MS THYROLAR-1/2 ORAL TABLET 30 ( ) MG (MCG) 3 MS THYROLAR-1/4 ORAL TABLET 15 ( ) MG (MCG) 3 MS THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG) 3 MS THYROLAR-3 ORAL TABLET 180 ( ) MG (MCG) 3 MS 65

75 NAME unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) 1 MS LYSODREN ORAL TABLET 500 MG 3 MS Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) SENSIPAR ORAL TABLET 30 MG 3 MS; QL (60 EA per 30 days) SENSIPAR ORAL TABLET 60 MG 5* MS; QL (60 EA per 30 days) SENSIPAR ORAL TABLET 90 MG 5* MS; QL (120 EA per 30 days) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline oral tablet 0.5 mg ELIGARD SUBCUTANEOUS* KIT 22.5 MG, 30 MG, 7.5 MG 4 PA-NS; MS ELIGARD SUBCUTANEOUS* KIT 45 MG 5* PA-NS; MS leuprolide acetate injection kit 1 mg/0.2ml 2 PA-NS; MS octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml SANDOSTATIN LAR DEPOT INTRAMUSCULAR* KIT 10 MG, 20 MG, 30 MG SOMATULINE DEPOT SUBCUTANEOUS* SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML SOMAVERT SUBCUTANEOUS* SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG 2 PA; MS 5* PA; MS 5* PA; MS 5* PA; MS 5* PA; LA SYNAREL NASAL SOLUTION 2 MG/ML 5* MS TRELSTAR DEPOT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG 5* PA-BvsD; MS; QL (1 EA per 28 days) TRELSTAR DEPOT MIXJECT INTRAMUSCULAR* 5* PA-BvsD; LA; QL (1 EA per 28 days) SUSPENSION RECONSTITUTED 3.75 MG 66

76 NAME TRELSTAR LA INTRAMUSCULAR* SUSPENSION RECONSTITUTED MG TRELSTAR LA MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED MG 5* PA-BvsD; MS; QL (1 EA per 84 days) 5* PA-BvsD; LA; QL (1 EA per 84 days) TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 22.5 MG Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents 5* PA-BvsD; MS; QL (1 EA per 168 days) methimazole oral tablet 10 mg, 5 mg propylthiouracil oral tablet 50 mg Immunological Agents Angioedema (Hae) Agents CINRYZE INTRAVENOUS* SOLUTION RECONSTITUTED 500 UNIT 5* PA; MS FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML 5* PA; MS kalbitor subcutaneous* solution 10 mg/ml 5* PA; MS Immune Suppressants AFINITOR ORAL TABLET 2.5 MG 5* PA-NS; MS; QL (30 EA per 30 days) AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG, 5 MG 5* PA-NS; MS; QL (56 EA per 28 days) 4 PA-NS; MS azathioprine oral tablet 50 mg 2 PA-BvsD; MS CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML 5* PA-BvsD; MS cyclosporine intravenous* solution 50 mg/ml 2 PA-BvsD; MS cyclosporine oral capsule 100 mg, 25 mg 2 PA-BvsD; MS cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg 2 PA-BvsD; MS cyclosporine modified oral solution 100 mg/ml 2 PA-BvsD; MS ENBREL SUBCUTANEOUS* 25 MG/0.5ML, 50 MG/ML 5* PA; MS; QL (8 ML per 28 days) ENBREL SUBCUTANEOUS* KIT 25 MG 5* PA; MS; QL (8 EA per 28 days) gengraf oral capsule 100 mg, 25 mg 2 PA-BvsD; MS 67

77 NAME gengraf oral solution 100 mg/ml 2 PA-BvsD; MS hecoria oral capsule 0.5 mg, 1 mg 2 PA-BvsD; MS hecoria oral capsule 5 mg 5* PA-BvsD; MS HUMIRA SUBCUTANEOUS* 10 MG/0.2ML 5* PA; MS HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML 5* PA; MS HUMIRA PEN SUBCUTANEOUS* KIT 40 MG/0.8ML 5* PA; MS HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML 5* PA; MS 5* PA; MS mercaptopurine oral tablet 50 mg methotrexate oral tablet 2.5 mg methotrexate sodium injection solution reconstituted 1 gm 2 PA-BvsD; MS methotrexate sodium (pf) injection solution 1 gm/40ml 2 PA-BvsD; MS mycophenolate mofetil oral capsule 250 mg 2 PA-BvsD; MS mycophenolate mofetil oral suspension reconstituted 200 mg/ml 5* PA-BvsD; MS mycophenolate mofetil oral tablet 500 mg 2 PA-BvsD; MS mycophenolic acid oral tablet delayed release 180 mg, 360 mg NULOJIX INTRAVENOUS* SOLUTION RECONSTITUTED 250 MG 2 PA-BvsD; MS 5* PA-BvsD; MS PROGRAF INTRAVENOUS* SOLUTION 5 MG/ML 3 PA-BvsD; MS PURIXAN ORAL SUSPENSION 2000 MG/100ML 5* PA-NS; MS RAPAMUNE ORAL SOLUTION 1 MG/ML 5* PA-BvsD; MS RAPAMUNE ORAL TABLET 1 MG, 2 MG 5* PA-BvsD; MS REMICADE INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG 5* PA; MS SANDIMMUNE ORAL SOLUTION 100 MG/ML 4 PA-BvsD; MS sirolimus oral tablet 0.5 mg, 1 mg 2 PA-BvsD; MS sirolimus oral tablet 2 mg 5* PA-BvsD; MS 68

78 NAME tacrolimus oral capsule 0.5 mg, 1 mg 2 PA-BvsD; MS tacrolimus oral capsule 5 mg 5* PA-BvsD; MS TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 4 MS ZORTRESS ORAL TABLET 0.25 MG 4 PA-BvsD; MS ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 5* PA-BvsD; MS Immunizing Agents, Passive CARIMUNE NF INTRAVENOUS* SOLUTION RECONSTITUTED 12 GM, 6 GM 5* PA; MS GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML 5* PA; MS SYNAGIS INTRAMUSCULAR* SOLUTION 50 MG/0.5ML 5* PA; MS THYMOGLOBULIN INTRAVENOUS* SOLUTION RECONSTITUTED 25 MG VARIZIG INJECTION SOLUTION RECONSTITUTED 125 UNIT Immunomodulators ACTIMMUNE SUBCUTANEOUS* SOLUTION UNIT/0.5ML ARCALYST SUBCUTANEOUS* SOLUTION RECONSTITUTED 220 MG 3 PA-NS; MS 4 MS 5* PA-NS; LA 5* PA; MS leflunomide oral tablet 10 mg, 20 mg RIDAURA ORAL CAPSULE 3 MG 5* MS Vaccines ACTHIB INTRAMUSCULAR* SOLUTION RECONSTITUTED ADACEL INTRAMUSCULAR* SUSPENSION LF-MCG/0.5 BOOSTRIX INTRAMUSCULAR* SUSPENSION CERVARIX INTRAMUSCULAR* SUSPENSION 3 COMVAX INTRAMUSCULAR* SUSPENSION MCG/0.5ML 3 DAPTACEL INTRAMUSCULAR* SUSPENSION

79 NAME DIPHTHERIA-TETANUS TOXOIDS DT INTRAMUSCULAR* SUSPENSION 25-5 LFU/0.5ML ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 20 MCG/ML GARDASIL INTRAMUSCULAR* SUSPENSION 3 GARDASIL 9 INTRAMUSCULAR* 3 GARDASIL 9 INTRAMUSCULAR* SUSPENSION 3 HAVRIX INTRAMUSCULAR* SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG IMOVAX RABIES INTRAMUSCULAR* INJECTABLE 2.5 UNIT/ML INFANRIX INTRAMUSCULAR* SUSPENSION IPOL INJECTION INJECTABLE 3 IXIARO INTRAMUSCULAR* SUSPENSION 3 KINRIX INTRAMUSCULAR* SUSPENSION 4 M-M-R II SUBCUTANEOUS* INJECTABLE 4 MENACTRA INTRAMUSCULAR* INJECTABLE 4 MENOMUNE SUBCUTANEOUS* INJECTABLE 3 MENVEO INTRAMUSCULAR* SOLUTION RECONSTITUTED 3 3 PA-BvsD 3 4 MS 3 PA-BvsD PEDIARIX INTRAMUSCULAR* SUSPENSION 3 PA-BvsD PEDVAX HIB INTRAMUSCULAR* SUSPENSION 7.5 MCG/0.5ML PENTACEL INTRAMUSCULAR* SUSPENSION RECONSTITUTED PROQUAD SUBCUTANEOUS* INJECTABLE 3 RABAVERT INTRAMUSCULAR* SUSPENSION RECONSTITUTED RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION RECONSTITUTED PA-BvsD 4 PA-BvsD 3 PA-BvsD 70

80 NAME ROTATEQ ORAL SOLUTION 3 TETANUS TOXOID ADSORBED INTRAMUSCULAR* SOLUTION 5 LFU TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR* SUSPENSION 2-2 LF/0.5ML 3 PA-BvsD 3 TRUMENBA INTRAMUSCULAR* 4 TWINRIX INTRAMUSCULAR* SUSPENSION PA-BvsD TYPHIM VI INTRAMUSCULAR* SOLUTION 25 MCG/0.5ML VAQTA INTRAMUSCULAR* SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS* INJECTABLE 1350 PFU/0.5ML YF-VAX SUBCUTANEOUS* INJECTABLE 3 ZOSTAVAX SUBCUTANEOUS* SOLUTION RECONSTITUTED UNT/0.65ML Inflammatory Bowel Disease Agents Aminosalicylates APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR GM 4 QL (1 EA per 365 days) 4 MS balsalazide disodium oral capsule 750 mg DIPENTUM ORAL CAPSULE 250 MG 5* MS LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM 3 MS mesalamine-cleanser kit 4 gm Glucocorticoids colocort enema 100 mg/60ml CORTIFOAM FOAM 90 MG 4 MS hydrocortisone enema 100 mg/60ml Sulfonamides sulfasalazine oral tablet 500 mg sulfazine ec oral tablet delayed release 500 mg 71

81 NAME Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate sodium oral solution 70 mg/75ml alendronate sodium oral tablet 10 mg, 5 mg 1 MS alendronate sodium oral tablet 35 mg, 70 mg 1 MS; QL (4 EA per 28 days) alendronate sodium oral tablet 40 mg calcitonin (salmon) nasal solution 200 unit/act calcitriol intravenous* solution 1 mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml etidronate disodium oral tablet 200 mg, 400 mg FORTEO SUBCUTANEOUS* SOLUTION 600 MCG/2.4ML 5* PA; MS; QL (2.4 ML per 28 days) ibandronate sodium intravenous* solution 3 mg/3ml 2 PA; MS; QL (3 ML per 84 days) ibandronate sodium oral tablet 150 mg ; QL (1 EA per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML 4 PA; MS pamidronate disodium intravenous* solution 30 mg/10ml, 90 mg/10ml paricalcitol intravenous* solution 5 mcg/ml paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML 4 ST; MS; QL (1 ML per 180 days) XGEVA SUBCUTANEOUS* SOLUTION 120 MG/1.7ML 5* PA-NS; MS ZEMPLAR INTRAVENOUS* SOLUTION 2 MCG/ML, 5 MCG/ML 3 MS zoledronic acid intravenous* concentrate 4 mg/5ml 2 PA; MS zoledronic acid intravenous* solution 5 mg/100ml 2 PA-BvsD; MS ZOMETA INTRAVENOUS* SOLUTION 4 MG/100ML 5* PA; MS Ophthalmic Agents Ophthalmic Agents bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % bacitracin-polymyxin b ophthalmic ointment unit/gm 72

82 NAME neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-gramicidin ophthalmic solution neomycin-polymyxin-hc ophthalmic suspension polymyxin b-trimethoprim ophthalmic solution unit/ml-% sulfacetamide-prednisolone ophthalmic solution % tobramycin-dexamethasone ophthalmic suspension % ZYLET OPHTHALMIC SUSPENSION % 4 MS Ophthalmic Agents, Other LACRISERT OPHTHALMIC INSERT 5 MG 4 MS naphazoline hcl ophthalmic solution 0.1 % 1 MS RESTASIS OPHTHALMIC EMULSION 0.05 % 4 MS tropicamide ophthalmic solution 0.5 %, 1 % Ophthalmic Anti-Allergy Agents ALOCRIL OPHTHALMIC SOLUTION 2 % 3 MS cromolyn sodium ophthalmic solution 4 % PATADAY OPHTHALMIC SOLUTION 0.2 % 4 MS PATANOL OPHTHALMIC SOLUTION 0.1 % 4 MS Ophthalmic Antiglaucoma Agents ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 % 4 MS AZOPT OPHTHALMIC SUSPENSION 1 % 3 MS betaxolol hcl ophthalmic solution 0.5 % brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % carteolol hcl ophthalmic solution 1 % 73

83 NAME COMBIGAN OPHTHALMIC SOLUTION % 4 MS dorzolamide hcl ophthalmic solution 2 % dorzolamide hcl-timolol mal ophthalmic solution mg/ml levobunolol hcl ophthalmic solution 0.25 %, 0.5 % metipranolol ophthalmic solution 0.3 % pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % SIMBRINZA OPHTHALMIC SUSPENSION % 4 MS timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 %, 0.5 % Ophthalmic Anti-Inflammatories ALREX OPHTHALMIC SUSPENSION 0.2 % 4 MS bromfenac sodium ophthalmic solution 0.09 % bromfenac sodium (once-daily) ophthalmic solution 0.09 % dexamethasone sodium phosphate ophthalmic solution 0.1 % diclofenac sodium ophthalmic solution 0.1 % DUREZOL OPHTHALMIC EMULSION 0.05 % 4 MS fluorometholone ophthalmic suspension 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % ILEVRO OPHTHALMIC SUSPENSION 0.3 % 4 MS ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % LOTEMAX OPHTHALMIC 0.5 % 4 MS LOTEMAX OPHTHALMIC OINTMENT 0.5 % 4 MS LOTEMAX OPHTHALMIC SUSPENSION 0.5 % 4 MS NEVANAC OPHTHALMIC SUSPENSION 0.1 % 4 MS prednisolone acetate ophthalmic suspension 1 % PROLENSA OPHTHALMIC SOLUTION 0.07 % 4 MS 74

84 NAME Ophthalmic Prostaglandin And Prostamide Analogs latanoprost ophthalmic solution % LUMIGAN OPHTHALMIC SOLUTION 0.01 % 4 MS; QL (5 ML per 30 days) TRAVATAN Z OPHTHALMIC SOLUTION % 4 MS Otic Agents Otic Agents acetasol hc otic solution 2-1 % acetic acid-aluminum acetate otic solution 2 % CIPRODEX OTIC SUSPENSION % 4 MS hydrocortisone-acetic acid otic solution 1-2 % neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension Respiratory Tract/ Pulmonary Agents Antihistamines arbinoxa oral solution 4 mg/5ml 2 PA; MS arbinoxa oral tablet 4 mg 2 PA; MS azelastine hcl nasal solution 137 mcg/spray carbinoxamine maleate oral solution 4 mg/5ml 2 PA; MS carbinoxamine maleate oral tablet 4 mg 2 PA; MS clemastine fumarate oral tablet 2.68 mg 2 PA; MS cyproheptadine hcl oral syrup 2 mg/5ml 2 PA; MS cyproheptadine hcl oral tablet 4 mg 2 PA; MS diphenhydramine hcl injection solution 50 mg/ml hydroxyzine hcl oral solution 10 mg/5ml 2 PA; MS hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg 2 PA; MS hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg 2 PA; MS levocetirizine dihydrochloride oral solution 2.5 mg/5ml levocetirizine dihydrochloride oral tablet 5 mg ; QL (30 EA per 30 days) olopatadine hcl nasal solution 0.6 % PATANASE NASAL SOLUTION 0.6 % 4 MS 75

85 NAME Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT ARNUITY ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST 3 MS; QL (60 EA per 30 days) 3 MS; QL (12 GM per 30 days) 3 MS 3 MS 3 MS 3 MS 3 MS 3 MS; QL (60 EA per 30 days) FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT 3 MS; QL (12 GM per 30 days) FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT 3 MS; QL (24 GM per 30 days) FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT 3 MS; QL (10.6 GM per 30 days) flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension 50 mcg/act NASONEX NASAL SUSPENSION 50 MCG/ACT 4 MS PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT Antileukotrienes 4 MS; QL (1 EA per 30 days) montelukast sodium oral tablet 10 mg 1 MS; QL (30 EA per 30 days) montelukast sodium oral tablet chewable 5 mg 1 MS; QL (30 EA per 30 days) 76

86 NAME zafirlukast oral tablet 10 mg, 20 mg ; QL (60 EA per 30 days) Bronchodilators, Anticholinergic ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED 62.5 MCG/INH 3 MS; QL (25.8 GM per 30 days) 3 MS ipratropium bromide inhalation solution 0.02 % 2 PA-BvsD; MS ipratropium bromide nasal solution 0.03 %, 0.06 % TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT Bronchodilators, Sympathomimetic albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml 3 MS; QL (1 EA per 30 days) 2 PA-BvsD; MS albuterol sulfate oral syrup 2 mg/5ml 1 MS albuterol sulfate oral tablet 2 mg, 4 mg albuterol sulfate er oral tablet extended release 12 hr* 4 mg, 8 mg ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG 4 MS AUVI-Q INJECTION 0.15 MG/0.15ML, 0.3 MG/0.3ML 4 MS; QL (2 EA per 30 days) BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/INH DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT 3 MS; QL (60 EA per 30 days) 3 MS; QL (13 GM per 30 days) metaproterenol sulfate oral syrup 10 mg/5ml metaproterenol sulfate oral tablet 10 mg, 20 mg SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE 3 MS; QL (60 EA per 30 days) terbutaline sulfate injection solution 1 mg/ml terbutaline sulfate oral tablet 2.5 mg, 5 mg VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT 3 MS; QL (36 GM per 30 days) 77

87 NAME Cystic Fibrosis Agents KALYDECO ORAL TABLET 150 MG 5* PA; MS; QL (60 EA per 30 days) Mast Cell Stabilizers cromolyn sodium inhalation nebulization solution 20 mg/2ml 2 PA-BvsD; MS cromolyn sodium oral concentrate 100 mg/5ml Phosphodiesterase Inhibitors, Airways Disease aminophylline intravenous* solution 25 mg/ml DALIRESP ORAL TABLET 500 MCG 4 MS; QL (30 EA per 30 days) THEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG, 400 MG theophylline er oral tablet extended release 12 hr* 100 mg, 200 mg, 300 mg, 450 mg theophylline er oral tablet extended release 24 hr* 400 mg, 600 mg Pulmonary Antihypertensives 3 MS ADCIRCA ORAL TABLET 20 MG 5* PA; MS; QL (60 EA per 30 days) LETAIRIS ORAL TABLET 10 MG, 5 MG 5* PA; LA; QL (30 EA per 30 days) REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML 5* PA; LA sildenafil citrate oral tablet 20 mg 5* PA; MS; QL (90 EA per 30 days) TRACLEER ORAL TABLET 125 MG, 62.5 MG 5* PA; LA Respiratory Tract Agents, Other acetylcysteine inhalation solution 10 %, 20 % 2 PA-BvsD; MS ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/INH LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG PROLASTIN-C INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG Respiratory Tract/ Pulmonary Agents COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION MCG/ACT 3 MS 5* PA-BvsD; LA 5* PA-BvsD; LA 3 MS; QL (8 GM per 20 days) 78

88 NAME ipratropium-albuterol inhalation solution (3) mg/3ml 2 PA-BvsD; MS promethazine vc plain oral syrup mg/5ml 2 PA; MS PULMOZYME INHALATION SOLUTION 1 MG/ML 5* PA-BvsD; MS XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants 5* PA; LA carisoprodol oral tablet 350 mg 2 ST; MS; QL (120 EA per 30 days) cyclobenzaprine hcl oral tablet 10 mg, 5 mg 2 ST; MS; QL (90 EA per 30 days) methocarbamol oral tablet 500 mg, 750 mg 2 ST; MS Sleep Disorder Agents Gaba Receptor Modulators flurazepam hcl oral capsule 15 mg ; QL (60 EA per 30 days) flurazepam hcl oral capsule 30 mg ; QL (30 EA per 30 days) temazepam oral capsule 15 mg, 30 mg ; QL (30 EA per 30 days) zaleplon oral capsule 10 mg, 5 mg 2 PA; MS; QL (90 EA per 365 days) zolpidem tartrate oral tablet 10 mg, 5 mg 2 PA; MS; QL (90 EA per 365 days) Sleep Disorders, Other modafinil oral tablet 100 mg 2 PA; MS; QL (60 EA per 30 days) modafinil oral tablet 200 mg 5* PA; MS; QL (60 EA per 30 days) XYREM ORAL SOLUTION 500 MG/ML 5* PA; LA; QL (540 ML per 30 days) Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/ Mineral Modifiers EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG 5* PA; LA kionex oral powder SAMSCA ORAL TABLET 15 MG, 30 MG 5* PA; MS sodium polystyrene sulfonate oral suspension 15 gm/60ml SYPRINE ORAL CAPSULE 250 MG 5* MS 79

89 NAME Electrolyte/ Mineral Replacement ISOLYTE-S INTRAVENOUS* SOLUTION 4 MS klor-con oral tablet extendedrelease* 8 meq klor-con 10 oral tablet extendedrelease* 10 meq klor-con m10 oral tablet extendedrelease* 10 meq klor-con m15 oral tablet extendedrelease* 15 meq klor-con m20 oral tablet extendedrelease* 20 meq magnesium sulfate injection solution 50 % NORMOSOL-R PH 7.4 INTRAVENOUS* SOLUTION 3 MS PHYSIOLYTE IRRIGATION SOLUTION 4 MS PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 4 MS PLASMA-LYTE 148 INTRAVENOUS* SOLUTION 4 MS PLASMA-LYTE A INTRAVENOUS* SOLUTION 4 MS potassium chloride intravenous* solution 0.4 meq/ml, 10 meq/50ml, 2 meq/ml POTASSIUM CHLORIDE INTRAVENOUS* SOLUTION 10 MEQ/100ML, 20 MEQ/100ML, 40 MEQ/100ML potassium chloride crys er oral tablet extendedrelease* 10 meq, 20 meq potassium chloride er oral capsule extended release* 10 meq, 8 meq potassium chloride er oral tablet extendedrelease* 10 meq, 8 meq POTASSIUM CHLORIDE IN NACL INTRAVENOUS* SOLUTION MEQ/L-%, MEQ/L-%, MEQ/L-% 4 MS 4 MS sodium chloride injection solution 2.5 meq/ml sodium chloride intravenous* solution 0.45 %, 0.9 %, 3 %, 5 % sodium chloride irrigation solution 0.9 % SUPREP BOWEL PREP ORAL SOLUTION 3 MS Therapeutic Nutrients/ Minerals/ Electrolytes AMINOSYN II INTRAVENOUS* SOLUTION 10 %, 8.5 % 4 PA-BvsD; MS 80

90 NAME AMINOSYN II INTRAVENOUS* SOLUTION 15 %, 7 % 3 PA-BvsD; MS AMINOSYN II/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 % 3 PA-BvsD; MS AMINOSYN M INTRAVENOUS* SOLUTION 3.5 % 3 PA-BvsD; MS AMINOSYN-HBC INTRAVENOUS* SOLUTION 7 % 3 PA-BvsD; MS AMINOSYN-PF INTRAVENOUS* SOLUTION 10 % 4 PA-BvsD; MS AMINOSYN-PF INTRAVENOUS* SOLUTION 7 % 3 PA-BvsD; MS AMINOSYN/ELECTROLYTES INTRAVENOUS* SOLUTION 8.5 % CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS* SOLUTION 2.75 % CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS* SOLUTION 2.75 % CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS* SOLUTION 4.25 % CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS* SOLUTION 4.25 % CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5 % CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS* SOLUTION 5 % CLINIMIX E/DEXTROSE (5/25) INTRAVENOUS* SOLUTION 5 % CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS* SOLUTION 2.75 % CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS* SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS* SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS* SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS* SOLUTION 4.25 % 3 PA-BvsD; MS 4 MS 4 MS 4 MS 4 MS 4 MS 4 MS 4 MS 4 PA-BvsD; MS 4 PA-BvsD; MS 4 PA-BvsD; MS 4 PA-BvsD; MS 4 PA-BvsD; MS 81

91 NAME CLINIMIX/DEXTROSE (5/15) INTRAVENOUS* SOLUTION 5 % CLINIMIX/DEXTROSE (5/20) INTRAVENOUS* SOLUTION 5 % CLINIMIX/DEXTROSE (5/25) INTRAVENOUS* SOLUTION 5 % 4 PA-BvsD; MS 4 PA-BvsD; MS 4 PA-BvsD; MS CLINISOL SF INTRAVENOUS* SOLUTION 15 % 3 PA-BvsD; MS cvs prenatal oral tablet mg 1 MS DEXTROSE INTRAVENOUS* SOLUTION 10 %, 5 % 3 MS DEXTROSE IN LACTATED RINGERS INTRAVENOUS* SOLUTION 5 % DEXTROSE-NACL INTRAVENOUS* SOLUTION %, %, %, %, %, %, %, % 3 MS 3 MS fomepizole intravenous* solution 1 gm/ml 5* MS HEPATAMINE INTRAVENOUS* SOLUTION 8 % 4 PA-BvsD; MS HEPATASOL INTRAVENOUS* SOLUTION 8 % 4 PA-BvsD; MS INTRALIPID INTRAVENOUS* EMULSION 20 %, 30 % 4 PA-BvsD; MS IONOSOL-B IN D5W INTRAVENOUS* SOLUTION 4 MS IONOSOL-MB IN D5W INTRAVENOUS* SOLUTION 4 MS ISOLYTE-P IN D5W INTRAVENOUS* SOLUTION 4 MS KCL IN DEXTROSE-NACL INTRAVENOUS* SOLUTION MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-%, MEQ/L-%-% KCL-LACTATED RINGERS-D5W INTRAVENOUS* SOLUTION 20 MEQ/L 4 MS 4 MS LACTATED RINGERS INTRAVENOUS* SOLUTION 3 MS LACTATED RINGERS IRRIGATION SOLUTION 3 MS LIPOSYN III INTRAVENOUS* EMULSION 10 % 3 PA-BvsD; MS LIPOSYN III INTRAVENOUS* EMULSION 20 % 4 PA-BvsD; MS NEPHRAMINE INTRAVENOUS* SOLUTION 5.4 % 4 PA-BvsD; MS 82

92 NAME NORMOSOL-M IN D5W INTRAVENOUS* SOLUTION 4 MS NORMOSOL-R IN D5W INTRAVENOUS* SOLUTION 3 MS nutrilipid intravenous* emulsion 20 % 4 PA-BvsD; MS PLASMA-LYTE-56 IN D5W INTRAVENOUS* SOLUTION 4 MS POTASSIUM CHLORIDE IN DEXTROSE INTRAVENOUS* SOLUTION 20-5 MEQ/L-%, 40-5 MEQ/L-% 4 MS PREMASOL INTRAVENOUS* SOLUTION 10 %, 6 % 4 PA-BvsD; MS PROCALAMINE INTRAVENOUS* SOLUTION 3 % 4 PA-BvsD; MS prosol intravenous* solution 20 % 2 PA-BvsD; MS RINGERS INTRAVENOUS* SOLUTION 4 MS RINGERS IRRIGATION IRRIGATION SOLUTION 4 MS SODIUM LACTATE INTRAVENOUS* SOLUTION 5 MEQ/ML 4 MS tpn electrolytes intravenous* solution TRAVASOL INTRAVENOUS* SOLUTION 10 % 4 PA-BvsD; MS TROPHAMINE INTRAVENOUS* SOLUTION 10 %, 6 % 4 PA-BvsD; MS 83

93 84

94 Index of Drugs 8-MOP abacavir sulfate abacavir-lamivudine-zidovudine ABELCET ABILIFY ABILIFY DISCMELT ABILIFY MAINTENA acamprosate calcium... 4 acarbose acebutolol hcl acetaminophen-codeine... 1 acetaminophen-codeine # acetaminophen-codeine # acetaminophen-codeine # acetasol hc acetazolamide acetazolamide er acetazolamide sodium acetic acid... 5 acetic acid-aluminum acetate acetylcysteine acitretin ACTHIB ACTIMMUNE acyclovir acyclovir sodium ADACEL ADAGEN ADCIRCA adefovir dipivoxil ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR AFINITOR DISPERZ AGGRENOX ala cort ALBENZA albuterol sulfate albuterol sulfate er alclometasone dipropionate alcohol pads... 5 ALDURAZYME alendronate sodium alfuzosin hcl er ALIMTA ALINIA allopurinol ALOCRIL ALPHAGAN P alprazolam ALREX amantadine hcl AMBISOME amcinonide amethia amethyst amifostine amikacin sulfate... 4 amiloride hcl amiloride-hydrochlorothiazide aminophylline AMINOSYN II... 80, 81 AMINOSYN II/ELECTROLYTES AMINOSYN M AMINOSYN/ELECTROLYTES AMINOSYN-HBC AMINOSYN-PF amiodarone hcl AMITIZA amitriptyline hcl amlodipine besy-benazepril hcl amlodipine besylate amlodipine besylate-valsartan amlodipine-valsartan-hctz ammonium lactate amnesteem amoxapine amoxicillin... 8 amoxicillin-pot clavulanate... 8, 9 amphetamine-dextroamphetami ne amphotericin b ampicillin... 9 ampicillin sodium ampicillin-sulbactam sodium... 9 AMPYRA ANADROL anagrelide hcl anastrozole androxy ANORO ELLIPTA APOKYN apri APRISO APTIOM APTIVUS aranelle arbinoxa ARCALYST ARCAPTA NEOHALER ARMOUR THYROID ARNUITY ELLIPTA ARZERRA ASMANEX 120 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ASMANEX HFA ASSURE ID INSULIN SAFETY SYR ASTAGRAF XL atenolol atenolol-chlorthalidone atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRIPLA atropine sulfate ATROVENT HFA AUBAGIO aubra AUVI-Q AVASTIN aviane avita AVODART azacitidine azathioprine... 67

95 azelastine hcl AZELEX AZILECT azithromycin AZOPT aztreonam... 8 baciim... 5 bacitracin... 5 bacitracin-polymyxin b bacitra-neomycin-polymyxin-hc baclofen bactocill in dextrose... 9 balsalazide disodium balziva BANZEL BARACLUDE BD INSULIN SYRINGE benazepril hcl benazepril-hydrochlorothiazide benzoyl peroxide-erythromycin benztropine mesylate BESIVANCE betamethasone dipropionate betamethasone dipropionate aug betamethasone valerate betaxolol hcl bethanechol chloride bicalutamide BICILLIN C-R... 9 BICILLIN C-R 900/ BICILLIN L-A... 9 bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin sulfate BLINCYTO BOOSTRIX BOSULIF BREO ELLIPTA briellyn BRILINTA brimonidine tartrate BRINTELLIX bromfenac sodium bromfenac sodium (once-daily) bromocriptine mesylate budesonide er bumetanide buprenorphine hcl... 4 buproban bupropion hcl bupropion hcl er (sr) bupropion hcl er (xl) buspirone hcl butalbital-acetaminophen... 1 butalbital-apap-caff-cod... 1 butalbital-apap-caffeine... 1 butalbital-aspirin-caffeine... 1 BYDUREON BYETTA 10 MCG PEN BYETTA 5 MCG PEN BYSTOLIC cabergoline calcipotriene calcitonin (salmon) calcitriol calcium acetate camila CANCIDAS CAPASTAT SULFATE CAPRELSA captopril captopril-hydrochlorothiazide CARAC CARAFATE carbamazepine carbamazepine er carbidopa carbidopa-levodopa carbidopa-levodopa er carbinoxamine maleate CARIMUNE NF carisoprodol carteolol hcl cartia xt carvedilol cefaclor... 7 cefadroxil... 7 cefazolin sodium... 7 cefdinir cefepime hcl... 7 cefotaxime sodium... 7 cefoxitin sodium... 7 cefpodoxime proxetil... 7 cefprozil... 7 ceftazidime... 7 ceftazidime and dextrose... 7 ceftriaxone sodium... 7 cefuroxime axetil... 7, 8 cefuroxime sodium... 8 CELLCEPT CELONTIN cephalexin... 8 CEREZYME CERVARIX CHANTIX... 4 CHANTIX STARTING MONTH PAK... 4 chloramphenicol sod succinate... 5 chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorothiazide sodium chlorpromazine hcl chlorthalidone cholestyramine cholestyramine light chorionic gonadotropin CIALIS ciclopirox... 18, 19 ciclopirox olamine cilostazol cimetidine cimetidine hcl CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 10, 11 ciprofloxacin in d5w citalopram hydrobromide claravis clarithromycin clarithromycin er clemastine fumarate clindacin pac... 5 clindamycin hcl... 5 clindamycin phosphate... 5, 6

96 clindamycin phosphate in d5w... 6 CLINIMIX E/DEXTROSE (2.75/10) CLINIMIX E/DEXTROSE (2.75/5) CLINIMIX E/DEXTROSE (4.25/25) CLINIMIX E/DEXTROSE (4.25/5) CLINIMIX E/DEXTROSE (5/15) CLINIMIX E/DEXTROSE (5/20) CLINIMIX E/DEXTROSE (5/25) CLINIMIX/DEXTROSE (2.75/5) CLINIMIX/DEXTROSE (4.25/10) CLINIMIX/DEXTROSE (4.25/20) CLINIMIX/DEXTROSE (4.25/25) CLINIMIX/DEXTROSE (4.25/5) CLINIMIX/DEXTROSE (5/15) CLINIMIX/DEXTROSE (5/20) CLINIMIX/DEXTROSE (5/25) CLINISOL SF clobetasol propionate clobetasol propionate e clocortolone pivalate pump clodan CLODERM PUMP clomipramine hcl clonazepam... 34, 35 clonidine hcl clonidine hcl er clopidogrel bisulfate clorazepate dipotassium clorpres clotrimazole clotrimazole-betamethasone clozapine COARTEM codeine sulfate... 3 colchicine-probenecid COLCRYS colestipol hcl colistimethate sodium... 5 colocort COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMETRIQ (100 MG DAILY DOSE) COMETRIQ (140 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) COMPLERA compro COMVAX CONDYLOX constulose COPAXONE COREG CR CORTIFOAM cortisone acetate COUMADIN CREON CRESTOR CRIXIVAN cromolyn sodium cryselle CUBICIN... 6 CUPRIMINE CURITY GAUZE cvs prenatal cyclafem 1/ cyclafem 7/7/ cyclobenzaprine hcl cyclophosphamide CYCLOSET cyclosporine cyclosporine modified cyproheptadine hcl CYSTADANE CYSTAGON DALIRESP danazol DAPSONE DAPTACEL DARAPRIM deblitane delyla demeclocycline hcl DEMSER DENAVIR desipramine hcl desmopressin ace rhinal tube desmopressin ace spray refrig desmopressin acetate desmopressin acetate spray desogestrel-ethinyl estradiol desonide desoximetasone dexamethasone dexamethasone intensol dexamethasone sod phosphate pf dexamethasone sodium phosphate dexedrine DEXILANT dexmethylphenidate hcl dextroamphetamine sulfate dextroamphetamine sulfate er DEXTROSE DEXTROSE IN LACTATED RINGERS DEXTROSE-NACL diazepam diazepam intensol diclofenac potassium... 1 diclofenac sodium... 1 diclofenac sodium er... 1 dicloxacillin sodium... 9 dicyclomine hcl didanosine DIFICID diflunisal... 1 digitek digoxin... 45, 46 dihydroergotamine mesylate DILANTIN DILANTIN INFATABS... 14

97 diltiazem hcl diltiazem hcl er diltiazem hcl er beads diltiazem hcl er coated beads dilt-xr DIOVAN DIPENTUM diphenhydramine hcl diphenoxylate-atropine DIPHTHERIA-TETANUS TOXOIDS DT dipyridamole disopyramide phosphate disulfiram... 4 divalproex sodium divalproex sodium er donepezil hcl DORIBAX... 8 dorzolamide hcl dorzolamide hcl-timolol mal doxazosin mesylate doxepin hcl doxycycline hyclate... 11, 12 doxycycline monohydrate dronabinol drospirenone-ethinyl estradiol DROXIA DUAVEE DULERA duloxetine hcl duramorph... 2 DUREZOL e.e.s E.E.S. GRANULES e.s.p econazole nitrate EDARBI EDARBYCLOR EDURANT EFFIENT EGRIFTA ELAPRASE ELIDEL ELIGARD eliphos ELIQUIS ELITEK ELLA ELMIRON EMCYT EMEND emoquette EMSAM EMTRIVA enalapril maleate enalapril-hydrochlorothiazide ENBREL endocet... 1 ENGERIX-B enoxaparin sodium enpresse entacapone entecavir enulose epitol EPIVIR EPIVIR HBV EPZICOM ergoloid mesylates ERIVEDGE errin ERYPED ery-tab erythrocin lactobionate erythrocin stearate erythromycin erythromycin base erythromycin ethylsuccinate escitalopram oxalate esomeprazole sodium estazolam ESTRACE estradiol... 60, 61 estradiol-norethindrone acet estropipate ethambutol hcl ethosuximide etidronate disodium etodolac... 1 etodolac er... 2 EXEL PEN NEEDLES 1/3" EXELON exemestane EXFORGE EXFORGE HCT EXJADE EXTAVIA FABRAZYME falmina famciclovir famotidine famotidine premixed FANAPT FANAPT TITRATION PACK FARESTON FASLODEX FAZACLO felbamate felodipine er fenofibrate fenofibrate micronized fenoprofen calcium... 2 fentanyl... 2 fentanyl citrate... 3 FETZIMA FETZIMA TITRATION FINACEA finasteride FIRAZYR flecainide acetate FLOVENT DISKUS FLOVENT HFA fluconazole fluconazole in dextrose fluconazole in sodium chloride flucytosine fludrocortisone acetate flunisolide fluocinolone acetonide fluocinolone acetonide body fluocinonide fluocinonide-e fluorometholone FLUOROURACIL fluorouracil fluoxetine hcl fluphenazine decanoate fluphenazine hcl flurazepam hcl flurbiprofen... 2

98 flurbiprofen sodium flutamide fluticasone propionate fluvoxamine maleate fomepizole fondaparinux sodium FORTEO foscarnet sodium fosinopril sodium fosinopril sodium-hctz fosphenytoin sodium FOSRENOL furosemide FUZEON FYCOMPA gabapentin GABITRIL galantamine hydrobromide galantamine hydrobromide er GAMMAGARD ganciclovir sodium GARDASIL GARDASIL gatifloxacin gavilyte-c gavilyte-g gavilyte-n with flavor pack gemfibrozil generlac gengraf... 67, 68 GENOTROPIN GENOTROPIN MINIQUICK gentak... 4 gentamicin in saline... 4 gentamicin sulfate... 4, 5 GEODON gianvi gildagia gildess 1.5/ GILENYA GILOTRIF GLEEVEC glimepiride glipizide glipizide er glipizide-metformin hcl GLUCAGEN HYPOKIT GLUCAGON EMERGENCY glyburide glyburide micronized glyburide-metformin glycopyrrolate GNP ULTRA COM INSULIN SYRINGE GRALISE GRALISE STARTER granisetron hcl griseofulvin microsize griseofulvin ultramicrosize guanfacine hcl guanidine hcl HALDOL DECANOATE halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX hecoria heparin (porcine) in d5w heparin (porcine) in nacl heparin sod (porcine) in d5w heparin sodium (porcine) HEPATAMINE HEPATASOL HEXALEN HIBERIX HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50/ HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/ HUMALOG MIX 75/25 KWIKPEN HUMATROPE HUMIRA HUMIRA PEN HUMIRA PEN-CROHNS STARTER HUMIRA PEN-PSORIASIS STARTER HUMULIN 70/ HUMULIN 70/30 PEN HUMULIN N HUMULIN N PEN HUMULIN R HUMULIN R U-500 (CONCENTRATED) hydralazine hcl hydrochlorothiazide hydrocodone-acetaminophen... 1 hydrocodone-ibuprofen... 1 hydrocortisone hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid hydromorphone hcl... 3 hydromorphone hcl pf... 3 hydroxychloroquine sulfate hydroxyurea hydroxyzine hcl hydroxyzine pamoate ibandronate sodium ibuprofen... 2 ICLUSIG ifosfamide ILEVRO ilotycin IMBRUVICA imipenem-cilastatin... 8 imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES INCRELEX INCRUSE ELLIPTA indapamide indomethacin... 2 INFANRIX INLYTA INTELENCE INTRALIPID INTRON A INTRON-A introvale INVANZ... 8 INVEGA INVEGA SUSTENNA INVIRASE INVOKAMET INVOKANA IONOSOL-B IN D5W... 82

99 IONOSOL-MB IN D5W IPOL ipratropium bromide ipratropium-albuterol ISENTRESS ISOLYTE-P IN D5W ISOLYTE-S isoniazid isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er itraconazole ivermectin IXEMPRA KIT IXIARO JAKAFI JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jinteli jolivette junel 1.5/ junel 1/ junel fe 1.5/ junel fe 1/ JUXTAPID kalbitor KALETRA KALYDECO kariva KCL IN DEXTROSE-NACL KCL-LACTATED RINGERS-D5W kelnor 1/ ketoconazole ketoprofen... 2 ketoprofen er... 2 ketorolac tromethamine KINRIX kionex klor-con klor-con klor-con m klor-con m klor-con m KOMBIGLYZE XR KORLYM KUVAN labetalol hcl LACRISERT LACTATED RINGERS lactulose lamivudine lamivudine-zidovudine lamotrigine LANOXIN LANOXIN PEDIATRIC LANTUS LANTUS SOLOSTAR larin 1.5/ larin 1/ larin fe 1.5/ larin fe 1/ latanoprost LATUDA LAZANDA... 3 leena leflunomide lessina LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide acetate LEVEMIR LEVEMIR FLEXTOUCH levetiracetam levetiracetam in nacl levobunolol hcl levocetirizine dihydrochloride levofloxacin levofloxacin in d5w levonest levonorgest-eth estrad 91-day levora 0.15/30 (28) levothyroxine sodium levoxyl LEXIVA LIALDA lidocaine... 3 lidocaine hcl... 3 lidocaine hcl (cardiac)... 3 lidocaine hcl (pf)... 3 lidocaine viscous... 4 lidocaine-prilocaine... 4 LIDODERM... 4 liothyronine sodium LIPOSYN III lisinopril lisinopril-hydrochlorothiazide lithium lithium carbonate lithium carbonate er LIVALO lokara lomustine loperamide hcl lorazepam loryna losartan potassium losartan potassium-hctz LOTEMAX LOTRONEX lovastatin low-ogestrel loxapine succinate LUMIGAN LUMIZYME lutera LYNPARZA LYRICA LYSODREN lyza magnesium sulfate malathion maprotiline hcl marlissa MARPLAN MATULANE matzim la meclizine hcl MEDROL medroxyprogesterone acetate mefloquine hcl megestrol acetate... 64

100 MEKINIST meloxicam... 2 MENACTRA MENEST MENOMUNE MENVEO meprobamate mercaptopurine meropenem... 8 mesalamine-cleanser mesna MESNEX MESTINON metadate er metaproterenol sulfate metformin hcl metformin hcl er metformin hcl er (osm) methadone hcl... 2 methazolamide methenamine hippurate... 6 methimazole methocarbamol methotrexate methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine bromide methyclothiazide methyldopa methyldopa-hydrochlorothiazide methylphenidate hcl methylphenidate hcl er methylprednisolone methylprednisolone (pak) methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate er metoprolol tartrate metoprolol-hydrochlorothiazide metronidazole... 6 metronidazole in nacl... 6 mexiletine hcl MIACALCIN microgestin 1.5/ microgestin 1/ microgestin fe 1.5/ microgestin fe 1/ midodrine hcl MIGERGOT MIGRANAL millipred mimvey lo minitran minocycline hcl minoxidil mirtazapine misoprostol mitoxantrone hcl M-M-R II modafinil moexipril hcl moexipril-hydrochlorothiazide mometasone furoate mononessa montelukast sodium morphine sulfate... 2 morphine sulfate (concentrate)... 2 morphine sulfate (pf)... 3 morphine sulfate er... 3 MOVIPREP MOXEZA MOZOBIL MULTAQ mupirocin... 6 mupirocin calcium... 6 MYCAMINE mycophenolate mofetil mycophenolic acid myorisan MYOZYME nabumetone... 2 nadolol NAFTIN NAGLAZYME naloxone hcl... 4 naltrexone hcl... 4 NAMENDA NAMENDA TITRATION PAK NAMENDA XR NAMENDA XR TITRATION PACK naphazoline hcl naproxen... 2 naproxen dr... 2 naproxen sodium... 2 naratriptan hcl NASONEX NATACYN nateglinide NATURE-THROID NEBUPENT necon 0.5/35 (28) necon 1/35 (28) necon 1/50 (28) necon 10/11 (28) necon 7/7/ nefazodone hcl neomycin sulfate... 5 neomycin-bacitracin zn-polymyx neomycin-polymyxin b gu... 5 neomycin-polymyxin-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc NEPHRAMINE NEUMEGA NEUPOGEN NEUPRO NEVANAC nevirapine nevirapine er NEXAVAR NEXIUM niacin er (antihyperlipidemic) NIACOR nicardipine hcl NICOTROL NS... 4 nifedical xl nifedipine nifedipine er osmotic nikki NILANDRON... 22

101 nimodipine NITRO-BID nitrofurantoin macrocrystal... 6 nitrofurantoin monohyd macro... 6 nitroglycerin NITROSTAT nora-be NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX PEN norethindrone norethindrone acetate norlyroc NORMOSOL-M IN D5W NORMOSOL-R IN D5W NORMOSOL-R PH NORPACE CR nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/ nortriptyline hcl NORVIR... 33, 34 NOXAFIL np thyroid NUEDEXTA NULOJIX nutrilipid NUTROPIN AQ NUSPIN NUTROPIN AQ PEN nyamyc nystatin... 19, 20 nystatin-triamcinolone nystop ocella octreotide acetate ofloxacin ogestrel olanzapine olopatadine hcl OLYSIO omega-3-acid ethyl esters omeprazole OMNITROPE ondansetron ondansetron hcl ONFI ONGLYZA OPANA ER... 3 ORAP ORFADIN orsythia oxacillin sodium... 9 oxandrolone oxaprozin... 2 oxazepam oxcarbazepine oxybutynin chloride oxybutynin chloride er oxycodone hcl... 3 oxycodone-acetaminophen... 1 oxymorphone hcl er... 3 pacerone pamidronate disodium PANRETIN pantoprazole sodium paricalcitol paromomycin sulfate... 5 paroxetine hcl PASER PATADAY PATANASE PATANOL PAXIL PEDIARIX pedi-dri PEDVAX HIB peg 3350/electrolytes peg-3350/electrolytes PEGANONE PEG-INTRON PEG-INTRON REDIPEN penicillin g potassium... 9 PENICILLIN G PROCAINE... 9 penicillin v potassium... 9 PENTACEL PENTAM pentoxifylline er perindopril erbumine periogard permethrin perphenazine PERTZYE phenadoz phenelzine sulfate phenergan phenobarbital phenytoin phenytoin sodium phenytoin sodium extended PHYSIOLYTE PHYSIOSOL IRRIGATION pilocarpine hcl pimtrea pindolol pioglitazone hcl pioglitazone hcl-glimepiride pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so... 9 pirmella 1/ piroxicam... 2 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN D5W podofilox polyethylene glycol polymyxin b-trimethoprim POMALYST portia potassium chloride POTASSIUM CHLORIDE potassium chloride crys er potassium chloride er POTASSIUM CHLORIDE IN DEXTROSE POTASSIUM CHLORIDE IN NACL potassium citrate er POTIGA PRADAXA pramipexole dihydrochloride PRANDIMET pravastatin sodium prazosin hcl prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate prednisone prednisone intensol... 59

102 prefest PREMARIN PREMASOL PREMPHASE PREMPRO prevalite previfem PREZISTA PRIFTIN primaquine phosphate primidone PRISTIQ probenecid procainamide hcl PROCALAMINE prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT proctosol hc proctozone-hc PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine hcl promethazine vc plain promethegan propafenone hcl propantheline bromide propranolol hcl... 42, 43 propranolol hcl er propranolol-hctz propylthiouracil PROQUAD prosol protriptyline hcl PULMICORT FLEXHALER PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide quasense quetiapine fumarate quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate er quinidine sulfate quinidine sulfate er quinine sulfate RABAVERT raloxifene hcl ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE REBIF REBIF REBIDOSE REBIF REBIDOSE TITRATION PACK REBIF TITRATION PACK reclipsen RECOMBIVAX HB REGRANEX RELENZA DISKHALER RELION INSULIN SYRINGE RELISTOR REMICADE REMODULIN RENVELA repaglinide RESCRIPTOR reserpine RESTASIS RETROVIR REVLIMID REYATAZ ribasphere RIBASPHERE RIBAPAK ribavirin RIDAURA rifabutin rifampin riluzole rimantadine hcl RINGERS RINGERS IRRIGATION RISPERDAL CONSTA risperidone RITUXAN rivastigmine tartrate ropinirole hcl ROTARIX ROTATEQ roxicet... 1 SABRIL SAIZEN SAMSCA SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS SAVELLA SAVELLA TITRATION PACK selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL XR sertraline hcl sharobel sildenafil citrate silver sulfadiazine SIMBRINZA simvastatin sirolimus sivextro... 6 sodium chloride SODIUM LACTATE sodium polystyrene sulfonate SOLTAMOX SOMATULINE DEPOT SOMAVERT sorine sotalol hcl sotalol hcl (af) SOVALDI spironolactone spironolactone-hctz sprintec SPRYCEL sronyx ssd stavudine STIVARGA STRATTERA streptomycin sulfate... 5

103 STRIBILD STROMECTOL SUBOXONE... 4 SUCRAID sucralfate sulfacetamide sodium sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-tmp ds sulfamethoxazole-trimethoprim sulfasalazine sulfazine ec sulindac... 2 sumatriptan sumatriptan succinate... 20, 21 SUPRAX... 8 SUPREP BOWEL PREP SURMONTIL SUSTIVA SUTENT SYLATRON SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID... 5 SYNRIBO SYNTHROID SYPRINE TABLOID tacrolimus TAFINLAR TAMIFLU tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN tarina fe 1/ TASIGNA TASMAR TAZORAC... 51, 52 taztia xt TECFIDERA TEFLARO... 8 TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hctz temazepam terazosin hcl terbinafine hcl terbutaline sulfate terconazole TESTIM testosterone cypionate testosterone enanthate TETANUS TOXOID ADSORBED TETANUS-DIPHTHERIA TOXOIDS TD tetracycline hcl THALOMID THEO theophylline er thioridazine hcl thiothixene THYMOGLOBULIN THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine hcl ticlopidine hcl TIKOSYN TIMENTIN... 9 timolol maleate TIVICAY tizanidine hcl TOBI PODHALER... 5 tobramycin... 5 tobramycin sulfate... 5 tobramycin-dexamethasone tolazamide tolbutamide topiramate torsemide tpn electrolytes TRACLEER tramadol hcl... 3 tramadol-acetaminophen... 1 trandolapril tranexamic acid TRANSDERM-SCOP tranylcypromine sulfate TRAVASOL TRAVATAN Z trazodone hcl TREANDA TRECATOR TRELSTAR DEPOT TRELSTAR DEPOT MIXJECT TRELSTAR LA TRELSTAR LA MIXJECT TRELSTAR MIXJECT tretinoin TREXALL triamcinolone acetonide triamterene-hctz triazolam triderm trifluoperazine hcl trifluridine trihexyphenidyl hcl tri-legest fe trilyte trimethoprim... 6 trinessa (28) tri-previfem TRISENOX tri-sprintec TRIUMEQ trivora (28) TROKENDI XR TROPHAMINE tropicamide trospium chloride TRUMENBA TRUVADA TUDORZA PRESSAIR TWINRIX TYBOST TYGACIL... 6 TYKERB TYPHIM VI TYSABRI TYZEKA ULORIC unithroid ursodiol valacyclovir hcl... 31

104 VALCHLOR VALCYTE valganciclovir hcl valproate sodium valproic acid valsartan-hydrochlorothiazide vancomycin hcl... 6 vandazole... 6 VAQTA VARIVAX VARIZIG VASCEPA VELCADE velivet venlafaxine hcl venlafaxine hcl er VENTOLIN HFA verapamil hcl verapamil hcl er VERSACLOZ VESICARE vestura V-GO V-GO V-GO VICTRELIS VIDEX VIGAMOX VIIBRYD VIMPAT VIRACEPT VIRAMUNE XR VIRAZOLE VIREAD VIVELLE-DOT VOLTAREN voriconazole VOTRIENT VPRIV vyfemla warfarin sodium WELCHOL wymzya fe XALKORI XENAZINE XGEVA XIFAXAN... 6 XOLAIR XTANDI XYREM YF-VAX zafirlukast zaleplon ZAVESCA zazole ZELAPAR ZELBORAF ZEMPLAR zenatane zenchent zenchent fe ZENPEP ZETIA ZIAGEN zidovudine ziprasidone hcl ZIRGAN zoledronic acid ZOLINZA zolpidem tartrate ZOMETA zonisamide ZORTRESS ZOSTAVAX zovia 1/35e (28) zovia 1/50e (28) ZOVIRAX ZYDELIG ZYKADIA ZYLET ZYTIGA ZYVOX

105 We re always just a phone call away! If you re ready to enroll or have enrollment questions, call , 8 a.m. to 8 p.m., 7 days a week. If you re already a member, call the number for your state/plan listed below. Arkansas: WellCare Comp Access (HMO SNP) Connecticut: WellCare Access (HMO SNP) WellCare Rx (HMO) Georgia: WellCare Access (HMO SNP) Hawai i: Ohana Liberty (HMO-POS SNP) Illinois: WellCare Access or Rx (HMO/HMO SNP) Kentucky: WellCare Access (HMO SNP) Mississippi: New York: South Carolina: WellCare Access or Comp Access (HMO SNP) WellCare Access (HMO SNP) WellCare Liberty (HMO SNP) WellCare Rx (HMO) WellCare Comp Access (HMO SNP) Tennessee: WellCare Comp Access (HMO SNP) Texas: WellCare Access (HMO SNP) Hours of operation are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are available Monday Sunday, 8 a.m. to 8 p.m., or visit us anytime at or Nurse Advice Line (24 hours, 7 days a week) TTY for all of the above

106

107 This information is available for free in other languages. Please call our Customer Service number at , Monday-Friday, 8 am to 8 p.m. Between October 1and February 14, representatives are available Monday-Sunday, 8 a.m. to 8 p.m. TTY users should call Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de Servicio al Cliente al , de lunes a viernes, de 8 a.m. a 8 p.m. Entre el 1de octubre y el 14 de febrero, los representantes están disponibles de lunes a domingo de 8 a.m. a 8 p.m. Los usuarios de TTY deben llamar al 本資訊免費提供其它語言版本 請撥打 與我們的客戶服務部聯繋, 服務時間為週一至週五, 上午 8 點至晚上 8 點 在十月 1 日至二月 14 日之間, 代表的服務時間為週一至週日, 上午 8 點至晚上 8 點 TTY 用戶請撥打 Thông tin này hiện có miễn phí bằng các ngôn ngữ khác. X in gọi Dịch Vụ Khách Hàng của chúng tô i tại số , Thứ H ai-thứ Sáu, 8 sáng tớ i 8 tố i Trong khoảng Ngày 1 Tháng M ười va 14 Tháng Hai, các đại diện có sẵn Thứ H ai-c hủ Nhật, 8 sáng tớ i 8 tố i những người sử dụng TTY nên gọi số Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare (HMO) is a Medicare Advantage organization with a Medicare contract. Enrollment in WellCare (HMO) depends on contract renewal. WellCare (HMO SNP) is a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid programs. Enrollment in WellCare/ Ohana (HMO SNP) depends on contract renewal. WellCare/ Ohana uses a formulary. Some plans are available to those who have medical assistance from both the state and Medicare. Premiums, co-pays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, co-payments and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/coinsurance may change on January 1of each year. This formulary was updated on 03/01/2015. For more recent information or other questions, please contact WellCare/ Ohana at the telephone number listed on the inside front and back covers of this formulary or visit or P.O. Box Tampa, FL

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