Drug List 3 Tiers. for employer-sponsored plans

Transcription

1 Drug List Tiers for employer-sponsored plans 208

2 This document is the complete ConnectiCare pharmacy drug list, or formulary, that is covered by your employer-sponsored plan with three-tier drug benefits. This drug list is effective for plan year 208. It is updated monthly and the last update was on January, 208. The list is subject to change as new drugs come to market or are removed from the market. Please check the Pharmacy Center on connecticare.com for the most up-to-date drug list covered by your plan. What is a drug list? It s a list of covered drugs both generic and brand-name drugs selected by ConnectiCare in consultation with a team of health care providers. It includes the prescription therapies believed to be a necessary part of a quality treatment program. ConnectiCare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a ConnectiCare network pharmacy and other plan rules are followed. How do I use the formulary? To search for your drug within the formulary, please refer to the: Table of Contents on page and look for your drug under the therapeutic class sections; or Index, which starts on page 7 and look for your drug and the corresponding page. This formulary will tell you what tier your drug is in. A drug tier is a group of medications included within a similar price range. Check your benefit summary to see what your costshare is for the drugs in each tier. Tier Tier 0 Tier Tier 2 Tier What drugs are included Drugs covered under health care reform Generic drugs Preferred brand-name drugs Non-preferred brand name drugs If your doctor prescribes a drug that is not listed, please contact ConnectiCare for further information on coverage of the product in question. If it s appropriate, ask your doctor about a generic medication or a more affordable alternative that is included in the drug list. Refer to your benefit summary by logging in on connecticare.com to determine actual cost-share amounts applicable to your plan. What are generic drugs and brand-name drugs? A generic drug is approved by the U.S. Food and Drug Administration (FDA) as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. This formulary differentiates between the two kinds of drugs by how they are presented on the list: generic drugs are italicized and spelled out in lowercase letters brand-name drugs are not italicized and spelled out in uppercase letters Under your plan, a pharmacist will fill a generic drug for a prescription whenever a generic is available. For the most part, this will happen even if your prescription is written for a brand-name drug. But you or your doctor can specifically instruct the pharmacist to fill the prescription with a brand-name drug. When this happens, you may pay more and the cost will depend on your plan benefits. Please refer to your plan documents for details. i

3 Are there any limitations on my coverage? Some covered drugs may have additional requirements or on coverage. These are indicated in the formulary with initials after their names. Here is a key to the limitations and how you will see them noted in the formulary: Preauthorization (PA) Some drugs require preauthorization. This means that you or your doctor will need to get approval from us before you fill your prescriptions. If you don t get approval, the drug may not be covered and you may be responsible for the entire cost of the medication. Preauthorization requests can be faxed to the ConnectiCare Pharmacy Services Department at by the prescribing physician s office. A form for submitting a request can be found on connecticare.com. If we deny a preauthorization request, we will notify you and your doctor in writing with the reason and information on how to appeal. Some drugs that require preauthorization must be filled at a specialty pharmacy. Please refer to the limited availability section below for more information. Quantity (QL) For certain medications, ConnectiCare the amount of the drug that we will cover. For example, ConnectiCare covers MAXALT (or its generic version, rizatriptan) for 9 tablets per 0 days. This may be in addition to a standard one-month or three-month supply. Step therapy (ST) In some cases, ConnectiCare 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. Limited availability (LA) Drugs labeled LA for limited availability must be filled by ConnectiCare s preferred specialty pharmacy, Accredo, and are limited to a 0-day supply. These drugs are prescription medications used to treat complex conditions and often require special storage, handling and close monitoring by you, your doctor or pharmacist. For more information, please visit accredo.com. Over the counter (OTC) ConnectiCare does not cover over-the-counter drugs unless they are listed in this formulary and have been prescribed by a doctor. The formulary notes which drugs have any additional requirements or. Affordable Care Act (ACA) This refers to the preventive care guidelines of the federal Affordable Care Act, also known as health care reform. Drugs marked ACA may be free to you if they are prescribed under the preventive care guidelines of the ACA. You will not have to pay any copayment, coinsurance or anything toward your deductible. More information on ACA-covered drugs is available here. Can I get my prescriptions delivered to my home? Our pharmacy benefit manager, Express Scripts, provides convenient home delivery by mail. Home delivery may save you money if you refill drugs every month and think you will be on the same drug(s) for six months or longer. Home delivery is as safe as going to your local pharmacy. Express Scripts pharmacists check every order for accuracy and are available 24/7 to answer your questions. To ii

4 compare costs and sign up for home delivery, visit express-scripts.com or call Express Scripts at How do I contact someone at ConnectiCare? To reach Member Services: Call (TTY: ) Monday-Thursday, 8 a.m. to 6 p.m., and Friday from 8 a.m. to 5 p.m. Send a secure message by logging into connecticare.com. For general questions only, us at info@connecticare.com. Please do not use this address to send any personal, confidential or medical information, such as member ID, Social Security number or medical information. This is a regular address that is not secure. To reach Provider Services: Call Monday-Thursday, 8 a.m. to 6 p.m., and Friday from 9 a.m. to 5 p.m. For preauthorization requests or any medical management issue, call Monday-Friday from 8 a.m. to 5 p.m. Use our website at connecticare.com/providers to check benefit eligibility and claims status, review medical criteria and find forms. If you need to mail us anything, send to: ConnectiCare Attention: Pharmacy Department 75 Scott Swamp Road P.O. Box 4050 Farmington, CT More contact information is available at connecticare.com. Accessibility and Nondiscrimination Notice: ConnectiCare complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ConnectiCare does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. ConnectiCare: Provides free aids and services to people with disabilities to communicate effectively with us including qualified interpreters and information in alternate formats. Provides free language services to people whose primary language is not English, including translated documents and oral interpretation. If you need these services, contact The Committee for Civil Rights. If you believe that ConnectiCare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: The Committee for Civil Rights ConnectiCare 75 Scott Swamp Road Farmington, CT (TTY: ) You can file a grievance in person at 75 Scott Swamp Road, Farmington, CT, or by mail or fax (860) If you need help filing a grievance, The Committee for Civil Rights is iii

5 available to help you. You can also file a civil rights complaint with the U.S, Department of Health and Human Services, Office for Civil Rights, electronically through the Office of Civil Rights Complaint Portal, available at: or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, DC (TTY: ) Complaint forms are available at: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: ). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: ). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ) ب رقم اتص ل.بالمج ان ل ك تتواف ر اللغوي ة المس اعدة خدمات ف إن اللغ ة اذك ر تتح دث كن ت إذا :ملحوظة.( :والبك م الص م ھ اتف رق م) 7722 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: ). य न द : य द आप ह द ब लत ह त आपक लए म त म भ ष सह यत स व ए उपल ध ह (TTY: ) पर क ल कर PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). iv

6 ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). របយ តន ប ស នជ អនកន យ យ ភ ស ខមរ, សវ ជ ន យ ផនកភ ស ដ យម នគ តឈន ល គ អ ចម នស រ ប ប រ អនក ច រ ទ រស ពទ (TTY: ) સ ચન : જ તમ ગ જર ત બ લત હ, ત ન:શ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલ ધ છ. ફ ન કર (TTY: ). Intro Rev v

7 Table of Contents Anti - Infectives... Antineoplastic & Immunosuppressant Drugs... Autonomic & Cns Drugs, Neurology & Psych... 8 Cardiovascular, Hypertension & Lipids... 5 Dermatologicals/Topical Therapy Diagnostics & Miscellaneous Agents Ear, Nose & Throat Medications Endocrine/Diabetes Gastroenterology... 7 Immunology, Vaccines & Biotechnology Musculoskeletal & Rheumatology Obstetrics & Gynecology Ophthalmology... 9 Respiratory, Allergy, Cough & Cold Urologicals Vitamins, Hematinics & Electrolytes... 0 Index...

8 List of Abbreviations ACA: Affordable Care Act. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan 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. 2

9 Anti - Infectives Antifungal Agents ABELCET PA AMBISOME PA amphotericin b PA ANCOBON clotrimazole mucous membrane CRESEMBA INTRAVENOUS PA CRESEMBA ORAL QL DIFLUCAN ERAXIS(WATER DILUENT) fluconazole fluconazole in dextrose(iso-o) flucytosine griseofulvin microsize griseofulvin ultramicrosize GRIS-PEG (ULTRAMICROSIZ E) PA PA itraconazole PA; QL ketoconazole oral LAMISIL ORAL TABLET MYCAMINE PA NOXAFIL INTRAVENOUS NOXAFIL ORAL PA nystatin oral powder 50 million unit, 500 million unit nystatin oral suspension nystatin oral tablet ONMEL PA ORAVIG ST; QL SPORANOX ORAL SOLUTION SPORANOX PULSEPAK terbinafine hcl oral PA; QL PA; QL VFEND QL VFEND IV PA voriconazole intravenous PA voriconazole oral QL Antivirals abacavir abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir amantadine hcl APTIVUS PA

10 ATRIPLA BARACLUDE cidofovir PA COMBIVIR COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DAKLINZA PA; LA DESCOVY didanosine EDURANT EMTRIVA 2 entecavir EPCLUSA PA; LA EPIVIR EPIVIR HBV ORAL SOLUTION EPIVIR HBV ORAL TABLET EPZICOM EVOTAZ famciclovir FLUMADINE ORAL TABLET foscarnet PA FOSCAVIR PA FUZEON SUBCUTANEOUS RECON SOLN GENVOYA 2 2 PA; LA HARVONI PA; LA; QL HEPSERA INTELENCE INVIRASE 2 ISENTRESS HD 2 ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE KALETRA ORAL SOLUTION KALETRA ORAL TABLET lamivudine lamivudinezidovudine LEXIVA lopinavir-ritonavir MAVYRET PA; LA nevirapine NORVIR 2 ODEFSEY OLYSIO 2 PA; LA oseltamivir QL PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG RAPIVAB PA RELENZA DISKHALER RESCRIPTOR QL 4

11 RETROVIR INTRAVENOUS RETROVIR ORAL CAPSULE RETROVIR ORAL SYRUP REYATAZ ORAL CAPSULE 50 MG, 200 MG, 00 MG REYATAZ ORAL POWDER IN PACKET PA; LA ribavirin inhalation PA rimantadine SELZENTRY SITAVIG PA SOVALDI 2 PA; LA stavudine STRIBILD SUSTIVA 2 SYNAGIS PA; LA; QL TAMIFLU ORAL CAPSULE TAMIFLU ORAL SUSPENSION FOR RECONSTITUTIO N 2 QL 2 QL TECHNIVIE PA; LA TIVICAY TRIUMEQ TRIZIVIR TRUVADA TYBOST valacyclovir VALCYTE ORAL RECON SOLN VALCYTE ORAL TABLET valganciclovir oral recon soln valganciclovir oral tablet VALTREX VEMLIDY VIDEX 2 GRAM PEDIATRIC VIDEX EC QL QL VIEKIRA PAK PA; LA; QL VIEKIRA XR PA; LA VIRACEPT ORAL TABLET VIRAMUNE VIRAMUNE XR VIRAZOLE PA VIREAD ORAL POWDER VIREAD ORAL TABLET VOSEVI PA; LA; QL ZEPATIER 2 PA; LA ZERIT ZIAGEN ORAL SOLUTION ZIAGEN ORAL TABLET zidovudine ZOVIRAX ORAL Cephalosporins AVYCAZ PA CEDAX cefaclor oral capsule

12 cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml, 75 mg/5 ml cefaclor oral tablet extended release 2 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, 2 gram/50 ml CEFAZOLIN IN DEXTROSE (ISO- OS) INTRAVENOUS PIGGYBACK 2 GRAM/00 ML CEFAZOLIN IN DEXTROSE 5 % INTRAVENOUS SOLUTION CEFAZOLIN IN STERILE WATER INTRAVENOUS SYRINGE 2 GRAM/20 ML cefdinir cefditoren pivoxil cefepime PA 6 CEFEPIME IN DEXTROSE 5 % cefepime in dextrose,iso-osm PA cefixime QL CEFOTAN PA cefotaxime PA cefotetan PA CEFOTETAN IN DEXTROSE, ISO- OSM PA cefoxitin PA cefoxitin in dextrose, iso-osm PA cefpodoxime QL cefprozil ceftazidime PA CEFTAZIDIME IN D5W ceftibuten CEFTIN ORAL SUSPENSION FOR RECONSTITUTIO N ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln gram, 0 gram, 2 gram, 250 mg, 500 mg CEFTRIAXONE INJECTION RECON SOLN 00 GRAM ceftriaxone intravenous cefuroxime axetil oral tablet PA PA PA PA PA

13 cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous cephalexin PA PA DAXBIA PA FORTAZ PA FORTAZ IN DEXTROSE 5 % KEFLEX ORAL CAPSULE PA MAXIPIME PA SPECTRACEF ORAL TABLET 400 MG SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N SUPRAX ORAL TABLET,CHEWAB LE QL QL QL TAZICEF PA TEFLARO PA ZERBAXA PA ZINACEF IN STERILE WATER ZINACEF INJECTION RECON SOLN 750 MG ZINACEF INTRAVENOUS PA PA PA Erythromycins & Other Macrolides azithromycin intravenous azithromycin oral clarithromycin PA DIFICID PA; QL e.e.s. 400 oral tablet E.E.S. GRANULES ERYPED ERYPED ery-tab oral tablet,delayed release (dr/ec) 250 mg, mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet PCE ZITHROMAX INTRAVENOUS 2 PA PA 7

14 ZITHROMAX ORAL ZITHROMAX TRI- PAK ZITHROMAX Z- PAK ZMAX Miscellaneous Antiinfectives ALBENZA ALINIA QL amikacin injection solution,000 mg/4 ml, 500 mg/2 ml atovaquone PA atovaquoneproguanil PA AZACTAM PA AZACTAM IN DEXTROSE (ISO- OSM) PA aztreonam PA baciim PA bacitracin intramuscular BETHKIS BILTRICIDE PA CAPASTAT PA CAYSTON PA chloramphenicol sod succinate chloroquine phosphate CLEOCIN HCL CLEOCIN IN 5 % DEXTROSE PA PA PA CLEOCIN INJECTION CLEOCIN INTRAVENOUS SOLUTION 600 MG/4 ML, 900 MG/6 ML CLEOCIN PEDIATRIC PA PA CLIN SINGLE USE PA clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate intravenous solution 600 mg/4 ml, 900 mg/6 ml PA PA PA COARTEM PA colistin (colistimethate na) COLY-MYCIN M PARENTERAL CYCLOSERINE PA PA DALVANCE PA dapsone DARAPRIM 2 PA EMVERM ethambutol FLAGYL 8

15 gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 00 MG/50 ML, 20 MG/00 ML gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 00 mg/0 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML hydroxychloroquine imipenem-cilastatin PA IMPAVIDO PA INVANZ PA isoniazid injection PA isoniazid oral ivermectin KITABIS PAK linezolid intravenous PA linezolid oral QL linezolid-0.9% sodium chloride PA MALARONE PA MALARONE PEDIATRIC PA mefloquine PA MEPRON PA meropenem PA MERREM PA metro i.v. PA metronidazole in nacl (iso-os) metronidazole oral MYAMBUTOL ORAL TABLET 400 MG MYCOBUTIN NEBUPENT neomycin PA ORBACTIV PA paromomycin PASER PENTAM PA PLAQUENIL polymyxin b sulfate PA PRIFTIN 2 PRIMAQUINE 2 PRIMAXIN IV INTRAVENOUS RECON SOLN 500 MG pyrazinamide PA QUALAQUIN PA quinine sulfate rifabutin RIFADIN INTRAVENOUS PA 9

16 RIFADIN ORAL RIFAMATE rifampin intravenous PA rifampin oral RIFATER SIRTURO SIVEXTRO INTRAVENOUS SIVEXTRO ORAL PA STREPTOMYCIN PA STROMECTOL SYNERCID PA TIGECYCLINE PA TINDAMAX ORAL TABLET 500 MG QL tinidazole QL TOBI TOBI PODHALER tobramycin in % nacl tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate TOBRAMYCIN WITH NEBULIZER TRECATOR TYGACIL PA XIFAXAN ZYVOX INTRAVENOUS PA ZYVOX ORAL QL Penicillins amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate ampicillin oral capsule ampicillin sodium PA ampicillin-sulbactam injection ampicillin-sulbactam intravenous recon soln.5 gram AUGMENTIN ES- 600 AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML AUGMENTIN ORAL TABLET MG, MG AUGMENTIN XR PA PA BICILLIN C-R PA 2 0

17 BICILLIN L-A dicloxacillin MOXATAG nafcillin PA nafcillin in dextrose iso-osm oxacillin in dextrose(iso-osm) PA PA oxacillin injection PA oxacillin intravenous recon soln 2 gram PENICILLIN G POT IN DEXTROSE penicillin g potassium PA PA PA penicillin g procaine PA penicillin g sodium PA penicillin v potassium pfizerpen-g PA UNASYN INJECTION ZOSYN IN DEXTROSE (ISO- OSM) Quinolones AVELOX AVELOX IN NACL (ISO-OSMOTIC) CIPRO IN D5W INTRAVENOUS PIGGYBACK 400 MG/200 ML PA PA PA PA CIPRO ORAL SUSPENSION,MIC ROCAPSULE RECON CIPRO ORAL TABLET 250 MG, 500 MG CIPRO XR ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose PA ciprofloxacin lactate PA FACTIVE LEVAQUIN ORAL TABLET levofloxacin in d5w PA levofloxacin intravenous levofloxacin oral moxifloxacin oral MOXIFLOXACIN- SOD.ACE,SUL- WATER ofloxacin oral tablet 00 mg, 400 mg Sulfa's & Related Agents BACTRIM BACTRIM DS sulfadiazine sulfamethoxazoletrimethoprim intravenous PA PA PA

18 sulfamethoxazoletrimethoprim oral sulfatrim Tetracyclines ACTICLATE PA avidoxy AVIDOXY DK PA demeclocycline DORYX MPC PA DORYX ORAL TABLET,DELAYE D RELEASE (DR/EC) 200 MG, 50 MG 2 PA doxy-00 PA doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg, 20 mg doxycycline hyclate oral tablet 50 mg, 75 mg doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR - DELAY REL,BIPHASE doxycycline monohydrate oral suspension for reconstitution PA PA doxycycline monohydrate oral tablet MINOCIN PA minocycline oral capsule minocycline oral tablet minocycline oral tablet extended release 24 hr mondoxyne nl PA MONODOX PA ORACEA PA SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 05 MG, 5 MG, 55 MG, 65 MG, 80 MG PA TARGADOX PA tetracycline VIBRAMYCIN ORAL CAPSULE 00 MG VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTIO N VIBRAMYCIN ORAL SYRUP Urinary Tract Agents FURADANTIN HIPREX MACROBID MACRODANTIN 2

19 methenamine hippurate methenamine mandelate MONUROL QL nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst PRIMSOL trimethoprim Vancomycin VANCOCIN vancomycin intravenous vancomycin oral capsule VIBATIV INTRAVENOUS RECON SOLN 750 MG PA Antineoplastic & Immunosuppressant Drugs Adjunctive Agents amifostine crystalline PA; LA ELITEK PA; LA ETHYOL PA; LA KEPIVANCE PA; LA leucovorin calcium injection recon soln leucovorin calcium oral PA; LA mesna PA; LA MESNEX INTRAVENOUS MESNEX ORAL PA; LA VISTOGARD PA VORAXAZE PA XGEVA QL Antineoplastic & Immunosuppressant Drugs ABRAXANE PA; LA ADCETRIS PA adriamycin intravenous solution PA; LA adrucil PA; LA AFINITOR PA; LA AFINITOR DISPERZ PA; LA ALECENSA PA; LA ALIMTA PA; LA ALKERAN INTRAVENOUS ALKERAN ORAL PA; LA ALUNBRIG PA; LA anastrozole ARIMIDEX AROMASIN ARRANON PA; LA ARZERRA PA; LA ASTAGRAF XL AVASTIN PA; LA azacitidine PA; LA AZASAN azathioprine azathioprine sodium PA

20 BAVENCIO PA BELEODAQ PA BENDEKA PA; LA bexarotene PA bicalutamide BICNU PA; LA bleo 5k PA bleomycin PA; LA BLINCYTO INTRAVENOUS KIT PA BOSULIF PA; LA; QL busulfan PA; LA BUSULFEX PA; LA CABOMETYX PA; LA CAMPTOSAR PA; LA capecitabine PA; LA CAPRELSA PA; QL carboplatin intravenous solution CASODEX CELLCEPT CELLCEPT INTRAVENOUS PA; LA PA; LA cisplatin PA; LA cladribine PA; LA clofarabine PA; LA CLOLAR PA; LA COMETRIQ PA COSMEGEN PA; LA COTELLIC PA; LA cyclophosphamide intravenous PA; LA CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule PA; LA CYRAMZA PA cytarabine PA; LA cytarabine (pf) injection solution PA; LA dacarbazine PA; LA DACOGEN PA; LA DARZALEX PA; LA daunorubicin PA; LA decitabine PA; LA DOCEFREZ PA; LA docetaxel intravenous solution 60 mg/6 ml (0 mg/ml), 60 mg/8 ml (20 mg/ml), 20 mg/2 ml (0 mg/ml), 20 mg/ml ( ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (0 mg/ml) DOCETAXEL INTRAVENOUS SOLUTION 20 MG/ML PA; LA PA; LA DOXIL PA; LA doxorubicin PA; LA doxorubicin, pegliposomal DROXIA 2 PA 4

21 ELIGARD LA ELIGARD ( MONTH) ELIGARD (4 MONTH) ELIGARD (6 MONTH) LA LA LA ELLENCE PA; LA EMCYT EMPLICITI PA; LA ENVARSUS XR epirubicin intravenous recon soln 200 mg epirubicin intravenous solution PA; LA PA; LA ERBITUX PA; LA ERIVEDGE PA; LA; QL ERWINAZE PA; LA ETOPOPHOS PA; LA etoposide intravenous etoposide oral PA; LA EVOMELA PA exemestane FARESTON 2 FARYDAK PA; LA FASLODEX PA FEMARA FIRMAGON KIT W DILUENT SYRINGE PA floxuridine PA; LA fludarabine PA; LA fluorouracil intravenous flutamide PA; LA FOLOTYN PA; LA GAZYVA PA; LA gemcitabine PA; LA GEMZAR PA; LA gengraf GILOTRIF PA; LA; QL GLEEVEC PA; LA GLEOSTINE GLIADEL WAFER HALAVEN PA; LA HERCEPTIN PA; LA HEXALEN HYCAMTIN PA; LA HYDREA hydroxyurea IBRANCE PA; LA; QL ICLUSIG PA IDAMYCIN PFS PA; LA idarubicin PA; LA IDHIFA PA; LA; QL IFEX PA; LA ifosfamide PA; LA ifosfamide-mesna PA; LA imatinib PA; LA IMBRUVICA PA; QL IMFINZI PA; LA IMLYGIC PA; LA IMURAN INLYTA PA; LA; QL 5

22 IODOPEN PA IRESSA PA irinotecan intravenous solution 00 mg/5 ml, 40 mg/2 ml irinotecan intravenous solution 500 mg/25 ml PA; LA LA ISTODAX PA; LA IXEMPRA PA; LA JAKAFI PA; LA; QL JEVTANA PA; LA KADCYLA PA; LA KEYTRUDA PA KISQALI PA; LA KISQALI FEMARA CO-PACK PA; LA KYPROLIS PA; LA LARTRUVO PA; LA LENVIMA PA; LA letrozole LEUKERAN 2 leuprolide subcutaneous kit lipodox PA; LA LONSURF PA; LA LUPRON DEPOT LUPRON DEPOT ( MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED LUPRON DEPOT- PED ( MONTH) LYNPARZA PA; LA LYSODREN MARQIBO PA MATULANE 2 MEGACE ES megestrol oral suspension 400 mg/0 ml (40 mg/ml), 625 mg/5 ml megestrol oral tablet MEKINIST PA; LA; QL melphalan melphalan hcl PA; LA mercaptopurine methotrexate sodium methotrexate sodium (pf) mitomycin PA; LA mitoxantrone PA; LA MUSTARGEN PA; LA mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYFORTIC MYLERAN 2 PA; LA NAVELBINE PA; LA NEORAL NERLYNX PA; LA; QL 6

23 NEXAVAR PA; LA NILANDRON nilutamide NINLARO PA; LA NIPENT PA; LA NULOJIX PA; LA octreotide acetate PA ODOMZO PA; LA; QL ONCASPAR PA; LA OPDIVO PA oxaliplatin PA; LA paclitaxel PA; LA PERJETA PA; LA PHOTOFRIN PA; LA PROGRAF INTRAVENOUS PROGRAF ORAL PURIXAN RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET PA; LA RITUXAN PA; LA RITUXAN HYCELA 2 PA; LA RUBRACA PA RYDAPT PA; LA SANDIMMUNE INTRAVENOUS SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION PA SANDOSTATIN PA 2 SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON PA; LA; QL SIGNIFOR PA; LA SIGNIFOR LAR PA; LA; QL SIMULECT PA; LA sirolimus SOLTAMOX 0 ACA SOMATULINE DEPOT PA SPRYCEL PA; LA STIVARGA PA; LA; QL SUTENT PA; LA; QL SYLVANT PA; LA SYNRIBO PA TABLOID 2 tacrolimus oral TAFINLAR PA; LA; QL TAGRISSO PA; LA tamoxifen 0 ACA TARCEVA PA; LA; QL TARGRETIN ORAL TARGRETIN TOPICAL PA TASIGNA PA; LA TAXOTERE INTRAVENOUS SOLUTION 20 MG/ML ( ML), 80 MG/4 ML (20 MG/ML) 2 PA; LA 7

24 TECENTRIQ PA; LA TEMODAR PA; LA temozolomide PA; LA TENIPOSIDE TEPADINA PA; LA THALOMID PA; LA; QL thiotepa PA; LA toposar PA; LA topotecan PA; LA TORISEL PA; LA TREANDA INTRAVENOUS RECON SOLN PA; LA TRELSTAR PA; LA tretinoin (chemotherapy) TREXALL TRISENOX PA; LA TYKERB PA; LA; QL UNITUXIN PA; LA VECTIBIX PA; LA VELCADE PA; LA VENCLEXTA ORAL TABLET 00 MG PA VIDAZA PA; LA vinblastine intravenous solution PA; LA vincasar pfs PA; LA vincristine PA; LA vinorelbine PA; LA VOTRIENT PA; LA XALKORI PA; LA; QL XATMEP PA XELODA PA; LA XERMELO PA XTANDI PA; LA; QL YERVOY PA; LA YONDELIS PA; LA ZALTRAP PA; LA ZANOSAR PA; LA ZEJULA PA; QL ZELBORAF PA; LA; QL ZEVALIN (Y-90) PA; LA ZOLADEX LA ZOLINZA PA; LA ZORTRESS PA; LA ZYDELIG PA ZYKADIA PA; LA ZYTIGA PA; LA; QL Autonomic & Cns Drugs, Neurology & Psych Anticonvulsants APTIOM BANZEL BRIVIACT INTRAVENOUS BRIVIACT ORAL carbamazepine oral capsule, er multiphase 2 hr carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet PA 8

25 carbamazepine oral tablet extended release 2 hr carbamazepine oral tablet,chewable CARBATROL CELONTIN ORAL CAPSULE 00 MG CEREBYX PA clonazepam DEPACON PA DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES DIASTAT 2 DIASTAT ACUDIAL diazepam rectal DILANTIN 2 DILANTIN EXTENDED DILANTIN INFATABS DILANTIN-25 divalproex epitol EQUETRO ethosuximide felbamate FELBATOL fosphenytoin PA FYCOMPA ORAL SUSPENSION 2 FYCOMPA ORAL TABLET gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 2 MG, 6 MG GABITRIL ORAL TABLET 2 MG, 4 MG GRALISE PA GRALISE 0-DAY STARTER PACK KEPPRA INTRAVENOUS KEPPRA ORAL KEPPRA XR KLONOPIN LAMICTAL ODT LAMICTAL ODT STARTER (BLUE) LAMICTAL ODT STARTER (GREEN) LAMICTAL ODT STARTER (ORANGE) LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG 2 PA PA 9

26 LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT PA PA PA LAMICTAL XR PA LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) lamotrigine oral tablet lamotrigine oral tablet disintegrating, dose pk lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating levetiracetam intravenous levetiracetam oral PA PA PA 20 PA PA LYRICA PA MYSOLINE NEURONTIN ONFI ORAL SUSPENSION ONFI ORAL TABLET 0 MG, 20 MG oxcarbazepine OXTELLAR XR PA PEGANONE phenobarbital PHENYTEK phenytoin oral suspension 25 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium PA phenytoin sodium extended primidone QUDEXY XR PA roweepra SABRIL TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL XR tiagabine TOPAMAX topiramate oral capsule, sprinkle TOPIRAMATE ORAL CAPSULE,SPRINK LE,ER 24HR topiramate oral tablet TRILEPTAL

27 TROKENDI XR PA valproate sodium PA valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml vigabatrin VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET ZARONTIN ZONEGRAN ORAL CAPSULE 00 MG, 25 MG zonisamide Antiparkinsonism Agents PA APOKYN PA; LA; QL AZILECT benztropine injection PA benztropine oral bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone COGENTIN PA COMTAN DUOPA ELDEPRYL entacapone LODOSYN MIRAPEX MIRAPEX ER NEUPRO PARLODEL pramipexole rasagiline REQUIP ORAL TABLET 0.25 MG, 0.5 MG, MG, 2 MG REQUIP ORAL TABLET MG, 4 MG, 5 MG QL REQUIP XL PA ropinirole oral tablet 0.25 mg, 0.5 mg, mg, 2 mg ropinirole oral tablet mg, 4 mg, 5 mg ropinirole oral tablet extended release 24 hr RYTARY selegiline hcl SINEMET SINEMET CR STALEVO 00 STALEVO 25 STALEVO 50 STALEVO 200 STALEVO 50 STALEVO 75 TASMAR ORAL TABLET 00 MG tolcapone QL 2

28 trihexyphenidyl XADAGO PA ZELAPAR Migraine & Cluster Headache Therapy almotriptan malate QL ALSUMA PA; QL AMERGE QL AXERT QL CAFERGOT D.H.E.45 dihydroergotamine injection dihydroergotamine nasal 22 QL eletriptan hbr PA; QL ERGOMAR ergotamine-caffeine frovatriptan QL IMITREX QL IMITREX STATDOSE KIT REFILL IMITREX STATDOSE PEN isometh-dichloralacetaminophn isomethepten-cafacetaminophen oral tablet mg QL QL MAXALT QL MAXALT-MLT QL migergot MIGRANAL QL naratriptan QL nodolor ONZETRA XSAIL PA; QL PRODRIN ORAL TABLET MG RELPAX ST; QL rizatriptan QL sumatriptan QL sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml SUMAVEL DOSEPRO QL QL QL QL QL PA TREXIMET PA; QL ZEMBRACE SYMTOUCH PA; QL zolmitriptan QL ZOMIG NASAL 2 QL ZOMIG ORAL QL ZOMIG ZMT QL Miscellaneous Neurological Therapy AMPYRA PA; LA; QL

29 ARICEPT ORAL TABLET 0 MG, 5 MG ARICEPT ORAL TABLET 2 MG PA AUSTEDO PA donepezil oral tablet donepezil oral tablet,disintegrating EXELON TRANSDERMAL PA PA galantamine PA HORIZANT PA; QL INGREZZA PA KEVEYIS PA memantine oral solution memantine oral tablet MEMANTINE ORAL TABLETS,DOSE PACK NAMENDA ORAL TABLET NAMENDA TITRATION PAK PA PA PA PA PA NAMENDA XR PA NAMZARIC PA NUEDEXTA PA; QL RAZADYNE ER PA RAZADYNE ORAL TABLET PA rivastigmine PA rivastigmine tartrate PA tetrabenazine PA; LA; QL TYSABRI PA; LA XENAZINE PA; LA; QL Muscle Relaxants & Antispasmodic Therapy AMRIX PA; QL baclofen carisoprodol carisoprodol-asacodeine carisoprodol-aspirin chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet DANTRIUM INTRAVENOUS DANTRIUM ORAL CAPSULE 25 MG, 50 MG dantrolene PA FEXMID PA LORZONE meprobamate MESTINON ORAL MESTINON TIMESPAN metaxall metaxalone methocarbamol injection methocarbamol oral orphenadrine citrate injection orphenadrine citrate oral PA PA 2

30 PARAFON FORTE DSC pyridostigmine bromide regonol PA revonto PA ROBAXIN INJECTION ROBAXIN ORAL ROBAXIN PA RYANODEX PA SKELAXIN SOMA tizanidine ZANAFLEX Narcotic Analgesics ABSTRAL PA; QL acetaminophen-caffdihydrocod oral capsule ACETAMINOPHE N-CAFF- DIHYDROCOD ORAL TABLET MG acetaminophencodeine oral solution 20-2 mg/5 ml acetaminophencodeine oral tablet PA ACTIQ PA; QL ALLZITAL ARYMO ER PA ascomp with codeine ASTRAMORPH-PF INJECTION SOLUTION 0.5 MG/ML astramorph-pf injection solution mg/ml PA PA BELBUCA PA BUPAP ORAL TABLET MG BUPRENEX PA BUPRENORPHINE QL buprenorphine hcl injection buprenorphine hcl sublingual butalbital compound w/codeine aspirin-caffeinedihydrocodein butalbitalacetaminop-caf-cod butalbitalacetaminophen butalbitalacetaminophen-caff oral capsule butalbitalacetaminophen-caff oral tablet mg butalbital-aspirincaffeine PA BUTRANS 2 QL capacet CAPITAL WITH CODEINE codeine sulfate oral tablet 2 24

31 codeine-butalbitalasa-caff DEMEROL (PF) INJECTION SOLUTION 00 MG/2 ML, 25 MG/0.5 ML, 75 MG/.5 ML demerol (pf) injection solution 00 mg/ml DEMEROL (PF) INJECTION SYRINGE DEMEROL INJECTION DEMEROL ORAL TABLET 00 MG DILAUDID INJECTION DILAUDID ORAL diskets DOLOPHINE ORAL DURAGESIC PA duramorph (pf) PA EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL endocet oral tablet 0-25 mg, mg, 5-25 mg, mg ESGIC EXALGO ER QL fentanyl citrate PA; QL fentanyl citrate (pf) intravenous syringe 00 mcg/2 ml (50 mcg/ml) fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTANYL TRANSDERMAL PATCH 72 HOUR 7.5 MCG/HOUR, 62.5 MCG/HOUR, 87.5 MCG/HOUR PA FENTORA PA; QL FIORICET ORAL CAPSULE FIORINAL FIORINAL- CODEINE # hydrocodoneacetaminophen oral solution mg/5 ml hydrocodoneacetaminophen oral tablet 0-00 mg, 0-25 mg, mg, 5-00 mg, 5-25 mg, mg, mg hydrocodoneibuprofen oral tablet mg, mg, mg hydromorphone (pf) PA hydromorphone injection solution PA 25

32 HYDROMORPHO NE INJECTION SYRINGE 0.5 MG/0.5 ML hydromorphone injection syringe mg/ml, 2 mg/ml, 4 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr hydromorphone rectal HYSINGLA ER IBUDONE PA PA 26 QL ibuprofen-oxycodone QL INFUMORPH P/F PA KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 0 MG, 00 MG, 20 MG, 200 MG, 0 MG, 40 MG, 50 MG, 60 MG, 80 MG ST LAZANDA PA; QL levorphanol tartrate lorcet (hydrocodone) lorcet hd lorcet plus oral tablet mg LORTAB ELIXIR ORAL SOLUTION 0-00 MG/5 ML marten-tab meperidine (pf) injection solution 00 mg/ml, 25 mg/ml, 50 mg/ml meperidine injection cartridge meperidine oral methadone injection solution methadone oral concentrate methadone oral solution methadone oral tablet methadone oral tablet,soluble methadose oral concentrate methadose oral tablet,soluble MORPHABOND ER morphine (pf) in 0.9 % nacl intravenous syringe 2 mg/2 ml ( mg/ml) morphine (pf) injection solution 0.5 mg/ml, mg/ml morphine (pf) intravenous patient control.analgesia soln morphine concentrate oral solution morphine injection solution 5 mg/ml, 8 mg/ml PA PA PA PA PA PA

33 morphine injection syringe 0 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml MORPHINE INTRAMUSCULA R morphine intravenous cartridge 0 mg/ml, 2 mg/ml, 4 mg/ml MORPHINE INTRAVENOUS CARTRIDGE 8 MG/ML morphine intravenous pt controlled analgesia syring morphine intravenous solution 0 mg/ml, 00 mg/4 ml, 25 mg/ml, 250 mg/0 ml, 50 mg/ml MORPHINE INTRAVENOUS SOLUTION 4 MG/ML, 8 MG/ML MORPHINE INTRAVENOUS SYRINGE 0 MG/ML, 8 MG/ML morphine intravenous syringe 2 mg/ml, 4 mg/ml morphine oral morphine rectal MS CONTIN NORCO OPANA PA PA PA PA PA PA PA OXAYDO PA oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 20 MG, 40 MG, 80 MG oxycodoneacetaminophen oral solution oxycodoneacetaminophen oral tablet 0-25 mg, mg, 5-25 mg, mg oxycodone-aspirin OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR oxymorphone PERCOCET ORAL TABLET 0-25 MG, MG, 5-25 MG, MG PRIMLEV ROXICODONE PA; QL 2 QL SUBSYS PA; QL SYNALGOS-DC 27

34 tencon oral tablet mg TREZIX ORAL CAPSULE MG TYLENOL- CODEINE # TYLENOL- CODEINE #4 VANATOL LQ verdrocet vicodin vicodin es vicodin hp XODOL 0/00 XODOL 5/00 XODOL 7.5/00 XTAMPZA ER PA xylon 0 zamicet zebutal oral capsule mg ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 2HR Non-Narcotic Analgesics ANAPROX DS 28 PA; QL ARTHROTEC 50 PA ARTHROTEC 75 PA aspir-8 0 ACA; OTC aspirin low dose 0 ACA; OTC aspirin oral tablet 0 ACA; OTC aspirin oral tablet,chewable 0 ACA; OTC aspirin oral tablet,delayed release (dr/ec) 25 mg, 8 mg 0 ACA; OTC aspir-low 0 ACA; OTC aspir-trin 0 ACA; OTC bayer aspirin 0 ACA; OTC BUNAVAIL QL butorphanol tartrate injection butorphanol tartrate nasal CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (00 MG/ML) PA PA QL PA CAMBIA PA; QL CELEBREX QL celecoxib QL children's aspirin 0 ACA; OTC choline,magnesium salicylate CONZIP ST DAYPRO diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel % buprenorphinenaloxone diclofenacmisoprostol diflunisal QL

35 DISALCID DUEXIS PA; QL DYLOJECT PA e.c. prin 0 ACA; OTC EC-NAPROSYN ecotrin 0 ACA; OTC ecotrin low strength 0 ACA; OTC etodolac EUFLEXXA PA; LA; QL EVZIO QL FELDENE fenoprofen oral tablet FLECTOR flurbiprofen FROTEK PA ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg INDOCIN ORAL 2 INDOCIN RECTAL indomethacin oral ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac oral QL lite coat aspirin 0 ACA; OTC LODINE ORAL TABLET meclofenamate mefenamic acid meloxicam MOBIC ORAL TABLET nabumetone nalbuphine PA naloxone naltrexone NAPRELAN CR NAPROSYN ORAL SUSPENSION NAPROSYN ORAL TABLET 500 MG naproxen naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION NUCYNTA NUCYNTA ER oxaprozin PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP pentazocinenaloxone piroxicam PONSTEL REVIA QL PA 29

36 salsalate SPRIX PA; QL SUBOXONE 2 QL sulindac TALWIN PA TIVORBEX PA tolmetin TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 7-8 TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR tramadol oral tablet tramadol oral tablet extended release 24 hr tramadol oral tablet, er multiphase 24 hr tramadolacetaminophen ULTRACET ULTRAM ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 00 MG PA PA VIMOVO PA VIVITROL QL VOLTAREN TOPICAL VOLTAREN-XR ZIPSOR PA ZORVOLEX 2 PA ZUBSOLV Psychotherapeutic Drugs ABILIFY MAINTENA ABILIFY ORAL TABLET ADASUVE ADDERALL ADDERALL XR ADZENYS XR- ODT alprazolam alprazolam intensol AMBIEN AMBIEN CR amitriptyline amitriptylinechlordiazepoxide amoxapine ANAFRANIL QL QL APLENZIN PA APTENSIO XR aripiprazole oral solution aripiprazole oral tablet aripiprazole oral tablet,disintegrating QL QL ARISTADA QL armodafinil PA; QL ATIVAN ORAL atomoxetine 0

37 BELSOMRA PA; QL BRISDELLE bupropion hcl buspirone BUTISOL ORAL TABLET 0 MG CELEXA ORAL TABLET chlordiazepoxide hcl chlorpromazine injection chlorpromazine oral citalopram clomipramine clonidine hcl oral tablet extended release 2 hr clorazepate dipotassium clozapine oral tablet clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 25 mg CLOZAPINE ORAL TABLET,DISINTE GRATING 50 MG, 200 MG CLOZARIL CONCERTA COTEMPLA XR- ODT CYMBALTA DAYTRANA desipramine PA PA; QL DESOXYN DESVENLAFAXIN E DESVENLAFAXIN E FUMARATE desvenlafaxine succinate DEXEDRINE SPANSULE dexmethylphenidate dextroamphetamine dextroamphetamineamphetamine ST ST QL diazepam injection PA diazepam intensol diazepam oral solution 5 mg/5 ml ( mg/ml) diazepam oral tablet DORAL doxepin oral duloxetine DYANAVEL XR EDLUAR PA EFFEXOR XR EMSAM ergoloid escitalopram oxalate estazolam eszopiclone QL EVEKEO FANAPT ST; QL FAZACLO FETZIMA ST

38 flumazenil PA fluoxetine oral capsule fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 0 mg, 20 mg FLUOXETINE ORAL TABLET 60 MG fluphenazine decanoate fluphenazine hcl injection fluphenazine hcl oral flurazepam fluvoxamine FOCALIN FOCALIN XR 2 QL ST PA FORFIVO XL PA GEODON INTRAMUSCULA R PA GEODON ORAL QL guanfacine oral tablet extended release 24 hr guanidine HALCION ORAL TABLET 0.25 MG HALDOL PA HALDOL DECANOATE haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate oral PA HETLIOZ PA; LA imipramine hcl imipramine pamoate INTERMEZZO INTUNIV ER INVEGA QL INVEGA SUSTENNA INVEGA TRINZA QL IRENKA PA KAPVAY KHEDEZLA ST LATUDA PA; QL LEXAPRO ORAL TABLET lithium carbonate lithium citrate oral solution 8 meq/5 ml LITHOBID lorazepam intensol lorazepam oral loxapine succinate LUNESTA QL maprotiline MARPLAN metadate er methamphetamine

39 METHYLIN ORAL SOLUTION methylphenidate hcl mirtazapine modafinil PA; QL MYDAYIS QL NARDIL nefazodone NORPRAMIN ORAL TABLET 0 MG, 25 MG nortriptyline NUPLAZID PA; LA NUVIGIL PA; QL olanzapine intramuscular PA; QL olanzapine oral QL ORAP oxazepam paliperidone QL PAMELOR PARNATE paroxetine hcl oral tablet paroxetine hcl oral tablet extended release 24 hr PAXIL CR PAXIL ORAL SUSPENSION PAXIL ORAL TABLET perphenazine 2 olanzapinefluoxetine perphenazineamitriptyline PEXEVA ST phenelzine pimozide PRISTIQ QL procentra protriptyline PROVIGIL PA; QL PROZAC ORAL CAPSULE quazepam quetiapine oral tablet 00 mg, 200 mg, 25 mg, 00 mg quetiapine oral tablet 400 mg, 50 mg quetiapine oral tablet extended release 24 hr QUILLICHEW ER QUILLIVANT XR REMERON REMERON SOLTAB RESTORIL QL QL REXULTI PA RISPERDAL RISPERDAL CONSTA RISPERDAL M- TAB risperidone oral solution risperidone oral tablet QL QL

40 risperidone oral tablet,disintegrating RITALIN RITALIN LA ORAL CAPSULE,ER BIPHASIC MG, 20 MG, 0 MG, 40 MG QL ROZEREM QL SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG, 5 MG SARAFEM ORAL TABLET 0 MG, 20 MG seconal sodium SEROQUEL ORAL TABLET 00 MG, 200 MG, 25 MG, 00 MG SEROQUEL ORAL TABLET 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR sertraline ST; QL QL QL SILENOR PA SONATA STRATTERA SURMONTIL SYMBYAX temazepam thioridazine thiothixene TOFRANIL TRANXENE T- TAB ORAL TABLET 7.5 MG tranylcypromine trazodone triazolam trifluoperazine trimipramine TRINTELLIX ST VALIUM venlafaxine VERSACLOZ VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (2) 2 ST ST VRAYLAR PA; QL VYVANSE WELLBUTRIN SR WELLBUTRIN XL XANAX XANAX XR XYREM PA; LA; QL zaleplon zenzedi oral tablet 0 mg, 5 mg ZENZEDI ORAL TABLET 5 MG, 2.5 MG, 20 MG, 0 MG, 7.5 MG ziprasidone hcl QL 4

41 ZOLOFT zolpidem ZOLPIMIST PA ZYPREXA INTRAMUSCULA R PA; QL ZYPREXA ORAL QL ZYPREXA RELPREVV ZYPREXA ZYDIS QL Cardiovascular, Hypertension & Lipids Antiarrhythmic Agents amiodarone oral BETAPACE BETAPACE AF disopyramide phosphate oral capsule dofetilide flecainide mexiletine MULTAQ NORPACE NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 00 MG NORPACE CR ORAL CAPSULE, EXTENDED RELEASE 50 MG pacerone oral tablet 00 mg, 200 mg, 400 mg 2 procainamide injection propafenone quinidine gluconate injection quinidine gluconate oral quinidine sulfate oral tablet RYTHMOL SR sotalol af SOTALOL INTRAVENOUS sotalol oral SOTYLIZE TIKOSYN PA PA PA Antihypertensive Therapy ACCUPRIL ACCURETIC acebutolol ADALAT CC afeditab cr ALDACTAZIDE ALDACTONE ALTACE amiloride amlodipine amiloridehydrochlorothiazide amlodipinebenazepril amlodipineolmesartan amlodipinevalsartan 5

42 ATACAND ATACAND HCT atenolol AVALIDE AVAPRO AZOR benazepril BENICAR BENICAR HCT betaxolol oral BIDIL bisoprolol fumarate BREVIBLOC IN NACL (ISO-OSM) BREVIBLOC INTRAVENOUS SOLUTION 00 MG/0 ML (0 MG/ML) bumetanide injection PA bumetanide oral BYSTOLIC 2 BYVALSON CALAN CALAN SR candesartan 6 captopril amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide CARDENE IV PA CARDENE IV IN DEXTROSE CARDENE IV IN SODIUM CHLORIDE CARDIZEM CD CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 20 MG CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR 80 MG, 240 MG, 00 MG, 60 MG, 420 MG CARDIZEM ORAL TABLET 20 MG, 0 MG, 60 MG CARDURA CARDURA XL ST cartia xt carvedilol CATAPRES CATAPRES-TTS- CATAPRES-TTS-2 CATAPRES-TTS- chlorothiazide chlorothiazide sodium 2 PA

43 chlorthalidone oral tablet 25 mg, 50 mg CLEVIPREX INTRAVENOUS EMULSION 25 MG/50 ML CLEVIPREX INTRAVENOUS EMULSION 50 MG/00 ML clonidine clonidine hcl oral tablet clorpres oral tablet 0.-5 mg, mg CLORPRES ORAL TABLET 0.-5 MG COREG COREG CR CORGARD PA CORLOPAM PA CORZIDE COZAAR DEMADEX ORAL TABLET 0 MG, 20 MG DEMSER DIBENZYLINE diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg diltiazem hcl oral capsule,extended release 2 hr diltiazem hcl oral capsule,extended release 24 hr 240 mg, 420 mg diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr 80 mg, 240 mg, 00 mg, 60 mg dilt-xr DIOVAN DIOVAN HCT DIURIL DIURIL IV PA doxazosin DUTOPROL 2 DYAZIDE DYRENIUM EDARBI ST EDARBYCLOR ST EDECRIN enalapril maleate enalaprilat intravenous solution enalaprilhydrochlorothiazide EPANED ORAL SOLUTION eplerenone epoprostenol (glycine) PA PA PA; LA 7

44 eprosartan esmolol intravenous solution ethacrynate sodium PA ethacrynic acid EXFORGE EXFORGE HCT felodipine FLOLAN PA; LA fosinopril furosemide injection PA furosemide oral solution 0 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet guanfacine oral tablet HEMANGEOL hydralazine injection PA hydralazine oral hydrochlorothiazide HYZAAR indapamide INDERAL LA INDERAL XL INNOPRAN XL 2 INSPRA irbesartan isradipine labetalol intravenous solution labetalol intravenous syringe 20 mg/4 ml (5 mg/ml) labetalol oral LASIX LEVATOL lisinopril LOPRESSOR HCT LOPRESSOR ORAL losartan LOTENSIN HCT LOTENSIN ORAL TABLET 20 MG, 40 MG LOTREL ORAL CAPSULE 0-20 MG, 0-40 MG, 5-0 MG, 5-20 MG matzim la MAXZIDE MAXZIDE-25MG methyclothiazide methyldopa fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide lisinoprilhydrochlorothiazide losartanhydrochlorothiazide methyldopahydrochlorothiazide PA PA methyldopate PA metolazone 8

45 metoprolol succinate METOPROLOL SU- HYDROCHLOROT HIAZ metoprolol tartrate intravenous metoprolol tartrate oral MICARDIS MICARDIS HCT MICROZIDE MINIPRESS minoxidil oral moexipril nadolol nicardipine intravenous solution nicardipine oral nifedipine PA PA PA nimodipine PA nisoldipine NORVASC NYMALIZE PA olmesartan ORENITRAM PA; LA papaverine injection solution perindopril erbumine phenoxybenzamine phentolamine injection recon soln pindolol prazosin PA PRESTALIA PA PRINIVIL ORAL TABLET 0 MG, 20 MG, 5 MG PROCARDIA PROCARDIA XL propranolol intravenous propranolol oral PA QBRELIS PA quinapril ramipril REMODULIN PA; LA SODIUM EDECRIN spironolactone metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide nadololbendroflumethiazide olmesartanamlodipin-hcthiazid olmesartanhydrochlorothiazide propranololhydrochlorothiazid quinaprilhydrochlorothiazide spironolactonhydrochlorothiaz PA 9

46 SULAR ORAL TABLET EXTENDED RELEASE 24 HR 7 MG, 4 MG, 8.5 MG TARKA taztia xt TEKTURNA ST TEKTURNA HCT ST telmisartan TENORETIC 00 TENORETIC 50 TENORMIN terazosin TIAZAC timolol maleate oral TOPROL XL torsemide oral trandolapril TRIBENZOR TWYNSTA UPTRAVI PA; LA valsartan telmisartanamlodipine telmisartanhydrochlorothiazid trandolaprilverapamil triamterenehydrochlorothiazid valsartanhydrochlorothiazide VASERETIC VASOTEC veletri PA; LA verapamil intravenous verapamil oral VERELAN VERELAN PM ZESTORETIC ZESTRIL ZIAC Cardiac Glycosides digitek digox PA digoxin injection PA digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN INJECTION LANOXIN ORAL LANOXIN PEDIATRIC Coagulation Therapy PA PA ADVATE PA; LA ADYNOVATE PA; LA AFSTYLA PA; LA AGGRENOX ALPHANATE PA; LA ALPHANINE SD PA; LA AMICAR aminocaproic acid intravenous PA ANGIOMAX PA 40

47 ARGATROBAN IN 0.9 % SOD CHLOR INTRAVENOUS PARENTERAL SOLUTION ARIXTRA aspirin-dipyridamole PA BEBULIN PA; LA BENEFIX PA; LA bivalirudin PA BRILINTA 2 CEPROTIN (BLUE BAR) CEPROTIN (GREEN BAR) cilostazol clopidogrel PA; LA PA; LA CORIFACT PA; LA COUMADIN ORAL CYKLOKAPRON PA dipyridamole oral DURLAZA PA EFFIENT ELIQUIS 2 QL ELOCTATE PA; LA enoxaparin FEIBA NF PA; LA fondaparinux FRAGMIN SUBCUTANEOUS SOLUTION FRAGMIN SUBCUTANEOUS SYRINGE HELIXATE FS PA; LA HEMOFIL M HIGH PA; LA HEMOFIL M LOW PA; LA HEMOFIL M MID PA; LA HEMOFIL M SUPER HIGH hep flush-0 (pf) heparin (porcine) in 5 % dex intravenous parenteral solution 2,500 unit/250 ml heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(00 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) heparin (porcine) injection cartridge heparin (porcine) injection solution heparin (porcine) injection syringe 5,000 unit/ml heparin flush(porcine)- 0.9nacl heparin lock flush heparin lock flush (porcine) intravenous solution 00 unit/ml heparin lockflush(porcine)(pf ) PA; LA PA PA 4

48 HEPARIN(PORCIN E) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 2,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml heparin, porcine (pf) injection heparin, porcine (pf) intravenous solution 00 unit/ml ( ml) heparin, porcine (pf) intravenous syringe 42 PA HUMATE-P PA; LA IPRIVASK PA; QL IXINITY PA; LA jantoven KCENTRA PA KOATE PA; LA KOGENATE FS PA; LA KOVALTRY PA; LA LOVENOX SUBCUTANEOUS SOLUTION LOVENOX SUBCUTANEOUS SYRINGE MEPHYTON 2 PA MONOCLATE-P PA; LA MONONINE PA; LA NOVOSEVEN RT PA; LA NPLATE PA; LA pentoxifylline PHYTONADIONE (VITAMIN K) INJECTION PLAVIX PRADAXA ORAL CAPSULE 50 MG, 75 MG prasugrel PA PA; QL PROFILNINE PA; LA PROMACTA PA; LA protamine PA RECOMBINATE PA; LA RIASTAP PA; LA RIXUBIS PA; LA SAVAYSA PA ticlopidine tranexamic acid intravenous PA TRETTEN PA; LA vitamin k PA vitamin k injection PA VONVENDI PA; LA warfarin WILATE INTRAVENOUS RECON SOLN,000-,000 UNIT, UNIT PA; LA XARELTO PA XYNTHA PA; LA XYNTHA SOLOFUSE PA; LA ZONTIVITY PA Lipid/Cholesterol Lowering Agents