2017 Comprehensive Formulary. (List of Covered Drugs) SMALL GROUP AND INDIVIDUAL

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1 07 Comprehensive Formulary (List of Covered Drugs) SMALL GROUP AND INDIVIDUAL

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3 SummaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, religion, gender identity or sex. SummaCare does not exclude people or treat them differently because of race, color, national origin, age, disability, religion, gender identity or sex. SummaCare: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service. If you believe that SummaCare has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, religion, gender identity or sex, you can file a grievance through Customer Service: Civil Rights Coordinator PO Box 07 Akron, OH Toll-free: TTY: Fax: appeals@summacare.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Appeals and Grievances Department, is 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 for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 00 Independence Avenue SW., Room 09F, HHH Building, Washington, DC 00, , (TDD). Complaint forms are available at Commercial & Individual - Customer Service

4 ATTENTION: Interpreter Services available. Someone who speaks your language can assist you. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (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: ) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Wann du schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (TTY: ). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ).) 번으로전화해주십시오. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel (TTY: ). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: ). ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (TTY: ). Commercial & Individual - Customer Service

5 07 SUMMACARE COMPREHENSIVE FORMULARY SMALL GROUP AND INDIVIDUAL PRESCRIPTION DRUG BENEFITS The following is a listing by drug class of medications most commonly prescribed under the SummaCare Prescription Drug Benefit. Brand-name drugs are capitalized and generic drugs are listed in lowercase. Prescription drug benefits vary, but in most cases, brand name medications that have a generic equivalent require the patient to pay the difference in cost between the brand and generic medication. Some benefits may exclude certain drugs on this list. Refer to your plan documents for more coverage information. ABOUT TIERS Prescription Drug Tier Tier Tier Tier 3 Tier Tier Tier 6 Description Zero Cost Share Preventive Drugs (This tier will contain low cost medications that may be preferred generic, single source, or multi-source Brand Drugs.) Preferred Generics Non-Preferred Generics Preferred Brand Non-Preferred Brand Specialty Drugs Note: Some benefits may require a deductible be met before copays apply. Refer to your plan documents for further information. USING YOUR SUMMACARE ID CARD It is important to show your SummaCare ID card when filling prescriptions. When you show your SummaCare ID card, safety checks are performed such as drug-drug interactions, therapeutic duplications and dose checks, even if you use multiple pharmacies, including mail order. MEDIMPACT MedImpact is SummaCare s Pharmacy Benefit Manager and is responsible for processing pharmacy claims for SummaCare members. MedImpact also handles pharmacy benefit customer service and utilization management requests on SummaCare s behalf. To reach MedImpact, members should call the SummaCare customer service number on the back of their ID card. WOMEN S PREVENTIVE DRUGS Your cost share for selected women s preventive care services may be waived when provided by a network pharmacy provider. Please refer to your benefit documents for further information. PHARMACY UTILIZATION PROGRAMS SummaCare s Prescription Drug Benefit incorporates utilization management programs (prior authorization, step therapy and quantity limits). Drugs requiring utilization management are indicated on the formulary document with a PA, PA NSO, QL or ST. If you are prescribed one of these drugs, the prescriber may need to contact MedImpact to provide supporting medical information. Prior Authorization = PA Prior Authorization requirements are placed on medications when they have limited conditions for which they are prescribed, special monitoring or dispensing requirements or an extremely high cost. Guidelines for approving coverage for Prior Authorization drugs are developed and

6 approved by a panel of practicing physicians and pharmacists. Prior Authorization for New Starts Only = PA NSO If you are a new member, you may be required to get Prior Authorization on particular drugs before you fill your prescription. In this scenario, the same requirements as listed above under Prior Authorization would apply. Step Therapy = ST Step Therapy is the practice of initiating drug therapy for a medical condition with the most cost- effective and safest drug, and then progressing to other more costly or risky drugs only if necessary (i.e., you must try drug A before you can get drug B ). The goal is to control costs and minimize risks. Step therapy is an automated process. If you present a prescription for a step therapy drug (i.e., B ) to a pharmacy, an automated check of your prescription history will occur. If the system finds that you have received the qualifying drug(s) (i.e., A ), your prescription will be processed. If the system does not find that you received a qualifying drug (i.e., A ) in recent history, a prior authorization will be necessary. Quantity Limits = QL When a drug has a Quantity Limit, the amount of medication per prescription is limited to a specified amount per 30 days. These limitations are usually in place due to safety issues or because the use of a dose higher than what is recommended has been shown to result in minimal additional benefit to the patient. Gender Edits = GF or GM Gender edits may be added to certain medications when they are only to be prescribed for a male or female based on FDA prescribing indications. Drugs that are only to be prescribed for females will be indicated with a GF and drugs that are only to be prescribed for males will be indicated with a GM. EXCEPTION PROCESS FOR NON-FORMULARY DRUGS What is an exception request? Exception requests are a kind of coverage determination. Exceptions can be requested by you and/or your authorized representative, or your prescribing physician may request an exception to seek coverage of a drug that: Is not on the formulary (list of drugs the plan covers) Requires prior authorization Has quantity limitations There are two types of exception requests. The first one is an expedited exception request, which is defined under exigent circumstances only and if the drug is not approved may seriously jeopardize life, health or ability to regain maximum function, or may jeopardize undergoing current treatment using a non-formulary drug. The second is a standard exception request. If SummaCare s formulary does not include a drug that you or your prescribing physician feel is necessary, then you or your prescribing physician may request an exception so that you may obtain coverage of this drug. The exception request must include your prescribing physician s statement that he/she has determined that the preferred formulary drug either would not be as effective or would have adverse effects for you. If the Plan does not grant the requested exception, then you or your prescribing physician may file an appeal. Exception requests can be made verbally by contacting SummaCare s Pharmacy Benefit Manager, MedImpact Healthcare Systems, Inc., at or can be sent via fax to When will I receive a decision on my exception request? SummaCare must notify you and your prescriber of our decision no more than hours following receipt of an Expedited Request and 7 hours following the receipt of a Standard Exception Request. If your request is denied, then you or your prescribing physician may file an appeal. If the exception request is granted, we will treat the excepted drug as an Essential Health Benefit and the cost share will be counted towards your

7 annual limitation on cost-sharing and we will cover the drug for the duration of the prescription including refills. FOR MORE INFORMATION ABOUT SUMMACARE S PRESCRIPTION DRUG BENEFIT CALL: Employers and Members: Please refer to the number on the back of your Member ID card or call Group Customer Service at Persons with Hearing or Speech Disabilities: Call Ohio Relay (TTY) at Providers: Call SummaCare Provider Services at To view the most recent formulary, please visit mysummacare.com. 096

8 Table of Contents Analgesics...3 Anesthetics... Anti-Addiction/Substance Abuse Treatment Agents... Antianxiety Agents...3 Antibacterials... Anticancer Agents... 0 Anticholinergic Agents... 6 Anticonvulsants...6 Antidementia Agents...3 Antidepressants Antidiabetic Agents Antifungals... Antigout Agents... Antihistamines... Anti-Infectives (Skin And Mucous Membrane)...6 Antimigraine Agents...6 Antimycobacterials...7 Antinausea Agents...8 Antiparasite Agents...9 Antiparkinsonian Agents...0 Antipsychotic Agents... Antivirals (Systemic)... Blood Products/Modifiers/Volume Expanders... 9 Caloric Agents...63 Cardiovascular Agents Central Nervous System Agents Contraceptives...8 Cough And Cold Products Dental And Oral Agents...93 Dermatological Agents...9 Devices... 0 Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents... 3 Genitourinary Agents... 9 Heavy Metal Antagonists... 0

9 Hormonal Agents, Stimulant/Replacement/Modifying... Immunological Agents...8 Inflammatory Bowel Disease Agents... 3 Metabolic Bone Disease Agents...3 Miscellaneous Therapeutic Agents...33 Ophthalmic Agents...3 Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants... 3 Sleep Disorder Agents... Vasodilating Agents... Vitamins And Minerals...6

10 Analgesics Analgesics, Miscellaneous ABSTRAL SUBLINGUAL TABLET 00 MCG, 00 MCG, 300 MCG, 00 MCG, 600 MCG, 800 MCG acetaminophen-codeine oral solution 0- / ml acetaminophen-codeine oral tablet 300- acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet alagesic lq oral solution / ml aspirin-caffeine-dihydrocodein oral capsule belladonna alkaloids-opium rectal suppository belladonna-opium rectal suppository buprenorphine transdermal patch weekly 0 mcg/hour, mcg/hour, 0 mcg/hour, mcg/hour, 7. mcg/hour butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule butalbital-acetaminop-caf-cod oral capsule butalbital-acetaminophen oral tablet butalbital-acetaminophen oral tablet 0-3 butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-acetaminophen-caff oral tablet (Tylenol-Codeine #3) (Tylenol-Codeine #) (Synalgos-DC) 3 PA; QL (0 per 30 (Butrans) 3 QL ( per 8 (Bupap) (Tencon) (Esgic) (Esgic)

11 butalbital-aspirin-caffeine oral capsule (Fiorinal) butalbital-aspirin-caffeine oral tablet butorphanol tartrate nasal spray,nonaerosol 0 /ml 3 BUTRANS TRANSDERMAL QL ( per 8 PATCH WEEKLY 0 MCG/HOUR, MCG/HOUR, 0 MCG/HOUR, MCG/HOUR, 7. MCG/HOUR capacet oral capsule CAPITAL WITH CODEINE ORAL SUSPENSION 0- / ML CODEINE SULFATE ORAL 3 SOLUTION 30 / ML codeine sulfate oral tablet, 30, 3 60 DEMEROL (PF) INJECTION SYRINGE /ML, 0 /ML DILAUDID ORAL LIQUID /ML DISKETS ORAL TABLET,SOLUBLE 0 EMBEDA ORAL CAPSULE,ORAL QL (0 per 30 ONLY,EXT.REL PELL 00- EMBEDA ORAL CAPSULE,ORAL QL (60 per 30 ONLY,EXT.REL PELL 0-0.8, 30-., 0-, 60-., endocet oral tablet 0-3,.-3, -3, 7.-3 ENDODAN ORAL TABLET.83-3 ESGIC-PLUS ORAL CAPSULE fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, (Actiq) 3 PA; QL (0 per mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/hr (Duragesic) 3

12 fentanyl transdermal patch 7 hour mcg/hour, 6. mcg/hour, 87. mcg/hour FENTORA BUCCAL TABLET, EFFERVESCENT 00 MCG, 00 PA; QL ( per 30 MCG, 00 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution.-67 / ml, -63 /7.ml(7.ml) hydrocodone-acetaminophen oral solution (Hycet) 7.-3 / ml hydrocodone-acetaminophen oral tablet (Xodol 0/300) QL (390 per hydrocodone-acetaminophen oral tablet (Norco) QL (360 per , -3, 7.-3 hydrocodone-acetaminophen oral tablet (Verdrocet) QL (360 per hydrocodone-acetaminophen oral tablet (Xodol /300) QL (390 per hydrocodone-acetaminophen oral tablet (Xodol 7./300) QL (390 per hydrocodone-ibuprofen oral tablet 0-00 (Ibudone) 3, -00 hydrocodone-ibuprofen oral tablet.- (Reprexain) 3 00 hydrocodone-ibuprofen oral tablet hydromorphone oral liquid /ml (Dilaudid) hydromorphone oral tablet,, 8 (Dilaudid) hydromorphone oral tablet extended (Exalgo ER) 3 QL (30 per 30 release hr, 6, 8 hydromorphone oral tablet extended (Exalgo ER) 3 QL (60 per 30 release hr 3 hydromorphone rectal suppository 3 HYSINGLA ER ORAL QL (30 per 30 TABLET,ORAL ONLY,EXT.REL. HR 00, 0, 0, 30, 0, 60, 80 ibuprofen-oxycodone oral tablet 00-

13 KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 30, 0, 00, 0, 70 LAZANDA NASAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 300 MCG/SPRAY, 00 MCG/SPRAY QL (60 per 30 PA; QL ( per 30 levorphanol tartrate oral tablet lorcet (hydrocodone) oral tablet -3 3 QL (360 per 30 lorcet hd oral tablet QL (360 per 30 lorcet plus oral tablet QL (360 per 30 MAGNACET ORAL TABLET 0-00, -00 margesic oral capsule marten-tab oral tablet 0-3 meperidine (pf) injection solution 00 (Demerol (PF)) /ml, 0 /ml meperidine (pf) injection solution /ml meperidine injection cartridge 0 /ml meperidine oral solution 0 / ml meperidine oral tablet 00 (Demerol) meperidine oral tablet 0 methadone oral concentrate 0 /ml (Methadose) methadone oral solution 0 / ml, / ml methadone oral tablet 0, (Dolophine) METHADOSE ORAL CONCENTRATE 0 /ML methadose oral tablet,soluble 0 morphine concentrate oral solution 00 / ml (0 /ml) morphine in 0.9 % nacl intravenous syringe /ml ( ml), /ml ( ml) morphine intramuscular pen injector 0 /0.7 ml morphine intravenous cartridge /ml, /ml, /ml, 8 /ml morphine intravenous solution 0 /ml 6

14 morphine oral capsule, er multiphase 3 QL (30 per 30 hr 0,, 7, 90 morphine oral capsule, er multiphase hr 30, 60 3 QL (60 per 30 morphine oral capsule,extend.release (Kadian) 3 pellets 0 morphine oral capsule,extend.release (Kadian) 3 QL (60 per 30 pellets 00, 0, 30, 0, 60, 80 morphine oral solution 0 / ml, 0 / ml ( /ml) MORPHINE ORAL TABLET, 30 3 morphine oral tablet extended release 00 (MS Contin) 3,, 00, 30, 60 morphine rectal suppository 0, 0 3, 30, NUCYNTA ER ORAL TABLET QL (60 per 30 EXTENDED RELEASE HR 00, 0, 00, 0, 0 NUCYNTA ORAL TABLET 00, QL (80 per 30 0, 7 ONSOLIS BUCCAL FILM,00 MCG, 00 MCG, 00 MCG, 600 MCG, PA; QL (0 per MCG OXAYDO ORAL TABLET, ORAL ONLY, 7. OXECTA ORAL TABLET, ORAL ONLY, 7. oxycodone oral capsule oxycodone oral concentrate 0 /ml oxycodone oral solution / ml oxycodone oral tablet 0, 0 oxycodone oral tablet, 30, (Roxicodone) oxycodone oral tablet,oral only,ext.rel. (OxyContin) 3 QL (60 per 30 hr 0,, 0, 30, 0, 60 oxycodone oral tablet,oral only,ext.rel. hr 80 (OxyContin) 3 QL (0 per 30 7

15 oxycodone-acetaminophen oral solution -3 / ml oxycodone-acetaminophen oral tablet 0- (Percocet) 3,.-3 oxycodone-acetaminophen oral tablet - (Endocet) 3, 7.-3 oxycodone-aspirin oral tablet.83-3 OXYCONTIN ORAL QL (60 per 30 TABLET,ORAL ONLY,EXT.REL. HR 0,, 0, 30, 0, 60 OXYCONTIN ORAL QL (0 per 30 TABLET,ORAL ONLY,EXT.REL. HR 80 oxymorphone oral tablet 0, (Opana) QL (0 per 30 oxymorphone oral tablet extended release 3 QL (60 per 30 hr 0, 0, 30, 0, oxymorphone oral tablet extended release 3 QL (0 per 30 hr oxymorphone oral tablet extended release 3 hr 7. pentazocine-acetaminophen oral tablet -60 pentazocine-naloxone oral tablet 0-0. PHRENILIN FORTE ORAL CAPSULE 0-60 PRIMLEV ORAL TABLET 0-300, -300, promacet oral tablet 0-60 reprexain oral tablet 0-00,.-00 3, -00 roxicet oral solution -3 / ml roxicet oral tablet -3 SUBSYS SUBLINGUAL SPRAY,NON-AEROSOL,00 MCG (600 MCG/SPRAY X ),,600 MCG (800 MCG/SPRAY X ), 00 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY PA; QL (0 per 30 8

16 tencon oral tablet 0-3 tramadol oral tablet 0 (Ultram) tramadol oral tablet extended release hr 00, 00, QL (30 per 30 tramadol-acetaminophen oral tablet 37.- (Ultracet) 3 trezix oral capsule vicodin es oral tablet QL (390 per 30 vicodin hp oral tablet QL (390 per 30 vicodin oral tablet -300 QL (390 per 30 XARTEMIS XR ORAL TAB,ORAL QL (360 per 30 ONLY,IR - ER, BIPHASE 7.-3 xylon 0 oral tablet ZAMICET ORAL SOLUTION 0-3 / ML zebutal oral capsule ZEBUTAL ORAL CAPSULE Nonsteroidal Anti-Inflammatory Agents aspirin oral tablet,delayed release (dr/ec) 60 aspirin rectal suppository 300, 600 CAMBIA ORAL POWDER IN ST; QL (9 per 30 PACKET 0 celecoxib oral capsule 00, 0 (Celebrex) 3 PA; QL (60 per 30 celecoxib oral capsule 00, 00 (Celebrex) 3 PA; QL (30 per 30 choline,magnesium salicylate oral liquid 00 / ml diclofenac potassium oral tablet 0 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 00 diclofenac sodium oral tablet,delayed release (dr/ec), 0, 7 diclofenac sodium topical drops. % 3 diclofenac sodium topical gel % (Voltaren) 3 diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic 0-00 mcg (Arthrotec 0) 3 9

17 diclofenac-misoprostol oral (Arthrotec 7) 3 tablet,ir,delayed rel,biphasic 7-00 mcg diflunisal oral tablet 00 3 DUEXIS ORAL TABLET ST; QL (90 per 30 etodolac oral capsule 00, 300 etodolac oral tablet 00 (Lodine) etodolac oral tablet 00 etodolac oral tablet extended release 3 hr 00, 00, 600 fenoprofen oral capsule 00, 00 (Fenortho) fenoprofen oral tablet 600 FLECTOR TRANSDERMAL PATCH HOUR.3 % flurbiprofen oral tablet 00, 0 ibuprofen oral suspension 00 / ml (Child Ibuprofen) ibuprofen oral tablet 00, 600, 800 INDOCIN ORAL SUSPENSION / ML INDOCIN RECTAL SUPPOSITORY 0 indomethacin oral capsule, 0 indomethacin oral capsule, extended release 7 ketoprofen oral capsule 0, 7 ketoprofen oral capsule,ext rel. pellets 3 hr 00 ketorolac oral tablet 0 LEVACET ORAL TABLET meclofenamate oral capsule 00, 0 mefenamic acid oral capsule 0 (Ponstel) meloxicam oral suspension 7. / ml meloxicam oral tablet, 7. (Mobic) nabumetone oral tablet 00, 70 NAPRELAN CR ORAL TABLET, ER MULTIPHASE HR 70 naproxen oral suspension / ml (Naprosyn) 0

18 naproxen oral tablet 0, 37 naproxen oral tablet 00 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) 3 (dr/ec) 37, 00 naproxen sodium oral tablet 7 naproxen sodium oral tablet 0 (Anaprox DS) naproxen sodium oral tablet, er (Naprelan CR) 3 multiphase hr 37, 00 oxaprozin oral tablet 600 (Daypro) piroxicam oral capsule 0, 0 (Feldene) salsalate oral tablet 00, 70 (Disalcid) SPRIX NASAL SPRAY,NON- QL ( per 30 AEROSOL.7 /SPRAY sulindac oral tablet 0, 00 tolmetin oral capsule 00 tolmetin oral tablet 00, 600 VIMOVO ORAL ST; QL (60 per 30 TABLET,IR,DELAYED REL,BIPHASIC 37-0, 00-0 VOLTAREN TOPICAL GEL % ZIPSOR ORAL CAPSULE ST; QL (0 per 30 Anesthetics Local Anesthetics CIDALEAZE TOPICAL CREAM 3 % glydo mucous membrane jelly in 3 applicator % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution % (0 /ml) lidocaine hcl topical cream 3 % (Lidopin) lidocaine hcl topical lotion 3 % (Lido-K) lidocaine hcl-hydrocortison ac rectal kit 3 3- % (7 gram) lidocaine hcl-hydrocortison ac topical cream 3-0. % lidocaine topical adhesive (Lidoderm) 3 patch,medicated % lidocaine topical ointment %

19 lidocaine viscous mucous membrane solution % lidocaine-hydrocortisone-aloe rectal kit (Ana-Lex Kit) 3 - % lidocaine-hydrocortisone-aloe rectal kit 3-. % (7 gram) lidocaine-prilocaine topical cream.-. % lidocaine-prilocaine topical kit.-. % (LP Lite Pak) lidocaine-tetracaine topical cream 7-7 % (Pliaglis) 3 SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl sublingual tablet, 8 3 PA; QL (90 per 30 buprenorphine-naloxone sublingual tablet -0., 8-3 PA; QL (90 per 30 buproban oral tablet extended release hr 0 bupropion hcl (smoking deter) oral tablet (Zyban) extended release hr 0 CHANTIX CONTINUING MONTH QL (336 per 36 BOX ORAL TABLET CHANTIX ORAL TABLET 0. QL (67 per 36 CHANTIX ORAL TABLET QL (336 per 36 CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0. ()- () QL (06 per 36 disulfiram oral tablet 0, 00 (Antabuse) 3 naloxone injection solution 0. /ml 3 naloxone injection syringe /ml 3 naltrexone oral tablet 0 (Revia) 3 NARCAN NASAL SPRAY,NON- AEROSOL /ACTUATION, /ACTUATION QL ( per 30

20 NICOTROL INHALATION CARTRIDGE 0 NICOTROL NS NASAL SPRAY,NON-AEROSOL 0 /ML SUBOXONE SUBLINGUAL FILM -3, 8- SUBOXONE SUBLINGUAL FILM - 0., - ZYBAN ORAL TABLET EXTENDED RELEASE HR 0 Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL ORAL CONCENTRATE /ML alprazolam oral tablet 0., 0.,, alprazolam oral tablet extended release hr 0.,,, 3 alprazolam oral tablet,disintegrating 0., 0.,, chlordiazepoxide hcl oral capsule 0,, clonazepam oral tablet 0.,, clonazepam oral tablet,disintegrating 0., 0., 0.,, clorazepate dipotassium oral tablet, 3.7 clorazepate dipotassium oral tablet 7. diazepam intensol oral concentrate /ml diazepam oral solution / ml ( /ml) (Xanax) (Xanax XR) 3 (Klonopin) (Tranxene T-Tab) diazepam oral tablet 0,, (Valium) diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit. (Diastat) 3 estazolam oral tablet, flurazepam oral capsule, 30 lorazepam oral concentrate /ml (Lorazepam Intensol) PA; QL (60 per 30 PA; QL (30 per

21 lorazepam oral tablet 0.,, (Ativan) midazolam oral syrup /ml ONFI ORAL SUSPENSION. /ML PA; QL (80 per 30 ONFI ORAL TABLET 0, 0, PA; QL (60 per 30 oxazepam oral capsule 0,, 30 quazepam oral tablet (Doral) 3 temazepam oral capsule,., (Restoril) 30, 7. triazolam oral tablet 0. triazolam oral tablet 0. (Halcion) Antibacterials Aminoglycosides neomycin oral tablet 00 TOBI INHALATION SOLUTION 6 FOR NEBULIZATION 300 / ML TOBI PODHALER INHALATION 6 CAPSULE, W/INHALATION DEVICE 8 tobramycin in 0. % nacl inhalation (Tobi) 6 solution for nebulization 300 / ml Antibacterials, Miscellaneous clindamycin hcl oral capsule 0, 300 (Cleocin HCl), 7 clindamycin palmitate hcl oral recon soln (Clindamycin 7 / ml Pediatric) FLAGYL ER ORAL TABLET EXTENDED RELEASE 70 hyolev mb oral tablet linezolid oral suspension for (Zyvox) 3 PA reconstitution 00 / ml linezolid oral tablet 600 (Zyvox) 3 PA MACRODANTIN ORAL CAPSULE methenamine hippurate oral tablet (Hiprex) gram methenamine mandelate oral tablet 0. g, gram metronidazole oral capsule 37 (Flagyl)

22 metronidazole oral tablet 0, 00 (Flagyl) MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule (Macrodantin) 00,, 0 nitrofurantoin monohyd/m-cryst oral capsule 00 (Macrobid) nitrofurantoin oral suspension / ml (Furadantin) PHOSPHASAL ORAL TABLET PRIMSOL ORAL SOLUTION 0 / ML SIVEXTRO ORAL TABLET 00 6 trimethoprim oral tablet 00 ur n-c oral tablet uretron d-s oral tablet URETRON D-S ORAL TABLET URIN DS ORAL TABLET uro-8 oral tablet uro-blue oral tablet urogesic-blue oral tablet urolet mb oral tablet UROQID-ACID NO. ORAL TABLET vancomycin oral capsule, 0 (Vancocin) 3 XIFAXAN ORAL TABLET 00 QL (63 per XIFAXAN ORAL TABLET 0 PA; QL (60 per 30 Cephalosporins cefaclor oral capsule 0, 00 cefaclor oral suspension for reconstitution / ml, 0 / ml, 37 / ml cefaclor oral tablet extended release 3 hr 00 cefadroxil oral capsule 00 cefadroxil oral suspension for reconstitution 0 / ml, 00 / ml cefadroxil oral tablet gram

23 cefdinir oral capsule 300 cefdinir oral suspension for reconstitution / ml, 0 / ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 00 (Spectracef) cefixime oral suspension for (Suprax) reconstitution 00 / ml, 00 / ml cefpodoxime oral suspension for reconstitution 00 / ml, 0 / ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution / ml, 0 / ml cefprozil oral tablet 0, 00 ceftibuten oral capsule 00 (Cedax) 3 ceftibuten oral suspension for (Cedax) 3 reconstitution 80 / ml CEFTIN ORAL SUSPENSION FOR RECONSTITUTION / ML, 0 / ML cefuroxime axetil oral tablet 0, 00 cephalexin oral capsule 0, 00, (Keflex) 70 cephalexin oral suspension for reconstitution / ml, 0 / ml cephalexin oral tablet 0, 00 DAXBIA ORAL CAPSULE 333 SUPRAX ORAL CAPSULE 00 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 / ML, 00 / ML, 00 / ML SUPRAX ORAL TABLET 00 SUPRAX ORAL TABLET,CHEWABLE 00, 00 Macrolides azithromycin oral packet gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 00 / ml, 00 / ml azithromycin oral tablet 0 (Zithromax Z-Pak) azithromycin oral tablet 00, 600 (Zithromax) 6

24 clarithromycin oral suspension for reconstitution / ml, 0 / ml clarithromycin oral tablet 0, 00 clarithromycin oral tablet extended 3 release hr 00 DIFICID ORAL TABLET 00 ST; QL (0 per 0 e.e.s. 00 oral tablet 00 e.e.s. granules oral suspension for reconstitution 00 / ml ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 / ML ery-tab oral tablet,delayed release (dr/ec) 0 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 333 ery-tab oral tablet,delayed release 3 (dr/ec) 00 erythrocin (as stearate) oral tablet 0 erythromycin ethylsuccinate oral (EryPed 00) suspension for reconstitution 00 / ml erythromycin ethylsuccinate oral tablet (E.E.S. 00) 00 erythromycin oral capsule,delayed release(dr/ec) 0 erythromycin oral tablet 0, 00 erythromycin-sulfisoxazole oral suspension for reconstitution / ml KETEK ORAL TABLET 300, 00 PCE ORAL TABLET, PARTICLES/CRYSTALS 333, 00 ZMAX ORAL SUSPENSION,EXTENDED REL RECON GRAM/60 ML 7

25 Miscellaneous B-Lactam Antibiotics CAYSTON INHALATION SOLUTION FOR NEBULIZATION 7 /ML Penicillins amoxicillin oral capsule 0, 00 amoxicillin oral suspension for reconstitution / ml, 00 / ml, 0 / ml, 00 / ml amoxicillin oral tablet 00, 87 amoxicillin oral tablet, er multiphase (Moxatag) hr 77 amoxicillin oral tablet,chewable, 0, 00 amoxicillin-pot clavulanate oral suspension for reconstitution / ml, 00-7 / ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution 0-6. / ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution / ml amoxicillin-pot clavulanate oral tablet 0- amoxicillin-pot clavulanate oral tablet (Augmentin) 00-, 87- amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release hr, amoxicillin-pot clavulanate oral tablet,chewable 00-8., 00-7 ampicillin oral capsule 0, 00 ampicillin oral suspension for reconstitution / ml, 0 / ml AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION -3. / ML dicloxacillin oral capsule 0, 00 penicillin v potassium oral recon soln / ml, 0 / ml penicillin v potassium oral tablet 0, 00 6 PA; QL (8 per 6 8

26 Quinolones ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase hr,000, 00 ciprofloxacin hcl oral tablet 00, 70 ciprofloxacin hcl oral tablet 0, 00 (Cipro) ciprofloxacin oral (Cipro) 3 suspension,microcapsule recon 0 / ml, 00 / ml FACTIVE ORAL TABLET 30 levofloxacin oral solution 0 /0 ml levofloxacin oral tablet 0, 00, (Levaquin) 70 moxifloxacin oral tablet 00 (Avelox) 3 NOROXIN ORAL TABLET 00 ofloxacin oral tablet 00, 300, 00 Sulfonamides sulfadiazine oral tablet 00 sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-0 / ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet sulfasalazine oral tablet 00 (Sulfazine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 00 Tetracyclines demeclocycline oral tablet 0, 300 DORYX ORAL TABLET,DELAYED RELEASE (DR/EC) 00, 0 PA doxycycline hyclate oral capsule 00, (Morgidox) 0 doxycycline hyclate oral tablet 00, 0 doxycycline hyclate oral tablet 0, (Acticlate) 7 doxycycline hyclate oral tablet,delayed release (dr/ec) 00, 0, 7 9

27 doxycycline hyclate oral tablet,delayed (Doryx) 3 PA release (dr/ec) 00, 0 doxycycline monohydrate oral capsule (Mondoxyne NL) 00, 0 doxycycline monohydrate oral capsule 0 doxycycline monohydrate oral capsule,ir (Oracea) 3 - delay rel,biphase 0 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution / ml doxycycline monohydrate oral tablet 00 (Avidoxy) doxycycline monohydrate oral tablet 0, 0, 7 MINOCIN KIT WITH WIPES COMBO PACK 00, 0 minocycline oral capsule 00, 0, (Minocin) 7 minocycline oral tablet 00, 0, 7 minocycline oral tablet extended release 3 PA hr 3,, 90 MONDOXYNE NL ORAL CAPSULE PA 00, 0, 7 MORGIDOX X00 KIT 00 MORGIDOX ORAL CAPSULE 0 tetracycline oral capsule 0, 00 VIBRAMYCIN ORAL SYRUP 0 / ML Anticancer Agents Anticancer Agents AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION, 3, 6 PA; QL ( per 8 AFINITOR ORAL TABLET 0, 7. 6 PA; QL (60 per 30 AFINITOR ORAL TABLET., 6 PA; QL (30 per 30 ALECENSA ORAL CAPSULE 0 6 PA; QL (0 per 30 ALKERAN ORAL TABLET 0

28 ALUNBRIG ORAL TABLET 30 6 PA QL (80 per 30 anastrozole oral tablet (Arimidex) AROMASIN ORAL TABLET ST bexarotene oral capsule 7 (Targretin) 6 PA NSO; QL (0 per 30 bicalutamide oral tablet 0 (Casodex) BOSULIF ORAL TABLET 00 6 PA; QL (0 per 30 BOSULIF ORAL TABLET 00 6 PA; QL (30 per 30 CABOMETYX ORAL TABLET 0, 60 6 PA; QL (30 per 30 CABOMETYX ORAL TABLET 0 6 PA; QL (60 per 30 capecitabine oral tablet 0, 00 (Xeloda) 6 CAPRELSA ORAL TABLET 00 6 PA; QL (60 per 30 CAPRELSA ORAL TABLET PA; QL (30 per 30 COMETRIQ ORAL CAPSULE 00 /DAY(80 X-0 X), 0 /DAY(80 X-0 X3), 60 /DAY (0 X 3/DAY) 6 PA; QL ( per 8 COTELLIC ORAL TABLET 0 6 PA; QL (63 per 8 CYCLOPHOSPHAMIDE ORAL 6 CAPSULE, 0 cyclophosphamide oral tablet, 0 6 DROXIA ORAL CAPSULE 00, 300, 00 EMCYT ORAL CAPSULE 0 6 ERIVEDGE ORAL CAPSULE 0 6 PA; QL (30 per 30 etoposide oral capsule 0 exemestane oral tablet (Aromasin) ST FARESTON ORAL TABLET 60 6 FARYDAK ORAL CAPSULE 0 6 PA; QL (6 per,, 0 flutamide oral capsule GILOTRIF ORAL TABLET 0, 30, 0 6 PA; QL (30 per 30

29 GLEEVEC ORAL TABLET 00 6 PA; QL (60 per 30 GLEEVEC ORAL TABLET 00 6 PA; QL (30 per 30 GLEOSTINE ORAL CAPSULE 0 6, 00, 0, HEXALEN ORAL CAPSULE 0 6 HYCAMTIN ORAL CAPSULE 0. 6, HYDREA ORAL CAPSULE 00 hydroxyurea oral capsule 00 (Hydrea) IBRANCE ORAL CAPSULE 00,, 7 6 PA; QL ( per 8 ICLUSIG ORAL TABLET 6 PA; QL (60 per 30 ICLUSIG ORAL TABLET 6 PA; QL (30 per 30 imatinib oral tablet 00 (Gleevec) 6 PA; QL (60 per 30 imatinib oral tablet 00 (Gleevec) 6 PA; QL (30 per 30 IMBRUVICA ORAL CAPSULE 0 6 PA; QL (0 per 30 INLYTA ORAL TABLET 6 PA; QL (80 per 30 INLYTA ORAL TABLET 6 PA; QL (0 per 30 IRESSA ORAL TABLET 0 6 PA; QL (60 per 30 JAKAFI ORAL TABLET 0,, 0,, 6 PA; QL (60 per 30 KISQALI FEMARA CO-PACK ORAL TABLET 00 /DAY(00 X )-. KISQALI FEMARA CO-PACK ORAL TABLET 00 /DAY(00 X )-. KISQALI FEMARA CO-PACK ORAL TABLET 600 /DAY(00 X 3)-. KISQALI ORAL TABLET 00 /DAY (00 X ) 6 PA; QL (9 per 8 6 PA; QL (70 per 8 6 PA; QL (9 per 8 6 PA; QL ( per 8

30 KISQALI ORAL TABLET 00 /DAY (00 X ) KISQALI ORAL TABLET 600 /DAY (00 X 3) LENVIMA ORAL CAPSULE 0 /DAY (0 X /DAY) LENVIMA ORAL CAPSULE /DAY(0 X - X ), 0 /DAY (0 X ), 8 /DAY ( X ) LENVIMA ORAL CAPSULE 8 /DAY (0 X - X), /DAY(0 X - X ) letrozole oral tablet. (Femara) LEUKERAN ORAL TABLET 6 leuprolide subcutaneous kit /0. ml 6 PA 6 PA; QL ( per 8 6 PA; QL (63 per 8 6 PA; QL (30 per 30 6 PA; QL (60 per 30 6 PA; QL (90 per 30 lomustine oral capsule 0, 00, 0 (Gleostine) 6 LONSURF ORAL TABLET PA; QL (00 per 8 LONSURF ORAL TABLET PA; QL (80 per 8 LYNPARZA ORAL CAPSULE 0 6 PA; QL (80 per 30 LYSODREN ORAL TABLET 00 6 MATULANE ORAL CAPSULE 0 6 megestrol oral tablet 0, 0 MEKINIST ORAL TABLET 0. 6 PA; QL (90 per 30 MEKINIST ORAL TABLET 6 PA; QL (30 per 30 melphalan oral tablet (Alkeran) mercaptopurine oral tablet 0 methotrexate sodium (pf) injection recon soln gram methotrexate sodium (pf) injection solution /ml methotrexate sodium injection solution /ml methotrexate sodium oral tablet. MYLERAN ORAL TABLET 6 3

31 NEXAVAR ORAL TABLET 00 6 PA; QL (0 per 30 NILANDRON ORAL TABLET 0 6 nilutamide oral tablet 0 (Nilandron) 6 NINLARO ORAL CAPSULE.3, 6 PA; QL (3 per 8 3, ODOMZO ORAL CAPSULE 00 6 PA; QL (30 per 30 POMALYST ORAL CAPSULE,, 3, 6 PA; QL ( per 8 PURINETHOL ORAL TABLET 0 PURIXAN ORAL SUSPENSION 0 /ML REVLIMID ORAL CAPSULE 0,,., 0,, 6 PA; QL (8 per 8 RHEUMATREX ORAL TABLETS,DOSE PACK. RUBRACA ORAL TABLET 00, 0, PA; QL (0 per 30 RYDAPT ORAL CAPSULE 6 PA; QL (0 per 30 SOLTAMOX ORAL SOLUTION 0 / ML SPRYCEL ORAL TABLET 00, 0, 0, 70, 80 6 PA; QL (30 per 30 SPRYCEL ORAL TABLET 0 6 PA; QL (60 per 30 STIVARGA ORAL TABLET 0 6 PA; QL (8 per 8 SUTENT ORAL CAPSULE.,, 37., 0 6 PA; QL (30 per 30 SYNRIBO SUBCUTANEOUS RECON SOLN 3. 6 PA; QL (8 per 8 TABLOID ORAL TABLET 0 6 TAFINLAR ORAL CAPSULE 0, 7 6 PA; QL (0 per 30 TAGRISSO ORAL TABLET 0, 80 6 PA; QL (30 per 30 tamoxifen oral tablet 0, 0

32 TARCEVA ORAL TABLET 00, 6 PA; QL (60 per 30 TARCEVA ORAL TABLET 0 6 PA; QL (90 per 30 TARGRETIN ORAL CAPSULE 7 6 PA NSO; QL (0 per 30 TARGRETIN TOPICAL GEL % 6 PA NSO; QL (60 per 30 TASIGNA ORAL CAPSULE 0, 00 6 PA; QL (0 per 30 TEMODAR ORAL CAPSULE 00, 0, 80, 0, 0, 6 temozolomide oral capsule 00, 0 (Temodar) 6, 80, 0, 0, tretinoin (chemotherapy) oral capsule 0 6 TREXALL ORAL TABLET 0,,, 7. TYKERB ORAL TABLET 0 6 PA; QL (80 per 30 VENCLEXTA ORAL TABLET 0 6 PA; QL (60 per 30 VENCLEXTA ORAL TABLET 00 6 PA; QL (0 per 30 VENCLEXTA ORAL TABLET 0 6 PA; QL (30 per 30 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 6 PA; QL ( per VOTRIENT ORAL TABLET 00 6 PA; QL (0 per 30 XALKORI ORAL CAPSULE 00, 0 6 PA; QL (60 per 30 XATMEP ORAL SOLUTION. 6 /ML XELODA ORAL TABLET 0, 6 PA 00 XTANDI ORAL CAPSULE 0 6 PA; QL (0 per 30 ZEJULA ORAL CAPSULE 00 6 PA; QL (90 per 30

33 ZELBORAF ORAL TABLET 0 6 PA; QL (0 per 30 ZOLINZA ORAL CAPSULE 00 6 ZYDELIG ORAL TABLET 00, 6 0 ZYKADIA ORAL CAPSULE 0 6 PA; QL (0 per 8 ZYTIGA ORAL TABLET 0 6 PA; QL (0 per 30 ZYTIGA ORAL TABLET 00 6 PA; QL (60 per 30 Anticholinergic Agents Antimuscarinics/Antispasmodics BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-.8 MCG chlordiazepoxide-clidinium oral capsule -. DONNATAL ORAL TABLET me-pb-hyos oral elixir / ml PAMINE FQ ORAL COMBO PACK -8 BILLION -CELL phenobarb-hyoscy-atropine-scop oral tablet (Librax (with clidinium)) (Phenohytro) ST; QL (0.7 per 30 propantheline oral tablet Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00, ST; QL (30 per 30 00, 800 APTIOM ORAL TABLET 600 ST; QL (60 per 30 BANZEL ORAL SUSPENSION 0 /ML BANZEL ORAL TABLET 00, 00 carbamazepine oral capsule, er (Carbatrol) multiphase hr 00, 00, 300 carbamazepine oral suspension 00 / (Tegretol) ml carbamazepine oral tablet 00 (Epitol) 6

34 carbamazepine oral tablet extended (Tegretol XR) release hr 00, 00, 00 carbamazepine oral tablet,chewable 00 CARBATROL ORAL CAPSULE, ER MULTIPHASE HR 00, 00, 300 CELONTIN ORAL CAPSULE 300 DEPAKENE ORAL CAPSULE 0 DEPAKENE ORAL SOLUTION 0 / ML DEPAKOTE ER ORAL TABLET EXTENDED RELEASE HR 0, 00 DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC), 0, 00 DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE DILANTIN EXTENDED ORAL CAPSULE 00 DILANTIN INFATABS ORAL TABLET,CHEWABLE 0 DILANTIN ORAL CAPSULE 30 DILANTIN- ORAL SUSPENSION / ML divalproex oral capsule, delayed rel sprinkle (Depakote Sprinkles) divalproex oral tablet extended release (Depakote ER) 3 hr 0, 00 divalproex oral tablet,delayed release (Depakote) (dr/ec), 0, 00 epitol oral tablet 00 EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00, 00, 300 ethosuximide oral capsule 0 (Zarontin) ethosuximide oral solution 0 / ml (Zarontin) felbamate oral suspension 600 / ml (Felbatol) 7

35 felbamate oral tablet 00, 600 (Felbatol) FELBATOL ORAL SUSPENSION 600 / ML FELBATOL ORAL TABLET 00, 600 FYCOMPA ORAL SUSPENSION 0. /ML ST; QL (680 per 8 FYCOMPA ORAL TABLET 0, ST; QL (30 per 30, 8 FYCOMPA ORAL TABLET ST; QL (0 per 30 FYCOMPA ORAL TABLET, 6 ST; QL (60 per 30 gabapentin oral capsule 00, 300, (Neurontin) 00 gabapentin oral solution 0 / ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) GABITRIL ORAL TABLET, 6 GRALISE 30-DAY STARTER PACK ST; QL (78 per 30 ORAL TABLET EXTENDED RELEASE HR 300 (9)- 600 (69) GRALISE ORAL TABLET ST; QL (90 per 30 EXTENDED RELEASE HR 300, 600 HORIZANT ORAL TABLET ST; QL (30 per 30 EXTENDED RELEASE 300 HORIZANT ORAL TABLET ST; QL (60 per 30 EXTENDED RELEASE 600 LAMICTAL ODT ORAL TABLET,DISINTEGRATING 00, 00,, 0 LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK () -0 (7) LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 0 () -00 () 8

36 LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK ()-0 ()-00 (7) LAMICTAL ORAL TABLET 00, 0, 00, LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE, LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK (3) LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK (8) -00 () LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK () -00 (7) LAMICTAL XR ORAL TABLET EXTENDED RELEASE HR 00, 00,, 0, 300, 0 LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK () -0 (7) LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK 0 ()-00 ()-00 (7) LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK ()-0 ()-00 (7) lamotrigine oral tablet 00, 0, 00, lamotrigine oral tablet disintegrating, dose pk () -0 (7) lamotrigine oral tablet disintegrating, dose pk ()-0 ()-00 (7) lamotrigine oral tablet disintegrating, dose pk 0 () -00 () (Lamictal) (Lamictal ODT Starter (Blue)) (Lamictal ODT Starter (Orange)) (Lamictal ODT Starter (Green))

37 lamotrigine oral tablet extended release (Lamictal XR) 3 hr 00, 00,, 0, 300, 0 lamotrigine oral tablet, chewable (Lamictal) dispersible, lamotrigine oral tablet,disintegrating 00 (Lamictal ODT) 3, 00,, 0 lamotrigine oral tablets,dose pack (Lamictal Starter (3) (Blue) Kit) levetiracetam oral solution 00 /ml (Keppra) levetiracetam oral tablet,000, 0 (Keppra) levetiracetam oral tablet 00, 70 (Roweepra) levetiracetam oral tablet extended release (Keppra XR) 3 hr 00, 70 LYRICA ORAL CAPSULE 00, 0, 00,,, 300, 0, 7 LYRICA ORAL SOLUTION 0 /ML oxcarbazepine oral suspension 300 / (Trileptal) ml (60 /ml) oxcarbazepine oral tablet 0, 300, 600 (Trileptal) OXTELLAR XR ORAL TABLET EXTENDED RELEASE HR 0, 300 ST; QL (30 per 30 OXTELLAR XR ORAL TABLET EXTENDED RELEASE HR 600 PEGANONE ORAL TABLET 0 phenobarbital oral elixir 0 / ml ( /ml) phenobarbital oral tablet 00,, 6., 30, 3., 60, 6.8, 97. PHENYTEK ORAL CAPSULE 00, 300 phenytoin oral suspension / ml (Dilantin-) phenytoin oral tablet,chewable 0 (Dilantin Infatabs) ST; QL (0 per 30 30

38 phenytoin sodium extended oral capsule (Dilantin Extended) 00 phenytoin sodium extended oral capsule 00, 300 (Phenytek) POTIGA ORAL TABLET 00, ST; QL (90 per , 00 POTIGA ORAL TABLET 0 ST; QL (70 per 30 primidone oral tablet 0, 0 (Mysoline) QUDEXY XR ORAL ST; QL (30 per 30 CAPSULE,SPRINKLE,ER HR 00,, 0 QUDEXY XR ORAL ST; QL (60 per 30 CAPSULE,SPRINKLE,ER HR 0, 00 SABRIL ORAL POWDER IN PACKET 00 SABRIL ORAL TABLET 00 SPRITAM ORAL TABLET FOR ST; QL (60 per 30 SUSPENSION,000 SPRITAM ORAL TABLET FOR SUSPENSION 0, 00, 70 ST; QL (0 per 30 STAVZOR ORAL CAPSULE,DELAYED RELEASE(DR/EC), 0, 00 TEGRETOL ORAL SUSPENSION 00 / ML TEGRETOL ORAL TABLET 00 TEGRETOL XR ORAL TABLET EXTENDED RELEASE HR 00, 00, 00 tiagabine oral tablet, (Gabitril) 3 TOPAMAX ORAL CAPSULE, SPRINKLE, TOPAMAX ORAL TABLET 00, 00,, 0 topiragen oral tablet 00, 00,, 0 topiramate oral capsule, sprinkle, (Topamax) 3

39 topiramate oral tablet 00, 00, (Topamax), 0 TRILEPTAL ORAL SUSPENSION 300 / ML (60 /ML) valproic acid (as sodium salt) oral (Depakene) solution 0 / ml valproic acid oral capsule 0 (Depakene) VIMPAT ORAL SOLUTION 0 /ML VIMPAT ORAL TABLET 00, 0, 00, 0 ZARONTIN ORAL CAPSULE 0 ZARONTIN ORAL SOLUTION 0 / ML ZONEGRAN ORAL CAPSULE 00, zonisamide oral capsule 00, (Zonegran) zonisamide oral capsule 0 Antidementia Agents Antidementia Agents donepezil oral tablet 0, (Aricept) donepezil oral tablet 3 (Aricept) 3 donepezil oral tablet,disintegrating 0, EXELON ORAL SOLUTION /ML galantamine oral capsule,ext rel. pellets (Razadyne ER) 3 hr 6,, 8 galantamine oral solution /ml galantamine oral tablet,, 8 (Razadyne) memantine oral solution /ml memantine oral tablet 0, (Namenda) memantine oral tablets,dose pack -0 (Namenda Titration Pak) NAMENDA XR ORAL CAP,SPRINKLE,ER HR DOSE PACK

40 NAMENDA XR ORAL CAPSULE,SPRINKLE,ER HR,, 8, 7 NAMZARIC ORAL ST; QL (8 per 8 CAP,SPRINKLE,ER HR DOSE PACK 7///8-0 NAMZARIC ORAL ST; QL (30 per 30 CAPSULE,SPRINKLE,ER HR - 0, -0, 8-0, 7-0 rivastigmine tartrate oral capsule., 3,., 6 rivastigmine transdermal patch hour (Exelon) / hour,.6 / hr, 9. / hr Antidepressants Antidepressants amitriptyline oral tablet 0, 00, 0,, 0, 7 amitriptyline-chlordiazepoxide oral tablet.-, -0 amoxapine oral tablet 00, 0,, 0 APLENZIN ORAL TABLET QL (30 per 30 EXTENDED RELEASE HR 7, 38, BRINTELLIX ORAL TABLET 0 ST; QL (30 per 30, 0, budeprion sr oral tablet extended release hr 00, 0 bupropion hcl oral tablet 00, 7 bupropion hcl oral tablet extended release (Wellbutrin SR) hr 00, 0, 00 bupropion hcl oral tablet extended release (Wellbutrin XL) hr 0, 300 citalopram oral solution 0 / ml citalopram oral tablet 0, 0, 0 (Celexa) clomipramine oral capsule, 0, (Anafranil) 7 desipramine oral tablet 0, (Norpramin) 33

41 desipramine oral tablet 00, 0, 0, 7 DESVENLAFAXINE FUMARATE ST; QL (30 per 30 ORAL TABLET EXTENDED RELEASE HR 00, 0 DESVENLAFAXINE ORAL ST; QL (30 per 30 TABLET EXTENDED RELEASE HR 00, 0 desvenlafaxine oral tablet extended (Khedezla) 3 ST; QL (30 per 30 release hr 00, 0 desvenlafaxine succinate oral tablet (Pristiq) 3 ST; QL (30 per 30 extended release hr 00,, 0 doxepin oral capsule 0, 00, 0,, 0, 7 doxepin oral concentrate 0 /ml duloxetine oral capsule,delayed (Cymbalta) 3 release(dr/ec) 0, 30, 60 duloxetine oral capsule,delayed (Irenka) 3 release(dr/ec) 0 EMSAM TRANSDERMAL PATCH HOUR / HR, 6 / HR, 9 / HR escitalopram oxalate oral solution / ml escitalopram oxalate oral tablet 0, (Lexapro) 0, FETZIMA ORAL CAPSULE,EXT ST; QL (30 per 30 REL HR DOSE PACK 0 ()- 0 (6) FETZIMA ORAL ST; QL (30 per 30 CAPSULE,EXTENDED RELEASE HR 0, 0, 0, 80 fluoxetine oral capsule 0, 0, 0 (Prozac) fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) 90 fluoxetine oral solution 0 / ml ( /ml) fluoxetine oral tablet 0, 0 (Sarafem) FLUOXETINE ORAL TABLET 60 3

42 fluvoxamine oral capsule,extended 3 release hr 00, 0 fluvoxamine oral tablet 00,, 0 FORFIVO XL ORAL TABLET EXTENDED RELEASE HR 0 ST; QL (30 per 30 imipramine hcl oral tablet 0,, (Tofranil) 3 0 imipramine pamoate oral capsule 00, 3, 0, 7 maprotiline oral tablet, 0, 7 MARPLAN ORAL TABLET 0 mirtazapine oral tablet, 30, (Remeron) mirtazapine oral tablet 7. mirtazapine oral tablet,disintegrating (Remeron SolTab) 3, 30, nefazodone oral tablet 00, 0, 00, 0, 0 nortriptyline oral capsule 0,, (Pamelor) 0, 7 nortriptyline oral solution 0 / ml olanzapine-fluoxetine oral capsule - (Symbyax), -0, 3-, 6-, 6-0 OLEPTRO ER ORAL TABLET EXTENDED RELEASE HR 0, 300 paroxetine hcl oral tablet 0, 0, (Paxil) 30, 0 paroxetine hcl oral tablet extended (Paxil CR) 3 release hr.,, 37. PAXIL ORAL SUSPENSION 0 / ML perphenazine-amitriptyline oral tablet - 0, -, -0, -, -0 PEXEVA ORAL TABLET 0, 0, 30, 0 phenelzine oral tablet (Nardil) 3

43 PRISTIQ ORAL TABLET ST; QL (30 per 30 EXTENDED RELEASE HR 00,, 0 protriptyline oral tablet 0, SARAFEM ORAL TABLET 0, 0 sertraline oral concentrate 0 /ml (Zoloft) sertraline oral tablet 00,, 0 (Zoloft) SURMONTIL ORAL CAPSULE 00,, 0 tranylcypromine oral tablet 0 (Parnate) trazodone oral tablet 00, 0, 0 trazodone oral tablet 300 trimipramine oral capsule 00,, (Surmontil) 0 TRINTELLIX ORAL TABLET 0, 0, ST; QL (30 per 30 venlafaxine oral capsule,extended release (Effexor XR) hr 0, 37., 7 venlafaxine oral tablet 00,, 37., 0, 7 venlafaxine oral tablet extended release hr 0,, 37., 7 VIIBRYD ORAL TABLET 0, 0, 0 VIIBRYD ORAL TABLETS,DOSE PACK 0 (7)- 0 (3), 0 (7)-0 (7)-0 (6) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 00,, 0 (Precose) ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE HR -,000, 30-,000 alogliptin oral tablet.,, (Nesina) ST; QL (30 per alogliptin-metformin oral tablet.-,000,.-00 (Kazano) ST; QL (30 per 30 36

44 alogliptin-pioglitazone oral tablet.-,.-30,.-, -, -30, - AVANDAMET ORAL TABLET -,000, -00, -,000, - 00 AVANDARYL ORAL TABLET -, -, -, 8-, 8- AVANDIA ORAL TABLET,, 8 BYDUREON SUBCUTANEOUS PEN INJECTOR /0.6 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(0 MCG/ML). ML BYETTA SUBCUTANEOUS PEN INJECTOR MCG/DOSE (0 MCG/ML). ML (Oseni) ST; QL (30 per 30 ST ST ST ST; QL ( per 8 ST; QL ( per 8 ST; QL (. per 30 ST; QL (. per 30 CYCLOSET ORAL TABLET 0.8 FARXIGA ORAL TABLET 0, ST; QL (30 per 30 GLYSET ORAL TABLET 00,, 0 GLYXAMBI ORAL TABLET 0- ST; QL (30 per 30, - INVOKAMET ORAL TABLET 0- ST; QL (60 per 30,000, 0-00, 0-,000, 0-00 INVOKAMET XR ORAL TABLET, ST; QL (60 per 30 IR - ER, BIPHASIC HR 0-,000, 0-00, 0-,000, 0-00 INVOKANA ORAL TABLET 00 ST; QL (30 per 30, 300 JANUMET ORAL TABLET 0-,000,

45 JANUMET XR ORAL TABLET, ER MULTIPHASE HR 00-,000, 0-,000, 0-00 JANUVIA ORAL TABLET 00,, 0 JARDIANCE ORAL TABLET 0 ST; QL (30 per 30, JENTADUETO ORAL TABLET.- QL (60 per 30,000,.-00,.-80 JENTADUETO XR ORAL TABLET, QL (60 per 30 IR - ER, BIPHASIC HR.-,000 JENTADUETO XR ORAL TABLET, QL (30 per 30 IR - ER, BIPHASIC HR -,000 KAZANO ORAL TABLET.-,000 ST; QL (60 per 30,.-00 KOMBIGLYZE XR ORAL TABLET, ST; QL (60 per 30 ER MULTIPHASE HR.-,000 KOMBIGLYZE XR ORAL TABLET, ST; QL (30 per 30 ER MULTIPHASE HR -,000, -00 KORLYM ORAL TABLET PA; QL (0 per 30 metformin oral tablet,000, 00, (Glucophage) 80 metformin oral tablet extended release (Glucophage XR) hr 00 metformin oral tablet extended release (Glucophage XR) hr 70 metformin oral tablet extended release (Fortamet) hr,000, 00 miglitol oral tablet 00,, 0 (Glyset) 3 nateglinide oral tablet 0, 60 (Starlix) NESINA ORAL TABLET., ST; QL (30 per 30, 6. ONGLYZA ORAL TABLET., ST; QL (30 per 30 OSENI ORAL TABLET.-,.-30,.-, -, -30, - ST; QL (30 per 30 38

46 pioglitazone oral tablet, 30, (Actos) pioglitazone-glimepiride oral tablet 30- (DUETACT) 3, 30- pioglitazone-metformin oral tablet - (Actoplus MET) 00, -80 repaglinide oral tablet 0. 3 repaglinide oral tablet, (Prandin) 3 repaglinide-metformin oral tablet -00 3, -00 RIOMET ORAL SOLUTION 00 / ML SYMLINPEN 0 SUBCUTANEOUS PEN INJECTOR,700 MCG/.7 ML PA; QL (0.8 per 8 SYMLINPEN 60 SUBCUTANEOUS PA; QL (6 per 8 PEN INJECTOR,00 MCG/. ML SYNJARDY ORAL TABLET.- ST; QL (60 per 30,000,.-00, -,000, -00 SYNJARDY XR ORAL TABLET, IR ST; QL (30 per 30 - ER, BIPHASIC HR 0-,000, -,000 SYNJARDY XR ORAL TABLET, IR ST; QL (60 per 30 - ER, BIPHASIC HR.-,000, -,000 TRADJENTA ORAL TABLET TRULICITY SUBCUTANEOUS PEN ST; QL ( per 8 INJECTOR 0.7 /0. ML,. /0. ML VICTOZA ST; QL (9 per 8 XIGDUO XR ORAL TABLET, IR - ST; QL (60 per 30 ER, BIPHASIC HR 0-,000, 0-00, -,000, -00 Insulins APIDRA SOLOSTAR ST SUBCUTANEOUS INSULIN PEN 00 UNIT/ML APIDRA SUBCUTANEOUS ST SOLUTION 00 UNIT/ML BASAGLAR KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) ST 39

47 HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML, 00 UNIT/ML (3 ML) HUMALOG MIX 0-0 KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (0-0) HUMALOG MIX 0-0 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (0-0) HUMALOG MIX 7- KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (7-) HUMALOG MIX 7- SUBCUTANEOUS SUSPENSION 00 UNIT/ML (7-) HUMALOG SUBCUTANEOUS CARTRIDGE 00 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) HUMULIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML HUMULIN R U-00 INJECTION SOLUTION 00 UNIT/ML HUMULIN R U-00 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) HUMULIN R U-00 (CONCENTRATED) SUBCUTANEOUS SOLUTION 00 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) 0

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