(List of Covered Drugs)

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1 (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on April 1, 018. For more recent information or other questions, please contact SummaCare at or, for TTY users, From October 1 through February 14, a representative will be available to take your call from 8:00 a.m. until 8:00 p.m., seven days a week. From February 15 through September 30, a representative will be available to take your call from 8:00 a.m. until 8:00 p.m., Monday through Friday. Or visit H3660_18_17 Approved Formulary ID: , Version: 11 Effective: April 1, 018

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our it means SummaCare. When it refers to plan or our plan, it means a SummaCare Medicare Advantage Plan. This document includes a list of the drugs (formulary) for our plan, which is current as of April 1, 018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change after January 1, 018 and from time to time during the year. What is the SummaCare Formulary? A formulary is a list of covered drugs selected by SummaCare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. SummaCare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SummaCare network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of April 1, 018. To get updated information about the drugs covered by SummaCare, please contact us. Our contact information appears on the front and back cover pages. Or, visit our website at and click on Find Your Drug. SummaCare 018 Part D Formulary Formulary ID: , Version: 11 Effective: April 1, 018

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 3. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category cardiovascular agents. If you know what your drug is used for, look for the category name in the list that begins on page 3. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? SummaCare covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: SummaCare requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from SummaCare before you fill your prescriptions. If you don t get approval, SummaCare may not cover the drug. Quantity Limits: For certain drugs, SummaCare limits the amount of the drug that SummaCare will cover. For example, SummaCare provides tablets per prescription for metformin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, SummaCare 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, SummaCare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, SummaCare will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 3. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send SummaCare 018 Part D Formulary Formulary ID: , Version: 11 Effective: April 1, 018

4 you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask SummaCare to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the SummaCare formulary? on the next page for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. SummaCare pays for certain generic OTC drugs if prescribed by a doctor, and presented with a prescription. Generic Name DRUG Reference Brand Name Dosage Form cetirizine hydrochloride cetirizine hydrochloride/ pseudoephedrine hydrochloride (Zyrtec) (Zyrtec D) Chewable Tablets, Solution, Tablets 1 Hour Tablets fexofenadine hydrochloride (Allegra) Oral Solution, Tablets Fexofenadine hydrochloride/pseudoephedrine hydrochloride (Allegra D) Tablets levocetirizine dihydrochloride (Xyzal) Oral Solution, Tablets loratadine (Claritin) Solution, Tablets loratadine/ pseudoephedrine sulfate (Claritin D) 1 Hour Tablets 4 Hour Tablets ketotifen fumarate (Zaditor) Eye Drops SummaCare will provide these generic OTC drugs at no cost to you. The cost to SummaCare of these generic OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap.) What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. SummaCare 018 Part D Formulary Formulary ID: , Version: 11 Effective: April 1, 018

5 If you learn that SummaCare does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by SummaCare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by SummaCare. You can ask SummaCare to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the SummaCare Formulary? You can ask SummaCare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, SummaCare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, SummaCare will only approve your request for an exception if the alternative drugs included on the plan s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to SummaCare 018 Part D Formulary Formulary ID: , Version: 11 Effective: April 1, 018

6 your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. If you are a current member of SummaCare and experience a change in your level of care from one treatment setting to another, we will cover a transition supply of each drug that is on our formulary but may have certain requirements or limits on coverage. For more information For more detailed information about your SummaCare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about SummaCare, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit SummaCare s Formulary The formulary that begins on page 3 provides coverage information about the drugs covered by SummaCare. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR ) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if SummaCare has any special requirements for coverage of your drug. SummaCare 018 Part D Formulary Formulary ID: , Version: 11 Effective: April 1, 018

7 The following abbreviations may be found within the body of this document COVERAGE NOTE ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION PA PA BvD PA-HRM PA NSO QL ST LA Prior Authorization Restriction Prior Authorization Restriction for Part B vs. Part D Determination Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction You (or your physician) are required to get prior authorization from SummaCare before you fill your prescription for this drug. Without prior approval, SummaCare may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from SummaCare to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, SummaCare may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 years or older are required to get prior authorization from SummaCare before you fill your prescription for this drug. Without prior approval, SummaCare may not cover this drug. If you are a new member, you (or your physician) are required to get prior authorization from SummaCare before you fill your prescription for this drug. Without prior approval, SummaCare may not cover this drug. SummaCare limits the amount of this drug that is covered per prescription, or within a specific time frame. Before SummaCare will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. Other Special Requirements for Coverage This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at for additional information. TTY users should call From February 15 through Limited Access Drug September 30 a representative will be available to take your call from 8:00 a.m. until 8:00 p.m. Monday through Friday. From October 1 through February 14, a representative will be available to take your call from 8:00 a.m. until 8:00 p.m., seven days a week. SummaCare 018 Part D Formulary Formulary ID: , Version: 11 Effective: April 1, 018

8 GC NM NDS Gap Coverage Non-Mail Order Drug Non-Extended Days Supply We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. You may be able to receive greater than a 1-month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column. This drug is not available for extended day supply and is limited to a 30 day supply. SummaCare 018 Part D Formulary Formulary ID: , Version: 11 Effective: April 1, 018

9 Table of Contents Analgesics...3 Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents...11 Antibacterials Anticancer Agents... 4 Anticholinergic Agents Anticonvulsants...35 Antidementia Agents...39 Antidepressants Antidiabetic Agents Antifungals...48 Antigout Agents Antihistamines...50 Anti-Infectives (Skin And Mucous Membrane)...51 Antimigraine Agents...51 Antimycobacterials...5 Antinausea Agents...53 Antiparasite Agents...54 Antiparkinsonian Agents...55 Antipsychotic Agents...57 Antivirals (Systemic)...61 Blood Products/Modifiers/Volume Expanders Caloric Agents...70 Cardiovascular Agents Central Nervous System Agents Contraceptives...89 Dental And Oral Agents...96 Dermatological Agents...96 Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying

10 Immunological Agents...11 Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals...147

11 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet ascomp with codeine oral capsule BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0.3 /ml buprenorphine hcl injection syringe 0.3 /ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule , butalbital-acetaminophen oral tablet butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule QL (700 per 30 QL (360 per 30 (Tylenol-Codeine #3) QL (360 per 30 (Tylenol-Codeine #4) QL (180 per 30 (Buprenex) PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) 3 QL (60 per 30 (Butrans) QL (4 per 8 PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) (Marten-Tab) PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) (Capacet) PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) (Esgic) PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) (Fiorinal) PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) 3

12 butalbital-aspirin-caffeine oral tablet PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) QL (5 per 8 butorphanol tartrate nasal spray,nonaerosol 10 /ml BUTRANS TRANSDERMAL 3 QL (4 per 8 PATCH WEEKLY 7.5 MCG/HOUR capacet oral capsule PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) codeine sulfate oral tablet 15, 30, QL (180 per EMBEDA ORAL CAPSULE,ORAL 4 QL (60 per 30 ONLY,EXT.REL PELL MG, MG, MG, 50- MG, MG, MG endocet oral tablet QL (40 per 30 endocet oral tablet.5-35, 5-35 QL (360 per 30 endocet oral tablet QL (300 per 30 fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, (Actiq) 5 PA; NDS; QL (10 per mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 (Duragesic) QL (10 per 30 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution QL (700 per /5 ml, /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (700 per /15 ml hydrocodone-acetaminophen oral tablet (Vicodin HP) QL (390 per hydrocodone-acetaminophen oral tablet (Lorcet HD) QL (360 per hydrocodone-acetaminophen oral tablet (Verdrocet) QL (360 per hydrocodone-acetaminophen oral tablet (Vicodin) QL (390 per hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) QL (360 per hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (390 per 30 4

13 hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (360 per hydrocodone-ibuprofen oral tablet (Ibudone) QL (150 per 30, 5-00 hydrocodone-ibuprofen oral tablet 7.5- QL (150 per hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone injection solution /ml, 4 /ml hydromorphone injection syringe (Dilaudid) /ml, 4 /ml hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 30 hydromorphone oral tablet, 4, 8 (Dilaudid) QL (180 per 30 HYSINGLA ER ORAL 3 QL (30 per 30 TABLET,ORAL ONLY,EXT.REL.4 HR 100 MG, 10 MG, 0 MG, 30 MG, 40 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, PA; NDS; QL (30 per 30 MCG/SPRAY, 400 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-35 QL (360 per 30 lorcet hd oral tablet QL (360 per 30 lorcet plus oral tablet QL (360 per 30 methadone injection solution 10 /ml methadone oral solution 10 /5 ml, 5 QL (1800 per 30 /5 ml methadone oral tablet 10 (Dolophine) QL (360 per 30 methadone oral tablet 5 (Dolophine) QL (180 per 30 methadose oral tablet,soluble 40 QL (90 per 30 morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine 4 /ml carpuject outer,l/f,p/f, sdv 4 /ml morphine 8 /ml carpuject sdv, l/f, outer 8 /ml morphine concentrate oral solution 100 /5 ml (0 /ml) QL (180 per 30 5

14 morphine intravenous syringe 10 /ml, /ml, 4 /ml, 8 /ml morphine oral solution 10 /5 ml QL (700 per 30 morphine oral solution 0 /5 ml (4 QL (300 per 30 /ml) MORPHINE ORAL TABLET 15 MG 4 QL (180 per 30 MORPHINE ORAL TABLET 30 MG 4 QL (10 per 30 morphine oral tablet extended release 100 (MS Contin) QL (60 per 30, 00, 60 morphine oral tablet extended release 15 (MS Contin) QL (90 per 30, 30 morphine sulfate 10 /ml vial 10 /ml NUCYNTA ER ORAL TABLET 3 QL (60 per 30 EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 3 QL (181 per MG, 75 MG oxycodone oral capsule 5 QL (180 per 30 oxycodone oral concentrate 0 /ml QL (10 per 30 oxycodone oral solution 5 /5 ml QL (1300 per 30 oxycodone oral tablet 10 QL (180 per 30 oxycodone oral tablet 15, 30 (Roxicodone) QL (10 per 30 oxycodone oral tablet 0 QL (10 per 30 oxycodone oral tablet 5 (Roxicodone) QL (180 per 30 oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 30 hr 10, 15, 0, 30, 40, 60 oxycodone oral tablet,oral only,ext.rel.1 hr 80 (OxyContin) ; QL (10 per 30 oxycodone-acetaminophen oral solution QL (1800 per /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (40 per oxycodone-acetaminophen oral tablet (Endocet) QL (360 per , 5-35 oxycodone-acetaminophen oral tablet (Endocet) QL (300 per oxycodone-aspirin oral tablet QL (360 per 30 6

15 OXYCONTIN ORAL 3 QL (60 per 30 TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL 3 QL (10 per 30 TABLET,ORAL ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 (Opana) QL (10 per 30 oxymorphone oral tablet 5 (Opana) QL (180 per 30 oxymorphone oral tablet extended release QL (60 per 30 1 hr 10, 15, 0, 30, 40, 5, 7.5 reprexain oral tablet 10-00,.5-00 QL (150 per 30, 5-00 SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML, 300 MG/1.5 ML tencon oral tablet PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) tramadol oral tablet 50 (Ultram) 1 GC; QL (40 per 30 tramadol-acetaminophen oral tablet (Ultracet) QL (40 per vicodin es oral tablet QL (390 per 30 vicodin hp oral tablet QL (390 per 30 vicodin oral tablet QL (390 per 30 XARTEMIS XR ORAL TAB,ORAL 3 QL (300 per 30 ONLY,IR - ER, BIPHASE MG XTAMPZA ER ORAL 3 QL (60 per 30 CAPSULE,SPRINKLE,ER 1HR TMPRR 13.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL 3 QL (10 per 30 CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG XTAMPZA ER ORAL 3 QL (40 per 30 CAPSULE,SPRINKLE,ER 1HR TMPRR 36 MG xylon 10 oral tablet QL (150 per 30 7

16 zebutal oral capsule PA-HRM; QL (180 per 30 ; AGE (Max 64 Years) ZOHYDRO ER ORAL CAPSULE, 4 QL (60 per 30 ORAL ONLY, ER 1HR 10 MG, 15 MG, 0 MG, 30 MG, 40 MG, 50 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS 4 RECON SOLN 800 MG/8 ML (100 MG/ML) celecoxib oral capsule 100, 00, (Celebrex) QL (60 per , 50 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release 4 hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 DUEXIS ORAL TABLET MG 5 PA; NDS; QL (90 per 30 etodolac oral capsule 00, 300 etodolac oral tablet 400 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release 4 hr 400, 500, 600 fenoprofen oral tablet 600 (ProFeno) flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 400, 600, 1 GC 800 indomethacin oral capsule 5 1 PA-HRM; GC; QL (40 per 30 ; AGE (Max 64 Years) 8

17 indomethacin oral capsule 50 1 PA-HRM; GC; QL (10 per 30 ; AGE (Max 64 Years) indomethacin oral capsule, extended release 75 PA-HRM; QL (60 per 30 ; AGE (Max 64 Years) indomethacin sodium intravenous recon soln 1 ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac injection cartridge 15 /ml QL (40 per 30 ketorolac injection cartridge 30 /ml QL (0 per 30 ketorolac injection solution 15 /ml QL (40 per 30 ketorolac injection solution 30 /ml (1 QL (0 per 30 ml) ketorolac intramuscular cartridge 60 QL (0 per 30 / ml ketorolac intramuscular solution 60 / QL (0 per 30 ml ketorolac intramuscular syringe 60 / QL (0 per 30 ml ketorolac oral tablet 10 PA-HRM; QL (0 per 30 ; AGE (Max 64 Years) mefenamic acid oral capsule 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) 1 GC nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, GC naproxen oral tablet 500 (Naprosyn) 1 GC naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 375, 500 piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet 150, 00 tolmetin oral capsule 400 tolmetin oral tablet 00, 600 9

18 VIMOVO ORAL TABLET,IR,DELAYED REL,BIPHASIC MG, MG Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 10 /ml (1 %), 15 /ml (1.5 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine (pf) injection solution 40 /ml (4 %) lidocaine hcl injection solution 10 /ml (1 %), 0 /ml ( %), 5 /ml (0.5 %) (Xylocaine-MPF) (Xylocaine) 5 PA; NDS; QL (60 per 30 lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution 4 % (40 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 30 lidocaine topical ointment 5 % PA; QL (90 per 30 lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) 333 BUNAVAIL BUCCAL FILM QL (30 per 30 MG BUNAVAIL BUCCAL FILM QL (60 per 30 MG, MG buprenorphine hcl sublingual tablet, QL (90 per 30 8 buprenorphine-naloxone sublingual tablet -0.5, 8- QL (90 per 30 10

19 bupropion hcl (smoking deter) oral tablet (Zyban) extended release 1 hr 150 CHANTIX CONTINUING MONTH 3 QL (168 per 84 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 3 QL (168 per 84 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (4) 3 QL (53 per 8 disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, 1 /ml naltrexone oral tablet 50 NARCAN NASAL SPRAY,NON- 3 QL (4 per 30 AEROSOL MG/ACTUATION, 4 MG/ACTUATION NICOTROL INHALATION 4 QL (1008 per 90 CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 3 QL (60 per MG, 8- MG SUBOXONE SUBLINGUAL FILM - 3 QL (30 per MG, 4-1 MG ZUBSOLV SUBLINGUAL TABLET 3 QL (30 per MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG 3 QL (60 per 30 Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 GC; QL (10 per 30 alprazolam oral tablet (Xanax) 1 GC; QL (150 per 30 alprazolam oral tablet extended release 4 hr 0.5, 1, alprazolam oral tablet extended release 4 hr 3 buspirone oral tablet 10, 15, 30, 5, 7.5 (Xanax XR) QL (10 per 30 (Xanax XR) QL (90 per 30 11

20 chlordiazepoxide hcl oral capsule 10, 5, 5 1 GC; QL (10 per 30 clonazepam oral tablet 0.5, 1 (Klonopin) 1 GC; QL (90 per 30 clonazepam oral tablet (Klonopin) 1 GC; QL (300 per 30 clonazepam oral tablet,disintegrating QL (90 per , 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (300 per 30 clorazepate dipotassium oral tablet 15 QL (180 per 30, 3.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (180 per 30 DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT.5 MG 4 diazepam injection solution 5 /ml QL (10 per 8 diazepam intensol oral concentrate 5 QL (100 per 30 /ml diazepam oral solution 5 /5 ml (1 QL (100 per 30 /ml) diazepam oral tablet 10,, 5 (Valium) 1 GC; QL (10 per 30 diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit.5 (Diastat) estazolam oral tablet 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 ; AGE (Max 64 Years) 1

21 estazolam oral tablet PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) flurazepam oral capsule 15 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 ; AGE (Max 64 Years) flurazepam oral capsule 30 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) lorazepam injection solution /ml, 4 (Ativan) QL ( per 30 /ml lorazepam injection syringe /ml QL ( per 30 lorazepam oral concentrate /ml (Lorazepam Intensol) QL (150 per 30 lorazepam oral tablet 0.5, 1 (Ativan) 1 GC; QL (90 per 30 lorazepam oral tablet (Ativan) 1 GC; QL (150 per 30 midazolam oral syrup /ml QL (10 per 30 ONFI ORAL SUSPENSION.5 MG/ML 5 PA NSO; NDS; QL (480 per 30 13

22 ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NDS; QL (60 per 30 oxazepam oral capsule 10, 15, 30 QL (10 per 30 temazepam oral capsule 15, 30 (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) triazolam oral tablet 0.15 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (10 per 30 ; AGE (Max 64 Years) triazolam oral tablet 0.5 (Halcion) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 30 ; AGE (Max 64 Years) Antibacterials Aminoglycosides BETHKIS INHALATION 5 PA BvD; NDS SOLUTION FOR NEBULIZATION 300 MG/4 ML gentamicin 10 /ml vial sdv 60 /6 ml 14

23 gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 10 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 0 / ml, 40 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml neomycin oral tablet GC streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 300 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 40 /ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram clindamycin hcl oral capsule 150, 300, 75 clindamycin in 5 % dextrose intravenous piggyback 300 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution 150 /ml ; QL (4 per 8 (Tobi) 5 PA BvD; NDS (BACiiM) (Cleocin HCl) (Cleocin in 5 % dextrose) (Cleocin Pediatric) (Cleocin) 15

24 clindamycin phosphate intravenous (Cleocin) solution 600 /4 ml colistin (colistimethate na) injection (Coly-Mycin M recon soln 150 Parenteral) daptomycin intravenous recon soln 500 (Cubicin) linezolid intravenous parenteral solution (Zyvox) 600 /300 ml linezolid oral suspension for (Zyvox) reconstitution 100 /5 ml linezolid oral tablet 600 (Zyvox) linezolid-0.9% nacl 600 / /300 ml methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 /100 ml (Metro I.V.) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 100, 5, 50 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 30 ; AGE (Max 64 Years) nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 30 ; AGE (Max 64 Years) 16

25 nitrofurantoin oral suspension 5 /5 ml (Furadantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (400 per 30 ; AGE (Max 64 Years) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet GC vancomycin in dextrose 5 % intravenous piggyback 1 gram/00 ml, 500 /100 ml, 750 /150 ml vancomycin intravenous recon soln 1,000, 10 gram, 5 gram, 500, 750 vancomycin oral capsule 15, 50 (Vancocin) XIFAXAN ORAL TABLET 00 MG 5 PA; NDS; QL (9 per 30 XIFAXAN ORAL TABLET 550 MG 5 PA; NDS Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 375 /5 ml cefaclor oral tablet extended release 1 hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin in 0.9% sod chloride intravenous solution gram/100 ml cefazolin in dextrose (iso-os) intravenous piggyback gram/100 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule

26 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 400 (Spectracef) CEFEPIME 1 GM INJECTION 1 4 GRAM/50 ML CEFEPIME INJECTION RECON (Maxipime) 4 SOLN 1 GRAM, GRAM CEFEPIME-DEXTROSE GM/50 4 ML GRAM/50 ML cefixime oral suspension for (Suprax) reconstitution 100 /5 ml, 00 /5 ml cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln 10 gram, (Claforan) gram cefoxitin gm piggyback bag gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftibuten oral capsule 400 ceftibuten oral suspension for reconstitution 180 /5 ml ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml ceftriaxone gm piggyback l/f, single use gram/50 ml ceftriaxone injection recon soln 1 gram, gram ceftriaxone injection recon soln 10 gram, 50,

27 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cefuroxime-dextrose (iso-osm) intravenous piggyback 1.5 gram/50 ml, 750 /50 ml cephalexin oral capsule 50, 500 (Keflex) 1 GC cephalexin oral capsule 750 (Keflex) cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 MEFOXIN IN DEXTROSE (ISO- 4 OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 400 MG 4 SUPRAX ORAL SUSPENSION FOR 4 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL 4 TABLET,CHEWABLE 100 MG, 00 MG tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON 4 SOLN 400 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 (3 pack) azithromycin oral tablet 50, 500, (Zithromax) 600 clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml 19

28 clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 DIFICID ORAL TABLET 00 MG 5 ST; NDS; QL (0 per 10 e.e.s. 400 oral tablet E.E.S. GRANULES ORAL 4 SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION 4 FOR RECONSTITUTION 00 MG/5 ML ERYPED 400 ORAL SUSPENSION 4 FOR RECONSTITUTION 400 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL 4 TABLET,DELAYED RELEASE (DR/EC) 333 MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG 4 erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet (E.E.S. 400) 400 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram (Azactam) CAYSTON INHALATION 5 LA; NDS SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon soln 50 0

29 imipenem-cilastatin intravenous recon (Primaxin IV) soln 500 INVANZ INJECTION RECON SOLN 4 1 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, GC amoxicillin oral suspension for 1 GC reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, GC amoxicillin oral tablet,chewable 15, 1 GC 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, GC ampicillin oral suspension for 1 GC reconstitution 15 /5 ml, 50 /5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram (Unasyn) 1

30 BICILLIN C-R INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/300K) BICILLIN L-A INTRAMUSCULAR 4 SYRINGE 1,00,000 UNIT/ ML,,400,000 UNIT/4 ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram nafcillin intravenous recon soln gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 10 gram, gram oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous (Zosyn) recon soln.5 gram, gram, 4.5 gram, 40.5 gram Quinolones BAXDELA ORAL TABLET 450 MG 5 PA; NDS; QL (8 per 14

31 ciprofloxacin (mixture) oral tablet, er multiphase 4 hr 1,000, 500 (Cipro XR) ciprofloxacin hcl oral tablet 100, GC ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 GC ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 400 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 400 /40 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50, 500, (Levaquin) 750 moxifloxacin oral tablet 400 (Avelox) ofloxacin oral tablet 300, 400 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 GC tablet sulfatrim oral suspension /5 ml Tetracyclines demeclocycline oral tablet 150, 300 doxy-100 intravenous recon soln 100 3

32 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline hyclate oral tablet,delayed release (dr/ec) 100, 150, 75 doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 00, 50 doxycycline monohydrate oral capsule (Mondoxyne NL) 100, 50, 75 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 150, 50, 75 MINOCIN INTRAVENOUS RECON SOLN 100 MG minocycline oral capsule 100, 50, (Minocin) 75 minocycline oral tablet 100, 50, 75 minocycline oral tablet extended release (CoreMino) 4 hr 135, 45, 90 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 /5 PA BvD ml, 0 /10 ml adrucil intravenous solution.5 gram/50 PA BvD ml, 500 /10 ml AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 3 MG, 5 MG 5 PA NSO; NDS; QL (11 per 8 4

33 AFINITOR ORAL TABLET 10 MG 5 PA NSO; NDS; QL (56 per 8 AFINITOR ORAL TABLET.5 MG, 5 MG, 7.5 MG 5 PA NSO; NDS; QL (8 per 8 ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (40 per 30 ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG 5 PA NSO; NDS; QL (3 per 8 ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA NSO; NDS; QL (30 per 30 ALUNBRIG ORAL TABLET 30 MG 5 PA NSO; NDS; QL (180 per 30 ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (3) 5 PA NSO; NDS; QL (30 per 30 anastrozole oral tablet 1 (Arimidex) 1 GC AVASTIN INTRAVENOUS 5 PA NSO; NDS SOLUTION 5 MG/ML, 5 MG/ML (16 ML) azacitidine injection recon soln 100 (Vidaza) BAVENCIO INTRAVENOUS 5 PA NSO; NDS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS 5 PA NSO; NDS RECON SOLN 500 MG BENDEKA INTRAVENOUS 5 PA NSO; NDS SOLUTION 5 MG/ML BESPONSA INTRAVENOUS 5 PA NSO; NDS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 5 PA NSO; NDS; QL (40 per 30 bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 15 unit, 30 PA BvD unit BLINCYTO INTRAVENOUS KIT 35 MCG 5 PA NSO; NDS; QL (5 per 365 BORTEZOMIB INTRAVENOUS 5 PA NSO; NDS RECON SOLN 3.5 MG BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; QL (10 per 30 5

34 BOSULIF ORAL TABLET 400 MG, 500 MG 5 PA NSO; NDS; QL (30 per 30 CABOMETYX ORAL TABLET 0 MG, 60 MG 5 PA NSO; NDS; QL (30 per 30 CABOMETYX ORAL TABLET 40 MG 5 PA NSO; NDS; QL (60 per 30 CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (60 per 30 CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (60 per 30 CAPRELSA ORAL TABLET 300 MG 5 PA NSO; NDS; QL (30 per 30 carboplatin intravenous solution 10 /ml cladribine intravenous solution 10 /10 PA BvD ml clofarabine intravenous solution 0 /0 (Clolar) ml COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), 140 MG/DAY(80 MG X1-0 MG X3), 60 MG/DAY (0 MG X 3/DAY) 5 PA NSO; NDS; QL (11 per 8 COTELLIC ORAL TABLET 0 MG 5 PA NSO; LA; NDS; QL (63 per 8 cyclophosphamide intravenous recon soln 5 PA BvD; NDS 1 gram, gram, 500 CYCLOPHOSPHAMIDE ORAL 4 PA BvD; ST CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NDS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS 5 PA NSO; LA; NDS SOLUTION 0 MG/ML decitabine intravenous recon soln 50 (Dacogen) docetaxel intravenous solution 140 /7 ml (0 /ml), 160 /16 ml (10 /ml), 0 /ml docetaxel intravenous solution 80 /4 (Taxotere) ml (0 /ml) doxorubicin intravenous solution 10 /5 ml, /ml, 0 /10 ml, 50 /5 ml (Adriamycin) PA BvD 6

35 doxorubicin, peg-liposomal intravenous (Doxil) 5 PA BvD; NDS suspension /ml DROXIA ORAL CAPSULE 00 MG, MG, 400 MG ELIGARD (3 MONTH) 4 SUBCUTANEOUS SYRINGE.5 MG ELIGARD (4 MONTH) 4 SUBCUTANEOUS SYRINGE 30 MG ELIGARD (6 MONTH) 4 SUBCUTANEOUS SYRINGE 45 MG ELIGARD SUBCUTANEOUS 4 SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS 5 PA NSO; NDS RECON SOLN 300 MG, 400 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (30 per 30 ERLEADA ORAL TABLET 60 MG 5 PA NSO; NDS; QL (10 per 30 ETOPOPHOS INTRAVENOUS 4 RECON SOLN 100 MG etoposide intravenous solution 0 /ml (Toposar) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 5 PA NSO; NDS MG, 15 MG, 0 MG FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML floxuridine injection recon soln 0.5 gram PA BvD fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution 5 (Adrucil) PA BvD gram/100 ml, 500 /10 ml flutamide oral capsule 15 GAZYVA INTRAVENOUS 5 PA NSO; NDS SOLUTION 1,000 MG/40 ML gemcitabine intravenous recon soln 1 (Gemzar) gram, 00 gemcitabine intravenous recon soln gram 7

36 gemcitabine intravenous solution 1 gram/6.3 ml (38 /ml), 100 /ml, gram/5.6 ml (38 /ml), 00 /5.6 ml (38 /ml) GILOTRIF ORAL TABLET 0 MG, 30 MG, 40 MG 5 PA NSO; NDS; QL (30 per 30 GLEOSTINE ORAL CAPSULE 10 4 MG, 100 MG, 40 MG, 5 MG HERCEPTIN INTRAVENOUS 5 PA NSO; NDS RECON SOLN 150 MG, 440 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG 5 PA NSO; NDS; QL (1 per 8 ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NDS; QL (60 per 30 ICLUSIG ORAL TABLET 45 MG 5 PA NSO; NDS; QL (30 per 30 IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA NSO; NDS; QL (30 per 30 ifosfamide intravenous recon soln 1 gram, (Ifex) PA BvD 3 gram ifosfamide intravenous solution 1 gram/0 PA BvD ml, 3 gram/60 ml ifosfamide-mesna intravenous kit 1-1 gram, 3,000-1,000 5 PA BvD; NDS imatinib oral tablet 100 (Gleevec) 5 PA NSO; NDS; QL (90 per 30 imatinib oral tablet 400 (Gleevec) 5 PA NSO; NDS; QL (60 per 30 IMBRUVICA ORAL CAPSULE PA NSO; NDS MG IMFINZI INTRAVENOUS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) 5 PA NSO; NDS IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML 5 PA NSO; NDS; QL (4 per PA NSO; NDS; QL (8 per 8 8

37 INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; QL (180 per 30 INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 per 30 IRESSA ORAL TABLET 50 MG 5 PA NSO; NDS; QL (60 per 30 irinotecan intravenous solution 100 /5 (Camptosar) ml, 40 / ml irinotecan intravenous solution 500 /5 ml IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 45 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG 5 PA NSO; NDS; QL (60 per 30 KEYTRUDA INTRAVENOUS RECON SOLN 50 MG 5 PA NSO; NDS; QL (4 per 1 KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML 5 PA NSO; NDS; QL (8 per 1 KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(00 MG X )-.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(00 MG X 3)-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1), 400 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X 3) KYPROLIS INTRAVENOUS RECON SOLN 30 MG, 60 MG LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML, 10 MG/ML (19 ML) 5 PA NSO; NDS; QL (49 per 8 5 PA NSO; NDS; QL (70 per 8 5 PA NSO; NDS; QL (91 per 8 5 PA NSO; NDS; QL (63 per 8 5 PA NSO; NDS 5 PA NSO; LA; NDS 9

38 LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X), 0 MG/DAY (10 MG X ), 4 MG/DAY(10 MG X -4 MG X 1), 8 MG/DAY (4 MG X ) 5 PA NSO; NDS letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG 4 leuprolide subcutaneous kit 1 /0. ml LONSURF ORAL TABLET MG 5 PA NSO; NDS; QL (100 per 8 LONSURF ORAL TABLET MG 5 PA NSO; NDS; QL (80 per 8 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 45 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (448 per 8 LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (10 per 30 LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 MG/31 ML(0.16 MG/ML) FINAL 5 PA NSO; NDS; QL (4 per 8 MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 0, 40 PA NSO-HRM; AGE (Max 64 Years) MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NDS; QL (90 per 30 MEKINIST ORAL TABLET MG 5 PA NSO; NDS; QL (30 per 30 30

39 melphalan hcl intravenous recon soln 50 (Alkeran) mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon PA BvD soln 1 gram methotrexate sodium (pf) injection PA BvD solution 5 /ml, 5 /ml (10 ml) methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD; ST mitoxantrone intravenous concentrate /ml MYLOTARG INTRAVENOUS 5 PA NSO; NDS RECON SOLN 4.5 MG (1 MG/ML INITIAL CONC) NERLYNX ORAL TABLET 40 MG 5 PA NSO; NDS; QL (180 per 30 NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NDS; QL (10 per 30 nilutamide oral tablet 150 (Nilandron) NINLARO ORAL CAPSULE.3 MG, 3 MG, 4 MG 5 PA NSO; NDS; QL (3 per 8 ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; LA; NDS ONCASPAR INJECTION 5 PA NSO; NDS SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS 5 PA BvD; NDS DISPERSION 4.3 MG/ML OPDIVO INTRAVENOUS 5 PA NSO; NDS SOLUTION 100 MG/10 ML, 40 MG/4 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 100, 50 oxaliplatin intravenous solution 100 /0 ml, 50 /10 ml (5 /ml) paclitaxel intravenous concentrate 6 /ml PERJETA INTRAVENOUS 5 PA NSO; NDS SOLUTION 40 MG/14 ML (30 MG/ML) POMALYST ORAL CAPSULE 1 MG, MG, 3 MG, 4 MG 5 PA NSO; NDS; QL (1 per 8 31

40 PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (10 MG/ML), 1600 MG/13.4 ML (10 MG/ML) RITUXAN INTRAVENOUS CONCENTRATE 10 MG/ML, 10 MG/ML (10 ML) RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG 5 PA NSO; NDS; QL (100 per 1 5 PA NSO; LA; NDS 5 PA NSO; NDS 5 PA NSO; NDS 5 PA NSO; NDS; QL (10 per 30 RYDAPT ORAL CAPSULE 5 MG 5 PA NSO; NDS; QL (4 per 8 SOLTAMOX ORAL SOLUTION 10 4 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NDS; QL (30 per 30 SPRYCEL ORAL TABLET 0 MG 5 PA NSO; NDS; QL (60 per 30 STIVARGA ORAL TABLET 40 MG 5 PA NSO; NDS; QL (84 per 8 SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 37.5 MG, 50 MG 5 PA NSO; NDS; QL (30 per 30 SYLVANT INTRAVENOUS RECON 5 PA NSO; NDS SOLN 100 MG, 400 MG SYNRIBO SUBCUTANEOUS RECON SOLN 3.5 MG 5 PA NSO; NDS; QL (8 per 8 TABLOID ORAL TABLET 40 MG 4 TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA NSO; NDS; QL (10 per 30 TAGRISSO ORAL TABLET 40 MG, 80 MG 5 PA NSO; LA; NDS; QL (30 per 30 tamoxifen oral tablet 10, 0 3

41 TARCEVA ORAL TABLET 100 MG, 5 MG 5 PA NSO; NDS; QL (60 per 30 TARCEVA ORAL TABLET 150 MG 5 PA NSO; NDS; QL (90 per 30 TARGRETIN TOPICAL GEL 1 % 5 PA NSO; NDS; QL (60 per 8 TASIGNA ORAL CAPSULE 150 MG, 00 MG 5 PA NSO; NDS; QL (11 per 8 TECENTRIQ INTRAVENOUS SOLUTION 1,00 MG/0 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG 5 PA NSO; NDS; QL (0 per 1 5 PA NSO; NDS thiotepa injection recon soln 15 (Tepadina) toposar intravenous solution 0 /ml topotecan intravenous recon soln 4 (Hycamtin) topotecan intravenous solution 4 /4 ml (1 /ml) TORISEL INTRAVENOUS RECON SOLN 30 MG/3 ML (10 MG/ML) (FIRST) TREANDA INTRAVENOUS RECON SOLN 100 MG, 5 MG TRELSTAR 11.5 MG VIAL INNER, SDV 11.5 MG TRELSTAR.5 MG VIAL INNER,SDV.5 MG TRELSTAR 3.75 MG VIAL INNER, SDV 3.75 MG TRELSTAR INTRAMUSCULAR SYRINGE 11.5 MG/ ML TRELSTAR INTRAMUSCULAR SYRINGE.5 MG/ ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/ ML tretinoin (chemotherapy) oral capsule 10 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG 5 PA BvD; NDS; QL (4 per 8 ; QL (1 per 84 ; QL (1 per 168 ; QL (1 per 84 ; QL (1 per PA BvD; ST TYKERB ORAL TABLET 50 MG 33

42 UNITUXIN INTRAVENOUS 5 PA NSO; NDS SOLUTION 3.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 40 MG/ML VECTIBIX INTRAVENOUS 5 PA NSO; NDS SOLUTION 100 MG/5 ML (0 MG/ML), 400 MG/0 ML (0 MG/ML) VELCADE INJECTION RECON 5 PA NSO; NDS SOLN 3.5 MG VENCLEXTA ORAL TABLET 10 MG 3 PA NSO; LA; QL (60 per 30 VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; LA; NDS; QL (10 per 30 VENCLEXTA ORAL TABLET 50 MG 3 PA NSO; LA; QL (30 per 30 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 5 PA NSO; LA; NDS; QL (4 per 8 MG-50 MG- 100 MG VERZENIO ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG 5 PA NSO; NDS; QL (56 per 8 vinblastine intravenous recon soln 10 PA BvD vinblastine intravenous solution 1 /ml PA BvD vincasar pfs intravenous solution 1 PA BvD /ml, / ml vincristine intravenous solution 1 /ml, (Vincasar PFS) PA BvD / ml vinorelbine intravenous solution 10 (Navelbine) /ml, 50 /5 ml VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NDS; QL (10 per 30 VYXEOS INTRAVENOUS RECON 5 PA BvD; NDS SOLN MG XALKORI ORAL CAPSULE 00 MG, 50 MG 5 PA NSO; NDS; QL (60 per 30 XATMEP ORAL SOLUTION.5 4 PA BvD; ST MG/ML XTANDI ORAL CAPSULE 40 MG 5 PA NSO; NDS; QL (10 per 30 34

43 YERVOY INTRAVENOUS 5 PA NSO; NDS SOLUTION 00 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS 5 PA NSO; NDS RECON SOLN 1 MG ZALTRAP INTRAVENOUS 5 PA NSO; NDS SOLUTION 100 MG/4 ML (5 MG/ML), 00 MG/8 ML (5 MG/ML) ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (90 per 30 ZELBORAF ORAL TABLET 40 MG 5 PA NSO; NDS; QL (40 per 30 ZOLADEX SUBCUTANEOUS 4 QL (1 per 84 IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS 4 QL (1 per 8 IMPLANT 3.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (60 per 30 ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (140 per 8 ZYTIGA ORAL TABLET 50 MG, 500 MG Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 /ml, 0.1 /ml 5 PA NSO; NDS; QL (10 per 30 propantheline oral tablet 15 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 400 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 00 MG, 400 MG BRIVIACT INTRAVENOUS 4 QL (80 per 30 SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML 4 QL (600 per 30 35

44 BRIVIACT ORAL TABLET 10 MG, 100 MG, 5 MG, 50 MG, 75 MG ; QL (60 per 30 carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 300 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr 100, 00, 400 carbamazepine oral tablet,chewable 100 CELONTIN ORAL CAPSULE MG DILANTIN ORAL CAPSULE 30 MG divalproex oral capsule, delayed rel sprinkle 15 (Depakote Sprinkles) divalproex oral tablet extended release 4 (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (Depakote) (dr/ec) 15, 50, 500 epitol oral tablet 00 ethosuximide oral capsule 50 (Zarontin) ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) felbamate oral tablet 400, 600 (Felbatol) fosphenytoin injection solution 100 (Cerebyx) pe/ ml, 500 pe/10 ml FYCOMPA ORAL SUSPENSION MG/ML FYCOMPA ORAL TABLET 10 MG, 4 1 MG, MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100, 300, (Neurontin) 400 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) GABITRIL ORAL TABLET 1 MG, 16 MG 3 GRALISE 30-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 4 HR 300 MG (9)- 600 MG (69) 4 ST; QL (78 per 30 36

45 GRALISE ORAL TABLET EXTENDED RELEASE 4 HR 300 MG, 600 MG lamotrigine oral tablet 100, 150, 00, 5 lamotrigine oral tablet disintegrating, dose pk 5 (1) -50 (7) lamotrigine oral tablet disintegrating, dose pk 5 (14)-50 (14)-100 (7) lamotrigine oral tablet disintegrating, dose pk 50 (4) -100 (14) lamotrigine oral tablet extended release 4hr 100, 00, 5, 50, 300, 50 lamotrigine oral tablet, chewable dispersible 5, 5 lamotrigine oral tablet,disintegrating 100, 00, 5, 50 levetiracetam in nacl (iso-os) intravenous piggyback 1,000 /100 ml, 1,500 /100 ml, 500 /100 ml levetiracetam intravenous solution 500 /5 ml (Lamictal) (Lamictal ODT Starter (Blue)) (Lamictal ODT Starter (Orange)) (Lamictal ODT Starter (Green)) (Lamictal XR) (Lamictal) (Lamictal ODT) (Keppra) 4 ST; QL (90 per 30 levetiracetam oral solution 100 /ml (Keppra) levetiracetam oral tablet 1,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 (Keppra XR) LYRICA ORAL CAPSULE 100 MG, 3 QL (90 per MG, 00 MG, 5 MG, 5 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 0 MG/ML 3 QL (900 per 30 oxcarbazepine oral suspension 300 /5 (Trileptal) ml (60 /ml) oxcarbazepine oral tablet 150, 300 (Trileptal), 600 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 4 HR 150 MG, 300 MG, 600 MG 4 37

46 PEGANONE ORAL TABLET 50 3 MG phenobarbital oral elixir 0 /5 ml (4 /ml) PA NSO-HRM; AGE (Max 64 Years) phenobarbital oral tablet PA NSO-HRM; GC; AGE (Max 64 Years) phenobarbital oral tablet 15, 16., 30, 3.4, 60, 64.8, 97. PA NSO-HRM; AGE (Max 64 Years) phenytoin oral suspension 15 /5 ml (Dilantin-15) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 100 phenytoin sodium extended oral capsule (Phenytek) 00, 300 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml POTIGA ORAL TABLET 00 MG, 300 MG, 400 MG ; QL (90 per 30 POTIGA ORAL TABLET 50 MG ; QL (70 per 30 primidone oral tablet 50, 50 (Mysoline) ROWEEPRA ORAL TABLET 1,000 MG, 500 MG, 750 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR 4 ST; QL (60 per 30 SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 50 MG, 500 MG, 750 MG 4 ST; QL (10 per 30 tiagabine oral tablet, 4 (Gabitril) topiramate oral capsule, sprinkle 15, (Topamax) 5 topiramate oral capsule,sprinkle,er 4hr (Qudexy XR) 100, 150, 00, 5, 50 topiramate oral tablet 100, 00, (Topamax) 50 topiramate oral tablet 5 (Topamax) 1 GC 38

47 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 4HR 100 MG, 5 MG, 50 MG TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 4HR 00 MG valproate sodium intravenous solution 500 /5 ml (100 /ml) valproic acid (as sodium salt) oral solution 50 /5 ml (Depacon) (Depakene) 4 QL (30 per 30 ; QL (60 per 30 valproic acid oral capsule 50 (Depakene) vigabatrin oral powder in packet 500 (Sabril) VIMPAT INTRAVENOUS 3 QL (00 per 5 SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 10 3 QL (100 per 30 MG/ML VIMPAT ORAL TABLET 100 MG, 3 QL (60 per MG, 00 MG, 50 MG zonisamide oral capsule 100, 5 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 10, 3, 5 (Aricept) QL (30 per 30 donepezil oral tablet,disintegrating 10 QL (30 per 30, 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) QL (30 per 30 4 hr 16, 4, 8 galantamine oral solution 4 /ml QL (00 per 30 galantamine oral tablet 1, 4, 8 (Razadyne) QL (60 per 30 memantine oral capsule,sprinkle,er 4hr (Namenda XR) QL (30 per 30 14, 1, 8, 7 memantine oral solution /ml QL (360 per 30 memantine oral tablet 10, 5 (Namenda) QL (60 per 30 memantine oral tablets,dose pack 5-10 (Namenda Titration QL (49 per 8 Pak) NAMENDA XR ORAL CAP,SPRINKLE,ER 4HR DOSE PACK MG 3 QL (8 per 8 39

48 NAMENDA XR ORAL 3 QL (30 per 30 CAPSULE,SPRINKLE,ER 4HR 14 MG, 1 MG, 8 MG, 7 MG NAMZARIC ORAL 3 QL (56 per 365 CAP,SPRINKLE,ER 4HR DOSE PACK 7/14/1/8 MG-10 MG NAMZARIC ORAL 3 QL (30 per 30 CAPSULE,SPRINKLE,ER 4HR MG, 1-10 MG, 8-10 MG, 7-10 MG rivastigmine tartrate oral capsule 1.5, QL (60 per 30 3, 4.5, 6 rivastigmine transdermal patch 4 hour (Exelon) QL (30 per /4 hour, 4.6 /4 hr, 9.5 /4 hr Antidepressants Antidepressants amitriptyline oral tablet 10, 100, 150, 5, 50, 75 PA NSO-HRM; AGE (Max 64 Years) amitriptyline-chlordiazepoxide oral tablet 1.5-5, 5-10 PA NSO-HRM; AGE (Max 64 Years) amoxapine oral tablet 100, 150, 5, 50 PA NSO-HRM; AGE (Max 64 Years) bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release (Wellbutrin SR) 1 hr 100, 150, 00 bupropion hcl oral tablet extended release (Wellbutrin XL) 4 hr 150, 300 citalopram oral solution 10 /5 ml QL (600 per 30 citalopram oral tablet 10, 0, 40 (Celexa) 1 GC; QL (30 per 30 clomipramine oral capsule 5, 50, 75 (Anafranil) PA NSO-HRM; AGE (Max 64 Years) desipramine oral tablet 10, 5 (Norpramin) PA NSO-HRM; AGE (Max 64 Years) desipramine oral tablet 100, 150, 50, 75 PA NSO-HRM; AGE (Max 64 Years) desvenlafaxine succinate oral tablet extended release 4 hr 100, 5, 50 (Pristiq) QL (30 per 30 40

49 doxepin oral capsule 10, 100, 150, 5, 50, 75 PA NSO-HRM; AGE (Max 64 Years) doxepin oral concentrate 10 /ml PA NSO-HRM; AGE (Max 64 Years) duloxetine oral capsule,delayed (Cymbalta) QL (60 per 30 release(dr/ec) 0, 60 duloxetine oral capsule,delayed (Cymbalta) QL (30 per 30 release(dr/ec) 30 duloxetine oral capsule,delayed QL (30 per 30 release(dr/ec) 40 EMSAM TRANSDERMAL PATCH 4 HOUR 1 MG/4 HR, 6 MG/4 ; QL (30 per 30 HR, 9 MG/4 HR escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 0, 5 (Lexapro) 1 GC FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK 0 MG ()- 40 MG (6) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 10 MG, 0 MG, 40 MG, 80 MG fluoxetine oral capsule 10, 0, 40 fluoxetine oral capsule,delayed release(dr/ec) 90 fluoxetine oral solution 0 /5 ml (4 /ml) (Prozac) 1 GC 4 ST; QL (56 per ST; QL (30 per 30 QL (4 per 8 fluoxetine oral tablet 10, 0 (Sarafem) FLUOXETINE ORAL TABLET 60 4 MG fluvoxamine oral capsule,extended release 4hr 100, 150 fluvoxamine oral tablet 100, 5, 50 imipramine hcl oral tablet 10, 5, 50 (Tofranil) PA NSO-HRM; AGE (Max 64 Years) imipramine pamoate oral capsule 100, 15, 150, 75 PA NSO-HRM; AGE (Max 64 Years) 41

50 maprotiline oral tablet 5, 50, 75 MARPLAN ORAL TABLET 10 MG 4 mirtazapine oral tablet 15 (Remeron) 1 GC mirtazapine oral tablet 30, 45 (Remeron) mirtazapine oral tablet 7.5 mirtazapine oral tablet,disintegrating 15 (Remeron SolTab), 30, 45 nefazodone oral tablet 100, 150, 00, 50, 50 nortriptyline oral capsule 10, 5, 50, 75 (Pamelor) 1 PA NSO-HRM; GC; AGE (Max 64 Years) nortriptyline oral solution 10 /5 ml PA NSO-HRM; AGE (Max 64 Years) paroxetine hcl oral tablet 10, 0, 30, 40 (Paxil) 1 PA NSO-HRM; GC; AGE (Max 64 Years) paroxetine hcl oral tablet extended release 4 hr 1.5, 5, 37.5 (Paxil CR) PA NSO-HRM; AGE (Max 64 Years) PAXIL ORAL SUSPENSION 10 MG/5 ML 4 PA NSO-HRM; AGE (Max 64 Years) perphenazine-amitriptyline oral tablet - 10, -5, 4-10, 4-5, 4-50 PA NSO-HRM; AGE (Max 64 Years) phenelzine oral tablet 15 (Nardil) protriptyline oral tablet 10, 5 PA NSO-HRM; AGE (Max 64 Years) sertraline oral concentrate 0 /ml (Zoloft) sertraline oral tablet 100, 5, 50 (Zoloft) 1 GC SURMONTIL ORAL CAPSULE 100 MG, 5 MG, 50 MG 4 PA NSO-HRM; AGE (Max 64 Years) tranylcypromine oral tablet 10 (Parnate) trazodone oral tablet 100, 50 1 GC trazodone oral tablet 150, 300 trimipramine oral capsule 100, 5, (Surmontil) PA NSO-HRM; AGE 50 (Max 64 Years) TRINTELLIX ORAL TABLET 10 MG, 0 MG, 5 MG 3 ST; QL (30 per 30 venlafaxine oral capsule,extended release 4hr 150 (Effexor XR) QL (30 per 30 4

51 venlafaxine oral capsule,extended release 4hr 37.5, 75 venlafaxine oral tablet 100, 5, 37.5, 50, 75 venlafaxine oral tablet extended release 4hr 150, 37.5, 75 venlafaxine oral tablet extended release 4hr 5 VIIBRYD ORAL TABLET 10 MG, 0 MG, 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG (3) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100, 5, 50 (Effexor XR) QL (90 per ST; QL (30 per 30 3 ST; QL (30 per 180 (Precose) QL (90 per 30 CYCLOSET ORAL TABLET 0.8 MG 4 QL (180 per 30 GLUCAGEN HYPOKIT INJECTION 3 RECON SOLN 1 MG GLUCAGON EMERGENCY KIT 4 (HUMAN) INJECTION KIT 1 MG GLYXAMBI ORAL TABLET ST; QL (30 per 30 MG, 5-5 MG INVOKAMET ORAL TABLET ST; QL (60 per 30 1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG 3 ST; QL (10 per 30 INVOKAMET XR ORAL TABLET, 3 ST; QL (60 per 30 IR - ER, BIPHASIC 4HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET ST; QL (60 per 30 MG INVOKANA ORAL TABLET ST; QL (30 per 30 MG JANUMET ORAL TABLET 50-1,000 3 QL (60 per 30 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 100-1,000 MG 3 QL (30 per 30 43

52 JANUMET XR ORAL TABLET, ER 3 QL (60 per 30 MULTIPHASE 4 HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 3 QL (30 per 30 5 MG, 50 MG JARDIANCE ORAL TABLET 10 3 ST; QL (30 per 30 MG, 5 MG JENTADUETO ORAL TABLET.5-3 QL (60 per 30 1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, 3 QL (60 per 30 IR - ER, BIPHASIC 4HR.5-1,000 MG JENTADUETO XR ORAL TABLET, 3 QL (30 per 30 IR - ER, BIPHASIC 4HR 5-1,000 MG KAZANO ORAL TABLET 1.5-1,000 4 QL (60 per 30 MG, MG KORLYM ORAL TABLET 300 MG 5 PA; NDS; QL (11 per 8 metformin oral tablet 1,000 (Glucophage) 1 GC; QL (75 per 30 metformin oral tablet 500 (Glucophage) 1 GC; QL (150 per 30 metformin oral tablet 850 (Glucophage) 1 GC; QL (90 per 30 metformin oral tablet extended release 4 hr 500 (Glucophage XR) 1 GC; QL (10 per 30 metformin oral tablet extended release 4 hr 750 (Glucophage XR) 1 GC; QL (90 per 30 miglitol oral tablet 100, 5, 50 (Glyset) QL (90 per 30 nateglinide oral tablet 10, 60 (Starlix) QL (90 per 30 NESINA ORAL TABLET 1.5 MG, 5 4 QL (30 per 30 MG, 6.5 MG OSENI ORAL TABLET MG, 4 QL (30 per MG, MG, 5-15 MG, 5-30 MG, 5-45 MG pioglitazone oral tablet 15, 30, 45 (Actos) QL (30 per 30 pioglitazone-glimepiride oral tablet 30- (DUETACT) QL (30 per 30, 30-4 pioglitazone-metformin oral tablet , (Actoplus MET) QL (90 per 30 44

53 repaglinide oral tablet 0.5 QL (40 per 30 repaglinide oral tablet 1, (Prandin) QL (40 per 30 repaglinide-metformin oral tablet QL (150 per 30, -500 SYMLINPEN 10 SUBCUTANEOUS PEN INJECTOR,700 MCG/.7 ML 5 PA; NDS; QL (10.8 per 8 SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML 5 PA; NDS; QL (10.8 per 8 SYNJARDY ORAL TABLET ST; QL (60 per 30 1,000 MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR 3 ST; QL (30 per 30 - ER, BIPHASIC 4HR 10-1,000 MG, 5-1,000 MG SYNJARDY XR ORAL TABLET, IR 3 ST; QL (60 per 30 - ER, BIPHASIC 4HR 1.5-1,000 MG, 5-1,000 MG TRADJENTA ORAL TABLET 5 MG 3 QL (30 per 30 TRULICITY SUBCUTANEOUS PEN 3 QL ( per 8 INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA SUBCUTANEOUS PEN 3 QL (9 per 30 INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) Insulins FIASP FLEXTOUCH U QL (30 per 8 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) FIASP U-100 INSULIN 3 QL (40 per 8 SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG JUNIOR KWIKPEN U- 4 ST; QL (30 per SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML HUMALOG KWIKPEN INSULIN 4 ST; QL (30 per 8 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 00 UNIT/ML (3 ML) HUMALOG MIX INSULN U- 100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) 4 ST; QL (40 per 8 45

54 HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX 75-5 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-5) HUMALOG MIX 75-5(U- 100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-5) HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 INSULIN PEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) 4 ST; QL (30 per 8 4 ST; QL (30 per 8 4 ST; QL (40 per 8 4 ST; QL (30 per 8 4 ST; QL (40 per 8 4 ST; QL (30 per 8 4 ST; QL (40 per 8 4 ST; QL (30 per 8 4 ST; QL (30 per 8 4 ST; QL (40 per 8 4 ST; QL (40 per 8 3 QL (40 per 8 3 QL (4 per 8 3 QL (30 per 8 46

55 LANTUS U-100 INSULIN 3 QL (40 per 8 SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 U-100 INSULIN 3 QL (40 per 8 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N NPH U-100 INSULIN 3 QL (40 per 8 SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U QL (40 per 8 INSULN INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U QL (30 per 8 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX U QL (40 per 8 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U- 3 QL (30 per SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG PENFILL U QL (30 per 8 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN 3 QL (40 per 8 ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML SOLIQUA 100/33 SUBCUTANEOUS 3 ST; QL (30 per 30 INSULIN PEN 100 UNIT-33 MCG/ML TOUJEO SOLOSTAR U QL (13.5 per 8 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) XULTOPHY 100/3.6 3 ST; QL (15 per 8 SUBCUTANEOUS INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML) Sulfonylureas glimepiride oral tablet 1, (Amaryl) 1 GC; QL (30 per 30 glimepiride oral tablet 4 (Amaryl) 1 GC; QL (60 per 30 47

56 glipizide oral tablet 10 (Glucotrol) 1 GC; QL (10 per 30 glipizide oral tablet 5 (Glucotrol) 1 GC; QL (60 per 30 glipizide oral tablet extended release 4hr 10 (Glucotrol XL) 1 GC; QL (60 per 30 glipizide oral tablet extended release 4hr.5, 5 (Glucotrol XL) 1 GC; QL (30 per 30 glipizide-metformin oral tablet.5-50 QL (40 per 30 glipizide-metformin oral tablet.5-500, QL (10 per 30 glyburide micronized oral tablet 1.5, 3 (Glynase) PA-HRM; AGE (Max, 6 64 Years) glyburide oral tablet 1.5,.5, 5 PA-HRM; AGE (Max 64 Years) glyburide-metformin oral tablet PA-HRM; AGE (Max 64 Years) glyburide-metformin oral tablet.5-500, (Glucovance) PA-HRM; AGE (Max 64 Years) tolazamide oral tablet 50 QL (10 per 30 tolazamide oral tablet 500 QL (60 per 30 tolbutamide oral tablet 500 QL (180 per 30 Antifungals Antifungals ABELCET INTRAVENOUS 5 PA BvD; NDS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS 5 PA BvD; NDS SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 PA BvD CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG caspofungin intravenous recon soln 50 (Cancidas), 70 ciclopirox topical cream 0.77 % (Ciclodan) ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Ciclodan) ciclopirox topical suspension 0.77 % (Loprox (as olamine)) 48

57 clotrimazole mucous membrane troche 10 clotrimazole topical cream 1 % (Antifungal (clotrimazole)) clotrimazole topical solution 1 % clotrimazole-betamethasone topical (Lotrisone) cream % clotrimazole-betamethasone topical lotion % econazole topical cream 1 % EXELDERM TOPICAL CREAM 1 % 4 EXELDERM TOPICAL SOLUTION 4 1 % fluconazole in nacl (iso-osm) intravenous piggyback 100 /50 ml, 400 /00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 /100 ml fluconazole oral suspension for (Diflucan) reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 150, (Diflucan) 00, 50 fluconazole-dext 00 /100 ml inner, suv 00 /100 ml flucytosine oral capsule 50, 500 (Ancobon) griseofulvin microsize oral suspension 15 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 15 (Gris-PEG, 50 (ultramicrosize)) itraconazole oral capsule 100 (Sporanox) ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical shampoo % (Nizoral) miconazole-3 vaginal suppository 00 NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7 ML NOXAFIL ORAL SUSPENSION 00 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG 49

58 nyamyc topical powder 100,000 unit/gram nyata topical powder 100,000 unit/gram nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 (Nyamyc) unit/gram nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% nystop topical powder 100,000 unit/gram SPORANOX ORAL SOLUTION 10 MG/ML terbinafine hcl oral tablet 50 (Lamisil) 1 GC voriconazole intravenous solution 00 (Vfend IV) voriconazole oral suspension for (Vfend) reconstitution 00 /5 ml (40 /ml) voriconazole oral tablet 00, 50 (Vfend) Antigout Agents Antigout Agents, Other allopurinol oral tablet 100, 300 (Zyloprim) 1 GC COLCRYS ORAL TABLET 0.6 MG probenecid oral tablet 500 probenecid-colchicine oral tablet ULORIC ORAL TABLET 40 MG, 80 3 QL (30 per 30 MG ZURAMPIC ORAL TABLET 00 MG 3 ST; QL (30 per 30 Antihistamines Antihistamines carbinoxamine maleate oral liquid 4 /5 ml carbinoxamine maleate oral tablet 4 clemastine oral tablet.68 cyproheptadine oral syrup /5 ml PA-HRM; AGE (Max 64 Years) 50

59 cyproheptadine oral tablet 4 PA-HRM; AGE (Max 64 Years) diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl injection syringe 50 /ml diphenhydramine hcl oral elixir 1.5 /5 (Children's Allergy 1 PA-HRM; GC; AGE ml (diphenhyd)) (Max 64 Years) hydroxyzine hcl intramuscular solution 5 /ml PA-HRM; AGE (Max 64 Years) hydroxyzine hcl intramuscular solution 50 /ml PA-HRM; AGE (Max 64 Years) hydroxyzine hcl oral solution 10 /5 ml PA-HRM; AGE (Max 64 Years) hydroxyzine hcl oral tablet 10, 5, 50 PA-HRM; AGE (Max 64 Years) levocetirizine oral solution.5 /5 ml (Xyzal) levocetirizine oral tablet 5 (Xyzal) 1 GC promethazine oral syrup 6.5 /5 ml PA-HRM; AGE (Max 64 Years) promethazine vc oral syrup /5 ml Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL VAGINAL CREAM 15 % 3 clindamycin phosphate vaginal cream % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) terconazole vaginal cream 0.4 % (Terazol 7) terconazole vaginal cream 0.8 % terconazole vaginal suppository 80 Antimigraine Agents Antimigraine Agents dihydroergotamine injection solution 1 /ml (D.H.E.45) ; QL (30 per 8 dihydroergotamine nasal spray,nonaerosol 0.5 /pump act. (4 /ml) (Migranal) ; QL (8 per 8 51

60 ERGOMAR SUBLINGUAL TABLET 3 QL (40 per 8 MG naratriptan oral tablet 1,.5 (Amerge) QL (18 per 8 rizatriptan oral tablet 10, 5 (Maxalt) QL (18 per 8 rizatriptan oral tablet,disintegrating 10 (Maxalt-MLT) QL (18 per 8, 5 sumatriptan nasal spray,non-aerosol 0 (Imitrex) QL (1 per 8 /actuation, 5 /actuation sumatriptan succinate oral tablet 100, (Imitrex) QL (18 per 8 5, 50 sumatriptan succinate subcutaneous (Imitrex STATdose Kit QL (4 per 8 cartridge 4 /0.5 ml, 6 /0.5 ml Refill) sumatriptan succinate subcutaneous pen (Imitrex STATdose QL (4 per 8 injector 4 /0.5 ml, 6 /0.5 ml Pen) sumatriptan succinate subcutaneous (Imitrex) QL (4 per 8 solution 6 /0.5 ml sumatriptan succinate subcutaneous QL (4 per 8 syringe 6 /0.5 ml zolmitriptan oral tablet.5, 5 (Zomig) QL (1 per 8 zolmitriptan oral tablet,disintegrating.5 (Zomig ZMT) QL (1 per 8, 5 Antimycobacterials Antimycobacterials CAPASTAT INJECTION RECON 4 SOLN 1 GRAM dapsone oral tablet 100, 5 ethambutol oral tablet 100 ethambutol oral tablet 400 (Myambutol) isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, GC PASER ORAL GRANULES DR FOR 4 SUSP IN PACKET 4 GRAM PRIFTIN ORAL TABLET 150 MG 4 pyrazinamide oral tablet 500 rifabutin oral capsule 150 (Mycobutin) rifampin intravenous recon soln 600 (Rifadin) rifampin oral capsule 150, 300 (Rifadin) RIFATER ORAL TABLET MG 4 5

61 SIRTURO ORAL TABLET 100 MG 5 PA; NDS; QL (188 per 168 TRECATOR ORAL TABLET 50 MG 4 Antinausea Agents Antinausea Agents AKYNZEO ORAL CAPSULE PA BvD MG aprepitant oral capsule 15 (Emend) PA BvD; QL ( per 8 aprepitant oral capsule 40 (Emend) PA BvD; QL (1 per 8 aprepitant oral capsule 80 (Emend) PA BvD; QL (4 per 8 aprepitant oral capsule,dose pack 15 (1)- 80 () (Emend) PA BvD; QL (6 per 8 CINVANTI INTRAVENOUS 4 QL (36 per 8 EMULSION 7. MG/ML compro rectal suppository 5 dimenhydrinate injection solution 50 /ml dronabinol oral capsule 10,.5, 5 (Marinol) PA EMEND (FOSAPREPITANT) INTRAVENOUS RECON SOLN 150 MG 4 QL ( per 8 EMEND ORAL SUSPENSION FOR RECONSTITUTION 15 MG (5 MG/ ML FINAL CONC.) granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution 1 /ml, 1 /ml (1 ml) 4 PA BvD; QL (6 per 8 granisetron hcl oral tablet 1 PA BvD meclizine oral tablet 1.5 PA-HRM; AGE (Max 64 Years) meclizine oral tablet 5 (Dramamine Less Drowsy) PA-HRM; AGE (Max 64 Years) ondansetron hcl (pf) injection solution 4 / ml ondansetron hcl (pf) injection syringe 4 / ml 53

62 ondansetron hcl oral solution 4 /5 ml (Zofran (as PA BvD hydrochloride)) ondansetron hcl oral tablet 4 PA BvD ondansetron hcl oral tablet 4, 8 (Zofran (as PA BvD hydrochloride)) ondansetron oral tablet,disintegrating 4 (Zofran ODT) PA BvD, 8 phenadoz rectal suppository 1.5, 5 PA-HRM; AGE (Max 64 Years) prochlorperazine edisylate injection solution 10 / ml (5 /ml) prochlorperazine maleate oral tablet 10 (Compazine) 1 GC, 5 prochlorperazine rectal suppository 5 (Compazine) promethazine injection solution 5 /ml, (Phenergan) PA-HRM; AGE (Max 50 /ml 64 Years) promethazine oral tablet 1.5, 5, 50 PA-HRM; AGE (Max 64 Years) promethazine rectal suppository 1.5, 5 (Phenadoz) PA-HRM; AGE (Max 64 Years) promethazine rectal suppository 50 (Phenergan) PA-HRM; AGE (Max 64 Years) promethegan rectal suppository 1.5, 5, 50 PA-HRM; AGE (Max 64 Years) scopolamine base transdermal patch 3 (Transderm-Scop) QL (10 per 30 day 1 over 3 days SYNDROS ORAL SOLUTION 5 4 PA MG/ML TRANSDERM-SCOP 4 QL (10 per 30 TRANSDERMAL PATCH 3 DAY 1 MG OVER 3 DAYS Antiparasite Agents Antiparasite Agents ALBENZA ORAL TABLET 00 MG ALINIA ORAL SUSPENSION FOR 4 RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG 4 atovaquone oral suspension 750 /5 ml (Mepron) atovaquone-proguanil oral tablet (Malarone) 54

63 atovaquone-proguanil oral tablet (Malarone Pediatric) benznidazole oral tablet 100, chloroquine phosphate oral tablet 50, 500 COARTEM ORAL TABLET 0-10 MG 4 DARAPRIM ORAL TABLET 5 MG 5 PA; NDS hydroxychloroquine oral tablet 00 (Plaquenil) IMPAVIDO ORAL CAPSULE 50 MG 5 PA; NDS; QL (84 per 8 ivermectin oral tablet 3 (Stromectol) mefloquine oral tablet 50 NEBUPENT INHALATION RECON 4 PA BvD SOLN 300 MG paromomycin oral capsule 50 PENTAM INJECTION RECON 4 SOLN 300 MG PRIMAQUINE ORAL TABLET MG quinine sulfate oral capsule 34 (Qualaquin) PA; QL (4 per 7 tinidazole oral tablet 50 tinidazole oral tablet 500 (Tindamax) Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 100 APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML ; QL (60 per 30 benztropine injection solution / ml (Cogentin) PA-HRM; AGE (Max 64 Years) benztropine oral tablet 0.5, 1, PA-HRM; AGE (Max 64 Years) bromocriptine oral capsule 5 (Parlodel) bromocriptine oral tablet.5 (Parlodel) cabergoline oral tablet 0.5 carbidopa oral tablet 5 (Lodosyn) carbidopa-levodopa oral tablet , 5-100, 5-50 (Sinemet) 55

64 carbidopa-levodopa oral tablet extended (Sinemet CR) release 5-100, carbidopa-levodopa oral tablet,disintegrating , 5-100, 5-50 carbidopa-levodopa-entacapone oral (Stalevo 50) tablet carbidopa-levodopa-entacapone oral (Stalevo 75) tablet carbidopa-levodopa-entacapone oral (Stalevo 100) tablet carbidopa-levodopa-entacapone oral (Stalevo 15) tablet carbidopa-levodopa-entacapone oral (Stalevo 150) tablet carbidopa-levodopa-entacapone oral (Stalevo 00) tablet entacapone oral tablet 00 (Comtan) GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 4HR 137 MG 5 PA; NDS; QL (60 per 30 GOCOVRI ORAL CAPSULE,EXTENDED RELEASE 4HR 68.5 MG NEUPRO TRANSDERMAL PATCH 4 HOUR 1 MG/4 HOUR, MG/4 HOUR, 3 MG/4 HOUR, 4 MG/4 HOUR, 6 MG/4 HOUR, 8 MG/4 HOUR pramipexole oral tablet 0.15, 0.5, 0.75, 1, 1.5 (Mirapex) 5 PA; NDS; QL (30 per 30 3 QL (30 per 30 pramipexole oral tablet 0.5 (Mirapex) 1 GC rasagiline oral tablet 0.5, 1 (Azilect) ropinirole oral tablet 0.5, 0.5, 1 (Requip),, 3, 4, 5 ropinirole oral tablet extended release 4 (Requip XL) hr 1,, 4, 6, 8 selegiline hcl oral capsule 5 (Eldepryl) selegiline hcl oral tablet 5 trihexyphenidyl oral elixir 0.4 /ml PA-HRM; AGE (Max 64 Years) 56

65 trihexyphenidyl oral tablet, 5 PA-HRM; AGE (Max 64 Years) XADAGO ORAL TABLET 100 MG, 50 MG 5 PA; NDS; QL (30 per 30 Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG ; QL (1 per 8 ; QL (1 per 8 aripiprazole oral solution 1 /ml QL (900 per 30 aripiprazole oral tablet 10, 15, 0 (Abilify) QL (30 per 30, 30, 5 aripiprazole oral tablet (Abilify) QL (60 per 30 aripiprazole oral tablet,disintegrating 10 QL (90 per 30 aripiprazole oral tablet,disintegrating 15 QL (60 per 30 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML ; QL (3.9 per 56 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 66 MG/.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 88 MG/3. ML chlorpromazine injection solution 5 /ml chlorpromazine oral tablet 10, 100, 00, 5, 50 ; QL (1.6 per 8 ; QL (.4 per 8 ; QL (3. per 8 clozapine oral tablet 100 (Clozaril) QL (70 per 30 clozapine oral tablet 00 QL (135 per 30 clozapine oral tablet 5 (Clozaril) QL (90 per 30 57

66 clozapine oral tablet 50 QL (90 per 30 clozapine oral tablet,disintegrating 100 (FazaClo) ST; QL (90 per 30, 1.5, 5 clozapine oral tablet,disintegrating 150 (FazaClo) ST; QL (180 per 30 clozapine oral tablet,disintegrating 00 (FazaClo) ST; QL (10 per 30 FANAPT ORAL TABLET 1 MG, 4 ST; QL (60 per 30 MG, 4 MG FANAPT ORAL TABLET 10 MG, 1 MG, 6 MG, 8 MG 5 ST; NDS; QL (60 per 30 FANAPT ORAL TABLETS,DOSE 4 ST; QL (8 per 8 PACK 1MG()-MG()- 4MG()- 6MG() fluphenazine decanoate injection solution 5 /ml fluphenazine hcl injection solution.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir.5 /5 ml fluphenazine hcl oral tablet 1, 10,.5, 5 GEODON INTRAMUSCULAR 4 QL (6 per 8 RECON SOLN 0 MG/ML (FINAL CONC.) haloperidol decanoate intramuscular solution 100 /ml (1 ml) haloperidol decanoate intramuscular (Haldol Decanoate) solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 (Haldol) /ml haloperidol lactate oral concentrate /ml haloperidol oral tablet 0.5, 1, 10,, 0, 5 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML ; QL (0.75 per 8 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML ; QL (1 per 8 58

67 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 34 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 73 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/.65 ML LATUDA ORAL TABLET 10 MG, 0 MG, 40 MG, 60 MG, 80 MG loxapine succinate oral capsule 10, 5, 5, 50 ; QL (1.5 per 8 4 QL (0.5 per 8 ; QL (0.5 per 8 ; QL (0.875 per 84 ; QL (1.315 per 84 ; QL (1.75 per 84 ; QL (.65 per 84 3 QL (30 per 30 molindone oral tablet 10 QL (40 per 30 molindone oral tablet 5 QL (70 per 30 molindone oral tablet 5 QL (10 per 30 NUPLAZID ORAL TABLET 17 MG 5 PA NSO; NDS; QL (60 per 30 olanzapine intramuscular recon soln 10 (Zyprexa) QL (30 per 30 olanzapine oral tablet 10, 15,.5 (Zyprexa) QL (30 per 30, 0, 5, 7.5 olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis) QL (30 per 30, 15, 0, 5 paliperidone oral tablet extended release 4hr 1.5, 3, 9 (Invega) ; QL (30 per 30 paliperidone oral tablet extended release 4hr 6 (Invega) ; QL (60 per 30 59

68 perphenazine oral tablet 16,, 4, 8 pimozide oral tablet 1, (Orap) quetiapine oral tablet 100, 00, 5 (Seroquel) QL (90 per 30, 300, 400, 50 quetiapine oral tablet extended release 4 (Seroquel XR) QL (30 per 30 hr 150, 00, 50 quetiapine oral tablet extended release 4 (Seroquel XR) QL (60 per 30 hr 300, 400 REXULTI ORAL TABLET 0.5 MG 5 ST; NDS; QL (10 per 30 REXULTI ORAL TABLET 0.5 MG 5 ST; NDS; QL (60 per 30 REXULTI ORAL TABLET 1 MG, MG, 3 MG, 4 MG 5 ST; NDS; QL (30 per 30 RISPERDAL CONSTA 4 QL (4 per 8 INTRAMUSCULAR SYRINGE 1.5 MG/ ML, 5 MG/ ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 37.5 ; QL (4 per 8 MG/ ML, 50 MG/ ML risperidone oral solution 1 /ml (Risperdal) QL (480 per 30 risperidone oral tablet 0.5, 0.5, 1 (Risperdal) QL (60 per 30,, 3, 4 risperidone oral tablet,disintegrating 0.5 QL (60 per 30, risperidone oral tablet,disintegrating 0.5 (Risperdal M-TAB) QL (60 per 30, 1 risperidone oral tablet,disintegrating 3, 4 (Risperdal M-TAB) QL (10 per 30 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG,.5 MG, 5 MG thioridazine oral tablet 10, 100, 5, 50 thiothixene oral capsule 1, 10,, 5 trifluoperazine oral tablet 1, 10,, 5 VERSACLOZ ORAL SUSPENSION 50 MG/ML 5 ST; NDS; QL (60 per 30 5 ST; NDS; QL (540 per 30 60

69 VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 0, 40, 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 10 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG 5 ST; NDS; QL (30 per 30 4 ST; QL (7 per 30 (Geodon) QL (60 per 30 Antivirals (Systemic) Antiretrovirals abacavir oral solution 0 /ml (Ziagen) abacavir oral tablet 300 (Ziagen) 4 QL ( per 8 ; QL ( per 8 ; QL (1 per 8 abacavir-lamivudine oral tablet (Epzicom) abacavir-lamivudine-zidovudine oral (Trizivir) tablet APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION MG/ML atazanavir oral capsule 150, 00, (Reyataz) 300 ATRIPLA ORAL TABLET MG BIKTARVY ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 00 4 MG, 400 MG DESCOVY ORAL TABLET 00-5 MG didanosine oral capsule,delayed release(dr/ec) 15, 00, 50, 400 (Videx EC) 61

70 EDURANT ORAL TABLET 5 MG efavirenz oral capsule 00 (Sustiva) efavirenz oral capsule 50 (Sustiva) efavirenz oral tablet 600 (Sustiva) EMTRIVA ORAL CAPSULE 00 MG 3 EMTRIVA ORAL SOLUTION 10 3 MG/ML EPIVIR HBV ORAL SOLUTION 5 4 MG/5 ML (5 MG/ML) EVOTAZ ORAL TABLET MG fosamprenavir oral tablet 700 (Lexiva) FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG 3 INVIRASE ORAL CAPSULE 00 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN 3 PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL 3 TABLET,CHEWABLE 100 MG, 5 MG JULUCA ORAL TABLET 50-5 MG KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine oral solution 10 /ml (Epivir) lamivudine oral tablet 100 (Epivir HBV) lamivudine oral tablet 150, 300 (Epivir) lamivudine-zidovudine oral tablet (Combivir) 6

71 LEXIVA ORAL SUSPENSION 50 3 MG/ML LEXIVA ORAL TABLET 700 MG lopinavir-ritonavir oral solution (Kaletra) /5 ml nevirapine oral suspension 50 /5 ml (Viramune) nevirapine oral tablet 00 (Viramune) nevirapine oral tablet extended release 4 (Viramune XR) hr 100, 400 NORVIR ORAL CAPSULE 100 MG 3 NORVIR ORAL SOLUTION 80 3 MG/ML NORVIR ORAL TABLET 100 MG 3 ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION MG/ML PREZISTA ORAL TABLET 150 MG, 3 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG RESCRIPTOR ORAL TABLET 00 4 MG RESCRIPTOR ORAL TABLET, 4 DISPERSIBLE 100 MG RETROVIR INTRAVENOUS 3 SOLUTION 10 MG/ML REYATAZ ORAL CAPSULE 150 MG, 00 MG, 300 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL SOLUTION 0 4 MG/ML SELZENTRY ORAL TABLET 150 MG, 300 MG, 75 MG SELZENTRY ORAL TABLET 5 MG 4 stavudine oral capsule 15, 0, 30 (Zerit), 40 stavudine oral recon soln 1 /ml (Zerit) 63

72 STRIBILD ORAL TABLET MG SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 50 MG 4 SUSTIVA ORAL TABLET 600 MG tenofovir disoproxil fumarate oral tablet (Viread) 300 TIVICAY ORAL TABLET 10 MG 4 TIVICAY ORAL TABLET 5 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VEMLIDY ORAL TABLET 5 MG ; QL (30 per 30 VIDEX GM PEDIATRIC SOLN 10 3 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL 3 RECON SOLN 10 MG/ML (FINAL) VIRACEPT ORAL TABLET 50 MG, 4 65 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG, 300 MG ZERIT ORAL RECON SOLN 1 3 MG/ML ZIAGEN ORAL SOLUTION 0 4 MG/ML zidovudine oral capsule 100 (Retrovir) zidovudine oral syrup 10 /ml (Retrovir) zidovudine oral tablet 300 Antivirals, Miscellaneous foscarnet intravenous solution 4 /ml (Foscavir) PA BvD oseltamivir oral capsule 30 (Tamiflu) QL (84 per 180 oseltamivir oral capsule 45 (Tamiflu) QL (48 per 180 oseltamivir oral capsule 75 (Tamiflu) QL (4 per

73 oseltamivir oral suspension for (Tamiflu) QL (540 per 180 reconstitution 6 /ml PREVYMIS INTRAVENOUS SOLUTION 40 MG/1 ML 5 PA; NDS; QL (336 per 8 PREVYMIS INTRAVENOUS SOLUTION 480 MG/4 ML 5 PA; NDS; QL (67 per 8 PREVYMIS ORAL TABLET 40 MG, 480 MG 5 PA; NDS; QL (8 per 8 RELENZA DISKHALER 4 INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 (Flumadine) SYNAGIS INTRAMUSCULAR 5 PA; NDS SOLUTION 100 MG/ML, 50 MG/0.5 ML TAMIFLU ORAL SUSPENSION 3 QL (540 per 180 FOR RECONSTITUTION 6 MG/ML Hcv Antivirals DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG 5 PA; NDS; QL (8 per 8 EPCLUSA ORAL TABLET MG 5 PA; NDS; QL (8 per 8 HARVONI ORAL TABLET MG 5 PA; NDS; QL (30 per 30 MAVYRET ORAL TABLET MG 5 PA; NDS; QL (84 per 8 OLYSIO ORAL CAPSULE 150 MG 5 PA; NDS; QL (8 per 8 SOVALDI ORAL TABLET 400 MG 5 PA; NDS; QL (8 per 8 TECHNIVIE ORAL TABLET MG 5 PA; NDS; QL (56 per 8 VIEKIRA PAK ORAL TABLETS,DOSE PACK 1.5 MG-75 MG -50 MG/50 MG 5 PA; NDS; QL (11 per 8 VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 4HR 8.33 MG-50 MG MG-00 MG VOSEVI ORAL TABLET MG 5 PA; NDS; QL (84 per 8 5 PA; NDS; QL (8 per 8 65

74 ZEPATIER ORAL TABLET MG Interferons INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS CONVENIENCE PACK SUBCUTANEOUS KIT 180 MCG/0.5 ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG Nucleosides And Nucleotides acyclovir 1,000 /0 ml vial 10's,latexfree,sdv 50 /ml acyclovir oral capsule 00 (Zovirax) acyclovir oral suspension 00 /5 ml (Zovirax) acyclovir oral tablet 400, 800 (Zovirax) 5 PA; NDS; QL (30 per 30 5 PA NSO; NDS 5 PA NSO; NDS 5 PA NSO; NDS; QL (4 per 8 5 PA BvD; NDS acyclovir sodium intravenous recon soln 5 PA BvD; NDS 500 acyclovir sodium intravenous solution 50 PA BvD /ml adefovir oral tablet 10 (Hepsera) cidofovir intravenous solution 75 /ml entecavir oral tablet 0.5, 1 (Baraclude) famciclovir oral tablet 15, 50, 500 ganciclovir sodium intravenous recon soln 500 (Cytovene) PA BvD 66

75 ribasphere oral capsule 00 ribasphere oral tablet 00, 400, 600 ribasphere ribapak oral tablets,dose pack 00 (7)- 400 (7), (8)- (8), (8)- (8) ribavirin inhalation recon soln 6 gram (Virazole) 5 PA BvD; NDS ribavirin oral capsule 00 (Ribasphere) ribavirin oral tablet 00 (Moderiba) valacyclovir oral tablet 1 gram, 500 (Valtrex) valganciclovir oral recon soln 50 /ml (Valcyte) valganciclovir oral tablet 450 (Valcyte) Blood Products/Modifiers/Volume Expanders Anticoagulants BEVYXXA ORAL CAPSULE 40 MG, 4 QL (43 per 4 80 MG CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET.5 MG, 5 3 MG ELIQUIS ORAL TABLETS,DOSE 3 PACK 5 MG (74 TABS) enoxaparin subcutaneous solution 300 (Lovenox) /3 ml enoxaparin subcutaneous syringe 100 (Lovenox) /ml, 10 /0.8 ml, 150 /ml, 30 /0.3 ml, 40 /0.4 ml, 60 /0.6 ml, 80 /0.8 ml fondaparinux subcutaneous syringe 10 (Arixtra) /0.8 ml, 5 /0.4 ml, 7.5 /0.6 ml fondaparinux subcutaneous syringe.5 (Arixtra) /0.5 ml heparin (porcine) in 5 % dex intravenous parenteral solution 0,000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 5,000 unit/50 ml(100 unit/ml) 67

76 heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 0,000 unit/ml, 5,000 unit/ml heparin 5,000 unit/50 ml (100 unit/ml)-0.45% nacl bag l/f,inner,singleuse 5,000 unit/50 ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml IPRIVASK SUBCUTANEOUS RECON SOLN 15 MG jantoven oral tablet 1, 10,,.5, 3, 4, 5, 6, 7.5 PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG warfarin oral tablet 1, 10,,.5, 3, 4, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 0 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (4)- 0 MG (9) Blood Formation Modifiers CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) EPOGEN 10,000 UNITS/ML VIAL SDV, P/F, OUTER 10,000 UNIT/ML EPOGEN INJECTION SOLUTION,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML HAEGARDA SUBCUTANEOUS RECON SOLN,000 UNIT, 3,000 UNIT LEUKINE INJECTION RECON SOLN 50 MCG (Coumadin) 1 GC 5 PA; NDS; QL (4 per 8 1 GC 4 ST; QL (60 per PA; NDS 3 PA; QL (1 per 8 3 PA; QL (1 per 8 5 PA; NDS 68

77 MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 00 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL SUBCUTANEOUS SOLUTION 4 MG/1. ML (0 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ORAL TABLET 1.5 MG, 5 MG, 50 MG, 75 MG ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML 4 PA; QL (0.6 per 8 3 PA; QL (1 per 8 5 PA; NDS; QL (1 per 8 5 PA; NDS; QL (6 per 8 5 PA; NDS; QL (30 per 30 5 ST; NDS Hematologic Agents, Miscellaneous anagrelide oral capsule 0.5 (Agrylin) anagrelide oral capsule 1 protamine intravenous solution 10 /ml tranexamic acid intravenous solution (Cyklokapron) 1,000 /10 ml (100 /ml) tranexamic acid oral tablet 650 (Lysteda) QL (30 per 30 Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er (Aggrenox) multiphase 1 hr 5-00 BRILINTA ORAL TABLET 60 MG, 3 90 MG cilostazol oral tablet 100, 50 clopidogrel oral tablet 300 (Plavix) clopidogrel oral tablet 75 (Plavix) 1 GC 69

78 dipyridamole oral tablet 5, 50, 75 EFFIENT ORAL TABLET 10 MG, 5 4 QL (30 per 30 MG pentoxifylline oral tablet extended release 400 prasugrel oral tablet 10, 5 (Effient) QL (30 per 30 Caloric Agents Caloric Agents AMINOSYN 10 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 10 % AMINOSYN 7 % WITH 4 PA BvD ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %-ELECTROLYTES 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 15 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- 4 PA BvD ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M 3.5 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 3.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % 4 PA BvD 70

79 AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5. % INTRAVENOUS PARENTERAL SOLUTION 5. % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D5W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION.75 % CLINIMIX 4.5%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX 4.5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX 4.5%-D0W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX 4.5%-D5W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX 5%-D0W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION.75 % CLINIMIX E.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION.75 % CLINIMIX E 4.5%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 71

80 CLINIMIX E 4.5%/D5W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX E 4.5%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 4.5 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D0W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINISOL SF 15 % INTRAVENOUS PARENTERAL SOLUTION 15 % dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 5 % in water (d5w) intravenous syringe dextrose 40 % in water (d40w) intravenous parenteral solution 40 % dextrose 5 % in ringer's intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback 5 % dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD 4 PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 4 PA BvD 7

81 FREAMINE III 10 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 10 % HEPATAMINE 8% INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS 4 PA BvD EMULSION 0 %, 30 % KABIVEN INTRAVENOUS 4 PA BvD EMULSION % NEPHRAMINE 5.4 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 5.4 % NUTRILIPID INTRAVENOUS 4 PA BvD EMULSION 0 % PERIKABIVEN INTRAVENOUS 4 PA BvD EMULSION % PLENAMINE INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 15 % PREMASOL 10 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 6 % PROCALAMINE 3% 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 3 % PROSOL 0 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION smoflipid intravenous emulsion 0 % 4 PA BvD TRAVASOL 10 % INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 10 % TROPHAMINE 10 % 4 PA BvD INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS 4 PA BvD PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1, 0., (Catapres) 1 GC 0.3 clonidine transdermal patch weekly 0.1 /4 hr (Catapres-TTS-1) QL (4 per 8 73

82 clonidine transdermal patch weekly 0. (Catapres-TTS-) QL (4 per 8 /4 hr clonidine transdermal patch weekly 0.3 (Catapres-TTS-3) QL (8 per 8 /4 hr clorpres oral tablet , 0.-15, doxazosin oral tablet 1,, 4, 8 (Cardura) guanfacine oral tablet 1, PA-HRM; AGE (Max 64 Years) midodrine oral tablet 10,.5, 5 NORTHERA ORAL CAPSULE 100 MG, 00 MG, 300 MG 5 PA; NDS; QL (180 per 30 phenylephrine hcl injection solution 10 (Vazculep) /ml prazosin oral capsule 1,, 5 (Minipress) Angiotensin Ii Receptor Antagonists candesartan oral tablet 16, 3, 4 (Atacand), 8 candesartan-hydrochlorothiazid oral (Atacand HCT) tablet , 3-1.5, 3-5 EDARBI ORAL TABLET 40 MG, 80 3 MG EDARBYCLOR ORAL TABLET MG, 40-5 MG ENTRESTO ORAL TABLET QL (60 per 30 MG, MG, MG eprosartan oral tablet 600 irbesartan oral tablet 150, 300, 75 (Avapro) 1 GC irbesartan-hydrochlorothiazide oral (Avalide) tablet , losartan oral tablet 100, 5, 50 (Cozaar) 1 GC losartan-hydrochlorothiazide oral tablet (Hyzaar) 1 GC , 100-5, olmesartan oral tablet 0, 40, 5 (Benicar) 74

83 olmesartan-amlodipin-hcthiazid oral (Tribenzor) tablet , , , , olmesartan-hydrochlorothiazide oral (Benicar HCT) tablet 0-1.5, , 40-5 telmisartan oral tablet 0, 40, 80 (Micardis) telmisartan-amlodipine oral tablet (Twynsta), 40-5, 80-10, 80-5 telmisartan-hydrochlorothiazid oral (Micardis HCT) tablet , , 80-5 valsartan oral tablet 160, 30, 40 (Diovan), 80 valsartan-hydrochlorothiazide oral tablet (Diovan HCT) , 160-5, , 30-5, Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10, 5 1 GC benazepril oral tablet 0, 40 (Lotensin) 1 GC benazepril-hydrochlorothiazide oral (Lotensin HCT) tablet , 0-1.5, 0-5 benazepril-hydrochlorothiazide oral tablet captopril oral tablet 100, 1.5, 5, 50 captopril-hydrochlorothiazide oral tablet 5-15, 5-5, 50-15, 50-5 enalapril maleate oral tablet 10,.5 (Vasotec), 0, 5 enalaprilat intravenous solution 1.5 /ml enalapril-hydrochlorothiazide oral tablet (Vaseretic) 10-5 enalapril-hydrochlorothiazide oral tablet EPANED ORAL SOLUTION 1 4 ST MG/ML fosinopril oral tablet 10, 0, 40 1 GC fosinopril-hydrochlorothiazide oral tablet ,

84 lisinopril oral tablet 10, 0, 5 (Prinivil) 1 GC lisinopril oral tablet.5, 30, 40 (Zestril) 1 GC lisinopril-hydrochlorothiazide oral tablet (Zestoretic) 1 GC , 0-1.5, 0-5 moexipril oral tablet 15, 7.5 moexipril-hydrochlorothiazide oral tablet , 15-5, perindopril erbumine oral tablet, 4, 8 QBRELIS ORAL SOLUTION 1 4 ST MG/ML quinapril oral tablet 10, 0, 40 (Accupril) 1 GC, 5 quinapril-hydrochlorothiazide oral tablet (Accuretic) , 0-1.5, 0-5 ramipril oral capsule 1.5, 10,.5 (Altace) 1 GC, 5 trandolapril oral tablet 1,, 4 Antiarrhythmic Agents amiodarone intravenous solution 50 /ml amiodarone intravenous syringe 150 /3 ml amiodarone oral tablet 100, 400 (Pacerone) amiodarone oral tablet 00 (Pacerone) 1 GC disopyramide phosphate oral capsule 100 (Norpace), 150 dofetilide oral capsule 15 mcg, 50 mcg, (Tikosyn) 500 mcg flecainide oral tablet 100, 150, 50 lidocaine (pf) intravenous syringe 100 /5 ml ( %), 50 /5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 /ml (0.8 %) mexiletine oral capsule 150, 00, 50 MULTAQ ORAL TABLET 400 MG 3 pacerone oral tablet 100,

85 pacerone oral tablet 00 1 GC procainamide injection solution 100 /ml, 500 /ml propafenone oral capsule,extended (Rythmol SR) release 1 hr 5, 35, 45 propafenone oral tablet 150, 5, 300 quinidine gluconate oral tablet extended release 34 quinidine sulfate oral tablet 00, 300 Beta-Adrenergic Blocking Agents acebutolol oral capsule 00, 400 atenolol oral tablet 100, 5, 50 (Tenormin) 1 GC atenolol-chlorthalidone oral tablet (Tenoretic 100) atenolol-chlorthalidone oral tablet 50-5 (Tenoretic 50) betaxolol oral tablet 10, 0 bisoprolol fumarate oral tablet 10, 5 bisoprolol-hydrochlorothiazide oral tablet (Ziac) 1 GC ,.5-6.5, BYSTOLIC ORAL TABLET 10 MG, 3.5 MG, 0 MG, 5 MG BYVALSON ORAL TABLET MG carvedilol oral tablet 1.5, 5, (Coreg) 1 GC 3.15, 6.5 esmolol intravenous solution 100 /10 (Brevibloc) 5 PA BvD; NDS ml (10 /ml) labetalol intravenous solution 5 /ml labetalol oral tablet 100, 00, 300 metoprolol succinate oral tablet extended (Toprol XL) release 4 hr 100, 00, 5, 50 metoprolol ta-hydrochlorothiaz oral tablet 100-5, metoprolol ta-hydrochlorothiaz oral tablet 50-5 (Lopressor HCT) 77

86 metoprolol tartrate intravenous solution 5 (Lopressor) /5 ml metoprolol tartrate intravenous syringe 5 /5 ml metoprolol tartrate oral tablet 100, 50 (Lopressor) 1 GC metoprolol tartrate oral tablet 5 1 GC nadolol oral tablet 0, 40, 80 (Corgard) pindolol oral tablet 10, 5 propranolol intravenous solution 1 /ml propranolol oral capsule,extended release (Inderal LA) 4 hr 10, 160, 60, 80 propranolol oral solution 0 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 10, 0, 40, 60, 80 propranolol-hydrochlorothiazid oral tablet 40-5, 80-5 sorine oral tablet 10, 160, 40, 80 sotalol 10 tablet 10 (Betapace) sotalol af oral tablet 10 sotalol oral tablet 160, 40, 80 (Betapace) timolol maleate oral tablet 10, 0, 5 Calcium-Channel Blocking Agents cartia xt oral capsule,extended release 4hr 10, 180, 40, 300 diltiazem hcl intravenous solution 5 /ml diltiazem hcl oral capsule,extended release 1 hr 10, 60, 90 diltiazem hcl oral capsule,extended (Taztia XT) release 4 hr 360 diltiazem hcl oral capsule,extended (Tiazac) release 4 hr 40 diltiazem hcl oral capsule,extended (Cardizem CD) release 4hr 10, 180, 40, 300 diltiazem hcl oral tablet 10, 30, 60 (Cardizem) 1 GC 78

87 diltiazem hcl oral tablet 90 1 GC diltiazem hcl oral tablet extended release (Cardizem LA) 4 hr 180, 40, 300, 360, 40 dilt-xr oral capsule,ext.rel 4h degradable 10, 180, 40 matzim la oral tablet extended release 4 hr 180, 40, 300, 360, 40 taztia xt oral capsule,extended release 4 hr 10, 180, 40, 300, 360 verapamil intravenous syringe.5 /ml verapamil oral capsule, 4 hr er pellet ct (Verelan PM) 100, 00, 300 verapamil oral capsule,ext rel. pellets 4 (Verelan) hr 10, 180, 40, 360 verapamil oral tablet 10, 80 (Calan) 1 GC verapamil oral tablet 40 1 GC verapamil oral tablet extended release (Calan SR) 1 GC 10, 180, 40 Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG 3 PA; QL (60 per 30 DEMSER ORAL CAPSULE 50 MG digitek oral tablet 15 mcg PA-HRM; High Risk Med. PA Required for ages 65 and older and dose is greater than 15mcg per day; QL (30 per 30 ; AGE (Max 64 Years) digitek oral tablet 50 mcg PA-HRM; AGE (Max 64 Years) digox oral tablet 15 mcg PA-HRM; High Risk Med. PA Required for ages 65 and older and dose is greater than 15mcg per day; QL (30 per 30 ; AGE (Max 64 Years) 79

88 digox oral tablet 50 mcg PA-HRM; AGE (Max 64 Years) digoxin 0.5 /ml syringe 50 mcg/ml PA-HRM; AGE (Max 64 Years) digoxin injection solution 50 mcg/ml (Lanoxin) PA-HRM; AGE (Max 64 Years) DIGOXIN ORAL SOLUTION 50 MCG/ML 3 PA-HRM; AGE (Max 64 Years) digoxin oral tablet 15 mcg (Digitek) PA-HRM; High Risk Med. PA Required for ages 65 and older and dose is greater than 15mcg per day; QL (30 per 30 ; AGE (Max 64 Years) digoxin oral tablet 50 mcg (Digitek) PA-HRM; AGE (Max 64 Years) dobutamine in d5w intravenous PA BvD parenteral solution 1,000 /50 ml (4,000 mcg/ml), 50 /50 ml (1 /ml), 500 /50 ml (,000 mcg/ml) dobutamine intravenous solution 50 PA BvD /0 ml (1.5 /ml), 500 /40 ml (1.5 /ml) dopamine in 5 % dextrose intravenous PA BvD solution 00 /50 ml (800 mcg/ml), 400 /50 ml (1,600 mcg/ml), 800 /50 ml (3,00 mcg/ml) dopamine intravenous solution 00 /5 PA BvD ml (40 /ml), 400 /5 ml (80 /ml), 800 /10 ml (80 /ml), 800 /5 ml (160 /ml) epinephrine injection auto-injector 0.15 (EpiPen Jr) QL (4 per 30 /0.3 ml epinephrine injection auto-injector 0.3 (Auvi-Q) QL (4 per 30 /0.3 ml EPIPEN -PAK INJECTION AUTO- QL (4 per 30 INJECTOR 0.3 MG/0.3 ML EPIPEN INJECTION AUTO- QL (4 per 30 INJECTOR 0.3 MG/0.3 ML EPIPEN JR -PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML QL (4 per 30 80

89 FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML ; QL (18 per 30 hydralazine injection solution 0 /ml hydralazine oral tablet 10, 100, 5, 50 LANOXIN ORAL TABLET MCG 4 PA-HRM; QL (30 per 30 ; AGE (Max 64 Years) LANOXIN ORAL TABLET 6.5 MCG milrinone in 5 % dextrose intravenous piggyback 0 /100 ml (00 mcg/ml), 40 /00 ml (00 mcg/ml) 4 PA-HRM; High Risk Med. PA Required for ages 65 and older and dose is greater than 15mcg per day; QL (60 per 30 ; AGE (Max 64 Years) 5 PA BvD; NDS milrinone intravenous solution 1 /ml 5 PA BvD; NDS norepinephrine bitartrate intravenous (Levophed (bitartrate)) PA BvD solution 1 /ml RANEXA ORAL TABLET 3 EXTENDED RELEASE 1 HR 1,000 MG, 500 MG Dihydropyridines afeditab cr oral tablet extended release 30, 60 amlodipine oral tablet 10,.5, 5 (Norvasc) 1 GC amlodipine-benazepril oral capsule 10-0 (Lotrel), 10-40, 5-10, 5-0, 5-40 amlodipine-benazepril oral capsule.5-10 amlodipine-olmesartan oral tablet 10-0 (Azor), 10-40, 5-0, 5-40 amlodipine-valsartan oral tablet (Exforge), 10-30, 5-160, 5-30 amlodipine-valsartan-hcthiazid oral tablet , , , , (Exforge HCT) 81

90 CLEVIPREX INTRAVENOUS 4 EMULSION 5 MG/50 ML, 50 MG/100 ML felodipine oral tablet extended release 4 hr 10,.5, 5 isradipine oral capsule.5, 5 nicardipine oral capsule 0, 30 nifedipine oral capsule 10 (Procardia) PA-HRM; AGE (Max 64 Years) nifedipine oral capsule 0 PA-HRM; AGE (Max 64 Years) nifedipine oral tablet extended release (Procardia XL) 4hr 30, 60, 90 nifedipine oral tablet extended release 30 (Adalat CC), 60, 90 Diuretics amiloride oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 bumetanide injection solution 0.5 /ml bumetanide oral tablet 0.5, 1, chlorothiazide oral tablet 50, 500 chlorothiazide sodium intravenous recon (Diuril IV) soln 500 chlorthalidone oral tablet 5, 50 DYRENIUM ORAL CAPSULE MG, 50 MG furosemide injection solution 10 /ml furosemide injection syringe 10 /ml furosemide oral solution 10 /ml, 40 /5 ml (8 /ml) furosemide oral tablet 0, 40, 80 (Lasix) 1 GC hydrochlorothiazide oral capsule 1.5 (Microzide) 1 GC hydrochlorothiazide oral tablet 1.5, 1 GC 5, 50 indapamide oral tablet 1.5,.5 1 GC methyclothiazide oral tablet 5 8

91 metolazone oral tablet 10,.5, 5 spironolactone oral tablet 100 (Aldactone) spironolactone oral tablet 5, 50 (Aldactone) 1 GC spironolacton-hydrochlorothiaz oral (Aldactazide) tablet 5-5 torsemide oral tablet 10, 0 (Demadex) torsemide oral tablet 100 torsemide oral tablet 5 1 GC triamterene-hydrochlorothiazid oral (Dyazide) 1 GC capsule triamterene-hydrochlorothiazid oral capsule 50-5 triamterene-hydrochlorothiazid oral (Maxzide-5) 1 GC tablet triamterene-hydrochlorothiazid oral (Maxzide) 1 GC tablet Dyslipidemics amlodipine-atorvastatin oral tablet (Caduet), 10-0, 10-40, 10-80, 5-10, 5-0, 5-40, 5-80 amlodipine-atorvastatin oral tablet.5-10,.5-0,.5-40 atorvastatin oral tablet 10, 0, 40 (Lipitor) 1 GC, 80 cholestyramine (with sugar) oral powder (Questran) in packet 4 gram cholestyramine light oral powder 4 gram cholestyramine light packet 4 gram colestipol oral packet 5 gram (Colestid) colestipol oral tablet 1 gram (Colestid) ezetimibe oral tablet 10 (Zetia) ezetimibe-simvastatin oral tablet (Vytorin 10-10) ezetimibe-simvastatin oral tablet 10-0 (Vytorin 10-0) ezetimibe-simvastatin oral tablet (Vytorin 10-40) ezetimibe-simvastatin oral tablet (Vytorin 10-80) 83

92 fenofibrate micronized oral capsule 130, 134, 00, 43, 67 fenofibrate nanocrystallized oral tablet (Tricor) 145, 48 fenofibrate oral tablet 160, 54 fenofibric acid (choline) oral (Trilipix) capsule,delayed release(dr/ec) 135, 45 fenofibric acid oral tablet 105, 35 (Fibricor) fluvastatin oral capsule 0, 40 (Lescol) gemfibrozil oral tablet 600 (Lopid) 1 GC JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 60 MG 5 PA; NDS; QL (30 per 30 JUXTAPID ORAL CAPSULE 0 MG 5 PA; NDS; QL (90 per 30 JUXTAPID ORAL CAPSULE 5 MG 5 PA; NDS; QL (45 per 30 KYNAMRO SUBCUTANEOUS SYRINGE 00 MG/ML 5 PA; NDS; QL (4 per 8 LIVALO ORAL TABLET 1 MG, 3 QL (30 per 30 MG, 4 MG lovastatin oral tablet 10, 0, 40 1 GC niacin oral tablet extended release 4 hr (Niaspan Extended- 1,000, 500, 750 Release) niacor oral tablet 500 omega-3 acid ethyl esters oral capsule 1 (Lovaza) QL (10 per 30 gram PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 5 PA; NDS; QL ( per 8 MG/ML pravastatin oral tablet 10 pravastatin oral tablet 0, 40, 80 (Pravachol) prevalite oral powder in packet 4 gram REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 40 MG/3.5 ML REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML 5 PA; NDS; QL (3.5 per 8 5 PA; NDS; QL (3 per 8 84

93 REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML rosuvastatin oral tablet 10, 0, 40, 5 simvastatin oral tablet 10, 0, 40, 5 (Crestor) (Zocor) 1 GC 5 PA; NDS; QL (3 per 8 simvastatin oral tablet 80 (Zocor) 1 GC; QL (30 per 30 VASCEPA ORAL CAPSULE QL (40 per 30 GRAM VASCEPA ORAL CAPSULE 1 3 QL (10 per 30 GRAM WELCHOL ORAL POWDER IN 3 PACKET 3.75 GRAM WELCHOL ORAL TABLET 65 MG 3 Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 5, 50 (Inspra) TEKAMLO ORAL TABLET ST MG, MG, MG, MG TEKTURNA HCT ORAL TABLET 3 ST MG, MG, MG, MG TEKTURNA ORAL TABLET ST MG, 300 MG Vasodilators BIDIL ORAL TABLET MG 3 isosorbide dinitrate oral tablet 10, 0, 30 isosorbide dinitrate oral tablet 5 (Isordil Titradose) isosorbide dinitrate oral tablet extended (ISOCHRON) release 40 isosorbide mononitrate oral tablet 10 isosorbide mononitrate oral tablet 0 1 GC isosorbide mononitrate oral tablet extended release 4 hr 10, 60 isosorbide mononitrate oral tablet 1 GC extended release 4 hr 30 minitran transdermal patch 4 hour 0.1 /hr, 0. /hr, 0.6 /hr QL (30 per 30 85

94 minitran transdermal patch 4 hour 0.4 QL (60 per 30 /hr minoxidil oral tablet 10,.5 NITRO-BID TRANSDERMAL OINTMENT % nitroglycerin in 5 % dextrose intravenous solution 100 /50 ml (400 mcg/ml), 5 /50 ml (100 mcg/ml), 50 /50 ml (00 mcg/ml) nitroglycerin intravenous solution 50 /10 ml (5 /ml) nitroglycerin sublingual tablet 0.3, 0.4 (Nitrostat), 0.6 nitroglycerin transdermal patch 4 hour (Minitran) QL (30 per /hr, 0. /hr, 0.6 /hr nitroglycerin transdermal patch 4 hour 0.4 /hr (Minitran) QL (60 per 30 Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 1 HR 10 MG 5 PA; NDS; QL (60 per 30 atomoxetine oral capsule 10, 100, 18, 5, 40, 60, 80 (Strattera) AUBAGIO ORAL TABLET 14 MG, 7 MG 5 PA; NDS; QL (8 per 8 AUSTEDO ORAL TABLET 1 MG, 9 MG 5 PA; NDS; QL (10 per 30 AUSTEDO ORAL TABLET 6 MG 5 PA; NDS; QL (60 per 30 AVONEX (WITH ALBUMIN) 5 PA; NDS INTRAMUSCULAR KIT 30 MCG AVONEX INTRAMUSCULAR PEN 5 PA; NDS INJECTOR KIT 30 MCG/0.5 ML AVONEX INTRAMUSCULAR 5 PA; NDS SYRINGE KIT 30 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0.3 MG 5 PA; NDS caffeine citrate intravenous solution 60 /3 ml (0 /ml) (Cafcit) 86

95 caffeine citrate oral solution 60 /3 ml (0 /ml) clonidine hcl oral tablet extended release 1 hr 0.1 (Kapvay) COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML 5 PA; NDS; QL (1 per 8 dexmethylphenidate oral tablet 10, (Focalin) QL (60 per 30.5, 5 dextroamphetamine oral capsule, (Dexedrine Spansule) QL (10 per 30 extended release 10, 15, 5 dextroamphetamine oral tablet 10, 5 (Zenzedi) QL (180 per 30 dextroamphetamine-amphetamine oral (Adderall XR) QL (30 per 30 capsule,extended release 4hr 10, 15, 5 dextroamphetamine-amphetamine oral (Adderall XR) QL (60 per 30 capsule,extended release 4hr 0, 5, 30 dextroamphetamine-amphetamine oral (Adderall) QL (60 per 30 tablet 10, 1.5, 15, 0, 30, 5, 7.5 EXTAVIA SUBCUTANEOUS KIT 5 PA; NDS 0.3 MG flumazenil intravenous solution 0.1 /ml GILENYA ORAL CAPSULE 0.5 MG 5 PA; NDS; QL (8 per 8 glatiramer subcutaneous syringe 0 /ml (Copaxone) 5 PA; NDS; QL (30 per 30 glatiramer subcutaneous syringe 40 /ml (Copaxone) 5 PA; NDS; QL (1 per 8 glatopa subcutaneous syringe 0 /ml 5 PA; NDS; QL (30 per 30 guanfacine oral tablet extended release (Intuniv ER) 4 hr 1,, 3, 4 INGREZZA ORAL CAPSULE 40 MG 5 PA; NDS; QL (60 per 30 INGREZZA ORAL CAPSULE 80 MG 5 PA; NDS; QL (30 per 30 LEMTRADA INTRAVENOUS SOLUTION 1 MG/1. ML 5 PA; NDS 87

96 lithium carbonate oral capsule 150, 1 GC 300 lithium carbonate oral capsule 600 lithium carbonate oral tablet 300 lithium carbonate oral tablet extended (Lithobid) release 300 lithium carbonate oral tablet extended release 450 lithium citrate oral solution 8 meq/5 ml methylphenidate hcl oral capsule, er QL (30 per 30 biphasic , 0, 40, 50, 60 methylphenidate hcl oral capsule, er QL (60 per 30 biphasic methylphenidate hcl oral capsule,er (Ritalin LA) QL (30 per 30 biphasic , 40 methylphenidate hcl oral capsule,er (Ritalin LA) QL (60 per 30 biphasic methylphenidate hcl oral capsule,er biphasic QL (30 per 30 methylphenidate hcl oral solution 10 /5 (Methylin) QL (900 per 30 ml, 5 /5 ml methylphenidate hcl oral tablet 10, 0 (Ritalin) QL (90 per 30, 5 methylphenidate hcl oral tablet extended QL (90 per 30 release 10 methylphenidate hcl oral tablet extended (Metadate ER) QL (90 per 30 release 0 methylphenidate hcl oral tablet extended (Concerta) QL (30 per 30 release 4hr 18, 7, 54 methylphenidate hcl oral tablet extended (Concerta) QL (60 per 30 release 4hr 36 NUEDEXTA ORAL CAPSULE QL (60 per 30 MG OCREVUS INTRAVENOUS SOLUTION 30 MG/ML 5 PA; NDS; QL (0 per 180 PLEGRIDY SUBCUTANEOUS PEN INJECTOR 15 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML 5 PA; NDS 88

97 PLEGRIDY SUBCUTANEOUS 5 PA; NDS SYRINGE 15 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML RADICAVA INTRAVENOUS PIGGYBACK 30 MG/100 ML 5 PA; NDS; QL (800 per 8 REBIF (WITH ALBUMIN) 5 PA; NDS SUBCUTANEOUS SYRINGE MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE 5 PA; NDS SUBCUTANEOUS PEN INJECTOR MCG/0.5 ML, 44 MCG/0.5 ML, 8.8MCG/0.ML- MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.ML- MCG/0.5ML (6) 5 PA; NDS riluzole oral tablet 50 (Rilutek) SAVELLA ORAL TABLET 100 MG, 3 QL (60 per MG, 5 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 1.5 MG (5)-5 MG(8)-50 MG(4) 3 QL (60 per 30 TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10 MG (14)- 40 MG (46), 40 MG 5 PA; NDS; QL (14 per 30 5 PA; NDS; QL (60 per 30 tetrabenazine oral tablet 1.5, 5 (Xenazine) 5 PA; NDS; QL (11 per 8 ZINBRYTA SUBCUTANEOUS SYRINGE 150 MG/ML 5 PA; NDS; QL (1 per 8 Contraceptives Contraceptives altavera (8) oral tablet alyacen 1/35 (8) oral tablet 1-35 mcg alyacen 7/7/7 (8) oral tablet 0.5/0.75/1-35 mcg amethia lo oral tablets,dose pack,3 month mcg (84)/10 mcg (7) QL (91 per 84 89

98 amethia oral tablets,dose pack,3 month QL (91 per mcg (84)/10 mcg (7) apri oral tablet aranelle (8) oral tablet 0.5/1/ mcg ashlyna oral tablets,dose pack,3 month mcg (84)/10 mcg (7) aubra oral tablet mcg aviane oral tablet mcg azurette (8) oral tablet x1 /0.01 x 5 balziva (8) oral tablet mcg bekyree (8) oral tablet x1 /0.01 x 5 blisovi 4 fe oral tablet 1-0 mcg (4)/75 (4) blisovi fe 1.5/30 (8) oral tablet mcg (1)/75 (7) blisovi fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) briellyn oral tablet mcg camila oral tablet 0.35 camrese lo oral tablets,dose pack,3 month QL (91 per mcg (84)/10 mcg (7) camrese oral tablets,dose pack,3 month QL (91 per mcg (84)/10 mcg (7) caziant (8) oral tablet 0.1/.15/ mcg cryselle (8) oral tablet mcg cyclafem 1/35 (8) oral tablet 1-35 mcg cyclafem 7/7/7 (8) oral tablet 0.5/0.75/1-35 mcg cyred oral tablet dasetta 1/35 (8) oral tablet 1-35 mcg dasetta 7/7/7 (8) oral tablet 0.5/0.75/1-35 mcg daysee oral tablets,dose pack,3 month QL (91 per mcg (84)/10 mcg (7) deblitane oral tablet

99 delyla (8) oral tablet mcg desog-e.estradiol/e.estradiol oral tablet (Azurette (8)) x1 /0.01 x 5 desogestrel-ethinyl estradiol oral tablet (Apri) drospirenone-ethinyl estradiol oral tablet (Gianvi (8)) drospirenone-ethinyl estradiol oral tablet (Ocella) elinest oral tablet mcg ELLA ORAL TABLET 30 MG 4 QL (6 per 365 emoquette oral tablet enpresse oral tablet (6)/75-40 (5)/15-30(10) enskyce oral tablet errin oral tablet 0.35 estarylla oral tablet mcg ethynodiol diac-eth estradiol oral tablet (Kelnor 1/35 (8)) mcg ethynodiol diac-eth estradiol oral tablet (Zovia 1/50E (8)) mcg falmina (8) oral tablet mcg femynor oral tablet mcg gianvi (8) oral tablet gildagia oral tablet mcg heather oral tablet 0.35 introvale oral tablets,dose pack,3 month QL (91 per mcg isibloom oral tablet jencycla oral tablet 0.35 jolessa oral tablets,dose pack,3 month QL (91 per mcg jolivette oral tablet 0.35 juleber oral tablet junel 1.5/30 (1) oral tablet mcg junel 1/0 (1) oral tablet 1-0 -mcg junel fe 1.5/30 (8) oral tablet mcg (1)/75 (7) 91

100 junel fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) junel fe 4 oral tablet 1-0 mcg (4)/75 (4) kariva (8) oral tablet x1 /0.01 x 5 kelnor 1/35 (8) oral tablet mcg kimidess (8) oral tablet x1 /0.01 x 5 kurvelo oral tablet l norgest/e.estradiol-e.estrad oral (Amethia Lo) QL (91 per 84 tablets,dose pack,3 month mcg (84)/10 mcg (7) l norgest/e.estradiol-e.estrad oral (Fayosim) QL (91 per 84 tablets,dose pack,3 month mcg/ mcg l norgest/e.estradiol-e.estrad oral (Amethia) QL (91 per 84 tablets,dose pack,3 month mcg (84)/10 mcg (7) larin 1.5/30 (1) oral tablet mcg larin 1/0 (1) oral tablet 1-0 -mcg larin 4 fe oral tablet 1-0 mcg (4)/75 (4) larin fe 1.5/30 (8) oral tablet mcg (1)/75 (7) larin fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) larissia oral tablet mcg leena 8 oral tablet 0.5/1/ mcg lessina oral tablet mcg levonest (8) oral tablet (6)/75-40 (5)/15-30(10) levonorgestrel-ethinyl estrad oral tablet (Aubra) mcg levonorgestrel-ethinyl estrad oral tablet (Altavera (8)) QL (91 per levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month mcg (Introvale) QL (91 per 84 9

101 levonorg-eth estrad triphasic oral tablet (Enpresse) QL (91 per (6)/75-40 (5)/15-30(10) levora-8 oral tablet lillow oral tablet lomedia 4 fe oral tablet 1-0 mcg (4)/75 (4) loryna (8) oral tablet low-ogestrel (8) oral tablet mcg lutera (8) oral tablet mcg lyza oral tablet 0.35 marlissa oral tablet microgestin 1.5/30 (1) oral tablet mcg microgestin 1/0 (1) oral tablet 1-0 -mcg microgestin fe 1.5/30 (8) oral tablet GC -30 mcg (1)/75 (7) microgestin fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) mono-linyah oral tablet mcg mononessa (8) oral tablet mcg myzilra oral tablet (6)/75-40 (5)/15-30(10) necon 0.5/35 (8) oral tablet mcg necon 1/50 (8) oral tablet mcg necon 10/11 (8) oral tablet /1-35 -mcg/-mcg necon 7/7/7 (8) oral tablet 0.5/0.75/1-35 mcg nikki (8) oral tablet nora-be oral tablet 0.35 noreth-estrad-fe 1-0.0(1) (Blisovi Fe 1/0 (8)) mcg (1)/75 (7) noreth-ethinyl estradiol-iron oral (Wymzya Fe) tablet,chewable mcg(1) and 75 (7) norethindrone (contraceptive) oral tablet 0.35 (Camila) 93

102 norethindrone ac-eth estradiol oral tablet (Junel 1/0 (1)) 1-0 -mcg norethindrone-e.estradiol-iron oral tablet (Blisovi 4 Fe) 1-0 mcg (4)/75 (4) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen LO 0.18/0.15/0.5-5 mcg (8)) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen (8)) 0.18/0.15/ mcg (8) norgestimate-ethinyl estradiol oral tablet (Estarylla) mcg norlyda oral tablet 0.35 norlyroc oral tablet 0.35 nortrel 0.5/35 (8) oral tablet mcg nortrel 1/35 (1) oral tablet 1-35 mcg nortrel 1/35 (8) oral tablet 1-35 mcg nortrel 7/7/7 (8) oral tablet 0.5/0.75/1-35 mcg NUVARING VAGINAL RING QL (1 per MG/4 HR ocella oral tablet ogestrel (8) oral tablet mcg orsythia oral tablet mcg philith oral tablet mcg pimtrea (8) oral tablet x1 /0.01 x 5 pirmella oral tablet 0.5/0.75/1-35 mcg, mcg portia oral tablet previfem oral tablet mcg quasense oral tablets,dose pack,3 month QL (91 per mcg reclipsen (8) oral tablet setlakin oral tablets,dose pack,3 month QL (91 per mcg sharobel oral tablet 0.35 sprintec (8) oral tablet mcg sronyx oral tablet mcg 94

103 syeda oral tablet tarina fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) tilia fe oral tablet 1-0(5)/1-30(7) /1-35mcg (9) tri femynor oral tablet 0.18/0.15/ mcg (8) tri-estarylla oral tablet 0.18/0.15/ mcg (8) tri-legest fe oral tablet 1-0(5)/1-30(7) /1-35mcg (9) tri-linyah oral tablet 0.18/0.15/ mcg (8) tri-lo-estarylla oral tablet 0.18/0.15/0.5-5 mcg tri-lo-marzia oral tablet 0.18/0.15/0.5-5 mcg tri-lo-sprintec oral tablet 0.18/0.15/0.5-5 mcg trinessa (8) oral tablet 0.18/0.15/ mcg (8) tri-previfem (8) oral tablet 0.18/0.15/ mcg (8) tri-sprintec (8) oral tablet 0.18/0.15/ mcg (8) trivora (8) oral tablet (6)/75-40 (5)/15-30(10) tri-vylibra oral tablet 0.18/0.15/ mcg (8) velivet triphasic regimen (8) oral tablet 0.1/.15/ mcg vestura (8) oral tablet vienva oral tablet mcg viorele (8) oral tablet x1 /0.01 x 5 vyfemla (8) oral tablet mcg vylibra oral tablet mcg wera (8) oral tablet mcg wymzya fe oral tablet,chewable mcg(1) and 75 (7) 95

104 xulane transdermal patch weekly QL (3 per 8 mcg/4 hr zarah oral tablet zenchent (8) oral tablet mcg zenchent fe oral tablet,chewable mcg(1) and 75 (7) zovia 1/35e (8) oral tablet mcg zovia 1/50e (8) oral tablet mcg Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 30 (Evoxac) chlorhexidine gluconate mucous (Paroex Oral Rinse) membrane mouthwash 0.1 % oralone dental paste 0.1 % paroex oral rinse mucous membrane mouthwash 0.1 % periogard mucous membrane mouthwash 0.1 % pilocarpine hcl oral tablet 5, 7.5 (Salagen (pilocarpine)) triamcinolone acetonide dental paste 0.1 (Oralone) % Dermatological Agents Dermatological Agents, Other acitretin oral capsule 10, 17.5, 5 (Soriatane) acyclovir topical ointment 5 % (Zovirax) QL (30 per 30 ALCOHOL PADS TOPICAL PADS, 1 GC MEDICATED ALCOHOL PREP PADS 1 GC ammonium lactate topical cream 1 % (Geri-Hydrolac) ammonium lactate topical lotion 1 % (AmLactin) calcipotriene scalp solution % calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcitrene) calcitrene topical ointment % calcitriol topical ointment 3 mcg/gram (Vectical) CONDYLOX TOPICAL GEL 0.5 % 4 COSENTYX ( SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML 5 PA; NDS 96

105 COSENTYX PEN ( PENS) 5 PA; NDS SUBCUTANEOUS PEN INJECTOR 150 MG/ML DENAVIR TOPICAL CREAM 1 % diclofenac sodium topical drops 1.5 % QL (300 per 30 diclofenac sodium topical gel 3 % (Solaraze) 5 PA; NDS; QL (100 per 8 DUPIXENT SUBCUTANEOUS 5 PA; NDS SYRINGE 300 MG/ ML FLECTOR TRANSDERMAL 3 PA PATCH 1 HOUR 1.3 % fluorouracil topical cream 0.5 % (Carac) fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution %, 5 % imiquimod topical cream in packet 5 % (Aldara) PA NSO; QL (4 per 30 methoxsalen oral capsule,liqd-filled,rapid (Oxsoralen Ultra) rel 10 PANRETIN TOPICAL GEL 0.1 % PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 0 MG/GRAM /ACTUATION( %) 5 PA; NDS; QL (4 per 8 PICATO TOPICAL GEL % 3 QL (3 per 56 PICATO TOPICAL GEL 0.05 % 3 QL ( per 56 podofilox topical solution 0.5 % REGRANEX TOPICAL GEL 0.01 % 5 PA; NDS; QL (30 per 30 SANTYL TOPICAL OINTMENT 50 4 UNIT/GRAM SILIQ SUBCUTANEOUS SYRINGE 5 PA; NDS 10 MG/1.5 ML TALTZ AUTOINJECTOR 5 PA; NDS SUBCUTANEOUS AUTO- INJECTOR 80 MG/ML TALTZ SYRINGE 5 PA; NDS SUBCUTANEOUS SYRINGE 80 MG/ML TOLAK TOPICAL CREAM 4 % 4 TREMFYA SUBCUTANEOUS 5 PA; NDS SYRINGE 100 MG/ML VALCHLOR TOPICAL GEL % 97

106 VEREGEN TOPICAL OINTMENT 15 % VOLTAREN TOPICAL GEL 1 % zenatane oral capsule 10, 0, 30, 40 ZOVIRAX TOPICAL CREAM 5 % ; QL (5 per 4 Dermatological Antibacterials clindamycin phosphate topical foam 1 % (Evoclin) clindamycin phosphate topical gel 1 % (Cleocin T) clindamycin phosphate topical lotion 1 % (Cleocin T) clindamycin phosphate topical solution 1 (Cleocin T) % clindamycin phosphate topical swab 1 % (Cleocin T) clindamycin-benzoyl peroxide topical gel (Duac) 1. %(1 % base) -5 % clindamycin-benzoyl peroxide topical gel (Benzaclin) 1-5 % ery pads topical swab % erythromycin with ethanol topical gel % (Erygel) erythromycin with ethanol topical solution % erythromycin with ethanol topical swab (Ery Pads) % erythromycin-benzoyl peroxide topical (Aktipak) gel 3-5 % gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % metronidazole topical cream 0.75 % (MetroCream) metronidazole topical gel 0.75 % (Rosadan) metronidazole topical gel 1 % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) mupirocin calcium topical cream % (Bactroban) mupirocin topical ointment % (Centany) neomycin-polymyxin b gu irrigation solution 40-00,000 unit/ml neuac topical gel 1. %(1 % base) -5 % rosadan topical cream 0.75 % selenium sulfide topical lotion.5 % silver sulfadiazine topical cream 1 % (Silvadene) ssd topical cream 1 % 98

107 sulfacetamide sodium (acne) topical (Klaron) suspension 10 % Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 % ala-cort topical cream.5 % 1 GC ala-scalp topical lotion % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0.1 % betamethasone valerate topical foam 0.1 (Luxiq) % betamethasone valerate topical lotion 0.1 % betamethasone valerate topical ointment 0.1 % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical (Diprolene) ointment 0.05 % clobetasol 0.05% cream 0.05 % (Temovate) clobetasol emollient 0.05% crm 0.05 % clobetasol scalp solution 0.05 % (Cormax) clobetasol topical foam 0.05 % (Olux) clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol-emollient topical cream 0.05 % clobetasol-emollient topical foam 0.05 % (Olux-E) 99

108 clocortolone pivalate topical cream 0.1 % (Cloderm) cormax scalp solution 0.05 % desonide topical cream 0.05 % (DesOwen) desonide topical lotion 0.05 % (DesOwen) desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, (Topicort) 0.5 % desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, (Topicort) 0.5 % diflorasone topical cream 0.05 % (Psorcon) diflorasone topical ointment 0.05 % ELIDEL TOPICAL CREAM 1 % 3 EUCRISA TOPICAL OINTMENT 3 % fluocinolone topical cream 0.01 % fluocinolone topical cream 0.05 % (Synalar) fluocinolone topical ointment 0.05 % (Synalar) fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % fluticasone topical cream 0.05 % (Cutivate) fluticasone topical ointment % halobetasol propionate topical cream 0.05 (Ultravate) % halobetasol propionate topical ointment 0.05 % (Ultravate) hydrocortisone butyrate topical cream 0.1 (Locoid) % hydrocortisone butyrate topical ointment (Locoid) 0.1 % hydrocortisone butyrate topical solution (Locoid) 0.1 % hydrocortisone topical cream 1 %,.5 % (Ala-Cort) 1 GC hydrocortisone topical lotion.5 % hydrocortisone topical ointment 1 % (Anti-Itch (HC)) 1 GC hydrocortisone topical ointment.5 % 1 GC 100

109 hydrocortisone valerate topical cream 0. % hydrocortisone valerate topical ointment 0. % mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % prednicarbate topical cream 0.1 % (Dermatop) prednicarbate topical ointment 0.1 % (Dermatop) procto-med hc topical cream with perineal applicator.5 % procto-pak topical cream with perineal applicator 1 % proctosol hc topical cream with perineal applicator.5 % proctozone-hc topical cream with perineal applicator.5 % tacrolimus topical ointment 0.03 %, 0.1 % (Protopic) triamcinolone acetonide topical cream 1 GC 0.05 % triamcinolone acetonide topical cream 0.1 (Triderm) %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0.1 % triamcinolone acetonide topical ointment 1 GC 0.05 % triamcinolone acetonide topical ointment 0.1 %, 0.5 % tridesilon topical cream 0.05 % Dermatological Retinoids adapalene topical cream 0.1 % (Differin) adapalene topical gel 0.1 % (Differin) tazarotene topical cream 0.1 % (Avage) TAZORAC TOPICAL CREAM 0.05 % 4 tretinoin topical cream 0.05 % (Avita) PA tretinoin topical cream 0.05 %, 0.1 % (Retin-A) PA tretinoin topical gel 0.01 % (Retin-A) PA tretinoin topical gel 0.05 % (Avita) PA 101

110 Scabicides And Pediculicides malathion topical lotion 0.5 % (Ovide) permethrin topical cream 5 % (Elimite) spinosad topical suspension 0.9 % (Natroba) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 9 GAUGE X 1/" BD INSULIN SYR 0.3 ML 6MMX31G 0.3 ML 31 GAUGE X 15/64" BD INSULIN SYR 0.5 ML 6MMX31G 1/ ML 31 GAUGE X 15/64" BD INSULIN SYR 1 ML 6MMX31G 1 ML 31 GAUGE X 15/64" BD ULTRA-FINE PEN NDL 4MMX3G NANO 3 GAUGE X 5/3" GAUZE PAD TOPICAL BANDAGE X " 1 GC INSULIN SYRINGE-NEEDLE U-100 (Ultilet Insulin Syringe) SYRINGE 0.3 ML 9 GAUGE INSULIN SYRINGE-NEEDLE U-100 (Advocate Syringes) SYRINGE 1 ML 9 GAUGE X 1/" INSULIN SYRINGE-NEEDLE U-100 (Lite Touch Insulin SYRINGE 1/ ML 8 GAUGE Syringe) PEN NEEDLE, DIABETIC NEEDLE 9 GAUGE X 1/" (1st Tier Unifine Pentips) STERILE PADS " X " X " 1 GC VGO 40 DISPOSABLE DEVICE Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN INTRAMUSCULAR SOLUTION 50 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION.9 MG/5 ML CERDELGA ORAL CAPSULE 84 5 PA; NDS MG CEREZYME INTRAVENOUS RECON SOLN 400 UNIT 10

111 CREON ORAL 3 CAPSULE,DELAYED RELEASE(DR/EC) 1,000-38,000-60,000 UNIT, 4,000-76,000-10,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT ELAPRASE INTRAVENOUS SOLUTION 6 MG/3 ML ELITEK INTRAVENOUS RECON SOLN 1.5 MG, 7.5 MG FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG KANUMA INTRAVENOUS 5 PA; NDS SOLUTION MG/ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML KUVAN ORAL TABLET,SOLUBLE 100 MG NAGLAZYME INTRAVENOUS SOLUTION 5 MG/5 ML ORFADIN ORAL CAPSULE 10 MG, 5 PA; NDS 0 MG, 5 MG ORFADIN ORAL CAPSULE MG 5 PA; NDS ORFADIN ORAL SUSPENSION 4 5 PA; NDS MG/ML PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500-60,500 UNIT, 4,000-86,50-90,750 UNIT PERTZYE ORAL 4 CAPSULE,DELAYED RELEASE(DR/EC) 4,000-14,375-15,15 UNIT, 8,000-8,750-30,50 UNIT PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE 5 MG, 75 MG PULMOZYME INHALATION SOLUTION 1 MG/ML 5 PA BvD; NDS 103

112 STRENSIQ SUBCUTANEOUS 5 PA; LA; NDS SOLUTION 100 MG/ML, 40 MG/ML VIMIZIM INTRAVENOUS 5 PA; NDS SOLUTION 5 MG/5 ML (1 MG/ML) VPRIV INTRAVENOUS RECON SOLN 400 UNIT ZAVESCA ORAL CAPSULE 100 MG ; QL (90 per 30 ZENPEP ORAL 3 CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-8,000 UNIT, 0,000-63,000-84,000 UNIT, 0,000-68, ,000 UNIT, 5,000-79, ,000 UNIT, 5,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 40,000-16, ,000 UNIT, 40, ,000-18,000 UNIT, 5,000-17,000-7,000 UNIT, 5,000-17,000-4,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) OPHTHALMIC (EYE) GEL 3.5 % 4 apraclonidine ophthalmic (eye) drops 0.5 (Iopidine) % atropine ophthalmic (eye) drops 1 % azelastine nasal aerosol,spray 137 mcg QL (30 per 5 (0.1 %) azelastine nasal spray,non-aerosol 0.15 % (Astepro) QL (30 per 5 (05.5 mcg) azelastine ophthalmic (eye) drops 0.05 % BEPREVE OPHTHALMIC (EYE) 4 ST DROPS 1.5 % cromolyn ophthalmic (eye) drops 4 % cyclopentolate ophthalmic (eye) drops 0.5 %, 1 %, % (Cyclogyl) CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % epinastine ophthalmic (eye) drops 0.05 % (Elestat) 104

113 ipratropium bromide nasal spray,nonaerosol QL (30 per % ipratropium bromide nasal spray,nonaerosol QL (15 per 10 4 mcg (0.06 %) LACRISERT OPHTHALMIC (EYE) 3 INSERT 5 MG olopatadine nasal spray,non-aerosol 0.6 (Patanase) QL (30.5 per 30 % olopatadine ophthalmic (eye) drops 0.1 (Patanol) % olopatadine ophthalmic (eye) drops 0. (Pataday) % OTOVEL OTIC (EAR) SOLUTION % (0.5 ML) phenylephrine hcl ophthalmic (eye) drops 1 GC 10 % phenylephrine hcl ophthalmic (eye) drops.5 % proparacaine ophthalmic (eye) drops 0.5 % TYZINE NASAL DROPS 0.1 % 4 TYZINE NASAL SPRAY,NON- 4 AEROSOL 0.1 % Eye, Ear, Nose, Throat Anti-Infectives Agents acetasol hc otic (ear) drops 1- % acetic acid otic (ear) solution % bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) (Polycin) ointment ,000 unit/gram bleph-10 ophthalmic (eye) drops 10 % CILOXAN OPHTHALMIC (EYE) 4 OINTMENT 0.3 % CIPRODEX OTIC (EAR) 3 DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic (eye) drops (Ciloxan) 0.3 % ciprofloxacin hcl otic (ear) dropperette 0. % (Cetraxal) 105

114 COLY-MYCIN S OTIC (EAR) 4 DROPS,SUSPENSION MG/ML erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) gatifloxacin ophthalmic (eye) drops 0.5 (Zymaxid) % gentak ophthalmic (eye) ointment 0.3 % (3 /gram) gentamicin ophthalmic (eye) drops 0.3 % gentamicin ophthalmic (eye) ointment (Gentak) 0.3 % (3 /gram) hydrocortisone-acetic acid otic (ear) drops 1- % levofloxacin ophthalmic (eye) drops 0.5 % MOXEZA OPHTHALMIC (EYE) 3 DROPS, VISCOUS 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 (Vigamox) % NATACYN OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic (Neo-Polycin HC) (eye) ointment ,000 unit/g-1% neomycin-bacitracin-polymyxin (Neo-Polycin) ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) drops,suspension 3.5/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) ointment 3.5 /g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops ,000 unit-0.05/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension , unit-/ml 106

115 neomycin-polymyxin-hc otic (ear) drops,suspension ,000-1 /mlunit/ml-% neomycin-polymyxin-hc otic (ear) solution ,000-1 /ml-unit/ml-% neo-polycin hc ophthalmic (eye) ointment ,000 -unit/g-1% neo-polycin ophthalmic (eye) ointment ,000 -unit-unit/g ofloxacin ophthalmic (eye) drops 0.3 % (Ocuflox) ofloxacin otic (ear) drops 0.3 % (Floxin) polycin ophthalmic (eye) ointment ,000 unit/gram polymyxin b sulf-trimethoprim (Polytrim) 1 GC ophthalmic (eye) drops 10,000 unit- 1 /ml sulfacetamide sodium ophthalmic (eye) (Bleph-10) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.3 % (0.5 %) TOBRADEX OPHTHALMIC (EYE) 4 OINTMENT % TOBRADEX ST OPHTHALMIC 3 (EYE) DROPS,SUSPENSION % tobramycin ophthalmic (eye) drops 0.3 (Tobrex) % tobramycin-dexamethasone ophthalmic (TobraDex) (eye) drops,suspension % trifluridine ophthalmic (eye) drops 1 % (Viroptic) VIGAMOX OPHTHALMIC (EYE) 3 DROPS 0.5 % ZIRGAN OPHTHALMIC (EYE) GEL % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % 3 107

116 Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % bromfenac ophthalmic (eye) drops 0.09 % BROMSITE OPHTHALMIC (EYE) DROPS % dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) fluocinolone acetonide oil otic (ear) drops 0.01 % fluorometholone ophthalmic (eye) drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops 0.03 % fluticasone nasal spray,suspension 50 mcg/actuation ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3 % (DermOtic Oil) (FML Liquifilm) (4 Hour Allergy Relief) ketorolac ophthalmic (eye) drops 0.4 % (Acular LS) ketorolac ophthalmic (eye) drops 0.5 % (Acular) LOTEMAX OPHTHALMIC (EYE) 3 DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) 3 OINTMENT 0.5 % prednisolone acetate ophthalmic (eye) (Omnipred) drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % PROLENSA OPHTHALMIC (EYE) DROPS 0.07 % 3 3 ST 3 3 QL (50 per 5 1 GC 3 108

117 RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral combo pack CARAFATE ORAL SUSPENSION 100 MG/ML (Prevpac) cimetidine hcl oral solution 300 /5 ml cimetidine oral tablet 00 (Acid Reducer (cimetidine)) cimetidine oral tablet 300, 400, 800 DEXILANT ORAL 3 ST CAPSULE,BIPHASE DELAYED RELEAS 30 MG, 60 MG esomeprazole sodium intravenous recon soln 0 esomeprazole sodium intravenous recon (Nexium IV) soln 40 famotidine (pf) intravenous solution 0 / ml famotidine (pf)-nacl (iso-os) intravenous piggyback 0 /50 ml famotidine intravenous solution 10 /ml famotidine oral suspension 40 /5 ml (8 (Pepcid) /ml) famotidine oral tablet 0 (Acid Controller) 1 GC famotidine oral tablet 40 (Pepcid) 1 GC lansoprazole oral capsule,delayed (Heartburn Treatment release(dr/ec) 15 4 Hour) lansoprazole oral capsule,delayed (Prevacid) release(dr/ec) 30 misoprostol oral tablet 100 mcg, 00 mcg (Cytotec) nizatidine oral capsule 150, 300 nizatidine oral solution 150 /10 ml omeprazole oral capsule,delayed release(dr/ec) 10 3 QL (60 per 30 4 PA; QL (60 per

118 omeprazole oral capsule,delayed release(dr/ec) 0, 40 1 GC pantoprazole intravenous recon soln 40 (Protonix) pantoprazole oral tablet,delayed release (Protonix) 1 GC (dr/ec) 0, 40 rabeprazole oral tablet,delayed release (Aciphex) ST; QL (30 per 30 (dr/ec) 0 ranitidine hcl injection solution 5 /ml, (Zantac) 50 / ml (5 /ml) ranitidine hcl oral syrup 15 /ml ranitidine hcl oral tablet 150 (Acid Control 1 GC (ranitidine)) ranitidine hcl oral tablet 300 (Zantac) 1 GC sucralfate oral tablet 1 gram (Carafate) Gastrointestinal Agents, Other AMITIZA ORAL CAPSULE 4 MCG, 3 QL (60 per 30 8 MCG BUPHENYL ORAL TABLET 500 MG CARBAGLU ORAL TABLET, DISPERSIBLE 00 MG constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 /5 ml (Gastrocrom) dicyclomine oral capsule 10 dicyclomine oral solution 10 /5 ml dicyclomine oral tablet 0 diphenoxylate-atropine oral liquid /5 ml PA-HRM; AGE (Max 64 Years) diphenoxylate-atropine oral tablet (Lomotil) PA-HRM; AGE (Max 64 Years) enulose oral solution 10 gram/15 ml GATTEX 30-VIAL 5 PA; NDS SUBCUTANEOUS KIT 5 MG generlac oral solution 10 gram/15 ml glycopyrrolate injection solution 0. (Robinul) /ml glycopyrrolate oral tablet 1 (Robinul) glycopyrrolate oral tablet (Robinul Forte) kionex (with sorbitol) oral suspension gram/60 ml 110

119 lactulose oral solution 10 gram/15 ml (Constulose) LINZESS ORAL CAPSULE 145 MCG, 90 MCG, 7 MCG 3 QL (30 per 30 loperamide oral capsule (Anti-Diarrheal (loperamide)) methscopolamine oral tablet.5, 5 metoclopramide hcl injection solution 5 /ml metoclopramide hcl oral solution 5 /5 1 GC ml metoclopramide hcl oral tablet 10, 5 (Reglan) 1 GC MOVANTIK ORAL TABLET QL (30 per 30 MG, 5 MG NUTRESTORE ORAL POWDER IN 4 PACKET 5 GRAM OCALIVA ORAL TABLET 10 MG, 5 MG 5 PA; NDS; QL (30 per 30 RAVICTI ORAL LIQUID PA; NDS GRAM/ML RELISTOR ORAL TABLET 150 MG 5 PA; NDS; QL (90 per 30 RELISTOR SUBCUTANEOUS SOLUTION 1 MG/0.6 ML 5 PA; NDS; QL (8 per 8 RELISTOR SUBCUTANEOUS SYRINGE 1 MG/0.6 ML, 8 MG/0.4 5 PA; NDS; QL (8 per 8 ML sod polystyren sulf 15 g/60 ml sorbitol free 15 gram/60 ml sodium phenylbutyrate oral tablet 500 (Buphenyl) sodium polystyrene sulfonate oral powder (Kionex) sps (with sorbitol) oral suspension 15-0 gram/60 ml ursodiol oral capsule 300 (Actigall) ursodiol oral tablet 50 (URSO 50) ursodiol oral tablet 500 (URSO Forte) VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 5. GRAM, 8.4 GRAM 3 QL (30 per

120 VIBERZI ORAL TABLET 100 MG, 75 MG 5 ST; NDS; QL (60 per 30 XERMELO ORAL TABLET 50 MG 5 PA; NDS; QL (90 per 30 Laxatives CLENPIQ ORAL SOLUTION 10 MG GRAM -1 GRAM/160 ML gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 40 gram MOVIPREP ORAL POWDER IN PACKET GRAM 3 peg 3350-electrolytes oral recon soln 36- (GaviLyte-G) gram peg 3350-electrolytes oral recon soln 40- (Colyte with Flavor 1 GC gram Packs) peg-electrolyte soln oral recon soln 40 (GaviLyte-N) gram polyethylene glycol 3350 oral powder 17 (ClearLax) gram/dose PREPOPIK ORAL POWDER IN 4 PACKET 10 MG-3.5 GRAM-1 GRAM SUPREP BOWEL PREP KIT ORAL 3 RECON SOLN GRAM trilyte with flavor packets oral recon soln 40 gram Phosphate Binders AURYXIA ORAL TABLET 10 MG 4 IRON calcium acetate oral capsule 667 calcium acetate oral tablet 667 (Calphron) eliphos oral tablet 667 FOSRENOL ORAL POWDER IN 4 PACKET 1,000 MG, 750 MG FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG 11

121 lanthanum oral tablet,chewable 1,000, (Fosrenol) 500, 750 PHOSLYRA ORAL SOLUTION MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 400 MG, MG RENVELA ORAL TABLET 800 MG 3 sevelamer carbonate oral powder in (Renvela) packet 0.8 gram,.4 gram sevelamer carbonate oral tablet 800 (Renvela) VELPHORO ORAL 3 TABLET,CHEWABLE 500 MG Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 10, (Urecholine) 5, 5, 50 flavoxate oral tablet 100 MYRBETRIQ ORAL TABLET EXTENDED RELEASE 4 HR 5 MG, 50 MG 3 oxybutynin chloride oral syrup 5 /5 ml 1 GC oxybutynin chloride oral tablet 5 oxybutynin chloride oral tablet extended (Ditropan XL) release 4hr 10, 15, 5 tolterodine oral capsule,extended release (Detrol LA) 4hr, 4 tolterodine oral tablet 1, (Detrol) TOVIAZ ORAL TABLET 3 EXTENDED RELEASE 4 HR 4 MG, 8 MG trospium oral capsule,extended release 4hr 60 trospium oral tablet 0 VESICARE ORAL TABLET 10 MG, 5 3 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release 4 (Uroxatral) hr 10 dutasteride oral capsule 0.5 (Avodart) dutasteride-tamsulosin oral capsule, er multiphase 4 hr (Jalyn) QL (30 per

122 finasteride oral tablet 5 (Proscar) 1 GC tamsulosin oral capsule,extended release (Flomax) 4hr 0.4 terazosin oral capsule 1, 10,, 1 GC 5 Heavy Metal Antagonists Heavy Metal Antagonists CUPRIMINE ORAL CAPSULE 50 MG 5 PA; NDS deferoxamine injection recon soln gram, (Desferal) PA 500 DEPEN TITRATABS ORAL 5 PA; NDS TABLET 50 MG EXJADE ORAL TABLET, 5 PA; NDS DISPERSIBLE 15 MG, 50 MG, 500 MG FERRIPROX ORAL SOLUTION PA; NDS MG/ML FERRIPROX ORAL TABLET PA; NDS MG JADENU ORAL TABLET 180 MG, 5 PA; NDS 360 MG, 90 MG JADENU SPRINKLE ORAL 5 PA; NDS GRANULES IN PACKET 180 MG, 360 MG, 90 MG SYPRINE ORAL CAPSULE 50 MG 5 PA; NDS; QL (40 per 30 trientine oral capsule 50 (Syprine) 5 PA; NDS; QL (40 per 30 Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANADROL-50 ORAL TABLET 50 MG 5 PA; NDS ANDRODERM TRANSDERMAL PATCH 4 HOUR MG/4 HOUR, 4 MG/4 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 0.5 MG/1.5 GRAM (1.6 %) 3 PA; QL (30 per 30 3 PA; QL (150 per

123 ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (0.5 MG/1.5 GRAM), 1.6 % (40.5 MG/.5 GRAM) 3 PA; QL (150 per 30 androxy oral tablet 10 danazol oral capsule 100, 00, 50 oxandrolone oral tablet 10,.5 (Oxandrin) testosterone cypionate intramuscular oil (Depo-Testosterone) PA 100 /ml, 00 /ml testosterone enanthate intramuscular oil PA; QL (5 per 8 00 /ml testosterone transdermal gel in packet 1 % (5 /.5gram), 1 % (50 /5 (AndroGel) PA; QL (300 per 30 gram) Estrogens And Antiestrogens amabelz oral tablet , COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY MG/4 HR, MG/4 HR DUAVEE ORAL TABLET MG ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) 3 PA-HRM; QL (8 per 8 ; AGE (Max 64 Years) 3 PA-HRM; AGE (Max 64 Years) 3 estradiol oral tablet 0.5, 1, (Estrace) PA-HRM; AGE (Max 64 Years) estradiol transdermal patch semiweekly 0.05 /4 hr, 0.05 /4 hr, /4 hr, 0.1 /4 hr (Alora) PA-HRM; QL (8 per 8 ; AGE (Max 64 Years) estradiol transdermal patch semiweekly /4 hr estradiol transdermal patch weekly 0.05 /4 hr, /4 hr, 0.05 /4 hr, 0.06 /4 hr, /4 hr, 0.1 /4 hr estradiol vaginal cream 0.01 % (0.1 /gram) (Minivelle) PA-HRM; QL (8 per 8 ; AGE (Max 64 Years) (Climara) PA-HRM; QL (4 per 8 ; AGE (Max 64 Years) (Estrace) estradiol vaginal tablet 10 mcg (Vagifem) QL (18 per 8 estradiol valerate intramuscular oil 0 (Delestrogen) /ml, 40 /ml 115

124 estradiol-norethindrone acet oral tablet , (Activella) PA-HRM; AGE (Max 64 Years) ESTRING VAGINAL RING MG 4 QL (1 per 84 (7.5 MCG /4 HOUR) estropipate oral tablet 0.75, 1.5, 3 PA-HRM; AGE (Max 64 Years) FEMRING VAGINAL RING QL (1 per 84 MG/4 HR, 0.1 MG/4 HR fyavolv oral tablet 1-5 -mcg PA-HRM; AGE (Max 64 Years) jinteli oral tablet 1-5 -mcg PA-HRM; AGE (Max 64 Years) lopreeza oral tablet , PA-HRM; AGE (Max 64 Years) MENEST ORAL TABLET 0.3 MG, 0.65 MG, 1.5 MG 4 PA-HRM; AGE (Max 64 Years) mimvey lo oral tablet PA-HRM; AGE (Max 64 Years) mimvey oral tablet PA-HRM; AGE (Max 64 Years) norethindrone ac-eth estradiol oral tablet mcg (Femhrt Low Dose) PA-HRM; AGE (Max 64 Years) norethindrone ac-eth estradiol oral tablet 1-5 -mcg (Fyavolv) PA-HRM; AGE (Max 64 Years) PREMARIN INJECTION RECON 3 SOLN 5 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.65 MG, 0.9 MG, 1.5 MG 3 PA-HRM; AGE (Max 64 Years) PREMARIN VAGINAL CREAM MG/GRAM PREMPHASE ORAL TABLET 0.65 MG (14)/ 0.65MG-5MG(14) 3 PA-HRM; AGE (Max 64 Years) PREMPRO ORAL TABLET MG, MG, MG, 3 PA-HRM; AGE (Max 64 Years) MG raloxifene oral tablet 60 (Evista) yuvafem vaginal tablet 10 mcg QL (18 per 8 Glucocorticoids/Mineralocorticoids a-hydrocort injection recon soln 100 betamethasone acet,sod phos injection suspension 6 /ml (Celestone Soluspan) 116

125 cortisone oral tablet 5 PA BvD dexamethasone oral elixir 0.5 /5 ml PA BvD dexamethasone oral tablet 0.5, 0.75 (Decadron) 1 PA BvD; GC, 4 dexamethasone oral tablet 1, PA BvD; GC dexamethasone oral tablet PA BvD dexamethasone oral tablet 6 (Decadron) PA BvD dexamethasone sodium phosphate injection solution 10 /ml, 4 /ml EMFLAZA ORAL SUSPENSION.75 MG/ML 5 PA; NDS; QL (39 per 30 EMFLAZA ORAL TABLET 18 MG 5 PA; NDS; QL (30 per 30 EMFLAZA ORAL TABLET 30 MG, 36 MG, 6 MG 5 PA; NDS; QL (60 per 30 fludrocortisone oral tablet 0.1 hydrocortisone oral tablet 10, 0, (Cortef) PA BvD 5 KENALOG INJECTION 4 SUSPENSION 10 MG/ML, 40 MG/ML methylprednisolone acetate injection (Depo-Medrol) suspension 40 /ml, 80 /ml methylprednisolone oral tablet 16, 3 (Medrol) PA BvD, 4, 8 methylprednisolone oral tablets,dose pack (Medrol (Pak)) PA BvD 4 methylprednisolone sodium succ injection recon soln 15, 40 methylprednisolone sodium succ (Solu-Medrol) intravenous recon soln 1,000 prednisolone 15 /5 ml soln a/f, d/f 15 PA BvD /5 ml (3 /ml) prednisolone oral solution 15 /5 ml PA BvD prednisolone sodium phosphate oral PA BvD solution 5 /5 ml (5 /ml) prednisolone sodium phosphate oral (Pediapred) PA BvD solution 5 base/5 ml (6.7 /5 ml) prednisone 10 tablet 10 1 PA BvD; GC prednisone oral solution 5 /5 ml PA BvD prednisone oral tablet 1 PA BvD 117

126 prednisone oral tablet 10,.5, 5 1 PA BvD; GC, 50 prednisone oral tablet 0 (Deltasone) 1 PA BvD; GC prednisone oral tablets,dose pack 10, PA BvD 10 (48 pack), 5, 5 (48 pack) SOLU-CORTEF (PF) INJECTION 4 RECON SOLN 1,000 MG/8 ML, 100 MG/ ML, 50 MG/ ML, 500 MG/4 ML triamcinolone acetonide injection (Kenalog) suspension 40 /ml Pituitary desmopressin 10 mcg/0.1 ml spr 10 (DDAVP) mcg/spray (0.1 ml) desmopressin injection solution 4 mcg/ml (DDAVP) desmopressin nasal solution 0.1 /ml (DDAVP) (refrigerate) desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1, 0. (DDAVP) GENOTROPIN MINIQUICK 4 PA SUBCUTANEOUS SYRINGE 0. MG/0.5 ML GENOTROPIN MINIQUICK 5 PA; NDS SUBCUTANEOUS SYRINGE 0.4 MG/0.5 ML, 0.6 MG/0.5 ML, 0.8 MG/0.5 ML, 1 MG/0.5 ML, 1. MG/0.5 ML, 1.4 MG/0.5 ML, 1.6 MG/0.5 ML, 1.8 MG/0.5 ML, MG/0.5 ML GENOTROPIN SUBCUTANEOUS 5 PA; NDS CARTRIDGE 1 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML) HUMATROPE INJECTION 5 PA; NDS CARTRIDGE 1 MG (36 UNIT), 4 MG (7 UNIT), 6 MG (18 UNIT) HUMATROPE INJECTION RECON 5 PA; NDS SOLN 5 (15 UNIT) MG INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML 118

127 LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.5 MG, 15 MG NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 30 MG/3 ML (10 MG/ML) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 5 MG/1.5 ML (3.3 MG/ML) NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/ ML (5 MG/ML), 0 MG/ ML (10 MG/ML), 5 MG/ ML (.5 MG/ML) octreotide acet 100 mcg/ml syr outer,single-dose, mcg/ml (1 ml) octreotide acet 50 mcg/ml syr outer,single-dose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml octreotide acetate injection solution 00 mcg/ml OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG SAIZEN CLICK.EASY SUBCUTANEOUS CARTRIDGE 8.8 MG/1.51 ML (FINAL CONC.) SAIZEN SUBCUTANEOUS RECON SOLN 5 MG, 8.8 MG 5 PA; NDS 4 PA 5 PA; NDS (Sandostatin) (Sandostatin) (Sandostatin) 5 PA; NDS 5 PA; NDS 5 PA; NDS 5 PA; NDS 119

128 SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 0 MG, 30 MG SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 10 MG/0.5 ML, 60 MG/0. ML, 90 MG/0.3 ML SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 0 MG, 5 MG, 30 MG STIMATE NASAL SPRAY,NON- AEROSOL 150 MCG/SPRAY (0.1 ML) SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) SYNAREL NASAL SPRAY,NON- AEROSOL MG/ML TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 MG ZOMACTON SUBCUTANEOUS RECON SOLN 10 MG ZOMACTON SUBCUTANEOUS RECON SOLN 5 MG ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG Progestins DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML hydroxyprogesterone caproate intramuscular oil 50 /ml medroxyprogesterone intramuscular suspension 150 /ml 5 PA; NDS ; QL (60 per 30 ; QL (1 per 8 4 ; QL (1 per 360 ; QL (1 per PA; NDS 4 PA 5 PA; NDS 4 QL (10 per 8 PA NSO (Depo-Provera) QL (1 per 84 10

129 medroxyprogesterone intramuscular (Depo-Provera) QL (1 per 84 syringe 150 /ml medroxyprogesterone oral tablet 10, (Provera) 1 GC.5, 5 megestrol oral suspension 400 /10 ml (40 /ml) PA-HRM; AGE (Max 64 Years) norethindrone acetate oral tablet 5 (Aygestin) progesterone in oil intramuscular oil 50 /ml progesterone micronized oral capsule 100 (Prometrium), 00 Thyroid And Antithyroid Agents levothyroxine intravenous recon soln 100 mcg, 00 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 11 (Levo-T) 1 GC mcg, 15 mcg, 137 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine intravenous solution 10 mcg/ml (Triostat) liothyronine oral tablet 5 mcg, 5 mcg, 50 (Cytomel) mcg methimazole oral tablet 10 (Tapazole) methimazole oral tablet 5 (Tapazole) 1 GC propylthiouracil oral tablet 50 Immunological Agents Immunological Agents ACTEMRA INTRAVENOUS 5 PA; NDS SOLUTION 00 MG/10 ML (0 MG/ML), 400 MG/0 ML (0 MG/ML), 80 MG/4 ML (0 MG/ML) ACTEMRA SUBCUTANEOUS 5 PA; NDS SYRINGE 16 MG/0.9 ML ARCALYST SUBCUTANEOUS RECON SOLN 0 MG ASTAGRAF XL ORAL 4 PA BvD CAPSULE,EXTENDED RELEASE 4HR 0.5 MG, 1 MG, 5 MG azathioprine oral tablet 50 (Imuran) PA BvD azathioprine sodium injection recon soln 100 PA BvD 11

130 CARIMUNE NF NANOFILTERED 5 PA BvD; NDS INTRAVENOUS RECON SOLN 1 GRAM, 3 GRAM, 6 GRAM CIMZIA POWDER FOR RECONST 5 PA; NDS SUBCUTANEOUS KIT 400 MG (00 MG X VIALS) CIMZIA SUBCUTANEOUS 5 PA; NDS SYRINGE KIT 400 MG/ ML (00 MG/ML X ) cyclosporine intravenous solution 50 (Sandimmune) PA BvD /5 ml cyclosporine modified oral capsule 100 (Gengraf) PA BvD, 5, 50 cyclosporine modified oral solution 100 (Gengraf) PA BvD /ml cyclosporine oral capsule 100, 5 (Sandimmune) PA BvD ENBREL SUBCUTANEOUS RECON 5 PA; NDS SOLN 5 MG (1 ML) ENBREL SUBCUTANEOUS 5 PA; NDS SYRINGE 5 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK 5 PA; NDS SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET 4 PA BvD EXTENDED RELEASE 4 HR 0.75 MG, 1 MG, 4 MG FLEBOGAMMA DIF 5 PA BvD; NDS INTRAVENOUS SOLUTION 10 %, 5 % GAMASTAN S/D 3 PA BvD INTRAMUSCULAR SOLUTION % RANGE, % RANGE (10 ML), % RANGE ( ML) GAMMAGARD LIQUID 5 PA BvD; NDS INJECTION SOLUTION 10 % GAMMAGARD S-D (IGA < 1 5 PA BvD; NDS MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % 5 PA BvD; NDS 1

131 GAMMAPLEX INTRAVENOUS 5 PA BvD; NDS SOLUTION 10 %, 10 % (100 ML), 10 % (00 ML) GAMUNEX INTRAVENOUS 5 PA BvD; NDS SOLUTION 10 % GAMUNEX-C INJECTION 5 PA BvD; NDS SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %),.5 GRAM/5 ML (10 %), 0 GRAM/00 ML (10 %), 40 GRAM/400 ML (10 %), 5 GRAM/50 ML (10 %) gengraf oral capsule 100, 5, 50 PA BvD gengraf oral solution 100 /ml PA BvD HUMIRA PEDIATRIC CROHN'S 5 PA; NDS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML, 40 MG/0.8 ML (6 PACK) HUMIRA PEN CROHN'S-UC-HS 5 PA; NDS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS 5 PA; NDS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS 5 PA; NDS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS 5 PA; NDS SYRINGE KIT 10 MG/0. ML, 0 MG/0.4 ML, 40 MG/0.8 ML HYPERRAB S/D (PF) 4 INTRAMUSCULAR SOLUTION 150 UNIT/ML, 150 UNIT/ML (10 ML) HYQVIA SUBCUTANEOUS 5 PA BvD; NDS SOLUTION 10 GRAM /100 ML (10 %),.5 GRAM /5 ML (10 %), 0 GRAM /00 ML (10 %), 30 GRAM /300 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 180 MG/1. ML (150 MG/ML) 5 PA; NDS 13

132 ILARIS (PF) SUBCUTANEOUS 5 PA; NDS SOLUTION 150 MG/ML IMOGAM RABIES-HT (PF) 4 INTRAMUSCULAR SOLUTION 150 UNIT/ML INFLECTRA INTRAVENOUS 5 PA; NDS RECON SOLN 100 MG KEVZARA SUBCUTANEOUS SYRINGE 150 MG/1.14 ML, 00 5 PA; NDS; QL (.8 per 8 MG/1.14 ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML 5 PA; NDS; QL (18.76 per 8 leflunomide oral tablet 10, 0 (Arava) mycophenolate mofetil hcl intravenous (CellCept Intravenous) PA BvD recon soln 500 mycophenolate mofetil oral capsule 50 (CellCept) PA BvD mycophenolate mofetil oral suspension for reconstitution 00 /ml (CellCept) 5 PA BvD; NDS mycophenolate mofetil oral tablet 500 (CellCept) PA BvD mycophenolate sodium oral (Myfortic) PA BvD tablet,delayed release (dr/ec) 180, 360 NULOJIX INTRAVENOUS RECON 5 PA BvD; NDS SOLN 50 MG OCTAGAM INTRAVENOUS 5 PA BvD; NDS SOLUTION 10 %, 5 % ORENCIA (WITH MALTOSE) 5 PA; NDS INTRAVENOUS RECON SOLN 50 MG ORENCIA CLICKJECT 5 PA; NDS SUBCUTANEOUS AUTO- INJECTOR 15 MG/ML ORENCIA SUBCUTANEOUS 5 PA; NDS SYRINGE 15 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML OTEZLA ORAL TABLET 30 MG 5 PA; NDS; QL (60 per 30 14

133 OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-0 MG (4)-30 MG (47), 10 MG (4)-0 MG (4)-30 MG(19) OTREXUP (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.4 ML, 1.5 MG/0.4 ML, 15 MG/0.4 ML, 17.5 MG/0.4 ML, 0 MG/0.4 ML,.5 MG/0.4 ML, 5 MG/0.4 ML PRIVIGEN INTRAVENOUS SOLUTION 10 % PROGRAF INTRAVENOUS SOLUTION 5 MG/ML RAPAMUNE ORAL SOLUTION 1 MG/ML RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0. ML, 1.5 MG/0.5 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 0 MG/0.4 ML,.5 MG/0.45 ML, 5 MG/0.5 ML, 7.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML REMICADE INTRAVENOUS RECON SOLN 100 MG 5 PA; NDS; QL (60 per PA BvD; NDS 4 PA BvD 5 PA BvD; NDS 3 5 PA; NDS RIDAURA ORAL CAPSULE 3 MG SIMPONI ARIA INTRAVENOUS 5 PA; NDS SOLUTION 1.5 MG/ML SIMPONI SUBCUTANEOUS PEN 5 PA; NDS INJECTOR 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS 5 PA; NDS SYRINGE 100 MG/ML, 50 MG/0.5 ML sirolimus oral tablet 0.5, 1 (Rapamune) PA BvD sirolimus oral tablet (Rapamune) 5 PA BvD; NDS STELARA INTRAVENOUS 5 PA; NDS SOLUTION 130 MG/6 ML STELARA SUBCUTANEOUS 5 PA; NDS SOLUTION 45 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML 5 PA; NDS 15

134 tacrolimus oral capsule 0.5, 1, 5 (Prograf) PA BvD TYSABRI INTRAVENOUS SOLUTION 300 MG/15 ML 5 PA; LA; NDS; QL (15 per 8 XELJANZ ORAL TABLET 5 MG 5 PA; NDS; QL (60 per 30 XELJANZ XR ORAL TABLET EXTENDED RELEASE 4 HR 11 5 PA; NDS; QL (30 per 30 MG ZORTRESS ORAL TABLET PA BvD; NDS MG, 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) INTRAMUSCULAR 6 GC RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP 6 GC ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION LF-( MCG)-5LF/0.5 ML ADACEL(TDAP 6 GC ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE LF- ( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) 3 PA BvD PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR 6 GC SYRINGE MCG/0.5 ML BOOSTRIX TDAP 6 GC INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML BOOSTRIX TDAP 6 GC INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML CERVARIX VACCINE (PF) 6 GC INTRAMUSCULAR SYRINGE 0-0 MCG/0.5 ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML 6 GC 16

135 ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML 6 PA BvD; GC 6 PA BvD; GC 6 PA BvD; GC 6 PA BvD; GC 6 GC; QL (1.5 per GC; QL (1.5 per GC; QL (1.5 per GC 6 GC 6 GC 6 PA BvD; GC 6 GC 6 GC 6 GC 6 GC 17

136 KINRIX (PF) INTRAMUSCULAR SUSPENSION 5 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 5 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN 5-.5 MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-1,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-5LF-5 MCG- 10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-0 MCG-5 LF/0.5 ML PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 6 GC 6 GC 6 GC 6 GC 6 GC 6 GC 6 GC 6 GC 6 GC 6 GC 6 GC 6 GC 6 GC 18

137 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB 5 MCG/0.5 ML VL OUTER, P/F, SDV 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION ML SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5- LF UNIT/0.5 ML TENIVAC VIAL L/F, P/F, OUTER, SUV 5 LF UNIT- LF UNIT/0.5ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-5 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION - LF UNIT/0.5 ML TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 70 ELISA UNIT -0 MCG/ML 6 GC 6 PA BvD; GC 6 PA BvD; GC 6 PA BvD; GC 6 PA BvD; GC 6 GC 6 GC 6 GC; QL ( per GC 6 GC 6 GC 6 GC 3 PA BvD 6 GC 6 GC 19

138 TWINRIX (PF) INTRAMUSCULAR SYRINGE 70 ELISA UNIT -0 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 5 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 5 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 5 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents 6 GC 6 GC 6 GC 6 GC 6 GC 6 GC; QL ( per GC 6 GC; QL (1 per 365 alosetron oral tablet 0.5, 1 (Lotronex) APRISO ORAL 3 CAPSULE,EXTENDED RELEASE 4HR GRAM balsalazide oral capsule 750 (Colazal) budesonide oral (Entocort EC) capsule,delayed,extend.release 3 CANASA RECTAL SUPPOSITORY 3 1,000 MG colocort rectal enema 100 /60 ml DELZICOL ORAL CAPSULE (WITH 3 DEL REL TABLETS) 400 MG DIPENTUM ORAL CAPSULE 50 MG 5 ST; NDS 130

139 hydrocortisone rectal enema 100 /60 (Colocort) ml LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC) 1. GRAM mesalamine oral tablet,delayed release (Asacol HD) (dr/ec) 800 sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 500 UCERIS RECTAL FOAM 3 MG/ACTUATION Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.5 % LACTATED RINGERS 3 IRRIGATION SOLUTION ringer's irrigation solution sodium chloride irrigation solution 0.9 % (Sterile Saline) sorbitol irrigation solution 3 %, 3.3 % sorbitol-mannitol urethral solution g/100 ml water for irrigation, sterile irrigation (Curity Sterile Water) solution Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 /75 ml QL (300 per 8 alendronate oral tablet 10, 5 1 GC alendronate oral tablet 35 1 GC; QL (4 per 8 alendronate oral tablet 40 alendronate oral tablet 70 (Fosamax) 1 GC; QL (4 per 8 calcitonin (salmon) nasal spray,nonaerosol QL (3.7 per 8 00 unit/actuation calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule 0.5 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) doxercalciferol intravenous solution 4 (Hectorol) mcg/ ml doxercalciferol oral capsule 0.5 mcg, 1 mcg,.5 mcg (Hectorol) 131

140 etidronate disodium oral tablet 00, 400 FORTEO SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE PA; QL (.4 per 8 MCG/.4 ML ibandronate intravenous solution 3 /3 QL (3 per 84 ml ibandronate intravenous syringe 3 /3 (Boniva) QL (3 per 84 ml ibandronate oral tablet 150 (Boniva) QL (1 per 8 MIACALCIN INJECTION 3 SOLUTION 00 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 5 5 PA; NDS; QL ( per 8 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous recon soln 30, 90 pamidronate intravenous solution 30 /10 ml (3 /ml), 60 /10 ml (6 /ml), 90 /10 ml (9 /ml) PARICALCITOL 10 MCG/ ML VIAL MDV,INNER,LATEX-FREE 5 MCG/ML paricalcitol hemodialysis port injection solution mcg/ml paricalcitol intravenous solution mcg/ml (Zemplar) PARICALCITOL INTRAVENOUS (Zemplar) SOLUTION 5 MCG/ML paricalcitol oral capsule 1 mcg, mcg (Zemplar) paricalcitol oral capsule 4 mcg PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML 3 QL (1 per 180 RAYALDEE ORAL CAPSULE,EXTENDED RELEASE 4 HR 30 MCG ; QL (60 per 30 risedronate oral tablet 150 (Actonel) QL (1 per 8 risedronate oral tablet 30, 5 (Actonel) QL (30 per 30 risedronate oral tablet 35 (Actonel) QL (4 per 8 risedronate oral tablet 35 (1 pack), 35 (4 pack) QL (4 per 8 13

141 SENSIPAR ORAL TABLET 30 MG 3 QL (60 per 30 SENSIPAR ORAL TABLET 60 MG ; QL (60 per 30 SENSIPAR ORAL TABLET 90 MG ; QL (10 per 30 TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,10 MCG/1.56 ML) XGEVA SUBCUTANEOUS SOLUTION 10 MG/1.7 ML (70 MG/ML) zoledronic acid intravenous recon soln 4 zoledronic acid intravenous solution 4 /5 ml zoledronic acid-mannitol-water intravenous piggyback 5 /100 ml zoledronic ac-mannitol-0.9nacl intravenous piggyback 4 /100 ml ZOMETA INTRAVENOUS PIGGYBACK 4 MG/100 ML Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTHAR H.P. INJECTION GEL 80 UNIT/ML ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML amifostine crystalline intravenous recon soln 500 BENLYSTA INTRAVENOUS RECON SOLN 10 MG, 400 MG BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 00 MG/ML BENLYSTA SUBCUTANEOUS SYRINGE 00 MG/ML BOTOX INJECTION RECON SOLN 100 UNIT BOTOX INJECTION RECON SOLN 00 UNIT (Zometa) 3 PA; QL (1.56 per 30 5 PA; NDS (Reclast) QL (100 per 300 (Ethyol) 5 PA; NDS; QL (35 per 8 5 PA; NDS 5 PA; NDS; QL (4 per 8 5 PA; NDS; QL (4 per 8 4 PA; QL (4 per 90 4 PA; QL (1 per

142 CETYLEV ORAL TABLET, 4 EFFERVESCENT.5 GRAM, 500 MG CYSTADANE ORAL POWDER 1 GRAM/1.7 ML dexrazoxane hcl intravenous recon soln (Zinecard (as HCl)) 50, 500 droperidol injection solution.5 /ml ELMIRON ORAL CAPSULE 100 MG 4 ENDARI ORAL POWDER IN PACKET 5 GRAM 5 PA; NDS; QL (180 per 30 ergoloid oral tablet 1 EXONDYS 51 INTRAVENOUS 5 PA; LA; NDS SOLUTION 50 MG/ML, 50 MG/ML (10 ML) fomepizole intravenous solution 1 gram/ml guanidine oral tablet 15 hydroxyzine pamoate oral capsule 100 PA-HRM; AGE (Max 64 Years) hydroxyzine pamoate oral capsule 5, 50 (Vistaril) PA-HRM; AGE (Max 64 Years) KEVEYIS ORAL TABLET 50 MG 5 PA; NDS; QL (10 per 30 leucovorin calcium 100 vial sdv,p/f,latex-free 100 leucovorin calcium 00 vial latex-free, p/f, sdv 00 leucovorin calcium injection recon soln 100, 350, 50 leucovorin calcium injection solution 500 /50 ml leucovorin calcium oral tablet 10, 15, 5, 5 levocarnitine (with sugar) oral solution (Carnitor) 100 /ml levocarnitine intravenous solution 00 (Carnitor) /ml levocarnitine oral tablet 330 (Carnitor) 134

143 LEVOLEUCOVORIN 4 INTRAVENOUS RECON SOLN 175 MG levoleucovorin intravenous recon soln 50 (Fusilev) mesna intravenous solution 100 /ml (Mesnex) MESNEX ORAL TABLET 400 MG MESTINON ORAL SYRUP 60 MG/5 ML methylergonovine injection solution 0. /ml (1 ml) MYOBLOC INTRAMUSCULAR 4 PA; QL ( per 90 SOLUTION 10,000 UNIT/ ML MYOBLOC INTRAMUSCULAR SOLUTION,500 UNIT/0.5 ML 4 PA; QL (0.5 per 90 MYOBLOC INTRAMUSCULAR 4 PA; QL (1 per 90 SOLUTION 5,000 UNIT/ML NPLATE SUBCUTANEOUS RECON SOLN 50 MCG, 500 MCG 5 PA; NDS; QL (8 per 8 PROGLYCEM ORAL SUSPENSION 4 50 MG/ML pyridostigmine bromide oral tablet 60 (Mestinon) pyridostigmine bromide oral tablet (Mestinon Timespan) extended release 180 RENFLEXIS INTRAVENOUS 5 PA; NDS RECON SOLN 100 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 00 MG, 50 MG 5 PA NSO; NDS; QL (60 per 30 THIOLA ORAL TABLET 100 MG TOTECT INTRAVENOUS RECON SOLN 500 MG TYBOST ORAL TABLET 150 MG 3 QL (30 per 30 VISTOGARD ORAL GRANULES IN PACKET 10 GRAM ; QL (4 per 14 XURIDEN ORAL GRANULES IN PACKET GRAM Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 15, 50 5 PA; NDS; QL (10 per

144 acetazolamide sodium injection recon soln 500 ALPHAGAN P OPHTHALMIC 3 (EYE) DROPS 0.1 % AZOPT OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 1 % betaxolol ophthalmic (eye) drops 0.5 % bimatoprost ophthalmic (eye) drops 0.03 % brimonidine ophthalmic (eye) drops 0.15 % (Alphagan P) brimonidine ophthalmic (eye) drops 0. 1 GC % carteolol ophthalmic (eye) drops 1 % 1 GC COMBIGAN OPHTHALMIC (EYE) DROPS % 3 dorzolamide ophthalmic (eye) drops % (Trusopt) dorzolamide-timolol ophthalmic (eye) drops /ml (Cosopt) latanoprost ophthalmic (eye) drops (Xalatan) % levobunolol ophthalmic (eye) drops 0.5 % (Betagan) LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % 3 QL (.5 per 5 methazolamide oral tablet 5 (Neptazane) methazolamide oral tablet 50 metipranolol ophthalmic (eye) drops 0.3 % PHOSPHOLINE IODIDE 3 OPHTHALMIC (EYE) DROPS 0.15 % pilocarpine hcl ophthalmic (eye) drops 1 (Isopto Carpine) %, %, 4 % SIMBRINZA OPHTHALMIC (EYE) 3 DROPS,SUSPENSION 1-0. % timolol maleate ophthalmic (eye) drops (Timoptic) 1 GC 0.5 %, 0.5 % timolol maleate ophthalmic (eye) drops, once daily 0.5 % (Istalol) 1 GC 136

145 timolol maleate ophthalmic (eye) gel forming solution 0.5 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) DROPS % ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE % Replacement Preparations Replacement Preparations calcium chloride intravenous solution 100 /ml (10 %) calcium chloride intravenous syringe 100 /ml (10 %) d10 %-0.45 % sodium chloride intravenous parenteral solution d.5 %-0.45 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.45 % sodium chloride intravenous parenteral solution dextrose 10 % and 0. % nacl intravenous parenteral solution dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0. % sod chloride intravenous parenteral solution dextrose 5%-0.3 % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution 5-0. % electrolyte-48 in d5w intravenous parenteral solution IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % (Timoptic-XE) 3 QL (.5 per 5 3 QL (30 per

146 ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq klor-con m0 oral tablet,er particles/crystals 0 meq klor-con sprinkle oral capsule, extended release 10 meq, 8 meq magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml magnesium sulfate in water intravenous parenteral solution 0 gram/500 ml (4 %), 40 gram/1,000 ml (4 %) magnesium sulfate in water intravenous piggyback gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % potassium acetate intravenous solution meq/ml potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l

147 potassium chlorid-d5-0.45%nacl intravenous parenteral solution 0 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 0 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride intravenous piggyback 10 meq/100 ml, 10 meq/50 ml, 0 meq/100 ml, 0 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride intravenous solution meq/ml potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 0 meq/15 ml, 40 meq/15 ml potassium chloride oral tablet extended release 10 meq, 0 meq, 8 meq potassium chloride oral tablet,er particles/crystals 10 meq potassium chloride oral tablet,er particles/crystals 0 meq potassium chloride-0.45 % nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.%nacl intravenous parenteral solution 10 meq/l, 0 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium citrate oral tablet extended release 10 meq (1,080 ) potassium citrate oral tablet extended release 15 meq (Klor-Con Sprinkle) (K-Tab) (Klor-Con M10) (Klor-Con M0) (Urocit-K 10) (Urocit-K 15) 139

148 potassium citrate oral tablet extended (Urocit-K 5) release 5 meq (540 ) potassium citrate-citric acid oral packet (Cytra K Crystals) 3,300-1,00 ringer's intravenous parenteral solution sodium acetate intravenous solution meq/ml sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.9 % intravenous parenteral solution sodium chloride 0.9 % intravenous piggyback sodium chloride 100 meq/40 ml 5's, sdv.5 meq/ml sodium chloride intravenous parenteral solution.5 meq/ml sodium lactate intravenous solution 5 meq/ml sodium phosphate intravenous solution 3 mmol/ml TPN ELECTROLYTES II IV SOLN 4 5'S,0ML/50ML FTV MEQ/0 ML TPN ELECTROLYTES 4 INTRAVENOUS SOLUTION MEQ/0 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION 3 QL (60 per 30 BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, 30-1 MCG/ACTUATION, 45-1 MCG/ACTUATION 3 QL (1 per 8 140

149 ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 00 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, 00-5 MCG/DOSE budesonide inhalation suspension for nebulization 0.5 / ml, 0.5 / ml, 1 / ml DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, 00-5 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION QVAR INHALATION AEROSOL 80 MCG/ACTUATION SYMBICORT MCG INHALER 60 INHALATIONS MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION 3 QL (30 per 30 3 QL (60 per 30 (Pulmicort) PA BvD 3 QL (13 per 8 3 QL (60 per 30 3 QL (10 per 30 3 QL (1 per 8 3 QL (4 per 8 3 QL (1. per 8 3 QL (17.4 per 5 3 QL (17.4 per 5 3 QL (1 per 5 3 QL (11 per 5 141

150 Antileukotrienes montelukast oral granules in packet 4 (Singulair) montelukast oral tablet 10 (Singulair) 1 GC montelukast oral tablet,chewable 4, 5 (Singulair) zafirlukast oral tablet 10, 0 (Accolate) Bronchodilators albuterol sulfate inhalation solution for PA BvD nebulization 0.63 /3 ml, 1.5 /3 ml,.5 /3 ml (0.083 %), 5 /ml albuterol sulfate oral syrup /5 ml albuterol sulfate oral tablet, 4 albuterol sulfate oral tablet extended release 1 hr 4, 8 ANORO ELLIPTA INHALATION 3 QL (60 per 30 BLISTER WITH DEVICE MCG/ACTUATION ATROVENT HFA INHALATION 3 QL (5.8 per 8 HFA AEROSOL INHALER 17 MCG/ACTUATION COMBIVENT RESPIMAT 3 QL (8 per 30 INHALATION MIST MCG/ACTUATION elixophyllin oral elixir 80 /15 ml FORADIL AEROLIZER 3 QL (60 per 30 INHALATION CAPSULE, W/INHALATION DEVICE 1 MCG INCRUSE ELLIPTA INHALATION 3 BLISTER WITH DEVICE 6.5 MCG/ACTUATION ipratropium bromide inhalation solution PA BvD 0.0 % levalbuterol tartrate inhalation hfa (Xopenex HFA) QL (30 per 30 aerosol inhaler 45 mcg/actuation metaproterenol oral syrup 10 /5 ml 1 GC metaproterenol oral tablet 10, 0 PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION 3 14

151 PROAIR RESPICLICK 3 INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION 3 QL (60 per 30 BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION 3 MIST 1.5 MCG/ACTUATION,.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER 3 INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT 3 QL (4 per 8 INHALATION MIST.5-.5 MCG/ACTUATION STRIVERDI RESPIMAT 3 QL (4 per 8 INHALATION MIST.5 MCG/ACTUATION terbutaline oral tablet.5, 5 terbutaline subcutaneous solution 1 /ml theophylline in dextrose 5 % intravenous parenteral solution 00 /100 ml, 00 /50 ml, 400 /50 ml, 400 /500 ml, 800 /50 ml theophylline oral solution 80 /15 ml theophylline oral tablet extended release (Theochron) 1 hr 100, 00, 300 theophylline oral tablet extended release 1 hr 450 theophylline oral tablet extended release 4 hr 400, 600 TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG 3 VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION 4 ST 143

152 Respiratory Tract Agents, Other acetylcysteine intravenous solution 00 (Acetadote) PA BvD /ml (0 %) acetylcysteine solution 100 /ml (10 PA BvD %), 00 /ml (0 %) CINQAIR INTRAVENOUS 5 PA; NDS SOLUTION 10 MG/ML cromolyn inhalation solution for PA BvD nebulization 0 / ml DALIRESP ORAL TABLET QL (30 per 30 MCG ESBRIET ORAL CAPSULE 67 MG 5 PA; NDS; QL (70 per 30 ESBRIET ORAL TABLET 67 MG 5 PA; NDS; QL (70 per 30 ESBRIET ORAL TABLET 801 MG 5 PA; NDS; QL (90 per 30 FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML 5 PA; NDS; QL (1 per 8 KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG 5 PA; NDS; QL (60 per 30 KALYDECO ORAL TABLET 150 MG 5 PA; NDS; QL (60 per 30 NUCALA SUBCUTANEOUS RECON SOLN 100 MG 5 PA; LA; NDS; QL (3 per 8 OFEV ORAL CAPSULE 100 MG, 150 MG 5 PA; NDS; QL (60 per 30 ORKAMBI ORAL TABLET MG, MG 5 PA; NDS; QL (10 per 30 PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG SYMDEKO ORAL TABLETS, SEQUENTIAL MG (D)/ 150 MG (N) 5 PA; NDS; QL (56 per 8 XOLAIR SUBCUTANEOUS RECON 5 PA; NDS SOLN 150 MG Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10, 0 144

153 carisoprodol oral tablet 50, 350 (Soma) PA-HRM; QL (10 per 30 ; AGE (Max 64 Years) chlorzoxazone oral tablet 500 PA-HRM; AGE (Max 64 Years) cyclobenzaprine oral tablet 10, 5 PA-HRM; AGE (Max 64 Years) cyclobenzaprine oral tablet 7.5 (Fexmid) PA-HRM; AGE (Max 64 Years) dantrolene oral capsule 100 dantrolene oral capsule 5, 50 (Dantrium) methocarbamol oral tablet 500 (Robaxin) PA-HRM; AGE (Max 64 Years) methocarbamol oral tablet 750 (Robaxin-750) PA-HRM; AGE (Max 64 Years) revonto intravenous recon soln 0 tizanidine oral capsule, 4, 6 (Zanaflex) tizanidine oral tablet tizanidine oral tablet 4 (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150, 00, (Nuvigil) 50, 50 BELSOMRA ORAL TABLET 10 MG, 3 QL (30 per MG, 0 MG, 5 MG eszopiclone oral tablet 1,, 3 (Lunesta) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) HETLIOZ ORAL CAPSULE 0 MG 5 PA; NDS; QL (30 per 30 SILENOR ORAL TABLET 3 MG, 6 MG 3 QL (30 per 30 XYREM ORAL SOLUTION 500 MG/ML 5 LA; NDS; QL (540 per

154 zaleplon oral capsule 10, 5 (Sonata) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 ; AGE (Max 64 Years) zolpidem oral tablet 10, 5 (Ambien) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) zolpidem oral tablet,ext release multiphase 1.5, 6.5 (Ambien CR) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 ; AGE (Max 64 Years) Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 0 MG 5 PA; NDS; QL (60 per 30 ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, MG,.5 MG CIALIS ORAL TABLET.5 MG, 5 MG epoprostenol (glycine) intravenous recon soln 0.5 epoprostenol (glycine) intravenous recon soln PA; NDS; QL (90 per 30 3 PA; QL (30 per 30 (Flolan) PA (Flolan) 5 PA; NDS 146

155 LETAIRIS ORAL TABLET 10 MG, 5 MG 5 PA; NDS; QL (30 per 30 OPSUMIT ORAL TABLET 10 MG 5 PA; NDS; QL (30 per 30 ORENITRAM ORAL TABLET 3 PA EXTENDED RELEASE 0.15 MG ORENITRAM ORAL TABLET 5 PA; NDS EXTENDED RELEASE 0.5 MG, 1 MG,.5 MG, 5 MG REMODULIN INJECTION 5 PA; NDS SOLUTION 1 MG/ML, 10 MG/ML,.5 MG/ML, 5 MG/ML sildenafil (antihypertensive) intravenous solution 10 /1.5 ml (Revatio) 5 PA; NDS; QL (37.5 per 1 day) sildenafil (antihypertensive) oral tablet 0 (Revatio) PA; QL (90 per 30 TRACLEER ORAL TABLET 15 MG, 6.5 MG 5 PA; LA; NDS; QL (60 per 30 TRACLEER ORAL TABLET FOR SUSPENSION 3 MG 5 PA; NDS; QL (11 per 8 TYVASO INHALATION SOLUTION 5 PA; NDS FOR NEBULIZATION 1.74 MG/.9 ML (0.6 MG/ML) UPTRAVI ORAL TABLET 1,000 MCG, 1,00 MCG, 1,400 MCG, 1,600 5 PA; NDS; QL (60 per 30 MCG, 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLET 00 MCG 5 PA; NDS; QL (40 per 30 UPTRAVI ORAL TABLETS,DOSE PACK 00 MCG (140)- 800 MCG (60) Vitamins And Minerals Vitamins And Minerals fluoride (sodium) oral tablet 1 (. sod. fluoride) pnv prenatal plus multivit tab s/f, glutenfree 7 iron- 1 5 PA; NDS; QL (400 per ALL RX PRENATAL VITAMINS COVERABLE UNDER PART D 147

156 prenatal vitamin plus low iron oral tablet 7 iron- 1 sodium fluoride 0.5 /ml drop d/f, s/f,gluten-free 0.5 (1.1 sod.fluorid)/ml 3 ALL RX PRENATAL VITAMINS COVERABLE UNDER PART D 148

157 abacavir...61 abacavir-lamivudine abacavir-lamivudine-zidovudine 61 ABELCET ABILIFY MAINTENA ABRAXANE...4 acamprosate acarbose acebutolol acetaminophen-codeine... 3 acetasol hc acetazolamide acetazolamide sodium acetic acid , 131 acetylcysteine acitretin ACTEMRA ACTHAR H.P ACTHIB (PF) ACTIMMUNE acyclovir... 66, 96 acyclovir sodium ADACEL(TDAP ADOLESN/ADULT)(PF)...16 ADAGEN...10 adapalene ADCIRCA adefovir ADEMPAS adriamycin...4 adrucil... 4 ADVAIR DISKUS ADVAIR HFA afeditab cr AFINITOR... 5 AFINITOR DISPERZ... 4 a-hydrocort AKTEN (PF) INDEX AKYNZEO ala-cort...99 ala-scalp ALBENZA albuterol sulfate alclometasone ALCOHOL PADS...96 ALCOHOL PREP PADS...96 ALDURAZYME ALECENSA... 5 alendronate alfuzosin ALIMTA... 5 ALINIA...54 ALIQOPA... 5 allopurinol alosetron ALPHAGAN P alprazolam...11 ALREX altavera (8) ALUNBRIG...5 alyacen 1/35 (8) alyacen 7/7/7 (8) amabelz amantadine hcl...55 AMBISOME amethia...90 amethia lo...89 amifostine crystalline amiloride... 8 amiloride-hydrochlorothiazide..8 AMINOSYN 10 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 %...70 AMINOSYN II 15 %...70 AMINOSYN II 7 %...70 AMINOSYN II 8.5 %...70 AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 %...70 AMINOSYN-HBC 7%...70 AMINOSYN-PF 10 %...71 AMINOSYN-PF 7 % (SULFITE-FREE)...71 AMINOSYN-RF 5. %...71 amiodarone...76 AMITIZA amitriptyline amitriptyline-chlordiazepoxide. 40 amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-olmesartan...81 amlodipine-valsartan...81 amlodipine-valsartan-hcthiazid.81 ammonium lactate...96 amoxapine amoxicil-clarithromy-lansopraz amoxicillin...1 amoxicillin-pot clavulanate... 1 amphotericin b ampicillin...1 ampicillin sodium... 1 ampicillin-sulbactam... 1 AMPYRA...86 ANADROL anagrelide...69 anastrozole... 5 ANDRODERM ANDROGEL...114, 115 I-1

158 androxy ANORO ELLIPTA APOKYN...55 apraclonidine aprepitant apri...90 APRISO APTIOM APTIVUS aranelle (8) ARCALYST...11 aripiprazole ARISTADA armodafinil ARNUITY ELLIPTA ascomp with codeine... 3 ashlyna aspirin-dipyridamole ASSURE ID INSULIN SAFETY...10 ASTAGRAF XL atazanavir...61 atenolol...77 atenolol-chlorthalidone...77 atomoxetine...86 atorvastatin atovaquone atovaquone-proguanil... 54, 55 ATRIPLA...61 atropine...35, 104 ATROVENT HFA AUBAGIO aubra AURYXIA AUSTEDO AVASTIN... 5 AVC VAGINAL aviane AVONEX AVONEX (WITH ALBUMIN)...86 azacitidine... 5 azathioprine azathioprine sodium azelastine azithromycin...19 AZOPT aztreonam...0 azurette (8) baciim...15 bacitracin... 15, 105 bacitracin-polymyxin b baclofen balsalazide balziva (8)...90 BANZEL BAVENCIO... 5 BAXDELA... BCG VACCINE, LIVE (PF) 16 BD INSULIN SYRINGE ULTRA-FINE...10 BD ULTRA-FINE NANO PEN NEEDLES bekyree (8)...90 BELBUCA... 3 BELEODAQ... 5 BELSOMRA benazepril benazepril-hydrochlorothiazide.75 BENDEKA... 5 BENLYSTA benznidazole benztropine BEPREVE BESPONSA...5 betamethasone acet,sod phos betamethasone dipropionate betamethasone valerate betamethasone, augmented...99 BETASERON betaxolol... 77, 136 bethanechol chloride BETHKIS...14 BEVYXXA...67 bexarotene...5 BEXSERO bicalutamide... 5 BICILLIN C-R... BICILLIN L-A... BIDIL BIKTARVY bimatoprost bisoprolol fumarate...77 bisoprolol-hydrochlorothiazide. 77 bleomycin... 5 bleph BLINCYTO...5 blisovi 4 fe...90 blisovi fe 1.5/30 (8)...90 blisovi fe 1/0 (8) BOOSTRIX TDAP...16 BORTEZOMIB...5 BOSULIF... 5, 6 BOTOX BREO ELLIPTA briellyn BRILINTA...69 brimonidine BRIVIACT... 35, 36 bromfenac bromocriptine BROMSITE budesonide...130, 141 bumetanide... 8 BUNAVAIL BUPHENYL buprenorphine...3 buprenorphine hcl...3, 10 buprenorphine-naloxone...10 I-

159 bupropion hcl bupropion hcl (smoking deter). 11 buspirone butalbital compound w/codeine...3 butalbital-acetaminop-caf-cod...3 butalbital-acetaminophen...3 butalbital-acetaminophen-caff...3 butalbital-aspirin-caffeine... 3, 4 butorphanol tartrate... 4 BUTRANS...4 BYSTOLIC...77 BYVALSON...77 cabergoline CABOMETYX...6 caffeine citrate... 86, 87 calcipotriene calcitonin (salmon) calcitrene calcitriol...96, 131 calcium acetate calcium chloride CALDOLOR...8 CALQUENCE... 6 camila...90 camrese camrese lo...90 CANASA CANCIDAS candesartan candesartan-hydrochlorothiazid74 capacet... 4 CAPASTAT... 5 CAPRELSA... 6 captopril captopril-hydrochlorothiazide...75 CARAFATE CARBAGLU carbamazepine carbidopa...55 carbidopa-levodopa... 55, 56 carbidopa-levodopa-entacapone 56 carbinoxamine maleate carboplatin... 6 CARIMUNE NF NANOFILTERED...1 carisoprodol carteolol cartia xt...78 carvedilol caspofungin...48 CAYSTON... 0 caziant (8) cefaclor...17 cefadroxil cefazolin cefazolin in 0.9% sod chloride...17 cefazolin in dextrose (iso-os) cefdinir...17, 18 cefditoren pivoxil CEFEPIME CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM...18 cefixime...18 cefotaxime...18 cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil...18 ceftazidime ceftibuten...18 ceftriaxone ceftriaxone in dextrose,iso-os cefuroxime axetil cefuroxime sodium cefuroxime-dextrose (iso-osm) 19 celecoxib... 8 CELONTIN cephalexin...19 CEPROTIN (BLUE BAR)...67 CERDELGA CEREZYME CERVARIX VACCINE (PF) CETYLEV cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX...11 CHANTIX STARTING MONTH BOX...11 chloramphenicol sod succinate..15 chlordiazepoxide hcl...1 chlorhexidine gluconate...96 chloroquine phosphate...55 chlorothiazide... 8 chlorothiazide sodium... 8 chlorpromazine chlorthalidone... 8 chlorzoxazone cholestyramine (with sugar) cholestyramine light...83 CIALIS ciclopirox...48 cidofovir cilostazol CILOXAN cimetidine cimetidine hcl CIMZIA... 1 CIMZIA POWDER FOR RECONST...1 CINQAIR CINRYZE CINVANTI CIPRODEX ciprofloxacin...3 ciprofloxacin (mixture)... 3 ciprofloxacin hcl...3, 105 I-3

160 ciprofloxacin in 5 % dextrose... 3 ciprofloxacin lactate... 3 citalopram cladribine...6 clarithromycin...19, 0 clemastine...50 CLENPIQ...11 CLEVIPREX...8 clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl...15 clindamycin phosphate... 15, 16, 51, 98 clindamycin-benzoyl peroxide.. 98 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE CLINIMIX.75%/D5W SULFIT FREE...71 CLINIMIX 4.5%/D10W SULF FREE...71 CLINIMIX 4.5%/D5W SULFIT FREE...71 CLINIMIX 4.5%-D0W SULF-FREE CLINIMIX 4.5%-D5W SULF-FREE CLINIMIX 5%- D0W(SULFITE-FREE) CLINIMIX E.75%/D10W SUL FREE CLINIMIX E.75%/D5W SULF FREE...71 CLINIMIX E 4.5%/D10W SUL FREE CLINIMIX E 4.5%/D5W SUL FREE... 7 CLINIMIX E 4.5%/D5W SULF FREE...7 CLINIMIX E 5%/D15W SULFIT FREE...7 CLINIMIX E 5%/D0W SULFIT FREE...7 CLINIMIX E 5%/D5W SULFIT FREE...7 CLINISOL SF 15 %... 7 clobetasol...99 clobetasol-emollient clocortolone pivalate clofarabine...6 clomipramine clonazepam...1 clonidine...73, 74 clonidine hcl... 73, 87 clopidogrel...69 clorazepate dipotassium... 1 clorpres...74 clotrimazole...49 clotrimazole-betamethasone clozapine...57, 58 COARTEM codeine sulfate... 4 COLCRYS colestipol colistin (colistimethate na) colocort COLY-MYCIN S COMBIGAN COMBIPATCH COMBIVENT RESPIMAT. 14 COMETRIQ...6 COMPLERA...61 compro CONDYLOX constulose COPAXONE CORLANOR cormax cortisone COSENTYX ( SYRINGES).96 COSENTYX PEN ( PENS).. 97 COTELLIC... 6 CREON CRIXIVAN cromolyn...104, 110, 144 cryselle (8)...90 CUPRIMINE cyclafem 1/35 (8) cyclafem 7/7/7 (8) cyclobenzaprine cyclopentolate cyclophosphamide... 6 CYCLOPHOSPHAMIDE... 6 CYCLOSET cyclosporine... 1 cyclosporine modified...1 cyproheptadine...50, 51 CYRAMZA...6 cyred CYSTADANE CYSTARAN d10 %-0.45 % sodium chloride 137 d.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride..137 DAKLINZA...65 DALIRESP danazol dantrolene dapsone...5 DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin DARAPRIM DARZALEX... 6 dasetta 1/35 (8)...90 dasetta 7/7/7 (8)...90 I-4

161 daysee...90 deblitane...90 decitabine... 6 deferoxamine delyla (8) DELZICOL demeclocycline...3 DEMSER DENAVIR DEPEN TITRATABS DEPO-PROVERA DESCOVY desipramine desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone desvenlafaxine succinate dexamethasone dexamethasone sodium phosphate , 117 DEXILANT dexmethylphenidate dexrazoxane hcl dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0. % nacl. 137 dextrose 10 % in water (d10w) 7 dextrose 0 % in water (d0w) 7 dextrose 5 % in water (d5w) 7 dextrose 40 % in water (d40w) 7 dextrose 5 % in ringer's... 7 dextrose 5 % in water (d5w)... 7 dextrose 5 %-lactated ringers. 137 dextrose 5%-0. % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) 7 dextrose 70 % in water (d70w) 7 dextrose with sodium chloride.137 DIASTAT...1 DIASTAT ACUDIAL... 1 diazepam... 1 diazepam intensol...1 diclofenac potassium...8 diclofenac sodium... 8, 97, 108 diclofenac-misoprostol... 8 dicloxacillin... dicyclomine didanosine...61 DIFICID... 0 diflorasone diflunisal...8 digitek digox...79, 80 digoxin DIGOXIN dihydroergotamine DILANTIN diltiazem hcl...78, 79 dilt-xr dimenhydrinate DIPENTUM diphenhydramine hcl diphenoxylate-atropine dipyridamole...70 disopyramide phosphate disulfiram divalproex...36 dobutamine dobutamine in d5w docetaxel... 6 dofetilide...76 donepezil...39 dopamine dopamine in 5 % dextrose...80 dorzolamide dorzolamide-timolol doxazosin doxepin...41 doxercalciferol doxorubicin...6 doxorubicin, peg-liposomal...7 doxy doxycycline hyclate...4 doxycycline monohydrate...4 dronabinol droperidol drospirenone-ethinyl estradiol.. 91 DROXIA...7 DUAVEE DUEXIS...8 DULERA duloxetine...41 DUPIXENT DUREZOL dutasteride dutasteride-tamsulosin DYRENIUM... 8 e.e.s E.E.S. GRANULES... 0 econazole...49 EDARBI...74 EDARBYCLOR EDURANT... 6 efavirenz... 6 EFFIENT ELAPRASE electrolyte-48 in d5w ELIDEL ELIGARD...7 ELIGARD (3 MONTH)... 7 ELIGARD (4 MONTH)... 7 ELIGARD (6 MONTH)... 7 elinest eliphos ELIQUIS I-5

162 ELITEK elixophyllin ELLA...91 ELMIRON EMBEDA...4 EMCYT...7 EMEND EMEND (FOSAPREPITANT) EMFLAZA emoquette EMPLICITI...7 EMSAM EMTRIVA... 6 enalapril maleate enalaprilat enalapril-hydrochlorothiazide...75 ENBREL... 1 ENBREL SURECLICK...1 ENDARI endocet... 4 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF)...17 enoxaparin...67 enpresse enskyce...91 entacapone...56 entecavir ENTRESTO enulose ENVARSUS XR... 1 EPANED...75 EPCLUSA epinastine epinephrine EPIPEN...80 EPIPEN -PAK...80 EPIPEN JR -PAK epitol EPIVIR HBV...6 eplerenone...85 EPOGEN...68 epoprostenol (glycine) eprosartan ergoloid ERGOMAR... 5 ERIVEDGE... 7 ERLEADA...7 errin ery pads ERYPED ERYPED ery-tab...0 ERY-TAB...0 ERYTHROCIN... 0 erythrocin (as stearate)... 0 erythromycin...0, 106 erythromycin ethylsuccinate...0 erythromycin with ethanol...98 erythromycin-benzoyl peroxide 98 ESBRIET escitalopram oxalate...41 esmolol esomeprazole sodium estarylla...91 estazolam...1, 13 ESTRACE estradiol estradiol valerate estradiol-norethindrone acet ESTRING estropipate eszopiclone ethambutol...5 ethosuximide...36 ethynodiol diac-eth estradiol...91 etidronate disodium...13 etodolac...8 ETOPOPHOS...7 etoposide...7 EUCRISA EVOTAZ... 6 EXELDERM...49 exemestane... 7 EXJADE EXONDYS EXTAVIA ezetimibe ezetimibe-simvastatin...83 FABRAZYME falmina (8)...91 famciclovir...66 famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 109 FANAPT...58 FARESTON...7 FARYDAK...7 FASENRA FASLODEX...7 felbamate...36 felodipine...8 FEMRING femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized fenofibric acid...84 fenofibric acid (choline)...84 fenoprofen... 8 fentanyl... 4 fentanyl citrate... 4 FERRIPROX FETZIMA FIASP FLEXTOUCH U-100 INSULIN FIASP U-100 INSULIN...45 finasteride FIRAZYR I-6

163 flavoxate FLEBOGAMMA DIF... 1 flecainide FLECTOR...97 FLOVENT DISKUS FLOVENT HFA floxuridine... 7 fluconazole fluconazole in dextrose(iso-o)..49 fluconazole in nacl (iso-osm) flucytosine fludrocortisone flumazenil...87 flunisolide fluocinolone fluocinolone acetonide oil fluocinonide fluocinonide-e fluoride (sodium) , 148 fluorometholone fluorouracil... 7, 97 fluoxetine...41 FLUOXETINE fluphenazine decanoate fluphenazine hcl flurazepam...13 flurbiprofen... 8 flurbiprofen sodium flutamide... 7 fluticasone , 108 fluvastatin...84 fluvoxamine fomepizole fondaparinux FORADIL AEROLIZER FORTEO fosamprenavir... 6 foscarnet...64 fosinopril fosinopril-hydrochlorothiazide..75 fosphenytoin FOSRENOL...11 FREAMINE HBC 6.9 %...7 FREAMINE III 10 %...73 furosemide... 8 FUZEON... 6 fyavolv FYCOMPA gabapentin GABITRIL...36 galantamine GAMASTAN S/D... 1 GAMMAGARD LIQUID... 1 GAMMAGARD S-D (IGA < 1 MCG/ML)... 1 GAMMAPLEX...13 GAMMAPLEX (WITH SORBITOL)... 1 GAMUNEX GAMUNEX-C ganciclovir sodium GARDASIL (PF) GARDASIL 9 (PF)...17 gatifloxacin GATTEX 30-VIAL GAUZE PAD gavilyte-c gavilyte-g...11 gavilyte-n...11 GAZYVA... 7 gemcitabine...7, 8 gemfibrozil...84 generlac gengraf GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 15, 98, 106 gentamicin in nacl (iso-osm)...15 gentamicin sulfate (ped) (pf).. 15 gentamicin sulfate (pf)...14, 15 GENVOYA... 6 GEODON...58 gianvi (8) gildagia...91 GILENYA...87 GILOTRIF...8 glatiramer...87 glatopa GLEOSTINE...8 glimepiride...47 glipizide glipizide-metformin...48 GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN)...43 glyburide...48 glyburide micronized...48 glyburide-metformin glycopyrrolate glydo GLYXAMBI GOCOVRI GRALISE...37 GRALISE 30-DAY STARTER PACK granisetron (pf)...53 granisetron hcl GRANIX...68 griseofulvin microsize...49 griseofulvin ultramicrosize guanfacine...74, 87 guanidine HAEGARDA...68 halobetasol propionate haloperidol...58 haloperidol decanoate haloperidol lactate I-7

164 HARVONI HAVRIX (PF) heather heparin (porcine)...68 heparin (porcine) in 5 % dex...67 heparin(porcine) in 0.45% nacl 68 heparin, porcine (pf)...68 HEPATAMINE 8%...73 HERCEPTIN... 8 HETLIOZ HEXALEN...8 HIBERIX (PF) HUMALOG JUNIOR KWIKPEN U HUMALOG KWIKPEN INSULIN HUMALOG MIX INSULN U HUMALOG MIX KWIKPEN...46 HUMALOG MIX 75-5 KWIKPEN...46 HUMALOG MIX 75-5(U- 100)INSULN HUMALOG U-100 INSULIN HUMATROPE HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S- UC-HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN 70/30 INSULIN PEN HUMULIN 70/30 U-100 INSULIN HUMULIN 70/30 U-100 KWIKPEN...46 HUMULIN N NPH INSULIN KWIKPEN...46 HUMULIN N NPH U-100 INSULIN HUMULIN R REGULAR U-100 INSULN HUMULIN R U-500 (CONC) INSULIN...46 HUMULIN R U-500 (CONC) KWIKPEN hydralazine hydrochlorothiazide... 8 hydrocodone-acetaminophen.. 4, 5 hydrocodone-ibuprofen... 5 hydrocortisone , 117, 131 hydrocortisone butyrate hydrocortisone valerate hydrocortisone-acetic acid hydromorphone...5 hydromorphone (pf)... 5 hydroxychloroquine hydroxyprogesterone caproate10 hydroxyurea... 8 hydroxyzine hcl...51 hydroxyzine pamoate HYPERRAB S/D (PF) HYQVIA HYSINGLA ER...5 ibandronate...13 IBRANCE... 8 ibuprofen... 8 ICLUSIG...8 IDHIFA...8 ifosfamide...8 ifosfamide-mesna... 8 ILARIS (PF)... 13, 14 ILEVRO imatinib... 8 IMBRUVICA...8 IMFINZI...8 imipenem-cilastatin... 0, 1 imipramine hcl imipramine pamoate...41 imiquimod...97 IMLYGIC... 8 IMOGAM RABIES-HT (PF) IMOVAX RABIES VACCINE (PF) IMPAVIDO...55 INCRELEX INCRUSE ELLIPTA indapamide... 8 indomethacin... 8, 9 indomethacin sodium...9 INFANRIX (DTAP) (PF) INFLECTRA INGREZZA INLYTA...9 INSULIN SYRINGE- NEEDLE U INTELENCE... 6 INTRALIPID...73 INTRON A introvale INVANZ... 1 INVEGA SUSTENNA...58, 59 INVEGA TRINZA INVIRASE... 6 INVOKAMET INVOKAMET XR...43 INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IPOL ipratropium bromide , 14 IPRIVASK irbesartan I-8

165 irbesartan-hydrochlorothiazide.74 IRESSA... 9 irinotecan...9 ISENTRESS... 6 ISENTRESS HD... 6 isibloom ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid... 5 isosorbide dinitrate...85 isosorbide mononitrate isradipine...8 itraconazole ivermectin IXEMPRA... 9 IXIARO (PF)...17 JADENU JADENU SPRINKLE JAKAFI...9 jantoven...68 JANUMET...43 JANUMET XR... 43, 44 JANUVIA JARDIANCE jencycla JENTADUETO...44 JENTADUETO XR...44 jinteli jolessa...91 jolivette...91 juleber JULUCA... 6 junel 1.5/30 (1)...91 junel 1/0 (1)...91 junel fe 1.5/30 (8) junel fe 1/0 (8)...9 junel fe JUXTAPID KABIVEN...73 KALETRA...6 KALYDECO KANUMA kariva (8)...9 KAZANO...44 kelnor 1/35 (8)... 9 KENALOG ketoconazole...49 ketoprofen... 9 ketorolac...9, 108 KEVEYIS KEVZARA...14 KEYTRUDA... 9 kimidess (8)... 9 KINERET KINRIX (PF) kionex (with sorbitol) KISQALI...9 KISQALI FEMARA CO- PACK... 9 klor-con m klor-con m klor-con m klor-con sprinkle KORLYM KRYSTEXXA kurvelo... 9 KUVAN KYNAMRO...84 KYPROLIS... 9 l norgest/e.estradiol-e.estrad...9 labetalol...77 LACRISERT LACTATED RINGERS lactulose lamivudine... 6 lamivudine-zidovudine... 6 lamotrigine LANOXIN lansoprazole lanthanum LANTUS SOLOSTAR U-100 INSULIN LANTUS U-100 INSULIN...47 larin 1.5/30 (1)... 9 larin 1/0 (1)...9 larin 4 fe... 9 larin fe 1.5/30 (8)... 9 larin fe 1/0 (8)... 9 larissia...9 LARTRUVO...9 latanoprost LATUDA LAZANDA... 5 leena leflunomide LEMTRADA LENVIMA lessina...9 LETAIRIS letrozole...30 leucovorin calcium LEUKERAN...30 LEUKINE...68 leuprolide...30 levalbuterol tartrate levetiracetam levetiracetam in nacl (iso-os)...37 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine...51 levofloxacin...3, 106 levofloxacin in d5w... 3 LEVOLEUCOVORIN levoleucovorin levonest (8)... 9 levonorgestrel-ethinyl estrad...9 levonorg-eth estrad triphasic levora I-9

166 levothyroxine LEXIVA LIALDA lidocaine lidocaine (pf)...10, 76 lidocaine hcl...10 lidocaine in 5 % dextrose (pf).. 76 lidocaine viscous lidocaine-prilocaine...10 lillow linezolid linezolid-0.9% sodium chloride. 16 LINZESS liothyronine...11 lisinopril lisinopril-hydrochlorothiazide...76 lithium carbonate lithium citrate LIVALO lomedia 4 fe LONSURF loperamide lopinavir-ritonavir...63 lopreeza lorazepam...13 lorcet (hydrocodone)...5 lorcet hd... 5 lorcet plus...5 loryna (8)...93 losartan losartan-hydrochlorothiazide...74 LOTEMAX lovastatin...84 low-ogestrel (8)...93 loxapine succinate...59 LUMIGAN LUPRON DEPOT LUPRON DEPOT (3 MONTH)...30 LUPRON DEPOT (4 MONTH)...30 LUPRON DEPOT (6 MONTH)...30 LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) lutera (8)...93 LYNPARZA LYRICA...37 LYSODREN lyza magnesium sulfate magnesium sulfate in d5w magnesium sulfate in water malathion...10 maprotiline... 4 marlissa MARPLAN...4 MARQIBO...30 MATULANE matzim la...79 MAVYRET meclizine...53 medroxyprogesterone... 10, 11 mefenamic acid...9 mefloquine MEFOXIN IN DEXTROSE (ISO-OSM) megestrol... 30, 11 MEKINIST meloxicam... 9 melphalan hcl...31 memantine MENACTRA (PF) MENEST MENHIBRIX (PF)...18 MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W- 135 (PF) MENVEO A-C-Y-W-135-DIP (PF)...18 mercaptopurine...31 meropenem... 1 mesalamine mesna MESNEX MESTINON metaproterenol...14 metformin...44 methadone... 5 methadose...5 methazolamide methenamine hippurate methimazole...11 methocarbamol methotrexate sodium...31 methotrexate sodium (pf) methoxsalen...97 methscopolamine methyclothiazide...8 methylergonovine methylphenidate hcl methylprednisolone methylprednisolone acetate methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz 77 metoprolol tartrate...78 metronidazole... 16, 51, 98 metronidazole in nacl (iso-os)..16 mexiletine MIACALCIN...13 miconazole I-10

167 microgestin 1.5/30 (1) microgestin 1/0 (1) microgestin fe 1.5/30 (8)...93 microgestin fe 1/0 (8)...93 midazolam midodrine...74 miglitol milrinone milrinone in 5 % dextrose...81 mimvey mimvey lo minitran... 85, 86 MINOCIN...4 minocycline...4 minoxidil MIRCERA mirtazapine...4 misoprostol mitoxantrone M-M-R II (PF) moexipril moexipril-hydrochlorothiazide..76 molindone mometasone mono-linyah...93 mononessa (8)...93 montelukast morphine...5, 6 MORPHINE... 6 morphine concentrate...5 MOVANTIK MOVIPREP...11 MOXEZA moxifloxacin... 3, 106 MOZOBIL...69 MULTAQ mupirocin...98 mupirocin calcium...98 mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYLOTARG...31 MYOBLOC MYRBETRIQ myzilra nabumetone... 9 nadolol...78 nafcillin... NAGLAZYME naloxone...11 naltrexone NAMENDA XR...39, 40 NAMZARIC naproxen... 9 naratriptan... 5 NARCAN...11 NATACYN nateglinide NATPARA...13 NEBUPENT...55 necon 0.5/35 (8) necon 1/50 (8) necon 10/11 (8) necon 7/7/7 (8) nefazodone...4 neomycin neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b gu...98 neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc.. 106, 107 neo-polycin neo-polycin hc NEPHRAMINE 5.4 % NERLYNX NESINA...44 neuac NEULASTA...69 NEUPOGEN...69 NEUPRO nevirapine NEXAVAR niacin...84 niacor nicardipine...8 NICOTROL nifedipine...8 nikki (8)...93 nilutamide...31 NINLARO NITRO-BID nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/mcryst nitroglycerin nitroglycerin in 5 % dextrose...86 nizatidine nora-be NORDITROPIN FLEXPRO norepinephrine bitartrate...81 noreth-ethinyl estradiol-iron...93 norethindrone (contraceptive)..93 norethindrone acetate...11 norethindrone ac-eth estradiol...94, 116 norethindrone-e.estradiol-iron... 93, 94 norgestimate-ethinyl estradiol.. 94 norlyda norlyroc...94 NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA I-11

168 nortrel 0.5/35 (8)...94 nortrel 1/35 (1)...94 nortrel 1/35 (8)...94 nortrel 7/7/7 (8)...94 nortriptyline...4 NORVIR NOVOLIN 70/30 U-100 INSULIN NOVOLIN N NPH U-100 INSULIN NOVOLIN R REGULAR U- 100 INSULN NOVOLOG FLEXPEN U- 100 INSULIN...47 NOVOLOG MIX U- 100 INSULN NOVOLOG MIX 70-30FLEXPEN U NOVOLOG PENFILL U-100 INSULIN NOVOLOG U-100 INSULIN ASPART...47 NOXAFIL...49 NPLATE NUCALA NUCYNTA...6 NUCYNTA ER... 6 NUEDEXTA...88 NULOJIX...14 NUPLAZID NUTRESTORE NUTRILIPID NUTROPIN AQ NUSPIN NUVARING...94 nyamyc...50 nyata nystatin...50 nystatin-triamcinolone nystop...50 OCALIVA ocella...94 OCREVUS OCTAGAM...14 octreotide acetate ODEFSEY...63 ODOMZO OFEV ofloxacin... 3, 107 ogestrel (8) olanzapine olmesartan...74 olmesartan-amlodipin-hcthiazid75 olmesartan-hydrochlorothiazide75 olopatadine OLYSIO omega-3 acid ethyl esters omeprazole , 110 OMNITROPE ONCASPAR ondansetron ondansetron hcl...54 ondansetron hcl (pf) ONFI... 13, 14 ONIVYDE OPDIVO...31 OPSUMIT oralone ORENCIA...14 ORENCIA (WITH MALTOSE)...14 ORENCIA CLICKJECT ORENITRAM ORFADIN ORKAMBI orsythia oseltamivir... 64, 65 OSENI OTEZLA OTEZLA STARTER...15 OTOVEL OTREXUP (PF) oxacillin... oxacillin in dextrose(iso-osm).. oxaliplatin oxandrolone oxazepam oxcarbazepine...37 OXTELLAR XR...37 oxybutynin chloride oxycodone... 6 oxycodone-acetaminophen... 6 oxycodone-aspirin...6 OXYCONTIN...7 oxymorphone...7 pacerone...76, 77 paclitaxel...31 paliperidone pamidronate...13 PANRETIN pantoprazole PARICALCITOL...13 paricalcitol...13 paroex oral rinse...96 paromomycin paroxetine hcl... 4 PASER... 5 PAXIL... 4 PEDIARIX (PF)...18 PEDVAX HIB (PF)...18 peg 3350-electrolytes...11 PEGANONE...38 PEGASYS PEGASYS CONVENIENCE PACK PEGASYS PROCLICK peg-electrolyte soln PEGINTRON PEN NEEDLE, DIABETIC.10 penicillin g pot in dextrose... penicillin g potassium... I-1

169 penicillin g procaine... penicillin v potassium... PENNSAID...97 PENTACEL (PF) PENTACEL DTAP-IPV COMPNT (PF) PENTAM pentoxifylline...70 PERIKABIVEN...73 perindopril erbumine periogard PERJETA...31 permethrin perphenazine...60 perphenazine-amitriptyline...4 PERTZYE pfizerpen-g... phenadoz phenelzine...4 phenobarbital...38 phenylephrine hcl...74, 105 phenytoin...38 phenytoin sodium phenytoin sodium extended...38 philith PHOSLYRA PHOSPHOLINE IODIDE PICATO pilocarpine hcl... 96, 136 pimozide pimtrea (8)...94 pindolol...78 pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam... pirmella piroxicam... 9 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY...88, 89 PLENAMINE podofilox polycin polyethylene glycol polymyxin b sulfate...17 polymyxin b sulf-trimethoprim107 POMALYST portia...94 PORTRAZZA...3 potassium acetate potassium chlorid-d5-0.45%nacl...138, 139 potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex.139 potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate , 140 potassium citrate-citric acid POTIGA...38 PRADAXA PRALUENT PEN...84 pramipexole...56 prasugrel...70 pravastatin...84 prazosin...74 prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate...108, 117 prednisone , 118 PREMARIN PREMASOL 10 %...73 PREMASOL 6 %...73 PREMPHASE PREMPRO prenatal plus (calcium carb) prenatal vitamin plus low iron.148 PREPOPIK...11 prevalite...84 previfem...94 PREVYMIS...65 PREZCOBIX...63 PREZISTA PRIFTIN...5 PRIMAQUINE primidone...38 PRIVIGEN...15 PROAIR HFA...14 PROAIR RESPICLICK probenecid probenecid-colchicine procainamide PROCALAMINE 3%...73 prochlorperazine prochlorperazine edisylate...54 prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone in oil...11 progesterone micronized...11 PROGLYCEM PROGRAF...15 PROLASTIN-C I-13

170 PROLENSA PROLEUKIN... 3 PROLIA PROMACTA promethazine...51, 54 promethazine vc promethegan propafenone propantheline proparacaine propranolol propranolol-hydrochlorothiazid 78 propylthiouracil PROQUAD (PF) PROSOL 0 %...73 protamine protriptyline...4 PULMOZYME PURIXAN...3 pyrazinamide... 5 pyridostigmine bromide QBRELIS QUADRACEL (PF)...19 quasense quetiapine quinapril quinapril-hydrochlorothiazide...76 quinidine gluconate quinidine sulfate...77 quinine sulfate...55 QVAR RABAVERT (PF) rabeprazole RADICAVA...89 raloxifene ramipril RANEXA...81 ranitidine hcl RAPAMUNE rasagiline...56 RASUVO (PF)...15 RAVICTI RAYALDEE REBIF (WITH ALBUMIN).. 89 REBIF REBIDOSE...89 REBIF TITRATION PACK..89 reclipsen (8) RECOMBIVAX HB (PF)...19 REGRANEX RELENZA DISKHALER RELISTOR REMICADE...15 REMODULIN RENAGEL RENFLEXIS RENVELA repaglinide...45 repaglinide-metformin...45 REPATHA PUSHTRONEX. 84 REPATHA SURECLICK...84 REPATHA SYRINGE reprexain... 7 RESCRIPTOR RESTASIS RETROVIR REVLIMID...3 revonto REXULTI REYATAZ ribasphere...67 ribasphere ribapak ribavirin...67 RIDAURA rifabutin...5 rifampin...5 RIFATER... 5 riluzole rimantadine ringer's , 140 risedronate...13 RISPERDAL CONSTA...60 risperidone...60 RITUXAN... 3 RITUXAN HYCELA... 3 rivastigmine rivastigmine tartrate rizatriptan... 5 ropinirole...56 rosadan...98 rosuvastatin ROTARIX...19 ROTATEQ VACCINE...19 ROWEEPRA...38 RUBRACA... 3 RYDAPT...3 SABRIL...38 SAIZEN SAIZEN CLICK.EASY SANDOSTATIN LAR DEPOT...10 SANTYL SAPHRIS (BLACK CHERRY)...60 SAVAYSA...68 SAVELLA scopolamine base selegiline hcl selenium sulfide...98 SELZENTRY...63 SENSIPAR SEREVENT DISKUS SEROSTIM sertraline... 4 setlakin...94 sevelamer carbonate sharobel...94 SHINGRIX (PF) SIGNIFOR...10 sildenafil (antihypertensive) SILENOR I-14

171 SILIQ...97 silver sulfadiazine...98 SIMBRINZA SIMPONI SIMPONI ARIA simvastatin sirolimus SIRTURO smoflipid...73 sodium acetate sodium chloride...131, 140 sodium chloride 0.45 % sodium chloride 0.9 % sodium lactate sodium phenylbutyrate sodium phosphate sodium polystyrene (sorb free) sodium polystyrene sulfonate..111 SOLIQUA 100/ SOLTAMOX...3 SOLU-CORTEF (PF) SOMATULINE DEPOT...10 SOMAVERT sorbitol sorbitol-mannitol sorine...78 sotalol...78 sotalol af...78 SOVALDI spinosad...10 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone...83 spironolacton-hydrochlorothiaz 83 SPORANOX sprintec (8) SPRITAM SPRYCEL... 3 sps (with sorbitol) sronyx ssd stavudine...63 STELARA STERILE PADS...10 STIMATE...10 STIOLTO RESPIMAT STIVARGA...3 STRENSIQ streptomycin STRIBILD...64 STRIVERDI RESPIMAT SUBLOCADE...7 SUBOXONE sucralfate sulfacetamide sodium sulfacetamide sodium (acne)...99 sulfacetamide-prednisolone sulfadiazine...3 sulfamethoxazole-trimethoprim 3 sulfasalazine sulfatrim...3 sulindac... 9 sumatriptan... 5 sumatriptan succinate... 5 SUPPRELIN LA...10 SUPRAX...19 SUPREP BOWEL PREP KIT SURMONTIL... 4 SUSTIVA SUTENT... 3 syeda SYLATRON SYLVANT... 3 SYMBICORT SYMDEKO SYMLINPEN SYMLINPEN SYNAGIS...65 SYNAREL SYNDROS SYNERCID SYNJARDY...45 SYNJARDY XR SYNRIBO... 3 SYPRINE TABLOID... 3 tacrolimus , 16 TAFINLAR... 3 TAGRISSO... 3 TALTZ AUTOINJECTOR...97 TALTZ SYRINGE TAMIFLU tamoxifen... 3 tamsulosin TARCEVA TARGRETIN tarina fe 1/0 (8) TASIGNA tazarotene tazicef...19 TAZORAC taztia xt...79 TECENTRIQ TECFIDERA TECHNIVIE TEFLARO TEKAMLO TEKTURNA...85 TEKTURNA HCT...85 telmisartan telmisartan-amlodipine...75 telmisartan-hydrochlorothiazid.75 temazepam TEMODAR...33 tencon...7 TENIVAC (PF) tenofovir disoproxil fumarate I-15

172 terazosin terbinafine hcl...50 terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD...19 tetrabenazine tetracycline...4 THALOMID theophylline theophylline in dextrose 5 % THIOLA thioridazine...60 thiotepa thiothixene...60 tiagabine...38 TICE BCG...19 tigecycline...4 tilia fe...95 timolol maleate... 78, 136, 137 tinidazole...55 TIVICAY tizanidine TOBI PODHALER...15 TOBRADEX TOBRADEX ST tobramycin tobramycin in 0.5 % nacl tobramycin in 0.9 % nacl...15 tobramycin sulfate tobramycin-dexamethasone TOLAK tolazamide tolbutamide...48 tolmetin... 9 tolterodine topiramate toposar topotecan...33 TORISEL torsemide...83 TOTECT TOUJEO SOLOSTAR U-300 INSULIN TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA tramadol...7 tramadol-acetaminophen...7 trandolapril...76 tranexamic acid TRANSDERM-SCOP...54 tranylcypromine...4 TRAVASOL 10 % TRAVATAN Z trazodone...4 TREANDA TRECATOR TRELEGY ELLIPTA TRELSTAR TREMFYA tretinoin tretinoin (chemotherapy)...33 TREXALL tri femynor...95 triamcinolone acetonide... 96, 101, 118 triamterene-hydrochlorothiazid 83 triazolam tridesilon trientine tri-estarylla...95 trifluoperazine trifluridine trihexyphenidyl... 56, 57 tri-legest fe tri-linyah...95 tri-lo-estarylla...95 tri-lo-marzia tri-lo-sprintec...95 trilyte with flavor packets...11 trimethoprim...17 trimipramine...4 trinessa (8)...95 TRINTELLIX...4 tri-previfem (8) TRIPTODUR...10 tri-sprintec (8)...95 TRIUMEQ trivora (8) tri-vylibra TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUVADA TWINRIX (PF)...19, 130 TYBOST TYKERB...33 TYMLOS TYPHIM VI TYSABRI TYVASO TYZINE UCERIS ULORIC...50 UNITUXIN UPTRAVI ursodiol valacyclovir...67 VALCHLOR I-16

173 valganciclovir...67 valproate sodium...39 valproic acid valproic acid (as sodium salt).. 39 valsartan...75 valsartan-hydrochlorothiazide.. 75 VALSTAR...34 vancomycin...17 vancomycin in dextrose 5 % VAQTA (PF) VARIVAX (PF) VASCEPA VECTIBIX VELCADE velivet triphasic regimen (8)...95 VELPHORO VELTASSA VEMLIDY VENCLEXTA...34 VENCLEXTA STARTING PACK venlafaxine...4, 43 VENTOLIN HFA verapamil...79 VEREGEN...98 VERSACLOZ...60 VERZENIO...34 VESICARE vestura (8) VGO VIBERZI vicodin...7 vicodin es...7 vicodin hp... 7 VICTOZA VIDEX GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIEKIRA PAK VIEKIRA XR vienva vigabatrin VIGAMOX VIIBRYD VIMIZIM VIMOVO...10 VIMPAT...39 vinblastine...34 vincasar pfs...34 vincristine vinorelbine viorele (8) VIRACEPT VIREAD...64 VISTOGARD VOLTAREN voriconazole...50 VOSEVI...65 VOTRIENT...34 VPRIV VRAYLAR vyfemla (8) vylibra VYXEOS warfarin...68 water for irrigation, sterile WELCHOL wera (8) wymzya fe...95 XADAGO XALKORI XARELTO XARTEMIS XR... 7 XATMEP XELJANZ XELJANZ XR...16 XERMELO XGEVA XIFAXAN XIIDRA XOLAIR XTAMPZA ER... 7 XTANDI xulane...96 XULTOPHY 100/ XURIDEN xylon XYREM YERVOY YF-VAX (PF) YONDELIS...35 yuvafem zafirlukast...14 zaleplon ZALTRAP...35 zarah ZARXIO...69 ZAVESCA zebutal...8 ZEJULA...35 ZELBORAF...35 zenatane zenchent (8) zenchent fe...96 ZENPEP ZEPATIER...66 ZERIT ZIAGEN...64 zidovudine...64 ZINBRYTA ZIOPTAN (PF) ziprasidone hcl ZIRGAN ZOHYDRO ER... 8 ZOLADEX...35 zoledronic acid zoledronic acid-mannitol-water I-17

174 zoledronic ac-mannitol-0.9nacl ZOLINZA zolmitriptan... 5 zolpidem ZOMACTON ZOMETA zonisamide...39 ZORBTIVE ZORTRESS...16 ZOSTAVAX (PF) zovia 1/35e (8) zovia 1/50e (8) ZOVIRAX...98 ZUBSOLV...11 ZURAMPIC...50 ZYDELIG ZYKADIA ZYLET ZYPREXA RELPREVV...61 ZYTIGA...35 I-18

175 This formulary was updated on April 1, 018. For more recent information or other questions, please contact SummaCare at or, for TTY users, From October 1 through February 14, a representative will be available to take your call from 8:00 a.m. until 8:00 p.m., seven days a week. From February 15 through September 30, a representative will be available to take your call from 8:00 a.m. until 8:00 p.m., Monday through Friday. Or visit SummaCare 018 Part D Formulary Formulary ID: , Version: 11 Effective: April 1, 018 SC18_03

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