Table of Contents Senior Care Plus Drug List and Handbook Formulary ID: Version: 19

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1 Table of Contents Analgesics... Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials... 1 Anticancer Agents Anticholinergic Agents... 7 Anticonvulsants... 7 Antidementia Agents... 2 Antidepressants... Antidiabetic Agents... 6 Antifungals... 2 Antihistamines... Anti-Infectives (Skin And Mucous Membrane)... Antimigraine Agents... Antimycobacterials... 6 Antinausea Agents... 6 Antiparasite Agents... 7 Antiparkinsonian Agents... 8 Antipsychotic Agents Antivirals (Systemic)... 6 Blood Products/Modifiers/Volume Expanders Caloric Agents... 7 Cardiovascular Agents Central Nervous System Agents Contraceptives... 9 Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents... 1 Irrigating Solutions... 1 Metabolic Bone Disease Agents... 1 Miscellaneous Therapeutic Agents

2 Ophthalmic Agents... 1 Replacement Preparations... 1 Respiratory Tract Agents Skeletal Muscle Relaxants... 1 Sleep Disorder Agents... 1 Vasodilating Agents... 1 Vitamins And Minerals

3 Analgesics Analgesics, Miscellaneous acetaminophen-codeine 120 mg-12 mg/ ml solution mg/ ml acetaminophen-codeine oral solution 00 mg-0 mg /12. ml acetaminophen-codeine oral tablet 00-1 mg, 00-0 mg acetaminophen-codeine oral tablet mg BELBUCA BUCCAL FILM 10 MCG, 00 MCG, 0 MCG, 600 MCG, 7 MCG, 70 MCG, 900 MCG buprenorphine hcl injection syringe 0. mg/ml butalbital-acetaminop-caf-cod oral capsule mg, mg butorphanol tartrate nasal spray,non-aerosol 10 mg/ml BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 1 MCG/HOUR, 20 MCG/HOUR, MCG/HOUR, 7. MCG/HOUR codeine sulfate oral tablet 1 mg, 0 mg, 60 mg EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 100- MG, MG, MG, 0-2 MG, MG, MG endocet oral tablet 10-2 mg, 2.-2 mg, -2 mg, 7.-2 mg (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.) (Tylenol-Codeine No.) (Buprenorphine HCl) ; QL (2700 per 0 ; QL (2700 per 0 ; QL (60 per 0 ; QL (180 per 0 ST; QL (60 per 0 (Fioricet with Codeine) 2 PA-HRM; GC; QL (180 per 0 ; AGE (Max 6 Years) (Butorphanol Tartrate) ; QL ( per 28 QL ( per 28 (Codeine Sulfate) ; QL (180 per 0 QL (60 per 0 (Xolox) ; QL (60 per 0 endodan oral tablet.8-2 mg (Percodan) ; QL (60 per 0 fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 00 mcg, 600 mcg, 800 mcg (Actiq) PA; QL (120 per 0

4 fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 2 mcg/hr, 7. mcg/hour, 0 mcg/hr, 62. mcg/hour, 7 mcg/hr, 87. mcg/hour hydrocodone-acetaminophen oral solution 10-2 mg/1 ml(1 ml), mg/ ml, 7.-2 mg/1 ml hydrocodone-acetaminophen oral tablet mg, -00 mg, mg hydrocodone-acetaminophen oral tablet 10-2 mg, 2.-2 mg, -2 mg, 7.-2 mg hydrocodone-ibuprofen oral tablet mg, mg, -200 mg, mg hydromorphone (pf) injection solution 10 mg/ml hydromorphone injection solution 2 mg/ml, mg/ml (Duragesic) ; QL (10 per 0 (Hycet) ; QL (2700 per 0 (Norco) ; (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 (Norco) ; QL (60 per 0 (Ibudone) ; QL (10 per 0 (Dilaudid-HP) (Hydromorphone HCl) hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) ; QL (1200 per 0 hydromorphone oral tablet 2 mg, mg (Dilaudid) ; QL (180 per 0 hydromorphone oral tablet 8 mg (Dilaudid) ; QL (20 per 0 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 100 MG, 120 MG, 20 MG, 0 MG, 0 MG, 60 MG, 80 MG QL (0 per 0 LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY lorcet (hydrocodone) oral tablet -2 mg PA; QL (0 per 0 (Norco) ; QL (60 per 0

5 lorcet hd oral tablet 10-2 mg (Norco) ; QL (60 per 0 lorcet plus oral tablet 7.-2 mg (Norco) ; QL (60 per 0 methadone injection solution 10 mg/ml (Methadone HCl) methadone oral solution 10 mg/ ml, mg/ ml (Methadone HCl) ; QL (1800 per 0 methadone oral tablet 10 mg, mg (Diskets) ; QL (60 per 0 methadose oral tablet,soluble 0 mg (Diskets) ; QL (90 per 0 morphine (pf) in 0.9 % nacl intravenous pt controlled analgesia syring 0 mg/2 ml (2 mg/ml) (Morphine Sulfate/0.9% Nacl/PF) morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject outer, (Morphine Sulfate) latex-f, p/f 2 mg/ml morphine mg/ml carpuject (Morphine Sulfate) outer,latex-free,p/f mg/ml morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution 100 mg/ ml (20 mg/ml) (Morphine Sulfate) ; QL (200 per 0 morphine in dextrose % injection pt (Morphine controlled analgesia syring 100 mg/0 ml (2 mg/ml), 0 mg/2 ml (2 mg/ml) Sulfate/DW) morphine injection solution 1 mg/ml, 8 (Morphine Sulfate) mg/ml morphine injection syringe 10 mg/ml (Morphine Sulfate) morphine intramuscular pen injector 10 (Morphine Sulfate) mg/0.7 ml morphine intravenous cartridge 1 mg/ml (Morphine Sulfate) morphine intravenous solution 2 mg/ml, 0 mg/ml (Morphine Sulfate) morphine intravenous syringe 10 mg/ml, 2 (Morphine Sulfate) mg/ml, mg/ml, 8 mg/ml

6 morphine oral solution 10 mg/ ml (Morphine Sulfate) ; QL (700 per 0 morphine oral solution 20 mg/ ml ( mg/ml) (Morphine Sulfate) ; QL (00 per 0 MORPHINE ORAL TABLET 1 MG, 0 MG QL (180 per 0 morphine oral tablet extended release 100 (MS Contin) ; QL (120 per 0 mg, 0 mg, 60 mg morphine oral tablet extended release 1 mg, 200 mg (MS Contin) ; QL (180 per 0 morphine rectal suppository 10 mg, 20 (Morphine Sulfate) mg, 0 mg, mg NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE 12 HR 100 MG, 10 MG, 200 MG, 20 MG, 0 MG NUCYNTA ORAL TABLET 100 MG, QL (181 per 0 0 MG, 7 MG oxycodone oral capsule mg (Oxycodone HCl) ; QL (180 per 0 oxycodone oral concentrate 20 mg/ml (Oxycodone HCl) ; QL (180 per 0 oxycodone oral solution mg/ ml (Oxycodone HCl) ; QL (100 per 0 oxycodone oral tablet 10 mg, 1 mg, 20 mg, 0 mg, mg (Roxicodone) ; QL (180 per 0 oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 1 mg, 20 mg, 0 mg, 0 mg, (Oxycontin) ; QL (60 per 0 60 mg oxycodone oral tablet,oral only,ext.rel.12 (Oxycontin) QL (120 per 0 hr 80 mg oxycodone-acetaminophen oral solution -2 mg/ ml (Oxycodone HCl/Acetaminophen) ; QL (1800 per 0 oxycodone-acetaminophen oral tablet 10-2 mg, 2.-2 mg, -2 mg, 7.-2 mg (Xolox) ; QL (60 per 0 6

7 oxycodone-acetaminophen oral tablet mg (Xolox) ; QL (180 per 0 oxycodone-acetaminophen oral tablet mg (Xolox) ; QL (20 per 0 oxycodone-aspirin oral tablet.8-2 mg (Percodan) ; QL (60 per 0 OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 1 MG, 20 MG, 0 MG, 0 MG, 60 MG OXYCONTIN ORAL QL (120 per 0 TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg, mg (Opana) ; QL (180 per 0 oxymorphone oral tablet extended release (Opana ER) ; QL (60 per 0 12 hr 10 mg, 1 mg, 20 mg, mg, 7. mg oxymorphone oral tablet extended release (Opana ER) ; QL (120 per 0 12 hr 0 mg, 0 mg reprexain oral tablet mg, mg, -200 mg (Ibudone) ; QL (10 per 0 roxicet oral solution -2 mg/ ml (Oxycodone HCl/Acetaminophen) ; QL (1800 per 0 tramadol oral tablet 0 mg (Ultram) ; QL (20 per 0 tramadol-acetaminophen oral tablet 7.-2 mg (Ultracet) ; QL (20 per 0 vicodin es oral tablet mg (Norco) ; (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 vicodin hp oral tablet mg (Norco) ; (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 7

8 vicodin oral tablet -00 mg (Norco) ; (includes Vicodin, Vicodin ES and Vicodin HP); QL (90 per 0 XARTEMIS XR ORAL TAB,ORAL QL (60 per 0 ONLY,IR - ER, BIPHASE 7.-2 MG XTAMPZA ER ORAL QL (60 per 0 CAPSULE,SPRINKLE,ER 12HR TMPRR 1. MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (120 per 0 CAPSULE,SPRINKLE,ER 12HR TMPRR 27 MG XTAMPZA ER ORAL QL (20 per 0 CAPSULE,SPRINKLE,ER 12HR TMPRR 6 MG xylon 10 oral tablet mg (Ibudone) ; QL (10 per 0 ZOHYDRO ER ORAL CAPSULE, QL (60 per 0 ORAL ONLY, ER 12HR 10 MG, 1 MG, 20 MG, 0 MG, 0 MG, 0 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 00 MG/ ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 mg, 00 mg, 0 mg (Celebrex) ; QL (60 per 0 choline,magnesium salicylate oral liquid (Choline Sal/Mag 00 mg/ ml Salicylate) diclofenac potassium oral tablet 0 mg (Diclofenac Potassium) diclofenac sodium oral tablet extended (Voltaren-XR) release 2 hr 100 mg diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) 2 mg, 0 mg, 7 mg diclofenac sodium topical gel 1 % (Voltaren) diclofenac sodium topical gel % (Voltaren) 8

9 diclofenac-misoprostol oral (Arthrotec 0) tablet,ir,delayed rel,biphasic mg-mcg, mg-mcg diflunisal oral tablet 00 mg (Diflunisal) etodolac oral capsule 200 mg, 00 mg (Etodolac) etodolac oral tablet 00 mg, 00 mg (Etodolac) etodolac oral tablet extended release 2 (Etodolac) hr 00 mg, 00 mg, 600 mg fenoprofen oral capsule 200 mg (Nalfon) fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL 2 PA; GC PATCH 12 HOUR 1. % flurbiprofen oral tablet 100 mg, 0 mg (Flurbiprofen) ibuprofen oral suspension 100 mg/ ml (Ibuprofen) ibuprofen oral tablet 00 mg, 600 mg, (Ibuprofen) 1 GC 800 mg ketoprofen oral capsule 0 mg, 7 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 2 (Ketoprofen) hr 200 mg ketorolac injection cartridge 1 mg/ml (Ketorolac Tromethamine) ; QL (0 per 0 ketorolac injection cartridge 0 mg/ml (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac injection solution 1 mg/ml (Ketorolac Tromethamine) ; QL (0 per 0 ketorolac injection solution 0 mg/ml (1 ml) (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac injection syringe 0 mg/ml (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac intramuscular solution 60 mg/2 ml (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac oral tablet 10 mg (Ketorolac Tromethamine) ; QL (20 per 0 mefenamic acid oral capsule 20 mg (Ponstel) meloxicam oral suspension 7. mg/ ml (Mobic) meloxicam oral tablet 1 mg, 7. mg (Mobic) 1 GC 9

10 nabumetone oral tablet 00 mg, 70 mg (Nabumetone) naproxen oral suspension 12 mg/ ml (Naprosyn) naproxen oral tablet 20 mg, 7 mg, 00 (Naprosyn) 1 GC mg naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 7 mg, 00 mg naproxen sodium oral tablet 27 mg, 0 (Anaprox) 1 GC mg piroxicam oral capsule 10 mg, 20 mg (Feldene) sulindac oral tablet 10 mg, 200 mg (Sulindac) tolmetin oral capsule 00 mg (Tolmetin Sodium) tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 1 mg/ml (Xylocaine-MPF) (1. %), 0 mg/ml ( %), mg/ml (0. %) lidocaine (pf) intravenous syringe 100 (Lidocaine HCl/PF) mg/ ml (2 %) lidocaine 2% viscous soln 2 % (Xylocaine) lidocaine hcl injection solution 10 mg/ml (Xylocaine) (1 %), 20 mg/ml (2 %) lidocaine hcl mucous membrane gel 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution (Xylocaine) 2 %, % (0 mg/ml) lidocaine topical adhesive (Lidoderm) 2 PA; GC patch,medicated % lidocaine topical ointment % (Lidocaine) lidocaine-prilocaine topical cream % (EMLA) 10

11 Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (Acamprosate (dr/ec) mg Calcium) buprenorphine hcl sublingual tablet 2 mg, 8 mg (Buprenorphine HCl) 2 PA; GC; QL (90 per 0 buprenorphine-naloxone sublingual tablet 2-0. mg, 8-2 mg (Buprenorphine HCl/Naloxone HCl) 2 PA; GC; QL (90 per 0 bupropion hcl sr 10 mg tablet f/c 10 mg (Zyban) CHANTIX CONTINUING MONTH QL (168 per 8 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0. MG, 1 QL (168 per 8 MG CHANTIX STARTING MONTH QL ( per 28 BOX ORAL TABLETS,DOSE PACK 0. MG (11)- 1 MG (2) disulfiram oral tablet 20 mg, 00 mg (Antabuse) naloxone injection solution 0. mg/ml (Naloxone HCl) naloxone injection syringe 0. mg/ml, 1 (Naloxone HCl) mg/ml naltrexone oral tablet 0 mg (Revia) NARCAN NASAL QL ( per 0 SPRAY,NON-AEROSOL MG/ACTUATION NICOTROL INHALATION QL (1008 per 90 CARTRIDGE 10 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG,.7-1. MG, MG PA; QL (90 per 0 Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.2 mg, 0. mg, 1 mg, 2 mg (Xanax) ; QL (120 per 0 11

12 alprazolam oral tablet extended release 2 hr 0. mg, 1 mg, 2 mg (Xanax XR) ; QL (120 per 0 alprazolam oral tablet extended release 2 hr mg (Xanax XR) ; QL (90 per 0 chlordiazepoxide hcl oral capsule 10 mg, 2 mg, mg (Chlordiazepoxide HCl) ; QL (120 per 0 clonazepam oral tablet 0. mg, 1 mg (Klonopin) ; QL (90 per 0 clonazepam oral tablet 2 mg (Klonopin) ; QL (00 per 0 clonazepam oral tablet,disintegrating 0.12 mg, 0.2 mg, 0. mg, 1 mg (Clonazepam) ; QL (90 per 0 clonazepam oral tablet,disintegrating 2 mg (Clonazepam) ; QL (00 per 0 clorazepate dipotassium oral tablet 1 mg (Tranxene T-Tab) ; QL (120 per 0 clorazepate dipotassium oral tablet.7 mg, 7. mg (Tranxene T-Tab) ; QL (60 per 0 diazepam injection syringe mg/ml (Diazepam) ; QL (10 per 28 diazepam intensol oral concentrate mg/ml (Diazepam) ; QL (1200 per 0 diazepam oral solution mg/ ml (1 mg/ml) (Diazepam) ; QL (1200 per 0 diazepam oral tablet 10 mg, 2 mg, mg (Valium) ; QL (120 per 0 diazepam rectal kit mg, 2. mg, mg (Diastat) 12

13 estazolam oral tablet 1 mg (Estazolam) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 ; AGE (Max 6 Years) estazolam oral tablet 2 mg (Estazolam) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 6 Years) flurazepam oral capsule 1 mg (Flurazepam HCl) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 ; AGE (Max 6 Years) 1

14 flurazepam oral capsule 0 mg (Flurazepam HCl) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 6 Years) lorazepam intensol oral concentrate 2 mg/ml (Ativan) ; QL (10 per 0 lorazepam oral tablet 0. mg, 1 mg, 2 mg (Ativan) ; QL (90 per 0 midazolam oral syrup 2 mg/ml (Midazolam HCl) ; QL (10 per 0 ONFI ORAL SUSPENSION 2. MG/ML PA NSO; QL (80 per 0 temazepam oral capsule 1 mg, 22. mg, 0 mg (Restoril) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 ; AGE (Max 6 Years) 1

15 temazepam oral capsule 7. mg (Restoril) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (120 per 0 ; AGE (Max 6 Years) triazolam oral tablet 0.12 mg (Halcion) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (120 per 0 ; AGE (Max 6 Years) triazolam oral tablet 0.2 mg (Halcion) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (60 per 0 ; AGE (Max 6 Years) Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 00 MG/ ML PA BvD 1

16 gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/0 ml, 60 mg/0 ml, 70 mg/0 ml, 80 mg/100 ml, 80 mg/0 ml, 90 mg/100 ml (Gentamicin In Nacl, Iso-Osm) gentamicin injection solution 0 mg/ml (Gentamicin Sulfate) gentamicin ped 20 mg/2 ml vial (Gentamicin latex-free, sdv 20 mg/2 ml Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution 80 mg/8 ml Sulfate/PF) neomycin oral tablet 00 mg (Neomycin Sulfate) streptomycin intramuscular recon soln 1 (Streptomycin Sulfate) gram TOBI PODHALER INHALATION QL (22 per 28 CAPSULE, W/INHALATION DEVICE 28 MG tobramycin in 0.22 % nacl inhalation (Tobi) PA BvD solution for nebulization 00 mg/ ml tobramycin in 0.9 % nacl intravenous (Tobramycin/Sodium piggyback 60 mg/0 ml, 80 mg/100 ml Chloride) tobramycin sulfate injection solution 10 (Tobramycin Sulfate) mg/ml, 0 mg/ml Antibacterials, Miscellaneous baciim intramuscular recon soln 0,000 (Bacitracin) unit bacitracin intramuscular recon soln (Bacitracin) 0,000 unit chloramphenicol sod succinate (Chloramphenicol Sod intravenous recon soln 1 gram Succ) clindamycin 7 mg/ ml soln 7 mg/ ml (Cleocin Palmitate) clindamycin hcl oral capsule 10 mg, 00 (Cleocin HCl) mg, 7 mg clindamycin in % dextrose intravenous (Cleocin Phosphate In piggyback 00 mg/0 ml, 600 mg/0 ml, 900 mg/0 ml Dw) clindamycin pediatric oral recon soln 7 mg/ ml (Cleocin Palmitate) 16

17 clindamycin phosphate injection solution (Cleocin Phosphate) 10 mg/ml clindamycin phosphate intravenous (Cleocin Phosphate) solution 600 mg/ ml colistin (colistimethate na) injection (Coly-Mycin M recon soln 10 mg Parenteral) CUBICIN INTRAVENOUS RECON SOLN 00 MG daptomycin intravenous recon soln 00 (Cubicin) mg linezolid intravenous parenteral solution (Zyvox) 600 mg/00 ml linezolid oral suspension for (Zyvox) reconstitution 100 mg/ ml linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) (Metronidazole/Sodiu intravenous piggyback 00 mg/100 ml m Chloride) metronidazole oral capsule 7 mg (Flagyl) metronidazole oral tablet 20 mg, 00 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 2 mg, 0 mg (Macrodantin/Macrobi d) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 0 ; AGE (Max 6 Years) 17

18 nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg (7/2) (Macrobid) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 0 ; AGE (Max 6 Years) (Macrobid) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 0 ; AGE (Max 6 Years) nitrofurantoin oral suspension 2 mg/ ml (Furadantin) 2 PA-HRM; GC; (High Risk Med. QL applies to all members; PA required for 6 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (200 per 0 ; AGE (Max 6 Years) polymyxin b sulfate injection recon soln (Polymyxin B Sulfate) 00,000 unit SYNERCID INTRAVENOUS RECON SOLN 00 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin Hcl In gram/200 ml Dextrose %) vancomycin in 0.9% sodium cl (Vancomycin/0.9 % intravenous solution 1. gram/00 ml Sod Chloride) vancomycin intravenous recon soln 1,000 mg, 10 gram, 70 mg (Vancomycin HCl) 18

19 vancomycin intravenous recon soln 00 (Vancomycin Hcl In mg Dextrose %) vancomycin oral capsule 12 mg, 20 mg (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG PA; QL (9 per 0 XIFAXAN ORAL TABLET 0 MG PA ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/ ML Cephalosporins cefaclor oral capsule 20 mg, 00 mg (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 12 mg/ ml, 20 mg/ ml, 7 mg/ ml cefaclor oral tablet extended release 12 (Cefaclor) hr 00 mg cefadroxil oral capsule 00 mg (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 20 mg/ ml, 00 mg/ ml cefadroxil oral tablet 1 gram (Cefadroxil) cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback 1 gram/0 ml, 2 gram/0 ml Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram, 10 (Cefazolin Sodium) gram, 00 mg cefdinir oral capsule 00 mg (Cefdinir) cefdinir oral suspension for reconstitution (Cefdinir) 12 mg/ ml, 20 mg/ ml cefditoren pivoxil oral tablet 200 mg, 00 (Spectracef) mg CEFEPIME 2 GM INJECTION 2 GRAM/100 ML CEFEPIME IN DEXTROSE % INTRAVENOUS PIGGYBACK 1 GRAM/0 ML, 2 GRAM/0 ML cefepime injection recon soln 1 gram, 2 (Maxipime) gram cefixime oral suspension for reconstitution 100 mg/ ml, 200 mg/ ml (Suprax) 19

20 cefotaxime injection recon soln 1 gram, (Claforan) 10 gram, 2 gram, 00 mg cefoxitin in dextrose, iso-osm intravenous (Cefoxitin piggyback 2 gram/0 ml Sodium/Dextrose, Iso) cefoxitin intravenous recon soln 1 gram, (Cefoxitin Sodium) 10 gram, 2 gram cefpodoxime oral suspension for (Cefpodoxime Proxetil) reconstitution 100 mg/ ml, 0 mg/ ml cefpodoxime oral tablet 100 mg, 200 mg (Cefpodoxime Proxetil) cefprozil oral suspension for (Cefprozil) reconstitution 12 mg/ ml, 20 mg/ ml cefprozil oral tablet 20 mg, 00 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 (Fortaz) gram ceftibuten oral capsule 00 mg (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 180 mg/ ml ceftriaxone 1 gm piggyback 0ml (Ceftriaxone galaxycontainer 1 gram/0 ml Na/Dextrose, Iso) ceftriaxone 1 gm vial 10's, fliptop,l/f 1 (Rocephin) gram ceftriaxone 2 gm piggyback 0ml (Ceftriaxone galaxycontainer 2 gram/0 ml Na/Dextrose, Iso) ceftriaxone injection recon soln 10 gram, (Rocephin) 20 mg, 00 mg ceftriaxone intravenous recon soln 1 (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) cefuroxime axetil oral tablet 20 mg, 00 (Ceftin) mg cefuroxime sodium injection recon soln (Zinacef) 1. gram, 70 mg cefuroxime sodium intravenous recon soln (Zinacef) 7. gram cephalexin oral capsule 20 mg, 00 mg, 70 mg (Keflex) 1 GC 20

21 cephalexin oral suspension for (Cephalexin) 1 GC reconstitution 12 mg/ ml, 20 mg/ ml cephalexin oral tablet 20 mg, 00 mg (Cephalexin) 1 GC MEFOXIN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 1 GRAM/0 ML, 2 GRAM/0 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/ ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 (Fortaz) gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG Macrolides azithromycin intravenous recon soln 00 (Zithromax) mg azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 mg/ ml, 200 mg/ ml azithromycin oral tablet 20 mg, 20 mg (Zithromax) (6 pack), 600 mg azithromycin oral tablet 00 mg (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution 12 mg/ ml, 20 mg/ ml clarithromycin oral tablet 20 mg, 00 (Biaxin) mg clarithromycin oral tablet extended (Clarithromycin) release 2 hr 00 mg DIFICID ORAL TABLET 200 MG QL (20 per 10 e.e.s. 00 oral tablet 00 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for reconstitution 200 mg/ ml (Eryped 200) 21

22 ery-tab oral tablet,delayed release (Erythromycin Base) (dr/ec) 20 mg, 00 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 20 (Erythromycin mg Stearate) ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 00 MG erythromycin ethylsuccinate oral (Eryped 200) suspension for reconstitution 200 mg/ ml erythromycin ethylsuccinate oral tablet (Erythromycin 00 mg Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin Base) release(dr/ec) 20 mg erythromycin oral tablet 20 mg, 00 mg (Erythromycin Base) Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram (Azactam) CAYSTON INHALATION LA SOLUTION FOR NEBULIZATION 7 MG/ML imipenem-cilastatin intravenous recon (Primaxin) soln 20 mg, 00 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 00 (Merrem) mg meropenem iv 1 gm vial outer, latex-free (Merrem) 1 gram Penicillins amoxicillin oral capsule 20 mg, 00 mg (Amoxicillin) 1 GC amoxicillin oral suspension for (Amoxicillin) 1 GC reconstitution 12 mg/ ml, 200 mg/ ml, 20 mg/ ml, 00 mg/ ml amoxicillin oral tablet 00 mg, 87 mg (Amoxicillin) 1 GC 22

23 amoxicillin oral tablet,chewable 12 mg, (Amoxicillin) 1 GC 20 mg amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution mg/ ml, mg/ ml, 00-7 mg/ ml, mg/ ml amoxicillin-pot clavulanate oral tablet (Augmentin) mg, mg, mg amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 12 hr 1, mg amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable mg, 00-7 mg Clav) ampicillin 2 gm vial 10's, latex-free 2 (Ampicillin Sodium) gram ampicillin oral capsule 20 mg, 00 mg (Ampicillin Trihydrate) 1 GC ampicillin oral suspension for (Ampicillin Trihydrate) 1 GC reconstitution 12 mg/ ml, 20 mg/ ml ampicillin sodium injection recon soln 1 (Ampicillin Sodium) gram, 10 gram, 12 mg ampicillin sodium intravenous recon soln (Ampicillin Sodium) 2 gram ampicillin-sulbactam injection recon soln (Unasyn) 1. gram, 1 gram, gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/00K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 20 mg, 00 mg (Dicloxacillin Sodium) nafcillin 2 gm vial sterile, latex-free 2 (Nafcillin Sodium) gram nafcillin injection recon soln 1 gram, 10 (Nafcillin Sodium) gram nafcillin intravenous recon soln 2 gram (Nafcillin Sodium) 2

24 oxacillin 1 gm add-vantage vl (Oxacillin Sodium) add-vantage, inner 1 gram oxacillin in dextrose(iso-osm) (Oxacillin intravenous piggyback 1 gram/0 ml, 2 gram/0 ml Sodium/Dextrose, Iso) oxacillin injection recon soln 10 gram (Oxacillin Sodium) oxacillin intravenous recon soln 2 gram (Oxacillin Sodium) penicillin g pot in dextrose intravenous (Pen G piggyback 1 million unit/0 ml, 2 million unit/0 ml, million unit/0 ml Pot/Dextrose-Water) penicillin g potassium injection recon soln (Penicillin G million unit Potassium) penicillin g procaine intramuscular (Penicillin G Procaine) syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million (Penicillin G unit Potassium) penicillin v potassium oral recon soln 12 (Penicillin V mg/ ml, 20 mg/ ml Potassium) penicillin v potassium oral tablet 20 mg, 00 mg (Penicillin V Potassium) pfizerpen-g injection recon soln 20 million (Penicillin G unit Potassium) piperacillin-tazobactam intravenous (Zosyn) recon soln 2.2 gram,.7 gram,. gram piperacil-tazobact 0. gram p/f, (Zosyn) latex-free 0. gram Quinolones ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase 2 hr 1,000 mg, 00 mg ciprofloxacin hcl oral tablet 100 mg, 20 (Cipro) 1 GC mg, 00 mg, 70 mg ciprofloxacin in % dextrose intravenous (Cipro I.V.) piggyback 200 mg/100 ml ciprofloxacin lactate intravenous solution 00 mg/0 ml (Ciprofloxacin Lactate) 2

25 ciprofloxacin oral (Cipro) suspension,microcapsule recon 20 mg/ ml, 00 mg/ ml ciprofloxacn-dw 00 mg/200 ml (Cipro I.V.) p/f,latex/f, in dw 00 mg/200 ml levofloxacin in dw intravenous (Levaquin) piggyback 00 mg/100 ml, 70 mg/10 ml levofloxacin intravenous solution 2 (Levofloxacin) mg/ml levofloxacin oral solution 20 mg/10 ml (Levaquin) levofloxacin oral tablet 20 mg, 00 mg, (Levaquin) 1 GC 70 mg moxifloxacin oral tablet 00 mg (Avelox) ofloxacin oral tablet 00 mg (Ofloxacin) Sulfonamides sulfadiazine oral tablet 00 mg (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Tri intravenous solution mg/ ml methoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tri suspension mg/ ml methoprim) sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet mg, mg sulfasalazine oral tablet 00 mg (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine) (dr/ec) 00 mg sulfatrim oral suspension mg/ ml (Sulfamethoxazole/Tri methoprim) Tetracyclines demeclocycline oral tablet 10 mg, 00 (Demeclocycline HCl) mg doxy-100 intravenous recon soln 100 mg (Doxycycline Hyclate) doxycycline hyclate 100 mg cap 100 mg (Morgidox) doxycycline hyclate 100 mg tab 100 mg (Doryx) doxycycline hyclate intravenous recon (Doxycycline Hyclate) soln 100 mg doxycycline hyclate oral capsule 100 mg (Adoxa) 2

26 doxycycline hyclate oral capsule 0 mg (Morgidox) doxycycline hyclate oral tablet 100 mg, (Avidoxy) 0 mg doxycycline hyclate oral tablet 20 mg (Doryx) doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 100 mg, 10 mg, 200 mg, 0 mg, 7 mg doxycycline mono 100 mg cap 100 mg (Adoxa) doxycycline mono 100 mg tablet f/c 100 (Avidoxy) mg doxycycline mono 0 mg tablet 0 mg (Avidoxy) doxycycline monohydrate oral capsule (Adoxa) 10 mg, 0 mg, 7 mg doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 2 mg/ ml doxycycline monohydrate oral tablet 10 (Avidoxy) mg, 7 mg MINOCIN INTRAVENOUS RECON SOLN 100 MG minocycline oral capsule 100 mg, 0 mg, (Minocin) 7 mg minocycline oral tablet 100 mg, 0 mg, (Minocycline HCl) 7 mg minocycline oral tablet extended release (Minocycline HCl) 2 hr 1 mg, mg, 90 mg tetracycline oral capsule 20 mg, 00 mg (Tetracycline HCl) TYGACIL INTRAVENOUS RECON SOLN 0 MG Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 0 MG PA NSO; QL ( per 21 26

27 adriamycin intravenous recon soln 10 mg, (Doxorubicin HCl) 2 PA BvD; GC 20 mg, 0 mg adriamycin intravenous solution 10 mg/ (Doxorubicin HCl) 2 PA BvD; GC ml adrucil 2,00 mg/0 ml vial outer, latex-free 2. gram/0 ml (Fluorouracil) 2 PA BvD; GC adrucil intravenous solution 00 mg/10 ml (Fluorouracil) 2 PA BvD; GC AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, PA NSO; QL (112 per 28 MG, MG AFINITOR ORAL TABLET 10 MG PA NSO; QL (6 per 28 AFINITOR ORAL TABLET 2. MG, MG, 7. MG PA NSO; QL (28 per 28 ALECENSA ORAL CAPSULE 10 MG PA NSO; QL (20 per 0 ALIMTA INTRAVENOUS RECON SOLN 00 MG anastrozole oral tablet 1 mg (Arimidex) AVASTIN INTRAVENOUS PA NSO SOLUTION 2 MG/ML, 2 MG/ML (16 ML) azacitidine injection recon soln 100 mg (Vidaza) BELEODAQ INTRAVENOUS PA NSO RECON SOLN 00 MG BENDEKA INTRAVENOUS PA NSO SOLUTION 2 MG/ML bexarotene oral capsule 7 mg (Targretin) PA NSO; QL (20 per 0 bicalutamide oral tablet 0 mg (Casodex) bleomycin injection recon soln 0 unit (Bleomycin Sulfate) 2 PA BvD; GC bleomycin sulfate 1 unit vial latex-free 1 unit (Bleomycin Sulfate) 2 PA BvD; GC BLINCYTO INTRAVENOUS KIT MCG PA NSO; QL (10 per 6 27

28 BOSULIF ORAL TABLET 100 MG PA NSO; QL (120 per 0 BOSULIF ORAL TABLET 00 MG PA NSO; QL (0 per 0 CABOMETYX ORAL TABLET 20 MG, 60 MG PA NSO; QL (0 per 0 CABOMETYX ORAL TABLET 0 MG PA NSO; QL (60 per 0 CAPRELSA ORAL TABLET 100 MG PA NSO; QL (60 per 0 CAPRELSA ORAL TABLET 00 MG PA NSO; QL (0 per 0 carboplatin intravenous solution 10 (Carboplatin) mg/ml cladribine intravenous solution 10 mg/10 ml (Cladribine) 2 PA BvD; GC COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 10 MG/DAY(80 MG X1-20 MG X), 60 MG/DAY (20 MG X /DAY) PA NSO; QL (112 per 28 COTELLIC ORAL TABLET 20 MG PA NSO; LA; QL (6 per 28 cyclophosphamide intravenous recon soln (Cyclophosphamide) 2 PA BvD; GC 1 gram, 2 gram, 00 mg CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 2 MG, 0 MG cyclophosphamide oral tablet 2 mg, 0 (Cyclophosphamide) 2 PA BvD; ST; GC mg CYRAMZA INTRAVENOUS PA NSO SOLUTION 10 MG/ML, 10 MG/ML (0 ML) dactinomycin intravenous recon soln 0. (Dactinomycin) mg DARZALEX INTRAVENOUS PA NSO; LA SOLUTION 20 MG/ML DAUNOXOME INTRAVENOUS SOLUTION 2 MG/ML 28

29 decitabine intravenous recon soln 0 mg (Dacogen) docetaxel 160 mg/16 ml vial mdv 160 (Taxotere) mg/16 ml (10 mg/ml) docetaxel intravenous solution 20 mg/2 (Taxotere) ml (final), 80 mg/ ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin, peg-liposomal intravenous (Doxil) PA BvD suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 00 MG, 00 MG ELIGARD ( MONTH) QL (1 per 8 SUBCUTANEOUS SYRINGE 22. MG ELIGARD ( MONTH) QL (1 per 112 SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) QL (1 per 168 SUBCUTANEOUS SYRINGE MG ELIGARD SUBCUTANEOUS SYRINGE 7. MG (1 MONTH) EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS PA NSO RECON SOLN 00 MG, 00 MG ERIVEDGE ORAL CAPSULE 10 MG PA NSO; QL (0 per 0 ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Etoposide) exemestane oral tablet 2 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 PA NSO MG, 1 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 20 MG/ ML floxuridine injection recon soln 0. gram (Floxuridine) 2 PA BvD; GC fluorouracil,000 mg/100 ml latex-free gram/100 ml (Fluorouracil) 2 PA BvD; GC 29

30 fluorouracil intravenous solution 1 (Fluorouracil) 2 PA BvD; GC gram/20 ml, 2. gram/0 ml, 00 mg/10 ml flutamide oral capsule 12 mg (Flutamide) GAZYVA INTRAVENOUS PA NSO SOLUTION 1,000 MG/0 ML gemcitabine intravenous recon soln 1 (Gemzar) gram GILOTRIF ORAL TABLET 20 MG, 0 MG, 0 MG PA NSO; QL (0 per 0 GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG HERCEPTIN INTRAVENOUS PA NSO RECON SOLN 0 MG HEXALEN ORAL CAPSULE 0 MG hydroxyurea oral capsule 00 mg (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 12 MG, 7 MG PA NSO; QL (21 per 28 ICLUSIG ORAL TABLET 1 MG PA NSO; QL (60 per 0 ICLUSIG ORAL TABLET MG PA NSO; QL (0 per 0 ifosfamide 1 gm/20 ml vial suv 1 gram/20 (Ifex) 2 PA BvD; GC ml ifosfamide intravenous recon soln 1 gram (Ifex) 2 PA BvD; GC ifosfamide-mesna intravenous kit 1-1 (Ifosfamide/Mesna) PA BvD gram,,000-1,000 mg imatinib oral tablet 100 mg (Gleevec) PA NSO; QL (90 per 0 imatinib oral tablet 00 mg (Gleevec) PA NSO; QL (60 per 0 IMBRUVICA ORAL CAPSULE 10 MG PA NSO IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML PA NSO; QL ( per 6 0

31 IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML PA NSO; QL (8 per 28 INLYTA ORAL TABLET 1 MG PA NSO; QL (180 per 0 INLYTA ORAL TABLET MG PA NSO; QL (60 per 0 IRESSA ORAL TABLET 20 MG PA NSO; QL (60 per 0 irinotecan intravenous solution 100 mg/ (Camptosar) ml, 00 mg/2 ml IXEMPRA 1 MG KIT WITH DILUENT 1 MG IXEMPRA INTRAVENOUS RECON SOLN MG JAKAFI ORAL TABLET 10 MG, 1 MG, 20 MG, 2 MG, MG PA NSO; QL (60 per 0 KEYTRUDA INTRAVENOUS PA NSO RECON SOLN 0 MG KEYTRUDA INTRAVENOUS PA NSO SOLUTION 100 MG/ ML (2 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 0 MG PA NSO; QL (12 per 28 KYPROLIS INTRAVENOUS RECON SOLN 60 MG PA NSO; QL (6 per 28 LARTRUVO INTRAVENOUS PA NSO; LA SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 PA NSO MG/DAY (10 MG X 1/DAY), 1 MG/DAY(10 MG X 1- MG X 1), 18 MG/DAY (10 MG X 1- MG X2), 20 MG/DAY (10 MG X 2), 2 MG/DAY(10 MG X 2- MG X 1), 8 MG/DAY ( MG X 2) letrozole oral tablet 2. mg (Femara) LEUKERAN ORAL TABLET 2 MG 1

32 leuprolide subcutaneous kit 1 mg/0.2 ml (Leuprolide Acetate) lipodox 0 intravenous suspension 2 (Doxil) PA BvD mg/ml lipodox intravenous suspension 2 mg/ml (Doxil) PA BvD lomustine oral capsule 10 mg, 100 mg, 0 (Lomustine) mg LONSURF ORAL TABLET MG PA NSO; QL (100 per 28 LONSURF ORAL TABLET MG PA NSO; QL (80 per 28 LUPRON DEPOT ( MONTH) QL (1 per 8 INTRAMUSCULAR SYRINGE KIT 11.2 MG, 22. MG LUPRON DEPOT ( MONTH) QL (1 per 8 INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) QL (1 per 168 INTRAMUSCULAR SYRINGE KIT MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.7 MG, 7. MG LYNPARZA ORAL CAPSULE 0 MG PA NSO; QL (80 per 0 LYSODREN ORAL TABLET 00 MG MARQIBO INTRAVENOUS KIT MG/1 ML(0.16 MG/ML) FINAL PA NSO; QL ( per 28 MATULANE ORAL CAPSULE 0 MG megestrol oral tablet 20 mg, 0 mg (Megestrol Acetate) MEKINIST ORAL TABLET 0. MG PA NSO; QL (90 per 0 MEKINIST ORAL TABLET 2 MG PA NSO; QL (0 per 0 melphalan hcl intravenous recon soln 0 (Alkeran) mg mercaptopurine oral tablet 0 mg (Mercaptopurine) 2

33 methotrexate 0 mg/2 ml vial latex-free, (Methotrexate Sodium) 2 PA BvD; GC 's, mdv 2 mg/ml methotrexate sodium (pf) injection recon (Methotrexate 2 PA BvD; GC soln 1 gram Sodium/PF) methotrexate sodium (pf) injection (Methotrexate Sodium) 2 PA BvD; GC solution 2 mg/ml methotrexate sodium oral tablet 2. mg (Methotrexate Sodium) 2 PA BvD; ST; GC mitoxantrone intravenous concentrate 2 (Mitoxantrone HCl) mg/ml NEXAVAR ORAL TABLET 200 MG PA NSO; QL (120 per 0 NILANDRON ORAL TABLET 10 MG nilutamide oral tablet 10 mg (Nilandron) NINLARO ORAL CAPSULE 2. MG, MG, MG PA NSO; QL ( per 28 ODOMZO ORAL CAPSULE 200 MG PA NSO; LA ONCASPAR INJECTION PA NSO SOLUTION 70 UNIT/ML onxol intravenous concentrate 6 mg/ml (Paclitaxel) OPDIVO INTRAVENOUS PA NSO SOLUTION 0 MG/ ML oxaliplatin intravenous solution 100 (Eloxatin) mg/20 ml paclitaxel intravenous concentrate 6 (Paclitaxel) mg/ml PERJETA INTRAVENOUS PA NSO SOLUTION 20 MG/1 ML (0 MG/ML) POMALYST ORAL CAPSULE 1 MG, 2 MG, MG, MG PA NSO; QL (21 per 28 PORTRAZZA INTRAVENOUS SOLUTION 800 MG/0 ML (16 PA NSO; QL (100 per 21 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT

34 PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 PA NSO; LA MG, 1 MG, 2. MG, 20 MG, 2 MG, MG RITUXAN INTRAVENOUS PA NSO CONCENTRATE 10 MG/ML SOLTAMOX ORAL SOLUTION 10 MG/ ML SPRYCEL ORAL TABLET 100 MG, 10 MG, 0 MG, 70 MG, 80 MG PA NSO; QL (0 per 0 SPRYCEL ORAL TABLET 20 MG PA NSO; QL (60 per 0 STIVARGA ORAL TABLET 0 MG PA NSO; QL (8 per 28 SUTENT ORAL CAPSULE 12. MG, 2 MG, 7. MG, 0 MG PA NSO; QL (0 per 0 SYLVANT INTRAVENOUS RECON PA NSO SOLN 100 MG, 00 MG SYNRIBO SUBCUTANEOUS RECON SOLN. MG PA NSO; QL (28 per 28 TABLOID ORAL TABLET 0 MG TAFINLAR ORAL CAPSULE 0 MG, 7 MG PA NSO; QL (120 per 0 TAGRISSO ORAL TABLET 0 MG, 80 MG PA NSO; LA; QL (0 per 0 tamoxifen oral tablet 10 mg, 20 mg (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 2 MG PA NSO; QL (60 per 0 TARCEVA ORAL TABLET 10 MG PA NSO; QL (90 per 0 TARGRETIN ORAL CAPSULE 7 MG PA NSO; QL (20 per 0 TARGRETIN TOPICAL GEL 1 % PA NSO; QL (60 per 28 TASIGNA ORAL CAPSULE 10 MG, 200 MG PA NSO; QL (112 per 28

35 TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG teniposide intravenous solution 0 mg/ ml (Teniposide) PA NSO; QL (20 per 21 PA NSO; (vial only) thiotepa injection recon soln 1 mg (Thiotepa) toposar intravenous solution 20 mg/ml (Etoposide) topotecan hcl mg/ ml vial (Hycamtin) suv,latex-free mg/ ml (1 mg/ml) topotecan intravenous recon soln mg (Hycamtin) TORISEL INTRAVENOUS RECON SOLN 0 MG/ ML (10 MG/ML) PA BvD; QL ( per 28 (FIRST) TREANDA 2 MG VIAL 2 MG TREANDA INTRAVENOUS RECON SOLN 100 MG TREANDA INTRAVENOUS SOLUTION 180 MG/2 ML, MG/0. ML TRELSTAR 22. MG SYRINGE QL (1 per 168 OUTER 22. MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 168 SUSPENSION FOR RECONSTITUTION 22. MG TRELSTAR INTRAMUSCULAR QL (1 per 8 SYRINGE 11.2 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE.7 MG/2 ML tretinoin (chemotherapy) oral capsule 10 (Tretinoin) (capsule: 10mg) mg TREXALL ORAL TABLET 10 MG, PA BvD; ST 1 MG, MG, 7. MG TYKERB ORAL TABLET 20 MG UNITUXIN INTRAVENOUS SOLUTION. MG/ML PA NSO

36 VALSTAR INTRAVESICAL SOLUTION 0 MG/ML VECTIBIX INTRAVENOUS PA NSO SOLUTION 100 MG/ ML (20 MG/ML) VELCADE INJECTION RECON PA NSO SOLN. MG VENCLEXTA ORAL TABLET 10 PA NSO; LA MG, 0 MG VENCLEXTA ORAL TABLET 100 PA NSO; LA MG VENCLEXTA STARTING PACK PA NSO; LA ORAL TABLETS,DOSE PACK 10 MG-0 MG- 100 MG vinblastine intravenous solution 1 mg/ml (Vinblastine Sulfate) 2 PA BvD; GC vincasar pfs 2 mg/2 ml vial 2 mg/2 ml (Vincristine Sulfate) 2 PA BvD; GC vincasar pfs intravenous solution 1 mg/ml (Vincristine Sulfate) 2 PA BvD; GC vincristine 2 mg/2 ml vial p/f, sdv 2 mg/2 (Vincristine Sulfate) 2 PA BvD; GC ml vincristine intravenous solution 1 mg/ml (Vincristine Sulfate) 2 PA BvD; GC vinorelbine intravenous solution 0 mg/ (Navelbine) ml VOTRIENT ORAL TABLET 200 MG PA NSO; QL (120 per 0 XALKORI ORAL CAPSULE 200 MG, 20 MG PA NSO; QL (60 per 0 XTANDI ORAL CAPSULE 0 MG PA NSO; QL (120 per 0 YERVOY INTRAVENOUS PA NSO SOLUTION 0 MG/10 ML ( MG/ML) YONDELIS INTRAVENOUS PA NSO RECON SOLN 1 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/ ML (2 MG/ML) PA NSO 6

37 ZELBORAF ORAL TABLET 20 MG PA NSO; QL (20 per 0 ZOLADEX SUBCUTANEOUS QL (1 per 8 IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS QL (1 per 28 IMPLANT.6 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 10 MG PA NSO; QL (60 per 0 ZYKADIA ORAL CAPSULE 10 MG PA NSO; QL (10 per 28 ZYTIGA ORAL TABLET 20 MG PA NSO; QL (120 per 0 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0. mg/ml, 1 (Atropine Sulfate) mg/ml atropine injection syringe 0.0 mg/ml, 0.1 (Atropine Sulfate) mg/ml atropine intravenous syringe 0.8 mg/2 ml (Atropine Sulfate) (0. mg/ml) propantheline oral tablet 1 mg (Propantheline Bromide) STIOLTO RESPIMAT QL ( per 28 INHALATION MIST MCG/ACTUATION Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 00 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 0 MG/ML BANZEL ORAL TABLET 200 MG, 00 MG BRIVIACT INTRAVENOUS SOLUTION 0 MG/ ML QL (80 per 0 7

38 BRIVIACT ORAL SOLUTION 10 QL (600 per 0 MG/ML BRIVIACT ORAL TABLET 10 MG, QL (60 per MG, 2 MG, 0 MG, 7 MG carbamazepine oral capsule, er (Carbatrol) multiphase 12 hr 100 mg, 200 mg, 00 mg carbamazepine oral suspension 100 mg/ (Tegretol) ml carbamazepine oral tablet 200 mg (Tegretol) carbamazepine oral tablet extended (Tegretol XR) release 12 hr 100 mg, 200 mg, 00 mg carbamazepine oral tablet,chewable 100 (Carbamazepine) mg CELONTIN ORAL CAPSULE 00 MG DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, sprinkle 12 mg (Depakote Sprinkle) divalproex oral tablet extended release 2 (Depakote ER) hr 20 mg, 00 mg divalproex oral tablet,delayed release (Depakote) (dr/ec) 12 mg, 20 mg, 00 mg epitol oral tablet 200 mg (Tegretol) ethosuximide oral capsule 20 mg (Zarontin) ethosuximide oral solution 20 mg/ ml (Zarontin) felbamate oral suspension 600 mg/ ml (Felbatol) felbamate oral tablet 00 mg, 600 mg (Felbatol) fosphenytoin 00 mg pe/10 ml (Cerebyx) 10's,sdv,latex-free 00 mg pe/10 ml fosphenytoin injection solution 100 mg (Cerebyx) pe/2 ml FYCOMPA ORAL SUSPENSION 0. MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 00 mg, 00 mg (Neurontin) 8

39 gabapentin oral solution 20 mg/ ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG GRALISE 0-DAY STARTER PACK ST; QL (78 per 0 ORAL TABLET EXTENDED RELEASE 2 HR 00 MG (9)- 600 MG (69) GRALISE ORAL TABLET ST; QL (90 per 0 EXTENDED RELEASE 2 HR 00 MG, 600 MG LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK 2 MG (21) -0 MG (7) LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK 0 MG (2) -100 MG (1) LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK 2 MG(1)-0 MG (1)-100 MG (7) LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet 100 mg, 10 mg, (Lamictal) 200 mg, 2 mg lamotrigine oral tablet disintegrating, (Lamictal Odt (Blue)) dose pk 2 mg (21) -0 mg (7), 2 mg(1)-0 mg (1)-100 mg (7), 0 mg (2) -100 mg (1) lamotrigine oral tablet extended release (Lamictal XR) 2hr 100 mg, 200 mg, 2 mg, 20 mg, 00 mg, 0 mg lamotrigine oral tablet, chewable (Lamictal) dispersible 2 mg, mg lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 2 mg, 0 mg (Lamictal Odt) 9

40 lamotrigine oral tablets,dose pack 2 mg () (Lamictal (Blue)) levetiracetam in nacl (iso-os) intravenous (Levetiracetam In Nacl piggyback 1,000 mg/100 ml, 1,00 (Iso-Os)) mg/100 ml, 00 mg/100 ml levetiracetam intravenous solution 00 (Keppra) mg/ ml levetiracetam oral solution 100 mg/ml (Keppra) levetiracetam oral tablet 1,000 mg, 20 (Roweepra) mg, 00 mg, 70 mg levetiracetam oral tablet extended release (Keppra XR) 2 hr 00 mg, 70 mg LYRICA ORAL CAPSULE 100 MG, QL (90 per 0 10 MG, 200 MG, 22 MG, 2 MG, 00 MG, 0 MG, 7 MG LYRICA ORAL SOLUTION 20 QL (900 per 0 MG/ML oxcarbazepine oral suspension 00 mg/ (Trileptal) ml oxcarbazepine oral tablet 10 mg, 00 (Trileptal) mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE 2 HR 10 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 20 MG phenobarbital oral elixir 20 mg/ ml ( mg/ml) (Phenobarbital) ; QL (100 per 0 phenobarbital oral tablet 100 mg, 1 mg, 16.2 mg, 2. mg, 60 mg, 6.8 mg, 97.2 (Phenobarbital) ; QL (90 per 0 mg phenobarbital oral tablet 0 mg (Phenobarbital) ; QL (200 per 0 phenobarbital sodium injection solution (Phenobarbital ; QL (2 per 0 10 mg/ml, 6 mg/ml Sodium) PHENYTEK ORAL CAPSULE 200 MG, 00 MG 0

41 phenytoin oral suspension 12 mg/ ml (Dilantin-12) phenytoin oral tablet,chewable 0 mg (Dilantin) phenytoin sodium extended oral capsule (Phenytek) 100 mg, 200 mg, 00 mg phenytoin sodium intravenous solution 0 (Phenytoin Sodium) mg/ml phenytoin sodium intravenous syringe 0 (Phenytoin Sodium) mg/ml POTIGA ORAL TABLET 200 MG, QL (90 per 0 00 MG, 00 MG POTIGA ORAL TABLET 0 MG QL (270 per 0 primidone oral tablet 20 mg, 0 mg (Mysoline) ROWEEPRA ORAL TABLET 00 MG SABRIL ORAL POWDER IN PACKET 00 MG SABRIL ORAL TABLET 00 MG SPRITAM ORAL TABLET FOR ST; QL (60 per 0 SUSPENSION 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION 20 MG, 00 MG, 70 ST; QL (120 per 0 MG TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG tiagabine oral tablet 2 mg, mg (Gabitril) topiragen oral tablet 100 mg, 200 mg, 2 (Topamax) mg, 0 mg topiramate oral capsule, sprinkle 1 mg, (Topamax) 2 mg topiramate oral capsule,sprinkle,er 2hr (Qudexy XR) 100 mg, 10 mg, 200 mg, 2 mg, 0 mg topiramate oral tablet 100 mg, 200 mg, 2 mg, 0 mg (Topamax) 1

42 TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 2HR 100 MG, 200 MG, 2 MG, 0 MG valproate sodium intravenous solution (Depacon) 00 mg/ ml (100 mg/ml) valproic acid (as sodium salt) oral (Depakene) solution 20 mg/ ml valproic acid oral capsule 20 mg (Depakene) VIMPAT INTRAVENOUS QL (200 per SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 QL (1200 per 0 MG/ML VIMPAT ORAL TABLET 100 MG, QL (60 per 0 10 MG, 200 MG, 0 MG zonisamide oral capsule 100 mg, 2 mg, (Zonegran) 0 mg Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 2 mg, mg (Aricept) ; QL (0 per 0 donepezil oral tablet,disintegrating 10 mg, mg (Donepezil HCl) ; QL (0 per 0 galantamine oral capsule,ext rel. pellets 2 hr 16 mg, 2 mg, 8 mg (Razadyne ER) ; QL (0 per 0 galantamine oral solution mg/ml (Galantamine Hbr) ; QL (200 per 0 galantamine oral tablet 12 mg, mg, 8 mg (Razadyne) ; QL (60 per 0 memantine oral solution 2 mg/ml (Namenda) ; QL (60 per 0 memantine oral tablet 10 mg, mg (Namenda) ; QL (60 per 0 memantine oral tablets,dose pack -10 mg (Namenda) ; QL (9 per 28 2

43 NAMENDA XR ORAL CAP,SPRINKLE,ER 2HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 2HR 1 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 2HR 1-10 MG, MG, MG, 7-10 MG rivastigmine tartrate oral capsule 1. mg, mg,. mg, 6 mg rivastigmine transdermal patch 2 hour 1. mg/2 hour,.6 mg/2 hr, 9. mg/2 hr Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 10 mg, 2 mg, 0 mg, 7 mg amoxapine oral tablet 100 mg, 10 mg, 2 mg, 0 mg BRINTELLIX ORAL TABLET 10 MG, 20 MG, MG buproban oral tablet extended release 10 mg bupropion hcl (smoking deter) oral tablet extended release 10 mg QL (28 per 28 QL (0 per 0 (Exelon) ; QL (60 per 0 (Exelon) ; QL (0 per 0 (Amitriptyline HCl) 2 PA NSO-HRM; GC (Amoxapine) (Wellbutrin SR) (Wellbutrin SR) bupropion hcl oral tablet 100 mg, 7 mg (Wellbutrin) bupropion hcl oral tablet extended release 100 mg, 10 mg, 200 mg (Wellbutrin SR) bupropion hcl oral tablet extended release (Wellbutrin XL) 2 hr 10 mg, 00 mg citalopram oral solution 10 mg/ ml (Citalopram Hydrobromide) citalopram oral tablet 10 mg, 20 mg, 0 mg (Celexa) 1 GC; QL (0 per 0

44 clomipramine oral capsule 2 mg, 0 mg, (Anafranil) 2 PA NSO-HRM; GC 7 mg desipramine oral tablet 10 mg, 100 mg, (Norpramin) 10 mg, 2 mg, 0 mg, 7 mg DESVENLAFAXINE FUMARATE QL (0 per 0 ORAL TABLET EXTENDED RELEASE 2HR 100 MG, 0 MG doxepin oral capsule 10 mg, 100 mg, 10 (Doxepin HCl) 2 PA NSO-HRM; GC mg, 2 mg, 0 mg, 7 mg doxepin oral concentrate 10 mg/ml (Doxepin HCl) 2 PA NSO-HRM; GC duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Duloxetine) ; (Cymbalta); QL (60 per 0 duloxetine oral capsule,delayed release(dr/ec) 0 mg (Duloxetine) ; (Cymbalta); QL (0 per 0 duloxetine oral capsule,delayed release(dr/ec) 0 mg (Duloxetine) ; (Irenka); QL (0 per 0 EMSAM TRANSDERMAL PATCH QL (0 per 0 2 HOUR 12 MG/2 HR, 6 MG/2 HR, 9 MG/2 HR escitalopram oxalate oral solution mg/ (Lexapro) ml escitalopram oxalate oral tablet 10 mg, (Lexapro) 20 mg, mg FETZIMA ORAL CAPSULE,EXT REL 2HR DOSE PACK 20 MG (2)- 0 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 2 HR 120 MG, 20 MG, 0 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 0 (Prozac) 1 GC mg fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) 90 mg fluoxetine oral solution 20 mg/ ml ( (Fluoxetine HCl) mg/ml) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl)

45 FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral capsule,extended (Fluvoxamine Maleate) release 2hr 100 mg, 10 mg fluvoxamine oral tablet 100 mg, 2 mg, (Fluvoxamine Maleate) 0 mg imipramine hcl oral tablet 10 mg, 2 mg, 0 mg (Tofranil) 2 PA NSO-HRM; GC imipramine pamoate oral capsule 100 mg, (Tofranil-Pm) 2 PA NSO-HRM; GC 12 mg, 10 mg, 7 mg maprotiline oral tablet 2 mg, 0 mg, 7 (Maprotiline HCl) mg MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 1 mg, 0 mg, (Remeron) mg, 7. mg mirtazapine oral tablet,disintegrating 1 (Remeron) mg, 0 mg, mg nefazodone oral tablet 100 mg, 10 mg, (Nefazodone HCl) 200 mg, 20 mg, 0 mg nortriptyline oral capsule 10 mg, 2 mg, (Pamelor) 0 mg, 7 mg nortriptyline oral solution 10 mg/ ml (Nortriptyline HCl) olanzapine-fluoxetine oral capsule 12-2 (Symbyax) mg, 12-0 mg, -2 mg, 6-2 mg, 6-0 mg paroxetine hcl oral tablet 10 mg, 20 mg, (Paxil) 0 mg, 0 mg paroxetine hcl oral tablet extended (Paxil CR) release 2 hr 12. mg, 2 mg, 7. mg PAXIL ORAL SUSPENSION 10 MG/ ML phenelzine oral tablet 1 mg (Nardil) PRISTIQ ORAL TABLET QL (0 per 0 EXTENDED RELEASE 2 HR 100 MG, 2 MG, 0 MG protriptyline oral tablet 10 mg, mg (Protriptyline HCl)

46 sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 2 mg, 0 (Zoloft) 1 GC mg SILENOR ORAL TABLET MG, 6 QL (0 per 0 MG SURMONTIL ORAL CAPSULE 100 PA NSO-HRM MG, 2 MG, 0 MG tranylcypromine oral tablet 10 mg (Parnate) trazodone oral tablet 100 mg, 10 mg, 00 mg, 0 mg (Trazodone HCl) 1 GC trimipramine oral capsule 100 mg, 2 mg, (Trimipramine 2 PA NSO-HRM; GC 0 mg Maleate) TRINTELLIX ORAL TABLET 10 MG, 20 MG, MG venlafaxine oral capsule,extended release (Effexor XR) 2hr 10 mg, 7. mg, 7 mg venlafaxine oral tablet 100 mg, 2 mg, (Venlafaxine HCl) 7. mg, 0 mg, 7 mg venlafaxine oral tablet extended release (Venlafaxine HCl) 2hr 10 mg, 7. mg, 7 mg venlafaxine oral tablet extended release (Venlafaxine HCl) 2hr 22 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 0 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (2), 10 MG (7)-20 MG (7)-0 MG (16) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 2 mg, 0 mg (Precose) ; QL (90 per 0 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 2 HR 1-1,000 MG, 0-1,000 MG QL (60 per 0 6

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