Formulary Medi-Cal 2017

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1 ormulary Medi-Cal 2017

2 IEHP Medi-Cal 2017 ormulary Table of Contents Analgesics... 3 Anesthetics... 4 Antiarthritics... 4 Antiasthmatics... 5 Antibiotics... 6 Anticoagulants Antifungals Antihistamine and Decongestant Combination Antihistamines Antihyperglycemics Antiinfectives/Miscellaneous Antineoplastics Antiparkinson Drugs Antiplatelet Drugs Antivirals Autonomic Drugs Biologicals Blood Cardiac Drugs Cardiovascular Central Nervous System (CNS) Drugs Colony Stimulating actors Contraceptives Cough/Cold Preparations Diagnostic Diuretics Eye, Ear, Nose, and Throat (EENT) Preps Electrolyte/Caloric/H2O Gastrointestinal Hormones Immunosuppressants Miscellaneous Medical Supplies, Devices, Non-Drug

3 Muscle Relaxants Pre-Natal Vitamins Psychotherapeutic Drugs Sedative/Hypnotics Skin Preps Smoking Deterrents Thyroid Preps Unclassified Drug Products Vitamins Index

4 IEHP Medi-Cal 2017 ormulary List of Covered Drugs CURRENT AS O 10/1/2017 lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs Tier = Code 1 = ormulary NC= Not Covered Requirements/Limits PA= Prior Authorization = Quantity Limit SPO= Specialty Pharmacy Only ST= Step Therapy Drug Name Analgesics acetaminophen oral drops, suspension 80 mg/0.8 ml acetaminophen oral elixir 160 mg/5 ml acetaminophen oral liquid 160 mg/5 ml acetaminophen oral solution 160 mg/5 ml (5 ml) acetaminophen oral suspension 160 mg/5 ml acetaminophen oral tablet 325 mg acetaminophen oral tablet 500 mg acetaminophen rectal suppository 120 mg acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet mg, mg, mg aspirin oral tablet 325 mg aspirin oral tablet, delayed release (dr/ec) 325 mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg CAPITAL WITH CODEINE ORAL SUSPENSION MG/5 ML CHILDREN'S NON-ASPIRIN ORAL TABLET, CHEWABLE 80 MG choline, magnesium salicylate oral liquid 500 mg/5 ml diclofenac potassium oral tablet 50 mg dihydroergotamine injection solution 1 mg/ml ELMIRON ORAL CAPSULE 100 MG ergotamine-caffeine oral tablet mg fentanyl transdermal patch 72 hour 100 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr 3

5 EVERALL RECTAL SUPPOSITORY 325 MG, 80 MG hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg infant's non-aspirin oral drops 100 mg/ml isometh-dichloral-acetaminophn oral capsule mg KADIAN ORAL CAPSULE, EXTEND.RELEASE PELLETS 200 MG ketorolac oral tablet 10 mg MIGERGOT RECTAL SUPPOSITORY MG MIGRAINE ORMULA ORAL TABLET MG morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule, extend. release pellets 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml) morphine oral tablet 15 mg, 30 mg morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg non-aspirin jr strength oral tablet, chewable 160 mg nortemp oral drops 80 mg/0.8 ml oxycodone-acetaminophen oral tablet mg, mg, mg oxycodone-aspirin oral tablet mg rizatriptan oral tablet 10 mg, 5 mg sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg tramadol oral tablet 50 mg Anesthetics BUCALSEP MUCOUS MEMBRANE SOLUTION lidocaine topical adhesive patch, medicated 5 % LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 % lidocaine-prilocaine topical cream % phenazopyridine oral tablet 100 mg, 200 mg Antiarthritics allopurinol oral tablet 100 mg, 300 mg celecoxib oral capsule 100 mg, 200 mg, 50 mg ST colchicine oral capsule 0.6 mg 4

6 colchicine oral tablet 0.6 mg diclofenac sodium oral tablet extended release 24 hr 100 mg diclofenac sodium oral tablet, delayed release (dr/ec) 25 mg, 50 mg, 75 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg ibuprofen oral capsule 200 mg ibuprofen oral suspension 100 mg/5 ml ibuprofen oral tablet 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg, 50 mg leflunomide oral tablet 10 mg, 20 mg meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral suspension 125 mg/5 ml naproxen oral tablet 250 mg, 375 mg, 500 mg naproxen sodium oral tablet 220 mg, 275 mg, 550 mg piroxicam oral capsule 10 mg, 20 mg probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg RIDAURA ORAL CAPSULE 3 MG salsalate oral tablet 500 mg, 750 mg sulindac oral tablet 150 mg, 200 mg Antiasthmatics acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) ATROVENT HA INHALATION HA AEROSOL INHALER 17 MCG/ACTUATION budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml 5

7 COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION cromolyn nasal spray, non-aerosol 5.2 mg/spray (4 %) LOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION LOVENT HA INHALATION HA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION fluticasone-salmeterol inhalation aerosol powdr breath activated mcg/actuation, mcg/actuation, mcg/actuation INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg (2.5 mg base)/3 ml levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg montelukast oral tablet 10 mg montelukast oral tablet, chewable 4 mg, 5 mg PULMICORT LEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg THEO-24 ORAL CAPSULE, EXTENDED RELEASE 24HR 100 MG, 200 MG, 300 MG, 400 MG theophylline oral solution 80 mg/15 ml theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg theophylline oral tablet extended release 24 hr 400 mg TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION VENTOLIN HA INHALATION HA AEROSOL INHALER 90 MCG/ACTUATION Antibiotics 6 ST;

8 amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet, chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet, chewable mg, mg ampicillin oral capsule 250 mg, 500 mg ampicillin-sulbactam injection recon soln 3 gram AUGMENTIN ORAL SUSPENSION OR RECONSTITUTION MG/5 ML azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg, 600 mg bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin topical ointment 500 unit/gram bacitracin zinc topical ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment ,000 unit/gram bacitracin-polymyxin b topical ointment ,000 unit/gram bacitracin-polymyxin b topical packet ,000 unit/gram bactroban nasal nasal ointment 2 % BLEPHAMIDE OPHTHALMIC (EYE) DROPS, SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT % cefaclor oral capsule 250 mg, 500 mg cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr 500 mg cefazolin injection recon soln 1 gram, 10 gram cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml ceftazidime injection recon soln 1 gram, 2 gram, 6 gram 7

9 ceftibuten oral capsule 400 mg ceftibuten oral suspension for reconstitution 180 mg/5 ml ceftriaxone injection recon soln 10 gram, 250 mg, 500 mg cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % CIPRO HC OTIC (EAR) DROPS, SUSPENSION % CIPRODEX OTIC (EAR) DROPS, SUSPENSION % ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg ciprofloxacin hcl ophthalmic (eye) drops 0.3 % ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg ciprofloxacin oral suspension, microcapsule recon 250 mg/5 ml, 500 mg/5 ml clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg clarithromycin oral tablet extended release 24 hr 500 mg clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg clindamycin palmitate hcl oral recon soln 75 mg/5 ml clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % clindamycin phosphate vaginal cream 2 % CORTISPORIN TOPICAL OINTMENT 1 % cycloserine oral capsule 250 mg dapsone oral tablet 100 mg, 25 mg dicloxacillin oral capsule 250 mg, 500 mg double antibiotic (b.tracn zn) topical ointment ,000 unit/gram doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg E.E.S. 400 ORAL TABLET 400 MG ERYPED 400 ORAL SUSPENSION OR RECONSTITUTION 400 MG/5 ML ERY-TAB ORAL TABLET, DELAYED RELEASE (DR/EC) 250 MG, 333 MG 8

10 ery-tab oral tablet, delayed release (dr/ec) 500 mg erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) erythromycin oral capsule, delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg erythromycin stearate oral tablet 250 mg erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % erythromycin-benzoyl peroxide topical gel 3-5 % ethambutol oral tablet 100 mg, 400 mg GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) gentamicin injection solution 40 mg/ml gentamicin ophthalmic (eye) drops 0.3 % gentamicin topical cream 0.1 % isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 100 mg, 300 mg levofloxacin in d5w intravenous piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin ophthalmic (eye) drops 0.5 % levofloxacin oral tablet 250 mg, 500 mg, 750 mg methenamine mandelate oral tablet 0.5 g, 1 gram metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml metronidazole oral tablet 250 mg, 500 mg metronidazole vaginal gel 0.75 % minocycline oral capsule 100 mg, 50 mg, 75 mg minocycline oral tablet 100 mg mupirocin calcium topical cream 2 % mupirocin topical ointment 2 % neomycin oral tablet 500 mg neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 mgunit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) drops, suspension 3.5mg/ml- 10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 % 9

11 neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit mg/ml neomycin-polymyxin-hc ophthalmic (eye) drops, suspension , mgunit-mg/ml neomycin-polymyxin-hc otic (ear) drops, suspension ,000-1 mg/ml-unit/ml- % neomycin-polymyxin-hc otic (ear) solution ,000-1 mg/ml-unit/ml-% nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin oral suspension 25 mg/5 ml ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin otic (ear) drops 0.3 % PCE ORAL TABLET, PARTICLES/CRYSTALS 333 MG, 500 MG penicillin g potassium injection recon soln 5 million unit penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml PRIMSOL ORAL SOLUTION 50 MG/5 ML pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg RIAMATE ORAL CAPSULE MG rifampin oral capsule 150 mg, 300 mg silver sulfadiazine topical cream 1 % sulfacetamide sodium ophthalmic (eye) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg tetracycline oral capsule 250 mg, 500 mg TOBRADEX OPHTHALMIC (EYE) OINTMENT % tobramycin ophthalmic (eye) drops 0.3 % tobramycin-dexamethasone ophthalmic (eye) drops, suspension % TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % 10

12 trimethoprim oral tablet 100 mg TRIPLE ANTIBIOTIC (PRAM) EXTRA TOPICAL OINTMENT ,000 MG-UNIT-UNIT/G TRIPLE ANTIBIOTIC TOPICAL OINTMENT 3.5MG-400 UNIT- 5,000 UNIT/GRAM VIGAMOX OPHTHALMIC (EYE) DROPS 0.5 % Anticoagulants COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG ELIQUIS ORAL TABLET 2.5 MG, 5 MG enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS, DOSE PACK 15 MG (42)- 20 MG (9) Antifungals 3 DAY VAGINAL VAGINAL CREAM 200 MG/5 GRAM (4 %) antifungal (tolnaftate) topical cream 1 % ATHLETE'S OOT (TERBINAINE) TOPICAL CREAM 1 % clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % clotrimazole topical solution 1 % clotrimazole vaginal cream 1 % clotrimazole-betamethasone topical cream % clotrimazole-betamethasone topical lotion % econazole topical cream 1 % fluconazole oral suspension for reconstitution 10 mg/ml, 40 mg/ml fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 125 mg/5 ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 125 mg, 250 mg ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % 11

13 MEDI-IRST ANTI-UNGAL TOPICAL PACKET 1 % miconazole nitrate topical cream 2 % miconazole nitrate vaginal comb pack, prefill appl, cream 4 % (200 mg)- 2 % (9 gram) miconazole nitrate vaginal cream 2 % miconazole nitrate vaginal suppository 100 mg MICONAZOLE-3 VAGINAL KIT 200 MG- 2 % (9 GRAM) MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG NATACYN OPHTHALMIC (EYE) DROPS, SUSPENSION 5 % nystatin oral powder 150 million unit 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-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM terbinafine hcl oral tablet 250 mg terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg tolnaftate topical solution 1 % Antihistamine and Decongestant Combination ALAVERT D-12 ALLERGY-SINUS ORAL TABLET EXTENDED RELEASE 12 HR MG cetirizine-pseudoephedrine oral tablet extended release 12 hr mg DIMETAPP COLD-ALLERGY (PE) ORAL SOLUTION MG/5 ML LOHIST - D ORAL LIQUID 2-30 MG/5 ML LORATADINE-D ORAL TABLET EXTENDED RELEASE 24 HR MG PROMETHAZINE VC ORAL SYRUP MG/5 ML RITIED ORAL SYRUP MG/5 ML RYNEX PSE ORAL LIQUID 1-15 MG/5 ML WAL-ACT D COLD AND ALLERGY ORAL TABLET MG WAL-PHED ORAL TABLET 4-60 MG Antihistamines 12

14 BENADRYL ALLERGY ORAL LIQUID 12.5 MG/5 ML cetirizine oral solution 1 mg/ml cetirizine oral tablet 10 mg, 5 mg cetirizine oral tablet, chewable 10 mg, 5 mg CHILDREN'S CLARITIN ORAL TABLET, CHEWABLE 5 MG CHILDREN'S WAL-DRYL ALLERGY ORAL PREILLED SPOON 12.5 MG/5 ML chlorpheniramine maleate oral tablet 4 mg chlorpheniramine maleate oral tablet extended release 12 mg cyproheptadine oral syrup 2 mg/5 ml cyproheptadine oral tablet 4 mg diphenhydramine hcl oral capsule 25 mg, 50 mg diphenhydramine hcl oral elixir 12.5 mg/5 ml diphenhydramine hcl oral syrup 12.5 mg/5 ml diphenhydramine hcl oral tablet 25 mg ed chlorped jr oral syrup 2 mg/5 ml hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg loratadine oral solution 5 mg/5 ml loratadine oral tablet 10 mg loratadine oral tablet, disintegrating 10 mg olopatadine ophthalmic (eye) drops 0.1 % promethazine oral syrup 6.25 mg/5 ml promethazine oral tablet 12.5 mg, 25 mg, 50 mg ZADITOR OPHTHALMIC (EYE) DROPS % (0.035 %) Antihyperglycemics acarbose oral tablet 100 mg, 25 mg, 50 mg alogliptin oral tablet 12.5 mg, 25 mg, 6.25 mg ST; alogliptin-metformin oral tablet ,000 mg, mg ST; APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML APIDRA SUBCUTANEOUS SOLUTION 100 UNIT/ML BASAGLAR KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) glimepiride oral tablet 1 mg, 2 mg, 4 mg 13

15 glipizide oral tablet 10 mg, 5 mg glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg glipizide-metformin oral tablet mg, mg, mg glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg glyburide-metformin oral tablet mg, mg, mg HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMALOG SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R U-100 INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG, MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, MG, 50-1,000 MG, MG 14 ST; ST; INVOKANA ORAL TABLET 100 MG, 300 MG ST; JANUMET ORAL TABLET 50-1,000 MG, MG ST; JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG, MG ST; JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG ST; LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML metformin oral tablet 1,000 mg, 500 mg, 850 mg

16 metformin oral tablet extended release 24 hr 500 mg, 750 mg NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG LEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX LEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG MIX SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG PENILL SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML pioglitazone oral tablet 15 mg, 30 mg, 45 mg Antiinfectives/Miscellaneous atovaquone oral suspension 750 mg/5 ml chloroquine phosphate oral tablet 250 mg, 500 mg hydroxychloroquine oral tablet 200 mg NEBUPENT INHALATION RECON SOLN 300 MG paromomycin oral capsule 250 mg primaquine oral tablet 26.3 mg REESE'S PINWORM MEDICINE ORAL SUSPENSION 50 MG/ML Antineoplastics 15 AINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG PA; SPO anastrozole oral tablet 1 mg SPO AVASTIN INTRAVENOUS SOLUTION 25 MG/ML PA bexarotene oral capsule 75 mg SPO COTELLIC ORAL TABLET 20 MG PA; SPO CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML PA DARZALEX INTRAVENOUS SOLUTION 20 MG/ML PA doxorubicin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml EMPLICITI INTRAVENOUS RECON SOLN 300 MG, 400 MG PA etoposide oral capsule 50 mg SPO ARYDAK ORAL CAPSULE 10 MG, 20 MG PA farydak oral capsule 15 mg PA LUOROPLEX TOPICAL CREAM 1 % fluorouracil topical cream 5 %

17 flutamide oral capsule 125 mg HALAVEN INTRAVENOUS SOLUTION 1 MG/2 ML (0.5 MG/ML) PA HERCEPTIN INTRAVENOUS RECON SOLN 440 MG PA hydroxyurea oral capsule 500 mg ifosfamide intravenous solution 3 gram/60 ml IRESSA ORAL TABLET 250 MG PA irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml, 500 mg/25 ml KADCYLA INTRAVENOUS RECON SOLN 100 MG PA LARTRUVO INTRAVENOUS SOLUTION 10 MG/ML PA LEUKERAN ORAL TABLET 2 MG SPO MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 40 mg mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection solution 25 mg/ml methotrexate sodium injection solution 25 mg/ml methotrexate sodium oral tablet 2.5 mg MYLERAN ORAL TABLET 2 MG SPO ODOMZO ORAL CAPSULE 200 MG PA; SPO OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML PA SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG PA TABLOID ORAL TABLET 40 MG SPO tamoxifen oral tablet 10 mg, 20 mg tretinoin (chemotherapy) oral capsule 10 mg VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG PA vinblastine intravenous solution 1 mg/ml YERVOY INTRAVENOUS SOLUTION 200 MG/40 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25 MG/ML), 200 MG/8 ML (25 MG/ML) Antiparkinson Drugs bromocriptine oral capsule 5 mg bromocriptine oral tablet 2.5 mg carbidopa-levodopa oral tablet mg, mg, mg carbidopa-levodopa oral tablet extended release mg, mg PA PA 16

18 carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg entacapone oral tablet 200 mg pramipexole oral tablet mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg Antiplatelet Drugs anagrelide oral capsule 0.5 mg, 1 mg aspirin oral tablet, chewable 81 mg aspirin oral tablet, delayed release (dr/ec) 81 mg cilostazol oral tablet 100 mg, 50 mg CLOPIDOGREL ORAL TABLET 300 MG clopidogrel oral tablet 75 mg Antivirals ABREVA TOPICAL CREAM 10 % acyclovir oral capsule 200 mg acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet 400 mg, 800 mg famciclovir oral tablet 125 mg, 250 mg, 500 mg oseltamivir oral capsule 30 mg, 45 mg, 75 mg TAMILU ORAL SUSPENSION OR RECONSTITUTION 6 MG/ML trifluridine ophthalmic (eye) drops 1 % valacyclovir oral tablet 1 gram, 500 mg Autonomic Drugs ADRENALIN INJECTION SOLUTION 1 MG/ML (1 ML) bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg dextroamphetamine oral tablet 10 mg, 5 mg dextroamphetamine-amphetamine oral capsule, extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg donepezil oral tablet 10 mg, 5 mg donepezil oral tablet, disintegrating 10 mg, 5 mg 17

19 epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml, 0.3 mg/0.3 ml epinephrine injection solution 1 mg/ml (1 ml) epinephrine injection syringe 0.1 mg/ml galantamine oral tablet 12 mg, 4 mg, 8 mg MESTINON ORAL SYRUP 60 MG/5 ML MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE 180 MG midodrine oral tablet 10 mg, 2.5 mg, 5 mg pyridostigmine bromide oral tablet 60 mg rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg Biologicals ACTHIB (P) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL (TDAP ADOLESN/ADULT) (P) INTRAMUSCULAR SUSPENSION 2 L-( MCG)-5L/0.5 ML ADACEL (TDAP ADOLESN/ADULT) (P) INTRAMUSCULAR SYRINGE 2 L-( MCG)-5L/0.5 ML ALURIA (P) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML ALURIA INTRAMUSCULAR SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML ALURIA QUAD (P) INTRAMUSCULAR SYRINGE 60 MCG/0.5 ML ALURIA QUAD INTRAMUSCULAR SUSPENSION 60 MCG/0.5 ML BCG VACCINE, LIVE (P) PERCUTANEOUS SUSPENSION OR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BIOTHRAX INTRAMUSCULAR SUSPENSION 0.5 ML/DOSE BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION L-MCG- L/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE L-MCG- L/0.5ML DAPTACEL (DTAP PEDIATRIC) (P) INTRAMUSCULAR SUSPENSION L-MCG-L/0.5ML ENGERIX-B (P) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (P) INTRAMUSCULAR SYRINGE 20 MCG/ML 18

20 ENGERIX-B PEDIATRIC (P) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (P) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML LUAD (65 YR UP) (P) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML LUBLOK (P) INTRAMUSCULAR SOLUTION 135 MCG (45 MCG X 3)/0.5 ML LUBLOK QUAD (P) INTRAMUSCULAR SYRINGE 180 MCG (45 MCG X 4)/0.5 ML LUCELVAX QUAD (P) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML LUCELVAX QUAD INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML LULAVAL QUAD (P) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML LULAVAL QUAD INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML LUVIRIN (P) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML LUVIRIN INTRAMUSCULAR SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML LUZONE HIGH-DOSE (P) INTRAMUSCULAR SYRINGE 180 MCG/0.5 ML LUZONE INTRADERM QUAD INTRADERMAL SYRINGE 36 MCG/0.1 ML LUZONE QUAD (P) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML LUZONE QUAD (P) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML LUZONE QUAD PEDI (P) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML GARDASIL 9 (P) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (P) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (P) INTRAMUSCULAR SUSPENSION 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HAVRIX (P) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HEPAGAM B INJECTION SOLUTION >312 UNIT/ML, GREATR THAN 312 UNIT/ML (5 ML) 19

21 HYPERHEP B S/D INTRAMUSCULAR SOLUTION 220 UNIT/ML, 220 UNIT/ML (5 ML) HYPERHEP B S/D INTRAMUSCULAR SYRINGE 220 UNIT/ML HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE 110 UNIT/0.5 ML HYPERRAB S/D (P) INTRAMUSCULAR SOLUTION 150 UNIT/ML HYPERTET S/D (P) INTRAMUSCULAR SYRINGE 250 UNIT IMOVAX RABIES VACCINE (P) INTRAMUSCULAR RECON SOLN 2.5 UNIT INANRIX (DTAP) (P) INTRAMUSCULAR SUSPENSION L- MCG-L/0.5ML INANRIX (DTAP) (P) INTRAMUSCULAR SYRINGE L- MCG-L/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IXIARO (P) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (P) INTRAMUSCULAR SUSPENSION 25 L-58 MCG-10 L/0.5 ML KINRIX (P) INTRAMUSCULAR SYRINGE 25 L-58 MCG-10 L/0.5 ML MENACTRA (P) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENHIBRIX (P) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-135 (P) SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-135-DIP (P) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (P) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML NABI-HB INTRAMUSCULAR SOLUTION GREATER THAN 1,560 UNIT/5 ML, GREATR THAN 312 UNIT/ML PEDIARIX (P) INTRAMUSCULAR SYRINGE 10 MCG-25L-25 MCG- 10L/0.5 ML PEDVAX HIB (P) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (P) INTRAMUSCULAR KIT 15 L UNIT-20 MCG-5 L/0.5 ML PENTACEL DTAP-IPV COMPNT (P) INTRAMUSCULAR SUSPENSION 15 L-48 MCG- 5 L UNIT/0.5ML PNEUMOVAX 23 INJECTION SOLUTION 25 MCG/0.5 ML PNEUMOVAX 23 INJECTION SYRINGE 25 MCG/0.5 ML 20

22 PREVNAR 13 (P) INTRAMUSCULAR SYRINGE 0.5 ML PROQUAD (P) SUBCUTANEOUS SUSPENSION OR RECONSTITUTION 10EXP TCID50/0.5 RABAVERT (P) INTRAMUSCULAR SUSPENSION OR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (P) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (P) INTRAMUSCULAR SUSPENSION 5 MCG/0.5 ML RECOMBIVAX HB (P) INTRAMUSCULAR SYRINGE 10 MCG/ML RECOMBIVAX HB (P) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION OR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML STAMARIL (P) SUBCUTANEOUS SUSPENSION OR RECONSTITUTION 1,000 UNIT/0.5 ML TENIVAC (P) INTRAMUSCULAR SUSPENSION 5 L UNIT- 2 L UNIT/0.5ML TENIVAC (P) INTRAMUSCULAR SYRINGE 5-2 L UNIT/0.5 ML tetanus, diphtheria tox ped(pf) intramuscular suspension 5-25 lf unit/0.5 ml TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION 2-2 L UNIT/0.5 ML TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (P) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (P) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML VAQTA (P) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (P) SUBCUTANEOUS SUSPENSION OR RECONSTITUTION 1,350 UNIT/0.5 ML VARIZIG INTRAMUSCULAR RECON SOLN 125 UNIT VIVOTI BERNA VACCINE ORAL CAPSULE, DELAYED RELEASE(DR/EC) 2 BILLION UNIT Y-VAX (P) SUBCUTANEOUS SUSPENSION OR RECONSTITUTION 10 EXP4.74 UNIT/0.5 ML 21

23 ZOSTAVAX (P) SUBCUTANEOUS SUSPENSION OR RECONSTITUTION 19,400 UNIT/0.65 ML Blood pentoxifylline oral tablet extended release 400 mg Cardiac Drugs amiodarone oral tablet 200 mg amlodipine oral tablet 10 mg, 2.5 mg, 5 mg digoxin oral solution 50 mcg/ml digoxin oral tablet 125 mcg, 250 mcg DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE 40 MG diltiazem hcl oral capsule, extended release 12 hr 120 mg, 60 mg, 90 mg diltiazem hcl oral capsule, extended release 24 hr 360 mg, 420 mg diltiazem hcl oral capsule, extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg DILT-XR ORAL CAPSULE, EXT.REL 24H DEGRADABLE 120 MG, 180 MG, 240 MG felodipine oral tablet extended release 24 hr 10 mg, 2.5 mg, 5 mg ISORDIL ORAL TABLET 40 MG isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg isosorbide dinitrate oral tablet extended release 40 mg isosorbide mononitrate oral tablet 10 mg, 20 mg isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg LANOXIN ORAL TABLET 125 MCG, 250 MCG mexiletine oral capsule 150 mg, 200 mg, 250 mg nifedipine oral capsule 10 mg, 20 mg nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg propafenone oral capsule, extended release 12 hr 225 mg propafenone oral capsule, extended release 12 hr 325 mg, 425 mg propafenone oral tablet 150 mg, 225 mg, 300 mg quinidine gluconate oral tablet extended release 324 mg 22

24 TAZTIA XT ORAL CAPSULE, EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 300 MG verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg verapamil oral capsule, ext rel. pellets 24 hr 120 mg, 180 mg, 240 mg verapamil oral tablet 120 mg, 40 mg, 80 mg verapamil oral tablet extended release 120 mg, 180 mg, 240 mg Cardiovascular amlodipine-benazepril oral capsule mg, mg, mg, 5-10 mg, 5-20 mg, 5-40 mg atenolol oral tablet 100 mg, 25 mg, 50 mg atenolol-chlorthalidone oral tablet mg, mg atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet mg, mg, mg, mg captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg carvedilol oral tablet 12.5 mg, 25 mg, mg, 6.25 mg cholestyramine (with sugar) oral powder 4 gram cholestyramine (with sugar) oral powder in packet 4 gram CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg fenofibrate micronized oral capsule 134 mg, 67 mg fenofibrate micronized oral capsule 200 mg fenofibrate nanocrystallized oral tablet 145 mg, 48 mg fenofibrate oral tablet 160 mg, 54 mg fenofibric acid (choline) oral capsule, delayed release(dr/ec) 135 mg, 45 mg gemfibrozil oral tablet 600 mg guanfacine oral tablet 1 mg, 2 mg hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg irbesartan oral tablet 150 mg, 300 mg, 75 mg labetalol intravenous solution 5 mg/ml 23

25 labetalol oral tablet 100 mg, 200 mg, 300 mg lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet mg, mg, mg losartan oral tablet 100 mg, 25 mg, 50 mg losartan-hydrochlorothiazide oral tablet mg, mg, mg lovastatin oral tablet 10 mg, 20 mg, 40 mg methyldopa oral tablet 250 mg, 500 mg methyldopa-hydrochlorothiazide oral tablet mg, mg metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg minoxidil oral tablet 10 mg, 2.5 mg niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg NIACOR ORAL TABLET 500 MG pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg prazosin oral capsule 1 mg, 2 mg, 5 mg propranolol oral capsule, extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet mg, mg, mg, mg, mg Central Nervous System (CNS) Drugs carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet 200 mg carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg carbamazepine oral tablet, chewable 100 mg CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 300 MG clonazepam oral tablet 0.5 mg, 1 mg, 2 mg DEPAKENE ORAL CAPSULE 250 MG 24

26 DEPAKENE ORAL SOLUTION 250 MG/5 ML DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR 250 MG, 500 MG DEPAKOTE ORAL TABLET, DELAYED RELEASE (DR/EC) 125 MG, 250 MG, 500 MG DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE 125 MG diazepam rectal kit mg, 2.5 mg, mg DILANTIN EXTENDED ORAL CAPSULE 100 MG DILANTIN INATABS ORAL TABLET, CHEWABLE 50 MG DILANTIN ORAL CAPSULE 30 MG DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML divalproex oral capsule, delayed rel sprinkle 125 mg divalproex oral tablet extended release 24 hr 250 mg, 500 mg divalproex oral tablet, delayed release (dr/ec) 125 mg, 250 mg, 500 mg ethosuximide oral capsule 250 mg ethosuximide oral solution 250 mg/5 ml gabapentin oral capsule 100 mg, 300 mg, 400 mg gabapentin oral tablet 600 mg, 800 mg lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg levetiracetam oral solution 100 mg/ml levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg memantine oral tablet 10 mg, 5 mg memantine oral tablets, dose pack 5-10 mg oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet, chewable 50 mg phenytoin sodium extended oral capsule 100 mg primidone oral tablet 250 mg, 50 mg riluzole oral tablet 50 mg TEGRETOL ORAL SUSPENSION 100 MG/5 ML TEGRETOL ORAL TABLET 200 MG 25

27 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 400 MG topiramate oral capsule, sprinkle 15 mg, 25 mg topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid oral capsule 250 mg zonisamide oral capsule 100 mg, 25 mg, 50 mg Colony Stimulating actors EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Contraceptives AZURETTE (28) ORAL TABLET MGX21 /0.01 MG X 5 BALZIVA (28) ORAL TABLET MG-MCG CAMRESE ORAL TABLETS, DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7) 26 CAYA CONTOURED VAGINAL DIAPHRAGM MM CAZIANT (28) ORAL TABLET 0.1/.125/ MG-MCG CONCEPTROL VAGINAL GEL 4 % CONDOMS-PREM LUBRICATED DEVICE drospirenone-e.estradiol-lm.fa oral tablet mg (24) (4) ELLA ORAL TABLET 30 MG emoquette oral tablet mg fc2 female condom GIANVI (28) ORAL TABLET MG GYNOL II VAGINAL GEL 3 % JUNEL E 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7) JUNEL E 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7) l norgest/e.estradiol-e.estrad oral tablets, dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) LEENA 28 ORAL TABLET 0.5/1/ MG-MCG levonorgestrel-ethinyl estrad oral tablet mcg LEVORA-28 ORAL TABLET MG LOW-OGESTREL (28) ORAL TABLET MG-MCG

28 medroxyprogesterone intramuscular suspension 150 mg/ml medroxyprogesterone intramuscular syringe 150 mg/ml MICROGESTIN 1.5/30 (21) ORAL TABLET MG-MCG MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG MONONESSA (28) ORAL TABLET MG-MCG my way oral tablet 1.5 mg NECON 0.5/35 (28) ORAL TABLET MG-MCG NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG NECON 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG noreth-ethinyl estradiol-iron oral tablet, chewable 0.4mg-35mcg (21) and 75 mg (7), 0.8mg-25mcg (24) and 75 mg (4) norethindrone (contraceptive) oral tablet 0.35 mg norethindrone-e. estradiol-iron oral tablet 1 mg-20 mcg (24)/75 mg (4) norethindrone-e. estradiol-iron oral tablet, chewable 1 mg-20 mcg (24) /75 mg (4) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg nortrel 1/35 (28) oral tablet 1-35 mg-mcg NUVARING VAGINAL RING MG/24 HR OCELLA ORAL TABLET MG OGESTREL (28) ORAL TABLET MG-MCG QUASENSE ORAL TABLETS, DOSE PACK,3 MONTH 0.15 MG-30 MCG rivelsa oral tablets, dose pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg SRONYX ORAL TABLET MG-MCG TILIA E ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9) TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28) TRIVORA (28) ORAL TABLET (6)/75-40 (5)/125-30(10) VAGINAL CONTRACEPTIVE ILM VAGINAL ILM 28 % VAGINAL CONTRACEPTIVE OAM VAGINAL OAM 12.5 % WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM 60 MM WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM 65 MM WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM 70 MM WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM 75 MM WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM 80 MM WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM 85 MM WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM 90 MM 27

29 WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM 95 MM xulane transdermal patch weekly mcg/24 hr ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG Cough/Cold Preparations ADULT ROBITUSSIN PEAK COLD M-S ORAL LIQUID MG/5 ML allergy relief(chlorphen-acet) oral tablet mg benzonatate oral capsule 100 mg, 200 mg BIO-S-PRES DX ORAL DROPS MG/ML BROMED DM ORAL SYRUP MG/5 ML BROTAPP DM ORAL ELIXIR MG/5 ML CHILD MUCINEX STUY NOSE-COLD ORAL LIQUID MG/5 ML DIABETIC TUSSIN DM ORAL LIQUID MG/5 ML DIMETAPP DM COLD-COUGH (PE) ORAL SOLUTION MG/5 ML EXPECTORANT ORAL LIQUID 100 MG/5 ML GUAIENESIN AC ORAL LIQUID MG/5 ML guaifenesin oral tablet extended release 12hr 600 mg hydrocodone-homatropine oral syrup mg/5 ml MUCINEX COUGH MINI-MELTS ORAL GRANULES IN PACKET MG MUCINEX D MAXIMUM STRENGTH ORAL TABLET EXTENDED RELEASE 12 HR 120-1,200 MG MUCINEX D ORAL TABLET EXTENDED RELEASE 12 HR MG MUCINEX ORAL TABLET EXTENDED RELEASE 12HR 1,200 MG mucus dm oral tablet extended release 12 hr mg mucus relief cough oral liquid mg/5 ml NEO-TUSS ORAL LIQUID MG/5 ML nohist-dm oral liquid mg/5 ml PEDIA RELIE COUGH-COLD ORAL LIQUID MG/5 ML PROMETHAZINE VC-CODEINE ORAL SYRUP MG/5 ML promethazine-codeine oral syrup mg/5 ml promethazine-dm oral syrup mg/5 ml pseudoephedrine hcl oral tablet 30 mg, 60 mg 28

30 pseudoephedrine hcl oral tablet extended release 120 mg ROBITUSSIN PEDIATRIC ORAL SYRUP 7.5 MG/5 ML SCOT-TUSSIN DM ORAL LIQUID 2-15 MG/5 ML SCOT-TUSSIN SENIOR ORAL LIQUID MG/5 ML SUPHEDRIN ORAL LIQUID 15 MG/5 ML TUSSIN DM ORAL LIQUID MG/5 ML TUSSIN DM ORAL SYRUP MG/5 ML Diagnostic CHEMSTRIP K STRIP DIASTIX STRIP GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MG/ML KETO-DIASTIX STRIP MULTISTIX 10 SG STRIP ONETOUCH VERIO STRIP SPO Diuretics acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 125 mg, 250 mg ALDACTAZIDE ORAL TABLET MG bumetanide oral tablet 0.5 mg, 1 mg, 2 mg chlorothiazide oral tablet 250 mg, 500 mg chlorthalidone oral tablet 25 mg, 50 mg DIURIL ORAL SUSPENSION 250 MG/5 ML DYRENIUM ORAL CAPSULE 50 MG ethacrynic acid oral tablet 25 mg furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 20 mg, 40 mg, 80 mg hydrochlorothiazide oral capsule 12.5 mg hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg indapamide oral tablet 1.25 mg, 2.5 mg spironolactone oral tablet 100 mg, 25 mg, 50 mg spironolacton-hydrochlorothiaz oral tablet mg triamterene-hydrochlorothiazid oral capsule mg, mg triamterene-hydrochlorothiazid oral tablet mg, mg Eye, Ear, Nose, and Throat (EENT) Preps 29

31 acetic acid otic (ear) solution 2 % allergy eye (naphazoline-phen) ophthalmic (eye) drops % ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % ARTIICIAL TEARS(DEXT70-HYPRO) OPHTHALMIC (EYE) DROPS ARTIICIAL TEARS(PVALCH-POVID) OPHTHALMIC (EYE) DROPS % atropine ophthalmic (eye) drops 1 % atropine ophthalmic (eye) ointment 1 % AYR SALINE NASAL DROPS 0.65 % azelastine nasal aerosol, spray 137 mcg (0.1 %) betaxolol ophthalmic (eye) drops 0.5 % BETIMOL OPHTHALMIC (EYE) DROPS 0.25 %, 0.5 % brimonidine ophthalmic (eye) drops 0.2 % carbamoxide ear drops otic (ear) drops 6.5 % cromolyn ophthalmic (eye) drops 4 % CYCLOGYL OPHTHALMIC (EYE) DROPS 0.5 % cyclopentolate ophthalmic (eye) drops 1 %, 2 % dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % dorzolamide ophthalmic (eye) drops 2 % dorzolamide-timolol ophthalmic (eye) drops mg/ml EYE ALLERGY RELIE OPHTHALMIC (EYE) DROPS % LAREX OPHTHALMIC (EYE) DROPS, SUSPENSION 0.1 % fluorometholone ophthalmic (eye) drops, suspension 0.1 % fluticasone nasal spray, suspension 50 mcg/actuation ML ORTE OPHTHALMIC (EYE) DROPS, SUSPENSION 0.25 % for sty relief ophthalmic (eye) ointment GENTEAL MILD OPHTHALMIC (EYE) DROPS 0.2 % HOMATROPAIRE OPHTHALMIC (EYE) DROPS 5 % ISOPTO TEARS OPHTHALMIC (EYE) DROPS 0.5 % ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % latanoprost ophthalmic (eye) drops % levobunolol ophthalmic (eye) drops 0.5 % lubricant eye drops (glyc-pg) ophthalmic (eye) drops % 30

32 lubricant eye drops ophthalmic (eye) drops 0.5 % LUBRICANT EYE OPHTHALMIC (EYE) OINTMENT % lubricant eye ophthalmic (eye) ointment % MAXIDEX OPHTHALMIC (EYE) DROPS, SUSPENSION 0.1 % metipranolol ophthalmic (eye) drops 0.3 % MURO 128 OPHTHALMIC (EYE) DROPS 2 % NASACORT NASAL AEROSOL, SPRAY 55 MCG NASAL SPRAY EXTRA MOISTURIZING NASAL SPRAY, NON- AEROSOL 0.05 % PHENYLEPHRINE HCL OPHTHALMIC (EYE) DROPS 2.5 % pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % polyvinyl alcohol ophthalmic (eye) drops 1.4 % PRED MILD OPHTHALMIC (EYE) DROPS, SUSPENSION 0.12 % prednisolone acetate ophthalmic (eye) drops, suspension 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % proparacaine ophthalmic (eye) drops 0.5 % PURE AND GENTLE EYE OPHTHALMIC (EYE) DROPS 0.3 % RERESH LACRI-LUBE OPHTHALMIC (EYE) OINTMENT % RERESH P.M. OPHTHALMIC (EYE) OINTMENT % saline nasal nasal aerosol, spray 0.65 % sodium chloride ophthalmic (eye) drops 5 % sodium chloride ophthalmic (eye) ointment 5 % SYSTANE NIGHTTIME OPHTHALMIC (EYE) OINTMENT 94-3 % tears again ophthalmic (eye) ointment % TEARS NATURALE ORTE OPHTHALMIC (EYE) DROPS % timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % tropicamide ophthalmic (eye) drops 0.5 %, 1 % Electrolyte/Caloric/H2O amino acids 15 % intravenous parenteral solution 15 % CALCIUM 600 ORAL TABLET 600 MG CALCIUM (1,500 MG) calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg calcium carbonate oral tablet 500 mg calcium (1,250 mg), 650 mg calcium (1,625 mg) 31

33 calcium gluconate oral tablet 45 mg (500 mg), 60 mg (650 mg) calcium lactate oral tablet 84 mg (648 mg) CHELATED ZINC ORAL TABLET 50 MG dextrose 5 % in water (d5w) intravenous parenteral solution EER-K ORAL TABLET, EERVESCENT 10 MEQ, 20 MEQ, 25 MEQ ferrous sulfate oral drops 15 mg iron (75 mg)/ml ferrous sulfate oral elixir 220 mg (44 mg iron)/5 ml ferrous sulfate oral liquid 300 mg (60 mg iron)/5 ml ferrous sulfate oral solution 220 mg (44 mg iron)/5 ml ferrous sulfate oral tablet, delayed release (dr/ec) 324 mg (65 mg iron), 325 mg (65 mg iron) ERROUSUL ORAL TABLET 325 MG (65 MG IRON) LUOR-A-DAY ORAL DROPS 2.5 MG (5.56 MG SOD.LUORID)/ML fluoride (sodium) oral drops 0.5 mg (1.1 mg sod. fluorid)/ml fluoride (sodium) oral tablet, chewable 0.25 mg (0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid) LUORITAB ORAL TABLET, CHEWABLE 1 MG (2.2 MG SOD. LUORIDE) GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG glucose oral tablet, chewable 4 gram kionex (with sorbitol) oral suspension gram/60 ml lactated ringers intravenous parenteral solution magnesium oxide oral tablet 250 mg, 400 mg, 420 mg, 500 mg PEDIATRIC ELECTROLYTE ORAL SOLUTION potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride oral capsule, extended release 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml potassium chloride oral tablet extended release 10 meq, 8 meq potassium chloride oral tablet, er particles/crystals 10 meq, 20 meq RENAGEL ORAL TABLET 400 MG, 800 MG sevelamer carbonate oral tablet 800 mg sf 5000 plus dental cream 1.1 % sodium chloride 0.9 % intravenous parenteral solution 0.9 % sodium citrate-citric acid oral solution mg/5 ml 32

34 sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 15 gram/60 ml SSKI ORAL SOLUTION 1 GRAM/ML zinc gluconate oral tablet 50 mg Gastrointestinal ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION MG/5 ML ANTACID MAXIMUM STRENGTH ORAL SUSPENSION MG/5 ML ANTI-DIARRHEAL (LOPERAMIDE) ORAL LIQUID 1 MG/5 ML aprepitant oral capsule 125 mg, 40 mg, 80 mg aprepitant oral capsule, dose pack 125 mg (1)- 80 mg (2) balsalazide oral capsule 750 mg bisacodyl oral tablet, delayed release (dr/ec) 5 mg BISMUTH MAXIMUM STRENGTH ORAL SUSPENSION 525 MG/15 ML calcium carbonate oral tablet 260 mg calcium (648 mg) CARAATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 300 mg/5 ml cimetidine oral tablet 200 mg, 300 mg, 400 mg, 800 mg CITRUCEL ORAL TABLET 500 MG CREON ORAL CAPSULE, DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT DICLEGIS ORAL TABLET, DELAYED RELEASE (DR/EC) MG PA; dicyclomine oral capsule 10 mg dicyclomine oral solution 10 mg/5 ml dicyclomine oral tablet 20 mg diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg docusate sodium oral capsule 100 mg, 250 mg docusate sodium oral liquid 50 mg/5 ml docusate sodium oral syrup 60 mg/15 ml docusate sodium oral tablet 100 mg DONNATAL ORAL ELIXIR MG/5 ML enema rectal enema 19-7 gram/118 ml 33

35 ENULOSE ORAL SOLUTION 10 GRAM/15 ML famotidine oral suspension 40 mg/5 ml (8 mg/ml) famotidine oral tablet 10 mg, 20 mg, 40 mg fiber (calcium polycarbophil) oral tablet 625 mg fiber (psyllium husk/sugar) oral powder 3.4 gram/12 gram IBER (PSYLLIUM HUSK/SUGAR) ORAL POWDER 3.4 GRAM/7 GRAM foaming antacid oral tablet, chewable mg GAVILYTE-G ORAL RECON SOLN GRAM GAVISCON ORAL TABLET, CHEWABLE MG glycerin (adult) rectal suppository glycerin (child) rectal suppository hydrocortisone acetate rectal suppository 25 mg, 30 mg konsyl (sugar) oral powder in packet 3.4 gram lactulose oral solution 10 gram/15 ml lansoprazole oral capsule, delayed release(dr/ec) 15 mg lansoprazole oral capsule, delayed release(dr/ec) 30 mg LAXATIVE (BISACODYL) ORAL TABLET 5 MG loperamide oral capsule 2 mg LOPERAMIDE ORAL TABLET 2 MG magnesium citrate oral solution meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet, chewable 25 mg METAMUCIL ORAL CAPSULE 0.52 GRAM metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 10 mg, 5 mg MILK O MAGNESIA CONCENTRATED ORAL SUSPENSION 2,400 MG/10 ML MILK O MAGNESIA ORAL SUSPENSION 400 MG/5 ML MINTOX PLUS ORAL TABLET, CHEWABLE MG misoprostol oral tablet 100 mcg, 200 mcg NATURAL IBER LAXATIVE THERAPY ORAL POWDER natural psyllium fiber oral powder 3.4 gram/5.8 gram NEXIUM 24HR ORAL CAPSULE, DELAYED RELEASE(DR/EC) 22.3 MG 34

36 NUTRILIPID INTRAVENOUS EMULSION 20 % NUTRISOURCE IBER ORAL POWDER omeprazole oral capsule, delayed release(dr/ec) 10 mg, 20 mg omeprazole oral capsule, delayed release(dr/ec) 40 mg omeprazole oral tablet, delayed release (dr/ec) 20 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron oral tablet, disintegrating 4 mg, 8 mg pantoprazole oral tablet, delayed release (dr/ec) 20 mg, 40 mg PEDIA-LAX STOOL SOTENER ORAL SYRUP 50 MG/15 ML PEDIATRIC ENEMA RECTAL ENEMA GRAM/59 ML peg 3350-electrolytes oral recon soln gram phenohytro oral tablet mg pink bismuth oral suspension 262 mg/15 ml PINK BISMUTH ORAL TABLET 262 MG PINK BISMUTH ORAL TABLET, CHEWABLE 262 MG polyethylene glycol 3350 oral powder 17 gram/dose PREVACID 24HR ORAL CAPSULE, DELAYED RELEASE(DR/EC) 15 MG PRILOSEC OTC ORAL TABLET, DELAYED RELEASE (DR/EC) 20 MG prochlorperazine edisylate injection solution 5 mg/ml prochlorperazine maleate oral tablet 10 mg, 5 mg prochlorperazine rectal suppository 25 mg PROCTOOAM HC RECTAL OAM 1-1 % promethazine rectal suppository 12.5 mg, 25 mg PROMETHEGAN RECTAL SUPPOSITORY 50 MG rabeprazole oral tablet, delayed release (dr/ec) 20 mg ranitidine hcl oral syrup 15 mg/ml ranitidine hcl oral tablet 150 mg, 300 mg, 75 mg scopolamine base transdermal patch 3 day 1 mg over 3 days SENNA LAX ORAL TABLET 8.6 MG SENNA ORAL SYRUP 8.8 MG/5 ML SENNA PLUS ORAL TABLET MG SIMETHICONE ORAL DROPS, SUSPENSION 40 MG/0.6 ML simethicone oral tablet, chewable 80 mg 35

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