Analgesics Analgesics

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1 07 5 Tier Standard Member Formulary Formulary ID: 79 Effective Date: 7//07 Last Updated: 6/0/07 Drug Name Drug Tier Requirements/Limits Analgesics Analgesics acetaminophen-codeine oral solution 0 - /5 ml (5 ml), 0- /5 ml, 00-0 /.5 ml acetaminophen-codeine oral tablet 00-5, 00-0, ascomp with codeine oral capsule butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule carisoprodol-asa-codeine oral tablet PA PA PA PA carisoprodol-aspirin oral tablet 00-5 PA codeine-butalbital-asa-caff oral capsule endocet oral tablet 0-5, 5-5, hydrocodone-acetaminophen oral tablet 0-5,.5-5, 5-5, hydrocodone-ibuprofen oral tablet 0-00, 5-00, oxycodone-acetaminophen oral tablet 0-5,.5-5, 5-5, oxycodone-aspirin oral tablet PA pentazocine-naloxone oral tablet PA tramadol-acetaminophen oral tablet Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 00, 00, 00, 50 comfort pac-ibuprofen kit 800

2 comfort pac-meloxicam kit 5 comfort pac-naproxen kit 500 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical gel % diclofenac sodium topical gel % 5 diflunisal oral tablet 500 etodolac oral capsule 00, 00 etodolac oral tablet 00, 500 flurbiprofen oral tablet 00, 50 ibuprofen oral suspension 00 /5 ml ibuprofen oral tablet 00, 600, 800 ibuprofen-oxycodone oral tablet 00-5 indomethacin oral capsule 5, 50 PA indomethacin oral capsule, extended release 75 ketoprofen oral capsule 50, 75 PA ketorolac injection cartridge 0 /ml PA ketorolac injection solution 5 /ml, 0 /ml, 0 /ml ( ml) PA ketorolac intramuscular solution 60 / ml PA ketorolac oral tablet 0 PA meclofenamate oral capsule 00, 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5, 7.5 nabumetone oral tablet 500, 750 NAPRELAN CR ORAL TABLET, ER MULTIPHASE HR 750 MG naproxen oral suspension 5 /5 ml naproxen oral tablet 50, 75, 500 naproxen oral tablet,delayed release (dr/ec) 75, 500

3 naproxen sodium oral tablet 75, 550 piroxicam oral capsule 0, 0 sulindac oral tablet 50, 00 tolmetin oral capsule 00 tolmetin oral tablet 00 VOLTAREN TOPICAL GEL % ZORVOLEX ORAL CAPSULE 8 MG, 5 MG ST Opioid Analgesics, Long-Acting duramorph (pf) injection solution 0.5 /ml, /ml fentanyl citrate buccal lozenge on a handle,00 mcg,,600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 7.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour methadone oral solution 0 /5 ml, 5 /5 ml methadone oral tablet 0, 5 B/D PA; QL (0 EA per 0 days) QL (0 EA per 0 days) morphine oral tablet 5, 0 QL (80 EA per 0 days) morphine oral tablet extended release 00, 5, 00, 0, 60 oxycodone oral tablet,oral only,ext.rel. hr 0, 5, 0, 0, 0, 60, 80 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL. HR 5 MG, 0 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL. HR 60 MG Opioid Analgesics, Short-Acting butorphanol tartrate injection solution /ml, /ml butorphanol tartrate nasal spray,non-aerosol 0 /ml hydromorphone (pf) injection solution 0 (/ml) (5 ml), 0 /ml hydromorphone injection solution /ml, /ml, /ml hydromorphone injection syringe /ml QL (60 EA per 0 days) PA; QL (60 EA per 0 days) PA; QL (60 EA per 0 days) ; QL (60 EA per 0 days) B/D

4 hydromorphone oral tablet,, 8 QL (80 EA per 0 days) LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 00 MCG/SPRAY, 00 MCG/SPRAY PA; QL (600 EA per 0 days) PA; QL (50 EA per 0 days) meperidine oral solution 50 /5 ml PA; QL (600 ML per 0 days) meperidine oral tablet 00, 50 PA; QL (0 EA per 0 days) nalbuphine injection solution 0 /ml, 0 /ml B/D oxycodone oral solution 5 /5 ml QL (500 ML per 0 days) oxycodone oral tablet 0, 5, 0, 0, 5 QL (80 EA per 0 days) tramadol oral tablet 50 QL (0 EA per 0 days) Anesthetics Local Anesthetics dermacinrx empricaine topical kit.5-.5 % lidocaine (pf) injection solution 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl injection solution 5 /ml (0.5 %) lidocaine hcl laryngotracheal solution % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane jelly in applicator % lidocaine hcl mucous membrane solution % (0 /ml) lidocaine hcl urethral gel % lidocaine topical adhesive patch,medicated 5 % PA; QL (90 EA per 0 days) lidocaine topical ointment 5 % lidocaine-prilocaine topical cream.5-.5 % lidocaine-prilocaine topical kit.5-.5 % LIDOPAC TOPICAL KIT 5 % lidopril topical kit.5-.5 % lidopril xr topical kit.5-.5 % lido-prilo caine pack topical kit.5-.5 % liprozonepak topical kit.5-.5 % livixil pak topical kit.5-.5 %

5 lp lite pak topical kit.5-.5 % prilolid topical kit.5-.5 % Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/ Anti-Craving acamprosate oral tablet,delayed release (dr/ec) disulfiram oral tablet 50, 500 naltrexone oral tablet 50 Opioid Dependence Treatments buprenorphine hcl sublingual tablet, 8 buprenorphine-naloxone sublingual tablet -0.5, 8- ZUBSOLV SUBLINGUAL TABLET MG,.-0.6 MG,.-.9 MG, MG, MG, MG Opioid Reversal Agents naloxone injection solution 0. /ml naloxone injection syringe /ml Smoking Cessation Agents CHANTIX CONTINUING MONTH BOX ORAL TABLET MG PA QL (6 EA per 68 days) CHANTIX ORAL TABLET 0.5 MG, MG QL (6 EA per 68 days) CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG () NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 0 MG/ML Antibacterials Aminoglycosides amikacin injection solution,000 / ml, 500 / ml gentak ophthalmic ointment 0. % ( /gram) gentamicin injection solution 0 / ml gentamicin ophthalmic drops 0. % QL (6 EA per 68 days) 5

6 gentamicin ophthalmic ointment 0. % ( /gram) gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 00 /0 ml, 80 /8 ml gentamicin sulfate (pf) intravenous solution 60 /6 ml gentamicin topical cream 0. % gentamicin topical ointment 0. % neomycin oral tablet 500 neomycin-polymyxin b gu irrigation solution 0-00,000 unit/ml paromomycin oral capsule 50 streptomycin intramuscular recon soln gram TOBRADEX OPHTHALMIC OINTMENT % tobramycin in 0.5 % nacl inhalation solution for nebulization 00 /5 ml tobramycin ophthalmic drops 0. % tobramycin sulfate injection recon soln. gram tobramycin sulfate injection solution 0 /ml, 0 /ml tobramycin with nebulizer inhalation solution for nebulization 00 /5 ml Antibacterials, Other acetic acid otic solution % acetic acid-aluminum acetate otic drops % alcohol pads topical pads, medicated bacitracin ophthalmic ointment 500 unit/gram BACTROBAN NASAL NASAL OINTMENT % chloramphenicol sod succinate intravenous recon soln gram clindamycin hcl oral capsule 50, 00, 75 6

7 clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 50 (/ml) (6 ml) clindamycin phosphate injection solution 50 /ml clindamycin phosphate intravenous solution 00 / ml, 600 / ml clindamycin phosphate intravenous solution 900 /6 ml clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin phosphate vaginal cream % colistin (colistimethate na) injection recon soln 50 CUBICIN INTRAVENOUS RECON SOLN 500 MG CUBICIN RF INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 lincomycin injection solution 00 /ml linezolid intravenous parenteral solution 600 /00 ml linezolid oral suspension for reconstitution 00 /5 ml linezolid oral tablet 600 linezolid-0.9% sodium chloride intravenous parenteral solution 600 /00 ml methenamine hippurate oral tablet gram metro i.v. intravenous piggyback 500 /00 ml 7

8 metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml metronidazole oral capsule 75 metronidazole oral tablet 50, 500 metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, % metronidazole topical gel with pump % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % mupirocin topical ointment % nitrofurantoin macrocrystal oral capsule 00, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 00, 00 (75/5) polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 00 vancomycin in 0.9% sodium cl intravenous piggyback gram/00 ml, 500 /00 ml, 750 /50 ml vancomycin in 0.9% sodium cl intravenous solution.5 gram/50 ml, 750 /50 ml vancomycin in dextrose 5 % intravenous piggyback gram/00 ml, 500 /00 ml, 750 /50 ml vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 VANCOMYCIN ORAL CAPSULE 5 MG, 50 MG Beta-Lactam, Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral tablet extended release hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml 8 PA; QL (60 EA per 65 days) PA; QL (60 EA per 65 days) B/D B/D B/D B/D PA

9 cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln gram cefazolin intravenous recon soln gram cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefepime in dextrose 5 % intravenous piggyback gram/50 ml, gram/50 ml cefepime in dextrose,iso-osm intravenous piggyback gram/50 ml, gram/00 ml cefepime injection recon soln gram, gram cefotaxime injection recon soln gram, gram, 500 cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml, gram/50 ml cefoxitin intravenous recon soln gram, 0 gram, gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 50 MG/5 ML ceftriaxone in dextrose,iso-os intravenous piggyback gram/50 ml, gram/50 ml ceftriaxone injection recon soln gram, gram, 500 ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln.5 gram cefuroxime sodium intravenous recon soln.5 gram cephalexin oral capsule 50, 500 9

10 cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 SUPRAX ORAL CAPSULE 00 MG TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG Beta-Lactam, Other aztreonam injection recon soln gram, gram DORIBAX INTRAVENOUS RECON SOLN 500 MG PA PA doripenem intravenous recon soln 50, 500 PA imipenem-cilastatin intravenous recon soln 50, 500 PA INVANZ INJECTION RECON SOLN GRAM PA INVANZ INTRAVENOUS RECON SOLN GRAM meropenem intravenous recon soln gram, 500 meropenem-0.9% sodium chloride intravenous piggyback gram/50 ml, 500 /50 ml Beta-Lactam, Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet 50-5, 500-5, amoxicillin-pot clavulanate oral tablet extended release hr, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, 500 PA 0

11 ampicillin oral suspension for reconstitution 5 /5 ml, 50 /5 ml ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln.5 gram ampicillin-sulbactam injection recon soln 5 gram, gram ampicillin-sulbactam intravenous recon soln.5 gram, gram BICILLIN L-A INTRAMUSCULAR SYRINGE,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml, gram/00 ml nafcillin injection recon soln gram, gram nafcillin intravenous recon soln gram, gram penicillin g procaine intramuscular syringe. million unit/ ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 piperacillin-tazobactam intravenous recon soln.5 gram piperacillin-tazobactam intravenous recon soln.5 gram,.75 gram,.5 gram, 0.5 gram Macrolides azithromycin intravenous recon soln 500, 500 ( /ml) azithromycin oral packet gram azithromycin oral suspension for reconstitution 00 /5 ml, 00 /5 ml azithromycin oral tablet 50, 50 (6 pack), 500, 500 ( pack), 600

12 clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release hr 500 E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ery pads topical swab % ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet 00 erythromycin ophthalmic ointment 5 /gram (0.5 %) erythromycin oral tablet 50, 500 erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % KETEK ORAL TABLET 00 MG, 00 MG PA; QL (0 EA per 0 days) Quinolones AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK 00 MG/50 ML ciprofloxacin (mixture) oral tablet, er multiphase hr,000, 500 ciprofloxacin hcl ophthalmic drops 0. % ciprofloxacin hcl oral tablet 00 ciprofloxacin hcl oral tablet 50, 500, 750 ciprofloxacin lactate intravenous solution 00 /0 ml, 00 /0 ml levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500, 750 MOXEZA OPHTHALMIC DROPS, VISCOUS 0.5 %

13 moxifloxacin oral tablet 00 moxifloxacin-sod.ace,sul-water intravenous piggyback 00 /50 ml ofloxacin ophthalmic drops 0. % ofloxacin oral tablet 00, 00 ofloxacin otic drops 0. % VIGAMOX OPHTHALMIC DROPS 0.5 % Sulfonamides silver sulfadiazine topical cream % ssd topical cream % sulfacetamide sodium (acne) topical suspension 0 % sulfacetamide sodium ophthalmic drops 0 % sulfacetamide sodium ophthalmic ointment 0 % sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral tablet 00-80, Tetracyclines demeclocycline oral tablet 50, 00 doxy-00 intravenous recon soln 00 doxycycline hyclate intravenous recon soln 00 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00, 0 doxycycline monohydrate oral capsule 00, 50 doxycycline monohydrate oral tablet 00, 50, 50, 75 minocycline oral capsule 00, 50, 75 minocycline oral tablet 00, 50, 75 morgidox oral capsule 50 Anticonvulsants

14 Anticonvulsants, Other BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 0 MG/ML BRIVIACT ORAL TABLET 0 MG, 00 MG, 5 MG, 50 MG, 75 MG levetiracetam in nacl (iso-os) intravenous piggyback,000 /00 ml,,500 /00 ml, 500 /00 ml levetiracetam intravenous solution 500 /5 ml levetiracetam oral solution 00 /ml, 500 /5 ml (5 ml) levetiracetam oral tablet,000, 50, 500, 750 levetiracetam oral tablet extended release hr 500, 750 POTIGA ORAL TABLET 00 MG, 00 MG, 00 MG, 50 MG roweepra oral tablet,000, 750 roweepra oral tablet 500 SPRITAM ORAL TABLET FOR SUSPENSION,000 MG, 50 MG, 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 750 MG Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 00 MG ethosuximide oral capsule 50 ethosuximide oral solution 50 /5 ml zonisamide oral capsule 00, 5, 50 Gamma-Aminobutyric Acid (Gaba) Augmenting Agents ST; QL (90 EA per 0 days) ST; QL (60 EA per 0 days) 5 ST; QL (0 EA per 0 days) clonazepam oral tablet 0.5, PA; QL (90 EA per 0 days) clonazepam oral tablet PA; QL (00 EA per 0 days) clonazepam oral tablet,disintegrating 0.5, 0.5, 0.5, PA; QL (90 EA per 0 days) clonazepam oral tablet,disintegrating PA; QL (00 EA per 0 days) diazepam rectal kit PA; QL (0 EA per 0 days)

15 diazepam rectal kit.5 PA; QL (5 EA per 0 days) diazepam rectal kit PA; QL (0 EA per 0 days) divalproex oral capsule, delayed rel sprinkle 5 divalproex oral tablet extended release hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 5, 50, 500 gabapentin oral capsule 00, 00, 00 gabapentin oral solution 50 /5 ml, 50 /5 ml (5 ml), 00 /6 ml (6 ml) gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET MG, 6 MG ONFI ORAL SUSPENSION.5 MG/ML PA; QL (80 ML per 0 days) ONFI ORAL TABLET 0 MG, 0 MG PA; QL (60 EA per 0 days) phenobarbital oral elixir 0 /5 ml ( /ml) PA phenobarbital oral tablet 00, 5, 6., 0,., 60, 6.8, 97. primidone oral tablet 50, 50 PA SABRIL ORAL POWDER IN PACKET 500 MG PA SABRIL ORAL TABLET 500 MG PA; QL (80 EA per 0 days) tiagabine oral tablet, valproate sodium intravenous solution 500 /5 ml (00 /ml) valproic acid (as sodium salt) oral solution 50 /5 ml, 50 /5 ml (5 ml), 500 /0 ml (0 ml) valproic acid oral capsule 50 Glutamate Reducing Agents felbamate oral suspension 600 /5 ml felbamate oral tablet 00, 600 FYCOMPA ORAL SUSPENSION 0.5 MG/ML ST FYCOMPA ORAL TABLET 0 MG, MG, MG, MG, 6 MG, 8 MG FYCOMPA ORAL TABLETS,DOSE PACK MG (7)- MG (7) ST; QL (0 EA per 0 days) 5

16 lamotrigine oral tablet 00, 50, 00, 5 lamotrigine oral tablet extended release hr 00, 00, 5, 50, 00, 50 lamotrigine oral tablet, chewable dispersible 5, 5 topiramate oral capsule, sprinkle 5, 5 topiramate oral tablet 00, 00, 5, 50 Sodium Channel Agents APTIOM ORAL TABLET 00 MG ST; QL (0 EA per 0 days) APTIOM ORAL TABLET 00 MG, 800 MG 5 ST; QL (0 EA per 0 days) APTIOM ORAL TABLET 600 MG ST; QL (60 EA per 0 days) BANZEL ORAL SUSPENSION 0 MG/ML ; QL (00 ML per 0 days) BANZEL ORAL TABLET 00 MG PA; QL (0 EA per 0 days) BANZEL ORAL TABLET 00 MG ; QL (0 EA per 0 days) carbamazepine oral suspension 00 /5 ml carbamazepine oral tablet 00 carbamazepine oral tablet extended release hr 00, 00, 00 carbamazepine oral tablet,chewable 00 DILANTIN ORAL CAPSULE 0 MG epitol oral tablet 00 EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG, 00 MG, 00 MG fosphenytoin injection solution 00 pe/ ml, 500 pe/0 ml oxcarbazepine oral suspension 00 /5 ml (60 /ml) oxcarbazepine oral tablet 50, 00, 600 PEGANONE ORAL TABLET 50 MG phenytoin oral suspension 00 / ml, 5 /5 ml phenytoin oral tablet,chewable 50 6

17 phenytoin sodium extended oral capsule 00, 00, 00 phenytoin sodium intravenous solution 50 /ml VIMPAT INTRAVENOUS SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 0 MG/ML 5 ST; QL (00 ML per 0 days) VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG Antidementia Agents Antidementia Agents, Other ergoloid oral tablet PA Cholinesterase Inhibitors donepezil oral tablet 0,, 5 donepezil oral tablet,disintegrating 0, 5 rivastigmine tartrate oral capsule.5,,.5, 6 rivastigmine transdermal patch hour. / hour,.6 / hr, 9.5 / hr N-Methyl-D-Aspartate (Nmda) Receptor Antagonist memantine oral tablet 0, 5 memantine oral tablets,dose pack 5-0 NAMENDA XR ORAL CAP,SPRINKLE,ER HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER HR MG, MG, 8 MG, 7 MG Antidepressants Antidepressants, Other APLENZIN ORAL TABLET EXTENDED RELEASE HR 7 MG, 8 MG, 5 MG buproban oral tablet extended release hr 50 bupropion hcl (smoking deter) oral tablet extended release hr 50 bupropion hcl oral tablet 00, 75 ST; QL (60 EA per 0 days) ST ST; QL (0 EA per 0 days) 7

18 bupropion hcl oral tablet extended release hr 00, 50, 00 bupropion hcl oral tablet extended release hr 50, 00 FORFIVO XL ORAL TABLET EXTENDED RELEASE HR 50 MG maprotiline oral tablet 5, 50, 75 mirtazapine oral tablet 5, 0, 5, 7.5 mirtazapine oral tablet,disintegrating 5, 0, 5 nefazodone oral tablet 00, 50, 00, 50, 50 perphenazine-amitriptyline oral tablet -0, - 5, -0, -5, -50 quetiapine oral tablet extended release hr 50, 00 quetiapine oral tablet extended release hr 00, 00, 50 trazodone oral tablet 00, 50, 00, 50 Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL PATCH HOUR MG/ HR, 6 MG/ HR, 9 MG/ HR MARPLAN ORAL TABLET 0 MG phenelzine oral tablet 5 tranylcypromine oral tablet 0 Ssris/ Snris citalopram oral solution 0 /5 ml citalopram oral tablet 0, 0, 0 desvenlafaxine fumarate oral tablet extended release hr 00, 50 desvenlafaxine oral tablet extended release hr 00, 50 desvenlafaxine oral tablet extended release hr 00, 50 desvenlafaxine succinate oral tablet extended release hr 00, 5, 50 8 PA QL (0 EA per 0 days) QL (60 EA per 0 days)

19 duloxetine oral capsule,delayed release(dr/ec) 0, 0, 60 escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 0, 0, 5 FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK 0 MG ()- 0 MG (6) FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG, 0 MG, 0 MG, 80 MG fluoxetine oral capsule 0, 0, 0 fluoxetine oral capsule,delayed release(dr/ec) 90 fluoxetine oral solution 0 /5 ml ( /ml) fluoxetine oral tablet 0 fluoxetine oral tablet 0 fluvoxamine oral tablet 00, 5, 50 paroxetine hcl oral tablet 0, 0, 0, 0 paroxetine hcl oral tablet extended release hr.5, 5 PAXIL ORAL SUSPENSION 0 MG/5 ML PRISTIQ ORAL TABLET EXTENDED RELEASE HR 00 MG, 5 MG, 50 MG sertraline oral concentrate 0 /ml sertraline oral tablet 00, 5, 50 TRINTELLIX ORAL TABLET 0 MG, 0 MG, 5 MG venlafaxine oral capsule,extended release hr 50, 7.5, 75 venlafaxine oral tablet 00, 5, 7.5, 50, 75 venlafaxine oral tablet extended release hr 50, 5, 7.5, 75 VIIBRYD ORAL TABLET 0 MG, 0 MG, 0 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 0 MG () ST ST ST ST ST 9

20 Tricyclics amitriptyline oral tablet 0, 00, 50, 5, 50, 75 amoxapine oral tablet 00, 50, 5, 50 0 PA clomipramine oral capsule 5, 50, 75 PA desipramine oral tablet 0, 00, 50, 5, 50, 75 doxepin oral capsule 0, 00, 50, 5, 50, 75 PA doxepin oral concentrate 0 /ml PA imipramine hcl oral tablet 0, 5, 50 PA imipramine pamoate oral capsule 00, 5, 50, 75 nortriptyline oral capsule 0, 5, 50, 75 nortriptyline oral solution 0 /5 ml protriptyline oral tablet 0, 5 PA trimipramine oral capsule 00, 5, 50 PA Antiemetics Antiemetics, Other chlorpromazine injection solution 5 /ml chlorpromazine oral tablet 0, 00, 00, 5, 50 compro rectal suppository 5 diphenhydramine hcl injection solution 50 /ml PA hydroxyzine hcl oral solution 0 /5 ml PA hydroxyzine hcl oral tablet 0, 5, 50 PA hydroxyzine pamoate oral capsule 00, 5, 50 meclizine oral tablet.5, 5 metoclopramide hcl injection solution 5 /ml metoclopramide hcl oral solution 5 /5 ml metoclopramide hcl oral tablet 0, 5 perphenazine oral tablet 6,,, 8 PA

21 phenadoz rectal suppository.5 PA prochlorperazine edisylate injection solution 0 / ml (5 /ml), 5 /ml prochlorperazine maleate oral tablet 0, 5 prochlorperazine rectal suppository 5 promethazine oral syrup 6.5 /5 ml PA promethazine oral tablet.5, 5, 50 PA promethazine rectal suppository.5, 5 PA promethegan rectal suppository 5, 50 PA TRANSDERM-SCOP TRANSDERMAL PATCH DAY.5 MG ( MG OVER DAYS) trimethobenzamide oral capsule 00 PA Emetogenic Therapy Adjuncts aprepitant oral capsule 5, 0, 80 B/D aprepitant oral capsule,dose pack 5 ()- 80 () B/D dronabinol oral capsule 0,.5, 5 B/D EMEND ORAL CAPSULE 5 MG, 0 MG, 80 MG EMEND ORAL CAPSULE,DOSE PACK 5 MG ()- 80 MG () EMEND ORAL SUSPENSION FOR RECONSTITUTION 5 MG (5 MG/ ML FINAL CONC.) granisetron (pf) intravenous solution /ml ( ml), 00 mcg/ml granisetron hcl intravenous solution /ml, /ml ( ml) B/D B/D B/D PA PA granisetron hcl oral tablet PA ondansetron hcl (pf) injection solution / ml ondansetron hcl (pf) injection syringe / ml ondansetron hcl intravenous solution /ml ondansetron hcl oral solution /5 ml B/D ondansetron hcl oral tablet B/D; QL (5 EA per 0 days) ondansetron hcl oral tablet, 8 B/D ondansetron oral tablet,disintegrating, 8 B/D

22 Antifungals Antifungals abelcet intravenous suspension 5 /ml B/D AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION 50 MG B/D amphotericin b injection recon soln 50 B/D CANCIDAS INTRAVENOUS RECON SOLN 50 MG, 70 MG ciclopirox topical cream 0.77 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % ciclopirox-ure-camph-menth-euc topical solution 8 % clotrimazole mucous membrane troche 0 clotrimazole topical cream % clotrimazole topical solution % econazole topical cream % ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 00 MG, 50 MG fluconazole in dextrose(iso-o) intravenous piggyback 00 /00 ml, 00 /00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 /50 ml, 00 /00 ml, 00 /00 ml fluconazole oral suspension for reconstitution 0 /ml, 0 /ml fluconazole oral tablet 00, 50, 00, 50 flucytosine oral capsule 50, 500 griseofulvin microsize oral suspension 5 /5 ml itraconazole oral capsule 00 ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical shampoo % PA

23 LAMISIL ORAL GRANULES IN PACKET 5 MG, 87.5 MG MENTAX TOPICAL CREAM % MYCAMINE INTRAVENOUS RECON SOLN 00 MG MYCAMINE INTRAVENOUS RECON SOLN 50 MG NOXAFIL ORAL SUSPENSION 00 MG/5 ML (0 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 00 MG nyamyc topical powder 00,000 unit/gram nyata topical powder 00,000 unit/gram nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 unit/gram nystop topical powder 00,000 unit/gram terbinafine hcl oral tablet 50 terconazole vaginal cream 0. %, 0.8 % terconazole vaginal suppository 80 voriconazole intravenous solution 00 voriconazole oral suspension for reconstitution 00 /5 ml (0 /ml) voriconazole oral tablet 00 5 voriconazole oral tablet 50 Antigout Agents Antigout Agents allopurinol oral tablet 00, 00 colchicine oral tablet 0.6 probenecid oral tablet 500 probenecid-colchicine oral tablet PA PA ULORIC ORAL TABLET 0 MG, 80 MG ST Anti-Inflammatory Agents 5 5

24 Glucocorticoids a-hydrocort injection recon soln 00 betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0. % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % cortisone oral tablet 5 dexamethasone intensol oral drops /ml dexamethasone oral elixir 0.5 /5 ml dexamethasone oral solution 0.5 /5 ml dexamethasone oral tablet 0.5, 0.75,,.5,,, 6 dexamethasone sodium phos (pf) injection solution 0 /ml dexamethasone sodium phosphate injection solution 0 /ml, /ml dexamethasone sodium phosphate injection syringe /ml hydrocortisone oral tablet 0, 5 methylprednisolone acetate injection suspension 0 /ml, 80 /ml methylprednisolone oral tablet 6,,, 8 methylprednisolone oral tablets,dose pack methylprednisolone sodium succ injection recon soln 5, 0 methylprednisolone sodium succ intravenous recon soln,000

25 prednisolone acetate ophthalmic drops,suspension % prednisolone oral solution 5 /5 ml prednisolone sodium phosphate oral solution 5 /5 ml ( /ml), 5 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) prednisone oral solution 5 /5 ml prednisone oral tablet, 0,.5, 0, 5, 50 prednisone oral tablets,dose pack 0, 0 (8 pack), 5, 5 (8 pack) RAYOS ORAL TABLET,DELAYED RELEASE (DR/EC) MG, MG, 5 MG Antimigraine Agents Ergot Alkaloids dihydroergotamine injection solution /ml PA dihydroergotamine nasal spray,non-aerosol 0.5 /pump act. ( /ml) PA; QL (8 ML per 0 days) ERGOMAR SUBLINGUAL TABLET MG PA; QL (0 EA per 0 days) Serotonin (5-Ht) B/D Receptor Agonists naratriptan oral tablet,.5 QL ( EA per 0 days) sumatriptan nasal spray,non-aerosol 0 /actuation, 5 /actuation sumatriptan succinate oral tablet 00, 5, 50 sumatriptan succinate subcutaneous cartridge /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous pen injector /0.5 ml, 6 /0.5 ml, 6 /0.5 ml (autoinjector) sumatriptan succinate subcutaneous solution 6 /0.5 ml sumatriptan succinate subcutaneous syringe 6 /0.5 ml SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR MG/0.5 ML, 6 MG/0.5 ML QL ( EA per 0 days) QL ( EA per 0 days) QL ( ML per 0 days) QL ( ML per 0 days) QL ( ML per 0 days) QL ( ML per 0 days) QL ( ML per 0 days) 5

26 TREXIMET ORAL TABLET 0-60 MG, MG Antimyasthenic Agents Parasympathomimetics guanidine oral tablet 5 pyridostigmine bromide oral tablet 60 Antimycobacterials Antimycobacterials, Other dapsone oral tablet 00, 5 rifabutin oral capsule 50 Antituberculars CAPASTAT INJECTION RECON SOLN GRAM ethambutol oral tablet 00, 00 isoniazid injection solution 00 /ml isoniazid oral tablet 00, 00 PASER ORAL GRANULES DR FOR SUSP IN PACKET GRAM PRIFTIN ORAL TABLET 50 MG pyrazinamide oral tablet 500 rifampin intravenous recon soln 600 rifampin oral capsule 50, 00 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 00 MG TRECATOR ORAL TABLET 50 MG Antineoplastics Alkylating Agents BUSULFAN INTRAVENOUS SOLUTION 60 MG/0 ML BUSULFEX INTRAVENOUS SOLUTION 60 MG/0 ML 6 carboplatin intravenous solution 0 /ml B/D cisplatin intravenous solution /ml B/D cyclophosphamide oral capsule 5, 50 B/D

27 GLEOSTINE ORAL CAPSULE 0 MG, 00 MG, 0 MG PA GLEOSTINE ORAL CAPSULE 5 MG PA HEXALEN ORAL CAPSULE 50 MG PA LEUKERAN ORAL TABLET MG MATULANE ORAL CAPSULE 50 MG melphalan hcl intravenous recon soln 50 oxaliplatin intravenous solution 00 /0 ml B/D thiotepa injection recon soln 5 5 B/D VALCHLOR TOPICAL GEL 0.06 % Antiandrogens bicalutamide oral tablet 50 flutamide oral capsule 5 NILANDRON ORAL TABLET 50 MG nilutamide oral tablet 50 XTANDI ORAL CAPSULE 0 MG ZYTIGA ORAL TABLET 50 MG, 500 MG Antiangiogenic Agents POMALYST ORAL CAPSULE MG, MG, MG, MG REVLIMID ORAL CAPSULE 0 MG, 5 MG, 5 MG, 5 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 00 MG, 50 MG Antiestrogens/Modifiers ; LA EMCYT ORAL CAPSULE 0 MG PA FARESTON ORAL TABLET 60 MG PA SOLTAMOX ORAL SOLUTION 0 MG/5 ML tamoxifen oral tablet 0, 0 Antimetabolites DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG fludarabine intravenous recon soln 50 PA 5 7

28 gemcitabine intravenous recon soln gram, 00 gemcitabine intravenous recon soln gram gemcitabine intravenous solution gram/6. ml (8 /ml), gram/5.6 ml (8 /ml), 00 /5.6 ml (8 /ml) hydroxyurea oral capsule 500 PURIXAN ORAL SUSPENSION 0 MG/ML 5 TABLOID ORAL TABLET 0 MG PA Antineoplastics adriamycin intravenous solution 0 /0 ml B/D AVASTIN INTRAVENOUS SOLUTION 5 MG/ML (6 ML) docetaxel intravenous solution 0 /ml, 80 /8 ml (0 /ml) docetaxel intravenous solution 80 / ml (0 /ml) doxorubicin, peg-liposomal intravenous suspension /ml B/D B/D PA epirubicin intravenous solution 00 /00 ml B/D irinotecan intravenous solution 00 /5 ml B/D levoleucovorin intravenous solution 0 /ml B/D mitomycin intravenous recon soln 0, 0, 5 B/D paclitaxel intravenous concentrate 6 /ml B/D Antineoplastics, Other ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 00 MG amifostine crystalline intravenous recon soln 500 COTELLIC ORAL TABLET 0 MG fludarabine intravenous solution 50 / ml PA FUSILEV INTRAVENOUS RECON SOLN 50 MG ISTODAX INTRAVENOUS RECON SOLN 0 MG/ ML 8

29 KISQALI ORAL TABLET 00 MG/DAY (00 MG X ), 00 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X ) KYPROLIS INTRAVENOUS RECON SOLN 0 MG, 60 MG leucovorin calcium injection recon soln 00, 00, 50, 500 leucovorin calcium oral tablet 0, 5, 5, 5 B/D levoleucovorin intravenous recon soln 75 B/D levoleucovorin intravenous recon soln 50 PA LONSURF ORAL TABLET 5-6. MG, MG LYNPARZA ORAL CAPSULE 50 MG mesna intravenous solution 00 /ml B/D MESNEX ORAL TABLET 00 MG mitoxantrone intravenous concentrate /ml NINLARO ORAL CAPSULE. MG, MG, MG ODOMZO ORAL CAPSULE 00 MG REVLIMID ORAL CAPSULE.5 MG, 0 MG ; LA RUBRACA ORAL TABLET 00 MG, 00 MG SYLATRON -PACK SUBCUTANEOUS KIT 00 MCG, 00 MCG, 600 MCG SYLATRON SUBCUTANEOUS KIT 00 MCG, 00 MCG, 600 MCG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG VELCADE INJECTION RECON SOLN.5 MG VENCLEXTA ORAL TABLET 0 MG, 50 MG PA VENCLEXTA ORAL TABLET 00 MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG YONDELIS INTRAVENOUS RECON SOLN MG 9

30 ZALTRAP INTRAVENOUS SOLUTION 00 MG/ ML (5 MG/ML), 00 MG/8 ML (5 MG/ML) 0 ZOLINZA ORAL CAPSULE 00 MG Aromatase Inhibitors, Rd Generation anastrozole oral tablet exemestane oral tablet 5 letrozole oral tablet.5 Enzyme Inhibitors ETOPOPHOS INTRAVENOUS RECON SOLN 00 MG PA etoposide intravenous solution 0 /ml B/D FARYDAK ORAL CAPSULE 0 MG, 5 MG, 0 MG IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG toposar intravenous solution 0 /ml B/D topotecan intravenous recon soln topotecan intravenous solution / ml ( /ml) ZYDELIG ORAL TABLET 00 MG, 50 MG Molecular Target Inhibitors AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 50 MG BOSULIF ORAL TABLET 00 MG, 500 MG CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG CAPRELSA ORAL TABLET 00 MG, 00 MG COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 0 MG/DAY(80 MG X-0 MG X), 60 MG/DAY (0 MG X /DAY) ERIVEDGE ORAL CAPSULE 50 MG GILOTRIF ORAL TABLET 0 MG, 0 MG, 0 MG

31 ICLUSIG ORAL TABLET 5 MG, 5 MG imatinib oral tablet 00, 00 PA IMBRUVICA ORAL CAPSULE 0 MG INLYTA ORAL TABLET MG, 5 MG IRESSA ORAL TABLET 50 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), MG/DAY(0 MG X - MG X ), 8 MG/DAY (0 MG X - MG X), 0 MG/DAY (0 MG X ), MG/DAY(0 MG X - MG X ), 8 MG/DAY ( MG X ) MEKINIST ORAL TABLET 0.5 MG, MG NEXAVAR ORAL TABLET 00 MG OFEV ORAL CAPSULE 00 MG, 50 MG SPRYCEL ORAL TABLET 00 MG, 0 MG, 0 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 0 MG SUTENT ORAL CAPSULE.5 MG, 5 MG, 7.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 0 MG, 80 MG TARCEVA ORAL TABLET 00 MG, 50 MG, 5 MG TASIGNA ORAL CAPSULE 50 MG, 00 MG TYKERB ORAL TABLET 50 MG VOTRIENT ORAL TABLET 00 MG XALKORI ORAL CAPSULE 00 MG, 50 MG ZELBORAF ORAL TABLET 0 MG ZYKADIA ORAL CAPSULE 50 MG Monoclonal Antibodies BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML

32 CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 0 MG/ML EMPLICITI INTRAVENOUS RECON SOLN 00 MG, 00 MG HERCEPTIN INTRAVENOUS RECON SOLN 50 MG, 0 MG KEYTRUDA INTRAVENOUS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS SOLUTION 00 MG/ ML (5 MG/ML) LARTRUVO INTRAVENOUS SOLUTION 0 MG/ML OPDIVO INTRAVENOUS SOLUTION 00 MG/0 ML, 0 MG/ ML RITUXAN INTRAVENOUS CONCENTRATE 0 MG/ML TECENTRIQ INTRAVENOUS SOLUTION,00 MG/0 ML (60 MG/ML) YERVOY INTRAVENOUS SOLUTION 50 MG/0 ML (5 MG/ML) Retinoids bexarotene oral capsule 75 5 PANRETIN TOPICAL GEL 0. % PA TARGRETIN TOPICAL GEL % PA tretinoin (chemotherapy) oral capsule 0 5 Antiparasitics Anthelmintics ALBENZA ORAL TABLET 00 MG BILTRICIDE ORAL TABLET 600 MG Antiprotozoals ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5 ml 5

33 atovaquone-proguanil oral tablet chloroquine phosphate oral tablet 50, 500 COARTEM ORAL TABLET 0-0 MG DARAPRIM ORAL TABLET 5 MG hydroxychloroquine oral tablet 00 MALARONE ORAL TABLET MG mefloquine oral tablet 50 NEBUPENT INHALATION RECON SOLN 00 MG B/D PENTAM INJECTION RECON SOLN 00 MG PA PRIMAQUINE ORAL TABLET 6. MG quinine sulfate oral capsule Pediculicides/ Scabicides lindane topical shampoo % malathion topical lotion 0.5 % permethrin topical cream 5 % Antiparkinson Agents Anticholinergics benztropine oral tablet 0.5,, PA Antiparkinson Agents, Other amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 00 APOKYN SUBCUTANEOUS CARTRIDGE 0 MG/ML entacapone oral tablet 00 rasagiline oral tablet 0.5 tolcapone oral tablet 00 trihexyphenidyl oral elixir 0. /ml PA trihexyphenidyl oral tablet, 5 PA Dopamine Agonists bromocriptine oral capsule 5 bromocriptine oral tablet.5

34 NEUPRO TRANSDERMAL PATCH HOUR MG/ HOUR, MG/ HOUR, MG/ HOUR, MG/ HOUR, 6 MG/ HOUR, 8 MG/ HOUR pramipexole oral tablet 0.5, 0.5, 0.5, 0.75,,.5 pramipexole oral tablet extended release hr 0.75, 0.75,.5,.5,,.75,.5 ropinirole oral tablet 0.5, 0.5,,,,, 5 PA Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa-levodopa oral tablet 0-00, 5-00, 5-50 carbidopa-levodopa oral tablet extended release 5-00, Monoamine Oxidase B (Mao-B) Inhibitors AZILECT ORAL TABLET MG rasagiline oral tablet 0.5, selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 Antipsychotics St Generation/ Typical fluphenazine decanoate injection solution 5 /ml fluphenazine hcl injection solution.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir.5 /5 ml fluphenazine hcl oral tablet, 0,.5, 5 haloperidol decanoate intramuscular solution 00 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate /ml haloperidol oral tablet 0.5,, 5 QL (90 EA per 0 days) haloperidol oral tablet QL (70 EA per 0 days)

35 haloperidol oral tablet 0, 0 QL (50 EA per 0 days) loxapine succinate oral capsule 0 QL (0 EA per 0 days) loxapine succinate oral capsule 5, 5 QL (90 EA per 0 days) loxapine succinate oral capsule 50 molindone oral tablet 0, 5 QL (0 EA per 0 days) molindone oral tablet 5 QL (70 EA per 0 days) pimozide oral tablet, thioridazine oral tablet 0, 00, 5, 50 thiothixene oral capsule, 0,, 5 trifluoperazine oral tablet, 0,, 5 Nd Generation/ Atypical abilify maintena intramuscular suspension,extended rel recon 00 ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 00 MG abilify maintena intramuscular suspension,extended rel syring 00, 00 PA ; QL ( EA per 8 days) ; QL ( EA per 8 days) ; QL ( EA per 8 days) aripiprazole oral solution /ml 5 QL (900 ML per 0 days) aripiprazole oral tablet 0, 5,, 0, 0, 5 aripiprazole oral tablet,disintegrating 0, 5 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING MG/.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 66 MG/. ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 88 MG/. ML QL (0 EA per 0 days) 5 QL (60 EA per 0 days) ; QL (.6 ML per 8 days) ; QL (. ML per 8 days) ; QL (. ML per 8 days) FANAPT ORAL TABLET MG, MG ST; QL (60 EA per 0 days) FANAPT ORAL TABLET 0 MG, MG, MG, 6 MG, 8 MG 5 ST; QL (60 EA per 0 days) 5

36 FANAPT ORAL TABLETS,DOSE PACK MG()-MG()- MG()-6MG() GEODON INTRAMUSCULAR RECON SOLN 0 MG/ML (FINAL CONC.) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 56 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE MG/.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 9 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 7 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 0 MG/.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 56 MG/.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 89 MG/.65 ML LATUDA ORAL TABLET 0 MG, 0 MG, 0 MG, 60 MG, 80 MG 6 ST PA; QL ( EA per 0 days) ; QL (0.75 ML per 8 days) ; QL ( ML per 8 days) ; QL (.5 ML per 8 days) PA; QL (0.5 ML per 8 days) ; QL (0.5 ML per 8 days) ; QL (0.875 ML per 8 days) ; QL (.5 ML per 8 days) ; QL (.75 ML per 8 days) ; QL (.65 ML per 8 days) 5 ST; QL (0 EA per 0 days) NUPLAZID ORAL TABLET 7 MG ; QL (60 EA per 0 days) olanzapine intramuscular recon soln 0 QL (90 EA per 0 days) olanzapine oral tablet 0, 5,.5, 0, 5, 7.5 olanzapine oral tablet,disintegrating 0, 5, 0, 5 paliperidone oral tablet extended release hr.5,, 9 paliperidone oral tablet extended release hr 6 quetiapine oral tablet 00, 00, 00, 00 QL (0 EA per 0 days) QL (0 EA per 0 days) PA; QL (0 EA per 0 days) PA; QL (60 EA per 0 days) QL (60 EA per 0 days) quetiapine oral tablet 5, 50 QL (90 EA per 0 days) quetiapine oral tablet extended release hr 50, 00 QL (0 EA per 0 days)

37 quetiapine oral tablet extended release hr 00, 00, 50 REXULTI ORAL TABLET 0.5 MG, 0.5 MG, MG, MG, MG, MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE.5 MG/ ML, 5 MG/ ML RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 7.5 MG/ ML, 50 MG/ ML QL (60 EA per 0 days) ; QL (0 EA per 0 days) PA; QL ( EA per 8 days) ; QL ( EA per 8 days) risperidone oral solution /ml QL (0 ML per 0 days) risperidone oral tablet 0.5, 0.5,,,, risperidone oral tablet,disintegrating 0.5, 0.5,,,, SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG,.5 MG, 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE HR 50 MG, 00 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE HR 00 MG, 00 MG, 50 MG VRAYLAR ORAL CAPSULE.5 MG, MG,.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK.5 MG ()- MG (6) ziprasidone hcl oral capsule 0, 0, 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 0 MG ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 00 MG, 05 MG Treatment-Resistant QL (60 EA per 0 days) QL (60 EA per 0 days) QL (60 EA per 0 days) QL (0 EA per 0 days) QL (60 EA per 0 days) 5 ST; QL (0 EA per 0 days) ST; QL (8 EA per 8 days) QL (60 EA per 0 days) PA clozapine oral tablet 00 QL (70 EA per 0 days) clozapine oral tablet 00 QL (0 EA per 0 days) clozapine oral tablet 5, 50 QL (90 EA per 0 days) clozapine oral tablet,disintegrating.5, 5 clozapine oral tablet,disintegrating 50 QL (80 EA per 0 days) 7

38 clozapine oral tablet,disintegrating 00 QL (0 EA per 0 days) VERSACLOZ ORAL SUSPENSION 50 MG/ML 5 QL (50 ML per 0 days) Antispasticity Agents Antispasticity Agents baclofen oral tablet 0, 0 comfort pac-tizanidine kit dantrolene oral capsule 00, 5, 50 tizanidine oral tablet, Antivirals Anti-Cytomegalovirus (Cmv) Agents cidofovir intravenous solution 75 /ml ganciclovir sodium intravenous recon soln 500 B/D VALCYTE ORAL RECON SOLN 50 MG/ML 5 valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 50 5 ZIRGAN OPHTHALMIC GEL 0.5 % ST Anti-Hepatitis B (Hbv) Agents ADEFOVIR ORAL TABLET 0 MG PA BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, 5 EPIVIR HBV ORAL SOLUTION 5 MG/5 ML (5 MG/ML) INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML lamivudine oral solution 0 /ml lamivudine oral tablet 00, 50, 00 TYZEKA ORAL TABLET 600 MG VEMLIDY ORAL TABLET 5 MG 5 VIREAD ORAL POWDER 0 MG/SCOOP (0 MG/GRAM) 8 PA PA PA 5

39 VIREAD ORAL TABLET 50 MG, 00 MG, 50 MG, 00 MG Anti-Hepatitis C (Hcv) Agents EPCLUSA ORAL TABLET MG HARVONI ORAL TABLET MG MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 00 MG (7)- 00 MG (7), 600 MG (7)- 600 MG (7) 5 moderiba oral tablet 00 PA PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 5 MCG/0.5 ML, 80 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 0 MCG/0.5 ML, 50 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 0 MCG/0.5 ML, 50 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML REBETOL ORAL SOLUTION 0 MG/ML PA ribasphere oral capsule 00 PA ribasphere oral tablet 00 PA RIBASPHERE ORAL TABLET 00 MG PA RIBASPHERE ORAL TABLET 600 MG ribasphere ribapak oral tablets,dose pack 00 (8)- 00 (8), 00 (7)- 00 (7) RIBASPHERE RIBAPAK ORAL TABLETS,DOSE PACK 00 MG (7)- 00 MG (7), MG (8)-MG (8), 600 MG (7)- 00 MG (7), 600 MG (7)- 600 MG (7), MG (8)-MG (8), MG (8)-MG (8) RIBATAB DOSE PACK ORAL TABLETS,DOSE PACK MG (8)-MG (8) ribavirin oral capsule 00 PA ribavirin oral tablet 00 PA 9

40 SOVALDI ORAL TABLET 00 MG ZEPATIER ORAL TABLET MG Antiherpetic Agents acyclovir oral capsule 00 acyclovir oral suspension 00 /5 ml acyclovir oral tablet 00, 800 acyclovir sodium intravenous recon soln,000, B/D acyclovir sodium intravenous solution 50 /ml B/D acyclovir topical ointment 5 % DENAVIR TOPICAL CREAM % 5 famciclovir oral tablet 5, 50, 500 trifluridine ophthalmic drops % valacyclovir oral tablet gram, 500 ZOVIRAX TOPICAL CREAM 5 % 5 Anti-Hiv Agents, Integrase Inhibitors (Insti) GENVOYA ORAL TABLET MG ISENTRESS ORAL POWDER IN PACKET 00 MG 5 QL (0 EA per 0 days) ISENTRESS ORAL TABLET 00 MG 5 QL (0 EA per 0 days) ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 5 MG STRIBILD ORAL TABLET MG QL (80 EA per 0 days) 5 QL (0 EA per 0 days) TIVICAY ORAL TABLET 0 MG QL (00 EA per 0 days) TIVICAY ORAL TABLET 5 MG 5 QL (0 EA per 0 days) TIVICAY ORAL TABLET 50 MG 5 QL (60 EA per 0 days) VITEKTA ORAL TABLET 50 MG, 85 MG 5 QL (0 EA per 0 days) Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Nnrti) COMPLERA ORAL TABLET MG 5 QL (0 EA per 0 days) EDURANT ORAL TABLET 5 MG 5 QL (0 EA per 0 days) INTELENCE ORAL TABLET 00 MG, 5 MG QL (0 EA per 0 days) INTELENCE ORAL TABLET 00 MG 5 QL (60 EA per 0 days)

41 nevirapine oral suspension 50 /5 ml nevirapine oral tablet 00 QL (60 EA per 0 days) nevirapine oral tablet extended release hr 00 nevirapine oral tablet extended release hr 00 QL (0 EA per 0 days) QL (0 EA per 0 days) RESCRIPTOR ORAL TABLET 00 MG QL (80 EA per 0 days) RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG QL (60 EA per 0 days) SUSTIVA ORAL CAPSULE 00 MG QL (0 EA per 0 days) SUSTIVA ORAL CAPSULE 50 MG QL (60 EA per 0 days) SUSTIVA ORAL TABLET 600 MG 5 QL (0 EA per 0 days) Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti) abacavir oral tablet 00 QL (60 EA per 0 days) abacavir-lamivudine oral tablet QL (0 EA per 0 days) abacavir-lamivudine-zidovudine oral tablet QL (60 EA per 0 days) ATRIPLA ORAL TABLET MG 5 QL (0 EA per 0 days) DESCOVY ORAL TABLET 00-5 MG 5 QL (0 EA per 0 days) didanosine oral capsule,delayed release(dr/ec) 5 didanosine oral capsule,delayed release(dr/ec) 00 didanosine oral capsule,delayed release(dr/ec) 50, 00 QL (90 EA per 0 days) QL (60 EA per 0 days) QL (0 EA per 0 days) EMTRIVA ORAL CAPSULE 00 MG QL (0 EA per 0 days) EMTRIVA ORAL SOLUTION 0 MG/ML EPZICOM ORAL TABLET MG 5 QL (0 EA per 0 days) lamivudine-zidovudine oral tablet QL (60 EA per 0 days) RETROVIR INTRAVENOUS SOLUTION 0 MG/ML stavudine oral capsule 5, 0 QL (0 EA per 0 days) stavudine oral capsule 0, 0 QL (60 EA per 0 days) TRUVADA ORAL TABLET MG, - 00 MG, MG 5 QL (0 EA per 0 days) TRUVADA ORAL TABLET MG 5 QL (0 EA per 0 days)

42 VIDEX GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIDEX GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) zerit oral recon soln /ml ZIAGEN ORAL SOLUTION 0 MG/ML zidovudine oral capsule 00 QL (80 EA per 0 days) zidovudine oral syrup 0 /ml zidovudine oral tablet 00 QL (60 EA per 0 days) Anti-Hiv Agents, Other FUZEON SUBCUTANEOUS RECON SOLN 90 MG ODEFSEY ORAL TABLET MG 5 QL (0 EA per 0 days) SELZENTRY ORAL TABLET 50 MG 5 QL (60 EA per 0 days) SELZENTRY ORAL TABLET 5 MG QL (0 EA per 0 days) SELZENTRY ORAL TABLET 00 MG 5 QL (0 EA per 0 days) SELZENTRY ORAL TABLET 75 MG QL (60 EA per 0 days) TRIUMEQ ORAL TABLET MG 5 QL (0 EA per 0 days) TYBOST ORAL TABLET 50 MG QL (0 EA per 0 days) Anti-Hiv Agents, Protease Inhibitors APTIVUS ORAL CAPSULE 50 MG QL (0 EA per 0 days) APTIVUS ORAL SOLUTION 00 MG/ML CRIXIVAN ORAL CAPSULE 00 MG QL (60 EA per 0 days) CRIXIVAN ORAL CAPSULE 00 MG QL (80 EA per 0 days) EVOTAZ ORAL TABLET MG 5 QL (0 EA per 0 days) INVIRASE ORAL CAPSULE 00 MG QL (00 EA per 0 days) INVIRASE ORAL TABLET 500 MG 5 QL (0 EA per 0 days) KALETRA ORAL SOLUTION MG/5 ML KALETRA ORAL TABLET 00-5 MG QL (0 EA per 0 days) KALETRA ORAL TABLET MG 5 QL (0 EA per 0 days) LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG 5 QL (0 EA per 0 days) NORVIR ORAL CAPSULE 00 MG QL (60 EA per 0 days) 5 5

43 NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG QL (60 EA per 0 days) PREZCOBIX ORAL TABLET MG-MG 5 QL (0 EA per 0 days) PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG 5 QL (80 EA per 0 days) PREZISTA ORAL TABLET 600 MG 5 QL (60 EA per 0 days) PREZISTA ORAL TABLET 75 MG 5 QL (00 EA per 0 days) PREZISTA ORAL TABLET 800 MG 5 QL (0 EA per 0 days) REYATAZ ORAL CAPSULE 50 MG, 00 MG 5 QL (0 EA per 0 days) REYATAZ ORAL CAPSULE 00 MG 5 QL (60 EA per 0 days) REYATAZ ORAL POWDER IN PACKET 50 MG VIRACEPT ORAL TABLET 50 MG QL (00 EA per 0 days) VIRACEPT ORAL TABLET 65 MG 5 QL (0 EA per 0 days) Anti-Hiv-Specific Agents, Protease Inhibitor lopinavir-ritonavir oral solution /5 ml Anti-Influenza Agents oseltamivir oral capsule 0 QL (8 EA per 80 days) oseltamivir oral capsule 5 QL ( EA per 80 days) oseltamivir oral capsule 75 QL (8 EA per 80 days) RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 00 5 QL (60 EA per 80 days) TAMIFLU ORAL CAPSULE 0 MG QL (8 EA per 80 days) TAMIFLU ORAL CAPSULE 5 MG QL ( EA per 80 days) TAMIFLU ORAL CAPSULE 75 MG QL (8 EA per 80 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML Anxiolytics Anxiolytics, Other buspirone oral tablet 0, 5, 0, 5, 7.5 meprobamate oral tablet 00, 00 PA Benzodiazepines QL (50 ML per 80 days)

44 alprazolam oral tablet 0.5, 0.5, QL (0 EA per 0 days) alprazolam oral tablet QL (50 EA per 0 days) clorazepate dipotassium oral tablet 5 PA; QL (80 EA per 0 days) clorazepate dipotassium oral tablet.75, 7.5 PA; QL (90 EA per 0 days) diazepam intensol oral concentrate 5 /ml PA; QL (0 ML per 0 days) diazepam oral concentrate 5 /ml PA; QL (0 ML per 0 days) diazepam oral solution 5 /5 ml ( /ml), 5 /5 ml ( /ml, 5 ml) PA; QL (00 ML per 0 days) diazepam oral tablet 0,, 5 PA; QL (0 EA per 0 days) lorazepam intensol oral concentrate /ml QL (50 ML per 0 days) lorazepam oral concentrate /ml QL (50 ML per 0 days) lorazepam oral tablet 0.5, QL (90 EA per 0 days) lorazepam oral tablet QL (50 EA per 0 days) Bipolar Agents Mood Stabilizers carbamazepine oral capsule, er multiphase hr 00, 00, 00 lithium carbonate oral capsule 50, 00, 600 lithium carbonate oral tablet 00 lithium carbonate oral tablet extended release 00, 50 lithium citrate oral solution 8 meq/5 ml Blood Glucose Regulators Antidiabetic Agents acarbose oral tablet 00, 5, 50 ST AVANDIA ORAL TABLET MG ST; QL (0 EA per 0 days) AVANDIA ORAL TABLET MG ST; QL (60 EA per 0 days) glimepiride oral tablet QL (0 EA per 0 days) glimepiride oral tablet QL (0 EA per 0 days) glimepiride oral tablet QL (60 EA per 0 days) glipizide oral tablet 0 QL (0 EA per 0 days) glipizide oral tablet 5 QL (0 EA per 0 days)

45 glipizide oral tablet extended release hr 0 QL (60 EA per 0 days) glipizide oral tablet extended release hr.5 QL (0 EA per 0 days) glipizide oral tablet extended release hr 5 QL (0 EA per 0 days) glipizide-metformin oral tablet.5-50 QL (0 EA per 0 days) glipizide-metformin oral tablet.5-500, QL (0 EA per 0 days) glyburide micronized oral tablet.5 PA; QL (0 EA per 0 days) glyburide micronized oral tablet PA; QL (0 EA per 0 days) glyburide micronized oral tablet 6 PA; QL (60 EA per 0 days) glyburide oral tablet.5 PA; QL (80 EA per 0 days) glyburide oral tablet.5 PA; QL (0 EA per 0 days) glyburide oral tablet 5 PA; QL (0 EA per 0 days) glyburide-metformin oral tablet.5-50 PA; QL (0 EA per 0 days) glyburide-metformin oral tablet.5-500, PA; QL (0 EA per 0 days) GLYXAMBI ORAL TABLET 0-5 MG ST; QL (0 EA per 0 days) GLYXAMBI ORAL TABLET 5-5 MG ST; QL (60 EA per 0 days) INVOKAMET ORAL TABLET 50-,000 MG, MG, 50-,000 MG ST; QL (60 EA per 0 days) INVOKAMET ORAL TABLET MG ST; QL (0 EA per 0 days) INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC HR 50-,000 MG, MG, 50-,000 MG, MG ST; QL (60 EA per 0 days) INVOKANA ORAL TABLET 00 MG ST; QL (90 EA per 0 days) INVOKANA ORAL TABLET 00 MG ST; QL (0 EA per 0 days) JANUMET ORAL TABLET 50-,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE HR 00-,000 MG JANUMET XR ORAL TABLET, ER MULTIPHASE HR 50-,000 MG, MG ST; QL (60 EA per 0 days) ST; QL (0 EA per 0 days) ST; QL (60 EA per 0 days) JANUVIA ORAL TABLET 00 MG ST; QL (0 EA per 0 days) JANUVIA ORAL TABLET 5 MG ST; QL (0 EA per 0 days) JANUVIA ORAL TABLET 50 MG ST; QL (60 EA per 0 days) JARDIANCE ORAL TABLET 0 MG, 5 MG ST; QL (0 EA per 0 days) 5