2016 Provider Directory. Drug Formulary

Transcription

1 2016 Provider Directory Drug Formulary

2 lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs Drug Tier Notes Antihistamine Drugs Ethanolamine Derivatives clemastine oral tablet diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule diphenhydramine hcl oral liquid diphenhydramine hcl oral tablet 25 mg SLEEP AID (DOXYLAMINE) First Gen. Antihist. Derivatives, Misc. cyproheptadine First Generation Antihistamines clemastine oral tablet cyproheptadine diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule diphenhydramine hcl oral liquid diphenhydramine hcl oral tablet 25 mg SLEEP AID (DOXYLAMINE) Phenothiazine Derivatives promethazine injection solution promethazine oral 1

3 promethazine rectal suppository 12.5 mg, 25 mg PROMETHAZINE VC PROMETHAZINE VC-CODEINE Piperazine Derivatives hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet hydroxyzine pamoate meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable Propylamine Derivatives M-END DMX Second Generation Antihistamines ALLEGRA ALLERGY ORAL TABLET 180 MG ALLERGY RELIEF,NASAL DECONGEST cetirizine oral solution 1 mg/ml cetirizine oral tablet cetirizine-pseudoephedrine CLARINEX ORAL SYRUP T3 PA CLARINEX ORAL TABLET T3 PA fexofenadine oral suspension ST fexofenadine oral tablet 180 mg ST levocetirizine oral solution T3 PA levocetirizine oral tablet loratadine oral solution loratadine oral tablet loratadine oral tablet,disintegrating LORATADINE-D Anti-Infective Agents Adamantanes 2 ST

4 amantadine hcl oral capsule amantadine hcl oral solution Allylamines terbinafine hcl oral QL (90 DS per 365 DYs) Amebicides metronidazole oral tablet paromomycin PA; QL (10 DS per 30 DYs) Aminoglycosides paromomycin PA; QL (10 DS per 30 DYs) Aminopenicillins amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule Anthelmintics BILTRICIDE Antifungals, Miscellaneous griseofulvin microsize oral suspension griseofulvin ultramicrosize SSKI Antimalarials chloroquine phosphate DARAPRIM PA hydroxychloroquine 3

5 mefloquine primaquine quinidine sulfate oral tablet Antimycobacterials, Miscellaneous dapsone oral Antiprotozoals, Miscellaneous atovaquone PA dapsone oral metronidazole oral tablet Antituberculosis Agents ciprofloxacin ciprofloxacin hcl oral tablet 250 mg, 500 mg QL (68 QY per 34 DYs) ciprofloxacin hcl oral tablet 750 mg QL (28 QY per 30 DYs) clarithromycin QL (1 FL per 30 DYs) ethambutol isoniazid oral levofloxacin oral solution QL (1 FL per 30 DYs) levofloxacin oral tablet QL (14 QY per 30 DYs) moxifloxacin oral QL (10 QY per 30 DYs) pyrazinamide rifampin oral Azoles fluconazole oral suspension for reconstitution fluconazole oral tablet 100 mg, 200 mg, 50 mg fluconazole oral tablet 150 mg QL (2 QY per 30 DYs) ketoconazole oral VFEND T3 PA Chloramphenicol chloramphenicol sod succinate Erythromycins 4

6 ERY-TAB ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) First Generation Cephalosporins cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution Glycopeptides vancomycin oral capsule ST Lincomycins clindamycin hcl oral capsule 150 mg, 300 mg clindamycin palmitate hcl Macrolides ERY-TAB ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) Natural Penicillins penicillin v potassium Neuraminidase Inhibitors oseltamivir QL (1 FL per 180 DYs) RELENZA DISKHALER QL (1 FL per 180 DYs) Nucleosides And Nucleotides acyclovir oral capsule 5

7 acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet entecavir HEPSERA T3 PA valacyclovir Other Macrolides azithromycin oral packet QL (1 FL per 30 DYs) azithromycin oral suspension for reconstitution QL (1 FL per 30 DYs) azithromycin oral tablet 250 mg, 500 mg QL (6 QY per 30 DYs) azithromycin oral tablet 600 mg QL (8 QY per 30 DYs) clarithromycin QL (1 FL per 30 DYs) ZMAX QL (1 QY per 30 DYs) Oxazolidinones linezolid oral T3 PA Penicillinase-Resistant Penicillins dicloxacillin Polyenes nystatin oral powder 150 million unit, 500 million unit nystatin oral suspension nystatin oral tablet Quinolones ciprofloxacin ciprofloxacin hcl oral tablet 250 mg, 500 mg QL (68 QY per 34 DYs) ciprofloxacin hcl oral tablet 750 mg QL (28 QY per 30 DYs) levofloxacin oral solution QL (1 FL per 30 DYs) levofloxacin oral tablet QL (14 QY per 30 DYs) moxifloxacin oral QL (10 QY per 30 DYs) Rifamycins rifampin oral 6

8 Second Generation Cephalosporins cefaclor oral capsule cefprozil oral suspension for reconstitution CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 250 MG/5 ML cefuroxime axetil oral suspension for reconstitution 125 mg/5 ml cefuroxime axetil oral tablet Sulfonamides (Systemic) sulfadiazine sulfamethoxazole-trimethoprim oral sulfasalazine Tetracyclines doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg minocycline oral capsule 100 mg, 50 mg tetracycline Third Generation Cephalosporins cefdinir oral suspension for reconstitution cefpodoxime oral suspension for reconstitution SUPRAX ORAL CAPSULE Urinary Anti-Infectives nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst trimethoprim Antineoplastic Agents Antineoplastic Agents ALKERAN ORAL 7

9 bicalutamide cyclophosphamide oral capsule DROXIA EMCYT PA FARESTON PA flutamide GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG HEXALEN PA hydroxyurea letrozole QL (1 QY per 1 DY) LEUKERAN LYSODREN PA MATULANE PA megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral suspension 625 mg/5 ml QL (150 ML per 30 days) megestrol oral tablet mercaptopurine methotrexate sodium methotrexate sodium (pf) injection solution PA MYLERAN TABLOID tamoxifen TREXALL ORAL TABLET 7.5 MG Antitoxins,Immune Glob,Toxoids,Vaccines Toxoids ADACEL(TDAP ADOLESN/ADULT)(PF) BOOSTRIX TDAP Vaccines AFLURIA QL (0.5 ML per 180 days) 8 PA

10 AFLURIA (PF) QL (0.5 ML per 180 days) AFLURIA QUAD QL (0.5 ML per 180 days) AFLURIA QUAD (PF) QL (0.5 ML per 180 days) FLUARIX QUAD (PF) QL (0.5 ML per 180 days) FLUCELVAX QUAD QL (0.5 ML per 180 days) FLUCELVAX QUAD (PF) QL (0.5 ML per 180 days) FLULAVAL QUAD QL (0.5 ML per 180 days) FLULAVAL QUAD (PF) QL (0.5 ML per 180 days) FLUVIRIN QL (0.5 ML per 180 days) FLUVIRIN (PF) QL (0.5 ML per 180 days) FLUZONE HIGH-DOSE (PF) QL (0.5 ML per 180 days) FLUZONE INTRADERM QUAD QL (0.1 ML per 180 days) FLUZONE QUAD (PF) INTRAMUSCULAR SUSPENSION PNEUMOVAX 23 ZOSTAVAX (PF) Autonomic Drugs Alpha- And Beta-Adrenergic Agonists ALAVERT D-12 ALLERGY-SINUS ALLERGY RELIEF,NASAL DECONGEST brompheniramine-pseudoeph-dm oral syrup cetirizine-pseudoephedrine epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml LORATADINE-D M-END DMX pseudoephedrine hcl oral tablet 60 mg pseudoephedrine-guaifenesin Alpha-Adrenergic Agonists clonidine clonidine hcl oral tablet 9 QL (0.5 ML per 180 days) QL (2 EA per 30 days)

11 CLORPRES methyldopa methyldopa-hydrochlorothiazide PROMETHAZINE VC PROMETHAZINE VC-CODEINE ROBAFEN CF (PHENYLEPHRINE) Antimuscarinics/Antispasmodics ANORO ELLIPTA ATROVENT HFA COMBIVENT RESPIMAT dicyclomine oral capsule dicyclomine oral tablet diphenoxylate-atropine glycopyrrolate oral tablet 1 mg, 2 mg hydrocodone-homatropine oral syrup mg/5 ml hydrocodone-homatropine oral tablet hyoscyamine sulfate oral ipratropium bromide inhalation ipratropium-albuterol propantheline SPIRIVA RESPIMAT Antiparkinsonian Agents benztropine oral trihexyphenidyl Autonomic Drugs, Miscellaneous CHANTIX QL (360 QY per 365 DYs) CHANTIX STARTING MONTH BOX QL (360 QY per 365 DYs) nicotine (polacrilex) buccal gum nicotine (polacrilex) buccal mini lozenge 10

12 nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr Centrally Acting Skeletal Muscle Relaxnt carisoprodol oral tablet 350 mg chlorzoxazone oral tablet 500 mg cyclobenzaprine oral tablet 10 mg, 5 mg methocarbamol oral tizanidine oral tablet Gaba-Derivative Skeletal Muscle Relaxant baclofen Non-Sel. Beta-Adrenergic Blocking Agents carvedilol labetalol oral nadolol nadolol-bendroflumethiazide pindolol propranolol oral propranolol-hydrochlorothiazid sotalol oral timolol maleate oral Non-Sel.Alpha-1-Adrenergic Blocking Agts doxazosin prazosin terazosin Non-Sel.Alpha-Adrenergic Blocking Agents dihydroergotamine injection dihydroergotamine nasal QL (1 QY per 30 DYs) ERGOMAR phenoxybenzamine PA Parasympathomimetic (Cholinergic Agents) 11

13 bethanechol chloride donepezil oral tablet 10 mg, 5 mg donepezil oral tablet,disintegrating MESTINON ORAL SYRUP pyridostigmine bromide rivastigmine rivastigmine tartrate Selective Alpha-1-Adrenergic Block.Agent alfuzosin carvedilol labetalol oral tamsulosin Selective Beta-2-Adrenergic Agonists albuterol sulfate inhalation solution for nebulization 2.5 mg /3 ml (0.083 %), 5 mg/ml albuterol sulfate oral syrup albuterol sulfate oral tablet ANORO ELLIPTA BREO ELLIPTA COMBIVENT RESPIMAT DULERA QL (13 QY per 30 DYs) ipratropium-albuterol SEREVENT DISKUS terbutaline oral VENTOLIN HFA QL (1 QY per 30 DYs) Selective Beta-Adrenergic Blocking Agent atenolol bisoprolol fumarate bisoprolol-hydrochlorothiazide metoprolol succinate 12

14 metoprolol ta-hydrochlorothiaz oral tablet mg, mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg Skeletal Muscle Relaxants, Miscellaneous XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT, 50 UNIT Blood Formation, Coagulation, Thrombosis Coumarin Derivatives warfarin Direct Factor Xa Inhibitors ELIQUIS XARELTO Direct Thrombin Inhibitors PRADAXA Hemorrheologic Agents pentoxifylline Hemostatics AMICAR ORAL SOLUTION AMICAR ORAL TABLET 500 MG desmopressin nasal solution PA desmopressin nasal spray,non-aerosol PA desmopressin oral PA Heparins enoxaparin subcutaneous solution T3 PA enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 150 mg/ml T3 PA heparin (porcine) injection solution 10,000 unit/ml, 5,000 unit/ml T3 T3 PA 13

15 LOVENOX SUBCUTANEOUS SYRINGE 100 MG/ML, 120 MG/0.8 ML, 30 MG/0.3 ML, 40 MG/0.4 ML, 60 MG/0.6 ML, 80 MG/0.8 ML Iron Preparations CADEAU DHA DAILY PRENATAL DAILY VITES/IRON FE C PLUS FERRETTS ferrous gluconate oral tablet 324 mg (37.5 mg iron), 324 mg (38 mg iron) ferrous sulfate oral drops ferrous sulfate oral liquid ferrous sulfate oral solution ferrous sulfate oral tablet 325 mg (65 mg iron) ferrous sulfate oral tablet,delayed release (dr/ec) 325 mg (65 mg iron) MULTIGEN MULTIGEN FOLIC MULTIGEN PLUS MULTI-VIT WITH FLUORIDE-IRON MYNATAL ADVANCE MYNATAL PLUS MYNATAL-Z OBSTETRIX DHA OBTREX DHA ONE DAILY PRENATAL ORAL COMBO PACK MG-MCG-MG ONE-A-DAY WOMENS FORMULA ORAL TABLET 18 MG IRON-400 MCG-500 MG CA ONE-A-DAY WOMEN'S PRENATAL 1 PR NATAL T3

16 PR NATAL 400 EC PR NATAL 430 PRENATAL + DHA ORAL COMBO PACK 28 MG IRON-800 MCG-200 MG PRENATAL 19 (WITH DOCUSATE) PRENATAL LOW IRON PRENATAL MULTI-DHA (ALGAL OIL) PRENATAL MULTI-DHA ORAL CAPSULE 27 MG IRON-800 MCG-228 MG PRENATAL PLUS PRENATAL PLUS DHA ORAL COMBO PACK PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG PRENATAL VITAMIN PLUS LOW IRON PRORENAL QD SE-NATAL 19 SE-NATAL 19 (WITH DOCUSATE) TRICARE TRIVEEN-DUO DHA TRI-VIT WITH FLUORIDE AND IRON VINATE GT VINATE ONE VINATE ULTRA VOL-NATE VOL-TAB RX WOMEN'S PRENATAL + DHA Platelet-Aggregation Inhibitors aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg 15

17 aspirin-dipyridamole cilostazol clopidogrel dipyridamole oral prasugrel ticlopidine Thrombolytic Agents aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg Cardiovascular Drugs Alpha-Adrenergic Blocking Agents carvedilol doxazosin labetalol oral prazosin terazosin Alpha-Adrenergic Blocking Agt.(Hypoten) doxazosin labetalol oral prazosin terazosin Angiotensin Ii Receptor Antagon.(Hypotn) amlodipine-valsartan ST irbesartan ST irbesartan-hydrochlorothiazide ST losartan losartan-hydrochlorothiazide olmesartan ST 16

18 olmesartan-hydrochlorothiazide oral tablet mg, mg telmisartan ST valsartan ST valsartan-hydrochlorothiazide ST Angiotensin Ii Receptor Antagonists amlodipine-valsartan ST irbesartan ST irbesartan-hydrochlorothiazide ST losartan losartan-hydrochlorothiazide olmesartan ST olmesartan-hydrochlorothiazide oral tablet mg, mg telmisartan ST valsartan ST valsartan-hydrochlorothiazide ST Angiotensin-Convert.Enzyme Inhib(Hypotn) benazepril benazepril-hydrochlorothiazide captopril captopril-hydrochlorothiazide enalapril maleate enalapril-hydrochlorothiazide fosinopril fosinopril-hydrochlorothiazide lisinopril lisinopril-hydrochlorothiazide moexipril moexipril-hydrochlorothiazide perindopril erbumine oral tablet 4 mg, 8 mg 17 ST ST

19 quinapril-hydrochlorothiazide trandolapril Angiotensin-Converting Enzyme Inhibitors benazepril benazepril-hydrochlorothiazide captopril captopril-hydrochlorothiazide enalapril maleate enalapril-hydrochlorothiazide fosinopril fosinopril-hydrochlorothiazide lisinopril lisinopril-hydrochlorothiazide moexipril moexipril-hydrochlorothiazide perindopril erbumine oral tablet 4 mg, 8 mg quinapril-hydrochlorothiazide trandolapril Antiarrhythmics, Miscellaneous digoxin oral tablet Antilipemic Agents, Miscellaneous niacin oral capsule, extended release 250 mg, 500 mg NIACOR Beta-Adrenergic Blocking Agents atenolol bisoprolol fumarate bisoprolol-hydrochlorothiazide carvedilol labetalol oral 18

20 metoprolol succinate metoprolol ta-hydrochlorothiaz oral tablet mg, mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol nadolol-bendroflumethiazide pindolol propranolol oral propranolol-hydrochlorothiazid sotalol oral timolol maleate oral Beta-Adrenergic Blocking Agt.(Hypoten) atenolol bisoprolol fumarate bisoprolol-hydrochlorothiazide labetalol oral metoprolol succinate metoprolol ta-hydrochlorothiaz oral tablet mg, mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol nadolol-bendroflumethiazide pindolol propranolol oral propranolol-hydrochlorothiazid sotalol oral timolol maleate oral Bile Acid Sequestrants cholestyramine (with sugar) 19

21 CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET colestipol oral tablet PREVALITE Calcium-Channel Block.Agt,Misc(Hypoten) diltiazem hcl oral capsule,ext.rel 24h degradable diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg diltiazem hcl oral capsule,extended release 24 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral tablet DILT-XR TAZTIA XT verapamil oral capsule,ext rel. pellets 24 hr 360 mg verapamil oral tablet verapamil oral tablet extended release Calcium-Channel Blocking Agents amlodipine amlodipine-valsartan ST diltiazem hcl oral capsule,ext.rel 24h degradable diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg diltiazem hcl oral capsule,extended release 24 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral tablet DILT-XR nifedipine oral capsule nifedipine oral tablet extended release 24hr 20

22 nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg TAZTIA XT verapamil oral capsule,ext rel. pellets 24 hr 360 mg verapamil oral tablet verapamil oral tablet extended release Calcium-Channel Blocking Agents, Misc. diltiazem hcl oral capsule,ext.rel 24h degradable diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg diltiazem hcl oral capsule,extended release 24 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral tablet DILT-XR TAZTIA XT verapamil oral capsule,ext rel. pellets 24 hr 360 mg verapamil oral tablet verapamil oral tablet extended release Carbonic Anhydrase Inhibitors(Hypoten) acetazolamide Cardiotonic Agents DIGOX digoxin oral tablet Central Alpha-Agonists clonidine clonidine hcl oral tablet CLORPRES guanfacine 21

23 methyldopa methyldopa-hydrochlorothiazide Cholesterol Absorption Inhibitors ZETIA Class Ia Antiarrhythmics disopyramide phosphate oral capsule NORPACE CR quinidine gluconate oral quinidine sulfate oral tablet Class Ib Antiarrhythmics DILANTIN DILANTIN INFATABS mexiletine phenytoin oral suspension phenytoin sodium extended oral capsule 100 mg Class Ic Antiarrhythmics flecainide propafenone oral tablet Class Ii Antiarrhythmics atenolol bisoprolol fumarate bisoprolol-hydrochlorothiazide carvedilol labetalol oral metoprolol succinate metoprolol ta-hydrochlorothiaz oral tablet mg, mg metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg nadolol 22

24 nadolol-bendroflumethiazide pindolol propranolol oral propranolol-hydrochlorothiazid sotalol oral timolol maleate oral Class Iii Antiarrhythmics amiodarone oral tablet 100 mg, 200 mg sotalol oral Class Iv Antiarrhythmics diltiazem hcl oral capsule,ext.rel 24h degradable diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg diltiazem hcl oral capsule,extended release 24 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral tablet DILT-XR TAZTIA XT verapamil oral capsule,ext rel. pellets 24 hr 360 mg verapamil oral tablet verapamil oral tablet extended release Dihydropyridines amlodipine amlodipine-valsartan ST nifedipine oral capsule nifedipine oral tablet extended release 24hr nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg Dihydropyridines (Hypotensive Agents) 23

25 amlodipine amlodipine-valsartan ST nifedipine oral capsule nifedipine oral tablet extended release 24hr nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 30 mg, 34 mg, 40 mg, 8.5 mg Direct Vasodilators hydralazine oral minoxidil oral Diuretics, Miscellaneous (Hypotensive) THEO-24 theophylline oral tablet extended release 12 hr 200 mg, 300 mg Fibric Acid Derivatives fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg fenofibrate oral tablet 160 mg, 54 mg gemfibrozil Hmg-Coa Reductase Inhibitors atorvastatin fluvastatin ST lovastatin pravastatin ST rosuvastatin simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Hypotensive Agents, Miscellaneous carvedilol doxazosin phenoxybenzamine PA pindolol propranolol oral 24

26 sotalol oral terazosin timolol maleate oral Loop Diuretics (Hypotensive Agents) bumetanide oral furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet torsemide oral Mineralocorticoid (Aldosterone) Antagnts spironolactone spironolacton-hydrochlorothiaz Mineralocorticoid(Aldoster.)Antag(Hypot) spironolactone spironolacton-hydrochlorothiaz Nitrates And Nitrites ISORDIL isosorbide dinitrate oral isosorbide mononitrate NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin oral nitroglycerin transdermal patch 24 hour NITROSTAT Phosphodiesterase Type 5 Inhibitors cilostazol sildenafil (antihypertensive) oral PA Potassium-Sparing Diuretics (Hypoten) amiloride amiloride-hydrochlorothiazide 25

27 spironolactone spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid oral tablet Thiazide Diuretics(Hypotensive Agents) amiloride-hydrochlorothiazide benazepril-hydrochlorothiazide bisoprolol-hydrochlorothiazide captopril-hydrochlorothiazide chlorothiazide DIURIL enalapril-hydrochlorothiazide fosinopril-hydrochlorothiazide hydrochlorothiazide irbesartan-hydrochlorothiazide ST lisinopril-hydrochlorothiazide losartan-hydrochlorothiazide methyldopa-hydrochlorothiazide metoprolol ta-hydrochlorothiaz oral tablet mg, mg moexipril-hydrochlorothiazide nadolol-bendroflumethiazide olmesartan-hydrochlorothiazide oral tablet mg, mg propranolol-hydrochlorothiazid quinapril-hydrochlorothiazide spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid oral tablet valsartan-hydrochlorothiazide ST Thiazide-Like Diuretics(Hypotensive Agt) chlorthalidone oral tablet 25 mg, 50 mg CLORPRES 26 ST

28 indapamide metolazone Vasodilating Agents, Miscellaneous amlodipine amlodipine-valsartan ST aspirin-dipyridamole diltiazem hcl oral capsule,ext.rel 24h degradable diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg diltiazem hcl oral capsule,extended release 24 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral tablet DILT-XR dipyridamole oral LETAIRIS PA nifedipine oral capsule nifedipine oral tablet extended release 24hr TAZTIA XT verapamil oral capsule,ext rel. pellets 24 hr 360 mg verapamil oral tablet verapamil oral tablet extended release Central Nervous System Agents Adamantanes (Cns) amantadine hcl oral capsule amantadine hcl oral solution Amphetamines dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamine-amphetamine 27

29 VYVANSE Analgesics And Antipyretics, Misc. acetaminophen oral elixir acetaminophen oral suspension 160 mg/5 ml acetaminophen-codeine oral solution mg/5 ml acetaminophen-codeine oral tablet ARTHRITIS PAIN RELIEVER butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral tablet mg ENDOCET ORAL TABLET MG gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg INFANT'S PAIN RELIEF ORAL DROPS,SUSPENSION 80 MG/0.8 ML oxycodone-acetaminophen oral tablet mg Anticholinergic Agents (Cns) benztropine oral trihexyphenidyl Anticonvulsants, Miscellaneous BANZEL ORAL TABLET T3 PA carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 28

30 carbamazepine oral tablet,chewable divalproex gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible lamotrigine oral tablets,dose pack levetiracetam oral solution 100 mg/ml levetiracetam oral tablet oxcarbazepine topiramate oral capsule, sprinkle topiramate oral tablet valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml Antidepressants, Miscellaneous bupropion hcl mirtazapine Antimanic Agents divalproex lithium carbonate lithium citrate oral solution 8 meq/5 ml valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml Antimigraine Agents, Miscellaneous aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg 29

31 BUTALBITAL COMPOUND W/CODEINE butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen-caff oral tablet mg dihydroergotamine injection dihydroergotamine nasal QL (1 QY per 30 DYs) divalproex ERGOMAR propranolol oral timolol maleate oral valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml Antipsychotics, Miscellaneous loxapine succinate pimozide Anxiolytics,Sedatives,And Hypnotics,Misc AMBIEN CR T3 PA buspirone oral tablet 15 mg, 30 mg, 5 mg, 7.5 mg droperidol injection solution EDLUAR T3 PA eszopiclone ST hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet hydroxyzine pamoate meprobamate promethazine injection solution promethazine oral promethazine rectal suppository 12.5 mg, 25 mg ROZEREM ST 30

32 SLEEP AID (DOXYLAMINE) zaleplon zolpidem oral tablet zolpidem oral tablet,ext release multiphase 12.5 mg Atypical Antipsychotics aripiprazole clozapine oral tablet LATUDA olanzapine oral tablet quetiapine oral tablet risperidone oral solution risperidone oral tablet SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 5 MG ziprasidone hcl Barbiturates (Anticonvulsants) phenobarbital primidone Barbiturates (Anxiolytic, Sedative/Hyp) BUTALBITAL COMPOUND W/CODEINE butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral tablet mg phenobarbital Benzodiazepines (Anticonvulsants) clonazepam oral tablet clorazepate dipotassium diazepam oral tablet 31 T3 PA

33 diazepam rectal QL (2 EA per 30 DYs) lorazepam oral tablet Benzodiazepines (Anxiolytic,Sedativ/Hyp) alprazolam oral tablet amitriptyline-chlordiazepoxide chlordiazepoxide hcl clonazepam oral tablet clorazepate dipotassium DIASTAT QL (2 QY per 30 DYs) DIASTAT ACUDIAL QL (2 QY per 30 DYs) diazepam oral tablet diazepam rectal QL (2 EA per 30 DYs) estazolam lorazepam oral tablet oxazepam temazepam oral capsule 15 mg, 30 mg triazolam Butyrophenones haloperidol decanoate haloperidol lactate haloperidol oral tablet 0.5 mg, 1 mg, 2 mg, 20 mg, 5 mg haloperidol oral tablet 10 mg Central Nervous System Agents, Misc. atomoxetine guanfacine memantine oral tablet memantine oral tablets,dose pack riluzole Cyclooxygenase-2 (Cox-2) Inhibitors 32 T3

34 celecoxib oral capsule 100 mg, 200 mg, 50 mg QL (2 EA per 1 day) celecoxib oral capsule 400 mg QL (1 EA per 1 day) Dopamine Precursors carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release Ergot-Deriv. Dopamine Receptor Agonists bromocriptine cabergoline PA Fibromyalgia Agents duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg SAVELLA Hydantoins DILANTIN DILANTIN INFATABS phenytoin oral suspension phenytoin sodium extended oral capsule 100 mg Monoamine Oxidase B Inhibitors selegiline hcl Monoamine Oxidase Inhibitors phenelzine selegiline hcl tranylcypromine Nonergot-Deriv.Dopamine Receptor Agonist pramipexole oral tablet ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg Opiate Agonists acetaminophen-codeine oral solution mg/5 ml 33

35 acetaminophen-codeine oral tablet BUTALBITAL COMPOUND W/CODEINE butalbital-acetaminop-caf-cod oral capsule mg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-ibuprofen oral tablet mg T3 PA hydromorphone oral liquid hydromorphone oral tablet hydromorphone rectal meperidine oral methadone oral concentrate methadone oral solution methadone oral tablet methadone oral tablet,soluble morphine concentrate oral solution morphine oral capsule, er multiphase 24 hr T3 PA morphine oral solution morphine oral tablet morphine oral tablet extended release oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet oxycodone-acetaminophen oral tablet mg PROMETHAZINE VC-CODEINE tramadol oral tablet Opiate Antagonists QL (10 QY per 30 DYs) 34

36 naltrexone NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION 35 QL (4 EA per 30 days) VIVITROL QL (1 EA per 30 days) Opiate Partial Agonists buprenorphine hcl sublingual T3 PA buprenorphine-naloxone sublingual tablet mg QL (120 EA per 30 days) buprenorphine-naloxone sublingual tablet 8-2 mg QL (90 EA per 30 days) butorphanol tartrate nasal PA nalbuphine SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG QL (60 EA per 30 days) SUBOXONE SUBLINGUAL FILM 8-2 MG QL (90 EA per 30 days) ZUBSOLV SUBLINGUAL TABLET MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG, MG Other Nonsteroidal Anti-Inflam. Agents CHILDREN'S IBUPROFEN diclofenac potassium diclofenac sodium oral diclofenac sodium topical gel 1 % ST fenoprofen oral tablet flurbiprofen oral tablet 100 mg hydrocodone-ibuprofen oral tablet mg T3 PA ibuprofen oral capsule ibuprofen oral tablet ibuprofen oral tablet,chewable indomethacin oral capsule INFANT'S IBUPROFEN T3 T3 PA

37 ketoprofen oral capsule meloxicam oral tablet naproxen naproxen sodium oral capsule naproxen sodium oral tablet piroxicam sulindac Phenothiazines chlorpromazine oral fluphenazine decanoate fluphenazine hcl injection fluphenazine hcl oral tablet perphenazine perphenazine-amitriptyline prochlorperazine prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate thioridazine PA trifluoperazine Respiratory And Cns Stimulants BUTALBITAL COMPOUND W/CODEINE butalbital-acetaminop-caf-cod oral capsule mg butalbital-acetaminophen-caff oral tablet mg caffeine citrate oral dexmethylphenidate oral capsule,er biphasic mg, 15 mg, 20 mg, 25 mg, 30 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 36

38 FOCALIN XR ORAL CAPSULE,ER BIPHASIC MG methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral solution 10 mg/5 ml methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release 20 mg methylphenidate hcl oral tablet extended release 24hr methylphenidate hcl oral tablet,chewable Salicylates aspirin oral tablet aspirin oral tablet,chewable aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg aspirin-dipyridamole BUTALBITAL COMPOUND W/CODEINE choline,magnesium salicylate salsalate Sel.Serotonin,Norepi Reuptake Inhibitor duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg SAVELLA venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet venlafaxine oral tablet extended release 24hr 225 mg, 37.5 mg Selective Serotonin Agonists eletriptan hbr T3 PA; QL (12 EA per 30 DYs) FROVA T3 PA; QL (12 QY per 30 DYs) naratriptan oral tablet 1 mg T3 PA; QL (12 EA per 30 days) 37

39 rizatriptan QL (12 QY per 30 DYs) sumatriptan QL (6 QY per 30 DYs) sumatriptan succinate oral QL (12 QY per 30 DYs) sumatriptan succinate subcutaneous cartridge QL (2 QY per 30 DYs) sumatriptan succinate subcutaneous pen injector QL (2 QY per 30 DYs) sumatriptan succinate subcutaneous solution QL (4 QY per 30 DYs) zolmitriptan T3 PA; QL (12 EA per 30 days) ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG Selective-Serotonin Reuptake Inhibitors citalopram escitalopram oxalate fluoxetine oral capsule fluoxetine oral solution fluvoxamine oral tablet paroxetine hcl oral tablet paroxetine hcl oral tablet extended release 24 hr PAXIL ORAL SUSPENSION sertraline oral concentrate sertraline oral tablet 100 mg 38 T3 PA; QL (1 QY per 30 DYs) sertraline oral tablet 25 mg, 50 mg QL (45 EA per 30 days) Serotonin Modulators nefazodone trazodone Succinimides ethosuximide Thioxanthenes thiothixene Tricyclics, Other Norepi-Ru Inhibitors amitriptyline

40 amitriptyline-chlordiazepoxide amoxapine clomipramine desipramine doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate imipramine hcl maprotiline nortriptyline oral capsule perphenazine-amitriptyline Devices Devices ACCU-CHEK AVIVA CONTROL SOLN QL (1 QY per 365 DYs) ACCU-CHEK AVIVA PLUS METER QL (1 QY per 365 DYs) ACCU-CHEK FASTCLIX ACCU-CHEK GUIDE GLUCOSE METER ACCU-CHEK GUIDE L1-L2 CTRL SOL ACCU-CHEK MULTICLIX LANCET ACCU-CHEK NANO ACCU-CHEK SMARTVIEW CONTRL SOL ACCU-CHEK SOFT DEV LANCETS ACCU-CHEK SOFTCLIX LANCET DEV ACCU-CHEK SOFTCLIX LANCETS eye patch QL (40 EA per 30 days) insulin syringe-needle u-100 syringe 0.5 ml 29 gauge x 1/2", 1 ml 29 gauge x 1/2", 1 ml 30 gauge x 1/2", 1 ml 30 gauge x 5/16, 1/2 ml 30 gauge x 1/2", 1/2 ml 30 gauge x 5/16 39

41 MONOJECT HYPODERMIC NEEDLES NEEDLE 22 GAUGE X 1 1/2", 22 GAUGE X 1", 23 GAUGE X 1", 23 GAUGE X 1/2", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25 GAUGE X 5/8", 26 GAUGE X 1 1/2", 27 GAUGE X 1/2", 30 GAUGE X 3/4" MONOJECT INSULIN SAFETY SYRING SYRINGE 0.3 ML 30 GAUGE X 5/16, 0.5 ML 29 GAUGE X 1/2", 1/2 ML 30 GAUGE X 5/16 MONOJECT INSULIN SYRINGE SYRINGE 1 ML, 1 ML 28 GAUGE X 1/2", 1 ML 30 GAUGE X 5/16 MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE OPTICHAMBER ADULT MASK-LARGE QL (2 EA per 365 days) PEN NEEDLE NEEDLE 30 GAUGE X 5/16", 31 GAUGE X 3/16", 31 GAUGE X 5/16" SOFT TOUCH LANCETS Diagnostic Agents Diabetes Mellitus ACCU-CHEK AVIVA PLUS TEST STRP ACCU-CHEK GUIDE ACCU-CHEK SMARTVIEW TEST STRIP Roentgenography MAGNEVIST INTRAVENOUS SOLUTION 10 MMOL/20 ML ( MG/ML) Electrolytic, Caloric, And Water Balance Alkalinizing Agents potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) Ammonia Detoxicants ENULOSE Caloric Agents glucose oral tablet,chewable 4 gram 40

42 Carbonic Anhydrase Inhibitors acetazolamide Diuretics, Miscellaneous THEO-24 theophylline oral tablet extended release 12 hr 200 mg, 300 mg Loop Diuretics bumetanide oral furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet torsemide oral Phosphate-Removing Agents calcium acetate oral capsule lanthanum sevelamer carbonate oral tablet Potassium-Removing Agents SODIUM POLYSTYRENE (SORB FREE) sodium polystyrene sulfonate rectal enema 30 gram/120 ml Potassium-Sparing Diuretics amiloride amiloride-hydrochlorothiazide spironolactone spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid oral tablet Replacement Preparations ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 300 MG (750 MG) CALCIUM 500 WITH D 41

43 CALCIUM D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT CALCIUM ANTACID ORAL TABLET,CHEWABLE 400 MG CALCIUM (1,000 MG) calcium carbonate oral tablet 500 mg calcium (1,250 mg) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg) calcium carbonate-vitamin d3 oral tablet 500 mg(1,250mg) -200 unit calcium citrate oral tablet 250 mg calcium calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit, mg-unit DAILY PRENATAL KLOR-CON KLOR-CON M10 KLOR-CON M20 LIQUID CALCIUM WITH VITAMIN D magnesium chloride oral MYNATAL ADVANCE MYNATAL PLUS MYNATAL-Z ONE DAILY PRENATAL ORAL COMBO PACK MG-MCG-MG ONE-A-DAY WOMENS FORMULA ORAL TABLET 18 MG IRON-400 MCG-500 MG CA ONE-A-DAY WOMEN'S PRENATAL 1 OYSTER SHELL CALCIUM 500 OYSTER SHELL CALCIUM-VIT D2 ORAL TABLET 250 (625)-125 MG-UNIT PEDIATRIC ELECTROLYTE ORAL SOLUTION 42

44 potassium chloride oral capsule, extended release 10 meq potassium chloride oral liquid potassium chloride oral tablet extended release 10 meq, 8 meq potassium chloride oral tablet,er particles/crystals PR NATAL 400 PR NATAL 400 EC PR NATAL 430 PRENATAL LOW IRON PRENATAL PLUS PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG PRENATAL VITAMIN PLUS LOW IRON TRIVEEN-DUO DHA VINATE ONE VINATE ULTRA VOL-NATE VOL-TAB RX Thiazide Diuretics amiloride-hydrochlorothiazide benazepril-hydrochlorothiazide bisoprolol-hydrochlorothiazide captopril-hydrochlorothiazide chlorothiazide DIURIL enalapril-hydrochlorothiazide fosinopril-hydrochlorothiazide hydrochlorothiazide irbesartan-hydrochlorothiazide ST lisinopril-hydrochlorothiazide 43

45 losartan-hydrochlorothiazide methyldopa-hydrochlorothiazide metoprolol ta-hydrochlorothiaz oral tablet mg, mg moexipril-hydrochlorothiazide nadolol-bendroflumethiazide olmesartan-hydrochlorothiazide oral tablet mg, mg propranolol-hydrochlorothiazid quinapril-hydrochlorothiazide spironolacton-hydrochlorothiaz triamterene-hydrochlorothiazid oral tablet valsartan-hydrochlorothiazide ST Thiazide-Like Diuretics chlorthalidone oral tablet 25 mg, 50 mg CLORPRES indapamide metolazone Uricosuric Agents probenecid probenecid-colchicine Eye, Ear, Nose And Throat (Eent) Preps. Alpha-Adrenergic Agonists (Eent) brimonidine Antiallergic Agents ALAWAY QL (1 QY per 30 DYs) ASTEPRO NASAL SPRAY,NON-AEROSOL azelastine nasal aerosol,spray azelastine ophthalmic (eye) ST cromolyn nasal ST 44

46 cromolyn ophthalmic (eye) ketotifen fumarate QL (1 QY per 30 DYs) olopatadine ophthalmic (eye) drops 0.1 % ST; QL (1 EA per 30 DYs) ZADITOR QL (1 QY per 30 DYs) Antibacterials (Eent) bacitracin-polymyxin b ophthalmic (eye) CIPRODEX T3 PA; ST ciprofloxacin hcl ophthalmic (eye) erythromycin ophthalmic (eye) GENTAK OPHTHALMIC (EYE) OINTMENT MOXEZA ST moxifloxacin ophthalmic (eye) neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc ofloxacin ophthalmic (eye) ofloxacin otic (ear) polymyxin b sulf-trimethoprim sulfacetamide sodium ophthalmic (eye) drops sulfacetamide-prednisolone tobramycin tobramycin-dexamethasone TOBREX OPHTHALMIC (EYE) OINTMENT Antivirals (Eent) trifluridine Beta-Adrenergic Blocking Agents (Eent) carteolol dorzolamide-timolol QL (10 ML per 60 days) 45

47 levobunolol ophthalmic (eye) drops 0.5 % timolol maleate ophthalmic (eye) TIMOPTIC OCUDOSE (PF) Carbonic Anhydrase Inhibitors (Eent) acetazolamide dorzolamide dorzolamide-timolol QL (10 ML per 60 days) Corticosteroids (Eent) BECONASE AQ T3 PA CHILDREN'S NASACORT ST CIPRODEX T3 PA; ST dexamethasone sodium phosphate ophthalmic (eye) FLAREX fluorometholone fluticasone nasal FML FORTE FML S.O.P. hydrocortisone-acetic acid MAXIDEX NASACORT ST NASAL ALLERGY ST neomycin-bacitracin-poly-hc neomycin-polymyxin b-dexameth neomycin-polymyxin-hc ophthalmic (eye) OMNARIS T3 PA PRED MILD prednisolone acetate prednisolone sodium phosphate ophthalmic (eye) tobramycin-dexamethasone 46

48 triamcinolone acetonide nasal T3 PA Eent Anti-Infectives, Miscellaneous acetic acid otic (ear) chlorhexidine gluconate mucous membrane hydrocortisone-acetic acid Eent Anti-Inflammatory Agents, Misc. RESTASIS ST RESTASIS MULTIDOSE ST XIIDRA ST Eent Drugs, Miscellaneous apraclonidine ARTIFICIAL TEARS (POLYVIN ALC) IOPIDINE OPHTHALMIC (EYE) DROPPERETTE ipratropium bromide nasal Eent Nonsteroidal Anti-Inflam. Agents flurbiprofen sodium ketorolac ophthalmic (eye) Local Anesthetics (Eent) lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 4 % (40 mg/ml) LIDOCAINE VISCOUS Miotics PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % Mydriatics cyclopentolate ophthalmic (eye) drops 2 % Prostaglandin Analogs 47

49 latanoprost TRAVATAN Z Vasoconstrictors ADRENALIN NASAL phenylephrine hcl ophthalmic (eye) Gastrointestinal Drugs 5-Ht3 Receptor Antagonists granisetron hcl oral ST ondansetron hcl oral solution QL (50 QY per 30 DYs) ondansetron hcl oral tablet 4 mg ondansetron hcl oral tablet 8 mg QL (15 QY per 30 DYs) ondansetron oral tablet,disintegrating 4 mg ondansetron oral tablet,disintegrating 8 mg QL (15 QY per 30 DYs) Antacids And Adsorbents aluminum hydroxide gel oral suspension 320 mg/5 ml ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 300 MG (750 MG) ANTACID-SIMETHICONE CALCIUM ANTACID ORAL TABLET,CHEWABLE 400 MG CALCIUM (1,000 MG) calcium carbonate oral tablet,chewable 200 mg calcium (500 mg) magnesium oxide oral tablet 200 mg magnesium, 250 mg, 420 mg, 500 mg PINK BISMUTH ORAL TABLET,CHEWABLE sodium bicarbonate oral tablet 650 mg Antidiarrhea Agents diphenoxylate-atropine loperamide oral capsule 48

50 PINK BISMUTH ORAL TABLET,CHEWABLE Antiemetics, Miscellaneous DICLEGIS PA scopolamine base T3 PA Antiflatulents ANTACID-SIMETHICONE Antihistamines (Gi Drugs) DICLEGIS PA meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable prochlorperazine prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate Anti-Inflammatory Agents (Gi Drugs) balsalazide CANASA mesalamine oral tablet,delayed release (dr/ec) 1.2 gram mesalamine rectal PENTASA sulfasalazine Cathartics And Laxatives AMITIZA docusate calcium docusate sodium oral capsule 100 mg docusate sodium oral syrup GENTLE LAXATIVE ORAL MILK OF MAGNESIA mineral oil oral 49

51 NATURAL FIBER LAXATIVE (SUGAR) ORAL POWDER 3.4 GRAM/7 GRAM NATURAL FIBER LAXATIVE THERAPY peg 3350-electrolytes oral recon soln gram polyethylene glycol 3350 oral powder SE-NATAL 19 (WITH DOCUSATE) SENNA LAXATIVE ORAL TABLET 8.6 MG SENNA-S VINATE ULTRA Cholelitholytic Agents ursodiol Digestants CREON ZENPEP Gi Drugs, Miscellaneous LINZESS Histamine H2-Antagonists cimetidine cimetidine hcl oral famotidine oral tablet nizatidine oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet Neurokinin-1 Receptor Antagonists EMEND ORAL CAPSULE 125 MG, 80 MG EMEND ORAL CAPSULE 40 MG QL (1 QY per 30 DYs) EMEND ORAL CAPSULE,DOSE PACK Prokinetic Agents metoclopramide hcl oral solution 50

52 metoclopramide hcl oral tablet Prostaglandins misoprostol Protectants CARAFATE ORAL SUSPENSION sucralfate oral tablet Proton-Pump Inhibitors esomeprazole magnesium T3 PA lansoprazole oral capsule,delayed release(dr/ec) ST; QL (2 EA per 1 day) NEXIUM 24HR ORAL TABLET,DELAYED RELEASE (DR/EC) NEXIUM PACKET T3 PA 51 ST; QL (2 EA per 1 DY) omeprazole oral capsule,delayed release(dr/ec) QL (2 EA per 1 day) omeprazole-sodium bicarbonate oral capsule mg-gram omeprazole-sodium bicarbonate oral capsule mg-gram omeprazole-sodium bicarbonate oral packet 40-1,680 mg T3 ST; QL (1 EA per 1 day) pantoprazole oral QL (2 EA per 1 day) PREVACID SOLUTAB T3 PA PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON PRILOSEC OTC T3 PA PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET rabeprazole T3 PA ZEGERID ORAL PACKET 20-1,680 MG T3 PA Gold Compounds Gold Compounds RIDAURA Heavy Metal Antagonists T3 T3 PA PA QL (2 EA per 1 day) PA

53 Heavy Metal Antagonists CHEMET EXJADE T3 PA JADENU T3 PA Hormones And Synthetic Substitutes Adrenals ARNUITY ELLIPTA ASMANEX HFA ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (14 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES) BREO ELLIPTA budesonide inhalation suspension for nebulization 0.25 mg/2 ml budesonide inhalation suspension for nebulization 0.5 mg/2 ml budesonide inhalation suspension for nebulization 1 mg/2 ml cortisone dexamethasone DEXAMETHASONE INTENSOL dexamethasone sodium phos (pf) QL (1 QY per 30 DYs) QL (1 QY per 7 DYs) QL (60 QY per 30 DYs) QL (120 QY per 30 DYs) QL (60 ML per 30 days) DULERA QL (13 QY per 30 DYs) ENTOCORT EC T3 PA FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION QL (120 QY per 30 DYs) QL (240 QY per 30 DYs) 52

54 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION fludrocortisone hydrocortisone oral INTRAROSA MEDROL ORAL TABLET 2 MG methylprednisolone prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone PREDNISONE INTENSOL QVAR INHALATION AEROSOL 40 MCG/ACTUATION QVAR INHALATION AEROSOL 80 MCG/ACTUATION Androgens danazol PA TESTIM T3 PA QL (60 QY per 30 DYs) QL (12 QY per 30 DYs) QL (24 QY per 30 DYs) QL (10.6 QY per 30 DYs) QL (8.7 QY per 30 DYs) QL (17.4 QY per 30 DYs) testosterone cypionate QL (2 ML per 28 days) testosterone enanthate QL (5 ML per 28 DYs) testosterone transdermal gel in metered-dose pump testosterone transdermal gel in packet 1 % (25 mg/2.5gram) PA PA 53

55 testosterone transdermal solution in metered pump w/app Antiestrogens letrozole QL (1 QY per 1 DY) Antiparathyroid Agents calcitonin (salmon) Antithyroid Agents methimazole oral tablet 10 mg, 5 mg propylthiouracil SSKI Biguanides alogliptin-metformin ST glipizide-metformin glyburide-metformin JANUMET ST JANUMET XR ST metformin oral tablet metformin oral tablet extended release 24 hr pioglitazone-metformin ST Contraceptives APRI ARANELLE (28) AVIANE BALZIVA (28) CAMILA CAMRESE CRYSELLE (28) ELLA ENPRESSE ERRIN 54 PA

56 JOLESSA JOLIVETTE JUNEL 1.5/30 (21) JUNEL 1/20 (21) JUNEL FE 1.5/30 (28) JUNEL FE 1/20 (28) KARIVA (28) KELNOR 1/35 (28) LEENA 28 LESSINA LEVORA-28 LOW-OGESTREL (28) LUTERA (28) MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) MICROGESTIN FE 1/20 (28) MONONESSA (28) NECON 1/50 (28) NECON 7/7/7 (28) NEXT CHOICE ONE DOSE NORA-BE norethindrone (contraceptive) norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg NORTREL 0.5/35 (28) NORTREL 1/35 (21) NORTREL 1/35 (28) NORTREL 7/7/7 (28) NUVARING OCELLA 55

57 OGESTREL (28) PORTIA QUASENSE RECLIPSEN (28) SPRINTEC (28) SRONYX TILIA FE TRINESSA (28) TRI-SPRINTEC (28) TRIVORA (28) VELIVET TRIPHASIC REGIMEN (28) XULANE ZOVIA 1/35E (28) ZOVIA 1/50E (28) Dipeptidyl Peptidase-4(Dpp-4) Inhibitors alogliptin ST alogliptin-metformin ST alogliptin-pioglitazone ST JANUMET ST JANUMET XR ST JANUVIA ST Estrogen Agonist-Antagonists FARESTON PA raloxifene tamoxifen Estrogens estradiol oral estradiol transdermal estropipate JINTELI 56

58 MENEST ORAL TABLET 0.3 MG, MG, 1.25 MG norethindrone ac-eth estradiol oral tablet mg-mcg PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG PREMARIN ORAL TABLET 1.25 MG F PREMARIN VAGINAL PREMPHASE PREMPRO Glycogenolytic Agents GLUCAGEN HYPOKIT QL (2 QY per 30 DYs) GLUCAGON EMERGENCY KIT (HUMAN) QL (2 QY per 30 DYs) Incretin Mimetics TRULICITY ST VICTOZA 2-PAK ST VICTOZA 3-PAK ST Insulins APIDRA QL (30 QY per 30 DYs) APIDRA SOLOSTAR QL (30 QY per 30 DYs) BASAGLAR KWIKPEN QL (30 ML per 30 days) HUMALOG QL (30 QY per 30 DYs) HUMALOG JUNIOR KWIKPEN QL (30 ML per 30 days) HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML 57 QL (30 QY per 30 DYs) HUMALOG MIX QL (30 QY per 30 DYs) HUMALOG MIX KWIKPEN QL (30 QY per 30 DYs) HUMALOG MIX QL (30 QY per 30 DYs) HUMALOG MIX KWIKPEN QL (30 QY per 30 DYs) HUMULIN 70/30 QL (30 QY per 30 DYs) HUMULIN N QL (30 QY per 30 DYs)

59 HUMULIN R U-100 QL (30 QY per 30 DYs) HUMULIN R U-500 (CONCENTRATED) QL (30 QY per 30 DYs) Parathyroid And Antiparathyroid Agents calcitonin (salmon) Pituitary desmopressin nasal solution PA desmopressin nasal spray,non-aerosol PA desmopressin oral PA Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION JINTELI medroxyprogesterone megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral suspension 625 mg/5 ml QL (150 ML per 30 days) megestrol oral tablet norethindrone acetate norethindrone ac-eth estradiol oral tablet mg-mcg Sulfonylureas glimepiride glipizide glipizide-metformin glyburide glyburide micronized glyburide-metformin Thiazolidinediones alogliptin-pioglitazone ST pioglitazone ST pioglitazone-metformin ST 58

60 Thyroid Agents ARMOUR THYROID levothyroxine oral liothyronine oral NATURE-THROID ORAL TABLET 195 MG THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 Miscellaneous Therapeutic Agents 5-Alpha-Reductase Inhibitors finasteride oral tablet 5 mg Alcohol Deterrents disulfiram naltrexone VIVITROL QL (1 EA per 30 days) Antidotes CHEMET FOSRENOL ORAL TABLET,CHEWABLE 750 MG GLUCAGEN HYPOKIT QL (2 QY per 30 DYs) GLUCAGON EMERGENCY KIT (HUMAN) QL (2 QY per 30 DYs) lanthanum leucovorin calcium oral tablet 10 mg, 15 mg PA leucovorin calcium oral tablet 25 mg, 5 mg MEPHYTON NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION sevelamer carbonate oral tablet QL (4 EA per 30 days) 59

61 SODIUM POLYSTYRENE (SORB FREE) sodium polystyrene sulfonate rectal enema 30 gram/120 ml SPS (WITH SORBITOL) RECTAL SSKI Antigout Agents allopurinol colchicine oral tablet ST; QL (60 EA per 30 days) indomethacin oral capsule naproxen naproxen sodium oral capsule naproxen sodium oral tablet probenecid probenecid-colchicine Bone Resorption Inhibitors alendronate oral tablet calcitonin (salmon) etidronate disodium raloxifene Cariostatic Agents CLINPRO 5000 fluoride (sodium) dental fluoride (sodium) oral drops fluoride (sodium) oral tablet,chewable MULTI-VIT WITH FLUORIDE-IRON MULTI-VITAMIN WITH FLUORIDE ORAL DROPS MVC-FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG, 1 MG PHOS-FLUR SF 60

62 SF 5000 PLUS TRI-VIT WITH FLUORIDE AND IRON TRI-VITAMIN WITH FLUORIDE Disease-Modifying Antirheumatic Agents azathioprine cyclosporine modified oral capsule 100 mg, 25 mg cyclosporine oral capsule GENGRAF ORAL CAPSULE 100 MG, 25 MG hydroxychloroquine leflunomide methotrexate sodium methotrexate sodium (pf) injection solution PA RIDAURA SANDIMMUNE ORAL SOLUTION sulfasalazine TREXALL ORAL TABLET 7.5 MG Immunomodulatory Agents azathioprine cyclosporine modified oral capsule 100 mg, 25 mg cyclosporine oral capsule hydroxychloroquine leflunomide methotrexate sodium methotrexate sodium (pf) injection solution PA RIDAURA SANDIMMUNE ORAL SOLUTION sulfasalazine TREXALL ORAL TABLET 7.5 MG Immunosuppressive Agents azathioprine 61

63 cyclophosphamide oral capsule cyclosporine modified oral capsule 100 mg, 25 mg cyclosporine oral capsule ELIDEL PA GENGRAF ORAL CAPSULE 100 MG, 25 MG mercaptopurine methotrexate sodium methotrexate sodium (pf) injection solution PA mycophenolate mofetil SANDIMMUNE ORAL SOLUTION tacrolimus oral TREXALL ORAL TABLET 7.5 MG Other Miscellaneous Therapeutic Agents acetylcysteine DEMSER levocarnitine oral tablet XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT, 50 UNIT Protective Agents ELMIRON QL (90 EA per 30 days) Respiratory Tract Agents Alpha And Beta Adrenergic Agonist(Respr) ALAVERT D-12 ALLERGY-SINUS ALLERGY RELIEF,NASAL DECONGEST BROMFED DM brompheniramine-pseudoeph-dm oral syrup cetirizine-pseudoephedrine epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml LORATADINE-D T3 PA QL (2 EA per 30 days) 62

64 M-END DMX pseudoephedrine hcl oral tablet 60 mg pseudoephedrine-guaifenesin Anticholinergic Agents (Respir.Tract) ANORO ELLIPTA ATROVENT HFA COMBIVENT RESPIMAT diphenoxylate-atropine ipratropium bromide inhalation ipratropium-albuterol SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION Antitussives benzonatate oral capsule 100 mg, 200 mg BROMFED DM brompheniramine-pseudoeph-dm oral syrup CHERATUSSIN AC codeine-guaifenesin hydrocodone-homatropine oral syrup mg/5 ml hydrocodone-homatropine oral tablet M-END DMX PROMETHAZINE VC-CODEINE promethazine-codeine promethazine-dm ROBAFEN CF (PHENYLEPHRINE) ROBAFEN DM Expectorants CHERATUSSIN AC codeine-guaifenesin guaifenesin oral liquid 63

65 pseudoephedrine-guaifenesin ROBAFEN CF (PHENYLEPHRINE) ROBAFEN DM SSKI First Generation Antihist.(Respir Tract) BROMFED DM brompheniramine-pseudoeph-dm oral syrup clemastine oral tablet cyproheptadine DICLEGIS PA diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule diphenhydramine hcl oral liquid diphenhydramine hcl oral tablet 25 mg M-END DMX promethazine injection solution promethazine oral PROMETHAZINE VC PROMETHAZINE VC-CODEINE promethazine-codeine promethazine-dm SLEEP AID (DOXYLAMINE) Leukotriene Modifiers montelukast Mast-Cell Stabilizers cromolyn nasal cromolyn ophthalmic (eye) Mucolytic Agents acetylcysteine 64