2017 FORMULARY GUIDE

Transcription

1 017 FORMULARY GUIDE 1

2 Table of Contents ANTI - INFECTIVES... 4 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH... 1 CARDIOVASCULAR, HYPERTENSION & LIPIDS DERMATOLOGICALS/TOPICAL THERAPY DIAGNOSTICS & MISCELLANEOUS AGENTS EAR, NOSE & THROAT MEDICATIONS... 5 ENDOCRINE/DIABETES GASTROENTEROLOGY IMMUNOLOGY, VACCINES & BIOTECHNOLOGY MUSCULOSKELETAL & RHEUMATOLOGY OBSTETRICS & GYNECOLOGY... 7 OPHTHALMOLOGY RESPIRATORY, ALLERGY, COUGH & COLD UROLOGICALS VITAMINS, HEMATINICS & ELECTROLYTES Index

3 List of Abbreviations ACA: Affordable Care Act. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 3

4 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 4 AMBISOME 4 amphotericin b CANCIDAS 4 caspofungin intravenous recon soln 50 mg 4 CASPOFUNGIN INTRAVENOUS RECON SOLN 70 MG clotrimazole mucous membrane CRESEMBA 5 QL ERAXIS(WATER DILUENT) 4 fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/100 ml, 400 mg/00 ml fluconazole oral suspension for reconstitution fluconazole oral tablet QL flucytosine 5 griseofulvin microsize griseofulvin ultramicrosize itraconazole PA; QL ketoconazole oral MYCAMINE 4 NOXAFIL ORAL SUSPENSION 5 PA NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nystatin oral powder 150 million unit, 500 million unit nystatin oral suspension nystatin oral tablet PA; QL ONMEL 4 PA; QL ORAVIG 4 PA; QL SPORANOX ORAL SOLUTION 4 PA terbinafine hcl oral PA voriconazole intravenous

5 voriconazole oral QL ANTIVIRALS abacavir oral solution abacavir oral tablet QL abacavir-lamivudine QL abacavir-lamivudine-zidovudine QL acyclovir oral capsule acyclovir oral suspension 00 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir 5 PA amantadine hcl APTIVUS ORAL CAPSULE 5 QL APTIVUS ORAL SOLUTION 5 ATRIPLA 5 QL BARACLUDE ORAL SOLUTION 5 PA cidofovir COMPLERA 5 CRIXIVAN ORAL CAPSULE 00 MG, 400 MG 3 QL DAKLINZA 5 PA; LA; QL didanosine EDURANT 5 QL EMTRIVA ORAL CAPSULE 3 QL EMTRIVA ORAL SOLUTION 3 entecavir 5 PA EPCLUSA 5 PA; LA; QL EPIVIR HBV ORAL SOLUTION 3 PA EPIVIR ORAL SOLUTION 3 EVOTAZ 5 QL famciclovir QL fosamprenavir foscarnet FUZEON SUBCUTANEOUS RECON SOLN 5 QL 5

6 ganciclovir sodium GENVOYA 4 QL HARVONI 5 PA; LA; QL INTELENCE 5 PA; QL INVIRASE 5 QL ISENTRESS 5 QL ISENTRESS HD 5 QL KALETRA ORAL TABLET 5 QL lamivudine oral solution lamivudine oral tablet 100 mg lamivudine oral tablet 150 mg, 300 mg QL lamivudine-zidovudine QL LEXIVA 5 QL lopinavir-ritonavir MAVYRET 5 PA; LA; QL nevirapine oral suspension nevirapine oral tablet QL nevirapine oral tablet extended release 4 hr QL NORVIR 3 QL ODEFSEY 5 QL OLYSIO 5 PA; LA; QL oseltamivir oral capsule QL PREZCOBIX 5 QL PREZISTA ORAL SUSPENSION 5 PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 5 QL RELENZA DISKHALER 4 QL RESCRIPTOR 3 QL RETROVIR INTRAVENOUS 5 REYATAZ ORAL CAPSULE 150 MG, 00 MG, 300 MG 5 QL REYATAZ ORAL POWDER IN PACKET 5 QL rimantadine 6

7 SELZENTRY ORAL SOLUTION 5 PA; QL SELZENTRY ORAL TABLET 150 MG, 300 MG 5 PA; QL SELZENTRY ORAL TABLET 5 MG, 75 MG 5 PA SOVALDI 5 PA; LA; QL stavudine QL STRIBILD 5 QL SUSTIVA 5 QL SYNAGIS 5 PA; LA; QL TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 4 QL TECHNIVIE 5 PA; LA; QL TIVICAY 5 TRIUMEQ 5 QL TRUVADA 5 QL TYBOST 3 valacyclovir QL valganciclovir VEMLIDY 5 PA; QL VIDEX GRAM PEDIATRIC 3 QL VIEKIRA PAK 5 PA; LA; QL VIEKIRA XR 5 PA; LA; QL VIRACEPT ORAL TABLET 5 QL VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 4 HR 100 MG 5 QL VIREAD 5 QL VOSEVI 5 PA; LA; QL ZEPATIER 5 PA; LA; QL ZIAGEN ORAL SOLUTION 3 QL zidovudine QL CEPHALOSPORINS CEDAX ORAL CAPSULE 4 cefaclor oral capsule cefaclor oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml, 375 mg/5 ml 7

8 cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin CEFAZOLIN IN 0.9% SOD CHLORIDE INTRAVENOUS PIGGYBACK cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, gram/50 ml CEFAZOLIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK GRAM/50 ML cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % 4 cefepime in dextrose,iso-osm cefixime cefotaxime cefotetan cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil ceftazidime CEFTAZIDIME IN D5W 4 CEFTIN ORAL SUSPENSION FOR RECONSTITUTION ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln 1 gram, 10 gram, gram, 50 mg, 500 mg ceftriaxone intravenous cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous

9 cephalexin oral capsule 50 mg, 500 mg 1 cephalexin oral capsule 750 mg cephalexin oral suspension for reconstitution cephalexin oral tablet MAXIPIME INTRAVENOUS 4 SPECTRACEF ORAL TABLET 400 MG 4 SUPRAX ORAL CAPSULE 4 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 4 TEFLARO 4 ZINACEF IN STERILE WATER 4 ERYTHROMYCINS & OTHER MACROLIDES azithromycin clarithromycin DIFICID 5 ST; QL e.e.s. 400 oral tablet E.E.S. GRANULES 4 ERYPED 00 4 ERYPED ery-tab oral tablet,delayed release (dr/ec) 50 mg, 333 mg erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA 3 ALINIA

10 amikacin injection solution 1,000 mg/4 ml, 500 mg/ ml atovaquone atovaquone-proguanil PA AZACTAM IN DEXTROSE (ISO-OSM) 4 aztreonam baciim bacitracin intramuscular BETHKIS 5 QL BILTRICIDE 3 CAPASTAT 4 CAYSTON 5 QL chloramphenicol sod succinate chloroquine phosphate PA clindamycin hcl CLINDAMYCIN IN 0.9 % SOD CHLOR 4 clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate intravenous COARTEM 3 colistin (colistimethate na) CUBICIN 4 CYCLOSERINE 4 dapsone oral daptomycin DARAPRIM 4 PA DORIBAX 4 DORIPENEM 4 ethambutol gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml 10

11 GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, 10 MG/100 ML gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML hydroxychloroquine imipenem-cilastatin INVANZ 4 isoniazid ivermectin LINCOCIN 4 lincomycin linezolid intravenous linezolid oral QL linezolid-0.9% sodium chloride mefloquine PA meropenem metro i.v. metronidazole in nacl (iso-os) metronidazole oral NEBUPENT 3 neomycin paromomycin PASER 3 PENTAM 4 polymyxin b sulfate PRIFTIN 4 PRIMAQUINE 4 PA pyrazinamide quinine sulfate PA 11 4

12 rifabutin RIFAMATE 4 rifampin RIFATER 4 SIRTURO 5 PA SIVEXTRO 5 QL STREPTOMYCIN 4 STROMECTOL 3 SYNERCID 4 TIGECYCLINE 4 tinidazole TOBI PODHALER 5 QL tobramycin in 0.5 % nacl QL tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate TRECATOR 4 TYGACIL 4 XIFAXAN ORAL TABLET 00 MG 4 QL XIFAXAN ORAL TABLET 550 MG 5 PA; QL ZYVOX INTRAVENOUS PARENTERAL SOLUTION 00 MG/100 ML PENICILLINS amoxicillin oral capsule 1 amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15 mg, 50 mg amoxicillin-pot clavulanate ampicillin oral capsule 1 ampicillin sodium ampicillin-sulbactam injection ampicillin-sulbactam intravenous recon soln 1.5 gram 4 1

13 AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML BICILLIN C-R 4 BICILLIN L-A 4 dicloxacillin nafcillin nafcillin in dextrose iso-osm oxacillin in dextrose(iso-osm) oxacillin injection oxacillin intravenous recon soln gram PENICILLIN G POT IN DEXTROSE 4 penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium oral recon soln penicillin v potassium oral tablet 50 mg 1 penicillin v potassium oral tablet 500 mg pfizerpen-g piperacillin-tazobactam intravenous recon soln.5 gram, gram, 4.5 gram, 40.5 gram QUINOLONES AVELOX IN NACL (ISO-OSMOTIC) 4 CIPRO ORAL SUSPENSION,MICROCAPSULE RECON ciprofloxacin ciprofloxacin (mixture) QL ciprofloxacin hcl oral tablet 100 mg, 750 mg ciprofloxacin hcl oral tablet 50 mg, 500 mg 1 ciprofloxacin in 5 % dextrose ciprofloxacin lactate FACTIVE 4 QL levofloxacin in d5w levofloxacin intravenous levofloxacin oral

14 moxifloxacin oral MOXIFLOXACIN-SOD.ACE,SUL-WATER 4 ofloxacin oral tablet 300 mg, 400 mg SULFA'S & RELATED AGENTS sulfadiazine sulfamethoxazole-trimethoprim TETRACYCLINES demeclocycline doxy-100 doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 0 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet MINOCIN INTRAVENOUS 4 minocycline oral capsule minocycline oral tablet morgidox oral capsule 100 mg 3 tetracycline URINARY TRACT AGENTS methenamine hippurate methenamine mandelate MONUROL 4 PA nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst trimethoprim VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK 4 14

15 VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS SOLUTION 1 GRAM/50 ML, 1.5 GRAM/50 ML, 1.5 GRAM/50 ML, 1.5 GRAM/500 ML, 1.75 GRAM/50 ML, 1.75 GRAM/500 ML, GRAM/500 ML, 750 MG/150 ML, 750 MG/50 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/100 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 750 MG/150 ML vancomycin intravenous vancomycin oral capsule VIBATIV INTRAVENOUS RECON SOLN 750 MG ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline 5 dexrazoxane hcl 5 LA ELITEK 5 LA KEPIVANCE 5 leucovorin calcium oral mesna 5 LA MESNEX ORAL 5 VORAXAZE 5 PA XGEVA 5 PA; QL ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ABRAXANE 5 LA adriamycin intravenous solution 5 LA adrucil 5 LA AFINITOR 5 PA; QL AFINITOR DISPERZ 5 PA; QL ALECENSA 5 PA; LA; QL ALIMTA 5 LA ALKERAN ORAL 3 ALUNBRIG 5 LA; QL

16 anastrozole ARRANON 5 LA ARZERRA 5 PA AVASTIN 5 LA azathioprine azathioprine sodium bexarotene 5 PA bicalutamide BICNU 5 LA bleo 15k 5 bleomycin 5 LA BOSULIF 5 PA; QL busulfan 5 LA BUSULFEX 5 LA CABOMETYX 5 PA; LA capecitabine 5 PA CAPRELSA 5 PA; QL carboplatin intravenous solution 5 LA CELLCEPT INTRAVENOUS 5 CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION cisplatin 5 LA cladribine 5 LA COMETRIQ 5 PA; QL COTELLIC 5 PA; LA; QL cyclophosphamide intravenous 5 LA CYCLOPHOSPHAMIDE ORAL CAPSULE 5 cyclosporine intravenous 5 cyclosporine modified cyclosporine oral capsule cytarabine 5 LA cytarabine (pf) injection solution 5 LA dacarbazine 5 LA 16 5

17 daunorubicin 5 LA doxorubicin 5 LA doxorubicin, peg-liposomal LA ELIGARD 5 PA; QL ELIGARD (3 MONTH) 5 PA; QL ELIGARD (4 MONTH) 5 PA; QL ELIGARD (6 MONTH) 5 PA; QL EMCYT 5 PA epirubicin intravenous recon soln 00 mg 5 LA epirubicin intravenous solution 5 LA ERBITUX 5 LA ERIVEDGE 5 PA; LA; QL ETOPOPHOS 5 LA etoposide intravenous 5 PA; LA etoposide oral 5 PA exemestane FARESTON 5 PA FARYDAK 5 PA; LA; QL FASLODEX 5 LA FIRMAGON KIT W DILUENT SYRINGE 5 PA; LA; QL floxuridine 5 LA fludarabine 5 LA fluorouracil intravenous 5 LA flutamide gemcitabine 5 LA gengraf GILOTRIF 5 PA; LA; QL GLEEVEC 5 PA; QL GLEOSTINE 5 PA HEXALEN 4 HYCAMTIN INTRAVENOUS 5 LA HYCAMTIN ORAL 5 PA hydroxyurea 17

18 IBRANCE 5 PA; LA; QL ICLUSIG 5 PA; QL idarubicin 5 LA IDHIFA 5 PA; LA ifosfamide 5 LA ifosfamide-mesna 5 LA IMBRUVICA 5 PA; QL INLYTA 5 PA; LA; QL IODOPEN 4 IRESSA 5 PA; LA; QL irinotecan 5 LA IXEMPRA 5 LA JAKAFI 5 PA; LA; QL KISQALI FEMARA CO-PACK 5 LA; QL LENVIMA 5 PA; LA; QL letrozole QL LEUKERAN 3 leuprolide subcutaneous kit 5 PA; LA lipodox 5 LA LONSURF 5 PA; LA LUPRON DEPOT 5 PA; LA; QL LUPRON DEPOT (3 MONTH) 5 PA; LA; QL LUPRON DEPOT (4 MONTH) 5 PA; LA; QL LUPRON DEPOT (6 MONTH) 5 PA; LA; QL LUPRON DEPOT-PED 5 PA; LA; QL LUPRON DEPOT-PED (3 MONTH) 5 PA; LA; QL LYNPARZA ORAL CAPSULE 5 PA; QL LYNPARZA ORAL TABLET 5 PA; LA; QL LYSODREN 5 PA; LA MATULANE 4 megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet 18

19 MEKINIST 5 PA; LA; QL melphalan melphalan hcl 5 LA mercaptopurine methotrexate sodium (pf) 5 methotrexate sodium injection 5 methotrexate sodium oral mitomycin 5 LA mitoxantrone 5 LA MUSTARGEN 5 LA mycophenolate mofetil hcl 5 mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium MYLERAN 3 LA NERLYNX 5 PA; LA; QL NEXAVAR 5 PA; LA; QL nilutamide 5 PA; LA NINLARO 5 PA; LA; QL NULOJIX 5 PA; LA octreotide acetate 5 LA ODOMZO 5 PA; LA; QL ONCASPAR 5 LA oxaliplatin 5 LA paclitaxel 5 LA PHOTOFRIN 5 LA PROGRAF INTRAVENOUS 5 RAPAMUNE ORAL SOLUTION 5 PA RITUXAN 5 PA; LA; QL RUBRACA 5 PA; QL RYDAPT 5 PA; LA; QL 19 5

20 SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 5 PA; LA; QL SIGNIFOR 5 PA; LA; QL SIGNIFOR LAR 5 PA; LA; QL SIMULECT 5 LA sirolimus PA SOMATULINE DEPOT 5 PA; LA; QL SPRYCEL 5 PA; QL STIVARGA 5 PA; LA; QL SUPPRELIN LA 5 PA; LA; QL SUTENT 5 PA; LA; QL SYLVANT 5 PA; LA TABLOID 3 PA tacrolimus oral TAFINLAR 5 PA; LA; QL TAGRISSO 5 PA; LA; QL tamoxifen TARCEVA ORAL TABLET 100 MG, 150 MG 5 PA; LA; QL TARCEVA ORAL TABLET 5 MG 5 PA; LA TARGRETIN TOPICAL 5 PA TASIGNA 5 PA; QL TEMODAR INTRAVENOUS 5 temozolomide 5 PA; LA THALOMID 5 PA; LA; QL toposar 5 LA topotecan 5 LA TORISEL 5 LA TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 5 PA; QL TRELSTAR INTRAMUSCULAR SYRINGE 5 PA; LA; QL tretinoin (chemotherapy) 5 TRISENOX 5 LA TYKERB 5 PA; LA; QL 0

21 VANTAS 5 PA; LA; QL VENCLEXTA ORAL TABLET 100 MG 5 PA; QL vinblastine intravenous solution 5 LA vincasar pfs 5 LA vincristine 5 LA vinorelbine 5 LA VOTRIENT 5 PA; LA; QL XALKORI 5 PA; LA; QL XERMELO 5 PA XTANDI 5 PA; LA; QL ZANOSAR 5 LA ZEJULA 5 QL ZELBORAF 5 PA; LA; QL ZOLADEX 5 PA; LA; QL ZOLINZA 5 PA; LA; QL ZORTRESS 5 PA ZYDELIG 5 PA; QL ZYKADIA 5 PA; LA; QL ZYTIGA 5 PA; LA; QL AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ANTICONVULSANTS APTIOM 4 PA; QL BANZEL 4 PA BRIVIACT 4 PA; QL carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG 3 clonazepam oral tablet clonazepam oral tablet,disintegrating ST diazepam rectal 1

22 DILANTIN 3 divalproex epitol ethosuximide felbamate fosphenytoin FYCOMPA ORAL SUSPENSION 4 PA; QL FYCOMPA ORAL TABLET 4 PA; QL gabapentin oral capsule gabapentin oral solution 50 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GRALISE 4 PA; QL GRALISE 30-DAY STARTER PACK 4 PA; QL lamotrigine oral tablet lamotrigine oral tablet, chewable dispersible QL lamotrigine oral tablets,dose pack 5 mg (35) lamotrigine oral tablets,dose pack 5 mg (4) -100 mg (7), 5 mg (84) -100 mg (14) levetiracetam in nacl (iso-os) levetiracetam intravenous levetiracetam oral solution levetiracetam oral tablet QL levetiracetam oral tablet extended release 4 hr QL LYRICA 4 PA; QL ONFI ORAL SUSPENSION 4 PA; QL ONFI ORAL TABLET 10 MG, 0 MG 4 PA; QL oxcarbazepine PEGANONE 4 PA phenobarbital phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium phenytoin sodium extended

23 primidone roweepra SABRIL 5 PA; LA; QL tiagabine topiramate oral capsule, sprinkle QL topiramate oral tablet valproate sodium valproic acid valproic acid (as sodium salt) oral solution 50 mg/5 ml vigabatrin PA; LA; QL VIMPAT INTRAVENOUS 4 PA VIMPAT ORAL SOLUTION 4 PA VIMPAT ORAL TABLET 4 PA zonisamide ANTIPARKINSONISM AGENTS APOKYN 5 PA; QL benztropine bromocriptine carbidopa ST carbidopa-levodopa carbidopa-levodopa-entacapone DUOPA 5 PA; LA entacapone pramipexole oral tablet rasagiline ropinirole oral tablet ropinirole oral tablet extended release 4 hr ST selegiline hcl TASMAR ORAL TABLET 100 MG 4 ST tolcapone ST trihexyphenidyl MIGRAINE & CLUSTER HEADACHE THERAPY 3

24 almotriptan malate ST; QL dihydroergotamine injection dihydroergotamine nasal QL eletriptan hbr QL ERGOMAR 4 PA; QL frovatriptan ST; QL isometh-dichloral-acetaminophn MIGRANAL 3 QL naratriptan QL nodolor rizatriptan QL sumatriptan QL sumatriptan succinate oral QL sumatriptan succinate subcutaneous cartridge QL sumatriptan succinate subcutaneous pen injector QL sumatriptan succinate subcutaneous solution QL zolmitriptan QL ZOMIG NASAL 4 QL MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; LA; QL AUSTEDO 5 PA; QL donepezil oral tablet 10 mg, 5 mg PA donepezil oral tablet,disintegrating PA galantamine PA HORIZANT 4 PA; QL KEVEYIS 5 PA; QL memantine oral solution PA memantine oral tablet PA MEMANTINE ORAL TABLETS,DOSE PACK 3 PA NAMENDA TITRATION PAK 3 PA NAMENDA XR 3 PA; QL NUEDEXTA 5 PA; QL rivastigmine PA 4

25 rivastigmine tartrate PA tetrabenazine oral tablet 1.5 mg PA; LA; QL tetrabenazine oral tablet 5 mg 5 PA; LA; QL TYSABRI 5 PA; LA; QL MUSCLE RELAXANTS & ANTISPASMODIC THERAPY baclofen carisoprodol oral tablet 350 mg carisoprodol-asa-codeine carisoprodol-aspirin chlorzoxazone cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene meprobamate metaxall 4 PA; QL metaxalone oral tablet 800 mg 4 PA; QL methocarbamol orphenadrine citrate pyridostigmine bromide oral tablet regonol ROBAXIN INJECTION 4 tizanidine oral tablet NARCOTIC ANALGESICS ABSTRAL 5 PA; QL acetaminophen-codeine oral solution 10-1 mg/5 ml acetaminophen-codeine oral tablet ascomp with codeine astramorph-pf injection solution 1 mg/ml BUPRENEX 4 BUPRENORPHINE 4 PA; QL buprenorphine hcl injection buprenorphine hcl sublingual PA; QL butalbital compound w/codeine 5

26 butalbital-acetaminop-caf-cod butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine BUTRANS 4 PA; QL capacet codeine sulfate oral tablet DEMEROL (PF) INJECTION SOLUTION 100 MG/ ML, 5 MG/0.5 ML, 75 MG/1.5 ML demerol (pf) injection solution 100 mg/ml 4 DEMEROL (PF) INJECTION SYRINGE 4 DEMEROL INJECTION 4 diskets duramorph (pf) EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL endocet oral tablet mg,.5-35 mg, 5-35 mg, mg PA; QL EXALGO ER 4 PA; QL fentanyl citrate 5 PA; QL fentanyl citrate (pf) intravenous syringe 100 mcg/ ml (50 mcg/ml) fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr PA QL FENTORA 5 PA; QL hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg hydrocodone-ibuprofen oral tablet mg, 5-00 mg hydrocodone-ibuprofen oral tablet mg hydromorphone (pf) QL

27 hydromorphone in 0.9 % nacl intravenous pt controlled analgesia syring 15 mg/30 ml (0.5 mg/ml) hydromorphone injection solution HYDROMORPHONE INJECTION SYRINGE 0.5 MG/0.5 ML hydromorphone injection syringe 1 mg/ml, mg/ml, 4 mg/ml hydromorphone oral tablet hydromorphone oral tablet extended release 4 hr PA; QL hydromorphone rectal ibuprofen-oxycodone QL LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY LAZANDA NASAL SPRAY,NON-AEROSOL 400 MCG/SPRAY levorphanol tartrate lorcet (hydrocodone) lorcet hd lorcet plus oral tablet mg marten-tab meperidine (pf) injection solution 100 mg/ml, 5 mg/ml, 50 mg/ml meperidine injection cartridge meperidine oral methadone injection solution methadone oral concentrate methadone oral solution methadone oral tablet methadone oral tablet,soluble methadose oral concentrate methadose oral tablet,soluble morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml morphine (pf) intravenous patient control.analgesia soln PA; QL 3 PA; QL

28 morphine concentrate oral solution morphine injection solution 15 mg/ml, 8 mg/ml morphine injection syringe 10 mg/ml, mg/ml, 4 mg/ml, 5 mg/ml, 8 mg/ml MORPHINE INTRAMUSCULAR 4 morphine intravenous cartridge 10 mg/ml, mg/ml, 4 mg/ml MORPHINE INTRAVENOUS CARTRIDGE 8 MG/ML morphine intravenous pt controlled analgesia syring morphine intravenous solution 10 mg/ml, 100 mg/4 ml, 5 mg/ml, 50 mg/10 ml, 50 mg/ml morphine intravenous syringe mg/ml, 4 mg/ml morphine oral solution morphine oral tablet morphine oral tablet extended release QL morphine rectal oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.1 HR oxycodone-acetaminophen oral solution oxycodone-acetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg oxycodone-aspirin OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.1 HR oxymorphone oral tablet 4 4 PA; QL 4 PA; QL oxymorphone oral tablet extended release 1 hr QL PROBUPHINE 5 PA; QL 8

29 SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 1,00 MCG (600 MCG/SPRAY X ), 1,600 MCG (800 MCG/SPRAY X ), 100 MCG/SPRAY, 00 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 400 MCG/SPRAY tencon oral tablet mg verdrocet zamicet NON-NARCOTIC ANALGESICS 5 PA; QL 3 PA; QL aspir-81 6 ACA; OTC aspirin low dose 6 ACA; OTC aspirin oral tablet 6 ACA; OTC aspirin oral tablet,chewable 6 ACA; OTC aspirin oral tablet,delayed release (dr/ec) 35 mg, 81 mg 6 ACA; OTC aspir-low 6 ACA; OTC aspir-trin 6 ACA; OTC bayer aspirin 6 ACA; OTC BUNAVAIL 4 PA; QL buprenorphine-naloxone 4 PA; QL butorphanol tartrate injection butorphanol tartrate nasal QL CALDOLOR INTRAVENOUS RECON SOLN 800 MG/8 ML (100 MG/ML) celecoxib ST; QL children's aspirin 6 ACA; OTC choline,magnesium salicylate diclofenac potassium diclofenac sodium oral diclofenac sodium topical gel 1 % QL diclofenac-misoprostol diflunisal e.c. prin 6 ACA; OTC 9 4

30 ecotrin 6 ACA; OTC ecotrin low strength 6 ACA; OTC etodolac EUFLEXXA 5 PA; LA; QL EVZIO 5 PA; QL fenoprofen oral tablet 4 PA flurbiprofen ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral ketoprofen oral capsule ketorolac injection QL ketorolac intramuscular solution QL ketorolac intramuscular syringe QL ketorolac oral QL lite coat aspirin 6 ACA; OTC meclofenamate oral capsule 100 mg meclofenamate oral capsule 50 mg 4 PA mefenamic acid PA meloxicam nabumetone nalbuphine naloxone naltrexone naproxen naproxen sodium oral tablet 75 mg, 550 mg NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION 4 QL NUCYNTA 4 PA; QL NUCYNTA ER 4 PA; QL oxaprozin pentazocine-naloxone piroxicam salsalate 30

31 SUBOXONE 3 PA; QL sulindac TALWIN 4 tolmetin oral capsule tolmetin oral tablet 00 mg 4 PA tolmetin oral tablet 600 mg tramadol oral tablet QL tramadol oral tablet extended release 4 hr QL tramadol oral tablet, er multiphase 4 hr QL tramadol-acetaminophen QL VIVITROL 5 PA; LA; QL ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG, MG PSYCHOTHERAPEUTIC DRUGS 3 PA 3 PA; QL ABILIFY MAINTENA 5 PA; QL ADDERALL XR QL ADDYI 5 PA; QL alprazolam intensol alprazolam oral tablet alprazolam oral tablet extended release 4 hr alprazolam oral tablet,disintegrating ST amitriptyline amitriptyline-chlordiazepoxide amoxapine aripiprazole PA; ST; QL ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML, 66 MG/.4 ML, 88 MG/3. ML 5 QL 5 PA; QL armodafinil 4 PA; QL atomoxetine QL 31

32 bupropion hcl buspirone chlordiazepoxide hcl chlorpromazine PA citalopram oral solution citalopram oral tablet QL clomipramine ST clonidine hcl oral tablet extended release 1 hr ST; QL clorazepate dipotassium clozapine oral tablet PA clozapine oral tablet,disintegrating 100 mg, 1.5 mg, 5 mg CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 00 MG desipramine PA; ST; QL 4 PA; ST; QL DESVENLAFAXINE 4 ST; QL DESVENLAFAXINE FUMARATE 4 ST; QL desvenlafaxine succinate ST; QL dexmethylphenidate oral capsule,er biphasic PA; QL dexmethylphenidate oral tablet QL dextroamphetamine oral capsule, extended release PA; QL dextroamphetamine oral tablet PA; QL dextroamphetamine-amphetamine QL diazepam injection diazepam intensol diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet doxepin oral duloxetine oral capsule,delayed release(dr/ec) 0 mg, 30 mg, 60 mg QL EMSAM 4 PA; QL ergoloid escitalopram oxalate QL 3

33 estazolam eszopiclone QL FANAPT 4 PA; QL FETZIMA 4 PA; QL flumazenil fluoxetine oral capsule fluoxetine oral solution fluoxetine oral tablet 10 mg, 0 mg fluphenazine decanoate PA fluphenazine hcl PA flurazepam fluvoxamine oral tablet GEODON INTRAMUSCULAR 4 PA guanfacine oral tablet extended release 4 hr QL guanidine haloperidol PA haloperidol decanoate PA haloperidol lactate PA HETLIOZ 5 PA; LA; QL imipramine hcl imipramine pamoate INVEGA SUSTENNA 5 PA; QL INVEGA TRINZA 5 PA; QL KHEDEZLA 4 ST; QL LATUDA 4 PA; ST; QL lithium carbonate lithium citrate oral solution 8 meq/5 ml lorazepam intensol lorazepam oral loxapine succinate PA maprotiline MARPLAN 4 ST metadate er PA; QL 33

34 methamphetamine PA; QL methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule,er biphasic PA; QL PA; QL methylphenidate hcl oral solution PA; QL methylphenidate hcl oral tablet QL methylphenidate hcl oral tablet extended release PA; QL methylphenidate hcl oral tablet extended release 4hr PA; QL methylphenidate hcl oral tablet,chewable PA; QL midazolam oral syrup mg/ml mirtazapine modafinil PA; QL nefazodone nortriptyline NUPLAZID 5 PA; LA; QL olanzapine intramuscular PA olanzapine oral PA; QL olanzapine-fluoxetine PA; QL oxazepam paliperidone PA; QL paroxetine hcl oral tablet paroxetine mesylate QL perphenazine PA perphenazine-amitriptyline phenelzine pimozide PA protriptyline quazepam quetiapine PA; QL RISPERDAL CONSTA 5 PA; QL risperidone oral solution PA risperidone oral tablet PA; QL 34

35 risperidone oral tablet,disintegrating PA; QL ROZEREM 4 PA; QL SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET.5 MG, 5 MG sertraline temazepam oral capsule 15 mg, 30 mg 4 PA; QL 4 PA; ST; QL thioridazine PA thiothixene PA tranylcypromine trazodone oral tablet 100 mg, 150 mg, 50 mg triazolam trifluoperazine PA trimipramine TRINTELLIX 4 PA; QL venlafaxine oral capsule,extended release 4hr QL venlafaxine oral tablet VIIBRYD ORAL TABLET 4 PA; QL VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG (3) 4 PA; QL VYVANSE ORAL CAPSULE 4 PA; QL XYREM 5 PA; LA; QL zaleplon ziprasidone hcl PA; QL zolpidem oral tablet QL ZYPREXA RELPREVV 5 QL CARDIOVASCULAR, HYPERTENSION & LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral disopyramide phosphate oral capsule dofetilide flecainide mexiletine 35

36 MULTAQ 3 pacerone oral tablet 100 mg, 00 mg, 400 mg propafenone quinidine gluconate quinidine sulfate oral tablet sotalol af SOTALOL INTRAVENOUS 4 sotalol oral ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr amiloride amiloride-hydrochlorothiazide amlodipine amlodipine-benazepril atenolol 1 atenolol-chlorthalidone 1 benazepril 1 benazepril-hydrochlorothiazide BENICAR 4 PA betaxolol oral bisoprolol fumarate bisoprolol-hydrochlorothiazide 1 bumetanide injection bumetanide oral tablet 0.5 mg, 1 mg 1 bumetanide oral tablet mg BYSTOLIC 4 ST BYVALSON 4 PA candesartan candesartan-hydrochlorothiazid captopril 1 captopril-hydrochlorothiazide cartia xt 36

37 carvedilol 1 chlorothiazide chlorothiazide sodium chlorthalidone oral tablet 5 mg, 50 mg clonidine clonidine hcl oral tablet DEMSER 5 PA diltiazem hcl oral capsule,ext.rel 4h degradable 40 mg diltiazem hcl oral capsule,extended release 1 hr diltiazem hcl oral capsule,extended release 4 hr 40 mg, 40 mg diltiazem hcl oral capsule,extended release 4hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 4 hr 180 mg, 40 mg, 300 mg, 360 mg dilt-xr DIURIL 4 doxazosin DYRENIUM 4 ST EDARBI 4 ST EDARBYCLOR 4 ST EDECRIN 4 PA; QL enalapril maleate enalaprilat intravenous solution enalapril-hydrochlorothiazide eplerenone epoprostenol (glycine) 5 PA; LA eprosartan esmolol intravenous solution ethacrynate sodium 5 ethacrynic acid 4 felodipine fosinopril 37

38 fosinopril-hydrochlorothiazide furosemide injection furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 1 guanfacine oral tablet HEMANGEOL 4 PA; QL hydralazine hydrochlorothiazide oral capsule 1 hydrochlorothiazide oral tablet 1.5 mg hydrochlorothiazide oral tablet 5 mg, 50 mg 1 indapamide irbesartan irbesartan-hydrochlorothiazide isradipine labetalol intravenous solution labetalol intravenous syringe 0 mg/4 ml (5 mg/ml) labetalol oral LEVATOL 4 ST lisinopril oral tablet 10 mg,.5 mg, 0 mg, 5 mg 1 lisinopril oral tablet 30 mg, 40 mg lisinopril-hydrochlorothiazide 1 losartan losartan-hydrochlorothiazide methyclothiazide methyldopa methyldopa-hydrochlorothiazide methyldopate metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate intravenous 38

39 metoprolol tartrate oral tablet 100 mg, 5 mg, 50 mg minoxidil oral moexipril moexipril-hydrochlorothiazide nadolol nadolol-bendroflumethiazide nicardipine intravenous solution nicardipine oral nifedipine nimodipine nisoldipine ST olmesartan PA ORENITRAM 5 PA; LA papaverine injection solution perindopril erbumine phenoxybenzamine 5 PA phentolamine injection recon soln pindolol prazosin propranolol intravenous propranolol oral capsule,extended release 4 hr propranolol oral solution propranolol oral tablet 10 mg, 0 mg, 40 mg, 80 mg propranolol oral tablet 60 mg propranolol-hydrochlorothiazid quinapril quinapril-hydrochlorothiazide ramipril REMODULIN 5 PA; LA spironolactone oral tablet 100 mg, 50 mg spironolactone oral tablet 5 mg

40 spironolacton-hydrochlorothiaz taztia xt TEKTURNA 3 ST TEKTURNA HCT 3 ST telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid terazosin timolol maleate oral torsemide oral trandolapril trandolapril-verapamil triamterene-hydrochlorothiazid oral capsule mg triamterene-hydrochlorothiazid oral capsule 50-5 mg triamterene-hydrochlorothiazid oral tablet 1 UPTRAVI 5 PA; LA; QL valsartan valsartan-hydrochlorothiazide veletri 5 PA; LA verapamil intravenous verapamil oral capsule,ext rel. pellets 4 hr 10 mg, 180 mg, 40 mg verapamil oral tablet verapamil oral tablet extended release CARDIAC GLYCOSIDES digitek digox digoxin injection digoxin oral solution 50 mcg/ml digoxin oral tablet COAGULATION THERAPY aminocaproic acid intravenous 40 1

41 ARGATROBAN IN NACL (ISO-OS) 4 aspirin-dipyridamole bivalirudin BRILINTA 4 QL cilostazol clopidogrel dipyridamole oral ELIQUIS 3 QL enoxaparin 5 QL fondaparinux 5 QL FRAGMIN SUBCUTANEOUS SOLUTION 5 QL FRAGMIN SUBCUTANEOUS SYRINGE 5 QL hep flush-10 (pf) HEPARIN (PORCINE) IN 0.9% NACL INTRAVENOUS PARENTERAL SOLUTION 1,000 UNIT/1000 ML (1 UNIT/ML) HEPARIN (PORCINE) IN 0.9% NACL INTRAVENOUS PARENTERAL SOLUTION,000 UNIT/500 ML (4 UNIT/ML), 4000 UNIT/1000 ML (4 UNIT/ML), 6,000 UNIT/1000 ML (6 UNIT/ML) heparin (porcine) in 5 % dex intravenous parenteral solution 0,000 unit/500 ml (40 unit/ml), 5,000 unit/50 ml(100 unit/ml), 5,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) heparin (porcine) injection cartridge heparin (porcine) injection solution heparin (porcine) injection syringe 5,000 unit/ml heparin flush(porcine)-0.9nacl heparin lock flush heparin lock flush (porcine) intravenous solution 100 unit/ml heparin lockflush(porcine)(pf) HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 1,500 UNIT/50 ML

42 heparin(porcine) in 0.45% nacl intravenous parenteral solution 5,000 unit/50 ml, 5,000 unit/500 ml heparin, porcine (pf) injection heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml) heparin, porcine (pf) intravenous syringe jantoven MEPHYTON 4 NPLATE 5 PA; LA pentoxifylline PRADAXA ORAL CAPSULE 110 MG 4 PRADAXA ORAL CAPSULE 150 MG, 75 MG 4 QL prasugrel QL PROMACTA 5 PA; LA; QL protamine ticlopidine tranexamic acid intravenous vitamin k vitamin k1 injection warfarin XARELTO 3 QL ZONTIVITY 4 PA; QL LIPID/CHOLESTEROL LOWERING AGENTS amlodipine-atorvastatin atorvastatin cholestyramine (with sugar) cholestyramine light colestipol ezetimibe fenofibrate micronized fenofibrate nanocrystallized fenofibrate oral tablet fenofibric acid 4

43 fenofibric acid (choline) ST fluvastatin oral capsule gemfibrozil JUXTAPID 5 PA; QL KYNAMRO 5 PA; LA; QL LIVALO 4 PA lovastatin LOVAZA 4 niacin oral tablet extended release 4 hr omega-3 acid ethyl esters PRALUENT PEN 5 PA; LA; QL pravastatin prevalite REPATHA PUSHTRONEX 5 PA; QL REPATHA SURECLICK 5 PA; QL rosuvastatin PA simvastatin triklo 3 VASCEPA 3 WELCHOL 3 ZETIA 3 MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR 4 PA; QL ENTRESTO 3 PA; QL RANEXA 3 NITRATES isosorbide dinitrate oral isosorbide mononitrate nitro-bid NITRO-DUR TRANSDERMAL PATCH 4 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin in 5 % dextrose nitroglycerin intravenous 43 4

44 nitroglycerin oral nitroglycerin sublingual nitroglycerin transdermal patch 4 hour nitroglycerin translingual nitro-time DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin 5 ST calcipotriene calcitrene calcitriol topical QL COSENTYX 5 PA; LA; QL COSENTYX ( SYRINGES) 5 PA; LA; QL COSENTYX PEN 5 PA; LA; QL COSENTYX PEN ( PENS) 5 PA; LA; QL drithocreme hp hydrocortisone-pramoxine topical seb-prev selenium sulfide topical lotion selenium sulfide topical shampoo.5 % SILIQ 5 LA; QL STELARA INTRAVENOUS 5 PA; LA STELARA SUBCUTANEOUS SOLUTION 5 PA; LA STELARA SUBCUTANEOUS SYRINGE 5 PA; LA; QL sulfacetamide sodium topical cleanser TACLONEX TOPICAL SUSPENSION 4 PA TALTZ AUTOINJECTOR 5 PA; LA; QL TALTZ AUTOINJECTOR ( PACK) 5 PA; LA; QL TALTZ AUTOINJECTOR (3 PACK) 5 PA; LA; QL TALTZ SYRINGE 5 PA; LA; QL TALTZ SYRINGE ( PACK) 5 PA; LA; QL TALTZ SYRINGE (3 PACK) 5 PA; LA; QL TREMFYA 5 PA; LA 44

45 BURN THERAPY silver sulfadiazine ssd KERATOLYTICS salicylic acid topical cream salicylic acid topical cream,extended release salicylic acid topical gel salicylic acid topical liquid 6 % salicylic acid topical lotion,extended release salicylic acid topical shampoo MISCELLANEOUS DERMATOLOGICALS ammonium lactate topical cream avo cream diclofenac sodium topical gel 3 % DUPIXENT 5 QL ELIDEL 4 PA EUCRISA 4 PA; QL fluorouracil topical cream 5 % fluorouracil topical solution methoxsalen 5 PA PANRETIN 5 PA PICATO 4 PA podofilox prutect QUTENZA 5 PA; QL REGRANEX 4 QL silver nitrate silver nitrate applicators tacrolimus topical PA urea topical cream 40 %, 50 % urea topical lotion 40 % ure-k UVADEX 4 45

46 VALCHLOR 5 PA; LA VEREGEN 4 THERAPY FOR ACNE adapalene topical cream PA adapalene topical gel 0.1 % PA adapalene-benzoyl peroxide 4 PA amnesteem AVAR LS TOPICAL PADS, MEDICATED 4 PA avar topical cleanser AVAR TOPICAL PADS, MEDICATED 4 PA avita topical cream bp 10-1 claravis clindacin p clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab clindamycin-benzoyl peroxide topical gel 1-5 % PA clindamycin-tretinoin 4 PA EPIDUO TOPICAL GEL WITH PUMP 4 PA ery pads erythromycin with ethanol erythromycin-benzoyl peroxide PA FABIOR 4 PA FINACEA TOPICAL GEL 4 PA metronidazole topical MIRVASO 4 PA RHOFADE 4 PA sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w) sulfact na-sul-avobnz-otn-ocsa tazarotene PA 46

47 TAZORAC 4 PA tretinoin topical cream tretinoin topical gel 0.01 %, 0.05 % zenatane ZIANA 4 PA TOPICAL ANESTHETICS ethyl chloride glydo lidocaine (pf) injection solution lidocaine hcl injection solution lidocaine hcl injection syringe 10 mg/ml (1 %) lidocaine hcl laryngotracheal lidocaine hcl mucous membrane jelly lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl topical cream 3 % lidocaine hcl topical lotion lidocaine hcl-hydrocortison ac topical lidocaine topical adhesive patch,medicated ST; QL lidocaine topical ointment lidocaine viscous lidocaine-epinephrine lidocaine-prilocaine lido-k lidopin topical cream 3 % lta pre-attached SYNERA 4 PA XYLOCAINE-MPF INJECTION SOLUTION 15 MG/ML (1.5 %) TOPICAL ANTIBACTERIALS ALTABAX 4 CORTISPORIN TOPICAL

48 gentamicin topical mupirocin mupirocin calcium NEO-SYNALAR 4 PA; QL SILVRSTAT 4 sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM 4 TOPICAL ANTIFUNGALS ciclodan ciclopirox topical cream ciclopirox topical solution clotrimazole-betamethasone econazole ERTACZO 4 PA EXELDERM 4 KERYDIN 5 PA ketoconazole topical cream ketoconazole topical shampoo LUZU 4 PA MENTAX 4 PA NAFTIN TOPICAL GEL 1 % 4 PA nyamyc nyata nystatin topical nystatin-triamcinolone nystop OXISTAT TOPICAL CREAM 4 PA TOPICAL ANTIVIRALS acyclovir topical DENAVIR 4 ST ZOVIRAX TOPICAL CREAM 4 ST TOPICAL CORTICOSTEROIDS ala-cort topical cream.5 % 48

49 alclometasone amcinonide ST betamethasone dipropionate betamethasone valerate topical cream betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented clobetasol scalp clobetasol topical cream clobetasol topical gel clobetasol topical ointment CLODERM 4 PA cormax scalp desonide topical cream desonide topical ointment desoximetasone ST diflorasone ST fluocinolone fluocinolone and shower cap fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-e fluocinonide-emollient halobetasol propionate hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone butyr-emollient hydrocortisone topical cream.5 % hydrocortisone topical lotion.5 % hydrocortisone topical ointment.5 % hydrocortisone valerate 49

50 hydrocortisone-min oil-wht pet mometasone topical prednicarbate triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.05 %, 0.1 %, 0.5 % triderm topical cream 0.1 % TOPICAL ENZYMES SANTYL 4 TOPICAL SCABICIDES / PEDICULICIDES EURAX 4 lindane topical shampoo malathion permethrin topical cream SKLICE 4 PA spinosad ULESFIA 4 DIAGNOSTICS & MISCELLANEOUS AGENTS ANOREXIANTS CONTRAVE 4 PA; QL IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringer's irrigation tis-u-sol pentalyte MISCELLANEOUS AGENTS acamprosate acetic acid irrigation ADAGEN 5 PA alendronate oral tablet 40 mg anagrelide ARALAST NP 5 PA; LA 50

51 BUPHENYL ORAL TABLET 5 PA; LA CARBAGLU 5 PA; LA cevimeline CHEMET 4 PA disulfiram etidronate disodium EXJADE 5 PA; LA FERRIPROX 5 PA GLASSIA 5 PA; LA INCRELEX 5 PA; LA JADENU 5 PA JADENU SPRINKLE 5 PA; LA levocarnitine (with sugar) levocarnitine oral tablet midodrine NITYR 5 PA ORFADIN 5 PA pilocarpine hcl oral tablet 5 mg PROLASTIN-C 5 PA RAVICTI 5 PA; LA; QL riluzole 5 PA; QL risedronate oral tablet 30 mg ST sodium chloride 0.9 % injection solution sodium chloride 0.9 % injection syringe sodium chloride 0.9 % intravenous sodium chloride irrigation sodium ferric gluconat-sucrose sodium phenylbutyrate oral powder 5 PA; LA sodium phenylbutyrate oral tablet PA SOLIRIS 5 PA; LA SYPRINE 5 PA THIOLA 4 water for irrigation, sterile 51

52 XURIDEN 5 PA; QL ZEMAIRA 5 PA; LA zoledronic acid-mannitol-water 5 LA; QL SMOKING DETERRENTS bupropion hcl (smoking deter) 6 ACA; QL CHANTIX 6 ST; ACA; QL CHANTIX CONTINUING MONTH BOX 6 ST; ACA; QL CHANTIX STARTING MONTH BOX 6 ST; ACA; QL nicorelief 6 ACA; OTC; QL nicorette buccal gum 4 mg 6 ACA; OTC; QL nicotine (polacrilex) 6 ACA; OTC; QL nicotine transdermal patch 4 hour 14 mg/4 hr, 1 mg/4 hr, 7 mg/4 hr 6 ACA; OTC; QL nicotine transdermal patch, td daily, sequential 6 ACA; OTC; QL NICOTROL 6 ST; ACA; QL NICOTROL NS 6 ST; ACA; QL nts step 1 6 OTC; QL quit buccal gum 6 ACA; OTC; QL quit 4 buccal gum 6 ACA; OTC; QL stop smoking aid 6 ACA; OTC; QL EAR, NOSE & THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal chlorhexidine gluconate mucous membrane denta 5000 plus dentagel fluoride (sodium) dental GELCLAIR 4 ipratropium bromide nasal olopatadine nasal ST oralone ORAMAGICRX 4 paroex oral rinse 5

53 periogard pilocarpine hcl oral tablet 7.5 mg sf sf 5000 plus triamcinolone acetonide dental MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) ciprofloxacin hcl otic (ear) floxin otic (ear) drops fluocinolone acetonide oil hydrocortisone-acetic acid ofloxacin otic (ear) OTIC STEROID / ANTIBIOTIC CIPRO HC 3 CIPRODEX 3 COLY-MYCIN S 4 neomycin-polymyxin-hc otic (ear) ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. 5 PA; LA; QL betamethasone acet,sod phos cortisone deltasone oral tablet 0 mg DEPO-MEDROL INJECTION SUSPENSION 0 MG/ML dexamethasone dexamethasone intensol dexamethasone sodium phosphate injection EMFLAZA 5 fludrocortisone hydrocortisone oral KENALOG INJECTION 4 methylprednisolone 53 4

54 methylprednisolone acetate millipred dp prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisone prednisone intensol triamcinolone acetonide injection TRIESENCE (PF) 4 ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg propylthiouracil SSKI 4 BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES ONETOUCH ULTRA TEST 3 OTC; QL ONETOUCH VERIO 3 OTC; QL DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT EASIVENT HOLDING CHAMBER 4 QL GLUCAGEN DIAGNOSTIC KIT 3 QL GLUCAGON HCL 3 QL INSPIRACHAMBER WITH MASK-LARGE 4 QL INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.5 ML 9 GAUGE X 1/" LITEAIRE MDI CHAMBER 4 QL GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 3 QL GLUCAGON EMERGENCY KIT (HUMAN) 3 QL PROGLYCEM 4 INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU LANCETS 33 GAUGE 3 OTC; QL LANCING DEVICE 3 OTC ONETOUCH ULTRA 3 OTC ONETOUCH ULTRAMINI 3 OTC 54 3

55 ONETOUCH VERIO FLEX 3 OTC ONETOUCH VERIO IQ METER 3 OTC ONETOUCH VERIO SYSTEM 3 OTC PEN NEEDLE NEEDLE 31 GAUGE X 1/4" 3 OTC INSULIN THERAPY AFREZZA 4 PA APIDRA 4 ST; QL APIDRA SOLOSTAR 4 ST; QL HUMALOG 3 QL HUMALOG JUNIOR KWIKPEN 3 QL HUMALOG KWIKPEN 3 QL HUMALOG MIX QL HUMALOG MIX KWIKPEN 3 QL HUMALOG MIX QL HUMALOG MIX 75-5 KWIKPEN 3 QL HUMULIN 70/30 3 QL HUMULIN 70/30 KWIKPEN 3 QL HUMULIN N 3 QL HUMULIN N KWIKPEN 3 QL HUMULIN R U QL HUMULIN R U-500 (CONC) KWIKPEN 3 QL HUMULIN R U-500 (CONCENTRATED) 3 QL LANTUS 3 QL LANTUS SOLOSTAR 3 QL LEVEMIR 3 QL LEVEMIR FLEXTOUCH 3 QL NOVOLOG 3 QL NOVOLOG FLEXPEN 3 QL NOVOLOG MIX QL NOVOLOG MIX FLEXPEN 3 QL NOVOLOG PENFILL 3 QL TRESIBA FLEXTOUCH U QL TRESIBA FLEXTOUCH U-00 3 QL 55

56 MISCELLANEOUS HORMONES ALDURAZYME 5 PA; LA ANADROL-50 4 PA ANDRODERM 4 PA ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 0.5 MG/1.5 GRAM (1.6 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (0.5 MG/1.5 GRAM), 1.6 % (40.5 MG/.5 GRAM) 3 PA 3 PA AVEED 4 PA cabergoline calcitonin (salmon) calcitriol intravenous solution 1 mcg/ml calcitriol oral CERDELGA 5 PA; LA; QL CEREZYME INTRAVENOUS RECON SOLN 400 UNIT 5 PA; LA CHORIONIC GONADOTROPIN, HUMAN 5 PA danazol PA desmopressin nasal solution desmopressin nasal spray,non-aerosol desmopressin oral doxercalciferol ELAPRASE 5 PA; LA ELELYSO 5 PA FABRAZYME 5 PA; LA FORTESTA 4 PA HECTOROL INTRAVENOUS 4 KANUMA 5 PA; LA KORLYM 5 PA; QL KUVAN ORAL POWDER IN PACKET 500 MG 5 PA; LA KUVAN ORAL TABLET,SOLUBLE 5 PA; LA LUMIZYME 5 PA; LA 56

57 METHITEST 4 PA methyltestosterone oral capsule 5 PA MYALEPT 5 PA; LA; QL NAGLAZYME 5 PA; LA NATPARA 5 PA; LA; QL NOVAREL INTRAMUSCULAR RECON SOLN 10,000 UNIT oxandrolone PA pamidronate 5 LA PARICALCITOL HEMODIALYSIS PORT INJECTION paricalcitol intravenous paricalcitol oral SAMSCA 5 PA; LA; QL SENSIPAR 3 serophene SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 0 MG, 5 MG, 30 MG PA; LA; QL STRENSIQ 5 PA STRIANT 4 PA SYNAREL 5 PA; QL TESTIM 4 PA testosterone cypionate PA testosterone enanthate PA TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP 10 MG/0.5 GRAM /ACTUATION testosterone transdermal gel in metered-dose pump 1.5 mg/ 1.5 gram (1 %) 4 PA 4 PA testosterone transdermal gel in packet PA testosterone transdermal solution in metered pump w/app PA VIMIZIM 5 PA; LA VPRIV 5 PA; LA ZAVESCA 5 PA; LA

58 ZEMPLAR INTRAVENOUS 4 zoledronic acid 5 LA ZOLEDRONIC AC-MANNITOL-0.9NACL 5 ST; LA ZOMETA INTRAVENOUS PIGGYBACK 5 LA; QL NON-INSULIN HYPOGLYCEMIC AGENTS acarbose ADLYXIN 4 ST; QL AVANDIA ORAL TABLET MG, 4 MG 5 BYDUREON 4 QL BYETTA 4 ST; QL chlorpropamide CYCLOSET 4 FARXIGA 4 PA; QL glimepiride glipizide glipizide-metformin glyburide glyburide micronized glyburide-metformin GLYXAMBI 3 QL INVOKAMET 3 QL INVOKAMET XR 3 QL INVOKANA 3 QL JANUMET 3 JANUMET XR 3 JANUVIA 3 JARDIANCE 3 QL JENTADUETO 3 JENTADUETO XR 3 QL KAZANO 4 ST KOMBIGLYZE XR 4 ST metformin oral tablet metformin oral tablet extended release 4 hr 58

59 metformin oral tablet extended release 4hr 500 mg miglitol nateglinide NESINA 4 ST ONGLYZA 4 ST OSENI 4 pioglitazone pioglitazone-metformin repaglinide repaglinide-metformin QL SYMLINPEN 10 3 ST; QL SYMLINPEN 60 3 ST; QL SYNJARDY 3 QL SYNJARDY XR 3 QL TANZEUM 4 ST; QL tolazamide tolbutamide TRADJENTA 3 TRULICITY 3 QL VICTOZA -PAK 3 VICTOZA 3-PAK 3 THYROID HORMONES ARMOUR THYROID 4 LEVOTHYROXINE INTRAVENOUS RECON SOLN 100 MCG levothyroxine intravenous recon soln 00 mcg, 500 mcg levothyroxine oral tablet 100 mcg, 11 mcg, 15 mcg, 137 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine oral tablet 300 mcg levoxyl oral tablet 100 mcg, 11 mcg, 15 mcg, 137 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 50 mcg, 75 mcg, 88 mcg

60 liothyronine nature-throid np thyroid thyroid (pork) THYROLAR-1 4 THYROLAR-1/ 4 THYROLAR-1/4 4 THYROLAR- 4 THYROLAR-3 4 TIROSINT 4 unithroid westhroid oral tablet 130 mg, 195 mg, 3.5 mg, 65 mg, 97.5 mg WP THYROID 4 GASTROENTEROLOGY ANTIDIARRHEALS & ANTISPASMODICS anaspaz atropine injection solution atropine injection syringe 0.05 mg/ml, 0.1 mg/ml belladonna alkaloids-opium belladonna-opium chlordiazepoxide-clidinium CUVPOSA 5 PA dicyclomine intramuscular dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet diphenoxylate-atropine ed-spaz glycopyrrolate injection glycopyrrolate oral tablet 1 mg, mg hyoscyamine sulfate hyosyne 60

61 LEVSIN INJECTION 4 PA loperamide oral capsule methscopolamine MYTESI 5 PA; QL oscimin oscimin sl oscimin sr paregoric phenohytro propantheline MISCELLANEOUS GASTROINTESTINAL AGENTS AKYNZEO 4 QL alophen 6 ACA; OTC alosetron 5 PA ALOXI 4 ST; QL AMITIZA 3 QL anucort-hc ANZEMET ORAL 4 ST; QL aprepitant QL APRISO 3 ASACOL HD 3 AURYXIA 3 balsalazide bisacodyl oral 6 ACA; OTC bisa-lax 6 ACA; OTC budesonide oral calcium acetate oral capsule calcium acetate oral tablet 667 mg CANASA 4 CESAMET 4 ST CIMZIA 5 PA; LA; QL CIMZIA POWDER FOR RECONST 5 PA; LA; QL citroma 6 ACA; OTC 61

62 clearlax oral powder 6 ACA; OTC colocort compro constulose CREON 3 cromolyn oral CYSTADANE 5 PA DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) dimenhydrinate injection solution DIPENTUM 4 ST dronabinol droperidol injection solution ducodyl 6 ACA; OTC eliphos EMEND (FOSAPREPITANT) 4 QL EMEND ORAL 3 QL ENTYVIO 5 PA; LA; QL enulose fleet laxative 6 ACA; OTC FOSRENOL 4 ST GATTEX 30-VIAL 5 PA; LA; QL gavilax oral powder 6 ACA; OTC gavilyte-c 6 ACA gavilyte-g 6 ACA gavilyte-n 6 ACA generlac gentle laxative oral 6 ACA; OTC gentlelax 6 ACA; OTC glycolax oral powder 6 ACA; OTC granisetron (pf) ST granisetron hcl intravenous ST granisetron hcl oral ST; QL 6 3

63 healthylax 6 ACA; OTC hemmorex-hc hydrocortisone acetate rectal hydrocortisone rectal hydrocortisone topical cream with perineal applicator hydrocortisone-pramoxine rectal kionex kionex (with sorbitol) lactulose oral solution 10 gram/15 ml lanthanum ST laxaclear 6 ACA; OTC laxative (bisacodyl) oral 6 ACA; OTC laxative feminine 6 ACA; OTC LIALDA 4 ST LIDOCAINE HCL-HYDROCORTISON AC RECTAL CREAM 3 %-1 % (7 GRAM) lidocaine hcl-hydrocortison ac rectal cream % LINZESS 3 QL magnesium citrate oral solution 6 ACA; OTC meclizine oral tablet 1.5 mg, 5 mg mesalamine oral tablet,delayed release (dr/ec) 1. gram mesalamine rectal mesalamine with cleansing wipe metoclopramide hcl injection metoclopramide hcl oral solution metoclopramide hcl oral tablet 63 3 ST; ACA; LA milk of magnesia 6 ACA; OTC milk of magnesia concentrated 6 ACA; OTC miralax oral powder in packet 6 ACA; OTC MOVANTIK 4 PA; QL MOVIPREP 3

64 OCALIVA 5 PA; LA; QL ondansetron QL ondansetron hcl (pf) ondansetron hcl intravenous ondansetron hcl oral solution ondansetron hcl oral tablet QL oral saline laxative oral liquid 6 ACA; OTC OSMOPREP 4 peg 3350-electrolytes 6 ACA peg ACA; OTC peg-electrolyte soln 6 ACA peg-prep 6 ACA PENTASA 4 polyethylene glycol 3350 oral powder 6 ACA powderlax 6 ACA; OTC pramcort PREPOPIK 4 prochlorperazine prochlorperazine edisylate prochlorperazine maleate procto-med hc proctosol hc topical proctozone-hc purelax 6 ACA; OTC RECTIV 4 PA RELISTOR ORAL 5 PA; QL RELISTOR SUBCUTANEOUS SOLUTION 5 PA; QL RELISTOR SUBCUTANEOUS SYRINGE 5 PA; QL REMICADE 5 PA; LA RENAGEL 3 RENVELA 3 SANCUSO 4 ST; QL scopolamine base 64

65 sevelamer carbonate smoothlax 6 ACA; OTC sodium polystyrene sulfonate oral sodium polystyrene sulfonate rectal enema 30 gram/10 ml SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/00 ML sps (with sorbitol) SUCRAID 5 PA; LA sulfasalazine SUPREP BOWEL PREP KIT 3 TIGAN INTRAMUSCULAR 4 TRANSDERM-SCOP 4 trilyte with flavor packets 6 ACA trimethobenzamide oral UCERIS 4 PA ursodiol VELPHORO 4 ST VELTASSA 5 PA; LA; QL VIBERZI 5 PA; QL woman's laxative oral tablet,delayed release (dr/ec) ACA; OTC women's gentle laxative(bisac) 6 ACA; OTC women's laxative (bisacodyl) oral tablet 6 ACA; OTC ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-8,000 UNIT, 0,000-68, ,000 UNIT, 5,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT, 40, ,000-18,000 UNIT ULCER THERAPY 4 ST ACIPHEX 4 PA; QL amoxicil-clarithromy-lansopraz CARAFATE ORAL SUSPENSION 4 cimetidine