(List of Covered Drugs)

Transcription

1 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Assurance Rx (HMO-POS) Essence Rx (HMO-POS) Esteem Rx (HMO-POS) Promise Rx (HMO-POS) Spirit Rx (HMO-POS) Surety Rx (HMO-POS) This formulary was updated on April 26, For more recent information or other questions, please contact Security Health Plan Customer Service at or, for TTY users, 711, from 8 a.m. to 8 p.m., 7 days a week, or visit Y0117_MC C pending Effective date 5/1/2018 Updated /26/2018 Formulary ID , v.1

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Security Health Plan. When it refers to plan or our plan, it means Assurance Rx (HMO-POS), Essence Rx (HMO-POS), Promise Rx (HMO-POS), Spirit Rx (HMO- POS) or Surety Rx (HMO-POS). This document includes a list of the drugs (formulary) for our plan which is current as of May 1, For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network and/or copayments/coinsurance may change on Jan. 1, 2019, and from time to time during the year. Security Health Plan of Wisconsin, Inc., is an HMO, MSA and D-SNP plan with a Medicare contract. Enrollment in Security Health Plan depends on contract renewal. This document is available in alternate formats. Call Customer Service at the number on the covers for more information.

3 What is the Security Health Plan Formulary? A formulary is a list of covered drugs selected by Security Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Security Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Security Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of May 1, To get updated information about the drugs covered by Security Health Plan, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page vii. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 109. The index provides an alphabetical list of all of the drugs included i

4 in this document. Both brand name drugs and generic drugs are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list. What are generic drugs? Security Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Security Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Security Health Plan before you fill your prescriptions. If you don t get approval, Security Health Plan may not cover the drug. Quantity Limits: For certain drugs, Security Health Plan limits the amount of the drug that your Medicare Advantage plan will cover. For example, Security Health Plan provides 18 tablets per prescription for sumatriptan. This may be in addition to a standard 1-month or - month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page vii. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online a document that explains our prior authorization restriction. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Security Health Plan to make an exception to these restrictions or limits or for a list of other drugs that may treat your health condition. See the section, How do I request an exception to Security Health Plan s formulary? on page iii for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that Security Health Plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Security Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Security Health Plan. ii

5 You can ask Security Health Plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Security Health Plan Formulary? You can ask Security Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Security Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Security Health Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 2 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. iii

6 If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 9-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. There are times outside of your first 90 days of new membership when the prescription drug transition process will also apply. One of the more common examples would be if you experience a change in your level of care (for example, when you are discharged from a hospital to either your home or to a long-term care facility, or if you end your long-term care facility stay and return to your home). Security Health Plan will ensure you have an effective transition of care, including your medication therapy, anytime you experience a change in your level of care. For more information For more detailed information about your Security Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Security Health Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 2 hours a day/7 days a week. TTY users should call Or, visit iv

7 Notice of Nondiscrimination Discrimination is against the law Security Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations. Security Health Plan does not exclude people or treat them differently because of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status. Security Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service at (TTY: 711). If you believe that Security Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status, you can file a grievance with: Security Health Plan Attn: Grievances 1515 North Saint Joseph Avenue Marshfield, WI Phone: (TTY: 711) Fax: shp.appeals.grievance@securityhealth.org You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Security Health Plan can help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC Phone: or (TDD) Complaint forms are available at Language Assistance Services ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). v

8 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). (Arabic) ةيبرعلا ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 117). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Deitsch (Pennsylvania Dutch) Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: (TTY: 711). ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ (TTY: 711). າພາສາ ລາວ, ການບ ລການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແ ມ ນ ມ ພ ອມໃຫ ທ ານ. ໂທຣ Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ह द (Hindi) ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng a serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Oroomiffa (Oromo/Somalia) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711). Large print If you require materials in large print, please call (TTY: 711). vi

9 Security Health Plan Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Security Health Plan. If you have trouble finding your drug in the list, turn to the index that begins on page 109. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZETIA) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if Security Health Plan has any special requirements for coverage of your drug. Deductibles and initial coverage period copay amounts: (0-day supply) Tier 1 Preferred generic drugs 2 Generic drugs Preferred brand drugs Nonpreferred drugs 5 Specialty drugs 6 Select Part D vaccines Assurance Rx (HMO-POS) $75 deductible (Tiers -5 only) Essence Rx (HMO-POS) $00 deductible (Tiers -5 only) Esteem Rx (HMO-POS) $00 deductible (Tiers -5 only) vii Promise Rx (HMO-POS) $200 deductible (Tiers -5 only) Spirit Rx (HMO-POS) No deductible Surety Rx (HMO-POS) $00 deductible (Tiers -5 only) $5 $5 $5 $6 $9 $5 $1 $1 $20 $20 $20 $20 $5 $5 $5 $5 $7 $5 $98 $100 $100 $100 $100 $100 25% of the cost Requirements/Limits key: PA = Prior authorization required 25% of the cost 25% of the cost 25% of the cost % of the cost 25% of the cost $0 $0 $0 $0 $0 $0 PA NSO = Prior authorization required on new starts only PA B vs. D = Prior authorization required for Part B vs. Part D coverage HI = Home infusion coverage This prescription drug may be covered under our medical benefit. For more information call Customer Service at , Monday through Sunday from 8 a.m. to 8 p.m. TTY users should call 711. LA = Limited access This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , Monday through Sunday from 8 a.m. 8 p.m. TTY users should call 711. QL = Quantity limit NDS = Non-extended day supply (Limited to 0-day supply)

10 Table of Contents Analgesics... Anesthetics... 6 Anti-Addiction/ Substance Abuse Treatment Agents... 7 Antibacterials... 7 Anticonvulsants Antidementia Agents Antidepressants Antiemetics Antifungals... 2 Antigout Agents... 2 Anti-Inflammatory Agents Antimigraine Agents Antimyasthenic Agents Antimycobacterials Antineoplastics Antiparasitics... Antiparkinson Agents... 5 Antipsychotics... 6 Antispasticity Agents... 9 Antivirals... 9 Anxiolytics... Bipolar Agents... 5 Blood Glucose Regulators... 5 Blood Products/ Modifiers/ Volume Expanders Cardiovascular Agents... 5 Central Nervous System Agents Dental And Oral Agents

11 Dermatological Agents... 6 Electrolytes/Minerals/Metals/Vitamins Gastrointestinal Agents Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment... 7 Genitourinary Agents Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Thyroid) Immunological Agents Inflammatory Bowel Disease Agents Metabolic Bone Disease Agents Ophthalmic Agents Otic Agents Respiratory Tract/ Pulmonary Agents Skeletal Muscle Relaxants Sleep Disorder Agents

12 Analgesics Analgesics acetaminophen-codeine oral solution /5 ml acetaminophen-codeine oral tablet 00-15, 00-0, ascomp with codeine oral capsule QL (60 per 0 days) butalbital compound w/codeine oral capsule 0- QL (60 per 0 days) butalbital-acetaminop-caf-cod oral capsule 50- QL (60 per 0 days) butalbital-acetaminop-caf-cod oral capsule butalbital-acetaminophen oral tablet QL (180 per 0 days) butalbital-acetaminophen-caff oral capsule 50- QL (180 per 0 days) 00-0 butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet capacet oral capsule endocet oral tablet 10-25, , 5-25, hydrocodone-acetaminophen oral solution /15 ml hydrocodone-acetaminophen oral tablet 10-00, 10-25, , 5-00, 5-25, , hydrocodone-ibuprofen oral tablet , 5-200, lorcet (hydrocodone) oral tablet 5-25 lorcet hd oral tablet lorcet plus oral tablet marten-tab oral tablet QL (180 per 0 days) oxycodone-acetaminophen oral tablet 10-25, , 5-25, oxycodone-aspirin oral tablet

13 phrenilin forte(with caffeine) oral capsule 50- QL (180 per 0 days) 00-0 reprexain oral tablet , , tencon oral tablet QL (180 per 0 days) tramadol-acetaminophen oral tablet QL (20 per 0 days) vicodin es oral tablet vicodin hp oral tablet vicodin oral tablet 5-00 xylon 10 oral tablet Nonsteroidal Anti-Inflammatory Drugs celecoxib oral capsule 100, 200, 00, QL (60 per 0 days) 50 diclofenac sodium topical gel % PA diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic mcg, mcg diflunisal oral tablet 500 etodolac oral capsule 200, 00 etodolac oral tablet 00, 500 etodolac oral tablet extended release 2 hr 00, 500, 600 flurbiprofen oral tablet 100, 50 2 ibu oral tablet 00, 600, ibuprofen oral suspension 100 /5 ml 1 ibuprofen oral tablet 00, 600, indomethacin oral capsule 25, 50 indomethacin oral capsule, extended release 75 ketorolac injection solution 15 /ml QL (20 per 5 days) ketorolac injection solution 0 /ml (1 ml) ketorolac oral tablet 10 QL (120 per 0 days) meloxicam oral tablet 15 1 QL (0 per 0 days) meloxicam oral tablet QL (60 per 0 days) nabumetone oral tablet 500, sulindac oral tablet 150, Opioid Analgesics, Long-Acting ARYMO ER ORAL TABLET,ORAL ONLY,EXTND RELEASE 15 MG, 0 MG, 60 MG buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour, 7.5 mcg/hour

14 DURAMORPH (PF) INJECTION SOLUTION 0.5 MG/ML, 1 MG/ML fentanyl transdermal patch 72 hour 100 mcg/hr, QL (20 per 0 days) 12 mcg/hr, 7.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr fentanyl transdermal patch 72 hour 25 mcg/hr QL (15 per 0 days) hydromorphone (pf) injection solution 10 /ml hydromorphone oral tablet extended release 2 hr 12, 16, 2, 8 levorphanol tartrate oral tablet 2 QL (180 per 0 days) methadone injection solution 10 /ml QL (00 per 0 days) methadone oral solution 10 /5 ml QL (50 per 0 days) methadone oral solution 5 /5 ml QL (900 per 0 days) methadone oral tablet 10, 5 QL (180 per 0 days) morphine concentrate oral solution 100 /5 ml (20 /ml) morphine oral solution 10 /5 ml, 20 /5 ml ( /ml) MORPHINE ORAL TABLET 15 MG, 0 MG QL (180 per 0 days) morphine oral tablet extended release 100, 15 QL (120 per 0 days), 0, 60 morphine oral tablet extended release 200 QL (180 per 0 days) NUCYNTA ER ORAL TABLET EXTENDED QL (60 per 0 days) RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG OPANA ER ORAL TABLET,ORAL QL (60 per 0 days) ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 0 MG, 0 MG, 5 MG, 7.5 MG oxycodone oral tablet,oral only,ext.rel.12 hr 10 QL (90 per 0 days), 15, 20, 0, 0, 60 oxycodone oral tablet,oral only,ext.rel.12 hr 80 QL (120 per 0 days) OXYCONTIN ORAL TABLET,ORAL QL (90 per 0 days) ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 0 MG, 0 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (120 per 0 days) ONLY,EXT.REL.12 HR 80 MG tramadol hcl er 00 tablet 00 QL (0 per 0 days) tramadol oral tablet extended release 2 hr 100 QL (90 per 0 days) tramadol oral tablet extended release 2 hr 200 QL (60 per 0 days) 5

15 tramadol oral tablet, er multiphase 2 hr 00 QL (0 per 0 days) Opioid Analgesics, Short-Acting butorphanol tartrate injection solution 1 /ml QL (960 per 0 days) butorphanol tartrate injection solution 2 /ml QL (80 per 0 days) butorphanol tartrate nasal spray,non-aerosol 10 QL (5 per 28 days) /ml codeine sulfate oral tablet 15, 0, 60 fentanyl citrate buccal lozenge on a handle 1,200 5 PA; NDS; QL (120 per 0 days) mcg, 1,600 mcg, 200 mcg, 00 mcg, 600 mcg, 800 mcg hydromorphone oral liquid 1 /ml hydromorphone oral tablet 2,, 8 meperidine oral solution 50 /5 ml QL (900 per 0 days) meperidine oral tablet 100 meperidine oral tablet 50 QL (180 per 0 days) morphine 2 /ml carpuject outer, l/f, p/f, sdv 2 /ml morphine /ml carpuject outer,l/f,p/f, sdv /ml morphine 8 /ml carpuject sdv, l/f, outer 8 /ml morphine injection syringe 5 /ml morphine intravenous syringe 10 /ml, 2 /ml, /ml, 8 /ml morphine sulfate 10 /ml vial 10 /ml NUCYNTA ORAL TABLET 100 MG, 50 MG, QL (180 per 0 days) 75 MG oxycodone oral concentrate 20 /ml QL (60 per 0 days) oxycodone oral solution 5 /5 ml QL (7200 per 0 days) oxycodone oral tablet 10, 15, 20, 0 QL (60 per 0 days), 5 oxymorphone oral tablet 10, 5 tramadol oral tablet 50 QL (20 per 0 days) Anesthetics Local Anesthetics lidocaine (pf) injection solution 5 /ml (0.5 %) 2 lidocaine (pf) injection syringe 0 /2 ml (2%) 2 lidocaine hcl injection solution 10 /ml (1 %), 2 20 /ml (2 %), 5 /ml (0.5 %) lidocaine hcl injection syringe 10 /ml (1 %) 2 lidocaine hcl mucous membrane jelly 2 % 6

16 lidocaine hcl mucous membrane solution % (0 /ml) lidocaine hcl(pf) in 0.9% nacl injection syringe 100 /10 ml (1 %) lidocaine topical adhesive patch,medicated 5 % PA NSO; QL (90 per 0 days) lidocaine topical ointment 5 % lidocaine viscous mucous membrane solution 2 % 2 lidocaine-prilocaine topical cream % Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/Anti-Craving acamprosate oral tablet,delayed release (dr/ec) disulfiram oral tablet 250, 500 Opioid Dependence Treatments buprenorphine hcl injection syringe 0. /ml buprenorphine hcl sublingual tablet 2, 8 QL (90 per 0 days) buprenorphine-naloxone sublingual tablet 2-0.5, 8-2 naltrexone oral tablet 50 2 SUBOXONE SUBLINGUAL FILM 12- MG QL (60 per 0 days) SUBOXONE SUBLINGUAL FILM MG, QL (90 per 0 days) -1 MG, 8-2 MG Opioid Reversal Agents naloxone injection solution 0. /ml 2 naloxone injection syringe 1 /ml 2 NARCAN NASAL SPRAY,NON-AEROSOL MG/ACTUATION Smoking Cessation Agents bupropion hcl (smoking deter) oral tablet 2 QL (60 per 0 days) extended release 12 hr 150 CHANTIX CONTINUING MONTH BOX QL (60 per 0 days) ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 MG QL (60 per 0 days) CHANTIX STARTING MONTH BOX ORAL QL (60 per 0 days) TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (2) NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 10 MG/ML Antibacterials 7 2 2

17 Aminoglycosides amikacin injection solution 1,000 / ml, 500 HI /2 ml BETHKIS INHALATION SOLUTION FOR 5 PA; LA; NDS; QL (22 per 28 days) NEBULIZATION 00 MG/ ML gentak ophthalmic (eye) ointment 0. % ( 2 /gram) gentamicin 80 /2 ml vial 25's,mdv,latex-free 0 /ml gentamicin in nacl (iso-osm) intravenous HI piggyback 100 /100 ml, 80 /50 ml gentamicin in nacl (iso-osm) intravenous piggyback 60 /50 ml gentamicin in nacl (iso-osm) intravenous 2 HI piggyback 80 /100 ml gentamicin injection solution 0 /ml gentamicin ophthalmic (eye) drops 0. % 2 gentamicin ophthalmic (eye) ointment 0. % ( 2 /gram) gentamicin sulfate (ped) (pf) injection solution 20 /2 ml gentamicin sulfate (pf) intravenous solution 60 2 /6 ml gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % neomycin oral tablet 500 neomycin-polymyxin b gu irrigation solution 0-200,000 unit/ml paromomycin oral capsule 250 streptomycin intramuscular recon soln 1 gram TOBRADEX OPHTHALMIC (EYE) OINTMENT % tobramycin in % nacl inhalation solution 5 PA; NDS for nebulization 00 /5 ml tobramycin ophthalmic (eye) drops 0. % 2 tobramycin sulfate injection solution 10 /ml, 2 HI 0 /ml TOBREX OPHTHALMIC (EYE) OINTMENT 0. % Antibacterials colistin (colistimethate na) injection recon soln 150 HI 8

18 SYNERCID INTRAVENOUS RECON SOLN 5 HI; NDS 500 MG Antibacterials, Other acetic acid irrigation solution 0.25 % acetic acid otic (ear) solution 2 % 2 ALCOHOL PADS TOPICAL PADS, 1 MEDICATED ALCOHOL PREP PADS 1 aztreonam injection recon soln 2 gram HI baciim intramuscular recon soln 50,000 unit bacitracin intramuscular recon soln 50,000 unit 2 bacitracin ophthalmic (eye) ointment 500 unit/gram BACTROBAN NASAL NASAL OINTMENT 2 % chloramphenicol sod succinate intravenous recon HI soln 1 gram clindamycin hcl oral capsule 150, 00, 75 2 clindamycin in 5 % dextrose intravenous HI piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 HI (/ml) (6 ml) clindamycin phosphate injection solution 150 HI /ml clindamycin phosphate intravenous solution 600 HI / ml clindamycin phosphate topical foam 1 % clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % clindamycin phosphate topical swab 1 % 2 clindamycin phosphate vaginal cream 2 % daptomycin intravenous recon soln 500 HI lincomycin injection solution 00 /ml linezolid intravenous parenteral solution PA; HI; NDS /00 ml linezolid oral suspension for reconstitution 100 /5 ml 5 PA; NDS 9

19 linezolid oral tablet PA; NDS linezolid-0.9% nacl 600 / /00 ml 5 PA; HI; NDS mafenide acetate topical packet 50 gram methenamine hippurate oral tablet 1 gram 2 metronidazole in nacl (iso-os) intravenous HI piggyback 500 /100 ml metronidazole oral capsule 75 metronidazole oral tablet 250, metronidazole topical cream 0.75 % metronidazole topical gel 0.75 %, 1 % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % mupirocin calcium topical cream 2 % mupirocin topical ointment 2 % 2 nitrofurantoin macrocrystal oral capsule 100, 50 nitrofurantoin monohyd/m-cryst oral capsule 100 nitrofurantoin oral suspension 25 /5 ml polymyxin b sulfate injection recon soln 500,000 HI unit rosadan topical cream 0.75 % SIVEXTRO INTRAVENOUS RECON SOLN 5 PA; HI; NDS; QL (6 per 28 days) 200 MG SIVEXTRO ORAL TABLET 200 MG 5 PA; NDS; QL (6 per 28 days) SULFAMYLON TOPICAL CREAM 85 MG/G SULFAMYLON TOPICAL PACKET 50 GRAM tinidazole oral tablet 250, 500 trimethoprim oral tablet TRIMPEX ORAL SOLUTION 50 MG/5 ML TYGACIL INTRAVENOUS RECON SOLN 50 5 HI; NDS MG vancomycin intravenous recon soln 1,000, 10 PA BvD; HI gram, 5 gram, 500 vancomycin intravenous recon soln 750 vancomycin oral capsule 125, NDS XIFAXAN ORAL TABLET 200 MG 5 NDS; QL (9 per 0 days) XIFAXAN ORAL TABLET 550 MG 5 NDS; QL (8 per 28 days) Beta-Lactam, Cephalosporins cefaclor oral capsule 250, 500 cefaclor oral suspension for reconstitution 125 /5 ml, 250 /5 ml, 75 /5 ml 10

20 cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin in 0.9% sod chloride intravenous HI solution 2 gram/100 ml cefazolin injection recon soln 1 gram, 10 gram, HI 500 cefdinir oral capsule 00 2 cefdinir oral suspension for reconstitution 125 /5 ml, 250 /5 ml CEFEPIME 1 GM INJECTION 1 GRAM/50 ML HI CEFEPIME INJECTION RECON SOLN 1 HI GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 HI GRAM/50 ML cefixime oral suspension for reconstitution 100 /5 ml, 200 /5 ml cefotaxime injection recon soln 1 gram, 2 gram 2 HI cefotaxime injection recon soln 10 gram cefotaxime injection recon soln cefotetan injection recon soln 1 gram, 2 gram cefotetan-dextr 1 g duplex bag 1 gram/50 ml cefotetan-dextr 2 g duplex bag 2 gram/50 ml cefoxitin 2 gm piggyback bag 2 gram/50 ml HI cefoxitin intravenous recon soln 1 gram, 10 gram, HI 2 gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 200 cefprozil oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 ceftazidime injection recon soln 1 gram, 2 gram, HI 6 gram ceftriaxone 1 gm piggyback l/g, single use 1 HI gram/50 ml ceftriaxone 2 gm piggyback l/f, single use 2 HI gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, HI 2 gram, 250, 500 cefuroxime axetil oral tablet 250,

21 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln 1.5 gram cefuroxime sodium intravenous recon soln 7.5 HI gram cefuroxime-dextrose (iso-osm) intravenous piggyback 1.5 gram/50 ml, 750 /50 ml cephalexin oral capsule 250, cephalexin oral suspension for reconstitution /5 ml, 250 /5 ml SUPRAX ORAL CAPSULE 00 MG TEFLARO INTRAVENOUS RECON SOLN HI 00 MG, 600 MG ZERBAXA INTRAVENOUS RECON SOLN 5 NDS 1.5 GRAM Beta-Lactam, Other aztreonam injection recon soln 1 gram HI imipenem-cilastatin intravenous recon soln 250 HI imipenem-cilastatin intravenous recon soln 500 HI INVANZ INJECTION RECON SOLN 1 GRAM HI meropenem intravenous recon soln 1 gram HI meropenem intravenous recon soln 500 HI Beta-Lactam, Penicillins amoxicillin oral capsule 250, amoxicillin oral suspension for reconstitution /5 ml, 200 /5 ml, 250 /5 ml, 00 /5 ml amoxicillin oral tablet 500, amoxicillin oral tablet,chewable 125, amoxicillin-pot clavulanate oral suspension for 2 reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 250, ampicillin oral suspension for reconstitution /5 ml, 250 /5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 125, 500 HI 12

22 ampicillin sodium injection recon soln 250 HI ampicillin-sulbactam injection recon soln 1.5 HI gram, 15 gram, gram BICILLIN C-R INTRAMUSCULAR SYRINGE 2 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/00K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 250, nafcillin 2 gm vial sterile, latex-free 2 gram HI nafcillin injection recon soln 1 gram, 10 gram HI penicillin g pot in dextrose intravenous piggyback HI 2 million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln 20 HI million unit penicillin v potassium oral recon soln 125 /5 2 ml, 250 /5 ml penicillin v potassium oral tablet 250, pfizerpen-g injection recon soln 20 million unit piperacillin-tazobactam intravenous recon soln HI 2.25 gram,.75 gram,.5 gram piperacillin-tazobactam intravenous recon soln 0.5 gram Macrolides AZASITE OPHTHALMIC (EYE) DROPS 1 % azithromycin intravenous recon soln HI azithromycin oral packet 1 gram azithromycin oral suspension for reconstitution /5 ml, 200 /5 ml azithromycin oral tablet 250, 250 (6 1 pack), 500, 500 ( pack), 600 clarithromycin oral suspension for reconstitution 125 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 clarithromycin oral tablet extended release 2 hr 500 DIFICID ORAL TABLET 200 MG 5 PA; NDS; QL (20 per 10 days) ery pads topical swab 2 % ery-tab oral tablet,delayed release (dr/ec) 250, 500 1

23 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) MG ERYTHROCIN INTRAVENOUS RECON 1 HI SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 /5 ml erythromycin ethylsuccinate oral tablet 00 erythromycin ophthalmic (eye) ointment 5 2 /gram (0.5 %) erythromycin oral tablet 250, 500 erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 % Quinolones AVELOX IN NACL (ISO-OSMOTIC) HI INTRAVENOUS PIGGYBACK 00 MG/250 ML BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % CILOXAN OPHTHALMIC (EYE) OINTMENT 0. % ciprofloxacin hcl ophthalmic (eye) drops 0. % 1 ciprofloxacin hcl oral tablet 100, 250, 500 1, 750 ciprofloxacin lactate intravenous solution HI /20 ml, 00 /0 ml ciprofloxacin oral suspension,microcapsule recon /5 ml, 500 /5 ml gatifloxacin ophthalmic (eye) drops 0.5 % QL (2.5 per 25 days) levofloxacin 750 /0 ml vial suv 25 /ml levofloxacin in d5w intravenous piggyback 500 HI /100 ml levofloxacin in d5w intravenous piggyback 750 /150 ml levofloxacin intravenous solution 25 /ml HI levofloxacin ophthalmic (eye) drops 0.5 % levofloxacin oral solution 250 /10 ml 1 levofloxacin oral tablet 250, 500, MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 % 2 moxifloxacin oral tablet 00 1

24 moxifloxacin-sod.ace,sul-water intravenous 2 HI piggyback 00 /250 ml ofloxacin ophthalmic (eye) drops 0. % 2 ofloxacin oral tablet 200, 00 ofloxacin otic (ear) drops 0. % Sulfonamides bleph-10 ophthalmic (eye) drops 10 % 2 silver sulfadiazine topical cream 1 % 2 ssd topical cream 1 % 2 sulfacetamide sodium (acne) topical suspension 10 % sulfacetamide sodium ophthalmic (eye) drops 10 2 % sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous 1 HI solution /5 ml sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim oral tablet , sulfatrim oral suspension /5 ml Tetracyclines demeclocycline oral tablet 150, 00 doxy-100 intravenous recon soln 100 HI doxycycline hyclate oral capsule 100, 50 doxycycline hyclate oral tablet 100, 20 doxycycline monohydrate oral capsule 100, 1 QL (60 per 0 days) 50 doxycycline monohydrate oral capsule 150, QL (60 per 0 days) 75 doxycycline monohydrate oral tablet 100, 150, 50, 75 minocycline oral capsule 100, 50, 75 2 tetracycline oral capsule 250, 500 Anticonvulsants Anticonvulsants, Other BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 MG/ML 5 NDS; QL (600 per 0 days) BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG 5 NDS; QL (60 per 0 days) 15

25 levetiracetam in nacl (iso-os) intravenous 2 piggyback 1,000 /100 ml, 1,500 /100 ml, 500 /100 ml levetiracetam intravenous solution 500 /5 ml levetiracetam oral solution 100 /ml 2 levetiracetam oral tablet 1,000, 250, 500 2, 750 levetiracetam oral tablet extended release 2 hr 500, 750 POTIGA ORAL TABLET 200 MG, 00 MG, 5 NDS 00 MG, 50 MG ROWEEPRA ORAL TABLET 1,000 MG, MG ROWEEPRA XR ORAL TABLET EXTENDED 2 RELEASE 2 HR 500 MG, 750 MG SPRITAM ORAL TABLET FOR SUSPENSION QL (90 per 0 days) 1,000 MG SPRITAM ORAL TABLET FOR SUSPENSION QL (60 per 0 days) 250 MG SPRITAM ORAL TABLET FOR SUSPENSION QL (180 per 0 days) 500 MG SPRITAM ORAL TABLET FOR SUSPENSION QL (120 per 0 days) 750 MG Calcium Channel Modifying Agents CELONTIN ORAL CAPSULE 00 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5 ml LYRICA ORAL CAPSULE 100 MG, 150 MG, QL (90 per 0 days) 200 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG QL (60 per 0 days) LYRICA ORAL CAPSULE 25 MG LYRICA ORAL SOLUTION 20 MG/ML QL (900 per 0 days) zonisamide oral capsule 100, 25, 50 2 Gamma-Aminobutyric Acid (Gaba) Augmenting Agents DIASTAT ACUDIAL RECTAL KIT MG, MG DIASTAT RECTAL KIT 2.5 MG diazepam rectal kit 2.5, divalproex oral capsule, delayed rel sprinkle

26 divalproex oral tablet extended release 2 hr 250 2, 500 divalproex oral tablet,delayed release (dr/ec) 125 2, 250, 500 gabapentin oral capsule 100, 00, 00 2 QL (270 per 0 days) gabapentin oral solution 250 /5 ml gabapentin oral tablet 600, QL (180 per 0 days) GABITRIL ORAL TABLET 12 MG, 16 MG ONFI ORAL SUSPENSION 2.5 MG/ML QL (80 per 0 days) ONFI ORAL TABLET 10 MG, 20 MG QL (60 per 0 days) phenobarbital oral elixir 20 /5 ml ( /ml) QL (1500 per 0 days) phenobarbital oral tablet 100, 16.2, 2. QL (90 per 0 days), 6.8, 97.2 phenobarbital oral tablet 15, 60 QL (120 per 0 days) phenobarbital oral tablet 0 QL (00 per 0 days) primidone oral tablet 250, 50 2 SABRIL ORAL POWDER IN PACKET 500 MG 5 NDS; QL (180 per 0 days) SABRIL ORAL TABLET 500 MG 5 NDS; QL (180 per 0 days) tiagabine oral tablet 12, 16, 2, valproate sodium intravenous solution 500 /5 ml (100 /ml) valproic acid (as sodium salt) oral solution /5 ml valproic acid oral capsule vigabatrin oral powder in packet NDS Glutamate Reducing Agents felbamate oral suspension 600 /5 ml 5 NDS felbamate oral tablet 00, 600 FYCOMPA ORAL SUSPENSION 0.5 MG/ML QL (680 per 28 days) FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 QL (0 per 0 days) MG, MG, 6 MG, 8 MG lamotrigine oral tablet 100, 150, 200, 2 25 lamotrigine oral tablet extended release 2hr 100, 200, 25, 00, 50 lamotrigine oral tablet, chewable dispersible 25 2, 5 lamotrigine oral tablets,dose pack 25 (5), 25 2 (2) -100 (7), 25 (8) -100 (1) topiramate oral capsule, sprinkle 15, 25 2 topiramate oral capsule,sprinkle,er 2hr 100, 150, 200, 25, 50 17

27 topiramate oral tablet 100, 200, 50 2 QL (120 per 0 days) topiramate oral tablet 25 2 QL (90 per 0 days) Sodium Channel Agents APTIOM ORAL TABLET 200 MG, 00 MG, QL (0 per 0 days) 800 MG APTIOM ORAL TABLET 600 MG QL (60 per 0 days) BANZEL ORAL SUSPENSION 0 MG/ML 5 NDS; QL (2760 per 0 days) BANZEL ORAL TABLET 200 MG 5 NDS; QL (80 per 0 days) BANZEL ORAL TABLET 00 MG 5 NDS; QL (20 per 0 days) carbamazepine oral suspension 100 /5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr 100, 200, 00 carbamazepine oral tablet,chewable 100 DILANTIN EXTENDED ORAL CAPSULE 100 MG DILANTIN INFATABS ORAL TABLET,CHEWABLE 50 MG DILANTIN ORAL CAPSULE 0 MG DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML epitol oral tablet 200 EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG, 200 MG, 00 MG fosphenytoin injection solution 100 pe/2 ml, pe/10 ml oxcarbazepine oral suspension 00 /5 ml (60 /ml) oxcarbazepine oral tablet 150, 00, 600 PEGANONE ORAL TABLET 250 MG PHENYTEK ORAL CAPSULE 200 MG, 00 MG phenytoin oral suspension 125 /5 ml 2 phenytoin oral tablet,chewable 50 2 phenytoin sodium extended oral capsule 100, 2 200, 00 phenytoin sodium intravenous solution 50 /ml TEGRETOL ORAL SUSPENSION 100 MG/5 ML TEGRETOL ORAL TABLET 200 MG 18

28 VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML QL (195 per 0 days) VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG Antidementia Agents Antidementia Agents, Other ergoloid oral tablet 1 Cholinesterase Inhibitors donepezil oral tablet 10 1 QL (60 per 0 days) donepezil oral tablet 2 QL (0 per 0 days) donepezil oral tablet 5 1 QL (0 per 0 days) donepezil oral tablet,disintegrating 10, 5 1 QL (0 per 0 days) galantamine oral capsule,ext rel. pellets 2 hr 16 QL (0 per 0 days), 2, 8 galantamine oral solution /ml QL (200 per 0 days) galantamine oral tablet 12,, 8 QL (60 per 0 days) rivastigmine tartrate oral capsule 1.5, QL (90 per 0 days) rivastigmine tartrate oral capsule.5, 6 QL (60 per 0 days) rivastigmine transdermal patch 2 hour 1. /2 hour,.6 /2 hr, 9.5 /2 hr N-Methyl-D-Aspartate (Nmda) Receptor Antagonist memantine oral capsule,sprinkle,er 2hr 1, 21, 28, 7 QL (0 per 0 days) QL (0 per 0 days) memantine oral solution 2 /ml QL (60 per 0 days) memantine oral tablet 10, 5 1 QL (60 per 0 days) memantine oral tablets,dose pack QL (98 per 0 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 2HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 2HR 1 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL CAP,SPRINKLE,ER 2HR DOSE PACK 7/1/21/28 MG-10 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 2HR 1-10 MG, MG, MG, 7-10 MG Antidepressants Antidepressants amitriptyline-chlordiazepoxide oral tablet , QL (28 per 0 days) QL (0 per 0 days) QL (28 per 28 days) QL (0 per 0 days) 19

29 perphenazine-amitriptyline oral tablet 2-10, 2-25, -10, -25, -50 Antidepressants, Other bupropion hcl oral tablet QL (180 per 0 days) bupropion hcl oral tablet 75 2 bupropion hcl oral tablet extended release 12 hr 2 QL (120 per 0 days) 100 bupropion hcl oral tablet extended release 12 hr 2 QL (90 per 0 days) 150 bupropion hcl oral tablet extended release 12 hr 2 QL (60 per 0 days) 200 bupropion hcl oral tablet extended release 2 hr 2 QL (90 per 0 days) 150 bupropion hcl oral tablet extended release 2 hr 2 QL (60 per 0 days) 00 maprotiline oral tablet 25, 50, 75 mirtazapine oral tablet 15, 0, 5, QL (0 per 0 days) mirtazapine oral tablet,disintegrating 15, 0 QL (0 per 0 days), 5 nefazodone oral tablet 100, 150, 200, 250, 50 trazodone oral tablet 100, 150, 50 1 trazodone oral tablet 00 2 Monoamine Oxidase Inhibitors EMSAM TRANSDERMAL PATCH 2 HOUR 5 NDS; QL (0 per 0 days) 12 MG/2 HR, 6 MG/2 HR, 9 MG/2 HR MARPLAN ORAL TABLET 10 MG phenelzine oral tablet 15 tranylcypromine oral tablet 10 Ssris/ Snris citalopram oral solution 10 /5 ml citalopram oral tablet 10, 0 1 QL (0 per 0 days) citalopram oral tablet 20 1 QL (60 per 0 days) desvenlafaxine succinate oral tablet extended release 2 hr 100, 25, 50 duloxetine oral capsule,delayed release(dr/ec) 20 2 QL (60 per 0 days), 0, 60 duloxetine oral capsule,delayed release(dr/ec) 0 QL (60 per 0 days) escitalopram oxalate oral solution 5 /5 ml QL (600 per 0 days) escitalopram oxalate oral tablet 10 1 QL (5 per 0 days) 20

30 escitalopram oxalate oral tablet 20, 5 1 QL (0 per 0 days) FETZIMA ORAL CAPSULE,EXT REL 2HR QL (28 per 28 days) DOSE PACK 20 MG (2)- 0 MG (26) FETZIMA ORAL CAPSULE,EXTENDED QL (0 per 0 days) RELEASE 2 HR 120 MG, 20 MG, 0 MG, 80 MG fluoxetine oral capsule 10, 0 1 QL (60 per 0 days) fluoxetine oral capsule 20 1 QL (120 per 0 days) fluoxetine oral solution 20 /5 ml ( /ml) 2 fluvoxamine oral capsule,extended release 2hr 100, 150 fluvoxamine oral tablet 100, 25, 50 QL (90 per 0 days) paroxetine hcl oral tablet 10, 20 1 QL (0 per 0 days) paroxetine hcl oral tablet 0, 0 1 QL (60 per 0 days) PAXIL ORAL SUSPENSION 10 MG/5 ML sertraline oral concentrate 20 /ml sertraline oral tablet QL (60 per 0 days) sertraline oral tablet 25, 50 1 QL (00 per 0 days) TRINTELLIX ORAL TABLET 10 MG, 20 MG, QL (0 per 0 days) 5 MG venlafaxine oral capsule,extended release 2hr 2 QL (60 per 0 days) 150 venlafaxine oral capsule,extended release 2hr 2 QL (0 per 0 days) 7.5 venlafaxine oral capsule,extended release 2hr 2 QL (90 per 0 days) 75 venlafaxine oral tablet 100, 25, 7.5, 2 50, 75 VIIBRYD ORAL TABLET 10 MG, 20 MG, 0 QL (0 per 0 days) MG VIIBRYD ORAL TABLETS,DOSE PACK 10 QL (0 per 0 days) MG (7)- 20 MG (2), 10 MG (7)-20 MG (7)-0 MG (16) Tricyclics amitriptyline oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine oral capsule 25, 50, 75 desipramine oral tablet 10, 100, 150, 25, 50,

31 doxepin oral capsule 10, 100, 150, 25, 50, 75 doxepin oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 imipramine pamoate oral capsule 100, 125, 150, 75 nortriptyline oral capsule 10, 25, 50, 1 75 nortriptyline oral solution 10 /5 ml protriptyline oral tablet 10, 5 SILENOR ORAL TABLET MG, 6 MG trimipramine oral capsule 100, 25, 50 Antiemetics Antiemetics, Other compro rectal suppository 25 2 diphenhydramine hcl injection solution 50 /ml hydroxyzine hcl intramuscular solution 25 /ml hydroxyzine hcl oral solution 10 /5 ml hydroxyzine hcl oral tablet 10, 25, 50 meclizine oral tablet 12.5, 25 2 perphenazine oral tablet 16, 2,, 8 phenadoz rectal suppository 12.5 phenadoz rectal suppository 25 prochlorperazine edisylate injection solution 10 /2 ml (5 /ml) prochlorperazine maleate oral tablet 10, 5 1 prochlorperazine rectal suppository 25 promethazine injection solution 25 /ml, 50 /ml promethazine oral syrup 6.25 /5 ml promethazine oral tablet 12.5, 25, 50 promethazine rectal suppository 12.5, 25, 50 promethegan rectal suppository 12.5, 25, 50 scopolamine base transdermal patch day 1 2 over days TRANSDERM-SCOP TRANSDERMAL QL (10 per 0 days) PATCH DAY 1 MG OVER DAYS Emetogenic Therapy Adjuncts AKYNZEO ORAL CAPSULE MG 22

32 ANZEMET ORAL TABLET 100 MG 5 PA BvD; NDS ANZEMET ORAL TABLET 50 MG PA BvD aprepitant oral capsule 125, 0, 80 2 PA BvD aprepitant oral capsule,dose pack 125 (1)- 80 PA BvD (2) CESAMET ORAL CAPSULE 1 MG 5 PA BvD; NDS dronabinol oral capsule 10, 2.5, 5 PA BvD; QL (120 per 0 days) granisetron (pf) intravenous solution 100 mcg/ml granisetron hcl intravenous solution 1 /ml, 1 /ml (1 ml) granisetron hcl oral tablet 1 PA BvD; QL (28 per 28 days) ondansetron hcl (pf) injection solution /2 ml 2 PA BvD; HI ondansetron hcl (pf) injection syringe /2 ml 2 PA BvD; HI ondansetron hcl oral solution /5 ml PA BvD ondansetron hcl oral tablet 2,, 8 2 PA BvD; QL (50 per 0 days) ondansetron oral tablet,disintegrating, 8 2 PA BvD; QL (50 per 0 days) Antifungals Antifungals ABELCET INTRAVENOUS SUSPENSION 5 MG/ML 5 PA BvD; NDS AMBISOME INTRAVENOUS SUSPENSION PA BvD FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 PA BvD CANCIDAS INTRAVENOUS RECON SOLN 5 HI; NDS 50 MG, 70 MG caspofungin intravenous recon soln 50, 70 5 NDS ciclopirox topical cream 0.77 % 2 ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % ciclopirox topical solution 8 % 2 ciclopirox topical suspension 0.77 % clotrimazole mucous membrane troche 10 2 clotrimazole topical cream 1 % 2 clotrimazole topical solution 1 % econazole topical cream 1 % fluconazole in nacl (iso-osm) intravenous HI piggyback 200 /100 ml, 00 /200 ml fluconazole oral suspension for reconstitution 10 2 /ml, 0 /ml fluconazole oral tablet 100, 150, 200,

33 fluconazole-dext 200 /100 ml inner, suv 200 HI /100 ml flucytosine oral capsule 250, NDS griseofulvin microsize oral suspension 125 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 PA; QL (120 per 0 days) ketoconazole oral tablet ketoconazole topical cream 2 % 2 ketoconazole topical shampoo 2 % 2 miconazole- vaginal suppository 200 naftifine topical cream 1 %, 2 % NAFTIN TOPICAL GEL 1 %, 2 % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % NOXAFIL ORAL SUSPENSION 200 MG/5 ML 5 PA; NDS; QL (80 per 28 days) (0 MG/ML) NOXAFIL ORAL TABLET,DELAYED 5 PA; NDS; QL (9 per 0 days) RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram 2 nyata topical powder 100,000 unit/gram 2 nystatin oral powder 500 million unit 2 nystatin oral suspension 100,000 unit/ml 2 nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram 2 nystatin topical ointment 100,000 unit/gram 2 nystatin topical powder 100,000 unit/gram 2 nystop topical powder 100,000 unit/gram 2 SPORANOX ORAL SOLUTION 10 MG/ML 5 PA; NDS terbinafine hcl oral tablet QL (90 per 65 days) terconazole vaginal cream 0. %, 0.8 % 2 terconazole vaginal suppository 80 2 voriconazole intravenous solution 200 voriconazole oral suspension for reconstitution 200 /5 ml (0 /ml) 5 PA; NDS; QL (00 per 0 days) voriconazole oral tablet 200, 50 5 PA; NDS; QL (120 per 0 days) Antigout Agents Antigout Agents allopurinol oral tablet 100,

34 colchicine oral capsule 0.6 colchicine oral tablet 0.6 COLCRYS ORAL TABLET 0.6 MG QL (120 per 0 days) probenecid oral tablet 500 probenecid-colchicine oral tablet ULORIC ORAL TABLET 0 MG, 80 MG QL (0 per 0 days) Anti-Inflammatory Agents Glucocorticoids betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion % betamethasone dipropionate topical ointment % betamethasone valerate topical cream 0.1 % 2 betamethasone valerate topical lotion 0.1 % 2 betamethasone valerate topical ointment 0.1 % 2 betamethasone, augmented topical cream 0.05 % 2 betamethasone, augmented topical gel 0.05 % 2 betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment % BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT % cortisone oral tablet 25 deltasone oral tablet 20 1 DEPO-MEDROL INJECTION SUSPENSION 0 MG/ML, 80 MG/ML dexamethasone oral elixir 0.5 /5 ml 2 dexamethasone oral tablet 0.5, 0.75, 1, 2 1.5, 2,, 6 dexamethasone sodium phosphate injection 2 solution 10 /ml, /ml hydrocortisone oral tablet 20, 5 2 methylprednisolone oral tablet 16, 2, 2, 8 methylprednisolone sodium succ injection recon HI soln 0 methylprednisolone sodium succ intravenous recon soln 1,

35 PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 % prednisolone 15 /5 ml soln a/f, d/f 15 /5 ml 2 ( /ml) prednisolone oral solution 15 /5 ml 2 prednisone oral tablet 1, 2.5, 20, 5, 1 50 prednisone oral tablet 10 1 SOLU-CORTEF (PF) INJECTION RECON SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250 MG/2 ML, 500 MG/ ML SOLU-MEDROL (PF) INJECTION RECON HI SOLN 125 MG/2 ML, 0 MG/ML SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 1,000 MG/8 ML, 500 MG/ ML SOLU-MEDROL INTRAVENOUS RECON SOLN 1,000 MG, 2 GRAM sulfacetamide-prednisolone ophthalmic (eye) 2 drops 10 %-0.2 % (0.25 %) Nonsteroidal Anti-Inflammatory Drugs diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release 2 2 hr 100 diclofenac sodium oral tablet,delayed release 2 (dr/ec) 25, 50, 75 FLECTOR TRANSDERMAL PATCH 12 HOUR PA NSO; QL (60 per 0 days) 1. % ketoprofen oral capsule 50, 75 naproxen oral suspension 125 /5 ml naproxen oral tablet 250, 75, naproxen oral tablet,delayed release (dr/ec) 75 2, 500 naproxen sodium oral tablet 275, 550 naproxen sodium oral tablet, er multiphase 2 hr 75, 500 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 Antimigraine Agents Ergot Alkaloids dihydroergotamine injection solution 1 /ml dihydroergotamine nasal spray,non-aerosol 0.5 /pump act. ( /ml) 26

36 ergotamine-caffeine oral tablet MIGERGOT RECTAL SUPPOSITORY MG Serotonin (5-Ht) 1B/1D Receptor Agonists almotriptan malate oral tablet 12.5, 6.25 QL (12 per 0 days) eletriptan hbr oral tablet 20, 0 QL (12 per 0 days) frovatriptan oral tablet 2.5 QL (12 per 0 days) naratriptan oral tablet 1, 2.5 QL (18 per 0 days) rizatriptan oral tablet 10, 5 QL (18 per 0 days) rizatriptan oral tablet,disintegrating 10, 5 QL (18 per 0 days) sumatriptan nasal spray,non-aerosol 20 QL (12 per 0 days) /actuation sumatriptan nasal spray,non-aerosol 5 QL (6 per 0 days) /actuation sumatriptan succinate oral tablet 100, 25, 2 QL (18 per 0 days) 50 sumatriptan succinate subcutaneous cartridge QL (8 per 0 days) /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous pen injector QL (8 per 0 days) /0.5 ml, 6 /0.5 ml sumatriptan succinate subcutaneous solution 6 QL (8 per 0 days) /0.5 ml sumatriptan succinate subcutaneous syringe 6 QL (8 per 0 days) /0.5 ml zolmitriptan oral tablet 2.5, 5 QL (12 per 0 days) zolmitriptan oral tablet,disintegrating 2.5, 5 QL (12 per 0 days) Antimyasthenic Agents Parasympathomimetics guanidine oral tablet 125 pyridostigmine bromide oral tablet 60 pyridostigmine bromide oral tablet extended release 180 Antimycobacterials Antimycobacterials, Other dapsone oral tablet 100, 25 PRIFTIN ORAL TABLET 150 MG rifabutin oral capsule 150 Antituberculars CAPASTAT INJECTION RECON SOLN 1 GRAM ethambutol oral tablet 100, 00 27

37 isoniazid injection solution 100 /ml 1 isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, 00 1 PASER ORAL GRANULES DR FOR SUSP IN PACKET GRAM pyrazinamide oral tablet 500 rifampin intravenous recon soln 600 rifampin oral capsule 150, 00 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG 5 NDS; QL (68 per 28 days) TRECATOR ORAL TABLET 250 MG Antineoplastics Alkylating Agents CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG PA BvD cyclophosphamide oral tablet 25, 50 PA BvD HEXALEN ORAL CAPSULE 50 MG 5 NDS LEUKERAN ORAL TABLET 2 MG MATULANE ORAL CAPSULE 50 MG 5 LA; NDS VALCHLOR TOPICAL GEL % 5 NDS; QL (60 per 28 days) Antiandrogens bicalutamide oral tablet 50 1 QL (0 per 0 days) ERLEADA ORAL TABLET 60 MG 5 PA NSO; NDS; QL (0 per 0 days) flutamide oral capsule nilutamide oral tablet NDS; QL (60 per 0 days) XTANDI ORAL CAPSULE 0 MG 5 PA NSO; NDS; QL (120 per 0 days) ZYTIGA ORAL TABLET 250 MG 5 PA NSO; NDS; QL (120 per 0 days) ZYTIGA ORAL TABLET 500 MG 5 PA NSO; NDS; QL (2 per 1 day) Antiangiogenic Agents POMALYST ORAL CAPSULE 1 MG, 2 MG, MG, MG 5 PA NSO; LA; NDS; QL (21 per 28 days) REVLIMID ORAL CAPSULE 10 MG, 15 MG, 5 PA NSO; LA; NDS; QL (28 per 28 days) 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, PA NSO; NDS; QL (0 per 0 days) MG, 50 MG THALOMID ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (60 per 0 days) Antiestrogens/Modifiers EMCYT ORAL CAPSULE 10 MG FARESTON ORAL TABLET 60 MG 5 NDS; QL (0 per 0 days) SOLTAMOX ORAL SOLUTION 10 MG/5 ML tamoxifen oral tablet 10,

38 Antimetabolites DROXIA ORAL CAPSULE 200 MG, 00 MG, 00 MG hydroxyurea oral capsule LONSURF ORAL TABLET MG 5 PA NSO; NDS; QL (100 per 0 days) LONSURF ORAL TABLET MG 5 PA NSO; NDS; QL (80 per 0 days) PURIXAN ORAL SUSPENSION 20 MG/ML 5 NDS; QL (00 per 0 days) TABLOID ORAL TABLET 0 MG Antineoplastics adrucil intravenous solution 2.5 gram/50 ml adrucil intravenous solution 500 /10 ml PA BvD ALIMTA INTRAVENOUS RECON SOLN NDS MG, 500 MG AVASTIN INTRAVENOUS SOLUTION 25 5 NDS MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln NDS BELEODAQ INTRAVENOUS RECON SOLN 5 NDS 500 MG BICNU INTRAVENOUS RECON SOLN 100 MG bleomycin injection recon soln 15 unit bleomycin injection recon soln 0 unit PA BvD BORTEZOMIB INTRAVENOUS RECON 5 NDS SOLN.5 MG carboplatin intravenous solution 10 /ml dexrazoxane hcl intravenous recon soln 250, 500 doxorubicin, peg-liposomal intravenous suspension 2 /ml ELITEK INTRAVENOUS RECON SOLN NDS MG epirubicin intravenous solution 200 /100 ml FASLODEX INTRAMUSCULAR SYRINGE 5 NDS; QL (0 per 0 days) 250 MG/5 ML GLEOSTINE ORAL CAPSULE 10 MG, 100 PA NSO MG, 0 MG, 5 MG HERCEPTIN INTRAVENOUS RECON SOLN 5 NDS 150 MG, 0 MG KADCYLA INTRAVENOUS RECON SOLN 5 NDS 100 MG, 160 MG levoleucovorin intravenous solution 10 /ml 5 NDS LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; LA; NDS; QL (8 per 28 days) 29

39 LYNPARZA ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL ( per 1 day) mesna intravenous solution 100 /ml MESNEX INTRAVENOUS SOLUTION 100 MG/ML MESNEX ORAL TABLET 00 MG MUSTARGEN INJECTION RECON SOLN 10 MG NINLARO ORAL CAPSULE 2. MG, MG, 5 PA NSO; NDS; QL ( per 28 days) MG oxaliplatin intravenous recon soln 100 PA NSO paclitaxel intravenous concentrate 6 /ml PERJETA INTRAVENOUS SOLUTION 20 5 PA NSO; NDS MG/1 ML (0 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 5 NDS 22 MILLION UNIT RUBRACA ORAL TABLET 200 MG, 00 MG 5 PA NSO; NDS TREANDA INTRAVENOUS RECON SOLN 5 PA NSO; NDS 100 MG, 25 MG TRISENOX INTRAVENOUS SOLUTION 10 MG/10 ML, 2 MG/ML VELCADE INJECTION RECON SOLN.5 MG 5 NDS VENCLEXTA ORAL TABLET 10 MG PA NSO; QL (28 per 28 days) VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (120 per 0 days) VENCLEXTA ORAL TABLET 50 MG PA NSO; QL (1 per 28 days) VENCLEXTA STARTING PACK ORAL 5 PA NSO; NDS; QL (2 per 28 days) TABLETS,DOSE PACK 10 MG-50 MG- 100 MG VYXEOS INTRAVENOUS RECON SOLN - 5 PA BvD; NDS 100 MG YONDELIS INTRAVENOUS RECON SOLN 1 5 PA NSO; NDS MG ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; NDS Antineoplastics, Other ABRAXANE INTRAVENOUS SUSPENSION 5 NDS FOR RECONSTITUTION 100 MG leucovorin calcium 100 vial sdv,p/f,latex-free leucovorin calcium 200 vial latex-free, p/f, 2 sdv 200 leucovorin calcium injection recon soln leucovorin calcium injection solution 500 /50 ml 2 0

40 leucovorin calcium oral tablet 10, 15, 25, 5 mitoxantrone intravenous concentrate 2 /ml NAVELBINE INTRAVENOUS SOLUTION 10 PA BvD MG/ML, 50 MG/5 ML REVLIMID ORAL CAPSULE 2.5 MG, 20 MG 5 PA NSO; LA; NDS SYLATRON SUBCUTANEOUS KIT 200 MCG, 5 PA NSO; NDS; QL ( per 28 days) 00 MCG, 600 MCG SYNRIBO SUBCUTANEOUS RECON SOLN 5 PA NSO; NDS; QL (28 per 28 days).5 MG YERVOY INTRAVENOUS SOLUTION 50 5 NDS; QL (250 per 21 days) MG/10 ML (5 MG/ML) Aromatase Inhibitors, Rd Generation anastrozole oral tablet 1 1 QL (0 per 0 days) exemestane oral tablet 25 2 QL (60 per 0 days) letrozole oral tablet QL (0 per 0 days) Enzyme Inhibitors ALIQOPA INTRAVENOUS RECON SOLN 60 5 PA BvD; NDS MG ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 /ml FARYDAK ORAL CAPSULE 10 MG, 15 MG, 5 PA NSO; NDS; QL (6 per 21 days) 20 MG HYCAMTIN INTRAVENOUS RECON SOLN 5 NDS MG IBRANCE ORAL CAPSULE 100 MG, 125 MG, 5 PA NSO; NDS; QL (21 per 28 days) 75 MG IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA NSO; NDS; QL (1 per 1 day) KISQALI FEMARA CO-PACK ORAL 5 PA NSO; NDS TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 00 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X )-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 5 PA NSO; NDS MG X 1), 00 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X ) toposar intravenous solution 20 /ml topotecan intravenous recon soln 5 NDS topotecan intravenous solution / ml (1 5 NDS /ml) VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG 5 PA NSO; NDS; QL (56 per 28 days) 1

41 ZOLINZA ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (120 per 0 days) ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (60 per 0 days) Molecular Target Inhibitors AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 5 PA NSO; NDS; QL (0 per 0 days) MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA NSO; NDS; QL (0 per 0 days) ALUNBRIG ORAL TABLET 0 MG 5 PA NSO; NDS ALUNBRIG ORAL TABLETS,DOSE PACK 90 5 PA NSO; NDS; QL (0 per 0 days) MG (7)- 180 MG (2) BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; QL (120 per 0 days) BOSULIF ORAL TABLET 00 MG 5 PA NSO; NDS; QL (1 per 1 day) BOSULIF ORAL TABLET 500 MG 5 PA NSO; NDS; QL (0 per 0 days) CABOMETYX ORAL TABLET 20 MG, 0 5 PA NSO; NDS; QL (0 per 0 days) MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG 5 PA NSO; NDS; QL (2 per 1 day) CAPRELSA ORAL TABLET 100 MG 5 PA NSO; LA; NDS; QL (60 per 0 days) CAPRELSA ORAL TABLET 00 MG 5 PA NSO; LA; NDS; QL (0 per 0 days) COMETRIQ ORAL CAPSULE PA NSO; LA; NDS; QL (56 per 28 days) MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 10 5 PA NSO; LA; NDS; QL (112 per 28 days) MG/DAY(80 MG X1-20 MG X) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 5 PA NSO; LA; NDS; QL (8 per 28 days) MG X /DAY) COTELLIC ORAL TABLET 20 MG 5 PA NSO; LA; NDS; QL (6 per 28 days) ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (28 per 28 days) GILOTRIF ORAL TABLET 20 MG, 0 MG, 0 5 PA NSO; NDS; QL (0 per 0 days) MG ICLUSIG ORAL TABLET 15 MG, 5 MG 5 PA NSO; LA; NDS; QL (0 per 0 days) imatinib oral tablet 100, 00 5 PA NSO; NDS IMBRUVICA ORAL CAPSULE 10 MG 5 PA NSO; NDS; QL (120 per 0 days) IMBRUVICA ORAL CAPSULE 70 MG 5 PA NSO; NDS; QL (0 per 0 days) IMBRUVICA ORAL TABLET 10 MG, PA NSO; NDS; QL (0 per 0 days) MG, 20 MG, 560 MG INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; QL (180 per 0 days) INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 per 0 days) IRESSA ORAL TABLET 250 MG 5 PA NSO; LA; NDS; QL (0 per 0 days) JAKAFI ORAL TABLET 10 MG, 15 MG, 20 5 PA NSO; NDS; QL (60 per 0 days) MG, 25 MG, 5 MG LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY) 5 PA NSO; LA; NDS; QL (0 per 0 days) 2

42 LENVIMA ORAL CAPSULE 1 MG/DAY(10 5 PA NSO; LA; NDS; QL (60 per 0 days) MG X 1- MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY ( MG X 2) LENVIMA ORAL CAPSULE 18 MG/DAY (10 5 PA NSO; LA; NDS; QL (90 per 0 days) MG X 1- MG X2), 2 MG/DAY(10 MG X 2- MG X 1) MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NDS; QL (120 per 0 days) MEKINIST ORAL TABLET 2 MG 5 PA NSO; NDS; QL (0 per 0 days) NERLYNX ORAL TABLET 0 MG 5 PA NSO; NDS; QL (180 per 0 days) NEXAVAR ORAL TABLET 200 MG 5 NDS; QL (120 per 0 days) ODOMZO ORAL CAPSULE 200 MG 5 PA NSO; LA; NDS; QL (0 per 0 days) RYDAPT ORAL CAPSULE 25 MG 5 PA NSO; NDS SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 5 PA NSO; NDS; QL (60 per 0 days) MG, 80 MG SPRYCEL ORAL TABLET 10 MG 5 PA NSO; NDS; QL (0 per 0 days) SPRYCEL ORAL TABLET 20 MG 5 PA NSO; NDS; QL (90 per 0 days) STIVARGA ORAL TABLET 0 MG 5 PA NSO; NDS; QL (8 per 28 days) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 5 PA NSO; NDS; QL (28 per 28 days) 7.5 MG, 50 MG TAFINLAR ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (180 per 0 days) TAFINLAR ORAL CAPSULE 75 MG 5 PA NSO; NDS; QL (120 per 0 days) TAGRISSO ORAL TABLET 0 MG, 80 MG 5 PA NSO; LA; NDS; QL (0 per 0 days) TARCEVA ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (0 per 0 days) TARCEVA ORAL TABLET 25 MG 5 PA NSO; NDS; QL (90 per 0 days) TASIGNA ORAL CAPSULE 150 MG, 200 MG 5 PA NSO; NDS TYKERB ORAL TABLET 250 MG 5 PA NSO; NDS; QL (150 per 0 days) VOTRIENT ORAL TABLET 200 MG 5 PA NSO; NDS; QL (120 per 0 days) XALKORI ORAL CAPSULE 200 MG, 250 MG 5 PA NSO; NDS; QL (60 per 0 days) ZELBORAF ORAL TABLET 20 MG 5 PA NSO; NDS; QL (20 per 0 days) ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (150 per 0 days) Monoclonal Antibody/Antibody-Drug Conjugate BAVENCIO INTRAVENOUS SOLUTION 20 5 PA BvD; NDS MG/ML BESPONSA INTRAVENOUS RECON SOLN 5 PA BvD; NDS 0.9 MG (0.25 MG/ML INITIAL) CYRAMZA INTRAVENOUS SOLUTION 10 5 PA NSO; NDS; QL (200 per 28 days) MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS SOLUTION 20 5 PA NSO; LA; NDS; QL (00 per 0 days) MG/ML EMPLICITI INTRAVENOUS RECON SOLN 00 MG, 00 MG 5 PA NSO; NDS

43 IMFINZI INTRAVENOUS SOLUTION 50 5 PA BvD; NDS MG/ML, 50 MG/ML (10 ML) KEYTRUDA INTRAVENOUS RECON SOLN 5 PA NSO; NDS 50 MG KEYTRUDA INTRAVENOUS SOLUTION 25 5 PA NSO; NDS MG/ML LARTRUVO INTRAVENOUS SOLUTION 10 5 PA NSO; NDS MG/ML, 10 MG/ML (19 ML) MYLOTARG INTRAVENOUS RECON SOLN 5 PA BvD; NDS.5 MG (1 MG/ML INITIAL CONC) OPDIVO INTRAVENOUS SOLUTION NDS; QL (80 per 28 days) MG/10 ML, 20 MG/2 ML, 0 MG/ ML RITUXAN INTRAVENOUS CONCENTRATE 5 NDS 10 MG/ML, 10 MG/ML (10 ML) TECENTRIQ INTRAVENOUS SOLUTION 5 PA NSO; NDS; QL (20 per 21 days) 1,200 MG/20 ML (60 MG/ML) Retinoids bexarotene oral capsule 75 5 PA NSO; NDS; QL (00 per 0 days) PANRETIN TOPICAL GEL 0.1 % 5 NDS TARGRETIN TOPICAL GEL 1 % 5 NDS tretinoin (chemotherapy) oral capsule 10 5 NDS Antiparasitics Anthelmintics ALBENZA ORAL TABLET 200 MG 5 NDS BILTRICIDE ORAL TABLET 600 MG ivermectin oral tablet Antiprotozoals ALINIA ORAL SUSPENSION FOR QL (150 per 0 days) RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG QL (0 per 0 days) atovaquone oral suspension 750 /5 ml 5 NDS atovaquone-proguanil oral tablet , chloroquine phosphate oral tablet 250, 500 COARTEM ORAL TABLET MG QL (2 per 0 days) DARAPRIM ORAL TABLET 25 MG PA hydroxychloroquine oral tablet mefloquine oral tablet 250 MEPRON ORAL SUSPENSION 750 MG/5 ML 5 NDS NEBUPENT INHALATION RECON SOLN 00 MG PA BvD

44 PENTAM INJECTION RECON SOLN 00 MG PRIMAQUINE ORAL TABLET 26. MG quinine sulfate oral capsule 2 PA; QL (2 per 7 days) Pediculicides/Scabicides lindane topical shampoo 1 % malathion topical lotion 0.5 % permethrin topical cream 5 % Antiparkinson Agents Anticholinergics benztropine oral tablet 0.5, 1, 2 trihexyphenidyl oral elixir 0. /ml trihexyphenidyl oral tablet 2, 5 Antiparkinson Agents carbidopa oral tablet 25 carbidopa-levodopa-entacapone oral tablet , , , , , Antiparkinson Agents, Other amantadine hcl oral capsule 100 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 100 entacapone oral tablet 200 QL (00 per 0 days) tolcapone oral tablet 100 Dopamine Agonists APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML 5 NDS; QL (60 per 28 days) bromocriptine oral capsule 5 bromocriptine oral tablet 2.5 NEUPRO TRANSDERMAL PATCH 2 HOUR QL (0 per 0 days) 1 MG/2 HOUR, 2 MG/2 HOUR, MG/2 HOUR, MG/2 HOUR, 6 MG/2 HOUR, 8 MG/2 HOUR pramipexole oral tablet 0.125, 0.25, 0.5 2, 0.75, 1, 1.5 pramipexole oral tablet extended release 2 hr 0.75, 0.75, 1.5, 2.25,,.75,.5 ropinirole oral tablet 0.25, 0.5, 1, 2 2,,, 5 ropinirole oral tablet extended release 2 hr 12, 2,, 6, 8 5

45 Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors carbidopa-levodopa oral tablet , , carbidopa-levodopa oral tablet extended release , carbidopa-levodopa oral tablet,disintegrating , , Monoamine Oxidase B (Mao-B) Inhibitors rasagiline oral tablet 0.5, 1 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 XADAGO ORAL TABLET 100 MG, 50 MG Antipsychotics 1St Generation/Typical chlorpromazine injection solution 25 /ml chlorpromazine oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5 ml fluphenazine hcl oral tablet 1, 10, 2.5, 2 5 haloperidol decanoate intramuscular solution 100 /ml, 100 /ml (1 ml), 50 /ml haloperidol lactate injection solution 5 /ml 2 haloperidol lactate intramuscular syringe 5 2 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2 2, 20, 5 loxapine succinate oral capsule 10, 25, 5 2, 50 molindone oral tablet 10 QL (20 per 0 days) molindone oral tablet 25 QL (270 per 0 days) molindone oral tablet 5 QL (60 per 0 days) pimozide oral tablet 1, 2 thioridazine oral tablet 10, 100, 25, 50 thiothixene oral capsule 1, 10, 2, 5 6

46 trifluoperazine oral tablet 1, 10, 2, 5 2Nd Generation/Atypical ABILIFY MAINTENA INTRAMUSCULAR 5 NDS; QL (1 per 28 days) SUSPENSION,EXTENDED REL RECON 00 MG ABILIFY MAINTENA INTRAMUSCULAR 5 NDS SUSPENSION,EXTENDED REL RECON 00 MG ABILIFY MAINTENA INTRAMUSCULAR 5 NDS; QL (1 per 28 days) SUSPENSION,EXTENDED REL SYRING 00 MG, 00 MG aripiprazole oral solution 1 /ml QL (900 per 0 days) aripiprazole oral tablet 10, 15, 2, 20 QL (0 per 0 days), 0, 5 aripiprazole oral tablet,disintegrating 10, 15 5 NDS; QL (60 per 0 days) ARISTADA INTRAMUSCULAR 5 NDS SUSPENSION,EXTENDED REL SYRING 1,06 MG/.9 ML ARISTADA INTRAMUSCULAR 5 NDS; QL (1.6 per 28 days) SUSPENSION,EXTENDED REL SYRING 1 MG/1.6 ML ARISTADA INTRAMUSCULAR 5 NDS; QL (2. per 28 days) SUSPENSION,EXTENDED REL SYRING 662 MG/2. ML ARISTADA INTRAMUSCULAR 5 NDS; QL (.2 per 28 days) SUSPENSION,EXTENDED REL SYRING 882 MG/.2 ML FANAPT ORAL TABLET 1 MG, 2 MG, MG QL (60 per 0 days) FANAPT ORAL TABLET 10 MG, 12 MG, 6 5 NDS; QL (60 per 0 days) MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK QL (60 per 0 days) 1MG(2)-2MG(2)- MG(2)-6MG(2) GEODON INTRAMUSCULAR RECON SOLN 20 MG/ML (FINAL CONC.) INVEGA SUSTENNA INTRAMUSCULAR 5 NDS; QL (1.5 per 28 days) SYRINGE 117 MG/0.75 ML, 2 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR 5 NDS; QL (1 per 28 days) SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 9 MG/0.25 ML, 78 MG/0.5 ML QL (1.5 per 28 days) 7

47 INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (0.87 per 28 days) SYRINGE 27 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (1.1 per 28 days) SYRINGE 10 MG/1.15 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (1.75 per 28 days) SYRINGE 56 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR 5 NDS; QL (2.62 per 28 days) SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 0 5 NDS; QL (0 per 0 days) MG, 60 MG LATUDA ORAL TABLET 80 MG 5 NDS; QL (60 per 0 days) NUPLAZID ORAL TABLET 17 MG 5 NDS; QL (60 per 0 days) olanzapine intramuscular recon soln 10 olanzapine oral tablet 10, 2.5, 5, 7.5 QL (0 per 0 days) olanzapine oral tablet 15, 20 QL (60 per 0 days) olanzapine oral tablet,disintegrating 10, 5 QL (0 per 0 days) olanzapine oral tablet,disintegrating 15, 20 QL (60 per 0 days) paliperidone oral tablet extended release 2hr 5 NDS; QL (0 per 0 days) 1.5,, 9 paliperidone oral tablet extended release 2hr 6 5 NDS; QL (60 per 0 days) quetiapine oral tablet 100, 200, 25, 2 00, 00, 50 quetiapine oral tablet extended release 2 hr 150 QL (90 per 0 days) quetiapine oral tablet extended release 2 hr 200 QL (0 per 0 days) quetiapine oral tablet extended release 2 hr 00 QL (60 per 0 days), 00 quetiapine oral tablet extended release 2 hr 50 QL (120 per 0 days) REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 5 NDS; QL (0 per 0 days) MG, 2 MG, MG, MG RISPERDAL CONSTA INTRAMUSCULAR QL (2 per 28 days) SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 7.5 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR 5 NDS; QL (2 per 28 days) SYRINGE 50 MG/2 ML risperidone oral solution 1 /ml 2 QL (20 per 0 days) risperidone oral tablet 0.25, 1, 2, 1 QL (60 per 0 days), 8

48 risperidone oral tablet QL (120 per 0 days) risperidone oral tablet,disintegrating 0.25, 1 QL (60 per 0 days), 2,, risperidone oral tablet,disintegrating 0.5 QL (120 per 0 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL 5 NDS; QL (60 per 0 days) TABLET 10 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL QL (60 per 0 days) TABLET 2.5 MG, 5 MG VRAYLAR ORAL CAPSULE 1.5 MG, MG, 5 NDS; QL (0 per 0 days).5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- MG (6) ziprasidone hcl oral capsule 20, 0, 60 2 QL (60 per 0 days), 80 ZYPREXA RELPREVV INTRAMUSCULAR QL ( per 28 days) SUSPENSION FOR RECONSTITUTION 210 MG, 00 MG, 05 MG Treatment-Resistant clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet,disintegrating 100, 12.5, 150, 200, 25 FAZACLO ORAL 5 NDS TABLET,DISINTEGRATING 100 MG, 150 MG, 200 MG FAZACLO ORAL TABLET,DISINTEGRATING 12.5 MG, 25 MG VERSACLOZ ORAL SUSPENSION 50 MG/ML QL (50 per 0 days) Antispasticity Agents Antispasticity Agents baclofen oral tablet 10, 20 1 dantrolene oral capsule 100, 25, 50 tizanidine oral tablet 2, 1 Antivirals Anti-Cytomegalovirus (Cmv) Agents cidofovir intravenous solution 75 /ml ganciclovir sodium intravenous recon soln 500 PA BvD; HI valganciclovir oral recon soln 50 /ml 5 NDS valganciclovir oral tablet 50 5 NDS ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % QL (5 per 0 days) Anti-Hepatitis B (Hbv) Agents 9

49 adefovir oral tablet 10 5 NDS BARACLUDE ORAL SOLUTION 0.05 MG/ML 5 NDS; QL (60 per 0 days) entecavir oral tablet 0.5, 1 5 NDS; QL (0 per 0 days) EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) INTRON A INJECTION RECON SOLN 10 5 PA NSO; NDS MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 6 5 PA NSO; NDS MILLION UNIT/ML ribasphere oral capsule 200 QL (168 per 28 days) ribasphere oral tablet 200 QL (168 per 28 days) VEMLIDY ORAL TABLET 25 MG 5 NDS VIREAD ORAL TABLET 00 MG 5 NDS; QL (0 per 0 days) Anti-Hepatitis C (Hcv) Agents MAVYRET ORAL TABLET MG 5 PA; NDS; QL (8 per 28 days) VOSEVI ORAL TABLET MG 5 PA; NDS; QL (1 per 1 day) Anti-Hepatitis C (Hcv) Agents, Others EPCLUSA ORAL TABLET MG 5 PA; NDS HARVONI ORAL TABLET MG 5 PA; NDS; QL (28 per 28 days) INTRON A INJECTION RECON SOLN 18 5 PA NSO; NDS MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 5 PA NSO; NDS MILLION UNIT/ML PEGASYS CONVENIENCE PACK 5 PA; NDS; QL (2 per 28 days) SUBCUTANEOUS KIT 180 MCG/0.5 ML PEGASYS PROCLICK SUBCUTANEOUS PEN 5 PA; NDS; QL (2 per 28 days) INJECTOR 15 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION PA; NDS; QL ( per 28 days) MCG/ML PEGASYS SUBCUTANEOUS SYRINGE PA; NDS; QL (2 per 28 days) MCG/0.5 ML PEGINTRON REDIPEN SUBCUTANEOUS 5 PA; NDS; QL ( per 28 days) PEN INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT PA; NDS; QL ( per 28 days) MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML ribavirin oral capsule 200 QL (168 per 28 days) ribavirin oral tablet 200 QL (168 per 28 days) 0

50 VIRAZOLE INHALATION RECON SOLN 6 5 NDS GRAM ZEPATIER ORAL TABLET MG 5 PA; NDS Antiherpetic Agents acyclovir 1,000 /20 ml vial 10's,latex-free,sdv PA BvD 50 /ml acyclovir oral capsule acyclovir oral suspension 200 /5 ml acyclovir oral tablet 00, acyclovir sodium intravenous recon soln 500 acyclovir sodium intravenous solution 50 /ml PA BvD; HI acyclovir topical ointment 5 % famciclovir oral tablet 125, 250, 500 QL (90 per 0 days) trifluridine ophthalmic (eye) drops 1 % valacyclovir oral tablet 1 gram, QL (120 per 0 days) Anti-Hiv Agents, Integrase Inhibitors (Insti) GENVOYA ORAL TABLET NDS; QL (0 per 0 days) MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 100 QL (00 per 0 days) MG ISENTRESS ORAL TABLET 00 MG 5 NDS; QL (120 per 0 days) ISENTRESS ORAL TABLET,CHEWABLE 100 QL (180 per 0 days) MG ISENTRESS ORAL TABLET,CHEWABLE 25 QL (720 per 0 days) MG STRIBILD ORAL TABLET NDS; QL (0 per 0 days) MG TIVICAY ORAL TABLET 10 MG QL (60 per 0 days) TIVICAY ORAL TABLET 25 MG, 50 MG 5 NDS; QL (60 per 0 days) Anti-Hiv Agents, Non-Nucleoside Reverse Transcriptase Inhibitors (Nnrti) COMPLERA ORAL TABLET MG 5 NDS; QL (0 per 0 days) EDURANT ORAL TABLET 25 MG 5 NDS; QL (0 per 0 days) efavirenz oral capsule 200, 50 efavirenz oral tablet 600 INTELENCE ORAL TABLET 100 MG 5 NDS; QL (120 per 0 days) INTELENCE ORAL TABLET 200 MG 5 NDS; QL (60 per 0 days) INTELENCE ORAL TABLET 25 MG QL (120 per 0 days) nevirapine oral suspension 50 /5 ml QL (1200 per 0 days) nevirapine oral tablet QL (60 per 0 days) 1

51 nevirapine oral tablet extended release 2 hr 100 QL (120 per 0 days) nevirapine oral tablet extended release 2 hr 00 QL (0 per 0 days) RESCRIPTOR ORAL TABLET 200 MG QL (180 per 0 days) RESCRIPTOR ORAL TABLET, DISPERSIBLE QL (60 per 0 days) 100 MG SUSTIVA ORAL CAPSULE 200 MG 5 NDS; QL (120 per 0 days) SUSTIVA ORAL CAPSULE 50 MG QL (80 per 0 days) SUSTIVA ORAL TABLET 600 MG 5 NDS; QL (0 per 0 days) Anti-Hiv Agents, Nucleoside And Nucleotide Reverse Transcriptase Inhibitors (Nrti) abacavir oral solution 20 /ml abacavir oral tablet 00 QL (60 per 0 days) abacavir-lamivudine oral tablet NDS; QL (0 per 0 days) abacavir-lamivudine-zidovudine oral tablet 00-5 NDS; QL (60 per 0 days) ATRIPLA ORAL TABLET MG 5 NDS; QL (0 per 0 days) BIKTARVY ORAL TABLET MG 5 NDS; QL (0 per 0 days) DESCOVY ORAL TABLET MG 5 NDS; QL (0 per 0 days) didanosine oral capsule,delayed release(dr/ec) QL (90 per 0 days) 125 didanosine oral capsule,delayed release(dr/ec) QL (60 per 0 days) 200 didanosine oral capsule,delayed release(dr/ec) QL (0 per 0 days) 250, 00 EMTRIVA ORAL CAPSULE 200 MG QL (0 per 0 days) EMTRIVA ORAL SOLUTION 10 MG/ML QL (680 per 28 days) EPZICOM ORAL TABLET MG 5 NDS; QL (0 per 0 days) JULUCA ORAL TABLET MG 5 NDS lamivudine oral solution 10 /ml QL (960 per 0 days) lamivudine oral tablet 100, 00 QL (0 per 0 days) lamivudine oral tablet 150 QL (60 per 0 days) lamivudine-zidovudine oral tablet QL (60 per 0 days) ODEFSEY ORAL TABLET MG 5 NDS; QL (0 per 0 days) RETROVIR INTRAVENOUS SOLUTION 10 MG/ML stavudine oral capsule 15, 20 QL (120 per 0 days) stavudine oral capsule 0, 0 QL (60 per 0 days) SYMFI LO ORAL TABLET MG 5 NDS; QL (0 per 0 days) tenofovir disoproxil fumarate oral tablet 00 2

52 TROGARZO INTRAVENOUS SOLUTION NDS MG/1. ML (150 MG/ML) TRUVADA ORAL TABLET MG, 1-5 NDS; QL (0 per 0 days) 200 MG, MG, MG VIDEX 2 GM PEDIATRIC SOLN 10 MG/ML QL (1200 per 0 days) (FINAL) VIDEX GRAM PEDIATRIC ORAL RECON QL (1200 per 0 days) SOLN 10 MG/ML (FINAL) VIREAD ORAL POWDER 0 MG/SCOOP (0 5 NDS; QL (20 per 0 days) MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 5 NDS; QL (0 per 0 days) 250 MG ZERIT ORAL RECON SOLN 1 MG/ML ZIAGEN ORAL SOLUTION 20 MG/ML QL (960 per 0 days) zidovudine oral capsule 100 QL (180 per 0 days) zidovudine oral syrup 10 /ml QL (1680 per 28 days) zidovudine oral tablet 00 2 QL (60 per 0 days) Anti-Hiv Agents, Other FUZEON SUBCUTANEOUS RECON SOLN 90 5 NDS; QL (60 per 0 days) MG SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 150 MG 5 NDS; QL (20 per 0 days) SELZENTRY ORAL TABLET 25 MG SELZENTRY ORAL TABLET 00 MG 5 NDS; QL (120 per 0 days) SELZENTRY ORAL TABLET 75 MG 5 NDS TRIUMEQ ORAL TABLET MG 5 NDS; QL (0 per 0 days) TYBOST ORAL TABLET 150 MG QL (0 per 0 days) Anti-Hiv Agents, Protease Inhibitors APTIVUS ORAL CAPSULE 250 MG 5 NDS; QL (120 per 0 days) APTIVUS ORAL SOLUTION 100 MG/ML 5 NDS; QL (285 per 28 days) atazanavir oral capsule 150, NDS; QL (60 per 0 days) atazanavir oral capsule 00 5 NDS; QL (0 per 0 days) CRIXIVAN ORAL CAPSULE 200 MG QL (50 per 0 days) CRIXIVAN ORAL CAPSULE 00 MG QL (270 per 0 days) EVOTAZ ORAL TABLET MG 5 NDS; QL (0 per 0 days) fosamprenavir oral tablet 700 INVIRASE ORAL CAPSULE 200 MG 5 NDS; QL (00 per 0 days) INVIRASE ORAL TABLET 500 MG 5 NDS; QL (120 per 0 days) KALETRA ORAL SOLUTION MG/5 5 NDS; QL (600 per 0 days) ML KALETRA ORAL TABLET MG QL (00 per 0 days) KALETRA ORAL TABLET MG 5 NDS; QL (150 per 0 days)

53 LEXIVA ORAL SUSPENSION 50 MG/ML QL (1575 per 28 days) LEXIVA ORAL TABLET 700 MG 5 NDS; QL (120 per 0 days) lopinavir-ritonavir oral solution /5 ml NORVIR ORAL CAPSULE 100 MG QL (60 per 0 days) NORVIR ORAL SOLUTION 80 MG/ML QL (80 per 0 days) NORVIR ORAL TABLET 100 MG QL (60 per 0 days) PREZCOBIX ORAL TABLET MG-MG 5 NDS; QL (0 per 0 days) PREZISTA ORAL SUSPENSION 100 MG/ML 5 NDS; QL (60 per 0 days) PREZISTA ORAL TABLET 150 MG QL (20 per 0 days) PREZISTA ORAL TABLET 600 MG 5 NDS; QL (60 per 0 days) PREZISTA ORAL TABLET 75 MG QL (80 per 0 days) PREZISTA ORAL TABLET 800 MG 5 NDS; QL (0 per 0 days) REYATAZ ORAL CAPSULE 150 MG, 200 MG 5 NDS; QL (60 per 0 days) REYATAZ ORAL CAPSULE 00 MG 5 NDS; QL (0 per 0 days) REYATAZ ORAL POWDER IN PACKET 50 5 NDS; QL (20 per 0 days) MG ritonavir oral tablet 100 QL (60 per 0 days) VIRACEPT ORAL TABLET 250 MG 5 NDS; QL (00 per 0 days) VIRACEPT ORAL TABLET 625 MG 5 NDS; QL (120 per 0 days) Anti-Influenza Agents oseltamivir oral capsule 0, 5, 75 2 oseltamivir oral suspension for reconstitution 6 2 /ml RELENZA DISKHALER INHALATION QL (60 per 180 days) BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 TAMIFLU ORAL SUSPENSION FOR QL (720 per 65 days) RECONSTITUTION 6 MG/ML Anxiolytics Anxiolytics, Other buspirone oral tablet 10, 15, 0, 5, meprobamate oral tablet 200, 00 oxazepam oral capsule 10, 15, 0 Benzodiazepines alprazolam oral tablet 0.25, 0.5, 1, 2 2 QL (120 per 0 days) chlordiazepoxide hcl oral capsule 10, 25, 5 clonazepam oral tablet 0.5, 1, 2

54 clonazepam oral tablet,disintegrating 0.125, 0.25, 0.5, 1, 2 clorazepate dipotassium oral tablet 15,.75, 7.5 diazepam intensol oral concentrate 5 /ml QL (20 per 0 days) diazepam oral solution 5 /5 ml (1 /ml) QL (1200 per 0 days) diazepam oral tablet 10 QL (120 per 0 days) diazepam oral tablet 2, 5 QL (90 per 0 days) diazepam rectal kit lorazepam oral concentrate 2 /ml QL (150 per 0 days) lorazepam oral tablet 0.5, 1 2 QL (90 per 0 days) lorazepam oral tablet 2 2 QL (150 per 0 days) Bipolar Agents Mood Stabilizers carbamazepine oral capsule, er multiphase 12 hr 100, 200, 00 lithium carbonate oral capsule 150, 00, lithium carbonate oral tablet 00 2 lithium carbonate oral tablet extended release 2 00, 50 lithium citrate oral solution 8 meq/5 ml 2 Blood Glucose Regulators Antidiabetic Agents acarbose oral tablet 100, 25, 50 2 ADLYXIN SUBCUTANEOUS PEN INJECTOR 10 MCG/0.2 ML- 20 MCG/0.2 ML, 20 MCG/0.2 ML alogliptin oral tablet 12.5, 25, 6.25 alogliptin-metformin oral tablet ,000, alogliptin-pioglitazone oral tablet , , , 25-15, 25-0, 25-5 AVANDIA ORAL TABLET 2 MG, MG QL (60 per 0 days) BYDUREON BCISE SUBCUTANEOUS QL (. per 28 days) AUTO-INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS PEN QL ( per 28 days) INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG QL ( per 28 days) 5

55 BYETTA SUBCUTANEOUS PEN INJECTOR QL (2. per 0 days) 10 MCG/DOSE(250 MCG/ML) 2. ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET ORAL TABLET 0.8 MG QL (180 per 0 days) FARXIGA ORAL TABLET 10 MG, 5 MG QL (0 per 0 days) glimepiride oral tablet 1, 2, 1 glipizide oral tablet 10, 5 1 glipizide oral tablet extended release 2hr 10, 1 2.5, 5 GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG INVOKAMET ORAL TABLET 150-1,000 MG, QL (60 per 0 days) MG, 50-1,000 MG, MG INVOKAMET XR ORAL TABLET, IR - ER, QL (60 per 0 days) BIPHASIC 2HR 150-1,000 MG, MG, 50-1,000 MG INVOKAMET XR ORAL TABLET, IR - ER, QL (120 per 0 days) BIPHASIC 2HR MG INVOKANA ORAL TABLET 100 MG, 00 MG QL (0 per 0 days) JANUVIA ORAL TABLET 100 MG, 25 MG, 50 QL (0 per 0 days) MG JARDIANCE ORAL TABLET 10 MG, 25 MG QL (0 per 0 days) JENTADUETO ORAL TABLET 2.5-1,000 MG, QL (60 per 0 days) MG, MG JENTADUETO XR ORAL TABLET, IR - ER, QL (60 per 0 days) BIPHASIC 2HR 2.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, QL (0 per 0 days) BIPHASIC 2HR 5-1,000 MG metformin oral tablet 1,000, 500, metformin oral tablet extended release 2 hr QL (120 per 0 days) metformin oral tablet extended release 2 hr QL (60 per 0 days) miglitol oral tablet 100, 25, 50 nateglinide oral tablet 120, 60 ONGLYZA ORAL TABLET 2.5 MG, 5 MG QL (0 per 0 days) OZEMPIC SUBCUTANEOUS PEN INJECTOR PA; QL ( per 28 days) 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 MG/0.75 ML (2 MG/1.5 ML) pioglitazone oral tablet 15, 0, 5 1 QL (0 per 0 days) QTERN ORAL TABLET 10-5 MG repaglinide oral tablet 0.5, 1, 2 6

56 SOLIQUA 100/ SUBCUTANEOUS INSULIN QL (18 per 0 days) PEN 100 UNIT- MCG/ML SYMLINPEN 120 SUBCUTANEOUS PEN QL (10.8 per 0 days) INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN QL (10.5 per 0 days) INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET ,000 MG, QL (60 per 0 days) MG, 5-1,000 MG, MG TANZEUM SUBCUTANEOUS PEN PA INJECTOR 0 MG/0.5 ML, 50 MG/0.5 ML TRADJENTA ORAL TABLET 5 MG QL (0 per 0 days) TRULICITY SUBCUTANEOUS PEN PA; QL (2 per 28 days) INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA SUBCUTANEOUS PEN INJECTOR QL (9 per 0 days) 0.6 MG/0.1 ML (18 MG/ ML) XIGDUO XR ORAL TABLET, IR - ER, QL (0 per 0 days) BIPHASIC 2HR 10-1,000 MG, MG, 5-1,000 MG XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 2HR 2.5-1,000 MG, MG XULTOPHY 100/.6 SUBCUTANEOUS QL (15 per 0 days) INSULIN PEN 100 UNIT-.6 MG /ML ( ML) Blood Glucose Regulators glipizide-metformin oral tablet , , JANUMET ORAL TABLET 50-1,000 MG, 50- QL (60 per 0 days) 500 MG JANUMET XR ORAL TABLET, ER QL (0 per 0 days) MULTIPHASE 2 HR 100-1,000 MG JANUMET XR ORAL TABLET, ER QL (60 per 0 days) MULTIPHASE 2 HR 50-1,000 MG, MG KOMBIGLYZE XR ORAL TABLET, ER QL (60 per 0 days) MULTIPHASE 2 HR 2.5-1,000 MG KOMBIGLYZE XR ORAL TABLET, ER QL (0 per 0 days) MULTIPHASE 2 HR 5-1,000 MG, MG pioglitazone-glimepiride oral tablet 0-2, 0- QL (0 per 0 days) pioglitazone-metformin oral tablet , QL (90 per 0 days) Glycemic Agents GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG 7

57 GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG KORLYM ORAL TABLET 00 MG 5 NDS; QL (120 per 0 days) PROGLYCEM ORAL SUSPENSION 50 MG/ML Insulins ASSURE ID INSULIN SAFETY SYRINGE 1 1 ML 29 GAUGE X 1/2" BD INSULIN SYR 0. ML 6MMX1G 0. ML 1 1 GAUGE X 15/6" BD INSULIN SYR 0.5 ML 6MMX1G 1/2 ML 1 1 GAUGE X 15/6" BD INSULIN SYR 1 ML 6MMX1G 1 ML 1 1 GAUGE X 15/6" BD UF NANO PEN NEEDLE MMX2G 2 1 GAUGE X 5/2" FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML GAUZE PAD TOPICAL BANDAGE 2 X 2 " 1 HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML ( ML) HUMALOG MIX INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML 8

58 HUMULIN 70/0 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-0) HUMULIN 70/0 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML ( ML) INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0. ML 29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/0 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-0) NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML 1 9

59 NOVOLOG MIX 70-0 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-0) NOVOLOG MIX 70-0FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML PEN NEEDLE, DIABETIC NEEDLE 29 1 GAUGE X 1/2" STERILE PADS 2" X 2" 2 X 2 " 1 TOUJEO SOLOSTAR U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) TRESIBA FLEXTOUCH U-100 QL (0 per 0 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML ( ML) QL (27 per 0 days) VGO 0 DISPOSABLE DEVICE 1 Blood Products/ Modifiers/ Volume Expanders Anticoagulants COUMADIN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, MG, MG, 5 MG, 6 MG, 7.5 MG ELIQUIS ORAL TABLET 2.5 MG QL (60 per 0 days) ELIQUIS ORAL TABLET 5 MG QL (7 per 0 days) ELIQUIS ORAL TABLETS,DOSE PACK 5 MG QL (7 per 0 days) (7 TABS) enoxaparin subcutaneous solution 00 / ml QL (8 per 28 days) enoxaparin subcutaneous syringe 100 /ml, 150 QL (56 per 28 days) /ml enoxaparin subcutaneous syringe 120 /0.8 ml, 80 /0.8 ml enoxaparin subcutaneous syringe 0 /0. ml, QL (.6 per 28 days) 60 /0.6 ml enoxaparin subcutaneous syringe 0 /0. ml QL (22. per 28 days) 50

60 fondaparinux subcutaneous syringe 10 /0.8 ml 5 NDS; QL (2 per 0 days) fondaparinux subcutaneous syringe 2.5 /0.5 ml QL (15 per 0 days) fondaparinux subcutaneous syringe 5 /0. ml 5 NDS; QL (12 per 0 days) fondaparinux subcutaneous syringe 7.5 /0.6 ml 5 NDS; QL (18 per 0 days) heparin (porcine) in 5 % dex intravenous 1 parenteral solution 20,000 unit/500 ml (0 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml heparin (porcine) injection solution 1,000 unit/ml heparin (porcine) injection solution 10,000 HI unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin 25,000 unit/250 ml (100 unit/ml)-0.5% 1 nacl bag l/f,inner,single-use 25,000 unit/250 ml heparin sodium 10,000 units/ml vial 25's,mdv, latex-free 10,000 unit/ml HEPARIN(PORCINE) IN 0.5% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin-0.5% nacl 25,000 units/500 ml (50 1 units/ml) bag l/f,outer,single-use 25,000 unit/500 ml jantoven oral tablet 1, 10, 2, 2.5, 1,, 5, 6, 7.5 PRADAXA ORAL CAPSULE 110 MG, 150 QL (60 per 0 days) MG, 75 MG warfarin oral tablet 1, 10, 2, 2.5, 1,, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 20 MG QL (0 per 0 days) XARELTO ORAL TABLET 15 MG QL (60 per 0 days) XARELTO ORAL TABLETS,DOSE PACK 15 QL (51 per 0 days) MG (2)- 20 MG (9) Blood Formation Modifiers anagrelide oral capsule 0.5, 1 ARANESP (IN POLYSORBATE) INJECTION 5 NDS SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 00 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 0 MCG/ML 51

61 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0. ML, 25 MCG/0.2 ML, 0 MCG/0. ML ARANESP (IN POLYSORBATE) INJECTION 5 NDS SYRINGE 100 MCG/0.5 ML, 150 MCG/0. ML, 200 MCG/0. ML, 00 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0. ML GRANIX SUBCUTANEOUS SYRINGE 00 5 PA; NDS MCG/0.5 ML, 80 MCG/0.8 ML LEUKINE INJECTION RECON SOLN PA; NDS MCG MOZOBIL SUBCUTANEOUS SOLUTION 2 5 NDS; QL (9.6 per 0 days) MG/1.2 ML (20 MG/ML) NEULASTA SUBCUTANEOUS SYRINGE 6 5 PA; NDS; QL (1.2 per 28 days) MG/0.6ML NEUPOGEN INJECTION SOLUTION 00 5 PA; NDS MCG/ML, 80 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 00 5 PA; NDS MCG/0.5 ML, 80 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 QL (1 per 0 days) UNIT/ML, 2,000 UNIT/ML,,000 UNIT/ML,,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 5 NDS UNIT/2 ML PROCRIT INJECTION SOLUTION 20,000 5 NDS; QL (1 per 0 days) UNIT/ML, 0,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 75 MG 5 PA; NDS; QL (60 per 0 days) PROMACTA ORAL TABLET 25 MG 5 PA; NDS; QL (0 per 0 days) PROMACTA ORAL TABLET 50 MG 5 PA; NDS; QL (90 per 0 days) ZARXIO INJECTION SYRINGE 00 MCG/0.5 5 PA; NDS; QL (7 per 0 days) ML ZARXIO INJECTION SYRINGE 80 MCG/0.8 5 PA; NDS; QL (11.2 per 0 days) ML Hemostasis Agents tranexamic acid intravenous solution 1,000 /10 ml (100 /ml) tranexamic acid oral tablet 650 QL (0 per 5 days) Platelet Modifying Agents aspirin-dipyridamole oral capsule, er multiphase 12 hr BRILINTA ORAL TABLET 60 MG, 90 MG QL (60 per 0 days) cilostazol oral tablet 100, 50 2 clopidogrel oral tablet

62 clopidogrel oral tablet 75 1 QL (0 per 0 days) dipyridamole oral tablet 25, 50, 75 prasugrel oral tablet 10, 5 ZONTIVITY ORAL TABLET 2.08 MG Cardiovascular Agents Alpha-Adrenergic Agonists clonidine hcl oral tablet 0.1, 0.2, 0. 2 clonidine transdermal patch weekly 0.1 /2 hr, QL ( per 28 days) 0.2 /2 hr, 0. /2 hr clorpres oral tablet , , guanfacine oral tablet 1, 2 2 methyldopa oral tablet 250, 500 midodrine oral tablet 10, 2.5, 5 NORTHERA ORAL CAPSULE 100 MG, NDS; QL (90 per 0 days) MG NORTHERA ORAL CAPSULE 00 MG 5 NDS; QL (180 per 0 days) Alpha-Adrenergic Blocking Agents doxazosin oral tablet 1, 2,, 8 2 phenoxybenzamine oral capsule 10 5 NDS prazosin oral capsule 1, 2, 5 2 terazosin oral capsule 1, 10, 2, 5 1 Angiotensin Ii Receptor Antagonists candesartan oral tablet 16,, 8 QL (60 per 0 days) candesartan oral tablet 2 QL (0 per 0 days) ENTRESTO ORAL TABLET 2-26 MG, 9-51 QL (60 per 0 days) MG, MG eprosartan oral tablet irbesartan oral tablet 150, 00, 75 1 QL (0 per 0 days) losartan oral tablet 100, 25, 50 1 QL (60 per 0 days) olmesartan oral tablet 20, 0, 5 QL (0 per 0 days) olmesartan-hydrochlorothiazide oral tablet 20- QL (0 per 0 days) 12.5, , 0-25 telmisartan oral tablet 20, 0 2 QL (0 per 0 days) telmisartan oral tablet 80 2 QL (60 per 0 days) valsartan oral tablet 160, 20, 0, 80 1 QL (60 per 0 days) Angiotensin-Converting Enzyme (Ace) Inhibitors benazepril oral tablet 10, 20, 0, 5 1 5

63 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20 1, 5 fosinopril oral tablet 10, 20, 0 1 lisinopril oral tablet 10, 2.5, 20, 0 1, 0, 5 moexipril oral tablet 15, perindopril erbumine oral tablet 2,, 8 2 quinapril oral tablet 10, 20, 0, 5 1 ramipril oral capsule 1.25, 10, 2.5, 5 1 trandolapril oral tablet 1, 2, 1 Antiarrhythmics amiodarone oral tablet 100, 00 amiodarone oral tablet disopyramide phosphate oral capsule 100, 150 dofetilide oral capsule 125 mcg 2 QL (20 per 0 days) dofetilide oral capsule 250 mcg 2 QL (120 per 0 days) dofetilide oral capsule 500 mcg 2 QL (60 per 0 days) flecainide oral tablet 100, 150, 50 mexiletine oral capsule 150, 200, 250 MULTAQ ORAL TABLET 00 MG QL (60 per 0 days) pacerone oral tablet 100, 00 pacerone oral tablet propafenone oral capsule,extended release 12 hr 225, 25, 25 propafenone oral tablet 150, 225, 00 quinidine gluconate oral tablet extended release 2 quinidine sulfate oral tablet 200, 00 2 sorine oral tablet 120, 160, 20, 80 2 sotalol 120 tablet sotalol af oral tablet sotalol oral tablet 160, 20, 80 2 Beta-Adrenergic Blocking Agents acebutolol oral capsule 200, 00 2 atenolol oral tablet 100, 25, 50 1 betaxolol oral tablet 10, 20 2 bisoprolol fumarate oral tablet 10, 5 2 5

64 BYSTOLIC ORAL TABLET 10 MG QL (120 per 0 days) BYSTOLIC ORAL TABLET 2.5 MG, 5 MG QL (0 per 0 days) BYSTOLIC ORAL TABLET 20 MG QL (60 per 0 days) carvedilol oral tablet 12.5, 25,.125, carvedilol phosphate oral capsule, er multiphase QL (0 per 0 days) 2 hr 10, 20, 0, 80 COREG CR ORAL CAPSULE, ER QL (0 per 0 days) MULTIPHASE 2 HR 10 MG, 20 MG, 0 MG, 80 MG labetalol oral tablet 100, 200, 00 2 metoprolol succinate oral tablet extended release 1 QL (60 per 0 days) 2 hr 100, 200, 25, 50 metoprolol tartrate oral tablet 100, 25, 50 1 nadolol oral tablet 20, 0, 80 pindolol oral tablet 10, 5 propranolol oral capsule,extended release 2 hr 2 120, 160, 60, 80 propranolol oral solution 20 /5 ml ( /ml), 2 0 /5 ml (8 /ml) propranolol oral tablet 10, 20, 0, 60 2, 80 timolol maleate oral tablet 10, 20, 5 Calcium Channel Blocking Agents afeditab cr oral tablet extended release 0, 60 2 QL (60 per 0 days) amlodipine oral tablet 10, 2.5, 5 1 cartia xt oral capsule,extended release 2hr QL (60 per 0 days), 180, 20 cartia xt oral capsule,extended release 2hr 00 2 QL (0 per 0 days) diltiazem hcl intravenous recon soln 100 diltiazem hcl intravenous solution 5 /ml 2 diltiazem hcl oral capsule,extended release 12 hr 2 120, 60, 90 diltiazem hcl oral capsule,extended release 2 hr 2 QL (0 per 0 days) 60 diltiazem hcl oral capsule,extended release 2 hr 2 20 diltiazem hcl oral capsule,extended release 2hr 120, 180, 20 2 QL (60 per 0 days) 55

65 diltiazem hcl oral capsule,extended release 2hr 2 00 diltiazem hcl oral tablet 120, 0, 60, 2 90 diltiazem hcl oral tablet extended release 2 hr 2 QL (0 per 0 days) 20, 60, 20 dilt-xr oral capsule,ext.rel 2h degradable QL (60 per 0 days), 180, 20 felodipine oral tablet extended release 2 hr 10 2 QL (0 per 0 days), 2.5, 5 matzim la oral tablet extended release 2 hr 20 2 QL (0 per 0 days), 60, 20 nicardipine oral capsule 20, 0 nifedical xl oral tablet extended release 2hr 0 QL (60 per 0 days), 60 nifedipine oral tablet extended release 2hr 0 2 QL (60 per 0 days), 60, 90 nifedipine oral tablet extended release 0, 60 2 QL (60 per 0 days), 90 nimodipine oral capsule 0 nisoldipine oral tablet extended release 2 hr 17 QL (0 per 0 days), 20,, 0, 8.5 nisoldipine oral tablet extended release 2 hr QL (60 per 0 days) 25.5, 0 taztia xt oral capsule,extended release 2 hr QL (60 per 0 days), 180, 20 taztia xt oral capsule,extended release 2 hr 00 2 QL (0 per 0 days), 60 verapamil intravenous solution 2.5 /ml 2 verapamil oral capsule, 2 hr er pellet ct 100, QL (0 per 0 days) 00 verapamil oral capsule, 2 hr er pellet ct 200 QL (60 per 0 days) verapamil oral capsule,ext rel. pellets 2 hr 120 QL (60 per 0 days), 180, 20, 60 verapamil oral tablet 120, 0, 80 1 verapamil oral tablet extended release 120, 2 180, 20 Cardiovascular Agents amiloride-hydrochlorothiazide oral tablet amlodipine-atorvastatin oral tablet 10-10, 10- QL (0 per 0 days) 20, 10-0, 10-80, , 2.5-0, 5-10, 5-20,

66 amlodipine-atorvastatin oral tablet , 5-80 amlodipine-benazepril oral capsule 10-20, 2 QL (60 per 0 days) amlodipine-benazepril oral capsule QL (0 per 0 days) amlodipine-benazepril oral capsule 5-10, , 5-0 amlodipine-olmesartan oral tablet 10-20, 10- QL (0 per 0 days) 0, 5-20, 5-0 amlodipine-valsartan oral tablet , 10-2 QL (0 per 0 days) 20, amlodipine-valsartan oral tablet QL (60 per 0 days) atenolol-chlorthalidone oral tablet , benazepril-hydrochlorothiazide oral tablet , , 20-25, bisoprolol-hydrochlorothiazide oral tablet , , candesartan-hydrochlorothiazid oral tablet 16- QL (0 per 0 days) 12.5, , 2-25 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, DEMSER ORAL CAPSULE 250 MG 5 NDS enalapril-hydrochlorothiazide oral tablet , ezetimibe-simvastatin oral tablet 10-10, , 10-0, fosinopril-hydrochlorothiazide oral tablet , irbesartan-hydrochlorothiazide oral tablet QL (0 per 0 days) 12.5, lisinopril-hydrochlorothiazide oral tablet , , losartan-hydrochlorothiazide oral tablet QL (60 per 0 days), , methyldopa-hydrochlorothiazide oral tablet , metoprolol ta-hydrochlorothiaz oral tablet , , moexipril-hydrochlorothiazide oral tablet , 15-25, nadolol-bendroflumethiazide oral tablet 0-5,

67 olmesartan-amlodipin-hcthiazid oral tablet QL (0 per 0 days) 12.5, , , , propranolol-hydrochlorothiazid oral tablet 0-25, quinapril-hydrochlorothiazide oral tablet , , spironolacton-hydrochlorothiaz oral tablet telmisartan-hydrochlorothiazid oral tablet 0- QL (0 per 0 days) 12.5, telmisartan-hydrochlorothiazid oral tablet 80- QL (60 per 0 days) 12.5 triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet , valsartan-hydrochlorothiazide oral tablet QL (0 per 0 days) 12.5, , , 20-25, Cardiovascular Agents, Other CORLANOR ORAL TABLET 5 MG, 7.5 MG QL (60 per 0 days) digitek oral tablet 125 mcg 2 QL (0 per 0 days) digitek oral tablet 250 mcg 2 digox oral tablet 125 mcg 2 QL (0 per 0 days) digox oral tablet 250 mcg 2 digoxin 0.25 /ml syringe 250 mcg/ml digoxin injection solution 250 mcg/ml DIGOXIN ORAL SOLUTION 50 MCG/ML 2 digoxin oral tablet 125 mcg 2 QL (0 per 0 days) digoxin oral tablet 250 mcg 2 LANOXIN INJECTION SOLUTION 250 MCG/ML LANOXIN ORAL TABLET MCG, 62.5 QL (0 per 0 days) MCG pentoxifylline oral tablet extended release 00 2 RANEXA ORAL TABLET EXTENDED QL (120 per 0 days) RELEASE 12 HR 1,000 MG, 500 MG UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,00 MCG, 1,600 MCG, 800 MCG 5 PA; NDS; QL (60 per 0 days) 58

68 UPTRAVI ORAL TABLET 200 MCG, 00 5 PA; NDS MCG, 600 MCG UPTRAVI ORAL TABLETS,DOSE PACK PA; NDS MCG (10)- 800 MCG (60) Diuretics, Carbonic Anhydrase Inhibitors acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 125, 250 methazolamide oral tablet 25, 50 Diuretics, Loop bumetanide injection solution 0.25 /ml 2 HI bumetanide oral tablet 0.5, 1, 2 2 ethacrynic acid oral tablet 25 furosemide injection solution 10 /ml 1 HI furosemide injection syringe 10 /ml 1 HI furosemide oral solution 10 /ml, 0 /5 ml (8 1 /ml) furosemide oral tablet 20, 0, 80 1 torsemide oral tablet 10, 100, 20, 5 2 Diuretics, Potassium-Sparing amiloride oral tablet 5 eplerenone oral tablet 25, 50 spironolactone oral tablet 100, 25, 50 2 Diuretics, Thiazide chlorothiazide oral tablet 250, chlorothiazide sodium intravenous recon soln HI chlorthalidone oral tablet 25, 50 1 DIURIL ORAL SUSPENSION 250 MG/5 ML hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet 12.5, 25, 1 50 indapamide oral tablet 1.25, methyclothiazide oral tablet 5 metolazone oral tablet 10, 2.5, 5 2 Dyslipidemics, Fibric Acid Derivatives fenofibrate micronized oral capsule 1, QL (0 per 0 days) fenofibrate micronized oral capsule 67 2 QL (60 per 0 days) fenofibrate nanocrystallized oral tablet 15 2 QL (0 per 0 days) fenofibrate nanocrystallized oral tablet 8 2 QL (60 per 0 days) fenofibrate oral tablet QL (0 per 0 days) 59

69 fenofibrate oral tablet 5 2 QL (60 per 0 days) fenofibric acid (choline) oral capsule,delayed 2 QL (0 per 0 days) release(dr/ec) 15, 5 fenofibric acid oral tablet 5 2 gemfibrozil oral tablet 600 QL (60 per 0 days) Dyslipidemics, H Coa Reductase Inhibitors atorvastatin oral tablet 10, 20, 0 1 QL (60 per 0 days) atorvastatin oral tablet 80 1 QL (0 per 0 days) fluvastatin oral capsule 20, 0 QL (60 per 0 days) lovastatin oral tablet 10, 20, 0 1 QL (60 per 0 days) pravastatin oral tablet 10, 20, 0, 80 2 QL (60 per 0 days) rosuvastatin oral tablet 10, 20, 0, 5 1 QL (0 per 0 days) simvastatin oral tablet 10, 20, 0, 5 1 QL (60 per 0 days) simvastatin oral tablet 80 1 QL (0 per 0 days) Dyslipidemics, Other cholestyramine (with sugar) oral powder in packet gram cholestyramine light oral powder gram cholestyramine light packet gram colestipol oral packet 5 gram colestipol oral tablet 1 gram ezetimibe oral tablet 10 2 niacin oral tablet extended release 2 hr 1,000, 500, 750 omega- acid ethyl esters oral capsule 1 gram QL (120 per 0 days) PRALUENT PEN SUBCUTANEOUS PEN 5 PA; NDS INJECTOR 150 MG/ML, 75 MG/ML prevalite oral powder in packet gram REPATHA PUSHTRONEX SUBCUTANEOUS 5 PA; NDS; QL (.5 per 28 days) WEARABLE INJECTOR 20 MG/.5 ML REPATHA SURECLICK SUBCUTANEOUS 5 PA; NDS; QL ( per 28 days) PEN INJECTOR 10 MG/ML REPATHA SYRINGE SUBCUTANEOUS 5 PA; NDS; QL ( per 28 days) SYRINGE 10 MG/ML VASCEPA ORAL CAPSULE 0.5 GRAM QL (20 per 0 days) VASCEPA ORAL CAPSULE 1 GRAM QL (120 per 0 days) WELCHOL ORAL POWDER IN PACKET.75 GRAM WELCHOL ORAL TABLET 625 MG 60

70 Vasodilators, Direct-Acting Arterial hydralazine injection solution 20 /ml 2 hydralazine oral tablet 10, 100, 25, 50 2 minoxidil oral tablet 10, Vasodilators, Direct-Acting Arterial/ Venous isosorbide dinitrate oral tablet 10, 20, 0 2, 5 isosorbide dinitrate oral tablet extended release 0 isosorbide mononitrate oral tablet 10, 20 2 isosorbide mononitrate oral tablet extended 2 release 2 hr 120, 0, 60 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin intravenous solution 50 /10 ml (5 2 /ml) nitroglycerin sublingual tablet 0., 0., nitroglycerin transdermal patch 2 hour QL (0 per 0 days) /hr, 0.2 /hr, 0.6 /hr nitroglycerin transdermal patch 2 hour 0. 2 QL (60 per 0 days) /hr nitroglycerin translingual spray,non-aerosol 00 mcg/spray NITROSTAT SUBLINGUAL TABLET 0. MG, 0. MG, 0.6 MG Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine oral capsule, extended QL (180 per 0 days) release 10 dextroamphetamine oral capsule, extended QL (120 per 0 days) release 15 dextroamphetamine oral capsule, extended QL (60 per 0 days) release 5 dextroamphetamine oral tablet 10 QL (180 per 0 days) dextroamphetamine oral tablet 5 QL (150 per 0 days) dextroamphetamine-amphetamine oral capsule,extended release 2hr 10, 15, 5 QL (0 per 0 days) 61

71 dextroamphetamine-amphetamine oral QL (60 per 0 days) capsule,extended release 2hr 20, 25, 0 dextroamphetamine-amphetamine oral tablet 10 QL (90 per 0 days), 12.5, 15, 20, 5, 7.5 dextroamphetamine-amphetamine oral tablet 0 QL (60 per 0 days) VYVANSE ORAL CAPSULE 10 MG, 20 MG, QL (0 per 0 days) 0 MG, 0 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 0 MG, 0 MG, 50 MG, 60 MG zenzedi oral tablet 10 QL (180 per 0 days) zenzedi oral tablet 5 QL (150 per 0 days) Attention Deficit Hyperactivity Disorder Agents, Non-Amphetamines atomoxetine oral capsule 10, 100, 18, 25, 0, 60, 80 clonidine hcl oral tablet extended release 12 hr QL (120 per 0 days) 0.1 dexmethylphenidate oral capsule,er biphasic 50- QL (0 per 0 days) 50 10, 15, 20, 25, 0, 5, 0, 5 dexmethylphenidate oral tablet 10, 2.5, 5 QL (60 per 0 days) metadate er oral tablet extended release 20 methylphenidate hcl oral capsule, er biphasic , 20, 0, 0, 50, 60 methylphenidate hcl oral capsule,er biphasic 50- QL (0 per 0 days) 50 10, 20, 0, 0, 60 methylphenidate hcl oral solution 10 /5 ml, 5 /5 ml methylphenidate hcl oral tablet 10, 5 QL (90 per 0 days) methylphenidate hcl oral tablet 20 methylphenidate hcl oral tablet extended release QL (180 per 0 days) 10 methylphenidate hcl oral tablet extended release QL (90 per 0 days) 20 methylphenidate hcl oral tablet extended release 2hr 18, 27, 6, 5, 72 STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 0 MG, 60 MG, 80 MG Central Nervous System, Other 62

72 AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 5 PA; NDS MG NUEDEXTA ORAL CAPSULE MG PA; QL (60 per 28 days) riluzole oral tablet 50 tetrabenazine oral tablet PA; NDS; QL (20 per 0 days) tetrabenazine oral tablet 25 5 PA; NDS; QL (120 per 0 days) Fibromyalgia Agents SAVELLA ORAL TABLET 100 MG, 12.5 MG, QL (60 per 0 days) 25 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 12.5 QL (60 per 0 days) MG (5)-25 MG(8)-50 MG(2) Multiple Sclerosis Agents AMPYRA ORAL TABLET EXTENDED 5 PA; LA; NDS RELEASE 12 HR 10 MG AUBAGIO ORAL TABLET 1 MG, 7 MG 5 PA; LA; NDS AVONEX (WITH ALBUMIN) 5 NDS; QL ( per 28 days) INTRAMUSCULAR KIT 0 MCG AVONEX INTRAMUSCULAR PEN 5 NDS; QL (1 per 28 days) INJECTOR KIT 0 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 5 NDS; QL (1 per 28 days) 0 MCG/0.5 ML BETASERON SUBCUTANEOUS KIT 0. MG 5 PA; NDS; QL (15 per 0 days) COPAXONE SUBCUTANEOUS SYRINGE 0 5 NDS; QL (12 per 28 days) MG/ML EXTAVIA SUBCUTANEOUS KIT 0. MG 5 NDS GILENYA ORAL CAPSULE 0.5 MG 5 NDS; QL (0 per 0 days) glatiramer subcutaneous syringe 20 /ml, 0 5 NDS /ml glatopa subcutaneous syringe 20 /ml, 0 5 NDS /ml PLEGRIDY SUBCUTANEOUS PEN 5 PA; LA; NDS INJECTOR 125 MCG/0.5 ML, 6 MCG/0.5 ML- 9 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE PA; LA; NDS MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 6 5 PA; NDS MCG/0.5 ML- 9 MCG/0.5 ML REBIF (WITH ALBUMIN) SUBCUTANEOUS 5 PA; NDS; QL (6 per 28 days) SYRINGE 22 MCG/0.5 ML, MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, MCG/0.5 ML 5 PA; NDS; QL (6 per 28 days) 6

73 REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6) TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (1)- 20 MG (6), 20 MG TYSABRI INTRAVENOUS SOLUTION 00 MG/15 ML ZINBRYTA SUBCUTANEOUS SYRINGE 150 MG/ML Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 0 chlorhexidine gluconate mucous membrane 1 mouthwash 0.12 % denta 5000 plus dental cream 1.1 % 2 dentagel dental gel 1.1 % 2 oralone dental paste 0.1 % 2 paroex oral rinse mucous membrane mouthwash 0.12 % 5 PA; NDS; QL (.2 per 28 days) 5 PA; NDS; QL (.2 per 28 days) 5 LA; NDS 5 PA; NDS 5 PA; NDS; QL (1 per 0 days) periogard mucous membrane mouthwash 0.12 % 1 pilocarpine hcl oral tablet 5, 7.5 sf 5000 plus dental cream 1.1 % 2 triamcinolone acetonide dental paste 0.1 % 2 Dermatological Agents Dermatological Agents acitretin oral capsule 10, 17.5, 25 5 NDS adapalene topical cream 0.1 % PA adapalene topical gel 0.1 %, 0. % PA ammonium lactate topical cream 12 % ammonium lactate topical lotion 12 % amnesteem oral capsule 10, 20, 0 avita topical cream % PA avita topical gel % PA AZELEX TOPICAL CREAM 20 % calcipotriene scalp solution % QL (60 per 0 days) calcipotriene topical cream % QL (120 per 0 days) calcipotriene topical ointment % QL (120 per 0 days) calcitriol topical ointment mcg/gram claravis oral capsule 10, 20, 0, 0 6 1

74 clindamycin-benzoyl peroxide topical gel 1-5 %, 1.2 %(1 % base) -5 % clobetasol topical spray,non-aerosol 0.05 % clotrimazole-betamethasone topical cream % clotrimazole-betamethasone topical lotion % CORTISPORIN TOPICAL CREAM.5-10, MG/G-UNIT/G-% CORTISPORIN TOPICAL OINTMENT 1 % COSENTYX (2 SYRINGES) 5 PA; LA; NDS; QL (2 per 65 days) SUBCUTANEOUS SYRINGE 150 MG/ML COSENTYX PEN (2 PENS) SUBCUTANEOUS 5 PA; LA; NDS; QL (2 per 65 days) PEN INJECTOR 150 MG/ML dapsone topical gel 5 % diclofenac sodium topical gel 1 % 2 ELIDEL TOPICAL CREAM 1 % erythromycin-benzoyl peroxide topical gel -5 % FINACEA TOPICAL FOAM 15 % FINACEA TOPICAL GEL 15 % fluocinonide topical cream 0.1 % fluorouracil topical cream 0.5 % fluorouracil topical cream 5 % fluorouracil topical solution 2 %, 5 % fluticasone topical cream 0.05 % 2 fluticasone topical ointment % 2 imiquimod topical cream in packet 5 % QL (12 per 0 days) isotretinoin oral capsule 10, 20, 0, 0 methoxsalen oral capsule,liqd-filled,rapid rel 10 5 NDS myorisan oral capsule 10, 20, 0, 0 neuac topical gel 1.2 %(1 % base) -5 % nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% oxiconazole topical cream 1 % PICATO TOPICAL GEL % QL ( per 0 days) PICATO TOPICAL GEL 0.05 % QL (2 per 0 days) podofilox topical solution 0.5 % 65

75 prednicarbate topical cream 0.1 % REGRANEX TOPICAL GEL 0.01 % 5 PA; NDS SANTYL TOPICAL OINTMENT 250 UNIT/GRAM selenium sulfide topical lotion 2.5 % 2 SILIQ SUBCUTANEOUS SYRINGE PA; NDS MG/1.5 ML STELARA SUBCUTANEOUS SOLUTION 5 5 PA; NDS MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 5 5 PA; NDS MG/0.5 ML, 90 MG/ML tacrolimus topical ointment 0.0 %, 0.1 % TALTZ AUTOINJECTOR SUBCUTANEOUS 5 PA; LA; NDS AUTO-INJECTOR 80 MG/ML TALTZ SYRINGE SUBCUTANEOUS 5 PA; LA; NDS SYRINGE 80 MG/ML tazarotene topical cream 0.1 % TAZORAC TOPICAL CREAM 0.05 %, 0.1 % PA TAZORAC TOPICAL GEL 0.05 %, 0.1 % PA TOLAK TOPICAL CREAM % tretinoin topical cream %, 0.05 %, 0.1 % PA tretinoin topical gel 0.01 %, % PA zenatane oral capsule 10, 20, 0, 0 ZYCLARA TOPICAL CREAM IN METERED- QL (7.5 per 28 days) DOSE PUMP 2.5 % ZYCLARA TOPICAL CREAM IN METERED- QL (28 per 28 days) DOSE PUMP.75 % Electrolytes/Minerals/Metals/Vitamins Electrolyte/ Mineral Replacement CARBAGLU ORAL TABLET, DISPERSIBLE 5 PA; NDS 200 MG fluoride (sodium) oral tablet 1 (2.2 sod. 1 fluoride) KLOR-CON 10 ORAL TABLET EXTENDED 2 RELEASE 10 MEQ KLOR-CON 8 ORAL TABLET EXTENDED 2 RELEASE 8 MEQ klor-con m10 oral tablet,er particles/crystals 10 2 meq klor-con m15 oral tablet,er particles/crystals 15 meq 2 66

76 klor-con m20 oral tablet,er particles/crystals 20 2 meq klor-con sprinkle oral capsule, extended release 2 10 meq, 8 meq K-SOL ORAL LIQUID 0 MEQ/15 ML K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ, 8 MEQ magnesium sulfate injection solution meq/ml 2 HI (50 %) magnesium sulfate injection syringe meq/ml 2 HI PHYSIOSOL IRRIGATION IRRIGATION SOLUTION MEQ/L potassium chloride in water intravenous piggyback 20 meq/100 ml, 0 meq/100 ml potassium chloride intravenous solution 2 meq/ml potassium chloride oral capsule, extended release 2 10 meq, 8 meq potassium chloride oral liquid 20 meq/15 ml, 0 meq/15 ml potassium chloride oral tablet extended release 2 10 meq, 20 meq, 8 meq potassium chloride oral tablet,er 2 particles/crystals 10 meq, 20 meq sodium chloride 0.5 % intravenous parenteral 2 solution 0.5 % sodium chloride 0.9 % intravenous parenteral 2 solution sodium chloride 0.9 % intravenous piggyback 2 sodium chloride % intravenous parenteral 2 solution % sodium chloride 5 % intravenous parenteral 2 solution 5 % sodium chloride intravenous parenteral solution meq/ml sodium chloride irrigation solution 0.9 % 2 sodium fluoride 0.5 /ml drop d/f, s/f,gluten-free (1.1 sod.fluorid)/ml SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM Electrolyte/Mineral/Metal Modifiers AMINOSYN 7 % WITH ELECTROLYTES PA BvD; HI INTRAVENOUS PARENTERAL SOLUTION 7 % 67

77 AMINOSYN-RF 5.2 % INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 5.2 % DEPEN TITRATABS ORAL TABLET 250 MG 5 NDS EXJADE ORAL TABLET, DISPERSIBLE PA; LA; NDS MG, 250 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML 5 PA; NDS FERRIPROX ORAL TABLET 500 MG 5 PA; NDS FREAMINE HBC 6.9 % INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 6.9 % JADENU ORAL TABLET 180 MG, 60 MG, 90 5 PA; NDS MG JADENU SPRINKLE ORAL GRANULES IN 5 PA; NDS PACKET 180 MG, 60 MG, 90 MG kionex (with sorbitol) oral suspension gram/60 ml PLENAMINE INTRAVENOUS PARENTERAL PA BvD SOLUTION 15 % SAMSCA ORAL TABLET 15 MG, 0 MG 5 PA; NDS sod polystyren sulf 15 g/60 ml sorbitol free 15 gram/60 ml sodium polystyrene sulfonate oral powder sps (with sorbitol) oral suspension gram/60 ml SYPRINE ORAL CAPSULE 250 MG 5 NDS Electrolytes/Minerals/Metals/Vitamins AMINOSYN 8.5 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 8.5 % AMINOSYN 8.5 %-ELECTROLYTES PA BvD; HI INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 10 % AMINOSYN II 15 % INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 15 % AMINOSYN II 7 % INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES PA BvD; HI INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN-HBC 7% INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 7 % 68

78 AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D25W SULFITE-FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 2.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX.25%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX.25%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX.25%-D20W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX.25%-D25W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX 5%-D20W(SULFITE-FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 2.75%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E 2.75%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION 2.75 % CLINIMIX E.25%/D10W SUL FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX E.25%/D25W SUL FREE INTRAVENOUS PARENTERAL SOLUTION.25 % PA BvD; HI PA BvD; HI PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 69

79 CLINIMIX E.25%/D5W SULF FREE INTRAVENOUS PARENTERAL SOLUTION.25 % CLINIMIX E 5%/D15W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D20W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX E 5%/D25W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION 5 % d10 %-0.5 % sodium chloride intravenous parenteral solution d2.5 %-0.5 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.5 % sodium chloride intravenous parenteral solution dextrose 10 % and 0.2 % nacl intravenous parenteral solution dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback 5 % dextrose 5 %-lactated ringers intravenous parenteral solution dextrose 5%-0.2 % sod chloride intravenous parenteral solution dextrose 5%-0. % sod.chloride intravenous parenteral solution HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % INTRALIPID INTRAVENOUS EMULSION 20 %, 0 % LACTATED RINGERS INTRAVENOUS PARENTERAL SOLUTION LACTATED RINGERS IRRIGATION SOLUTION PA BvD PA BvD PA BvD PA BvD PA BvD; HI PA BvD; HI

80 levocarnitine (with sugar) oral solution 100 /ml levocarnitine oral tablet 0 NEPHRAMINE 5. % INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 5. % NUTRILIPID INTRAVENOUS EMULSION 20 PA BvD; HI % pnv prenatal plus multivit tab s/f, gluten-free 27 2 iron- 1 potassium chlorid-d5-0.5%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 0 meq/l potassium chloride in lr-d5 intravenous 2 parenteral solution 0 meq/l potassium chloride intravenous solution 2 meq/ml potassium chloride-d5-0.%nacl intravenous 2 parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l PREMASOL 10 % INTRAVENOUS 1 PA BvD; HI PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS 1 PA BvD; HI PARENTERAL SOLUTION 6 % prenatal vitamin plus low iron oral tablet 27 2 iron- 1 PROSOL 20 % INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION ringer's irrigation solution 1 sodium chloride 100 meq/0 ml 25's, sdv meq/ml TPN ELECTROLYTES II IV SOLN 25'S,20ML/50ML FTV MEQ/20 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/20 ML TRAVASOL 10 % INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 10 % trientine oral capsule NDS TROPHAMINE 10 % INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PA BvD; HI PARENTERAL SOLUTION 6 % water for irrigation, sterile irrigation solution 2 71

81 Gastrointestinal Agents Antispasmodics, Gastrointestinal chlordiazepoxide-clidinium oral capsule QL (20 per 0 days) dicyclomine oral capsule 10 2 dicyclomine oral solution 10 /5 ml dicyclomine oral tablet 20 2 glycopyrrolate oral tablet 1, 2 methscopolamine oral tablet 2.5, 5 propantheline oral tablet 15 Gastrointestinal Agents amoxicil-clarithromy-lansopraz oral combo pack UCERIS ORAL TABLET,DELAYED AND 5 NDS EXT.RELEASE 9 MG UCERIS RECTAL FOAM 2 MG/ACTUATION Gastrointestinal Agents, Other CHOLBAM ORAL CAPSULE 250 MG, 50 MG 5 PA; NDS diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet GATTEX 0-VIAL SUBCUTANEOUS KIT 5 5 PA; NDS MG loperamide oral capsule 2 2 metoclopramide hcl injection solution 5 /ml 2 HI metoclopramide hcl oral solution 5 /5 ml 2 metoclopramide hcl oral tablet 10, 5 2 MOVANTIK ORAL TABLET 12.5 MG, 25 MG RELISTOR ORAL TABLET 150 MG 5 NDS; QL (90 per 0 days) RELISTOR SUBCUTANEOUS SOLUTION 12 5 NDS; QL (6 per 28 days) MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 12 5 NDS; QL (6 per 28 days) MG/0.6 ML RELISTOR SUBCUTANEOUS SYRINGE 8 5 NDS; QL (12 per 0 days) MG/0. ML ursodiol oral capsule 00 ursodiol oral tablet 250, 500 Histamine2 (H2) Receptor Antagonists cimetidine hcl oral solution 00 /5 ml cimetidine oral tablet 200, 00, 00, 800 famotidine (pf) intravenous solution 20 /2 ml 2 72

82 famotidine (pf)-nacl (iso-os) intravenous 2 piggyback 20 /50 ml famotidine oral suspension 0 /5 ml (8 /ml) famotidine oral tablet 20, 0 1 nizatidine oral capsule 00 nizatidine oral solution 150 /10 ml ranitidine hcl injection solution 50 /2 ml (25 2 /ml) ranitidine hcl oral syrup 15 /ml 1 ranitidine hcl oral tablet 150, 00 1 Irritable Bowel Syndrome Agents alosetron oral tablet 0.5, 1 5 NDS; QL (60 per 0 days) AMITIZA ORAL CAPSULE 2 MCG, 8 MCG QL (60 per 0 days) DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 00 MG GIAZO ORAL TABLET 1.1 GRAM 5 NDS LINZESS ORAL CAPSULE 15 MCG, 290 QL (0 per 0 days) MCG, 72 MCG VIBERZI ORAL TABLET 100 MG, 75 MG QL (60 per 0 days) Laxatives constulose oral solution 10 gram/15 ml 2 enulose oral solution 10 gram/15 ml 2 gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-h and bisacodyl oral kit gram 2 gavilyte-n oral recon soln 20 gram 2 generlac oral solution 10 gram/15 ml 2 lactulose oral solution 10 gram/15 ml 2 peg 50-electrolytes oral recon soln gram, gram peg-electrolyte soln oral recon soln 20 gram 2 polyethylene glycol 50 oral powder 17 2 gram/dose trilyte with flavor packets oral recon soln 20 2 gram Protectants CARAFATE ORAL SUSPENSION 100 MG/ML misoprostol oral tablet 100 mcg, 200 mcg sucralfate oral tablet 1 gram 2 Proton Pump Inhibitors 7

83 esomeprazole magnesium oral capsule,delayed release(dr/ec) 20, 0 lansoprazole oral capsule,delayed release(dr/ec) 15 lansoprazole oral capsule,delayed release(dr/ec) 0 lansoprazole oral tablet,disintegrat, delay rel 15 lansoprazole oral tablet,disintegrat, delay rel 0 omeprazole oral capsule,delayed release(dr/ec) 10, 20, 0 pantoprazole oral tablet,delayed release (dr/ec) 20, 0 rabeprazole oral tablet,delayed release (dr/ec) 20 Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment Genetic Or Enzyme Disorder: Replacement, Modifiers, Treatment ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML CEREZYME INTRAVENOUS RECON SOLN 00 UNIT CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-8,000-60,000 UNIT, 2,000-76, ,000 UNIT,,000-9,500-15,000 UNIT, 6,000-11, ,000 UNIT, 6,000-19,000-0,000 UNIT QL (0 per 0 days) QL (60 per 0 days) QL (0 per 0 days) QL (60 per 0 days) QL (0 per 0 days) 1 QL (60 per 0 days) 1 QL (60 per 0 days) 2 QL (0 per 0 days) 5 NDS 5 NDS CYSTADANE ORAL POWDER 1 GRAM/1.7 5 NDS ML FABRAZYME INTRAVENOUS RECON SOLN 5 NDS 5 MG KUVAN ORAL POWDER IN PACKET PA; NDS MG, 500 MG KUVAN ORAL TABLET,SOLUBLE 100 MG 5 PA; NDS NAGLAZYME INTRAVENOUS SOLUTION 5 5 NDS MG/5 ML PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-5,500-61,500 UNIT, 16,800-56,800-98,00 UNIT, 2,600-6,200-10,850 UNIT, 21,000-5,700-8,900 UNIT,,200-1,200-2,600 UNIT 7

84 PROCYSBI ORAL CAPSULE, DELAYED REL 5 NDS SPRINKLE 25 MG, 75 MG RAVICTI ORAL LIQUID 1.1 GRAM/ML 5 PA; NDS STRENSIQ SUBCUTANEOUS SOLUTION PA; NDS MG/ML, 0 MG/ML SUCRAID ORAL SOLUTION 8,500 UNIT/ML 5 NDS VPRIV INTRAVENOUS RECON SOLN 00 5 NDS UNIT ZAVESCA ORAL CAPSULE 100 MG 5 NDS; QL (90 per 0 days) ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-6,000-8,000 UNIT, 20,000-68, ,000 UNIT, 25,000-79, ,000 UNIT, 25,000-85,000-16,000 UNIT,,000-10,000-16,000 UNIT, 0, , ,000 UNIT, 0,000-16, ,000 UNIT, 5,000-17,000-27,000 UNIT, 5,000-17,000-2,000 UNIT Genitourinary Agents Antispasmodics, Urinary darifenacin oral tablet extended release 2 hr 15 QL (0 per 0 days), 7.5 flavoxate oral tablet 100 MYRBETRIQ ORAL TABLET EXTENDED QL (0 per 0 days) RELEASE 2 HR 25 MG, 50 MG oxybutynin chloride oral syrup 5 /5 ml 2 oxybutynin chloride oral tablet 5 2 oxybutynin chloride oral tablet extended release QL (60 per 0 days) 2hr 10, 15, 5 tolterodine oral capsule,extended release 2hr 2 2 QL (0 per 0 days), tolterodine oral tablet 1, 2 2 QL (60 per 0 days) TOVIAZ ORAL TABLET EXTENDED QL (0 per 0 days) RELEASE 2 HR MG, 8 MG trospium oral capsule,extended release 2hr 60 QL (0 per 0 days) trospium oral tablet 20 VESICARE ORAL TABLET 10 MG, 5 MG QL (0 per 0 days) Benign Prostatic Hypertrophy Agents alfuzosin oral tablet extended release 2 hr 10 CIALIS ORAL TABLET 2.5 MG, 5 MG PA 2 QL (0 per 0 days) 75

85 dutasteride oral capsule QL (0 per 0 days) dutasteride-tamsulosin oral capsule, er QL (0 per 0 days) multiphase 2 hr finasteride oral tablet 5 1 QL (0 per 0 days) RAPAFLO ORAL CAPSULE MG, 8 MG QL (0 per 0 days) tamsulosin oral capsule,extended release 2hr 1 QL (60 per 0 days) 0. Genitourinary Agents, Other bethanechol chloride oral tablet 10, 25, 5, 50 ELMIRON ORAL CAPSULE 100 MG potassium citrate oral tablet extended release 10 meq (1,080 ), 15 meq, 5 meq (50 ) sodium phenylbutyrate oral powder NDS gram/gram Phosphate Binders calcium acetate oral capsule 667 calcium acetate oral tablet 667 eliphos oral tablet 667 FOSRENOL ORAL POWDER IN PACKET 5 NDS 1,000 MG, 750 MG FOSRENOL ORAL TABLET,CHEWABLE 5 NDS 1,000 MG, 500 MG, 750 MG lanthanum oral tablet,chewable 1,000, 500 2, 750 PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)/5 ML RENAGEL ORAL TABLET 00 MG, 800 MG RENVELA ORAL POWDER IN PACKET 0.8 QL (50 per 0 days) GRAM RENVELA ORAL POWDER IN PACKET 2. QL (180 per 0 days) GRAM RENVELA ORAL TABLET 800 MG QL (50 per 0 days) sevelamer carbonate oral powder in packet 0.8 gram, 2. gram sevelamer carbonate oral tablet Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ala-cort topical cream 1 %, 2.5 % 2 alclometasone topical cream 0.05 % 76

86 alclometasone topical ointment 0.05 % ANALPRAM-HC RECTAL CREAM 1-1 % ANALPRAM-HC TOPICAL LOTION % clobetasol 0.05% cream 0.05 % clobetasol scalp solution 0.05 % clobetasol topical foam 0.05 % clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % clobetasol topical ointment 0.05 % clobetasol topical shampoo 0.05 % clobetasol-emollient topical cream 0.05 % clobetasol-emollient topical foam 0.05 % CORDRAN TAPE LARGE ROLL TOPICAL TAPE MCG/CM2 cormax scalp solution 0.05 % desonide topical cream 0.05 % desonide topical lotion 0.05 % desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, 0.25 % desoximetasone topical gel 0.05 % desoximetasone topical ointment 0.05 %, 0.25 % EMFLAZA ORAL SUSPENSION PA; NDS MG/ML EMFLAZA ORAL TABLET 18 MG, 0 MG, 6 5 PA; NDS MG, 6 MG fludrocortisone oral tablet fluocinolone 0.01% body oil 0.01 % fluocinolone acetonide oil otic (ear) drops 0.01 % fluocinolone and shower cap scalp oil 0.01 % fluocinolone topical cream 0.01 %, % fluocinolone topical ointment % fluocinolone topical solution 0.01 % fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocortisone butyrate topical cream 0.1 % hydrocortisone butyrate topical ointment 0.1 % 77

87 hydrocortisone butyrate topical solution 0.1 % hydrocortisone oral tablet 10 2 hydrocortisone topical cream 1 %, 2.5 % 2 hydrocortisone topical lotion 2.5 % 2 hydrocortisone topical ointment 1 %, 2.5 % 2 hydrocortisone valerate topical cream 0.2 % hydrocortisone valerate topical ointment 0.2 % methylprednisolone oral tablets,dose pack 2 methylprednisolone sodium succ injection recon HI soln 125 mometasone topical cream 0.1 % 2 mometasone topical ointment 0.1 % 2 mometasone topical solution 0.1 % 2 PRAMOSONE TOPICAL CREAM 1-1 % PRAMOSONE TOPICAL LOTION 1-1 % prednicarbate topical ointment 0.1 % prednisolone sodium phosphate oral solution 25 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) prednisone oral solution 5 /5 ml procto-pak topical cream with perineal 2 applicator 1 % proctozone-hc topical cream with perineal applicator 2.5 % triamcinolone acetonide topical cream %, %, 0.5 % triamcinolone acetonide topical lotion %, % triamcinolone acetonide topical ointment %, 0.1 %, 0.5 % triderm topical cream 0.1 %, 0.5 % 2 tridesilon topical cream 0.05 % Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) desmopressin 10 mcg/0.1 ml spr 10 mcg/spray (0.1 ml) desmopressin injection solution mcg/ml desmopressin nasal solution 0.1 /ml (refrigerate) desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) 78

88 desmopressin oral tablet 0.1, 0.2 EGRIFTA SUBCUTANEOUS RECON SOLN 1 5 PA; LA; NDS; QL (60 per 0 days) MG INCRELEX SUBCUTANEOUS SOLUTION 10 5 PA; NDS MG/ML methylergonovine oral tablet 0.2 MYALEPT SUBCUTANEOUS RECON SOLN 5 PA; NDS; QL (0 per 0 days) 5 MG/ML (FINAL CONC.) NORDITROPIN FLEXPRO SUBCUTANEOUS 5 PA; NDS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 0 MG/ ML (10 MG/ML), 5 MG/1.5 ML (. MG/ML) STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) Anabolic Steroids ANADROL-50 ORAL TABLET 50 MG 5 NDS oxandrolone oral tablet 10 5 NDS; QL (60 per 0 days) oxandrolone oral tablet 2.5 QL (120 per 0 days) Androgens ANDRODERM TRANSDERMAL PATCH 2 HOUR 2 MG/2 HOUR ANDRODERM TRANSDERMAL PATCH 2 HOUR MG/2 HR ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP MG/1.25 GRAM (1.62 %) PA NSO; QL (60 per 0 days) PA NSO; QL (0 per 0 days) PA NSO; QL (150 per 0 days) ANDROGEL TRANSDERMAL GEL IN PA NSO; QL (7.5 per 0 days) PACKET 1.62 % (20.25 MG/1.25 GRAM) ANDROGEL TRANSDERMAL GEL IN PA NSO; QL (150 per 0 days) PACKET 1.62 % (0.5 MG/2.5 GRAM) danazol oral capsule 100, 200, 50 DEPO-TESTOSTERONE INTRAMUSCULAR PA NSO OIL 200 MG/ML testosterone cypionate intramuscular oil 100 /ml testosterone cypionate intramuscular oil 200 PA NSO /ml testosterone enanthate intramuscular oil 200 /ml PA NSO; QL (.5 per 0 days) 79

89 testosterone transdermal gel in metered-dose PA NSO; QL (00 per 0 days) pump 12.5 / 1.25 gram (1 %) testosterone transdermal gel in packet 1 % (25 PA NSO; QL (00 per 0 days) /2.5gram), 1 % (50 /5 gram) Estrogens ALORA TRANSDERMAL PATCH QL (8 per 28 days) SEMIWEEKLY MG/2 HR, 0.05 MG/2 HR, MG/2 HR, 0.1 MG/2 HR ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM) estradiol oral tablet 0.5, 1, 2 estradiol transdermal patch semiweekly /2 hr estradiol transdermal patch semiweekly QL (8 per 28 days) /2 hr, 0.05 /2 hr, /2 hr, 0.1 /2 hr estradiol transdermal patch weekly /2 QL ( per 28 days) hr, /2 hr, 0.05 /2 hr, 0.06 /2 hr, /2 hr, 0.1 /2 hr estradiol vaginal cream 0.01 % (0.1 /gram) 2 ESTRING VAGINAL RING 2 MG (7.5 MCG QL (1 per 90 days) /2 HOUR) estropipate oral tablet 0.75, 1.5, MENEST ORAL TABLET 0. MG, MG, 1.25 MG PREMARIN ORAL TABLET 0. MG, 0.5 MG, MG, 0.9 MG, 1.25 MG PREMARIN VAGINAL CREAM MG/GRAM yuvafem vaginal tablet 10 mcg 2 Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) altavera (28) oral tablet alyacen 1/5 (28) oral tablet 1-5 -mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1-5 mcg amabelz oral tablet , amethia lo oral tablets,dose pack, month 0.10 QL (91 per 90 days) -20 mcg (8)/10 mcg (7) amethia oral tablets,dose pack, month QL (91 per 90 days) 0 mcg (8)/10 mcg (7) AMETHYST ORAL TABLET MCG apri oral tablet

90 aranelle (28) oral tablet 0.5/1/ mcg ashlyna oral tablets,dose pack, month mcg (8)/10 mcg (7) aubra oral tablet mcg aviane oral tablet mcg azurette (28) oral tablet x21 /0.01 x 5 balziva (28) oral tablet mcg bekyree (28) oral tablet x21 /0.01 x 5 blisovi 2 fe oral tablet 1-20 mcg (2)/75 () blisovi fe 1.5/0 (28) oral tablet mcg (21)/75 (7) blisovi fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) brevicon (28) oral tablet mcg briellyn oral tablet mcg camrese lo oral tablets,dose pack, month mcg (8)/10 mcg (7) camrese oral tablets,dose pack, month QL (91 per 90 days) 0 mcg (8)/10 mcg (7) caziant (28) oral tablet 0.1/.125/ mcg chateal oral tablet CLIMARA PRO TRANSDERMAL PATCH WEEKLY MG/2 HR cryselle (28) oral tablet mcg cyclafem 1/5 (28) oral tablet 1-5 -mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1-5 mcg cyred oral tablet dasetta 1/5 (28) oral tablet 1-5 -mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1-5 mcg deblitane oral tablet 0.5 delyla (28) oral tablet mcg desog-e.estradiol/e.estradiol oral tablet x21 /0.01 x 5 desogestrel-ethinyl estradiol oral tablet drospirenone-e.estradiol-lm.fa oral tablet (2) (), (21) (7) 81

91 drospirenone-ethinyl estradiol oral tablet -0.02, -0.0 elinest oral tablet mcg emoquette oral tablet enpresse oral tablet 50-0 (6)/75-0 (5)/125-0(10) enskyce oral tablet estarylla oral tablet mcg estradiol vaginal tablet 10 mcg 2 estradiol-norethindrone acet oral tablet estradiol-norethindrone acet oral tablet ethynodiol diac-eth estradiol oral tablet 1-5 mcg, mcg falmina (28) oral tablet mcg fayosim oral tablets,dose pack, month mcg/ mcg femynor oral tablet mcg fyavolv oral tablet mcg, 1-5 -mcg gianvi (28) oral tablet gildagia oral tablet mcg gildess 1.5/0 (21) oral tablet mcg gildess 2 fe oral tablet 1-20 mcg (2)/75 () heather oral tablet 0.5 introvale oral tablets,dose pack, month QL (91 per 0 days) 0 mcg isibloom oral tablet jencycla oral tablet 0.5 jinteli oral tablet 1-5 -mcg jolessa oral tablets,dose pack, month QL (91 per 90 days) 0 mcg juleber oral tablet junel 1.5/0 (21) oral tablet mcg junel 1/20 (21) oral tablet mcg junel fe 1.5/0 (28) oral tablet mcg (21)/75 (7) junel fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) junel fe 2 oral tablet 1-20 mcg (2)/75 () 82

92 kaitlib fe oral tablet,chewable mcg(2) and 75 () kariva (28) oral tablet x21 /0.01 x 5 kelnor 1/5 (28) oral tablet 1-5 -mcg kelnor 1-50 oral tablet mcg kimidess (28) oral tablet x21 /0.01 x 5 kurvelo oral tablet l norgest/e.estradiol-e.estrad oral tablets,dose QL (91 per 90 days) pack, month mcg (8)/10 mcg (7) l norgest/e.estradiol-e.estrad oral tablets,dose pack, month mcg/ mcg, mcg (8)/10 mcg (7) larin 1.5/0 (21) oral tablet mcg larin 1/20 (21) oral tablet mcg larin 2 fe oral tablet 1-20 mcg (2)/75 () larin fe 1.5/0 (28) oral tablet mcg (21)/75 (7) larin fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) larissia oral tablet mcg layolis fe oral tablet,chewable mcg(2) and 75 () leena 28 oral tablet 0.5/1/ mcg lessina oral tablet mcg levonest (28) oral tablet 50-0 (6)/75-0 (5)/125-0(10) levonorgestrel-ethinyl estrad oral tablet mcg, , mcg levonorgestrel-ethinyl estrad oral tablets,dose pack, month mcg levonorg-eth estrad triphasic oral tablet 50-0 (6)/75-0 (5)/125-0(10) levora-28 oral tablet lillow oral tablet lomedia 2 fe oral tablet 1-20 mcg (2)/75 () lopreeza oral tablet , loryna (28) oral tablet low-ogestrel (28) oral tablet mcg 8

93 lutera (28) oral tablet mcg marlissa oral tablet melodetta 2 fe oral tablet,chewable 1-20 mcg(2) /75 () mibelas 2 fe oral tablet,chewable 1-20 mcg(2) /75 () microgestin 1.5/0 (21) oral tablet mcg microgestin 1/20 (21) oral tablet mcg microgestin 2 fe oral tablet 1-20 mcg (2)/75 () microgestin fe 1.5/0 (28) oral tablet mcg (21)/75 (7) microgestin fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) mimvey lo oral tablet mimvey oral tablet mono-linyah oral tablet mcg mononessa (28) oral tablet mcg myzilra oral tablet 50-0 (6)/75-0 (5)/125-0(10) NATAZIA ORAL TABLET MG/2 MG-2 MG/ 2 MG- MG/1 MG necon 0.5/5 (28) oral tablet mcg necon 1/50 (28) oral tablet mcg necon 10/11 (28) oral tablet 0.5-5/1-5 mcg/-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1-5 mcg nikki (28) oral tablet nora-be oral tablet 0.5 noreth-estrad-fe (21) mcg (21)/75 (7) noreth-ethinyl estradiol-iron oral tablet,chewable 0.-5mcg(21) and 75 (7), mcg(2) and 75 () norethindrone ac-eth estradiol oral tablet mcg, mcg, 1-5 -mcg norethindrone-e.estradiol-iron oral tablet 1-20 mcg (2)/75 () norethindrone-e.estradiol-iron oral tablet,chewable 1-20 mcg(2) /75 () 8

94 norgestimate-ethinyl estradiol oral tablet 0.18/0.215/ mcg, 0.18/0.215/ mcg (28), mcg norinyl 1/5 (28) oral tablet 1-5 -mcg norlyda oral tablet 0.5 norlyroc oral tablet 0.5 nortrel 0.5/5 (28) oral tablet mcg nortrel 1/5 (21) oral tablet 1-5 -mcg nortrel 1/5 (28) oral tablet 1-5 -mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1-5 mcg ocella oral tablet -0.0 ogestrel (28) oral tablet mcg orsythia oral tablet mcg philith oral tablet mcg pimtrea (28) oral tablet x21 /0.01 x 5 pirmella oral tablet 0.5/0.75/1-5 mcg, 1-5 -mcg portia oral tablet PREMPHASE ORAL TABLET MG (1)/ 0.625MG-5MG(1) PREMPRO ORAL TABLET MG, MG, MG, MG previfem oral tablet mcg quasense oral tablets,dose pack, month mcg rajani oral tablet (2) () reclipsen (28) oral tablet rivelsa oral tablets,dose pack, month mcg/ mcg setlakin oral tablets,dose pack, month QL (91 per 90 days) 0 mcg sharobel oral tablet 0.5 sprintec (28) oral tablet mcg sronyx oral tablet mcg syeda oral tablet -0.0 tarina fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) tilia fe oral tablet 1-20(5)/1-0(7) /1-5mcg (9) 85

95 tri femynor oral tablet 0.18/0.215/ mcg (28) tri-estarylla oral tablet 0.18/0.215/ mcg (28) tri-legest fe oral tablet 1-20(5)/1-0(7) /1-5mcg (9) tri-linyah oral tablet 0.18/0.215/ mcg (28) tri-lo-estarylla oral tablet 0.18/0.215/ mcg tri-lo-sprintec oral tablet 0.18/0.215/ mcg trinessa (28) oral tablet 0.18/0.215/ mcg (28) trinessa lo oral tablet 0.18/0.215/ mcg tri-previfem (28) oral tablet 0.18/0.215/ mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/ mcg (28) trivora (28) oral tablet 50-0 (6)/75-0 (5)/125-0(10) tri-vylibra oral tablet 0.18/0.215/ mcg (28) tydemy oral tablet (21) (7) velivet triphasic regimen (28) oral tablet 0.1/.125/ mcg vestura (28) oral tablet vienva oral tablet mcg vyfemla (28) oral tablet mcg vylibra oral tablet mcg wera (28) oral tablet mcg wymzya fe oral tablet,chewable 0.-5mcg(21) and 75 (7) xulane transdermal patch weekly mcg/2 QL ( per 28 days) hr zarah oral tablet -0.0 zenchent (28) oral tablet mcg zenchent fe oral tablet,chewable 0.- 5mcg(21) and 75 (7) zovia 1/5e (28) oral tablet 1-5 -mcg zovia 1/50e (28) oral tablet mcg Progestins 86

96 camila oral tablet 0.5 DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MG/ML, 00 MG/ML DEPO-SUBQ PROVERA 10 QL (0.65 per 90 days) SUBCUTANEOUS SYRINGE 10 MG/0.65 ML errin oral tablet 0.5 jolivette oral tablet 0.5 lyza oral tablet 0.5 medroxyprogesterone intramuscular suspension 150 /ml medroxyprogesterone oral tablet 10, 2.5, 2 5 megestrol oral suspension 00 /10 ml (0 /ml), 625 /5 ml megestrol oral tablet 20, 0 norethindrone (contraceptive) oral tablet 0.5 norethindrone acetate oral tablet 5 progesterone micronized oral capsule 100, 200 Selective Estrogen Receptor Modifying Agents raloxifene oral tablet 60 QL (0 per 0 days) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) levothyroxine intravenous recon soln 100 mcg levothyroxine oral tablet 100 mcg, 112 mcg, mcg, 17 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 00 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 17 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine intravenous solution 10 mcg/ml 2 liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg SYNTHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 17 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 00 MCG, 50 MCG, 75 MCG, 88 MCG THYROLAR-1 ORAL TABLET MCG THYROLAR-1/2 ORAL TABLET MCG 87

97 THYROLAR-1/ ORAL TABLET MCG THYROLAR-2 ORAL TABLET MCG THYROLAR- ORAL TABLET MCG Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN ORAL TABLET 500 MG 5 NDS Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline oral tablet 0.5 QL (16 per 28 days) FIRMAGON KIT W DILUENT SYRINGE 5 NDS SUBCUTANEOUS RECON SOLN 120 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG leuprolide subcutaneous kit 1 /0.2 ml LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT MG, 22.5 MG QL (1 per 90 days) LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG octreotide acet 100 mcg/ml syr outer,singledose, mcg/ml (1 ml) octreotide acet 50 mcg/ml syr outer,singledose,10 50 mcg/ml (1 ml) octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 10 MG, 20 MG, 0 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0. MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) 88 QL (1 per 112 days) 5 NDS; QL (1 per 168 days) QL (1 per 0 days) 5 NDS; QL (1 per 0 days) PA PA PA 5 PA; NDS 5 NDS; QL (60 per 0 days)

98 SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0. ML SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON SOLN 25 MG, 0 MG SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole oral tablet 10, 5 2 propylthiouracil oral tablet 50 Immunological Agents 5 PA NSO; NDS 5 NDS; QL (60 per 0 days) 5 NDS; QL (0 per 0 days) 5 NDS Angioedema Agents CINRYZE INTRAVENOUS RECON SOLN PA; NDS; QL (20 per 0 days) UNIT (5 ML) FIRAZYR SUBCUTANEOUS SYRINGE 0 5 PA; NDS; QL (18 per 0 days) MG/ ML Immune Suppressants ACTEMRA SUBCUTANEOUS SYRINGE PA; NDS MG/0.9 ML AFINITOR DISPERZ ORAL TABLET FOR 5 PA NSO; NDS SUSPENSION 2 MG, MG, 5 MG ATGAM INTRAVENOUS SOLUTION 50 HI MG/ML azathioprine oral tablet 50 1 PA BvD azathioprine sodium injection recon soln 100 PA BvD BENLYSTA INTRAVENOUS RECON SOLN 5 HI; NDS; QL (20 per 28 days) 120 MG BENLYSTA INTRAVENOUS RECON SOLN 5 HI; NDS; QL (6 per 28 days) 00 MG BENLYSTA SUBCUTANEOUS AUTO- 5 NDS INJECTOR 200 MG/ML BENLYSTA SUBCUTANEOUS SYRINGE NDS MG/ML CELLCEPT ORAL CAPSULE 250 MG PA BvD CELLCEPT ORAL SUSPENSION FOR 5 PA BvD; NDS RECONSTITUTION 200 MG/ML CELLCEPT ORAL TABLET 500 MG 5 PA BvD; NDS 89

99 CIMZIA POWDER FOR RECONST 5 PA; NDS SUBCUTANEOUS KIT 00 MG (200 MG X 2 VIALS) CIMZIA SUBCUTANEOUS SYRINGE KIT 00 5 PA; NDS MG/2 ML (200 MG/ML X 2) cyclosporine modified oral capsule 100, 25 PA BvD, 50 cyclosporine modified oral solution 100 /ml PA BvD cyclosporine oral capsule 100, 25 PA BvD ENBREL SUBCUTANEOUS RECON SOLN 25 5 PA; NDS; QL (8 per 28 days) MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 5 PA; NDS; QL (.08 per 28 days) MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 5 PA; NDS; QL (7.8 per 28 days) MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS 5 PA; NDS; QL (7.8 per 28 days) PEN INJECTOR 50 MG/ML (0.98 ML) ENVARSUS XR ORAL TABLET EXTENDED PA BvD RELEASE 2 HR 0.75 MG, 1 MG, MG gengraf oral capsule 100, 25, 50 PA BvD gengraf oral solution 100 /ml PA BvD HUMIRA PEDIATRIC CROHN'S START 5 PA; NDS; QL (6 per 28 days) SUBCUTANEOUS SYRINGE KIT 0 MG/0.8 ML HUMIRA PEN CROHN'S-UC-HS START 5 PA; NDS; QL (6 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS 5 PA; NDS; QL (6 per 28 days) SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN 5 PA; NDS; QL (6 per 28 days) INJECTOR KIT 0 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 5 PA; NDS; QL (2 per 28 days) MG/0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 5 PA; NDS; QL (6 per 28 days) MG/0. ML, 0 MG/0.8 ML KEVZARA SUBCUTANEOUS SYRINGE PA; NDS MG/1.1 ML, 200 MG/1.1 ML KINERET SUBCUTANEOUS SYRINGE PA; NDS MG/0.67 ML mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln 1 gram 2 90

100 methotrexate sodium (pf) injection solution 25 2 /ml, 25 /ml (10 ml) methotrexate sodium injection solution 25 /ml 2 methotrexate sodium oral tablet mycophenolate mofetil hcl intravenous recon soln PA BvD 500 mycophenolate mofetil oral capsule 250 PA BvD mycophenolate mofetil oral suspension for PA BvD reconstitution 200 /ml mycophenolate mofetil oral tablet 500 PA BvD mycophenolate sodium oral tablet,delayed PA BvD release (dr/ec) 180, 60 NULOJIX INTRAVENOUS RECON SOLN PA BvD; NDS; QL (20 per 0 days) MG ORENCIA CLICKJECT SUBCUTANEOUS 5 PA; NDS AUTO-INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SYRINGE PA; NDS MG/ML, 50 MG/0. ML, 87.5 MG/0.7 ML OTEZLA ORAL TABLET 0 MG 5 PA; NDS OTEZLA STARTER ORAL TABLETS,DOSE 5 PA; NDS PACK 10 MG ()-20 MG ()-0 MG (7), 10 MG ()-20 MG ()-0 MG(19) PROGRAF INTRAVENOUS SOLUTION 5 PA BvD MG/ML RAPAMUNE ORAL SOLUTION 1 MG/ML PA BvD RAPAMUNE ORAL TABLET 0.5 MG, 1 MG, 2 PA BvD MG REMICADE INTRAVENOUS RECON SOLN 5 NDS 100 MG RENFLEXIS INTRAVENOUS RECON SOLN 5 NDS 100 MG SANDIMMUNE INTRAVENOUS SOLUTION PA BvD 250 MG/5 ML SANDIMMUNE ORAL SOLUTION 100 PA BvD MG/ML SIMPONI ARIA INTRAVENOUS SOLUTION 5 PA; NDS 12.5 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 5 PA; NDS; QL (1 per 0 days) 100 MG/ML, 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 50 5 PA; NDS; QL (1 per 0 days) MG/0.5 ML sirolimus oral tablet 0.5, 1, 2 PA BvD 91

101 tacrolimus oral capsule 0.5, 1, 5 PA BvD TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG XATMEP ORAL SOLUTION 2.5 MG/ML PA BvD XELJANZ ORAL TABLET 5 MG 5 PA; NDS; QL (60 per 0 days) XELJANZ XR ORAL TABLET EXTENDED 5 PA; NDS; QL (0 per 0 days) RELEASE 2 HR 11 MG ZORTRESS ORAL TABLET 0.25 MG, 0.75 MG PA BvD; QL (60 per 0 days) ZORTRESS ORAL TABLET 0.5 MG PA BvD; QL (120 per 0 days) Immunizing Agents, Passive CARIMUNE NF NANOFILTERED 5 PA BvD; NDS INTRAVENOUS RECON SOLN 12 GRAM, GRAM, 6 GRAM GAMASTAN S/D INTRAMUSCULAR PA BvD SOLUTION % RANGE GAMASTAN S/D INTRAMUSCULAR PA BvD SOLUTION % RANGE (2 ML) GAMMAGARD LIQUID INJECTION 5 PA BvD; NDS SOLUTION 10 % GAMMAPLEX (WITH SORBITOL) 5 PA BvD; NDS INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS SOLUTION 5 PA BvD; NDS 10 %, 10 % (100 ML), 10 % (200 ML) GAMUNEX-C INJECTION SOLUTION 1 5 PA BvD; NDS GRAM/10 ML (10 %) PRIVIGEN INTRAVENOUS SOLUTION 10 % 5 PA BvD; NDS THYMOGLOBULIN INTRAVENOUS RECON 5 NDS SOLN 25 MG Immunological Agents leflunomide oral tablet 10, 20 2 QL (0 per 0 days) SYNAGIS INTRAMUSCULAR SOLUTION 5 NDS; QL ( per 28 days) 100 MG/ML SYNAGIS INTRAMUSCULAR SOLUTION 50 5 NDS MG/0.5 ML Immunomodulators ACTIMMUNE SUBCUTANEOUS SOLUTION 5 NDS 100 MCG/0.5 ML ARCALYST SUBCUTANEOUS RECON SOLN 5 NDS 220 MG ILARIS (PF) SUBCUTANEOUS RECON SOLN 5 PA; NDS 180 MG/1.2 ML (150 MG/ML) RIDAURA ORAL CAPSULE MG 5 NDS 92

102 SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION 10 MCG/0.5 ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL (PF) INTRAMUSCULAR SUSPENSION MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,0 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML 5 PA; NDS 6 NDS 6 NDS 6 NDS 6 NDS 6 NDS 6 NDS PA BvD PA BvD PA BvD PA BvD QL (1.5 per 65 days) QL (1.5 per 65 days) QL (1.5 per 65 days) 9

103 HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,0 ELISA UNIT/ML, 720 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 2.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IPOL INJECTION SYRINGE UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION MCG/0.5 ML MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN MCG/0.5 ML MENOMUNE - A/C/Y/W-15 (PF) SUBCUTANEOUS RECON SOLN 50 MCG MENOMUNE - A/C/Y/W-15 SUBCUTANEOUS RECON SOLN 50 MCG MENVEO A-C-Y-W-15-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-12,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-8 MCG- 5 LF UNIT/0.5ML 6 NDS 6 NDS 6 NDS 6 NDS 6 NDS 6 NDS 6 NDS 9

104 PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR 6 NDS SUSPENSION 15 LF-8 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 2.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR PA BvD SUSPENSION 10 MCG/ML, 0 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR PA BvD SYRINGE 10 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB 5 MCG/0.5 ML VL PA BvD OUTER, P/F, SDV 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION 2 ML SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 6 NDS; QL (2 per 65 days); AGE (Min 50 Years) MCG/0.5 ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 6 NDS 5-2 LF UNIT/0.5 ML TENIVAC VIAL L/F, P/F, OUTER, SUV 5 LF 6 NDS UNIT- 2 LF UNIT/0.5ML TETANUS,DIPHTHERIA TOX PED(PF) 6 NDS INTRAMUSCULAR SUSPENSION 5-25 LF UNIT/0.5 ML TETANUS-DIPHTHERIA TOXOIDS-TD 6 NDS INTRAMUSCULAR SUSPENSION 2-2 LF UNIT/0.5 ML TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT -20 MCG/ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT -20 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML, 50 UNIT/ML 95

105 VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,50 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP.7 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,00 UNIT/0.65 ML Inflammatory Bowel Disease Agents Aminosalicylates balsalazide oral capsule NDS; QL (1 per 65 days); AGE (Min 9 Years) CANASA RECTAL SUPPOSITORY 1,000 MG QL (0 per 0 days) LIALDA ORAL TABLET,DELAYED QL (120 per 0 days) RELEASE (DR/EC) 1.2 GRAM mesalamine oral tablet,delayed release (dr/ec) 1.2 gram, 800 mesalamine rectal enema gram/60 ml PENTASA ORAL CAPSULE, EXTENDED QL (150 per 0 days) RELEASE 250 MG PENTASA ORAL CAPSULE, EXTENDED QL (00 per 0 days) RELEASE 500 MG Glucocorticoids budesonide oral capsule,delayed,extend.release colocort rectal enema 100 /60 ml hydrocortisone rectal enema 100 /60 ml procto-med hc topical cream with perineal applicator 2.5 % proctosol hc topical cream with perineal applicator 2.5 % Sulfonamides sulfasalazine oral tablet sulfasalazine oral tablet,delayed release (dr/ec) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 /75 ml alendronate oral tablet 10, 0, 5 1 QL (0 per 0 days) alendronate oral tablet 5, 70 1 QL (12 per 8 days)

106 calcitonin (salmon) nasal spray,non-aerosol 200 QL (.7 per 28 days) unit/actuation calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg 2 calcitriol oral solution 1 mcg/ml 2 doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg etidronate disodium oral tablet 200, 00 FORTEO SUBCUTANEOUS PEN INJECTOR PA; QL (2. per 28 days) 20 MCG/DOSE MCG/2. ML ibandronate oral tablet QL (1 per 28 days) MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS CARTRIDGE 5 NDS; QL (2 per 28 days) 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE pamidronate intravenous recon soln 0, 90 pamidronate intravenous solution 0 /10 ml ( /ml), 60 /10 ml (6 /ml), 90 /10 ml (9 /ml) PARICALCITOL 10 MCG/2 ML VIAL MDV,INNER,LATEX-FREE 5 MCG/ML paricalcitol 2 mcg/ml vial sdv,inner,latex-free 2 mcg/ml paricalcitol intravenous solution 2 mcg/ml PARICALCITOL INTRAVENOUS SOLUTION 5 MCG/ML paricalcitol oral capsule 1 mcg, 2 mcg, mcg PROLIA SUBCUTANEOUS SYRINGE 60 PA; QL (1 per 180 days) MG/ML RAYALDEE ORAL CAPSULE,EXTENDED 5 NDS RELEASE 2 HR 0 MCG risedronate oral tablet 150 QL (1 per 0 days) risedronate oral tablet 0, 5 QL (0 per 0 days) risedronate oral tablet 5 (12 pack) QL (12 per 8 days) risedronate oral tablet 5, 5 ( pack) QL ( per 28 days) risedronate oral tablet,delayed release (dr/ec) 5 QL ( per 28 days) SENSIPAR ORAL TABLET 0 MG, 60 MG PA BvD; QL (120 per 0 days) SENSIPAR ORAL TABLET 90 MG PA BvD 97

107 TYMLOS SUBCUTANEOUS PEN INJECTOR 5 PA; NDS 80 MCG (,120 MCG/1.56 ML) XGEVA SUBCUTANEOUS SOLUTION PA; NDS; QL (1.7 per 28 days) MG/1.7 ML (70 MG/ML) zoledronic acid intravenous recon soln QL (15 per 21 days) zoledronic acid intravenous solution /5 ml QL (15 per 21 days) zoledronic acid-mannitol-water intravenous QL (100 per 65 days) piggyback 5 /100 ml zoledronic ac-mannitol-0.9nacl intravenous piggyback /100 ml PA BvD Ophthalmic Agents Ophthalmic Agents bacitracin-polymyxin b ophthalmic (eye) ointment ,000 unit/gram naphazoline ophthalmic (eye) drops 0.1 % 2 neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 -unit/g-1% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b-dexameth ophthalmic 2 (eye) drops,suspension.5/ml-10,000 unit/ml- 0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment.5 /g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops ,000 unit-0.025/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension.5-10, unit-/ml neo-polycin hc ophthalmic (eye) ointment ,000 -unit/g-1% neo-polycin ophthalmic (eye) ointment ,000 -unit-unit/g NEOSPORIN (NEO-POLYM-GRAMICID) OPHTHALMIC (EYE) DROPS 1.75 MG-10,000 UNIT-0.025MG/ML polycin ophthalmic (eye) ointment ,000 unit/gram polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 /ml TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION %

108 tobramycin-dexamethasone ophthalmic (eye) 2 drops,suspension % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % Ophthalmic Agents, Other atropine ophthalmic (eye) drops 1 % 2 CYSTARAN OPHTHALMIC (EYE) DROPS 5 NDS; QL (60 per 28 days) 0. % proparacaine ophthalmic (eye) drops 0.5 % 1 RESTASIS OPHTHALMIC (EYE) QL (60 per 0 days) DROPPERETTE 0.05 % sulfacetamide sodium ophthalmic (eye) ointment 10 % Ophthalmic Anti-Allergy Agents ALOCRIL OPHTHALMIC (EYE) DROPS 2 % ALOMIDE OPHTHALMIC (EYE) DROPS 0.1 % azelastine ophthalmic (eye) drops 0.05 % BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % cromolyn ophthalmic (eye) drops % 2 epinastine ophthalmic (eye) drops 0.05 % LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 % olopatadine ophthalmic (eye) drops 0.1 % olopatadine ophthalmic (eye) drops 0.2 % PATADAY OPHTHALMIC (EYE) DROPS 0.2 % Ophthalmic Antiglaucoma Agents ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % apraclonidine ophthalmic (eye) drops 0.5 % AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % betaxolol ophthalmic (eye) drops 0.5 % BETOPTIC S OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % bimatoprost ophthalmic (eye) drops 0.0 % brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % carteolol ophthalmic (eye) drops 1 % 2 99

109 COMBIGAN OPHTHALMIC (EYE) DROPS % COSOPT (PF) OPHTHALMIC (EYE) QL (60 per 0 days) DROPPERETTE % COSOPT OPHTHALMIC (EYE) DROPS 22.- QL (10 per 0 days) 6.8 MG/ML cyclopentolate ophthalmic (eye) drops 0.5 %, 1 2 %, 2 % dorzolamide ophthalmic (eye) drops 2 % 2 QL (10 per 0 days) dorzolamide-timolol ophthalmic (eye) drops QL (10 per 0 days) 6.8 /ml levobunolol ophthalmic (eye) drops 0.5 % 2 metipranolol ophthalmic (eye) drops 0. % 2 PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS % pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 2 % SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION % timolol maleate ophthalmic (eye) drops 0.25 %, % timolol maleate ophthalmic (eye) drops, once 1 daily 0.5 % timolol maleate ophthalmic (eye) gel forming 2 solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.00 % TRUSOPT OPHTHALMIC (EYE) DROPS 2 % Ophthalmic Anti-Inflammatories ACUVAIL (PF) OPHTHALMIC (EYE) DROPPERETTE 0.5 % ALREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.2 % bromfenac ophthalmic (eye) drops 0.09 % dexamethasone sodium phosphate ophthalmic 2 (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % 2 DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % 100

110 fluorometholone ophthalmic (eye) drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops % FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % FML LIQUIFILM OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % ketorolac ophthalmic (eye) drops 0. %, 0.5 % 2 LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic (eye) drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % Ophthalmic Prostaglandin And Prostamide Analogs latanoprost ophthalmic (eye) drops % 1 QL (5 per 25 days) LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 QL (2.5 per 25 days) % travoprost (benzalkonium) ophthalmic (eye) drops 0.00 % ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE % Otic Agents Otic Agents acetasol hc otic (ear) drops 1-2 % 101

111 CETRAXAL OTIC (EAR) DROPPERETTE 0.2 % CIPRO HC OTIC (EAR) DROPS,SUSPENSION % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION MG/ML hydrocortisone-acetic acid otic (ear) drops 1-2 % neomycin-polymyxin-hc otic (ear) 2 drops,suspension.5-10,000-1 /ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution.5-10,000-1 /ml-unit/ml-% ofloxacin oral tablet 00 Respiratory Tract/ Pulmonary Agents Antihistamines azelastine nasal aerosol,spray 17 mcg (0.1 %) QL (0 per 25 days) azelastine nasal spray,non-aerosol 0.15 % (205.5 QL (0 per 25 days) mcg) cetirizine oral solution 1 /ml 2 QL (00 per 0 days) clemastine oral tablet 2.68 cyproheptadine oral syrup 2 /5 ml cyproheptadine oral tablet desloratadine oral tablet 5 2 QL (0 per 0 days) levocetirizine oral tablet 5 1 QL (0 per 0 days) olopatadine nasal spray,non-aerosol 0.6 % QL (0.5 per 0 days) Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, 5-21 MCG/ACTUATION AEROSPAN INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION, 80 MCG/ACTUATION ARMONAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 11 MCG/ACTUATION, 22 MCG/ACTUATION, 55 MCG/ACTUATION QL (60 per 0 days) QL (12 per 0 days) 102

112 ARNUITY ELLIPTA INHALATION BLISTER QL (0 per 0 days) WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (0 DOSES), 220 MCG (120 DOSES), 220 MCG (1 DOSES), 220 MCG (0 DOSES), 220 MCG (60 DOSES) BECONASE AQ NASAL SPRAY,NON- AEROSOL 2 MCG (0.02 %) budesonide inhalation suspension for PA BvD nebulization 0.25 /2 ml, 0.5 /2 ml, 1 /2 ml FLOVENT DISKUS INHALATION BLISTER QL (60 per 0 days) WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (2 per 0 days) AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg 2 QL (50 per 0 days) (0.025 %) fluticasone nasal spray,suspension 50 1 QL (16 per 0 days) mcg/actuation mometasone nasal spray,non-aerosol 50 QL ( per 0 days) mcg/actuation OMNARIS NASAL SPRAY,NON-AEROSOL QL (12.5 per 0 days) 50 MCG PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QNASL NASAL HFA AEROSOL INHALER 0 MCG/ACTUATION, 80 MCG/ACTUATION Antileukotrienes montelukast oral granules in packet QL (0 per 0 days) montelukast oral tablet 10 1 QL (0 per 0 days) montelukast oral tablet,chewable, 5 1 QL (0 per 0 days) zafirlukast oral tablet 10, 20 QL (60 per 0 days) zileuton oral tablet, er multiphase 12 hr NDS 10

113 ZYFLO ORAL TABLET 600 MG 5 NDS Bronchodilators, Anticholinergic ATROVENT HFA INHALATION HFA QL (25.8 per 0 days) AEROSOL INHALER 17 MCG/ACTUATION INCRUSE ELLIPTA INHALATION BLISTER QL (0 per 0 days) WITH DEVICE 62.5 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % 2 PA BvD ipratropium bromide nasal spray,non-aerosol 2 QL (0 per 0 days) 0.0 % ipratropium bromide nasal spray,non-aerosol 2 2 QL (5 per 0 days) mcg (0.06 %) SPIRIVA RESPIMAT INHALATION MIST QL ( per 28 days) 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION QL (0 per 0 days) CAPSULE, W/INHALATION DEVICE 18 MCG TUDORZA PRESSAIR INHALATION QL (1 per 0 days) AEROSOL POWDR BREATH ACTIVATED 00 MCG/ACTUATION, 00 MCG/ACTUATION (0 ACTUAT) Bronchodilators, Sympathomimetic albuterol sulfate inhalation solution for 2 PA BvD nebulization 0.6 / ml, 1.25 / ml, 2.5 / ml (0.08 %), 5 /ml albuterol sulfate oral syrup 2 /5 ml 2 albuterol sulfate oral tablet 2, albuterol sulfate oral tablet extended release 12 hr, 8 ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG BREO ELLIPTA INHALATION BLISTER QL (60 per 0 days) WITH DEVICE MCG/DOSE, MCG/DOSE BROVANA INHALATION SOLUTION FOR PA BvD; QL (120 per 0 days) NEBULIZATION 15 MCG/2 ML DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION epinephrine injection auto-injector 0.15 /0.15 ml, 0.15 /0. ml, 0. /0. ml fluticasone-salmeterol inhalation aerosol powdr breath activated 11-1 mcg/actuation, 22-1 mcg/actuation, 55-1 mcg/actuation 2 10

114 levalbuterol hcl inhalation solution for PA BvD nebulization 0.1 / ml, 0.6 / ml, 1.25 /0.5 ml levalbuterol tartrate inhalation hfa aerosol QL (0 per 0 days) inhaler 5 mcg/actuation metaproterenol oral syrup 10 /5 ml metaproterenol oral tablet 10, 20 PERFOROMIST INHALATION SOLUTION PA BvD; QL (120 per 0 days) FOR NEBULIZATION 20 MCG/2 ML PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER QL (60 per 0 days) WITH DEVICE 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION terbutaline oral tablet 2.5, 5 terbutaline subcutaneous solution 1 /ml 5 NDS VENTOLIN HFA INHALATION HFA QL (6 per 0 days) AEROSOL INHALER 90 MCG/ACTUATION Cystic Fibrosis Agents CAYSTON INHALATION SOLUTION FOR 5 PA; NDS; QL (8 per 28 days) NEBULIZATION 75 MG/ML KALYDECO ORAL GRANULES IN PACKET 5 PA; NDS; QL (56 per 28 days) 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG 5 PA; NDS; QL (60 per 0 days) ORKAMBI ORAL TABLET MG, PA; LA; NDS; QL (112 per 28 days) 125 MG PULMOZYME INHALATION SOLUTION 1 5 PA; NDS; QL (150 per 0 days) MG/ML SYMDEKO ORAL TABLETS, SEQUENTIAL 5 PA; NDS; QL (60 per 0 days) MG (D)/ 150 MG (N) TOBI PODHALER INHALATION CAPSULE, 5 PA; NDS; QL (22 per 28 days) W/INHALATION DEVICE 28 MG Mast Cell Stabilizers cromolyn inhalation solution for nebulization 20 PA BvD /2 ml cromolyn oral concentrate 100 /5 ml Phosphodiesterase Inhibitors, Airways Disease DALIRESP ORAL TABLET 500 MCG QL (0 per 0 days) 105

115 theophylline oral tablet extended release 12 hr 2 100, 200, 50 theophylline oral tablet extended release 12 hr 2 00 theophylline oral tablet extended release 2 hr 2 00, 600 Pulmonary Antihypertensives ADCIRCA ORAL TABLET 20 MG 5 PA; NDS; QL (60 per 0 days) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, PA; NDS; QL (90 per 0 days) MG, 2 MG, 2.5 MG LETAIRIS ORAL TABLET 10 MG, 5 MG 5 NDS; QL (0 per 0 days) OPSUMIT ORAL TABLET 10 MG 5 PA; NDS; QL (0 per 28 days) ORENITRAM ORAL TABLET EXTENDED PA RELEASE MG ORENITRAM ORAL TABLET EXTENDED 5 PA; NDS RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG REVATIO ORAL SUSPENSION FOR 5 PA; NDS; QL (180 per 0 days) RECONSTITUTION 10 MG/ML sildenafil (antihypertensive) oral tablet 20 PA; QL (90 per 0 days) TRACLEER ORAL TABLET 125 MG, 62.5 MG 5 LA; NDS; QL (60 per 0 days) VENTAVIS INHALATION SOLUTION FOR 5 PA BvD; NDS; QL (270 per 0 days) NEBULIZATION 10 MCG/ML VENTAVIS INHALATION SOLUTION FOR 5 PA BvD; NDS; QL (90 per 0 days) NEBULIZATION 20 MCG/ML Respiratory Tract Agents, Other acetylcysteine solution 100 /ml (10 %), 200 PA BvD /ml (20 %) ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ARALAST NP INTRAVENOUS RECON SOLN 5 PA; NDS 1,000 MG BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER 9-.8 MCG GLASSIA INTRAVENOUS SOLUTION 1 5 PA; NDS GRAM/50 ML (2 %) LUMIZYME INTRAVENOUS RECON SOLN 5 NDS 50 MG PROLASTIN-C INTRAVENOUS RECON 5 PA; NDS SOLN 1,000 MG STIOLTO RESPIMAT INHALATION MIST QL ( per 28 days) MCG/ACTUATION TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG 106

116 ZEMAIRA INTRAVENOUS RECON SOLN 5 PA; NDS 1,000 MG Respiratory Tract/ Pulmonary Agents COMBIVENT RESPIMAT INHALATION QL ( per 20 days) MIST MCG/ACTUATION DYMISTA NASAL SPRAY,NON-AEROSOL MCG/SPRAY ESBRIET ORAL CAPSULE 267 MG 5 PA; NDS; QL (270 per 0 days) ESBRIET ORAL TABLET 267 MG, 801 MG 5 PA; NDS ipratropium-albuterol inhalation solution for 1 PA BvD nebulization (2.5 base)/ ml OFEV ORAL CAPSULE 100 MG, 150 MG 5 PA; NDS; QL (60 per 0 days) SYMBICORT MCG INHALER 60 QL (12 per 0 days) INHALATIONS MCG/ACTUATION SYMBICORT MCG INHALER 60 QL (1.8 per 0 days) INHALATIONS MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL QL (10.2 per 0 days) INHALER MCG/ACTUATION, MCG/ACTUATION XOLAIR SUBCUTANEOUS RECON SOLN 150 MG 5 NDS; QL (6 per 28 days) Skeletal Muscle Relaxants Skeletal Muscle Relaxants carisoprodol oral tablet 250, 50 PA; AGE (Max 6 Years) chlorzoxazone oral tablet 250, 500 cyclobenzaprine oral tablet 10, 5 PA; AGE (Max 6 Years) metaxall oral tablet 800 QL (120 per 0 days) metaxalone oral tablet 00 metaxalone oral tablet 800 QL (120 per 0 days) methocarbamol oral tablet 500, 750 orphenadrine citrate oral tablet extended release 100 Sleep Disorder Agents Gaba Receptor Modulators eszopiclone oral tablet 1, 2, QL (0 per 0 days) flurazepam oral capsule 15, 0 temazepam oral capsule 15, 0 2 QL (0 per 0 days) zaleplon oral capsule 10, 5 QL (0 per 0 days) zolpidem oral tablet 10 QL (0 per 0 days) zolpidem oral tablet 5 QL (60 per 0 days) 107

117 zolpidem oral tablet,ext release multiphase 12.5 QL (0 per 0 days) zolpidem oral tablet,ext release multiphase 6.25 QL (60 per 0 days) Sleep Disorders, Other armodafinil oral tablet 150, 200, 250 PA; QL (0 per 0 days) armodafinil oral tablet 50 PA; QL (60 per 0 days) BELSOMRA ORAL TABLET 10 MG, 15 MG, QL (0 per 0 days) 20 MG, 5 MG HETLIOZ ORAL CAPSULE 20 MG 5 PA; NDS; QL (0 per 28 days) modafinil oral tablet 100, 200 PA; QL (60 per 0 days) ROZEREM ORAL TABLET 8 MG QL (0 per 0 days) XYREM ORAL SOLUTION 500 MG/ML 5 PA; LA; NDS; QL (50 per 0 days) 108

118 INDEX A abacavir... 2 abacavir-lamivudine... 2 abacavir-lamivudine-zidovudine... 2 ABELCET... 2 ABILIFY MAINTENA... 7 ABRAXANE... 0 acamprosate... 7 acarbose... 5 acebutolol... 5 acetaminophen-codeine... acetasol hc acetazolamide acetic acid... 9 acetylcysteine acitretin... 6 ACTEMRA ACTHIB (PF)... 9 ACTIMMUNE ACUVAIL (PF) acyclovir... 1 acyclovir sodium... 1 ADACEL(TDAP ADOLESN/ADULT)(PF).. 9 ADAGEN... 7 adapalene... 6 ADCIRCA adefovir... 0 ADEMPAS ADLYXIN... 5 adrucil ADVAIR DISKUS ADVAIR HFA AEROSPAN afeditab cr AFINITOR... 2 AFINITOR DISPERZ AKYNZEO ala-cort ALBENZA... albuterol sulfate alclometasone... 76, 77 ALCOHOL PADS... 9 ALCOHOL PREP PADS... 9 ALECENSA... 2 alendronate alfuzosin ALIMTA ALINIA... ALIQOPA... 1 allopurinol... 2 almotriptan malate ALOCRIL alogliptin... 5 alogliptin-metformin... 5 alogliptin-pioglitazone... 5 ALOMIDE ALORA alosetron... 7 ALPHAGAN P alprazolam... ALREX altavera (28) ALUNBRIG... 2 ALVESCO alyacen 1/5 (28) alyacen 7/7/7 (28) amabelz amantadine hcl... 5 AMBISOME... 2 amethia amethia lo AMETHYST amikacin... 8 amiloride amiloride-hydrochlorothiazide56 AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone... 5 AMITIZA... 7 amitriptyline amitriptyline-chlordiazepoxide amlodipine amlodipine-atorvastatin... 56, 57 amlodipine-benazepril amlodipine-olmesartan amlodipine-valsartan ammonium lactate... 6 amnesteem... 6 amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate amphotericin b... 2 ampicillin ampicillin sodium... 12, 1 ampicillin-sulbactam

119 AMPYRA... 6 ANADROL anagrelide ANALPRAM-HC anastrozole... 1 ANDRODERM ANDROGEL ANORO ELLIPTA ANZEMET... 2 APOKYN... 5 apraclonidine aprepitant... 2 apri APTIOM APTIVUS... ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE)... 51, 52 ARCALYST ARCAPTA NEOHALER aripiprazole... 7 ARISTADA... 7 armodafinil ARMONAIR RESPICLICK 102 ARNUITY ELLIPTA ARYMO ER... ascomp with codeine... ashlyna ASMANEX HFA ASMANEX TWISTHALER 10 aspirin-dipyridamole ASSURE ID INSULIN SAFETY... 8 atazanavir... atenolol... 5 atenolol-chlorthalidone ATGAM atomoxetine atorvastatin atovaquone... atovaquone-proguanil... ATRIPLA... 2 atropine ATROVENT HFA AUBAGIO... 6 aubra AUSTEDO... 6 AVANDIA... 5 AVASTIN AVELOX IN NACL (ISO- OSMOTIC)... 1 aviane avita... 6 AVONEX... 6 AVONEX (WITH ALBUMIN)... 6 azacitidine AZASITE... 1 azathioprine azathioprine sodium azelastine... 99, 102 AZELEX... 6 azithromycin... 1 AZOPT aztreonam... 9, 12 azurette (28) B baciim... 9 bacitracin... 9 bacitracin-polymyxin b baclofen... 9 BACTROBAN NASAL... 9 balsalazide balziva (28) BANZEL BARACLUDE... 0 BAVENCIO... BCG VACCINE, LIVE (PF).. 9 BD INSULIN SYRINGE ULTRA-FINE... 8 BD ULTRA-FINE NANO PEN NEEDLE... 8 BECONASE AQ bekyree (28) BELEODAQ BELSOMRA benazepril... 5 benazepril-hydrochlorothiazide BENLYSTA benztropine... 5 BEPREVE BESIVANCE... 1 BESPONSA... betamethasone dipropionate betamethasone valerate betamethasone, augmented BETASERON... 6 betaxolol... 5, 99 bethanechol chloride BETHKIS... 8 BETOPTIC S BEVESPI AEROSPHERE bexarotene... BEXSERO... 9 bicalutamide BICILLIN C-R... 1 BICILLIN L-A... 1 BICNU BIKTARVY... 2 BILTRICIDE... bimatoprost bisoprolol fumarate... 5 bisoprolol-hydrochlorothiazide bleomycin bleph BLEPHAMIDE BLEPHAMIDE S.O.P blisovi 2 fe blisovi fe 1.5/0 (28) blisovi fe 1/20 (28) BOOSTRIX TDAP... 9 BORTEZOMIB BOSULIF

120 BREO ELLIPTA brevicon (28) briellyn BRILINTA brimonidine BRIVIACT bromfenac bromocriptine... 5 BROVANA budesonide... 96, 10 bumetanide buprenorphine... buprenorphine hcl... 7 buprenorphine-naloxone... 7 bupropion hcl bupropion hcl (smoking deter). 7 buspirone... butalbital compound w/codeine butalbital-acetaminop-caf-cod.. butalbital-acetaminophen... butalbital-acetaminophen-caff.. butalbital-aspirin-caffeine... butorphanol tartrate... 6 BYDUREON... 5 BYDUREON BCISE... 5 BYETTA... 6 BYSTOLIC C cabergoline CABOMETYX... 2 calcipotriene... 6 calcitonin (salmon) calcitriol... 6, 97 calcium acetate CALQUENCE... 2 camila camrese camrese lo CANASA CANCIDAS... 2 candesartan... 5 candesartan-hydrochlorothiazid capacet... CAPASTAT CAPRELSA... 2 captopril... 5 captopril-hydrochlorothiazide 57 CARAFATE... 7 CARBAGLU carbamazepine... 18, 5 carbidopa... 5 carbidopa-levodopa... 6 carbidopa-levodopa-entacapone... 5 carboplatin CARIMUNE NF NANOFILTERED carisoprodol carteolol cartia xt carvedilol carvedilol phosphate caspofungin... 2 CAYSTON caziant (28) cefaclor cefadroxil cefazolin cefazolin in 0.9% sod chloride11 cefdinir CEFEPIME CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM cefixime cefotaxime cefotetan cefotetan in dextrose, iso-osm 11 cefoxitin cefoxitin in dextrose, iso-osm 11 cefpodoxime cefprozil ceftazidime ceftriaxone ceftriaxone in dextrose,iso-os. 11 cefuroxime axetil cefuroxime sodium cefuroxime-dextrose (iso-osm) celecoxib... CELLCEPT CELONTIN cephalexin CEREZYME... 7 CESAMET... 2 cetirizine CETRAXAL cevimeline... 6 CHANTIX... 7 CHANTIX CONTINUING MONTH BOX... 7 CHANTIX STARTING MONTH BOX... 7 chateal chloramphenicol sod succinate. 9 chlordiazepoxide hcl... chlordiazepoxide-clidinium chlorhexidine gluconate... 6 chloroquine phosphate... chlorothiazide chlorothiazide sodium chlorpromazine... 6 chlorthalidone chlorzoxazone CHOLBAM cholestyramine (with sugar) cholestyramine light CIALIS ciclopirox... 2 cidofovir... 9 cilostazol CILOXAN... 1 cimetidine

121 cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRO HC CIPRODEX ciprofloxacin... 1 ciprofloxacin hcl... 1 ciprofloxacin lactate... 1 citalopram claravis... 6 clarithromycin... 1 clemastine CLIMARA PRO clindamycin hcl... 9 clindamycin in 5 % dextrose... 9 clindamycin palmitate hcl... 9 clindamycin phosphate... 9 clindamycin-benzoyl peroxide65 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX.25%/D10W SULF FREE CLINIMIX.25%/D5W SULFIT FREE CLINIMIX.25%-D20W SULF-FREE CLINIMIX.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E.25%/D10W SUL FREE CLINIMIX E.25%/D25W SUL FREE CLINIMIX E.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE clobetasol... 65, 77 clobetasol-emollient clomipramine clonazepam..., 5 clonidine... 5 clonidine hcl... 5, 62 clopidogrel... 52, 5 clorazepate dipotassium... 5 clorpres... 5 clotrimazole... 2 clotrimazole-betamethasone clozapine... 9 COARTEM... codeine sulfate... 6 colchicine COLCRYS colestipol colistin (colistimethate na)... 8 colocort COLY-MYCIN S COMBIGAN COMBIVENT RESPIMAT. 107 COMETRIQ... 2 COMPLERA... 1 compro constulose... 7 COPAXONE... 6 CORDRAN TAPE LARGE ROLL COREG CR CORLANOR cormax cortisone CORTISPORIN COSENTYX (2 SYRINGES). 65 COSENTYX PEN (2 PENS).. 65 COSOPT COSOPT (PF) COTELLIC... 2 COUMADIN CREON... 7 CRIXIVAN... cromolyn... 99, 105 cryselle (28) cyclafem 1/5 (28) cyclafem 7/7/7 (28) cyclobenzaprine cyclopentolate cyclophosphamide CYCLOPHOSPHAMIDE CYCLOSET... 6 cyclosporine cyclosporine modified cyproheptadine CYRAMZA... cyred CYSTADANE... 7 CYSTARAN D d10 %-0.5 % sodium chloride d2.5 %-0.5 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.5 % sodium chloride 70 DALIRESP danazol dantrolene... 9 dapsone... 27, 65 DAPTACEL (DTAP PEDIATRIC) (PF)... 9 daptomycin... 9 DARAPRIM

122 darifenacin DARZALEX... dasetta 1/5 (28) dasetta 7/7/7 (28) deblitane deltasone delyla (28) DELZICOL... 7 demeclocycline DEMSER denta 5000 plus... 6 dentagel... 6 DEPEN TITRATABS DEPO-MEDROL DEPO-PROVERA DEPO-SUBQ PROVERA DEPO-TESTOSTERONE DESCOVY... 2 desipramine desloratadine desmopressin... 78, 79 desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol desonide desoximetasone desvenlafaxine succinate dexamethasone dexamethasone sodium phosphate... 25, 100 dexmethylphenidate dexrazoxane hcl dextroamphetamine dextroamphetamineamphetamine... 61, 62 dextrose 10 % and 0.2 % nacl 70 dextrose 10 % in water (d10w) dextrose 5 % in water (d5w).. 70 dextrose 5 %-lactated ringers. 70 dextrose 5%-0.2 % sod chloride dextrose 5%-0. % sod.chloride DIASTAT DIASTAT ACUDIAL diazepam... 16, 5 diazepam intensol... 5 diclofenac potassium diclofenac sodium., 26, 65, 100 diclofenac-misoprostol... dicloxacillin... 1 dicyclomine didanosine... 2 DIFICID... 1 diflunisal... digitek digox digoxin DIGOXIN dihydroergotamine DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN diltiazem hcl... 55, 56 dilt-xr diphenhydramine hcl diphenoxylate-atropine dipyridamole... 5 disopyramide phosphate... 5 disulfiram... 7 DIURIL divalproex... 16, 17 dofetilide... 5 donepezil dorzolamide dorzolamide-timolol doxazosin... 5 doxepin doxercalciferol doxorubicin, peg-liposomal doxy doxycycline hyclate doxycycline monohydrate dronabinol... 2 drospirenone-e.estradiol-lm.fa 81 drospirenone-ethinyl estradiol 82 DROXIA DULERA duloxetine DURAMORPH (PF)... 5 DUREZOL dutasteride dutasteride-tamsulosin DYMISTA E econazole... 2 EDURANT... 1 efavirenz... 1 EGRIFTA eletriptan hbr ELIDEL elinest eliphos ELIQUIS ELITEK ELMIRON EMCYT EMFLAZA emoquette EMPLICITI... EMSAM EMTRIVA... 2 enalapril maleate... 5 enalapril-hydrochlorothiazide. 57 ENBREL ENBREL SURECLICK endocet... ENGERIX-B (PF)... 9 ENGERIX-B PEDIATRIC (PF)... 9 enoxaparin enpresse enskyce entacapone

123 entecavir... 0 ENTRESTO... 5 enulose... 7 ENVARSUS XR EPCLUSA... 0 epinastine epinephrine epirubicin epitol EPIVIR HBV... 0 eplerenone eprosartan... 5 EPZICOM... 2 EQUETRO ergoloid ergotamine-caffeine ERIVEDGE... 2 ERLEADA errin ery pads... 1 ery-tab... 1 ERY-TAB... 1 ERYTHROCIN... 1 erythromycin... 1 erythromycin ethylsuccinate.. 1 erythromycin with ethanol... 1 erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate... 20, 21 esomeprazole magnesium... 7 estarylla ESTRACE estradiol... 80, 82 estradiol-norethindrone acet ESTRING estropipate eszopiclone ethacrynic acid ethambutol ethosuximide ethynodiol diac-eth estradiol.. 82 etidronate disodium etodolac... ETOPOPHOS... 1 etoposide... 1 EVOTAZ... exemestane... 1 EXJADE EXTAVIA... 6 ezetimibe ezetimibe-simvastatin F FABRAZYME... 7 falmina (28) famciclovir... 1 famotidine... 7 famotidine (pf) famotidine (pf)-nacl (iso-os). 7 FANAPT... 7 FARESTON FARXIGA... 6 FARYDAK... 1 FASLODEX fayosim FAZACLO... 9 felbamate felodipine femynor fenofibrate... 59, 60 fenofibrate micronized fenofibrate nanocrystallized fenofibric acid fenofibric acid (choline) fentanyl... 5 fentanyl citrate... 6 FERRIPROX FETZIMA FIASP FLEXTOUCH U-100 INSULIN... 8 FIASP U-100 INSULIN... 8 FINACEA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE FLAREX flavoxate flecainide... 5 FLECTOR FLOVENT DISKUS FLOVENT HFA fluconazole... 2 fluconazole in dextrose(iso-o) 2 fluconazole in nacl (iso-osm). 2 flucytosine... 2 fludrocortisone flunisolide fluocinolone fluocinolone acetonide oil fluocinolone and shower cap.. 77 fluocinonide... 65, 77 fluocinonide-e fluoride (sodium)... 66, 67 fluorometholone fluorouracil fluoxetine fluphenazine decanoate... 6 fluphenazine hcl... 6 flurazepam flurbiprofen... flurbiprofen sodium flutamide fluticasone... 65, 10 fluticasone-salmeterol fluvastatin fluvoxamine FML FORTE FML LIQUIFILM FML S.O.P fondaparinux FORTEO fosamprenavir... fosinopril... 5 fosinopril-hydrochlorothiazide

124 fosphenytoin FOSRENOL FREAMINE HBC 6.9 % frovatriptan furosemide FUZEON... fyavolv FYCOMPA G gabapentin GABITRIL galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMMAPLEX (WITH SORBITOL) GAMUNEX-C ganciclovir sodium... 9 GARDASIL (PF)... 9 GARDASIL 9 (PF)... 9 gatifloxacin... 1 GATTEX 0-VIAL GAUZE PAD... 8 gavilyte-c... 7 gavilyte-g... 7 gavilyte-h and bisacodyl... 7 gavilyte-n... 7 gemfibrozil generlac... 7 gengraf gentak... 8 gentamicin... 8 gentamicin in nacl (iso-osm)... 8 gentamicin sulfate (ped) (pf)... 8 gentamicin sulfate (pf)... 8 GENVOYA... 1 GEODON... 7 gianvi (28) GIAZO... 7 gildagia gildess 1.5/0 (21) gildess 2 fe GILENYA... 6 GILOTRIF... 2 GLASSIA glatiramer... 6 glatopa... 6 GLEOSTINE glimepiride... 6 glipizide... 6 glipizide-metformin... 7 GLUCAGEN HYPOKIT... 7 GLUCAGON EMERGENCY KIT (HUMAN)... 8 glycopyrrolate GLYXAMBI... 6 granisetron (pf)... 2 granisetron hcl... 2 GRANIX griseofulvin microsize... 2 griseofulvin ultramicrosize... 2 guanfacine... 5 guanidine H halobetasol propionate haloperidol... 6 haloperidol decanoate... 6 haloperidol lactate... 6 HARVONI... 0 HAVRIX (PF)... 9, 9 heather heparin (porcine) heparin (porcine) in 5 % dex.. 51 heparin (porcine) in nacl (pf).. 51 heparin(porcine) in 0.5% nacl HEPARIN(PORCINE) IN 0.5% NACL heparin, porcine (pf) HEPATAMINE 8% HERCEPTIN HETLIOZ HEXALEN HIBERIX (PF)... 9 HUMALOG KWIKPEN INSULIN... 8 HUMALOG MIX INSULN U HUMALOG MIX KWIKPEN... 8 HUMALOG MIX KWIKPEN... 8 HUMALOG MIX 75-25(U- 100)INSULN... 8 HUMALOG U-100 INSULIN 8 HUMIRA HUMIRA PEDIATRIC CROHN'S START HUMIRA PEN HUMIRA PEN CROHN'S-UC- HS START HUMIRA PEN PSORIASIS- UVEITIS HUMULIN 70/0 U-100 INSULIN... 9 HUMULIN 70/0 U-100 KWIKPEN... 9 HUMULIN N NPH INSULIN KWIKPEN... 9 HUMULIN N NPH U-100 INSULIN... 9 HUMULIN R REGULAR U- 100 INSULN... 9 HUMULIN R U-500 (CONC) INSULIN... 9 HUMULIN R U-500 (CONC) KWIKPEN... 9 HYCAMTIN... 1 hydralazine hydrochlorothiazide hydrocodone-acetaminophen... hydrocodone-ibuprofen... hydrocortisone... 25, 78, 96 hydrocortisone butyrate... 77, 78 hydrocortisone valerate

125 hydrocortisone-acetic acid hydromorphone... 5, 6 hydromorphone (pf)... 5 hydroxychloroquine... hydroxyurea hydroxyzine hcl I ibandronate IBRANCE... 1 ibu... ibuprofen... ICLUSIG... 2 IDHIFA... 1 ILARIS (PF) ILEVRO imatinib... 2 IMBRUVICA... 2 IMFINZI... imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES VACCINE (PF)... 9 INCRELEX INCRUSE ELLIPTA indapamide indomethacin... INFANRIX (DTAP) (PF)... 9 INLYTA... 2 INSULIN SYRINGE-NEEDLE U INTELENCE... 1 INTRALIPID INTRON A... 0 introvale INVANZ INVEGA SUSTENNA... 7 INVEGA TRINZA... 8 INVIRASE... INVOKAMET... 6 INVOKAMET XR... 6 INVOKANA... 6 IPOL... 9 ipratropium bromide ipratropium-albuterol irbesartan... 5 irbesartan-hydrochlorothiazide IRESSA... 2 ISENTRESS... 1 ISENTRESS HD... 1 isibloom isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin itraconazole... 2 ivermectin... IXIARO (PF)... 9 J JADENU JADENU SPRINKLE JAKAFI... 2 jantoven JANUMET... 7 JANUMET XR... 7 JANUVIA... 6 JARDIANCE... 6 jencycla JENTADUETO... 6 JENTADUETO XR... 6 jinteli jolessa jolivette juleber JULUCA... 2 junel 1.5/0 (21) junel 1/20 (21) junel fe 1.5/0 (28) junel fe 1/20 (28) junel fe K KADCYLA kaitlib fe... 8 KALETRA... KALYDECO kariva (28)... 8 kelnor 1/5 (28)... 8 kelnor ketoconazole... 2 ketoprofen ketorolac..., 101 KEVZARA KEYTRUDA... kimidess (28)... 8 KINERET KINRIX (PF)... 9 kionex (with sorbitol) KISQALI... 1 KISQALI FEMARA CO-PACK... 1 KLOR-CON KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle KOMBIGLYZE XR... 7 KORLYM... 8 K-SOL K-TAB kurvelo... 8 KUVAN... 7 L l norgest/e.estradiol-e.estrad... 8 labetalol LACTATED RINGERS lactulose... 7 lamivudine... 2 lamivudine-zidovudine... 2 lamotrigine LANOXIN lansoprazole... 7 lanthanum

126 LANTUS SOLOSTAR U-100 INSULIN... 9 LANTUS U-100 INSULIN... 9 larin 1.5/0 (21)... 8 larin 1/20 (21)... 8 larin 2 fe... 8 larin fe 1.5/0 (28)... 8 larin fe 1/20 (28)... 8 larissia... 8 LARTRUVO... LASTACAFT latanoprost LATUDA... 8 layolis fe... 8 leena leflunomide LENVIMA... 2, lessina... 8 LETAIRIS letrozole... 1 leucovorin calcium... 0, 1 LEUKERAN LEUKINE leuprolide levalbuterol hcl levalbuterol tartrate LEVEMIR FLEXTOUCH U- 100 INSULN... 9 LEVEMIR U-100 INSULIN.. 9 levetiracetam levetiracetam in nacl (iso-os). 16 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 1 levofloxacin in d5w... 1 levoleucovorin levonest (28)... 8 levonorgestrel-ethinyl estrad.. 8 levonorg-eth estrad triphasic.. 8 levora levorphanol tartrate... 5 levothyroxine LEVOXYL LEXIVA... LIALDA lidocaine... 7 lidocaine (pf)... 6 lidocaine hcl... 6, 7 lidocaine hcl(pf) in 0.9% nacl.. 7 lidocaine viscous... 7 lidocaine-prilocaine... 7 lillow... 8 lincomycin... 9 lindane... 5 linezolid... 9, 10 linezolid-0.9% sodium chloride LINZESS... 7 liothyronine lisinopril... 5 lisinopril-hydrochlorothiazide 57 lithium carbonate... 5 lithium citrate... 5 lomedia 2 fe... 8 LONSURF loperamide lopinavir-ritonavir... lopreeza... 8 lorazepam... 5 lorcet (hydrocodone)... lorcet hd... lorcet plus... loryna (28)... 8 losartan... 5 losartan-hydrochlorothiazide.. 57 LOTEMAX lovastatin low-ogestrel (28)... 8 loxapine succinate... 6 LUMIGAN LUMIZYME LUPRON DEPOT LUPRON DEPOT ( MONTH) LUPRON DEPOT ( MONTH) LUPRON DEPOT (6 MONTH) lutera (28)... 8 LYNPARZA... 29, 0 LYRICA LYSODREN lyza M mafenide acetate magnesium sulfate malathion... 5 maprotiline marlissa... 8 MARPLAN marten-tab... MATULANE matzim la MAVYRET... 0 MAXIDEX meclizine medroxyprogesterone mefloquine... megestrol MEKINIST... melodetta 2 fe... 8 meloxicam... memantine MENACTRA (PF)... 9 MENEST MENHIBRIX (PF)... 9 MENOMUNE - A/C/Y/W MENOMUNE - A/C/Y/W-15 (PF)... 9 MENVEO A-C-Y-W-15-DIP (PF)... 9 meperidine... 6 meprobamate

127 MEPRON... mercaptopurine meropenem mesalamine mesna... 0 MESNEX... 0 metadate er metaproterenol metaxall metaxalone metformin... 6 methadone... 5 methazolamide methenamine hippurate methimazole methocarbamol methotrexate sodium methotrexate sodium (pf). 90, 91 methoxsalen methscopolamine methyclothiazide methyldopa... 5 methyldopa-hydrochlorothiazide methylergonovine methylphenidate hcl methylprednisolone... 25, 78 methylprednisolone sodium succ... 25, 78 metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole metronidazole in nacl (iso-os) 10 mexiletine... 5 MIACALCIN mibelas 2 fe... 8 miconazole microgestin 1.5/0 (21)... 8 microgestin 1/20 (21)... 8 microgestin 2 fe... 8 microgestin fe 1.5/0 (28)... 8 microgestin fe 1/20 (28)... 8 midodrine... 5 MIGERGOT miglitol... 6 mimvey... 8 mimvey lo... 8 minocycline minoxidil mirtazapine misoprostol... 7 mitoxantrone... 1 M-M-R II (PF)... 9 modafinil moexipril... 5 moexipril-hydrochlorothiazide molindone... 6 mometasone... 78, 10 mono-linyah... 8 mononessa (28)... 8 montelukast morphine... 5, 6 MORPHINE... 5 morphine concentrate... 5 MOVANTIK MOXEZA... 1 moxifloxacin... 1 moxifloxacin-sod.ace,sul-water MOZOBIL MULTAQ... 5 mupirocin mupirocin calcium MUSTARGEN... 0 MYALEPT mycophenolate mofetil mycophenolate mofetil hcl mycophenolate sodium MYLOTARG... myorisan MYRBETRIQ myzilra... 8 N nabumetone... nadolol nadolol-bendroflumethiazide.. 57 nafcillin... 1 naftifine... 2 NAFTIN... 2 NAGLAZYME... 7 naloxone... 7 naltrexone... 7 NAMENDA XR NAMZARIC naphazoline naproxen naproxen sodium naratriptan NARCAN... 7 NATACYN... 2 NATAZIA... 8 nateglinide... 6 NATPARA NAVELBINE... 1 NEBUPENT... necon 0.5/5 (28)... 8 necon 1/50 (28)... 8 necon 10/11 (28)... 8 necon 7/7/7 (28)... 8 nefazodone neomycin... 8 neomycin-bacitracin-poly-hc.. 98 neomycin-bacitracin-polymyxin neomycin-polymyxin b gu... 8 neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc. 98,

128 neo-polycin neo-polycin hc NEOSPORIN (NEO-POLYM- GRAMICID) NEPHRAMINE 5. % NERLYNX... neuac NEULASTA NEUPOGEN NEUPRO... 5 NEVANAC nevirapine... 1, 2 NEXAVAR... niacin nicardipine NICOTROL... 7 NICOTROL NS... 7 nifedical xl nifedipine nikki (28)... 8 nilutamide nimodipine NINLARO... 0 nisoldipine NITRO-BID nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst nitroglycerin NITROSTAT nizatidine... 7 nora-be... 8 NORDITROPIN FLEXPRO.. 79 noreth-ethinyl estradiol-iron... 8 norethindrone (contraceptive) 87 norethindrone acetate norethindrone ac-eth estradiol 8 norethindrone-e.estradiol-iron 8 norgestimate-ethinyl estradiol 85 norinyl 1/5 (28) norlyda norlyroc NORTHERA... 5 nortrel 0.5/5 (28) nortrel 1/5 (21) nortrel 1/5 (28) nortrel 7/7/7 (28) nortriptyline NORVIR... NOVOLIN 70/0 U-100 INSULIN... 9 NOVOLIN N NPH U-100 INSULIN... 9 NOVOLIN R REGULAR U- 100 INSULN... 9 NOVOLOG FLEXPEN U-100 INSULIN... 9 NOVOLOG MIX 70-0 U-100 INSULN NOVOLOG MIX 70-0FLEXPEN U NOVOLOG PENFILL U-100 INSULIN NOVOLOG U-100 INSULIN ASPART NOXAFIL... 2 NUCYNTA... 6 NUCYNTA ER... 5 NUEDEXTA... 6 NULOJIX NUPLAZID... 8 NUTRILIPID nyamyc... 2 nyata... 2 nystatin... 2 nystatin-triamcinolone nystop... 2 O ocella octreotide acetate ODEFSEY... 2 ODOMZO... OFEV ofloxacin... 15, 102 ogestrel (28) olanzapine... 8 olmesartan... 5 olmesartan-amlodipin-hcthiazid olmesartan-hydrochlorothiazide... 5 olopatadine... 99, 102 omega- acid ethyl esters omeprazole... 7 OMNARIS ondansetron... 2 ondansetron hcl... 2 ondansetron hcl (pf)... 2 ONFI ONGLYZA... 6 OPANA ER... 5 OPDIVO... OPSUMIT oralone... 6 ORENCIA ORENCIA CLICKJECT ORENITRAM ORKAMBI orphenadrine citrate orsythia oseltamivir... OTEZLA OTEZLA STARTER oxaliplatin... 0 oxandrolone oxaprozin oxazepam... oxcarbazepine oxiconazole oxybutynin chloride oxycodone... 5, 6 oxycodone-acetaminophen... oxycodone-aspirin... OXYCONTIN... 5 oxymorphone

129 OZEMPIC... 6 P pacerone... 5 paclitaxel... 0 paliperidone... 8 pamidronate PANCREAZE... 7 PANRETIN... pantoprazole... 7 paricalcitol PARICALCITOL paroex oral rinse... 6 paromomycin... 8 paroxetine hcl PASER PATADAY PAXIL PEDIARIX (PF)... 9 PEDVAX HIB (PF)... 9 peg 50-electrolytes... 7 PEGANONE PEGASYS... 0 PEGASYS CONVENIENCE PACK... 0 PEGASYS PROCLICK... 0 peg-electrolyte soln... 7 PEGINTRON... 0 PEGINTRON REDIPEN... 0 PEN NEEDLE, DIABETIC penicillin g pot in dextrose... 1 penicillin g potassium... 1 penicillin v potassium... 1 PENTACEL (PF)... 9 PENTACEL DTAP-IPV COMPNT (PF)... 9 PENTAM... 5 PENTASA pentoxifylline PERFOROMIST perindopril erbumine... 5 periogard... 6 PERJETA... 0 permethrin... 5 perphenazine perphenazine-amitriptyline pfizerpen-g... 1 phenadoz phenelzine phenobarbital phenoxybenzamine... 5 PHENYTEK phenytoin phenytoin sodium phenytoin sodium extended philith PHOSLYRA PHOSPHOLINE IODIDE phrenilin forte(with caffeine)... PHYSIOSOL IRRIGATION.. 67 PICATO pilocarpine hcl... 6, 100 pimozide... 6 pimtrea (28) pindolol pioglitazone... 6 pioglitazone-glimepiride... 7 pioglitazone-metformin... 7 piperacillin-tazobactam... 1 pirmella piroxicam PLEGRIDY... 6 PLENAMINE podofilox polycin polyethylene glycol polymyxin b sulfate polymyxin b sulf-trimethoprim POMALYST portia potassium chlorid-d5-0.5%nacl potassium chloride... 67, 71 potassium chloride in lr-d potassium chloride in water potassium chloride-d5-0.%nacl potassium chloride-d5-0.9%nacl potassium citrate POTIGA PRADAXA PRALUENT PEN pramipexole... 5 PRAMOSONE prasugrel... 5 pravastatin prazosin... 5 PRED MILD prednicarbate... 66, 78 prednisolone prednisolone acetate prednisolone sodium phosphate... 26, 78, 101 prednisone... 26, 78 PREMARIN PREMASOL 10 % PREMASOL 6 % PREMPHASE PREMPRO prenatal plus (calcium carb) prenatal vitamin plus low iron 71 prevalite previfem PREZCOBIX... PREZISTA... PRIFTIN PRIMAQUINE... 5 primidone PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine prochlorperazine prochlorperazine edisylate

130 prochlorperazine maleate PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc PROCYSBI progesterone micronized PROGLYCEM... 8 PROGRAF PROLASTIN-C PROLEUKIN... 0 PROLIA PROMACTA promethazine promethegan propafenone... 5 propantheline proparacaine propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSOL 20 % protriptyline PULMICORT FLEXHALER PULMOZYME PURIXAN pyrazinamide pyridostigmine bromide Q QNASL QTERN... 6 QUADRACEL (PF) quasense quetiapine... 8 quinapril... 5 quinapril-hydrochlorothiazide 58 quinidine gluconate... 5 quinidine sulfate... 5 quinine sulfate... 5 R RABAVERT (PF) rabeprazole... 7 rajani raloxifene ramipril... 5 RANEXA ranitidine hcl... 7 RAPAFLO RAPAMUNE rasagiline... 6 RAVICTI RAYALDEE REBIF (WITH ALBUMIN)... 6 REBIF REBIDOSE... 6, 6 REBIF TITRATION PACK... 6 reclipsen (28) RECOMBIVAX HB (PF) REGRANEX RELENZA DISKHALER... RELISTOR REMICADE RENAGEL RENFLEXIS RENVELA repaglinide... 6 REPATHA PUSHTRONEX.. 60 REPATHA SURECLICK REPATHA SYRINGE reprexain... RESCRIPTOR... 2 RESTASIS RETROVIR... 2 REVATIO REVLIMID... 28, 1 REXULTI... 8 REYATAZ... ribasphere... 0 ribavirin... 0 RIDAURA rifabutin rifampin RIFATER riluzole... 6 rimantadine... ringer's risedronate RISPERDAL CONSTA... 8 risperidone... 8, 9 ritonavir... RITUXAN... rivastigmine rivastigmine tartrate rivelsa rizatriptan ropinirole... 5 rosadan rosuvastatin ROTARIX ROTATEQ VACCINE ROWEEPRA ROWEEPRA XR ROZEREM RUBRACA... 0 RYDAPT... S SABRIL SAMSCA SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS (BLACK CHERRY)... 9 SAVELLA... 6 scopolamine base selegiline hcl... 6 selenium sulfide SELZENTRY... SENSIPAR SEREVENT DISKUS sertraline setlakin

131 sevelamer carbonate sf 5000 plus... 6 sharobel SHINGRIX (PF) SIGNIFOR sildenafil (antihypertensive). 106 SILENOR SILIQ silver sulfadiazine SIMBRINZA SIMPONI... 91, 9 SIMPONI ARIA simvastatin sirolimus SIRTURO SIVEXTRO sodium chloride... 67, 71 sodium chloride 0.5 % sodium chloride 0.9 % sodium chloride % sodium chloride 5 % sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate. 68 SOLIQUA 100/... 7 SOLTAMOX SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF) SOMATULINE DEPOT SOMAVERT sorine... 5 sotalol... 5 sotalol af... 5 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX... 2 sprintec (28) SPRITAM SPRYCEL... sps (with sorbitol) sronyx ssd stavudine... 2 STELARA STERILE PADS STIMATE STIOLTO RESPIMAT STIVARGA... STRATTERA STRENSIQ streptomycin... 8 STRIBILD... 1 STRIVERDI RESPIMAT SUBOXONE... 7 SUCRAID sucralfate... 7 sulfacetamide sodium... 15, 99 sulfacetamide sodium (acne).. 15 sulfacetamide-prednisolone sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine sulfatrim sulindac... sumatriptan sumatriptan succinate SUPRAX SUPREP BOWEL PREP KIT 67 SUSTIVA... 2 SUTENT... syeda SYLATRON... 1 SYMBICORT SYMDEKO SYMFI LO... 2 SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID... 9 SYNJARDY... 7 SYNRIBO... 1 SYNTHROID SYPRINE T TABLOID tacrolimus... 66, 92 TAFINLAR... TAGRISSO... TALTZ AUTOINJECTOR TALTZ SYRINGE TAMIFLU... tamoxifen tamsulosin TANZEUM... 7 TARCEVA... TARGRETIN... tarina fe 1/20 (28) TASIGNA... tazarotene TAZORAC taztia xt TECENTRIQ... TECFIDERA... 6 TEFLARO TEGRETOL telmisartan... 5 telmisartan-hydrochlorothiazid temazepam tencon... TENIVAC (PF) tenofovir disoproxil fumarate. 2 terazosin... 5 terbinafine hcl... 2 terbutaline terconazole... 2 testosterone

132 testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine... 6 tetracycline THALOMID theophylline thioridazine... 6 thiothixene... 6 THYMOGLOBULIN THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine tilia fe timolol maleate... 55, 100 tinidazole TIVICAY... 1 tizanidine... 9 TOBI PODHALER TOBRADEX... 8 TOBRADEX ST tobramycin... 8 tobramycin in % nacl... 8 tobramycin sulfate... 8 tobramycin-dexamethasone TOBREX... 8 TOLAK tolcapone... 5 tolterodine topiramate... 17, 18 toposar... 1 topotecan... 1 torsemide TOUJEO SOLOSTAR U-00 INSULIN TOVIAZ TPN ELECTROLYTES TPN ELECTROLYTES II TRACLEER TRADJENTA... 7 tramadol... 5, 6 tramadol-acetaminophen... trandolapril... 5 tranexamic acid TRANSDERM-SCOP tranylcypromine TRAVASOL 10 % TRAVATAN Z travoprost (benzalkonium) trazodone TREANDA... 0 TRECATOR TRELEGY ELLIPTA TRESIBA FLEXTOUCH U TRESIBA FLEXTOUCH U tretinoin tretinoin (chemotherapy)... TREXALL tri femynor triamcinolone acetonide... 6, 78 triamterene-hydrochlorothiazid triderm tridesilon trientine tri-estarylla trifluoperazine... 7 trifluridine... 1 trihexyphenidyl... 5 tri-legest fe tri-linyah tri-lo-estarylla tri-lo-sprintec trilyte with flavor packets... 7 trimethoprim trimipramine TRIMPEX trinessa (28) trinessa lo TRINTELLIX tri-previfem (28) TRISENOX... 0 tri-sprintec (28) TRIUMEQ... trivora (28) tri-vylibra TROGARZO... TROPHAMINE 10 % TROPHAMINE 6% trospium TRULICITY... 7 TRUMENBA TRUSOPT TRUVADA... TUDORZA PRESSAIR TWINRIX (PF) TYBOST... tydemy TYGACIL TYKERB... TYMLOS TYPHIM VI TYSABRI... 6 U UCERIS ULORIC UPTRAVI... 58, 59 ursodiol V valacyclovir... 1 VALCHLOR valganciclovir... 9 valproate sodium valproic acid valproic acid (as sodium salt). 17 valsartan... 5 valsartan-hydrochlorothiazide 58 vancomycin

133 VAQTA (PF)... 95, 96 VARIVAX (PF) VASCEPA VELCADE... 0 velivet triphasic regimen (28) 86 VEMLIDY... 0 VENCLEXTA... 0 VENCLEXTA STARTING PACK... 0 venlafaxine VENTAVIS VENTOLIN HFA verapamil VERSACLOZ... 9 VERZENIO... 1 VESICARE vestura (28) VGO VIBERZI... 7 vicodin... vicodin es... vicodin hp... VICTOZA... 7 VIDEX 2 GRAM PEDIATRIC... VIDEX GRAM PEDIATRIC... vienva vigabatrin VIIBRYD VIMPAT VIRACEPT... VIRAZOLE... 1 VIREAD... 0, voriconazole... 2 VOSEVI... 0 VOTRIENT... VPRIV VRAYLAR... 9 vyfemla (28) vylibra VYVANSE VYXEOS... 0 W warfarin water for irrigation, sterile WELCHOL wera (28) wymzya fe X XADAGO... 6 XALKORI... XARELTO XATMEP XELJANZ XELJANZ XR XGEVA XIFAXAN XIGDUO XR... 7 XIIDRA XOLAIR XTANDI xulane XULTOPHY 100/ xylon XYREM Y YERVOY... 1 YF-VAX (PF) YONDELIS... 0 yuvafem Z zafirlukast zaleplon zarah ZARXIO ZAVESCA ZEJULA... 0 ZELBORAF... ZEMAIRA zenatane zenchent (28) zenchent fe ZENPEP zenzedi ZEPATIER... 1 ZERBAXA ZERIT... ZIAGEN... zidovudine... zileuton ZINBRYTA... 6 ZIOPTAN (PF) ziprasidone hcl... 9 ZIRGAN... 9 zoledronic acid zoledronic acid-mannitol-water zoledronic ac-mannitol-0.9nacl ZOLINZA... 2 zolmitriptan zolpidem , 108 zonisamide ZONTIVITY... 5 ZORTRESS ZOSTAVAX (PF) zovia 1/5e (28) zovia 1/50e (28) ZYCLARA ZYDELIG... 2 ZYFLO ZYKADIA... ZYLET ZYPREXA RELPREVV... 9 ZYTIGA

134 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI TTY 711 Fax a.m. 8 p.m., 7 days a week This formulary was updated on April 26, For more recent information or other questions, please contact Security Health Plan Customer Service at or, for TTY users, 711, from 8 a.m. to 8 p.m., 7 days a week, or visit Security Health Plan of Wisconsin, Inc.