2018 Formulary. (List of Covered Prescription and Over-the-Counter Drugs)

Transcription

1 08 Formulary (List of Covered Prescription and Over-the-Counter Drugs) UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC Plus) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THESE PLANS. Other drug coverage: If you have Medicare, you need to get most of your prescription drugs through the Medicare Prescription Drug Program (Medicare Part D). You must be enrolled in a Medicare prescription drug plan to get these services. UCare does not pay for prescriptions that are covered under the Medicare Prescription Drug Program. PMAP MnCare MSC+ SNBC_07_ DHS Approved (707)

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3 Civil Rights Notice Discrimination is against the law. UCare does not discriminate on the basis of any of the following: Race Sex (including sex stereotypes and Color gender identity) National Origin Marital Status Creed Political Beliefs Religion Medical Condition Sexual Orientation Health Status Public Assistance Status Receipt of Health Care Services Age Claims Experience Disability (including physical or Medical History mental impairment) Genetic Information Auxiliary Aids and Services. UCare provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner, to ensure an equal opportunity to participate in our health care programs. Contact UCare at (voice) or (voice), (TTY), or (TTY). Language Assistance Services. UCare provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact UCare at (voice) or (voice), (TTY), or (TTY). Civil Rights Complaints You have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by UCare. You may contact any of the following four agencies directly to file a discrimination complaint. U.S. Department of Health and Human Services Office for Civil Rights (OCR) You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following: Race Color National Origin Age Disability Sex (including sex stereotypes and gender identity)

4 Contact the OCR directly to file a complaint: Director U.S. Department of Health and Human Services Office for Civil Rights 00 Independence Avenue SW Room 509F HHH Building Washington, DC (Voice) (TDD) Complaint Portal Minnesota Department of Human Rights (MDHR) In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following: Race Sex Color Sexual Orientation National Origin Marital Status Religion Public Assistance Status Creed Disability Contact the MDHR directly to file a complaint: Minnesota Department of Human Rights Freeman Building, 65 North Robert Street St. Paul, MN (voice) (toll free) 7 or (MN Relay) (Fax) Info.MDHR@state.mn.us ( ) Minnesota Department of Human Services (DHS) You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following: Race Sex (including sex stereotypes and Color gender identity) National Origin Marital Status Creed Political Beliefs Religion Medical Condition Sexual Orientation Health Status Public Assistance Status Receipt of Health Care Services Age Claims Experience Disability (including physical or Medical History mental impairment) Genetic Information

5 Complaints must be in writing and filed within 80 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint. DHS will notify you in writing of the investigation s outcome. You have a right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome period. Be brief and state why you disagree with the decision. Include additional information you think is important. If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administration actions Contact DHS directly to file a discrimination complaint: ATTN: Civil Rights Coordinator Minnesota Department of Human Services Equal Opportunity and Access Division P.O. Box St. Paul, MN (voice) or use your preferred relay service UCare Complaint Notice You have the right to file a complaint with UCare if you believe you have been discriminated against in our health care programs because of any of the following: Race Color National Origin Creed Religion Sexual Orientation Public Assistance Status Age Disability (including physical or mental impairment) Phone: or toll free TTY: or toll free cag@ucare.org Fax: Sex (including sex stereotypes and gender identity) Marital Status Political Beliefs Medical Condition Health Status Receipt of Health Care Services Claims Experience Medical History Genetic Information Mailing address UCare Attn: Appeals and Grievances PO Box 5 Minneapolis, MN American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral

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7 What is the UCare Formulary? The UCare formulary is a list of prescription and over-the-counter (OTC) drugs that are covered by your health plan. The list is reviewed and updated by a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The most recent version of the formulary can be found on the UCare website at How do I use the Formulary? In the formulary, brand name drugs are capitalized (e.g. EPIPEN) and generic drugs are listed in lowercase italics (e.g. maprotiline tablet). UCare covers both brand name drugs and generic drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs, but work just as well and are equally as safe as the branded product. How to find prescription drugs in the formulary There are two ways to find your prescription drugs in the formulary. You can search by medical condition associated with your drug or by alphabetical listing. Search by Medical Condition Drugs listed by medical condition begin on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions they are used to treat. If you know what your drug is used for, look for the category in the list that begins on page. Then look under the category name for your drug. Search by Alphabetical Listing If you are not sure what category to look under, you can look for your drug in the Index. The Index gives an alphabetical list of all of the drugs included in the formulary. Both brand name 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 within the formulary. Tier (Notes) for prescription drugs The numbers in the Tier (Notes) column on the prescription drug formulary tell you the difference between brand name drug copays and generic drug copays. The number shows that the drug is a generic drug and may have a generic drug copay. The number shows that the drug is a brand name drug and may have a brand name drug copay. For more detailed information about copays, please review your Evidence of Coverage. The abbreviations in the Tier (Notes) column on the formulary tell you if UCare has any special requirements or limits on coverage for that drug. Use the key below to help understand the meaning of each abbreviation. PA = Prior authorization UCare requires you or your doctor to get prior authorization for certain drugs. This means that your provider will need to work with UCare to get coverage approval before you can fill your prescriptions. If you don t get approval, UCare may not cover the drug. ST = Step therapy Even though this drug is on the formulary, UCare requires that you try one or more alternative drugs on the formulary before this drug will be covered. Note: In many cases, if you are already on this drug prior to enrolling in UCare, UCare will pay for your drug and not require you to try other formulary drugs first. QL = Quantity limits For certain drugs, UCare limits the amount of the drug that UCare will cover. i

8 SP = Specialty drugs Fairview Specialty Pharmacy is the exclusive network provider of specialty drugs for UCare State Public Program (Medicaid) members. Specialty drugs are costly injectable or oral drugs that often require special handling or monitoring by a trained pharmacist. Your specialty medication and any needed supplies will be shipped to your home, work, or doctor s office. You can also contact Fairview Specialty Pharmacy and arrange to pick up your medication at one of their retail locations. A Fairview pharmacist is available 4 hours a day, seven days a week, to answer any questions related to your specialty medication. If you use a specialty medication, please have your physician send your prescription to Fairview Specialty Pharmacy via e-prescribing and select FAIRVIEW MAIL ORDER/SPECIALTY PHARMACY or fax it to You can also have your current pharmacy transfer the prescription to Fairview Specialty Pharmacy. For any questions, please contact Fairview at or (toll free), 4 hours a day, seven days a week. How to find OTC drugs in the formulary A list of covered OTC drugs is located in the back of the formulary. Covered OTC drugs are listed by medical condition. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact UCare Customer Services to confirm that your drug is not covered. Call Customer Services at or toll free or, for TTY users, , 8 a.m. - 5 p.m., Monday - Friday, or visit ucare.org. If you learn that UCare does not cover your drug, you can: Take a copy of this formulary to your doctor and ask him or her to prescribe a similar drug that is covered by UCare. Ask your doctor to request a formulary exception.* *Note: Generally, UCare will only approve your doctor s request for a formulary exception if the alternative drugs included on UCare s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects. For more information For more detailed information about your UCare prescription or OTC drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions, please call the UCare Customer Services number on the back of your member ID card. TTY/TDD users should call toll free. Or visit ii

9 UCare Minnesota Health Care Program Formulary List of Covered Drugs Drug Tier Notes ANTIHISTAMINE DRUGS carbinoxamine maleate oral liquid 4 mg/5 ml carbinoxamine maleate oral tablet 4 mg clemastine oral tablet.68 mg cyproheptadine oral syrup mg/5 ml cyproheptadine oral tablet 4 mg dimenhydrinate injection solution 50 mg/ml diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe 50 mg/ml hydroxyzine hcl intramuscular solution 5 mg/ml, 50 mg/ml hydroxyzine hcl oral solution 0 mg/5 ml hydroxyzine hcl oral tablet 0 mg, 5 mg, 50 mg hydroxyzine pamoate oral capsule 00 mg, 5 mg, 50 mg promethazine injection solution 5 mg/ml, 50 mg/ml promethazine oral syrup 6.5 mg/5 ml promethazine oral tablet.5 mg, 5 mg, 50 mg promethazine rectal suppository.5 mg, 5 mg ANTI-INFECTIVE AGENTS abacavir oral solution 0 mg/ml abacavir oral tablet 300 mg abacavir-lamivudine oral tablet mg abacavir-lamivudine-zidovudine oral tablet mg acyclovir oral capsule 00 mg acyclovir oral suspension 00 mg/5 ml acyclovir oral tablet 400 mg, 800 mg Effective January, 08

10 acyclovir sodium intravenous recon soln,000 mg, 500 mg acyclovir sodium intravenous solution 50 mg/ml adefovir oral tablet 0 mg SP ALBENZA ORAL TABLET 00 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ALINIA ORAL TABLET 500 MG amantadine hcl oral capsule 00 mg amantadine hcl oral solution 50 mg/5 ml amantadine hcl oral tablet 00 mg amikacin injection solution,000 mg/4 ml, 500 mg/ ml amoxicillin oral capsule 50 mg, 500 mg amoxicillin oral suspension for reconstitution 5 mg/5 ml, 00 mg/5 ml, 50 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 5 mg, 50 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet 50-5 mg, mg, mg amoxicillin-pot clavulanate oral tablet extended release hr, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg amphotericin b injection recon soln 50 mg ampicillin oral capsule 50 mg, 500 mg ampicillin sodium injection recon soln gram, 0 gram, 5 mg, gram, 50 mg, 500 mg ampicillin sodium intravenous recon soln gram, gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram Effective January, 08

11 ampicillin-sulbactam intravenous recon soln.5 gram, 3 gram APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION 00 MG/ML atovaquone oral suspension 750 mg/5 ml atovaquone-proguanil oral tablet mg, mg ATRIPLA ORAL TABLET MG azithromycin intravenous recon soln 500 mg azithromycin oral packet gram azithromycin oral suspension for reconstitution 00 mg/5 ml, 00 mg/5 ml azithromycin oral tablet 50 mg, 500 mg, 600 mg BACIIM INTRAMUSCULAR RECON SOLN 50,000 UNIT bacitracin intramuscular recon soln 50,000 unit BARACLUDE ORAL SOLUTION 0.05 MG/ML SP BILTRICIDE ORAL TABLET 600 MG CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML SP; QL cefaclor oral capsule 50 mg, 500 mg cefaclor oral tablet extended release hr 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, gram/50 ml cefazolin injection recon soln gram, 0 gram, 00 gram, 0 gram, 300 g, 500 mg cefazolin intravenous recon soln gram cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml Effective January, 08 3

12 cefditoren pivoxil oral tablet 00 mg cefepime in dextrose,iso-osm intravenous piggyback gram/50 ml, gram/00 ml cefepime injection recon soln gram, gram cefotaxime injection recon soln gram, 0 gram, gram, 500 mg cefotetan injection recon soln gram, gram cefotetan intravenous recon soln 0 gram cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml, gram/50 ml cefoxitin intravenous recon soln gram, 0 gram, gram cefpodoxime oral suspension for reconstitution 00 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 00 mg, 00 mg cefprozil oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cefprozil oral tablet 50 mg, 500 mg ceftazidime injection recon soln gram, gram, 6 gram ceftriaxone in dextrose,iso-os intravenous piggyback gram/50 ml, gram/50 ml ceftriaxone injection recon soln gram, 0 gram, gram, 50 mg, 500 mg ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet 50 mg, 500 mg cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 50 mg, 500 mg cephalexin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml cephalexin oral tablet 50 mg, 500 mg chloramphenicol sod succinate intravenous recon soln gram chloroquine phosphate oral tablet 50 mg, 500 mg Effective January, 08 4

13 ciprofloxacin (mixture) oral tablet, er multiphase 4 hr,000 mg, 500 mg ciprofloxacin hcl oral tablet 00 mg, 50 mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous piggyback 00 mg/00 ml, 400 mg/00 ml ciprofloxacin lactate intravenous solution 00 mg/0 ml, 400 mg/40 ml ciprofloxacin oral suspension,microcapsule recon 50 mg/5 ml, 500 mg/5 ml clarithromycin oral suspension for reconstitution 5 mg/5 ml, 50 mg/5 ml clarithromycin oral tablet 50 mg, 500 mg clarithromycin oral tablet extended release 4 hr 500 mg clindamycin hcl oral capsule 50 mg, 300 mg clindamycin palmitate hcl oral recon soln 75 mg/5 ml CLINDAMYCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML clindamycin phosphate injection solution 50 mg/ml clindamycin phosphate intravenous solution 300 mg/ ml, 600 mg/4 ml, 900 mg/6 ml COARTEM ORAL TABLET 0-0 MG colistin (colistimethate na) injection recon soln 50 mg COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 00 MG, 400 MG dapsone oral tablet 00 mg, 5 mg daptomycin intravenous recon soln 500 mg DARAPRIM ORAL TABLET 5 MG PA DESCOVY ORAL TABLET 00-5 MG dicloxacillin oral capsule 50 mg, 500 mg didanosine oral capsule,delayed release(dr/ec) 5 mg, 00 mg, 50 mg, 400 mg Effective January, 08 5

14 doxycycline hyclate oral capsule 00 mg, 50 mg doxycycline hyclate oral tablet 00 mg doxycycline monohydrate oral capsule 00 mg, 50 mg, 50 mg EDURANT ORAL TABLET 5 MG EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLUTION 0 MG/ML entecavir oral tablet 0.5 mg, mg SP EPCLUSA ORAL TABLET MG PA; SP EPIVIR HBV ORAL SOLUTION 5 MG/5 ML (5 MG/ML) SP EPIVIR ORAL SOLUTION 0 MG/ML ERYTHROCIN (AS STEARATE) ORAL TABLET 50 MG erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) 50 mg erythromycin oral tablet 50 mg, 500 mg ethambutol oral tablet 00 mg, 400 mg EVOTAZ ORAL TABLET MG famciclovir oral tablet 5 mg, 50 mg, 500 mg QL fluconazole in dextrose(iso-o) intravenous piggyback 00 mg/00 ml, 400 mg/00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 mg/50 ml, 00 mg/00 ml, 400 mg/00 ml fluconazole oral suspension for reconstitution 0 mg/ml, 40 mg/ml fluconazole oral tablet 00 mg, 00 mg, 50 mg fluconazole oral tablet 50 mg QL fosamprenavir oral tablet 700 mg foscarnet intravenous solution 4 mg/ml FUZEON SUBCUTANEOUS RECON SOLN 90 MG SP Effective January, 08 6

15 gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml gentamicin injection solution 0 mg/ ml, 40 mg/ml gentamicin sulfate (ped) (pf) injection solution 0 mg/ ml gentamicin sulfate (pf) intravenous solution 00 mg/0 ml GENVOYA ORAL TABLET MG griseofulvin microsize oral suspension 5 mg/5 ml griseofulvin microsize oral tablet 500 mg griseofulvin ultramicrosize oral tablet 5 mg, 50 mg HARVONI ORAL TABLET MG PA; SP hydroxychloroquine oral tablet 00 mg HYOPHEN ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, 00 MG, 5 MG INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( SP ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML SP INVANZ INJECTION RECON SOLN GRAM INVANZ INTRAVENOUS RECON SOLN GRAM INVIRASE ORAL CAPSULE 00 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 5 MG isoniazid injection solution 00 mg/ml Effective January, 08 7

16 isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 00 mg, 300 mg itraconazole oral capsule 00 mg QL ivermectin oral tablet 3 mg KALETRA ORAL TABLET 00-5 MG, MG ketoconazole oral tablet 00 mg lamivudine oral solution 0 mg/ml lamivudine oral tablet 00 mg, 50 mg, 300 mg lamivudine-zidovudine oral tablet mg levofloxacin oral solution 50 mg/0 ml levofloxacin oral tablet 50 mg, 500 mg, 750 mg LEXIVA ORAL SUSPENSION 50 MG/ML linezolid intravenous parenteral solution 600 mg/300 ml linezolid oral suspension for reconstitution 00 mg/5 ml linezolid oral tablet 600 mg linezolid-0.9% sodium chloride intravenous parenteral solution 600 mg/300 ml lopinavir-ritonavir oral solution mg/5 ml LUGOLS ORAL SOLUTION 5 % MAVYRET ORAL TABLET MG PA; SP mefloquine oral tablet 50 mg meropenem intravenous recon soln gram, 500 mg methenamine hippurate oral tablet gram methenamine mandelate oral tablet 0.5 g, gram metronidazole in nacl (iso-os) intravenous piggyback 500 mg/00 ml metronidazole oral capsule 375 mg metronidazole oral tablet 50 mg, 500 mg Effective January, 08 8

17 minocycline oral capsule 00 mg, 50 mg, 75 mg MYCAMINE INTRAVENOUS RECON SOLN 00 MG, 50 MG nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml, gram/00 ml nafcillin injection recon soln gram, 0 gram, gram nafcillin intravenous recon soln gram, gram NEBUPENT INHALATION RECON SOLN 300 MG SP neomycin oral tablet 500 mg nevirapine oral suspension 50 mg/5 ml nevirapine oral tablet 00 mg nitrofurantoin macrocrystal oral capsule 00 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 00 mg nitrofurantoin oral suspension 5 mg/5 ml NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 00 MG nystatin oral powder 50 million unit, 500 million unit nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit ODEFSEY ORAL TABLET MG ofloxacin oral tablet 300 mg, 400 mg oseltamivir oral capsule 30 mg, 45 mg, 75 mg QL oseltamivir oral suspension for reconstitution 6 mg/ml oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, gram/50 ml oxacillin injection recon soln gram, 0 gram, gram oxacillin intravenous recon soln gram, gram Effective January, 08 9

18 paromomycin oral capsule 50 mg PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 35 MCG/0.5 ML, 80 SP; QL; QL ( per 30 days) MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML SP; QL PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML SP; QL penicillin g potassium injection recon soln 0 million unit, 5 million unit penicillin g procaine intramuscular syringe. million unit/ ml, 600,000 unit/ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 5 mg/5 ml, 50 mg/5 ml penicillin v potassium oral tablet 50 mg, 500 mg piperacillin-tazobactam intravenous recon soln.5 gram, gram, 4.5 gram, 40.5 gram polymyxin b sulfate injection recon soln 500,000 unit PREZCOBIX ORAL TABLET MG- MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG PRIFTIN ORAL TABLET 50 MG PYLERA ORAL CAPSULE MG pyrazinamide oral tablet 500 mg quinidine gluconate injection solution 80 mg/ml quinidine gluconate oral tablet extended release 34 mg quinidine sulfate oral tablet 00 mg, 300 mg quinine sulfate oral capsule 34 mg RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION QL Effective January, 08 0

19 RESCRIPTOR ORAL TABLET 00 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML REYATAZ ORAL CAPSULE 50 MG, 00 MG, 300 MG ribavirin oral capsule 00 mg SP ribavirin oral tablet 00 mg SP rifabutin oral capsule 50 mg rifampin intravenous recon soln 600 mg rifampin oral capsule 50 mg, 300 mg RIFATER ORAL TABLET MG rimantadine oral tablet 00 mg SELZENTRY ORAL SOLUTION 0 MG/ML SELZENTRY ORAL TABLET 50 MG, 300 MG SIRTURO ORAL TABLET 00 MG stavudine oral capsule 5 mg, 0 mg, 30 mg, 40 mg stavudine oral recon soln mg/ml STRIBILD ORAL TABLET MG STRONG IODINE ORAL SOLUTION 5 % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg sulfasalazine oral tablet 500 mg sulfasalazine oral tablet,delayed release (dr/ec) 500 mg SUSTIVA ORAL CAPSULE 00 MG, 50 MG SUSTIVA ORAL TABLET 600 MG SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SP Effective January, 08

20 SYNAGIS INTRAMUSCULAR SOLUTION 00 MG/ML, 50 MG/0.5 ML SP terbinafine hcl oral tablet 50 mg tetracycline oral capsule 50 mg, 500 mg TIVICAY ORAL TABLET 0 MG, 5 MG, 50 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 300 mg/5 ml SP; QL; QL (80 per 30 days) tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection recon soln. gram tobramycin sulfate injection solution 0 mg/ml, 40 mg/ml trimethoprim oral tablet 00 mg TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG UR N-C ORAL TABLET MG URIMAR-T ORAL TABLET MG UROGESIC-BLUE ORAL TABLET MG valacyclovir oral tablet gram, 500 mg QL valganciclovir oral recon soln 50 mg/ml valganciclovir oral tablet 450 mg vancomycin in dextrose 5 % intravenous piggyback gram/00 ml, 500 mg/00 ml vancomycin intravenous recon soln,000 mg, 0 gram, 5 gram, 500 mg, 750 mg vancomycin oral capsule 5 mg, 50 mg VEMLIDY ORAL TABLET 5 MG SP VIDEX GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIRACEPT ORAL TABLET 50 MG, 65 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) SP VIREAD ORAL TABLET 50 MG, 00 MG, 50 MG, 300 MG SP Effective January, 08

21 voriconazole intravenous solution 00 mg voriconazole oral suspension for reconstitution 00 mg/5 ml (40 mg/ml) PA voriconazole oral tablet 00 mg, 50 mg PA VOSEVI ORAL TABLET MG PA; SP XIFAXAN ORAL TABLET 00 MG, 550 MG ZEPATIER ORAL TABLET MG SP ZEPATIER ORAL TABLET MG PA; SP zidovudine oral capsule 00 mg zidovudine oral syrup 0 mg/ml zidovudine oral tablet 300 mg ANTINEOPLASTIC AGENTS ADRUCIL INTRAVENOUS SOLUTION.5 GRAM/50 ML, 5 GRAM/00 ML, 500 MG/0 ML AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 3 MG, 5 MG PA; SP AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG PA; SP ALECENSA ORAL CAPSULE 50 MG PA; SP; QL (40 per 30 days) ALUNBRIG ORAL TABLET 30 MG PA; SP anastrozole oral tablet mg azacitidine injection recon soln 00 mg SP BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG bexarotene oral capsule 75 mg bicalutamide oral tablet 50 mg bleomycin injection recon soln 5 unit, 30 unit BLINCYTO INTRAVENOUS KIT 35 MCG BOSULIF ORAL TABLET 00 MG, 500 MG PA; SP CABOMETYX ORAL TABLET 0 MG, 40 MG, 60 MG PA; SP capecitabine oral tablet 50 mg, 500 mg SP CAPRELSA ORAL TABLET 00 MG, 300 MG PA; SP Effective January, 08 3

22 carboplatin intravenous recon soln 50 mg carboplatin intravenous solution 0 mg/ml cisplatin intravenous solution mg/ml cladribine intravenous solution 0 mg/0 ml COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 MG X3), 60 MG/DAY PA; SP (0 MG X 3/DAY) COTELLIC ORAL TABLET 0 MG PA; SP; QL; QL (63 per 8 days) cyclophosphamide intravenous recon soln gram, gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML SP cytarabine (pf) injection solution 00 mg/5 ml (0 mg/ml), gram/0 ml (00 mg/ml), 0 mg/ml cytarabine injection solution 0 mg/ml dacarbazine intravenous recon soln 00 mg, 00 mg daunorubicin intravenous recon soln 0 mg daunorubicin intravenous solution 5 mg/ml DOCETAXEL INTRAVENOUS SOLUTION 60 MG/6 ML (0 MG/ML), 60 MG/8 ML (0 MG/ML), 0 MG/ ML (0 MG/ML), 0 MG/ML, 0 MG/ML ( ML), 80 MG/4 ML (0 MG/ML), 80 MG/8 ML (0 MG/ML) doxorubicin intravenous recon soln 0 mg, 50 mg doxorubicin intravenous solution 0 mg/5 ml, mg/ml, 0 mg/0 ml, 50 mg/5 ml DROXIA ORAL CAPSULE 00 MG, 300 MG, 400 MG EMCYT ORAL CAPSULE 40 MG epirubicin intravenous recon soln 00 mg, 50 mg epirubicin intravenous solution 50 mg/5 ml ERIVEDGE ORAL CAPSULE 50 MG PA; SP Effective January, 08 4

23 etoposide intravenous solution 0 mg/ml etoposide oral capsule 50 mg exemestane oral tablet 5 mg FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 0 MG PA; SP FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML SP floxuridine injection recon soln 0.5 gram SP fluorouracil intravenous solution gram/0 ml,.5 gram/50 ml, 5 gram/00 ml, 500 mg/0 ml flutamide oral capsule 5 mg GILOTRIF ORAL TABLET 0 MG PA; SP; QL; QL (30 per 30 days) GILOTRIF ORAL TABLET 30 MG, 40 MG PA; SP; QL HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG PA; SP ICLUSIG ORAL TABLET 5 MG PA; SP; QL ICLUSIG ORAL TABLET 45 MG PA; SP; QL; QL (30 per 30 days) idarubicin intravenous solution mg/ml ifosfamide intravenous recon soln gram, 3 gram ifosfamide intravenous solution gram/0 ml, 3 gram/60 ml ifosfamide-mesna intravenous kit - gram imatinib oral tablet 00 mg PA; SP imatinib oral tablet 400 mg PA; SP; QL (60 per 30 days) IMBRUVICA ORAL CAPSULE 40 MG PA; SP IMFINZI INTRAVENOUS SOLUTION 50 MG/ML SP INLYTA ORAL TABLET MG, 5 MG PA; SP INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), 50 MILLION UNIT ( ML) SP Effective January, 08 5

24 INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML SP IRESSA ORAL TABLET 50 MG PA; SP irinotecan intravenous solution 00 mg/5 ml, 40 mg/ ml JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG PA; SP KADCYLA INTRAVENOUS RECON SOLN 00 MG, 60 MG PA; SP KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X), 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (4 MG X ) PA letrozole oral tablet.5 mg LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit mg/0. ml SP LONSURF ORAL TABLET MG, MG PA; SP LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 PA; SP MG,.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG PA; SP LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG PA; SP LUPRON DEPOT-PED INTRAMUSCULAR KIT.5 MG, 5 MG, 7.5 MG (PED) PA; SP LYNPARZA ORAL CAPSULE 50 MG PA; SP LYNPARZA ORAL TABLET 00 MG, 50 MG PA; SP MATULANE ORAL CAPSULE 50 MG SP megestrol oral suspension 400 mg/0 ml (0 ml), 400 mg/0 ml (40 mg/ml), 800 mg/0 ml PA (0 ml) megestrol oral tablet 0 mg, 40 mg PA MEKINIST ORAL TABLET 0.5 MG, MG PA; SP melphalan hcl intravenous recon soln 50 mg Effective January, 08 6

25 mercaptopurine oral tablet 50 mg methotrexate sodium (pf) injection recon soln gram methotrexate sodium (pf) injection solution 5 mg/ml methotrexate sodium injection solution 5 mg/ml methotrexate sodium oral tablet.5 mg mitomycin intravenous recon soln 0 mg, 40 mg, 5 mg mitoxantrone intravenous concentrate mg/ml SP MYLERAN ORAL TABLET MG NEXAVAR ORAL TABLET 00 MG PA; SP nilutamide oral tablet 50 mg NINLARO ORAL CAPSULE.3 MG PA; SP; QL; QL (6 per 8 days) NINLARO ORAL CAPSULE 3 MG PA; SP; QL; QL (4 per 8 days) NINLARO ORAL CAPSULE 4 MG PA; SP; QL; QL (3 per 8 days) OPDIVO INTRAVENOUS SOLUTION 00 MG/0 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 00 mg, 50 mg oxaliplatin intravenous solution 00 mg/0 ml, 50 mg/0 ml (5 mg/ml) paclitaxel intravenous concentrate 6 mg/ml POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG SP PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT SP REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG PA; SP RITUXAN HYCELA SUBCUTANEOUS SOLUTION 400 MG/.7 ML (0 MG/ML), PA 600 MG/3.4 ML (0 MG/ML) RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG PA; SP RYDAPT ORAL CAPSULE 5 MG PA; SP SPRYCEL ORAL TABLET 00 MG, 40 MG, 0 MG, 50 MG, 70 MG, 80 MG PA; SP Effective January, 08 7

26 STIVARGA ORAL TABLET 40 MG PA; SP SUTENT ORAL CAPSULE.5 MG, 5 MG, 37.5 MG, 50 MG PA; SP SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SP SYLVANT INTRAVENOUS RECON SOLN 00 MG, 400 MG SP TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG PA; SP; QL; QL (80 per 30 days) TAFINLAR ORAL CAPSULE 75 MG PA; SP; QL TAGRISSO ORAL TABLET 40 MG PA; SP; QL; QL (60 per 30 days) TAGRISSO ORAL TABLET 80 MG PA; SP; QL; QL (30 per 30 days) tamoxifen oral tablet 0 mg, 0 mg TARCEVA ORAL TABLET 00 MG, 50 MG, 5 MG PA; SP TASIGNA ORAL CAPSULE 50 MG, 00 MG PA; SP TECENTRIQ INTRAVENOUS SOLUTION,00 MG/0 ML (60 MG/ML) SP TEMODAR INTRAVENOUS RECON SOLN 00 MG SP temozolomide oral capsule 00 mg, 40 mg, 80 mg, 0 mg, 50 mg, 5 mg SP TOPOSAR INTRAVENOUS SOLUTION 0 MG/ML tretinoin (chemotherapy) oral capsule 0 mg TRISENOX INTRAVENOUS SOLUTION 0 MG/0 ML SP TYKERB ORAL TABLET 50 MG PA; SP UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (0 MG/ML), 400 MG/0 ML (0 SP MG/ML) VELCADE INJECTION RECON SOLN 3.5 MG SP Effective January, 08 8

27 VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG PA; SP VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 PA; SP MG vinblastine intravenous solution mg/ml VINCASAR PFS INTRAVENOUS SOLUTION MG/ ML vincristine intravenous solution mg/ml, mg/ ml vinorelbine intravenous solution 0 mg/ml, 50 mg/5 ml VOTRIENT ORAL TABLET 00 MG PA; SP XALKORI ORAL CAPSULE 00 MG, 50 MG PA; SP XTANDI ORAL CAPSULE 40 MG PA; SP YONDELIS INTRAVENOUS RECON SOLN MG PA ZEJULA ORAL CAPSULE 00 MG PA; QL (90 per 30 days) ZELBORAF ORAL TABLET 40 MG PA; SP ZOLINZA ORAL CAPSULE 00 MG SP ZYDELIG ORAL TABLET 00 MG, 50 MG PA ZYKADIA ORAL CAPSULE 50 MG PA; SP ZYTIGA ORAL TABLET 50 MG, 500 MG PA; SP ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES AFLURIA (PF) INTRAMUSCULAR SYRINGE 45 MCG (5 MCG X 3)/0.5 ML AFLURIA INTRAMUSCULAR SUSPENSION 45 MCG (5 MCG X 3)/0.5 ML AFLURIA QUAD (PF) INTRAMUSCULAR SYRINGE 60 MCG/0.5 ML AFLURIA QUAD INTRAMUSCULAR SUSPENSION 60 MCG/0.5 ML BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML Effective January, 08 9

28 FLUAD (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (5 MCG X 3)/0.5 ML FLUARIX QUAD (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG X 4)/0.5 ML FLUCELVAX QUAD (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG X 4)/0.5 ML FLUCELVAX QUAD INTRAMUSCULAR SUSPENSION 60 MCG (5 MCG X 4)/0.5 ML FLULAVAL QUAD (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG X 4)/0.5 ML FLULAVAL QUAD INTRAMUSCULAR SUSPENSION 60 MCG (5 MCG X 4)/0.5 ML FLUVIRIN (PF) INTRAMUSCULAR SYRINGE 45 MCG (5 MCG X 3)/0.5 ML FLUVIRIN INTRAMUSCULAR SUSPENSION 45 MCG (5 MCG X 3)/0.5 ML FLUZONE INTRADERM QUAD 07-8 INTRADERMAL SYRINGE 36 MCG/0. ML FLUZONE QUAD (PF) INTRAMUSCULAR SUSPENSION 60 MCG (5 MCG X 4)/0.5 ML FLUZONE QUAD (PF) INTRAMUSCULAR SYRINGE 60 MCG (5 MCG X 4)/0.5 ML FLUZONE QUAD INTRAMUSCULAR SUSPENSION 60 MCG (5 MCG X 4)/0.5 ML FLUZONE QUAD PEDI 07-8 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.5 ML GAMASTAN S/D INTRAMUSCULAR SOLUTION 5-8 % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 0 % Effective January, 08 0 SP SP

29 GAMMAGARD S-D (IGA < MCG/ML) INTRAVENOUS RECON SOLN 0 GRAM, 5 GRAM GAMUNEX-C INJECTION SOLUTION GRAM/0 ML (0 %), 0 GRAM/00 ML (0 %),.5 GRAM/5 ML (0 %), 0 GRAM/00 ML (0 %), 5 GRAM/50 ML (0 %) HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML HIZENTRA SUBCUTANEOUS SOLUTION GRAM/5 ML (0 %), 0 GRAM/50 ML (0 %), GRAM/0 ML (0 %), 4 GRAM/0 ML (0 %) HYPERHEP B S/D INTRAMUSCULAR SOLUTION 0 UNIT/ML, 0 UNIT/ML (5 ML) HYPERHEP B S/D INTRAMUSCULAR SYRINGE 0 UNIT/ML HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE 0 UNIT/0.5 ML HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML HYPERRHO S/D INTRAMUSCULAR SYRINGE,500 UNIT (300 MCG), 50 UNIT (50 MCG) MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML PNEUMOVAX 3 INJECTION SOLUTION 5 MCG/0.5 ML PNEUMOVAX 3 INJECTION SYRINGE 5 MCG/0.5 ML PREVNAR 3 (PF) INTRAMUSCULAR SYRINGE 0.5 ML PRIVIGEN INTRAVENOUS SOLUTION 0 % QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML ROTATEQ VACCINE ORAL SOLUTION ML SP SP SP SP SP SP SP SP SP Effective January, 08

30 TRUMENBA INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X0EXP8 TO X 0EXP9 CF UNIT WINRHO SDF INJECTION SOLUTION,500 UNIT/.3 ML, 5,000 UNIT/3 ML, SP,500 UNIT/. ML, 5,000 UNIT/4.4 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML AUTONOMIC DRUGS acebutolol oral capsule 00 mg, 400 mg albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml,.5 mg/3 ml,.5 mg /3 ml (0.083 %),.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup mg/5 ml albuterol sulfate oral tablet mg, 4 mg albuterol sulfate oral tablet extended release hr 4 mg, 8 mg ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION atenolol oral tablet 00 mg, 5 mg, 50 mg atenolol-chlorthalidone oral tablet 00-5 mg, 50-5 mg atropine injection solution 0.4 mg/ml, mg/ml atropine injection syringe 0.05 mg/ml, 0. mg/ml baclofen oral tablet 0 mg, 0 mg benztropine injection solution mg/ ml benztropine oral tablet 0.5 mg, mg, mg betaxolol oral tablet 0 mg, 0 mg bethanechol chloride oral tablet 0 mg, 5 mg, 5 mg, 50 mg bisoprolol fumarate oral tablet 0 mg, 5 mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg BOTOX INJECTION RECON SOLN 00 UNIT, 00 UNIT PA; SP Effective January, 08

31 brompheniramine-pseudoeph-dm oral syrup mg/5 ml bupivacaine-epinephrine (pf) injection solution 0.5 %-:00,000, 0.5 %-:00,000 bupivacaine-epinephrine injection solution 0.5 %-:00,000, 0.5 %-:00,000 carvedilol oral tablet.5 mg, 5 mg, 3.5 mg, 6.5 mg cevimeline oral capsule 30 mg CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) chlorzoxazone oral tablet 50 mg, 500 mg clonidine (pf) epidural solution,000 mcg/0 ml (00 mcg/ml) clonidine hcl oral tablet 0. mg, 0. mg, 0.3 mg clonidine transdermal patch weekly 0. mg/4 hr, 0. mg/4 hr, 0.3 mg/4 hr QL COMBIVENT RESPIMAT INHALATION MIST 0-00 MCG/ACTUATION QL cyclobenzaprine oral tablet 0 mg, 5 mg dantrolene oral capsule 00 mg, 5 mg, 50 mg dicyclomine oral capsule 0 mg dicyclomine oral solution 0 mg/5 ml dicyclomine oral tablet 0 mg dihydroergotamine injection solution mg/ml diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg dobutamine in d5w intravenous parenteral solution,000 mg/50 ml (4,000 mcg/ml), 50 mg/50 ml ( mg/ml), 500 mg/50 ml (,000 mcg/ml) dobutamine intravenous solution 50 mg/0 ml (.5 mg/ml), 500 mg/40 ml (.5 mg/ml) Effective January, 08 3

32 donepezil oral tablet 0 mg, 5 mg donepezil oral tablet,disintegrating 0 mg, 5 mg dopamine in 5 % dextrose intravenous solution 00 mg/50 ml (800 mcg/ml), 400 mg/50 ml (,600 mcg/ml), 400 mg/500 ml (800 mcg/ml), 800 mg/50 ml (3,00 mcg/ml), 800 mg/500 ml (,600 mcg/ml) dopamine intravenous solution 00 mg/5 ml (40 mg/ml), 400 mg/0 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/0 ml (80 mg/ml), 800 mg/5 ml (60 mg/ml) doxazosin oral tablet mg, mg, 8 mg QL doxazosin oral tablet 4 mg QL; QL (30 per 30 days) DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, 00-5 QL MCG/ACTUATION DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT, 500 UNIT PA; SP ED-SPAZ ORAL TABLET,DISINTEGRATING 0.5 MG ephedrine sulfate injection solution 50 mg/ml epinephrine injection solution mg/ml, mg/ml ( ml) epinephrine injection syringe 0. mg/ml EPIPEN -PAK INJECTION AUTO- INJECTOR 0.3 MG/0.3 ML QL; QL ( per 30 days) EPIPEN JR -PAK INJECTION AUTO- INJECTOR 0.5 MG/0.3 ML QL; QL ( per 30 days) ergoloid oral tablet mg galantamine oral capsule,ext rel. pellets 4 hr 6 mg, 4 mg, 8 mg galantamine oral solution 4 mg/ml galantamine oral tablet mg, 4 mg, 8 mg glycopyrrolate injection solution 0. mg/ml glycopyrrolate oral tablet mg, mg guanidine oral tablet 5 mg hyoscyamine sulfate oral elixir 0.5 mg/5 ml hyoscyamine sulfate oral tablet 0.5 mg Effective January, 08 4

33 hyoscyamine sulfate oral tablet extended release hr mg hyoscyamine sulfate oral tablet,disintegrating 0.5 mg hyoscyamine sulfate sublingual tablet 0.5 mg ipratropium bromide inhalation solution 0.0 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(.5 mg base)/3 ml labetalol intravenous solution 5 mg/ml labetalol intravenous syringe 0 mg/4 ml (5 mg/ml) labetalol oral tablet 00 mg, 00 mg, 300 mg lidocaine-epinephrine injection solution 0.5 %-:00,000, %-:00,000, %-:00,000 metaproterenol oral syrup 0 mg/5 ml metaproterenol oral tablet 0 mg, 0 mg metaxalone oral tablet 800 mg methocarbamol oral tablet 500 mg, 750 mg methscopolamine oral tablet.5 mg, 5 mg methyldopa oral tablet 50 mg, 500 mg methyldopa-hydrochlorothiazide oral tablet 50-5 mg, 50-5 mg methyldopate intravenous solution 50 mg/5 ml metoprolol succinate oral tablet extended release 4 hr 00 mg, 00 mg, 5 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet 00-5 mg, mg, 50-5 mg metoprolol tartrate intravenous solution 5 mg/5 ml metoprolol tartrate intravenous syringe 5 mg/5 ml metoprolol tartrate oral tablet 00 mg, 5 mg, 50 mg midodrine oral tablet 0 mg,.5 mg, 5 mg nadolol oral tablet 0 mg, 40 mg, 80 mg Effective January, 08 5

34 nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON- AEROSOL 0 MG/ML norepinephrine bitartrate intravenous solution mg/ml orphenadrine citrate injection solution 30 mg/ml orphenadrine citrate oral tablet extended release 00 mg phenylephrine hcl injection solution 0 mg/ml physostigmine salicylate injection solution mg/ml pilocarpine hcl oral tablet 5 mg, 7.5 mg pindolol oral tablet 0 mg, 5 mg prazosin oral capsule mg, mg, 5 mg propantheline oral tablet 5 mg propranolol intravenous solution mg/ml propranolol oral capsule,extended release 4 hr 0 mg, 60 mg, 60 mg, 80 mg propranolol oral solution 0 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 0 mg, 0 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral tablet 40-5 mg, 80-5 mg pyridostigmine bromide oral tablet 60 mg REVONTO INTRAVENOUS RECON SOLN 0 MG rivastigmine tartrate oral capsule.5 mg, 3 mg, 4.5 mg, 6 mg rivastigmine transdermal patch 4 hour 3.3 mg/4 hour, 4.6 mg/4 hr, 9.5 mg/4 hr SORINE ORAL TABLET 0 MG, 60 MG, 40 MG, 80 MG SOTALOL AF ORAL TABLET 0 MG, 60 MG, 80 MG Effective January, 08 6

35 sotalol oral tablet 0 mg, 60 mg, 40 mg, 80 mg SPIRIVA RESPIMAT INHALATION MIST.5 MCG/ACTUATION,.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 QL; QL (90 per 30 days) MCG STRIVERDI RESPIMAT INHALATION MIST.5 MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, QL MCG/ACTUATION tamsulosin oral capsule,extended release 4hr 0.4 mg terazosin oral capsule mg, 0 mg, mg, 5 mg QL terbutaline oral tablet.5 mg, 5 mg terbutaline subcutaneous solution mg/ml timolol maleate oral tablet 0 mg, 0 mg, 5 mg tizanidine oral capsule mg, 4 mg, 6 mg tizanidine oral tablet mg, 4 mg trihexyphenidyl oral elixir 0.4 mg/ml trihexyphenidyl oral tablet mg, 5 mg VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION QL; QL (36 per 30 days) XEOMIN INTRAMUSCULAR RECON SOLN 00 UNIT, 50 UNIT PA; SP BLOOD DERIVATIVES albumin, human 5 % intravenous parenteral solution 5 % ALBURX (HUMAN) 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % ALBUTEIN 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % ALBUTEIN 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % Effective January, 08 7

36 BLOOD FORMATION, COAGULATION, THROMBOSIS ADVATE INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT,,000 (+/- ) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT ADYNOVATE INTRAVENOUS SOLUTION,000 (+/-) UNIT,,500 (+/-) UNIT,,000 (+/- ) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT AFSTYLA INTRAVENOUS RECON SOLN,000 (+/-) UNIT RANGE,,500 (+/-) UNIT RANGE,,000 (+/-) UNIT RANGE,,500 (+/- ) UNIT RANGE, 50 (+/-) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE ALPHANATE INTRAVENOUS RECON SOLN,000 (400 VWF) UNIT/0 ML,,500 (600 VWF) UNIT/0 ML, 50 (00 VWF) UNIT/5 ML, 500 (00 VWF) UNIT/5 ML SP SP SP ALPROLIX INTRAVENOUS RECON SOLN,000 UNIT,,000 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT aminocaproic acid intravenous solution 50 mg/ml anagrelide oral capsule 0.5 mg, mg ARANESP (IN POLYSORBATE) INJECTION SOLUTION 00 MCG/ML, 50 MCG/0.75 ML, 00 MCG/ML, 5 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML PA; SP ARANESP (IN POLYSORBATE) INJECTION SYRINGE 00 MCG/0.5 ML, 50 MCG/0.3 ML, 00 MCG/0.4 ML, 5 MCG/0.4 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML aspirin-dipyridamole oral capsule, er multiphase hr 5-00 mg BAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR MG BENEFIX INTRAVENOUS RECON SOLN,000 UNIT,,000 UNIT, 50 UNIT, 3,000 UNIT, 500 UNIT Effective January, 08 8 PA; SP SP

37 butalbital-aspirin-caffeine oral capsule mg butalbital-aspirin-caffeine oral tablet mg CATHFLO ACTIVASE INTRA-CATHETER RECON SOLN MG cilostazol oral tablet 00 mg, 50 mg clopidogrel oral tablet 300 mg, 75 mg COAGADEX INTRAVENOUS RECON SOLN 50 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE CORIFACT INTRAVENOUS RECON SOLN,000-,600 UNIT SP desmopressin injection solution 4 mcg/ml PA desmopressin nasal solution 0. mg/ml (refrigerate) desmopressin nasal spray,non-aerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0. mg, 0. mg PA dipyridamole intravenous solution 5 mg/ml dipyridamole oral tablet 5 mg, 50 mg, 75 mg ELITE-OB 400 ORAL CAPSULE MG ELOCTATE INTRAVENOUS RECON SOLN,000 UNIT,,500 UNIT,,000 UNIT, 50 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT SP enoxaparin subcutaneous solution 300 mg/3 ml enoxaparin subcutaneous syringe 00 mg/ml, 0 mg/0.8 ml, 50 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml EPOGEN INJECTION SOLUTION 0,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML SP SP PA; SP FEIBA NF INTRAVENOUS RECON SOLN,750-3,50 UNIT, UNIT, 65-,00 SP UNIT FOLIVANE-OB ORAL CAPSULE 85- MG Effective January, 08 9

38 HELIXATE FS INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT HEP FLUSH-0 (PF) INTRAVENOUS SOLUTION 0 UNIT/ML heparin (porcine) in 5 % dex intravenous parenteral solution 0,000 unit/500 ml (40 unit/ml), 5,000 unit/50 ml(00 unit/ml), 5,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml,,000 unit/,000 ml heparin (porcine) injection cartridge 5,000 unit/ml ( ml) heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 0,000 unit/ml, 5,000 unit/ml heparin flush(porcine)-0.9nacl intravenous kit 00 unit/ml heparin lock flush (porcine) intravenous syringe 00 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 0 UNIT/ML HEPARIN LOCK INTRAVENOUS SOLUTION 00 UNIT/ML HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 0 UNIT/ML, 00 UNIT/ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 5,000 unit/50 ml, 5,000 unit/500 ml heparin, porcine (pf) injection solution,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin, porcine (pf) intravenous syringe unit/ml, 00 unit/ml IDELVION INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 500 (+/-) UNIT Effective January, SP SP

39 INFED INJECTION SOLUTION 00 MG/ ML (50 MG/ML) IXINITY INTRAVENOUS RECON SOLN,000 UNIT,,500 UNIT,,000 UNIT, 50 UNIT, 3,000 UNIT, 500 UNIT JANTOVEN ORAL TABLET MG, 0 MG, MG,.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG KOVALTRY INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT LEUKINE INJECTION RECON SOLN 50 MCG MOZOBIL SUBCUTANEOUS SOLUTION 4 MG/. ML (0 MG/ML) MYNATAL ADVANCE ORAL TABLET MG MYNATAL ORAL CAPSULE 65 MG IRON- MG MYNATAL PLUS ORAL TABLET 65 MG IRON- MG MYNATAL-Z ORAL TABLET 65 MG IRON- MG NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML NOVOEIGHT INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT NUWIQ INTRAVENOUS RECON SOLN 000 (+/-) UNIT,,000 (+/-) UNIT,,500 UNIT, 50 (+/-) UNIT, 3,000 UNIT, 4,000 UNIT, 500 (+/-) UNIT OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE SP SP SP SP PA; SP; QL PA; SP; QL PA; SP PA; SP SP PA Effective January, 08 3

40 pentoxifylline oral tablet extended release 400 mg PNV OB+DHA ORAL COMBO PACK MG PNV-DHA + DOCUSATE ORAL CAPSULE MG PNV-DHA ORAL CAPSULE 7 MG IRON- MG -300 MG PNV-OMEGA ORAL CAPSULE MG PNV-SELECT ORAL TABLET 7- MG PR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 400 ORAL COMBO PACK MG PR NATAL 430 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 430 ORAL COMBO PACK 9 MG IRON- MG -430 MG PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG prasugrel oral tablet 0 mg, 5 mg PRENAISSANCE ORAL CAPSULE MG PRENAISSANCE PLUS ORAL CAPSULE MG PRENATABS FA ORAL TABLET 9- MG PRENATABS RX ORAL TABLET 9 MG IRON- MG PRENATAL LOW IRON ORAL TABLET 7 MG IRON- MG PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 7 MG IRON- MG PRENATAL PLUS ORAL TABLET 9 MG IRON- MG PROCRIT INJECTION SOLUTION 0,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML PA; SP Effective January, 08 3

41 PROMACTA ORAL TABLET.5 MG, 5 MG, 50 MG, 75 MG RECOMBINATE INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 500 (+/-) UNIT PA; SP SP SE-NATAL 9 (WITH DOCUSATE) ORAL TABLET 9 MG IRON- MG-5 MG SE-NATAL 9 ORAL TABLET,CHEWABLE 9 MG IRON- MG TARON-C DHA ORAL CAPSULE MG TARON-PREX PRENATAL-DHA ORAL CAPSULE 30 MG IRON-. MG-55 MG-65 MG ticlopidine oral tablet 50 mg TL-SELECT ORAL CAPSULE MG TRETTEN INTRAVENOUS RECON SOLN,500 UNIT SP TRIADVANCE ORAL TABLET MG TRINATAL GT ORAL TABLET MG TRINATAL RX ORAL TABLET 60 MG IRON- MG TRINATE ORAL TABLET 8 MG IRON- MG TRIVEEN-DUO DHA ORAL COMBO PACK MG TRIVEEN-ONE ORAL CAPSULE 7 MG IRON- MG -50 MG TRIVEEN-PRX RNF ORAL CAPSULE MG TRI-VIT WITH FLUORIDE AND IRON ORAL DROPS MG/ML ULTIMATECARE ONE NF ORAL CAPSULE MG ULTIMATECARE ONE ORAL CAPSULE MG VEMAVITE-PRX- ORAL CAPSULE MG Effective January, 08 33

42 VENA-BAL DHA ORAL COMBO PACK,TABLET AND CAP,DR MG VENOFER INTRAVENOUS SOLUTION 00 MG IRON/5 ML, 00 MG IRON/0 ML, 50 MG IRON/.5 ML VINACAL ORAL TABLET MG VINATE CARE ORAL TABLET,CHEWABLE 40 MG IRON- MG VINATE GT ORAL TABLET MG VINATE ONE ORAL TABLET 60 MG IRON- MG VINATE ULTRA ORAL TABLET MG VIRT-PN DHA ORAL CAPSULE 7 MG IRON- MG -300 MG VIRT-PN ORAL TABLET 7- MG VIRT-PN PLUS ORAL CAPSULE MG VIRT-SELECT ORAL CAPSULE MG VITAFOL-OB ORAL TABLET 65- MG VOL-NATE ORAL TABLET 8 MG IRON- MG VOL-TAB RX ORAL TABLET 9 MG IRON- MG VONVENDI INTRAVENOUS RECON SOLN,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE warfarin oral tablet mg, 0 mg, mg,.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 0 MG, 5 MG, 0 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (4)- 0 MG (9) XYNTHA INTRAVENOUS SOLUTION,000 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, SP 500 (+/-) UNIT XYNTHA SOLOFUSE INTRAVENOUS SYRINGE,000 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT SP Effective January, 08 34

43 ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PA; SP ZATEAN-CH ORAL CAPSULE MG ZATEAN-PN DHA ORAL CAPSULE 7 MG IRON- MG -300 MG ZATEAN-PN PLUS ORAL CAPSULE MG CARDIOVASCULAR DRUGS acebutolol oral capsule 00 mg, 400 mg acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 5 mg, 50 mg acetazolamide sodium injection recon soln 500 mg adenosine (diagnostic) intravenous solution 3 mg/ml adenosine intravenous solution 3 mg/ml alprostadil injection solution 500 mcg/ml amiloride-hydrochlorothiazide oral tablet 5-50 mg amiodarone intravenous solution 50 mg/ml amiodarone oral tablet 00 mg, 00 mg, 400 mg amlodipine oral tablet 0 mg,.5 mg, 5 mg amlodipine-benazepril oral capsule 0-0 mg, 0-40 mg,.5-0 mg, 5-0 mg, 5-0 mg, 5-40 mg aspirin-dipyridamole oral capsule, er multiphase hr 5-00 mg atenolol oral tablet 00 mg, 5 mg, 50 mg atenolol-chlorthalidone oral tablet 00-5 mg, 50-5 mg atorvastatin oral tablet 0 mg, 0 mg, 40 mg, 80 mg QL benazepril oral tablet 0 mg, 0 mg, 40 mg, 5 mg benazepril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg, 0-5 mg, mg Effective January, 08 35

44 betaxolol oral tablet 0 mg, 0 mg bisoprolol fumarate oral tablet 0 mg, 5 mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg bumetanide injection solution 0.5 mg/ml bumetanide oral tablet 0.5 mg, mg, mg captopril oral tablet 00 mg,.5 mg, 5 mg, 50 mg captopril-hydrochlorothiazide oral tablet 5-5 mg, 5-5 mg, 50-5 mg, 50-5 mg CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 4HR 0 MG, 80 MG, 40 MG, 300 MG carvedilol oral tablet.5 mg, 5 mg, 3.5 mg, 6.5 mg chlorothiazide oral tablet 50 mg, 500 mg chlorthalidone oral tablet 5 mg, 50 mg cholestyramine (with sugar) oral powder 4 gram cholestyramine (with sugar) oral powder in packet 4 gram CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM cilostazol oral tablet 00 mg, 50 mg clonidine (pf) epidural solution,000 mcg/0 ml (00 mcg/ml) clonidine hcl oral tablet 0. mg, 0. mg, 0.3 mg clonidine transdermal patch weekly 0. mg/4 hr, 0. mg/4 hr, 0.3 mg/4 hr QL colestipol oral granules 5 gram colestipol oral packet 5 gram colestipol oral tablet gram CORLANOR ORAL TABLET 5 MG, 7.5 MG PA DIGOX ORAL TABLET 5 MCG, 50 MCG digoxin injection solution 50 mcg/ml Effective January, 08 36

45 digoxin injection syringe 50 mcg/ml digoxin oral solution 50 mcg/ml digoxin oral tablet 5 mcg, 50 mcg DILANTIN ORAL CAPSULE 30 MG diltiazem hcl intravenous recon soln 00 mg diltiazem hcl intravenous solution 5 mg/ml diltiazem hcl oral capsule,ext.rel 4h degradable 0 mg, 80 mg, 40 mg diltiazem hcl oral capsule,extended release hr 0 mg, 60 mg, 90 mg diltiazem hcl oral capsule,extended release 4 hr 0 mg, 80 mg, 40 mg, 300 mg, 360 mg, 40 mg diltiazem hcl oral capsule,extended release 4hr 0 mg, 80 mg, 40 mg, 300 mg diltiazem hcl oral tablet 0 mg, 30 mg, 60 mg, 90 mg DILT-XR ORAL CAPSULE,EXT.REL 4H DEGRADABLE 0 MG, 80 MG, 40 MG dipyridamole intravenous solution 5 mg/ml dipyridamole oral tablet 5 mg, 50 mg, 75 mg disopyramide phosphate oral capsule 00 mg, 50 mg dobutamine in d5w intravenous parenteral solution,000 mg/50 ml (4,000 mcg/ml), 50 mg/50 ml ( mg/ml), 500 mg/50 ml (,000 mcg/ml) dobutamine intravenous solution 50 mg/0 ml (.5 mg/ml), 500 mg/40 ml (.5 mg/ml) dofetilide oral capsule 5 mcg, 50 mcg, 500 mcg dopamine in 5 % dextrose intravenous solution 00 mg/50 ml (800 mcg/ml), 400 mg/50 ml (,600 mcg/ml), 400 mg/500 ml (800 mcg/ml), 800 mg/50 ml (3,00 mcg/ml), 800 mg/500 ml (,600 mcg/ml) dopamine intravenous solution 00 mg/5 ml (40 mg/ml), 400 mg/0 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/0 ml (80 mg/ml), 800 mg/5 ml (60 mg/ml) Effective January, 08 37

46 doxazosin oral tablet mg, mg, 8 mg QL doxazosin oral tablet 4 mg QL; QL (30 per 30 days) enalapril maleate oral tablet 0 mg,.5 mg, 0 mg, 5 mg enalaprilat intravenous solution.5 mg/ml enalapril-hydrochlorothiazide oral tablet 0-5 mg, 5-.5 mg ENTRESTO ORAL TABLET 4-6 MG, 49-5 MG, MG ENTRESTO ORAL TABLET 4-6 MG, 49-5 MG, MG PA eplerenone oral tablet 5 mg, 50 mg epoprostenol (glycine) intravenous recon soln 0.5 mg,.5 mg SP ezetimibe oral tablet 0 mg QL felodipine oral tablet extended release 4 hr 0 mg,.5 mg, 5 mg fenofibrate micronized oral capsule 30 mg, 34 mg, 00 mg, 43 mg, 67 mg fenofibrate nanocrystallized oral tablet 45 mg, 48 mg fenofibrate oral tablet 60 mg, 54 mg fenofibric acid (choline) oral capsule,delayed release(dr/ec) 35 mg, 45 mg FISH OIL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0 MG-80 MG- 60 MG-,00 MG flecainide oral tablet 00 mg, 50 mg, 50 mg fosinopril oral tablet 0 mg, 0 mg, 40 mg fosinopril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg furosemide injection solution 0 mg/ml furosemide injection syringe 0 mg/ml furosemide oral solution 0 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 0 mg, 40 mg, 80 mg gemfibrozil oral tablet 600 mg guanfacine oral tablet mg, mg Effective January, 08 38

47 guanfacine oral tablet extended release 4 hr mg, mg, 3 mg, 4 mg hydralazine injection solution 0 mg/ml hydralazine oral tablet 0 mg, 00 mg, 5 mg, 50 mg hydrochlorothiazide oral capsule.5 mg hydrochlorothiazide oral tablet.5 mg, 5 mg, 50 mg indapamide oral tablet.5 mg,.5 mg irbesartan oral tablet 50 mg, 300 mg, 75 mg irbesartan-hydrochlorothiazide oral tablet mg, mg isosorbide dinitrate oral tablet 0 mg, 0 mg, 30 mg, 5 mg isosorbide dinitrate oral tablet extended release 40 mg isosorbide mononitrate oral tablet 0 mg, 0 mg isosorbide mononitrate oral tablet extended release 4 hr 0 mg, 30 mg, 60 mg isradipine oral capsule.5 mg, 5 mg labetalol intravenous solution 5 mg/ml labetalol intravenous syringe 0 mg/4 ml (5 mg/ml) labetalol oral tablet 00 mg, 00 mg, 300 mg LETAIRIS ORAL TABLET 0 MG, 5 MG PA; SP lidocaine (pf) intravenous solution 0 mg/ml ( %) lidocaine (pf) intravenous syringe 00 mg/5 ml ( %), 50 mg/5 ml ( %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) lisinopril oral tablet 0 mg,.5 mg, 0 mg, 30 mg, 40 mg, 5 mg lisinopril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg, 0-5 mg losartan oral tablet 00 mg, 5 mg, 50 mg losartan-hydrochlorothiazide oral tablet mg, 00-5 mg, mg Effective January, 08 39

48 lovastatin oral tablet 0 mg, 0 mg QL lovastatin oral tablet 40 mg QL; QL (30 per 30 days) magnesium sulfate in water intravenous parenteral solution 0 gram/500 ml (4 %), 40 gram/,000 ml (4 %) magnesium sulfate in water intravenous piggyback gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml mannitol 0 % intravenous parenteral solution 0 % mannitol 0 % intravenous parenteral solution 0 % mannitol 5 % intravenous solution 5 % mannitol 5 % intravenous parenteral solution 5 % methyldopa oral tablet 50 mg, 500 mg methyldopa-hydrochlorothiazide oral tablet 50-5 mg, 50-5 mg methyldopate intravenous solution 50 mg/5 ml metolazone oral tablet 0 mg,.5 mg, 5 mg metoprolol succinate oral tablet extended release 4 hr 00 mg, 00 mg, 5 mg, 50 mg metoprolol ta-hydrochlorothiaz oral tablet 00-5 mg, mg, 50-5 mg metoprolol tartrate intravenous solution 5 mg/5 ml metoprolol tartrate intravenous syringe 5 mg/5 ml metoprolol tartrate oral tablet 00 mg, 5 mg, 50 mg mexiletine oral capsule 50 mg, 00 mg, 50 mg milrinone in 5 % dextrose intravenous piggyback 0 mg/00 ml (00 mcg/ml), 40 mg/00 ml (00 mcg/ml) Effective January, 08 40

49 milrinone intravenous solution mg/ml minoxidil oral tablet 0 mg,.5 mg moexipril oral tablet 5 mg, 7.5 mg moexipril-hydrochlorothiazide oral tablet 5-.5 mg, 5-5 mg, mg nadolol oral tablet 0 mg, 40 mg, 80 mg nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg nicardipine intravenous solution 5 mg/0 ml nicardipine oral capsule 0 mg, 30 mg nifedipine oral capsule 0 mg, 0 mg nifedipine oral tablet extended release 4hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg nimodipine oral capsule 30 mg NITRO-BID TRANSDERMAL OINTMENT % nitroglycerin in 5 % dextrose intravenous solution 00 mg/50 ml (400 mcg/ml), 00 mg/500 ml (400 mcg/ml), 50 mg/50 ml (00 mcg/ml) nitroglycerin intravenous solution 50 mg/0 ml (5 mg/ml) nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg nitroglycerin transdermal patch 4 hour 0. mg/hr, 0. mg/hr, 0.4 mg/hr, 0.6 mg/hr nitroglycerin translingual spray,non-aerosol 400 mcg/spray omega-3 acid ethyl esters oral capsule gram PA papaverine injection solution 30 mg/ml perindopril erbumine oral tablet mg, 4 mg, 8 mg phenytoin oral suspension 00 mg/4 ml, 5 mg/5 ml phenytoin oral tablet,chewable 50 mg Effective January, 08 4

50 phenytoin sodium extended oral capsule 00 mg, 00 mg, 300 mg phenytoin sodium intravenous solution 50 mg/ml phenytoin sodium intravenous syringe 50 mg/ml pindolol oral tablet 0 mg, 5 mg PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML, 75 MG/ML PA; SP pravastatin oral tablet 0 mg, 0 mg, 40 mg, 80 mg QL prazosin oral capsule mg, mg, 5 mg procainamide injection solution 00 mg/ml, 500 mg/ml propafenone oral tablet 50 mg, 5 mg, 300 mg propranolol intravenous solution mg/ml propranolol oral capsule,extended release 4 hr 0 mg, 60 mg, 60 mg, 80 mg propranolol oral solution 0 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 0 mg, 0 mg, 40 mg, 60 mg, 80 mg propranolol-hydrochlorothiazid oral tablet 40-5 mg, 80-5 mg quinapril oral tablet 0 mg, 0 mg, 40 mg, 5 mg quinapril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg, 0-5 mg quinidine gluconate injection solution 80 mg/ml quinidine gluconate oral tablet extended release 34 mg quinidine sulfate oral tablet 00 mg, 300 mg ramipril oral capsule.5 mg, 0 mg,.5 mg, 5 mg REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 40 MG/3.5 ML PA Effective January, 08 4

51 REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 40 MG/ML PA; SP REPATHA SYRINGE SUBCUTANEOUS SYRINGE 40 MG/ML PA rosuvastatin oral tablet 0 mg, 0 mg, 40 mg, 5 mg ST sildenafil (antihypertensive) intravenous solution 0 mg/.5 ml PA; SP sildenafil (antihypertensive) oral tablet 0 mg PA; SP; QL simvastatin oral tablet 0 mg, 0 mg, 40 mg, 5 mg, 80 mg QL SORINE ORAL TABLET 0 MG, 60 MG, 40 MG, 80 MG SOTALOL AF ORAL TABLET 0 MG, 60 MG, 80 MG sotalol oral tablet 0 mg, 60 mg, 40 mg, 80 mg spironolactone oral tablet 00 mg, 5 mg, 50 mg spironolacton-hydrochlorothiaz oral tablet 5-5 mg terazosin oral capsule mg, 0 mg, mg, 5 mg QL THEOCHRON ORAL TABLET EXTENDED RELEASE HR 00 MG, 00 MG, 300 MG theophylline oral elixir 80 mg/5 ml theophylline oral solution 80 mg/5 ml theophylline oral tablet extended release hr 00 mg, 00 mg, 300 mg, 450 mg theophylline oral tablet extended release 4 hr 400 mg, 600 mg timolol maleate oral tablet 0 mg, 0 mg, 5 mg torsemide oral tablet 0 mg, 00 mg, 0 mg, 5 mg TRACLEER ORAL TABLET 5 MG, 6.5 MG PA; SP TRACLEER ORAL TABLET FOR SUSPENSION 3 MG PA; SP trandolapril oral tablet mg, mg, 4 mg Effective January, 08 43

52 triamterene-hydrochlorothiazid oral capsule mg, 50-5 mg triamterene-hydrochlorothiazid oral tablet mg, mg UPTRAVI ORAL TABLET,000 MCG,,00 MCG,,400 MCG,,600 MCG, 00 MCG, PA 400 MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLETS,DOSE PACK 00 MCG (40)- 800 MCG (60) PA valsartan oral tablet 60 mg, 30 mg, 40 mg, 80 mg valsartan-hydrochlorothiazide oral tablet mg, 60-5 mg, mg, 30-5 mg, mg VELETRI INTRAVENOUS RECON SOLN 0.5 MG,.5 MG SP verapamil intravenous solution.5 mg/ml verapamil intravenous syringe.5 mg/ml verapamil oral capsule, 4 hr er pellet ct 00 mg, 00 mg, 300 mg verapamil oral capsule,ext rel. pellets 4 hr 0 mg, 80 mg, 40 mg, 360 mg verapamil oral tablet 0 mg, 40 mg, 80 mg verapamil oral tablet extended release 0 mg, 80 mg, 40 mg WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 65 MG CENTRAL NERVOUS SYSTEM AGENTS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG acamprosate oral tablet,delayed release (dr/ec) 333 mg acetaminophen-codeine oral solution 0 mg- mg /5 ml (5 ml), 0- mg/5 ml QL (4500 per 30 days) Effective January, 08 44

53 acetaminophen-codeine oral solution 300 mg-30 mg /.5 ml QL; QL (4500 per 30 days) acetaminophen-codeine oral tablet mg, mg QL; QL (360 per 30 days) acetaminophen-codeine oral tablet mg QL; QL (80 per 30 days) alprazolam oral tablet 0.5 mg, 0.5 mg, mg, mg amantadine hcl oral capsule 00 mg amantadine hcl oral solution 50 mg/5 ml amantadine hcl oral tablet 00 mg amitriptyline oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg amitriptyline-chlordiazepoxide oral tablet.5-5 mg, 5-0 mg amoxapine oral tablet 00 mg, 50 mg, 5 mg, 50 mg aripiprazole oral solution mg/ml ST aripiprazole oral tablet 0 mg, 5 mg, mg, 0 mg, 30 mg, 5 mg ST; QL aripiprazole oral tablet,disintegrating 0 mg, 5 mg ST; QL ASCOMP WITH CODEINE ORAL CAPSULE MG QL; QL (80 per 30 days) aspirin-dipyridamole oral capsule, er multiphase hr 5-00 mg atomoxetine oral capsule 0 mg, 00 mg, 8 mg, 5 mg, 40 mg, 60 mg, 80 mg AUSTEDO ORAL TABLET MG, 6 MG, 9 MG PA BANZEL ORAL SUSPENSION 40 MG/ML PA BANZEL ORAL TABLET 00 MG, 400 MG PA belladonna alkaloids-opium rectal suppository mg QL; QL (0 per 30 days) BELLADONNA-OPIUM RECTAL SUPPOSITORY MG QL; QL (0 per 30 days) benztropine injection solution mg/ ml benztropine oral tablet 0.5 mg, mg, mg bromocriptine oral tablet.5 mg Effective January, 08 45

54 buprenorphine hcl injection syringe 0.3 mg/ml buprenorphine hcl sublingual tablet mg QL; QL (360 per 30 days) buprenorphine hcl sublingual tablet 8 mg QL; QL (90 per 30 days) buprenorphine-naloxone sublingual tablet mg QL; QL (360 per 30 days) buprenorphine-naloxone sublingual tablet 8- mg QL; QL (90 per 30 days) bupropion hcl oral tablet 00 mg, 75 mg bupropion hcl oral tablet extended release hr 00 mg, 50 mg QL bupropion hcl oral tablet extended release hr 00 mg QL; QL (60 per 30 days) bupropion hcl oral tablet extended release 4 hr 50 mg QL; QL (30 per 30 days) bupropion hcl oral tablet extended release 4 hr 300 mg QL buspirone oral tablet 0 mg, 5 mg, 30 mg, 5 mg, 7.5 mg BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE MG QL; QL (80 per 30 days) butalbital-acetaminop-caf-cod oral capsule mg QL; QL (80 per 30 days) butalbital-acetaminophen oral tablet mg QL (80 per 30 days) butalbital-acetaminophen-caff oral capsule mg QL (80 per 30 days) butalbital-acetaminophen-caff oral tablet mg QL (80 per 30 days) butalbital-aspirin-caffeine oral capsule mg cabergoline oral tablet 0.5 mg caffeine citrate intravenous solution 60 mg/3 ml (0 mg/ml) caffeine citrate oral solution 60 mg/3 ml (0 mg/ml) carbamazepine oral capsule, er multiphase hr 00 mg, 00 mg, 300 mg carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet 00 mg Effective January, 08 46

55 carbamazepine oral tablet extended release hr 00 mg, 00 mg, 400 mg carbamazepine oral tablet,chewable 00 mg carbidopa-levodopa oral tablet 0-00 mg, 5-00 mg, 5-50 mg carbidopa-levodopa oral tablet extended release 5-00 mg, mg carbidopa-levodopa oral tablet,disintegrating 0-00 mg, 5-00 mg, 5-50 mg carbidopa-levodopa-entacapone oral tablet mg, mg, mg, mg, mg, mg celecoxib oral capsule 00 mg, 00 mg, 400 mg, 50 mg ST CELONTIN ORAL CAPSULE 300 MG chlordiazepoxide hcl oral capsule 0 mg, 5 mg, 5 mg chlorpromazine injection solution 5 mg/ml chlorpromazine oral tablet 0 mg, 00 mg, 00 mg, 5 mg, 50 mg choline,magnesium salicylate oral liquid 500 mg/5 ml citalopram oral solution 0 mg/5 ml citalopram oral tablet 0 mg, 40 mg QL citalopram oral tablet 0 mg QL; QL (30 per 30 days) clomipramine oral capsule 5 mg, 50 mg, 75 mg clonazepam oral tablet 0.5 mg, mg, mg clonazepam oral tablet,disintegrating 0.5 mg, 0.5 mg, 0.5 mg, mg, mg clonidine (pf) epidural solution,000 mcg/0 ml (00 mcg/ml) clorazepate dipotassium oral tablet 5 mg, 3.75 mg, 7.5 mg clozapine oral tablet 00 mg, 00 mg, 5 mg, 50 mg codeine sulfate oral tablet 5 mg, 30 mg, 60 mg QL; QL (80 per 30 days) Effective January, 08 47

56 COMPRO RECTAL SUPPOSITORY 5 MG desipramine oral tablet 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg dexmethylphenidate oral tablet 0 mg,.5 mg, 5 mg QL dextroamphetamine oral capsule, extended release 0 mg, 5 mg, 5 mg QL dextroamphetamine oral tablet 0 mg, 5 mg QL dextroamphetamine-amphetamine oral capsule,extended release 4hr 0 mg, 5 QL mg, 0 mg, 5 mg, 30 mg, 5 mg dextroamphetamine-amphetamine oral tablet 0 mg,.5 mg, 5 mg, 0 mg, 30 mg, 5 mg, QL 7.5 mg diazepam injection solution 5 mg/ml diazepam injection syringe 5 mg/ml DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML diazepam oral solution 5 mg/5 ml ( mg/ml), 5 mg/5 ml ( mg/ml, 5 ml) diazepam oral tablet 0 mg, mg, 5 mg diclofenac potassium oral tablet 50 mg diclofenac sodium oral tablet extended release 4 hr 00 mg diclofenac sodium oral tablet,delayed release (dr/ec) 5 mg, 50 mg, 75 mg diclofenac sodium topical gel % diflunisal oral tablet 500 mg dihydroergotamine injection solution mg/ml DILANTIN ORAL CAPSULE 30 MG DISKETS ORAL TABLET,SOLUBLE 40 MG QL; QL (30 per 30 days) divalproex oral capsule, delayed rel sprinkle 5 mg divalproex oral tablet extended release 4 hr 50 mg, 500 mg divalproex oral tablet,delayed release (dr/ec) 5 mg, 50 mg, 500 mg doxepin oral capsule 0 mg, 00 mg, 50 mg, 5 mg, 50 mg, 75 mg Effective January, 08 48

57 doxepin oral concentrate 0 mg/ml droperidol injection solution.5 mg/ml duloxetine oral capsule,delayed release(dr/ec) 0 mg QL; QL (60 per 30 days) duloxetine oral capsule,delayed release(dr/ec) 30 mg, 60 mg QL duloxetine oral capsule,delayed release(dr/ec) 40 mg ENDOCET ORAL TABLET 0-35 MG, 5-35 MG, MG QL; QL (360 per 30 days) entacapone oral tablet 00 mg EPITOL ORAL TABLET 00 MG escitalopram oxalate oral solution 5 mg/5 ml escitalopram oxalate oral tablet 0 mg, 5 mg QL escitalopram oxalate oral tablet 0 mg QL; QL (30 per 30 days) estazolam oral tablet mg, mg eszopiclone oral tablet mg, mg, 3 mg ST; QL ethosuximide oral capsule 50 mg ethosuximide oral solution 50 mg/5 ml etodolac oral capsule 00 mg, 300 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 4 hr 400 mg, 500 mg, 600 mg EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML felbamate oral suspension 600 mg/5 ml felbamate oral tablet 400 mg, 600 mg FELBATOL ORAL SUSPENSION 600 MG/5 ML fentanyl citrate buccal lozenge on a handle,00 mcg PA; QL; QL (39 per 30 days) fentanyl citrate buccal lozenge on a handle,600 mcg PA; QL; QL (9 per 30 days) fentanyl citrate buccal lozenge on a handle 00 mcg PA; QL; QL (0 per 30 days) fentanyl citrate buccal lozenge on a handle 400 mcg PA; QL; QL (6 per 30 days) Effective January, 08 49

58 fentanyl citrate buccal lozenge on a handle 600 mcg PA; QL; QL (77 per 30 days) fentanyl citrate buccal lozenge on a handle 800 mcg PA; QL; QL (58 per 30 days) fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 QL; QL (0 per 30 days) mcg/hr flumazenil intravenous solution 0. mg/ml fluoxetine oral capsule 0 mg QL fluoxetine oral capsule 0 mg fluoxetine oral capsule 40 mg QL; QL (60 per 30 days) fluoxetine oral solution 0 mg/5 ml (4 mg/ml) fluphenazine decanoate injection solution 5 mg/ml fluphenazine hcl injection solution.5 mg/ml fluphenazine hcl oral concentrate 5 mg/ml fluphenazine hcl oral elixir.5 mg/5 ml fluphenazine hcl oral tablet mg, 0 mg,.5 mg, 5 mg flurazepam oral capsule 5 mg, 30 mg flurbiprofen oral tablet 00 mg, 50 mg fluvoxamine oral tablet 00 mg QL; QL (90 per 30 days) fluvoxamine oral tablet 5 mg QL fluvoxamine oral tablet 50 mg QL; QL (60 per 30 days) fosphenytoin injection solution 00 mg pe/ ml, 500 mg pe/0 ml FYCOMPA ORAL TABLET 0 MG, MG, MG, 4 MG, 6 MG, 8 MG PA gabapentin oral capsule 00 mg, 300 mg, 400 mg gabapentin oral solution 50 mg/5 ml, 50 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET MG, 6 MG guanfacine oral tablet mg, mg haloperidol decanoate intramuscular solution 00 mg/ml, 50 mg/ml haloperidol lactate injection solution 5 mg/ml Effective January, 08 50

59 haloperidol lactate oral concentrate mg/ml haloperidol oral tablet 0.5 mg, mg, 0 mg, mg, 0 mg, 5 mg hydrocodone-acetaminophen oral solution mg/5 ml QL; QL (5550 per 30 days) hydrocodone-acetaminophen oral tablet mg, 0-35 mg,.5-35 mg, mg, QL; QL (360 per 30 days) 5-35 mg, mg, mg hydrocodone-ibuprofen oral tablet 0-00 mg, 5-00 mg, mg QL; QL (50 per 30 days) hydromorphone oral liquid mg/ml QL; QL (500 per 30 days) hydromorphone oral tablet mg, 4 mg, 8 mg QL; QL (80 per 30 days) hydromorphone rectal suppository 3 mg QL; QL (0 per 30 days) hydroxyzine hcl intramuscular solution 5 mg/ml hydroxyzine hcl oral solution 0 mg/5 ml hydroxyzine hcl oral tablet 0 mg, 5 mg, 50 mg hydroxyzine pamoate oral capsule 00 mg, 5 mg, 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg imipramine hcl oral tablet 0 mg, 5 mg, 50 mg imipramine pamoate oral capsule 00 mg, 5 mg, 50 mg, 75 mg indomethacin oral capsule 5 mg, 50 mg INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML, 56 MG/ML, 34 MG/.5 ML, 39 MG/0.5 ML, 78 MG/0.5 ML ketoprofen oral capsule 50 mg, 75 mg ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg ketorolac injection cartridge 5 mg/ml, 30 mg/ml ketorolac injection solution 5 mg/ml, 30 mg/ml, 30 mg/ml ( ml) ketorolac intramuscular solution 60 mg/ ml Effective January, 08 5

60 ketorolac oral tablet 0 mg QL lamotrigine oral tablet 00 mg, 50 mg, 00 mg, 5 mg lamotrigine oral tablet, chewable dispersible 5 mg, 5 mg LATUDA ORAL TABLET 0 MG, 0 MG, 40 MG, 60 MG, 80 MG ST; QL levetiracetam intravenous solution 500 mg/5 ml levetiracetam oral solution 00 mg/ml, 500 mg/5 ml (5 ml) levetiracetam oral tablet,000 mg, 50 mg, 500 mg, 750 mg levetiracetam oral tablet extended release 4 hr 500 mg, 750 mg levorphanol tartrate oral tablet mg QL; QL (0 per 30 days) lithium carbonate oral capsule 50 mg, 300 mg, 600 mg lithium carbonate oral tablet 300 mg lithium carbonate oral tablet extended release 300 mg, 450 mg lithium citrate oral solution 8 meq/5 ml lorazepam injection solution mg/ml, 4 mg/ml lorazepam injection syringe mg/ml, 4 mg/ml LORAZEPAM INTENSOL ORAL CONCENTRATE MG/ML lorazepam oral concentrate mg/ml lorazepam oral tablet 0.5 mg, mg, mg LORCET (HYDROCODONE) ORAL TABLET 5-35 MG QL; QL (360 per 30 days) LORCET HD ORAL TABLET 0-35 MG QL; QL (360 per 30 days) loxapine succinate oral capsule 0 mg, 5 mg, 5 mg, 50 mg LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 5 MG, 300 MG, 50 MG, PA 75 MG magnesium chloride injection solution 00 mg/ml (0 %) Effective January, 08 5

61 magnesium sulfate in water intravenous parenteral solution 0 gram/500 ml (4 %), 40 gram/,000 ml (4 %) magnesium sulfate in water intravenous piggyback gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml maprotiline oral tablet 5 mg, 50 mg, 75 mg MARTEN-TAB ORAL TABLET MG QL (80 per 30 days) meclofenamate oral capsule 00 mg, 50 mg meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 5 mg meloxicam oral tablet 7.5 mg QL memantine oral solution mg/ml memantine oral tablet 0 mg, 5 mg memantine oral tablets,dose pack 5-0 mg meperidine oral solution 50 mg/5 ml QL; QL (00 per 30 days) meperidine oral tablet 00 mg QL; QL (0 per 30 days) meperidine oral tablet 50 mg QL; QL (40 per 30 days) meprobamate oral tablet 00 mg, 400 mg METADATE ER ORAL TABLET EXTENDED RELEASE 0 MG QL methadone oral concentrate 0 mg/ml QL; QL (0 per 30 days) methadone oral solution 0 mg/5 ml QL; QL (600 per 30 days) methadone oral solution 5 mg/5 ml QL; QL (00 per 30 days) methadone oral tablet 0 mg QL; QL (0 per 30 days) methadone oral tablet 5 mg QL; QL (40 per 30 days) methadone oral tablet,soluble 40 mg QL; QL (30 per 30 days) METHADOSE ORAL CONCENTRATE 0 MG/ML QL; QL (0 per 30 days) METHADOSE ORAL TABLET,SOLUBLE 40 MG QL; QL (30 per 30 days) METHYLIN ORAL SOLUTION 0 MG/5 ML, 5 MG/5 ML QL Effective January, 08 53

62 methylphenidate hcl oral capsule, er biphasic mg, 0 mg, 30 mg, 40 mg, 50 mg, QL 60 mg methylphenidate hcl oral capsule,er biphasic mg, 30 mg, 40 mg QL methylphenidate hcl oral solution 0 mg/5 ml, 5 mg/5 ml QL methylphenidate hcl oral tablet 0 mg, 0 mg, 5 mg QL methylphenidate hcl oral tablet extended release 0 mg, 0 mg QL methylphenidate hcl oral tablet extended release 4hr 8 mg, 7 mg, 36 mg, 54 mg QL methylphenidate hcl oral tablet,chewable 0 mg,.5 mg, 5 mg QL midazolam oral syrup mg/ml mirtazapine oral tablet 5 mg, 30 mg, 45 mg, 7.5 mg mirtazapine oral tablet,disintegrating 5 mg, 30 mg, 45 mg modafinil oral tablet 00 mg, 00 mg PA morphine concentrate oral solution 00 mg/5 ml (0 mg/ml) QL; QL (300 per 30 days) morphine oral solution 0 mg/5 ml, 0 mg/5 ml (4 mg/ml) QL; QL (900 per 30 days) morphine oral tablet 5 mg, 30 mg QL; QL (80 per 30 days) morphine oral tablet extended release 00 mg QL; QL (60 per 30 days) morphine oral tablet extended release 5 mg, 30 mg QL; QL (0 per 30 days) morphine oral tablet extended release 00 mg QL; QL (30 per 30 days) morphine oral tablet extended release 60 mg QL; QL (00 per 30 days) morphine rectal suppository 0 mg, 5 mg QL; QL (360 per 30 days) morphine rectal suppository 0 mg QL; QL (80 per 30 days) morphine rectal suppository 30 mg QL; QL (0 per 30 days) nabumetone oral tablet 500 mg, 750 mg nalbuphine injection solution 0 mg/ml, 0 mg/ml Effective January, 08 54

63 naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, mg/ml naltrexone oral tablet 50 mg naproxen oral suspension 5 mg/5 ml naproxen oral tablet 50 mg, 375 mg, 500 mg naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 mg NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION nefazodone oral tablet 00 mg, 50 mg, 00 mg, 50 mg, 50 mg nortriptyline oral capsule 0 mg, 5 mg, 50 mg, 75 mg nortriptyline oral solution 0 mg/5 ml NUEDEXTA ORAL CAPSULE 0-0 MG PA; QL; QL (60 per 30 days) olanzapine intramuscular recon soln 0 mg olanzapine oral tablet 0 mg QL; QL (30 per 30 days) olanzapine oral tablet 5 mg,.5 mg, 5 mg, 7.5 mg QL olanzapine oral tablet 0 mg olanzapine oral tablet,disintegrating 0 mg, 5 mg, 0 mg, 5 mg ST; QL oxaprozin oral tablet 600 mg oxazepam oral capsule 0 mg, 5 mg, 30 mg oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml) oxcarbazepine oral tablet 50 mg, 300 mg, 600 mg oxycodone oral capsule 5 mg QL; QL (360 per 30 days) oxycodone oral concentrate 0 mg/ml QL; QL (80 per 30 days) oxycodone oral solution 5 mg/5 ml QL; QL (360 per 30 days) oxycodone oral tablet 0 mg, 5 mg, 0 mg QL; QL (80 per 30 days) oxycodone oral tablet 30 mg QL; QL (34 per 30 days) oxycodone oral tablet 5 mg QL; QL (360 per 30 days) Effective January, 08 55

64 OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL. HR 0 MG, 5 MG, 0 ST; QL; QL (90 per 30 days) MG, 30 MG, 40 MG, 60 MG OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL. HR 80 MG ST; QL; QL (50 per 30 days) oxycodone-acetaminophen oral tablet 0-35 mg,.5-35 mg, 5-35 mg, mg QL; QL (360 per 30 days) oxycodone-aspirin oral tablet mg QL; QL (70 per 30 days) OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL. HR 0 MG, 5 MG, 0 ST; QL; QL (90 per 30 days) MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL. HR 80 MG ST; QL; QL (50 per 30 days) paroxetine hcl oral tablet 0 mg, 40 mg QL; QL (30 per 30 days) paroxetine hcl oral tablet 0 mg QL paroxetine hcl oral tablet 30 mg QL; QL (60 per 30 days) paroxetine hcl oral tablet extended release 4 hr.5 mg QL; QL (60 per 30 days) paroxetine hcl oral tablet extended release 4 hr 5 mg, 37.5 mg QL PEGANONE ORAL TABLET 50 MG pentazocine-naloxone oral tablet mg perphenazine oral tablet 6 mg, mg, 4 mg, 8 mg perphenazine-amitriptyline oral tablet -0 mg, -5 mg, 4-0 mg, 4-5 mg, 4-50 mg phenelzine oral tablet 5 mg phenobarbital oral elixir 0 mg/5 ml (4 mg/ml) phenobarbital oral tablet 00 mg, 5 mg, 6. mg, 30 mg, 3.4 mg, 60 mg, 64.8 mg, 97. mg phenobarbital sodium injection solution 30 mg/ml, 65 mg/ml phenytoin oral suspension 00 mg/4 ml, 5 mg/5 ml phenytoin oral tablet,chewable 50 mg phenytoin sodium extended oral capsule 00 mg, 00 mg, 300 mg Effective January, 08 56

65 phenytoin sodium intravenous solution 50 mg/ml phenytoin sodium intravenous syringe 50 mg/ml piroxicam oral capsule 0 mg, 0 mg pramipexole oral tablet 0.5 mg, 0.5 mg, 0.5 mg, 0.75 mg, mg,.5 mg primidone oral tablet 50 mg, 50 mg prochlorperazine edisylate injection solution 0 mg/ ml (5 mg/ml) prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 5 mg promethazine injection solution 5 mg/ml, 50 mg/ml promethazine oral syrup 6.5 mg/5 ml promethazine oral tablet.5 mg, 5 mg, 50 mg promethazine rectal suppository.5 mg, 5 mg propranolol intravenous solution mg/ml propranolol oral capsule,extended release 4 hr 0 mg, 60 mg, 60 mg, 80 mg propranolol oral solution 0 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml) propranolol oral tablet 0 mg, 0 mg, 40 mg, 60 mg, 80 mg protriptyline oral tablet 0 mg, 5 mg quetiapine oral tablet 00 mg, 5 mg QL; QL (90 per 30 days) quetiapine oral tablet 00 mg, 400 mg, 50 mg QL quetiapine oral tablet 300 mg QL; QL (60 per 30 days) quetiapine oral tablet extended release 4 hr 50 mg, 00 mg, 300 mg, 400 mg, 50 mg ST; QL riluzole oral tablet 50 mg RISPERDAL CONSTA INTRAMUSCULAR SYRINGE.5 MG/ ML, 5 MG/ ML, 37.5 MG/ ML, 50 MG/ ML risperidone oral solution mg/ml Effective January, 08 57

66 risperidone oral tablet 0.5 mg, mg, mg, 4 mg QL risperidone oral tablet 0.5 mg, 3 mg QL; QL (60 per 30 days) risperidone oral tablet,disintegrating 0.5 mg, mg, mg, 3 mg, 4 mg ST; QL risperidone oral tablet,disintegrating 0.5 mg ST; QL; QL (60 per 30 days) rizatriptan oral tablet 0 mg, 5 mg QL rizatriptan oral tablet,disintegrating 0 mg, 5 mg QL ropinirole oral tablet 0.5 mg, 0.5 mg, mg, mg, 3 mg, 4 mg, 5 mg salsalate oral tablet 500 mg, 750 mg SAVELLA ORAL TABLET 00 MG,.5 MG, 5 MG, 50 MG PA; QL SAVELLA ORAL TABLETS,DOSE PACK.5 MG (5)-5 MG(8)-50 MG(4) PA; QL SECONAL SODIUM ORAL CAPSULE 00 MG selegiline hcl oral capsule 5 mg selegiline hcl oral tablet 5 mg sertraline oral concentrate 0 mg/ml sertraline oral tablet 00 mg QL; QL (60 per 30 days) sertraline oral tablet 5 mg, 50 mg QL SUBOXONE SUBLINGUAL FILM -3 MG QL; QL (60 per 30 days) SUBOXONE SUBLINGUAL FILM 4- MG QL; QL (40 per 30 days) sulindac oral tablet 50 mg, 00 mg sumatriptan nasal spray,non-aerosol 0 mg/actuation, 5 mg/actuation QL sumatriptan succinate oral tablet 00 mg, 5 mg, 50 mg QL sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml QL sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml QL sumatriptan succinate subcutaneous solution 6 mg/0.5 ml QL temazepam oral capsule 5 mg,.5 mg, 30 mg, 7.5 mg Effective January, 08 58

67 tetrabenazine oral tablet.5 mg, 5 mg PA; SP thioridazine oral tablet 0 mg, 00 mg, 5 mg, 50 mg thiothixene oral capsule mg, 0 mg, mg, 5 mg tiagabine oral tablet mg, 4 mg timolol maleate oral tablet 0 mg, 0 mg, 5 mg tolmetin oral capsule 400 mg tolmetin oral tablet 00 mg, 600 mg topiramate oral capsule, sprinkle 5 mg, 5 mg topiramate oral tablet 00 mg, 00 mg, 5 mg, 50 mg tramadol oral tablet 50 mg QL; QL (40 per 30 days) tramadol-acetaminophen oral tablet mg QL; QL (40 per 30 days) tranylcypromine oral tablet 0 mg trazodone oral tablet 00 mg, 50 mg, 300 mg, 50 mg triazolam oral tablet 0.5 mg, 0.5 mg trifluoperazine oral tablet mg, 0 mg, mg, 5 mg trihexyphenidyl oral elixir 0.4 mg/ml trihexyphenidyl oral tablet mg, 5 mg valproate sodium intravenous solution 500 mg/5 ml (00 mg/ml) valproic acid (as sodium salt) oral solution 50 mg/5 ml, 50 mg/5 ml (5 ml), 500 mg/0 ml (0 ml) valproic acid oral capsule 50 mg venlafaxine oral capsule,extended release 4hr 50 mg, 37.5 mg, 75 mg QL venlafaxine oral tablet 00 mg, 5 mg, 37.5 mg, 75 mg QL venlafaxine oral tablet 50 mg QL; QL (90 per 30 days) venlafaxine oral tablet extended release 4hr 50 mg, 75 mg QL Effective January, 08 59

68 venlafaxine oral tablet extended release 4hr 5 mg, 37.5 mg QL; QL (30 per 30 days) VIMPAT INTRAVENOUS SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG VYVANSE ORAL CAPSULE 0 MG QL VYVANSE ORAL CAPSULE 0 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG PA; QL zaleplon oral capsule 0 mg QL zaleplon oral capsule 5 mg QL; QL (30 per 30 days) ziprasidone hcl oral capsule 0 mg, 40 mg, 60 mg, 80 mg QL zolmitriptan oral tablet.5 mg, 5 mg QL zolmitriptan oral tablet,disintegrating.5 mg, 5 mg QL zolpidem oral tablet 0 mg, 5 mg QL zolpidem oral tablet,ext release multiphase.5 mg QL zolpidem oral tablet,ext release multiphase 6.5 mg QL; QL (30 per 30 days) zonisamide oral capsule 00 mg, 5 mg, 50 mg ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 0 MG, 300 MG, 405 MG DEVICES ACE AEROSOL CLOUD ENHANCER SPACER BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE 0.9 % CLEO 90 INFUSION SET 4" INFUSION SET COMFORT SHORT INFUSION SET 3" INFUSION SET ECLIPSE SYRINGE SYRINGE 3 ML GAUGE X " Effective January, 08 60

69 HEP FLUSH-0 (PF) INTRAVENOUS SOLUTION 0 UNIT/ML heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml,,000 unit/,000 ml heparin flush(porcine)-0.9nacl intravenous kit 00 unit/ml heparin lock flush (porcine) intravenous syringe 00 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 0 UNIT/ML HEPARIN LOCK INTRAVENOUS SOLUTION 00 UNIT/ML HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 0 UNIT/ML, 00 UNIT/ML heparin, porcine (pf) intravenous syringe unit/ml, 00 unit/ml MONOJECT MAGELLAN SYRINGE SYRINGE 3 ML 0 GAUGE X " MONOJECT SYRINGE SYRINGE / ML 8 GAUGE NORMAL SALINE FLUSH INJECTION SYRINGE 0.9 % POLYFIN QR INFUSION SET sodium chloride 0.9 % injection syringe 0.9 % SYREX SODIUM CHLORIDE 0.9% INJECTION SYRINGE 0.9 % syringe with needle, safety syringe ml 5 gauge x 5/8" T:SLIM SUBCUTANEOUS CARTRIDGE DIAGNOSTIC AGENTS CANDIN INTRADERMAL ALLERGEN FDA STANDARD cosyntropin injection recon soln 0.5 mg cosyntropin intravenous solution 0.5 mg/ml E-Z-CAT DRY ORAL POWDER IN PACKET % (W/W) E-Z-HD BARIUM ORAL SUSPENSION FOR RECONSTITUTION 98 % Effective January, 08 6

70 E-Z-PAQUE ORAL SUSPENSION FOR RECONSTITUTION 96 % (W/W) fluorescein-proparacaine ophthalmic (eye) drops % GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN MG/ML GLUCAGON HCL INJECTION RECON SOLN MG ISOVUE-300 INTRAVENOUS SOLUTION 6 % ISOVUE-M 300 INTRATHECAL SOLUTION 6 % LIQUID E-Z PAQUE ORAL SUSPENSION 60 % (W/V) mannitol 0 % intravenous parenteral solution 0 % mannitol 0 % intravenous parenteral solution 0 % mannitol 5 % intravenous solution 5 % mannitol 5 % intravenous parenteral solution 5 % OMNIPAQUE 40 INTRAVENOUS SOLUTION 40 MG IODINE/ML OMNIPAQUE 40 INTRAVENOUS SOLUTION 40 MG IODINE/ML OMNIPAQUE 300 INTRAVENOUS SOLUTION 300 MG IODINE/ML ONETOUCH ULTRA TEST STRIP ONETOUCH VERIO STRIP READI-CAT ORAL SUSPENSION. % (W/V),.0 % (W/W) SITZMARKS ORAL CAPSULE 4 MARKERS TAGITOL V ORAL SUSPENSION 40 % (W/V) thallous chloride tl-0 intravenous solution 37 mbq/ml ( mci/ml) THYROGEN INTRAMUSCULAR RECON SOLN. MG SP Effective January, 08 6

71 VARIBAR THIN HONEY ORAL SUSPENSION 40 % (W/V) 9% (W/W) VARIBAR THIN LIQUID ORAL POWDER 40 % (W/V) VISIPAQUE INTRAVENOUS SOLUTION 70 MG IODINE/ML VOLUMEN ORAL SUSPENSION 0. % ELECTROLYTIC, CALORIC, AND WATER BALANCE acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 5 mg, 50 mg acetazolamide sodium injection recon soln 500 mg acetic acid irrigation solution 0.5 % amiloride-hydrochlorothiazide oral tablet 5-50 mg ammonium chloride intravenous solution 5 meq/ml atenolol-chlorthalidone oral tablet 00-5 mg, 50-5 mg BAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR MG BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE 0.9 % benazepril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg, 0-5 mg, mg bisoprolol-hydrochlorothiazide oral tablet mg, mg, mg bumetanide injection solution 0.5 mg/ml bumetanide oral tablet 0.5 mg, mg, mg calcium acetate oral capsule 667 mg calcium acetate oral tablet 667 mg calcium chloride intravenous solution 00 mg/ml (0 %) calcium chloride intravenous syringe 00 mg/ml (0 %) calcium gluconate intravenous solution 00 mg/ml (0%) Effective January, 08 63

72 captopril-hydrochlorothiazide oral tablet 5-5 mg, 5-5 mg, 50-5 mg, 50-5 mg CARBAGLU ORAL TABLET, DISPERSIBLE 00 MG SP chlorothiazide oral tablet 50 mg, 500 mg chlorthalidone oral tablet 5 mg, 50 mg chromium chloride intravenous solution 4 mcg/ml CONSTULOSE ORAL SOLUTION 0 GRAM/5 ML COPPER CHLORIDE INTRAVENOUS SOLUTION 0.4 MG/ML CYTRA K CRYSTALS ORAL PACKET 3,300-,00 MG CYTRA- ORAL SOLUTION MG/5 ML CYTRA-3 ORAL SOLUTION MG/5 ML CYTRA-K ORAL SOLUTION, MG/5 ML DELFLEX-LC/.5% DEXTROSE INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L DELFLEX-LC/.5% DEXTROSE INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L DELFLEX-LC/4.5% DEXTROSE INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L DELFLEX-SM WITH.5% DEXTROSE INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG.5 MEQ/L dextrose 5 % in ringer's intravenous parenteral solution 5 % dextrose 5 %-lactated ringers intravenous parenteral solution DIANEAL LOW CALCIUM/.5% DEX INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L Effective January, 08 64

73 DIANEAL PD- WITH.5 % DEX INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG 0.5 MEQ/L DIANEAL PD- WITH 4.5 % DEX INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG 0.5 MEQ/L DIANEAL PD-/.5% DEXTROSE INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG 0.5 MEQ/L DIANEAL WITH.5 % DEXTROSE INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L DIANEAL WITH 4.5 % DEXTROSE INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L EFFER-K ORAL TABLET, EFFERVESCENT 5 MEQ electrolyte-48 in d5w intravenous parenteral solution ELIPHOS ORAL TABLET 667 MG enalapril-hydrochlorothiazide oral tablet 0-5 mg, 5-.5 mg ENULOSE ORAL SOLUTION 0 GRAM/5 ML fosinopril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg FOSRENOL ORAL TABLET,CHEWABLE,000 MG, 500 MG, 750 MG furosemide injection solution 0 mg/ml furosemide injection syringe 0 mg/ml furosemide oral solution 0 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet 0 mg, 40 mg, 80 mg GENERLAC ORAL SOLUTION 0 GRAM/5 ML glycine urologic solution irrigation solution.5 % hetastarch 6 % in 0.9 % nacl intravenous solution 6 % hydrochlorothiazide oral capsule.5 mg Effective January, 08 65

74 hydrochlorothiazide oral tablet.5 mg, 5 mg, 50 mg indapamide oral tablet.5 mg,.5 mg IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION K-EFFERVESCENT ORAL TABLET, EFFERVESCENT 5 MEQ KIONEX (WITH SORBITOL) ORAL SUSPENSION GRAM/60 ML KLOR-CON 0 ORAL TABLET EXTENDED RELEASE 0 MEQ KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ KLOR-CON M0 ORAL TABLET,ER PARTICLES/CRYSTALS 0 MEQ KLOR-CON M5 ORAL TABLET,ER PARTICLES/CRYSTALS 5 MEQ KLOR-CON M0 ORAL TABLET,ER PARTICLES/CRYSTALS 0 MEQ KLOR-CON ORAL PACKET 0 MEQ KLOR-CON/EF ORAL TABLET, EFFERVESCENT 5 MEQ lactated ringers intravenous parenteral solution lactated ringers irrigation solution lactulose oral solution 0 gram/5 ml, 0 gram/5 ml (5 ml), 0 gram/30 ml lanthanum oral tablet,chewable,000 mg, 500 mg, 750 mg lisinopril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg, 0-5 mg Effective January, 08 66

75 losartan-hydrochlorothiazide oral tablet mg, 00-5 mg, mg manganese chloride intravenous solution 0. mg/ml mannitol 0 % intravenous parenteral solution 0 % mannitol 0 % intravenous parenteral solution 0 % mannitol 5 % intravenous solution 5 % mannitol 5 % intravenous parenteral solution 5 % methyldopa-hydrochlorothiazide oral tablet 50-5 mg, 50-5 mg metolazone oral tablet 0 mg,.5 mg, 5 mg metoprolol ta-hydrochlorothiaz oral tablet 00-5 mg, mg, 50-5 mg moexipril-hydrochlorothiazide oral tablet 5-.5 mg, 5-5 mg, mg MYNATAL ADVANCE ORAL TABLET MG MYNATAL ORAL CAPSULE 65 MG IRON- MG MYNATAL PLUS ORAL TABLET 65 MG IRON- MG MYNATAL-Z ORAL TABLET 65 MG IRON- MG nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg NORMAL SALINE FLUSH INJECTION SYRINGE 0.9 % NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION Effective January, 08 67

76 NUTRILYTE INTRAVENOUS SOLUTION MEQ/0 ML PHOSPHA 50 NEUTRAL ORAL TABLET 50 MG PHYSIOLYTE IRRIGATION SOLUTION MEQ/L PHYSIOSOL IRRIGATION IRRIGATION SOLUTION MEQ/L PLASMA-LYTE 48 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % PNV OB+DHA ORAL COMBO PACK MG PNV-DHA + DOCUSATE ORAL CAPSULE MG PNV-OMEGA ORAL CAPSULE MG potassium acetate intravenous solution meq/ml potassium bicarb and chloride oral tablet, effervescent 5 meq potassium bicarb-citric acid oral tablet, effervescent 5 meq potassium chlorid-d5-0.45%nacl intravenous parenteral solution 0 meq/l, 0 meq/l, 30 meq/l, 40 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride intravenous piggyback 0 meq/00 ml, 0 meq/50 ml, 0 meq/00 ml, 0 meq/50 ml, 30 meq/00 ml, 40 meq/00 ml Effective January, 08 68

77 potassium chloride intravenous solution meq/ml potassium chloride oral capsule, extended release 0 meq, 8 meq potassium chloride oral liquid 0 meq/5 ml, 40 meq/5 ml potassium chloride oral tablet extended release 0 meq, 8 meq potassium chloride oral tablet,er particles/crystals 0 meq, 0 meq potassium chloride-0.45 % nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium citrate oral tablet extended release 0 meq (,080 mg), 5 meq (540 mg) potassium citrate-citric acid oral solution, mg/5 ml potassium phosphate m-/d-basic intravenous solution 3 mmol/ml PR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 400 ORAL COMBO PACK MG PR NATAL 430 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 430 ORAL COMBO PACK 9 MG IRON- MG -430 MG PRENAISSANCE ORAL CAPSULE MG PRENAISSANCE PLUS ORAL CAPSULE MG PRENATABS FA ORAL TABLET 9- MG PRENATABS RX ORAL TABLET 9 MG IRON- MG Effective January, 08 69

78 PRENATAL LOW IRON ORAL TABLET 7 MG IRON- MG PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 7 MG IRON- MG PRENATAL PLUS ORAL TABLET 9 MG IRON- MG probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg propranolol-hydrochlorothiazid oral tablet 40-5 mg, 80-5 mg quinapril-hydrochlorothiazide oral tablet 0-.5 mg, 0-.5 mg, 0-5 mg RAVICTI ORAL LIQUID. GRAM/ML SP RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL TABLET 800 MG ringer's intravenous parenteral solution ringer's irrigation solution selenium intravenous solution 40 mcg/ml sevelamer carbonate oral powder in packet 0.8 gram,.4 gram sodium acetate intravenous solution meq/ml, 4 meq/ml sodium bicarbonate intravenous solution meq/ml (8.4 %), 4. % sodium bicarbonate intravenous syringe 0 meq/0 ml (8.4 %), 4. % (0.5 meq/ml), 7.5 % (0.9 meq/ml), 8.4 % ( meq/ml) sodium chlor 0.9% bacteriostat injection solution 0.9 % sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.45 % intravenous piggyback 0.45 % sodium chloride 0.9 % injection solution 0.9 % sodium chloride 0.9 % injection syringe 0.9 % sodium chloride 0.9 % intravenous parenteral solution 0.9 % Effective January, 08 70

79 sodium chloride 0.9 % intravenous piggyback 0.9 % sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution.5 meq/ml, 4 meq/ml sodium chloride irrigation solution 0.9 % sodium citrate-citric acid oral solution mg/5 ml sodium lactate intravenous solution 5 meq/ml sodium phenylbutyrate oral powder 0.94 gram/gram sodium phenylbutyrate oral tablet 500 mg sodium phosphate intravenous solution 3 mmol/ml SODIUM POLYSTYRENE (SORB FREE) ORAL SUSPENSION 5 GRAM/60 ML sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate rectal enema 30 gram/0 ml spironolactone oral tablet 00 mg, 5 mg, 50 mg spironolacton-hydrochlorothiaz oral tablet 5-5 mg SPS (WITH SORBITOL) ORAL SUSPENSION 5-0 GRAM/60 ML SPS (WITH SORBITOL) RECTAL ENEMA GRAM/0 ML SYREX SODIUM CHLORIDE 0.9% INJECTION SYRINGE 0.9 % THEOCHRON ORAL TABLET EXTENDED RELEASE HR 00 MG, 00 MG, 300 MG theophylline oral elixir 80 mg/5 ml theophylline oral solution 80 mg/5 ml theophylline oral tablet extended release hr 00 mg, 00 mg, 300 mg, 450 mg Effective January, 08 7

80 TL-SELECT ORAL CAPSULE MG torsemide oral tablet 0 mg, 00 mg, 0 mg, 5 mg TRIADVANCE ORAL TABLET MG triamterene-hydrochlorothiazid oral capsule mg, 50-5 mg triamterene-hydrochlorothiazid oral tablet mg, mg TRICITRATES ORAL SOLUTION MG/5 ML TRINATAL RX ORAL TABLET 60 MG IRON- MG TRINATE ORAL TABLET 8 MG IRON- MG TRIVEEN-DUO DHA ORAL COMBO PACK MG TRIVEEN-ONE ORAL CAPSULE 7 MG IRON- MG -50 MG TRIVEEN-PRX RNF ORAL CAPSULE MG ULTIMATECARE ONE NF ORAL CAPSULE MG ULTIMATECARE ONE ORAL CAPSULE MG valsartan-hydrochlorothiazide oral tablet mg, 60-5 mg, mg, 30-5 mg, mg VELTASSA ORAL POWDER IN PACKET 6.8 GRAM, 5. GRAM, 8.4 GRAM SP VEMAVITE-PRX- ORAL CAPSULE MG VENA-BAL DHA ORAL COMBO PACK,TABLET AND CAP,DR MG VINACAL ORAL TABLET MG VINATE ONE ORAL TABLET 60 MG IRON- MG VINATE ULTRA ORAL TABLET MG VIRT-PN PLUS ORAL CAPSULE MG Effective January, 08 7

81 VIRT-SELECT ORAL CAPSULE MG VITAFOL-OB ORAL TABLET 65- MG VOL-NATE ORAL TABLET 8 MG IRON- MG VOL-TAB RX ORAL TABLET 9 MG IRON- MG water for irrigation, sterile irrigation solution ZATEAN-CH ORAL CAPSULE MG ZATEAN-PN PLUS ORAL CAPSULE MG zinc chloride intravenous solution mg/ml zinc sulfate intravenous solution 5 mg/ml ENZYMES CATHFLO ACTIVASE INTRA-CATHETER RECON SOLN MG ELELYSO INTRAVENOUS RECON SOLN 00 UNIT PA; SP FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG PA; SP LUMIZYME INTRAVENOUS RECON SOLN 50 MG PA; SP PULMOZYME INHALATION SOLUTION MG/ML SP STRENSIQ SUBCUTANEOUS SOLUTION 00 MG/ML, 40 MG/ML PA SUCRAID ORAL SOLUTION 8,500 UNIT/ML SP VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML ( MG/ML) SP VPRIV INTRAVENOUS RECON SOLN 400 UNIT PA; SP EYE, EAR, NOSE AND THROAT (EENT) PREPS. acetazolamide oral capsule, extended release 500 mg acetazolamide oral tablet 5 mg, 50 mg acetazolamide sodium injection recon soln 500 mg Effective January, 08 73

82 acetic acid otic (ear) solution % apraclonidine ophthalmic (eye) drops 0.5 % atropine ophthalmic (eye) drops % atropine ophthalmic (eye) ointment % azelastine nasal aerosol,spray 37 mcg (0. %) QL; QL (60 per 30 days) azelastine nasal spray,non-aerosol 0.5 % (05.5 mcg) QL; QL (60 per 30 days) azelastine ophthalmic (eye) drops 0.05 % bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment 500-0,000 unit/gram BACTROBAN NASAL NASAL OINTMENT % BALANCED SALT INTRAOCULAR SOLUTION betaxolol ophthalmic (eye) drops 0.5 % BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 0-0. % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 0-0. % brimonidine ophthalmic (eye) drops 0.5 %, 0. % carteolol ophthalmic (eye) drops % chlorhexidine gluconate mucous membrane mouthwash 0. % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic (eye) drops 0.3 % cocaine topical solution 4 % cromolyn ophthalmic (eye) drops 4 % cyclopentolate ophthalmic (eye) drops %, % CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % SP dexamethasone sodium phosphate ophthalmic (eye) drops 0. % Effective January, 08 74

83 diclofenac sodium ophthalmic (eye) drops 0. % dorzolamide ophthalmic (eye) drops % dorzolamide-timolol ophthalmic (eye) drops mg/ml doxycycline hyclate oral tablet 0 mg erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) QL; QL (50 per 30 days) fluorescein-proparacaine ophthalmic (eye) drops % fluorometholone ophthalmic (eye) drops,suspension 0. % flurbiprofen sodium ophthalmic (eye) drops 0.03 % FLUROX OPHTHALMIC (EYE) DROPS % GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) gentamicin ophthalmic (eye) drops 0.3 % gentamicin ophthalmic (eye) ointment 0.3 % (3 mg/gram) HOMATROPAIRE OPHTHALMIC (EYE) DROPS 5 % hydrocortisone-acetic acid otic (ear) drops - % ipratropium bromide nasal spray,non-aerosol 0.03 %, 4 mcg (0.06 %) QL ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % latanoprost ophthalmic (eye) drops % levobunolol ophthalmic (eye) drops 0.5 % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane jelly in applicator % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) Effective January, 08 75

84 LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % metipranolol ophthalmic (eye) drops 0.3 % moxifloxacin ophthalmic (eye) drops 0.5 % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 mg-unit/g-% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-0,000 unit/ml-0. % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic (eye) drops.75 mg-0,000 unit-0.05mg/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-0,000-0 mg-unitmg/ml neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-0,000- mg/mlunit/ml-% neomycin-polymyxin-hc otic (ear) solution 3.5-0,000- mg/ml-unit/ml-% NEO-POLYCIN HC OPHTHALMIC (EYE) OINTMENT ,000 MG-UNIT/G-% ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin otic (ear) drops 0.3 % olopatadine ophthalmic (eye) drops 0. % PERIOGARD MUCOUS MEMBRANE MOUTHWASH 0. % phenylephrine hcl ophthalmic (eye) drops 0 %,.5 % PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.5 % pilocarpine hcl ophthalmic (eye) drops %, %, 4 % Effective January, 08 76

85 POLYCIN OPHTHALMIC (EYE) OINTMENT 500-0,000 UNIT/GRAM polymyxin b sulf-trimethoprim ophthalmic (eye) drops 0,000 unit- mg/ml PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % prednisolone acetate ophthalmic (eye) drops,suspension % prednisolone sodium phosphate ophthalmic (eye) drops % proparacaine ophthalmic (eye) drops 0.5 % RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % PA; QL sulfacetamide sodium ophthalmic (eye) drops 0 % sulfacetamide sodium ophthalmic (eye) ointment 0 % sulfacetamide-prednisolone ophthalmic (eye) drops 0 %-0.3 % (0.5 %) TETCAINE OPHTHALMIC (EYE) DROPS 0.5 % tetracaine hcl (pf) ophthalmic (eye) drops 0.5 % tetracaine hcl ophthalmic (eye) drops 0.5 % timolol maleate ophthalmic (eye) drops 0.5 %, 0.5 % timolol maleate ophthalmic (eye) gel forming solution 0.5 %, 0.5 % tobramycin ophthalmic (eye) drops 0.3 % tobramycin-dexamethasone ophthalmic (eye) drops,suspension % tropicamide ophthalmic (eye) drops 0.5 %, % XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % ZIRGAN OPHTHALMIC (EYE) GEL 0.5 % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % Effective January, 08 77

86 GASTROINTESTINAL DRUGS alosetron oral tablet 0.5 mg, mg aprepitant oral capsule 5 mg, 40 mg, 80 mg QL aprepitant oral capsule,dose pack 5 mg ()- 80 mg () QL ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 mg CANASA RECTAL SUPPOSITORY,000 MG CARAFATE ORAL SUSPENSION 00 MG/ML CESAMET ORAL CAPSULE MG cimetidine hcl oral solution 300 mg/5 ml cimetidine oral tablet 300 mg, 400 mg, 800 mg COMPRO RECTAL SUPPOSITORY 5 MG CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC),000-38,000-60,000 UNIT, 4,000-76,000-0,000 UNIT, 3,000-9,500-5,000 UNIT, 36,000-4,000-80,000 UNIT, 6,000-9,000-30,000 UNIT dimenhydrinate injection solution 50 mg/ml diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg dronabinol oral capsule 0 mg,.5 mg, 5 mg famotidine (pf) intravenous solution 0 mg/ ml famotidine (pf)-nacl (iso-os) intravenous piggyback 0 mg/50 ml famotidine intravenous solution 0 mg/ml famotidine oral tablet 40 mg GAVILYTE-C ORAL RECON SOLN GRAM GAVILYTE-G ORAL RECON SOLN GRAM Effective January, 08 78

87 GAVILYTE-N ORAL RECON SOLN 40 GRAM granisetron (pf) intravenous solution mg/ml ( ml), 00 mcg/ml granisetron hcl intravenous solution mg/ml, mg/ml ( ml) granisetron hcl oral tablet mg QL HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 PA; SP ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML PA; SP; QL HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0. ML, 0 MG/0.4 ML, 40 MG/0.8 ML PA; SP; QL lansoprazole oral capsule,delayed release(dr/ec) 30 mg QL LINZESS ORAL CAPSULE 45 MCG, 90 MCG mesalamine oral tablet,delayed release (dr/ec). gram mesalamine rectal enema 4 gram/60 ml metoclopramide hcl injection solution 5 mg/ml metoclopramide hcl injection syringe 5 mg/ml metoclopramide hcl oral solution 5 mg/5 ml metoclopramide hcl oral tablet 0 mg, 5 mg misoprostol oral tablet 00 mcg, 00 mcg nizatidine oral capsule 50 mg, 300 mg nizatidine oral solution 50 mg/0 ml OCALIVA ORAL TABLET 0 MG, 5 MG PA; SP omeprazole oral capsule,delayed release(dr/ec) 0 mg QL; QL (30 per 30 days) Effective January, 08 79

88 omeprazole oral capsule,delayed release(dr/ec) 0 mg omeprazole oral capsule,delayed release(dr/ec) 40 mg QL ondansetron hcl (pf) injection solution 4 mg/ ml ondansetron hcl (pf) injection syringe 4 mg/ ml ondansetron hcl intravenous solution mg/ml ondansetron hcl oral solution 4 mg/5 ml QL; QL (50 per 30 days) ondansetron hcl oral tablet 4 mg, 4 mg, 8 mg QL ondansetron oral tablet,disintegrating 4 mg, 8 mg QL pantoprazole oral tablet,delayed release (dr/ec) 0 mg QL pantoprazole oral tablet,delayed release (dr/ec) 40 mg peg 3350-electrolytes oral recon soln gram, gram peg-electrolyte soln oral recon soln 40 gram PENTASA ORAL CAPSULE, EXTENDED RELEASE 50 MG, 500 MG PNV OB+DHA ORAL COMBO PACK MG PNV-DHA + DOCUSATE ORAL CAPSULE MG PRENAISSANCE ORAL CAPSULE MG PRENAISSANCE PLUS ORAL CAPSULE MG prochlorperazine edisylate injection solution 0 mg/ ml (5 mg/ml) prochlorperazine maleate oral tablet 0 mg, 5 mg prochlorperazine rectal suppository 5 mg PYLERA ORAL CAPSULE MG ranitidine hcl oral syrup 5 mg/ml Effective January, 08 80

89 ranitidine hcl oral tablet 50 mg, 300 mg, 75 mg SE-NATAL 9 (WITH DOCUSATE) ORAL TABLET 9 MG IRON- MG-5 MG sucralfate oral suspension 00 mg/ml sucralfate oral tablet gram sulfasalazine oral tablet 500 mg sulfasalazine oral tablet,delayed release (dr/ec) 500 mg TARON-PREX PRENATAL-DHA ORAL CAPSULE 30 MG IRON-. MG-55 MG-65 MG TL-SELECT ORAL CAPSULE MG trimethobenzamide oral capsule 300 mg TRIVEEN-PRX RNF ORAL CAPSULE MG ursodiol oral capsule 300 mg ursodiol oral tablet 50 mg, 500 mg VEMAVITE-PRX- ORAL CAPSULE MG VIBERZI ORAL TABLET 00 MG, 75 MG VINACAL ORAL TABLET MG VINATE ULTRA ORAL TABLET MG VIRT-SELECT ORAL CAPSULE MG XERMELO ORAL TABLET 50 MG PA ZATEAN-CH ORAL CAPSULE MG HEAVY METAL ANTAGONISTS CHEMET ORAL CAPSULE 00 MG CUPRIMINE ORAL CAPSULE 50 MG deferoxamine injection recon soln gram, 500 mg EXJADE ORAL TABLET, DISPERSIBLE 5 MG, 50 MG, 500 MG PA; SP FERRIPROX ORAL TABLET 500 MG PA; SP Effective January, 08 8

90 HORMONES AND SYNTHETIC SUBSTITUTES acarbose oral tablet 00 mg, 5 mg, 50 mg ALTAVERA (8) ORAL TABLET MG QL ALYACEN /35 (8) ORAL TABLET -35 MG-MCG QL ALYACEN 7/7/7 (8) ORAL TABLET 0.5/0.75/ MG- 35 MCG QL AMETHIA LO ORAL TABLETS,DOSE PACK,3 MONTH 0.0 MG-0 MCG (84)/0 QL MCG (7) AMETHIA ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG (84)/0 MCG (7) QL AMETHYST ORAL TABLET 90-0 MCG QL anastrozole oral tablet mg ANDRODERM TRANSDERMAL PATCH 4 HOUR MG/4 HOUR, 4 MG/4 HR PA ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 0.5 MG/.5 PA GRAM (.6 %) ANDROGEL TRANSDERMAL GEL IN PACKET % (5 MG/.5GRAM), % (50 MG/5 GRAM),.6 % (0.5 MG/.5 GRAM),.6 % (40.5 MG/.5 GRAM) PA APRI ORAL TABLET MG QL ARANELLE (8) ORAL TABLET 0.5// MG-MCG QL ARMOUR THYROID ORAL TABLET 0 MG, 80 MG, 40 MG, 30 MG, 300 MG, 60 MG, 90 MG AUBRA ORAL TABLET 0.-0 MG-MCG QL AVIANE ORAL TABLET 0.-0 MG-MCG QL AZURETTE (8) ORAL TABLET MGX /0.0 MG X 5 QL BALZIVA (8) ORAL TABLET MG- MCG QL BASAGLAR KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) Effective January, 08 8

91 betamethasone acet,sod phos injection suspension 6 mg/ml BLISOVI 4 FE ORAL TABLET MG-0 MCG (4)/75 MG (4) BLISOVI FE.5/30 (8) ORAL TABLET.5 MG-30 MCG ()/75 MG (7) BLISOVI FE /0 (8) ORAL TABLET MG- 0 MCG ()/75 MG (7) BRIELLYN ORAL TABLET MG-MCG QL budesonide inhalation suspension for nebulization 0.5 mg/ ml, 0.5 mg/ ml, mg/ ml budesonide oral capsule,delayed,extend.release 3 mg BYDUREON SUBCUTANEOUS PEN INJECTOR MG/0.65 ML PA BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON PA; QL MG BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(50 MCG/ML).4 ML PA; QL BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (50 MCG/ML). ML PA; QL; QL (.4 per 30 days) calcitonin (salmon) nasal spray,non-aerosol 00 unit/actuation CAMILA ORAL TABLET 0.35 MG CAMRESE LO ORAL TABLETS,DOSE PACK,3 MONTH 0.0 MG-0 MCG (84)/0 QL MCG (7) CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG (84)/0 MCG (7) QL CAZIANT (8) ORAL TABLET 0./.5/.5-5 MG-MCG QL CHATEAL ORAL TABLET MG QL chlorpropamide oral tablet 00 mg, 50 mg cortisone oral tablet 5 mg CRYSELLE (8) ORAL TABLET MG- MCG QL CYCLAFEM /35 (8) ORAL TABLET -35 MG-MCG QL Effective January, 08 83

92 CYCLAFEM 7/7/7 (8) ORAL TABLET 0.5/0.75/ MG- 35 MCG QL cyred oral tablet mg danazol oral capsule 00 mg, 00 mg, 50 mg DASETTA /35 (8) ORAL TABLET -35 MG-MCG QL DASETTA 7/7/7 (8) ORAL TABLET 0.5/0.75/ MG- 35 MCG QL DAYSEE ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG (84)/0 MCG (7) QL DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML desmopressin injection solution 4 mcg/ml PA desmopressin nasal solution 0. mg/ml (refrigerate) desmopressin nasal spray,non-aerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0. mg, 0. mg PA desogestrel-ethinyl estradiol oral tablet mg QL DEXAMETHASONE INTENSOL ORAL DROPS MG/ML dexamethasone oral elixir 0.5 mg/5 ml dexamethasone oral solution 0.5 mg/5 ml dexamethasone oral tablet 0.5 mg, 0.75 mg, mg,.5 mg, mg, 4 mg, 6 mg dexamethasone sodium phos (pf) injection solution 0 mg/ml dexamethasone sodium phosphate injection solution 0 mg/ml, 4 mg/ml drospirenone-ethinyl estradiol oral tablet mg QL DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, 00-5 QL MCG/ACTUATION ELINEST ORAL TABLET MG-MCG QL ELLA ORAL TABLET 30 MG QL EMOQUETTE ORAL TABLET MG QL Effective January, 08 84

93 ENPRESSE ORAL TABLET (6)/75-40 (5)/5-30(0) QL ENSKYCE ORAL TABLET MG QL ERRIN ORAL TABLET 0.35 MG ESTARYLLA ORAL TABLET MG- MCG QL ESTRACE VAGINAL CREAM 0.0 % (0. MG/GRAM) estradiol oral tablet 0.5 mg, mg, mg estradiol transdermal patch semiweekly 0.05 mg/4 hr, mg/4 hr, QL; QL (8 per 8 days) mg/4 hr estradiol transdermal patch semiweekly 0.05 mg/4 hr, 0. mg/4 hr QL (8 per 8 days) estradiol valerate intramuscular oil 0 mg/ml, 40 mg/ml estradiol-norethindrone acet oral tablet mg, -0.5 mg ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP.5 QL GRAM/ACTUATION estropipate oral tablet 0.75 mg,.5 mg, 3 mg EVAMIST TRANSDERMAL SPRAY,NON- AEROSOL.53 MG/SPRAY (.7%) QL exemestane oral tablet 5 mg FALMINA (8) ORAL TABLET 0.-0 MG- MCG QL FARESTON ORAL TABLET 60 MG FEMHRT LOW DOSE ORAL TABLET MG-MCG QL FEMYNOR ORAL TABLET MG- MCG FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 QL MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 QL MCG/ACTUATION, 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QL; QL ( per 30 days) Effective January, 08 85

94 fludrocortisone oral tablet 0. mg FORTEO SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE MCG/.4 PA; SP; QL ML GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0. MG/0.5 ML, 0.4 MG/0.5 ML, 0.6 MG/0.5 ML, 0.8 MG/0.5 ML, MG/0.5 ML,. MG/0.5 ML,.4 MG/0.5 ML,.6 MG/0.5 ML,.8 MG/0.5 ML, MG/0.5 ML PA; SP GENOTROPIN SUBCUTANEOUS CARTRIDGE MG/ML (36 UNIT/ML), 5 PA; SP MG/ML (5 UNIT/ML) GIANVI (8) ORAL TABLET MG QL GILDAGIA ORAL TABLET MG-MCG QL glimepiride oral tablet mg QL glimepiride oral tablet mg QL; QL (50 per 30 days) glimepiride oral tablet 4 mg QL; QL (60 per 30 days) glipizide oral tablet 0 mg QL; QL (80 per 30 days) glipizide oral tablet 5 mg QL glipizide oral tablet extended release 4hr 0 mg, 5 mg QL; QL (60 per 30 days) glipizide oral tablet extended release 4hr.5 mg QL; QL (300 per 30 days) glipizide-metformin oral tablet.5-50 mg QL; QL (300 per 30 days) glipizide-metformin oral tablet mg, mg QL; QL (50 per 30 days) GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN MG/ML GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT MG GLUCAGON HCL INJECTION RECON SOLN MG glyburide micronized oral tablet.5 mg, 3 mg QL glyburide micronized oral tablet 6 mg QL; QL (60 per 30 days) glyburide oral tablet.5 mg,.5 mg, 5 mg QL glyburide-metformin oral tablet.5-50 mg QL; QL (300 per 30 days) Effective January, 08 86

95 glyburide-metformin oral tablet mg QL; QL (80 per 30 days) glyburide-metformin oral tablet mg QL HEATHER ORAL TABLET 0.35 MG HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMATROPE INJECTION CARTRIDGE MG (36 UNIT), 4 MG (7 UNIT), 6 MG (8 PA; SP UNIT) HUMATROPE INJECTION RECON SOLN 5 (5 UNIT) MG PA; SP HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) HUMULIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML HUMULIN R U-00 INJECTION SOLUTION 00 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML hydrocortisone oral tablet 0 mg, 0 mg, 5 mg hydroxyprogesterone capr(bulk) powder 00 % hydroxyprogesterone caproate intramuscular oil 50 mg/ml PA INTROVALE ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG QL INVOKAMET ORAL TABLET 50-,000 MG, MG, 50-,000 MG, MG INVOKANA ORAL TABLET 00 MG QL INVOKANA ORAL TABLET 300 MG QL; QL (30 per 30 days) JANUMET ORAL TABLET 50-,000 MG QL JANUMET ORAL TABLET MG QL; QL (60 per 30 days) JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 00-,000 MG, 50- QL,000 MG Effective January, 08 87

96 JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR MG QL; QL (30 per 30 days) JANUVIA ORAL TABLET 00 MG, 5 MG, 50 MG QL JENCYCLA ORAL TABLET 0.35 MG JINTELI ORAL TABLET -5 MG-MCG QL JOLESSA ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG QL JOLIVETTE ORAL TABLET 0.35 MG JULEBER ORAL TABLET MG JUNEL.5/30 () ORAL TABLET.5-30 MG-MCG QL JUNEL /0 () ORAL TABLET -0 MG- MCG QL JUNEL FE.5/30 (8) ORAL TABLET.5 MG-30 MCG ()/75 MG (7) QL JUNEL FE /0 (8) ORAL TABLET MG- 0 MCG ()/75 MG (7) QL JUNEL FE 4 ORAL TABLET MG-0 MCG (4)/75 MG (4) KAITLIB FE ORAL TABLET,CHEWABLE 0.8MG-5MCG(4) AND 75 MG (4) KARIVA (8) ORAL TABLET MGX /0.0 MG X 5 QL KELNOR /35 (8) ORAL TABLET -35 MG- MCG QL KIMIDESS (8) ORAL TABLET MGX /0.0 MG X 5 KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 4 HR.5-,000 MG, QL MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 4 HR 5-,000 MG QL; QL (30 per 30 days) KURVELO ORAL TABLET MG QL l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.0 mg-0 mcg (84)/0 mcg (7), 0.5 mg-30 mcg (84)/0 mcg (7) QL LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) Effective January, 08 88

97 LANTUS SUBCUTANEOUS SOLUTION 00 UNIT/ML larin.5/30 () oral tablet.5-30 mg-mcg LARIN /0 () ORAL TABLET -0 MG- MCG LARIN 4 FE ORAL TABLET MG-0 MCG (4)/75 MG (4) LARIN FE.5/30 (8) ORAL TABLET.5 MG-30 MCG ()/75 MG (7) QL LARIN FE /0 (8) ORAL TABLET MG-0 MCG ()/75 MG (7) QL LARISSIA ORAL TABLET 0.-0 MG-MCG LAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG-5MCG(4) AND 75 MG (4) LEENA 8 ORAL TABLET 0.5// MG- MCG QL LESSINA ORAL TABLET 0.-0 MG-MCG QL letrozole oral tablet.5 mg leuprolide subcutaneous kit mg/0. ml SP LEVONEST (8) ORAL TABLET (6)/75-40 (5)/5-30(0) QL levonorgestrel-ethinyl estrad oral tablet mg-mcg, mg QL levonorgestrel-ethinyl estrad oral tablet 90-0 mcg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.5 mg-30 mcg QL levonorg-eth estrad triphasic oral tablet (6)/75-40 (5)/5-30(0) LEVORA-8 ORAL TABLET MG QL levothyroxine intravenous recon soln 00 mcg, 500 mcg levothyroxine oral tablet 00 mcg, mcg, 5 mcg, 37 mcg, 50 mcg, 75 mcg, 00 mcg, 5 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 00 MCG, MCG, 5 MCG, 37 MCG, 50 MCG, 75 MCG, 00 MCG, 5 MCG, 50 MCG, 75 MCG, 88 MCG Effective January, 08 89

98 LILETTA INTRAUTERINE INTRAUTERINE DEVICE 9.5 MCG/4 HOUR (4 YEARS) liothyronine intravenous solution 0 mcg/ml liothyronine oral tablet 5 mcg, 5 mcg, 50 mcg LOMEDIA 4 FE ORAL TABLET MG-0 MCG (4)/75 MG (4) LORYNA (8) ORAL TABLET MG QL LOW-OGESTREL (8) ORAL TABLET MG-MCG QL LUGOLS ORAL SOLUTION 5 % LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 PA; SP MG,.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG PA; SP LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG PA; SP LUPRON DEPOT-PED INTRAMUSCULAR KIT.5 MG, 5 MG, 7.5 MG (PED) PA; SP LUTERA (8) ORAL TABLET 0.-0 MG- MCG QL LYZA ORAL TABLET 0.35 MG MAKENA INTRAMUSCULAR OIL 50 MG/ML, 50 MG/ML ( ML) PA; SP MARLISSA ORAL TABLET MG QL medroxyprogesterone intramuscular suspension 50 mg/ml QL medroxyprogesterone intramuscular syringe 50 mg/ml QL; QL ( per 30 days) medroxyprogesterone oral tablet 0 mg,.5 mg, 5 mg megestrol oral suspension 400 mg/0 ml (0 ml), 400 mg/0 ml (40 mg/ml), 800 mg/0 ml PA (0 ml) megestrol oral tablet 0 mg, 40 mg PA metformin oral tablet,000 mg, 500 mg QL metformin oral tablet 850 mg QL; QL (0 per 30 days) Effective January, 08 90

99 metformin oral tablet extended release 4 hr 500 mg, 750 mg QL metformin oral tablet extended release 4hr 500 mg QL methimazole oral tablet 0 mg, 5 mg METHITEST ORAL TABLET 0 MG methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml methylprednisolone oral tablet 6 mg, 3 mg, 4 mg, 8 mg methylprednisolone oral tablets,dose pack 4 mg methylprednisolone sodium succ injection recon soln 5 mg, 40 mg methylprednisolone sodium succ intravenous recon soln,000 mg MICROGESTIN.5/30 () ORAL TABLET.5-30 MG-MCG QL MICROGESTIN /0 () ORAL TABLET - 0 MG-MCG QL MICROGESTIN FE.5/30 (8) ORAL TABLET.5 MG-30 MCG ()/75 MG (7) QL MICROGESTIN FE /0 (8) ORAL TABLET MG-0 MCG ()/75 MG (7) QL MIMVEY ORAL TABLET -0.5 MG MONO-LINYAH ORAL TABLET MG- MCG QL MONONESSA (8) ORAL TABLET MG-MCG QL MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.) PA MYZILRA ORAL TABLET (6)/75-40 (5)/5-30(0) QL nateglinide oral tablet 0 mg, 60 mg NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG/DOSE, 5 MCG/DOSE, 50 PA MCG/DOSE, 75 MCG/DOSE NATURE-THROID ORAL TABLET 30 MG, 46.5 MG, 6.5 MG, 95 MG, 3.5 MG, MG, 65 MG, 8.5 MG Effective January, 08 9

100 NECON 0.5/35 (8) ORAL TABLET MG-MCG QL NECON 7/7/7 (8) ORAL TABLET 0.5/0.75/ MG- 35 MCG QL NEXPLANON SUBDERMAL IMPLANT 68 MG SP nikki (8) oral tablet mg NORA-BE ORAL TABLET 0.35 MG noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg() and 75 mg (7), 0.8mg-5mcg(4) and 75 mg (4) norethindrone (contraceptive) oral tablet 0.35 mg norethindrone acetate oral tablet 5 mg norethindrone ac-eth estradiol oral tablet mg-mcg, -0 mg-mcg, -5 mg-mcg norethindrone-e.estradiol-iron oral tablet mg-0 mcg ()/75 mg (7), mg-0 mcg (4)/75 mg (4) norgestimate-ethinyl estradiol oral tablet 0.8/0.5/0.5 mg-5 mcg norgestimate-ethinyl estradiol oral tablet 0.8/0.5/0.5 mg-35 mcg (8), QL mg-mcg NORTREL 0.5/35 (8) ORAL TABLET MG-MCG QL NORTREL /35 () ORAL TABLET -35 MG-MCG QL NORTREL /35 (8) ORAL TABLET -35 MG-MCG QL NORTREL 7/7/7 (8) ORAL TABLET 0.5/0.75/ MG- 35 MCG QL NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML Effective January, 08 9

101 NOVOLOG MIX FLEXPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG MIX SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 00 UNIT/ML NP THYROID ORAL TABLET 0 MG, 5 MG, 30 MG, 60 MG, 90 MG NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 0 MG/ ML (5 MG/ML), 0 MG/ ML (0 MG/ML), 5 MG/ ML (.5 MG/ML) PA; SP NUVARING VAGINAL RING MG/4 HR OCELLA ORAL TABLET MG QL octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml, 00 mcg/ml, 50 mcg/ml, SP 500 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 50 mcg/ml ( ml), 500 mcg/ml SP ( ml) OGESTREL (8) ORAL TABLET MG- MCG QL ONGLYZA ORAL TABLET.5 MG QL ONGLYZA ORAL TABLET 5 MG QL; QL (30 per 30 days) ORSYTHIA ORAL TABLET 0.-0 MG-MCG QL oxandrolone oral tablet 0 mg,.5 mg PA PHILITH ORAL TABLET MG-MCG QL PIMTREA (8) ORAL TABLET MGX /0.0 MG X 5 QL pioglitazone oral tablet 5 mg, 30 mg QL pioglitazone oral tablet 45 mg QL; QL (30 per 30 days) pioglitazone-metformin oral tablet mg, mg QL PIRMELLA ORAL TABLET 0.5/0.75/ MG- 35 MCG, -35 MG-MCG QL PORTIA ORAL TABLET MG QL Effective January, 08 93

102 prednisolone oral solution 5 mg/5 ml prednisolone sodium phosphate oral solution 5 mg/5 ml (3 mg/ml), 5 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 mg/5 ml prednisone oral tablet mg, 0 mg,.5 mg, 0 mg, 5 mg, 50 mg prednisone oral tablets,dose pack 0 mg, 5 mg PREMARIN INJECTION RECON SOLN 5 MG PREMARIN VAGINAL CREAM 0.65 MG/GRAM PREMPHASE ORAL TABLET 0.65 MG (4)/ 0.65MG-5MG(4) PREMPRO ORAL TABLET MG, MG, MG, MG PREVIFEM ORAL TABLET MG- MCG QL progesterone intramuscular oil 50 mg/ml progesterone micronized oral capsule 00 mg, 00 mg PROGLYCEM ORAL SUSPENSION 50 MG/ML propylthiouracil oral tablet 50 mg QUASENSE ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG QL QVAR INHALATION AEROSOL 40 MCG/ACTUATION QL; QL (8 per 30 days) QVAR INHALATION AEROSOL 80 MCG/ACTUATION QL; QL (7 per 30 days) raloxifene oral tablet 60 mg RECLIPSEN (8) ORAL TABLET MG QL repaglinide oral tablet 0.5 mg, mg, mg repaglinide-metformin oral tablet -500 mg, -500 mg QL Effective January, 08 94

103 SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SP SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG PA; SP SETLAKIN ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG QL SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML ( ML), 0.6 MG/ML ( ML), 0.9 PA; SP MG/ML ( ML) SOLU-CORTEF (PF) INJECTION RECON SOLN,000 MG/8 ML, 00 MG/ ML, 50 MG/ ML, 500 MG/4 ML SOLU-CORTEF INJECTION RECON SOLN 00 MG SOLU-MEDROL (PF) INJECTION RECON SOLN 5 MG/ ML, 40 MG/ML SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN,000 MG/8 ML, 500 MG/4 ML SOLU-MEDROL INTRAVENOUS RECON SOLN,000 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 0 MG/0.5 ML, 60 MG/0. ML, SP 90 MG/0.3 ML SPRINTEC (8) ORAL TABLET MG- MCG QL SRONYX ORAL TABLET 0.-0 MG-MCG QL STRONG IODINE ORAL SOLUTION 5 % SYEDA ORAL TABLET MG QL SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, QL MCG/ACTUATION SYMLINPEN 0 SUBCUTANEOUS PEN INJECTOR,700 MCG/.7 ML PA SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR,500 MCG/.5 ML PA SYNAREL NASAL SPRAY,NON-AEROSOL MG/ML tamoxifen oral tablet 0 mg, 0 mg Effective January, 08 95

104 tarina fe /0 (8) oral tablet mg-0 mcg ()/75 mg (7) testosterone cypionate intramuscular oil 00 mg/ml, 00 mg/ml testosterone enanthate intramuscular oil 00 mg/ml TESTOSTERONE TRANSDERMAL GEL 50 MG/5 GRAM ( %) testosterone transdermal gel in metereddose pump 0 mg/0.5 gram /actuation,.5 PA mg/.5 gram ( %) testosterone transdermal gel in packet % (5 mg/.5gram), % (50 mg/5 gram) PA THYROLAR- ORAL TABLET.5-50 MCG THYROLAR-/ ORAL TABLET MCG THYROLAR-/4 ORAL TABLET MCG THYROLAR- ORAL TABLET 5-00 MCG THYROLAR-3 ORAL TABLET MCG TILIA FE ORAL TABLET -0(5)/-30(7) /MG-35MCG (9) tolazamide oral tablet 50 mg QL tolazamide oral tablet 500 mg QL; QL (60 per 30 days) tolbutamide oral tablet 500 mg TRI-ESTARYLLA ORAL TABLET 0.8/0.5/0.5 MG-35 MCG (8) QL TRI-LEGEST FE ORAL TABLET -0(5)/- 30(7) /MG-35MCG (9) QL TRI-LINYAH ORAL TABLET 0.8/0.5/0.5 MG-35 MCG (8) QL tri-lo-estarylla oral tablet 0.8/0.5/0.5 mg- 5 mcg tri-lo-sprintec oral tablet 0.8/0.5/0.5 mg- 5 mcg TRINESSA (8) ORAL TABLET 0.8/0.5/0.5 MG-35 MCG (8) QL trinessa lo oral tablet 0.8/0.5/0.5 mg-5 mcg Effective January, 08 96

105 TRI-PREVIFEM (8) ORAL TABLET 0.8/0.5/0.5 MG-35 MCG (8) TRI-SPRINTEC (8) ORAL TABLET 0.8/0.5/0.5 MG-35 MCG (8) TRIVORA (8) ORAL TABLET (6)/75-40 (5)/5-30(0) UNITHROID ORAL TABLET 00 MCG, MCG, 5 MCG, 50 MCG, 75 MCG, 00 MCG, 5 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG QL QL QL unithroid oral tablet 37 mcg vasopressin injection solution 0 unit/ml VELIVET TRIPHASIC REGIMEN (8) ORAL TABLET 0./.5/.5-5 MG-MCG QL VESTURA (8) ORAL TABLET MG QL VICTOZA -PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0. ML (8 MG/3 ML) PA; QL VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0. ML (8 MG/3 ML) PA; QL; QL (9 per 30 days) VIENVA ORAL TABLET 0.-0 MG-MCG VIORELE (8) ORAL TABLET MGX /0.0 MG X 5 QL WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WELCHOL ORAL TABLET 65 MG WERA (8) ORAL TABLET MG-MCG QL WESTHROID ORAL TABLET 30 MG, 3.5 MG, 65 MG WYMZYA FE ORAL TABLET,CHEWABLE 0.4MG-35MCG() AND 75 MG (7) QL XULANE TRANSDERMAL PATCH WEEKLY MCG/4 HR QL yuvafem vaginal tablet 0 mcg ZARAH ORAL TABLET MG QL ZENCHENT (8) ORAL TABLET MG- MCG QL ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG PA; SP Effective January, 08 97

106 ZOVIA /35E (8) ORAL TABLET -35 MG- MCG QL ZOVIA /50E (8) ORAL TABLET -50 MG- MCG QL LOCAL ANESTHETICS (PARENTERAL) bupivacaine (pf) injection solution 0.5 % (.5 mg/ml), 0.5 % (5 mg/ml), 0.75 % (7.5 mg/ml) bupivacaine injection solution 0.5 % (.5 mg/ml), 0.5 % (5 mg/ml) bupivacaine-dextrose-water(pf) injection solution 0.75 % (7.5 mg/ml) bupivacaine-epinephrine (pf) injection solution 0.5 %-:00,000, 0.5 %-:00,000 bupivacaine-epinephrine injection solution 0.5 %-:00,000, 0.5 %-:00,000 lidocaine (pf) in d7.5w intrathecal solution 50 mg/ml (5 %) lidocaine (pf) injection solution 0 mg/ml ( %), 5 mg/ml (.5 %), 0 mg/ml ( %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine hcl injection solution 0 mg/ml ( %), 0 mg/ml ( %) lidocaine-epinephrine injection solution 0.5 %-:00,000, %-:00,000, %-:00,000 MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine solution 00 mg/ml (0 %), 00 mg/ml (0 %) ACTEMRA INTRAVENOUS SOLUTION 00 MG/0 ML (0 MG/ML), 400 MG/0 ML (0 PA; SP MG/ML), 80 MG/4 ML (0 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 6 MG/0.9 ML PA; SP alendronate oral solution 70 mg/75 ml QL alendronate oral tablet 0 mg, 40 mg, 5 mg QL alendronate oral tablet 35 mg, 70 mg QL; QL (4 per 30 days) allopurinol oral tablet 00 mg, 300 mg amifostine crystalline intravenous recon soln 500 mg Effective January, 08 98

107 AMPYRA ORAL TABLET EXTENDED RELEASE HR 0 MG PA; SP; QL ATGAM INTRAVENOUS SOLUTION 50 MG/ML SP AUBAGIO ORAL TABLET 4 MG, 7 MG PA; SP AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG PA; SP; QL AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML PA; SP; QL AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML PA; SP; QL azathioprine oral tablet 50 mg BETASERON SUBCUTANEOUS KIT 0.3 MG PA; SP; QL BOTOX INJECTION RECON SOLN 00 UNIT, 00 UNIT PA; SP calcitonin (salmon) nasal spray,non-aerosol 00 unit/actuation CERDELGA ORAL CAPSULE 84 MG CHEMET ORAL CAPSULE 00 MG COLCRYS ORAL TABLET 0.6 MG ST CUPRIMINE ORAL CAPSULE 50 MG cyclophosphamide intravenous recon soln gram, gram, 500 mg CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG cyclosporine intravenous solution 50 mg/5 ml cyclosporine modified oral capsule 00 mg, 5 mg, 50 mg SP cyclosporine modified oral solution 00 mg/ml SP cyclosporine oral capsule 00 mg, 5 mg CYSTAGON ORAL CAPSULE 50 MG, 50 MG SP deferoxamine injection recon soln gram, 500 mg DENTA 5000 PLUS DENTAL CREAM. % DENTAGEL DENTAL GEL. % Effective January, 08 99

108 dexrazoxane hcl intravenous recon soln 50 mg, 500 mg disulfiram oral tablet 50 mg, 500 mg dutasteride oral capsule 0.5 mg ST dutasteride-tamsulosin oral capsule, er multiphase 4 hr mg ST DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT, 500 UNIT PA; SP ELIDEL TOPICAL CREAM % PA ELMIRON ORAL CAPSULE 00 MG ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (0.98 ML) PA; SP ENBREL SUBCUTANEOUS RECON SOLN 5 MG ( ML) PA; SP; QL ENBREL SUBCUTANEOUS SYRINGE 5 MG/0.5ML (0.5), 50 MG/ML (0.98 ML) PA; SP; QL ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) PA; SP; QL etidronate disodium oral tablet 00 mg, 400 mg EVOTAZ ORAL TABLET MG EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML EXTAVIA SUBCUTANEOUS KIT 0.3 MG PA; SP; QL finasteride oral tablet 5 mg FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML PA; SP flumazenil intravenous solution 0. mg/ml FLUOR-A-DAY (WITH XYLITOL) ORAL TABLET,CHEWABLE 0.5 MG F (0.55 MG) MG, MG F (. MG) MG fluoride (sodium) oral drops 0.5 mg (. mg sod.fluorid)/ml fluoride (sodium) oral tablet,chewable 0.5 mg(0.55 mg sod. fluoride), 0.5 mg (. mg sodium fluorid), mg (. mg sod. fluoride) FLUORITAB ORAL TABLET,CHEWABLE 0.5 MG (. MG SODIUM FLUORID), MG (. MG SOD. FLUORIDE) Effective January, 08 00

109 fomepizole intravenous solution gram/ml FOSRENOL ORAL TABLET,CHEWABLE,000 MG, 500 MG, 750 MG GILENYA ORAL CAPSULE 0.5 MG PA; SP; QL glatiramer subcutaneous syringe 0 mg/ml, 40 mg/ml PA; SP GLATOPA SUBCUTANEOUS SYRINGE 0 MG/ML PA; SP; QL GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT MG HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 PA; SP ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML PA; SP; QL HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0. ML, 0 MG/0.4 ML, 40 MG/0.8 ML PA; SP; QL hydroxychloroquine oral tablet 00 mg ibandronate intravenous solution 3 mg/3 ml SP ibandronate intravenous syringe 3 mg/3 ml SP ibandronate oral tablet 50 mg ST; QL indomethacin oral capsule 5 mg, 50 mg INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( SP ML), 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML SP KIONEX (WITH SORBITOL) ORAL SUSPENSION GRAM/60 ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML PA; SP Effective January, 08 0

110 lanthanum oral tablet,chewable,000 mg, 500 mg, 750 mg leflunomide oral tablet 0 mg, 0 mg QL LEMTRADA INTRAVENOUS SOLUTION MG/. ML PA leucovorin calcium injection recon soln 00 mg, 00 mg, 350 mg, 50 mg, 500 mg SP leucovorin calcium oral tablet 0 mg, 5 mg, 5 mg, 5 mg SP levocarnitine (with sugar) oral solution 00 mg/ml levocarnitine oral tablet 330 mg levoleucovorin intravenous recon soln 75 mg SP LUDENT FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG(0.55 MG SOD. FLUORIDE), 0.5 MG (. MG SODIUM FLUORID), MG (. MG SOD. FLUORIDE) LUGOLS ORAL SOLUTION 5 % magnesium sulfate in water intravenous parenteral solution 0 gram/500 ml (4 %), 40 gram/,000 ml (4 %) magnesium sulfate in water intravenous piggyback gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml MEPHYTON ORAL TABLET 5 MG mercaptopurine oral tablet 50 mg mesna intravenous solution 00 mg/ml MESNEX ORAL TABLET 400 MG SP methotrexate sodium (pf) injection recon soln gram methotrexate sodium (pf) injection solution 5 mg/ml methotrexate sodium injection solution 5 mg/ml methotrexate sodium oral tablet.5 mg Effective January, 08 0

111 methylene blue (antidote) intravenous solution % (0 mg/ml) MITIGARE ORAL CAPSULE 0.6 MG MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG, 0.5 MG, MG MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG, MG mycophenolate mofetil hcl intravenous recon soln 500 mg SP mycophenolate mofetil oral capsule 50 mg SP mycophenolate mofetil oral suspension for reconstitution 00 mg/ml SP mycophenolate mofetil oral tablet 500 mg SP mycophenolate sodium oral tablet,delayed release (dr/ec) 80 mg, 360 mg SP naloxone injection solution 0.4 mg/ml naloxone injection syringe 0.4 mg/ml, mg/ml naltrexone oral tablet 50 mg naproxen oral suspension 5 mg/5 ml naproxen oral tablet 50 mg, 375 mg, 500 mg naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg naproxen sodium oral tablet 75 mg, 550 mg OCREVUS INTRAVENOUS SOLUTION 30 MG/ML PA octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml, 00 mcg/ml, 50 mcg/ml, SP 500 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 50 mcg/ml ( ml), 500 mcg/ml SP ( ml) ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 5 MG/ML PA; SP ORENCIA SUBCUTANEOUS SYRINGE 5 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML PA; SP Effective January, 08 03

112 ORFADIN ORAL CAPSULE 0 MG, MG, 5 MG SP OTEZLA ORAL TABLET 30 MG PA; SP; QL (60 per 30 days) OTEZLA STARTER ORAL TABLETS,DOSE PACK 0 MG (4)-0 MG (4)-30 MG (47) PA; SP; QL (55 per 365 days) OTEZLA STARTER ORAL TABLETS,DOSE PACK 0 MG (4)-0 MG (4)-30 MG(9) PA; SP; QL (7 per 365 days) pamidronate intravenous recon soln 30 mg, 90 mg pamidronate intravenous solution 30 mg/0 ml (3 mg/ml), 60 mg/0 ml (6 mg/ml), 90 mg/0 ml (9 mg/ml) physostigmine salicylate injection solution mg/ml PLEGRIDY SUBCUTANEOUS PEN INJECTOR 5 MCG/0.5 ML, 63 MCG/0.5 PA; SP ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 5 MCG/0.5 ML, 63 MCG/0.5 ML- 94 PA; SP MCG/0.5 ML POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG SP PREZCOBIX ORAL TABLET MG- MG probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT SP PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML PA; SP raloxifene oral tablet 60 mg RAPAMUNE ORAL SOLUTION MG/ML SP REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE MCG/0.5 ML, 44 MCG/0.5 ML PA; SP; QL REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR MCG/0.5 ML PA; SP; QL; QL (8 per 30 days) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 44 MCG/0.5 ML, 8.8MCG/0.ML- MCG/0.5ML (6) PA; SP; QL Effective January, 08 04

113 REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.ML- MCG/0.5ML PA; SP; QL (6) REMICADE INTRAVENOUS RECON SOLN 00 MG SP RENAGEL ORAL TABLET 400 MG, 800 MG RENVELA ORAL TABLET 800 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG PA; SP SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SP SF 5000 PLUS DENTAL CREAM. % SF DENTAL GEL. % sirolimus oral tablet 0.5 mg, mg, mg SODIUM POLYSTYRENE (SORB FREE) ORAL SUSPENSION 5 GRAM/60 ML sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate rectal enema 30 gram/0 ml sodium thiosulfate intravenous solution.5 gram/50 ml (50 mg/ml) SPS (WITH SORBITOL) ORAL SUSPENSION 5-0 GRAM/60 ML SPS (WITH SORBITOL) RECTAL ENEMA GRAM/0 ML STRONG IODINE ORAL SOLUTION 5 % sulfasalazine oral tablet 500 mg sulfasalazine oral tablet,delayed release (dr/ec) 500 mg tacrolimus oral capsule 0.5 mg, mg, 5 mg SP TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0 MG, 0 MG (4)- PA; SP 40 MG (46), 40 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 00 MG, 50 MG PA; SP TRI-VIT WITH FLUORIDE AND IRON ORAL DROPS MG/ML Effective January, 08 05

114 TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.5 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (. MG)/ML VISTOGARD ORAL GRANULES IN PACKET 0 GRAM VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.5 MG FLUOR. (0.55 MG)/ML XELJANZ ORAL TABLET 5 MG PA; SP; QL (60 per 30 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 4 HR MG PA; SP; QL (30 per 30 days) XEOMIN INTRAMUSCULAR RECON SOLN 00 UNIT, 50 UNIT PA; SP XGEVA SUBCUTANEOUS SOLUTION 0 MG/.7 ML (70 MG/ML) SP ZAVESCA ORAL CAPSULE 00 MG SP ZORTRESS ORAL TABLET 0.5 MG, 0.5 MG, 0.75 MG SP OXYTOCICS oxytocin injection solution 0 unit/ml RESPIRATORY TRACT AGENTS acetylcysteine solution 00 mg/ml (0 %), 00 mg/ml (0 %) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml,.5 mg/3 ml,.5 mg /3 ml (0.083 %),.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup mg/5 ml albuterol sulfate oral tablet mg, 4 mg albuterol sulfate oral tablet extended release hr 4 mg, 8 mg aminophylline intravenous solution 50 mg/0 ml, 500 mg/0 ml atropine injection solution 0.4 mg/ml, mg/ml atropine injection syringe 0.05 mg/ml, 0. mg/ml ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION QL brompheniramine-pseudoeph-dm oral syrup mg/5 ml Effective January, 08 06

115 budesonide inhalation suspension for nebulization 0.5 mg/ ml, 0.5 mg/ ml, mg/ ml carbinoxamine maleate oral liquid 4 mg/5 ml carbinoxamine maleate oral tablet 4 mg clemastine oral tablet.68 mg codeine sulfate oral tablet 5 mg, 30 mg, 60 mg QL; QL (80 per 30 days) COMBIVENT RESPIMAT INHALATION MIST 0-00 MCG/ACTUATION QL cromolyn ophthalmic (eye) drops 4 % cromolyn oral concentrate 00 mg/5 ml cyproheptadine oral syrup mg/5 ml cyproheptadine oral tablet 4 mg dimenhydrinate injection solution 50 mg/ml diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe 50 mg/ml diphenoxylate-atropine oral liquid mg/5 ml diphenoxylate-atropine oral tablet mg DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION, 00-5 QL MCG/ACTUATION ephedrine sulfate injection solution 50 mg/ml epinephrine injection auto-injector 0.5 mg/0.3 ml, 0.3 mg/0.3 ml epinephrine injection solution mg/ml, mg/ml ( ml) epinephrine injection syringe 0. mg/ml EPIPEN -PAK INJECTION AUTO- INJECTOR 0.3 MG/0.3 ML QL; QL ( per 30 days) EPIPEN JR -PAK INJECTION AUTO- INJECTOR 0.5 MG/0.3 ML QL; QL ( per 30 days) epoprostenol (glycine) intravenous recon soln 0.5 mg,.5 mg SP Effective January, 08 07

116 ESBRIET ORAL CAPSULE 67 MG PA; SP; QL; QL (306 per 34 days) ESBRIET ORAL TABLET 67 MG PA; SP; QL (306 per 34 days) ESBRIET ORAL TABLET 80 MG PA; SP; QL (0 per 34 days) FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 QL MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 QL MCG/ACTUATION, 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QL; QL ( per 30 days) flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) QL; QL (50 per 30 days) fluticasone-salmeterol inhalation aerosol powdr breath activated 3-4 mcg/actuation, 3-4 mcg/actuation, 55-4 mcg/actuation GASTROCROM ORAL CONCENTRATE 00 MG/5 ML ipratropium bromide inhalation solution 0.0 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(.5 mg base)/3 ml KALYDECO ORAL TABLET 50 MG PA; SP LETAIRIS ORAL TABLET 0 MG, 5 MG PA; SP LUGOLS ORAL SOLUTION 5 % metaproterenol oral syrup 0 mg/5 ml metaproterenol oral tablet 0 mg, 0 mg montelukast oral granules in packet 4 mg montelukast oral tablet 0 mg montelukast oral tablet,chewable 4 mg, 5 mg NUCALA SUBCUTANEOUS RECON SOLN 00 MG PA NUEDEXTA ORAL CAPSULE 0-0 MG PA; QL; QL (60 per 30 days) OFEV ORAL CAPSULE 00 MG, 50 MG PA; SP; QL ORKAMBI ORAL TABLET 00-5 MG, 00-5 MG PA; SP Effective January, 08 08

117 PROLASTIN-C INTRAVENOUS RECON SOLN,000 MG SP promethazine injection solution 5 mg/ml, 50 mg/ml promethazine oral syrup 6.5 mg/5 ml promethazine oral tablet.5 mg, 5 mg, 50 mg PULMOZYME INHALATION SOLUTION MG/ML SP QVAR INHALATION AEROSOL 40 MCG/ACTUATION QL; QL (8 per 30 days) QVAR INHALATION AEROSOL 80 MCG/ACTUATION QL; QL (7 per 30 days) sildenafil (antihypertensive) intravenous solution 0 mg/.5 ml PA; SP sildenafil (antihypertensive) oral tablet 0 mg PA; SP; QL SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 QL; QL (90 per 30 days) MCG STRIVERDI RESPIMAT INHALATION MIST.5 MCG/ACTUATION STRONG IODINE ORAL SOLUTION 5 % SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, QL MCG/ACTUATION terbutaline oral tablet.5 mg, 5 mg terbutaline subcutaneous solution mg/ml THEOCHRON ORAL TABLET EXTENDED RELEASE HR 00 MG, 00 MG, 300 MG theophylline oral elixir 80 mg/5 ml theophylline oral solution 80 mg/5 ml theophylline oral tablet extended release hr 00 mg, 00 mg, 300 mg, 450 mg TRACLEER ORAL TABLET 5 MG, 6.5 MG PA; SP TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED QL; QL ( per 30 days) 400 MCG/ACTUATION VELETRI INTRAVENOUS RECON SOLN 0.5 MG,.5 MG SP Effective January, 08 09

118 VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION QL; QL (36 per 30 days) XOLAIR SUBCUTANEOUS RECON SOLN 50 MG PA; SP zafirlukast oral tablet 0 mg, 0 mg QL SKIN AND MUCOUS MEMBRANE AGENTS acitretin oral capsule 0 mg, 7.5 mg, 5 mg SP acyclovir topical ointment 5 % adapalene topical cream 0. % PA adapalene topical gel 0. %, 0.3 % PA adapalene topical gel with pump 0.3 % PA alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % AZELEX TOPICAL CREAM 0 % benzoyl peroxide topical cleanser 7 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone valerate topical cream 0. % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % BP 0- TOPICAL CLEANSER 0- % BP-50% UREA TOPICAL EMULSION 50 % calcipotriene topical cream % ciclopirox topical cream 0.77 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % Effective January, 08 0

119 CLARAVIS ORAL CAPSULE 0 MG, 0 MG, 30 MG, 40 MG CLEANSING WASH TOPICAL CLEANSER % CLINDACIN ETZ TOPICAL SWAB % CLINDACIN P TOPICAL SWAB % clindamycin phosphate topical foam % clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin phosphate vaginal cream % clindamycin-tretinoin topical gel % PA clobetasol scalp solution 0.05 % clobetasol topical cream 0.05 % clobetasol topical foam 0.05 % clobetasol topical gel 0.05 % clobetasol topical ointment 0.05 % clobetasol-emollient topical cream 0.05 % clobetasol-emollient topical foam 0.05 % clotrimazole mucous membrane troche 0 mg clotrimazole-betamethasone topical cream % CORMAX SCALP SOLUTION 0.05 % COSENTYX ( SYRINGES) SUBCUTANEOUS SYRINGE 50 MG/ML PA; SP COSENTYX PEN ( PENS) SUBCUTANEOUS PEN INJECTOR 50 PA; SP MG/ML COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML PA; SP COSENTYX SUBCUTANEOUS SYRINGE 50 MG/ML PA; SP desonide topical cream 0.05 % desonide topical lotion 0.05 % desonide topical ointment 0.05 % Effective January, 08

120 diclofenac sodium topical gel % diclofenac sodium topical gel 3 % PA diflorasone topical cream 0.05 % diflorasone topical ointment 0.05 % DOVONEX TOPICAL CREAM % DRITHOCREME HP TOPICAL CREAM % DRYSOL TOPICAL SOLUTION 0 % DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/ ML PA; SP econazole topical cream % ELIDEL TOPICAL CREAM % PA ERY PADS TOPICAL SWAB % erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % erythromycin with ethanol topical swab % ethyl chloride topical aerosol,spray 00 % EURAX TOPICAL CREAM 0 % EURAX TOPICAL LOTION 0 % FEM PH VAGINAL GEL % FINACEA TOPICAL GEL 5 % fluocinolone topical cream 0.0 %, 0.05 % fluocinolone topical ointment 0.05 % fluocinolone topical solution 0.0 % fluocinonide topical cream 0.05 %, 0. % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % FLUOCINONIDE-E TOPICAL CREAM 0.05 % FLUOROPLEX TOPICAL CREAM % fluorouracil topical cream 5 % fluorouracil topical solution %, 5 % fluticasone topical cream 0.05 % fluticasone topical ointment % FORMADON TOPICAL SOLUTION 0 % Effective January, 08

121 FORMADON TOPICAL SOLUTION WITH APPLICATOR 0 % gentamicin topical cream 0. % gentamicin topical ointment 0. % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % hydrocortisone butyrate topical cream 0. % hydrocortisone butyrate topical ointment 0. % hydrocortisone butyrate topical solution 0. % hydrocortisone rectal enema 00 mg/60 ml hydrocortisone topical cream.5 % hydrocortisone topical lotion.5 % hydrocortisone topical ointment.5 % hydrocortisone valerate topical cream 0. % hydrocortisone valerate topical ointment 0. % imiquimod topical cream in packet 5 % KEPIVANCE INTRAVENOUS RECON SOLN 6.5 MG ketoconazole topical cream % ketoconazole topical shampoo % lidocaine hcl laryngotracheal solution 4 % lidocaine hcl topical cream 3 % lidocaine hcl topical lotion 3 % lidocaine hcl-hydrocortison ac rectal cream % lidocaine hcl-hydrocortison ac rectal kit %, 3- % (7 gram) lidocaine hcl-hydrocortison ac topical cream % lidocaine topical ointment 5 % lidocaine-hydrocortisone-aloe rectal gel % lidocaine-hydrocortisone-aloe rectal kit - %, 3-.5 % (7 gram) Effective January, 08 3

122 lidocaine-prilocaine topical cream.5-.5 % lidocaine-prilocaine topical kit.5-.5 % LTA PRE-ATTACHED LARYNGOTRACHEAL SOLUTION 4 % malathion topical lotion 0.5 % methoxsalen oral capsule,liqd-filled,rapid rel 0 mg SP metronidazole topical cream 0.75 % metronidazole topical gel 0.75 % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % MICONAZOLE-3 VAGINAL SUPPOSITORY 00 MG QL mometasone topical cream 0. % mometasone topical ointment 0. % mometasone topical solution 0. % mupirocin calcium topical cream % mupirocin topical ointment % MYORISAN ORAL CAPSULE 0 MG, 0 MG, 40 MG neomycin-polymyxin b gu irrigation solution 40 mg-00,000 unit/ml NYAMYC TOPICAL POWDER 00,000 UNIT/GRAM nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 unit/gram nystatin-triamcinolone topical cream 00, unit/g-% nystatin-triamcinolone topical ointment 00, unit/gram-% NYSTOP TOPICAL POWDER 00,000 UNIT/GRAM permethrin topical cream 5 % phenazopyridine oral tablet 00 mg, 00 mg PICATO TOPICAL GEL 0.05 %, 0.05 % podofilox topical solution 0.5 % Effective January, 08 4

123 prednicarbate topical cream 0. % prednicarbate topical ointment 0. % PROCTOFOAM HC RECTAL FOAM - % PROCTO-PAK TOPICAL CREAM WITH PERINEAL APPLICATOR % PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR.5 % RECTIV RECTAL OINTMENT 0.4 % (W/W) ROSADAN TOPICAL CREAM 0.75 % ROSADAN TOPICAL GEL 0.75 % salicylic acid er-ceramides topical combo pack 6 % salicylic acid er-ceramides topical kit,cleanser and cream er 6 % salicylic acid topical cream 6 % salicylic acid topical cream,extended release 6 % salicylic acid topical gel 6 % salicylic acid topical lotion 6 % salicylic acid topical lotion,extended release 6 % salicylic acid topical shampoo 6 % SANTYL TOPICAL OINTMENT 50 UNIT/GRAM SEB-PREV TOPICAL CLEANSER 0 % selenium sulfide topical shampoo.5 % silver nitrate topical ointment 0 % silver nitrate topical solution 0.5 %, 0 %, 5 %, 50 % silver sulfadiazine topical cream % spinosad topical suspension 0.9 % SSD TOPICAL CREAM % SSS 0-5 TOPICAL CREAM 0-5 % (W/W) STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML PA; SP STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML PA; SP Effective January, 08 5

124 sulfacetamide sodium (acne) topical suspension 0 % sulfacetamide sodium topical cleanser 0 % sulfacetamide sodium-sulfur topical cleanser 0-5 % (w/w) sulfacetamide sodium-sulfur topical cream 0-5 % (w/w) sulfacetamide sodium-sulfur topical lotion 0-5 % (w/v), 0-5 % (w/w) sulfacetamide sodium-sulfur topical pads, medicated 0-4 % sulfacetamide sodium-sulfur topical suspension 0-5 % sulfacetamide sod-sulfur-urea topical cleanser % sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream 9 %-4.5 % -spf 5 tacrolimus topical ointment 0.03 % PA tacrolimus topical ointment 0. % TARGRETIN TOPICAL GEL % tazarotene topical cream 0. % PA TAZORAC TOPICAL CREAM 0.05 % PA TAZORAC TOPICAL GEL 0.05 %, 0. % PA terconazole vaginal cream 0.4 %, 0.8 % QL terconazole vaginal suppository 80 mg QL tretinoin topical cream 0.05 %, 0.05 %, 0. % PA tretinoin topical gel 0.0 %, 0.05 % PA triamcinolone acetonide topical cream 0.05 %, 0. %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0. % triamcinolone acetonide topical ointment 0.05 %, 0. %, 0.5 % UREA NAIL STICK TOPICAL SOLUTION 50 % urea topical cream 50 % urea topical lotion 40 % Effective January, 08 6

125 VALCHLOR TOPICAL GEL 0.06 % SP VANDAZOLE VAGINAL GEL 0.75 % ZENATANE ORAL CAPSULE 0 MG, 0 MG, 40 MG ZYCLARA TOPICAL CREAM IN METERED- DOSE PUMP.5 %, 3.75 % ZYCLARA TOPICAL CREAM IN PACKET 3.75 % SMOOTH MUSCLE RELAXANTS aminophylline intravenous solution 50 mg/0 ml, 500 mg/0 ml oxybutynin chloride oral syrup 5 mg/5 ml oxybutynin chloride oral tablet 5 mg oxybutynin chloride oral tablet extended release 4hr 0 mg, 5 mg oxybutynin chloride oral tablet extended release 4hr 5 mg QL THEOCHRON ORAL TABLET EXTENDED RELEASE HR 00 MG, 00 MG, 300 MG theophylline oral elixir 80 mg/5 ml theophylline oral solution 80 mg/5 ml theophylline oral tablet extended release hr 00 mg, 00 mg, 300 mg, 450 mg tolterodine oral capsule,extended release 4hr mg, 4 mg tolterodine oral tablet mg, mg VITAMINS ascorbic acid (vitamin c) injection solution 500 mg/ml B COMPLEX 00 INJECTION SOLUTION MG/ML BAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR MG calcitriol intravenous solution mcg/ml calcitriol oral capsule 0.5 mcg, 0.5 mcg calcitriol oral solution mcg/ml COMPLETE NATAL DHA ORAL COMBO PACK MG Effective January, 08 7

126 COMPLETENATE ORAL TABLET,CHEWABLE 9 MG IRON- MG cyanocobalamin (vitamin b-) injection solution,000 mcg/ml ELITE OB WITH DHA ORAL CAPSULE MG ELITE-OB 400 ORAL CAPSULE MG ergocalciferol (vitamin d) oral capsule 50,000 unit folic acid injection solution 5 mg/ml FOLIVANE-OB ORAL CAPSULE 85- MG HECTOROL INTRAVENOUS SOLUTION MCG/ML ( ML) hydroxocobalamin intramuscular solution,000 mcg/ml M.V.I. ADULT INTRAVENOUS SOLUTION 3,300 UNIT- 50 MCG/0 ML MEPHYTON ORAL TABLET 5 MG MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG, 0.5 MG, MG MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG, MG MYNATAL ADVANCE ORAL TABLET MG MYNATAL ORAL CAPSULE 65 MG IRON- MG MYNATAL ORAL TABLET MG MYNATAL PLUS ORAL TABLET 65 MG IRON- MG MYNATAL-Z ORAL TABLET 65 MG IRON- MG MYNATE 90 PLUS ORAL TABLET EXTENDED RELEASE 90 MG IRON- MG MYNEPHROCAPS ORAL CAPSULE MG PNV OB+DHA ORAL COMBO PACK MG Effective January, 08 8

127 PNV-DHA + DOCUSATE ORAL CAPSULE MG PNV-DHA ORAL CAPSULE 7 MG IRON- MG -300 MG PNV-OMEGA ORAL CAPSULE MG PNV-SELECT ORAL TABLET 7- MG PR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 400 ORAL COMBO PACK MG PR NATAL 430 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 430 ORAL COMBO PACK 9 MG IRON- MG -430 MG PRENAISSANCE ORAL CAPSULE MG PRENAISSANCE PLUS ORAL CAPSULE MG PRENATABS FA ORAL TABLET 9- MG PRENATABS RX ORAL TABLET 9 MG IRON- MG PRENATAL LOW IRON ORAL TABLET 7 MG IRON- MG PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 7 MG IRON- MG PRENATAL PLUS ORAL TABLET 9 MG IRON- MG PRENATAL-U ORAL CAPSULE MG pyridoxine (vitamin b6) injection solution 00 mg/ml RENAL CAPS ORAL CAPSULE MG RENA-VITE RX ORAL TABLET MG-MG-MCG RENO CAPS ORAL CAPSULE MG SE-NATAL 9 (WITH DOCUSATE) ORAL TABLET 9 MG IRON- MG-5 MG SE-NATAL 9 ORAL TABLET,CHEWABLE 9 MG IRON- MG Effective January, 08 9

128 TARON-C DHA ORAL CAPSULE MG TARON-PREX PRENATAL-DHA ORAL CAPSULE 30 MG IRON-. MG-55 MG-65 MG TL-SELECT ORAL CAPSULE MG TRIADVANCE ORAL TABLET MG TRINATAL GT ORAL TABLET MG TRINATAL RX ORAL TABLET 60 MG IRON- MG TRINATE ORAL TABLET 8 MG IRON- MG TRIVEEN-DUO DHA ORAL COMBO PACK MG TRIVEEN-ONE ORAL CAPSULE 7 MG IRON- MG -50 MG TRIVEEN-PRX RNF ORAL CAPSULE MG TRI-VIT WITH FLUORIDE AND IRON ORAL DROPS MG/ML TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.5 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (. MG)/ML ULTIMATECARE ONE NF ORAL CAPSULE MG ULTIMATECARE ONE ORAL CAPSULE MG VEMAVITE-PRX- ORAL CAPSULE MG VENA-BAL DHA ORAL COMBO PACK,TABLET AND CAP,DR MG VINACAL ORAL TABLET MG VINATE CARE ORAL TABLET,CHEWABLE 40 MG IRON- MG VINATE GT ORAL TABLET MG VINATE II ORAL TABLET 9 MG IRON- MG VINATE M ORAL TABLET 7- MG Effective January, 08 0

129 VINATE ONE ORAL TABLET 60 MG IRON- MG VINATE PN CARE ORAL TABLET MG VINATE ULTRA ORAL TABLET MG VIRT-PN DHA ORAL CAPSULE 7 MG IRON- MG -300 MG VIRT-PN ORAL TABLET 7- MG VIRT-PN PLUS ORAL CAPSULE MG VIRT-SELECT ORAL CAPSULE MG VITAFOL-OB ORAL TABLET 65- MG VITAMIN D ORAL CAPSULE 50,000 UNIT VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.5 MG FLUOR. (0.55 MG)/ML VOL-CARE RX ORAL TABLET MG-MG-MCG VOL-NATE ORAL TABLET 8 MG IRON- MG VOL-TAB RX ORAL TABLET 9 MG IRON- MG ZATEAN-CH ORAL CAPSULE MG ZATEAN-PN DHA ORAL CAPSULE 7 MG IRON- MG -300 MG ZATEAN-PN PLUS ORAL CAPSULE MG Effective January, 08

130 Effective January, 08

131 Index abacavir... abacavir-lamivudine... abacavir-lamivudinezidovudine... ABILIFY MAINTENA...44 acamprosate...44 acarbose...8 ACE AEROSOL CLOUD ENHANCER acebutolol..., 35 acetaminophen-codeine.. 44, 45 acetazolamide... 35, 63, 73 acetazolamide sodium...35, 63, 73 acetic acid...63, 74 acetylcysteine... 98, 06 acitretin... 0 ACTEMRA acyclovir..., 0 acyclovir sodium... adapalene...0 adefovir... adenosine adenosine (diagnostic) ADRUCIL...3 ADVATE... 8 ADYNOVATE... 8 AFINITOR...3 AFINITOR DISPERZ... 3 AFLURIA AFLURIA (PF)... 9 AFLURIA QUAD AFLURIA QUAD (PF)...9 AFSTYLA...8 ALBENZA... albumin, human 5 %...7 ALBURX (HUMAN) 5 %... 7 ALBUTEIN 5 %...7 ALBUTEIN 5 %...7 albuterol sulfate..., 06 alclometasone... 0 ALECENSA... 3 alendronate...98 ALINIA... allopurinol alosetron...78 Effective January, 08 ALPHANATE... 8 alprazolam ALPROLIX... 8 alprostadil ALTAVERA (8)... 8 ALUNBRIG... 3 ALYACEN /35 (8)... 8 ALYACEN 7/7/7 (8)... 8 amantadine hcl..., 45 AMETHIA...8 AMETHIA LO...8 AMETHYST... 8 amifostine crystalline amikacin... amiloridehydrochlorothiazide... 35, 63 aminocaproic acid...8 aminophylline...06, 7 amiodarone...35 amitriptyline amitriptylinechlordiazepoxide...45 amlodipine amlodipine-benazepril ammonium chloride amoxapine amoxicillin... amoxicillin-pot clavulanate... amphotericin b... ampicillin... ampicillin sodium... ampicillin-sulbactam..., 3 AMPYRA anagrelide...8 anastrozole... 3, 8 ANDRODERM... 8 ANDROGEL... 8 ANORO ELLIPTA... apraclonidine aprepitant...78 APRI... 8 APTIVUS... 3 ARANELLE (8)... 8 ARANESP (IN POLYSORBATE)...8 aripiprazole ARMOUR THYROID... 8 ASACOL HD...78 ASCOMP WITH CODEINE ascorbic acid (vitamin c)... 7 aspirin-dipyridamole.. 8, 35, 45 atenolol..., 35 atenolol-chlorthalidone..., 35, 63 ATGAM...99 atomoxetine atorvastatin atovaquone...3 atovaquone-proguanil...3 ATRIPLA...3 atropine..., 74, 06 ATROVENT HFA...06 AUBAGIO AUBRA... 8 AUSTEDO AVIANE... 8 AVONEX...99 AVONEX (WITH ALBUMIN).. 99 azacitidine...3 azathioprine azelastine AZELEX...0 azithromycin... 3 AZURETTE (8)... 8 B COMPLEX BACIIM... 3 bacitracin... 3, 74 bacitracin-polymyxin b baclofen... BACTROBAN NASAL BALANCED SALT BAL-CARE DHA... 8, 63, 7 balsalazide...78 BALZIVA (8)... 8 BANZEL...45 BARACLUDE...3 BASAGLAR KWIKPEN...8 BAVENCIO... 3 BD PRE-FILLED NORMAL SALINE...60, 63 BELEODAQ...3 belladonna alkaloids-opium BELLADONNA-OPIUM benazepril

132 benazeprilhydrochlorothiazide... 35, 63 BENEFIX... 8 benzoyl peroxide... 0 benztropine..., 45 betamethasone acet,sod phos...83 betamethasone dipropionate...0 betamethasone valerate... 0 betamethasone, augmented 0 BETASERON betaxolol..., 36, 74 bethanechol chloride... bexarotene...3 BEXSERO... 9 bicalutamide... 3 BILTRICIDE...3 bisoprolol fumarate..., 36 bisoprololhydrochlorothiazide..., 36, 63 bleomycin... 3 BLEPHAMIDE BLEPHAMIDE S.O.P...74 BLINCYTO...3 BLISOVI 4 FE BLISOVI FE.5/30 (8)...83 BLISOVI FE /0 (8)...83 BOSULIF... 3 BOTOX..., 99 BP BP-50% UREA... 0 BRIELLYN brimonidine bromocriptine...45 brompheniraminepseudoeph-dm...3, 06 budesonide... 83, 07 bumetanide...36, 63 bupivacaine bupivacaine (pf) bupivacaine-dextrosewater(pf) bupivacaine-epinephrine. 3, 98 bupivacaine-epinephrine (pf)...3, 98 buprenorphine hcl...46 buprenorphine-naloxone...46 Effective January, 08 4 bupropion hcl buspirone...46 BUTALBITAL COMPOUND W/CODEINE...46 butalbital-acetaminop-cafcod...46 butalbital-acetaminophen butalbital-acetaminophencaff...46 butalbital-aspirin-caffeine.9, 46 BYDUREON BYETTA...83 cabergoline CABOMETYX... 3 caffeine citrate calcipotriene... 0 calcitonin (salmon)...83, 99 calcitriol...7 calcium acetate...63 calcium chloride...63 calcium gluconate...63 CAMILA CAMRESE...83 CAMRESE LO CANASA...78 CANDIN...6 capecitabine... 3 CAPRELSA... 3 captopril captopril-hydrochlorothiazide...36, 64 CARAFATE CARBAGLU...64 carbamazepine... 46, 47 carbidopa-levodopa carbidopa-levodopaentacapone...47 carbinoxamine maleate..., 07 carboplatin... 4 carteolol CARTIA XT...36 carvedilol... 3, 36 CATHFLO ACTIVASE... 9, 73 CAYSTON... 3 CAZIANT (8)...83 cefaclor... 3 cefadroxil... 3 cefazolin... 3 cefazolin in dextrose (iso-os)...3 cefdinir... 3 cefditoren pivoxil...4 cefepime... 4 cefepime in dextrose,isoosm...4 cefotaxime... 4 cefotetan...4 cefoxitin... 4 cefoxitin in dextrose, isoosm...4 cefpodoxime... 4 cefprozil... 4 ceftazidime... 4 ceftriaxone... 4 ceftriaxone in dextrose,isoos...4 cefuroxime axetil...4 cefuroxime sodium... 4 celecoxib...47 CELONTIN cephalexin... 4 CERDELGA...99 CESAMET cevimeline...3 CHANTIX...3 CHANTIX STARTING MONTH BOX...3 CHATEAL CHEMET... 8, 99 chloramphenicol sod succinate... 4 chlordiazepoxide hcl chlorhexidine gluconate...74 chloroquine phosphate... 4 chlorothiazide... 36, 64 chlorpromazine chlorpropamide...83 chlorthalidone... 36, 64 chlorzoxazone... 3 cholestyramine (with sugar)...36 CHOLESTYRAMINE LIGHT..36 choline,magnesium salicylate...47 chromium chloride ciclopirox...0 cilostazol...9, 36 cimetidine... 78

133 cimetidine hcl...78 CIPRODEX...74 ciprofloxacin...5 ciprofloxacin (mixture)... 5 ciprofloxacin hcl... 5, 74 ciprofloxacin in 5 % dextrose...5 ciprofloxacin lactate... 5 cisplatin...4 citalopram cladribine... 4 CLARAVIS... clarithromycin... 5 CLEANSING WASH... clemastine..., 07 CLEO 90 INFUSION SET 4" CLINDACIN ETZ... CLINDACIN P... clindamycin hcl... 5 clindamycin palmitate hcl...5 CLINDAMYCIN PEDIATRIC...5 clindamycin phosphate... 5, clindamycin-tretinoin... clobetasol... clobetasol-emollient... clomipramine clonazepam clonidine... 3, 36 clonidine (pf)... 3, 36, 47 clonidine hcl...3, 36 clopidogrel... 9 clorazepate dipotassium...47 clotrimazole... clotrimazole-betamethasone clozapine COAGADEX... 9 COARTEM...5 cocaine codeine sulfate... 47, 07 COLCRYS colestipol...36 colistin (colistimethate na)... 5 COMBIVENT RESPIMAT...3, 07 COMETRIQ... 4 COMFORT SHORT INFUSION SET 3" COMPLERA... 5 Effective January, 08 COMPLETE NATAL DHA...7 COMPLETENATE... 8 COMPRO... 48, 78 CONSTULOSE...64 COPPER CHLORIDE...64 CORIFACT... 9 CORLANOR CORMAX... cortisone COSENTYX... COSENTYX ( SYRINGES) COSENTYX PEN... COSENTYX PEN ( PENS) cosyntropin... 6 COTELLIC... 4 CREON...78 CRIXIVAN...5 cromolyn... 74, 07 CRYSELLE (8) CUPRIMINE... 8, 99 cyanocobalamin (vitamin b- )... 8 CYCLAFEM /35 (8)...83 CYCLAFEM 7/7/7 (8)...84 cyclobenzaprine...3 cyclopentolate...74 cyclophosphamide...4, 99 CYCLOPHOSPHAMIDE..4, 99 cyclosporine...99 cyclosporine modified cyproheptadine..., 07 CYRAMZA... 4 cyred...84 CYSTAGON CYSTARAN cytarabine... 4 cytarabine (pf)...4 CYTRA K CRYSTALS CYTRA CYTRA CYTRA-K...64 dacarbazine... 4 danazol dantrolene...3 dapsone...5 daptomycin... 5 DARAPRIM...5 DASETTA /35 (8)...84 DASETTA 7/7/7 (8)...84 daunorubicin... 4 DAYSEE deferoxamine...8, 99 DELFLEX-LC/.5% DEXTROSE...64 DELFLEX-LC/.5% DEXTROSE...64 DELFLEX-LC/4.5% DEXTROSE...64 DELFLEX-SM WITH.5% DEXTROSE...64 DENTA 5000 PLUS DENTAGEL DEPO-PROVERA...84 DESCOVY... 5 desipramine desmopressin... 9, 84 desogestrel-ethinyl estradiol..84 desonide... dexamethasone DEXAMETHASONE INTENSOL...84 dexamethasone sodium phos (pf) dexamethasone sodium phosphate...74, 84 dexmethylphenidate dexrazoxane hcl dextroamphetamine...48 dextroamphetamineamphetamine...48 dextrose 5 % in ringer's dextrose 5 %-lactated ringers...64 DIANEAL LOW CALCIUM/.5% DEX...64 DIANEAL PD- WITH.5 % DEX DIANEAL PD- WITH 4.5 % DEX DIANEAL PD-/.5% DEXTROSE...65 DIANEAL WITH.5 % DEXTROSE...65 DIANEAL WITH 4.5 % DEXTROSE...65 diazepam

134 DIAZEPAM INTENSOL diclofenac potassium diclofenac sodium...48, 75, dicloxacillin... 5 dicyclomine...3 didanosine... 5 diflorasone... diflunisal...48 DIGOX digoxin... 36, 37 dihydroergotamine...3, 48 DILANTIN... 37, 48 diltiazem hcl...37 DILT-XR...37 dimenhydrinate..., 78, 07 diphenhydramine hcl..., 07 diphenoxylate-atropine...3, 78, 07 dipyridamole... 9, 37 DISKETS disopyramide phosphate disulfiram divalproex dobutamine...3, 37 dobutamine in d5w... 3, 37 DOCETAXEL...4 dofetilide donepezil... 4 dopamine...4, 37 dopamine in 5 % dextrose...4, 37 dorzolamide dorzolamide-timolol DOVONEX... doxazosin... 4, 38 doxepin... 48, 49 doxorubicin... 4 doxycycline hyclate...6, 75 doxycycline monohydrate... 6 DRITHOCREME HP... dronabinol...78 droperidol...49 drospirenone-ethinyl estradiol DROXIA...4 DRYSOL... DULERA... 4, 84, 07 duloxetine Effective January, 08 6 DUPIXENT... dutasteride...00 dutasteride-tamsulosin DYSPORT... 4, 00 ECLIPSE SYRINGE econazole... ED-SPAZ... 4 EDURANT... 6 EFFER-K electrolyte-48 in d5w...65 ELELYSO ELIDEL... 00, ELINEST...84 ELIPHOS ELITE OB WITH DHA...8 ELITE-OB , 8 ELLA...84 ELMIRON ELOCTATE...9 EMCYT... 4 EMOQUETTE...84 EMTRIVA...6 enalapril maleate enalaprilat enalapril-hydrochlorothiazide...38, 65 ENBREL ENBREL MINI...00 ENBREL SURECLICK...00 ENDOCET enoxaparin...9 ENPRESSE ENSKYCE entacapone...49 entecavir... 6 ENTRESTO ENULOSE EPCLUSA...6 ephedrine sulfate... 4, 07 epinephrine...4, 07 EPIPEN -PAK... 4, 07 EPIPEN JR -PAK...4, 07 epirubicin... 4 EPITOL...49 EPIVIR...6 EPIVIR HBV... 6 eplerenone...38 EPOGEN... 9 epoprostenol (glycine)... 38, 07 ergocalciferol (vitamin d)... 8 ergoloid...4 ERIVEDGE... 4 ERRIN ERY PADS... ERYTHROCIN (AS STEARATE)... 6 erythromycin... 6, 75 erythromycin ethylsuccinate... 6 erythromycin with ethanol... ESBRIET escitalopram oxalate...49 ESTARYLLA...85 estazolam ESTRACE...85 estradiol estradiol valerate estradiol-norethindrone acet..85 ESTROGEL estropipate...85 eszopiclone...49 ethambutol...6 ethosuximide ethyl chloride... etidronate disodium etodolac etoposide... 5 EURAX... EVAMIST...85 EVOTAZ... 6, 00 EVZIO...49, 00 exemestane... 5, 85 EXJADE...8 EXTAVIA E-Z-CAT DRY...6 ezetimibe E-Z-HD BARIUM... 6 E-Z-PAQUE... 6 FABRAZYME...73 FALMINA (8)...85 famciclovir...6 famotidine famotidine (pf)...78 famotidine (pf)-nacl (iso-os)..78 FARESTON... 5, 85 FARYDAK...5 FASLODEX... 5

135 FEIBA NF... 9 felbamate...49 FELBATOL felodipine FEM PH... FEMHRT LOW DOSE FEMYNOR...85 fenofibrate...38 fenofibrate micronized fenofibrate nanocrystallized...38 fenofibric acid (choline)...38 fentanyl fentanyl citrate... 49, 50 FERRIPROX...8 FINACEA... finasteride FIRAZYR FISH OIL...38 flecainide FLOVENT DISKUS...85, 08 FLOVENT HFA...85, 08 floxuridine... 5 FLUAD (65 YR UP)(PF)... 0 FLUARIX QUAD (PF)...0 FLUCELVAX QUAD FLUCELVAX QUAD (PF)...0 fluconazole... 6 fluconazole in dextrose(isoo)... 6 fluconazole in nacl (iso-osm)... 6 fludrocortisone FLULAVAL QUAD FLULAVAL QUAD (PF)...0 flumazenil... 50, 00 flunisolide...75, 08 fluocinolone... fluocinonide... FLUOCINONIDE-E... FLUOR-A-DAY (WITH XYLITOL)...00 fluorescein-proparacaine. 6, 75 fluoride (sodium)...00 Effective January, 08 FLUORITAB fluorometholone...75 FLUOROPLEX... fluorouracil... 5, fluoxetine fluphenazine decanoate fluphenazine hcl...50 flurazepam...50 flurbiprofen...50 flurbiprofen sodium FLUROX flutamide... 5 fluticasone... fluticasone-salmeterol...08 FLUVIRIN FLUVIRIN (PF)... 0 fluvoxamine FLUZONE INTRADERM QUAD FLUZONE QUAD FLUZONE QUAD (PF)...0 FLUZONE QUAD PEDI 07-8 (PF)... 0 folic acid...8 FOLIVANE-OB... 9, 8 fomepizole... 0 FORMADON..., 3 FORTEO...86 fosamprenavir...6 foscarnet...6 fosinopril fosinoprilhydrochlorothiazide... 38, 65 fosphenytoin FOSRENOL...65, 0 furosemide...38, 65 FUZEON...6 FYCOMPA...50 gabapentin...50 GABITRIL galantamine... 4 GAMASTAN S/D... 0 GAMMAGARD LIQUID...0 GAMMAGARD S-D (IGA < MCG/ML)... GAMUNEX-C... GASTROCROM GAVILYTE-C GAVILYTE-G GAVILYTE-N gemfibrozil GENERLAC...65 GENOTROPIN GENOTROPIN MINIQUICK.. 86 GENTAK...75 gentamicin... 7, 75, 3 gentamicin in nacl (iso-osm)...7 gentamicin sulfate (ped) (pf)...7 gentamicin sulfate (pf)... 7 GENVOYA...7 GIANVI (8) GILDAGIA...86 GILENYA... 0 GILOTRIF... 5 glatiramer...0 GLATOPA...0 glimepiride glipizide...86 glipizide-metformin GLUCAGEN DIAGNOSTIC KIT... 6, 86 GLUCAGEN HYPOKIT..86, 0 GLUCAGON EMERGENCY KIT (HUMAN)... 86, 0 GLUCAGON HCL...6, 86 glyburide glyburide micronized...86 glyburide-metformin...86, 87 glycine urologic solution glycopyrrolate... 4 granisetron (pf) granisetron hcl griseofulvin microsize... 7 griseofulvin ultramicrosize... 7 guanfacine... 38, 39, 50 guanidine... 4 halobetasol propionate... 3 haloperidol... 5 haloperidol decanoate haloperidol lactate... 50, 5 HARVONI... 7 HEATHER HECTOROL...8 HELIXATE FS

136 HEP FLUSH-0 (PF)... 30, 6 heparin (porcine) heparin (porcine) in 5 % dex..30 heparin (porcine) in nacl (pf)...30, 6 heparin flush(porcine)- 0.9nacl... 30, 6 HEPARIN LOCK...30, 6 HEPARIN LOCK FLUSH. 30, 6 heparin lock flush (porcine)...30, 6 HEPARIN LOCKFLUSH(PORCINE)(PF )... 30, 6 heparin(porcine) in 0.45% nacl heparin, porcine (pf)... 30, 6 hetastarch 6 % in 0.9 % nacl.65 HEXALEN...5 HIBERIX (PF)... HIZENTRA... HOMATROPAIRE HUMALOG HUMATROPE...87 HUMIRA... 79, 0 HUMIRA PEDIATRIC CROHN'S START... 79, 0 HUMIRA PEN... 79, 0 HUMIRA PEN CROHN'S- UC-HS START... 79, 0 HUMIRA PEN PSORIASIS- UVEITIS...79, 0 HUMULIN 70/ HUMULIN 70/30 KWIKPEN...87 HUMULIN N...87 HUMULIN N KWIKPEN HUMULIN R U HUMULIN R U-500 (CONCENTRATED) hydralazine hydrochlorothiazide... 39, 65, 66 hydrocodoneacetaminophen... 5 hydrocodone-ibuprofen...5 hydrocortisone... 87, 3 hydrocortisone butyrate... 3 hydrocortisone valerate... 3 hydrocortisone-acetic acid...75 Effective January, 08 8 hydromorphone... 5 hydroxocobalamin... 8 hydroxychloroquine... 7, 0 hydroxyprogesterone capr(bulk)...87 hydroxyprogesterone caproate...87 hydroxyurea...5 hydroxyzine hcl..., 5 hydroxyzine pamoate..., 5 HYOPHEN...7 hyoscyamine sulfate... 4, 5 HYPERHEP B S/D... HYPERHEP B S-D NEONATAL... HYPERRAB S/D (PF)... HYPERRHO S/D... ibandronate...0 IBRANCE...5 ibuprofen...5 ICLUSIG... 5 idarubicin... 5 IDELVION...30 ifosfamide... 5 ifosfamide-mesna... 5 imatinib... 5 IMBRUVICA...5 IMFINZI...5 imipramine hcl... 5 imipramine pamoate... 5 imiquimod... 3 indapamide... 39, 66 indomethacin... 5, 0 INFED...3 INLYTA... 5 INTELENCE... 7 INTRON A... 7, 5, 6, 0 INTROVALE INVANZ... 7 INVEGA SUSTENNA... 5 INVIRASE...7 INVOKAMET INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W ipratropium bromide.5, 75, 08 ipratropium-albuterol...5, 08 irbesartan...39 irbesartanhydrochlorothiazide IRESSA... 6 irinotecan... 6 ISENTRESS... 7 ISENTRESS HD... 7 ISOLYTE S PH ISOLYTE-P IN 5 % DEXTROSE...66 ISOLYTE-S...66 isoniazid...7, 8 isosorbide dinitrate isosorbide mononitrate ISOVUE ISOVUE-M isradipine itraconazole... 8 ivermectin... 8 IXINITY... 3 JAKAFI... 6 JANTOVEN... 3 JANUMET...87 JANUMET XR...87, 88 JANUVIA JENCYCLA...88 JINTELI...88 JOLESSA JOLIVETTE JULEBER JUNEL.5/30 ()...88 JUNEL /0 ()...88 JUNEL FE.5/30 (8) JUNEL FE /0 (8) JUNEL FE KADCYLA...6 KAITLIB FE...88 KALETRA... 8 KALYDECO KARIVA (8) K-EFFERVESCENT KELNOR /35 (8) KEPIVANCE... 3 ketoconazole... 8, 3 ketoprofen...5 ketorolac... 5, 5, 75 KEYTRUDA... 6 KIMIDESS (8)... 88

137 KIONEX (WITH SORBITOL)...66, 0 KLOR-CON...66 KLOR-CON KLOR-CON KLOR-CON M KLOR-CON M KLOR-CON M KLOR-CON/EF KOMBIGLYZE XR KOVALTRY... 3 KRYSTEXXA... 0 KURVELO l norgest/e.estradiol-e.estrad.88 labetalol... 5, 39 lactated ringers lactulose lamivudine... 8 lamivudine-zidovudine... 8 lamotrigine... 5 lansoprazole lanthanum...66, 0 LANTUS LANTUS SOLOSTAR...88 larin.5/30 () LARIN /0 ()...89 LARIN 4 FE LARIN FE.5/30 (8) LARIN FE /0 (8) LARISSIA latanoprost...75 LATUDA... 5 LAYOLIS FE LEENA leflunomide... 0 LEMTRADA... 0 LENVIMA...6 LESSINA LETAIRIS...39, 08 letrozole... 6, 89 leucovorin calcium... 0 LEUKERAN... 6 LEUKINE... 3 leuprolide... 6, 89 levetiracetam... 5 levobunolol levocarnitine... 0 levocarnitine (with sugar)...0 Effective January, 08 levofloxacin...8 levoleucovorin...0 LEVONEST (8) levonorgestrel-ethinyl estrad.89 levonorg-eth estrad triphasic.89 LEVORA levorphanol tartrate...5 levothyroxine LEVOXYL LEXIVA... 8 lidocaine... 3 lidocaine (pf) in d7.5w...98 lidocaine (pf)... 39, 98 lidocaine hcl...75, 98, 3 lidocaine hcl-hydrocortison ac...3 lidocaine in 5 % dextrose (pf) lidocaine-epinephrine... 5, 98 lidocaine-hydrocortisonealoe...3 lidocaine-prilocaine...4 LILETTA linezolid...8 linezolid-0.9% sodium chloride... 8 LINZESS...79 liothyronine LIQUID E-Z PAQUE... 6 lisinopril...39 lisinopril-hydrochlorothiazide...39, 66 lithium carbonate... 5 lithium citrate... 5 LOMEDIA 4 FE...90 LONSURF... 6 lopinavir-ritonavir... 8 lorazepam...5 LORAZEPAM INTENSOL... 5 LORCET (HYDROCODONE)... 5 LORCET HD...5 LORYNA (8) losartan...39 losartan-hydrochlorothiazide...39, 67 LOTEMAX lovastatin LOW-OGESTREL (8) loxapine succinate... 5 LTA PRE-ATTACHED... 4 LUDENT FLUORIDE... 0 LUGOLS... 8, 90, 0, 08 LUMIZYME LUPRON DEPOT... 6, 90 LUPRON DEPOT (3 MONTH)... 6, 90 LUPRON DEPOT (4 MONTH)... 6, 90 LUPRON DEPOT-PED...6, 90 LUTERA (8) LYNPARZA...6 LYRICA...5 LYZA...90 M.V.I. ADULT... 8 magnesium chloride... 5 magnesium sulfate.. 40, 53, 0 magnesium sulfate in water...40, 53, 0 MAKENA malathion... 4 manganese chloride mannitol 0 %...40, 6, 67 mannitol 0 %...40, 6, 67 mannitol 5 %...40, 6, 67 mannitol 5 %...40, 6, 67 maprotiline MARLISSA MARTEN-TAB MATULANE... 6 MAVYRET... 8 meclofenamate medroxyprogesterone...90 mefloquine... 8 megestrol...6, 90 MEKINIST...6 meloxicam melphalan hcl... 6 memantine...53 MENACTRA (PF)... meperidine...53 MEPHYTON... 0, 8 meprobamate mercaptopurine...7, 0 meropenem... 8 mesalamine

138 mesna...0 MESNEX... 0 METADATE ER metaproterenol... 5, 08 metaxalone... 5 metformin...90, 9 methadone...53 METHADOSE...53 methenamine hippurate...8 methenamine mandelate... 8 methimazole... 9 METHITEST... 9 methocarbamol...5 methotrexate sodium... 7, 0 methotrexate sodium (pf)...7, 0 methoxsalen... 4 methscopolamine... 5 methyldopa... 5, 40 methyldopahydrochlorothiazide... 5, 40, 67 methyldopate... 5, 40 methylene blue (antidote) METHYLIN methylphenidate hcl...54 methylprednisolone... 9 methylprednisolone acetate...9 methylprednisolone sodium succ... 9 metipranolol metoclopramide hcl metolazone... 40, 67 metoprolol succinate...5, 40 metoprolol tahydrochlorothiaz... 5, 40, 67 metoprolol tartrate... 5, 40 metronidazole... 8, 4 metronidazole in nacl (isoos)...8 mexiletine MICONAZOLE MICROGESTIN.5/30 ()...9 MICROGESTIN /0 ()...9 MICROGESTIN FE.5/30 (8)... 9 MICROGESTIN FE /0 (8)... 9 midazolam Effective January, midodrine...5 milrinone... 4 milrinone in 5 % dextrose MIMVEY... 9 minocycline...9 minoxidil...4 mirtazapine misoprostol MITIGARE mitomycin... 7 mitoxantrone...7 modafinil moexipril... 4 moexiprilhydrochlorothiazide... 4, 67 mometasone...4 MONOJECT MAGELLAN SYRINGE... 6 MONOJECT SYRINGE... 6 MONO-LINYAH... 9 MONONESSA (8)...9 montelukast morphine...54 morphine concentrate...54 moxifloxacin...76 MOZOBIL... 3 MULTIVITAMIN WITH FLUORIDE... 03, 8 MULTI-VITAMIN WITH FLUORIDE... 03, 8 MULTIVITAMINS WITH FLUORIDE... 03, 8 mupirocin... 4 mupirocin calcium...4 MYALEPT...9 MYCAMINE... 9 mycophenolate mofetil...03 mycophenolate mofetil hcl mycophenolate sodium...03 MYLERAN... 7 MYNATAL...3, 67, 8 MYNATAL ADVANCE...3, 67, 8 MYNATAL PLUS... 3, 67, 8 MYNATAL-Z... 3, 67, 8 MYNATE 90 PLUS... 8 MYNEPHROCAPS... 8 MYORISAN... 4 MYZILRA... 9 nabumetone...54 nadolol... 5, 4 nadolol-bendroflumethiazide...6, 4, 67 nafcillin...9 nafcillin in dextrose iso-osm... 9 nalbuphine naloxone... 55, 03 naltrexone...55, 03 naproxen...55, 03 naproxen sodium... 55, 03 NARCAN NATACYN nateglinide... 9 NATPARA...9 NATURE-THROID...9 NEBUPENT... 9 NECON 0.5/35 (8)... 9 NECON 7/7/7 (8)... 9 nefazodone...55 neomycin... 9 neomycin-bacitracin-poly-hc..76 neomycin-bacitracinpolymyxin...76 neomycin-polymyxin b gu... 4 neomycin-polymyxin b- dexameth...76 neomycin-polymyxingramicidin neomycin-polymyxin-hc NEO-POLYCIN HC...76 NEULASTA...3 NEUPOGEN... 3 nevirapine... 9 NEXAVAR... 7 NEXPLANON... 9 nicardipine... 4 NICOTROL... 6 NICOTROL NS... 6 nifedipine... 4 nikki (8)... 9 nilutamide... 7 nimodipine... 4 NINLARO...7 NITRO-BID... 4 nitrofurantoin...9 nitrofurantoin macrocrystal... 9

139 nitrofurantoin monohyd/mcryst... 9 nitroglycerin... 4 nitroglycerin in 5 % dextrose.4 nizatidine NORA-BE... 9 norepinephrine bitartrate... 6 noreth-ethinyl estradiol-iron... 9 norethindrone (contraceptive)...9 norethindrone acetate...9 norethindrone ac-eth estradiol... 9 norethindrone-e.estradioliron...9 norgestimate-ethinyl estradiol... 9 NORMAL SALINE FLUSH...6, 67 NORMOSOL-M IN 5 % DEXTROSE...67 NORMOSOL-R...67 NORMOSOL-R IN 5 % DEXTROSE...67 NORMOSOL-R PH NORTREL 0.5/35 (8)... 9 NORTREL /35 ()... 9 NORTREL /35 (8)... 9 NORTREL 7/7/7 (8)... 9 nortriptyline NORVIR...9 NOVOEIGHT... 3 NOVOLIN 70/ NOVOLIN N...9 NOVOLIN R...9 NOVOLOG NOVOLOG FLEXPEN... 9 NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL...93 NP THYROID NUCALA NUEDEXTA... 55, 08 NUTRILYTE...68 NUTROPIN AQ NUSPIN NUVARING...93 NUWIQ... 3 Effective January, 08 NYAMYC... 4 nystatin... 9, 4 nystatin-triamcinolone...4 NYSTOP...4 OBIZUR... 3 OCALIVA OCELLA OCREVUS...03 octreotide acetate... 93, 03 ODEFSEY... 9 OFEV...08 ofloxacin... 9, 76 OGESTREL (8)...93 olanzapine olopatadine omega-3 acid ethyl esters... 4 omeprazole...79, 80 OMNIPAQUE OMNIPAQUE OMNIPAQUE ondansetron...80 ondansetron hcl ondansetron hcl (pf)...80 ONETOUCH ULTRA TEST... 6 ONETOUCH VERIO...6 ONGLYZA OPDIVO...7 ORENCIA ORENCIA CLICKJECT...03 ORFADIN ORKAMBI orphenadrine citrate...6 ORSYTHIA oseltamivir... 9 OTEZLA...04 OTEZLA STARTER...04 oxacillin...9 oxacillin in dextrose(isoosm)...9 oxaliplatin...7 oxandrolone...93 oxaprozin oxazepam oxcarbazepine oxybutynin chloride...7 oxycodone OXYCODONE oxycodone-acetaminophen oxycodone-aspirin OXYCONTIN oxytocin paclitaxel...7 pamidronate...04 pantoprazole...80 papaverine...4 paromomycin... 0 paroxetine hcl peg 3350-electrolytes PEGANONE PEGASYS... 0 PEGASYS PROCLICK... 0 peg-electrolyte soln penicillin g potassium... 0 penicillin g procaine... 0 penicillin g sodium... 0 penicillin v potassium...0 PENTASA...80 pentazocine-naloxone pentoxifylline...3 perindopril erbumine...4 PERIOGARD permethrin... 4 perphenazine...56 perphenazine-amitriptyline phenazopyridine... 4 phenelzine phenobarbital...56 phenobarbital sodium phenylephrine hcl... 6, 76 phenytoin... 4, 56 phenytoin sodium... 4, 57 phenytoin sodium extended...4, 56 PHILITH...93 PHOSPHA 50 NEUTRAL PHOSPHOLINE IODIDE PHYSIOLYTE PHYSIOSOL IRRIGATION...68 physostigmine salicylate 6, 04 PICATO... 4 pilocarpine hcl...6, 76 PIMTREA (8) pindolol... 6, 4 pioglitazone pioglitazone-metformin piperacillin-tazobactam...0 3

140 PIRMELLA...93 piroxicam PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE...68 PLEGRIDY PNEUMOVAX 3... PNV OB+DHA... 3, 68, 80, 8 PNV-DHA... 3, 9 PNV-DHA + DOCUSATE...3, 68, 80, 9 PNV-OMEGA...3, 68, 9 PNV-SELECT... 3, 9 podofilox... 4 POLYCIN...77 POLYFIN QR INFUSION SET...6 polymyxin b sulfate... 0 polymyxin b sulftrimethoprim...77 POMALYST... 7, 04 PORTIA potassium acetate potassium bicarb and chloride potassium bicarb-citric acid potassium chlorid-d5-0.45%nacl...68 potassium chloride...68, 69 potassium chloride in 0.9%nacl...68 potassium chloride in 5 % dex...68 potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.%nacl...69 potassium chloride-d5-0.3%nacl...69 potassium chloride-d5-0.9%nacl...69 potassium citrate potassium citrate-citric acid potassium phosphate m-/dbasic PR NATAL , 69, 9 Effective January, 08 3 PR NATAL 400 EC.. 3, 69, 9 PR NATAL , 69, 9 PR NATAL 430 EC.. 3, 69, 9 PRADAXA... 3 PRALUENT PEN... 4 pramipexole prasugrel...3 pravastatin... 4 prazosin... 6, 4 PRED MILD prednicarbate...5 prednisolone prednisolone acetate prednisolone sodium phosphate...77, 94 prednisone...94 PREDNISONE INTENSOL...94 PREMARIN...94 PREMPHASE PREMPRO PRENAISSANCE...3, 69, 80, 9 PRENAISSANCE PLUS...3, 69, 80, 9 PRENATABS FA... 3, 69, 9 PRENATABS RX...3, 69, 9 PRENATAL LOW IRON...3, 70, 9 PRENATAL PLUS... 3, 70, 9 PRENATAL PLUS (CALCIUM CARB)... 3, 70, 9 PRENATAL-U...9 PREVIFEM PREVNAR 3 (PF)... PREZCOBIX...0, 04 PREZISTA... 0 PRIFTIN...0 primidone...57 PRIVIGEN... probenecid...70, 04 probenecid-colchicine...70, 04 procainamide... 4 prochlorperazine...57, 80 prochlorperazine edisylate...57, 80 prochlorperazine maleate 57, 80 PROCRIT... 3 PROCTOFOAM HC...5 PROCTO-PAK...5 PROCTOZONE-HC...5 progesterone progesterone micronized PROGLYCEM...94 PROLASTIN-C PROLEUKIN...7, 04 PROLIA PROMACTA promethazine..., 57, 09 propafenone... 4 propantheline...6 proparacaine...77 propranolol...6, 4, 57 propranololhydrochlorothiazid... 6, 4, 70 propylthiouracil protriptyline PULMOZYME...73, 09 PYLERA... 0, 80 pyrazinamide... 0 pyridostigmine bromide... 6 pyridoxine (vitamin b6)... 9 QUADRACEL (PF)... QUASENSE...94 quetiapine quinapril... 4 quinapril-hydrochlorothiazide...4, 70 quinidine gluconate...0, 4 quinidine sulfate...0, 4 quinine sulfate... 0 QVAR... 94, 09 raloxifene... 94, 04 ramipril...4 ranitidine hcl... 80, 8 RAPAMUNE RAVICTI READI-CAT... 6 REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK RECLIPSEN (8)...94 RECOMBINATE RECTIV... 5 RELENZA DISKHALER...0 REMICADE...05 RENAGEL... 70, 05

141 RENAL CAPS...9 RENA-VITE RX... 9 RENO CAPS... 9 RENVELA...70, 05 repaglinide repaglinide-metformin...94 REPATHA PUSHTRONEX...4 REPATHA SURECLICK REPATHA SYRINGE RESCRIPTOR... RESTASIS...77 RETROVIR... REVLIMID...7, 05 REVONTO...6 REYATAZ... ribavirin... rifabutin... rifampin... RIFATER... riluzole rimantadine... ringer's...70 RISPERDAL CONSTA risperidone...57, 58 RITUXAN HYCELA... 7 rivastigmine... 6 rivastigmine tartrate... 6 rizatriptan...58 ropinirole...58 ROSADAN...5 rosuvastatin ROTATEQ VACCINE... RUBRACA... 7 RYDAPT... 7 salicylic acid...5 salicylic acid er-ceramides...5 salsalate SANTYL...5 SAVELLA...58 SEB-PREV... 5 SECONAL SODIUM selegiline hcl selenium selenium sulfide...5 SELZENTRY... SE-NATAL , 9 SE-NATAL 9 (WITH DOCUSATE)... 33, 8, 9 Effective January, 08 SENSIPAR... 95, 05 SEROSTIM...95 sertraline...58 SETLAKIN sevelamer carbonate SF SF 5000 PLUS...05 SIGNIFOR sildenafil (antihypertensive)...43, 09 silver nitrate... 5 silver sulfadiazine... 5 simvastatin...43 sirolimus SIRTURO... SITZMARKS... 6 sodium acetate sodium bicarbonate sodium chlor 0.9% bacteriostat sodium chloride... 7 sodium chloride 0.45 % sodium chloride 0.9 %...6, 70, 7 sodium chloride 3 %... 7 sodium chloride 5 %... 7 sodium citrate-citric acid... 7 sodium lactate... 7 sodium phenylbutyrate... 7 sodium phosphate... 7 SODIUM POLYSTYRENE (SORB FREE)... 7, 05 sodium polystyrene sulfonate... 7, 05 sodium thiosulfate...05 SOLU-CORTEF...95 SOLU-CORTEF (PF)...95 SOLU-MEDROL SOLU-MEDROL (PF) SOMATULINE DEPOT...95 SORINE...6, 43 sotalol... 7, 43 SOTALOL AF... 6, 43 spinosad... 5 SPIRIVA RESPIMAT... 7 SPIRIVA WITH HANDIHALER... 7, 09 spironolactone... 43, 7 spironolactonhydrochlorothiaz... 43, 7 SPRINTEC (8) SPRYCEL...7 SPS (WITH SORBITOL) 7, 05 SRONYX SSD... 5 SSS stavudine... STELARA... 5 STIVARGA... 8 STRENSIQ STRIBILD... STRIVERDI RESPIMAT 7, 09 STRONG IODINE..., 95, 05, 09 SUBOXONE SUCRAID sucralfate... 8 sulfacetamide sodium...77, 6 sulfacetamide sodium (acne)...6 sulfacetamide sodium-sulfur 6 sulfacetamide sod-sulfururea... 6 sulfacetamide-prednisolone...77 sulfact na-sul-avobnz-otnocsa... 6 sulfadiazine... sulfamethoxazoletrimethoprim... sulfasalazine..., 8, 05 sulindac sumatriptan...58 sumatriptan succinate...58 SUSTIVA... SUTENT... 8 SYEDA SYLATRON..., 8 SYLVANT... 8 SYMBICORT... 7, 95, 09 SYMLINPEN SYMLINPEN SYNAGIS... SYNAREL...95 SYREX SODIUM CHLORIDE 0.9%...6, 7 syringe with needle, safety

142 T:SLIM... 6 TABLOID... 8 tacrolimus... 05, 6 TAFINLAR... 8 TAGITOL V...6 TAGRISSO... 8 tamoxifen... 8, 95 tamsulosin... 7 TARCEVA...8 TARGRETIN...6 tarina fe /0 (8) TARON-C DHA...33, 0 TARON-PREX PRENATAL- DHA... 33, 8, 0 TASIGNA...8 tazarotene...6 TAZORAC... 6 TECENTRIQ...8 TECFIDERA temazepam...58 TEMODAR...8 temozolomide... 8 terazosin... 7, 43 terbinafine hcl... terbutaline...7, 09 terconazole... 6 TESTOSTERONE testosterone...96 testosterone cypionate testosterone enanthate...96 TETCAINE...77 tetrabenazine...59 tetracaine hcl tetracaine hcl (pf)...77 tetracycline... thallous chloride tl THALOMID THEOCHRON. 43, 7, 09, 7 theophylline... 43, 7, 09, 7 thioridazine thiothixene THYROGEN... 6 THYROLAR THYROLAR-/...96 THYROLAR-/ THYROLAR THYROLAR tiagabine Effective January, ticlopidine...33 TILIA FE timolol maleate... 7, 43, 59, 77 TIVICAY... tizanidine... 7 TL-SELECT... 33, 7, 8, 0 tobramycin tobramycin in 0.5 % nacl... tobramycin in 0.9 % nacl... tobramycin sulfate... tobramycin-dexamethasone.. 77 tolazamide tolbutamide tolmetin tolterodine...7 topiramate...59 TOPOSAR... 8 torsemide...43, 7 TRACLEER... 43, 09 tramadol...59 tramadol-acetaminophen...59 trandolapril...43 tranylcypromine trazodone...59 tretinoin...6 tretinoin (chemotherapy)...8 TRETTEN TRIADVANCE... 33, 7, 0 triamcinolone acetonide...6 triamterenehydrochlorothiazid... 44, 7 triazolam TRICITRATES... 7 TRI-ESTARYLLA...96 trifluoperazine trihexyphenidyl...7, 59 TRI-LEGEST FE...96 TRI-LINYAH...96 tri-lo-estarylla tri-lo-sprintec...96 trimethobenzamide... 8 trimethoprim... TRINATAL GT... 33, 0 TRINATAL RX... 33, 7, 0 TRINATE... 33, 7, 0 TRINESSA (8) trinessa lo TRI-PREVIFEM (8)...97 TRISENOX... 8 TRI-SPRINTEC (8) TRIUMEQ... TRIVEEN-DUO DHA...33, 7, 0 TRIVEEN-ONE... 33, 7, 0 TRIVEEN-PRX RNF...33, 7, 8, 0 TRI-VIT WITH FLUORIDE AND IRON... 33, 05, 0 TRI-VITAMIN WITH FLUORIDE... 06, 0 TRIVORA (8) tropicamide TRUMENBA... TRUVADA... TUDORZA PRESSAIR TYKERB... 8 ULTIMATECARE ONE...33, 7, 0 ULTIMATECARE ONE NF...33, 7, 0 UNITHROID...97 unithroid...97 UNITUXIN...8 UPTRAVI UR N-C... urea... 6 UREA NAIL STICK... 6 URIMAR-T... UROGESIC-BLUE... ursodiol... 8 valacyclovir... VALCHLOR... 7 valganciclovir... valproate sodium valproic acid...59 valproic acid (as sodium salt)...59 valsartan valsartanhydrochlorothiazide... 44, 7 vancomycin... vancomycin in dextrose 5 %.. VANDAZOLE...7 VARIBAR THIN HONEY...63 VARIBAR THIN LIQUID vasopressin... 97

143 VAXCHORA VACCINE... VECTIBIX... 8 VELCADE...8 VELETRI...44, 09 VELIVET TRIPHASIC REGIMEN (8) VELTASSA... 7 VEMAVITE-PRX-...33, 7, 8, 0 VEMLIDY... VENA-BAL DHA... 34, 7, 0 VENCLEXTA... 9 VENCLEXTA STARTING PACK...9 venlafaxine... 59, 60 VENOFER VENTOLIN HFA... 7, 0 verapamil VESTURA (8) VIBERZI...8 VICTOZA -PAK...97 VICTOZA 3-PAK...97 VIDEX GRAM PEDIATRIC. VIENVA VIMIZIM VIMPAT VINACAL... 34, 7, 8, 0 VINATE CARE...34, 0 VINATE GT...34, 0 VINATE II...0 VINATE M...0 VINATE ONE...34, 7, VINATE PN CARE... VINATE ULTRA.34, 7, 8, vinblastine...9 VINCASAR PFS... 9 vincristine...9 vinorelbine... 9 VIORELE (8)...97 VIRACEPT... VIREAD... VIRT-PN... 34, VIRT-PN DHA...34, VIRT-PN PLUS...34, 7, VIRT-SELECT... 34, 73, 8, VISIPAQUE VISTOGARD VITAFOL-OB... 34, 73, Effective January, 08 VITAMIN D... VITAMINS A,C,D AND FLUORIDE... 06, VOL-CARE RX... VOL-NATE...34, 73, VOL-TAB RX... 34, 73, VOLUMEN...63 VONVENDI...34 voriconazole... 3 VOSEVI... 3 VOTRIENT... 9 VPRIV...73 VYVANSE...60 warfarin...34 water for irrigation, sterile WELCHOL...44, 97 WERA (8) WESTHROID...97 WINRHO SDF... WYMZYA FE XALKORI... 9 XARELTO...34 XELJANZ...06 XELJANZ XR...06 XEOMIN... 7, 06 XERMELO... 8 XGEVA XIFAXAN... 3 XIIDRA...77 XOLAIR... 0 XTANDI... 9 XULANE XYNTHA XYNTHA SOLOFUSE YONDELIS... 9 yuvafem zafirlukast... 0 zaleplon ZARAH ZARXIO ZATEAN-CH... 35, 73, 8, ZATEAN-PN DHA...35, ZATEAN-PN PLUS..35, 73, ZAVESCA...06 ZEJULA... 9 ZELBORAF...9 ZENATANE... 7 ZENCHENT (8)...97 ZEPATIER... 3 zidovudine... 3 zinc chloride...73 zinc sulfate...73 ziprasidone hcl...60 ZIRGAN ZOLINZA... 9 zolmitriptan zolpidem zonisamide ZORBTIVE...97 ZORTRESS ZOSTAVAX (PF)... ZOVIA /35E (8) ZOVIA /50E (8) ZYCLARA... 7 ZYDELIG... 9 ZYKADIA... 9 ZYLET ZYPREXA RELPREVV...60 ZYTIGA

144 UCARE STATE PUBLIC PROGRAM OTC DRUG FORMULARY 08 The following list of over-the-counter (OTC) medications are covered by UCare for State Public Program members. The formulary only includes the generic version of products. Some brand products are listed in parentheses for reference purposes only. This list is subject to change. ANALGESICS AND ANTI-INFLAMMATORY DRUGS acetaminophen (TYLENOL) acetaminophen / pyrilamine / caffeine aspirin (BAYER) aspirin / acetaminophen/ caffeine (EXCEDRIN) aspirin / buffers (BUFFERIN) ibuprofen (MOTRIN) naproxen (ALEVE) COUGH AND COLD MEDICATIONS ANTIHISTAMINES cetirizine (ZYRTEC) chlorpheniramine (CHLOR-TRIMETON) diphenhydramine (BENADRYL) loratadine (CLARITIN) DECONGESTANTS phenylephrine (SUDAFED PE) pseudoephedrine (SUDAFED) ANTIHISTAMINE / DECONGESTANT COMBINATIONS brompheniramine / pseudoephedrine brompheniramine / phenylephrine cetirizine / pseudoephedrine (ZYRTEC - D) chlorpheniramine / phenylephrine chlorpheniramine / phenylephrine / acetaminophen chlorpheniramine / phenylephrine / dextromethorphan / acetaminophen chlorpheniramine / pseudoephedrine chlorpheniramine / pseudoephedrine / acetaminophen chlorpheniramine / pseudoephedrine / dextrometorphah / acetaminophen diphenhyydramine / pseudoephedrine / acetaminophen diphenydramine / pseudoephedrine loratadine / pseudoephedrine (CLARITIN - D) phenylephrine / acetaminophen phenylephrine / guaifenesin pseudoephedrine / ibuprofen psueodoephedrine / acetaminophen ANTITUSSIVES AND EXPECTORANT DRUGS dextromethorphan (ROBITUSSIN) dextromethorphan / chlorpheniramine dextromethorphan / phenylephrine