Express Scripts Medicare (PDP) 2015 Formulary (List of Covered Drugs)

Transcription

1 Express Scripts Medicare (PDP) 2015 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN Formulary ID Number: 15067, v9 This formulary was updated on 08/20/2014. For more recent information or other questions, please contact Express Scripts Medicare (PDP) Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at Note to current members: This formulary has changed since last year. Please review this document to understand your plan s drug coverage. When this drug list (formulary) refers to we, us or our, it means Express Scripts Insurance Company or Medco Containment Life Insurance Company. When it refers to plan or our plan, it means Express Scripts Medicare. This document includes the list of the covered drugs (formulary) for our plan, which is current as of August 20, For more recent information, please contact us. Our contact information, along with the date we last updated the formulary, appears above and on the back cover. You must use network pharmacies to fill your prescriptions to get the most from your benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. This information is available for free in other languages. Please call Express Scripts Medicare Customer Service at the numbers on the back of your member ID card for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Llame al Servicio al cliente de Express Scripts Medicare a los números que figuran al dorso de su tarjeta de identificación de miembro para obtener información adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana. This document is available in braille. Please contact Customer Service if you need plan information in another format. EME19169 CRP F0NP5O5A

2 What is the Express Scripts Medicare formulary? The list of drugs covered by the plan is also known as the formulary. It contains a list of highly utilized Medicare Part D drugs selected by Express Scripts Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The formulary also includes information on requirements or limits for some covered drugs that are part of Express Scripts Medicare s standard formulary rules. Your specific plan may provide coverage of additional drugs that are not listed in this formulary, and your plan may have different plan rules and coverage. For more information on your plan s specific drug coverage, please review your other plan materials, visit us on the Web at or contact Customer Service. Express Scripts Medicare will generally cover a drug as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your other plan materials. Can my drug coverage change? Generally, if you are taking a drug covered by your plan in 2015, Express Scripts Medicare will not discontinue or reduce coverage of the drug during the 2015 coverage year, except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our plan s coverage, will not affect members who are currently taking the drug. It will remain available at the same copayment or coinsurance amount for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If Express Scripts Medicare removes drugs from your plan s coverage, adds prior authorization, quantity limits, and/or step therapy restrictions on a drug, or moves a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective. If the Food and Administration (FDA) determines that a drug we cover is unsafe, or if the drug s manufacturer removes the drug from the market, we will immediately stop covering the drug and provide notice to members who are taking the drug. This enclosed formulary is current as of the date indicated on the front cover. To get updated information about the drugs covered, please visit us on the Web or contact our Customer Service department using the information provided on the front and back covers of this formulary. If there are any additional changes made to this plan s drug coverage that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time after the changes take effect. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular, Hypertension/Lipids. i

3 Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 97. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the Name column of the list. What are generic drugs? Both brand-name drugs and generic drugs are covered under this plan. A generic drug is approved by the FDA as having the same active ingredient(s) as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: You or your doctor is required to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don t get approval, the drugs may not be covered. These drugs are noted with PA next to them in the formulary. Some drugs may be covered under Part B or under Part D, depending on your medical condition. Your doctor will need to get a prior authorization for these drugs as well, so your pharmacy can process your prescription correctly. Quantity Limits: For certain drugs, the amount of the drug that will be covered by the plan is limited. The plan may limit how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. These drugs are noted with QL next to them in the formulary. Step Therapy: In some cases, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. These drugs are noted with ST next to them in the formulary. You may be able to find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 1. Note: This drug list includes all possible restrictions and limits on coverage. The requirements and limits may not apply to your plan s specific coverage. To confirm whether a particular drug is covered, visit us on the Web at or contact Customer Service. You can ask us to make an exception to these restrictions or limits. See the section How do I request an exception to the formulary? on the following page for information about how to request an exception. ii

4 What if my drug is not listed on this formulary? If your drug is not included in this list of covered drugs, you should first contact Customer Service and ask if your drug is covered. If you learn that your drug is not covered, you have two options: You can ask our Customer Service department for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers or request an exception so that the plan will cover the drug you are taking. How do I request an exception to the formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can request coverage of a drug that is not currently covered by this plan. If approved, the drug will be covered at a pre-determined cost-sharing level, and you will not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level. If your drug is contained in our Non-Preferred Brand tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in our Preferred Brand tier instead. If approved, this would lower the amount you must pay for your drug. You may not ask us to provide a higher level of coverage for drugs that are in our Specialty tier. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Express Scripts Medicare limits the amount of the drug it will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. You should contact us to ask for an initial coverage decision for an exception, utilization restriction exception or to ask the plan to cover a drug that is not currently covered. When you are requesting an exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. Generally, your request for an exception will only be approved if the alternative drugs that are covered, the lower-tiered drugs or the additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. iii

5 How do I request an appeal? If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. To start an appeal, you, your doctor or your representative must contact us. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. For more information about the appeals process, you may contact Customer Service using the information provided on the front and back covers of this document. Can I get a temporary transition supply while I wait for an exception decision? As a new or continuing member in our plan, you may be taking drugs that are not covered from one year to the next. Or, you may be taking a drug that is covered but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request an exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, or while you wait for a coverage decision from us, we may cover a temporary transition supply of your drug in certain cases during the first 90 days that you are enrolled in the plan or at the start of a new coverage year. For each of your drugs that has restrictions or limitations, we will cover a temporary transition supply when you go to a network pharmacy. This temporary transition supply will be for at least 30 days, or less if your prescription is written for fewer days. In that case, you will be allowed multiple fills to provide up to a total of at least a 30-day supply of the medication. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that has restrictions or limitations but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency transition supply of that drug (unless you have a prescription written for fewer while you pursue an exception. Other times when we will cover a temporary 31-day transition supply (or less, if you have a prescription written for fewer include: When you enter a long-term care facility When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized Express Scripts Medicare will send you a letter within 3 business days of your filling a temporary transition supply notifying you that this was a temporary supply and explaining your options. iv

6 Other coverage that your plan may provide Your plan may also cover categories of excluded drugs that are not normally covered by a Medicare prescription drug plan and are not listed in the formulary. s in the following categories may be covered subject to the rules and limitations of your specific plan: Prescription drugs when used for anorexia, weight loss or weight gain Prescription drugs when used to promote fertility Prescription drugs when used for cosmetic purposes or to promote hair growth Prescription drugs when used for the symptomatic relief of cough or colds Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are considered Part D drugs) s, such as CAVERJECT, CIALIS, EDEX, LEVITRA, MUSE and VIAGRA, when used for the treatment of sexual or erectile dysfunction Over-the-counter (OTC) diabetic supplies Federal Legend Part B medications for example, oral chemotherapy agents (e.g., TEMODAR, XELODA ) Non-prescription drugs, also known as over-the-counter (OTC) drugs. Please contact Customer Service for additional information about your plan s specific drug coverage and your cost-sharing amount. Please note: Costs for excluded drugs not normally covered by a Medicare prescription drug plan will not count toward your Medicare prescription drug yearly deductible (if applicable), total drug costs or yearly out-of-pocket expenses. Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by this plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 97. The Name column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR ) and generic drugs are listed in lowercase italics (e.g., atorvastatin). The information in the column tells you if there are any special requirements for coverage of that particular drug. If you are not sure whether your drug is covered, please visit our website or contact Customer Service using the information provided on the front and back covers of this formulary. Your Costs The amount you pay for a covered drug will depend on: Your coverage stage. Your plan has different stages of coverage. In each stage, the amount you pay for a drug may change. Please refer to your other plan documents for more information about your specific prescription drug benefit. The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different cost-sharing amount. The s chart on the following page explains what types of drugs are included in each tier and shows how costs may change with each tier. Your other plan materials have more information about your plan s coverage stages and list the specific cost-sharing amounts for each tier. v

7 s Includes Helpful tips 1: Preferred Generic s 2: Non-Preferred Generic s 3: Preferred Brand s 4: Non-Preferred Brand s 5: Specialty s This tier includes commonly prescribed preferred generic drugs. This tier includes prescribed non-preferred generic drugs. This tier includes preferred brand-name drugs as well as some generic drugs. This tier includes non-preferred brand-name drugs as well as some generic drugs. This tier includes very high cost brand-name and generic drugs. Use 1 drugs for the lowest cost-sharing amount. s in this tier will generally have lower cost-sharing amounts than brand drugs. s in this tier will generally have lower cost-sharing amounts than non-preferred brand drugs. Many non-preferred drugs have lower-cost alternatives in s 1, 2 and 3. Ask your doctor if switching to a lower-cost generic or preferred brand-name drug may be right for you. To learn more about medications in this tier, you may contact a pharmacist using the information provided on the front and back covers of this formulary. If you qualify for Extra Help If you qualify for Extra Help from Medicare to help pay for your prescription drugs, your cost-sharing amounts may be lower than your plan s standard benefit. Members who qualify for Extra Help will receive a notice called Important Information for Those Who Receive Extra Help Paying for Their Prescription s ( Low Income Rider or LIS Rider ). Please read it to find out what your costs are. You can also contact Customer Service with any questions using the information listed on the front and back covers of this formulary. For more information For more detailed information about your Medicare prescription drug coverage and your plan s specific costs, please review your other plan materials. If you need additional information on network pharmacies or if you have any other questions, please contact our Customer Service department using the information provided on the front and back covers of this formulary. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Or visit vi

8 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. Note: The following drug list includes all possible restrictions and limitations. Depending on your plan s specific benefit, you may not experience every restriction or limit indicated in the list. To confirm your plan s specific coverage, contact Customer Service using the information provided on the front and back covers of this List of abbreviations LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, contact Customer Service using the information provided on the front and back covers of this formulary. MO: Mail-Order. This prescription drug is available through our home delivery service, as well as through our retail network pharmacies. Consider using home delivery for your long-term (maintenance) medications, such as high blood pressure medications. Retail network pharmacies may be more appropriate for short-term prescriptions, such as antibiotics. PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover this drug. QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. vii

9 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 5 PA; MO AMBISOME 5 PA; MO amphotericin b 2 PA; MO ANCOBON CANCIDAS 5 PA; MO clotrimazole mucous membrane DIFLUCAN ERAXIS(WATER DILUENT) RECON SOLN 100 fluconazole fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml flucytosine GRIS-PEG (ULTRAMICROSIZ E) griseofulvin microsize griseofulvin ultramicrosize 2 itraconazole ; QL (120 ketoconazole oral Name LAMISIL ORAL GRANULES IN PACKET LAMISIL ORAL TABLET MYCAMINE RECON SOLN 100 MYCAMINE RECON SOLN 50 NOXAFIL ORAL nystatin oral suspension nystatin oral tablet ONMEL ; QL (30 SPORANOX ORAL CAPSULE SPORANOX ORAL SOLUTION SPORANOX PULSEPAK ; QL (120 ; QL (120 terbinafine oral VFEND VFEND IV voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 200 mg 1

10 Name voriconazole oral tablet 50 mg ANTIVIRALS abacavir abacavirlamivudinezidovudine acyclovir oral acyclovir sodium intravenous solution 2 PA adefovir amantadine hcl oral APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION BARACLUDE ORAL TABLET 5 cidofovir 5 PA; MO COMBIVIR COMPLERA COPEGUS CRIXIVAN CYTOVENE didanosine EDURANT EMTRIVA EPIVIR ORAL SOLUTION Name EPIVIR ORAL TABLET EPIVIR HBV ORAL SOLUTION EPIVIR HBV ORAL TABLET EPZICOM famciclovir FAMVIR FLUMADINE 4 foscarnet 2 PA; MO FUZEON ganciclovir sodium HEPSERA INCIVEK INTELENCE ORAL TABLET 100, 200 INTELENCE ORAL TABLET 25 INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE

11 Name ISENTRESS ORAL TABLET,CHEWAB LE 25 KALETRA ORAL SOLUTION KALETRA ORAL TABLET KALETRA ORAL TABLET lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET MODERIBA MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 400 (7)- 400 (7) MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 600 (7)- 600 (7) nevirapine NORVIR OLYSIO 5 PA; MO PREZISTA ORAL SUSPENSION Name PREZISTA ORAL TABLET 150, 75 PREZISTA ORAL TABLET 600, 800 REBETOL ORAL CAPSULE REBETOL ORAL SOLUTION RELENZA DISKHALER ; QL (60 per 180 RESCRIPTOR RETROVIR RETROVIR ORAL REYATAZ RIBAPAK DOSE PACK ORAL TABLETS,DOSE PACK (28)- (28), (28)- (28), (28)- (28) RIBASPHERE ORAL CAPSULE RIBASPHERE ORAL TABLET 200 RIBASPHERE ORAL TABLET 400 RIBASPHERE ORAL TABLET

12 Name ribavirin rimantadine SELZENTRY SOVALDI 5 PA; MO stavudine STRIBILD SUSTIVA SYNAGIS INTRAMUSCULA R SOLUTION 50 /0.5 ML TAMIFLU ORAL CAPSULE 30 TAMIFLU ORAL CAPSULE 45, 75 TAMIFLU ORAL SUSPENSION FOR RECONSTITUTIO N ; LA ; QL (84 per 180 ; QL (42 per 180 ; QL (600 per 180 TIVICAY TRIZIVIR TRUVADA TYZEKA valacyclovir ; QL (30 VALCYTE VALTREX ; QL (30 VICTRELIS VIDEX 2 GRAM PEDIATRIC VIDEX EC Name VIRACEPT VIRAMUNE VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 400 VIRAZOLE VIREAD VISTIDE 5 PA; MO ZERIT ZIAGEN ORAL SOLUTION ZIAGEN ORAL TABLET zidovudine ZOVIRAX ORAL SUSPENSION CEPHALOSPORINS CEDAX ORAL CAPSULE CEDAX ORAL SUSPENSION FOR RECONSTITUTIO N 180 /5 ML CEDAX ORAL SUSPENSION FOR RECONSTITUTIO N 90 /5 ML cefaclor 4 4

13 Name cefadroxil cefazolin injection recon soln 1 gram cefazolin injection recon soln 10 gram, 500 mg cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml 2 cefdinir cefditoren pivoxil 2 cefepime cefotaxime injection recon soln 1 gram, 2 gram, 500 mg cefotaxime injection recon soln 10 gram cefotetan 2 cefoxitin intravenous recon soln 1 gram cefoxitin intravenous recon soln 10 gram, 2 gram cefoxitin in dextrose, iso-osm 2 cefpodoxime cefprozil ceftazidime injection recon soln 1 gram, 6 gram ceftazidime injection recon soln 2 gram ceftazidime in d5w Name CEFTIN ceftriaxone injection recon soln 10 gram ceftriaxone injection recon soln 250 mg, 500 mg ceftriaxone intravenous 2 cefuroxime axetil cefuroxime sodium injection cefuroxime sodium intravenous cephalexin CLAFORAN INJECTION RECON SOLN 1 GRAM, 10 GRAM, 2 GRAM CLAFORAN INJECTION RECON SOLN 500 CLAFORAN RECON SOLN 1 GRAM CLAFORAN RECON SOLN 2 GRAM FORTAZ INJECTION RECON SOLN 2 GRAM

14 Name FORTAZ INJECTION RECON SOLN 6 GRAM FORTAZ KEFLEX MAXIPIME INJECTION ROCEPHIN INJECTION RECON SOLN SPECTRACEF SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 100 /5 ML, 200 /5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 /5 ML SUPRAX ORAL TABLET SUPRAX ORAL TABLET,CHEWAB LE 3 TEFLARO ZINACEF INJECTION RECON SOLN 1.5 GRAM Name ZINACEF INJECTION RECON SOLN 750 ZINACEF RECON SOLN 7.5 GRAM ERYTHROMYCINS / OTHER MACROLIDES azithromycin BIAXIN BIAXIN XL BIAXIN XL PAK clarithromycin DIFICID E.E.S. 400 E.E.S. GRANULES ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 250, 333 ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) ERYPED 200 ERYPED 400 ERYTHROCIN RECON SOLN 500 ERYTHROCIN (AS STEARATE) 3

15 Name erythromycin oral tablet erythromycin ethylsuccinate oral erythromycinsulfisoxazole PCE ZITHROMAX ZITHROMAX TRI- PAK ZITHROMAX Z- PAK ZMAX MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 500 mg/2 ml atovaquone atovaquoneproguanil AZACTAM INJECTION RECON SOLN 1 GRAM AZACTAM IN DEXTROSE (ISO- OSM) PIGGYBACK 1 GRAM/50 ML 3 Name AZACTAM IN DEXTROSE (ISO- OSM) PIGGYBACK 2 GRAM/50 ML aztreonam injection recon soln 1 gram BACIIM 2 bacitracin intramuscular 5 BETHKIS 5 PA; MO; QL (224 per 28 BILTRICIDE CAPASTAT 3 CAYSTON ; LA; QL (84 per 28 chloramphenicol sod succinate chloroquine phosphate oral CLEOCIN INJECTION 2 CLEOCIN ORAL CLEOCIN IN 5 % DEXTROSE PIGGYBACK 300 /50 ML, 600 /50 ML 7

16 Name CLEOCIN IN 5 % DEXTROSE PIGGYBACK 900 /50 ML clindamycin hcl clindamycin in dextrose 5 % CLINDAMYCIN PEDIATRIC clindamycin phosphate intravenous solution 600 mg/4 ml 4 2 COARTEM colistin (colistimethate na) COLY-MYCIN M PARENTERAL CUBICIN dapsone DARAPRIM DORIBAX SUSPENSION FOR RECONSTITUTIO N 500 ethambutol FLAGYL FLAGYL ER gentamicin injection solution 40 mg/ml 3 Name gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral 2 2 imipenem-cilastatin INVANZ INJECTION isoniazid injection 2 isoniazid oral KETEK LINCOCIN MALARONE MALARONE PEDIATRIC mefloquine MEPRON meropenem intravenous recon soln 500 mg MERREM RECON SOLN 500 metronidazole oral capsule 2 8

17 Name metronidazole oral tablet metronidazole in nacl (iso-os) MYAMBUTOL MYCOBUTIN NEBUPENT 3 PA; MO; QL (6 per 28 neomycin paromomycin PASER PENTAM PLAQUENIL polymyxin b sulfate PRIFTIN primaquine PRIMAXIN IV pyrazinamide QUALAQUIN quinine sulfate rifabutin RIFADIN RIFAMATE rifampin RIFATER SIRTURO ; LA SIVEXTRO 5 streptomycin intramuscular STROMECTOL Name SYNERCID 5 tinidazole TOBI 5 PA; MO; QL (280 per 28 TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in % nacl tobramycin in 0.9 % nacl intravenous piggyback 80 mg/100 ml tobramycin sulfate injection solution ; QL (224 per 28 5 PA; MO; QL (280 per 28 TRECATOR TYGACIL XIFAXAN ORAL TABLET 200 XIFAXAN ORAL TABLET 550 ZYVOX PARENTERAL SOLUTION 600 /300 ML ZYVOX ORAL PENICILLINS amoxicillin amoxicillin-pot clavulanate 9

18 Name ampicillin ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam injection recon soln 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N /5 ML 2 BICILLIN C-R BICILLIN L-A dicloxacillin MOXATAG 4 nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml oxacillin injection recon soln 10 gram oxacillin intravenous recon soln 2 gram 2 2 Name oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml penicillin g pot in dextrose intravenous piggyback 2 million unit/50 ml, 3 million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g sodium penicillin v potassium PFIZERPEN-G INJECTION RECON SOLN 5 MILLION UNIT piperacillintazobactam intravenous recon soln gram, 4.5 gram 2 10

19 Name TIMENTIN RECON SOLN 3.1 G UNASYN INJECTION RECON SOLN 15 GRAM UNASYN INJECTION RECON SOLN 3 GRAM ZOSYN RECON SOLN GRAM ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK GRAM/50 ML QUINOLONES 4 4 AVELOX AVELOX ABC PACK AVELOX IN NACL (ISO-OSMOTIC) CIPRO CIPRO IN D5W 4 Name ciprofloxacin intravenous solution 400 mg/40 ml ciprofloxacin oral suspension,microcap sule recon ciprofloxacin oral tablet ciprofloxacin (mixture) ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml 2 2 FACTIVE LEVAQUIN levofloxacin intravenous levofloxacin oral levofloxacin in d5w intravenous piggyback 500 mg/100 ml moxifloxacin ofloxacin oral SULFA'S / RELATED AGENTS BACTRIM BACTRIM DS sulfadiazine oral sulfamethoxazoletrimethoprim TETRACYCLINES 2 ADOXA 4 ST; MO 11

20 Name demeclocycline DORYX 4 ST; MO doxycycline hyclate intravenous doxycycline hyclate oral doxycycline monohydrate oral capsule 150 mg, 75 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet 150 mg, 50 mg, 75 mg 2 minocycline oral ORACEA 4 ST; MO SOLODYN 5 ST; MO tetracycline VIBRAMYCIN ORAL CAPSULE VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTIO N VIBRAMYCIN ORAL SYRUP 4 ST; MO URINARY TRACT AGENTS FURADANTIN HIPREX Name MACROBID MACRODANTIN ORAL CAPSULE 100 MACRODANTIN ORAL CAPSULE 25 methenamine hippurate MONUROL nitrofurantoin oral nitrofurantoin macrocrystal oral capsule 50 mg nitrofurantoin monohyd/m-cryst PRIMSOL trimethoprim VANCOMYCIN VANCOCIN vancomycin intravenous recon soln 1,000 mg, 10 gram, 500 mg vancomycin oral ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane intravenous recon soln 250 mg 5 12

21 Name ELITEK RECON SOLN 1.5 FUSILEV KEPIVANCE 5 leucovorin calcium injection recon soln 100 mg, 350 mg leucovorin calcium oral 5 mesna MESNEX MESNEX ORAL XGEVA ZINECARD RECON SOLN ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE AFINITOR ORAL TABLET 10 AFINITOR ORAL TABLET 2.5, 5, 7.5 AFINITOR DISPERZ ALIMTA RECON SOLN PA; MO; QL (60 per 30 5 PA; MO 5 PA; MO Name ALKERAN anastrozole ARIMIDEX AROMASIN ARRANON 5 ARZERRA SOLUTION 100 /5 ML 4 5 PA; MO ASTAGRAF XL 4 PA; MO AVASTIN azacitidine AZASAN 3 PA; MO azathioprine 2 PA; MO bicalutamide BICNU bleomycin injection recon soln 30 unit BOSULIF ORAL TABLET 100 BOSULIF ORAL TABLET 500 BUSULFEX 5 CAMPTOSAR SOLUTION 100 /5 ML CAPRELSA ORAL TABLET PA; MO 5 PA; MO; QL (30 per 30 ; LA 13

22 Name CAPRELSA ORAL TABLET 300 carboplatin intravenous solution ; LA; QL (30 per 30 CASODEX CELLCEPT ORAL CAPSULE CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N CELLCEPT ORAL TABLET CELLCEPT 4 PA; MO 5 PA; MO 5 PA; MO 3 PA cisplatin cladribine CLOLAR COMETRIQ 5 PA; MO COSMEGEN cyclophosphamide oral capsule cyclophosphamide oral tablet cyclosporine intravenous 3 PA 2 PA; MO 2 PA cyclosporine oral 2 PA; MO cyclosporine modified 2 PA; MO cytarabine Name cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml) dacarbazine intravenous recon soln 200 mg DACOGEN daunorubicin intravenous solution decitabine DOCEFREZ 5 docetaxel intravenous solution 80 mg/4 ml (20 mg/ml) docetaxel intravenous solution 80 mg/8 ml (10 mg/ml) 2 DOXIL doxorubicin intravenous solution 50 mg/25 ml 5 DROXIA ELIGARD 3 PA; MO ELLENCE SOLUTION 200 /100 ML ELOXATIN SOLUTION 100 /20 ML EMCYT 14

23 Name epirubicin intravenous solution 50 mg/25 ml ERBITUX SOLUTION 100 /50 ML ERIVEDGE 5 PA; MO; QL (30 per 30 ERWINAZE 5 ETOPOPHOS etoposide intravenous exemestane FARESTON FASLODEX FEMARA FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fluorouracil intravenous solution 2.5 gram/50 ml flutamide FOLOTYN SOLUTION 40 /2 ML (20 /ML) Name gemcitabine intravenous recon soln 1 gram GEMZAR RECON SOLN 1 GRAM GENGRAF 2 PA; MO GILOTRIF ORAL TABLET 20 GILOTRIF ORAL TABLET 30 GILOTRIF ORAL TABLET 40 GLEEVEC ORAL TABLET 100 GLEEVEC ORAL TABLET PA; MO; QL (60 per 30 5 PA; MO; QL (40 per 30 5 PA; MO; QL (30 per 30 5 PA; MO 5 PA; MO; QL (60 per 30 HALAVEN HERCEPTIN HEXALEN HYCAMTIN HYDREA hydroxyurea IDAMYCIN PFS idarubicin 2 IFEX RECON SOLN 1 GRAM 15

24 Name ifosfamide intravenous recon soln 1 gram IMBRUVICA 5 PA; MO; QL (120 per 30 IMURAN 4 PA; MO INLYTA ORAL TABLET 1 INLYTA ORAL TABLET 5 irinotecan intravenous solution 100 mg/5 ml 5 PA; MO 5 PA; MO; QL (120 per 30 ISTODAX IXEMPRA RECON SOLN 45 JAKAFI ORAL TABLET 10, 15, 20, 5 JAKAFI ORAL TABLET 25 5 PA; MO 5 PA; MO; QL (60 per 30 JEVTANA KADCYLA RECON SOLN 100 letrozole LEUKERAN leuprolide lomustine Name LUPRON DEPOT 5 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (NTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED INTRAMUSCULA R KIT 11.25, 15 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO LYSODREN MATULANE MEGACE MEGACE ES megestrol oral suspension 400 mg/10 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MEKINIST ORAL TABLET 2 melphalan 5 5 PA; MO; QL (120 per 30 5 PA; MO; QL (30 per 30 mercaptopurine methotrexate sodium oral methotrexate sodium (pf) injection recon soln 2 PA; MO 2 PA 16

25 Name methotrexate sodium (pf) injection solution mitomycin intravenous recon soln 20 mg 2 PA; MO mitoxantrone MUSTARGEN mycophenolate mofetil mycophenolate sodium 2 PA; MO 2 PA; MO MYFORTIC 4 PA; MO NEORAL 4 PA; MO NEXAVAR 5 PA; MO; LA NILANDRON NIPENT NULOJIX 5 PA; MO octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml ONCASPAR oxaliplatin intravenous solution 100 mg/20 ml paclitaxel PERJETA POMALYST Name PROGRAF PROGRAF ORAL CAPSULE 0.5, 1 PROGRAF ORAL CAPSULE 5 3 PA; MO 4 PA; MO 5 PA; MO PURINETHOL RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET 0.5 RAPAMUNE ORAL TABLET 1 RAPAMUNE ORAL TABLET 2 3 PA; MO 4 PA; MO 3 PA; MO 5 PA; MO REVLIMID 5 PA; MO; LA RHEUMATREX 4 PA; MO RITUXAN 5 PA; MO SANDIMMUNE 4 PA; MO SANDOSTATIN INJECTION SOLUTION 1,000 MCG/ML, 100 MCG/ML, 200 MCG/ML SANDOSTATIN INJECTION SOLUTION 50 MCG/ML, 500 MCG/ML SANDOSTATIN LAR DEPOT 17

26 Name SIGNIFOR 5 PA; MO SIMULECT RECON SOLN 20 3 PA; MO sirolimus 2 PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100, 20, 50, 80 SPRYCEL ORAL TABLET 140 SPRYCEL ORAL TABLET 70 5 PA; MO 5 PA; MO; QL (30 per 30 5 PA; MO; QL (60 per 30 STIVARGA 5 PA; MO; QL (84 per 28 SUTENT ORAL CAPSULE 12.5 SUTENT ORAL CAPSULE 25 SUTENT ORAL CAPSULE 50 SYLVANT RECON SOLN PA; MO 5 PA; MO; QL (60 per 30 5 PA; MO; QL (30 per 30 SYNRIBO TABLOID Name tacrolimus oral capsule 0.5 mg, 1 mg tacrolimus oral capsule 5 mg TAFINLAR ORAL CAPSULE 50 TAFINLAR ORAL CAPSULE 75 2 PA; MO 5 PA; MO 5 PA; MO; QL (180 per 30 5 PA; MO; QL (120 per 30 tamoxifen TARCEVA ORAL TABLET 100, 25 TARCEVA ORAL TABLET PA; MO 5 PA; MO; QL (30 per 30 TARGRETIN TASIGNA ORAL CAPSULE 150 TASIGNA ORAL CAPSULE 200 TAXOTERE SOLUTION 80 /4 ML (20 /ML) 5 PA; MO 5 PA; MO; QL (112 per 28 THALOMID 5 PA; MO TOPOSAR topotecan intravenous recon soln TORISEL 18

27 Name TREANDA RECON SOLN 100 TRELSTAR TRELSTAR DEPOT TRELSTAR LA 5 tretinoin (chemotherapy) 5 TREXALL 3 PA; MO TRISENOX TYKERB 5 PA; MO; LA; QL (180 per 30 VECTIBIX SOLUTION 100 /5 ML (20 /ML) 5 PA; MO VELCADE VIDAZA vinblastine intravenous solution vincristine intravenous solution 1 mg/ml vinorelbine intravenous solution 50 mg/5 ml VOTRIENT 5 PA; MO; QL (120 per 30 XALKORI ORAL CAPSULE PA; MO Name XALKORI ORAL CAPSULE PA; MO; QL (60 per 30 XTANDI 5 PA; MO; QL (120 per 30 YERVOY SOLUTION 50 /10 ML (5 /ML) ZALTRAP SOLUTION 100 /4 ML (25 /ML) ZANOSAR ZELBORAF 5 PA; MO; QL (240 per 30 ZOLINZA ZORTRESS ORAL TABLET 0.25 ZORTRESS ORAL TABLET 0.5, PA; MO 5 PA; MO ZYKADIA 5 PA; MO; QL (150 per 30 ZYTIGA 5 PA; MO; QL (120 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS 19

28 Name APTIOM ORAL TABLET 200, 400, 800 APTIOM ORAL TABLET 600 BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 BANZEL ORAL TABLET 400 carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension carbamazepine oral tablet carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable 1 MO 1 MO CARBATROL CELONTIN clonazepam 2 PA; MO DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES DIASTAT 4 PA; MO Name DIASTAT ACUDIAL 4 PA; MO diazepam rectal 2 PA; MO DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN-125 divalproex oral capsule, sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) 1 MO EPITOL 1 MO EQUETRO ethosuximide felbamate FELBATOL fosphenytoin injection solution 100 mg pe/2 ml FYCOMPA gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 1 MO 1 MO 20

29 Name GABITRIL ORAL TABLET 12, 16 GABITRIL ORAL TABLET 2, 4 GRALISE 4 PA; MO GRALISE 30-DAY STARTER PACK 4 PA; MO KEPPRA ORAL KEPPRA XR KLONOPIN 4 PA; MO LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25, 5 LAMICTAL ODT LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT LAMICTAL XR LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) Name LAMICTAL XR STARTER (ORANGE) lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible levetiracetam intravenous levetiracetam oral solution 100 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr 1 MO LYRICA 3 PA; MO MYSOLINE NEURONTIN 4 PA; MO ONFI 3 PA; MO oxcarbazepine OXTELLAR XR PEGANONE phenobarbital PHENYTEK phenytoin oral suspension 125 mg/5 ml phenytoin oral tablet,chewable 21

30 Name phenytoin sodium intravenous solution phenytoin sodium extended POTIGA primidone QUDEXY XR ORAL CAPSULE,SPRINK LE,ER 24HR 100, 25, 50 QUDEXY XR ORAL CAPSULE,SPRINK LE,ER 24HR 150, PA 5 PA SABRIL ; LA TEGRETOL TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 200, 400 tiagabine TOPAMAX 4 PA; MO topiramate oral capsule, sprinkle topiramate oral tablet 2 PA; MO 1 PA; MO TRILEPTAL Name TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 100, 25, 50 TROKENDI XR ORAL CAPSULE,EXTEN DED RELEASE 24HR PA; MO 5 PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml VIMPAT VIMPAT ORAL ZARONTIN ZONEGRAN 4 PA; MO zonisamide 2 PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone 3 COGENTIN COMTAN 22

31 Name ELDEPRYL entacapone LODOSYN MIRAPEX MIRAPEX ER NEUPRO PARCOPA pramipexole REQUIP REQUIP XL ropinirole selegiline hcl SINEMET SINEMET CR STALEVO 100 STALEVO 125 STALEVO 150 STALEVO 200 STALEVO 50 STALEVO 75 TASMAR ZELAPAR MIGRAINE / CLUSTER HEADACHE THERAPY ALSUMA ; QL (16 per 28 AMERGE ; QL (18 per 28 AXERT ORAL TABLET 12.5 ; QL (24 per 28 Name AXERT ORAL TABLET 6.25 ; QL (18 per 28 CAFERGOT dihydroergotamine injection ERGOMAR FROVA ; QL (27 per 28 IMITREX NASAL SPRAY,NON- AEROSOL 20 /ACTUATION IMITREX NASAL SPRAY,NON- AEROSOL 5 /ACTUATION ; QL (18 per 28 ; QL (36 per 28 IMITREX ORAL ; QL (18 per 28 IMITREX SUBCUTANEOUS IMITREX STATDOSE KIT REFILL ; QL (16 per 28 ; QL (16 per 28 MAXALT ; QL (36 per 28 MAXALT-MLT ; QL (36 per 28 MIGERGOT MIGRANAL ; QL (8 per 28 naratriptan ; QL (18 per 28 RELPAX ; QL (18 per 28 23

32 Name rizatriptan ; QL (36 per 28 sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution SUMAVEL DOSEPRO ; QL (18 per 28 ; QL (36 per 28 ; QL (18 per 28 ; QL (16 per 28 ; QL (16 per 28 ; QL (18 per 28 TREXIMET ; QL (18 per 28 zolmitriptan ; QL (18 per 28 ZOMIG ; QL (18 per 28 ZOMIG ZMT ; QL (18 per 28 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA ARICEPT ARICEPT ODT AUBAGIO 5 PA; MO Name COPAXONE SUBCUTANEOUS SYRINGE COPAXONE SUBCUTANEOUS SYRINGE KIT donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 23 mg donepezil oral tablet,disintegrating 5 PA; MO; QL (12 per 28 5 PA; MO; QL (30 per 30 1 MO EXELON ORAL EXELON TRANSDERMAL galantamine GILENYA 5 PA; MO HORIZANT 4 PA; MO NAMENDA 3 PA; MO NAMENDA TITRATION PAK 3 PA; MO NAMENDA XR 3 PA; MO NUEDEXTA RAZADYNE RAZADYNE ER rivastigmine tartrate TECFIDERA 5 PA; MO TYSABRI 5 PA; MO; LA XENAZINE 5 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen 24

33 Name cyclobenzaprine 2 PA; MO DANTRIUM dantrolene GABLOFEN INTRATHECAL SOLUTION 10,000 MCG/20ML (500 MCG/ML), 40,000 MCG/20ML (2,000 MCG/ML) GABLOFEN INTRATHECAL SYRINGE 50 MCG/ML (1 ML) LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP MESTINON ORAL TABLET MESTINON TIMESPAN pyridostigmine bromide 3 PA; MO 3 PA; MO 3 PA; MO 3 PA tizanidine ZANAFLEX NARCOTIC ANALGESICS Name ABSTRAL SUBLINGUAL TABLET, SUBLINGUAL 100 MCG, 200 MCG, 300 MCG ABSTRAL SUBLINGUAL TABLET, SUBLINGUAL 400 MCG ABSTRAL SUBLINGUAL TABLET, SUBLINGUAL 600 MCG ABSTRAL SUBLINGUAL TABLET, SUBLINGUAL 800 MCG acetaminophencodeine oral solution 300 mg-30 mg /12.5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg ACTIQ BUCCAL LOZENGE ON A HANDLE 1,200 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG 5 PA; QL (120 5 PA; QL (116 5 PA; MO; QL (77 per 30 5 PA; MO; QL (58 per 30 2 QL (4500 per 30 ; QL (360 ; QL (180 5 PA; MO; QL (120 per 30 25

34 Name AVINZA ORAL CAPSULE, ER MULTIPHASE 24 HR 120 AVINZA ORAL CAPSULE, ER MULTIPHASE 24 HR 30, 45, 60, 75, 90 ; QL (50 ; QL (60 BUPRENEX ; QL (267 buprenorphine injection syringe buprenorphine sublingual tablet, sublingual 2 mg buprenorphine sublingual tablet, sublingual 8 mg 2 QL (267 per 30 ; QL (300 ; QL (75 BUTRANS ; QL (4 per 28 CAPITAL WITH CODEINE codeine sulfate oral tablet DILAUDID ORAL LIQUID DILAUDID ORAL TABLET DILAUDID (PF) INJECTION SOLUTION 1 /ML ; QL (4500 ; QL (180 ; QL (1500 ; QL (180 ; QL (300 Name DILAUDID (PF) INJECTION SOLUTION 2 /ML DILAUDID (PF) INJECTION SOLUTION 4 /ML DILAUDID-HP (PF) INJECTION SOLUTION DOLOPHINE ORAL TABLET 10 DOLOPHINE ORAL TABLET 5 DURAGESIC TRANSDERMAL PATCH 72 HOUR 100 MCG/HR DURAGESIC TRANSDERMAL PATCH 72 HOUR 12 MCG/HR, 25 MCG/HR, 50 MCG/HR DURAGESIC TRANSDERMAL PATCH 72 HOUR 75 MCG/HR DURAMORPH (PF) INJECTION SOLUTION 0.5 /ML ; QL (150 ; QL (75 4 QL (30 per 30 ; QL (120 ; QL (240 ; QL (9 per 30 ; QL (10 ; QL (10 ; QL (

35 Name DURAMORPH (PF) INJECTION SOLUTION 1 /ML ENDOCET ORAL TABLET , 5-325, QL (2000 per 30 ; QL (360 ENDODAN ; QL (360 EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 12, 8 EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 16 EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 32 fentanyl citrate buccal lozenge on a handle 1,200 mcg fentanyl citrate buccal lozenge on a handle 1,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg ; QL (60 ; QL (60 ; QL (47 5 PA; MO; QL (39 per 30 5 PA; MO; QL (29 per 30 5 PA; MO; QL (120 per 30 5 PA; MO; QL (116 per 30 Name fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl patches transdermal patch 72 hour 100 mcg/hr fentanyl patches transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 200 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 400 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 600 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 800 MCG 5 PA; MO; QL (77 per 30 5 PA; MO; QL (58 per 30 ; QL (9 per 30 ; QL (10 5 PA; MO; QL (120 per 30 5 PA; MO; QL (116 per 30 5 PA; MO; QL (77 per 30 5 PA; MO; QL (58 per 30 HYCET ; QL (5550 hydrocodoneacetaminophen oral solution mg/15 ml ; QL (

36 Name hydrocodoneacetaminophen oral tablet mg, mg, mg, mg, mg, mg hydrocodoneibuprofen oral tablet mg hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 12 mg, 8 mg hydromorphone oral tablet extended release 24 hr 16 mg hydromorphone (pf) injection solution 10 mg/ml IBUDONE ORAL TABLET ; QL (360 ; QL (50 ; QL (300 ; QL (180 ; QL (60 ; QL (60 ; QL (120 ; QL (50 ibuprofen-oxycodone ; QL (28 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 10, 20, 30, 40, 50, 60 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 100 ; QL (90 ; QL (60 Name KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 130 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 150 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 200 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 70 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 80 ; QL (46 ; QL (40 ; QL (30 ; QL (86 ; QL (75 LAZANDA 5 PA; MO; QL (23 per 30 levorphanol tartrate ; QL (120 LORCET (HYDROCODONE) 2 QL (360 per 30 LORCET HD ; QL (360 LORCET PLUS 2 QL (360 per 30 LORTAB ; QL (360 LORTAB ; QL (360 LORTAB ; QL (360 28

37 Name LORTAB ELIXIR ; QL (6000 methadone injection 2 QL (160 per 30 methadone oral solution 10 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg morphine intravenous syringe 2 mg/ml morphine intravenous syringe 4 mg/ml morphine oral capsule, er multiphase 24 hr 120 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.relea se pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.relea se pellets 100 mg ; QL (600 ; QL (1200 ; QL (120 ; QL (240 2 QL (1000 per 30 2 QL (500 per 30 ; QL (50 ; QL (60 ; QL (90 ; QL (60 Name morphine oral capsule,extend.relea se pellets 80 mg morphine oral solution ; QL (75 ; QL (900 morphine oral tablet ; QL (180 morphine oral tablet extended release 100 mg morphine oral tablet extended release 15 mg, 30 mg morphine oral tablet extended release 200 mg morphine oral tablet extended release 60 mg morphine concentrate oral solution MS CONTIN ORAL TABLET EXTENDED RELEASE 100 MS CONTIN ORAL TABLET EXTENDED RELEASE 15, 30 MS CONTIN ORAL TABLET EXTENDED RELEASE 200 ; QL (60 ; QL (120 ; QL (30 ; QL (100 ; QL (300 ; QL (60 ; QL (120 ; QL (30 29

38 Name MS CONTIN ORAL TABLET EXTENDED RELEASE 60 ; QL (100 NORCO ; QL (360 OPANA ORAL TABLET 10 OPANA ORAL TABLET 5 OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10, 15, 20, 5, 7.5 OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 30 OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 40 ; QL (200 ; QL (180 ; QL (90 ; QL (67 ; QL (50 OXECTA ; QL (360 oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 20 mg oxycodone oral tablet 30 mg ; QL (360 ; QL (180 ; QL (1200 ; QL (180 ; QL (134 Name oxycodone oral tablet 5 mg oxycodoneacetaminophen ; QL (360 ; QL (360 oxycodone-aspirin ; QL (360 OXYCONTIN ORAL TABLET EXTENDED RELEASE 12 HR 10, 15, 20, 30, 40 OXYCONTIN ORAL TABLET EXTENDED RELEASE 12 HR 60 OXYCONTIN ORAL TABLET EXTENDED RELEASE 12 HR 80 oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 30 mg oxymorphone oral tablet extended release 12 hr 40 mg ; QL (90 ; QL (67 ; QL (50 ; QL (200 ; QL (180 ; QL (90 ; QL (67 ; QL (50 30

39 Name PERCOCET ; QL (360 PERCODAN ; QL (360 PRIMLEV ; QL (360 REPREXAIN ; QL (50 ROXICET ORAL SOLUTION ROXICODONE ORAL TABLET 15 ROXICODONE ORAL TABLET 30 ROXICODONE ORAL TABLET 5 SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 200 MCG/SPRAY SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 400 MCG/SPRAY SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 600 MCG/SPRAY ; QL (800 ; QL (180 ; QL (133 ; QL (360 5 PA; MO; LA; QL (120 per 30 5 PA; MO; LA; QL (84 per 30 5 PA; MO; LA; QL (56 per 30 Name SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 800 MCG/SPRAY 5 PA; MO; LA; QL (42 per 30 SYNALGOS-DC ; QL (300 TYLENOL- CODEINE #3 TYLENOL- CODEINE #4 ; QL (360 ; QL (180 VICODIN ; QL (360 VICODIN ES ; QL (360 VICODIN HP ; QL (360 VICOPROFEN ; QL (50 XARTEMIS XR ; QL (120 XODOL 10/300 ; QL (360 XODOL 5/300 ; QL (360 XODOL 7.5/300 ; QL (360 ZAMICET ; QL (5550 ZOHYDRO ER ; QL (90 NON-NARCOTIC ANALGESICS ANAPROX ANAPROX DS 31

40 Name ARTHROTEC 50 ARTHROTEC 75 butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal 2 PA; MO; QL (90 per 30 ; QL (720 ; QL (360 ; QL (40 CAMBIA 4 ST; MO; QL (9 CATAFLAM CELEBREX CONZIP ; QL (30 DAYPRO diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops buprenorphinenaloxone diclofenacmisoprostol diflunisal DUEXIS 4 ST; MO EC-NAPROSYN ORAL TABLET,DELAYE D RELEASE (DR/EC) 375 Name EC-NAPROSYN ORAL TABLET,DELAYE D RELEASE (DR/EC) ST; MO etodolac EVZIO 4 QL (0.8 per 30 FELDENE fenoprofen oral tablet FLECTOR 4 PA; MO; QL (60 per 30 flurbiprofen ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MO ketoprofen meclofenamate oral mefenamic acid meloxicam oral suspension meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg MOBIC ORAL SUSPENSION MOBIC ORAL TABLET 15 1 MO 1 MO; QL (30 32

41 Name MOBIC ORAL TABLET 7.5 ; QL (30 nabumetone nalbuphine injection solution 10 mg/ml nalbuphine injection solution 20 mg/ml naloxone injection syringe 1 mg/ml ; QL (200 ; QL (100 naltrexone NAPRELAN CR 4 ST; MO NAPROSYN 4 ST; MO naproxen oral suspension naproxen oral tablet 1 MO naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg NUCYNTA ORAL TABLET 100 NUCYNTA ORAL TABLET 50 NUCYNTA ORAL TABLET 75 1 MO 1 MO ; QL (181 ; QL (362 ; QL (242 NUCYNTA ER ; QL (60 oxaprozin PENNSAID 4 ST; MO piroxicam PONSTEL Name REVIA SPRIX 4 ST; MO SUBOXONE SUBLINGUAL FILM 12-3 SUBOXONE SUBLINGUAL FILM 2-0.5, 4-1, PA; MO; QL (60 per 30 3 PA; MO; QL (90 per 30 sulindac oral 1 MO tolmetin tramadol oral tablet ; QL (240 tramadol oral tablet extended release 24 hr 100 mg, 200 mg tramadol oral tablet, er multiphase 24 hr 300 mg tramadolacetaminophen ; QL (30 ; QL (30 ; QL (240 ULTRACET ; QL (240 ULTRAM ; QL (240 ULTRAM ER ; QL (30 VIMOVO 4 ST; MO VIVITROL VOLTAREN GEL VOLTAREN-XR ZIPSOR 4 ST; MO ZORVOLEX 4 ST; MO 33

42 Name ZUBSOLV 3 PA; MO; QL (90 per 30 PSYCHOTHERAPEUTIC DRUGS ABILIFY INTRAMUSCULA R ABILIFY ORAL SOLUTION ABILIFY ORAL TABLET 10 ABILIFY ORAL TABLET 15 ABILIFY ORAL TABLET 2 ABILIFY ORAL TABLET 20 ABILIFY ORAL TABLET 30 ABILIFY ORAL TABLET 5 ABILIFY DISCMELT ORAL TABLET,DISINTE GRATING 10 ABILIFY DISCMELT ORAL TABLET,DISINTE GRATING 15 ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 300 ; QL (90 ; QL (60 ; QL (450 ; QL (60 ; QL (30 ; QL (180 ; QL (90 ; QL (60 Name ADDERALL ORAL TABLET 20 ADDERALL XR alprazolam oral tablet AMBIEN 4 ST; MO; QL (30 per 30 AMBIEN CR 4 ST; MO; QL (30 per 30 amitriptyline 2 PA; MO amoxapine AMPHETAMINE SALT COMBO ANAFRANIL 4 PA; MO APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 348 APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 522 ; QL (90 ; QL (60 ; QL (30 ATIVAN ORAL 4 PA; MO BRINTELLIX ORAL TABLET 10 ; QL (60 34

43 Name BRINTELLIX ORAL TABLET 20 BRINTELLIX ORAL TABLET 5 ; QL (30 ; QL (120 BRISDELLE ; QL (30 bupropion hcl oral tablet bupropion hcl oral tablet extended release 100 mg bupropion hcl oral tablet extended release 150 mg bupropion hcl oral tablet extended release 200 mg bupropion hcl oral tablet extended release 24 hr 150 mg bupropion hcl oral tablet extended release 24 hr 300 mg ; QL (120 ; QL (90 ; QL (60 ; QL (90 ; QL (60 buspirone CELEXA ORAL TABLET 10 CELEXA ORAL TABLET 20 CELEXA ORAL TABLET 40 ; QL (120 ; QL (60 ; QL (30 chlorpromazine citalopram oral solution Name citalopram oral tablet 10 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg 1 MO; QL (120 1 MO; QL (60 1 MO; QL (30 clomipramine 2 PA; MO clonidine hcl oral tablet extended release 12 hr clorazepate dipotassium clozapine oral tablet 2 2 PA; MO CLOZARIL CONCERTA CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20 CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 60 4 ST; MO; QL (180 per 30 4 ST; MO; QL (120 per 30 4 ST; MO; QL (60 per 30 DAYTRANA desipramine oral DESOXYN 35

44 Name desvenlafaxine oral tablet extended release 24 hr 100 mg desvenlafaxine oral tablet extended release 24 hr 50 mg DEXEDRINE SPANSULE 4 ST; MO; QL (120 per 30 4 ST; MO; QL (240 per 30 dexmethylphenidate dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamineamphetamine diazepam oral solution 5 mg/5 ml 2 PA; MO diazepam oral tablet 2 PA; MO DIAZEPAM INTENSOL 2 PA; MO doxepin oral 2 PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 150 ; QL (180 ; QL (120 ; QL (60 4 ST; MO; QL (60 per 30 Name EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 37.5 EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 75 4 ST; MO; QL (180 per 30 4 ST; MO; QL (90 per 30 EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ; QL (60 ; QL (30 ; QL (120 eszopiclone 2 ST; MO; QL (30 per 30 FANAPT ORAL TABLET 1 FANAPT ORAL TABLET 10, 8 FANAPT ORAL TABLET 12 FANAPT ORAL TABLET 2 FANAPT ORAL TABLET 4 FANAPT ORAL TABLET 6 ; QL (720 ; QL (90 ; QL (60 ; QL (360 ; QL (180 ; QL (120 36

45 Name FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 100, 12.5, 25 FAZACLO ORAL TABLET,DISINTE GRATING 150, 200 FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 120 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 fluoxetine oral capsule 10 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg 3 QL (8 per ST; MO; QL (28 per 28 3 ST; MO; QL (30 per 30 3 ST; MO; QL (180 per 30 3 ST; MO; QL (90 per 30 3 ST; MO; QL (45 per 30 ; QL (240 ; QL (60 Name fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 20 mg fluoxetine oral tablet 60 mg fluphenazine decanoate ; QL (4 per 28 ; QL (240 fluphenazine hcl fluvoxamine oral capsule,extended release 24hr 100 mg fluvoxamine oral capsule,extended release 24hr 150 mg fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg ; QL (90 ; QL (60 ; QL (90 ; QL (360 ; QL (180 FOCALIN FOCALIN XR FORFIVO XL ; QL (30 GEODON INTRAMUSCULA R GEODON ORAL CAPSULE 20 ; QL (240 37

46 Name GEODON ORAL CAPSULE 40 GEODON ORAL CAPSULE 60 GEODON ORAL CAPSULE 80 ; QL (120 ; QL (80 ; QL (60 guanidine HALDOL HALDOL DECANOATE haloperidol 1 MO haloperidol decanoate haloperidol lactate imipramine hcl 2 PA; MO imipramine pamoate 2 PA; MO INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 ; QL (240 ; QL (120 ; QL (60 ; QL (41 Name INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 /0.75 ML, 156 /ML, 234 /1.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 /0.25 ML, 78 /0.5 ML KAPVAY KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 LATUDA ORAL TABLET 120 LATUDA ORAL TABLET 20 LATUDA ORAL TABLET 40 LATUDA ORAL TABLET 60, 80 LEXAPRO ORAL SOLUTION LEXAPRO ORAL TABLET 10 4 ST; MO; QL (120 per 30 4 ST; MO; QL (240 per 30 ; QL (30 ; QL (240 ; QL (120 ; QL (60 ; QL (60 38

47 Name LEXAPRO ORAL TABLET 20 LEXAPRO ORAL TABLET 5 ; QL (30 ; QL (120 lithium carbonate 1 MO lithium citrate LITHOBID lorazepam oral tablet LORAZEPAM INTENSOL 2 PA; MO 2 PA; MO loxapine succinate LOXITANE LUNESTA 4 ST; MO; QL (30 per 30 LUVOX CR ORAL CAPSULE,EXTEN DED RELEASE 24HR 100 LUVOX CR ORAL CAPSULE,EXTEN DED RELEASE 24HR 150 ; QL (90 ; QL (60 maprotiline MARPLAN METADATE CD METADATE ER methamphetamine METHYLIN methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg Name methylphenidate oral capsule,er biphasic methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr mirtazapine oral tablet mirtazapine oral tablet,disintegrating 1 MO modafinil 2 PA; MO NARDIL nefazodone NORPRAMIN nortriptyline NUVIGIL 4 PA; MO olanzapine intramuscular olanzapine oral tablet 10 mg olanzapine oral tablet 15 mg, 20 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 5 mg ; QL (60 ; QL (30 ; QL (240 ; QL (120 39

48 Name olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 10 mg olanzapine oral tablet,disintegrating 15 mg, 20 mg olanzapine oral tablet,disintegrating 5 mg ; QL (81 ; QL (60 ; QL (30 ; QL (120 ORAP oxazepam 2 PA; MO PAMELOR PARNATE paroxetine hcl oral tablet 10 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 12.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg 1 MO; QL (180 1 MO; QL (90 1 MO; QL (60 1 MO; QL (45 ; QL (180 ; QL (90 Name paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION PAXIL ORAL TABLET 10 PAXIL ORAL TABLET 20 PAXIL ORAL TABLET 30 PAXIL ORAL TABLET 40 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 12.5 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 25 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 37.5 ; QL (60 ; QL (180 ; QL (90 ; QL (60 ; QL (45 ; QL (180 ; QL (90 ; QL (60 perphenazine olanzapinefluoxetine perphenazineamitriptyline PEXEVA ORAL TABLET 10 PEXEVA ORAL TABLET 20 2 PA; MO ; QL (180 ; QL (90 40

49 Name PEXEVA ORAL TABLET 30 PEXEVA ORAL TABLET 40 ; QL (60 ; QL (45 phenelzine PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 3 ST; MO; QL (120 per 30 3 ST; MO; QL (240 per 30 PROCENTRA protriptyline PROVIGIL 4 PA; MO PROZAC ORAL CAPSULE 10 PROZAC ORAL CAPSULE 20 PROZAC ORAL CAPSULE 40 ; QL (240 ; QL (60 PROZAC WEEKLY ; QL (4 per 28 quetiapine oral tablet 100 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg ; QL (240 ; QL (120 ; QL (902 ; QL (81 Name quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg ; QL (60 ; QL (480 QUILLIVANT XR REMERON REMERON SOLTAB RESTORIL 4 PA; MO RISPERDAL ORAL SOLUTION RISPERDAL ORAL TABLET 0.25 RISPERDAL ORAL TABLET 0.5 RISPERDAL ORAL TABLET 1 RISPERDAL ORAL TABLET 2 RISPERDAL ORAL TABLET 3 RISPERDAL ORAL TABLET 4 RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 12.5 /2 ML, 25 /2 ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 /2 ML, 50 /2 ML ; QL (480 ; QL (1920 ; QL (960 ; QL (480 ; QL (240 ; QL (161 ; QL (120 41

50 Name RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 0.5 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 1 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 2 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 3 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 4 risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet 1 mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.25 mg ; QL (960 ; QL (480 ; QL (240 ; QL (161 ; QL (120 ; QL (480 1 MO; QL ( MO; QL (960 1 MO; QL (480 1 MO; QL (240 1 MO; QL (161 1 MO; QL (120 ; QL (1920 Name risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating 1 mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ; QL (960 ; QL (480 ; QL (240 ; QL (161 ; QL (120 RITALIN RITALIN LA RITALIN SR ROZEREM ; QL (30 SAPHRIS SUBLINGUAL TABLET, SUBLINGUAL 10 SAPHRIS SUBLINGUAL TABLET, SUBLINGUAL 5 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET, SUBLINGUAL 10 ; QL (60 ; QL (120 ; QL (60 42

51 Name SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET, SUBLINGUAL 5 ; QL (120 SARAFEM SEROQUEL ORAL TABLET 100 SEROQUEL ORAL TABLET 200 SEROQUEL ORAL TABLET 25 SEROQUEL ORAL TABLET 300 SEROQUEL ORAL TABLET 400 SEROQUEL ORAL TABLET 50 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 ; QL (240 ; QL (120 ; QL (902 ; QL (81 ; QL (60 ; QL (480 ; QL (161 ; QL (120 ; QL (81 Name SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 sertraline oral concentrate sertraline oral tablet 100 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg ; QL (60 ; QL (480 1 MO; QL (60 1 MO; QL (240 1 MO; QL (120 SILENOR ; QL (30 SONATA ORAL CAPSULE 10 SONATA ORAL CAPSULE 5 4 ST; MO; QL (60 per 30 4 ST; MO; QL (30 per 30 STRATTERA SURMONTIL 4 PA; MO SYMBYAX temazepam 2 PA; MO thioridazine thiothixene 1 MO TOFRANIL 4 PA; MO TOFRANIL-PM 4 PA; MO 43

52 Name TRANXENE T- TAB 4 PA; MO tranylcypromine trazodone 1 MO trifluoperazine VALIUM 4 PA; MO venlafaxine oral capsule,extended release 24hr 150 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 100 mg, 75 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg venlafaxine oral tablet extended release 24hr 150 mg venlafaxine oral tablet extended release 24hr 225 mg venlafaxine oral tablet extended release 24hr 37.5 mg venlafaxine oral tablet extended release 24hr 75 mg ; QL (60 ; QL (180 ; QL (90 ; QL (90 ; QL (270 ; QL (180 ; QL (150 ; QL (60 ; QL (30 ; QL (180 ; QL (90 Name VERSACLOZ 5 LA VIIBRYD ORAL TABLET 10 VIIBRYD ORAL TABLET 20 VIIBRYD ORAL TABLET 40 VIIBRYD ORAL TABLETS,DOSE PACK ; QL (120 ; QL (60 ; QL (30 ; QL (30 VIVACTIL VYVANSE WELLBUTRIN WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 100 WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 150 WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 200 WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 300 ; QL (120 ; QL (90 ; QL (60 ; QL (90 ; QL (60 XYREM ; LA 44

53 Name zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg ZENZEDI ORAL TABLET 10, 5 ZENZEDI ORAL TABLET 15, 20, 30 ZENZEDI ORAL TABLET 2.5, 7.5 ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg ziprasidone hcl oral capsule 80 mg ZOLOFT ORAL CONCENTRATE ZOLOFT ORAL TABLET 100 ZOLOFT ORAL TABLET 25 ZOLOFT ORAL TABLET 50 2 ST; MO; QL (60 per 30 2 ST; MO; QL (30 per 30 3 ; QL (240 ; QL (120 ; QL (80 ; QL (60 ; QL (60 ; QL (240 ; QL (120 zolpidem 2 ST; MO; QL (30 per 30 ZOLPIMIST 4 ST; MO; QL (8 Name ZYPREXA INTRAMUSCULA R ZYPREXA ORAL TABLET 10 ZYPREXA ORAL TABLET 15, 20 ZYPREXA ORAL TABLET 2.5 ZYPREXA ORAL TABLET 5 ZYPREXA ORAL TABLET 7.5 ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 10 ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 15, 20 ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 5 ; QL (60 ; QL (30 ; QL (240 ; QL (120 ; QL (81 ; QL (60 ; QL (30 ; QL (120 CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution amiodarone oral tablet 200 mg, 400 mg 2 PA; MO BETAPACE AF 45

54 Name flecainide mexiletine MULTAQ NEXTERONE 4 PA PACERONE procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml propafenone quinidine gluconate quinidine sulfate RYTHMOL RYTHMOL SR SORINE ORAL TABLET 120, 160, 80 SORINE ORAL TABLET 240 sotalol oral tablet 160 mg, 240 mg, 80 mg SOTALOL AF ORAL TABLET TIKOSYN ANTIHYPERTENSIVE THERAPY ACCUPRIL ACCURETIC acebutolol oral Name ADALAT CC AFEDITAB CR ALDACTAZIDE ALDACTONE ALTACE amiloride 1 MO amlodipine 1 MO AMTURNIDE ATACAND 4 ST; MO ATACAND HCT 4 ST; MO atenolol 1 MO 1 MO AVALIDE 4 ST; MO AVAPRO 4 ST; MO AZOR 3 ST; MO benazepril 1 MO 1 MO BENICAR 3 ST; MO BENICAR HCT 3 ST; MO betaxolol oral BIDIL bisoprolol fumarate amiloridehydrochlorothiazide amlodipinebenazepril atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide 1 MO bumetanide injection 46

55 Name bumetanide oral 1 MO BYSTOLIC CALAN CALAN SR candesartan captopril 1 MO candesartanhydrochlorothiazid captoprilhydrochlorothiazide CARDENE IV IN SODIUM CHLORIDE 1 MO CARDENE SR CARDIZEM CARDIZEM CD CARDIZEM LA CARDURA ORAL TABLET 1, 2, 4 CARDURA ORAL TABLET ST; MO; QL (30 per 30 4 ST; MO; QL (60 per 30 CARDURA XL 4 ST; MO; QL (30 per 30 CARTIA XT carvedilol 1 MO CATAPRES CATAPRES-TTS-1 ; QL (4 per 28 CATAPRES-TTS-2 ; QL (4 per 28 Name CATAPRES-TTS-3 ; QL (4 per 28 chlorothiazide 1 MO chlorothiazide sodium chlorthalidone 1 MO clonidine ; QL (4 per 28 clonidine hcl oral tablet CLORPRES ORAL TABLET CLORPRES ORAL TABLET MO COREG COREG CR CORGARD CORZIDE COZAAR 4 ST; MO DEMADEX DEMSER DIBENZYLINE DILACOR XR DILT-XR diltiazem hcl intravenous diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg 2 47

56 Name diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr 120 mg, 240 mg, 300 mg diltiazem hcl oral tablet 1 MO DIOVAN 4 ST; MO DIOVAN HCT 4 ST; MO DIURIL DIURIL IV 5 doxazosin oral tablet 1 mg, 2 mg, 4 mg doxazosin oral tablet 8 mg 1 MO; QL (30 1 MO; QL (60 DUTOPROL DYAZIDE DYRENIUM EDARBI 4 ST; MO EDARBYCLOR 4 ST; MO EDECRIN enalapril maleate 1 MO 1 MO EPANED eplerenone eprosartan EXFORGE 4 ST; MO EXFORGE HCT 4 ST; MO felodipine Name fosinopril 1 MO furosemide injection solution furosemide oral solution furosemide oral tablet 1 MO hydralazine hydrochlorothiazide 1 MO HYZAAR 4 ST; MO indapamide 1 MO INDERAL LA INNOPRAN XL INSPRA irbesartan 1 MO isradipine labetalol intravenous solution labetalol oral LASIX lisinopril 1 MO enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide lisinoprilhydrochlorothiazide 1 MO LOPRESSOR LOPRESSOR HCT losartan 1 MO 48

57 Name losartanhydrochlorothiazide 1 MO LOTENSIN LOTREL MATZIM LA MAVIK MAXZIDE MAXZIDE-25 methyclothiazide methyldopa metolazone metoprolol succinate metoprolol tartrate intravenous solution metoprolol tartrate oral 1 MO MICARDIS 4 ST; MO MICARDIS HCT 4 ST; MO MICROZIDE MINIPRESS minoxidil oral moexipril nadolol 1 MO nicardipine NIFEDICAL XL Name nifedipine oral tablet extended release 24hr nimodipine nisoldipine NORVASC ORENITRAM ORAL TABLET EXTENDED RELEASE ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25, 1, 2.5 perindopril erbumine 4 PA; MO 5 PA; MO pindolol prazosin 1 MO PRINIVIL PROCARDIA XL propranolol intravenous propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide nadololbendroflumethiazide propranololhydrochlorothiazid 2 1 MO 1 MO 1 MO quinapril 1 MO 49

58 Name ramipril 1 MO REMODULIN 5 PA; MO; LA SECTRAL 1 MO spironolactone 1 MO SULAR TARKA TAZTIA XT TEKAMLO TEKTURNA TEKTURNA HCT telmisartan 1 MO 1 MO TENORETIC 100 TENORETIC 50 TENORMIN terazosin oral capsule 1 mg, 2 mg, 5 mg terazosin oral capsule 10 mg 1 MO; QL (30 1 MO; QL (60 TEVETEN 4 ST; MO TEVETEN HCT 4 ST; MO TIAZAC timolol maleate oral 1 MO Name TOPROL XL torsemide intravenous solution 20 mg/2 ml (10 mg/ml) torsemide oral 1 MO trandolapril 1 MO 2 1 MO TRIBENZOR 3 ST; MO TWYNSTA 4 ST; MO UNIRETIC UNIVASC quinaprilhydrochlorothiazide spironolactonhydrochlorothiaz telmisartanamlodipine telmisartanhydrochlorothiazid triamterenehydrochlorothiazid valsartanhydrochlorothiazide VASERETIC VASOTEC verapamil intravenous solution verapamil oral 1 MO VERELAN VERELAN PM ZAROXOLYN ZEBETA ZESTORETIC ZESTRIL ZIAC CARDIAC GLYCOSIDES digoxin oral 50

59 Name LANOXIN ORAL TABLET 125 MCG, 250 MCG LANOXIN ORAL TABLET MCG LANOXIN ORAL TABLET 62.5 MCG 3 COAGULATION THERAPY AGGRENOX argatroban argatroban in 0.9 % sod chlor ARIXTRA SUBCUTANEOUS SYRINGE 10 /0.8 ML, 5 /0.4 ML, 7.5 /0.6 ML ARIXTRA SUBCUTANEOUS SYRINGE 2.5 /0.5 ML 5 BRILINTA cilostazol clopidogrel COUMADIN CYKLOKAPRON dipyridamole oral EFFIENT ELIQUIS enoxaparin subcutaneous solution Name enoxaparin subcutaneous syringe 100 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 150 mg/ml fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml FRAGMIN SUBCUTANEOUS SOLUTION FRAGMIN SUBCUTANEOUS SYRINGE 10,000 UNIT/ML, 12,500 UNIT/0.5 ML, 15,000 UNIT/0.6 ML, 18,000 UNIT/0.72 ML, 7,500 UNIT/0.3 ML FRAGMIN SUBCUTANEOUS SYRINGE 2,500 UNIT/0.2 ML, 5,000 UNIT/0.2 ML heparin (porcine) injection solution 51

60 Name heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml 2 JANTOVEN 1 MO LOVENOX pentoxifylline PERSANTINE PLAVIX PLETAL PRADAXA 2 PROMACTA 5 PA; MO; LA ticlopidine tranexamic acid intravenous warfarin 1 MO XARELTO ZONTIVITY 4 LIPID/CHOLESTEROL LOWERING AGENTS Name ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-20, ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-40, ; QL (60 ; QL (30 ALTOPREV ; QL (30 amlodipineatorvastatin ANTARA ORAL CAPSULE 130, 43, 90 ANTARA ORAL CAPSULE 30 1 MO; QL (30 atorvastatin 1 MO; QL (30 CADUET ; QL (30 CHOLESTYRAMI NE LIGHT ORAL POWDER IN PACKET COLESTID ORAL GRANULES COLESTID ORAL TABLET colestipol oral granules 4 colestipol oral tablet CRESTOR ; QL (30 52

61 Name fenofibrate oral capsule fenofibrate oral tablet fenofibrate micronized fenofibrate nanocrystallized fenofibric acid (choline) FENOGLIDE FIBRICOR fluvastatin oral capsule 20 mg fluvastatin oral capsule 40 mg ; QL (30 ; QL (60 gemfibrozil oral JUXTAPID ; LA KYNAMRO ; LA LESCOL ORAL CAPSULE 20 LESCOL ORAL CAPSULE 40 ; QL (30 ; QL (60 LESCOL XL ; QL (30 LIPITOR ; QL (30 LIPOFEN LIPTRUZET ; QL (30 LIVALO ; QL (30 LOFIBRA Name LOPID lovastatin oral tablet 10 mg lovastatin oral tablet 20 mg, 40 mg 1 MO; QL (30 1 MO; QL (60 LOVAZA niacin oral tablet extended release 24 hr NIACOR NIASPAN EXTENDED- RELEASE omega-3 acid ethyl esters PRAVACHOL ; QL (30 pravastatin 1 MO; QL (30 PREVALITE ORAL POWDER QUESTRAN ORAL POWDER IN PACKET SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-20, SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR 1,000-40, , ; QL (60 ; QL (30 53

62 Name simvastatin 1 MO; QL (30 TRICOR TRIGLIDE TRILIPIX VASCEPA VYTORIN ; QL (30 VYTORIN ; QL (30 VYTORIN ; QL (30 VYTORIN ; QL (30 WELCHOL ZETIA ZOCOR ; QL (30 MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA VECAMYL 5 NITRATES ISORDIL ISORDIL TITRADOSE isosorbide dinitrate isosorbide mononitrate 1 MO MINITRAN NITRO-BID NITRO-DUR Name nitroglycerin intravenous nitroglycerin transdermal nitroglycerin translingual spray,non-aerosol 2 PA NITROLINGUAL NITROMIST NITROSTAT DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 10 mg acitretin oral capsule 17.5 mg, 25 mg calcipotriene calcipotrienebetamethasone calcitriol topical DOVONEX selenium sulfide topical suspension SORIATANE SORILUX STELARA 5 PA; MO TACLONEX VECTICAL BURN THERAPY SILVADENE 54

63 Name silver sulfadiazine SSD MISCELLANEOUS DERMATOLOGICALS 8-MOP ALDARA ammonium lactate CARAC CONDYLOX TOPICAL GEL diclofenac sodium topical gel 2 PA; MO EFUDEX ELIDEL 4 PA; MO fluorouracil topical imiquimod LAC-HYDRIN methoxsalen rapid 5 OXSORALEN OXSORALEN ULTRA PANRETIN PICATO podofilox PROTOPIC 3 PA; MO PRUDOXIN REGRANEX ; QL (15 SOLARAZE 4 PA; MO U-CORT 4 ST; MO Name UVADEX 3 VEREGEN ZONALON ZYCLARA THERAPY FOR ACNE ABSORICA ACANYA ACZONE adapalene 2 PA; MO AKNE-MYCIN AMNESTEEM ATRALIN 4 PA; MO AVITA TOPICAL CREAM AVITA TOPICAL GEL 2 PA; MO 4 PA; MO AZELEX BENZAMYCIN CLARAVIS CLEOCIN T CLINDACIN PAC clindamycin phosphate topical clindamycin-benzoyl peroxide topical gel DIFFERIN 4 PA; MO EPIDUO TOPICAL GEL WITH PUMP 4 PA; MO ERY PADS erythromycin with ethanol topical gel 55

64 Name erythromycin with ethanol topical solution erythromycinbenzoyl peroxide FABIOR FINACEA METROCREAM METROGEL TOPICAL GEL METROLOTION metronidazole topical cream metronidazole topical gel metronidazole topical lotion MYORISAN 2 NORITATE RETIN-A 4 PA; MO RETIN-A MICRO 4 PA; MO RETIN-A MICRO PUMP TOPICAL GEL 0.08 % 4 PA TAZORAC 3 PA; MO tretinoin topical cream %, 0.05 %, 0.1 % tretinoin topical cream 0.05 % 2 PA; MO 4 PA; MO tretinoin topical gel 2 PA; MO VELTIN 4 PA; MO ZENATANE Name ZIANA 4 PA; MO TOPICAL ANESTHETICS EMLA lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine (pf) injection solution 10 mg/ml (1 %), 5 mg/ml (0.5 %) lidocaine hcl injection solution 20 mg/ml (2 %) lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 2 % lidocaine hcl mucous membrane solution 4 % lidocaine-prilocaine topical cream 2 PA; MO 2 LIDODERM 4 PA; MO SYNERA XYLOCAINE INJECTION SOLUTION 20 /ML (2 %) 4 56

65 Name XYLOCAINE MUCOUS MEMBRANE XYLOCAINE-MPF INJECTION SOLUTION 10 /ML (1 %) 4 TOPICAL ANTIBACTERIALS ALTABAX BACTROBAN CORTISPORIN TOPICAL gentamicin topical KLARON mafenide acetate mupirocin mupirocin calcium sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM SULFAMYLON TOPICAL PACKET TOPICAL ANTIFUNGALS ciclopirox clotrimazole topical econazole topical ERTACZO EXELDERM EXTINA Name JUBLIA 4 ketoconazole topical KETODAN KIT LOPROX LOTRISONE LUZU MENTAX NAFTIN NIZORAL NYAMYC nystatin topical clotrimazolebetamethasone nystatintriamcinolone NYSTOP OXISTAT PEDI-DRI TOPICAL ANTIVIRALS acyclovir topical DENAVIR XERESE ZOVIRAX TOPICAL CREAM ZOVIRAX TOPICAL OINTMENT TOPICAL CORTICOSTEROIDS ALA-CORT ALA-SCALP 4 ST; MO alclometasone amcinonide 57

66 Name APEXICON E betamethasone dipropionate betamethasone valerate betamethasone, augmented CAPEX 4 ST; MO clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution clobetasol-emollient topical cream CLOBEX 4 ST; MO CLODERM 4 ST; MO CORDRAN TAPE LARGE ROLL 4 ST; MO CUTIVATE 4 ST; MO DERMATOP 4 ST; MO DESONATE 4 ST; MO desonide DESOWEN TOPICAL CREAM 4 ST Name DESOWEN TOPICAL LOTION 4 ST; MO desoximetasone diflorasone DIPROLENE 4 ST; MO DIPROLENE AF 4 ST; MO ELOCON 4 ST; MO fluocinolone fluocinonide topical cream 0.1 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution FLUOCINONIDE-E fluticasone topical halobetasol propionate HALOG 4 ST; MO hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone butyr-emollient 58

67 Name hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone valerate KENALOG TOPICAL 4 ST; MO mometasone OLUX 4 ST; MO PANDEL 4 ST; MO prednicarbate SYNALAR CREAM KIT 4 ST; MO TEMOVATE 4 ST; MO TOPICORT 4 ST; MO triamcinolone acetonide topical TRIDERM ULTRAVATE 4 ST; MO VANOS 4 ST; MO TOPICAL ENZYMES SANTYL TOPICAL SCABICIDES / PEDICULICIDES EURAX lindane malathion OVIDE Name permethrin topical cream SKLICE spinosad ULESFIA DIAGNOSTICS / MISCELLANEOUS AGENTS IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu PHYSIOLYTE 4 PHYSIOSOL IRRIGATION ringers irrigation MISCELLANEOUS AGENTS acamprosate ACTONEL ORAL TABLET ; QL (30 ADAGEN AGRYLIN alendronate oral tablet 40 mg 1 MO; QL (30 anagrelide ANTABUSE ARALAST NP RECON SOLN 500 ; LA CAMPRAL CARBAGLU ; LA

68 Name CARNITOR cevimeline CHEMET CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE d10 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 10 % & 0.2 % nacl dextrose 10 % in water (d10w) dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 %- lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride 3 PA disulfiram 2 2 Name etidronate disodium EVOXAC EXJADE ORAL TABLET, DISPERSIBLE 125 EXJADE ORAL TABLET, DISPERSIBLE 250, 500 ; LA ; LA FERRIPROX FOSRENOL GLASSIA ; LA INCRELEX ; LA KAYEXALATE KIONEX ORAL POWDER levocarnitine intravenous levocarnitine oral tablet levocarnitine (with sugar) LITHOSTAT midodrine ORFADIN ; LA pilocarpine hcl oral PROLASTIN-C ; LA RAVICTI RECLAST 4 PA; MO RENAGEL RENVELA 60

69 Name RILUTEK riluzole SALAGEN sodium chloride irrigation sodium chloride 0.9 % intravenous parenteral solution sodium phenylbutyrate SODIUM POLYSTYRENE (SORB FREE) SYPRINE THIOLA VELPHORO water for irrigation, sterile 2 ZEMAIRA ; LA zoledronic acidmannitol-water intravenous solution SMOKING DETERRENTS 2 PA; MO BUPROBAN CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX 3 Name CHANTIX STARTING MONTH PAK NICOTROL NICOTROL NS ZYBAN EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTELIN ; QL (60 ASTEPRO ; QL (60 ATROVENT ; QL (30 azelastine nasal ; QL (60 BACTROBAN NASAL chlorhexidine gluconate mucous membrane ipratropium bromide nasal 61 3 ; QL (30 PATANASE ; QL (30.5 PERIOGARD triamcinolone acetonide dental TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS

70 Name ACETASOL HC acetic acid otic fluocinolone acetonide oil hydrocortisoneacetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRO HC CIPRODEX COLY-MYCIN S CORTISPORIN OTIC CORTISPORIN-TC neomycinpolymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORMONES A-HYDROCORT ACTHAR H.P. 5 PA; MO CORTEF cortisone DEPO-MEDROL dexamethasone oral elixir dexamethasone oral tablet DEXAMETHASON E INTENSOL dexamethasone sodium phosphate injection 1 MO Name DEXPAK 13 DAY FLO-PRED 4 fludrocortisone hydrocortisone oral KENALOG INJECTION MEDROL 4 PA; MO MEDROL (PAK) methylprednisolone oral tablet methylprednisolone oral tablets,dose pack methylprednisolone acetate methylprednisolone sodium succ injection recon soln 125 mg methylprednisolone sodium succ injection recon soln 40 mg MILLIPRED ORAL SOLUTION MILLIPRED ORAL TABLET 1 PA; MO 1 MO PA; MO ORAPRED ORAPRED ODT ORAL TABLET,DISINTE GRATING 15, 30 4 PA; MO

71 Name prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral solution 25 mg/5 ml (5 mg/ml) prednisone oral solution prednisone oral tablet PREDNISONE INTENSOL 2 1 PA; MO RAYOS 4 PA; MO SOLU-CORTEF (PF) INJECTION RECON SOLN 100 /2 ML, 250 /2 ML SOLU-MEDROL RECON SOLN 2 GRAM SOLU-MEDROL (PF) INJECTION SOLU-MEDROL (PF) RECON SOLN 500 /4 ML triamcinolone acetonide injection suspension 10 mg/ml 4 Name triamcinolone acetonide injection suspension 40 mg/ml VERIPRED 20 ANTITHYROID AGENTS methimazole propylthiouracil 1 MO TAPAZOLE DIABETES THERAPY acarbose oral tablet 100 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg 2 ; QL (90 ; QL (360 ; QL (180 ACTOPLUS MET ; QL (90 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 15-1,000 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-1,000 ; QL (60 ; QL (30 ACTOS ; QL (30 ALCOHOL PADS 3 AMARYL ORAL TABLET 1 AMARYL ORAL TABLET 2 ; QL (240 ; QL (120 63

72 Name AMARYL ORAL TABLET 4 ; QL (60 APIDRA APIDRA SOLOSTAR AVANDAMET ; LA; QL (60 per 30 AVANDARYL ; LA; QL (30 per 30 AVANDIA ORAL TABLET 2, 4 AVANDIA ORAL TABLET 8 BYDUREON SUBCUTANEOUS SUSPENSION,EXT ENDED REL RECON BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/0.04 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/0.02 ML ; LA; QL (60 per 30 ; LA; QL (30 per 30 3 PA; MO; QL (4 per 28 3 PA; MO; QL (2.4 per 30 3 PA; MO; QL (1.2 per 30 CYCLOSET ; QL (180 DUETACT ; QL (30 FARXIGA ORAL TABLET 10 ; QL (30 Name FARXIGA ORAL TABLET 5 FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 1,000 FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 500 gauze pads 2 x 2 3 glimepiride oral tablet 1 mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg ; QL (60 ; QL (75 ; QL (150 1 MO; QL (240 1 MO; QL (120 1 MO; QL (60 1 MO; QL (120 1 MO; QL (240 1 MO; QL (60 1 MO; QL (240 1 MO; QL (120 ; QL (240 64

73 Name glipizide-metformin oral tablet mg, mg GLUCAGEN 3 GLUCAGEN HYPOKIT GLUCAGON EMERGENCY GLUCOPHAGE ORAL TABLET 1,000 GLUCOPHAGE ORAL TABLET 500 GLUCOPHAGE ORAL TABLET 850 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 GLUCOTROL ORAL TABLET 10 GLUCOTROL ORAL TABLET 5 ; QL (120 ; QL (75 ; QL (150 ; QL (90 ; QL (120 ; QL (75 ; QL (120 ; QL (240 Name GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 10 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 5 GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 500 GLYSET ORAL TABLET 100 GLYSET ORAL TABLET 25 GLYSET ORAL TABLET 50 ; QL (60 ; QL (240 ; QL (120 ; QL (60 ; QL (120 ; QL (90 ; QL (360 ; QL (180 HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN 65

74 Name HUMALOG MIX HUMALOG MIX KWIKPEN HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN 70/30 PEN HUMULIN N HUMULIN N KWIKPEN HUMULIN N PEN HUMULIN R HUMULIN R U-500 "CONCENTRATED " insulin pen needle insulin syringe (disp) u ml insulin syringe (disp) u ml insulin syringe (disp) u-100 1/2 ml 3 INVOKANA ; QL (30 JANUMET ; QL (60 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000, ; QL (30 Name JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 ; QL (60 JANUVIA ; QL (30 JENTADUETO 4 ST; MO; QL (60 per 30 KAZANO 4 ST; MO; QL (60 per 30 KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000, ; QL (60 ; QL (30 LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg 1 MO; QL (75 1 MO; QL (150 1 MO; QL (90 66

75 Name metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr 1,000 mg nateglinide oral tablet 120 mg nateglinide oral tablet 60 mg needles, insulin disp.,safety 1 MO; QL (120 1 MO; QL (75 1 MO; QL (75 ; QL (90 ; QL (180 NESINA 4 ST; MO; QL (30 per 30 NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL 3 ONGLYZA ; QL (30 OSENI ; QL (30 Name pioglitazone ; QL (30 pioglitazoneglimepiride pioglitazonemetformin ; QL (30 ; QL (90 PRANDIMET ; QL (150 PRANDIN ORAL TABLET 0.5 PRANDIN ORAL TABLET 1 PRANDIN ORAL TABLET 2 PRECOSE ORAL TABLET 100 PRECOSE ORAL TABLET 25 PRECOSE ORAL TABLET 50 ; QL (960 ; QL (480 ; QL (240 ; QL (90 ; QL (360 ; QL (180 PROGLYCEM repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg repaglinide oral tablet 2 mg ; QL (960 ; QL (480 ; QL (240 RIOMET ; QL (765 STARLIX ORAL TABLET 120 STARLIX ORAL TABLET 60 ; QL (90 ; QL (180 67

76 Name SYMLINPEN PA; MO; QL (18.9 per 30 SYMLINPEN 60 3 PA; MO; QL (10.5 per 30 TANZEUM 4 PA; QL (2 per 28 tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg ; QL (120 ; QL (60 tolbutamide ; QL (180 TRADJENTA 4 ST; MO; QL (30 per 30 VGO 20 VGO 30 VGO 40 VICTOZA 2-PAK 3 PA; MO; QL (9 VICTOZA 3-PAK 3 PA; MO; QL (9 MISCELLANEOUS HORMONES ALDURAZYME ANADROL-50 5 PA; MO ANDRODERM 3 PA; MO ANDROGEL 3 PA; MO ANDROID ANDROXY AXIRON 4 PA; MO Name cabergoline ; QL (16 per 28 calcitonin (salmon) calcitriol intravenous calcitriol oral CEREZYME chorionic gonadotropin, human 2 PA; MO danazol oral DDAVP DEPO- TESTOSTERONE desmopressin injection desmopressin nasal spray,non-aerosol desmopressin oral doxercalciferol intravenous doxercalciferol oral ELAPRASE ELELYSO FABRAZYME RECON SOLN 35 2 FORTESTA 4 PA; MO FORTICAL 68

77 Name HECTOROL SOLUTION 4 MCG/2 ML HECTOROL ORAL KORLYM KUVAN ORAL TABLET,SOLUBL E ; LA LUMIZYME ; LA METHITEST MIACALCIN INJECTION MIACALCIN NASAL MYALEPT 5 PA; MO; LA MYOZYME NAGLAZYME ; LA NOVAREL 2 PA; MO oxandrolone oral tablet 10 mg oxandrolone oral tablet 2.5 mg pamidronate intravenous solution 5 PA; MO 2 PA; MO paricalcitol PREGNYL 4 PA; MO ROCALTROL SAMSCA ORAL TABLET 15 5 PA; MO; QL (30 per 30 Name SAMSCA ORAL TABLET 30 SENSIPAR ORAL TABLET 30 SENSIPAR ORAL TABLET 60, 90 5 PA; MO; QL (60 per 30 SOMAVERT ; LA STIMATE STRIANT 4 PA; MO SYNAREL TESTIM 4 PA; MO testosterone cypionate testosterone enanthate TESTRED VOGELXO TRANSDERMAL GEL IN PACKET 4 PA VPRIV ZAVESCA ; LA ZEMPLAR ZEMPLAR ORAL zoledronic acid intravenous solution ZOMETA THYROID HORMONES CYTOMEL 69

78 Name levothyroxine intravenous recon soln 100 mcg levothyroxine oral 1 MO LEVOXYL 1 MO liothyronine intravenous liothyronine oral SYNTHROID THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 TIROSINT UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG 2 1 MO GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection syringe BENTYL CANTIL CUVPOSA dicyclomine 2 Name diphenoxylateatropine FULYZAQ GLYCATE 4 glycopyrrolate LOMOTIL loperamide oral capsule methscopolamine oral PAMINE PAMINE FORTE ROBINUL ORAL ROBINUL FORTE MISCELLANEOUS GASTROINTESTINAL AGENTS ACTIGALL ALOXI ; QL (10 AMITIZA ANUSOL-HC RECTAL CREAM ANZEMET SOLUTION 100 /5 ML ANZEMET ORAL 4 PA; MO APRISO ASACOL HD AZULFIDINE AZULFIDINE EN- TABS 70

79 Name balsalazide budesonide oral CANASA CESAMET 5 PA; MO CHENODAL 5 PA; MO; LA CIMZIA 5 PA; MO CIMZIA POWDER FOR RECONST CIMZIA STARTER KIT 5 PA; MO 5 PA; MO COLAZAL COLOCORT COLYTE WITH FLAVOR PACKS ORAL RECON SOLN GRAM COMPRO CONSTULOSE CORTIFOAM CREON cromolyn oral CYSTADANE DELZICOL DIPENTUM dronabinol oral capsule 10 mg dronabinol oral capsule 2.5 mg, 5 mg EMEND 5 PA; MO 2 PA; MO EMEND ORAL 3 PA; MO Name ENTOCORT EC ENULOSE GASTROCROM GATTEX ONE- VIAL GAVILYTE-C GAVILYTE-G GAVILYTE-N GENERLAC GIAZO GOLYTELY granisetron intravenous solution 1 mg/ml (1 ml) granisetron oral 2 PA; MO granisetron (pf) intravenous solution 100 mcg/ml GRANISOL 2 PA; MO hydrocortisone rectal 2 KRISTALOSE lactulose oral solution 10 gram/15 ml LIALDA LINZESS LOTRONEX MARINOL ORAL CAPSULE 10, 5 5 PA; MO 71

80 Name MARINOL ORAL CAPSULE PA; MO meclizine oral tablet mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl oral solution metoclopramide hcl oral tablet 1 MO METOZOLV ODT MOVIPREP NULYTELY WITH FLAVOR PACKS ondansetron 2 PA; MO ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg ondansetron hcl (pf) injection solution 2 PA; MO 2 PA 2 PA; MO OSMOPREP PANCREAZE peg electrolytes oral recon soln gram PENTASA PERTZYE Name polyethylene glycol 3350 oral powder PREPOPIK prochlorperazine prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) prochlorperazine maleate oral 1 MO PROCTO-PAK PROCTOZONE-HC RECTIV REGLAN RELISTOR REMICADE 5 PA; MO SANCUSO SFROWASA SUCLEAR SUCRAID sulfasalazine oral tablet SULFAZINE EC SUPREP TRANSDERM- SCOP TRILYTE WITH FLAVOR PACKETS UCERIS ULTRESA URSO

81 Name URSO FORTE ursodiol VIOKACE ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10,000-34,000-55,000 UNIT, 15,000-51,000-82,000 UNIT, 20,000-68, ,000 UNIT, 25,000-85, ,000 UNIT, 3,000-10,000-16,000 UNIT ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 5,000-17,000-27,000 UNIT ZOFRAN (AS HYDROCHLORID E) ZOFRAN (AS HYDROCHLORID E) ORAL 4 PA; MO ZOFRAN ODT 4 PA; MO ULCER THERAPY ACIPHEX ACIPHEX SPRINKLE amoxicilclarithromylansopraz ; QL (30 ; QL (112 Name AXID CARAFATE ORAL SUSPENSION CARAFATE ORAL TABLET cimetidine CYTOTEC DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 30 DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 60 esomeprazole sodium esomeprazole strontium famotidine oral suspension famotidine oral tablet 20 mg, 40 mg ; QL ( MO famotidine (pf) famotidine (pf)-nacl (iso-os) lansoprazole oral capsule,delayed release(dr/ec) 15 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg 2 ; QL (30 misoprostol 73

82 Name NEXIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20 NEXIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40 NEXIUM IV RECON SOLN 20 NEXIUM IV RECON SOLN 40 NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 10, 2.5, 20, 5 NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 40 ; QL (30 4 ; QL (30 nizatidine OMECLAMOX- PAK omeprazole oral capsule,delayed release(dr/ec) 10 mg, 20 mg omeprazole oral capsule,delayed release(dr/ec) 40 mg ; QL (80 ; QL (30 Name omeprazole-sodium bicarbonate oral capsule mggram omeprazole-sodium bicarbonate oral capsule mggram pantoprazole intravenous pantoprazole oral tablet,delayed release (dr/ec) 20 mg pantoprazole oral tablet,delayed release (dr/ec) 40 mg ; QL (30 1 MO; QL (30 1 MO PEPCID PREVACID ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 15 PREVACID ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 PREVACID SOLUTAB ORAL TABLET,DISINTE GRAT, DELAY REL 15 ; QL (30 ; QL (30 74

83 Name PREVACID SOLUTAB ORAL TABLET,DISINTE GRAT, DELAY REL 30 PREVPAC ; QL (112 PRILOSEC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 10, 20 PRILOSEC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40 PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 10 PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 2.5 PROTONIX PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET PROTONIX ORAL TABLET,DELAYE D RELEASE (DR/EC) 20 ; QL (30 ; QL (900 ; QL (300 ; QL (30 Name PROTONIX ORAL TABLET,DELAYE D RELEASE (DR/EC) 40 PYLERA rabeprazole ranitidine hcl injection solution 25 mg/ml ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg 1 MO 1 MO sucralfate oral tablet ZANTAC INJECTION SOLUTION 25 /ML ZANTAC ORAL ZEGERID ORAL CAPSULE GRAM ZEGERID ORAL CAPSULE GRAM ZEGERID ORAL PACKET 20-1,680 ZEGERID ORAL PACKET 40-1,680 ; QL (30 ; QL (30 75

84 Name IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 300 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 25 MCG/0.42 ML, 40 MCG/0.4 ML, 60 MCG/0.3 ML 5 PA; MO 3 PA; MO 5 PA; MO 3 PA; MO ARCALYST 5 PA; MO Name AVONEX INTRAMUSCULA R KIT AVONEX INTRAMUSCULA R PEN INJECTOR KIT AVONEX INTRAMUSCULA R SYRINGE AVONEX ADMINISTRATIO N PACK BETASERON SUBCUTANEOUS KIT 5 PA; MO; QL (4 per 28 5 PA; MO; QL (4 per 28 5 PA; MO; QL (4 per 28 5 PA; MO; QL (4 per 28 5 PA; MO; QL (15 per 28 EGRIFTA 5 PA; MO EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML EXTAVIA SUBCUTANEOUS KIT 4 PA; MO 5 PA; MO; QL (15 per 28 GENOTROPIN 5 PA; MO GENOTROPIN MINIQUICK 4 PA; MO GRANIX 5 PA; MO HUMATROPE 5 PA; MO ILARIS (PF) 5 PA; MO; LA 76

85 Name INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML LEUKINE MOZOBIL NEULASTA 5 PA; MO; QL (2 NEUMEGA NEUPOGEN INJECTION SOLUTION 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX 5 PA; MO 5 PA; MO 5 PA; MO 5 PA; MO NUTROPIN AQ 5 PA; MO NUTROPIN AQ NUSPIN SUBCUTANEOUS CARTRIDGE 5 /2 ML (2.5 /ML) OMNITROPE SUBCUTANEOUS CARTRIDGE 5 PA; MO 3 PA; MO Name OMNITROPE SUBCUTANEOUS RECON SOLN 5 PA; MO PEGASYS ; QL (4 per 28 PEGASYS CONVENIENCE PACK PEGASYS PROCLICK ; QL (4 per 28 ; QL (4 per 28 PEGINTRON ; QL (4 per 28 PEGINTRON REDIPEN PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML ; QL (4 per 28 3 PA; MO 5 PA; MO PROLEUKIN REBIF (WITH ALBUMIN) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML 5 PA; MO; QL (6 per 28 5 PA; MO; QL (6 per 28 77

86 Name REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK 5 PA; MO; QL (12 per 28 5 PA; MO; QL (12 per 28 SAIZEN 5 PA; MO SAIZEN CLICK.EASY 5 PA; MO SEROSTIM 5 PA; MO SYLATRON TEV-TROPIN 4 PA; MO ZORBTIVE 5 PA; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT )(PF) INTRAMUSCULA R SUSPENSION ATGAM 5 PA bcg vaccine, live (pf) 3 BIVIGAM 5 PA; MO BOOSTRIX TDAP BOTOX INJECTION RECON SOLN 100 UNIT 3 PA; MO Name CARIMUNE NF NANOFILTERED RECON SOLN 3 GRAM CERVARIX VACCINE (PF) 5 PA COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) DYSPORT INTRAMUSCULA R RECON SOLN 300 UNIT ENGERIX-B (PF) INTRAMUSCULA R SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE 4 PA; MO 3 PA; MO 3 PA; MO 3 PA fomepizole GAMASTAN S/D GAMMAGARD LIQUID 5 PA; MO GAMMAPLEX 5 PA; MO GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %) 3 PA; MO 78

87 Name GARDASIL (PF) INTRAMUSCULA R SUSPENSION GRASTEK HAVRIX (PF) INTRAMUSCULA R SUSPENSION 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULA R SYRINGE 720 ELISA UNIT/0.5 ML IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULA R SUSPENSION IPOL INJECTION SUSPENSION 3 3 IXIARO (PF) M-M-R II (PF) MENACTRA (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y- W-135-DIP (PF) PEDVAX HIB (PF) PRIVIGEN 5 PA; MO PROQUAD (PF) 3 RABAVERT (PF) RAGWITEK Name RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION 10 MCG/ML, 40 MCG/ML ROTARIX 3 ROTATEQ VACCINE tetanus toxoid,adsorbed (pf) tetanus-diphtheria toxoids-td THYMOGLOBULI N TWINRIX (PF) INTRAMUSCULA R SUSPENSION TYPHIM VI INTRAMUSCULA R SOLUTION VAQTA (PF) INTRAMUSCULA R SUSPENSION 25 UNIT/0.5 ML 3 PA; MO 3 5 PA 3 VARIVAX (PF) XEOMIN INTRAMUSCULA R RECON SOLN 50 UNIT 4 PA; MO YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY 79

88 Name allopurinol 1 MO ALOPRIM 2 colchicineprobenecid COLCRYS probenecid ULORIC 3 ST; MO ZYLOPRIM OSTEOPOROSIS THERAPY ACTONEL ORAL TABLET 150 ACTONEL ORAL TABLET 35 ACTONEL ORAL TABLET 5 alendronate oral solution alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg ; QL (1 per 30 ; QL (4 per 28 ; QL (30 ; QL ( MO; QL (30 1 MO; QL (4 per 28 ATELVIA ; QL (4 per 28 BINOSTO ; QL (4 per 28 BONIVA 4 PA; MO BONIVA ORAL ; QL (1 per 30 EVISTA FORTEO 5 PA; MO; QL (2.4 per 28 Name FOSAMAX ; QL (4 per 28 FOSAMAX PLUS D ibandronate intravenous ; QL (4 per 28 3 PA; MO ibandronate oral ; QL (1 per 30 PROLIA 3 PA; MO raloxifene risedronate ; QL (1 per 30 OTHER RHEUMATOLOGICALS ACTEMRA 5 PA; MO ARAVA ; QL (30 BENLYSTA RECON SOLN 120 CUPRIMINE DEPEN TITRATABS ENBREL SUBCUTANEOUS KIT ENBREL SUBCUTANEOUS SYRINGE 25 /0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 /ML (0.98 ML) 5 PA; MO; QL (8 per 28 5 PA; MO; QL (8 per 28 5 PA; MO; QL (4 per 28 80

89 Name ENBREL SURECLICK HUMIRA SUBCUTANEOUS KIT 20 /0.4 ML HUMIRA SUBCUTANEOUS KIT 40 /0.8 ML HUMIRA CROHN'S DIS START PCK 5 PA; MO; QL (4 per 28 5 PA; MO; QL (2 per 28 5 PA; MO; QL (3.2 per 28 5 PA; MO; QL (4.8 per 180 HUMIRA PEN 5 PA; MO; QL (3.2 per 28 HUMIRA PSORIASIS STARTER PACK 5 PA; MO; QL (3.2 per 180 KINERET 5 PA; MO leflunomide ; QL (30 ORENCIA 5 PA; MO ORENCIA (WITH MALTOSE) 5 PA; MO OTEZLA 5 PA; MO OTEZLA STARTER 5 PA; MO OTREXUP (PF) RIDAURA SAVELLA ORAL TABLET SAVELLA ORAL TABLETS,DOSE PACK ; QL (60 ; QL (1 per 30 SIMPONI 5 PA; MO Name SIMPONI ARIA 5 PA; MO XELJANZ 5 PA; MO OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS ACTIVELLA ALORA ; QL (8 per 28 ANGELIQ ORAL TABLET AYGESTIN CAMILA CENESTIN ORAL TABLET 0.3, 0.45, 0.625, 0.9 CLIMARA ; QL (4 per 28 CRINONE VAGINAL GEL 4 % CRINONE VAGINAL GEL 8 % 4 PA; MO DELESTROGEN DEPO-ESTRADIOL DEPO-PROVERA INTRAMUSCULA R SOLUTION DEPO-PROVERA INTRAMUSCULA R SUSPENSION DEPO-SUBQ PROVERA

90 Name DIVIGEL TRANSDERMAL GEL IN PACKET 1 (0.1) (%) ; QL (30 DUAVEE ENJUVIA ERRIN ESTRACE ORAL ESTRACE VAGINAL estradiol oral estradiol transdermal estradiol valerate estradiolnorethindrone acet ; QL (4 per 28 ESTRASORB ; QL (98 per 28 ESTRING estropipate EVAMIST ; QL (16.2 FEMHRT LOW DOSE FEMRING JOLIVETTE LYZA 2 medroxyprogesteron e intramuscular suspension medroxyprogesteron e oral MENEST Name MENOSTAR ; QL (4 per 28 MIMVEY MIMVEY LO MINIVELLE ; QL (8 per 28 NOR-QD NORA-BE norethindrone (contraceptive) norethindrone acetate ORTHO MICRONOR PREMARIN progesterone micronized PROMETRIUM PROVERA VAGIFEM VIVELLE-DOT ; QL (8 per 28 MISCELLANEOUS OB/GYN CLEOCIN VAGINAL clindamycin phosphate vaginal GYNAZOLE-1 LUPANETA PACK (1 MONTH) LUPANETA PACK (NTH) 82

91 Name LYSTEDA METROGEL VAGINAL metronidazole vaginal MICONAZOLE-3 VAGINAL SUPPOSITORY NUVARING ORTHO EVRA TERAZOL 3 TERAZOL 7 terconazole tranexamic acid oral VANDAZOLE XULANE ORAL CONTRACEPTIVES / RELATED AGENTS AMETHIA AMETHYST APRI ARANELLE (28) AVIANE BALZIVA (28) BEYAZ BREVICON (28) BRIELLYN CRYSELLE (28) CYCLAFEM 1/35 (28) Name CYCLAFEM 7/7/7 (28) CYCLESSA (28) DESOGEN drospirenone-ethinyl estradiol ELLA EMOQUETTE ENPRESSE ESTROSTEP FE-28 FEMCON FE GENERESS FE GIANVI (28) GILDAGIA INTROVALE JUNEL 1.5/30 (21) JUNEL 1/20 (21) JUNEL FE 1.5/30 (28) 2 JUNEL FE 1/20 (28) KARIVA (28) KELNOR 1/35 (28) LARIN 1/20 (21) 2 LARIN FE LEENA 28 LESSINA LEVONEST (28) levonorgestrelethinyl estrad oral tablets,dose pack,3 month 83

92 Name LEVORA-28 LO LOESTRIN FE LO MINASTRIN FE LOMEDIA 24 FE LORYNA (28) LOSEASONIQUE LOW-OGESTREL (28) LUTERA (28) MARLISSA MICROGESTIN 1.5/30 (21) MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) MICROGESTIN FE 1/20 (28) MINASTRIN 24 FE MODICON (28) MONONESSA (28) NATAZIA NECON 0.5/35 (28) NECON 1/35 (28) NECON 1/50 (28) NECON 10/11 (28) NECON 7/7/7 (28) NORINYL 1+35 (28) Name NORINYL 1+50 (28) NORTREL 0.5/35 (28) NORTREL 1/35 (21) NORTREL 1/35 (28) NORTREL 7/7/7 (28) OCELLA OGESTREL (28) ORSYTHIA ORTHO TRI- CYCLEN (28) ORTHO TRI- CYCLEN LO (28) ORTHO-CEPT (28) ORTHO-CYCLEN (28) ORTHO-NOVUM 1/35 (28) ORTHO-NOVUM 7/7/7 (28) OVCON-35 (28) PIMTREA (28) PIRMELLA ORAL TABLET MCG PORTIA PREVIFEM QUARTETTE QUASENSE 84

93 Name RECLIPSEN (28) SAFYRAL SEASONIQUE SPRINTEC (28) SRONYX TRI-LEGEST FE TRI-NORINYL (28) TRI-PREVIFEM (28) TRI-SPRINTEC (28) TRINESSA (28) TRIVORA (28) VELIVET TRIPHASIC REGIMEN (28) VESTURA (28) VYFEMLA (28) YASMIN (28) YAZ (28) ZENCHENT (28) ZENCHENT FE ZOVIA 1/35E (28) ZOVIA 1/50E (28) OXYTOCICS methylergonovine oral OPHTHALMOLOGY ANTIBIOTICS AZASITE Name bacitracin ophthalmic bacitracinpolymyxin b ophthalmic BESIVANCE CILOXAN ciprofloxacin ophthalmic erythromycin ophthalmic 1 MO gatifloxacin GENTAK OPHTHALMIC OINTMENT gentamicin ophthalmic drops gentamicin ophthalmic ointment levofloxacin ophthalmic 1 MO 1 MO 1 MOXEZA NATACYN neomycinbacitracinpolymyxin neomycinpolymyxingramicidin NEOSPORIN (NEO-POLYM- GRAMICID) OCUFLOX ofloxacin ophthalmic 85

94 Name polymyxin b sulftrimethoprim 1 MO POLYTRIM tobramycin 1 MO TOBREX VIGAMOX ZYMAXID ANTIVIRALS trifluridine VIROPTIC ZIRGAN BETA-BLOCKERS BETAGAN betaxolol ophthalmic BETIMOL OPHTHALMIC DROPS 0.5 % BETOPTIC S carteolol 1 MO ISTALOL levobunolol ophthalmic drops 0.5 % 1 MO metipranolol timolol maleate ophthalmic TIMOPTIC OCUDOSE (PF) 1 MO TIMOPTIC-XE CHOLINESTERASE INHIBITOR MIOTICS Name PHOSPHOLINE IODIDE DIRECT ACTING MIOTICS ISOPTO CARPINE pilocarpine hcl ophthalmic MISCELLANEOUS OPHTHALMOLOGICS 1 MO ALOCRIL ALOMIDE azelastine ophthalmic BEPREVE cromolyn ophthalmic CYSTARAN ELESTAT EMADINE epinastine LACRISERT LASTACAFT OPTIVAR PATADAY PATANOL RESTASIS ; QL (60 NON-STEROIDAL ANTI- INFLAMMATORY AGENTS ACULAR ACULAR LS ACUVAIL (PF) 86

95 Name bromfenac diclofenac sodium ophthalmic flurbiprofen sodium ILEVRO ketorolac ophthalmic NEVANAC OCUFEN PROLENSA ORAL DRUGS FOR GLAUCOMA acetazolamide oral acetazolamide sodium DIAMOX SEQUELS 2 methazolamide oral OTHER GLAUCOMA DRUGS AZOPT COMBIGAN COSOPT dorzolamide dorzolamide-timolol latanoprost LUMIGAN RESCULA 4 ST; MO SIMBRINZA TRAVATAN Z travoprost (benzalkonium) Name TRUSOPT XALATAN 4 ST; MO ZIOPTAN (PF) 4 ST; MO STEROID-ANTIBIOTIC COMBINATIONS MAXITROL neomycinbacitracin-poly-hc neomycinpolymyxin-dexameth neomycinpolymyxin-hc ophthalmic 1 MO PRED-G PRED-G S.O.P. TOBRADEX TOBRADEX ST tobramycindexamethasone ZYLET STEROIDS ALREX dexamethasone sodium phosphate ophthalmic DUREZOL FLAREX FML FORTE FML LIQUIFILM FML S.O.P. LOTEMAX 87

96 Name MAXIDEX OMNIPRED PRED FORTE PRED MILD prednisolone acetate prednisolone sodium phosphate ophthalmic VEXOL STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE S.O.P. sulfacetamideprednisolone SULFONAMIDES BLEPH-10 sulfacetamide sodium ophthalmic drops sulfacetamide sodium ophthalmic ointment SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 % ALPHAGAN P OPHTHALMIC DROPS 0.15 % 1 MO apraclonidine brimonidine 1 MO Name IOPIDINE VASOCONSTRICTOR DECONGESTANTS naphazoline RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS ADRENALIN INJECTION SOLUTION 1 /ML (1:1,000) (1ML) AUVI-Q ; QL (2 per 30 cetirizine oral solution 1 mg/ml CLARINEX ORAL SYRUP CLARINEX ORAL TABLET CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR 2 ; QL (30 ; QL (60 ; QL (30 desloratadine ; QL (30 diphenhydramine hcl injection solution diphenhydramine hcl oral elixir 2 PA; MO EPIPEN 3 QL (4 per 30 EPIPEN 2-PAK ; QL (4 per 30 88

97 Name EPIPEN JR 3 QL (4 per 30 EPIPEN JR 2-PAK ; QL (4 per 30 hydroxyzine hcl oral tablet levocetirizine oral solution levocetirizine oral tablet 2 PA; MO ; QL (30 PHENERGAN promethazine injection solution PROMETHAZINE VC 2 PA; MO SEMPREX-D XYZAL ORAL SOLUTION XYZAL ORAL TABLET PULMONARY AGENTS ; QL (30 ACCOLATE acetylcysteine solution 2 PA; MO ADCIRCA 5 PA; MO; QL (60 per 30 ADEMPAS 5 PA; MO; LA ADVAIR DISKUS ; QL (60 ADVAIR HFA ; QL (12 AEROSPAN ; QL (17.8 Name albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml 2 PA; MO albuterol sulfate oral ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION ALVESCO INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION aminophylline intravenous solution 250 mg/10 ml ; QL (12.2 ; QL (6.1 ANORO ELLIPTA ; QL (60 ARCAPTA NEOHALER ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (30 DOSES) ; QL (30 ; QL (30 89

98 Name ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (60 DOSES) ; QL (240 ; QL (60 ATROVENT HFA ; QL (25.8 BECONASE AQ ; QL (50 BREO ELLIPTA ; QL (60 BROVANA 4 PA; MO budesonide inhalation 2 PA; MO budesonide nasal ; QL (17.2 CINRYZE 5 PA; MO COMBIVENT RESPIMAT ; QL (8 per 30 cromolyn inhalation 2 PA; MO DALIRESP 3 PA; MO DULERA ; QL (13 DYMISTA ; QL (23 ELIXOPHYLLIN Name FIRAZYR 5 PA; MO FLONASE ; QL (16 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION AEROSOL 110 MCG/ACTUATION FLOVENT HFA INHALATION AEROSOL 220 MCG/ACTUATION FLOVENT HFA INHALATION AEROSOL 44 MCG/ACTUATION ; QL (60 ; QL (240 ; QL (12 ; QL (24 ; QL (10.6 flunisolide ; QL (50 fluticasone nasal ; QL (16 FORADIL AEROLIZER ipratropium bromide inhalation ipratropiumalbuterol ; QL (60 2 PA; MO 2 PA; MO 90

99 Name KALBITOR KALYDECO LETAIRIS 5 PA; MO; LA levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml 2 PA; MO LUFYLLIN metaproterenol montelukast NASACORT AQ ; QL (16.5 NASONEX ; QL (34 OMNARIS ; QL (12.5 OPSUMIT 5 PA; MO; LA PERFOROMIST 3 PA; MO PROAIR HFA ; QL (17 PROVENTIL HFA ; QL (13.4 PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 0.25 /2 ML, 0.5 /2 ML PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 /2 ML 4 PA; MO 3 PA; MO Name PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION ; QL (2 per 30 ; QL (1 per 30 PULMOZYME 5 PA; MO QNASL ; QL (8.7 QVAR ; QL (17.4 REVATIO 5 PA; MO REVATIO ORAL 5 PA; MO; QL (90 per 30 RHINOCORT AQUA SEREVENT DISKUS ; QL (17.2 ; QL (60 sildenafil 2 PA; MO; QL (90 per 30 SINGULAIR SPIRIVA WITH HANDIHALER ; QL (90 91

100 Name SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION ; QL (10.2 ; QL (6.9 terbutaline oral terbutaline subcutaneous THEO-24 theophylline oral solution theophylline oral tablet extended release theophylline oral tablet extended release 12 hr 2 TRACLEER 5 PA; MO; LA triamcinolone acetonide nasal TUDORZA PRESSAIR ; QL (16.5 ; QL (1 per 30 TYVASO 5 PA; MO VENTAVIS 5 PA; MO VENTOLIN HFA ; QL (36 VERAMYST ; QL (10 VOSPIRE ER Name XOLAIR 5 PA; MO; LA; QL (6 per 28 XOPENEX 4 PA; MO XOPENEX HFA ; QL (30 zafirlukast ZETONNA ; QL (6.1 ZYFLO ZYFLO CR UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS DETROL 4 ST; MO DETROL LA 4 ST; MO DITROPAN XL 4 ST; MO ENABLEX 3 ST; MO flavoxate GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP GELNIQUE TRANSDERMAL GEL IN PACKET 4 ST; MO; QL (92 per 30 4 ST; MO; QL (30 per 30 MYRBETRIQ 3 ST; MO oxybutynin chloride oral OXYTROL 4 ST; MO; QL (8 per 28 SANCTURA 4 ST; MO 92

101 Name SANCTURA XR 4 ST; MO tolterodine TOVIAZ 3 ST; MO trospium VESICARE 3 ST; MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin AVODART finasteride oral tablet 5 mg FLOMAX 4 ST; MO JALYN PROSCAR RAPAFLO 3 ST; MO tamsulosin 1 MO UROXATRAL 4 ST; MO CHOLINERGIC STIMULANTS bethanechol chloride URECHOLINE MISCELLANEOUS UROLOGICALS ammonium chloride 3 CIALIS ORAL TABLET 2.5, 5 3 PA; MO; QL (30 per 30 CYSTAGON ; LA ELMIRON potassium citrate oral tablet extended release 10 meq, 5 meq Name UROCIT-K 10 UROCIT-K 15 UROCIT-K 5 VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate oral capsule ELIPHOS K-TAB KLOR-CON ORAL TABLET EXTENDED RELEASE 1 MO KLOR-CON 10 1 MO KLOR-CON M15 1 MO KLOR-CON M20 1 MO lactated ringers intravenous magnesium sulfate injection syringe NORMOSOL-R IN 5 % DEXTROSE PHOSLO PHOSLYRA potassium chloridd5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l

102 Name potassium chloridd5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride intravenous parenteral solution potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 40 meq/100 ml potassium chloride oral capsule, extended release potassium chloride oral tablet,er particles/crystals potassium chloride in 0.9%nacl potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride % nacl potassium chlorided5-0.2%nacl intravenous parenteral solution 20 meq/l 2 1 MO 1 MO Name potassium chlorided5-0.3%nacl potassium chlorided5-0.9%nacl ringers intravenous 2 sodium chloride intravenous parenteral solution 2.5 meq/ml sodium chloride 0.45 % intravenous parenteral solution 2 2 sodium chloride 3 % sodium chloride 5 % 2 sodium lactate intravenous TPN ELECTROLYTES MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % PA 3 PA 3 PA AMINOSYN II 7 % 3 PA AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % 3 PA 3 PA 3 PA 94

103 Name AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE- FREE) CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%- D20W SULF-FREE CLINIMIX 4.25%- D25W SULF-FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 5%- D20W(SULFITE- FREE) CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE 3 PA 3 PA 3 PA 3 PA 3 PA 3 PA 3 PA 3 PA 3 PA Name CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % 4 PA; MO HEPATAMINE 8% 3 PA HEPATASOL 8 % 3 PA INTRALIPID EMULSION 20 % INTRALIPID EMULSION 30 % IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 3 LIPOSYN III EMULSION 10 %, 20 % NEPHRAMINE 5.4 % NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH 7.4 PLASMA-LYTE 148 PLASMA-LYTE A 3 PLASMA-LYTE-56 IN 5 % DEXTROSE 3 2 PA; MO 4 PA PA 3 PA

104 Name PREMASOL 10 % 2 PA PREMASOL 6 % 3 PA PROCALAMINE 3% 3 PA PROSOL 20 % 4 PA; MO TRAVASOL 10 % 2 PA TROPHAMINE 10 % 3 PA TROPHAMINE 6% 3 PA VITAMINS / HEMATINICS PRENATAL VITAMIN sodium fluoride oral tablet

105 Index 8 8-MOP A abacavir... 2 abacavir-lamivudinezidovudine... 2 ABELCET... 1 ABILIFY ABILIFY DISCMELT ABILIFY MAINTENA ABRAXANE ABSORICA ABSTRAL acamprosate ACANYA acarbose ACCOLATE ACCUPRIL ACCURETIC acebutolol acetaminophen-codeine ACETASOL HC acetazolamide acetazolamide sodium acetic acid acetylcysteine ACIPHEX ACIPHEX SPRINKLE acitretin ACTEMRA ACTHAR H.P ACTHIB (PF) ACTIGALL ACTIMMUNE ACTIQ ACTIVELLA ACTONEL... 59, 80 ACTOPLUS MET ACTOPLUS MET XR ACTOS ACULAR ACULAR LS ACUVAIL (PF) acyclovir... 2, 57 acyclovir sodium... 2 ACZONE ADACEL(TDAP ADOLESN/ADULT)(PF) 78 ADAGEN ADALAT CC adapalene ADCIRCA ADDERALL ADDERALL XR adefovir... 2 ADEMPAS ADOXA ADRENALIN ADVAIR DISKUS ADVAIR HFA ADVICOR AEROSPAN AFEDITAB CR AFINITOR AFINITOR DISPERZ AGGRENOX AGRYLIN A-HYDROCORT AKNE-MYCIN ALA-CORT ALA-SCALP ALBENZA... 7 albuterol sulfate alclometasone ALCOHOL PADS ALDACTAZIDE ALDACTONE ALDARA ALDURAZYME alendronate... 59, 80 alfuzosin ALIMTA ALINIA... 7 ALKERAN allopurinol ALOCRIL ALOMIDE ALOPRIM ALORA ALOXI ALPHAGAN P alprazolam ALREX ALSUMA ALTABAX ALTACE ALTOPREV ALVESCO amantadine hcl... 2 AMARYL... 63, 64 AMBIEN AMBIEN CR AMBISOME... 1 amcinonide AMERGE AMETHIA AMETHYST amifostine crystalline amikacin... 7 amiloride amiloride-hydrochlorothiazide aminophylline AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) amiodarone AMITIZA amitriptyline amlodipine

106 amlodipine-atorvastatin amlodipine-benazepril ammonium chloride ammonium lactate AMNESTEEM amoxapine amoxicil-clarithromy-lansopraz amoxicillin... 9 amoxicillin-pot clavulanate... 9 AMPHETAMINE SALT COMBO amphotericin b... 1 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA AMTURNIDE ANADROL ANAFRANIL anagrelide ANAPROX ANAPROX DS anastrozole ANCOBON... 1 ANDRODERM ANDROGEL ANDROID ANDROXY ANGELIQ ANORO ELLIPTA ANTABUSE ANTARA ANUSOL-HC ANZEMET APEXICON E APIDRA APIDRA SOLOSTAR APLENZIN APOKYN apraclonidine APRI APRISO APTIOM APTIVUS... 2 ARALAST NP ARANELLE (28) ARANESP (IN POLYSORBATE) ARAVA ARCALYST ARCAPTA NEOHALER argatroban argatroban in 0.9 % sod chlor ARICEPT ARICEPT ODT ARIMIDEX ARIXTRA AROMASIN ARRANON ARTHROTEC ARTHROTEC ARZERRA ASACOL HD ASMANEX TWISTHALER... 89, 90 ASTAGRAF XL ASTELIN ASTEPRO ATACAND ATACAND HCT ATELVIA atenolol atenolol-chlorthalidone ATGAM ATIVAN atorvastatin atovaquone... 7 atovaquone-proguanil... 7 ATRALIN ATRIPLA... 2 atropine ATROVENT ATROVENT HFA AUBAGIO AUGMENTIN AUVI-Q AVALIDE AVANDAMET AVANDARYL AVANDIA AVAPRO AVASTIN AVELOX AVELOX ABC PACK AVELOX IN NACL (ISO- OSMOTIC) AVIANE AVINZA AVITA AVODART AVONEX AVONEX ADMINISTRATION PACK AXERT AXID AXIRON AYGESTIN azacitidine AZACTAM... 7 AZACTAM IN DEXTROSE (ISO-OSM)... 7 AZASAN AZASITE azathioprine azelastine... 61, 86 AZELEX AZILECT azithromycin... 6 AZOPT AZOR aztreonam... 7 AZULFIDINE AZULFIDINE EN-TABS B BACIIM... 7 bacitracin... 7, 85 bacitracin-polymyxin b baclofen BACTRIM BACTRIM DS BACTROBAN BACTROBAN NASAL

107 balsalazide BALZIVA (28) BANZEL BARACLUDE... 2 bcg vaccine, live (pf) BECONASE AQ benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA BENTYL BENZAMYCIN benztropine BEPREVE BESIVANCE BETAGAN betamethasone dipropionate. 58 betamethasone valerate betamethasone, augmented BETAPACE AF BETASERON betaxolol... 46, 86 bethanechol chloride BETHKIS... 7 BETIMOL BETOPTIC S BEYAZ BIAXIN... 6 BIAXIN XL... 6 BIAXIN XL PAK... 6 bicalutamide BICILLIN C-R BICILLIN L-A BICNU BIDIL BILTRICIDE... 7 BINOSTO bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM bleomycin BLEPH BLEPHAMIDE BLEPHAMIDE S.O.P BONIVA BOOSTRIX TDAP BOSULIF BOTOX BREO ELLIPTA BREVICON (28) BRIELLYN BRILINTA brimonidine BRINTELLIX... 34, 35 BRISDELLE bromfenac bromocriptine BROVANA budesonide... 71, 90 bumetanide... 46, 47 BUPRENEX buprenorphine buprenorphine-naloxone BUPROBAN bupropion hcl buspirone BUSULFEX butorphanol tartrate BUTRANS BYDUREON BYETTA BYSTOLIC C cabergoline CADUET CAFERGOT CALAN CALAN SR calcipotriene calcipotriene-betamethasone 54 calcitonin (salmon) calcitriol... 54, 68 calcium acetate CAMBIA CAMILA CAMPRAL CAMPTOSAR CANASA CANCIDAS... 1 candesartan candesartan-hydrochlorothiazid CANTIL CAPASTAT... 7 CAPEX CAPITAL WITH CODEINE CAPRELSA... 13, 14 captopril captopril-hydrochlorothiazide CARAC CARAFATE CARBAGLU carbamazepine CARBATROL carbidopa carbidopa-levodopa carbidopa-levodopaentacapone carboplatin CARDENE IV IN SODIUM CHLORIDE CARDENE SR CARDIZEM CARDIZEM CD CARDIZEM LA CARDURA CARDURA XL CARIMUNE NF NANOFILTERED CARNITOR carteolol CARTIA XT carvedilol CASODEX CATAFLAM CATAPRES CATAPRES-TTS CATAPRES-TTS CATAPRES-TTS CAYSTON

108 CEDAX... 4 cefaclor... 4 cefadroxil... 5 cefazolin... 5 cefazolin in dextrose (iso-os). 5 cefdinir... 5 cefditoren pivoxil... 5 cefepime... 5 cefotaxime... 5 cefotetan... 5 cefoxitin... 5 cefoxitin in dextrose, iso-osm 5 cefpodoxime... 5 cefprozil... 5 ceftazidime... 5 ceftazidime in d5w... 5 CEFTIN... 5 ceftriaxone... 5 cefuroxime axetil... 5 cefuroxime sodium... 5 CELEBREX CELEXA CELLCEPT CELLCEPT CELONTIN CENESTIN cephalexin... 5 CEREZYME CERVARIX VACCINE (PF) CESAMET cetirizine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX CHANTIX STARTING MONTH PAK CHEMET CHENODAL chloramphenicol sod succinate... 7 chlorhexidine gluconate chloroquine phosphate... 7 chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone CHOLESTYRAMINE LIGHT chorionic gonadotropin, human CIALIS ciclopirox cidofovir... 2 cilostazol CILOXAN cimetidine CIMZIA CIMZIA POWDER FOR RECONST CIMZIA STARTER KIT CINRYZE CIPRO CIPRO HC CIPRO IN D5W CIPRODEX ciprofloxacin... 11, 85 ciprofloxacin (mixture) ciprofloxacin in 5 % dextrose cisplatin citalopram cladribine CLAFORAN... 5 CLARAVIS CLARINEX CLARINEX-D 12 HOUR CLARINEX-D 24 HOUR clarithromycin... 6 CLEOCIN... 7, 82 CLEOCIN IN 5 % DEXTROSE... 7, 8 CLEOCIN T CLIMARA CLINDACIN PAC clindamycin hcl... 8 clindamycin in dextrose 5 %.. 8 CLINDAMYCIN PEDIATRIC... 8 clindamycin phosphate... 8, 55, 82 clindamycin-benzoyl peroxide CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE).. 95 CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % clobetasol clobetasol-emollient CLOBEX CLODERM CLOLAR

109 clomipramine clonazepam clonidine clonidine hcl... 35, 47 clopidogrel clorazepate dipotassium CLORPRES clotrimazole... 1, 57 clotrimazole-betamethasone. 57 clozapine CLOZARIL COARTEM... 8 codeine sulfate COGENTIN COLAZAL colchicine-probenecid COLCRYS COLESTID colestipol colistin (colistimethate na)... 8 COLOCORT COLY-MYCIN M PARENTERAL... 8 COLY-MYCIN S COLYTE WITH FLAVOR PACKS COMBIGAN COMBIVENT RESPIMAT. 90 COMBIVIR... 2 COMETRIQ COMPLERA... 2 COMPRO COMTAN COMVAX (PF) CONCERTA CONDYLOX CONSTULOSE CONZIP COPAXONE COPEGUS... 2 CORDRAN TAPE LARGE ROLL COREG COREG CR CORGARD CORTEF CORTIFOAM cortisone CORTISPORIN... 57, 62 CORTISPORIN-TC CORZIDE COSMEGEN COSOPT COUMADIN COZAAR CREON CRESTOR CRINONE CRIXIVAN... 2 cromolyn... 71, 86, 90 CRYSELLE (28) CUBICIN... 8 CUPRIMINE CUTIVATE CUVPOSA CYCLAFEM 1/35 (28) CYCLAFEM 7/7/7 (28) CYCLESSA (28) cyclobenzaprine cyclophosphamide CYCLOSET cyclosporine cyclosporine modified CYKLOKAPRON CYMBALTA CYSTADANE CYSTAGON CYSTARAN cytarabine cytarabine (pf) CYTOMEL CYTOTEC CYTOVENE... 2 D d10 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine DACOGEN DALIRESP danazol DANTRIUM dantrolene dapsone... 8 DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM... 8 daunorubicin DAYPRO DAYTRANA DDAVP decitabine DELESTROGEN DELZICOL DEMADEX demeclocycline DEMSER DENAVIR DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES DEPEN TITRATABS DEPO-ESTRADIOL DEPO-MEDROL DEPO-PROVERA DEPO-SUBQ PROVERA DEPO-TESTOSTERONE DERMATOP desipramine desloratadine desmopressin DESOGEN DESONATE desonide DESOWEN desoximetasone DESOXYN

110 desvenlafaxine DETROL DETROL LA dexamethasone DEXAMETHASONE INTENSOL dexamethasone sodium phosphate... 62, 87 DEXEDRINE SPANSULE.. 36 DEXILANT dexmethylphenidate DEXPAK 13 DAY dexrazoxane dextroamphetamine dextroamphetamineamphetamine dextrose 10 % & 0.2 % nacl. 60 dextrose 10 % in water (d10w) dextrose 5 % in water (d5w) 60 dextrose 5 %-lactated ringers60 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride DIAMOX SEQUELS DIASTAT DIASTAT ACUDIAL diazepam... 20, 36 DIAZEPAM INTENSOL DIBENZYLINE diclofenac potassium diclofenac sodium... 32, 55, 87 diclofenac-misoprostol dicloxacillin dicyclomine didanosine... 2 DIFFERIN DIFICID... 6 diflorasone DIFLUCAN... 1 diflunisal digoxin dihydroergotamine DILACOR XR DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN DILAUDID DILAUDID (PF) DILAUDID-HP (PF) diltiazem hcl... 47, 48 DILT-XR DIOVAN DIOVAN HCT DIPENTUM diphenhydramine hcl diphenoxylate-atropine DIPROLENE DIPROLENE AF dipyridamole disulfiram DITROPAN XL DIURIL DIURIL IV divalproex DIVIGEL DOCEFREZ docetaxel DOLOPHINE donepezil DORIBAX... 8 DORYX dorzolamide dorzolamide-timolol DOVONEX doxazosin doxepin doxercalciferol DOXIL doxorubicin doxycycline hyclate doxycycline monohydrate dronabinol drospirenone-ethinyl estradiol DROXIA DUAVEE DUETACT DUEXIS DULERA duloxetine DURAGESIC DURAMORPH (PF)... 26, 27 DUREZOL DUTOPROL DYAZIDE DYMISTA DYRENIUM DYSPORT E E.E.S E.E.S. GRANULES... 6 EC-NAPROSYN econazole EDARBI EDARBYCLOR EDECRIN EDURANT... 2 EFFEXOR XR EFFIENT EFUDEX EGRIFTA ELAPRASE ELDEPRYL ELELYSO ELESTAT ELIDEL ELIGARD ELIPHOS ELIQUIS ELITEK ELIXOPHYLLIN ELLA ELLENCE ELMIRON ELOCON ELOXATIN EMADINE EMCYT EMEND EMLA EMOQUETTE EMSAM

111 EMTRIVA... 2 ENABLEX enalapril maleate enalapril-hydrochlorothiazide ENBREL ENBREL SURECLICK ENDOCET ENDODAN ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) ENJUVIA enoxaparin ENPRESSE entacapone ENTOCORT EC ENULOSE EPANED EPIDUO epinastine EPIPEN EPIPEN 2-PAK EPIPEN JR EPIPEN JR 2-PAK epirubicin EPITOL EPIVIR... 2 EPIVIR HBV... 2 eplerenone EPOGEN eprosartan EPZICOM... 2 EQUETRO ERAXIS(WATER DILUENT)... 1 ERBITUX ergoloid ERGOMAR ERIVEDGE ERRIN ERTACZO ERWINAZE ERY PADS ERYPED ERYPED ERY-TAB... 6 ERYTHROCIN... 6 ERYTHROCIN (AS STEARATE)... 6 erythromycin... 7, 85 erythromycin ethylsuccinate... 7 erythromycin with ethanol... 55, 56 erythromycin-benzoyl peroxide erythromycin-sulfisoxazole... 7 escitalopram oxalate esomeprazole sodium esomeprazole strontium ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 82 ESTRASORB ESTRING estropipate ESTROSTEP FE eszopiclone ethambutol... 8 ethosuximide etidronate disodium etodolac ETOPOPHOS etoposide EURAX EVAMIST EVISTA EVOXAC EVZIO EXALGO ER EXELDERM EXELON exemestane EXFORGE EXFORGE HCT EXJADE EXTAVIA EXTINA F FABIOR FABRAZYME FACTIVE famciclovir... 2 famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 73 FAMVIR... 2 FANAPT... 36, 37 FARESTON FARXIGA FASLODEX FAZACLO felbamate FELBATOL FELDENE felodipine FEMARA FEMCON FE FEMHRT LOW DOSE FEMRING fenofibrate fenofibrate micronized fenofibrate nanocrystallized. 53 fenofibric acid (choline) FENOGLIDE fenoprofen fentanyl citrate fentanyl patches FENTORA FERRIPROX FETZIMA FIBRICOR FINACEA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE FLAGYL... 8 FLAGYL ER... 8 FLAREX flavoxate flecainide FLECTOR

112 FLOMAX FLONASE FLO-PRED FLOVENT DISKUS FLOVENT HFA fluconazole... 1 fluconazole in dextrose(iso-o) 1 flucytosine... 1 fludarabine fludrocortisone FLUMADINE... 2 flunisolide fluocinolone fluocinolone acetonide oil fluocinonide FLUOCINONIDE-E fluorouracil... 15, 55 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide fluticasone... 58, 90 fluvastatin fluvoxamine FML FORTE FML LIQUIFILM FML S.O.P FOCALIN FOCALIN XR FOLOTYN fomepizole fondaparinux FORADIL AEROLIZER FORFIVO XL FORTAMET FORTAZ... 5, 6 FORTEO FORTESTA FORTICAL FOSAMAX FOSAMAX PLUS D foscarnet... 2 fosinopril fosinopril-hydrochlorothiazide fosphenytoin FOSRENOL FRAGMIN FROVA FULYZAQ FURADANTIN furosemide FUSILEV FUZEON... 2 FYCOMPA G gabapentin GABITRIL GABLOFEN galantamine GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C ganciclovir sodium... 2 GARDASIL (PF) GASTROCROM gatifloxacin GATTEX ONE-VIAL gauze pads 2 x GAVILYTE-C GAVILYTE-G GAVILYTE-N GELNIQUE gemcitabine gemfibrozil GEMZAR GENERESS FE GENERLAC GENGRAF GENOTROPIN GENOTROPIN MINIQUICK GENTAK gentamicin... 8, 57, 85 gentamicin in nacl (iso-osm).. 8 gentamicin sulfate (pf)... 8 GEODON... 37, 38 GIANVI (28) GIAZO GILDAGIA GILENYA GILOTRIF GLASSIA GLEEVEC glimepiride glipizide glipizide-metformin... 64, 65 GLUCAGEN GLUCAGEN HYPOKIT GLUCAGON EMERGENCY GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUMETZA GLYCATE glycopyrrolate GLYSET GOLYTELY GRALISE GRALISE 30-DAY STARTER PACK granisetron granisetron (pf) GRANISOL GRANIX GRASTEK griseofulvin microsize... 1 griseofulvin ultramicrosize... 1 GRIS-PEG (ULTRAMICROSIZE)... 1 guanidine GYNAZOLE H HALAVEN HALDOL HALDOL DECANOATE halobetasol propionate HALOG haloperidol haloperidol decanoate

113 haloperidol lactate HAVRIX (PF) HECTOROL heparin (porcine) heparin (porcine) in 5 % dex 52 heparin (porcine) in nacl (pf) 52 HEPATAMINE 8% HEPATASOL 8 % HEPSERA... 2 HERCEPTIN HEXALEN HIPREX HORIZANT HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA HUMIRA CROHN'S DIS START PCK HUMIRA PEN HUMIRA PSORIASIS STARTER PACK HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN 70/30 PEN HUMULIN N HUMULIN N KWIKPEN HUMULIN N PEN HUMULIN R HUMULIN R U HYCAMTIN HYCET hydralazine HYDREA hydrochlorothiazide hydrocodone-acetaminophen... 27, 28 hydrocodone-ibuprofen hydrocortisone... 58, 62, 71 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydrocortisone-acetic acid hydromorphone hydromorphone (pf) hydroxychloroquine... 8 hydroxyurea hydroxyzine hcl HYZAAR I ibandronate IBUDONE ibuprofen ibuprofen-oxycodone IDAMYCIN PFS idarubicin IFEX ifosfamide ILARIS (PF) ILEVRO IMBRUVICA imipenem-cilastatin... 8 imipramine hcl imipramine pamoate imiquimod IMITREX IMITREX STATDOSE KIT REFILL IMOVAX RABIES VACCINE (PF) IMURAN INCIVEK... 2 INCRELEX indapamide INDERAL LA INFANRIX (DTAP) (PF) INLYTA INNOPRAN XL INSPRA insulin pen needle insulin syringe (disp) u ml insulin syringe (disp) u ml insulin syringe (disp) u-100 1/2 ml INTELENCE... 2 INTRALIPID INTRON A INTROVALE INVANZ... 8 INVEGA INVEGA SUSTENNA INVIRASE... 2 INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IOPIDINE IPOL ipratropium bromide... 61, 90 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide irinotecan ISENTRESS... 2, 3 ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid... 8 ISOPTO CARPINE ISORDIL ISORDIL TITRADOSE isosorbide dinitrate isosorbide mononitrate isradipine ISTALOL ISTODAX itraconazole... 1 IXEMPRA IXIARO (PF) J JAKAFI JALYN JANTOVEN JANUMET JANUMET XR

114 JANUVIA JENTADUETO JEVTANA JOLIVETTE JUBLIA JUNEL 1.5/30 (21) JUNEL 1/20 (21) JUNEL FE 1.5/30 (28) JUNEL FE 1/20 (28) JUXTAPID K KADCYLA KADIAN KALBITOR KALETRA... 3 KALYDECO KAPVAY KARIVA (28) KAYEXALATE KAZANO KEFLEX... 6 KELNOR 1/35 (28) KENALOG... 59, 62 KEPIVANCE KEPPRA KEPPRA XR KETEK... 8 ketoconazole... 1, 57 KETODAN KIT ketoprofen ketorolac KHEDEZLA KINERET KIONEX KLARON KLONOPIN KLOR-CON KLOR-CON KLOR-CON M KLOR-CON M KOMBIGLYZE XR KORLYM KRISTALOSE K-TAB KUVAN KYNAMRO L labetalol LAC-HYDRIN LACRISERT lactated ringers... 59, 93 lactulose LAMICTAL LAMICTAL ODT LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT LAMICTAL STARTER (ORANGE) KIT LAMICTAL XR LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) LAMISIL... 1 lamivudine... 3 lamivudine-zidovudine... 3 lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR LARIN 1/20 (21) LARIN FE LASIX LASTACAFT latanoprost LATUDA LAZANDA LEENA leflunomide LESCOL LESCOL XL LESSINA LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide levalbuterol hcl LEVAQUIN LEVEMIR LEVEMIR FLEXPEN LEVEMIR FLEXTOUCH levetiracetam levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 11, 85 levofloxacin in d5w LEVONEST (28) levonorgestrel-ethinyl estrad 83 LEVORA levorphanol tartrate levothyroxine LEVOXYL LEXAPRO... 38, 39 LEXIVA... 3 LIALDA lidocaine lidocaine (pf) lidocaine hcl lidocaine-prilocaine LIDODERM LINCOCIN... 8 lindane LINZESS LIORESAL liothyronine LIPITOR LIPOFEN LIPOSYN III LIPTRUZET lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate LITHOBID LITHOSTAT

115 LIVALO LO LOESTRIN FE LO MINASTRIN FE LODOSYN LOFIBRA LOMEDIA 24 FE LOMOTIL lomustine loperamide LOPID LOPRESSOR LOPRESSOR HCT LOPROX lorazepam LORAZEPAM INTENSOL. 39 LORCET (HYDROCODONE) LORCET HD LORCET PLUS LORTAB LORTAB LORTAB LORTAB ELIXIR LORYNA (28) losartan losartan-hydrochlorothiazide 49 LOSEASONIQUE LOTEMAX LOTENSIN LOTREL LOTRISONE LOTRONEX lovastatin LOVAZA LOVENOX LOW-OGESTREL (28) loxapine succinate LOXITANE LUFYLLIN LUMIGAN LUMIZYME LUNESTA LUPANETA PACK (1 MONTH) LUPANETA PACK (3 MONTH) LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUTERA (28) LUVOX CR LUZU LYRICA LYSODREN LYSTEDA LYZA M MACROBID MACRODANTIN mafenide acetate magnesium sulfate MALARONE... 8 MALARONE PEDIATRIC... 8 malathion maprotiline MARINOL... 71, 72 MARLISSA MARPLAN MATULANE MATZIM LA MAVIK MAXALT MAXALT-MLT MAXIDEX MAXIPIME... 6 MAXITROL MAXZIDE MAXZIDE meclizine meclofenamate MEDROL MEDROL (PAK) medroxyprogesterone mefenamic acid mefloquine... 8 MEGACE MEGACE ES megestrol MEKINIST meloxicam melphalan MENACTRA (PF) MENEST MENOMUNE - A/C/Y/W-135 (PF) MENOSTAR MENTAX MENVEO A-C-Y-W-135-DIP (PF) MEPRON... 8 mercaptopurine meropenem... 8 MERREM... 8 mesalamine with cleansing wipe mesna MESNEX MESTINON MESTINON TIMESPAN METADATE CD METADATE ER metaproterenol metformin... 66, 67 methadone methamphetamine methazolamide methenamine hippurate methimazole METHITEST methotrexate sodium methotrexate sodium (pf) 16, 17 methoxsalen rapid methscopolamine methyclothiazide methyldopa methylergonovine METHYLIN methylphenidate methylprednisolone

116 methylprednisolone acetate.. 62 methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate METOZOLV ODT METROCREAM METROGEL METROGEL VAGINAL METROLOTION metronidazole... 8, 9, 56, 83 metronidazole in nacl (iso-os) 9 mexiletine MIACALCIN MICARDIS MICARDIS HCT MICONAZOLE MICROGESTIN 1.5/30 (21) 84 MICROGESTIN 1/20 (21) MICROGESTIN FE 1.5/30 (28) MICROGESTIN FE 1/20 (28) MICROZIDE midodrine MIGERGOT MIGRANAL MILLIPRED MIMVEY MIMVEY LO MINASTRIN 24 FE MINIPRESS MINITRAN MINIVELLE minocycline minoxidil MIRAPEX MIRAPEX ER mirtazapine misoprostol mitomycin mitoxantrone M-M-R II (PF) MOBIC... 32, 33 modafinil MODERIBA... 3 MODERIBA DOSE PACK... 3 MODICON (28) moexipril moexipril-hydrochlorothiazide mometasone MONONESSA (28) montelukast MONUROL morphine morphine concentrate MOVIPREP MOXATAG MOXEZA moxifloxacin MOZOBIL MS CONTIN... 29, 30 MULTAQ mupirocin mupirocin calcium MUSTARGEN MYALEPT MYAMBUTOL... 9 MYCAMINE... 1 MYCOBUTIN... 9 mycophenolate mofetil mycophenolate sodium MYFORTIC MYORISAN MYOZYME MYRBETRIQ MYSOLINE N nabumetone nadolol nadolol-bendroflumethiazide 49 nafcillin nafcillin in dextrose iso-osm 10 NAFTIN NAGLAZYME nalbuphine naloxone naltrexone NAMENDA NAMENDA TITRATION PAK NAMENDA XR naphazoline NAPRELAN CR NAPROSYN naproxen naproxen sodium naratriptan NARDIL NASACORT AQ NASONEX NATACYN NATAZIA nateglinide NEBUPENT... 9 NECON 0.5/35 (28) NECON 1/35 (28) NECON 1/50 (28) NECON 10/11 (28) NECON 7/7/7 (28) needles, insulin disp.,safety.. 67 nefazodone neomycin... 9 neomycin-bacitracin-poly-hc 87 neomycin-bacitracinpolymyxin neomycin-polymyxin b gu neomycin-polymyxindexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc. 62, 87 NEORAL NEOSPORIN (NEO-POLYM- GRAMICID) NEPHRAMINE 5.4 % NESINA NEULASTA NEUMEGA

117 NEUPOGEN NEUPRO NEURONTIN NEVANAC nevirapine... 3 NEXAVAR NEXIUM NEXIUM IV NEXIUM PACKET NEXTERONE niacin NIACOR NIASPAN EXTENDED- RELEASE nicardipine NICOTROL NICOTROL NS NIFEDICAL XL nifedipine NILANDRON nimodipine NIPENT nisoldipine NITRO-BID NITRO-DUR nitrofurantoin nitrofurantoin macrocrystal.. 12 nitrofurantoin monohyd/mcryst nitroglycerin NITROLINGUAL NITROMIST NITROSTAT nizatidine NIZORAL NORA-BE NORCO NORDITROPIN FLEXPRO 77 NORDITROPIN NORDIFLEX norethindrone (contraceptive) norethindrone acetate NORINYL 1+35 (28) NORINYL 1+50 (28) NORITATE NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORPRAMIN NOR-QD NORTREL 0.5/35 (28) NORTREL 1/35 (21) NORTREL 1/35 (28) NORTREL 7/7/7 (28) nortriptyline NORVASC NORVIR... 3 NOVAREL NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL... 1 NUCYNTA NUCYNTA ER NUEDEXTA NULOJIX NULYTELY WITH FLAVOR PACKS NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING NUVIGIL NYAMYC nystatin... 1, 57 nystatin-triamcinolone NYSTOP O OCELLA octreotide acetate OCUFEN OCUFLOX ofloxacin... 11, 62, 85 OGESTREL (28) olanzapine... 39, 40 olanzapine-fluoxetine OLUX OLYSIO... 3 OMECLAMOX-PAK omega-3 acid ethyl esters omeprazole omeprazole-sodium bicarbonate OMNARIS OMNIPRED OMNITROPE ONCASPAR ondansetron ondansetron hcl ondansetron hcl (pf) ONFI ONGLYZA ONMEL... 1 OPANA OPANA ER OPSUMIT OPTIVAR ORACEA ORAP ORAPRED ORAPRED ODT ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM ORFADIN ORSYTHIA ORTHO EVRA ORTHO MICRONOR ORTHO TRI-CYCLEN (28) 84 ORTHO TRI-CYCLEN LO (28) ORTHO-CEPT (28) ORTHO-CYCLEN (28) ORTHO-NOVUM 1/35 (28) 84 ORTHO-NOVUM 7/7/7 (28)

118 OSENI OSMOPREP OTEZLA OTEZLA STARTER OTREXUP (PF) OVCON-35 (28) OVIDE oxacillin oxacillin in dextrose(iso-osm) oxaliplatin oxandrolone oxaprozin oxazepam oxcarbazepine OXECTA OXISTAT OXSORALEN OXSORALEN ULTRA OXTELLAR XR oxybutynin chloride oxycodone oxycodone-acetaminophen oxycodone-aspirin OXYCONTIN oxymorphone OXYTROL P PACERONE paclitaxel PAMELOR pamidronate PAMINE PAMINE FORTE PANCREAZE PANDEL PANRETIN pantoprazole PARCOPA paricalcitol PARNATE paromomycin... 9 paroxetine hcl PASER... 9 PATADAY PATANASE PATANOL PAXIL PAXIL CR PCE... 7 PEDI-DRI PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE PEGASYS PEGASYS CONVENIENCE PACK PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENNSAID PENTAM... 9 PENTASA pentoxifylline PEPCID PERCOCET PERCODAN PERFOROMIST perindopril erbumine PERIOGARD PERJETA permethrin perphenazine perphenazine-amitriptyline PERSANTINE PERTZYE PEXEVA... 40, 41 PFIZERPEN-G phenelzine PHENERGAN phenobarbital PHENYTEK phenytoin phenytoin sodium phenytoin sodium extended.. 22 PHOSLO PHOSLYRA PHOSPHOLINE IODIDE PHYSIOLYTE PHYSIOSOL IRRIGATION 59 PICATO pilocarpine hcl... 60, 86 PIMTREA (28) pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam PIRMELLA piroxicam PLAQUENIL... 9 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLAVIX PLETAL podofilox polyethylene glycol polymyxin b sulfate... 9 polymyxin b sulf-trimethoprim POLYTRIM POMALYST PONSTEL PORTIA potassium chlorid-d5-0.45%nacl... 93, 94 potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl

119 potassium chloride-d5-0.9%nacl potassium citrate POTIGA PRADAXA pramipexole PRANDIMET PRANDIN PRAVACHOL pravastatin prazosin PRECOSE PRED FORTE PRED MILD PRED-G PRED-G S.O.P prednicarbate prednisolone acetate prednisolone sodium phosphate... 63, 88 prednisone PREDNISONE INTENSOL 63 PREGNYL PREMARIN PREMASOL 10 % PREMASOL 6 % PRENATAL VITAMIN PREPOPIK PREVACID PREVACID SOLUTAB 74, 75 PREVALITE PREVIFEM PREVPAC PREZISTA... 3 PRIFTIN... 9 PRILOSEC primaquine... 9 PRIMAXIN IV... 9 primidone PRIMLEV PRIMSOL PRINIVIL PRISTIQ PRIVIGEN PROAIR HFA probenecid procainamide PROCALAMINE 3% PROCARDIA XL PROCENTRA prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT PROCTO-PAK PROCTOZONE-HC progesterone micronized PROGLYCEM PROGRAF PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine PROMETHAZINE VC PROMETRIUM propafenone propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) PROSCAR PROSOL 20 % PROTONIX PROTOPIC protriptyline PROVENTIL HFA PROVERA PROVIGIL PROZAC PROZAC WEEKLY PRUDOXIN PULMICORT PULMICORT FLEXHALER PULMOZYME PURINETHOL PYLERA pyrazinamide... 9 pyridostigmine bromide Q QNASL QUALAQUIN... 9 QUARTETTE QUASENSE QUDEXY XR QUESTRAN quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide quinidine gluconate quinidine sulfate quinine sulfate... 9 QVAR R RABAVERT (PF) rabeprazole RAGWITEK raloxifene ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE RAVICTI RAYOS RAZADYNE RAZADYNE ER REBETOL... 3 REBIF (WITH ALBUMIN). 77 REBIF REBIDOSE... 77, 78 REBIF TITRATION PACK. 78 RECLAST RECLIPSEN (28) RECOMBIVAX HB (PF) RECTIV REGLAN REGRANEX RELENZA DISKHALER... 3 RELISTOR RELPAX

120 REMERON REMERON SOLTAB REMICADE REMODULIN RENAGEL RENVELA repaglinide REPREXAIN REQUIP REQUIP XL RESCRIPTOR... 3 RESCULA RESTASIS RESTORIL RETIN-A RETIN-A MICRO RETIN-A MICRO PUMP RETROVIR... 3 REVATIO REVIA REVLIMID REYATAZ... 3 RHEUMATREX RHINOCORT AQUA RIBAPAK DOSE PACK... 3 RIBASPHERE... 3 ribavirin... 4 RIDAURA rifabutin... 9 RIFADIN... 9 RIFAMATE... 9 rifampin... 9 RIFATER... 9 RILUTEK riluzole rimantadine... 4 ringers... 59, 94 RIOMET risedronate RISPERDAL RISPERDAL CONSTA RISPERDAL M-TAB risperidone RITALIN RITALIN LA RITALIN SR RITUXAN rivastigmine tartrate rizatriptan ROBINUL ROBINUL FORTE ROCALTROL ROCEPHIN... 6 ropinirole ROTARIX ROTATEQ VACCINE ROXICET ROXICODONE ROZEREM RYTHMOL RYTHMOL SR S SABRIL SAFYRAL SAIZEN SAIZEN CLICK.EASY SALAGEN SAMSCA SANCTURA SANCTURA XR SANCUSO SANDIMMUNE SANDOSTATIN SANDOSTATIN LAR DEPOT SANTYL SAPHRIS SAPHRIS (BLACK CHERRY)... 42, 43 SARAFEM SAVELLA SEASONIQUE SECTRAL selegiline hcl selenium sulfide SELZENTRY... 4 SEMPREX-D SENSIPAR SEREVENT DISKUS SEROQUEL SEROQUEL XR SEROSTIM sertraline SFROWASA SIGNIFOR sildenafil SILENOR SILVADENE silver sulfadiazine SIMBRINZA SIMCOR SIMPONI SIMPONI ARIA SIMULECT simvastatin SINEMET SINEMET CR SINGULAIR sirolimus SIRTURO... 9 SIVEXTRO... 9 SKLICE sodium chloride... 61, 94 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium lactate sodium phenylbutyrate SODIUM POLYSTYRENE (SORB FREE) SOLARAZE SOLODYN SOLTAMOX SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF) SOMATULINE DEPOT SOMAVERT SONATA SORIATANE SORILUX SORINE sotalol

121 SOTALOL AF SOVALDI... 4 SPECTRACEF... 6 spinosad SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX... 1 SPORANOX PULSEPAK... 1 SPRINTEC (28) SPRIX SPRYCEL SRONYX SSD STALEVO STALEVO STALEVO STALEVO STALEVO STALEVO STARLIX stavudine... 4 STELARA STIMATE STIVARGA STRATTERA streptomycin... 9 STRIANT STRIBILD... 4 STROMECTOL... 9 SUBOXONE SUBSYS SUCLEAR SUCRAID sucralfate SULAR sulfacetamide sodium sulfacetamide sodium (acne) 57 sulfacetamide-prednisolone.. 88 sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine SULFAZINE EC sulindac sumatriptan sumatriptan succinate SUMAVEL DOSEPRO SUPRAX... 6 SUPREP SURMONTIL SUSTIVA... 4 SUTENT SYLATRON SYLVANT SYMBICORT SYMBYAX SYMLINPEN SYMLINPEN SYNAGIS... 4 SYNALAR CREAM KIT SYNALGOS-DC SYNAREL SYNERA SYNERCID... 9 SYNRIBO SYNTHROID SYPRINE T TABLOID TACLONEX tacrolimus TAFINLAR TAMIFLU... 4 tamoxifen tamsulosin TANZEUM TAPAZOLE TARCEVA TARGRETIN TARKA TASIGNA TASMAR TAXOTERE TAZORAC TAZTIA XT TECFIDERA TEFLARO... 6 TEGRETOL TEGRETOL XR TEKAMLO TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid temazepam TEMOVATE TENORETIC TENORETIC TENORMIN TERAZOL TERAZOL terazosin terbinafine... 1 terbutaline terconazole TESTIM testosterone cypionate testosterone enanthate TESTRED tetanus toxoid,adsorbed (pf). 79 tetanus-diphtheria toxoids-td 79 tetracycline TEVETEN TEVETEN HCT TEV-TROPIN THALOMID THEO theophylline THIOLA thioridazine thiothixene THYMOGLOBULIN THYROLAR THYROLAR-1/ THYROLAR-1/ THYROLAR THYROLAR tiagabine TIAZAC

122 ticlopidine TIKOSYN TIMENTIN timolol maleate... 50, 86 TIMOPTIC OCUDOSE (PF) TIMOPTIC-XE tinidazole... 9 TIROSINT TIVICAY... 4 tizanidine TOBI... 9 TOBI PODHALER... 9 TOBRADEX TOBRADEX ST tobramycin tobramycin in % nacl... 9 tobramycin in 0.9 % nacl... 9 tobramycin sulfate... 9 tobramycin-dexamethasone.. 87 TOBREX TOFRANIL TOFRANIL-PM tolazamide tolbutamide tolmetin tolterodine TOPAMAX TOPICORT topiramate TOPOSAR topotecan TOPROL XL TORISEL torsemide TOVIAZ TPN ELECTROLYTES TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril tranexamic acid... 52, 83 TRANSDERM-SCOP TRANXENE T-TAB tranylcypromine TRAVASOL 10 % TRAVATAN Z travoprost (benzalkonium) trazodone TREANDA TRECATOR... 9 TRELSTAR TRELSTAR DEPOT TRELSTAR LA tretinoin tretinoin (chemotherapy) TREXALL TREXIMET triamcinolone acetonide 59, 61, 63, 92 triamterene-hydrochlorothiazid TRIBENZOR TRICOR TRIDERM trifluoperazine trifluridine TRIGLIDE TRI-LEGEST FE TRILEPTAL TRILIPIX TRILYTE WITH FLAVOR PACKETS trimethoprim TRINESSA (28) TRI-NORINYL (28) TRI-PREVIFEM (28) TRISENOX TRI-SPRINTEC (28) TRIVORA (28) TRIZIVIR... 4 TROKENDI XR TROPHAMINE 10 % TROPHAMINE 6% trospium TRUSOPT TRUVADA... 4 TUDORZA PRESSAIR TWINRIX (PF) TWYNSTA TYGACIL... 9 TYKERB TYLENOL-CODEINE # TYLENOL-CODEINE # TYPHIM VI TYSABRI TYVASO TYZEKA... 4 TYZINE U UCERIS U-CORT ULESFIA ULORIC ULTRACET ULTRAM ULTRAM ER ULTRAVATE ULTRESA UNASYN UNIRETIC UNITHROID UNIVASC URECHOLINE UROCIT-K UROCIT-K UROCIT-K UROXATRAL URSO URSO FORTE ursodiol UVADEX V VAGIFEM valacyclovir... 4 VALCYTE... 4 VALIUM valproate sodium valproic acid valproic acid (as sodium salt) valsartan-hydrochlorothiazide VALTREX

123 VANCOCIN vancomycin VANDAZOLE VANOS VAQTA (PF) VARIVAX (PF) VASCEPA VASERETIC VASOTEC VECAMYL VECTIBIX VECTICAL VELCADE VELIVET TRIPHASIC REGIMEN (28) VELPHORO VELTIN venlafaxine VENTAVIS VENTOLIN HFA VERAMYST verapamil VEREGEN VERELAN VERELAN PM VERIPRED VERSACLOZ VESICARE VESTURA (28) VEXOL VFEND... 1 VFEND IV... 1 VGO VGO VGO VIBRAMYCIN VICODIN VICODIN ES VICODIN HP VICOPROFEN VICTOZA 2-PAK VICTOZA 3-PAK VICTRELIS... 4 VIDAZA VIDEX 2 GRAM PEDIATRIC... 4 VIDEX EC... 4 VIGAMOX VIIBRYD VIMOVO VIMPAT vinblastine vincristine vinorelbine VIOKACE VIRACEPT... 4 VIRAMUNE... 4 VIRAMUNE XR... 4 VIRAZOLE... 4 VIREAD... 4 VIROPTIC VISTIDE... 4 VIVACTIL VIVELLE-DOT VIVITROL VOGELXO VOLTAREN GEL VOLTAREN-XR voriconazole... 1, 2 VOSPIRE ER VOTRIENT VPRIV VYFEMLA (28) VYTORIN VYTORIN VYTORIN VYTORIN VYVANSE W warfarin water for irrigation, sterile WELCHOL WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL X XALATAN XALKORI XARELTO XARTEMIS XR XELJANZ XENAZINE XEOMIN XERESE XGEVA XIFAXAN... 9 XODOL 10/ XODOL 5/ XODOL 7.5/ XOLAIR XOPENEX XOPENEX HFA XTANDI XULANE XYLOCAINE... 56, 57 XYLOCAINE-MPF XYREM XYZAL Y YASMIN (28) YAZ (28) YERVOY YF-VAX (PF) Z zafirlukast zaleplon ZALTRAP ZAMICET ZANAFLEX ZANOSAR ZANTAC ZARONTIN ZAROXOLYN ZAVESCA ZEBETA ZEGERID ZELAPAR ZELBORAF ZEMAIRA ZEMPLAR ZENATANE ZENCHENT (28) ZENCHENT FE ZENPEP

124 ZENZEDI ZERIT... 4 ZESTORETIC ZESTRIL ZETIA ZETONNA ZIAC ZIAGEN... 4 ZIANA zidovudine... 4 ZINACEF... 6 ZINECARD ZIOPTAN (PF) ziprasidone hcl ZIPSOR ZIRGAN ZITHROMAX... 7 ZITHROMAX TRI-PAK... 7 ZITHROMAX Z-PAK... 7 ZMAX... 7 ZOCOR ZOFRAN (AS HYDROCHLORIDE) ZOFRAN ODT ZOHYDRO ER zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan ZOLOFT zolpidem ZOLPIMIST ZOMETA ZOMIG ZOMIG ZMT ZONALON ZONEGRAN zonisamide ZONTIVITY ZORBTIVE ZORTRESS ZORVOLEX ZOSTAVAX (PF) ZOSYN ZOSYN IN DEXTROSE (ISO- OSM) ZOVIA 1/35E (28) ZOVIA 1/50E (28) ZOVIRAX... 4, 57 ZUBSOLV ZYBAN ZYCLARA ZYFLO ZYFLO CR ZYKADIA ZYLET ZYLOPRIM ZYMAXID ZYPREXA ZYPREXA ZYDIS ZYTIGA ZYVOX

125

126 With Express Scripts Medicare, you will have access to over 68,000 network pharmacies nationally. You may fill your prescriptions at a retail, home infusion, long-term care or Indian Health Service / Tribal / Urban Indian Health Program (I/T/U) pharmacy, or through our convenient home delivery service. You must use network pharmacies to fill your prescriptions to get the most of your benefit. However, there are emergency circumstances under which you may be reimbursed for a covered prescription that is not filled at a network pharmacy. Limitations, copayments and restrictions may apply. This formulary was updated on 08/20/2014. For more recent information or other questions, please contact Express Scripts Medicare Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal Express Scripts Holding Company. All Rights Reserved. Express Scripts and E Logo are trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the property of their respective owners. F0NP5O5A