2016 Abridged Formulary (Partial List of Covered Drugs)

Transcription

1 2016 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN , 8 This abridged formulary was updated on 08/19/2015. This is not a complete list of drugs covered by our plan. For a complete listing or other questions, please contact us, Stanford Health Care Advantage Member Services, at or, for TTY users, 711, seven days a week from 8 am to 8 pm or visit H2986_PD_205 Accepted 2015

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11 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 120- (Acetaminophen with 2 GC; QL (2700 per mg/5 ml, 300 mg-30 mg /12.5 ml Codeine) acetaminophen-codeine oral tablet mg, mg (Tylenol-Codeine No.3) 2 GC; QL (360 per 30 acetaminophen-codeine oral tablet mg (Tylenol-Codeine No.3) 2 GC; QL (180 per 30 butalbital-acetaminophen-caff oral tablet mg (Esgic) 2 PA-HRM; GC; QL (180 per 30 CAPITAL WITH CODEINE 4 QL (2700 per 30 CONZIP 4 QL (30 per 30 DILAUDID ORAL LIQUID 4 QL (1200 per 30 DILAUDID ORAL TABLET 2 MG, 4 4 QL (180 per 30 MG DILAUDID ORAL TABLET 8 MG 4 QL (240 per 30 DOLOPHINE ORAL 4 QL (360 per 30 DURAGESIC TRANSDERMAL PATCH 5 PA; QL (10 per HOUR 100 MCG/HR, 75 MCG/HR DURAGESIC TRANSDERMAL PATCH 4 PA; QL (10 per HOUR 12 MCG/HR, 25 MCG/HR, 50 MCG/HR endocet oral tablet mg, mg, mg (Percocet) 2 GC; QL (360 per 30 ESGIC ORAL TABLET 4 PA-HRM; QL (180 per 30 EXALGO ER ORAL TABLET 4 PA; QL (30 per 30 EXTENDED RELEASE 24 HR 12 MG, 16 MG, 8 MG EXALGO ER ORAL TABLET 4 PA; QL (60 per 30 EXTENDED RELEASE 24 HR 32 MG fentanyl (Duragesic) 2 PA; GC; QL (10 per 30 HYCET 4 QL (2700 per 30 hydrocodone-acetaminophen oral solution mg/15 ml (Hycet) 2 GC; QL (2700 per 30 10

12 hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg (Norco) 2 (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 (Norco) 2 GC; QL (360 per 30 hydromorphone oral liquid (Dilaudid) 2 GC; QL (1200 per 30 hydromorphone oral tablet 2 mg, 4 mg (Dilaudid) 2 GC; QL (180 per 30 hydromorphone oral tablet 8 mg (Dilaudid) 2 GC; QL (240 per 30 hydromorphone oral tablet extended release 24 hr 12 mg, 16 mg, 8 mg (Exalgo) 2 PA; GC; QL (30 per 30 hydromorphone oral tablet extended release 24 hr 32 mg (Exalgo) 2 PA; GC; QL (60 per 30 KADIAN ORAL 4 ST; QL (60 per 30 CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG KADIAN ORAL 5 ST; QL (60 per 30 CAPSULE,EXTEND.RELEASE PELLETS 100 MG KADIAN ORAL CAPSULE,EXTEND.RELEASE 5 ST; QL (120 per 30 PELLETS 200 MG lorcet (hydrocodone) (Norco) 2 GC; QL (360 per 30 lorcet hd (Norco) 2 GC; QL (360 per 30 lorcet plus oral tablet mg (Norco) 2 GC; QL (360 per 30 LORTAB QL (360 per 30 LORTAB QL (360 per 30 LORTAB QL (360 per 30 methadone injection (Methadone HCl) 2 GC methadone oral solution (Methadone HCl) 2 GC; QL (1800 per 30 11

13 methadone oral tablet (Dolophine HCl) 2 GC; QL (360 per 30 morphine concentrate oral solution (Morphine Sulfate) 2 GC; QL (200 per 30 morphine intravenous cartridge 10 mg/ml, (Morphine Sulfate) 2 GC 2 mg/ml, 4 mg/ml, 8 mg/ml morphine intravenous syringe (Morphine Sulfate) 2 GC morphine oral capsule, er multiphase 24 hr 120 mg, 30 mg, 45 mg, 60 mg, 75 mg (Avinza) 2 ST; GC; QL (30 per 30 morphine oral capsule, er multiphase 24 (Avinza) 2 ST; GC; QL (60 per 30 hr 90 mg morphine oral capsule,extend.release pellets 10 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg (Kadian) 2 ST; GC; QL (60 per 30 morphine oral capsule,extend.release (Kadian) 5 ST; QL (60 per 30 pellets 100 mg morphine oral solution 10 mg/5 ml (Morphine Sulfate) 2 GC; QL (700 per 30 morphine oral solution 20 mg/5 ml (Morphine Sulfate) 2 GC; QL (300 per 30 MORPHINE ORAL TABLET 4 QL (180 per 30 morphine oral tablet extended release 100 mg, 30 mg, 60 mg (MS Contin) 2 GC; QL (120 per 30 morphine oral tablet extended release 15 mg, 200 mg (MS Contin) 2 GC; QL (180 per 30 MS CONTIN ORAL TABLET 4 QL (120 per 30 EXTENDED RELEASE 100 MG, 30 MG, 60 MG MS CONTIN ORAL TABLET 4 QL (180 per 30 EXTENDED RELEASE 15 MG, 200 MG NORCO 4 QL (360 per 30 oxycodone oral capsule (Oxycodone HCl) 2 GC; QL (180 per 30 oxycodone oral concentrate (Oxycodone HCl) 2 GC; QL (180 per 30 oxycodone oral solution (Oxycodone HCl) 2 GC; QL (1300 per 30 oxycodone oral tablet (Roxicodone) 2 GC; QL (180 per 30 12

14 oxycodone oral tablet,oral only,ext.rel.12 (Oxycodone HCl) 2 GC; QL (60 per 30 hr 10 mg, 20 mg, 40 mg oxycodone oral tablet,oral only,ext.rel.12 (Oxycodone HCl) 5 QL (120 per 30 hr 80 mg oxycodone-acetaminophen oral tablet mg, mg, mg, (Percocet) 2 GC; QL (360 per 30 mg OXYCONTIN ORAL TABLET,ORAL 3 QL (60 per 30 ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL 3 QL (120 per 30 ONLY,EXT.REL.12 HR 80 MG PERCOCET ORAL TABLET QL (360 per 30 MG, MG, MG, MG PRIMLEV 4 QL (390 per 30 roxicet oral solution (Oxycodone HCl/Acetaminophen) 2 GC; QL (1800 per 30 ROXICODONE 4 QL (180 per 30 SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, PA; QL (120 per 30 MCG/SPRAY, 400 MCG/SPRAY, 600 MCG/SPRAY, 800 MCG/SPRAY tramadol oral capsule,er biphase 24 hr (Conzip) 2 GC; QL (30 per tramadol oral capsule,er biphase 24 hr (Conzip) 2 GC; QL (30 per mg, 200 mg tramadol oral tablet (Ultram) 2 GC; QL (240 per 30 tramadol oral tablet extended release 24 (Ultram ER) 2 GC; QL (90 per 30 hr 100 mg tramadol oral tablet extended release 24 (Ultram ER) 2 GC; QL (30 per 30 hr 200 mg, 300 mg tramadol oral tablet, er multiphase 24 hr (Ultram ER) 2 GC; QL (30 per mg TYLENOL-CODEINE #3 4 QL (360 per 30 TYLENOL-CODEINE #4 4 QL (180 per 30 ULTRAM 4 QL (240 per 30 ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 100 MG 4 QL (90 per 30 13

15 ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 200 MG, 300 MG 4 QL (30 per 30 vicodin es oral tablet mg (Norco) 2 (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 vicodin hp oral tablet mg (Norco) 2 (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 vicodin oral tablet mg (Norco) 2 (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 XARTEMIS XR 3 QL (360 per 30 XODOL 10/300 4 QL (390 per 30 XODOL 5/300 4 QL (390 per 30 XODOL 7.5/300 4 QL (390 per 30 ZAMICET 4 QL (2700 per 30 Nonsteroidal Anti-Inflammatory Agents CELEBREX 4 QL (60 per 30 celecoxib (Celebrex) 2 GC; QL (60 per 30 diclofenac sodium oral tablet extended (Voltaren-XR) 2 GC release 24 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) 2 GC release (dr/ec) diclofenac sodium topical drops (Pennsaid) 2 GC diclofenac sodium topical gel (Solaraze) 5 EC-NAPROSYN 4 ibuprofen oral suspension (Ibuprofen) 2 GC ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) 1 GC mg INDOCIN ORAL 4 PA-HRM indomethacin oral capsule 25 mg (Indomethacin) 2 PA-HRM; GC; QL (240 per 30 indomethacin oral capsule 50 mg (Indomethacin) 2 PA-HRM; GC; QL (120 per 30 14

16 indomethacin oral capsule, extended release (Indomethacin) 2 PA-HRM; GC; QL (60 per 30 meloxicam oral suspension (Mobic) 2 GC meloxicam oral tablet (Mobic) 1 GC MOBIC 4 nabumetone (Nabumetone) 2 GC NAPROSYN ORAL TABLET 4 naproxen oral suspension (Naprosyn) 2 GC naproxen oral tablet (Naprosyn) 1 GC naproxen oral tablet,delayed release (Ec-Naprosyn) 2 GC (dr/ec) PENNSAID TOPICAL SOLUTION IN 4 METERED-DOSE PUMP SOLARAZE 5 VOLTAREN TOPICAL 3 VOLTAREN-XR 4 Anesthetics Local Anesthetics lidocaine hcl injection solution 20 mg/ml (Xylocaine) 2 PA BvD; (PA for ESRD Only); GC (2 %) lidocaine hcl mucous membrane gel (Lidocaine HCl) 2 GC lidocaine hcl mucous membrane jelly in (Lidocaine HCl) 2 GC applicator lidocaine hcl mucous membrane solution (Xylocaine) 2 GC lidocaine hcl urethral (Lidocaine HCl) 2 GC lidocaine topical adhesive (Lidoderm) 2 PA; GC patch,medicated lidocaine topical ointment (Lidocaine) 2 PA BvD; (PA for ESRD Only); GC lidocaine viscous (Xylocaine) 2 GC LIDODERM 4 PA XYLOCAINE INJECTION SOLUTION 20 MG/ML (2 %) XYLOCAINE MUCOUS MEMBRANE SOLUTION Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents

17 BUNAVAIL BUCCAL FILM MG 4 PA; QL (30 per 30 BUNAVAIL BUCCAL FILM PA; QL (60 per 30 MG, MG buprenorphine hcl sublingual (Subutex) 2 PA; GC; QL (90 per 30 buprenorphine-naloxone (Buprenorphine HCl/Naloxone HCl) 2 PA; GC; QL (90 per 30 CHANTIX 3 QL (168 per 84 CHANTIX CONTINUING MONTH 3 QL (56 per 28 BOX CHANTIX CONTINUING MONTH PAK 3 QL (56 per 28 CHANTIX STARTING MONTH BOX 3 QL (53 per 28 SUBOXONE SUBLINGUAL FILM PA; QL (60 per 30 MG SUBOXONE SUBLINGUAL FILM MG, 4-1 MG, 8-2 MG 4 PA; QL (90 per 30 ZUBSOLV 3 PA; QL (90 per 30 Antianxiety Agents Benzodiazepines ALPRAZOLAM INTENSOL 4 QL (300 per 30 alprazolam oral tablet (Xanax) 2 GC; QL (120 per 30 (Xanax XR) 2 GC; QL (120 per 30 (Xanax XR) 2 GC; QL (90 per 30 alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg alprazolam oral tablet extended release 24 hr 3 mg alprazolam oral tablet,disintegrating (Alprazolam) 2 GC; QL (120 per 30 ATIVAN ORAL 4 QL (90 per 30 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) 2 GC; QL (90 per 30 clonazepam oral tablet 2 mg (Klonopin) 2 GC; QL (300 per 30 clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating 2 mg KLONOPIN ORAL TABLET 0.5 MG, 1 MG (Clonazepam) 2 GC; QL (90 per 30 (Clonazepam) 2 GC; QL (300 per 30 4 QL (90 per 30 16

18 KLONOPIN ORAL TABLET 2 MG 4 QL (300 per 30 lorazepam intensol (Ativan) 2 GC; QL (150 per 30 lorazepam oral tablet (Ativan) 2 GC; QL (90 per 30 XANAX 4 QL (120 per 30 XANAX XR ORAL TABLET 4 QL (120 per 30 EXTENDED RELEASE 24 HR 0.5 MG, 1 MG, 2 MG XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR 3 MG 4 QL (90 per 30 Antibacterials Aminoglycosides gentamicin injection solution 40 mg/ml (Gentamicin Sulfate) 2 GC neomycin (Neomycin Sulfate) 2 GC TOBI 5 PA BvD tobramycin in % nacl (Tobi) 5 PA BvD Antibacterials, Miscellaneous CLEOCIN ORAL 4 clindamycin hcl (Cleocin HCl) 2 GC clindamycin palmitate hcl (Cleocin Palmitate) 2 GC clindamycin pediatric (Cleocin Palmitate) 2 GC FLAGYL 4 FLAGYL ER 4 MACROBID 4 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 17

19 MACRODANTIN 4 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 metronidazole oral (Flagyl) 2 GC nitrofurantoin macrocrystal oral capsule 100 mg (Macrodantin/Macrobid) 2 PA-HRM; GC; QL (120 per 30 nitrofurantoin macrocrystal oral capsule 50 mg (Macrodantin/Macrobid) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (120 per 30 nitrofurantoin monohyd/m-cryst (Macrobid) 2 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (120 per 30 PRIMSOL 4 trimethoprim (Trimethoprim) 2 GC VANCOCIN 5 vancomycin intravenous recon soln 1,000 (Vancomycin HCl) 2 GC mg, 10 gram vancomycin oral capsule (Vancocin HCl) 5 Cephalosporins cefadroxil oral capsule (Cefadroxil) 2 GC cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml (Cefadroxil) 2 GC 18

20 cefadroxil oral tablet (Cefadroxil) 2 GC cefdinir (Cefdinir) 2 GC cefpodoxime (Cefpodoxime Proxetil) 2 GC cefprozil (Cefprozil) 2 GC CEFTIN ORAL SUSPENSION FOR 4 RECONSTITUTION CEFTIN ORAL TABLET 250 MG, MG ceftriaxone injection recon soln 1 gram, (Rocephin) 2 GC 10 gram, 250 mg, 500 mg cefuroxime axetil oral tablet (Ceftin) 2 GC cephalexin oral capsule (Keflex) 1 GC cephalexin oral suspension for (Cephalexin) 1 GC reconstitution cephalexin oral tablet (Cephalexin) 1 GC KEFLEX ORAL CAPSULE 4 Macrolides azithromycin (Zithromax) 2 GC BIAXIN ORAL SUSPENSION FOR 4 RECONSTITUTION 250 MG/5 ML BIAXIN ORAL TABLET 4 clarithromycin oral suspension for (Biaxin) 2 GC reconstitution clarithromycin oral tablet (Biaxin) 2 GC clarithromycin oral tablet extended release 24 hr (Clarithromycin) 2 GC ZITHROMAX 4 ZITHROMAX TRI-PAK 4 ZITHROMAX Z-PAK 4 ZMAX 4 Miscellaneous B-Lactam Antibiotics CAYSTON 5 LA INVANZ INJECTION 4 Penicillins amoxicillin oral capsule (Amoxicillin) 1 GC amoxicillin oral suspension for (Amoxicillin) 1 GC reconstitution 19

21 amoxicillin oral tablet (Amoxicillin) 1 GC amoxicillin oral tablet,chewable 125 mg, (Amoxicillin) 1 GC 250 mg amoxicillin-pot clavulanate oral (Augmentin) 2 GC suspension for reconstitution amoxicillin-pot clavulanate oral tablet (Augmentin) 2 GC amoxicillin-pot clavulanate oral tablet (Augmentin XR) 2 GC extended release 12 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassium 2 GC tablet,chewable Clav) ampicillin (Ampicillin Trihydrate) 1 GC AUGMENTIN ORAL SUSPENSION 4 FOR RECONSTITUTION MG/5 ML dicloxacillin (Dicloxacillin Sodium) 2 GC penicillin v potassium (Penicillin V Potassium) 2 GC Quinolones AVELOX 4 AVELOX ABC PACK 4 CIPRO ORAL TABLET 250 MG, MG ciprofloxacin hcl oral (Cipro) 1 GC LEVAQUIN ORAL 4 levofloxacin intravenous (Levofloxacin) 2 GC levofloxacin oral solution (Levaquin) 2 GC levofloxacin oral tablet (Levaquin) 1 GC moxifloxacin (Avelox) 2 GC Sulfonamides AZULFIDINE 4 AZULFIDINE EN-TABS 4 BACTRIM 4 BACTRIM DS 4 sulfamethoxazole-trimethoprim (Sulfamethoxazole/Trim 2 GC intravenous ethoprim) sulfamethoxazole-trimethoprim oral suspension (Sulfamethoxazole/Trim ethoprim) 2 GC sulfamethoxazole-trimethoprim oral tablet (Bactrim DS) 1 GC sulfasalazine (Azulfidine) 2 GC 20

22 sulfazine ec (Azulfidine) 2 GC Tetracyclines ADOXA ORAL CAPSULE 4 doxycycline hyclate oral capsule 100 mg (Adoxa) 2 GC doxycycline hyclate oral tablet 100 mg, 50 (Avidoxy) 2 GC mg doxycycline monohydrate oral capsule (Adoxa) 2 GC doxycycline monohydrate oral suspension (Vibramycin) 2 GC for reconstitution doxycycline monohydrate oral tablet (Avidoxy) 2 GC MINOCIN ORAL CAPSULE 100 MG, 50 4 MG minocycline oral capsule (Minocin) 2 GC minocycline oral tablet (Minocycline HCl) 2 GC minocycline oral tablet extended release (Minocycline HCl) 2 GC 24 hr ORACEA 4 SOLODYN ORAL TABLET 5 EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION 4 Anticancer Agents Anticancer Agents AFINITOR DISPERZ 5 PA NSO; QL (112 per 28 AFINITOR ORAL TABLET 10 MG 5 PA NSO; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG anastrozole (Arimidex) 2 GC ARIMIDEX 4 AROMASIN 4 bicalutamide (Casodex) 2 GC CASODEX 4 DROXIA 3 ELIGARD SUBCUTANEOUS SYRINGE 22.5 MG (3 MONTH) 5 PA NSO; QL (28 per 28 4 QL (1 per 84 21

23 ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 4 QL (1 per MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE MG (1 MONTH) exemestane (Aromasin) 2 GC FEMARA 4 flutamide (Flutamide) 2 GC GLEEVEC ORAL TABLET 100 MG 5 PA NSO; QL (90 per 30 GLEEVEC ORAL TABLET 400 MG 5 PA NSO; QL (60 per 30 HYDREA 4 hydroxyurea (Hydrea) 2 GC INLYTA ORAL TABLET 1 MG 5 PA NSO; QL (180 per 30 INLYTA ORAL TABLET 5 MG 5 PA NSO; QL (60 per 30 JAKAFI 5 PA NSO; QL (60 per 30 letrozole (Femara) 2 GC LEUKERAN 4 leuprolide (Leuprolide Acetate) 2 GC LUPRON DEPOT 5 LUPRON DEPOT (3 MONTH) 5 QL (1 per 84 LUPRON DEPOT (4 MONTH) 5 QL (1 per 84 LUPRON DEPOT (6 MONTH) 5 QL (1 per 168 LYSODREN 3 megestrol oral tablet (Megestrol Acetate) 2 GC mercaptopurine (Mercaptopurine) 2 GC methotrexate sodium (pf) injection (Methotrexate Sodium) 2 PA BvD; GC solution methotrexate sodium injection (Methotrexate Sodium) 2 PA BvD; GC methotrexate sodium oral (Methotrexate Sodium) 2 PA BvD; ST; GC NEXAVAR 5 PA NSO; QL (120 per 30 22

24 POMALYST 5 PA NSO; QL (21 per 28 PURIXAN 5 REVLIMID 5 PA NSO; LA RHEUMATREX 4 PA BvD; ST SOLTAMOX 4 SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; QL (30 per 30 SPRYCEL ORAL TABLET 20 MG 5 PA NSO; QL (60 per 30 STIVARGA 5 PA NSO; QL (84 per 28 SUTENT 5 PA NSO; QL (30 per 30 tamoxifen (Tamoxifen Citrate) 2 GC TARCEVA ORAL TABLET 100 MG, 25 MG 5 PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 150 MG 5 PA NSO; QL (90 per 30 TARGRETIN ORAL 5 PA NSO; QL (420 per 30 TARGRETIN TOPICAL 5 PA NSO; QL (60 per 28 TASIGNA 5 PA NSO; QL (112 per 28 tretinoin (chemotherapy) (Tretinoin) 5 (capsule: 10mg) TREXALL 4 PA BvD; ST TYKERB 5 VOTRIENT 5 PA NSO; QL (120 per 30 XALKORI 5 PA NSO; QL (60 per 30 XTANDI 5 PA NSO; QL (120 per 30 ZELBORAF 5 PA NSO; QL (240 per 30 ZYTIGA 5 PA NSO; QL (120 per 30 23

25 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) 2 GC mg/ml propantheline (Propantheline Bromide) 2 GC Anticonvulsants Anticonvulsants carbamazepine oral capsule, er multiphase 12 hr (Carbatrol) 2 GC carbamazepine oral suspension 100 mg/5 (Tegretol) 2 GC ml carbamazepine oral tablet (Tegretol) 2 GC carbamazepine oral tablet extended (Tegretol XR) 2 GC release 12 hr carbamazepine oral tablet,chewable (Carbamazepine) 2 GC CARBATROL 4 DEPAKOTE 4 DEPAKOTE ER 4 DEPAKOTE SPRINKLES 4 DILANTIN 3 DILANTIN EXTENDED 4 divalproex oral capsule, sprinkle (Depakote Sprinkle) 2 GC divalproex oral tablet extended release 24 (Depakote ER) 2 GC hr divalproex oral tablet,delayed release (Depakote) 2 GC (dr/ec) epitol (Tegretol) 2 GC EQUETRO 4 gabapentin oral capsule (Neurontin) 2 GC gabapentin oral solution 250 mg/5 ml (Neurontin) 2 GC gabapentin oral tablet 600 mg, 800 mg (Neurontin) 2 GC GRALISE 4 ST; QL (90 per 30 GRALISE 30-DAY STARTER PACK 4 ST; QL (78 per 30 KEPPRA ORAL 4 KEPPRA XR 4 LAMICTAL ODT 4 LAMICTAL ORAL TABLET 4 24

26 LAMICTAL ORAL TABLET, 4 CHEWABLE DISPERSIBLE 25 MG, 5 MG LAMICTAL STARTER (BLUE) KIT 4 LAMICTAL STARTER (GREEN) KIT 4 LAMICTAL STARTER (ORANGE) KIT 4 LAMICTAL XR 4 LAMICTAL XR STARTER (BLUE) 4 LAMICTAL XR STARTER (GREEN) 4 LAMICTAL XR STARTER (ORANGE) 4 lamotrigine oral tablet (Lamictal) 2 GC lamotrigine oral tablet extended release (Lamictal XR) 2 GC 24hr lamotrigine oral tablet, chewable (Lamictal) 2 GC dispersible lamotrigine oral tablet,disintegrating (Lamictal Odt) 2 GC levetiracetam intravenous (Keppra) 2 GC levetiracetam oral solution 100 mg/ml (Keppra) 2 GC levetiracetam oral tablet (Keppra) 2 GC levetiracetam oral tablet extended release (Keppra XR) 2 GC 24 hr LYRICA ORAL CAPSULE 3 QL (90 per 30 LYRICA ORAL SOLUTION 3 QL (900 per 30 NEURONTIN 4 PHENYTEK 4 phenytoin sodium extended (Dilantin) 2 GC QUDEXY XR 4 TEGRETOL ORAL SUSPENSION 4 TEGRETOL ORAL TABLET 4 TEGRETOL XR ORAL TABLET 3 EXTENDED RELEASE 12 HR 100 MG TEGRETOL XR ORAL TABLET 4 EXTENDED RELEASE 12 HR 200 MG, 400 MG TOPAMAX 4 topiramate oral capsule, sprinkle (Topamax) 2 GC topiramate oral capsule,sprinkle,er 24hr (Qudexy XR) 2 GC topiramate oral tablet (Topamax) 2 GC 25

27 TROKENDI XR 4 Antidementia Agents Antidementia Agents ARICEPT 4 QL (30 per 30 donepezil oral tablet (Aricept) 2 GC; QL (30 per 30 donepezil oral tablet,disintegrating (Donepezil HCl) 2 GC; QL (30 per 30 NAMENDA ORAL SOLUTION 4 QL (360 per 30 NAMENDA ORAL TABLET 4 QL (60 per 30 NAMENDA TITRATION PAK 4 QL (49 per 28 NAMENDA XR ORAL 3 QL (28 per 28 CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR 3 QL (30 per 30 Antidepressants Antidepressants amitriptyline (Amitriptyline HCl) 2 PA NSO-HRM; GC buproban (Wellbutrin SR) 2 GC bupropion hcl oral tablet (Wellbutrin SR) 2 GC bupropion hcl oral tablet extended release (Wellbutrin SR) 2 GC bupropion hcl oral tablet extended release (Wellbutrin XL) 2 GC 24 hr CELEXA ORAL TABLET 4 QL (30 per 30 citalopram oral solution (Citalopram 2 GC Hydrobromide) citalopram oral tablet (Celexa) 1 GC; QL (30 per 30 CYMBALTA ORAL 4 QL (60 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 20 MG, 60 MG CYMBALTA ORAL 4 QL (30 per 30 CAPSULE,DELAYED RELEASE(DR/EC) 30 MG duloxetine oral capsule,delayed (Cymbalta) 2 GC; QL (60 per 30 release(dr/ec) 20 mg, 60 mg duloxetine oral capsule,delayed (Cymbalta) 2 GC; QL (30 per 30 release(dr/ec) 30 mg, 40 mg EFFEXOR XR 4 escitalopram oxalate (Lexapro) 2 GC 26

28 fluoxetine oral capsule (Prozac) 1 GC fluoxetine oral capsule,delayed (Prozac Weekly) 2 GC release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) 2 GC fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) 2 GC FLUOXETINE ORAL TABLET 60 MG 4 FORFIVO XL 4 IRENKA 4 QL (30 per 30 LEXAPRO 4 paroxetine hcl oral tablet (Paxil) 2 GC paroxetine hcl oral tablet extended release (Paxil CR) 2 GC 24 hr PAXIL 4 PAXIL CR 4 PROZAC ORAL CAPSULE 4 PROZAC WEEKLY 4 SARAFEM ORAL TABLET 10 MG, 20 4 MG sertraline oral concentrate (Zoloft) 2 GC sertraline oral tablet (Zoloft) 1 GC trazodone (Trazodone HCl) 1 GC venlafaxine oral capsule,extended release (Effexor XR) 2 GC 24hr venlafaxine oral tablet (Venlafaxine HCl) 2 GC venlafaxine oral tablet extended release (Venlafaxine HCl) 2 GC 24hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet extended release 24hr 225 mg (Venlafaxine HCl) 3 WELLBUTRIN 4 WELLBUTRIN SR 4 WELLBUTRIN XL 4 ZOLOFT 4 Antidiabetic Agents Antidiabetic Agents, Miscellaneous ACTOS 4 QL (30 per 30 BYDUREON 4 PA; ST; QL (4 per 28 27

29 BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 1,000 MG FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 500 MG GLUCOPHAGE ORAL TABLET 1,000 MG GLUCOPHAGE ORAL TABLET 500 MG GLUCOPHAGE ORAL TABLET 850 MG GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 MG GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 1,000 MG GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 500 MG 4 PA; ST; QL (2.4 per 28 4 PA; ST; QL (1.2 per 28 4 QL (60 per 30 4 QL (150 per 30 4 QL (60 per 30 4 QL (150 per 30 4 QL (90 per 30 4 QL (120 per 30 4 QL (60 per 30 4 QL (60 per 30 4 QL (120 per 30 JANUMET 3 QL (60 per 30 JANUMET XR ORAL TABLET, ER 3 QL (30 per 30 MULTIPHASE 24 HR 100-1,000 MG, MG JANUMET XR ORAL TABLET, ER 3 QL (60 per 30 MULTIPHASE 24 HR 50-1,000 MG JANUVIA 3 QL (30 per 30 metformin oral tablet 1,000 mg (Glucophage) 1 GC; QL (60 per 30 metformin oral tablet 500 mg (Glucophage) 1 GC; QL (150 per 30 metformin oral tablet 850 mg (Glucophage) 1 GC; QL (90 per 30 metformin oral tablet extended release 24 hr 500 mg (Glucophage XR) 2 GC; QL (120 per 30 metformin oral tablet extended release 24 hr 750 mg (Glucophage XR) 2 GC; QL (90 per 30 28

30 metformin oral tablet extended release (Glucophage XR) 2 GC; QL (60 per 30 24hr 1,000 mg ONGLYZA 4 QL (30 per 30 pioglitazone (Actos) 2 GC; QL (30 per 30 RIOMET 4 QL (765 per 30 TRADJENTA 3 QL (30 per 30 VICTOZA 3-PAK 3 ST; QL (9 per 28 Insulins HUMALOG KWIKPEN 6 GC; QL (30 per 28 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN 6 GC; QL (12 per 28 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) HUMALOG SUBCUTANEOUS 6 GC; QL (30 per 28 CARTRIDGE HUMALOG SUBCUTANEOUS 6 GC; QL (40 per 28 SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS 6 GC; QL (30 per 28 SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) LANTUS 6 GC; QL (40 per 28 LANTUS SOLOSTAR 6 GC; QL (30 per 28 NOVOLOG 6 GC; QL (40 per 28 NOVOLOG FLEXPEN 6 GC; QL (30 per 28 NOVOLOG PENFILL 6 GC; QL (30 per 28 TOUJEO SOLOSTAR 6 GC Sulfonylureas AMARYL ORAL TABLET 1 MG, 2 MG 4 QL (30 per 30 AMARYL ORAL TABLET 4 MG 4 QL (60 per 30 DIABETA ORAL TABLET 1.25 MG 4 PA-HRM; QL (280 per 30 DIABETA ORAL TABLET 2.5 MG 4 PA-HRM; QL (240 per 30 DIABETA ORAL TABLET 5 MG 4 PA-HRM; QL (120 per 30 glimepiride oral tablet 1 mg, 2 mg (Amaryl) 1 GC; QL (30 per 30 glimepiride oral tablet 4 mg (Amaryl) 1 GC; QL (60 per 30 29

31 glipizide oral tablet 10 mg (Glucotrol) 1 GC; QL (120 per 30 glipizide oral tablet 5 mg (Glucotrol) 1 GC; QL (60 per 30 glipizide oral tablet extended release 24hr (Glucotrol XL) 2 GC; QL (60 per mg glipizide oral tablet extended release 24hr (Glucotrol XL) 2 GC; QL (30 per mg, 5 mg GLUCOTROL ORAL TABLET 10 MG 4 QL (120 per 30 GLUCOTROL ORAL TABLET 5 MG 4 QL (30 per 30 GLUCOTROL XL ORAL TABLET 4 QL (60 per 30 EXTENDED RELEASE 24HR 10 MG GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 MG, 5 4 QL (30 per 30 MG glyburide oral tablet 1.25 mg (Glyburide) 2 PA-HRM; GC; QL (280 per 30 glyburide oral tablet 2.5 mg (Glyburide) 2 PA-HRM; GC; QL (240 per 30 glyburide oral tablet 5 mg (Glyburide) 2 PA-HRM; GC; QL (120 per 30 Antifungals Antifungals clotrimazole mucous membrane (Clotrimazole) 2 GC clotrimazole topical cream (Clotrimazole) 2 GC clotrimazole topical solution (Lotrimin) 2 GC clotrimazole-betamethasone topical cream (Lotrisone) 2 GC clotrimazole-betamethasone topical lotion (Clotrimazole/Betameth 2 GC asone Dip) DIFLUCAN 4 econazole topical (Econazole Nitrate) 2 GC EXTINA 4 fluconazole (Diflucan) 2 GC ketoconazole oral (Ketoconazole) 2 GC ketoconazole topical cream (Ketoconazole) 2 GC ketoconazole topical shampoo (Nizoral) 2 GC LAMISIL ORAL 4 LOTRISONE TOPICAL CREAM 4 NIZORAL TOPICAL SHAMPOO 4 30

32 nyamyc (Nystatin) 2 GC nystatin oral suspension (Nystatin) 2 GC nystatin oral tablet (Nystatin) 2 GC nystatin topical (Nystatin) 2 GC nystatin-triamcinolone (Nystatin/Triamcin) 2 GC nystop (Nystatin) 2 GC terbinafine hcl oral (Lamisil) 2 GC Antihistamines Antihistamines CLARINEX ORAL SYRUP 4 CLARINEX ORAL TABLET 4 cyproheptadine (Cyproheptadine HCl) 2 PA-HRM; GC desloratadine oral tablet (Clarinex) 2 GC desloratadine oral tablet,disintegrating (Desloratadine) 2 GC levocetirizine (Xyzal) 2 GC XYZAL 4 Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) METROGEL VAGINAL 4 metronidazole vaginal (Metrogel-Vaginal) 2 GC NUVESSA 4 TERAZOL 3 VAGINAL CREAM 4 TERAZOL 7 4 terconazole vaginal cream (Terazol 7) 2 GC terconazole vaginal suppository (Terconazole) 2 GC VANDAZOLE 4 Antimigraine Agents Antimigraine Agents ALSUMA 4 QL (4 per 28 IMITREX ORAL 4 QL (18 per 28 IMITREX STATDOSE KIT REFILL 4 QL (4 per 28 IMITREX SUBCUTANEOUS 4 QL (4 per 28 MAXALT 4 QL (18 per 28 MAXALT-MLT 4 QL (18 per 28 RELPAX 4 QL (12 per 28 rizatriptan oral tablet (Maxalt) 2 GC; QL (18 per 28 31

33 rizatriptan oral tablet,disintegrating (Maxalt Mlt) 2 GC; QL (18 per 28 sumatriptan succinate oral (Imitrex) 2 GC; QL (18 per 28 sumatriptan succinate subcutaneous (Imitrex) 2 GC; QL (4 per 28 cartridge 6 mg/0.5 ml sumatriptan succinate subcutaneous pen (Imitrex) 2 GC; QL (4 per 28 injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution (Imitrex) 2 GC; QL (4 per 28 SUMAVEL DOSEPRO 4 QL (4 per 28 Antimycobacterials Antimycobacterials dapsone (Dapsone) 2 GC ethambutol (Myambutol) 2 GC isoniazid injection (Isoniazid) 2 GC isoniazid oral solution (Isoniazid) 2 GC isoniazid oral tablet (Isoniazid) 1 GC MYAMBUTOL ORAL TABLET 400 MG 4 RIFADIN 4 rifampin intravenous (Rifadin) 2 GC rifampin oral (Rifadin) 2 GC Antinausea Agents Antinausea Agents meclizine oral tablet 12.5 mg, 25 mg (Antivert) 2 GC ondansetron (Zofran Odt) 2 PA BvD; GC phenadoz rectal suppository 12.5 mg (Phenergan) 2 PA-HRM; GC PHENERGAN 4 PA-HRM prochlorperazine maleate oral (Compazine) 1 GC promethazine injection solution 25 mg/ml (Promethazine HCl) 2 PA-HRM; GC promethazine injection solution 50 mg/ml (Phenergan) 2 PA-HRM; GC promethazine oral tablet (Promethazine HCl) 2 PA-HRM; GC promethazine rectal (Phenergan) 2 PA-HRM; GC promethegan rectal suppository 25 mg, 50 (Phenergan) 2 PA-HRM; GC mg TRANSDERM-SCOP 4 QL (10 per 30 ZOFRAN ODT 5 PA BvD ZUPLENZ 4 PA BvD 32

34 Antiparasite Agents Antiparasite Agents atovaquone-proguanil (Malarone) 2 GC hydroxychloroquine oral (Plaquenil) 2 GC MALARONE 4 MALARONE PEDIATRIC 4 mefloquine (Mefloquine HCl) 2 GC PLAQUENIL 4 TINDAMAX ORAL TABLET 500 MG 4 tinidazole (Tindamax) 2 GC Antiparkinsonian Agents Antiparkinsonian Agents benztropine injection (Cogentin) 2 PA-HRM; GC benztropine oral (Benztropine Mesylate) 2 PA-HRM; GC carbidopa-levodopa oral tablet (Sinemet ) 2 GC carbidopa-levodopa oral tablet extended (Sinemet CR) 2 GC release carbidopa-levodopa oral (Carbidopa/Levodopa) 2 GC tablet,disintegrating COGENTIN 4 PA-HRM MIRAPEX 4 MIRAPEX ER 4 pramipexole oral tablet (Mirapex) 2 GC pramipexole oral tablet extended release (Mirapex ER) 2 GC 24 hr 0.75 mg, 1.5 mg REQUIP 4 REQUIP XL 4 ropinirole oral tablet (Requip) 2 GC ropinirole oral tablet extended release 24 hr (Requip XL) 2 GC RYTARY 4 SINEMET 4 SINEMET CR 4 Antipsychotic Agents Antipsychotic Agents 33

35 ABILIFY DISCMELT ORAL 3 QL (90 per 30 TABLET,DISINTEGRATING 10 MG ABILIFY MAINTENA 5 INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA 5 QL (1 per 28 INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING ABILIFY ORAL TABLET 10 MG, 15 4 QL (30 per 30 MG, 20 MG, 30 MG, 5 MG ABILIFY ORAL TABLET 2 MG 4 QL (60 per 30 aripiprazole oral tablet 10 mg, 15 mg, 20 (Abilify) 2 GC; QL (30 per 30 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg (Abilify) 2 GC; QL (60 per 30 clozapine oral tablet 100 mg (Clozaril) 2 GC; QL (270 per 30 clozapine oral tablet 200 mg (Clozaril) 2 GC; QL (135 per 30 clozapine oral tablet 25 mg, 50 mg (Clozaril) 2 GC; QL (90 per 30 clozapine oral tablet,disintegrating (Fazaclo) 2 ST; GC CLOZARIL ORAL TABLET 100 MG 4 QL (270 per 30 CLOZARIL ORAL TABLET 25 MG 4 QL (90 per 30 FAZACLO ORAL 4 ST; QL (90 per 30 TABLET,DISINTEGRATING 100 MG, 12.5 MG, 25 MG FAZACLO ORAL TABLET,DISINTEGRATING 150 MG 4 ST; QL (180 per 30 FAZACLO ORAL TABLET,DISINTEGRATING 200 MG 4 ST; QL (120 per 30 GEODON ORAL 4 QL (60 per 30 haloperidol (Haloperidol) 2 GC olanzapine intramuscular (Zyprexa) 2 GC; QL (30 per 30 olanzapine oral tablet (Zyprexa) 2 GC; QL (30 per 30 olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis) 2 GC; QL (30 per 30 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating 20 mg (Zyprexa Zydis) 2 GC; QL (31 per 30 34

36 quetiapine (Seroquel) 2 GC; QL (90 per 30 RISPERDAL M-TAB ORAL 4 QL (60 per 30 TABLET,DISINTEGRATING 0.5 MG, 1 MG, 2 MG RISPERDAL M-TAB ORAL 4 QL (120 per 30 TABLET,DISINTEGRATING 3 MG, 4 MG RISPERDAL ORAL SOLUTION 4 QL (480 per 30 RISPERDAL ORAL TABLET 4 QL (60 per 30 risperidone oral solution (Risperdal) 2 GC; QL (480 per 30 risperidone oral tablet (Risperdal) 2 GC; QL (60 per 30 risperidone oral tablet,disintegrating 0.25 (Risperdal M-Tab) 2 GC; QL (60 per 30 mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 mg, 4 mg (Risperdal M-Tab) 2 GC; QL (120 per 30 SEROQUEL 4 QL (90 per 30 SEROQUEL XR ORAL TABLET 4 ST; QL (60 per 30 EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG 4 ST; QL (30 per 30 VERSACLOZ 5 ST; QL (540 per 30 ziprasidone hcl (Geodon) 2 GC; QL (60 per 30 ZYPREXA 4 QL (30 per 30 ZYPREXA ZYDIS 4 QL (30 per 30 Antivirals (Systemic) Antiretrovirals ATRIPLA 5 COMPLERA 5 EPZICOM 5 ISENTRESS ORAL POWDER IN 3 PACKET ISENTRESS ORAL TABLET 5 ISENTRESS ORAL 3 TABLET,CHEWABLE NORVIR 3 35

37 PREZISTA ORAL SUSPENSION 4 PREZISTA ORAL TABLET 150 MG, 75 3 MG PREZISTA ORAL TABLET 600 MG, MG REYATAZ ORAL CAPSULE 150 MG, MG, 300 MG REYATAZ ORAL POWDER IN 5 PACKET STRIBILD 5 TRUVADA 5 VIREAD 5 Antivirals, Miscellaneous SYNAGIS 5 TAMIFLU 3 Hcv Antivirals OLYSIO 5 PA; QL (28 per 28 SOVALDI 5 PA; QL (28 per 28 Interferons PEGASYS 5 PA PEGASYS PROCLICK 5 PA PEGINTRON 5 PA PEGINTRON REDIPEN 5 PA SYLATRON 5 PA NSO; QL (4 per 28 Nucleosides And Nucleotides acyclovir oral capsule (Zovirax) 2 GC acyclovir oral suspension 200 mg/5 ml (Zovirax) 2 GC acyclovir oral tablet (Zovirax) 2 GC famciclovir (Famvir) 2 GC FAMVIR 4 valacyclovir (Valtrex) 2 GC VALTREX 4 ZOVIRAX ORAL CAPSULE 4 ZOVIRAX ORAL SUSPENSION 4 Blood Products/Modifiers/Volume Expanders Anticoagulants 36

38 COUMADIN ORAL 4 enoxaparin subcutaneous solution (Lovenox) 2 GC; QL (36 per 30 enoxaparin subcutaneous syringe 100 (Lovenox) 5 QL (36 per 30 mg/ml enoxaparin subcutaneous syringe 120 (Lovenox) 5 QL (27.2 per 30 mg/0.8 ml enoxaparin subcutaneous syringe 150 (Lovenox) 5 QL (34 per 30 mg/ml enoxaparin subcutaneous syringe 30 (Lovenox) 2 GC; QL (18 per 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml (Lovenox) 2 GC; QL (13.6 per 30 enoxaparin subcutaneous syringe 60 mg/0.6 ml (Lovenox) 2 GC; QL (20.4 per 30 enoxaparin subcutaneous syringe 80 mg/0.8 ml (Lovenox) 2 GC; QL (27.2 per 30 jantoven (Coumadin) 1 GC LOVENOX SUBCUTANEOUS 4 QL (36 per 30 SOLUTION LOVENOX SUBCUTANEOUS 4 QL (36 per 30 SYRINGE 100 MG/ML LOVENOX SUBCUTANEOUS 4 QL (27.2 per 30 SYRINGE 120 MG/0.8 ML, 80 MG/0.8 ML LOVENOX SUBCUTANEOUS 4 QL (34 per 30 SYRINGE 150 MG/ML LOVENOX SUBCUTANEOUS 4 QL (18 per 30 SYRINGE 30 MG/0.3 ML LOVENOX SUBCUTANEOUS 4 QL (13.6 per 30 SYRINGE 40 MG/0.4 ML LOVENOX SUBCUTANEOUS 4 QL (20.4 per 30 SYRINGE 60 MG/0.6 ML warfarin (Coumadin) 1 GC XARELTO 3 Blood Formation Modifiers EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML 3 PA; QL (12 per 28 37

39 NEULASTA SUBCUTANEOUS 5 SYRINGE NEUPOGEN 5 PROCRIT INJECTION SOLUTION 3 PA; QL (12 per 28 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 5 PA; QL (12 per 28 20,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML 5 PA; QL (6 per 28 Hematologic Agents, Miscellaneous AGRYLIN 4 anagrelide (Agrylin) 2 GC CYKLOKAPRON 4 LYSTEDA 4 QL (30 per 30 tranexamic acid intravenous (Tranexamic Acid) 2 GC tranexamic acid oral (Lysteda) 2 GC; QL (30 per 30 Platelet-Aggregation Inhibitors cilostazol (Pletal) 2 GC clopidogrel (Plavix) 2 GC EFFIENT 3 QL (30 per 30 PLAVIX 4 PLETAL 4 Caloric Agents Caloric Agents CLINIMIX 5%-D20W(SULFITE-FREE) 4 PA BvD CLINIMIX E 4.25%/D25W SUL FREE 4 PA BvD CLINIMIX E 5%/D15W SULFIT FREE 4 PA BvD CLINIMIX E 5%/D20W SULFIT FREE 4 PA BvD CLINISOL SF 15 % 4 PA BvD dextrose 10 % in water (d10w) (Dextrose 10 % in 2 PA BvD; GC intravenous parenteral solution Water) dextrose 5 % in water (d5w) intravenous (Dextrose 5 % in Water) 2 GC parenteral solution INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % 4 PA BvD 38

40 NUTRILIPID 4 PA BvD PROSOL 20 % 4 PA BvD TRAVASOL 10 % 4 PA BvD TROPHAMINE 10 % 4 PA BvD Cardiovascular Agents Alpha-Adrenergic Agents CARDURA 4 CARDURA XL 4 CATAPRES 4 clonidine hcl oral tablet (Catapres) 1 GC doxazosin (Cardura) 2 GC guanfacine oral tablet (Tenex) 2 PA-HRM; GC TENEX 4 PA-HRM Angiotensin Ii Receptor Antagonists AVAPRO 4 ST COZAAR 4 DIOVAN 4 ST DIOVAN HCT 4 ST HYZAAR 4 irbesartan (Avapro) 2 GC losartan (Cozaar) 1 GC losartan-hydrochlorothiazide (Hyzaar) 2 GC valsartan (Diovan) 2 GC valsartan-hydrochlorothiazide (Diovan HCT) 2 GC Angiotensin-Converting Enzyme Inhibitors ALTACE 4 benazepril (Lotensin) 1 GC enalapril maleate (Vasotec) 1 GC EPANED 4 lisinopril (Zestril) 1 GC lisinopril-hydrochlorothiazide (Zestoretic) 1 GC LOTENSIN ORAL TABLET 20 MG, 40 4 MG PRINIVIL ORAL TABLET 10 MG, 20 4 MG, 5 MG ramipril (Altace) 2 GC VASOTEC 4 39

41 ZESTORETIC 4 ZESTRIL 4 Antiarrhythmic Agents amiodarone intravenous solution (Amiodarone HCl) 2 GC amiodarone oral tablet 200 mg, 400 mg (Cordarone) 2 GC flecainide (Tambocor) 2 GC pacerone oral tablet 100 mg, 200 mg, 400 mg (Cordarone) 2 GC propafenone oral capsule,extended release (Rythmol SR) 2 GC 12 hr propafenone oral tablet (Rythmol) 2 GC RYTHMOL ORAL TABLET 150 MG, 225 MG 4 RYTHMOL SR 4 Beta-Adrenergic Blocking Agents atenolol (Tenormin) 1 GC carvedilol (Coreg) 1 GC COREG 4 INDERAL LA 4 INNOPRAN XL 4 labetalol intravenous solution (Labetalol HCl) 2 GC labetalol oral (Trandate) 2 GC LOPRESSOR INTRAVENOUS 4 LOPRESSOR ORAL TABLET 100 MG 4 metoprolol succinate (Toprol XL) 2 GC metoprolol tartrate intravenous solution (Lopressor) 2 GC metoprolol tartrate oral (Lopressor) 1 GC propranolol intravenous (Propranolol HCl) 2 GC propranolol oral capsule,extended release (Inderal LA) 2 GC 24 hr propranolol oral solution (Propranolol HCl) 2 GC propranolol oral tablet (Propranolol HCl) 2 GC TENORMIN 4 TOPROL XL 4 Calcium-Channel Blocking Agents CALAN 4 CALAN SR 4 40

42 CARDIZEM CD 4 CARDIZEM LA 4 CARDIZEM ORAL TABLET 120 MG, 4 30 MG, 60 MG cartia xt (Cardizem CD) 2 GC diltiazem hcl intravenous (Cardizem CD) 2 GC diltiazem hcl oral capsule, extended (Cardizem CD) 2 GC release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended (Cardizem CD) 2 GC release 12 hr diltiazem hcl oral capsule,extended (Cardizem CD) 2 GC release 24hr diltiazem hcl oral tablet (Cardizem CD) 1 GC dilt-xr (Cardizem CD) 2 GC matzim la (Cardizem CD) 2 GC taztia xt (Cardizem CD) 2 GC TIAZAC 4 verapamil intravenous solution (Verapamil HCl) 2 GC verapamil oral capsule, 24 hr er pellet ct (Verelan Pm) 2 GC verapamil oral capsule,ext rel. pellets 24 hr (Verelan) 2 GC verapamil oral tablet (Calan SR) 1 GC verapamil oral tablet extended release (Calan SR) 2 GC VERELAN 4 VERELAN PM 4 Cardiovascular Agents, Miscellaneous digitek oral tablet 125 mcg (Lanoxin) 2 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); GC; QL (30 per 30 digitek oral tablet 250 mcg (Lanoxin) 2 PA-HRM; GC; QL (30 per 30 41

43 digox (Lanoxin) 2 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); GC; QL (30 per 30 digoxin injection (Digoxin) 2 PA-HRM; GC DIGOXIN ORAL SOLUTION 50 MCG/ML 3 PA-HRM; QL (300 per 30 digoxin oral tablet (Lanoxin) 2 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); GC; QL (30 per 30 hydralazine (Hydralazine HCl) 2 GC LANOXIN INJECTION 4 PA-HRM LANOXIN ORAL 4 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 Dihydropyridines ADALAT CC 4 afeditab cr (Adalat CC) 2 GC amlodipine (Norvasc) 1 GC amlodipine-benazepril (Lotrel) 2 GC LOTREL 4 nifedical xl (Procardia XL) 2 GC nifedipine oral capsule (Procardia) 2 PA-HRM; GC nifedipine oral tablet extended release (Adalat CC) 2 GC 24hr 30 mg nifedipine oral tablet extended release (Procardia XL) 2 GC 24hr 60 mg, 90 mg nifedipine oral tablet extended release 30 (Adalat CC) 2 GC mg NORVASC 4 PROCARDIA 4 PA-HRM 42

44 PROCARDIA XL 4 Diuretics chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) 1 GC DYAZIDE 4 furosemide injection (Furosemide) 2 GC furosemide oral solution 10 mg/ml, 40 (Furosemide) 2 GC mg/5 ml furosemide oral tablet (Lasix) 1 GC hydrochlorothiazide oral capsule (Microzide) 1 GC hydrochlorothiazide oral tablet (Hydrochlorothiazide) 1 GC LASIX 4 MAXZIDE 4 MAXZIDE-25MG 4 MICROZIDE 4 triamterene-hydrochlorothiazid oral capsule (Dyazide) 2 GC triamterene-hydrochlorothiazid oral tablet (Maxzide-25 Mg) 2 GC Dyslipidemics ALTOPREV 4 atorvastatin (Lipitor) 2 GC CRESTOR 3 ST fenofibrate oral capsule (Lipofen) 2 GC fenofibrate oral tablet 160 mg, 54 mg (Fenoglide) 2 GC FENOGLIDE 4 gemfibrozil oral (Lopid) 2 GC LIPITOR 4 LIPOFEN 4 LOFIBRA ORAL TABLET 4 LOPID 4 lovastatin (Mevacor) 1 GC PRAVACHOL 4 pravastatin (Pravachol) 1 GC simvastatin (Zocor) 1 GC; QL (30 per 30 ZOCOR 4 QL (30 per 30 Renin-Angiotensin-Aldosterone System Inhibitors ALDACTAZIDE 4 ALDACTONE 4 43

45 spironolactone (Aldactone) 2 GC spironolacton-hydrochlorothiaz (Aldactazide) 2 GC Vasodilators isosorbide mononitrate oral tablet (Isosorbide Mononitrate) 2 GC isosorbide mononitrate oral tablet (Imdur) 2 GC extended release 24 hr minitran transdermal patch 24 hour 0.1 (Nitro-Dur) 2 GC; QL (30 per 30 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 (Nitro-Dur) 2 GC; QL (60 per 30 mg/hr NITRO-BID 3 NITRO-DUR 4 nitroglycerin intravenous (Nitroglycerin) 2 GC nitroglycerin transdermal patch 24 hour (Nitro-Dur) 2 GC; QL (30 per mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour (Nitro-Dur) 2 GC; QL (60 per mg/hr nitroglycerin translingual spray,nonaerosol (Nitrolingual) 2 GC NITROLINGUAL 4 NITROMIST 4 NITROSTAT 3 Central Nervous System Agents Central Nervous System Agents ADDERALL ORAL TABLET 20 MG, 5 4 MG, 7.5 MG ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 MG, 15 MG, 5 MG ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 20 MG, 25 MG, 30 MG 4 QL (30 per 30 4 QL (60 per 30 amphetamine salt combo (Adderall) 2 GC; QL (60 per 30 CONCERTA ORAL TABLET 4 QL (30 per 30 EXTENDED RELEASE 24HR 18 MG, 27 MG, 54 MG CONCERTA ORAL TABLET EXTENDED RELEASE 24HR 36 MG 4 QL (60 per 30 44

46 dexmethylphenidate oral capsule,er (Focalin XR) 2 GC; QL (30 per 30 biphasic dexmethylphenidate oral tablet (Focalin) 2 GC; QL (60 per 30 dextroamphetamine-amphetamine oral (Adderall XR) 2 GC; QL (30 per 30 capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral (Adderall XR) 2 GC; QL (60 per 30 capsule,extended release 24hr 20 mg, 25 mg, 30 mg FOCALIN 4 QL (60 per 30 FOCALIN XR 4 QL (30 per 30 lithium carbonate oral capsule (Lithium Carbonate) 2 GC lithium carbonate oral tablet (Lithobid) 2 GC lithium carbonate oral tablet extended (Lithobid) 2 GC release LITHOBID 4 METADATE CD ORAL CAPSULE, ER 4 QL (30 per 30 BIPHASIC MG, 20 MG, 40 MG, 50 MG, 60 MG METADATE CD ORAL CAPSULE, ER 4 QL (60 per 30 BIPHASIC MG metadate er (Methylphenidate HCl) 4 QL (90 per 30 METHYLIN ORAL SOLUTION 4 QL (900 per 30 METHYLIN ORAL 4 QL (180 per 30 TABLET,CHEWABLE 10 MG METHYLIN ORAL 4 QL (90 per 30 TABLET,CHEWABLE 2.5 MG, 5 MG methylphenidate oral capsule, er biphasic (Metadate Cd) 2 GC; QL (30 per mg, 20 mg, 40 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic (Metadate Cd) 2 GC; QL (60 per mg methylphenidate oral capsule,er biphasic (Metadate Cd) 2 GC; QL (30 per mg, 40 mg methylphenidate oral capsule,er biphasic (Metadate Cd) 2 GC; QL (60 per mg methylphenidate oral solution (Methylin) 2 GC; QL (900 per 30 methylphenidate oral tablet (Ritalin) 2 GC; QL (90 per 30 45

47 methylphenidate oral tablet extended (Methylphenidate HCl) 2 GC; QL (90 per 30 release methylphenidate oral tablet extended (Concerta) 2 GC; QL (30 per 30 release 24hr 18 mg, 27 mg, 54 mg methylphenidate oral tablet extended (Concerta) 2 GC; QL (60 per 30 release 24hr 36 mg methylphenidate oral tablet,chewable 10 mg (Methylin) 2 GC; QL (180 per 30 methylphenidate oral tablet,chewable 2.5 (Methylin) 2 GC; QL (90 per 30 mg, 5 mg QUILLIVANT XR 3 RITALIN 4 QL (90 per 30 RITALIN LA ORAL CAPSULE,ER 4 QL (30 per 30 BIPHASIC MG, 20 MG, 40 MG, 60 MG RITALIN LA ORAL CAPSULE,ER BIPHASIC MG 4 QL (60 per 30 VYVANSE 4 PA; QL (30 per 30 Contraceptives Contraceptives AMETHYST 4 apri (Desogen) 2 GC aubra (Amethyst) 2 GC aviane (Amethyst) 2 GC CYCLESSA (28) 4 delyla (28) (Amethyst) 2 GC DESOGEN 4 drospirenone-ethinyl estradiol (Yaz) 2 GC emoquette (Desogen) 2 GC enpresse (Amethyst) 2 GC falmina (28) (Amethyst) 2 GC gianvi (28) (Yaz) 2 GC gildess 24 fe (Loestrin Fe) 2 GC introvale (Levonorgestrel-Ethin 2 GC; QL (91 per 84 Estradiol) junel fe 1.5/30 (28) (Loestrin Fe) 2 GC junel fe 1/20 (28) (Loestrin Fe) 2 GC junel fe 24 (Loestrin Fe) 2 GC 46

48 larin fe (Loestrin Fe) 2 GC lessina (Amethyst) 2 GC levonest (28) (Amethyst) 2 GC levonorgestrel-ethinyl estrad oral tablet (Amethyst) 2 GC mg-mcg, mcg levonorgestrel-ethinyl estrad oral tablet (Amethyst) 2 GC; QL (91 per mg levonorgestrel-ethinyl estrad oral (Amethyst) 2 GC; QL (91 per 84 tablets,dose pack,3 month levora-28 (Amethyst) 2 GC LO LOESTRIN FE 4 LOESTRIN FE 1.5/30 (28-DAY) 4 LOESTRIN FE 1/20 (28-DAY) 4 lomedia 24 fe (Loestrin Fe) 2 GC loryna (28) (Yaz) 2 GC lutera (28) (Amethyst) 2 GC marlissa (Amethyst) 2 GC microgestin fe 1.5/30 (28) (Loestrin Fe) 2 GC microgestin fe 1/20 (28) (Loestrin Fe) 2 GC MINASTRIN 24 FE 4 mononessa (28) (Ortho Tri-Cyclen) 2 GC nikki (28) (Yaz) 2 GC norethindrone-e.estradiol-iron oral tablet (Loestrin Fe) 2 GC 1 mg-20 mcg (24)/75 mg (4) ocella (Yaz) 2 GC orsythia (Amethyst) 2 GC ORTHO TRI-CYCLEN (28) 4 ORTHO TRI-CYCLEN LO (28) 4 ORTHO-CEPT (28) 4 ORTHO-CYCLEN (28) 4 portia (Amethyst) 2 GC previfem (Ortho Tri-Cyclen) 2 GC quasense (Levonorgestrel-Ethin 2 GC; QL (91 per 84 Estradiol) reclipsen (28) (Desogen) 2 GC sprintec (28) (Ortho Tri-Cyclen) 2 GC sronyx (Amethyst) 2 GC tarina fe (Loestrin Fe) 2 GC 47

49 tri-legest fe (Loestrin Fe) 2 GC trinessa (28) (Ortho Tri-Cyclen) 2 GC tri-previfem (28) (Ortho Tri-Cyclen) 2 GC tri-sprintec (28) (Ortho Tri-Cyclen) 2 GC trivora (28) (Amethyst) 2 GC velivet triphasic regimen (28) (Desogen) 2 GC vestura (28) (Yaz) 2 GC YASMIN (28) 4 YAZ (28) 4 Dental And Oral Agents Dental And Oral Agents chlorhexidine gluconate mucous (Peridex) 2 GC membrane periogard (Peridex) 2 GC triamcinolone acetonide dental (Triamcinolone 2 GC Acetonide) Dermatological Agents Dermatological Agents, Other ABSORICA 4 acyclovir topical (Zovirax) 2 GC; QL (30 per 30 ALDARA 4 PA NSO; QL (24 per 30 ammonium lactate topical (Lac-Hydrin) 2 GC amnesteem (Isotretinoin) 2 GC AZELEX 4 calcipotriene topical cream (Dovonex) 2 GC calcipotriene topical ointment (Calcipotriene) 2 GC calcipotriene topical solution (Calcipotriene) 2 GC CARAC 5 claravis (Isotretinoin) 2 GC DOVONEX TOPICAL CREAM 4 EFUDEX TOPICAL CREAM 4 FINACEA TOPICAL GEL 4 fluorouracil topical cream (Carac) 2 GC fluorouracil topical solution (Fluorouracil) 2 GC imiquimod (Aldara) 2 PA NSO; GC; QL (24 per 30 48

50 myorisan (Isotretinoin) 2 GC SORILUX 4 zenatane (Isotretinoin) 2 GC ZOVIRAX TOPICAL CREAM 3 QL (15 per 30 ZOVIRAX TOPICAL OINTMENT 4 QL (30 per 30 ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 2.5 % 4 PA NSO; QL (15 per 28 ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 3.75 % 4 PA NSO ZYCLARA TOPICAL CREAM IN PACKET 4 PA NSO Dermatological Antibacterials ACANYA 4 BACTROBAN TOPICAL OINTMENT 4 BENZACLIN 4 BENZACLIN PUMP 4 CLEOCIN T 4 CLINDACIN P 4 CLINDACIN PAC 4 CLINDAGEL 4 clindamycin phosphate topical foam (Evoclin) 2 GC clindamycin phosphate topical gel (Cleocin T) 2 GC clindamycin phosphate topical lotion (Cleocin T) 2 GC clindamycin phosphate topical solution (Cleocin T) 2 GC clindamycin phosphate topical swab (Cleocin T) 2 GC clindamycin-benzoyl peroxide topical gel (Duac) 2 GC 1-5 % EVOCLIN 4 METROCREAM 4 METROGEL TOPICAL GEL 1 % 4 METROLOTION 4 metronidazole topical cream (Metrocream) 2 GC metronidazole topical gel (Metrogel) 2 GC metronidazole topical lotion (Metrolotion) 2 GC mupirocin (Bactroban) 2 GC neuac (Duac) 2 GC NORITATE 4 49

51 ONEXTON 4 SILVADENE 4 silver sulfadiazine (Silvadene) 2 GC ssd (Silvadene) 2 GC Dermatological Anti-Inflammatory Agents ala-cort topical cream (Anusol-HC) 2 GC ala-scalp (Scalacort) 2 GC ANUSOL-HC RECTAL CREAM 4 betamethasone dipropionate (Betamethasone 2 GC Dipropionate) betamethasone, augmented topical gel (Betamethasone 2 GC Dipropionate) clobetasol topical cream (Temovate) 2 GC clobetasol topical foam (Olux) 2 GC clobetasol topical gel (Clobetasol Propionate) 2 GC clobetasol topical lotion (Clobex) 2 GC clobetasol topical ointment (Temovate) 2 GC clobetasol topical shampoo (Clobex) 2 GC clobetasol topical solution (Clobetasol Propionate) 2 GC clobetasol topical spray,non-aerosol (Clobex) 2 GC clobetasol-emollient topical cream (Temovate) 2 GC CLOBEX 4 CLODAN 4 colocort (Cortenema) 2 GC cormax topical solution (Clobetasol Propionate) 2 GC DESONATE 4 desonide topical cream (Desowen) 2 GC desonide topical lotion (Desowen) 2 GC desonide topical ointment (Desonide) 2 GC ELOCON 4 fluocinonide topical cream (Vanos) 2 GC fluocinonide topical gel (Fluocinonide) 2 GC fluocinonide topical ointment (Fluocinonide) 2 GC fluocinonide topical solution (Fluocinonide) 2 GC fluocinonide-e (Vanos) 2 GC hydrocortisone rectal enema (Cortenema) 2 GC hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) 2 GC 50

52 hydrocortisone topical lotion 2.5 % (Scalacort) 2 GC hydrocortisone topical ointment 1 %, 2.5 (Hydrocortisone) 2 GC % KENALOG TOPICAL 4 mometasone (Elocon) 2 GC OLUX 4 procto-pak (Anusol-HC) 2 GC proctosol hc (Hydrocortisone) 2 GC proctozone-hc (Hydrocortisone) 2 GC TEMOVATE TOPICAL CREAM 4 TEMOVATE TOPICAL OINTMENT 4 triamcinolone acetonide topical aerosol (Kenalog) 2 GC triamcinolone acetonide topical cream (Triamcinolone 2 GC Acetonide) triamcinolone acetonide topical lotion (Triamcinolone 2 GC Acetonide) triamcinolone acetonide topical ointment (Triamcinolone 2 GC %, 0.1 %, 0.5 % Acetonide) trianex (Triamcinolone 2 GC Acetonide) triderm topical cream (Triamcinolone Acetonide) 2 GC VANOS 5 Dermatological Retinoids adapalene topical cream (Differin) 2 GC adapalene topical gel (Differin) 2 GC ATRALIN 4 PA avita (Retin-A) 2 PA; GC DIFFERIN TOPICAL CREAM 4 DIFFERIN TOPICAL GEL 4 DIFFERIN TOPICAL LOTION 4 RETIN-A 4 PA tretinoin topical (Retin-A) 2 PA; GC Scabicides And Pediculicides malathion (Ovide) 2 GC OVIDE 4 permethrin topical cream (Elimite) 2 GC 51

53 Devices Devices BD INSULIN SYRINGE ULTRA-FINE SYRINGE 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" INSULIN SYRINGE-NEEDLE U-100 SYRINGE 1 ML 29 X 1/2", 1/2 ML 28 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers 2 GC 2 GC CREON 3 KUVAN ORAL POWDER IN PACKET MG KUVAN ORAL TABLET,SOLUBLE 5 ORFADIN 5 PANCREAZE 4 PERTZYE 4 PULMOZYME 5 PA BvD SUCRAID 5 ULTRESA 4 VIOKACE 4 ZENPEP ORAL CAPSULE,DELAYED 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, 40, , ,000 UNIT ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 5,000-17,000-27,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous ASTEPRO NASAL SPRAY,NON- 4 QL (30 per 25 AEROSOL atropine ophthalmic drops (Isopto Atropine) 2 GC ATROVENT NASAL SPRAY,NON- AEROSOL 0.03 % 4 QL (30 per

54 ATROVENT NASAL SPRAY,NON- 4 QL (15 per 10 AEROSOL 0.06 % azelastine nasal (Astepro) 2 GC; QL (30 per 25 azelastine ophthalmic (Azelastine HCl) 2 GC cromolyn ophthalmic (Cromolyn Sodium) 2 GC ipratropium bromide nasal spray,nonaerosol (Atrovent) 2 GC; QL (30 per % ipratropium bromide nasal spray,nonaerosol 0.06 % (Atrovent) 2 GC; QL (15 per 10 olopatadine (Patanase) 2 GC; QL (30.5 per 30 PATADAY 4 ST PATANASE 4 QL (30.5 per 30 PATANOL 4 ST PAZEO 4 ST Eye, Ear, Nose, Throat Anti-Infectives Agents CIPRODEX 3 CORTISPORIN OTIC SOLUTION 4 erythromycin ophthalmic (Ilotycin) 2 GC GARAMYCIN OPHTHALMIC DROPS 4 gentak ophthalmic ointment (Garamycin) 2 GC gentamicin ophthalmic (Garamycin) 2 GC ILOTYCIN 4 MAXITROL 4 MOXEZA 3 neomycin-polymyxin b-dexameth (Maxitrol) 2 GC neomycin-polymyxin-hc ophthalmic (Neomycin/Polymyxin B 2 GC Sulf/HC) neomycin-polymyxin-hc otic (Neomycin/Polymyxin B 2 GC drops,suspension Sulf/HC) neomycin-polymyxin-hc otic solution (Cortisporin) 2 GC OCUFLOX 4 ofloxacin ophthalmic (Ocuflox) 2 GC ofloxacin otic (Ocuflox) 2 GC TOBRADEX 4 TOBRADEX ST 3 tobramycin-dexamethasone (Tobradex) 2 GC 53