Table of Contents Senior Care Plus MA Drug List Formulary ID: Version: 6

Transcription

1 Table of Contents Analgesics... Anesthetics Anti-Addiction/Substance Abuse Treatment Agents Antianxiety Agents Antibacterials... 1 Anticancer Agents... 2 Anticholinergic Agents... Anticonvulsants... Antidementia Agents... 8 Antidepressants... 9 Antidiabetic Agents... 2 Antifungals... 8 Antigout Agents Antihistamines Anti-Infectives (Skin And Mucous Membrane) Antimigraine Agents Antimycobacterials Antinausea Agents Antiparasite Agents... 5 Antiparkinsonian Agents Antipsychotic Agents Antivirals (Systemic) Blood Products/Modifiers/Volume Expanders Caloric Agents Cardiovascular Agents... 7 Central Nervous System Agents Contraceptives Dental And Oral Agents Dermatological Agents Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying Immunological Agents Inflammatory Bowel Disease Agents... 1 Irrigating Solutions Metabolic Bone Disease Agents

2 Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents Vitamins And Minerals

3 Analgesics Analgesics, Miscellaneous acetaminophen-codeine 120 mg-12 mg/5 ml solution mg/5 ml acetaminophen-codeine oral solution 00 mg-0 mg /12.5 ml acetaminophen-codeine oral tablet mg, 00-0 mg acetaminophen-codeine oral tablet mg ALLZITAL ORAL TABLET MG ascomp with codeine oral capsule mg BELBUCA BUCCAL FILM 150 MCG, 00 MCG, 50 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0. mg/ml buprenorphine hcl injection syringe 0. mg/ml butalbital compound w/codeine oral capsule mg butalbital-acetaminop-caf-cod oral capsule mg, mg butalbital-acetaminophen oral tablet mg butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg butorphanol tartrate nasal spray,non-aerosol 10 mg/ml (Acetaminophen with Codeine) (Acetaminophen with Codeine) (Tylenol-Codeine No.) (Tylenol-Codeine No.) (Fiorinal with Codeine #) (Buprenorphine HCl) (Buprenorphine HCl) ; QL (2700 per 0 ; QL (2700 per 0 ; QL (60 per 0 ; QL (180 per 0 ; QL (60 per 0 ; QL (180 per 0 QL (60 per 0 (Fiorinal with Codeine #) ; QL (180 per 0 (Fioricet with Codeine) ; QL (180 per 0 (Tencon) ; QL (180 per 0 (Esgic) ; QL (180 per 0 (Esgic) ; QL (180 per 0 (Fiorinal) ; QL (180 per 0 (Butorphanol Tartrate) ; QL (5 per 28

4 BUTRANS TRANSDERMAL QL ( per 28 PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR capacet oral capsule mg (Esgic) ; QL (180 per 0 codeine sulfate oral tablet 15 mg, 0 mg, 60 mg (Codeine Sulfate) ; QL (180 per 0 EMBEDA ORAL CAPSULE,ORAL QL (60 per 0 ONLY,EXT.REL PELL 100- MG, MG, MG, 50-2 MG, MG, MG endocet oral tablet mg (Xolox) ; QL (20 per 0 endocet oral tablet mg, 5-25 mg (Xolox) ; QL (60 per 0 endocet oral tablet mg (Xolox) ; QL (00 per 0 endodan oral tablet mg (Oxycodone HCl/Aspirin) ; QL (60 per 0 fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 7.5 mcg/hour, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 72 hour 62.5 mcg/hour, 87.5 mcg/hour hydrocodone-acetaminophen oral solution mg/15 ml(15 ml), mg/5 ml, mg/15 ml hydrocodone-acetaminophen oral tablet mg, 5-00 mg, mg hydrocodone-acetaminophen oral tablet mg, mg, 5-25 mg, mg (Actiq) 5 PA; NDS; QL (120 per 0 (Duragesic) ; QL (10 per 0 (Duragesic) ; QL (10 per 0 (Hycet) ; QL (2700 per 0 (Norco) ; QL (90 per 0 (Norco) ; QL (60 per 0

5 hydrocodone-ibuprofen oral tablet mg, mg, mg (Ibudone) ; QL (150 per 0 hydromorphone (pf) injection solution 10 (Hydromorphone (mg/ml) (5 ml) HCl/PF) hydromorphone (pf) injection solution 10 (Dilaudid) mg/ml hydromorphone 10 mg/ml vial (Hydromorphone p/f,sdv,latex-f 10 mg/ml HCl/PF) hydromorphone injection solution 2 (Hydromorphone HCl) mg/ml, mg/ml hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) hydromorphone oral liquid 1 mg/ml (Dilaudid) ; QL (1200 per 0 hydromorphone oral tablet 2 mg, mg, 8 mg (Dilaudid) ; QL (180 per 0 HYSINGLA ER ORAL QL (0 per 0 TABLET,ORAL ONLY,EXT.REL.2 HR 100 MG, 120 MG, 20 MG, 0 MG, 0 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON-AEROSOL PA; NDS; QL (0 per 0 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-25 mg (Norco) ; QL (60 per 0 lorcet hd oral tablet mg (Norco) ; QL (60 per 0 lorcet plus oral tablet mg (Norco) ; QL (60 per 0 margesic oral capsule mg (Esgic) ; QL (180 per 0 methadone injection solution 10 mg/ml (Methadone HCl) methadone oral solution 10 mg/5 ml, 5 mg/5 ml (Methadone HCl) ; QL (1800 per 0 methadone oral tablet 10 mg (Diskets) ; QL (60 per 0 5

6 methadone oral tablet 5 mg (Diskets) ; QL (180 per 0 methadose oral tablet,soluble 0 mg (Diskets) ; QL (90 per 0 morphine 10 mg/ml carpuject 10 mg/ml (Morphine Sulfate) morphine 2 mg/ml carpuject outer, (Morphine Sulfate) latex-f, p/f 2 mg/ml morphine mg/ml syringe p/f, latex-free (Morphine Sulfate) mg/ml morphine 8 mg/ml syringe 8 mg/ml (Morphine Sulfate) morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) (Morphine Sulfate) ; QL (180 per 0 morphine intramuscular pen injector 10 (Morphine Sulfate) mg/0.7 ml morphine intravenous cartridge 15 mg/ml (Morphine Sulfate) morphine intravenous syringe 10 mg/ml, 2 (Morphine Sulfate) mg/ml, mg/ml, 8 mg/ml morphine oral solution 10 mg/5 ml (Morphine Sulfate) ; QL (700 per 0 morphine oral solution 20 mg/5 ml ( mg/ml) (Morphine Sulfate) ; QL (00 per 0 MORPHINE ORAL TABLET 15 MG QL (180 per 0 MORPHINE ORAL TABLET 0 MG QL (120 per 0 morphine oral tablet extended release 100 (MS Contin) ; QL (60 per 0 mg, 200 mg, 60 mg morphine oral tablet extended release 15 mg (MS Contin) ; QL (180 per 0 morphine oral tablet extended release 0 mg (MS Contin) ; QL (120 per 0 NUCYNTA ER ORAL TABLET QL (60 per 0 EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG QL (181 per 0 6

7 oxycodone oral capsule 5 mg (Oxycodone HCl) ; QL (180 per 0 oxycodone oral concentrate 20 mg/ml (Oxycodone HCl) ; QL (120 per 0 oxycodone oral solution 5 mg/5 ml (Oxycodone HCl) ; QL (100 per 0 oxycodone oral tablet 10 mg, 5 mg (Roxicodone) ; QL (180 per 0 oxycodone oral tablet 15 mg, 20 mg, 0 mg (Roxicodone) ; QL (120 per 0 oxycodone-acetaminophen oral solution 5-25 mg/5 ml (Oxycodone HCl/Acetaminophen) ; QL (1800 per 0 oxycodone-acetaminophen oral tablet mg (Xolox) ; QL (20 per 0 oxycodone-acetaminophen oral tablet mg, 5-25 mg (Xolox) ; QL (60 per 0 oxycodone-acetaminophen oral tablet mg (Xolox) ; QL (00 per 0 oxycodone-aspirin oral tablet mg (Oxycodone HCl/Aspirin) ; QL (60 per 0 OXYCONTIN ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 0 MG, 0 MG, 60 MG OXYCONTIN ORAL QL (120 per 0 TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet 10 mg (Opana) ; QL (120 per 0 oxymorphone oral tablet 5 mg (Opana) ; QL (180 per 0 oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 0 mg, 0 mg, 5 mg, 7.5 mg reprexain oral tablet mg, mg, mg (Opana ER) ; QL (60 per 0 (Ibudone) ; QL (150 per 0 7

8 tencon oral tablet mg (Tencon) ; QL (180 per 0 tramadol oral tablet 50 mg (Ultram) ; QL (20 per 0 tramadol-acetaminophen oral tablet mg (Ultracet) ; QL (20 per 0 vicodin es oral tablet mg (Norco) ; QL (90 per 0 vicodin hp oral tablet mg (Norco) ; QL (90 per 0 vicodin oral tablet 5-00 mg (Norco) ; QL (90 per 0 XARTEMIS XR ORAL TAB,ORAL QL (00 per 0 ONLY,IR - ER, BIPHASE MG XTAMPZA ER ORAL QL (60 per 0 CAPSULE,SPRINKLE,ER 12HR TMPRR 1.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (120 per 0 CAPSULE,SPRINKLE,ER 12HR TMPRR 27 MG XTAMPZA ER ORAL QL (20 per 0 CAPSULE,SPRINKLE,ER 12HR TMPRR 6 MG xylon 10 oral tablet mg (Ibudone) ; QL (150 per 0 zebutal oral capsule mg (Esgic) ; QL (180 per 0 ZOHYDRO ER ORAL CAPSULE, QL (60 per 0 ORAL ONLY, ER 12HR 10 MG, 15 MG, 20 MG, 0 MG, 0 MG, 50 MG Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 00 MG/ ML (100 MG/ML) celecoxib oral capsule 100 mg, 200 mg, 00 mg, 50 mg (Celebrex) ; QL (60 per 0 8

9 diclofenac potassium oral tablet 50 mg (Diclofenac Potassium) diclofenac sodium oral tablet extended (Voltaren-XR) release 2 hr 100 mg diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) 25 mg, 50 mg, 75 mg diclofenac sodium topical gel 1 % (Voltaren) diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mg-mcg, mg-mcg diflunisal oral tablet 500 mg (Diflunisal) etodolac oral capsule 200 mg, 00 mg (Etodolac) etodolac oral tablet 00 mg, 500 mg (Lodine) etodolac oral tablet extended release 2 (Etodolac) hr 00 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg (Fenoprofen Calcium) FLECTOR TRANSDERMAL PA PATCH 12 HOUR 1. % flurbiprofen oral tablet 100 mg, 50 mg (Flurbiprofen) ibuprofen oral suspension 100 mg/5 ml (Ibuprofen) ibuprofen oral tablet 00 mg, 600 mg, (Ibuprofen) 1 GC 800 mg indomethacin oral capsule 25 mg (Indomethacin) 1 GC; QL (20 per 0 indomethacin oral capsule 50 mg (Indomethacin) 1 GC; QL (120 per 0 indomethacin oral capsule, extended release 75 mg (Indomethacin) ; QL (60 per 0 indomethacin sodium intravenous recon (Indomethacin soln 1 mg Sodium) ketoprofen oral capsule 50 mg, 75 mg (Ketoprofen) ketoprofen oral capsule,ext rel. pellets 2 (Ketoprofen) hr 200 mg ketorolac injection cartridge 15 mg/ml (Ketorolac Tromethamine) ; QL (0 per 0 ketorolac injection cartridge 0 mg/ml (Ketorolac Tromethamine) ; QL (20 per 0 9

10 ketorolac injection solution 15 mg/ml (Ketorolac Tromethamine) ; QL (0 per 0 ketorolac injection solution 0 mg/ml (1 ml) (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac injection syringe 0 mg/ml (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac intramuscular solution 60 mg/2 ml (Ketorolac Tromethamine) ; QL (20 per 0 ketorolac oral tablet 10 mg (Ketorolac Tromethamine) ; QL (20 per 0 mefenamic acid oral capsule 250 mg (Ponstel) meloxicam oral suspension 7.5 mg/5 ml (Mobic) meloxicam oral tablet 15 mg, 7.5 mg (Mobic) 1 GC nabumetone oral tablet 500 mg, 750 mg (Nabumetone) naproxen oral suspension 125 mg/5 ml (Naprosyn) naproxen oral tablet 250 mg, 75 mg, 500 (Naprosyn) 1 GC mg naproxen oral tablet,delayed release (Ec-Naprosyn) (dr/ec) 75 mg, 500 mg naproxen sodium oral tablet 275 mg, 550 (Anaprox Ds) mg piroxicam oral capsule 10 mg, 20 mg (Feldene) sulindac oral tablet 150 mg, 200 mg (Sulindac) tolmetin oral capsule 00 mg (Tolmetin Sodium) tolmetin oral tablet 200 mg, 600 mg (Tolmetin Sodium) VOLTAREN TOPICAL GEL 1 % Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator 2 % (Lidocaine HCl) lidocaine (pf) injection solution 15 mg/ml (Xylocaine-MPF) (1.5 %), 0 mg/ml ( %), 5 mg/ml (0.5 %) lidocaine 2% viscous soln 2 % (Pre-Attached Lta Kit) lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %), 5 mg/ml (0.5 %) (Xylocaine) 10

11 lidocaine hcl mucous membrane jelly 2 % (Lidocaine HCl) lidocaine hcl mucous membrane solution (Pre-Attached Lta Kit) 2 %, % (0 mg/ml) lidocaine topical adhesive (Lidoderm) 2 PA; GC patch,medicated 5 % lidocaine topical ointment 5 % (Lidocaine) lidocaine-prilocaine topical cream % (EMLA) Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) mg (Acamprosate Calcium) BUNAVAIL BUCCAL FILM MG PA; QL (0 per 0 BUNAVAIL BUCCAL FILM MG, 6.-1 MG PA; QL (60 per 0 buprenorphine hcl sublingual tablet 2 mg, 8 mg (Buprenorphine HCl) 2 PA; GC; QL (90 per 0 buprenorphine-naloxone sublingual tablet mg, 8-2 mg (Buprenorphine HCl/Naloxone HCl) 2 PA; GC; QL (90 per 0 buproban oral tablet extended release 150 (Zyban) mg bupropion hcl (smoking deter) oral tablet (Zyban) extended release 150 mg CHANTIX CONTINUING MONTH QL (168 per 8 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (168 per 8 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (2) QL (5 per 28 disulfiram oral tablet 250 mg, 500 mg (Antabuse) naloxone injection solution 0. mg/ml (Naloxone HCl) 11

12 naloxone injection syringe 0. mg/ml, 1 (Naloxone HCl) mg/ml naltrexone oral tablet 50 mg (Revia) NARCAN NASAL QL ( per 0 SPRAY,NON-AEROSOL MG/ACTUATION NICOTROL INHALATION QL (1008 per 90 CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM 12- MG, 8-2 MG PA; QL (60 per 0 SUBOXONE SUBLINGUAL FILM MG, -1 MG PA; QL (0 per 0 ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG PA; QL (0 per 0 ZUBSOLV SUBLINGUAL TABLET MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg PA; QL (60 per 0 (Xanax) 1 GC; QL (120 per 0 alprazolam oral tablet 2 mg (Xanax) 1 GC; QL (150 per 0 alprazolam oral tablet extended release 2 hr 0.5 mg, 1 mg, 2 mg (Xanax XR) ; QL (120 per 0 alprazolam oral tablet extended release 2 hr mg (Xanax XR) ; QL (90 per 0 chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg (Chlordiazepoxide HCl) 1 GC; QL (120 per 0 clonazepam oral tablet 0.5 mg, 1 mg (Klonopin) 1 GC; QL (90 per 0 clonazepam oral tablet 2 mg (Klonopin) 1 GC; QL (00 per 0 clonazepam oral tablet,disintegrating mg, 0.25 mg, 0.5 mg, 1 mg (Clonazepam) ; QL (90 per 0 12

13 clonazepam oral tablet,disintegrating 2 mg (Clonazepam) ; QL (00 per 0 clorazepate dipotassium oral tablet 15 mg,.75 mg, 7.5 mg (Tranxene T-Tab) ; QL (180 per 0 diazepam injection solution 5 mg/ml (Diazepam) ; QL (10 per 28 diazepam intensol oral concentrate 5 mg/ml (Diazepam) ; QL (1200 per 0 diazepam oral solution 5 mg/5 ml (1 mg/ml) (Diazepam) ; QL (1200 per 0 diazepam oral tablet 10 mg, 2 mg, 5 mg (Valium) 1 GC; QL (120 per 0 diazepam rectal kit mg, (Diastat) 2.5 mg, mg estazolam oral tablet 1 mg (Estazolam) ; QL (60 per 0 estazolam oral tablet 2 mg (Estazolam) ; QL (0 per 0 flurazepam oral capsule 15 mg (Flurazepam HCl) ; QL (60 per 0 flurazepam oral capsule 0 mg (Flurazepam HCl) ; QL (0 per 0 lorazepam 2 mg/ml oral concent 2 mg/ml (Lorazepam) ; QL (150 per 0 lorazepam injection solution 2 mg/ml (Ativan) ; QL (2 per 0 lorazepam intensol oral concentrate 2 mg/ml (Lorazepam) ; QL (150 per 0 lorazepam oral tablet 0.5 mg, 1 mg (Ativan) 1 GC; QL (90 per 0 lorazepam oral tablet 2 mg (Ativan) 1 GC; QL (150 per 0 midazolam oral syrup 2 mg/ml (Midazolam HCl) ; QL (10 per 0 ONFI ORAL SUSPENSION 2.5 MG/ML 5 PA NSO; NDS; QL (80 per 0 ONFI ORAL TABLET 10 MG, 20 MG 5 PA NSO; NDS; QL (60 per 0 1

14 temazepam oral capsule 15 mg, 22.5 mg, 0 mg (Restoril) ; QL (0 per 0 temazepam oral capsule 7.5 mg (Restoril) ; QL (120 per 0 triazolam oral tablet mg (Halcion) ; QL (120 per 0 triazolam oral tablet 0.25 mg (Halcion) ; QL (60 per 0 Antibacterials Aminoglycosides BETHKIS INHALATION SOLUTION FOR NEBULIZATION 00 MG/ ML 5 PA BvD; NDS gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml (Gentamicin In Nacl, Iso-Osm) gentamicin injection solution 0 mg/ml (Gentamicin Sulfate) gentamicin ped 20 mg/2 ml vial (Gentamicin latex-free, sdv 20 mg/2 ml Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin solution 80 mg/8 ml Sulfate/PF) neomycin oral tablet 500 mg (Neomycin Sulfate) streptomycin intramuscular recon soln 1 (Streptomycin Sulfate) gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION ; QL (22 per 28 DEVICE 28 MG tobramycin in % nacl inhalation (Tobi) 5 PA BvD; NDS solution for nebulization 00 mg/5 ml tobramycin in 0.9 % nacl intravenous (Tobramycin/Sodium piggyback 60 mg/50 ml Chloride) tobramycin sulfate injection solution 10 (Tobramycin Sulfate) mg/ml, 0 mg/ml Antibacterials, Miscellaneous baciim intramuscular recon soln 50,000 unit (Bacitracin) 1

15 bacitracin intramuscular recon soln (Bacitracin) 50,000 unit chloramphenicol sod succinate (Chloramphenicol Sod intravenous recon soln 1 gram Succ) clindamycin 75 mg/5 ml soln 75 mg/5 ml (Cleocin Palmitate) clindamycin hcl oral capsule 150 mg, 00 (Cleocin HCl) mg, 75 mg clindamycin in 5 % dextrose intravenous (Cleocin Phosphate In piggyback 00 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml D5w) clindamycin pediatric oral recon soln 75 (Cleocin Palmitate) mg/5 ml clindamycin phosphate injection solution (Cleocin Phosphate) 150 (mg/ml) (6 ml), 150 mg/ml clindamycin phosphate intravenous (Cleocin Phosphate) solution 600 mg/ ml colistin (colistimethate na) injection (Coly-Mycin M recon soln 150 mg Parenteral) CUBICIN INTRAVENOUS RECON SOLN 500 MG daptomycin intravenous recon soln 500 (Cubicin) mg linezolid intravenous parenteral solution (Zyvox) 600 mg/00 ml linezolid oral suspension for (Zyvox) reconstitution 100 mg/5 ml linezolid oral tablet 600 mg (Zyvox) methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) (Metronidazole/Sodiu intravenous piggyback 500 mg/100 ml m Chloride) metronidazole oral capsule 75 mg (Flagyl) metronidazole oral tablet 250 mg, 500 mg (Flagyl) nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg (Macrodantin/Macrobi d) ; QL (120 per 0 15

16 nitrofurantoin monohyd/m-cryst oral capsule 100 mg (Macrobid) ; QL (60 per 0 nitrofurantoin oral suspension 25 mg/5 ml (Furadantin) ; QL (200 per 0 polymyxin b sulfate injection recon soln (Polymyxin B Sulfate) 500,000 unit SYNERCID INTRAVENOUS RECON SOLN 500 MG trimethoprim oral tablet 100 mg (Trimethoprim) vancomycin hcl 1g/200 ml bag 1 (Vancomycin Hcl In gram/200 ml Dextrose 5 %) vancomycin intravenous recon soln 1,000 (Vancomycin HCl) mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 (Vancomycin Hcl In mg Dextrose 5 %) vancomycin oral capsule 125 mg, 250 mg (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG 5 PA; NDS; QL (9 per 0 XIFAXAN ORAL TABLET 550 MG 5 PA; NDS Cephalosporins cefaclor oral capsule 250 mg, 500 mg (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 125 mg/5 ml, 250 mg/5 ml, 75 mg/5 ml cefaclor oral tablet extended release 12 (Cefaclor) hr 500 mg cefadroxil oral capsule 500 mg (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram (Cefadroxil) cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback 1 gram/50 ml, 2 gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram, 10 (Cefazolin Sodium) gram, 500 mg cefdinir oral capsule 00 mg (Cefdinir) cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml (Cefdinir) 16

17 cefditoren pivoxil oral tablet 200 mg, 00 (Spectracef) mg CEFEPIME 1 GM INJECTION 1 GRAM/50 ML cefepime hcl 1 gm vial 10's, sdv 1 gram (Cefepime HCl) cefepime hcl 2 gram vial latex/f, sdv, (Cefepime HCl) outer 2 gram CEFEPIME INJECTION RECON SOLN 1 GRAM, 2 GRAM CEFEPIME-DEXTROSE 2 GM/50 ML 2 GRAM/50 ML cefixime oral suspension for (Suprax) reconstitution 100 mg/5 ml, 200 mg/5 ml cefotaxime injection recon soln 1 gram, (Claforan) 10 gram, 2 gram, 500 mg cefoxitin 2 gm piggyback bag 2 gram/50 (Cefoxitin ml Sodium/Dextrose, Iso) cefoxitin 2 gm vial latex/f, outer 2 gram (Cefoxitin Sodium) cefoxitin intravenous recon soln 1 gram, (Cefoxitin Sodium) 10 gram cefoxitin intravenous recon soln 2 gram (Cefoxitin Sodium/Dextrose, Iso) cefpodoxime oral suspension for (Cefpodoxime Proxetil) reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg (Cefpodoxime Proxetil) cefprozil oral suspension for (Cefprozil) reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg (Cefprozil) ceftazidime injection recon soln 2 gram, 6 (Fortaz) gram ceftibuten oral capsule 00 mg (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 180 mg/5 ml ceftriaxone 1 gm piggyback latex-free 1 gram/50 ml (Ceftriaxone Na/Dextrose, Iso) 17

18 ceftriaxone 2 gm piggyback latex-free 2 (Ceftriaxone gram/50 ml Na/Dextrose, Iso) ceftriaxone injection recon soln 1 gram, (Ceftriaxone Sodium) 10 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln 1 (Ceftriaxone gram, 2 gram Na/Dextrose, Iso) cefuroxime axetil oral tablet 250 mg, 500 (Ceftin) mg cefuroxime sodium injection recon soln (Zinacef) 1.5 gram, 750 mg cefuroxime sodium intravenous recon soln (Zinacef) 7.5 gram cephalexin oral capsule 250 mg, 500 mg (Keflex) 1 GC cephalexin oral capsule 750 mg (Keflex) cephalexin oral suspension for (Cephalexin) 1 GC reconstitution 125 mg/5 ml, 250 mg/5 ml cephalexin oral tablet 250 mg, 500 mg (Cephalexin) 1 GC MEFOXIN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, 2 GRAM/50 ML SUPRAX ORAL CAPSULE 00 MG SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 200 MG tazicef injection recon soln 2 gram, 6 (Fortaz) gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) mg azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml (Zithromax) 18

19 azithromycin oral tablet 250 mg, 250 mg (Zithromax) (6 pack), 600 mg azithromycin oral tablet 500 mg (Zithromax) clarithromycin oral suspension for (Biaxin) reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 (Biaxin) mg clarithromycin oral tablet extended (Clarithromycin) release 2 hr 500 mg DIFICID ORAL TABLET 200 MG ; QL (20 per 10 e.e.s. 00 oral tablet 00 mg (Erythromycin Ethylsuccinate) e.e.s. granules oral suspension for (Eryped 200) reconstitution 200 mg/5 ml ery-tab oral tablet,delayed release (Erythromycin Base) (dr/ec) 250 mg, 500 mg ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 250 (Erythromycin mg Stearate) ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral (Eryped 200) suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet (Erythromycin 00 mg Ethylsuccinate) erythromycin oral capsule,delayed (Erythromycin Base) release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg (Erythromycin Base) Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, 2 gram (Azactam) 19

20 CAYSTON INHALATION 5 LA; NDS SOLUTION FOR NEBULIZATION 75 MG/ML imipenem-cilastatin intravenous recon (Primaxin) soln 250 mg, 500 mg INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 mg Penicillins amoxicillin oral capsule 250 mg, 500 mg (Amoxicillin) 1 GC amoxicillin oral suspension for (Amoxicillin) 1 GC reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 00 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg (Amoxicillin) 1 GC amoxicillin oral tablet,chewable 125 mg, (Amoxicillin) 1 GC 250 mg amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral tablet (Augmentin) mg, mg, mg amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 12 hr 1, mg amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable mg, mg Clav) ampicillin oral capsule 250 mg, 500 mg (Ampicillin Trihydrate) 1 GC ampicillin oral suspension for (Ampicillin Trihydrate) 1 GC reconstitution 125 mg/5 ml, 250 mg/5 ml ampicillin sodium injection recon soln 1 (Ampicillin Sodium) gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg ampicillin sodium intravenous recon soln (Ampicillin Sodium) 2 gram ampicillin-sulbactam 1.5 gm vl 10's,sdv,latex-free 1.5 gram (Unasyn) 20

21 ampicillin-sulbactam injection recon soln (Unasyn) 15 gram, gram ampicillin-sulbactam intravenous recon (Unasyn) soln 1.5 gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000 UNIT/ 2 ML(600K/600K), 1,200,000 UNIT/ 2 ML(900K/00K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,200,000 UNIT/2 ML, 2,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 250 mg, 500 mg (Dicloxacillin Sodium) nafcillin 2 gm vial 10's, latex-free 2 gram (Nafcillin Sodium) nafcillin injection recon soln 1 gram, 10 (Nafcillin Sodium) gram nafcillin intravenous recon soln 2 gram (Nafcillin Sodium) oxacillin 2 gm vial 10's,outer 2 gram (Oxacillin Sodium) oxacillin in dextrose(iso-osm) (Oxacillin intravenous piggyback 1 gram/50 ml, 2 gram/50 ml Sodium/Dextrose, Iso) oxacillin injection recon soln 10 gram (Oxacillin Sodium) oxacillin intravenous recon soln 2 gram (Oxacillin Sodium) penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, 2 million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe 1.2 million unit/2 ml, 600,000 unit/ml penicillin gk 20 million unit 20 million unit penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg (Pen G Pot/Dextrose-Water) (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin G Potassium) (Penicillin V Potassium) (Penicillin V Potassium) 21

22 pfizerpen-g injection recon soln 20 million (Penicillin G unit Potassium) piperacillin-tazobactam intravenous (Zosyn) recon soln 2.25 gram,.75 gram,.5 gram, 0.5 gram Quinolones ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase 2 hr 1,000 mg, 500 mg ciprofloxacin hcl oral tablet 100 mg, 250 (Cipro) 1 GC mg, 500 mg, 750 mg ciprofloxacin in 5 % dextrose intravenous (Cipro I.V.) piggyback 200 mg/100 ml, 00 mg/200 ml ciprofloxacin lactate intravenous solution (Ciprofloxacin Lactate) 200 mg/20 ml, 00 mg/0 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml levofloxacin in d5w intravenous (Levofloxacin/D5W) piggyback 250 mg/50 ml, 500 mg/100 ml, 750 mg/150 ml levofloxacin intravenous solution 25 (Levofloxacin) mg/ml levofloxacin oral solution 250 mg/10 ml (Levofloxacin) levofloxacin oral tablet 250 mg, 500 mg, (Levaquin) 1 GC 750 mg moxifloxacin oral tablet 00 mg (Avelox) ofloxacin oral tablet 00 mg (Ofloxacin) Sulfonamides sulfadiazine oral tablet 500 mg (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Tri intravenous solution mg/5 ml methoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Tri suspension mg/5 ml methoprim) sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet mg, mg sulfasalazine oral tablet 500 mg (Azulfidine) 22

23 sulfasalazine oral tablet,delayed release (dr/ec) 500 mg sulfatrim oral suspension mg/5 ml (Azulfidine) (Sulfamethoxazole/Tri methoprim) Tetracyclines demeclocycline oral tablet 150 mg, 00 (Demeclocycline HCl) mg doxy-100 intravenous recon soln 100 mg (Doxycycline Hyclate) doxycycline hyclate intravenous recon (Doxycycline Hyclate) soln 100 mg doxycycline hyclate oral capsule 100 mg, (Morgidox) 50 mg doxycycline hyclate oral tablet 100 mg, (Doryx) 20 mg doxycycline hyclate oral tablet,delayed (Doryx) release (dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule (Adoxa) 100 mg, 150 mg, 50 mg, 75 mg doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 25 mg/5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) mg, 150 mg, 50 mg, 75 mg MINOCIN INTRAVENOUS RECON SOLN 100 MG minocycline oral capsule 100 mg, 50 mg, (Minocin) 75 mg minocycline oral tablet 100 mg, 50 mg, (Minocycline HCl) 75 mg minocycline oral tablet extended release (Minocycline HCl) 2 hr 15 mg, 5 mg, 90 mg tetracycline oral capsule 250 mg, 500 mg (Tetracycline HCl) TYGACIL INTRAVENOUS RECON SOLN 50 MG 2

24 Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 100 MG ADCETRIS INTRAVENOUS RECON SOLN 50 MG 5 PA NSO; NDS; QL ( per 21 adrucil 2,500 mg/50 ml vial outer, latex-free 2.5 gram/50 ml (Fluorouracil) 2 PA BvD; GC adrucil intravenous solution 500 mg/10 ml (Fluorouracil) 2 PA BvD; GC AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, MG, 5 MG 5 PA NSO; NDS; QL (112 per 28 AFINITOR ORAL TABLET 10 MG 5 PA NSO; NDS; QL (56 per 28 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 5 PA NSO; NDS; QL (28 per 28 ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (20 per 0 ALIMTA INTRAVENOUS RECON SOLN 100 MG, 500 MG anastrozole oral tablet 1 mg (Arimidex) AVASTIN INTRAVENOUS 5 PA NSO; NDS SOLUTION 25 MG/ML, 25 MG/ML (16 ML) azacitidine injection recon soln 100 mg (Vidaza) BELEODAQ INTRAVENOUS 5 PA NSO; NDS RECON SOLN 500 MG BENDEKA INTRAVENOUS 5 PA NSO; NDS SOLUTION 25 MG/ML bexarotene oral capsule 75 mg (Targretin) 5 PA NSO; NDS; QL (20 per 0 bicalutamide oral tablet 50 mg (Casodex) bleomycin injection recon soln 15 unit, 0 unit (Bleomycin Sulfate) 2 PA BvD; GC 2

25 BLINCYTO INTRAVENOUS KIT 5 MCG 5 PA NSO; NDS; QL (10 per 65 BOSULIF ORAL TABLET 100 MG 5 PA NSO; NDS; QL (120 per 0 BOSULIF ORAL TABLET 500 MG 5 PA NSO; NDS; QL (0 per 0 CABOMETYX ORAL TABLET 20 MG, 60 MG 5 PA NSO; NDS; QL (0 per 0 CABOMETYX ORAL TABLET 0 MG 5 PA NSO; NDS; QL (60 per 0 CAPRELSA ORAL TABLET 100 MG 5 PA NSO; NDS; QL (60 per 0 CAPRELSA ORAL TABLET 00 MG 5 PA NSO; NDS; QL (0 per 0 carboplatin intravenous solution 10 (Carboplatin) mg/ml cladribine intravenous solution 10 mg/10 ml (Cladribine) 2 PA BvD; GC COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 10 MG/DAY(80 MG X1-20 MG X), 60 MG/DAY (20 MG X /DAY) 5 PA NSO; NDS; QL (112 per 28 COTELLIC ORAL TABLET 20 MG 5 PA NSO; LA; NDS; QL (6 per 28 cyclophosphamide intravenous recon soln (Cyclophosphamide) 5 PA BvD; NDS 1 gram, 2 gram, 500 mg CYCLOPHOSPHAMIDE ORAL PA BvD; ST CAPSULE 25 MG, 50 MG CYRAMZA INTRAVENOUS 5 PA NSO; NDS SOLUTION 10 MG/ML, 10 MG/ML (50 ML) DARZALEX INTRAVENOUS 5 PA NSO; LA; NDS SOLUTION 20 MG/ML decitabine intravenous recon soln 50 mg (Dacogen) docetaxel 160 mg/16 ml vial mdv, sterile,l/f 160 mg/16 ml (10 mg/ml) (Taxotere) 25

26 docetaxel intravenous solution 80 mg/ (Taxotere) ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) doxorubicin, peg-liposomal intravenous (Doxil) 5 PA BvD; NDS suspension 2 mg/ml DROXIA ORAL CAPSULE 200 MG, 00 MG, 00 MG ELIGARD ( MONTH) QL (1 per 8 SUBCUTANEOUS SYRINGE 22.5 MG ELIGARD ( MONTH) QL (1 per 112 SUBCUTANEOUS SYRINGE 0 MG ELIGARD (6 MONTH) QL (1 per 168 SUBCUTANEOUS SYRINGE 5 MG ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ORAL CAPSULE 10 MG EMPLICITI INTRAVENOUS 5 PA NSO; NDS RECON SOLN 00 MG, 00 MG ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (0 per 0 ETOPOPHOS INTRAVENOUS RECON SOLN 100 MG etoposide intravenous solution 20 mg/ml (Etoposide) exemestane oral tablet 25 mg (Aromasin) FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 5 PA NSO; NDS MG, 15 MG, 20 MG FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML floxuridine injection recon soln 0.5 gram (Floxuridine) 2 PA BvD; GC fluorouracil 5,000 mg/100 ml latex-free 5 (Fluorouracil) 2 PA BvD; GC gram/100 ml fluorouracil intravenous solution 1 (Fluorouracil) 2 PA BvD; GC gram/20 ml, 2.5 gram/50 ml, 500 mg/10 ml flutamide oral capsule 125 mg (Flutamide) 26

27 GAZYVA INTRAVENOUS 5 PA NSO; NDS SOLUTION 1,000 MG/0 ML gemcitabine intravenous recon soln 1 (Gemzar) gram, 2 gram, 200 mg gemcitabine intravenous solution 1 (Gemzar) gram/26. ml (8 mg/ml), 2 gram/52.6 ml (8 mg/ml), 200 mg/5.26 ml (8 mg/ml) GILOTRIF ORAL TABLET 20 MG, 0 MG, 0 MG 5 PA NSO; NDS; QL (0 per 0 GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG, 5 MG HERCEPTIN INTRAVENOUS 5 PA NSO; NDS RECON SOLN 0 MG HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 mg (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 5 PA NSO; NDS; QL (21 per 28 ICLUSIG ORAL TABLET 15 MG 5 PA NSO; NDS; QL (60 per 0 ICLUSIG ORAL TABLET 5 MG 5 PA NSO; NDS; QL (0 per 0 ifosfamide 1 gm/20 ml vial (Ifex) 2 PA BvD; GC sdv,p/f,latex-free 1 gram/20 ml ifosfamide intravenous recon soln 1 gram (Ifex) 2 PA BvD; GC ifosfamide-mesna intravenous kit 1-1 (Ifosfamide/Mesna) 5 PA BvD; NDS gram,,000-1,000 mg imatinib oral tablet 100 mg (Gleevec) 5 PA NSO; NDS; QL (90 per 0 imatinib oral tablet 00 mg (Gleevec) 5 PA NSO; NDS; QL (60 per 0 IMBRUVICA ORAL CAPSULE 10 5 PA NSO; NDS MG IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML 5 PA NSO; NDS; QL ( per 65 27

28 IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML 5 PA NSO; NDS; QL (8 per 28 INLYTA ORAL TABLET 1 MG 5 PA NSO; NDS; QL (180 per 0 INLYTA ORAL TABLET 5 MG 5 PA NSO; NDS; QL (60 per 0 IRESSA ORAL TABLET 250 MG 5 PA NSO; NDS; QL (60 per 0 irinotecan intravenous solution 100 mg/5 (Camptosar) ml, 0 mg/2 ml, 500 mg/25 ml IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 5 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG 5 PA NSO; NDS; QL (60 per 0 KEYTRUDA INTRAVENOUS 5 PA NSO; NDS RECON SOLN 50 MG KEYTRUDA INTRAVENOUS 5 PA NSO; NDS SOLUTION 100 MG/ ML (25 MG/ML) KYPROLIS INTRAVENOUS RECON SOLN 0 MG 5 PA NSO; NDS; QL (12 per 28 KYPROLIS INTRAVENOUS RECON SOLN 60 MG 5 PA NSO; NDS; QL (6 per 28 LARTRUVO INTRAVENOUS 5 PA NSO; LA; NDS SOLUTION 10 MG/ML LENVIMA ORAL CAPSULE 10 5 PA NSO; NDS MG/DAY (10 MG X 1/DAY), 1 MG/DAY(10 MG X 1- MG X 1), 18 MG/DAY (10 MG X 1- MG X2), 20 MG/DAY (10 MG X 2), 2 MG/DAY(10 MG X 2- MG X 1), 8 MG/DAY ( MG X 2) letrozole oral tablet 2.5 mg (Femara) LEUKERAN ORAL TABLET 2 MG leuprolide subcutaneous kit 1 mg/0.2 ml (Leuprolide Acetate) 28

29 LONSURF ORAL TABLET MG 5 PA NSO; NDS; QL (100 per 28 LONSURF ORAL TABLET MG 5 PA NSO; NDS; QL (80 per 28 LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT ; QL (1 per MG, 22.5 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT ; QL (1 per 8 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT ; QL (1 per MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG 5 PA NSO; NDS; QL (80 per 0 LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 MG/1 ML(0.16 MG/ML) FINAL 5 PA NSO; NDS; QL ( per 28 MATULANE ORAL CAPSULE 50 MG megestrol oral tablet 20 mg, 0 mg (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 MG 5 PA NSO; NDS; QL (90 per 0 MEKINIST ORAL TABLET 2 MG 5 PA NSO; NDS; QL (0 per 0 melphalan hcl intravenous recon soln 50 (Alkeran) mg mercaptopurine oral tablet 50 mg (Mercaptopurine) methotrexate sodium (pf) injection recon (Methotrexate 2 PA BvD; GC soln 1 gram Sodium/PF) methotrexate sodium (pf) injection solution 25 mg/ml (Methotrexate Sodium/PF) 2 PA BvD; GC methotrexate sodium injection solution 25 (Methotrexate Sodium) 2 PA BvD; GC mg/ml 29

30 methotrexate sodium oral tablet 2.5 mg (Methotrexate Sodium) 2 PA BvD; ST; GC mitoxantrone intravenous concentrate 2 (Mitoxantrone HCl) mg/ml NEXAVAR ORAL TABLET 200 MG 5 PA NSO; NDS; QL (120 per 0 NILANDRON ORAL TABLET 150 MG nilutamide oral tablet 150 mg (Nilandron) NINLARO ORAL CAPSULE 2. MG, MG, MG 5 PA NSO; NDS; QL ( per 28 ODOMZO ORAL CAPSULE 200 MG 5 PA NSO; LA; NDS ONCASPAR INJECTION 5 PA NSO; NDS SOLUTION 750 UNIT/ML OPDIVO INTRAVENOUS 5 PA NSO; NDS SOLUTION 100 MG/10 ML, 0 MG/ ML oxaliplatin intravenous recon soln 100 (Oxaliplatin) mg, 50 mg oxaliplatin intravenous solution 100 (Oxaliplatin) mg/20 ml, 50 mg/10 ml (5 mg/ml) paclitaxel intravenous concentrate 6 (Paclitaxel) mg/ml PERJETA INTRAVENOUS 5 PA NSO; NDS SOLUTION 20 MG/1 ML (0 MG/ML) POMALYST ORAL CAPSULE 1 MG, 2 MG, MG, MG 5 PA NSO; NDS; QL (21 per 28 PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 5 PA NSO; NDS; QL (100 per 21 MG/ML) PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT PURIXAN ORAL SUSPENSION 20 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG 5 PA NSO; LA; NDS 0

31 RITUXAN INTRAVENOUS 5 PA NSO; NDS CONCENTRATE 10 MG/ML SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 10 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NDS; QL (0 per 0 SPRYCEL ORAL TABLET 20 MG 5 PA NSO; NDS; QL (60 per 0 STIVARGA ORAL TABLET 0 MG 5 PA NSO; NDS; QL (8 per 28 SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 7.5 MG, 50 MG 5 PA NSO; NDS; QL (0 per 0 SYLVANT INTRAVENOUS RECON 5 PA NSO; NDS SOLN 100 MG, 00 MG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG 5 PA NSO; NDS; QL (28 per 28 TABLOID ORAL TABLET 0 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG 5 PA NSO; NDS; QL (120 per 0 TAGRISSO ORAL TABLET 0 MG, 80 MG 5 PA NSO; LA; NDS; QL (0 per 0 tamoxifen oral tablet 10 mg, 20 mg (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 25 MG 5 PA NSO; NDS; QL (60 per 0 TARCEVA ORAL TABLET 150 MG 5 PA NSO; NDS; QL (90 per 0 TARGRETIN ORAL CAPSULE 75 MG 5 PA NSO; NDS; QL (20 per 0 TARGRETIN TOPICAL GEL 1 % 5 PA NSO; NDS; QL (60 per 28 TASIGNA ORAL CAPSULE 150 MG, 200 MG 5 PA NSO; NDS; QL (112 per 28 TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML) TEMODAR INTRAVENOUS RECON SOLN 100 MG 5 PA NSO; NDS; QL (20 per 21 5 PA NSO; NDS 1

32 teniposide intravenous solution 50 mg/5 (Teniposide) ml thiotepa injection recon soln 15 mg (Thiotepa) toposar intravenous solution 20 mg/ml (Etoposide) topotecan hcl mg/ ml vial p/f, suv, (Hycamtin) latex-free mg/ ml (1 mg/ml) topotecan intravenous recon soln mg (Hycamtin) TORISEL INTRAVENOUS RECON SOLN 0 MG/ ML (10 MG/ML) 5 PA BvD; NDS; QL ( per 28 (FIRST) TREANDA INTRAVENOUS RECON SOLN 100 MG TRELSTAR 22.5 MG SYRINGE OUTER, L/F, SDV 22.5 MG/2 ML ; QL (1 per 168 TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG TRELSTAR INTRAMUSCULAR SYRINGE MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE.75 MG/2 ML tretinoin (chemotherapy) oral capsule 10 mg TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG (Tretinoin) ; QL (1 per 168 ; QL (1 per 8 PA BvD; ST TYKERB ORAL TABLET 250 MG UNITUXIN INTRAVENOUS 5 PA NSO; NDS SOLUTION.5 MG/ML VALSTAR INTRAVESICAL SOLUTION 0 MG/ML VECTIBIX INTRAVENOUS 5 PA NSO; NDS SOLUTION 100 MG/5 ML (20 MG/ML), 00 MG/20 ML (20 MG/ML) VELCADE INJECTION RECON SOLN.5 MG 5 PA NSO; NDS 2

33 VENCLEXTA ORAL TABLET 10 MG PA NSO; LA; QL (60 per 0 VENCLEXTA ORAL TABLET 100 MG 5 PA NSO; LA; NDS; QL (120 per 0 VENCLEXTA ORAL TABLET 50 MG PA NSO; LA; QL (0 per 0 VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 5 PA NSO; LA; NDS; QL (2 per 28 MG-50 MG- 100 MG vinblastine intravenous solution 1 mg/ml (Vinblastine Sulfate) 2 PA BvD; GC vincasar pfs 2 mg/2 ml vial 2 mg/2 ml (Vincristine Sulfate) 2 PA BvD; GC vincasar pfs intravenous solution 1 mg/ml (Vincristine Sulfate) 2 PA BvD; GC vincristine 2 mg/2 ml vial p/f, sdv 2 mg/2 (Vincristine Sulfate) 2 PA BvD; GC ml vincristine intravenous solution 1 mg/ml (Vincristine Sulfate) 2 PA BvD; GC vinorelbine intravenous solution 10 (Navelbine) mg/ml, 50 mg/5 ml VOTRIENT ORAL TABLET 200 MG 5 PA NSO; NDS; QL (120 per 0 XALKORI ORAL CAPSULE 200 MG, 250 MG 5 PA NSO; NDS; QL (60 per 0 XTANDI ORAL CAPSULE 0 MG 5 PA NSO; NDS; QL (120 per 0 YERVOY INTRAVENOUS 5 PA NSO; NDS SOLUTION 200 MG/0 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONDELIS INTRAVENOUS 5 PA NSO; NDS RECON SOLN 1 MG ZALTRAP INTRAVENOUS 5 PA NSO; NDS SOLUTION 100 MG/ ML (25 MG/ML), 200 MG/8 ML (25 MG/ML) ZELBORAF ORAL TABLET 20 MG 5 PA NSO; NDS; QL (20 per 0 ZOLADEX SUBCUTANEOUS QL (1 per 8 IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT.6 MG QL (1 per 28

34 ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG 5 PA NSO; NDS; QL (60 per 0 ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NDS; QL (10 per 28 ZYTIGA ORAL TABLET 250 MG 5 PA NSO; NDS; QL (120 per 0 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) mg/ml propantheline oral tablet 15 mg (Propantheline Bromide) Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 200 MG, 00 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 0 MG/ML BANZEL ORAL TABLET 200 MG, 00 MG BRIVIACT INTRAVENOUS QL (80 per 0 SOLUTION 50 MG/5 ML BRIVIACT ORAL SOLUTION 10 QL (600 per 0 MG/ML BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG ; QL (60 per 0 carbamazepine oral capsule, er (Carbatrol) multiphase 12 hr 100 mg, 200 mg, 00 mg carbamazepine oral suspension 100 mg/5 (Tegretol) ml carbamazepine oral tablet 200 mg (Tegretol) carbamazepine oral tablet extended (Tegretol XR) release 12 hr 100 mg, 200 mg, 00 mg carbamazepine oral tablet,chewable 100 mg (Carbamazepine)

35 CELONTIN ORAL CAPSULE 00 MG DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, sprinkle 125 mg (Depakote Sprinkle) divalproex oral tablet extended release 2 (Depakote ER) hr 250 mg, 500 mg divalproex oral tablet,delayed release (Depakote) (dr/ec) 125 mg, 250 mg, 500 mg epitol oral tablet 200 mg (Tegretol) ethosuximide oral capsule 250 mg (Zarontin) ethosuximide oral solution 250 mg/5 ml (Zarontin) felbamate oral suspension 600 mg/5 ml (Felbatol) felbamate oral tablet 00 mg, 600 mg (Felbatol) fosphenytoin injection solution 100 mg (Cerebyx) pe/2 ml, 500 mg pe/10 ml FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, MG, 6 MG, 8 MG gabapentin oral capsule 100 mg, 00 mg, (Neurontin) 00 mg gabapentin oral solution 250 mg/5 ml (Neurontin) gabapentin oral tablet 600 mg, 800 mg (Neurontin) GABITRIL ORAL TABLET 12 MG, 16 MG GRALISE 0-DAY STARTER PACK ST; QL (78 per 0 ORAL TABLET EXTENDED RELEASE 2 HR 00 MG (9)- 600 MG (69) GRALISE ORAL TABLET ST; QL (90 per 0 EXTENDED RELEASE 2 HR 00 MG, 600 MG lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg (Lamictal) 5

36 lamotrigine oral tablet disintegrating, dose pk 25 mg (21) -50 mg (7), 25 mg(1)-50 mg (1)-100 mg (7), 50 mg (2) -100 mg (1) lamotrigine oral tablet extended release 2hr 100 mg, 200 mg, 25 mg, 250 mg, 00 mg, 50 mg lamotrigine oral tablet, chewable dispersible 25 mg, 5 mg lamotrigine oral tablet,disintegrating 100 mg, 200 mg, 25 mg, 50 mg lamotrigine oral tablets,dose pack 25 mg (5) levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml levetiracetam intravenous solution 500 mg/5 ml (Lamictal Odt (Blue)) (Lamictal XR) (Lamictal) (Lamictal Odt) (Lamictal (Blue)) (Levetiracetam In Nacl (Iso-Os)) (Keppra) levetiracetam oral solution 100 mg/ml (Keppra) levetiracetam oral tablet 1,000 mg, 250 (Roweepra) mg, 500 mg, 750 mg levetiracetam oral tablet extended release (Keppra XR) 2 hr 500 mg, 750 mg LYRICA ORAL CAPSULE 100 MG, QL (90 per MG, 200 MG, 225 MG, 25 MG, 00 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 QL (900 per 0 MG/ML oxcarbazepine oral suspension 00 mg/5 (Trileptal) ml oxcarbazepine oral tablet 150 mg, 00 (Trileptal) mg, 600 mg OXTELLAR XR ORAL TABLET EXTENDED RELEASE 2 HR 150 MG, 00 MG, 600 MG PEGANONE ORAL TABLET 250 MG 6

37 phenobarbital oral elixir 20 mg/5 ml ( mg/ml) (Phenobarbital) ; QL (1500 per 0 phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 2. mg, 60 mg, 6.8 mg, 97.2 (Phenobarbital) ; QL (90 per 0 mg phenobarbital oral tablet 0 mg (Phenobarbital) ; QL (200 per 0 phenytoin oral suspension 125 mg/5 ml (Dilantin-125) phenytoin oral tablet,chewable 50 mg (Dilantin) phenytoin sodium extended oral capsule (Dilantin) 100 mg, 200 mg, 00 mg phenytoin sodium intravenous solution 50 (Phenytoin Sodium) mg/ml phenytoin sodium intravenous syringe 50 (Phenytoin Sodium) mg/ml POTIGA ORAL TABLET 200 MG, 00 MG, 00 MG ; QL (90 per 0 POTIGA ORAL TABLET 50 MG ; QL (270 per 0 primidone oral tablet 250 mg, 50 mg (Mysoline) ROWEEPRA ORAL TABLET 500 MG SABRIL ORAL POWDER IN PACKET 500 MG SABRIL ORAL TABLET 500 MG SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG ST; QL (60 per 0 SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG tiagabine oral tablet 2 mg, mg (Gabitril) topiramate oral capsule, sprinkle 15 mg, (Topamax) 25 mg topiramate oral capsule,sprinkle,er 2hr 100 mg, 150 mg, 200 mg, 25 mg, 50 mg (Qudexy XR) ST; QL (120 per 0 7

38 topiramate oral tablet 100 mg, 200 mg, (Topamax) 25 mg, 50 mg TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 2HR 100 MG, 200 MG, 25 MG, 50 MG valproate sodium intravenous solution (Depacon) 500 mg/5 ml (100 mg/ml) valproic acid (as sodium salt) oral (Depakene) solution 250 mg/5 ml valproic acid oral capsule 250 mg (Depakene) VIMPAT INTRAVENOUS QL (200 per 5 SOLUTION 200 MG/20 ML VIMPAT ORAL SOLUTION 10 MG/ML ; QL (1200 per 0 VIMPAT ORAL TABLET 100 MG, QL (60 per MG, 200 MG, 50 MG zonisamide oral capsule 100 mg, 25 mg, (Zonegran) 50 mg Antidementia Agents Antidementia Agents donepezil oral tablet 10 mg, 2 mg, 5 mg (Aricept) ; QL (0 per 0 donepezil oral tablet,disintegrating 10 mg, 5 mg (Donepezil HCl) ; QL (0 per 0 galantamine oral capsule,ext rel. pellets 2 hr 16 mg, 2 mg, 8 mg (Razadyne ER) ; QL (0 per 0 galantamine oral solution mg/ml (Galantamine Hbr) ; QL (200 per 0 galantamine oral tablet 12 mg, mg, 8 mg (Razadyne) ; QL (60 per 0 memantine oral solution 2 mg/ml (Namenda) ; QL (60 per 0 memantine oral tablet 10 mg, 5 mg (Namenda) ; QL (60 per 0 8

39 memantine oral tablets,dose pack 5-10 mg NAMENDA XR ORAL CAP,SPRINKLE,ER 2HR DOSE PACK MG NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 2HR 1 MG, 21 MG, 28 MG, 7 MG NAMZARIC ORAL CAP,SPRINKLE,ER 2HR DOSE PACK 7/1/21/28 MG-10 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER 2HR 1-10 MG, MG, MG, 7-10 MG rivastigmine tartrate oral capsule 1.5 mg, mg,.5 mg, 6 mg rivastigmine transdermal patch 2 hour 1. mg/2 hour,.6 mg/2 hr, 9.5 mg/2 hr Antidepressants Antidepressants amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg BRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG (Namenda) ; QL (9 per 28 QL (28 per 28 QL (0 per 0 QL (56 per 65 QL (0 per 0 (Exelon) ; QL (60 per 0 (Exelon) ; QL (0 per 0 (Amitriptyline HCl) (Amoxapine) bupropion hcl oral tablet 100 mg, 75 mg (Wellbutrin) bupropion hcl oral tablet extended release 100 mg, 150 mg, 200 mg (Wellbutrin SR) bupropion hcl oral tablet extended release (Wellbutrin XL) 2 hr 150 mg, 00 mg citalopram oral solution 10 mg/5 ml (Citalopram Hydrobromide) ; QL (600 per 0 citalopram oral tablet 10 mg, 20 mg, 0 mg (Celexa) 1 GC; QL (0 per 0 9

40 clomipramine oral capsule 25 mg, 50 mg, (Anafranil) 75 mg desipramine oral tablet 10 mg, 100 mg, (Norpramin) 150 mg, 25 mg, 50 mg, 75 mg doxepin oral capsule 10 mg, 100 mg, 150 (Doxepin HCl) mg, 25 mg, 50 mg, 75 mg doxepin oral concentrate 10 mg/ml (Doxepin HCl) duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Irenka) ; (Cymbalta); QL (60 per 0 duloxetine oral capsule,delayed release(dr/ec) 0 mg (Irenka) ; (Cymbalta); QL (0 per 0 duloxetine oral capsule,delayed release(dr/ec) 0 mg (Irenka) ; (Irenka); QL (0 per 0 EMSAM TRANSDERMAL PATCH 2 HOUR 12 MG/2 HR, 6 MG/2 ; QL (0 per 0 HR, 9 MG/2 HR escitalopram oxalate oral solution 5 mg/5 (Lexapro) ml escitalopram oxalate oral tablet 10 mg, (Lexapro) 1 GC 20 mg, 5 mg FETZIMA ORAL CAPSULE,EXT REL 2HR DOSE PACK 20 MG (2)- 0 MG (26) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 2 HR 120 MG, 20 MG, 0 MG, 80 MG fluoxetine oral capsule 10 mg, 20 mg, 0 (Prozac) 1 GC mg fluoxetine oral capsule,delayed (Prozac Weekly) release(dr/ec) 90 mg fluoxetine oral solution 20 mg/5 ml ( (Fluoxetine HCl) mg/ml) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral capsule,extended release 2hr 100 mg, 150 mg (Fluvoxamine Maleate) 0

41 fluvoxamine oral tablet 100 mg, 25 mg, (Fluvoxamine Maleate) 50 mg imipramine hcl oral tablet 10 mg, 25 mg, 50 mg (Tofranil) imipramine pamoate oral capsule 100 mg, (Tofranil-Pm) 125 mg, 150 mg, 75 mg maprotiline oral tablet 25 mg, 50 mg, 75 (Maprotiline HCl) mg MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15 mg, 0 mg, 5 (Remeron) mg, 7.5 mg mirtazapine oral tablet,disintegrating 15 (Remeron) mg, 0 mg, 5 mg nefazodone oral tablet 100 mg, 150 mg, (Nefazodone HCl) 200 mg, 250 mg, 50 mg nortriptyline oral capsule 10 mg, 25 mg, (Pamelor) 50 mg, 75 mg nortriptyline oral solution 10 mg/5 ml (Nortriptyline HCl) olanzapine-fluoxetine oral capsule (Symbyax) mg, mg, -25 mg, 6-25 mg, 6-50 mg paroxetine hcl oral tablet 10 mg, 20 mg, (Paxil) 1 GC 0 mg paroxetine hcl oral tablet 0 mg (Paxil) paroxetine hcl oral tablet extended (Paxil CR) release 2 hr 12.5 mg, 25 mg, 7.5 mg PAXIL ORAL SUSPENSION 10 MG/5 ML perphenazine-amitriptyline oral tablet (Perphenazine/Amitript 2-10 mg, 2-25 mg, -10 mg, -25 mg, -50 mg yline HCl) phenelzine oral tablet 15 mg (Nardil) PRISTIQ ORAL TABLET QL (0 per 0 EXTENDED RELEASE 2 HR 100 MG, 25 MG, 50 MG protriptyline oral tablet 10 mg, 5 mg (Protriptyline HCl) 1

42 sertraline oral concentrate 20 mg/ml (Zoloft) sertraline oral tablet 100 mg, 25 mg, 50 (Zoloft) 1 GC mg SURMONTIL ORAL CAPSULE 100 MG, 25 MG, 50 MG tranylcypromine oral tablet 10 mg (Parnate) trazodone oral tablet 100 mg, 150 mg, 00 mg, 50 mg (Trazodone HCl) 1 GC trimipramine oral capsule 100 mg, 25 mg, (Trimipramine 50 mg Maleate) TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG venlafaxine oral capsule,extended release (Effexor XR) 2hr 150 mg, 7.5 mg, 75 mg venlafaxine oral tablet 100 mg, 25 mg, (Venlafaxine HCl) 7.5 mg, 50 mg, 75 mg venlafaxine oral tablet extended release (Venlafaxine HCl) 2hr 150 mg, 7.5 mg, 75 mg venlafaxine oral tablet extended release (Venlafaxine HCl) 2hr 225 mg VIIBRYD ORAL TABLET 10 MG, 20 MG, 0 MG VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG (2) Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100 mg, 25 mg, 50 mg (Precose) ; QL (90 per 0 alogliptin oral tablet 12.5 mg, 25 mg, (Nesina) QL (0 per mg alogliptin-metformin oral tablet ,000 mg, mg (Kazano) QL (60 per 0 alogliptin-pioglitazone oral tablet (Oseni) QL (0 per 0 mg, mg, mg, mg, 25-0 mg, 25-5 mg 2

43 CYCLOSET ORAL TABLET 0.8 MG QL (180 per 0 GLYXAMBI ORAL TABLET 10-5 ST; QL (0 per 0 MG, 25-5 MG INVOKAMET ORAL TABLET ST; QL (60 per ,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG ST; QL (120 per 0 INVOKAMET XR ORAL TABLET, ST; QL (60 per 0 IR - ER, BIPHASIC 2HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 ST; QL (60 per 0 MG INVOKANA ORAL TABLET 00 ST; QL (0 per 0 MG JANUMET ORAL TABLET 50-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 2 HR 100-1,000 MG, 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 ST; QL (0 per 0 MG, 25 MG JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 2HR 2.5-1,000 MG, 5-1,000 MG KAZANO ORAL TABLET ,000 QL (60 per 0 MG, MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 2 HR 2.5-1,000 MG, 5-1,000 MG, MG QL (0 per 0