Express Scripts Medicare (PDP) 2016 Formulary (List of Covered Drugs)

Transcription

1 Express Scripts Medicare (PDP) 206 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN Formulary ID Number: 6082, v5 This formulary was updated on 08//205. For more recent information or other questions, please contact Express Scripts Medicare (PDP) Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at Note to current members: This formulary has changed since last year. Please review this document to understand your plan s drug coverage. When this drug list (formulary) refers to we, us or our, it means Medco Containment Life Insurance Company. When it refers to plan or our plan, it means Express Scripts Medicare. This document includes the list of the covered drugs (formulary) for our plan, which is current as of August, 205. For more recent information, please contact us. Our contact information, along with the date we last updated the formulary, appears above and on the back cover. You must use network pharmacies to fill your prescriptions to get the most from your benefit. Benefits, premium and/or copayments/coinsurance may change on January, 207. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call Express Scripts Medicare Customer Service at the numbers on the back of your member ID card for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Llame al Servicio al cliente de Express Scripts Medicare a los números que figuran al dorso de su tarjeta de identificación de miembro para obtener información adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana. This document is available in braille. Please contact Customer Service if you need plan information in another format. EME969 CRP5_00 F0PA3Z6A

2 What is the Express Scripts Medicare formulary? The list of drugs covered by the plan is also known as the formulary. It contains a list of highly utilized Medicare Part D drugs selected by Express Scripts Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The formulary also includes information on requirements or limits for some covered drugs that are part of Express Scripts Medicare s standard formulary rules. Your specific plan may provide coverage of additional drugs that are not listed in this formulary, and your plan may have different plan rules and coverage. For more information on your plan s specific drug coverage, please review your other plan materials, visit us on the Web at or contact Customer Service. Express Scripts Medicare will generally cover a drug as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your other plan materials. Can my drug coverage change? Generally, if you are taking a drug covered by your plan in 206, Express Scripts Medicare will not discontinue or reduce coverage of the drug during the 206 coverage year, except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our plan s coverage, will not affect members who are currently taking the drug. It will remain available at the same copayment or coinsurance amount for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If Express Scripts Medicare removes drugs from your plan s coverage, adds prior authorization, quantity limits, and/or step therapy restrictions on a drug, or moves a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective. If the Food and Administration (FDA) determines that a drug we cover is unsafe, or if the drug s manufacturer removes the drug from the market, we will immediately stop covering the drug and provide notice to members who are taking the drug. This enclosed formulary is current as of the date indicated on the front cover. To get updated information about the drugs covered, please visit us on the Web or contact our Customer Service department using the information provided on the front and back covers of this formulary. If there are any additional changes made to this plan s drug coverage that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time after the changes take effect. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category Cardiovascular, Hypertension/Lipids. i

3 Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 0. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the Name column of the list. What are generic drugs? Both brand-name drugs and generic drugs are covered under this plan. A generic drug is approved by the FDA as having the same active ingredient(s) as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: You or your doctor is required to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don t get approval, the drugs may not be covered. These drugs are noted with PA next to them in the formulary. Some drugs may be covered under Part B or under Part D, depending on your medical condition. Your doctor will need to get a prior authorization for these drugs as well, so your pharmacy can process your prescription correctly. Quantity : For certain drugs, the amount of the drug that will be covered by the plan is limited. The plan may limit how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. These drugs are noted with QL next to them in the formulary. Step Therapy: In some cases, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. These drugs are noted with ST next to them in the formulary. You may be able to find out if your drug has any additional requirements or limits by looking in the drug list that begins on page. Note: This drug list includes all possible restrictions and limits on coverage. The requirements and limits may not apply to your plan s specific coverage. To confirm whether a particular drug is covered, visit us on the Web at or contact Customer Service. You can ask us to make an exception to these restrictions or limits. See the section How do I request an exception to the formulary? on the following page for information about how to request an exception. ii

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

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

6 Other coverage that your plan may provide Your plan may also cover categories of excluded drugs that are not normally covered by a Medicare prescription drug plan and are not listed in the formulary. s in the following categories may be covered subject to the rules and limitations of your specific plan: Prescription drugs when used for anorexia, weight loss or weight gain Prescription drugs when used to promote fertility Prescription drugs when used for cosmetic purposes or to promote hair growth Prescription drugs when used for the symptomatic relief of cough or colds Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are considered Part D drugs) s, such as CAVERJECT, CIALIS, EDEX, LEVITRA, MUSE and VIAGRA, when used for the treatment of sexual or erectile dysfunction Over-the-counter (OTC) diabetic supplies Federal Legend Part B medications for example, oral chemotherapy agents (e.g., TEMODAR, XELODA ) Non-prescription drugs, also known as over-the-counter (OTC) drugs Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale. Please contact Customer Service for additional information about your plan s specific drug coverage and your cost-sharing amount. Please note: Costs for excluded drugs not normally covered by a Medicare prescription drug plan will not count toward your Medicare prescription drug yearly deductible (if applicable), total drug costs or yearly out-of-pocket expenses. Formulary The formulary that begins on page provides coverage information about some of the drugs covered by this plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 0. The Name column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR ) and generic drugs are listed in lowercase italics (e.g., atorvastatin). The information in the column tells you if there are any special requirements for coverage of that particular drug. If you are not sure whether your drug is covered, please visit our website or contact Customer Service using the information provided on the front and back covers of this formulary. Your Costs The amount you pay for a covered drug will depend on: Your coverage stage. Your plan has different stages of coverage. In each stage, the amount you pay for a drug may change. Please refer to your other plan documents for more information about your specific prescription drug benefit. The drug tier for your drug. Each covered drug is in one of three drug tiers. Each tier may have a different cost-sharing amount. The s chart on the following page explains what types of drugs are included in each tier and shows how costs may change with each tier. v

7 Your other plan materials have more information about your plan s coverage stages and list the specific cost-sharing amounts for each tier. s Includes Helpful tips : Generic s 2: Preferred Brand s 3: Non-Preferred Brand s This tier includes many commonly prescribed generic drugs and may include other low-cost drugs. This tier includes preferred brand-name drugs as well as some generic drugs. This tier includes non-preferred brand-name drugs as well as some generic drugs. Use drugs for the lowest cost-sharing amount. s in this tier will generally have lower cost-sharing amounts than non-preferred brand drugs. Many non-preferred drugs have lower-cost alternatives in s and 2. Ask your doctor if switching to a lower-cost generic or preferred brand-name drug may be right for you. If you qualify for Extra Help If you qualify for Extra Help from Medicare to help pay for your prescription drugs, your cost-sharing amounts may be lower than your plan s standard benefit. Members who qualify for Extra Help will receive a notice called Important Information for Those Who Receive Extra Help Paying for Their Prescription s ( Low Income Rider or LIS Rider ). Please read it to find out what your costs are. You can also contact Customer Service with any questions using the information listed on the front and back covers of this formulary. For more information For more detailed information about your Medicare prescription drug coverage and your plan s specific costs, please review your other plan materials. If you need additional information on network pharmacies or if you have any other questions, please contact our Customer Service department using the information provided on the front and back covers of this formulary. If you have general questions about Medicare prescription drug coverage, please call Medicare at.800.medicare ( ), 24 hours a day, 7 days a week. TTY users should call Or visit vi

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

9 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 2 PA; MO AMBISOME 2 PA; MO amphotericin b PA; MO ANCOBON CANCIDAS 2 PA; MO clotrimazole mucous membrane CRESEMBA CRESEMBA ORAL DIFLUCAN ERAXIS(WATER DILUENT) RECON SOLN 00 2 fluconazole fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml flucytosine griseofulvin microsize griseofulvin ultramicrosize GRIS-PEG (ULTRAMICROSIZ E) itraconazole Name ketoconazole oral LAMISIL ORAL GRANULES IN PACKET LAMISIL ORAL TABLET MYCAMINE NOXAFIL ORAL nystatin oral suspension nystatin oral tablet ONMEL ; QL (30 per SPORANOX ORAL CAPSULE SPORANOX ORAL SOLUTION SPORANOX PULSEPAK terbinafine hcl oral VFEND VFEND IV voriconazole ANTIVIRALS abacavir abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml

10 Name acyclovir oral tablet acyclovir sodium intravenous solution PA; MO adefovir amantadine hcl oral APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION BARACLUDE ORAL TABLET 2 cidofovir PA; MO COMBIVIR COMPLERA COPEGUS CRIXIVAN ORAL CAPSULE 200, 400 CYTOVENE didanosine EDURANT EMTRIVA entecavir EPIVIR EPIVIR HBV ORAL SOLUTION EPIVIR HBV ORAL TABLET EPZICOM Name EVOTAZ famciclovir FAMVIR FLUMADINE ORAL TABLET foscarnet PA; MO FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium HARVONI 3 PA; MO; QL (28 per 28 days) HEPSERA INTELENCE ORAL TABLET 00, 200 INTELENCE ORAL TABLET 25 INVIRASE ISENTRESS KALETRA lamivudine lamivudinezidovudine 2 LEXIVA moderiba moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) nevirapine NORVIR 2

11 Name OLYSIO 3 PA; MO; QL (28 per 28 days) PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 50, 600, 75, 800 REBETOL ORAL CAPSULE REBETOL ORAL SOLUTION RELENZA DISKHALER RESCRIPTOR RETROVIR RETROVIR ORAL CAPSULE RETROVIR ORAL SYRUP REYATAZ ORAL CAPSULE 50, 200, 300 REYATAZ ORAL POWDER IN PACKET ribasphere ribasphere ribapak oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) Name ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY SOVALDI 2 PA; MO; QL (28 per 28 days) stavudine STRIBILD SUSTIVA SYNAGIS INTRAMUSCULA R SOLUTION 50 /0.5 ML ; LA TAMIFLU TIVICAY TRIUMEQ TRIZIVIR TRUVADA TYBOST TYZEKA valacyclovir ; QL (30 per VALCYTE ORAL RECON SOLN VALCYTE ORAL TABLET valganciclovir VALTREX ; QL (30 per 3

12 Name VIDEX 2 GRAM PEDIATRIC VIDEX EC VIEKIRA PAK 2 PA; MO; QL (2 per 28 days) VIRACEPT ORAL TABLET VIRAMUNE VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 00 VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 400 VIRAZOLE VIREAD VISTIDE 3 PA VITEKTA ZERIT ZIAGEN ORAL SOLUTION ZIAGEN ORAL TABLET zidovudine ZOVIRAX ORAL CAPSULE ZOVIRAX ORAL SUSPENSION CEPHALOSPORINS Name CEDAX ORAL CAPSULE CEDAX ORAL SUSPENSION FOR RECONSTITUTIO N 80 /5 ML CEDAX ORAL SUSPENSION FOR RECONSTITUTIO N 90 /5 ML cefaclor oral capsule cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 2 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 4 3 cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln gram, 500 mg cefazolin injection recon soln 0 gram cefdinir

13 Name cefditoren pivoxil oral tablet 200 mg cefepime CEFEPIME IN DEXTROSE 5 % cefixime cefotaxime injection recon soln gram, 2 gram, 500 mg cefotetan cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln gram cefoxitin intravenous recon soln 0 gram, 2 gram cefpodoxime cefprozil CEFTAZIDIME IN D5W ceftazidime injection recon soln gram, 2 gram ceftazidime injection recon soln 6 gram CEFTIN ORAL SUSPENSION FOR RECONSTITUTIO N CEFTIN ORAL TABLET 250, 500 ceftriaxone injection recon soln 0 gram 3 Name ceftriaxone injection recon soln 250 mg, 500 mg ceftriaxone intravenous recon soln cefuroxime axetil oral tablet cefuroxime sodium injection recon soln.5 gram, 750 mg cefuroxime sodium intravenous cephalexin CLAFORAN INJECTION RECON SOLN GRAM, 0 GRAM, 2 GRAM CLAFORAN INJECTION RECON SOLN 500 CLAFORAN RECON SOLN FORTAZ INJECTION RECON SOLN 2 GRAM FORTAZ INJECTION RECON SOLN 6 GRAM FORTAZ

14 Name KEFLEX ORAL CAPSULE MAXIPIME INJECTION SPECTRACEF ORAL TABLET 400 SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 00 /5 ML, 200 /5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 /5 ML SUPRAX ORAL TABLET,CHEWAB LE TAZICEF INJECTION RECON SOLN GRAM TAZICEF INJECTION RECON SOLN 2 GRAM, 6 GRAM 3 3 TEFLARO ZERBAXA 3 ZINACEF INJECTION RECON SOLN.5 GRAM Name ZINACEF INJECTION RECON SOLN 750 ZINACEF RECON SOLN 7.5 GRAM ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 500 mg azithromycin intravenous recon soln 500 mg (2 mg/ml) 3 3 azithromycin oral BIAXIN ORAL SUSPENSION FOR RECONSTITUTIO N 250 /5 ML BIAXIN ORAL TABLET clarithromycin DIFICID e.e.s. 400 oral tablet E.E.S. GRANULES ERYPED 200 ERYPED 400 ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg 6

15 Name ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN RECON SOLN 500 erythromycin ethylsuccinate oral tablet erythromycin oral tablet 2 PCE ZITHROMAX ZITHROMAX TRI- PAK ZITHROMAX Z- PAK ZMAX MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 500 mg/2 ml atovaquone atovaquoneproguanil AZACTAM IN DEXTROSE (ISO- OSM) 2 Name AZACTAM INJECTION RECON SOLN GRAM aztreonam injection recon soln gram baciim bacitracin intramuscular BETHKIS 2 PA; MO; QL (224 per 28 days) BILTRICIDE CAPASTAT 3 CAYSTON ; LA; QL (84 per 28 days) chloramphenicol sod succinate chloroquine phosphate oral CLEOCIN IN 5 % DEXTROSE PIGGYBACK 300 /50 ML, 600 /50 ML CLEOCIN IN 5 % DEXTROSE PIGGYBACK 900 /50 ML CLEOCIN INJECTION 3 CLEOCIN ORAL clindamycin hcl 7

16 Name clindamycin in 5 % dextrose clindamycin pediatric clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM colistin (colistimethate na) CUBICIN DALVANCE 3 DAPSONE DARAPRIM DORIBAX RECON SOLN 500 ethambutol FLAGYL FLAGYL ER gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml 3 Name gentamicin injection solution 40 mg/ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid injection isoniazid oral ivermectin oral KETEK LINCOCIN linezolid intravenous linezolid oral MALARONE MALARONE PEDIATRIC mefloquine MEPRON meropenem intravenous recon soln 500 mg MERREM RECON SOLN 500 metronidazole in nacl (iso-os) metronidazole oral 8

17 Name MYAMBUTOL ORAL TABLET 400 MYCOBUTIN NEBUPENT 2 PA; MO; QL (6 per 28 days) neomycin paromomycin PASER PENTAM PLAQUENIL polymyxin b sulfate PRIFTIN PRIMAQUINE PRIMAXIN IV pyrazinamide QUALAQUIN quinine sulfate rifabutin RIFADIN RIFAMATE rifampin intravenous rifampin oral RIFATER SIRTURO ; LA SIVEXTRO SIVEXTRO ORAL STREPTOMYCIN INTRAMUSCULA R 3 Name STROMECTOL SYNERCID 2 TINDAMAX ORAL TABLET 500 tinidazole TOBI 3 PA; MO; QL (280 per 28 days) TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in % nacl tobramycin in 0.9 % nacl intravenous piggyback 80 mg/00 ml tobramycin sulfate injection solution ; QL (224 per 28 days) PA; MO; QL (280 per 28 days) TRECATOR TYGACIL XIFAXAN ZYVOX PARENTERAL SOLUTION 600 /300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTIO N ZYVOX ORAL TABLET PENICILLINS 9

18 Name amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate ampicillin ampicillin sodium injection recon soln gram, 0 gram, 25 mg ampicillin-sulbactam injection recon soln 5 gram ampicillin-sulbactam injection recon soln 3 gram ampicillin-sulbactam intravenous recon soln.5 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N /5 ML BICILLIN C-R BICILLIN L-A dicloxacillin Name nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml nafcillin injection recon soln gram, 0 gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml oxacillin injection recon soln 0 gram oxacillin intravenous recon soln 2 gram PENICILLIN G POT IN DEXTROSE PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml 2 penicillin g sodium 0

19 Name penicillin v potassium piperacillintazobactam intravenous recon soln gram, 4.5 gram UNASYN INJECTION RECON SOLN 5 GRAM UNASYN INJECTION RECON SOLN 3 GRAM ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO- OSM) PIGGYBACK GRAM/50 ML ZOSYN RECON SOLN GRAM QUINOLONES 3 2 AVELOX AVELOX ABC PACK AVELOX IN NACL (ISO-OSMOTIC) Name CIPRO IN D5W PIGGYBACK 400 /200 ML CIPRO ORAL SUSPENSION,MIC ROCAPSULE RECON CIPRO ORAL TABLET 250, 500 ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/00 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml 3 FACTIVE LEVAQUIN ORAL levofloxacin in d5w intravenous piggyback 500 mg/00 ml levofloxacin intravenous levofloxacin oral moxifloxacin ofloxacin oral tablet 400 mg

20 Name SULFA'S / RELATED AGENTS BACTRIM BACTRIM DS sulfadiazine oral sulfamethoxazoletrimethoprim TETRACYCLINES ADOXA ORAL CAPSULE 3 ST; MO demeclocycline oral doxy-00 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg, 20 mg doxycycline hyclate oral tablet 50 mg doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet Name MINOCIN ORAL CAPSULE 00, 50 3 ST; MO minocycline oral ORACEA 3 ST; MO SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 05, 5, 55, 65, 80 3 ST; MO tetracycline VIBRAMYCIN ORAL CAPSULE 00 VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTIO N VIBRAMYCIN ORAL SYRUP 3 ST; MO URINARY TRACT AGENTS FURADANTIN HIPREX MACROBID MACRODANTIN ORAL CAPSULE 00, 50 MACRODANTIN ORAL CAPSULE 25 methenamine hippurate 2

21 Name MONUROL nitrofurantoin macrocrystal oral capsule 00 mg, 50 mg nitrofurantoin monohyd/m-cryst nitrofurantoin oral PRIMSOL trimethoprim VANCOMYCIN VANCOCIN vancomycin intravenous recon soln,000 mg, 0 gram, 500 mg vancomycin oral capsule ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 250 mg ELITEK RECON SOLN.5 FUSILEV KEPIVANCE 2 2 Name leucovorin calcium injection recon soln 00 mg, 350 mg leucovorin calcium oral LEVOLEUCOVORI N CALCIUM mesna MESNEX MESNEX ORAL XGEVA ZINECARD (AS HCL) RECON SOLN ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE adrucil intravenous solution 500 mg/0 ml AFINITOR DISPERZ AFINITOR ORAL TABLET 0 AFINITOR ORAL TABLET 2.5, 5, 7.5 ALIMTA RECON SOLN PA; MO 2 PA; MO; QL (60 per 2 PA; MO 3

22 Name ALKERAN anastrozole ARIMIDEX AROMASIN ARRANON 2 ARZERRA SOLUTION 00 /5 ML 3 2 PA; MO ASTAGRAF XL 3 PA; MO AVASTIN azacitidine AZASAN 3 PA; MO azathioprine PA; MO BELEODAQ bicalutamide BICNU bleomycin injection recon soln 30 unit BOSULIF ORAL TABLET 00 BOSULIF ORAL TABLET 500 BUSULFEX 2 CAMPTOSAR SOLUTION 00 /5 ML CAPRELSA ORAL TABLET 00 2 PA; MO 2 PA; MO; QL (30 per 2 PA; MO; LA; QL (90 per 30 days) Name CAPRELSA ORAL TABLET 300 carboplatin intravenous solution 2 PA; MO; LA; QL (30 per 30 days) CASODEX CELLCEPT CELLCEPT ORAL CAPSULE CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N CELLCEPT ORAL TABLET 2 PA; MO 3 PA; MO 2 PA; MO 3 PA; MO cisplatin cladribine CLOLAR COMETRIQ 2 PA; MO COSMEGEN CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule 2 PA; MO PA PA; MO PA; MO cytarabine 4

23 Name cytarabine (pf) injection solution 2 gram/20 ml (00 mg/ml) dacarbazine intravenous recon soln 200 mg DACOGEN daunorubicin intravenous solution DAUNOXOME decitabine DOCEFREZ RECON SOLN 20 docetaxel intravenous solution 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (0 mg/ml) 2 DOXIL doxorubicin intravenous solution 50 mg/25 ml DROXIA ELIGARD 3 PA; MO ELLENCE SOLUTION 200 /00 ML ELOXATIN SOLUTION 00 /20 ML EMCYT Name epirubicin intravenous solution 50 mg/25 ml ERBITUX SOLUTION 00 /50 ML ERIVEDGE 2 PA; MO; QL (30 per ERWINAZE ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 0 FARYDAK ORAL CAPSULE 5, 20 FASLODEX FEMARA FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fluorouracil intravenous solution 2.5 gram/50 ml 3 PA; MO; QL (2 per 2 days) 3 PA; MO; QL (6 per 2 days) flutamide 5

24 Name FOLOTYN SOLUTION 40 /2 ML (20 /ML) gemcitabine intravenous recon soln gram GEMZAR RECON SOLN GRAM gengraf PA; MO GILOTRIF ORAL TABLET 20 GILOTRIF ORAL TABLET 30 GILOTRIF ORAL TABLET 40 GLEEVEC ORAL TABLET 00 GLEEVEC ORAL TABLET PA; MO; QL (60 per 2 PA; MO; QL (40 per 2 PA; MO; QL (30 per 2 PA; MO GLEOSTINE HALAVEN HERCEPTIN HEXALEN HYCAMTIN 2 PA; MO; QL (60 per HYDREA hydroxyurea IBRANCE 2 PA; MO; QL (2 per 28 days) Name ICLUSIG ORAL TABLET 5 ICLUSIG ORAL TABLET 45 IDAMYCIN PFS idarubicin IFEX RECON SOLN GRAM ifosfamide intravenous recon soln gram 2 PA; MO; QL (90 per 2 PA; MO; QL (30 per IMBRUVICA 2 PA; MO; QL (20 per IMURAN 3 PA; MO INLYTA ORAL TABLET INLYTA ORAL TABLET 5 irinotecan intravenous solution 00 mg/5 ml 2 PA; MO 2 PA; MO; QL (20 per ISTODAX IXEMPRA RECON SOLN 45 JAKAFI ORAL TABLET 0, 5, 20, 5 JAKAFI ORAL TABLET 25 2 PA; MO JEVTANA 2 PA; MO; QL (60 per 6

25 Name KADCYLA RECON SOLN 00 KEYTRUDA RECON SOLN LENVIMA 2 PA; MO letrozole LEUKERAN leuprolide LOMUSTINE LUPRON DEPOT 2 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED INTRAMUSCULA R KIT.25, 5 2 PA; MO 2 PA; MO 2 PA; MO 2 PA; MO LYNPARZA 2 PA; MO LYSODREN MATULANE MEGACE MEGACE ES megestrol oral suspension 400 mg/0 ml (40 mg/ml) megestrol oral tablet Name MEKINIST ORAL TABLET 0.5 MEKINIST ORAL TABLET 2 melphalan hcl mercaptopurine methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium oral mitomycin intravenous recon soln 20 mg 2 PA; MO; QL (20 per 2 PA; MO; QL (30 per PA PA; MO PA; MO mitoxantrone MUSTARGEN mycophenolate mofetil mycophenolate sodium PA; MO PA; MO MYFORTIC 3 PA; MO NEORAL 3 PA; MO NEXAVAR 2 PA; MO; LA; QL (20 per 30 days) NILANDRON NIPENT NULOJIX 2 PA; MO octreotide acetate injection solution 7

26 Name ONCASPAR OPDIVO SOLUTION 40 /4 ML oxaliplatin intravenous solution 00 mg/20 ml paclitaxel PERJETA POMALYST PROGRAF 2 PA; MO PROGRAF ORAL 3 PA; MO PURIXAN RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET 2 PA; MO 3 PA; MO REVLIMID 2 PA; MO; LA RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 (DOSE PACK 2), 2.5 (DOSE PACK 6), 2.5 (DOSE PACK 20), 2.5 (DOSE PACK 8) 3 PA; MO 3 PA RITUXAN 2 PA; MO Name SANDIMMUNE SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION 3 PA; MO 3 PA; MO 2 PA; MO SANDOSTATIN SANDOSTATIN LAR DEPOT INTRAMUSCULA R KIT SIGNIFOR SIGNIFOR LAR SIMULECT RECON SOLN 20 2 PA; MO sirolimus PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 00, 20, 50, 80 SPRYCEL ORAL TABLET 40 SPRYCEL ORAL TABLET 70 2 PA; MO 2 PA; MO; QL (30 per 2 PA; MO; QL (60 per STIVARGA 2 PA; MO; QL (84 per 28 days) SUTENT ORAL CAPSULE PA; MO 8

27 Name SUTENT ORAL CAPSULE 25, 37.5 SUTENT ORAL CAPSULE 50 SYLVANT RECON SOLN 00 2 PA; MO; QL (60 per 2 PA; MO; QL (30 per SYNRIBO TABLOID tacrolimus oral PA; MO TAFINLAR ORAL CAPSULE 50 TAFINLAR ORAL CAPSULE 75 tamoxifen TARCEVA ORAL TABLET 00, 25 TARCEVA ORAL TABLET 50 2 PA; MO; QL (80 per 2 PA; MO; QL (20 per 2 PA; MO TARGRETIN TASIGNA ORAL CAPSULE 50 TASIGNA ORAL CAPSULE 200 TAXOTERE SOLUTION 80 /4 ML (20 /ML) 2 PA; MO; QL (30 per 2 PA; MO 2 PA; MO; QL (2 per 28 days) THALOMID 2 PA; MO toposar Name topotecan intravenous recon soln TORISEL TREANDA RECON SOLN 00 TREANDA SOLUTION 45 /0.5 ML TRELSTAR DEPOT TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N TRELSTAR INTRAMUSCULA R SYRINGE.25 /2 ML, 3.75 /2 ML TRELSTAR LA 2 tretinoin (chemotherapy) 2 TREXALL 3 PA; MO TRISENOX TYKERB 2 PA; MO; LA; QL (80 per 30 days) 9

28 Name VECTIBIX SOLUTION 00 /5 ML (20 /ML) 2 PA; MO VELCADE VIDAZA vinblastine intravenous solution vincasar pfs intravenous solution mg/ml vincristine intravenous solution mg/ml vinorelbine intravenous solution 50 mg/5 ml VOTRIENT 2 PA; MO; QL (20 per XALKORI ORAL CAPSULE 200 XALKORI ORAL CAPSULE PA; MO 2 PA; MO; QL (60 per XTANDI 2 PA; MO; QL (20 per YERVOY SOLUTION 50 /0 ML (5 /ML) ZALTRAP SOLUTION 00 /4 ML (25 /ML) Name ZANOSAR ZELBORAF 2 PA; MO; QL (240 per ZOLINZA ZORTRESS 2 PA; MO ZYDELIG 2 PA; MO; QL (90 per ZYKADIA 2 PA; MO; QL (50 per ZYTIGA 2 PA; MO; QL (20 per AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM BANZEL carbamazepine oral capsule, er multiphase 2 hr carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 2 hr carbamazepine oral tablet,chewable CARBATROL CELONTIN ORAL CAPSULE

29 Name CEREBYX INJECTION SOLUTION 500 PE/0 ML clonazepam PA; MO DEPACON DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLES 3 DIASTAT 3 PA; MO DIASTAT ACUDIAL 3 PA; MO diazepam rectal PA; MO DILANTIN 30 DILANTIN EXTENDED 00 DILANTIN INFATABS 50 DILANTIN /5 ML divalproex epitol EQUETRO ethosuximide felbamate FELBATOL fosphenytoin injection solution 00 mg pe/2 ml Name FYCOMPA gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 2, 6 GABITRIL ORAL TABLET 2, 4 GRALISE 2 PA; MO GRALISE 30-DAY STARTER PACK 2 PA; MO KEPPRA ORAL KEPPRA XR KLONOPIN 3 PA; MO LAMICTAL ODT LAMICTAL ORAL TABLET LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25, 5 LAMICTAL STARTER (BLUE) KIT LAMICTAL STARTER (GREEN) KIT 2

30 Name LAMICTAL STARTER (ORANGE) KIT LAMICTAL XR LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating LEVETIRACETAM IN NACL (ISO-OS) PIGGYBACK,000 /00 ML,,500 /00 ML LEVETIRACETAM IN NACL (ISO-OS) PIGGYBACK 500 /00 ML levetiracetam intravenous levetiracetam oral solution 00 mg/ml 2 Name levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA 2 PA; MO MYSOLINE NEURONTIN 3 PA; MO ONFI ORAL SUSPENSION ONFI ORAL TABLET 0, 20 2 PA; MO 2 PA; MO oxcarbazepine OXTELLAR XR PEGANONE phenobarbital oral elixir phenobarbital oral tablet 00 mg phenobarbital oral tablet 5 mg, 6.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg 22 PHENYTEK phenytoin oral suspension 25 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended

31 Name phenytoin sodium intravenous solution POTIGA primidone QUDEXY XR 3 PA; MO SABRIL ; LA TEGRETOL ORAL SUSPENSION TEGRETOL ORAL TABLET TEGRETOL XR ORAL TABLET EXTENDED RELEASE 2 HR 00 TEGRETOL XR ORAL TABLET EXTENDED RELEASE 2 HR 200, 400 tiagabine TOPAMAX 3 PA; MO topiramate oral capsule, sprinkle TOPIRAMATE ORAL CAPSULE,SPRINK LE,ER 24HR topiramate oral tablet PA; MO 3 PA; MO PA; MO TRILEPTAL TROKENDI XR 3 PA; MO valproate sodium valproic acid Name valproic acid (as sodium salt) oral solution 250 mg/5 ml VIMPAT VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 2 ZARONTIN ZONEGRAN ORAL CAPSULE 00, 25 3 PA; MO zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone COGENTIN COMTAN DUOPA 3 PA; MO ELDEPRYL entacapone LODOSYN MIRAPEX MIRAPEX ER 23

32 Name NEUPRO pramipexole oral tablet pramipexole oral tablet extended release 24 hr 0.75 mg,.5 mg REQUIP REQUIP XL ropinirole RYTARY selegiline hcl SINEMET SINEMET CR STALEVO 00 STALEVO 25 STALEVO 50 STALEVO 200 STALEVO 50 STALEVO 75 TASMAR ORAL TABLET 00 tolcapone ZELAPAR MIGRAINE / CLUSTER HEADACHE THERAPY ALSUMA ; QL (6 per 28 days) AMERGE ; QL (8 per 28 days) AXERT ORAL TABLET 2.5 ; QL (24 per 28 days) Name AXERT ORAL TABLET 6.25 CAFERGOT dihydroergotamine injection dihydroergotamine nasal ; QL (8 per 28 days) ERGOMAR ; QL (8 per 28 days) FROVA ; QL (27 per 28 days) IMITREX NASAL SPRAY,NON- AEROSOL 20 /ACTUATION IMITREX NASAL SPRAY,NON- AEROSOL 5 /ACTUATION ; QL (8 per 28 days) ; QL (36 per 28 days) IMITREX ORAL ; QL (8 per 28 days) IMITREX STATDOSE KIT REFILL IMITREX SUBCUTANEOUS ; QL (6 per 28 days) ; QL (6 per 28 days) MAXALT ; QL (36 per 28 days) MAXALT-MLT ; QL (36 per 28 days) migergot MIGRANAL ; QL (8 per 28 days) naratriptan ; QL (8 per 28 days) 24

33 Name RELPAX ; QL (8 per 28 days) rizatriptan ; QL (36 per 28 days) sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution SUMAVEL DOSEPRO ; QL (8 per 28 days) ; QL (36 per 28 days) ; QL (8 per 28 days) ; QL (6 per 28 days) ; QL (6 per 28 days) ; QL (9 per 28 days) TREXIMET ; QL (8 per 28 days) zolmitriptan ; QL (8 per 28 days) ZOMIG ; QL (8 per 28 days) ZOMIG ZMT ; QL (8 per 28 days) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 2 PA; MO; LA ARICEPT AUBAGIO 3 PA; MO Name COPAXONE SUBCUTANEOUS SYRINGE 20 /ML COPAXONE SUBCUTANEOUS SYRINGE 40 /ML donepezil EXELON ORAL CAPSULE EXELON TRANSDERMAL 3 PA; MO; QL (30 per 2 PA; MO; QL (2 per 28 days) galantamine GILENYA 2 PA; MO glatopa PA; MO; QL (30 per HORIZANT 3 PA; MO NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET NAMENDA TITRATION PAK 2 PA; MO 3 PA; MO 3 PA; MO NAMENDA XR 2 PA; MO NUEDEXTA RAZADYNE ER RAZADYNE ORAL TABLET rivastigmine tartrate TECFIDERA 2 PA; MO TYSABRI 2 PA; MO; LA XENAZINE 2 PA; MO; LA 25

34 Name MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen DANTRIUM ORAL CAPSULE 25, 50 dantrolene GABLOFEN INTRATHECAL SOLUTION 0,000 MCG/20ML (500 MCG/ML), 40,000 MCG/20ML (2,000 MCG/ML) GABLOFEN INTRATHECAL SYRINGE 50 MCG/ML ( ML) LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP MESTINON ORAL TABLET MESTINON TIMESPAN pyridostigmine bromide oral tablet 3 PA; MO 3 PA; MO 2 PA; MO 2 PA tizanidine Name ZANAFLEX NARCOTIC ANALGESICS ABSTRAL SUBLINGUAL TABLET 00 MCG, 200 MCG, 300 MCG ABSTRAL SUBLINGUAL TABLET 400 MCG ABSTRAL SUBLINGUAL TABLET 600 MCG ABSTRAL SUBLINGUAL TABLET 800 MCG acetaminophencodeine oral solution 300 mg-30 mg /2.5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg 3 PA; MO; QL (20 per 3 PA; MO; QL (6 per 3 PA; MO; QL (77 per 3 PA; MO; QL (58 per QL (4500 per 30 days) ; QL (360 per ; QL (80 per ACTIQ 3 PA; MO; QL (20 per BUPRENEX ; QL (267 per buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg QL (267 per 30 days) ; QL (300 per 26

35 Name buprenorphine hcl sublingual tablet 8 mg ; QL (75 per BUTRANS ; QL (4 per 28 days) CAPITAL WITH CODEINE codeine sulfate oral tablet DILAUDID (PF) INJECTION SOLUTION 2 /ML DILAUDID (PF) INJECTION SOLUTION 4 /ML DILAUDID ORAL LIQUID DILAUDID ORAL TABLET DILAUDID-HP (PF) INJECTION SOLUTION DOLOPHINE ORAL TABLET 0 DOLOPHINE ORAL TABLET 5 DURAGESIC TRANSDERMAL PATCH 72 HOUR 00 MCG/HR ; QL (4500 per ; QL (80 per ; QL (50 per ; QL (75 per ; QL (500 per ; QL (80 per 3 QL (30 per 30 days) ; QL (20 per ; QL (240 per ; QL (9 per Name DURAGESIC TRANSDERMAL PATCH 72 HOUR 2 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution mg/ml EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL 00-4 EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL , 30-.2, 50-2, EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL endocet oral tablet mg, mg, mg ; QL (0 per ; QL (4000 per QL (2000 per 30 days) ; QL (60 per ; QL (90 per ; QL (75 per ; QL (360 per endodan ; QL (360 per EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 2, 6, 8 ; QL (60 per 27

36 Name EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 32 fentanyl citrate buccal lozenge on a handle,200 mcg fentanyl citrate buccal lozenge on a handle,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg fentanyl transdermal patch 72 hour 00 mcg/hr fentanyl transdermal patch 72 hour 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR, 87.5 MCG/HOUR ; QL (47 per PA; MO; QL (39 per PA; MO; QL (29 per PA; MO; QL (20 per PA; MO; QL (6 per PA; MO; QL (77 per PA; MO; QL (58 per ; QL (9 per ; QL (0 per ; QL (0 per Name FENTORA BUCCAL TABLET, EFFERVESCENT 00 MCG, 200 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 400 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 600 MCG FENTORA BUCCAL TABLET, EFFERVESCENT 800 MCG 3 PA; MO; QL (20 per 3 PA; MO; QL (6 per 3 PA; MO; QL (77 per 3 PA; MO; QL (58 per HYCET ; QL (5550 per hydrocodoneacetaminophen oral solution mg/5 ml hydrocodoneacetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodoneibuprofen oral tablet mg hydromorphone (pf) injection solution 0 mg/ml hydromorphone oral liquid ; QL (5550 per ; QL (360 per ; QL (50 per ; QL (20 per ; QL (500 per 28

37 Name hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 2 mg, 6 mg, 8 mg hydromorphone oral tablet extended release 24 hr 32 mg HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 00, 20, 30, 40, 60, 80 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL.24 HR 20 IBUDONE ORAL TABLET ; QL (80 per ; QL (60 per ; QL (47 per ; QL (60 per ; QL (50 per ; QL (50 per ibuprofen-oxycodone ; QL (28 per KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 0, 20, 30, 40, 50, 60 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 00 ; QL (90 per ; QL (60 per Name KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 200 KADIAN ORAL CAPSULE,EXTEN D.RELEASE PELLETS 80 ; QL (30 per ; QL (75 per LAZANDA 3 PA; MO; QL (23 per levorphanol tartrate ; QL (20 per lorcet (hydrocodone) ; QL (360 per lorcet hd ; QL (360 per lorcet plus oral tablet mg ; QL (360 per lortab ; QL (360 per lortab ; QL (360 per lortab ; QL (360 per methadone injection QL (60 per 30 days) methadone oral solution 0 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 0 mg methadone oral tablet 5 mg ; QL (600 per ; QL (200 per ; QL (20 per ; QL (240 per 29

38 Name morphine concentrate oral solution MORPHINE SYRINGE 0 /ML morphine intravenous syringe 2 mg/ml morphine intravenous syringe 4 mg/ml MORPHINE SYRINGE 8 /ML morphine oral capsule, er multiphase 24 hr 20 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.relea se pellets 0 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.relea se pellets 00 mg morphine oral capsule,extend.relea se pellets 80 mg ; QL (300 per 3 QL (200 per 30 days) QL (000 per 30 days) QL (500 per 30 days) 3 QL (250 per 30 days) ; QL (50 per ; QL (60 per ; QL (90 per ; QL (60 per ; QL (75 per Name morphine oral solution ; QL (900 per morphine oral tablet ; QL (80 per morphine oral tablet extended release 00 mg morphine oral tablet extended release 5 mg, 30 mg morphine oral tablet extended release 200 mg morphine oral tablet extended release 60 mg MS CONTIN ORAL TABLET EXTENDED RELEASE 00 MS CONTIN ORAL TABLET EXTENDED RELEASE 5, 30 MS CONTIN ORAL TABLET EXTENDED RELEASE 200 MS CONTIN ORAL TABLET EXTENDED RELEASE 60 ; QL (60 per ; QL (20 per ; QL (30 per ; QL (00 per ; QL (60 per ; QL (20 per ; QL (30 per ; QL (00 per NORCO ; QL (360 per 30

39 Name OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 0, 5, 20, 5, 7.5 OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 30 OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 40 OPANA ORAL TABLET 0 OPANA ORAL TABLET 5 oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 0 mg, 5 mg, 20 mg oxycodone oral tablet 30 mg oxycodone oral tablet 5 mg OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 0, 20, 40 ; QL (90 per ; QL (67 per ; QL (50 per ; QL (200 per ; QL (80 per ; QL (360 per ; QL (80 per ; QL (200 per ; QL (80 per ; QL (34 per ; QL (360 per ; QL (90 per Name OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 80 oxycodoneacetaminophen oral tablet mg, mg, mg, mg ; QL (60 per ; QL (360 per oxycodone-aspirin ; QL (360 per OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 0, 5, 20, 30, 40 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 60 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 80 oxymorphone oral tablet 0 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 2 hr 0 mg, 5 mg, 20 mg, 5 mg, 7.5 mg ; QL (90 per ; QL (67 per ; QL (50 per ; QL (200 per ; QL (80 per ; QL (90 per 3

40 Name oxymorphone oral tablet extended release 2 hr 30 mg oxymorphone oral tablet extended release 2 hr 40 mg PERCOCET ORAL TABLET 0-325, , 5-325, ; QL (67 per ; QL (50 per ; QL (360 per PERCODAN ; QL (360 per PRIMLEV ; QL (360 per reprexain ; QL (50 per ROXICET ORAL SOLUTION ROXICODONE ORAL TABLET 5 ROXICODONE ORAL TABLET 30 ROXICODONE ORAL TABLET 5 SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 00 MCG/SPRAY, 200 MCG/SPRAY ; QL (800 per ; QL (80 per ; QL (34 per ; QL (360 per 3 PA; MO; LA; QL (20 per 30 days) Name SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 400 MCG/SPRAY SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 600 MCG/SPRAY SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 800 MCG/SPRAY 3 PA; MO; LA; QL (84 per 30 days) 3 PA; MO; LA; QL (56 per 30 days) 3 PA; MO; LA; QL (42 per 30 days) SYNALGOS-DC ; QL (300 per TREZIX ORAL CAPSULE TYLENOL- CODEINE #3 TYLENOL- CODEINE #4 vicodin es oral tablet mg vicodin hp oral tablet mg vicodin oral tablet mg ; QL (300 per ; QL (360 per ; QL (80 per ; QL (360 per ; QL (360 per ; QL (360 per VICOPROFEN ; QL (50 per XARTEMIS XR ; QL (20 per XODOL 0/300 ; QL (360 per 32

41 Name XODOL 5/300 ; QL (360 per XODOL 7.5/300 ; QL (360 per zamicet QL (5550 per 30 days) ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 2HR ; QL (90 per NON-NARCOTIC ANALGESICS ANAPROX ANAPROX DS ARTHROTEC 50 ARTHROTEC 75 BUNAVAIL BUCCAL FILM BUNAVAIL BUCCAL FILM , 6.3- buprenorphinenaloxone sublingual tablet mg buprenorphinenaloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution mg/ml butorphanol tartrate injection solution 2 mg/ml 3 PA; MO; QL (30 per 3 PA; MO; QL (60 per PA; MO; QL (360 per PA; MO; QL (90 per ; QL (720 per ; QL (360 per Name butorphanol tartrate nasal ; QL (5 per 28 days) CAMBIA 3 ST; MO; QL (9 per CELEBREX celecoxib CONZIP ; QL (30 per DAYPRO diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenacmisoprostol diflunisal DUEXIS 3 ST; MO EC-NAPROSYN etodolac EVZIO ; QL (0.8 per FELDENE fenoprofen oral tablet FLECTOR 3 PA; MO; QL (60 per flurbiprofen ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg 33

42 Name ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg meclofenamate oral mefenamic acid meloxicam oral suspension meloxicam oral tablet 5 mg meloxicam oral tablet 7.5 mg MOBIC ORAL SUSPENSION MOBIC ORAL TABLET 5 MOBIC ORAL TABLET 7.5 ; QL (30 per nabumetone nalbuphine injection solution 0 mg/ml nalbuphine injection solution 20 mg/ml naloxone injection syringe mg/ml ; QL (30 per ; QL (200 per ; QL (00 per naltrexone oral NAPRELAN CR 3 ST; MO NAPROSYN ORAL TABLET naproxen naproxen sodium oral tablet 275 mg, 550 mg Name naproxen sodium oral tablet, er multiphase 24 hr NUCYNTA ER ; QL (60 per NUCYNTA ORAL TABLET 00 NUCYNTA ORAL TABLET 50 NUCYNTA ORAL TABLET 75 oxaprozin PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP ; QL (8 per ; QL (362 per ; QL (242 per 3 ST; MO piroxicam PONSTEL SPRIX 3 ST; MO SUBOXONE SUBLINGUAL FILM 2-3 SUBOXONE SUBLINGUAL FILM SUBOXONE SUBLINGUAL FILM 4-, 8-2 sulindac oral 2 PA; MO; QL (60 per 2 PA; MO; QL (360 per 2 PA; MO; QL (90 per TIVORBEX 3 ST; MO; QL (90 per tolmetin oral capsule 34

43 Name tolmetin oral tablet 600 mg TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 7-83 TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR , QL (30 per 30 days) 3 QL (30 per 30 days) tramadol oral tablet ; QL (240 per tramadol oral tablet extended release 24 hr 00 mg, 200 mg tramadol oral tablet, er multiphase 24 hr 300 mg tramadolacetaminophen ; QL (30 per ; QL (30 per ; QL (240 per ULTRACET ; QL (240 per ULTRAM ; QL (240 per ULTRAM ER ; QL (30 per VIMOVO 3 ST; MO VIVITROL VOLTAREN GEL TOPICAL GEL % VOLTAREN-XR ZIPSOR 3 ST; MO Name ZORVOLEX 3 ST; MO ZUBSOLV SUBLINGUAL TABLET , ZUBSOLV SUBLINGUAL TABLET PA; MO; QL (90 per 3 PA; QL (60 per PSYCHOTHERAPEUTIC DRUGS ABILIFY DISCMELT ORAL TABLET,DISINTE GRATING 0 ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING ABILIFY ORAL TABLET 0 ABILIFY ORAL TABLET 5, 20 ABILIFY ORAL TABLET 2 ABILIFY ORAL TABLET 30 ; QL (90 per 2 ; QL (90 per ; QL (60 per ; QL (450 per ; QL (30 per 35

44 Name ABILIFY ORAL TABLET 5 ADDERALL ORAL TABLET 20, 5, 7.5 ; QL (80 per ADDERALL XR AMBIEN 3 ST; MO; QL (30 per AMBIEN CR 3 ST; MO; QL (30 per amitriptyline PA; MO amoxapine amphetamine salt combo ANAFRANIL 3 PA; MO APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 74 APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 348 APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 522 APTENSIO XR 3 aripiprazole oral tablet 0 mg aripiprazole oral tablet 5 mg, 20 mg ; QL (90 per ; QL (60 per ; QL (30 per ; QL (90 per ; QL (60 per Name aripiprazole oral tablet 2 mg aripiprazole oral tablet 30 mg aripiprazole oral tablet 5 mg ; QL (450 per ; QL (30 per ; QL (80 per ATIVAN ORAL 3 PA; MO BELSOMRA 3 ST; MO; QL (30 per BRINTELLIX ORAL TABLET 0 BRINTELLIX ORAL TABLET 20 BRINTELLIX ORAL TABLET 5 ; QL (60 per ; QL (30 per ; QL (20 per BRISDELLE ; QL (30 per bupropion hcl oral tablet bupropion hcl oral tablet extended release 00 mg bupropion hcl oral tablet extended release 50 mg bupropion hcl oral tablet extended release 200 mg bupropion hcl oral tablet extended release 24 hr 50 mg ; QL (20 per ; QL (90 per ; QL (60 per ; QL (90 per 36

45 Name bupropion hcl oral tablet extended release 24 hr 300 mg buspirone CELEXA ORAL TABLET 0 CELEXA ORAL TABLET 20 CELEXA ORAL TABLET 40 chlorpromazine citalopram oral solution citalopram oral tablet 0 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg ; QL (60 per ; QL (20 per ; QL (60 per ; QL (30 per ; QL (20 per ; QL (60 per ; QL (30 per clomipramine PA; MO clonidine hcl oral tablet extended release 2 hr clorazepate dipotassium clozapine oral tablet 00 mg, 25 mg, 50 mg clozapine oral tablet 200 mg clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 25 mg PA; MO Name CLOZAPINE ORAL TABLET,DISINTE GRATING 50, 200 CLOZARIL CONCERTA CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20 CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 CYMBALTA ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 60 DAYTRANA desipramine oral DESOXYN DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24 HR 00 DESVENLAFAXIN E ORAL TABLET EXTENDED RELEASE 24 HR ST; MO; QL (80 per 3 ST; MO; QL (20 per 3 ST; MO; QL (60 per 3 ST; MO; QL (20 per 3 ST; MO; QL (240 per

46 Name dexedrine DEXEDRINE SPANSULE dexmethylphenidate dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamineamphetamine oral capsule,extended release 24hr diazepam intensol PA; MO diazepam oral solution 5 mg/5 ml PA; MO diazepam oral tablet PA; MO doxepin oral PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 50 ; QL (80 per ; QL (20 per ; QL (90 per ; QL (60 per 3 ST; MO; QL (60 per Name EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 37.5 EFFEXOR XR ORAL CAPSULE,EXTEN DED RELEASE 24HR 75 EMSAM ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg 3 ST; MO; QL (80 per 3 ST; MO; QL (90 per ; QL (60 per ; QL (30 per ; QL (20 per eszopiclone ST; MO; QL (30 per EVEKEO 3 PA; MO FANAPT ORAL TABLET FANAPT ORAL TABLET 0, 8 FANAPT ORAL TABLET 2 FANAPT ORAL TABLET 2 FANAPT ORAL TABLET 4 ; QL (720 per ; QL (90 per ; QL (60 per ; QL (360 per ; QL (80 per 38

47 Name FANAPT ORAL TABLET 6 FANAPT ORAL TABLETS,DOSE PACK FAZACLO 3 FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 fluoxetine oral capsule 0 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution ; QL (20 per ; QL (8 per 28 days) 2 ST; MO; QL (28 per 28 days) 2 ST; MO; QL (30 per 2 ST; MO; QL (80 per 2 ST; MO; QL (90 per 2 ST; MO; QL (45 per ; QL (240 per ; QL (60 per ; QL (4 per 28 days) Name fluoxetine oral tablet 0 mg fluoxetine oral tablet 20 mg FLUOXETINE ORAL TABLET 60 fluphenazine decanoate ; QL (240 per fluphenazine hcl fluvoxamine oral capsule,extended release 24hr 00 mg fluvoxamine oral capsule,extended release 24hr 50 mg fluvoxamine oral tablet 00 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg FOCALIN FOCALIN XR ; QL (90 per ; QL (60 per ; QL (90 per ; QL (360 per ; QL (80 per FORFIVO XL ; QL (30 per GEODON INTRAMUSCULA R GEODON ORAL CAPSULE 20 GEODON ORAL CAPSULE 40 GEODON ORAL CAPSULE 60 ; QL (240 per ; QL (20 per ; QL (80 per 39

48 Name GEODON ORAL CAPSULE 80 guanidine HALDOL HALDOL DECANOATE ; QL (60 per haloperidol haloperidol decanoate haloperidol lactate HETLIOZ 3 PA; MO imipramine hcl PA; MO imipramine pamoate PA; MO INVEGA ORAL TABLET EXTENDED RELEASE 24HR.5 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 INVEGA SUSTENNA ; QL (240 per ; QL (20 per ; QL (60 per ; QL (4 per Name IRENKA ; QL (90 per KAPVAY KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 00 KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 LATUDA ORAL TABLET 20 LATUDA ORAL TABLET 20 LATUDA ORAL TABLET 40 LATUDA ORAL TABLET 60, 80 LEXAPRO ORAL SOLUTION LEXAPRO ORAL TABLET 0 LEXAPRO ORAL TABLET 20 LEXAPRO ORAL TABLET 5 3 ST; MO; QL (20 per 3 ST; MO; QL (240 per ; QL (30 per ; QL (240 per ; QL (20 per ; QL (60 per lithium carbonate lithium citrate oral solution 8 meq/5 ml ; QL (60 per ; QL (30 per ; QL (20 per LITHOBID lorazepam intensol PA; MO 40

49 Name lorazepam oral tablet PA; MO loxapine succinate LUNESTA 3 ST; MO; QL (30 per maprotiline MARPLAN METADATE CD metadate er methamphetamine METHYLIN ORAL SOLUTION METHYLIN ORAL TABLET,CHEWAB LE methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg methylphenidate oral capsule,er biphasic methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr methylphenidate oral tablet,chewable Name mirtazapine modafinil PA; MO NARDIL nefazodone NORPRAMIN nortriptyline NUVIGIL 3 PA; MO olanzapine intramuscular olanzapine oral tablet 0 mg olanzapine oral tablet 5 mg, 20 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 0 mg olanzapine oral tablet,disintegrating 5 mg, 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapinefluoxetine ; QL (60 per ; QL (30 per ; QL (240 per ; QL (20 per ; QL (8 per ; QL (60 per ; QL (30 per ; QL (20 per ORAP oxazepam PA; MO PAMELOR 4

50 Name PARNATE paroxetine hcl oral tablet 0 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 2.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 2.5 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 25 PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR 37.5 PAXIL ORAL SUSPENSION ; QL (80 per ; QL (90 per ; QL (60 per ; QL (45 per ; QL (80 per ; QL (90 per ; QL (60 per ; QL (80 per ; QL (90 per ; QL (60 per Name PAXIL ORAL TABLET 0 PAXIL ORAL TABLET 20 PAXIL ORAL TABLET 30 PAXIL ORAL TABLET 40 perphenazine PEXEVA ORAL TABLET 0 PEXEVA ORAL TABLET 20 PEXEVA ORAL TABLET 30 PEXEVA ORAL TABLET 40 phenelzine PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 00 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 procentra protriptyline ; QL (80 per ; QL (90 per ; QL (60 per ; QL (45 per ; QL (80 per ; QL (90 per ; QL (60 per ; QL (45 per 2 ST; MO; QL (20 per 2 ST; MO; QL (480 per 2 ST; MO; QL (240 per 42

51 Name PROVIGIL 3 PA; MO PROZAC ORAL CAPSULE 0 PROZAC ORAL CAPSULE 20 PROZAC ORAL CAPSULE 40 ; QL (240 per ; QL (60 per PROZAC WEEKLY ; QL (4 per 28 days) quetiapine oral tablet 00 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg QUILLIVANT XR REMERON REMERON SOLTAB ; QL (240 per ; QL (20 per ; QL (902 per ; QL (8 per ; QL (60 per ; QL (480 per RESTORIL 3 PA; MO RISPERDAL CONSTA RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 0.5 ; QL (960 per Name RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 2 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 3 RISPERDAL M- TAB ORAL TABLET,DISINTE GRATING 4 RISPERDAL ORAL SOLUTION RISPERDAL ORAL TABLET 0.25 RISPERDAL ORAL TABLET 0.5 RISPERDAL ORAL TABLET RISPERDAL ORAL TABLET 2 RISPERDAL ORAL TABLET 3 RISPERDAL ORAL TABLET 4 risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg ; QL (480 per ; QL (240 per ; QL (6 per ; QL (20 per ; QL (480 per ; QL (920 per ; QL (960 per ; QL (480 per ; QL (240 per ; QL (6 per ; QL (20 per ; QL (480 per ; QL (920 per ; QL (960 per 43

52 Name risperidone oral tablet mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg RITALIN RITALIN LA ; QL (480 per ; QL (240 per ; QL (6 per ; QL (20 per ; QL (920 per ; QL (960 per ; QL (480 per ; QL (240 per ; QL (6 per ; QL (20 per ROZEREM ; QL (30 per SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 ; QL (60 per Name SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 SARAFEM ORAL TABLET 0, 20 SEROQUEL ORAL TABLET 00 SEROQUEL ORAL TABLET 200 SEROQUEL ORAL TABLET 25 SEROQUEL ORAL TABLET 300 SEROQUEL ORAL TABLET 400 SEROQUEL ORAL TABLET 50 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 ; QL (240 per ; QL (20 per ; QL (240 per ; QL (20 per ; QL (902 per ; QL (8 per ; QL (60 per ; QL (480 per ; QL (6 per ; QL (20 per 44

53 Name SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 sertraline oral concentrate sertraline oral tablet 00 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg ; QL (8 per ; QL (60 per ; QL (480 per ; QL (60 per ; QL (240 per ; QL (20 per SILENOR ; QL (30 per SONATA ORAL CAPSULE 0 SONATA ORAL CAPSULE 5 STRATTERA 3 ST; MO; QL (60 per 3 ST; MO; QL (30 per SURMONTIL 3 PA; MO SYMBYAX temazepam PA; MO thioridazine thiothixene Name TOFRANIL 3 PA; MO TOFRANIL-PM 3 PA; MO TRANXENE T- TAB ORAL TABLET 3.75, PA; MO tranylcypromine trazodone trifluoperazine VALIUM 3 PA; MO venlafaxine oral capsule,extended release 24hr 50 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 00 mg, 75 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 ; QL (60 per ; QL (80 per ; QL (90 per ; QL (90 per ; QL (270 per ; QL (80 per ; QL (50 per ; QL (60 per 45

54 Name VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 225 VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 37.5 VENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 75 VERSACLOZ 2 LA VIIBRYD ORAL TABLET 0 VIIBRYD ORAL TABLET 20 VIIBRYD ORAL TABLET 40 VIIBRYD ORAL TABLETS,DOSE PACK 0 (7)- 20 (7)-40 (6) VYVANSE WELLBUTRIN WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 00 WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 50 ; QL (30 per ; QL (80 per ; QL (90 per ; QL (20 per ; QL (60 per ; QL (30 per ; QL (30 per ; QL (20 per ; QL (90 per Name WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE 200 WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 50 WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 300 ; QL (60 per ; QL (90 per ; QL (60 per XYREM ; LA zaleplon oral capsule 0 mg zaleplon oral capsule 5 mg zenzedi oral tablet 0 mg, 5 mg ZENZEDI ORAL TABLET 5, 2.5, 20, 30, 7.5 ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg ziprasidone hcl oral capsule 80 mg ZOLOFT ORAL CONCENTRATE ST; MO; QL (60 per ST; MO; QL (30 per ; QL (240 per ; QL (20 per ; QL (80 per ; QL (60 per 46

55 Name ZOLOFT ORAL TABLET 00 ZOLOFT ORAL TABLET 25 ZOLOFT ORAL TABLET 50 ; QL (60 per ; QL (240 per ; QL (20 per zolpidem ST; MO; QL (30 per ZOLPIMIST 3 ST; QL (8 per 30 days) ZYPREXA INTRAMUSCULA R ZYPREXA ORAL TABLET 0 ZYPREXA ORAL TABLET 5, 20 ZYPREXA ORAL TABLET 2.5 ZYPREXA ORAL TABLET 5 ZYPREXA ORAL TABLET 7.5 ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 20 ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 0 ; QL (60 per ; QL (30 per ; QL (240 per ; QL (20 per ; QL (8 per 2 LA ; QL (60 per Name ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 5, 20 ZYPREXA ZYDIS ORAL TABLET,DISINTE GRATING 5 CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution amiodarone oral tablet 200 mg, 400 mg ; QL (30 per ; QL (20 per PA; MO BETAPACE AF flecainide mexiletine MULTAQ NEXTERONE 3 PA pacerone oral tablet 00 mg, 200 mg, 400 mg procainamide injection solution 00 mg/ml procainamide injection solution 500 mg/ml propafenone quinidine gluconate 47

56 Name quinidine sulfate oral tablet RYTHMOL ORAL TABLET 50, 225 RYTHMOL SR sorine oral tablet 20 mg, 60 mg, 80 mg sorine oral tablet 240 mg sotalol af oral tablet 20 mg sotalol oral tablet 60 mg, 240 mg, 80 mg SOTYLIZE 2 TIKOSYN ANTIHYPERTENSIVE THERAPY ACCUPRIL ACCURETIC acebutolol oral ADALAT CC afeditab cr ALDACTAZIDE ALDACTONE ALTACE amiloride oral amlodipine Name ATACAND 3 ST; MO ATACAND HCT 3 ST; MO atenolol AVALIDE 3 ST; MO AVAPRO 3 ST; MO AZOR 2 ST; MO benazepril BENICAR 2 ST; MO BENICAR HCT 2 ST; MO betaxolol oral BIDIL bisoprolol fumarate bumetanide BYSTOLIC CALAN CALAN SR candesartan amiloridehydrochlorothiazide amlodipinebenazepril amlodipinevalsartan amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide candesartanhydrochlorothiazid 48

57 Name captopril captoprilhydrochlorothiazide CARDENE IV IN SODIUM CHLORIDE CARDIZEM CD CARDIZEM LA CARDIZEM ORAL TABLET 20, 30, 60 CARDURA ORAL TABLET, 2, 4 CARDURA ORAL TABLET ST; MO; QL (30 per 3 ST; MO; QL (60 per CARDURA XL 3 ST; MO; QL (30 per cartia xt carvedilol CATAPRES CATAPRES-TTS- ; QL (4 per 28 days) CATAPRES-TTS-2 ; QL (4 per 28 days) CATAPRES-TTS-3 ; QL (4 per 28 days) chlorothiazide chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg clonidine ; QL (4 per 28 days) Name clonidine hcl oral tablet clorpres oral tablet 0.-5 mg, mg CLORPRES ORAL TABLET COREG COREG CR CORGARD CORZIDE COZAAR 3 ST; MO DEMADEX DEMSER diltiazem hcl intravenous diltiazem hcl oral capsule, extended release 80 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 2 hr diltiazem hcl oral capsule,extended release 24hr 20 mg, 240 mg, 300 mg diltiazem hcl oral tablet 49 dilt-xr DIOVAN 3 ST; MO DIOVAN HCT 3 ST; MO DIURIL

58 Name DIURIL IV 3 doxazosin oral tablet mg, 2 mg, 4 mg doxazosin oral tablet 8 mg DUTOPROL DYAZIDE ; QL (30 per ; QL (60 per EDARBI 3 ST; MO EDARBYCLOR 3 ST; MO EDECRIN enalapril maleate EPANED eplerenone eprosartan EXFORGE 3 ST; MO EXFORGE HCT 3 ST; MO felodipine fosinopril furosemide injection furosemide oral solution 0 mg/ml, 40 mg/5 ml furosemide oral tablet hydralazine hydrochlorothiazide HYZAAR 3 ST; MO Name indapamide INDERAL LA INNOPRAN XL INSPRA irbesartan isradipine labetalol intravenous solution labetalol oral LASIX lisinopril enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide lisinoprilhydrochlorothiazide LOPRESSOR HCT ORAL TABLET LOPRESSOR LOPRESSOR ORAL TABLET 00 losartan losartanhydrochlorothiazide LOTENSIN ORAL TABLET 20, 40 LOTREL matzim la MAVIK 50

59 Name MAXZIDE MAXZIDE-25 methyclothiazide methyldopa metolazone metoprolol succinate metoprolol tartrate intravenous solution metoprolol tartrate oral MICARDIS 3 ST; MO MICARDIS HCT 3 ST; MO MICROZIDE MINIPRESS minoxidil oral moexipril nadolol nicardipine nifedical xl nifedipine oral tablet extended release 24hr nimodipine nisoldipine NORVASC Name ORENITRAM 3 PA; MO perindopril erbumine pindolol prazosin oral PRINIVIL ORAL TABLET 0, 20, 5 PROCARDIA XL propranolol intravenous propranolol oral quinapril ramipril REMODULIN 2 PA; MO; LA SECTRAL spironolactone metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide nadololbendroflumethiazide propranololhydrochlorothiazid quinaprilhydrochlorothiazide spironolactonhydrochlorothiaz SULAR ORAL TABLET EXTENDED RELEASE 24 HR 7, 34, 8.5 TARKA taztia xt TEKAMLO TEKTURNA 5

60 Name TEKTURNA HCT telmisartan TENORETIC 00 TENORETIC 50 TENORMIN terazosin oral capsule mg, 2 mg, 5 mg terazosin oral capsule 0 mg ; QL (30 per ; QL (60 per TEVETEN HCT 3 ST; MO TEVETEN ORAL TABLET ST; MO TIAZAC timolol maleate oral TOPROL XL torsemide oral trandolapril TRIBENZOR 2 ST; MO TWYNSTA 3 ST; MO valsartan telmisartanamlodipine telmisartanhydrochlorothiazid trandolaprilverapamil triamterenehydrochlorothiazid valsartanhydrochlorothiazide VASERETIC Name VASOTEC verapamil intravenous solution verapamil oral VERELAN VERELAN PM ZEBETA ZESTORETIC ZESTRIL ZIAC CARDIAC GLYCOSIDES digitek digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN ORAL TABLET 25 MCG, 250 MCG LANOXIN ORAL TABLET 87.5 MCG, 62.5 MCG COAGULATION THERAPY AGGRENOX ARGATROBAN ARGATROBAN IN 0.9 % SOD CHLOR SOLUTION ARIXTRA BRILINTA cilostazol clopidogrel 52 3

61 Name COUMADIN ORAL CYKLOKAPRON dipyridamole oral EFFIENT ELIQUIS enoxaparin fondaparinux FRAGMIN SUBCUTANEOUS SOLUTION FRAGMIN SUBCUTANEOUS SYRINGE heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(00 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) heparin (porcine) injection solution jantoven LOVENOX pentoxifylline PERSANTINE PLAVIX PLETAL PRADAXA Name PROMACTA 2 PA; MO; LA SAVAYSA ticlopidine tranexamic acid intravenous warfarin XARELTO ZONTIVITY LIPID/CHOLESTEROL LOWERING AGENTS ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR,000-20, ADVICOR ORAL TABLET, ER MULTIPHASE 24 HR,000-40, ; QL (60 per ; QL (30 per ALTOPREV ; QL (30 per amlodipineatorvastatin ANTARA ORAL CAPSULE 30, 90 ; QL (30 per atorvastatin ; QL (30 per CADUET ; QL (30 per cholestyramine light oral powder in packet 53

62 Name COLESTID ORAL GRANULES COLESTID ORAL TABLET colestipol oral granules colestipol oral tablet CRESTOR ; QL (30 per fenofibrate micronized fenofibrate nanocrystallized FENOFIBRATE ORAL CAPSULE fenofibrate oral tablet 60 mg, 54 mg fenofibric acid (choline) FENOGLIDE FIBRICOR fluvastatin oral capsule 20 mg fluvastatin oral capsule 40 mg gemfibrozil oral ; QL (30 per ; QL (60 per JUXTAPID ; LA KYNAMRO ; LA LESCOL ORAL CAPSULE 20 LESCOL ORAL CAPSULE 40 ; QL (30 per ; QL (60 per Name LESCOL XL ; QL (30 per LIPITOR ; QL (30 per LIPOFEN LIPTRUZET ; QL (30 per LIVALO ; QL (30 per LOFIBRA LOPID lovastatin oral tablet 0 mg lovastatin oral tablet 20 mg, 40 mg LOVAZA niacin oral tablet extended release 24 hr ; QL (30 per ; QL (60 per NIACOR NIASPAN EXTENDED- RELEASE omega-3 acid ethyl esters PRAVACHOL ; QL (30 per pravastatin ; QL (30 per prevalite oral powder QUESTRAN ORAL POWDER IN PACKET 54

63 Name SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR,000-20, SIMCOR ORAL TABLET, ER MULTIPHASE 24 HR,000-40, , ; QL (60 per ; QL (30 per simvastatin ; QL (30 per TRICOR TRIGLIDE ORAL TABLET 60 TRILIPIX VASCEPA VYTORIN 0-0 ; QL (30 per VYTORIN 0-20 ; QL (30 per VYTORIN 0-40 ; QL (30 per VYTORIN 0-80 ; QL (30 per WELCHOL ZETIA ZOCOR ; QL (30 per MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR 2 PA; MO RANEXA Name VECAMYL 3 NITRATES ISORDIL ISORDIL TITRADOSE ORAL TABLET 5 isosorbide dinitrate oral isosorbide mononitrate MINITRAN nitro-bid NITRO-DUR nitroglycerin intravenous nitroglycerin transdermal patch 24 hour nitroglycerin translingual spray,non-aerosol PA NITROLINGUAL NITROMIST NITROSTAT DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin calcipotriene calcipotrienebetamethasone 55

64 Name calcitriol topical COSENTYX PEN 2 PA; MO COSENTYX PEN (2 PENS) DOVONEX TOPICAL CREAM selenium sulfide topical suspension SORIATANE ORAL CAPSULE 0, 7.5, 25 2 PA; MO SORILUX STELARA SUBCUTANEOUS SYRINGE 2 PA; MO TACLONEX VECTICAL BURN THERAPY SILVADENE silver sulfadiazine ssd MISCELLANEOUS DERMATOLOGICALS 8-MOP ALDARA 3 ST; MO ammonium lactate topical CARAC CONDYLOX TOPICAL GEL diclofenac sodium topical gel PA; MO Name EFUDEX TOPICAL CREAM 3 ST; MO ELIDEL 3 PA; MO FLUOROURACIL TOPICAL CREAM 0.5 % fluorouracil topical cream 5 % fluorouracil topical solution 3 ST; MO imiquimod methoxsalen rapid OXSORALEN ULTRA PANRETIN PICATO 3 ST; MO podofilox PROTOPIC 3 PA; MO prudoxin REGRANEX SOLARAZE 3 PA; MO tacrolimus topical PA; MO UVADEX 3 VALCHLOR VEREGEN ZONALON ZYCLARA 3 ST; MO THERAPY FOR ACNE ABSORICA ORAL CAPSULE 0, 20, 30, 40 56

65 Name ABSORICA ORAL CAPSULE 25, 35 ACANYA ACZONE adapalene topical cream adapalene topical gel 3 PA; MO PA; MO amnesteem ATRALIN 3 PA; MO avita topical cream PA; MO AVITA TOPICAL GEL 3 PA; MO AZELEX BENZACLIN BENZAMYCIN claravis CLEOCIN T CLINDACIN PAC CLINDAGEL clindamycin phosphate topical clindamycin-benzoyl peroxide topical gel -5 % DIFFERIN TOPICAL CREAM DIFFERIN TOPICAL GEL DIFFERIN TOPICAL LOTION 3 PA; MO 3 PA; MO 3 PA; MO Name DUAC EPIDUO TOPICAL GEL WITH PUMP 3 PA; MO ery pads erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycinbenzoyl peroxide EVOCLIN FABIOR FINACEA METROCREAM METROGEL TOPICAL GEL % METROLOTION metronidazole topical cream metronidazole topical gel metronidazole topical lotion MIRVASO myorisan neuac NORITATE ONEXTON RETIN-A 3 PA; MO RETIN-A MICRO 3 PA; MO 57

66 Name RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.08 % 3 PA; MO SOOLANTRA TAZORAC 2 PA; MO tretinoin microspheres topical gel with pump PA; MO tretinoin topical PA; MO TRETIN-X TOPICAL CREAM % 3 PA; MO VELTIN 3 PA; MO zenatane ZIANA 3 PA; MO TOPICAL ANESTHETICS EMLA lidocaine (pf) injection solution 5 mg/ml (0.5 %) lidocaine hcl injection solution 20 mg/ml (2 %) lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) Name lidocaine hcl urethral lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine-prilocaine topical cream 58 PA; MO LIDODERM 3 PA; MO XYLOCAINE INJECTION SOLUTION 20 /ML (2 %) XYLOCAINE MUCOUS MEMBRANE SOLUTION TOPICAL ANTIBACTERIALS ALTABAX BACTROBAN CORTISPORIN TOPICAL 3 3 gentamicin topical KLARON mupirocin mupirocin calcium NEO-SYNALAR sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM SULFAMYLON TOPICAL PACKET

67 Name TOPICAL ANTIFUNGALS ciclopirox clotrimazole topical econazole topical ERTACZO EXELDERM EXTINA JUBLIA KERYDIN ketoconazole topical cream ketoconazole topical shampoo LOPROX TOPICAL SHAMPOO LOTRISONE TOPICAL CREAM LUZU MENTAX NAFTIFINE 3 NAFTIN NIZORAL TOPICAL SHAMPOO nyamyc nystatin topical clotrimazolebetamethasone nystatintriamcinolone nystop Name OXISTAT TOPICAL ANTIVIRALS acyclovir topical DENAVIR XERESE ZOVIRAX TOPICAL TOPICAL CORTICOSTEROIDS ala-cort topical cream ALA-SCALP 3 ST; MO alclometasone amcinonide APEXICON 3 ST apexicon e betamethasone dipropionate betamethasone valerate betamethasone, augmented CAPEX 2 ST; MO clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo 59

68 Name clobetasol topical solution clobetasol topical spray,non-aerosol clobetasol-emollient topical cream CLOBEX 3 ST; MO clodan CLODERM 3 ST; MO CORDRAN TAPE LARGE ROLL cormax topical solution CUTIVATE TOPICAL LOTION DERMATOP TOPICAL CREAM 2 ST; MO 3 ST; MO 3 ST; MO DESONATE 3 ST; MO desonide DESOWEN 3 ST; MO desoximetasone diflorasone DIPROLENE 3 ST; MO DIPROLENE AF 3 ST; MO ELOCON 3 ST; MO fluocinolone fluocinonide topical cream 0. % fluocinonide topical gel fluocinonide topical ointment Name fluocinonide topical solution fluocinonide-e fluticasone topical halobetasol propionate HALOG 3 ST; MO hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone butyr-emollient hydrocortisone topical cream %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment %, 2.5 % hydrocortisone valerate KENALOG TOPICAL LOCOID TOPICAL CREAM LOCOID TOPICAL LOTION LOCOID TOPICAL OINTMENT LOCOID TOPICAL SOLUTION 3 ST; MO 3 ST; MO 2 ST; MO 3 ST; MO 3 ST; MO 60

69 Name mometasone OLUX 3 ST; MO PANDEL 2 ST; MO prednicarbate SYNALAR CREAM KIT TEMOVATE TOPICAL CREAM TEMOVATE TOPICAL OINTMENT 3 ST; MO 3 ST; MO 3 ST; MO TOPICORT 3 ST; MO triamcinolone acetonide topical aerosol triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0. %, 0.5 % trianex triderm topical cream ULTRAVATE 3 ST; MO VANOS 3 ST; MO TOPICAL ENZYMES SANTYL TOPICAL SCABICIDES / PEDICULICIDES Name EURAX lindane malathion OVIDE permethrin topical cream SKLICE DIAGNOSTICS / MISCELLANEOUS AGENTS IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu PHYSIOLYTE 3 PHYSIOSOL IRRIGATION ringers irrigation MISCELLANEOUS AGENTS acamprosate ACTONEL ORAL TABLET 30 ADAGEN AGRYLIN alendronate oral tablet 40 mg anagrelide ANTABUSE ARALAST NP RECON SOLN ST; MO; QL (30 per ; QL (30 per ; LA

70 Name AURYXIA CARBAGLU ; LA CARNITOR cevimeline CHEMET CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE d0 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 0 % and 0.2 % nacl dextrose 0 % in water (d0w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 %- lactated ringers 2 PA 3 PA 3 PA Name dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride disulfiram etidronate disodium EVOXAC EXJADE ; LA FERRIPROX FOSRENOL ORAL POWDER IN PACKET FOSRENOL ORAL TABLET,CHEWAB LE 3 GLASSIA ; LA INCRELEX ; LA JADENU KAYEXALATE kionex oral powder levocarnitine (with sugar) levocarnitine intravenous levocarnitine oral tablet LITHOSTAT midodrine NORTHERA NUTRESTORE 62

71 Name ORFADIN 2 LA pilocarpine hcl oral PROLASTIN-C ; LA RAVICTI RECLAST 3 PA; MO RENAGEL RENVELA RILUTEK riluzole risedronate oral tablet 30 mg SALAGEN sodium chloride 0.9 % intravenous parenteral solution sodium chloride irrigation sodium phenylbutyrate sodium polystyrene (sorb free) ; QL (30 per SYPRINE THIOLA VELPHORO water for irrigation, sterile ZEMAIRA ; LA zoledronic acidmannitol-water intravenous solution SMOKING DETERRENTS PA; MO buproban Name CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX NICOTROL NICOTROL NS ZYBAN EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS ASTEPRO NASAL SPRAY,NON- AEROSOL ; QL (60 per ATROVENT ; QL (30 per azelastine nasal ; QL (60 per BACTROBAN NASAL chlorhexidine gluconate mucous membrane ipratropium bromide nasal ; QL (30 per olopatadine ; QL (30.5 per PATANASE ; QL (30.5 per periogard triamcinolone acetonide dental 63

72 Name TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS acetasol hc acetic acid otic fluocinolone acetonide oil hydrocortisoneacetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRO HC CIPRODEX COLY-MYCIN S CORTISPORIN OTIC SOLUTION CORTISPORIN-TC neomycinpolymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. 3 PA; MO a-hydrocort CORTEF cortisone DEPO-MEDROL INJECTION SUSPENSION 20 /ML Name DEPO-MEDROL INJECTION SUSPENSION 40 /ML, 80 /ML dexamethasone intensol dexamethasone oral elixir dexamethasone oral tablet dexamethasone sodium phosphate injection DEXPAK 3 DAY FLO-PRED 3 fludrocortisone hydrocortisone oral KENALOG INJECTION MEDROL 3 PA; MO MEDROL (PAK) methylprednisolone acetate methylprednisolone oral tablet methylprednisolone oral tablets,dose pack methylprednisolone sodium succ injection recon soln 25 mg, 40 mg MILLIPRED ORAL SOLUTION PA; MO 64

73 Name millipred oral tablet PA; MO ORAPRED ODT 3 PA; MO prednisolone sodium phosphate oral solution 5 mg/5 ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating PA; MO prednisone intensol PA; MO prednisone oral solution prednisone oral tablet PA; MO RAYOS 3 PA; MO SOLU-CORTEF (PF) INJECTION RECON SOLN 00 /2 ML, 250 /2 ML SOLU-MEDROL (PF) INJECTION SOLU-MEDROL (PF) RECON SOLN 500 /4 ML SOLU-MEDROL RECON SOLN 2 GRAM veripred 20 ANTITHYROID AGENTS Name methimazole oral tablet 0 mg, 5 mg propylthiouracil TAPAZOLE DIABETES THERAPY acarbose oral tablet 00 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg ; QL (90 per ; QL (360 per ; QL (80 per ACTOPLUS MET ; QL (90 per ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 5-,000 ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR 30-,000 ; QL (60 per ; QL (30 per ACTOS ; QL (30 per AFREZZA INHALATION CARTRIDGE, W/INHALATION DEVICE 4 UNIT, 4 UNIT (30)/ 8 UNIT (60), 4 UNIT (60)/ 8 UNIT (30) ALCOHOL PADS 2 AMARYL ORAL TABLET ; QL (240 per 65

74 Name AMARYL ORAL TABLET 2 AMARYL ORAL TABLET 4 ; QL (20 per ; QL (60 per APIDRA 3 ST; MO APIDRA SOLOSTAR AVANDAMET ORAL TABLET 2-,000 AVANDIA ORAL TABLET 2, 4 AVANDIA ORAL TABLET 8 3 ST; MO ; LA; QL (60 per ; LA; QL (60 per ; LA; QL (30 per BYDUREON 2 PA; MO; QL (4 per 28 days) BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML).2 ML 2 PA; MO; QL (2.4 per 2 PA; MO; QL (.2 per CYCLOSET ; QL (80 per DUETACT ; QL (30 per FARXIGA ORAL TABLET 0 FARXIGA ORAL TABLET 5 ; QL (30 per ; QL (60 per Name FORTAMET ORAL TABLET EXTENDED RELEASE 24HR,000 FORTAMET ORAL TABLET EXTENDED RELEASE 24HR 500 GAUZE PAD TOPICAL BANDAGE 2 X 2 " glimepiride oral tablet mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 0 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 0 mg glipizide oral tablet extended release 24hr 2.5 mg glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg ; QL (75 per ; QL (50 per 2 ; QL (240 per ; QL (20 per ; QL (60 per ; QL (20 per ; QL (240 per ; QL (60 per ; QL (240 per ; QL (20 per ; QL (240 per 66

75 Name glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) GLUCOPHAGE ORAL TABLET,000 GLUCOPHAGE ORAL TABLET 500 GLUCOPHAGE ORAL TABLET 850 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 GLUCOTROL ORAL TABLET 0 GLUCOTROL ORAL TABLET 5 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 0 ; QL (20 per ; QL (75 per ; QL (50 per ; QL (90 per ; QL (20 per ; QL (75 per ; QL (20 per ; QL (240 per ; QL (60 per Name GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 2.5 GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR 5 GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR,000 GLUMETZA ORAL TABLET,ER GAST.RETENTION 24 HR 500 GLYSET ORAL TABLET 00 GLYSET ORAL TABLET 25 GLYSET ORAL TABLET 50 ; QL (240 per ; QL (20 per ; QL (60 per ; QL (20 per ; QL (90 per ; QL (360 per ; QL (80 per GLYXAMBI 3 ST; MO; QL (30 per HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN 67

76 Name HUMALOG SUBCUTANEOUS CARTRIDGE HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML (PREFILLED SYRINGE) HUMULIN 70/30 HUMULIN 70/30 KWIKPEN 2 HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 "CONCENTRATED " INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U-00 ML INSULIN SYRINGE (DISP) U-00 /2 ML 2 INVOKAMET ; QL (60 per 2 Name INVOKANA ; QL (30 per JANUMET ; QL (60 per JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000, JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-,000 ; QL (30 per ; QL (60 per JANUVIA ; QL (30 per JARDIANCE ; QL (30 per JENTADUETO 3 ST; MO; QL (60 per KAZANO 3 ST; MO; QL (60 per KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-,000 KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-,000, LANTUS LANTUS SOLOSTAR ; QL (60 per ; QL (30 per LEVEMIR 68

77 Name LEVEMIR FLEXTOUCH metformin oral tablet,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr,000 mg nateglinide oral tablet 20 mg nateglinide oral tablet 60 mg NEEDLES, INSULIN DISP.,SAFETY ; QL (75 per ; QL (50 per ; QL (90 per ; QL (20 per ; QL (75 per ; QL (75 per ; QL (90 per ; QL (80 per NESINA 3 ST; MO; QL (30 per NOVOFINE 32 NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG 3 ST; MO NOVOLOG FLEXPEN 2 3 ST; MO Name NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL 3 ST; MO 3 ST; MO 3 ST; MO ONGLYZA ; QL (30 per OSENI ; QL (30 per pioglitazone ; QL (30 per pioglitazoneglimepiride pioglitazonemetformin ; QL (30 per ; QL (90 per PRANDIMET ; QL (50 per PRANDIN ORAL TABLET 0.5 PRANDIN ORAL TABLET PRANDIN ORAL TABLET 2 PRECOSE ORAL TABLET 00 PRECOSE ORAL TABLET 25 PRECOSE ORAL TABLET 50 PROGLYCEM repaglinide oral tablet 0.5 mg ; QL (960 per ; QL (480 per ; QL (240 per ; QL (90 per ; QL (360 per ; QL (80 per ; QL (960 per 69

78 Name repaglinide oral tablet mg repaglinide oral tablet 2 mg ; QL (480 per ; QL (240 per RIOMET ; QL (765 per STARLIX ORAL TABLET 20 STARLIX ORAL TABLET 60 ; QL (90 per ; QL (80 per SYMLINPEN 20 2 PA; MO; QL (8.9 per 30 days) SYMLINPEN 60 2 PA; MO; QL (0.5 per 30 days) TANZEUM 3 PA; MO; QL (2 per 28 days) tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg ; QL (20 per ; QL (60 per tolbutamide ; QL (80 per TOUJEO SOLOSTAR TRADJENTA 3 ST; MO; QL (30 per TRULICITY 3 PA; MO; QL (2 per 28 days) VGO 20 VGO 30 VGO 40 Name VICTOZA 3-PAK 2 PA; MO; QL (9 per XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR 0-,000 XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR 0-500, 5-,000, ; QL (30 per ; QL (60 per MISCELLANEOUS HORMONES ALDURAZYME ANADROL-50 2 PA; MO ANDRODERM 2 PA; MO ANDROGEL 2 PA; MO ANDROID AVEED AXIRON 3 PA; MO cabergoline calcitonin (salmon) calcitriol intravenous solution mcg/ml calcitriol oral CERDELGA CEREZYME RECON SOLN 400 UNIT chorionic gonadotropin, human PA; MO 70

79 Name danazol oral DDAVP DEPO- TESTOSTERONE desmopressin injection desmopressin nasal solution desmopressin nasal spray,non-aerosol desmopressin oral doxercalciferol intravenous doxercalciferol oral ELAPRASE ELELYSO FABRAZYME RECON SOLN 35 FORTESTA 3 PA; MO fortical HECTOROL SOLUTION 4 MCG/2 ML HECTOROL ORAL KORLYM KUVAN ORAL POWDER IN PACKET 500 KUVAN ORAL TABLET,SOLUBL E ; LA Name LUMIZYME METHITEST MIACALCIN MYALEPT 2 PA; MO; LA MYOZYME NAGLAZYME ; LA NATESTO 3 PA; MO NATPARA 2 PA; MO; LA novarel PA; MO oxandrolone PA; MO pamidronate intravenous solution PARICALCITOL HEMODIALYSIS PORT INJECTION paricalcitol oral PREGNYL 3 PA; MO ROCALTROL SAMSCA 2 PA; MO SENSIPAR SOMAVERT STIMATE STRIANT 3 PA; MO SYNAREL TESTIM 3 PA; MO testosterone cypionate testosterone enanthate 7 3

80 Name TESTOSTERONE TRANSDERMAL GEL IN METERED-DOSE PUMP TESTOSTERONE TRANSDERMAL GEL IN PACKET 3 PA; MO 3 PA; MO TESTRED VOGELXO TRANSDERMAL GEL VOGELXO TRANSDERMAL GEL IN METERED-DOSE PUMP 3 PA; MO 3 PA; MO VPRIV ZAVESCA ; LA ZEMPLAR ZEMPLAR ORAL CAPSULE MCG, 2 MCG zoledronic acid intravenous solution ZOMETA THYROID HORMONES CYTOMEL LEVOTHYROXINE RECON SOLN 00 MCG levothyroxine oral Name levoxyl oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine SYNTHROID THYROLAR- THYROLAR-/2 THYROLAR-/4 THYROLAR-2 THYROLAR-3 TIROSINT TRIOSTAT unithroid oral tablet 00 mcg, 2 mcg, 25 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection syringe 0.05 mg/ml, 0. mg/ml CANTIL CUVPOSA diphenoxylateatropine FULYZAQ 72

81 Name glycopyrrolate injection glycopyrrolate oral LOMOTIL loperamide oral capsule methscopolamine oral ROBINUL FORTE ROBINUL ORAL MISCELLANEOUS GASTROINTESTINAL AGENTS ACTIGALL AKYNZEO 2 PA; MO alosetron ALOXI AMITIZA ANUSOL-HC RECTAL CREAM ANZEMET SOLUTION 00 /5 ML ANZEMET ORAL 3 PA; MO APRISO ASACOL HD AZULFIDINE AZULFIDINE EN- TABS balsalazide budesonide oral CANASA Name CESAMET 3 PA; MO CHENODAL 2 PA; MO; LA CIMZIA 3 PA; MO CIMZIA POWDER FOR RECONST 3 PA; MO COLAZAL colocort COLYTE WITH FLAVOR PACKS ORAL RECON SOLN GRAM compro constulose CREON cromolyn oral CYSTADANE DELZICOL DIPENTUM dronabinol PA; MO EMEND RECON SOLN 50 EMEND ORAL 2 PA; MO ENTOCORT EC enulose GASTROCROM GATTEX ONE- VIAL gavilyte-c gavilyte-g 73

82 Name gavilyte-n generlac GIAZO GOLYTELY granisetron (pf) intravenous solution 00 mcg/ml granisetron hcl intravenous solution mg/ml ( ml) granisetron hcl oral PA; MO hydrocortisone rectal enema KRISTALOSE lactulose oral solution 0 gram/5 ml LIALDA LINZESS LOTRONEX MARINOL 3 PA; MO meclizine oral tablet 2.5 mg, 25 mg mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl oral METOZOLV ODT ORAL TABLET,DISINTE GRATING 5 Name MOVANTIK MOVIPREP NULYTELY WITH FLAVOR PACKS ondansetron PA; MO ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg 74 PA; MO PA PA; MO OSMOPREP PANCREAZE peg electrolytes oral recon soln gram PENTASA PERTZYE polyethylene glycol 3350 oral powder PREPOPIK prochlorperazine prochlorperazine edisylate injection solution 0 mg/2 ml (5 mg/ml) prochlorperazine maleate oral

83 Name procto-pak proctosol hc proctozone-hc RECTIV REGLAN ORAL RELISTOR SUBCUTANEOUS SOLUTION RELISTOR SUBCUTANEOUS SYRINGE REMICADE 2 PA; MO SANCUSO SFROWASA SUCLEAR SUCRAID sulfasalazine oral tablet sulfazine ec SUPREP BOWEL PREP KIT TRANSDERM- SCOP trilyte with flavor packets UCERIS ORAL UCERIS RECTAL ULTRESA URSO 250 URSO FORTE ursodiol Name VIOKACE ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 0,000-34,000-55,000 UNIT, 5,000-5,000-82,000 UNIT, 20,000-68,000-09,000 UNIT, 25,000-85,000-36,000 UNIT, 3,000-0,000-6,000 UNIT, 40,000-36,000-28,000 UNIT ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 5,000-7,000-27,000 UNIT ZOFRAN (AS HYDROCHLORID E) ZOFRAN (AS HYDROCHLORID E) ORAL 3 PA; MO ZOFRAN ODT 3 PA; MO ZUPLENZ 3 PA; MO ULCER THERAPY ACIPHEX ACIPHEX SPRINKLE amoxicilclarithromylansopraz ; QL (30 per ; QL (2 per 75

84 Name carafate oral suspension CARAFATE ORAL TABLET cimetidine cimetidine hcl oral CYTOTEC DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 30 DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 60 esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg ESOMEPRAZOLE MAGNESIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40 esomeprazole sodium ; QL (30 per ; QL (30 per famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine oral suspension famotidine oral tablet 20 mg, 40 mg Name lansoprazole oral capsule,delayed release(dr/ec) 5 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg ; QL (30 per misoprostol NEXIUM IV RECON SOLN 40 NEXIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 20 NEXIUM ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40 NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 0, 2.5, 20, 5 NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 40 ; QL (30 per ; QL (30 per nizatidine OMECLAMOX- PAK omeprazole oral capsule,delayed release(dr/ec) 0 mg, 20 mg ; QL (80 per ; QL (30 per 76

85 Name omeprazole oral capsule,delayed release(dr/ec) 40 mg omeprazole-sodium bicarbonate oral capsule 20-. mggram omeprazole-sodium bicarbonate oral capsule 40-. mggram pantoprazole oral tablet,delayed release (dr/ec) 20 mg pantoprazole oral tablet,delayed release (dr/ec) 40 mg PEPCID ORAL SUSPENSION PEPCID ORAL TABLET 20 PREVACID ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 5 PREVACID ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 30 PREVACID SOLUTAB ORAL TABLET,DISINTE GRAT, DELAY REL 5 ; QL (30 per ; QL (30 per ; QL (30 per ; QL (30 per Name PREVACID SOLUTAB ORAL TABLET,DISINTE GRAT, DELAY REL 30 PREVPAC ; QL (2 per PRILOSEC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 0, 20 PRILOSEC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 40 PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 0 PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON 2.5 PROTONIX PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET PROTONIX ORAL TABLET,DELAYE D RELEASE (DR/EC) 20 ; QL (30 per ; QL (900 per ; QL (300 per ; QL (30 per 77

86 Name PROTONIX ORAL TABLET,DELAYE D RELEASE (DR/EC) 40 PYLERA rabeprazole ranitidine hcl injection solution 25 mg/ml ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 50 mg, 300 mg sucralfate oral tablet ZANTAC INJECTION SOLUTION 25 /ML ZANTAC ORAL TABLET ZEGERID ORAL CAPSULE GRAM ZEGERID ORAL CAPSULE GRAM ZEGERID ORAL PACKET 20-,680 ZEGERID ORAL PACKET 40-,680 ; QL (30 per ; QL (30 per Name IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARANESP (IN POLYSORBATE) 3 PA; MO ARCALYST 2 PA; MO AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULA R PEN INJECTOR KIT AVONEX INTRAMUSCULA R SYRINGE KIT BETASERON SUBCUTANEOUS KIT EGRIFTA SUBCUTANEOUS RECON SOLN EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML EXTAVIA SUBCUTANEOUS KIT 2 PA; MO; QL (4 per 28 days) 2 PA; MO; QL (4 per 28 days) 2 PA; MO; QL (4 per 28 days) 2 PA; MO; QL (5 per 28 days) 3 PA 3 PA; MO 3 PA; MO; QL (5 per 28 days) GENOTROPIN 3 PA; MO 78

87 Name GENOTROPIN MINIQUICK 3 PA; MO GRANIX 3 PA; MO HUMATROPE 3 PA; MO ILARIS (PF) 2 PA; MO; LA INTRON A INJECTION RECON SOLN INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML LEUKINE INJECTION RECON SOLN MIRCERA MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE 2 PA; MO NEUMEGA NEUPOGEN 2 PA; MO NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 0 /.5 ML (6.7 /ML), 5 /.5 ML (0 /ML), 5 /.5 ML (3.3 /ML) NORDITROPIN NORDIFLEX 2 PA; MO 2 PA; MO Name NUTROPIN AQ NUSPIN SUBCUTANEOUS CARTRIDGE 5 /2 ML (2.5 /ML) NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 3 PA; MO 3 PA; MO OMNITROPE 2 PA; MO PEGASYS ; QL (4 per 28 days) PEGASYS PROCLICK ; QL (4 per 28 days) PEGINTRON ; QL (4 per 28 days) PEGINTRON REDIPEN PLEGRIDY SUBCUTANEOUS PEN INJECTOR 25 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 25 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML ; QL (4 per 28 days) 2 PA; MO; QL ( per 28 days) 2 PA; MO; QL ( per 80 days) 2 PA; MO; QL ( per 28 days) 2 PA; MO; QL ( per 80 days) 79

88 Name PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML 2 PA; MO PROLEUKIN REBIF (WITH ALBUMIN) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK 2 PA; MO; QL (6 per 28 days) 2 PA; MO; QL (6 per 28 days) 2 PA; MO; QL (4.2 per 80 days) 2 PA; MO; QL (2 per 28 days) SAIZEN 3 PA; MO SAIZEN CLICK.EASY SEROSTIM SUBCUTANEOUS RECON SOLN 4, 5, 6 3 PA; MO 3 PA; MO SYLATRON ZOMACTON 3 PA; MO ZORBTIVE 3 PA; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS Name ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT )(PF) INTRAMUSCULA R SUSPENSION ATGAM 3 PA BCG VACCINE, LIVE (PF) BEXSERO (PF) 2 2 BIVIGAM 3 PA; MO BOOSTRIX TDAP BOTOX 2 PA; MO CARIMUNE NF NANOFILTERED RECON SOLN 6 GRAM CERVARIX VACCINE (PF) 3 PA; MO COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) DYSPORT INTRAMUSCULA R RECON SOLN 300 UNIT ENGERIX-B (PF) INTRAMUSCULA R SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SUSPENSION 3 PA; MO 2 PA; MO 2 PA; MO 80

89 Name ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE FLEBOGAMMA DIF SOLUTION 0 % 2 PA 3 PA; MO fomepizole GAMASTAN S/D GAMMAGARD LIQUID GAMMAKED INJECTION SOLUTION GRAM/0 ML (0 %) 3 PA; MO 3 PA; MO GAMMAPLEX 3 PA; MO GAMUNEX-C INJECTION SOLUTION GRAM/0 ML (0 %) 3 PA; MO GARDASIL (PF) GARDASIL 9 (PF) GRASTEK 2 PA; MO HAVRIX (PF) INTRAMUSCULA R SUSPENSION,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULA R SYRINGE 720 ELISA UNIT/0.5 ML 2 Name HYPERRAB S/D (PF) IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULA R SUSPENSION 3 IPOL IXIARO (PF) MENACTRA (PF) INTRAMUSCULA R SOLUTION MENOMUNE - A/C/Y/W-35 (PF) MENVEO A-C-Y- W-35-DIP (PF) M-M-R II (PF) OCTAGAM 3 PA; MO PEDVAX HIB (PF) PRIVIGEN 2 PA; MO PROQUAD (PF) 2 QUADRACEL (PF) 2 RABAVERT (PF) RAGWITEK RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION 0 MCG/ML, 40 MCG/ML 2 PA; MO 8

90 Name RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 0 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 5 MCG/0.5 ML ROTARIX 2 ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULA R SYRINGE TETANUS,DIPHTH ERIA TOX PED(PF) TETANUS- DIPHTHERIA TOXOIDS-TD THYMOGLOBULI N TRUMENBA 2 TWINRIX (PF) INTRAMUSCULA R SUSPENSION TYPHIM VI INTRAMUSCULA R SOLUTION TYPHIM VI INTRAMUSCULA R SYRINGE VAQTA (PF) INTRAMUSCULA R SYRINGE 2 PA; MO 2 PA 2 PA 2 2 Name VARIVAX (PF) VARIZIG INTRAMUSCULA R SOLUTION XEOMIN INTRAMUSCULA R RECON SOLN 50 UNIT PA; MO YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol aloprim COLCHICINE ORAL colchicineprobenecid COLCRYS probenecid ULORIC 2 ST; MO ZYLOPRIM OSTEOPOROSIS THERAPY ACTONEL ORAL TABLET 50 ACTONEL ORAL TABLET 35 ACTONEL ORAL TABLET 5 alendronate oral solution 3 ST; MO; QL ( per 3 ST; MO; QL (4 per 28 days) 3 ST; MO; QL (30 per ; QL (286 per

91 Name alendronate oral tablet 0 mg, 5 mg alendronate oral tablet 35 mg, 70 mg ; QL (30 per ; QL (4 per 28 days) ATELVIA 3 ST; MO; QL (4 per 28 days) BINOSTO 3 ST; MO; QL (4 per 28 days) BONIVA 3 PA; MO BONIVA ORAL 3 ST; MO; QL ( per EVISTA FORTEO 2 PA; MO; QL (2.4 per 28 days) FOSAMAX ORAL TABLET 70 FOSAMAX PLUS D ibandronate intravenous solution 3 ST; MO; QL (4 per 28 days) 3 ST; MO; QL (4 per 28 days) PA; MO ibandronate oral ; QL ( per PROLIA 2 PA; MO raloxifene risedronate oral tablet 50 mg risedronate oral tablet 35 mg risedronate oral tablet 35 mg (2 pack) risedronate oral tablet 5 mg ; QL ( per ; QL (4 per 28 days) QL (4 per 28 days) ; QL (30 per Name risedronate oral tablet,delayed release (dr/ec) ; QL (4 per 28 days) OTHER RHEUMATOLOGICALS ACTEMRA 2 PA; MO ARAVA ; QL (30 per BENLYSTA RECON SOLN 20 CUPRIMINE DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 /0.5ML (0.5) ENBREL SUBCUTANEOUS SYRINGE 50 /ML (0.98 ML) ENBREL SURECLICK HUMIRA CROHN'S DIS START PCK HUMIRA SUBCUTANEOUS SYRINGE KIT 0 /0.2 ML 2 PA; MO; QL (8 per 28 days) 2 PA; MO; QL (8 per 28 days) 2 PA; MO; QL (4 per 28 days) 2 PA; MO; QL (4 per 28 days) 2 PA; MO; QL (4.8 per 80 days) 2 PA; MO; QL (0.4 per 28 days) 83

92 Name HUMIRA SUBCUTANEOUS SYRINGE KIT 20 /0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 /0.8 ML 2 PA; MO; QL (2 per 28 days) 2 PA; MO; QL (3.2 per 28 days) KINERET 3 PA; MO leflunomide ; QL (30 per ORENCIA 2 PA; MO ORENCIA (WITH MALTOSE) 2 PA; MO OTEZLA 2 PA; MO OTEZLA STARTER 2 PA; MO OTREXUP (PF) RASUVO (PF) RIDAURA SAVELLA ORAL TABLET SAVELLA ORAL TABLETS,DOSE PACK ; QL (60 per ; QL (55 per SIMPONI 3 PA; MO SIMPONI ARIA 3 PA; MO XELJANZ 3 PA; MO OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS ACTIVELLA ALORA ; QL (8 per 28 days) Name ANGELIQ ORAL TABLET 0.5- AYGESTIN camila CLIMARA ; QL (4 per 28 days) CRINONE VAGINAL GEL 4 % CRINONE VAGINAL GEL 8 % 3 PA; MO deblitane DELESTROGEN DEPO-ESTRADIOL DEPO-PROVERA INTRAMUSCULA R SOLUTION DEPO-PROVERA INTRAMUSCULA R SUSPENSION DEPO-SUBQ PROVERA 04 DIVIGEL ; QL (30 per DUAVEE ELESTRIN ; QL (52 per ENJUVIA errin ESTRACE ORAL ESTRACE VAGINAL 84

93 Name estradiol oral estradiol transdermal patch semiweekly estradiol transdermal patch weekly estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiolnorethindrone acet ; QL (8 per 28 days) ; QL (4 per 28 days) ESTRING estropipate EVAMIST ; QL (6.2 per FEMHRT LOW DOSE FEMRING jolivette LOPREEZA lyza medroxyprogesteron e intramuscular suspension medroxyprogesteron e oral MENEST MENOSTAR ; QL (4 per 28 days) mimvey mimvey lo Name MINIVELLE ; QL (8 per 28 days) nora-be norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol oral tablet mg-mcg, -5 mg-mcg norlyroc NOR-QD ORTHO MICRONOR PREMARIN INJECTION PREMARIN ORAL PREMARIN VAGINAL progesterone micronized PROMETRIUM PROVERA sharobel VAGIFEM VIVELLE-DOT ; QL (8 per 28 days) MISCELLANEOUS OB/GYN AVC VAGINAL CLEOCIN VAGINAL CREAM 85

94 Name CLEOCIN VAGINAL SUPPOSITORY clindamycin phosphate vaginal GYNAZOLE- VAGINAL CREAM LUPANETA PACK (NTH) LUPANETA PACK (NTH) LYSTEDA METROGEL VAGINAL metronidazole vaginal miconazole-3 vaginal suppository NUVARING NUVESSA TERAZOL 3 VAGINAL CREAM TERAZOL 7 terconazole tranexamic acid oral vandazole xulane ORAL CONTRACEPTIVES / RELATED AGENTS amethia amethyst apri Name aranelle (28) ashlyna aubra aviane balziva (28) BEYAZ BREVICON (28) briellyn cryselle (28) cyclafem /35 (28) cyclafem 7/7/7 (28) CYCLESSA (28) delyla (28) desoge.estradiol/e.estradio l DESOGEN drospirenone-ethinyl estradiol emoquette enpresse falmina (28) FEMCON FE GENERESS FE gianvi (28) gildagia gildess 24 fe gildess oral tablet.5-30 mg-mcg introvale 86

95 Name junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe 24 kariva (28) kelnor /35 (28) l norgest&e estradiol-e estrad oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (7) larin.5/30 (2) larin /20 (2) larin fe leena 28 lessina levonest (28) levonorgestrelethinyl estrad oral tablet mgmcg levonorgestrelethinyl estrad oral tablet mcg levonorgestrelethinyl estrad oral tablets,dose pack,3 month levora-28 LO LOESTRIN FE Name LOESTRIN.5/30 (2) LOESTRIN /20 (2) LOESTRIN FE.5/30 (28-DAY) LOESTRIN FE /20 (28-DAY) lomedia 24 fe loryna (28) LOSEASONIQUE lutera (28) marlissa microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28) microgestin fe /20 (28) MINASTRIN 24 FE MODICON (28) mononessa (28) NATAZIA necon 0.5/35 (28) necon /35 (28) necon /50 (28) necon 0/ (28) necon 7/7/7 (28) nikki (28) 87

96 Name noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) norethindronee.estradiol-iron oral tablet mg-20 mcg (24)/75 mg (4) NORINYL +35 (28) NORINYL +50 (28) nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) orsythia ORTHO TRI- CYCLEN (28) ORTHO TRI- CYCLEN LO (28) ORTHO-CEPT (28) ORTHO-CYCLEN (28) ORTHO-NOVUM /35 (28) ORTHO-NOVUM 7/7/7 (28) OVCON-35 (28) pimtrea (28) Name pirmella oral tablet -35 mg-mcg portia previfem QUARTETTE quasense reclipsen (28) SAFYRAL SEASONIQUE sprintec (28) sronyx tarina fe tri-legest fe trinessa (28) TRI-NORINYL (28) tri-previfem (28) tri-sprintec (28) trivora (28) velivet triphasic regimen (28) vestura (28) vyfemla (28) wymzya fe YASMIN (28) YAZ (28) zenchent (28) zenchent fe zovia /35e (28) zovia /50e (28) OXYTOCICS 88

97 Name methylergonovine oral OPHTHALMOLOGY ANTIBIOTICS AZASITE bacitracin ophthalmic bacitracinpolymyxin b ophthalmic BESIVANCE CILOXAN OPHTHALMIC DROPS CILOXAN OPHTHALMIC OINTMENT ciprofloxacin hcl ophthalmic erythromycin ophthalmic garamycin ophthalmic drops gatifloxacin gentak ophthalmic ointment gentamicin ophthalmic ILOTYCIN levofloxacin ophthalmic MOXEZA NATACYN Name neomycinbacitracinpolymyxin neomycinpolymyxingramicidin NEOSPORIN (NEO-POLYM- GRAMICID) OCUFLOX ofloxacin ophthalmic polymyxin b sulftrimethoprim POLYTRIM tobramycin TOBREX OPHTHALMIC DROPS TOBREX OPHTHALMIC OINTMENT VIGAMOX ZYMAXID ANTIVIRALS trifluridine VIROPTIC ZIRGAN BETA-BLOCKERS BETAGAN OPHTHALMIC DROPS 0.5 % betaxolol ophthalmic BETIMOL 89

98 Name BETOPTIC S carteolol ISTALOL levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic TIMOPTIC OCUDOSE (PF) TIMOPTIC-XE CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops DIRECT ACTING MIOTICS ISOPTO CARPINE pilocarpine hcl ophthalmic drops %, 2 %, 4 % MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL ALOMIDE azelastine ophthalmic BEPREVE Name cromolyn ophthalmic CYSTARAN ELESTAT EMADINE epinastine LACRISERT LASTACAFT PATADAY PATANOL PAZEO RESTASIS ; QL (60 per NON-STEROIDAL ANTI- INFLAMMATORY AGENTS ACULAR ACULAR LS ACUVAIL (PF) bromfenac diclofenac sodium ophthalmic flurbiprofen sodium ILEVRO ketorolac ophthalmic NEVANAC OCUFEN PROLENSA ORAL DRUGS FOR GLAUCOMA acetazolamide oral 90

99 Name acetazolamide sodium DIAMOX SEQUELS methazolamide oral OTHER GLAUCOMA DRUGS AZOPT bimatoprost COMBIGAN COSOPT dorzolamide dorzolamide-timolol latanoprost LUMIGAN OPHTHALMIC DROPS 0.0 % SIMBRINZA TRAVATAN Z travoprost (benzalkonium) TRUSOPT XALATAN 3 ST; MO ZIOPTAN (PF) 3 ST; MO STEROID-ANTIBIOTIC COMBINATIONS MAXITROL neomycin-polymyxin b-dexameth Name neomycinbacitracin-poly-hc neomycinpolymyxin-hc ophthalmic PRED-G PRED-G S.O.P. TOBRADEX TOBRADEX ST tobramycindexamethasone ZYLET STEROIDS ALREX dexamethasone sodium phosphate ophthalmic DUREZOL FLAREX fluorometholone FML FORTE FML LIQUIFILM FML S.O.P. LOTEMAX MAXIDEX OMNIPRED PRED FORTE PRED MILD prednisolone acetate prednisolone sodium phosphate ophthalmic VEXOL 9

100 Name STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE BLEPHAMIDE S.O.P. sulfacetamideprednisolone SULFONAMIDES BLEPH-0 sulfacetamide sodium ophthalmic SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0. % ALPHAGAN P OPHTHALMIC DROPS 0.5 % apraclonidine brimonidine IOPIDINE VASOCONSTRICTOR DECONGESTANTS naphazoline RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS adrenalin injection solution mg/ml (:,000) (ml) AUVI-Q ; QL (4 per Name cetirizine oral solution mg/ml CLARINEX ORAL SYRUP CLARINEX ORAL TABLET CLARINEX-D 2 HOUR ; QL (30 per ; QL (60 per desloratadine ; QL (30 per diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl oral elixir epinephrine injection autoinjector PA ; QL (4 per EPIPEN 2-PAK ; QL (4 per EPIPEN JR 2-PAK ; QL (4 per hydroxyzine hcl oral tablet levocetirizine oral solution levocetirizine oral tablet PHENERGAN INJECTION promethazine injection solution PA; MO ; QL (30 per promethazine oral PA; MO SEMPREX-D 92

101 Name XYZAL ORAL SOLUTION XYZAL ORAL TABLET PULMONARY AGENTS ACCOLATE acetylcysteine solution ; QL (30 per PA; MO ADCIRCA 2 PA; MO; QL (60 per ADEMPAS 2 PA; MO; LA ADVAIR DISKUS ; QL (60 per ADVAIR HFA ; QL (2 per AEROSPAN ; QL (7.8 per albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml,.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml PA; MO albuterol sulfate oral ALVESCO INHALATION HFA AEROSOL INHALER 60 MCG/ACTUATION ALVESCO INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION ; QL (2.2 per ; QL (6. per Name aminophylline intravenous solution 250 mg/0 ml ANORO ELLIPTA ; QL (60 per ARCAPTA NEOHALER ARNUITY ELLIPTA ; QL (30 per ; QL (30 per ASMANEX HFA ; QL (3 per ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (30 DOSES), 220 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (20 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (60 DOSES) ; QL (30 per ; QL (240 per ; QL (60 per ATROVENT HFA ; QL (25.8 per BECONASE AQ ; QL (50 per 93

102 Name BERINERT KIT 3 PA; MO BREO ELLIPTA ; QL (60 per BROVANA 3 PA; MO budesonide inhalation PA; MO budesonide nasal ; QL (7.2 per CINRYZE 2 PA; MO COMBIVENT RESPIMAT ; QL (8 per cromolyn inhalation PA; MO DALIRESP 2 PA; MO DULERA ; QL (3 per DYMISTA ; QL (23 per ELIXOPHYLLIN ORAL ELIXIR 80 /5 ML ESBRIET 2 PA; MO; QL (270 per FIRAZYR 2 PA; MO FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION ; QL (60 per Name FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) ; QL (240 per ; QL (2 per ; QL (24 per ; QL (0.6 per ; QL (50 per fluticasone nasal ; QL (6 per FORADIL AEROLIZER INCRUSE ELLIPTA ipratropium bromide inhalation ipratropiumalbuterol ; QL (60 per ; QL (30 per PA; MO PA; MO KALBITOR KALYDECO ORAL GRANULES IN PACKET 2 PA; MO; QL (56 per 28 days) 94

103 Name KALYDECO ORAL TABLET 2 PA; MO; QL (60 per LETAIRIS 2 PA; MO; LA levalbuterol hcl inhalation solution for nebulization 0.3 mg/3 ml, 0.63 mg/3 ml,.25 mg/0.5 ml PA; MO metaproterenol oral montelukast NASONEX ; QL (34 per OFEV 2 PA; MO; QL (60 per OMNARIS ; QL (2.5 per OPSUMIT 2 PA; MO; LA PERFOROMIST 2 PA; MO PROAIR HFA ; QL (7 per PROAIR RESPICLICK ; QL (7 per PROVENTIL HFA ; QL (3.4 per PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 80 MCG/ACTUATION ; QL (2 per Name PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 0.25 /2 ML, 0.5 /2 ML PULMICORT INHALATION SUSPENSION FOR NEBULIZATION /2 ML ; QL ( per 3 PA; MO 2 PA; MO PULMOZYME 2 PA; MO QNASL NASAL HFA AEROSOL INHALER 40 MCG/ACTUATION QNASL NASAL HFA AEROSOL INHALER 80 MCG/ACTUATION ; QL (4.9 per ; QL (8.7 per QVAR ; QL (7.4 per REVATIO REVATIO ORAL SUSPENSION FOR RECONSTITUTIO N REVATIO ORAL TABLET 3 PA; MO 3 PA; MO; QL (224 per 3 PA; MO; QL (90 per 95

104 Name RHINOCORT AQUA ; QL (7.2 per RUCONEST 3 PA; MO SEREVENT DISKUS sildenafil intravenous ; QL (60 per PA sildenafil oral PA; MO; QL (90 per SINGULAIR SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT STRIVERDI RESPIMAT ; QL (60 per ; QL (90 per 90 days) ; QL (4 per ; QL (4 per SYMBICORT ; QL (0.2 per terbutaline oral terbutaline subcutaneous THEO-24 theophylline oral solution theophylline oral tablet extended release theophylline oral tablet extended release 2 hr TRACLEER 2 PA; MO; LA Name triamcinolone acetonide nasal TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION (30 ACTUAT) ; QL (6.5 per ; QL ( per 2 QL ( per 30 days) TYVASO 2 PA; MO VENTAVIS 3 PA; MO VENTOLIN HFA ; QL (36 per VERAMYST ; QL (0 per VOSPIRE ER XOLAIR 2 PA; MO; LA; QL (6 per 28 days) XOPENEX 3 PA; MO XOPENEX HFA ; QL (30 per zafirlukast ZETONNA ; QL (6. per ZYFLO ZYFLO CR 96

105 Name UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS DETROL DETROL LA DITROPAN XL ENABLEX flavoxate GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP GELNIQUE TRANSDERMAL GEL IN PACKET MYRBETRIQ oxybutynin chloride oral ; QL (92 per ; QL (30 per OXYTROL ; QL (8 per 28 days) tolterodine TOVIAZ trospium VESICARE BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin AVODART finasteride oral tablet 5 mg FLOMAX 3 ST; MO Name JALYN PROSCAR RAPAFLO 2 ST; MO tamsulosin UROXATRAL 3 ST; MO CHOLINERGIC STIMULANTS bethanechol chloride URECHOLINE MISCELLANEOUS UROLOGICALS AMMONIUM CHLORIDE CIALIS ORAL TABLET 2.5, PA; MO; QL (30 per CYSTAGON ; LA ELMIRON potassium citrate PROCYSBI UROCIT-K 0 UROCIT-K 5 UROCIT-K 5 VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate oral capsule dextrose-kcl-nacl eliphos klor-con 0 klor-con 8 97

106 Name klor-con m5 klor-con m20 K-TAB ORAL TABLET EXTENDED RELEASE 0 MEQ, 20 MEQ k-tab oral tablet extended release 8 meq lactated ringers intravenous magnesium sulfate injection solution magnesium sulfate injection syringe NORMOSOL-R IN 5 % DEXTROSE PHOSLO PHOSLYRA potassium chloridd5-0.45%nacl intravenous parenteral solution 0 meq/l, 30 meq/l, 40 meq/l potassium chloridd5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l 2 Name potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l potassium chloride intravenous piggyback 0 meq/00 ml, 20 meq/00 ml, 40 meq/00 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals potassium chloride % nacl potassium chlorided5-0.2%nacl intravenous parenteral solution 20 meq/l 98

107 Name potassium chlorided5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.9%nacl intravenous parenteral solution 40 meq/l ringers intravenous sodium chloride 0.45 % intravenous parenteral solution sodium chloride 3 % sodium chloride 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml sodium lactate intravenous solution TPN ELECTROLYTES MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 %- ELECTROLYTES 3 2 PA 2 PA Name AMINOSYN II 0 % AMINOSYN II 5 % 2 PA 2 PA AMINOSYN II 7 % 2 PA AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE- FREE) AMINOSYN-RF 5.2 % CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%- D20W SULF-FREE 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 99

108 Name CLINIMIX 4.25%- D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE- FREE) CLINIMIX E 4.25%/D0W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE 2 PA 2 PA 3 PA 3 PA 3 PA 3 PA 3 PA 3 PA CLINISOL SF 5 % 3 PA; MO FREAMINE HBC 6.9 % 2 PA HEPATAMINE 8% 2 PA intralipid intravenous emulsion 20 % INTRALIPID EMULSION 30 % IONOSOL-B IN D5W PA; MO 2 PA 2 Name IONOSOL-MB IN D5W ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 2 NEPHRAMINE 5.4 % NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH PA NUTRILIPID 3 PA PLASMA-LYTE 48 PLASMA-LYTE A 2 PLASMA-LYTE-56 IN 5 % DEXTROSE premasol 0 % PA; MO PREMASOL 6 % 2 PA PROCALAMINE 3% 2 3 PA PROSOL 20 % 3 PA; MO travasol 0 % PA; MO TROPHAMINE 0 % 2 PA; MO TROPHAMINE 6% 2 PA VITAMINS / HEMATINICS PRENATAL VITAMIN ORAL TABLET SODIUM FLUORIDE ORAL TABLET 3 00

109 Index 8 8-MOP A abacavir... abacavir-lamivudinezidovudine... ABELCET... ABILIFY... 35, 36 ABILIFY DISCMELT ABILIFY MAINTENA ABRAXANE... 3 ABSORICA... 56, 57 ABSTRAL acamprosate... 6 ACANYA acarbose ACCOLATE ACCUPRIL ACCURETIC acebutolol acetaminophen-codeine acetasol hc acetazolamide acetazolamide sodium... 9 acetic acid acetylcysteine ACIPHEX ACIPHEX SPRINKLE acitretin ACTEMRA ACTHAR H.P ACTHIB (PF) ACTIGALL ACTIMMUNE ACTIQ ACTIVELLA ACTONEL... 6, 82 ACTOPLUS MET ACTOPLUS MET XR ACTOS ACULAR ACULAR LS ACUVAIL (PF) acyclovir..., 2, 59 acyclovir sodium... 2 ACZONE ADACEL(TDAP ADOLESN/ADULT)(PF) 80 ADAGEN... 6 ADALAT CC adapalene ADCIRCA ADDERALL ADDERALL XR adefovir... 2 ADEMPAS ADOXA... 2 adrenalin adrucil... 3 ADVAIR DISKUS ADVAIR HFA ADVICOR AEROSPAN afeditab cr AFINITOR... 3 AFINITOR DISPERZ... 3 AFREZZA AGGRENOX AGRYLIN... 6 a-hydrocort AKYNZEO ala-cort ALA-SCALP ALBENZA... 7 albuterol sulfate alclometasone ALCOHOL PADS ALDACTAZIDE ALDACTONE ALDARA ALDURAZYME alendronate... 6, 82, 83 alfuzosin ALIMTA... 3 ALINIA... 7 ALKERAN... 4 allopurinol ALOCRIL ALOMIDE aloprim ALORA alosetron ALOXI ALPHAGAN P ALREX... 9 ALSUMA ALTABAX ALTACE ALTOPREV ALVESCO amantadine hcl... 2 AMARYL... 65, 66 AMBIEN AMBIEN CR AMBISOME... amcinonide AMERGE amethia amethyst amifostine crystalline... 3 amikacin... 7 amiloride amiloride-hydrochlorothiazide aminophylline AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 %

110 AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone AMITIZA amitriptyline amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid AMMONIUM CHLORIDE. 97 ammonium lactate amnesteem amoxapine amoxicil-clarithromy-lansopraz amoxicillin... 0 amoxicillin-pot clavulanate.. 0 amphetamine salt combo amphotericin b... ampicillin... 0 ampicillin sodium... 0 ampicillin-sulbactam... 0 AMPYRA ANADROL ANAFRANIL anagrelide... 6 ANAPROX ANAPROX DS anastrozole... 4 ANCOBON... ANDRODERM ANDROGEL ANDROID ANGELIQ ANORO ELLIPTA ANTABUSE... 6 ANTARA ANUSOL-HC ANZEMET APEXICON apexicon e APIDRA APIDRA SOLOSTAR APLENZIN APOKYN apraclonidine apri APRISO APTENSIO XR APTIOM APTIVUS... 2 ARALAST NP... 6 aranelle (28) ARANESP (IN POLYSORBATE) ARAVA ARCALYST ARCAPTA NEOHALER ARGATROBAN ARGATROBAN IN 0.9 % SOD CHLOR ARICEPT ARIMIDEX... 4 aripiprazole ARIXTRA ARNUITY ELLIPTA AROMASIN... 4 ARRANON... 4 ARTHROTEC ARTHROTEC ARZERRA... 4 ASACOL HD ashlyna ASMANEX HFA ASMANEX TWISTHALER 93 ASTAGRAF XL... 4 ASTEPRO ATACAND ATACAND HCT ATELVIA atenolol atenolol-chlorthalidone ATGAM ATIVAN atorvastatin atovaquone... 7 atovaquone-proguanil... 7 ATRALIN ATRIPLA... 2 atropine... 72, 90 ATROVENT ATROVENT HFA AUBAGIO aubra AUGMENTIN... 0 AURYXIA AUVI-Q AVALIDE AVANDAMET AVANDIA AVAPRO AVASTIN... 4 AVC VAGINAL AVEED AVELOX... AVELOX ABC PACK... AVELOX IN NACL (ISO- OSMOTIC)... aviane avita AVITA AVODART AVONEX AVONEX (WITH ALBUMIN) AXERT AXIRON AYGESTIN azacitidine... 4 AZACTAM... 7 AZACTAM IN DEXTROSE (ISO-OSM)... 7 AZASAN... 4 AZASITE azathioprine... 4 azelastine... 63, 90 AZELEX AZILECT azithromycin... 6 AZOPT... 9 AZOR aztreonam

111 AZULFIDINE AZULFIDINE EN-TABS B baciim... 7 bacitracin... 7, 89 bacitracin-polymyxin b baclofen BACTRIM... 2 BACTRIM DS... 2 BACTROBAN BACTROBAN NASAL balsalazide balziva (28) BANZEL BARACLUDE... 2 BCG VACCINE, LIVE (PF) 80 BECONASE AQ BELEODAQ... 4 BELSOMRA benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA BENZACLIN BENZAMYCIN benztropine BEPREVE BERINERT BESIVANCE BETAGAN betamethasone dipropionate. 59 betamethasone valerate betamethasone, augmented BETAPACE AF BETASERON betaxolol... 48, 89 bethanechol chloride BETHKIS... 7 BETIMOL BETOPTIC S BEXSERO (PF) BEYAZ BIAXIN... 6 bicalutamide... 4 BICILLIN C-R... 0 BICILLIN L-A... 0 BICNU... 4 BIDIL BILTRICIDE... 7 bimatoprost... 9 BINOSTO bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM bleomycin... 4 BLEPH BLEPHAMIDE BLEPHAMIDE S.O.P BONIVA BOOSTRIX TDAP BOSULIF... 4 BOTOX BREO ELLIPTA BREVICON (28) briellyn BRILINTA brimonidine BRINTELLIX BRISDELLE bromfenac bromocriptine BROVANA budesonide... 73, 94 bumetanide BUNAVAIL BUPRENEX buprenorphine hcl... 26, 27 buprenorphine-naloxone buproban bupropion hcl... 36, 37 buspirone BUSULFEX... 4 butorphanol tartrate BUTRANS BYDUREON BYETTA BYSTOLIC C cabergoline CADUET CAFERGOT CALAN CALAN SR calcipotriene calcipotriene-betamethasone 55 calcitonin (salmon) calcitriol... 56, 70 calcium acetate CAMBIA camila CAMPTOSAR... 4 CANASA CANCIDAS... candesartan candesartan-hydrochlorothiazid CANTIL CAPASTAT... 7 CAPEX CAPITAL WITH CODEINE CAPRELSA... 4 captopril captopril-hydrochlorothiazide CARAC carafate CARAFATE CARBAGLU carbamazepine CARBATROL carbidopa carbidopa-levodopa carbidopa-levodopaentacapone carboplatin... 4 CARDENE IV IN SODIUM CHLORIDE CARDIZEM CARDIZEM CD CARDIZEM LA CARDURA

112 CARDURA XL CARIMUNE NF NANOFILTERED CARNITOR carteolol cartia xt carvedilol CASODEX... 4 CATAPRES CATAPRES-TTS CATAPRES-TTS CATAPRES-TTS CAYSTON... 7 CEDAX... 4 cefaclor... 4 cefadroxil... 4 cefazolin... 4 cefazolin in dextrose (iso-os). 4 cefdinir... 4 cefditoren pivoxil... 5 cefepime... 5 CEFEPIME IN DEXTROSE 5 %... 5 cefixime... 5 cefotaxime... 5 cefotetan... 5 cefoxitin... 5 cefoxitin in dextrose, iso-osm 5 cefpodoxime... 5 cefprozil... 5 ceftazidime... 5 CEFTAZIDIME IN D5W... 5 CEFTIN... 5 ceftriaxone... 5 cefuroxime axetil... 5 cefuroxime sodium... 5 CELEBREX celecoxib CELEXA CELLCEPT... 4 CELLCEPT... 4 CELONTIN cephalexin... 5 CERDELGA CEREBYX... 2 CEREZYME CERVARIX VACCINE (PF) CESAMET cetirizine cevimeline CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX CHEMET CHENODAL chloramphenicol sod succinate... 7 chlorhexidine gluconate chloroquine phosphate... 7 chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone cholestyramine light chorionic gonadotropin, human CIALIS ciclopirox cidofovir... 2 cilostazol CILOXAN cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRO... CIPRO HC CIPRO IN D5W... CIPRODEX ciprofloxacin... ciprofloxacin (mixture)... ciprofloxacin hcl..., 89 ciprofloxacin in 5 % dextrose... ciprofloxacin lactate... cisplatin... 4 citalopram cladribine... 4 CLAFORAN... 5 claravis CLARINEX CLARINEX-D 2 HOUR clarithromycin... 6 CLEOCIN... 7, 85, 86 CLEOCIN IN 5 % DEXTROSE... 7 CLEOCIN T CLIMARA CLINDACIN PAC CLINDAGEL clindamycin hcl... 7 clindamycin in 5 % dextrose.. 8 clindamycin pediatric... 8 clindamycin phosphate... 8, 57, 86 clindamycin-benzoyl peroxide CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE) 00 CLINIMIX E 2.75%/D0W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D0W SUL FREE

113 CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D5W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 5 % clobetasol... 59, 60 clobetasol-emollient CLOBEX clodan CLODERM CLOLAR... 4 clomipramine clonazepam... 2 clonidine clonidine hcl... 37, 49 clopidogrel clorazepate dipotassium clorpres CLORPRES clotrimazole..., 59 clotrimazole-betamethasone. 59 clozapine CLOZAPINE CLOZARIL COARTEM... 8 codeine sulfate COGENTIN COLAZAL COLCHICINE colchicine-probenecid COLCRYS COLESTID colestipol colistin (colistimethate na)... 8 colocort COLY-MYCIN S COLYTE WITH FLAVOR PACKS COMBIGAN... 9 COMBIVENT RESPIMAT. 94 COMBIVIR... 2 COMETRIQ... 4 COMPLERA... 2 compro COMTAN COMVAX (PF) CONCERTA CONDYLOX constulose CONZIP COPAXONE COPEGUS... 2 CORDRAN TAPE LARGE ROLL COREG COREG CR CORGARD CORLANOR cormax CORTEF cortisone CORTISPORIN... 58, 64 CORTISPORIN-TC CORZIDE COSENTYX PEN COSENTYX PEN (2 PENS) 56 COSMEGEN... 4 COSOPT... 9 COUMADIN COZAAR CREON CRESEMBA... CRESTOR CRINONE CRIXIVAN... 2 cromolyn... 73, 90, 94 cryselle (28) CUBICIN... 8 CUPRIMINE CUTIVATE CUVPOSA cyclafem /35 (28) cyclafem 7/7/7 (28) CYCLESSA (28) CYCLOPHOSPHAMIDE... 4 CYCLOSET cyclosporine... 4 cyclosporine modified... 4 CYKLOKAPRON CYMBALTA CYSTADANE CYSTAGON CYSTARAN cytarabine... 4 cytarabine (pf)... 5 CYTOMEL CYTOTEC CYTOVENE... 2 D d0 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine... 5 DACOGEN... 5 DALIRESP DALVANCE... 8 danazol... 7 DANTRIUM dantrolene DAPSONE... 8 DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM... 8 daunorubicin... 5 DAUNOXOME... 5 DAYPRO DAYTRANA DDAVP... 7 deblitane decitabine... 5 DELESTROGEN delyla (28) DELZICOL DEMADEX

114 demeclocycline... 2 DEMSER DENAVIR DEPACON... 2 DEPAKENE... 2 DEPAKOTE... 2 DEPAKOTE ER... 2 DEPAKOTE SPRINKLES.. 2 DEPEN TITRATABS DEPO-ESTRADIOL DEPO-MEDROL DEPO-PROVERA DEPO-SUBQ PROVERA DEPO-TESTOSTERONE... 7 DERMATOP desipramine desloratadine desmopressin... 7 desog-e.estradiol/e.estradiol. 86 DESOGEN DESONATE desonide DESOWEN desoximetasone DESOXYN DESVENLAFAXINE DETROL DETROL LA dexamethasone dexamethasone intensol dexamethasone sodium phosphate... 64, 9 dexedrine DEXEDRINE SPANSULE.. 38 DEXILANT dexmethylphenidate DEXPAK 3 DAY dexrazoxane hcl... 3 dextroamphetamine dextroamphetamineamphetamine dextrose 0 % and 0.2 % nacl dextrose 0 % in water (d0w) dextrose 5 % in water (d5w). 62 dextrose 5 %-lactated ringers62 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride dextrose-kcl-nacl DIAMOX SEQUELS... 9 DIASTAT... 2 DIASTAT ACUDIAL... 2 diazepam... 2, 38 diazepam intensol diclofenac potassium diclofenac sodium... 33, 56, 90 diclofenac-misoprostol dicloxacillin... 0 didanosine... 2 DIFFERIN DIFICID... 6 diflorasone DIFLUCAN... diflunisal digitek digoxin dihydroergotamine DILANTIN DILANTIN EXTENDED DILANTIN INFATABS DILANTIN /5 ML... 2 DILAUDID DILAUDID (PF) DILAUDID-HP (PF) diltiazem hcl dilt-xr DIOVAN DIOVAN HCT DIPENTUM diphenhydramine hcl diphenoxylate-atropine DIPROLENE DIPROLENE AF dipyridamole disulfiram DITROPAN XL DIURIL DIURIL IV divalproex... 2 DIVIGEL DOCEFREZ... 5 docetaxel... 5 DOLOPHINE donepezil DORIBAX... 8 dorzolamide... 9 dorzolamide-timolol... 9 DOVONEX doxazosin doxepin doxercalciferol... 7 DOXIL... 5 doxorubicin... 5 doxy doxycycline hyclate... 2 doxycycline monohydrate... 2 dronabinol drospirenone-ethinyl estradiol DROXIA... 5 DUAC DUAVEE DUETACT DUEXIS DULERA duloxetine DUOPA DURAGESIC duramorph (pf) DUREZOL... 9 DUTOPROL DYAZIDE DYMISTA DYSPORT

115 E e.e.s E.E.S. GRANULES... 6 EC-NAPROSYN econazole EDARBI EDARBYCLOR EDECRIN EDURANT... 2 EFFEXOR XR EFFIENT EFUDEX EGRIFTA ELAPRASE... 7 ELDEPRYL ELELYSO... 7 ELESTAT ELESTRIN ELIDEL ELIGARD... 5 eliphos ELIQUIS ELITEK... 3 ELIXOPHYLLIN ELLENCE... 5 ELMIRON ELOCON ELOXATIN... 5 EMADINE EMBEDA EMCYT... 5 EMEND EMLA emoquette EMSAM EMTRIVA... 2 ENABLEX enalapril maleate enalapril-hydrochlorothiazide ENBREL ENBREL SURECLICK endocet endodan ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF)... 80, 8 ENJUVIA enoxaparin enpresse entacapone entecavir... 2 ENTOCORT EC enulose EPANED EPIDUO epinastine epinephrine EPIPEN 2-PAK EPIPEN JR 2-PAK epirubicin... 5 epitol... 2 EPIVIR... 2 EPIVIR HBV... 2 eplerenone EPOGEN eprosartan EPZICOM... 2 EQUETRO... 2 ERAXIS(WATER DILUENT)... ERBITUX... 5 ergoloid ERGOMAR ERIVEDGE... 5 errin ERTACZO ERWINAZE... 5 ery pads ERYPED ERYPED ery-tab... 6 ERY-TAB... 7 ERYTHROCIN... 7 erythrocin (as stearate)... 7 erythromycin... 7, 89 erythromycin ethylsuccinate... 7 erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate esomeprazole magnesium ESOMEPRAZOLE MAGNESIUM esomeprazole sodium ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 85 ESTRING estropipate eszopiclone ethambutol... 8 ethosuximide... 2 etidronate disodium etodolac ETOPOPHOS... 5 etoposide... 5 EURAX... 6 EVAMIST EVEKEO EVISTA EVOCLIN EVOTAZ... 2 EVOXAC EVZIO EXALGO ER... 27, 28 EXELDERM EXELON exemestane... 5 EXFORGE EXFORGE HCT EXJADE EXTAVIA EXTINA F FABIOR FABRAZYME... 7 FACTIVE... falmina (28) famciclovir... 2 famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 76 07

116 FAMVIR... 2 FANAPT... 38, 39 FARESTON... 5 FARXIGA FARYDAK... 5 FASLODEX... 5 FAZACLO felbamate... 2 FELBATOL... 2 FELDENE felodipine FEMARA... 5 FEMCON FE FEMHRT LOW DOSE FEMRING fenofibrate FENOFIBRATE fenofibrate micronized fenofibrate nanocrystallized. 54 fenofibric acid (choline) FENOGLIDE fenoprofen fentanyl FENTANYL fentanyl citrate FENTORA FERRIPROX FETZIMA FIBRICOR FINACEA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE... 5 FLAGYL... 8 FLAGYL ER... 8 FLAREX... 9 flavoxate FLEBOGAMMA DIF... 8 flecainide FLECTOR FLOMAX FLO-PRED FLOVENT DISKUS FLOVENT HFA fluconazole... fluconazole in dextrose(iso-o) flucytosine... fludarabine... 5 fludrocortisone FLUMADINE... 2 flunisolide fluocinolone fluocinolone acetonide oil fluocinonide fluocinonide-e fluorometholone... 9 fluorouracil... 5, 56 FLUOROURACIL fluoxetine FLUOXETINE fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide... 5 fluticasone... 60, 94 fluvastatin fluvoxamine FML FORTE... 9 FML LIQUIFILM... 9 FML S.O.P FOCALIN FOCALIN XR FOLOTYN... 6 fomepizole... 8 fondaparinux FORADIL AEROLIZER FORFIVO XL FORTAMET FORTAZ... 5 FORTEO FORTESTA... 7 fortical... 7 FOSAMAX FOSAMAX PLUS D foscarnet... 2 fosinopril fosinopril-hydrochlorothiazide fosphenytoin... 2 FOSRENOL FRAGMIN FREAMINE HBC 6.9 % FROVA FULYZAQ FURADANTIN... 2 furosemide FUSILEV... 3 FUZEON... 2 FYCOMPA... 2 G gabapentin... 2 GABITRIL... 2 GABLOFEN galantamine GAMASTAN S/D... 8 GAMMAGARD LIQUID... 8 GAMMAKED... 8 GAMMAPLEX... 8 GAMUNEX-C... 8 ganciclovir sodium... 2 garamycin GARDASIL (PF)... 8 GARDASIL 9 (PF)... 8 GASTROCROM gatifloxacin GATTEX ONE-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GELNIQUE gemcitabine... 6 gemfibrozil GEMZAR... 6 GENERESS FE generlac gengraf... 6 GENOTROPIN GENOTROPIN MINIQUICK gentak gentamicin... 8, 58, 89 gentamicin in nacl (iso-osm)

117 gentamicin sulfate (pf)... 8 GEODON... 39, 40 gianvi (28) GIAZO gildagia gildess gildess 24 fe GILENYA GILOTRIF... 6 GLASSIA glatopa GLEEVEC... 6 GLEOSTINE... 6 glimepiride glipizide glipizide-metformin... 66, 67 GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUMETZA glycopyrrolate GLYSET GLYXAMBI GOLYTELY GRALISE... 2 GRALISE 30-DAY STARTER PACK... 2 granisetron (pf) granisetron hcl GRANIX GRASTEK... 8 griseofulvin microsize... griseofulvin ultramicrosize... GRIS-PEG (ULTRAMICROSIZE)... guanidine GYNAZOLE H HALAVEN... 6 HALDOL HALDOL DECANOATE halobetasol propionate HALOG haloperidol haloperidol decanoate haloperidol lactate HARVONI... 2 HAVRIX (PF)... 8 HECTOROL... 7 heparin (porcine) heparin (porcine) in 5 % dex 53 HEPATAMINE 8% HEPSERA... 2 HERCEPTIN... 6 HETLIOZ HEXALEN... 6 HIPREX... 2 HORIZANT HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMATROPE HUMIRA... 83, 84 HUMIRA CROHN'S DIS START PCK HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U HYCAMTIN... 6 HYCET hydralazine HYDREA... 6 hydrochlorothiazide hydrocodone-acetaminophen 28 hydrocodone-ibuprofen hydrocortisone... 60, 64, 74 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydrocortisone-acetic acid hydromorphone... 28, 29 hydromorphone (pf) hydroxychloroquine... 8 hydroxyurea... 6 hydroxyzine hcl HYPERRAB S/D (PF)... 8 HYSINGLA ER HYZAAR I ibandronate IBRANCE... 6 IBUDONE ibuprofen ibuprofen-oxycodone ICLUSIG... 6 IDAMYCIN PFS... 6 idarubicin... 6 IFEX... 6 ifosfamide... 6 ILARIS (PF) ILEVRO ILOTYCIN IMBRUVICA... 6 imipenem-cilastatin... 8 imipramine hcl imipramine pamoate imiquimod IMITREX IMITREX STATDOSE KIT REFILL IMOVAX RABIES VACCINE (PF)... 8 IMURAN... 6 INCRELEX INCRUSE ELLIPTA indapamide INDERAL LA INFANRIX (DTAP) (PF)... 8 INLYTA... 6 INNOPRAN XL INSPRA

118 INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U-00 ML INSULIN SYRINGE (DISP) U-00 /2 ML INTELENCE... 2 intralipid INTRALIPID INTRON A introvale INVANZ... 8 INVEGA INVEGA SUSTENNA INVIRASE... 2 INVOKAMET INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IOPIDINE IPOL... 8 ipratropium bromide... 63, 94 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRENKA irinotecan... 6 ISENTRESS... 2 ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid... 8 ISOPTO CARPINE ISORDIL ISORDIL TITRADOSE isosorbide dinitrate isosorbide mononitrate isradipine ISTALOL ISTODAX... 6 itraconazole... ivermectin... 8 IXEMPRA... 6 IXIARO (PF)... 8 J JADENU JAKAFI... 6 JALYN jantoven JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JEVTANA... 6 jolivette JUBLIA junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe JUXTAPID K KADCYLA... 7 KADIAN KALBITOR KALETRA... 2 KALYDECO... 94, 95 KAPVAY kariva (28) KAYEXALATE KAZANO KEFLEX... 6 kelnor /35 (28) KENALOG... 60, 64 KEPIVANCE... 3 KEPPRA... 2 KEPPRA XR... 2 KERYDIN KETEK... 8 ketoconazole..., 59 ketoprofen ketorolac KEYTRUDA... 7 KHEDEZLA KINERET kionex KLARON KLONOPIN... 2 klor-con klor-con klor-con m klor-con m KOMBIGLYZE XR KORLYM... 7 KRISTALOSE k-tab K-TAB KUVAN... 7 KYNAMRO L l norgest&e estradiol-e estrad labetalol LACRISERT lactated ringers... 6, 98 lactulose LAMICTAL... 2 LAMICTAL ODT... 2 LAMICTAL STARTER (BLUE) KIT... 2 LAMICTAL STARTER (GREEN) KIT... 2 LAMICTAL STARTER (ORANGE) KIT LAMICTAL XR LAMICTAL XR STARTER (BLUE) LAMICTAL XR STARTER (GREEN) LAMICTAL XR STARTER (ORANGE) LAMISIL... lamivudine... 2 lamivudine-zidovudine... 2 lamotrigine LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin.5/30 (2) larin /20 (2)

119 larin fe LASIX LASTACAFT latanoprost... 9 LATUDA LAZANDA leena leflunomide LENVIMA... 7 LESCOL LESCOL XL lessina LETAIRIS letrozole... 7 leucovorin calcium... 3 LEUKERAN... 7 LEUKINE leuprolide... 7 levalbuterol hcl LEVAQUIN... LEVEMIR LEVEMIR FLEXTOUCH levetiracetam LEVETIRACETAM IN NACL (ISO-OS) levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin..., 89 levofloxacin in d5w... LEVOLEUCOVORIN CALCIUM... 3 levonest (28) levonorgestrel-ethinyl estrad 87 levora levorphanol tartrate levothyroxine LEVOTHYROXINE levoxyl LEXAPRO LEXIVA... 2 LIALDA lidocaine lidocaine (pf) lidocaine hcl lidocaine-prilocaine LIDODERM LINCOCIN... 8 lindane... 6 linezolid... 8 LINZESS LIORESAL liothyronine LIPITOR LIPOFEN LIPTRUZET lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate LITHOBID LITHOSTAT LIVALO LO LOESTRIN FE LOCOID LODOSYN LOESTRIN.5/30 (2) LOESTRIN /20 (2) LOESTRIN FE.5/30 (28- DAY) LOESTRIN FE /20 (28-DAY) LOFIBRA lomedia 24 fe LOMOTIL LOMUSTINE... 7 loperamide LOPID LOPREEZA LOPRESSOR LOPRESSOR HCT LOPROX lorazepam... 4 lorazepam intensol lorcet (hydrocodone) lorcet hd lorcet plus lortab lortab lortab loryna (28) losartan losartan-hydrochlorothiazide 50 LOSEASONIQUE LOTEMAX... 9 LOTENSIN LOTREL LOTRISONE LOTRONEX lovastatin LOVAZA LOVENOX loxapine succinate... 4 LUMIGAN... 9 LUMIZYME... 7 LUNESTA... 4 LUPANETA PACK ( MONTH) LUPANETA PACK (3 MONTH) LUPRON DEPOT... 7 LUPRON DEPOT (3 MONTH)... 7 LUPRON DEPOT (4 MONTH)... 7 LUPRON DEPOT (6 MONTH)... 7 LUPRON DEPOT-PED... 7 lutera (28) LUZU LYNPARZA... 7 LYRICA LYSODREN... 7 LYSTEDA lyza M MACROBID... 2 MACRODANTIN... 2 magnesium sulfate MALARONE... 8 MALARONE PEDIATRIC... 8 malathion... 6 maprotiline... 4

120 MARINOL marlissa MARPLAN... 4 MATULANE... 7 matzim la MAVIK MAXALT MAXALT-MLT MAXIDEX... 9 MAXIPIME... 6 MAXITROL... 9 MAXZIDE... 5 MAXZIDE meclizine meclofenamate MEDROL MEDROL (PAK) medroxyprogesterone mefenamic acid mefloquine... 8 MEGACE... 7 MEGACE ES... 7 megestrol... 7 MEKINIST... 7 meloxicam melphalan hcl... 7 MENACTRA (PF)... 8 MENEST MENOMUNE - A/C/Y/W-35 (PF)... 8 MENOSTAR MENTAX MENVEO A-C-Y-W-35-DIP (PF)... 8 MEPRON... 8 mercaptopurine... 7 meropenem... 8 MERREM... 8 mesalamine with cleansing wipe mesna... 3 MESNEX... 3 MESTINON MESTINON TIMESPAN METADATE CD... 4 metadate er... 4 metaproterenol metformin methadone methamphetamine... 4 methazolamide... 9 methenamine hippurate... 2 methimazole METHITEST... 7 methotrexate sodium... 7 methotrexate sodium (pf)... 7 methoxsalen rapid methscopolamine methyclothiazide... 5 methyldopa... 5 methylergonovine METHYLIN... 4 methylphenidate... 4 methylprednisolone methylprednisolone acetate.. 64 methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone... 5 metoprolol succinate... 5 metoprolol ta-hydrochlorothiaz... 5 metoprolol tartrate... 5 METOZOLV ODT METROCREAM METROGEL METROGEL VAGINAL METROLOTION metronidazole... 8, 57, 86 metronidazole in nacl (iso-os) 8 mexiletine MIACALCIN... 7 MICARDIS... 5 MICARDIS HCT... 5 miconazole microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28) microgestin fe /20 (28) MICROZIDE... 5 midodrine migergot MIGRANAL millipred MILLIPRED mimvey mimvey lo MINASTRIN 24 FE MINIPRESS... 5 MINITRAN MINIVELLE MINOCIN... 2 minocycline... 2 minoxidil... 5 MIRAPEX MIRAPEX ER MIRCERA mirtazapine... 4 MIRVASO misoprostol mitomycin... 7 mitoxantrone... 7 M-M-R II (PF)... 8 MOBIC modafinil... 4 moderiba... 2 moderiba dose pack... 2 MODICON (28) moexipril... 5 moexipril-hydrochlorothiazide... 5 mometasone... 6 mononessa (28) montelukast MONUROL... 3 morphine MORPHINE morphine concentrate MOVANTIK MOVIPREP MOXEZA moxifloxacin... MOZOBIL MS CONTIN

121 MULTAQ mupirocin mupirocin calcium MUSTARGEN... 7 MYALEPT... 7 MYAMBUTOL... 9 MYCAMINE... MYCOBUTIN... 9 mycophenolate mofetil... 7 mycophenolate sodium... 7 MYFORTIC... 7 myorisan MYOZYME... 7 MYRBETRIQ MYSOLINE N nabumetone nadolol... 5 nadolol-bendroflumethiazide 5 nafcillin... 0 nafcillin in dextrose iso-osm 0 NAFTIFINE NAFTIN NAGLAZYME... 7 nalbuphine naloxone naltrexone NAMENDA NAMENDA TITRATION PAK NAMENDA XR naphazoline NAPRELAN CR NAPROSYN naproxen naproxen sodium naratriptan NARDIL... 4 NASONEX NATACYN NATAZIA nateglinide NATESTO... 7 NATPARA... 7 NEBUPENT... 9 necon 0.5/35 (28) necon /35 (28) necon /50 (28) necon 0/ (28) necon 7/7/7 (28) NEEDLES, INSULIN DISP.,SAFETY nefazodone... 4 neomycin... 9 neomycin-bacitracin-poly-hc 9 neomycin-bacitracinpolymyxin neomycin-polymyxin b gu... 6 neomycin-polymyxin b- dexameth... 9 neomycin-polymyxingramicidin neomycin-polymyxin-hc 64, 9 NEORAL... 7 NEOSPORIN (NEO-POLYM- GRAMICID) NEO-SYNALAR NEPHRAMINE 5.4 % NESINA neuac NEULASTA NEUMEGA NEUPOGEN NEUPRO NEURONTIN NEVANAC nevirapine... 2 NEXAVAR... 7 NEXIUM NEXIUM IV NEXIUM PACKET NEXTERONE niacin NIACOR NIASPAN EXTENDED- RELEASE nicardipine... 5 NICOTROL NICOTROL NS nifedical xl... 5 nifedipine... 5 nikki (28) NILANDRON... 7 nimodipine... 5 NIPENT... 7 nisoldipine... 5 nitro-bid NITRO-DUR nitrofurantoin... 3 nitrofurantoin macrocrystal.. 3 nitrofurantoin monohyd/mcryst... 3 nitroglycerin NITROLINGUAL NITROMIST NITROSTAT nizatidine NIZORAL nora-be NORCO NORDITROPIN FLEXPRO 79 NORDITROPIN NORDIFLEX noreth-ethinyl estradiol-iron. 88 norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol norethindrone-e.estradiol-iron NORINYL +35 (28) NORINYL +50 (28) NORITATE norlyroc NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORPRAMIN... 4 NOR-QD NORTHERA nortrel 0.5/35 (28) nortrel /35 (2)

122 nortrel /35 (28) nortrel 7/7/7 (28) nortriptyline... 4 NORVASC... 5 NORVIR... 2 novarel... 7 NOVOFINE NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL... NUCYNTA NUCYNTA ER NUEDEXTA NULOJIX... 7 NULYTELY WITH FLAVOR PACKS NUTRESTORE NUTRILIPID NUTROPIN AQ NUTROPIN AQ NUSPIN NUVARING NUVESSA NUVIGIL... 4 nyamyc nystatin..., 59 nystatin-triamcinolone nystop O ocella OCTAGAM... 8 octreotide acetate... 7 OCUFEN OCUFLOX OFEV ofloxacin..., 64, 89 ogestrel (28) olanzapine... 4 olanzapine-fluoxetine... 4 olopatadine OLUX... 6 OLYSIO... 3 OMECLAMOX-PAK omega-3 acid ethyl esters omeprazole... 76, 77 omeprazole-sodium bicarbonate OMNARIS OMNIPRED... 9 OMNITROPE ONCASPAR... 8 ondansetron ondansetron hcl ondansetron hcl (pf) ONEXTON ONFI ONGLYZA ONMEL... OPANA... 3 OPANA ER... 3 OPDIVO... 8 OPSUMIT ORACEA... 2 ORAP... 4 ORAPRED ODT ORENCIA ORENCIA (WITH MALTOSE) ORENITRAM... 5 ORFADIN orsythia ORTHO MICRONOR ORTHO TRI-CYCLEN (28) 88 ORTHO TRI-CYCLEN LO (28) ORTHO-CEPT (28) ORTHO-CYCLEN (28) ORTHO-NOVUM /35 (28) 88 ORTHO-NOVUM 7/7/7 (28) OSENI OSMOPREP OTEZLA OTEZLA STARTER OTREXUP (PF) OVCON-35 (28) OVIDE... 6 oxacillin... 0 oxacillin in dextrose(iso-osm)... 0 oxaliplatin... 8 oxandrolone... 7 oxaprozin oxazepam... 4 oxcarbazepine OXISTAT OXSORALEN ULTRA OXTELLAR XR oxybutynin chloride oxycodone... 3 OXYCODONE... 3 oxycodone-acetaminophen... 3 oxycodone-aspirin... 3 OXYCONTIN... 3 oxymorphone... 3, 32 OXYTROL P pacerone paclitaxel... 8 PAMELOR... 4 pamidronate... 7 PANCREAZE PANDEL... 6 PANRETIN pantoprazole paricalcitol... 7 PARICALCITOL... 7 PARNATE paromomycin... 9 paroxetine hcl PASER... 9 PATADAY PATANASE PATANOL PAXIL PAXIL CR PAZEO PCE... 7 PEDVAX HIB (PF)

123 peg 3350-electrolytes PEGANONE PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN PENICILLIN G POT IN DEXTROSE... 0 penicillin g potassium... 0 penicillin g procaine... 0 penicillin g sodium... 0 penicillin v potassium... PENNSAID PENTAM... 9 PENTASA pentoxifylline PEPCID PERCOCET PERCODAN PERFOROMIST perindopril erbumine... 5 periogard PERJETA... 8 permethrin... 6 perphenazine PERSANTINE PERTZYE PEXEVA phenelzine PHENERGAN phenobarbital PHENYTEK phenytoin phenytoin sodium phenytoin sodium extended.. 22 PHOSLO PHOSLYRA PHOSPHOLINE IODIDE PHYSIOLYTE... 6 PHYSIOSOL IRRIGATION 6 PICATO pilocarpine hcl... 63, 90 pimtrea (28) pindolol... 5 pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam... pirmella piroxicam PLAQUENIL... 9 PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLAVIX PLEGRIDY PLETAL podofilox polyethylene glycol polymyxin b sulfate... 9 polymyxin b sulf-trimethoprim POLYTRIM POMALYST... 8 PONSTEL portia potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate POTIGA PRADAXA pramipexole PRANDIMET PRANDIN PRAVACHOL pravastatin prazosin... 5 PRECOSE PRED FORTE... 9 PRED MILD... 9 PRED-G... 9 PRED-G S.O.P prednicarbate... 6 prednisolone acetate... 9 prednisolone sodium phosphate... 65, 9 prednisone prednisone intensol PREGNYL... 7 PREMARIN premasol 0 % PREMASOL 6 % PRENATAL VITAMIN ORAL TABLET PREPOPIK PREVACID PREVACID SOLUTAB prevalite previfem PREVPAC PREZCOBIX... 3 PREZISTA... 3 PRIFTIN... 9 PRILOSEC PRIMAQUINE... 9 PRIMAXIN IV... 9 primidone PRIMLEV PRIMSOL... 3 PRINIVIL... 5 PRISTIQ PRIVIGEN... 8 PROAIR HFA PROAIR RESPICLICK probenecid procainamide PROCALAMINE 3% PROCARDIA XL... 5 procentra prochlorperazine

124 prochlorperazine edisylate prochlorperazine maleate PROCRIT procto-pak proctosol hc proctozone-hc PROCYSBI progesterone micronized PROGLYCEM PROGRAF... 8 PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine PROMETRIUM propafenone propranolol... 5 propranolol-hydrochlorothiazid... 5 propylthiouracil PROQUAD (PF)... 8 PROSCAR PROSOL 20 % PROTONIX... 77, 78 PROTOPIC protriptyline PROVENTIL HFA PROVERA PROVIGIL PROZAC PROZAC WEEKLY prudoxin PULMICORT PULMICORT FLEXHALER PULMOZYME PURIXAN... 8 PYLERA pyrazinamide... 9 pyridostigmine bromide Q QNASL QUADRACEL (PF)... 8 QUALAQUIN... 9 QUARTETTE quasense QUDEXY XR QUESTRAN quetiapine QUILLIVANT XR quinapril... 5 quinapril-hydrochlorothiazide... 5 quinidine gluconate quinidine sulfate quinine sulfate... 9 QVAR R RABAVERT (PF)... 8 rabeprazole RAGWITEK... 8 raloxifene ramipril... 5 RANEXA ranitidine hcl RAPAFLO RAPAMUNE... 8 RASUVO (PF) RAVICTI RAYOS RAZADYNE RAZADYNE ER REBETOL... 3 REBIF (WITH ALBUMIN). 80 REBIF REBIDOSE REBIF TITRATION PACK. 80 RECLAST reclipsen (28) RECOMBIVAX HB (PF)... 8, 82 RECTIV REGLAN REGRANEX RELENZA DISKHALER... 3 RELISTOR RELPAX REMERON REMERON SOLTAB REMICADE REMODULIN... 5 RENAGEL RENVELA repaglinide... 69, 70 reprexain REQUIP REQUIP XL RESCRIPTOR... 3 RESTASIS RESTORIL RETIN-A RETIN-A MICRO RETIN-A MICRO PUMP RETROVIR... 3 REVATIO REVLIMID... 8 REYATAZ... 3 RHEUMATREX... 8 RHINOCORT AQUA ribasphere... 3 ribasphere ribapak... 3 ribavirin... 3 RIDAURA rifabutin... 9 RIFADIN... 9 RIFAMATE... 9 rifampin... 9 RIFATER... 9 RILUTEK riluzole rimantadine... 3 ringers... 6, 99 RIOMET risedronate... 63, 83 RISPERDAL RISPERDAL CONSTA RISPERDAL M-TAB risperidone... 43, 44 RITALIN RITALIN LA RITUXAN... 8 rivastigmine tartrate rizatriptan ROBINUL

125 ROBINUL FORTE ROCALTROL... 7 ropinirole ROTARIX ROTATEQ VACCINE ROXICET ROXICODONE ROZEREM RUCONEST RYTARY RYTHMOL RYTHMOL SR S SABRIL SAFYRAL SAIZEN SAIZEN CLICK.EASY SALAGEN SAMSCA... 7 SANCUSO SANDIMMUNE... 8 SANDOSTATIN... 8 SANDOSTATIN LAR DEPOT... 8 SANTYL... 6 SAPHRIS (BLACK CHERRY) SARAFEM SAVAYSA SAVELLA SEASONIQUE SECTRAL... 5 selegiline hcl selenium sulfide SELZENTRY... 3 SEMPREX-D SENSIPAR... 7 SEREVENT DISKUS SEROQUEL SEROQUEL XR... 44, 45 SEROSTIM sertraline SFROWASA sharobel SIGNIFOR... 8 SIGNIFOR LAR... 8 sildenafil SILENOR SILVADENE silver sulfadiazine SIMBRINZA... 9 SIMCOR SIMPONI SIMPONI ARIA SIMULECT... 8 simvastatin SINEMET SINEMET CR SINGULAIR sirolimus... 8 SIRTURO... 9 SIVEXTRO... 9 SKLICE... 6 sodium chloride... 63, 99 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % SODIUM FLUORIDE sodium lactate sodium phenylbutyrate sodium polystyrene (sorb free) SOLARAZE SOLODYN... 2 SOLTAMOX... 8 SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF) SOMATULINE DEPOT... 8 SOMAVERT... 7 SONATA SOOLANTRA SORIATANE SORILUX sorine sotalol sotalol af SOTYLIZE SOVALDI... 3 SPECTRACEF... 6 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone... 5 spironolacton-hydrochlorothiaz... 5 SPORANOX... SPORANOX PULSEPAK... sprintec (28) SPRIX SPRYCEL... 8 sronyx ssd STALEVO STALEVO STALEVO STALEVO STALEVO STALEVO STARLIX stavudine... 3 STELARA STIMATE... 7 STIOLTO RESPIMAT STIVARGA... 8 STRATTERA STREPTOMYCIN... 9 STRIANT... 7 STRIBILD... 3 STRIVERDI RESPIMAT STROMECTOL... 9 SUBOXONE SUBSYS SUCLEAR SUCRAID sucralfate SULAR... 5 sulfacetamide sodium sulfacetamide sodium (acne) 58 sulfacetamide-prednisolone.. 92 sulfadiazine... 2 sulfamethoxazole-trimethoprim... 2 SULFAMYLON

126 sulfasalazine sulfazine ec sulindac sumatriptan sumatriptan succinate SUMAVEL DOSEPRO SUPRAX... 6 SUPREP BOWEL PREP KIT SURMONTIL SUSTIVA... 3 SUTENT... 8, 9 SYLATRON SYLVANT... 9 SYMBICORT SYMBYAX SYMLINPEN SYMLINPEN SYNAGIS... 3 SYNALAR CREAM KIT... 6 SYNALGOS-DC SYNAREL... 7 SYNERCID... 9 SYNRIBO... 9 SYNTHROID SYPRINE T TABLOID... 9 TACLONEX tacrolimus... 9, 56 TAFINLAR... 9 TAMIFLU... 3 tamoxifen... 9 tamsulosin TANZEUM TAPAZOLE TARCEVA... 9 TARGRETIN... 9 tarina fe TARKA... 5 TASIGNA... 9 TASMAR TAXOTERE... 9 TAZICEF... 6 TAZORAC taztia xt... 5 TECFIDERA TEFLARO... 6 TEGRETOL TEGRETOL XR TEKAMLO... 5 TEKTURNA... 5 TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid temazepam TEMOVATE... 6 TENIVAC (PF) TENORETIC TENORETIC TENORMIN TERAZOL TERAZOL terazosin terbinafine hcl... terbutaline terconazole TESTIM... 7 TESTOSTERONE testosterone cypionate... 7 testosterone enanthate... 7 TESTRED TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetracycline... 2 TEVETEN TEVETEN HCT THALOMID... 9 THEO theophylline THIOLA thioridazine thiothixene THYMOGLOBULIN THYROLAR THYROLAR-/ THYROLAR-/ THYROLAR THYROLAR tiagabine TIAZAC ticlopidine TIKOSYN timolol maleate... 52, 90 TIMOPTIC OCUDOSE (PF) TIMOPTIC-XE TINDAMAX... 9 tinidazole... 9 TIROSINT TIVICAY... 3 TIVORBEX tizanidine TOBI... 9 TOBI PODHALER... 9 TOBRADEX... 9 TOBRADEX ST... 9 tobramycin tobramycin in % nacl... 9 tobramycin in 0.9 % nacl... 9 tobramycin sulfate... 9 tobramycin-dexamethasone.. 9 TOBREX TOFRANIL TOFRANIL-PM tolazamide tolbutamide tolcapone tolmetin... 34, 35 tolterodine TOPAMAX TOPICORT... 6 topiramate TOPIRAMATE toposar... 9 topotecan... 9 TOPROL XL TORISEL... 9 torsemide TOUJEO SOLOSTAR TOVIAZ

127 TPN ELECTROLYTES TRACLEER TRADJENTA tramadol TRAMADOL tramadol-acetaminophen trandolapril trandolapril-verapamil tranexamic acid... 53, 86 TRANSDERM-SCOP TRANXENE T-TAB tranylcypromine travasol 0 % TRAVATAN Z... 9 travoprost (benzalkonium)... 9 trazodone TREANDA... 9 TRECATOR... 9 TRELSTAR... 9 TRELSTAR DEPOT... 9 TRELSTAR LA... 9 tretinoin tretinoin (chemotherapy)... 9 tretinoin microspheres TRETIN-X TREXALL... 9 TREXIMET TREZIX triamcinolone acetonide 6, 63, 96 triamterene-hydrochlorothiazid trianex... 6 TRIBENZOR TRICOR triderm... 6 trifluoperazine trifluridine TRIGLIDE tri-legest fe TRILEPTAL TRILIPIX trilyte with flavor packets trimethoprim... 3 trinessa (28) TRI-NORINYL (28) TRIOSTAT tri-previfem (28) TRISENOX... 9 tri-sprintec (28) TRIUMEQ... 3 trivora (28) TRIZIVIR... 3 TROKENDI XR TROPHAMINE 0 % TROPHAMINE 6% trospium TRULICITY TRUMENBA TRUSOPT... 9 TRUVADA... 3 TUDORZA PRESSAIR TWINRIX (PF) TWYNSTA TYBOST... 3 TYGACIL... 9 TYKERB... 9 TYLENOL-CODEINE # TYLENOL-CODEINE # TYPHIM VI TYSABRI TYVASO TYZEKA... 3 TYZINE U UCERIS ULORIC ULTRACET ULTRAM ULTRAM ER ULTRAVATE... 6 ULTRESA UNASYN... unithroid URECHOLINE UROCIT-K UROCIT-K UROCIT-K UROXATRAL URSO URSO FORTE ursodiol UVADEX V VAGIFEM valacyclovir... 3 VALCHLOR VALCYTE... 3 valganciclovir... 3 VALIUM valproate sodium valproic acid valproic acid (as sodium salt) valsartan valsartan-hydrochlorothiazide VALTREX... 3 VANCOCIN... 3 vancomycin... 3 vandazole VANOS... 6 VAQTA (PF) VARIVAX (PF) VARIZIG VASCEPA VASERETIC VASOTEC VECAMYL VECTIBIX VECTICAL VELCADE velivet triphasic regimen (28) VELPHORO VELTIN venlafaxine VENLAFAXINE... 45, 46 VENTAVIS VENTOLIN HFA VERAMYST verapamil VEREGEN VERELAN VERELAN PM

128 veripred VERSACLOZ VESICARE vestura (28) VEXOL... 9 VFEND... VFEND IV... VGO VGO VGO VIBRAMYCIN... 2 vicodin vicodin es vicodin hp VICOPROFEN VICTOZA 3-PAK VIDAZA VIDEX 2 GRAM PEDIATRIC... 4 VIDEX EC... 4 VIEKIRA PAK... 4 VIGAMOX VIIBRYD VIMOVO VIMPAT vinblastine vincasar pfs vincristine vinorelbine VIOKACE VIRACEPT... 4 VIRAMUNE... 4 VIRAMUNE XR... 4 VIRAZOLE... 4 VIREAD... 4 VIROPTIC VISTIDE... 4 VITEKTA... 4 VIVELLE-DOT VIVITROL VOGELXO VOLTAREN GEL VOLTAREN-XR voriconazole... VOSPIRE ER VOTRIENT VPRIV vyfemla (28) VYTORIN VYTORIN VYTORIN VYTORIN VYVANSE W warfarin water for irrigation, sterile WELCHOL WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL wymzya fe X XALATAN... 9 XALKORI XARELTO XARTEMIS XR XELJANZ XENAZINE XEOMIN XERESE XGEVA... 3 XIFAXAN... 9 XIGDUO XR XODOL 0/ XODOL 5/ XODOL 7.5/ XOLAIR XOPENEX XOPENEX HFA XTANDI xulane XYLOCAINE XYREM XYZAL Y YASMIN (28) YAZ (28) YERVOY YF-VAX (PF) Z zafirlukast zaleplon ZALTRAP zamicet ZANAFLEX ZANOSAR ZANTAC ZARONTIN ZAVESCA ZEBETA ZEGERID ZELAPAR ZELBORAF ZEMAIRA ZEMPLAR zenatane zenchent (28) zenchent fe ZENPEP zenzedi ZENZEDI ZERBAXA... 6 ZERIT... 4 ZESTORETIC ZESTRIL ZETIA ZETONNA ZIAC ZIAGEN... 4 ZIANA zidovudine... 4 ZINACEF... 6 ZINECARD (AS HCL)... 3 ZIOPTAN (PF)... 9 ziprasidone hcl ZIPSOR ZIRGAN ZITHROMAX... 7 ZITHROMAX TRI-PAK... 7 ZITHROMAX Z-PAK... 7 ZMAX... 7 ZOCOR ZOFRAN (AS HYDROCHLORIDE)

129 ZOFRAN ODT ZOHYDRO ER zoledronic acid zoledronic acid-mannitol-water ZOLINZA zolmitriptan ZOLOFT... 46, 47 zolpidem ZOLPIMIST ZOMACTON ZOMETA ZOMIG ZOMIG ZMT ZONALON ZONEGRAN zonisamide ZONTIVITY ZORBTIVE ZORTRESS ZORVOLEX ZOSTAVAX (PF) ZOSYN... ZOSYN IN DEXTROSE (ISO- OSM)... zovia /35e (28) zovia /50e (28) ZOVIRAX... 4, 59 ZUBSOLV ZUPLENZ ZYBAN ZYCLARA ZYDELIG ZYFLO ZYFLO CR ZYKADIA ZYLET... 9 ZYLOPRIM ZYMAXID ZYPREXA ZYPREXA RELPREVV ZYPREXA ZYDIS ZYTIGA ZYVOX

130 With Express Scripts Medicare, you will have access to over 68,000 network pharmacies nationally. You may fill your prescriptions at a retail, home infusion, long-term care or Indian Health Service / Tribal / Urban Indian Health Program (I/T/U) pharmacy, or through our convenient home delivery service. You must use network pharmacies to fill your prescriptions to get the most out of your benefit. However, there are emergency circumstances under which you may be reimbursed for a covered prescription that is not filled at a network pharmacy. Limitations, copayments and restrictions may apply. This formulary was updated on 08//205. For more recent information or other questions, please contact Express Scripts Medicare Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal. 205 Express Scripts Holding Company. All Rights Reserved. Express Scripts and E Logo are trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the property of their respective owners. F0PA3Z6A