Memorial Hermann Advantage HMO & PPO Formulary. (List of Covered Drugs)

Transcription

1 Memorial Hermann Advantage H & PPO 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File , Version 11 This formulary was updated on 12/01/2016. For more recent information or other questions, please contact Memorial Hermann Advantage H at , Memorial Hermann Advantage PPO at or, for TTY users, 711, 24 hours a day, seven (7) days a week, or visit healthplan.memorialhermann.org/medicare. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Memorial Hermann Advantage H & PPO. When it refers to plan or our plan, it means Memorial Hermann Advantage H & PPO. This document includes a list of the drugs (formulary) for our plan which is current as of 12/01/2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. What is the Memorial Hermann Advantage H & PPO Formulary? A formulary is a list of covered drugs selected by Memorial Hermann Advantage H & PPO 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. Memorial Hermann Advantage H & PPO will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Memorial Hermann Advantage H & PPO network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Y0110_PH_CompFrmlry CMS Accepted 09/05/2016 i

2 Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 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 formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing 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 formulary 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 we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move 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, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 12/01/2016. To get updated information about the drugs covered by Memorial Hermann Advantage H & PPO, please contact us. Our contact information appears on the front and back cover pages. In the event of a mid-year non-maintenance formulary change, we will provide details in the Medicare Part D Explanation of Benefits or through direct member mailings. To review and/or print formulary changes during the year, please visit our website at healthplan.memorialhermann.org/medicare and refer to the Formulary Addendum on the Find a Drug page. If you would like to request a copy of the Formulary Addendum to be mailed to your home, please call Memorial Hermann Advantage H & PPO Customer Services at (H) or (PPO), 24 hours a day, seven (7) days week. TTY users should call 711. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page number 1. Then look under the category name for your drug. 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 112. 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 first column of the list. ii

3 What are generic drugs? Memorial Hermann Advantage H & PPO covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient 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: Memorial Hermann Advantage H & PPO requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Memorial Hermann Advantage H & PPO before you fill your prescriptions. If you don t get approval, Memorial Hermann Advantage H & PPO may not cover the drug. Quantity Limits: For certain drugs, Memorial Hermann Advantage H & PPO limits the amount of the drug that Memorial Hermann Advantage H & PPO will cover. For example, Memorial Hermann Advantage H & PPO provides 30 tablets per prescription for Digoxin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Memorial Hermann Advantage H & PPO requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Memorial Hermann Advantage H & PPO may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Memorial Hermann Advantage H & PPO will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Memorial Hermann Advantage H & PPO to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Memorial Hermann Advantage H & PPO s formulary? on page iv for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Services and ask if your drug is covered. If you learn that Memorial Hermann Advantage H & PPO does not cover your drug, you have two options: iii

4 You can ask Customer Services for a list of similar drugs that are covered by Memorial Hermann Advantage H & PPO. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Memorial Hermann Advantage H & PPO. You can ask Memorial Hermann Advantage H & PPO to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Memorial Hermann Advantage H & PPO s Formulary? You can ask Memorial Hermann Advantage H & PPO to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would 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 this drug is not on the specialty tier. 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, Memorial Hermann Advantage H & PPO limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Memorial Hermann Advantage H & PPO will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction 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 believe 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. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary 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 a formulary 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, we may cover your drug in certain cases during the first 90 days you are a member of our plan. iv

5 For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. 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 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 93 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 93 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. As a current member of our plan, if you have a covered inpatient stay in the hospital or in a skilled nursing facility, the drugs you obtain during your stay will be covered under your medical benefit rather than your Medicare Part D prescription drug benefit. When you are discharged home or to a long-term care facility, many outpatient prescription drugs you obtain at a pharmacy may be covered under your Medicare Part D coverage. This transfer from one treatment setting to another is called a level-of-care change. Since your drug coverage is different depending on the setting where you obtain the drug, it is possible that a drug you were taking that was covered under your medical benefit might not be covered by Medicare Part D (for example, vitamins, or cough medicine). If this happens, you will have to pay full price for that drug unless you have other coverage (for example, employer-sponsored group coverage). For more information For more detailed information about your Memorial Hermann Advantage H & PPO prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Memorial Hermann Advantage H & PPO, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit Memorial Hermann Advantage H & PPO s Formulary The formulary that begins on the next page provides coverage information about the drugs covered by Memorial Hermann Advantage H & PPO. If you have trouble finding your drug in the list, turn to the Index that begins on page 112. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine). The information in the Requirements/Limits column tells you if Memorial Hermann Advantage H & PPO has any special requirements for coverage of your drug. v

6 The Formulary may change at any time. You will receive notice when necessary. Memorial Hermann Advantage H and PPO are provided by Memorial Hermann Health Insurance Company and Memorial Hermann Health Plan, Inc., Medicare Advantage organizations with Medicare contracts. Enrollment in these plans depends on contract renewal. vi

7 ANALGESICS OPIOID ANALGESICS, LONG-ACTING EMBEDA ORAL CAPSULE EXTENDED RELEASE MG EMBEDA ORAL CAPSULE EXTENDED RELEASE MG, MG, 50-2 MG, MG, MG fentanyl transdermal patch 72 hr 100 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hr ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) ST; ; QL (10 EA per 30 days) fentanyl transdermal patch 72 hr 12 mcg/hr ; QL (10 EA per 30 days) hydromorphone hcl er oral 12, 16, 8 hydromorphone hcl er oral 32 methadone hcl injection solution 10 /ml methadone hcl oral solution 10 /5ml, 5 /5ml methadone hcl oral tablet 10 methadone hcl oral tablet 5 morphine sulfate er beads oral capsule extended release 24 hour 120, 30, 45, 60, 75, 90 morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, 50, 60, 80 morphine sulfate er oral tablet extendedrelease 100, 15, 30, 60 OPANA ER ORAL 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 5 MG, 7.5 MG OXYCONTIN ORAL 10 MG, 20 MG, 40 MG, 80 MG ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) ; QL (60 EA per 30 days) ; QL (90 EA per 30 days) ; QL (60 EA per 30 days) OXYCONTIN ORAL 15 MG, 30 MG, 60 MG PA; ; QL (60 EA per 30 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 1

8 oxymorphone hcl er oral tablet extended release 12 hr 10, 15, 20, 30, 40, 5, 7.5 OPIOID ANALGESICS, SHORT-ACTING ; QL (90 EA per 30 days) acetaminophen-codeine #2 oral tablet ; QL (400 EA per 30 days) acetaminophen-codeine #3 oral tablet ; QL (400 EA per 30 days) acetaminophen-codeine #4 oral tablet ; QL (400 EA per 30 days) acetaminophen-codeine oral solution /5ml ; QL (5000 ML per 30 days) ascomp-codeine oral capsule PA; ; HR; QL (180 EA per 30 days) butalbital-apap-caff-cod oral capsule butalbital-asa-caff-codeine oral capsule duramorph injection solution 0.5 /ml, 1 /ml FENTORA BUCCAL TABLET 200 MCG, 400 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution /15ml hydrocodone-acetaminophen oral tablet , 5-325, hydrocodone-acetaminophen oral tablet hydrocodone-ibuprofen oral tablet , 5-200, PA; ; HR; QL (180 EA per 30 days) PA; ; HR; QL (180 EA per 30 days) hydromorphone hcl oral liquid 1 /ml hydromorphone hcl oral tablet 2, 4 PA; hydromorphone hcl oral tablet 8 ; QL (5500 ML per 30 days) ; QL (370 EA per 30 days) ; QL (370 EA per 30 days) ; QL (150 EA per 30 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 2

9 LAZANDA NASAL SOLUTION 100 MCG/ACT, 300 MCG/ACT, 400 MCG/ACT morphine sulfate (concentrate) oral solution 100 /5ml morphine sulfate oral solution 10 /5ml, 20 /5ml PA; morphine sulfate oral tablet 15, 30 nalbuphine hcl injection solution 10 /ml, 20 /ml oxycodone hcl oral capsule 5 oxycodone hcl oral tablet 10, 20, 30, 5 oxycodone hcl oral tablet 15 oxycodone-acetaminophen oral solution /5ml oxycodone-acetaminophen oral tablet , , 5-325, oxycodone-aspirin oral tablet oxycodone-ibuprofen oral tablet oxymorphone hcl oral tablet 10, 5 pentazocine-naloxone hcl oral tablet PA; ; HR ; QL (1800 ML per 30 days) ; QL (370 EA per 30 days) tramadol hcl oral tablet 50 ; QL (240 EA per 30 days) tramadol-acetaminophen oral tablet ; QL (240 EA per 30 days) ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (pf) injection solution 0.5 % lidocaine hcl external gel 2 %, 2 % (10ml applicator) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 3

10 lidocaine hcl injection solution 2 % lidocaine-prilocaine external cream % ; QL (30 GM per 30 days) ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI-CRAVING ACAMPROSATE CALCIUM ORAL TABLET DELAYED RELEASE 333 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 4 disulfiram oral tablet 250, 500 naltrexone hcl oral tablet 50 OPIOID ANTAGONISTS buprenorphine hcl injection solution 0.3 /ml (cartridge) buprenorphine hcl sublingual tablet sublingual 2, 8 buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 EVZIO INJECTION 0.4 MG/0.4ML naloxone hcl injection solution 0.4 /ml naloxone hcl injection solution 1 /ml SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG SKING CESSATION AGENTS buproban oral tablet extended release 12 hr 150 bupropion hcl er (smoking det) oral tablet extended release 12 hr 150 CHANTIX CONTINUING NTH PAK ORAL TABLET 1 MG ; QL (56 EA per 28 days) CHANTIX ORAL TABLET 0.5 MG ; QL (60 EA per 30 days)

11 CHANTIX ORAL TABLET 1 MG ; QL (180 EA per 90 days) CHANTIX STARTING NTH PAK ORAL TABLET 0.5 MG X 11 & 1 MG X 42 NICOTROL INHALATION INHALER 10 MG ANTIBACTERIALS AMINOGLYCOSIDES gentamicin in saline intravenous solution /ml-%, /ml-%, /ml-% ; QL (53 EA per 28 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 5 gentamicin sulfate injection solution 40 /ml gentamicin sulfate intravenous solution 10 /ml neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 streptomycin sulfate intramuscular solution reconstituted 1 gm TOBI PODHALER INHALATION CAPSULE 28 MG tobramycin inhalation nebulization solution 300 /5ml tobramycin sulfate injection solution 10 /ml, 80 /2ml ANTIBACTERIALS, OTHER bacitracin intramuscular solution reconstituted unit chloramphenicol sod succinate intravenous solution reconstituted 1 gm clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml PA; ; QL (224 EA per 56 days) ; BvD

12 clindamycin phosphate in d5w intravenous solution 300 /50ml, 600 /50ml, 900 /50ml clindamycin phosphate injection solution 300 /2ml, 900 /6ml clindamycin phosphate injection solution 600 /4ml clindamycin phosphate intravenous solution 300 /2ml, 900 /6ml colistimethate sodium injection solution reconstituted 150 CUBICIN INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ; BvD dapsone oral tablet 100, 25 lincomycin hcl injection solution 300 /ml LINEZOLID INTRAVENOUS SOLUTION 600 MG/300ML linezolid oral tablet 600 metronidazole in nacl intravenous solution /100ml-% metronidazole oral capsule 375 metronidazole oral tablet 250, 500 NEBUPENT INHALATION SOLUTION RECONSTITUTED 300 MG nitrofurantoin macrocrystal oral capsule 100, 25, 50 nitrofurantoin monohyd macro oral capsule 100 PENTAM INJECTION SOLUTION RECONSTITUTED 300 MG ; BvD ; BvD PA; ; HR PA; ; HR pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 6

13 SYNERCID INTRAVENOUS SOLUTION RECONSTITUTED MG trimethoprim oral tablet 100 TYGACIL INTRAVENOUS SOLUTION RECONSTITUTED 50 MG vancomycin hcl intravenous solution reconstituted 10 gm, 1000 VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 500 MG vancomycin hcl oral capsule 125, 250 XIFAXAN ORAL TABLET 550 MG BETA-LACTAM PENICILLINS oxacillin sodium injection solution reconstituted 10 gm, 2 gm BETA-LACTAM, CEPHALOSPORINS cefaclor er oral tablet extended release 12 hr 500 cefaclor oral capsule 250, 500 cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml cefepime hcl injection solution reconstituted 1 gm, 2 gm cefixime oral suspension reconstituted 200 /5ml cefoxitin sodium injection solution reconstituted 10 gm pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 7

14 cefoxitin sodium intravenous solution reconstituted 1 gm, 2 gm cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 8 cefpodoxime proxetil oral tablet 100, 200 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 ceftriaxone sodium injection solution reconstituted 250, 500 ceftriaxone sodium intravenous solution reconstituted 10 gm cefuroxime axetil oral tablet 250, 500 cefuroxime sodium injection solution reconstituted 1.5 gm, 7.5 gm, 750 cephalexin oral capsule 250 cephalexin oral capsule 500 cephalexin oral suspension reconstituted 125 /5ml, 250 /5ml cephalexin oral tablet 250, 500 SUPRAX ORAL CAPSULE 400 MG tazicef injection solution reconstituted 2 gm ; BvD TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 400 MG, 600 MG ZERBAXA INTRAVENOUS SOLUTION RECONSTITUTED 1.5 (1-0.5) GM BETA-LACTAM, OTHER AZACTAM IN DEXTROSE INTRAVENOUS SOLUTION 2 GM

15 aztreonam injection solution reconstituted 1 gm CAYSTON INHALATION SOLUTION RECONSTITUTED 75 MG imipenem-cilastatin intravenous solution reconstituted 250, 500 INVANZ INJECTION SOLUTION RECONSTITUTED 1 GM meropenem intravenous solution reconstituted 500 BETA-LACTAM, PENICILLINS pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 9 amoxicillin oral capsule 250 amoxicillin oral capsule 500 amoxicillin oral suspension reconstituted 125 /5ml, 200 /5ml, 250 /5ml, 400 /5ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet chewable 125, 250 amoxicillin-pot clavulanate oral suspension reconstituted /5ml, /5ml, /5ml amoxicillin-pot clavulanate oral tablet , amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet chewable , ampicillin oral capsule 250, 500 ampicillin oral suspension reconstituted 125 /5ml, 250 /5ml ampicillin sodium injection solution reconstituted 1 gm, 125

16 ampicillin sodium intravenous solution reconstituted 10 gm ampicillin-sulbactam sodium injection solution reconstituted 3 (2-1) gm ampicillin-sulbactam sodium intravenous solution reconstituted 1.5 (1-0.5) gm, 15 (10-5) gm BICILLIN L-A INTRAMUSCULAR SUSPENSION UNIT/ML pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 10 dicloxacillin sodium oral capsule 250, 500 nafcillin sodium injection solution reconstituted 1 gm, 10 gm penicillin g potassium injection solution reconstituted unit penicillin g sodium injection solution reconstituted unit penicillin v potassium oral solution reconstituted 125 /5ml, 250 /5ml penicillin v potassium oral tablet 250, 500 piperacillin sod-tazobactam so intravenous solution reconstituted ( ) gm, 4.5 (4-0.5) gm MACROLIDES azithromycin intravenous solution reconstituted 500 azithromycin oral packet 1 gm azithromycin oral suspension reconstituted 100 /5ml, 200 /5ml azithromycin oral tablet 250, 250 (6 pack), 500, 600 ; BvD clarithromycin oral tablet 250, 500

17 DIFICID ORAL TABLET 200 MG ST; ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 11 erythrocin stearate oral tablet 250 erythromycin base oral capsule delayed release particles 250 erythromycin ethylsuccinate oral tablet 400 KETEK ORAL TABLET 300 MG, 400 MG QUINOLONES ciprofloxacin hcl oral tablet 100, 250, 750 ciprofloxacin hcl oral tablet 500 ciprofloxacin in d5w intravenous solution 200 /100ml ciprofloxacin intravenous solution 400 /40ml ciprofloxacin oral suspension reconstituted 250 /5ml (5%), 500 /5ml (10%) ciprofloxacin-ciproflox hcl er oral tablet extended release 24 hr 1000, 500 levofloxacin in d5w intravenous solution 500 /100ml, 750 /150ml levofloxacin intravenous solution 25 /ml levofloxacin oral solution 25 /ml levofloxacin oral tablet 250, 500, 750 moxifloxacin hcl intravenous solution 400 /250ml ofloxacin oral tablet 400 SULFONAMIDES

18 sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5ml sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet sulfamethoxazole-trimethoprim oral tablet TETRACYCLINES doxycycline hyclate intravenous solution reconstituted 100 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 12 doxycycline hyclate oral capsule 100 doxycycline hyclate oral capsule 50 doxycycline hyclate oral tablet 100, 20 doxycycline monohydrate oral capsule 100, 50 doxycycline monohydrate oral suspension reconstituted 25 /5ml doxycycline monohydrate oral tablet 100, 50 doxycycline monohydrate oral tablet 75 minocycline hcl oral capsule 100, 75 minocycline hcl oral capsule 50 minocycline hcl oral tablet 100, 50, 75 ANTICONVULSANTS ANTICONVULSANTS, OTHER BRIVIACT INTRAVENOUS SOLUTION 50 MG/5ML PA;

19 BRIVIACT ORAL SOLUTION 10 MG/ML PA; BRIVIACT ORAL TABLET 10 MG PA; BRIVIACT ORAL TABLET 100 MG, 25 MG, 50 MG, 75 MG levetiracetam er oral tablet extended release 24 hr 500, 750 LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 1000 MG/100ML, 1500 MG/100ML, 500 MG/100ML PA; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 13 levetiracetam intravenous solution 500 /5ml levetiracetam oral solution 100 /ml levetiracetam oral tablet 1000, 750 levetiracetam oral tablet 250, 500 POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG, 50 MG roweepra oral tablet 500 SPRITAM ORAL 1000 MG ; QL (90 EA per 30 days) SPRITAM ORAL 250 MG, 500 MG, 750 MG ; QL (120 EA per 30 days) BARBITURATES phenobarbital oral elixir 20 /5ml PA; ; HR phenobarbital oral tablet 100, 15, 16.2, 30, 32.4, 60, 64.8, 97.2 BENZODIAZEPINES clonazepam oral tablet 0.5, 1, 2 clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 PA; ; HR diazepam gel 10, 2.5, 20 ONFI ORAL SUSPENSION 2.5 MG/ML

20 ONFI ORAL TABLET 10 MG, 20 MG CALCIUM CHANNEL DIFYING AGENTS CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml LYRICA ORAL CAPSULE 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG LYRICA ORAL SOLUTION 20 MG/ML zonisamide oral capsule 100 zonisamide oral capsule 25, 50 GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS divalproex sodium er oral tablet extended release 24 hr 250, 500 divalproex sodium oral tablet delayed release 250 divalproex sodium oral tablet delayed release 500 FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG gabapentin oral capsule 100, 300, 400 gabapentin oral solution 250 /5ml gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET 12 MG, 16 MG primidone oral tablet 250 primidone oral tablet 50 SABRIL ORAL PACKET 500 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 14

21 SABRIL ORAL TABLET 500 MG tiagabine hcl oral tablet 2, 4 valproate sodium intravenous solution 500 /5ml valproic acid oral capsule 250 valproic acid oral syrup 250 /5ml GLUTAMATE REDUCING AGENTS felbamate oral suspension 600 /5ml felbamate oral tablet 400, 600 lamotrigine er oral tablet extended release 24 hr 100 lamotrigine er oral tablet extended release 24 hr 200, 25, 250, 300, 50 lamotrigine oral tablet 100, 150, 200 lamotrigine oral tablet 25 lamotrigine oral tablet chewable 25, 5 lamotrigine oral tablet dispersible 100, 200, 25, 50 topiramate er oral 100, 150, 200, 25, 50 topiramate oral capsule sprinkle 15, 25 topiramate oral tablet 200, 25, 50 TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG SODIUM CHANNEL AGENTS APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 15

22 BANZEL ORAL SUSPENSION 40 MG/ML BANZEL ORAL TABLET 200 MG, 400 MG carbamazepine er oral capsule extended release 12 hour 200, 300 carbamazepine er oral tablet extended release 12 hr 100, 200, 400 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 16 carbamazepine oral suspension 100 /5ml carbamazepine oral tablet 200 epitol oral tablet 200 fosphenytoin sodium injection solution 100 pe/2ml oxcarbazepine oral suspension 300 /5ml oxcarbazepine oral tablet 150, 600 oxcarbazepine oral tablet 300 OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 600 MG PEGANONE ORAL TABLET 250 MG phenytoin oral suspension 125 /5ml phenytoin oral tablet chewable 50 phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml VIMPAT INTRAVENOUS SOLUTION 200 MG/20ML VIMPAT ORAL SOLUTION 10 MG/ML VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG ANTIDEMENTIA AGENTS

23 ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates oral tablet 1 PA; ; HR CHOLINESTERASE INHIBITORS donepezil hcl oral tablet 10, 5 donepezil hcl oral tablet 23 donepezil hcl oral tablet dispersible 10, 5 EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR galantamine hydrobromide er oral capsule extended release 24 hour 16, 8 galantamine hydrobromide er oral capsule extended release 24 hour 24 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 17 galantamine hydrobromide oral solution 4 /ml galantamine hydrobromide oral tablet 12, 4, 8 rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl oral tablet 10, 5 ; QL (60 EA per 30 days) NAMENDA XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG NAMENDA XR TITRATION PACK ORAL CAPSULE EXTENDED RELEASE 24 HOUR 7 & 14 & 21 &28 MG NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR MG, MG ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER ; QL (30 EA per 30 days)

24 APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG, 522 MG bupropion hcl er (sr) oral tablet extended release 12 hr 100, 200 bupropion hcl er (sr) oral tablet extended release 12 hr 150 bupropion hcl er (xl) oral tablet extended release 24 hr 150, 300 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 18 bupropion hcl oral tablet 100, 75 FORFIVO XL ORAL TABLET EXTENDED RELEASE 24 HR 450 MG maprotiline hcl oral tablet 25, 50, 75 mirtazapine oral tablet 15, 30, 7.5 mirtazapine oral tablet 45 mirtazapine oral tablet dispersible 15 mirtazapine oral tablet dispersible 30, 45 nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 trazodone hcl oral tablet 300 TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG NOAMINE OXIDASE INHIBITORS EMSAM TRANSDERMAL PATCH 24 HR 12 MG/24HR, 6 MG/24HR, 9 MG/24HR ST; ; QL (30 EA per 30 days)

25 MARPLAN ORAL TABLET 10 MG phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 SEROTONIN/NOREPINEPHRINE REUPTAKE INHIBITORS BRISDELLE ORAL CAPSULE 7.5 MG citalopram hydrobromide oral solution 10 /5ml citalopram hydrobromide oral tablet 10, 20, 40 DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 50 MG duloxetine hcl oral capsule delayed release particles 20, 30, 40, 60 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 19 escitalopram oxalate oral solution 5 /5ml escitalopram oxalate oral tablet 10, 20, 5 FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MG FETZIMA TITRATION ORAL 20 & 40 MG fluoxetine hcl oral capsule 10 fluoxetine hcl oral capsule 20, 40 fluoxetine hcl oral capsule delayed release 90 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10 fluoxetine hcl oral tablet 20 FLUOXETINE HCL ORAL TABLET 60 MG fluvoxamine maleate er oral capsule extended release 24 hour 100, 150

26 fluvoxamine maleate oral tablet 100, 25, 50 olanzapine-fluoxetine hcl oral capsule 12-25, 12-50, 3-25, 6-25, 6-50 paroxetine hcl er oral tablet extended release 24 hr 12.5, 25, 37.5 paroxetine hcl oral tablet 10, 20 paroxetine hcl oral tablet 30, 40 PAXIL ORAL SUSPENSION 10 MG/5ML PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 25 MG, 50 MG sertraline hcl oral concentrate 20 /ml sertraline hcl oral tablet 100, 25, 50 venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl er oral tablet extended release 24 hr 150, 225, 37.5, 75 venlafaxine hcl oral tablet 100, 75 venlafaxine hcl oral tablet 25, 37.5, 50 TRICYCLICS amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 chlordiazepoxide-amitriptyline oral tablet 10-25, pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 20

27 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 21 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 imipramine pamoate oral capsule 100, 125, 150, 75 nortriptyline hcl oral capsule 10, 25 nortriptyline hcl oral capsule 50, 75 nortriptyline hcl oral solution 10 /5ml protriptyline hcl oral tablet 10, 5 trimipramine maleate oral capsule 100, 25, 50 ANTIEMETICS ANTIEMETICS, OTHER meclizine hcl oral tablet 12.5, 25 transderm-scop (1.5 ) transdermal patch 72 hr 1 /3days EMETOGENIC THERAPY ADJUNCTS AKYNZEO ORAL CAPSULE MG ; BvD dronabinol oral capsule 10 PA; ; QL (60 EA per 30 days) dronabinol oral capsule 2.5, 5 PA; ; QL (60 EA per 30 days) EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG ; BvD EMEND ORAL CAPSULE 125 MG ; BvD; QL (2 EA per 30 days)

28 EMEND ORAL CAPSULE 40 MG ; BvD; QL (1 EA per 30 days) EMEND ORAL CAPSULE 80 & 125 MG ; BvD; QL (12 EA per 30 days) EMEND ORAL CAPSULE 80 MG ; BvD; QL (8 EA per 30 days) EMEND ORAL SUSPENSION RECONSTITUTED 125 MG granisetron hcl intravenous solution 0.1 /ml, 1 /ml ; BvD ; BvD; QL (60 ML per 30 days) granisetron hcl oral tablet 1 ; BvD; QL (60 EA per 30 days) ondansetron hcl injection solution 4 /2ml ; BvD; QL (160 ML per 30 days) ondansetron hcl injection solution 4 /2ml (2ml syringe) ; BvD ondansetron hcl oral solution 4 /5ml ; BvD ondansetron hcl oral tablet 24 ; BvD; QL (30 EA per 30 days) ondansetron hcl oral tablet 4 ; BvD; QL (60 EA per 30 days) ondansetron hcl oral tablet 8 ; BvD; QL (60 EA per 30 days) ondansetron oral tablet dispersible 4, 8 ; BvD; QL (60 EA per 30 days) SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR ANTIFUNGALS ANTIFUNGALS ABELCET INTRAVENOUS SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS SUSPENSION RECONSTITUTED 50 MG amphotericin b injection solution reconstituted 50 CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 50 MG, 70 MG ; QL (4 EA per 28 days) ; BvD ; BvD ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 22

29 clotrimazole mouth/throat troche 10 ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG, 50 MG fluconazole in sodium chloride intravenous solution /100ml-%, /200ml- % fluconazole oral suspension reconstituted 10 /ml, 40 /ml fluconazole oral tablet 100, 150, 200, 50 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 23 ; BvD flucytosine oral capsule 250, 500 griseofulvin microsize oral suspension 125 /5ml itraconazole oral capsule 100 ketoconazole oral tablet 200 MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 50 MG NOXAFIL ORAL SUSPENSION 40 MG/ML NOXAFIL ORAL TABLET DELAYED RELEASE 100 MG nystatin oral tablet unit ORAVIG BUCCAL TABLET 50 MG terbinafine hcl oral tablet 250 VORICONAZOLE INTRAVENOUS SOLUTION RECONSTITUTED 200 MG voriconazole oral suspension reconstituted 40 /ml ; BvD voriconazole oral tablet 200

30 ANTIGOUT AGENTS ANTIGOUT AGENTS allopurinol oral tablet 100, 300 colchicine oral capsule 0.6 colchicine oral tablet 0.6 probenecid oral tablet 500 ULORIC ORAL TABLET 40 MG, 80 MG ST; ANTI-INFLAMMATORY AGENTS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib oral capsule 100, 200, 400, 50 diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hr 100 diclofenac sodium oral tablet delayed release 25, 50, 75 ; QL (60 EA per 30 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 24 diflunisal oral tablet 500 etodolac er oral tablet extended release 24 hr 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400 etodolac oral tablet 500 fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml ibuprofen oral tablet 400 ibuprofen oral tablet 600, 800

31 indomethacin er oral capsule extended release 75 PA; ; HR indomethacin oral capsule 25, 50 PA; ; HR ketoprofen er oral capsule extended release 24 hour 200 ketoprofen oral capsule 50, 75 ketorolac tromethamine injection solution 15 /ml, 30 /ml ketorolac tromethamine intramuscular solution 60 /2ml PA; ; HR PA; ; HR ketorolac tromethamine oral tablet 10 PA; ; HR meclofenamate sodium oral capsule 100, 50 meloxicam oral suspension 7.5 /5ml meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 naproxen dr oral tablet delayed release 375, 500 naproxen oral suspension 125 /5ml naproxen oral tablet 250, 375 naproxen oral tablet 500 naproxen sodium oral tablet 275, 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 tencon oral tablet PA; ; HR; QL (180 EA per 30 days) tolmetin sodium oral capsule 400 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 25

32 tolmetin sodium oral tablet 600 ANTIMIGRAINE AGENTS ANTIMIGRAINE AGENTS, PROPHYLACTIC divalproex sodium oral 125 divalproex sodium oral tablet delayed release 125 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 26 topiramate oral tablet 100 ERGOT ALKALOIDS dihydroergotamine mesylate injection solution 1 /ml dihydroergotamine mesylate nasal solution 4 /ml ERGOMAR SUBLINGUAL TABLET SUBLINGUAL 2 MG SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS ; QL (24 ML per 28 days) RELPAX ORAL TABLET 20 MG, 40 MG ST; ; QL (9 EA per 30 days) sumatriptan nasal solution 20 /act, 5 /act sumatriptan succinate oral tablet 100 ; QL (9 EA per 30 days) sumatriptan succinate oral tablet 25, 50 ; QL (9 EA per 30 days) sumatriptan succinate subcutaneous 6 /0.5ml ; QL (4.5 ML per 30 days) sumatriptan succinate subcutaneous solution 6 /0.5ml ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine hcl oral tablet 125 MESTINON ORAL SYRUP 60 MG/5ML pyridostigmine bromide oral tablet 60 ; QL (4.5 ML per 30 days)

33 ANTIMYCOBACTERIALS ANTITUBERCULARS CAPASTAT SULFATE INJECTION SOLUTION RECONSTITUTED 1 GM pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 27 ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral syrup 50 /5ml isoniazid oral tablet 100, 300 PASER ORAL PACKET 4 GM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin intravenous solution reconstituted 600 rifampin oral capsule 150, 300 RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG TRECATOR ORAL TABLET 250 MG ANTINEOPLASTICS ALKYLATING AGENTS cyclophosphamide oral capsule 25, 50 ; BvD GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG HEXALEN ORAL CAPSULE 50 MG LEUKERAN ORAL TABLET 2 MG THIOTEPA INJECTION SOLUTION RECONSTITUTED 15 MG ; BvD

34 ANTIANGIOGENIC AGENTS DEPEN TITRATABS ORAL TABLET 250 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG REVLIMID ORAL CAPSULE 2.5 MG, 20 MG SYPRINE ORAL CAPSULE 250 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG ANTIMETABOLITES ALIMTA INTRAVENOUS SOLUTION RECONSTITUTED 500 MG azacitidine injection suspension reconstituted 100 decitabine intravenous solution reconstituted 50 fludarabine phosphate intravenous solution reconstituted 50 GEMCITABINE HCL INTRAVENOUS SOLUTION RECONSTITUTED 1 GM pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 28 LA mercaptopurine oral tablet 50 methotrexate oral tablet 2.5 ; BvD methotrexate sodium (pf) injection solution 1 gm/40ml methotrexate sodium injection solution reconstituted 1 gm PURIXAN ORAL SUSPENSION 2000 MG/100ML ; BvD ; BvD TABLOID ORAL TABLET 40 MG ANTINEOPLASTICS

35 ABRAXANE INTRAVENOUS SUSPENSION RECONSTITUTED 100 MG ACTIMMUNE SUBCUTANEOUS SOLUTION UNIT/0.5ML ; BvD adrucil intravenous solution 500 /10ml ; BvD AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG PA; amifostine intravenous solution reconstituted 500 ARRANON INTRAVENOUS SOLUTION 5 MG/ML AVASTIN INTRAVENOUS SOLUTION 100 MG/4ML AVASTIN INTRAVENOUS SOLUTION 400 MG/16ML BELEODAQ INTRAVENOUS SOLUTION RECONSTITUTED 500 MG LA ; BvD PA; bexarotene oral capsule 75 PA; bicalutamide oral tablet 50 BICNU INTRAVENOUS SOLUTION RECONSTITUTED 100 MG bleomycin sulfate injection solution reconstituted 30 unit ; BvD ; BvD BOSULIF ORAL TABLET 100 MG, 500 MG PA; BUSULFEX INTRAVENOUS SOLUTION 6 MG/ML ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 29

36 CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG CAPRELSA ORAL TABLET 100 MG, 300 MG PA; carboplatin intravenous solution 150 /15ml ; BvD cisplatin intravenous solution 100 /100ml ; BvD cladribine intravenous solution 10 /10ml ; BvD CLOLAR INTRAVENOUS SOLUTION 1 MG/ML COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MG COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MG COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG COSMEGEN INTRAVENOUS SOLUTION RECONSTITUTED 0.5 MG ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 30 ; BvD COTELLIC ORAL TABLET 20 MG PA; LA CYRAMZA INTRAVENOUS SOLUTION 100 MG/10ML, 500 MG/50ML ; BvD cytarabine (pf) injection solution 100 /ml ; BvD cytarabine injection solution 20 /ml ; BvD dacarbazine intravenous solution reconstituted 200 DARZALEX INTRAVENOUS SOLUTION 100 MG/5ML ; BvD PA; LA daunorubicin hcl intravenous injectable 5 /ml ; BvD DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML dexrazoxane intravenous solution reconstituted 250 ; BvD

37 DOCEFREZ INTRAVENOUS SOLUTION RECONSTITUTED 20 MG DOCETAXEL INTRAVENOUS CONCENTRATE 80 MG/4ML DOCETAXEL INTRAVENOUS SOLUTION 80 MG/8ML ; BvD doxorubicin hcl intravenous solution 2 /ml ; BvD DOXORUBICIN HCL LIPOSOMAL INTRAVENOUS INJECTABLE 2 MG/ML ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45 MG, 7.5 MG ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 1.5 MG ELITEK INTRAVENOUS SOLUTION RECONSTITUTED 7.5 MG ; BvD ; BvD EMCYT ORAL CAPSULE 140 MG EMPLICITI INTRAVENOUS SOLUTION RECONSTITUTED 300 MG, 400 MG ERBITUX INTRAVENOUS SOLUTION 100 MG/50ML ERIVEDGE ORAL CAPSULE 150 MG ERWINAZE INJECTION SOLUTION RECONSTITUTED UNIT ETOPOPHOS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG PA; ; BvD PA; ; BvD etoposide intravenous solution 500 /25ml ; BvD FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG PA; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 31

38 FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 32 fluorouracil external solution 2 %, 5 % fluorouracil intravenous solution 2.5 gm/50ml ; BvD flutamide oral capsule 125 FOLOTYN INTRAVENOUS SOLUTION 40 MG/2ML GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG GLEEVEC ORAL TABLET 100 MG, 400 MG HALAVEN INTRAVENOUS SOLUTION 1 MG/2ML HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 440 MG HYDROXYPROGESTERONE CAPROATE INTRAMUSCULAR SOLUTION 1.25 GM/5ML ; BvD PA; hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ; BvD PA; PA; ICLUSIG ORAL TABLET 15 MG, 45 MG PA; idarubicin hcl intravenous solution 10 /10ml ; BvD ifosfamide intravenous solution reconstituted 1 gm ; BvD IMBRUVICA ORAL CAPSULE 140 MG PA; INLYTA ORAL TABLET 1 MG, 5 MG

39 INTRON A INJECTION SOLUTION UNIT/ML INTRON A INJECTION SOLUTION RECONSTITUTED UNIT intron a injection solution reconstituted unit, unit pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 33 IRESSA ORAL TABLET 250 MG irinotecan hcl intravenous solution 100 /5ml ; BvD ISTODAX INTRAVENOUS SOLUTION RECONSTITUTED 10 MG JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG JEVTANA INTRAVENOUS SOLUTION 60 MG/1.5ML KADCYLA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG KEPIVANCE INTRAVENOUS SOLUTION RECONSTITUTED 6.25 MG KEYTRUDA INTRAVENOUS SOLUTION 100 MG/4ML KEYTRUDA INTRAVENOUS SOLUTION RECONSTITUTED 50 MG ; BvD LENVIMA 10 MG DAILY DOSE ORAL 10 MG LENVIMA 14 MG DAILY DOSE ORAL 10 & 4 MG LENVIMA 18 MG DAILY DOSE ORAL 10 & 4 (2) MG LENVIMA 20 MG DAILY DOSE ORAL 10 (2) MG LENVIMA 24 MG DAILY DOSE ORAL 10 (2) & 4 MG ; BvD PA; PA;

40 LENVIMA 8 MG DAILY DOSE ORAL 4 (2) MG leucovorin calcium injection solution reconstituted 100, 350 leucovorin calcium oral tablet 10, 15, 25, 5 leuprolide acetate injection kit 1 /0.2ml levoleucovorin calcium intravenous solution 175 /17.5ml LONSURF ORAL TABLET MG, MG LUPRON DEPOT INTRAMUSCULAR KIT MG, 22.5 MG LUPRON DEPOT INTRAMUSCULAR KIT 3.75 MG, 30 MG LUPRON DEPOT INTRAMUSCULAR KIT 45 MG ; BvD PA; PA; PA; PA; LYNPARZA ORAL CAPSULE 50 MG PA; LYSODREN ORAL TABLET 500 MG MATULANE ORAL CAPSULE 50 MG megestrol acetate oral suspension 40 /ml PA; ; HR megestrol acetate oral tablet 20, 40 PA; ; HR MEKINIST ORAL TABLET 0.5 MG, 2 MG LA melphalan hcl intravenous solution reconstituted 50 ; BvD mesna intravenous solution 100 /ml ; BvD MESNEX ORAL TABLET 400 MG mitomycin intravenous solution reconstituted 20, 40, 5 ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 34

41 mitoxantrone hcl intravenous concentrate 25 /12.5ml MUSTARGEN INJECTION SOLUTION RECONSTITUTED 10 MG NEXAVAR ORAL TABLET 200 MG LA pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 35 NILANDRON ORAL TABLET 150 MG nilutamide oral tablet 150 NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ; BvD PA; ODOMZO ORAL CAPSULE 200 MG PA; LA OPDIVO INTRAVENOUS SOLUTION 40 MG/4ML PA; oxaliplatin intravenous solution 100 /20ml ; BvD paclitaxel intravenous concentrate 300 /50ml ; BvD PERJETA INTRAVENOUS SOLUTION 420 MG/14ML POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG PROLEUKIN INTRAVENOUS SOLUTION RECONSTITUTED UNIT RITUXAN INTRAVENOUS SOLUTION 500 MG/50ML LA SOLTAX ORAL SOLUTION 10 MG/5ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG STIVARGA ORAL TABLET 40 MG PA; SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

42 SYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED 3.5 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG LA TAGRISSO ORAL TABLET 40 MG, 80 MG PA; LA pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 36 tamoxifen citrate oral tablet 10 tamoxifen citrate oral tablet 20 TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG TASIGNA ORAL CAPSULE 150 MG, 200 MG TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML ; BvD toposar intravenous solution 1 gm/50ml ; BvD topotecan hcl intravenous solution reconstituted 4 TORISEL INTRAVENOUS SOLUTION 25 MG/ML TREANDA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED MG, 22.5 MG, 3.75 MG ; BvD ; BvD ; BvD tretinoin oral capsule 10 TRISENOX INTRAVENOUS SOLUTION 10 MG/10ML TYKERB ORAL TABLET 250 MG UVADEX INJECTION SOLUTION 20 MCG/ML ; BvD VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML VELCADE INJECTION SOLUTION RECONSTITUTED 3.5 MG ; BvD

43 VENCLEXTA ORAL TABLET 10 MG, 50 MG PA; LA VENCLEXTA ORAL TABLET 100 MG PA; LA VENCLEXTA STARTING PACK ORAL 10 & 50 & 100 MG PA; LA vinblastine sulfate intravenous solution 1 /ml ; BvD vincasar pfs intravenous solution 1 /ml ; BvD vincristine sulfate intravenous solution 1 /ml ; BvD vinorelbine tartrate intravenous solution 50 /5ml VOTRIENT ORAL TABLET 200 MG ; BvD XALKORI ORAL CAPSULE 200 MG, 250 MG PA; XTANDI ORAL CAPSULE 40 MG ST; YERVOY INTRAVENOUS SOLUTION 50 MG/10ML YONDELIS INTRAVENOUS SOLUTION RECONSTITUTED 1 MG ZALTRAP INTRAVENOUS SOLUTION 100 MG/4ML ZANOSAR INTRAVENOUS SOLUTION RECONSTITUTED 1 GM pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 37 PA; ZELBORAF ORAL TABLET 240 MG ZOLINZA ORAL CAPSULE 100 MG ZYDELIG ORAL TABLET 100 MG, 150 MG ZYKADIA ORAL CAPSULE 150 MG ZYTIGA ORAL TABLET 250 MG AROMATASE INHIBITORS, 3RD GENERATION anastrozole oral tablet 1 exemestane oral tablet 25 ; BvD

44 letrozole oral tablet 2.5 ANTIPARASITICS ANTHELMINTICS ALBENZA ORAL TABLET 200 MG EMVERM ORAL TABLET CHEWABLE 100 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 38 ivermectin oral tablet 3 ANTIPROTOZOALS ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5ML ALINIA ORAL TABLET 500 MG atovaquone oral suspension 750 /5ml atovaquone-proguanil hcl oral tablet , chloroquine phosphate oral tablet 250, 500 COARTEM ORAL TABLET MG DARAPRIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 PRIMAQUINE PHOSPHATE ORAL TABLET 26.3 MG quinine sulfate oral capsule 324 PA; ANTIPARKINSON AGENTS ANTICHOLINERGICS benztropine mesylate injection solution 1 /ml benztropine mesylate oral tablet 0.5, 1, 2

45 trihexyphenidyl hcl oral elixir 0.4 /ml trihexyphenidyl hcl oral tablet 2, 5 ANTIPARKINSON AGENTS, OTHER amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 entacapone oral tablet 200 tolcapone oral tablet 100 DOPAMINE AGONISTS APOKYN SUBCUTANEOUS SOLUTION 10 MG/ML bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 NEUPRO TRANSDERMAL PATCH 24 HR 1 MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6 MG/24HR, 8 MG/24HR pramipexole dihydrochloride er oral tablet extended release 24 hr 3, 3.75 pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 1 pramipexole dihydrochloride oral tablet 0.75, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 4, 5 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 39 LA ropinirole hcl oral tablet 1, 2, 3 DOPAMINE PRECURSORS/ L-AMINO ACID DECARBOXYLASE INHIBITORS carbidopa-levodopa er oral tablet extendedrelease

46 carbidopa-levodopa er oral tablet extendedrelease pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 40 carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet , carbidopa-levodopa oral tablet dispersible , , carbidopa-levodopa-entacapone oral tablet , , , , , NOAMINE OXIDASE B (MAO-B) INHIBITORS AZILECT ORAL TABLET 0.5 MG, 1 MG selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 ANTIPSYCHOTICS 1ST GENERATION/TYPICAL chlorpromazine hcl injection solution 50 /2ml ; BvD chlorpromazine hcl oral tablet 10 ; BvD chlorpromazine hcl oral tablet 100, 200, 25, 50 compro suppository 25 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl injection solution 2.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5

47 haloperidol decanoate intramuscular solution 100 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate 2 /ml haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 loxapine succinate oral capsule 10, 25, 5, 50 molindone hcl oral tablet 10, 25, 5 perphenazine oral tablet 16, 2, 4, 8 perphenazine-amitriptyline oral tablet 2-10, 2-25, 4-10, 4-25, 4-50 pimozide oral tablet 1, 2 prochlorperazine edisylate injection solution 5 /ml prochlorperazine maleate oral tablet 10, 5 prochlorperazine suppository 25 thioridazine hcl oral tablet 10, 100, 25, 50 thiothixene oral capsule 1, 10, 2, 5 trifluoperazine hcl oral tablet 1, 10, 2, 5 2ND GENERATION/ATYPICAL ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 300 MG (1.5ML SYRINGE), 400 MG aripiprazole oral tablet 10, 15, 2, 5 aripiprazole oral tablet 20, 30 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 41

48 ARIPIPRAZOLE ORAL TABLET DISPERSIBLE 10 MG, 15 MG ARISTADA INTRAMUSCULAR 441 MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MG GEODON INTRAMUSCULAR SOLUTION RECONSTITUTED 20 MG INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION 39 MG/0.25ML, 78 MG/0.5ML INVEGA TRINZA INTRAMUSCULAR SUSPENSION 273 MG/0.875ML, 410 MG/1.315ML, 546 MG/1.75ML, 819 MG/2.625ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 42 ST; NUPLAZID ORAL TABLET 17 MG PA; olanzapine intramuscular solution reconstituted 10 olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet dispersible 10, 15, 20, 5 paliperidone er oral tablet extended release 24 hr 1.5, 3, 6, 9 quetiapine fumarate oral tablet 100, 25, 50

49 quetiapine fumarate oral tablet 200, 300, 400 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG ST; risperidone oral solution 1 /ml risperidone oral tablet 0.25, 2, 3, 4 risperidone oral tablet 0.5, 1 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG VRAYLAR ORAL 1.5 & 3 MG ST; VRAYLAR ORAL CAPSULE 1.5 MG ST; ; QL (120 EA per 30 days) VRAYLAR ORAL CAPSULE 3 MG ST; ; QL (60 EA per 30 days) VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG ST; ; QL (30 EA per 30 days) ziprasidone hcl oral capsule 20, 40, 60, 80 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG TREATMENT-RESISTANT pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 43

50 clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 100, 12.5, 150, 25 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 44 clozapine oral tablet dispersible 200 FAZACLO ORAL TABLET DISPERSIBLE 100 MG, 12.5 MG, 25 MG VERSACLOZ ORAL SUSPENSION 50 MG/ML ANTIVIRALS ANTI-CYTOMEGALOVIRUS (CMV) AGENTS ganciclovir sodium intravenous solution reconstituted 500 valganciclovir hcl oral tablet 450 ANTIHEPATITIS AGENTS adefovir dipivoxil oral tablet 10 BARACLUDE ORAL SOLUTION 0.05 MG/ML DAKLINZA ORAL TABLET 30 MG, 60 MG, 90 MG entecavir oral tablet 0.5, 1 EPIVIR HBV ORAL SOLUTION 5 MG/ML ; BvD PA; HARVONI ORAL TABLET MG PA; lamivudine oral tablet 100 PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/0.5ML, 180 MCG/ML PEG-INTRON REDIPEN SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML

51 PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5ML, 150 MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML ribasphere oral tablet 400 ribasphere ribapak oral tablet 400 & 600, 400 ribavirin oral capsule 200 ribavirin oral tablet 200 SOVALDI ORAL TABLET 400 MG PA; TYZEKA ORAL TABLET 600 MG ZEPATIER ORAL TABLET MG PA; ANTIHERPETIC AGENTS acyclovir oral capsule 200 acyclovir oral suspension 200 /5ml acyclovir oral tablet 400 acyclovir oral tablet 800 acyclovir sodium intravenous solution 50 /ml ; BvD famciclovir oral tablet 125, 250, 500 valacyclovir hcl oral tablet 1 gm valacyclovir hcl oral tablet 500 ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG EDURANT ORAL TABLET 25 MG GENVOYA ORAL TABLET MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 45

52 INTELENCE ORAL TABLET 100 MG, 200 MG INTELENCE ORAL TABLET 25 MG nevirapine er oral tablet extended release 24 hr 100, 400 nevirapine oral suspension 50 /5ml nevirapine oral tablet 200 ODEFSEY ORAL TABLET MG RESCRIPTOR ORAL TABLET 100 MG, 200 MG SUSTIVA ORAL CAPSULE 200 MG, 50 MG SUSTIVA ORAL TABLET 600 MG ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS abacavir sulfate oral tablet 300 abacavir-lamivudine-zidovudine oral tablet DESCOVY ORAL TABLET MG didanosine oral capsule delayed release 125, 200, 250, 400 EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPZICOM ORAL TABLET MG EVOTAZ ORAL TABLET MG lamivudine oral solution 10 /ml lamivudine oral tablet 150, 300 lamivudine-zidovudine oral tablet PREZCOBIX ORAL TABLET MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 46

53 RETROVIR INTRAVENOUS SOLUTION 10 MG/ML stavudine oral capsule 15, 20, 30, 40 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 47 stavudine oral solution reconstituted 1 /ml TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG VIDEX ORAL SOLUTION RECONSTITUTED 2 GM VIREAD ORAL POWDER 40 MG/GM VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG ZIAGEN ORAL SOLUTION 20 MG/ML zidovudine oral capsule 100 zidovudine oral syrup 50 /5ml zidovudine oral tablet 300 ANTI-HIV AGENTS, OTHER FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED 90 MG ISENTRESS ORAL PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET CHEWABLE 100 MG ISENTRESS ORAL TABLET CHEWABLE 25 MG SELZENTRY ORAL TABLET 150 MG, 300 MG STRIBILD ORAL TABLET MG

54 TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 25 MG, 50 MG TYBOST ORAL TABLET 150 MG VITEKTA ORAL TABLET 150 MG, 85 MG ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML CRIXIVAN ORAL CAPSULE 200 MG, 400 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG KALETRA ORAL SOLUTION MG/5ML pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 48 KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG LEXIVA ORAL SUSPENSION 50 MG/ML LEXIVA ORAL TABLET 700 MG NORVIR ORAL CAPSULE 100 MG NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 75 MG REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL PACKET 50 MG VIRACEPT ORAL TABLET 250 MG, 625 MG

55 ANTI-INFLUENZA AGENTS RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER rimantadine hcl oral tablet 100 TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML VIRAZOLE INHALATION SOLUTION RECONSTITUTED 6 GM ANXIOLYTICS ANXIOLYTICS, OTHER buspirone hcl oral tablet 10 buspirone hcl oral tablet 15, 30, 5, 7.5 hydroxyzine hcl intramuscular solution 25 /ml, 50 /ml hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100, 25, 50 meprobamate oral tablet 200, 400 BENZODIAZEPINES alprazolam er oral tablet extended release 24 hr 0.5 alprazolam er oral tablet extended release 24 hr 1 ; QL (600 EA per 30 days) ; QL (300 EA per 30 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 49

56 alprazolam er oral tablet extended release 24 hr 2 alprazolam er oral tablet extended release 24 hr 3 alprazolam intensol oral concentrate 1 /ml ; QL (150 EA per 30 days) ; QL (100 EA per 30 days) alprazolam oral tablet 0.25 ; QL (1200 EA per 30 days) alprazolam oral tablet 0.5 ; QL (600 EA per 30 days) alprazolam oral tablet 1 ; QL (300 EA per 30 days) alprazolam oral tablet 2 ; QL (150 EA per 30 days) alprazolam oral tablet dispersible 0.25 ; QL (1200 EA per 30 days) alprazolam oral tablet dispersible 0.5 ; QL (600 EA per 30 days) alprazolam oral tablet dispersible 1 ; QL (300 EA per 30 days) alprazolam oral tablet dispersible 2 ; QL (150 EA per 30 days) alprazolam xr oral tablet extended release 24 hr 0.5 chlordiazepoxide hcl oral capsule 10, 25, 5 ; QL (600 EA per 30 days) ; QL (120 EA per 30 days) clorazepate dipotassium oral tablet 15 ; QL (180 EA per 30 days) clorazepate dipotassium oral tablet 3.75 ; QL (720 EA per 30 days) clorazepate dipotassium oral tablet 7.5 ; QL (360 EA per 30 days) diazepam intensol oral concentrate 5 /ml ; QL (240 ML per 30 days) diazepam oral solution 1 /ml ; QL (1200 ML per 30 days) diazepam oral tablet 10 ; QL (120 EA per 30 days) diazepam oral tablet 2 ; QL (600 EA per 30 days) diazepam oral tablet 5 ; QL (240 EA per 30 days) lorazepam intensol oral concentrate 2 /ml lorazepam oral tablet 0.5 ; QL (600 EA per 30 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 50

57 lorazepam oral tablet 1 ; QL (300 EA per 30 days) lorazepam oral tablet 2 ; QL (150 EA per 30 days) oxazepam oral capsule 10, 15, 30 ; QL (120 EA per 30 days) BIPOLAR AGENTS OD STABILIZERS carbamazepine er oral capsule extended release 12 hour 100 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 51 carbamazepine oral tablet chewable 100 lithium carbonate er oral tablet extendedrelease 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml BLOOD GLUCOSE REGULATORS ANTIDIABETIC AGENTS acarbose oral tablet 100, 25, 50 assure id insulin safety syr 29g x 1/2" 1 ml AVANDIA ORAL TABLET 2 MG, 4 MG BYDUREON SUBCUTANEOUS 2 MG BYETTA 10 MCG PEN SUBCUTANEOUS 10 MCG/0.04ML BYETTA 5 MCG PEN SUBCUTANEOUS 5 MCG/0.02ML chlorpropamide oral tablet 100, 250 PA; ; HR comfort assist insulin syringe 29g x 1/2" 1 ml cvs gauze sterile pad 2"x2"

58 CYCLOSET ORAL TABLET 0.8 MG exel comfort point pen needle 29g x 12mm exel pen needles 1/2" 29g x 12mm glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hr 10, 2.5, 5 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 52 glipizide oral tablet 10, 5 glipizide-metformin hcl oral tablet , , global alcohol prep ease pad 70 % glyburide micronized oral tablet 1.5, 3, 6 PA; ; HR glyburide oral tablet 1.25, 2.5, 5 PA; ; HR glyburide-metformin oral tablet , , INVOKAMET ORAL TABLET MG, MG, MG, MG PA; ; HR INVOKANA ORAL TABLET 100 MG, 300 MG JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR MG, MG, MG JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG JARDIANCE ORAL TABLET 10 MG, 25 MG JENTADUETO ORAL TABLET MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HR MG ; QL (60 EA per 30 days)

59 JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HR MG metformin hcl er oral tablet extended release 24 hr 500, 750 ; QL (30 EA per 30 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 53 metformin hcl oral tablet 1000, 500 metformin hcl oral tablet 850 miglitol oral tablet 100, 25, 50 nateglinide oral tablet 120, 60 pioglitazone hcl oral tablet 15, 30, 45 pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 pioglitazone hcl-metformin hcl oral tablet , preferred plus insulin syringe 28g x 1/2" 0.5 ml reli-on insulin syringe 29g 0.3 ml repaglinide oral tablet 0.5, 1, 2 repaglinide-metformin hcl oral tablet 1-500, RIOMET ORAL SOLUTION 500 MG/5ML SYMLINPEN 120 SUBCUTANEOUS 2700 MCG/2.7ML SYMLINPEN 60 SUBCUTANEOUS 1500 MCG/1.5ML SYNJARDY ORAL TABLET MG, MG, MG, MG tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 TRADJENTA ORAL TABLET 5 MG VICTOZA SUBCUTANEOUS 18 MG/3ML

60 GLYCEMIC AGENTS GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG PROGLYCEM ORAL SUSPENSION 50 MG/ML INSULINS LANTUS SOLOSTAR SUBCUTANEOUS 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS 100 UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS (70-30) 100 UNIT/ML NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG PENFILL SUBCUTANEOUS 100 UNIT/ML pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 54

61 NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO SOLOSTAR SUBCUTANEOUS 300 UNIT/ML TRESIBA FLEXTOUCH SUBCUTANEOUS 100 UNIT/ML, 200 UNIT/ML BLOOD PRODUCTS/DIFIERS/ VOLUME EXPANDERS ANTICOAGULANTS ELIQUIS ORAL TABLET 2.5 MG, 5 MG ; QL (60 EA per 30 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 55 enoxaparin sodium injection solution 300 /3ml enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 /0.8ml fondaparinux sodium subcutaneous solution 10 /0.8ml, 5 /0.4ml, 7.5 /0.6ml fondaparinux sodium subcutaneous solution 2.5 /0.5ml FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, UNT/0.72ML FRAGMIN SUBCUTANEOUS SOLUTION 2500 UNIT/0.2ML, 5000 UNIT/0.2ML heparin (porcine) in d5w intravenous solution 40-5 unit/ml-%, 50-5 unit/ml-% heparin sod (porcine) in d5w intravenous solution 100 unit/ml heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml jantoven oral tablet 1, 10, 2, 2.5, 3, 4, 6, 7.5

62 jantoven oral tablet 5 PRADAXA ORAL CAPSULE 110 MG, 150 MG ST; ; QL (60 EA per 30 days) PRADAXA ORAL CAPSULE 75 MG ; QL (120 EA per 30 days) warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6 warfarin sodium oral tablet 7.5 XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO STARTER PACK ORAL 15 & 20 MG BLOOD FORMATION DIFIERS LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG MIRCERA INJECTION 100 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML ZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2ML NEUPOGEN INJECTION 300 MCG/0.5ML, 480 MCG/0.8ML NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6ML PROCRIT INJECTION SOLUTION UNIT/ML, 4000 UNIT/ML PROCRIT INJECTION SOLUTION 2000 UNIT/ML PROCRIT INJECTION SOLUTION UNIT/ML PROCRIT INJECTION SOLUTION 3000 UNIT/ML ; BvD PA; PA; ; QL (12 ML per 28 days) PA; ; QL (23 ML per 30 days) PA; ; QL (12 ML per 28 days) PA; ; QL (16 ML per 30 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 56

63 PROCRIT INJECTION SOLUTION UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG tranexamic acid intravenous solution 1000 /10ml PA; ; QL (12 ML per 30 days) PA; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 57 tranexamic acid oral tablet 650 ZARXIO INJECTION 300 MCG/0.5ML, 480 MCG/0.8ML PLATELET DIFYING AGENTS anagrelide hcl oral capsule 0.5 aspirin-dipyridamole er oral capsule extended release 12 hour BRILINTA ORAL TABLET 60 MG, 90 MG ; QL (60 EA per 30 days) cilostazol oral tablet 100 cilostazol oral tablet 50 clopidogrel bisulfate oral tablet 300 clopidogrel bisulfate oral tablet 75 dipyridamole oral tablet 25, 50, 75 PA; ; HR CARDIOVASCULAR AGENTS ALPHA-ADRENERGIC AGONISTS clonidine hcl oral tablet 0.1, 0.2 clonidine hcl oral tablet 0.3 clonidine hcl transdermal patch weekly 0.1 /24hr, 0.2 /24hr clonidine hcl transdermal patch weekly 0.3 /24hr methyldopa oral tablet 250, 500 PA; ; HR ; QL (4 EA per 28 days) ; QL (8 EA per 28 days)

64 methyldopate hcl intravenous solution 250 /5ml midodrine hcl oral tablet 10, 2.5 midodrine hcl oral tablet 5 ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate oral tablet 1, 2, 4, 8 PA; ; HR pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 58 prazosin hcl oral capsule 1, 2, 5 terazosin hcl oral capsule 1, 10, 2 terazosin hcl oral capsule 5 ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG candesartan cilexetil oral tablet 16, 32, 4, 8 eprosartan mesylate oral tablet 600 irbesartan oral tablet 150, 300, 75 losartan potassium oral tablet 100, 25, 50 telmisartan oral tablet 20, 80 telmisartan oral tablet 40 valsartan oral tablet 160, 320, 40, 80 ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS benazepril hcl oral tablet 10, 5 benazepril hcl oral tablet 20, 40 captopril oral tablet 100, 12.5, 25, 50

65 enalapril maleate oral tablet 10, 2.5, 20, 5 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 59 fosinopril sodium oral tablet 10, 20 fosinopril sodium oral tablet 40 lisinopril oral tablet 10, 2.5, 20, 40, 5 lisinopril oral tablet 30 moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2, 4, 8 quinapril hcl oral tablet 10, 20 quinapril hcl oral tablet 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 trandolapril oral tablet 1, 2, 4 ANTIARRHYTHMICS amiodarone hcl intravenous solution 150 /3ml amiodarone hcl oral tablet 200 amiodarone hcl oral tablet 400 disopyramide phosphate oral capsule 100, 150 dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg flecainide acetate oral tablet 100, 50 flecainide acetate oral tablet 150 mexiletine hcl oral capsule 150, 200, 250 PA; ; HR MULTAQ ORAL TABLET 400 MG pacerone oral tablet 100 procainamide hcl injection solution 100 /ml

66 propafenone hcl oral tablet 150, 225 propafenone hcl oral tablet 300 quinidine gluconate er oral tablet extendedrelease 324 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 60 quinidine sulfate oral tablet 200, 300 ANTIHYPERTENSIVE COMBINATIONS amiloride-hydrochlorothiazide oral tablet 5-50 amlodipine besy-benazepril hcl oral capsule 10-20, , 5-40 amlodipine besy-benazepril hcl oral capsule 10-40, 5-10, 5-20 amlodipine besylate-valsartan oral tablet , , 5-160, amlodipine-valsartan-hctz oral tablet , , , , atenolol-chlorthalidone oral tablet , AZOR ORAL TABLET MG, MG, 5-20 MG, 5-40 MG benazepril-hydrochlorothiazide oral tablet , 20-25, benazepril-hydrochlorothiazide oral tablet BENICAR HCT ORAL TABLET MG, MG, MG bisoprolol-hydrochlorothiazide oral tablet , , candesartan cilexetil-hctz oral tablet , , 32-25

67 captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet , irbesartan-hydrochlorothiazide oral tablet irbesartan-hydrochlorothiazide oral tablet lisinopril-hydrochlorothiazide oral tablet , , losartan potassium-hctz oral tablet , , methyldopa-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet , metoprolol-hydrochlorothiazide oral tablet moexipril-hydrochlorothiazide oral tablet , 15-25, nadolol-bendroflumethiazide oral tablet 40-5, 80-5 PA; ; HR propranolol-hctz oral tablet 40-25, quinapril-hydrochlorothiazide oral tablet , , spironolactone-hctz oral tablet pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 61

68 telmisartan-amlodipine oral tablet 40-10, 40-5, 80-10, 80-5 telmisartan-hctz oral tablet , , trandolapril-verapamil hcl er oral tablet extendedrelease 1-240, 2-180, 2-240, triamterene-hctz oral capsule , triamterene-hctz oral tablet , TRIBENZOR ORAL TABLET MG, MG, MG, MG, MG valsartan-hydrochlorothiazide oral tablet , , , , BETA-ADRENERGIC BLOCKING AGENTS acebutolol hcl oral capsule 200 acebutolol hcl oral capsule 400 atenolol oral tablet 100, 25, 50 betaxolol hcl oral tablet 10, 20 bisoprolol fumarate oral tablet 10 bisoprolol fumarate oral tablet 5 carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl intravenous solution 5 /ml labetalol hcl oral tablet 100, 200, 300 metoprolol succinate er oral tablet extended release 24 hr 100, 200, 25, 50 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 62

69 metoprolol tartrate intravenous solution 1 /ml, 5 /5ml metoprolol tartrate oral tablet 100, 25, 50 ; BvD nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120 propranolol hcl er oral capsule extended release 24 hour 160, 60, 80 propranolol hcl intravenous solution 1 /ml propranolol hcl oral solution 20 /5ml, 40 /5ml propranolol hcl oral tablet 10, 60, 80 propranolol hcl oral tablet 20, 40 sotalol hcl (af) oral tablet 120 sotalol hcl oral tablet 160, 240 sotalol hcl oral tablet 80 timolol maleate oral tablet 10, 20, 5 CALCIUM CHANNEL BLOCKING AGENTS amlodipine besylate oral tablet 10, 2.5, 5 diltiazem hcl er beads oral capsule extended release 24 hour 180 diltiazem hcl er beads oral capsule extended release 24 hour 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 240, 300 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 63

70 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 64 diltiazem hcl intravenous solution 50 /10ml diltiazem hcl intravenous solution reconstituted 100 diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 120, 180, 240 felodipine er oral tablet extended release 24 hr 10, 2.5, 5 isradipine oral capsule 2.5, 5 nicardipine hcl oral capsule 20, 30 nifedical xl oral tablet extended release 24 hr 30, 60 nifedipine er osmotic release oral tablet extended release 24 hr 30, 60, 90 nifedipine oral capsule 10, 20 PA; ; HR nimodipine oral capsule 30 nisoldipine er oral tablet extended release 24 hr 20, 30, 40 taztia xt oral capsule extended release 24 hour 120, 180, 240, 300 taztia xt oral capsule extended release 24 hour 360 verapamil hcl er oral capsule extended release 24 hour 100, 120, 180, 200, 240, 300, 360 verapamil hcl er oral tablet extendedrelease 120

71 verapamil hcl er oral tablet extendedrelease 180, 240 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 65 verapamil hcl intravenous solution 2.5 /ml verapamil hcl oral tablet 120, 40, 80 CARDIOVASCULAR AGENTS, OTHER amlodipine-atorvastatin oral tablet 10-10, 10-20, 10-40, 10-80, , , , 5-10, 5-20, 5-40, 5-80 CINRYZE INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT PA; digitek oral tablet 125 mcg ; QL (30 EA per 30 days) digitek oral tablet 250 mcg PA; ; HR digoxin injection solution 0.25 /ml PA; ; HR digoxin oral solution 0.05 /ml PA; ; HR digoxin oral tablet 125 mcg ; QL (30 EA per 30 days) digoxin oral tablet 250 mcg PA; ; HR FIRAZYR SUBCUTANEOUS SOLUTION 30 MG/3ML NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG pentoxifylline er oral tablet extendedrelease 400 RANEXA ORAL TABLET EXTENDED RELEASE 12 HR 1000 MG, 500 MG PA; reserpine oral tablet 0.1 PA; ; HR DIURETICS, CARBONIC ANHYDRASE INHIBITORS acetazolamide er oral capsule extended release 12 hour 500 acetazolamide oral tablet 125

72 acetazolamide oral tablet 250 METHAZOLAMIDE ORAL TABLET 25 MG, 50 MG DIURETICS, LOOP pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 66 bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5, 2 bumetanide oral tablet 1 furosemide injection solution 10 /ml furosemide oral solution 10 /ml, 8 /ml furosemide oral tablet 20, 40, 80 torsemide oral tablet 10, 100, 20, 5 DIURETICS, POTASSIUM-SPARING amiloride hcl oral tablet 5 DEMSER ORAL CAPSULE 250 MG eplerenone oral tablet 25, 50 spironolactone oral tablet 100, 25, 50 DIURETICS, THIAZIDE chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 25 chlorthalidone oral tablet 50 hydrochlorothiazide oral capsule 12.5 hydrochlorothiazide oral tablet 12.5, 25 hydrochlorothiazide oral tablet 50 indapamide oral tablet 1.25 indapamide oral tablet 2.5 methyclothiazide oral tablet 5

73 metolazone oral tablet 10, 5 metolazone oral tablet 2.5 DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES fenofibrate micronized oral capsule 134 fenofibrate micronized oral capsule 200, 67 fenofibrate oral capsule 150, 50 fenofibrate oral tablet 145 fenofibrate oral tablet 160, 48, 54 fenofibric acid oral tablet 105 fenofibric acid oral tablet 35 gemfibrozil oral tablet 600 DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 10, 20, 40, 80 fluvastatin sodium er oral tablet extended release 24 hr 80 fluvastatin sodium oral capsule 20, 40 LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG lovastatin oral tablet 10 lovastatin oral tablet 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 rosuvastatin calcium oral tablet 10, 20, 40, 5 simvastatin oral tablet 10, 20, 40, 80 simvastatin oral tablet 5 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 67

74 DYSLIPIDEMICS, OTHER cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose colestipol hcl oral granules 5 gm colestipol hcl oral tablet 1 gm JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG PA; KYNAMRO SUBCUTANEOUS 200 MG/ML PA; niacin er (antihyperlipidemic) oral tablet extendedrelease 1000, 500, 750 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 68 niacor oral tablet 500 omega-3-acid ethyl esters oral capsule 1 gm PRALUENT SUBCUTANEOUS 150 MG/ML, 75 MG/ML REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS 420 MG/3.5ML PA; PA; REPATHA SUBCUTANEOUS 140 MG/ML PA; REPATHA SURECLICK SUBCUTANEOUS 140 MG/ML PA; ZETIA ORAL TABLET 10 MG ; QL (30 EA per 30 days) VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS isosorbide dinitrate er oral tablet extendedrelease 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hr 120 isosorbide mononitrate er oral tablet extended release 24 hr 30, 60

75 isosorbide mononitrate oral tablet 10, 20 nitroglycerin intravenous solution 5 /ml nitroglycerin transdermal patch 24 hr 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual solution 0.4 /spray NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG VASODILATORS, DIRECT-ACTING ARTERIAL hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 25, 50 hydralazine hcl oral tablet 100 minoxidil oral tablet 10, 2.5 CENTRAL NERVOUS SYSTEM AGENTS ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 30, 5, 7.5 dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON- AMPHETAMINES CLONIDINE HCL ER ORAL TABLET EXTENDED RELEASE 12 HR 0.1 MG dexmethylphenidate hcl er oral capsule extended release 24 hour 5 guanfacine hcl er oral tablet extended release 24 hr 1, 2, 3, 4 PA; ; HR pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 69

76 methylphenidate hcl er (cd) oral capsule extended release 10 methylphenidate hcl er oral tablet extendedrelease 20 methylphenidate hcl oral solution 10 /5ml, 5 /5ml methylphenidate hcl oral tablet 10, 20, 5 methylphenidate hcl oral tablet chewable 10, 2.5, 5 STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG CENTRAL NERVOUS SYSTEM, OTHER pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 70 NUEDEXTA ORAL CAPSULE MG riluzole oral tablet 50 tetrabenazine oral tablet 12.5, 25 FIBROMYALGIA AGENTS LYRICA ORAL CAPSULE 100 MG, 150 MG SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG MULTIPLE SCLEROSIS AGENTS AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG PA; AUBAGIO ORAL TABLET 14 MG, 7 MG PA; ST; LA AVONEX INTRAMUSCULAR KIT 30 MCG PA; AVONEX PREFILLED INTRAMUSCULAR 30 MCG/0.5ML PA;

77 BETASERON SUBCUTANEOUS KIT 0.3 MG PA; COPAXONE SUBCUTANEOUS 20 MG/ML, 40 MG/ML PA; GILENYA ORAL CAPSULE 0.5 MG PA; PLEGRIDY SUBCUTANEOUS 125 MCG/0.5ML PA; TECFIDERA ORAL 120 & 240 MG PA; TECFIDERA ORAL CAPSULE DELAYED RELEASE 120 MG, 240 MG TYSABRI INTRAVENOUS CONCENTRATE 300 MG/15ML SLEEP DISORDERS, OTHER armodafinil oral tablet 150, 200, 250, 50 DENTAL AND ORAL AGENTS DENTAL AND ORAL AGENTS chlorhexidine gluconate mouth/throat solution 0.12 % PA; PA; PA; ; QL (30 EA per 30 days) lidocaine viscous mouth/throat solution 2 % nystatin mouth/throat suspension unit/ml pilocarpine hcl oral tablet 5, 7.5 triamcinolone acetonide mouth/throat paste 0.1 % DERMATOLOGICAL AGENTS DERMATOLOGICAL AGENTS 8-P ORAL CAPSULE 10 MG acitretin oral capsule 10, 17.5, 25 amcinonide external cream 0.1 % pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 71

78 amcinonide external lotion 0.1 % amcinonide external ointment 0.1 % ammonium lactate external cream 12 % ammonium lactate external lotion 12 % benzoyl peroxide-erythromycin external gel 5-3 % betamethasone dipropionate aug external lotion 0.05 % betamethasone dipropionate external cream 0.05 % betamethasone dipropionate external ointment 0.05 % betamethasone valerate external cream 0.1 % betamethasone valerate external lotion 0.1 % betamethasone valerate external ointment 0.1 % calcipotriene external solution % calcitriol external ointment 3 mcg/gm ciclopirox external gel 0.77 % ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % ciclopirox olamine external suspension 0.77 % claravis oral capsule 10, 20, 30, 40 clindamycin phos-benzoyl perox external gel 1-5 % clindamycin phosphate external gel 1 % clindamycin phosphate external lotion 1 % clindamycin phosphate external solution 1 % clindamycin phosphate external swab 1 % pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 72

79 clobetasol propionate e external cream 0.05 % clobetasol propionate external gel 0.05 % clobetasol propionate external ointment 0.05 % clobetasol propionate external solution 0.05 % clotrimazole external cream 1 % clotrimazole external solution 1 % clotrimazole-betamethasone external cream % clotrimazole-betamethasone external lotion % CONDYLOX EXTERNAL GEL 0.5 % ST; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 73 desonide external cream 0.05 % desonide external lotion 0.05 % desonide external ointment 0.05 % desoximetasone external cream 0.05 % desoximetasone external cream 0.25 % desoximetasone external gel 0.05 % desoximetasone external ointment 0.25 % diclofenac sodium transdermal gel 1 % diclofenac sodium transdermal gel 3 % diclofenac sodium transdermal solution 1.5 % diflorasone diacetate external cream 0.05 % diflorasone diacetate external ointment 0.05 % econazole nitrate external cream 1 % ELIDEL EXTERNAL CREAM 1 % PA; erythromycin external gel 2 % erythromycin external solution 2 %

80 EURAX EXTERNAL CREAM 10 % fluocinolone acetonide body external oil 0.01 % fluocinolone acetonide external cream 0.01 %, % fluocinolone acetonide external ointment % fluocinolone acetonide external solution 0.01 % fluocinonide external gel 0.05 % fluocinonide external ointment 0.05 % fluocinonide external solution 0.05 % fluocinonide-e external cream 0.05 % fluorouracil external cream 5 % fluticasone propionate external cream 0.05 % fluticasone propionate external ointment % gentamicin sulfate external cream 0.1 % gentamicin sulfate external ointment 0.1 % halobetasol propionate external cream 0.05 % halobetasol propionate external ointment 0.05 % hydrocortisone external cream 1 % hydrocortisone external cream 2.5 % hydrocortisone external lotion 2.5 % hydrocortisone external ointment 1 %, 2.5 % hydrocortisone valerate external cream 0.2 % hydrocortisone valerate external ointment 0.2 % imiquimod external cream 5 % ketoconazole external cream 2 % ketoconazole external foam 2 % pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 74

81 ketoconazole external shampoo 2 % lidocaine external ointment 5 % LIDOCAINE EXTERNAL PATCH 5 % PA; ; QL (90 EA per 30 days) lidocaine hcl external solution 4 % lindane external shampoo 1 % methoxsalen rapid oral capsule 10 metronidazole external cream 0.75 % metronidazole external gel 0.75 % metronidazole external lotion 0.75 % mometasone furoate external cream 0.1 % mometasone furoate external ointment 0.1 % mometasone furoate external solution 0.1 % mupirocin calcium external cream 2 % mupirocin external ointment 2 % myorisan oral capsule 30 nystatin external cream unit/gm nystatin external ointment unit/gm nystatin external powder unit/gm nystatin-triamcinolone external cream unit/gm-% nystatin-triamcinolone external ointment unit/gm-% pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 75 PANRETIN EXTERNAL GEL 0.1 % permethrin external cream 5 % PICATO EXTERNAL GEL %, 0.05 % ST; podofilox external solution 0.5 % prednicarbate external cream 0.1 %

82 prednicarbate external ointment 0.1 % procto-med hc cream 2.5 % procto-pak cream 1 % proctozone-hc cream 2.5 % REGRANEX EXTERNAL GEL 0.01 % PA; SANTYL EXTERNAL OINTMENT 250 UNIT/GM selenium sulfide external lotion 2.5 % silver sulfadiazine external cream 1 % sulfacetamide sodium external suspension 10 % TARGRETIN EXTERNAL GEL 1 % TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % TAZORAC EXTERNAL GEL 0.05 %, 0.1 % TOLAK EXTERNAL CREAM 4 % triamcinolone acetonide external cream %, 0.5 % triamcinolone acetonide external cream 0.1 % triamcinolone acetonide external lotion %, 0.1 % triamcinolone acetonide external ointment %, 0.5 % triamcinolone acetonide external ointment 0.1 % UCERIS FOAM 2 MG/ACT ST; VALCHLOR EXTERNAL GEL % ENZYME REPLACEMENT/ DIFIERS ENZYME REPLACEMENT/ DIFIERS pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 76

83 ADAGEN INTRAMUSCULAR SOLUTION 250 UNIT/ML ALDURAZYME INTRAVENOUS SOLUTION 2.9 MG/5ML CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT CREON ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, 6000 UNIT LA LA LA CYSTADANE ORAL POWDER ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML FABRAZYME INTRAVENOUS SOLUTION RECONSTITUTED 35 MG KANUMA INTRAVENOUS SOLUTION 20 MG/10ML KUVAN ORAL PACKET 100 MG, 500 MG KUVAN ORAL TABLET SOLUBLE 100 MG LA levocarnitine oral solution 1 gm/10ml levocarnitine oral tablet 330 LUMIZYME INTRAVENOUS SOLUTION RECONSTITUTED 50 MG NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG ORFADIN ORAL SUSPENSION 4 MG/ML LA LA PA; RAVICTI ORAL LIQUID 1.1 GM/ML pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 77

84 VPRIV INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT ZAVESCA ORAL CAPSULE 100 MG ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES UNIT, UNIT, UNIT, UNIT, UNIT, UNIT, 5000 UNIT GASTROINTESTINAL AGENTS ANTISPASDICS, GASTROINTESTINAL atropine sulfate injection solution 0.05 /ml, 0.1 /ml dicyclomine hcl intramuscular solution 10 /ml dicyclomine hcl oral capsule 10 dicyclomine hcl oral solution 10 /5ml dicyclomine hcl oral tablet 20 methscopolamine bromide oral tablet 2.5 GASTROINTESTINAL AGENTS, OTHER diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet loperamide hcl oral capsule 2 metoclopramide hcl injection solution 5 /ml metoclopramide hcl oral solution 5 /5ml metoclopramide hcl oral tablet 10, 5 VANTIK ORAL TABLET 12.5 MG, 25 MG PA; RELISTOR ORAL TABLET 150 MG PA; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 78

85 RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 12 MG/0.6ML (0.6ML SYRINGE), 8 MG/0.4ML ursodiol oral tablet 250, 500 HISTAMINE2 (H2) RECEPTOR ANTAGONISTS famotidine intravenous solution 20 /2ml famotidine oral tablet 20, 40 famotidine premixed intravenous solution /50ml-% PA; ranitidine hcl injection solution 150 /6ml ranitidine hcl oral capsule 150, 300 ranitidine hcl oral syrup 15 /ml ranitidine hcl oral tablet 150, 300 IRRITABLE BOWEL SYNDROME AGENTS alosetron hcl oral tablet 0.5, 1 AMITIZA ORAL CAPSULE 24 MCG, 8 MCG PA; GATTEX SUBCUTANEOUS KIT 5 MG LINZESS ORAL CAPSULE 145 MCG, 290 MCG LAXATIVES enulose oral solution 10 gm/15ml generlac oral solution 10 gm/15ml lactulose oral solution 10 gm/15ml peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm polyethylene glycol 3350 oral powder PREPOPIK ORAL PACKET MG-GM- GM pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 79

86 PROTECTANTS CARAFATE ORAL SUSPENSION 1 GM/10ML misoprostol oral tablet 100 mcg, 200 mcg sucralfate oral tablet 1 gm PROTON PUMP INHIBITORS esomeprazole sodium intravenous solution reconstituted 20 lansoprazole oral capsule delayed release 15, 30 omeprazole oral capsule delayed release 10, 20, 40 pantoprazole sodium oral tablet delayed release 20, 40 GENITOURINARY AGENTS ANTISPASDICS, URINARY DARIFENACIN HYDROBROMIDE ER ORAL TABLET EXTENDED RELEASE 24 HR 15 MG, 7.5 MG MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG, 50 MG oxybutynin chloride er oral tablet extended release 24 hr 10, 5 oxybutynin chloride er oral tablet extended release 24 hr 15 ST; oxybutynin chloride oral syrup 5 /5ml oxybutynin chloride oral tablet 5 tolterodine tartrate oral tablet 1, 2 VESICARE ORAL TABLET 10 MG, 5 MG ST; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 80

87 BENIGN PROSTATIC HYPERTROPHY AGENTS alfuzosin hcl er oral tablet extended release 24 hr 10 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 81 dutasteride oral capsule 0.5 dutasteride-tamsulosin hcl oral capsule finasteride oral tablet 5 RAPAFLO ORAL CAPSULE 4 MG, 8 MG ST; tamsulosin hcl oral capsule 0.4 GENITOURINARY AGENTS, OTHER CYSTAGON ORAL CAPSULE 150 MG, 50 MG ELMIRON ORAL CAPSULE 100 MG lithostat oral tablet 250 neomycin-polymyxin b gu irrigation solution potassium citrate er oral tablet extendedrelease 15 meq (1620 ) sodium chloride irrigation solution 0.9 % PHOSPHATE BINDERS calcium acetate (phos binder) oral capsule 667 RENVELA ORAL PACKET 0.8 GM, 2.4 GM RENVELA ORAL TABLET 800 MG VAGINAL PRODUCTS clindamycin phosphate vaginal cream 2 % metronidazole vaginal gel 0.75 % miconazole 3 vaginal suppository 200 terconazole vaginal cream 0.4 % terconazole vaginal suppository 80

88 zazole vaginal cream 0.8 % HORNAL AGENTS, STIMULANT/ REPLACEMENT/ DIFYING (ADRENAL) GLUCOCORTICOIDS/MINERALOCORTICOIDS budesonide oral capsule delayed release particles 3 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 82 dexamethasone oral elixir 0.5 /5ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 2, 6 dexamethasone oral tablet 4 dexamethasone sodium phosphate injection solution 10 /ml dexamethasone sodium phosphate injection solution 120 /30ml ; BvD fludrocortisone acetate oral tablet 0.1 hydrocortisone oral tablet 10, 5 methylprednisolone acetate injection suspension 40 /ml, 80 /ml methylprednisolone oral 4 methylprednisolone oral tablet 16, 32, 4, 8 methylprednisolone sodium succ injection solution reconstituted 125, 40 prednisolone sodium phosphate oral solution 15 /5ml, 25 /5ml, 6.7 (5 base) /5ml prednisolone sodium phosphate oral tablet dispersible 10, 15, 30 prednisone oral 10 (21), 10 (48), 5 (21), 5 (48) prednisone oral solution 5 /5ml

89 prednisone oral tablet 1, 10, 20, 5 prednisone oral tablet 2.5, 50 UCERIS ORAL TABLET EXTENDED RELEASE 24 HR 9 MG ST; HORNAL AGENTS, STIMULANT/ REPLACEMENT/ DIFYING (SEX HORNES/ DIFIERS) ANABOLIC STEROIDS ANADROL-50 ORAL TABLET 50 MG oxandrolone oral tablet 10, 2.5 ANDROGENS ANDRODERM TRANSDERMAL PATCH 24 HR 2 MG/24HR, 4 MG/24HR danazol oral capsule 100, 200, 50 methyltestosterone oral capsule 10 testosterone cypionate intramuscular solution 100 /ml testosterone cypionate intramuscular solution 200 /ml testosterone enanthate intramuscular solution 200 /ml CONTRACEPTIVES apri oral tablet mcg bekyree oral tablet /0.01 (21/5) blisovi 24 fe oral tablet mcg(24) blisovi fe 1.5/30 oral tablet mcg blisovi fe 1/20 oral tablet mcg caziant oral tablet 0.1/0.125/ pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 83

90 cyclafem 1/35 oral tablet mcg deblitane oral tablet 0.35 desogestrel-ethinyl estradiol oral tablet /0.01 (21/5) drospirenone-ethinyl estradiol oral tablet emoquette oral tablet mcg enpresse-28 oral tablet gianvi oral tablet gildess 24 fe oral tablet mcg(24) introvale oral tablet ; QL (91 EA per 91 days) juleber oral tablet mcg junel fe 1/20 oral tablet mcg junel fe 24 oral tablet mcg(24) kaitlib fe oral tablet chewable mcg kariva oral tablet /0.01 (21/5) KIMIDESS ORAL TABLET /0.01 MG (21/5) larin fe 1/20 oral tablet mcg larissia oral tablet mcg levonest oral tablet levonorgest-eth estrad 91-day oral tablet levonorg-eth estrad triphasic oral tablet lomedia 24 fe oral tablet mcg(24) loryna oral tablet lyza oral tablet 0.35 ; QL (91 EA per 91 days) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 84

91 medroxyprogesterone acetate intramuscular suspension 150 /ml microgestin fe 1/20 oral tablet mcg necon 1/35 (28) oral tablet mcg nikki oral tablet norethin ace-eth estrad-fe oral tablet 1-20 mcg(24) norethindrone oral tablet 0.35 norgestim-eth estrad triphasic oral tablet 0.18/0.215/ mcg, 0.18/0.215/ mcg nortrel 1/35 (21) oral tablet mcg nortrel 1/35 (28) oral tablet mcg pimtrea oral tablet /0.01 (21/5) pirmella 1/35 oral tablet mcg quasense oral tablet ; QL (91 EA per 91 days) reclipsen oral tablet mcg setlakin oral tablet ; QL (91 EA per 91 days) tarina fe 1/20 oral tablet mcg tri-lo-estarylla oral tablet 0.18/0.215/ mcg tri-lo-sprintec oral tablet 0.18/0.215/ mcg trinessa (28) oral tablet 0.18/0.215/ mcg tri-previfem oral tablet 0.18/0.215/ mcg tri-sprintec oral tablet 0.18/0.215/ mcg trivora (28) oral tablet pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 85

92 vestura oral tablet vienva oral tablet mcg ESTROGENS estradiol oral tablet 0.5, 1, 2 PA; ; HR FYAVOLV ORAL TABLET MG-MCG, 1-5 MG-MCG menest oral tablet 0.3, 0.625, 1.25, 2.5 PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, MG, 0.9 MG, 1.25 MG PA; ; HR PA; ; HR pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 86 PREMARIN VAGINAL CREAM MG/GM PA; ; HR PREMPHASE ORAL TABLET MG PA; ; HR PREMPRO ORAL TABLET MG, MG, MG, MG PROGESTINS MAKENA INTRAMUSCULAR OIL 250 MG/ML medroxyprogesterone acetate oral tablet 10, 5 PA; ; HR PA; medroxyprogesterone acetate oral tablet 2.5 megestrol acetate oral suspension 625 /5ml PA; ; HR norethindrone acetate oral tablet 5 SELECTIVE ESTROGEN RECEPTOR DIFYING AGENTS raloxifene hcl oral tablet 60 HORNAL AGENTS, STIMULANT/REPLACEMENT/ DIFYING (PITUITARY)

93 HORNAL AGENTS, STIMULANT/REPLACEMENT/ DIFYING (PITUITARY) cabergoline oral tablet 0.5 chorionic gonadotropin intramuscular solution reconstituted unit desmopressin ace rhinal tube nasal solution 0.01 % desmopressin ace spray refrig nasal solution 0.01 % PA; desmopressin acetate injection solution 4 mcg/ml desmopressin acetate oral tablet 0.1, 0.2 INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML LUPRON DEPOT INTRAMUSCULAR KIT 7.5 MG NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION 10 MG/1.5ML, 15 MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML LA PA; PA; HORNAL AGENTS, STIMULANT/REPLACEMENT/ DIFYING (THYROID) HORNAL AGENTS, STIMULANT/REPLACEMENT/ DIFYING (THYROID) levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine sodium oral tablet 300 mcg levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine sodium oral tablet 25 mcg, 5 mcg liothyronine sodium oral tablet 50 mcg pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 87

94 synthroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg HORNAL AGENTS, SUPPRESSANT (PARATHYROID) HORNAL AGENTS, SUPPRESSANT (PARATHYROID) pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 88 SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 MG HORNAL AGENTS, SUPPRESSANT (PITUITARY) HORNAL AGENTS, SUPPRESSANT (PITUITARY) KORLYM ORAL TABLET 300 MG PA; LA LUPRON DEPOT-PED INTRAMUSCULAR KIT MG, 15 MG octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 50 mcg/ml octreotide acetate injection solution 1000 mcg/ml, 500 mcg/ml SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT 10 MG, 20 MG, 30 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/ML SOMATULINE DEPOT SUBCUTANEOUS SOLUTION 120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED 10 MG, 15 MG, 20 MG PA; SYNAREL NASAL SOLUTION 2 MG/ML LA

95 HORNAL AGENTS, SUPPRESSANT (THYROID) ANTITHYROID AGENTS methimazole oral tablet 10, 5 propylthiouracil oral tablet 50 IMMUNOLOGICAL AGENTS IMMUNE SUPPRESSANTS ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML ST; ACTEMRA SUBCUTANEOUS 162 MG/0.9ML ST; ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG, 1 MG ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG ; BvD ; BvD AZASAN ORAL TABLET 100 MG, 75 MG ; BvD azathioprine oral tablet 50 ; BvD azathioprine sodium injection solution reconstituted 100 BENLYSTA INTRAVENOUS SOLUTION RECONSTITUTED 120 MG, 400 MG CELLCEPT INTRAVENOUS INTRAVENOUS SOLUTION RECONSTITUTED 500 MG CIMZIA PREFILLED SUBCUTANEOUS KIT 2 X 200 MG/ML ; BvD ; BvD ; BvD ST; CIMZIA SUBCUTANEOUS KIT 2 X 200 MG ST; cyclosporine intravenous solution 50 /ml ; BvD cyclosporine modified oral capsule 100, 25, 50 ; BvD cyclosporine modified oral solution 100 /ml ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 89

96 cyclosporine oral capsule 100, 25 ; BvD ENBREL SUBCUTANEOUS 25 MG/0.5ML, 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS 50 MG/ML ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HR 0.75 MG, 1 MG, 4 MG PA; PA; PA; ; BvD gengraf oral capsule 100, 25, 50 ; BvD gengraf oral solution 100 /ml ; BvD HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS 40 MG/0.8ML, 40 MG/0.8ML (6 PACK) HUMIRA PEN SUBCUTANEOUS 40 MG/0.8ML HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS 40 MG/0.8ML HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS 40 MG/0.8ML HUMIRA SUBCUTANEOUS 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML PA; PA; PA; PA; PA; KINERET SUBCUTANEOUS 100 MG/0.67ML ST; mycophenolate mofetil oral capsule 250 ; BvD mycophenolate mofetil oral suspension reconstituted 200 /ml ; BvD mycophenolate mofetil oral tablet 500 ; BvD mycophenolic acid oral tablet delayed release 180, 360 ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 90

97 NULOJIX INTRAVENOUS SOLUTION RECONSTITUTED 250 MG PROGRAF INTRAVENOUS SOLUTION 5 MG/ML ; BvD ; BvD RAPAMUNE ORAL SOLUTION 1 MG/ML ; BvD RHEUMATREX ORAL TABLET 2.5 MG ; BvD SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG ; BvD SANDIMMUNE ORAL SOLUTION 100 MG/ML ; BvD SIMPONI ARIA INTRAVENOUS SOLUTION 50 MG/4ML SIMPONI SUBCUTANEOUS 100 MG/ML, 50 MG/0.5ML ST; ST; sirolimus oral tablet 0.5, 1 ; BvD sirolimus oral tablet 2 ; BvD STELARA SUBCUTANEOUS 45 MG/0.5ML ST; tacrolimus oral capsule 0.5, 1, 5 ; BvD TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG ; BvD XELJANZ ORAL TABLET 5 MG ST; ZORTRESS ORAL TABLET 0.25 MG ; BvD ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG ; BvD IMMUNIZING AGENTS, PASSIVE ATGAM INTRAVENOUS INJECTABLE 50 MG/ML BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 6 GM ; BvD ; BvD ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 91

98 FLEBOGAMMA DIF INTRAVENOUS SOLUTION 5 GM/50ML GAMMAGARD INJECTION SOLUTION 2.5 GM/25ML GAMMAKED INJECTION SOLUTION 1 GM/10ML GAMMAPLEX INTRAVENOUS SOLUTION 10 GM/200ML HYPERRAB S/D INTRAMUSCULAR INJECTABLE 150 UNIT/ML, 150 UNIT/ML (10ML) SYNAGIS INTRAMUSCULAR SOLUTION 50 MG/0.5ML THYGLOBULIN INTRAVENOUS SOLUTION RECONSTITUTED 25 MG VARIZIG INTRAMUSCULAR SOLUTION 125 UNIT/1.2ML IMMUNODULATORS ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED 220 MG COSENTYX SENSOREADY PEN SUBCUTANEOUS 150 MG/ML ; BvD ; BvD ; BvD ; BvD ; BvD ST; COSENTYX SUBCUTANEOUS 150 MG/ML ST; ILARIS SUBCUTANEOUS SOLUTION RECONSTITUTED 180 MG leflunomide oral tablet 10 leflunomide oral tablet 20 ORENCIA CLICKJECT SUBCUTANEOUS 125 MG/ML ST; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 92

99 ORENCIA INTRAVENOUS SOLUTION RECONSTITUTED 250 MG ST; ORENCIA SUBCUTANEOUS 125 MG/ML ST; VACCINES ACTHIB INTRAMUSCULAR SOLUTION RECONSTITUTED ADACEL INTRAMUSCULAR SUSPENSION LF-MCG/0.5 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 93 BCG VACCINE INJECTION INJECTABLE BEXSERO INTRAMUSCULAR BOOSTRIX INTRAMUSCULAR SUSPENSION , (0.5ML SYRINGE) CERVARIX INTRAMUSCULAR SUSPENSION DAPTACEL INTRAMUSCULAR SUSPENSION diphtheria-tetanus toxoids dt intramuscular suspension 25-5 lfu/0.5ml ENGERIX-B INJECTION SUSPENSION 10 MCG/0.5ML, 10 MCG/0.5ML (0.5ML SYRINGE), 20 MCG/ML GARDASIL 9 INTRAMUSCULAR GARDASIL 9 INTRAMUSCULAR SUSPENSION GARDASIL INTRAMUSCULAR SUSPENSION, (0.5ML SYRINGE) HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML HIBERIX INJECTION SOLUTION RECONSTITUTED 10 MCG ; BvD

100 IVAX RABIES INTRAMUSCULAR INJECTABLE 2.5 UNIT/ML INFANRIX INTRAMUSCULAR SUSPENSION pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 94 IPOL INJECTION INJECTABLE IXIARO INTRAMUSCULAR SUSPENSION MENACTRA INTRAMUSCULAR INJECTABLE MENHIBRIX INTRAMUSCULAR SOLUTION RECONSTITUTED MCG MENOMUNE SUBCUTANEOUS INJECTABLE MENVEO INTRAMUSCULAR SOLUTION RECONSTITUTED M-M-R II SUBCUTANEOUS INJECTABLE PEDVAX HIB INTRAMUSCULAR SUSPENSION 7.5 MCG/0.5ML PROQUAD SUBCUTANEOUS INJECTABLE QUADRACEL INTRAMUSCULAR SUSPENSION RABAVERT INTRAMUSCULAR SUSPENSION RECONSTITUTED RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 10 MCG/ML (1ML SYRINGE), 40 MCG/ML, 5 MCG/0.5ML ROTARIX ORAL SUSPENSION RECONSTITUTED ; BvD ; BvD ROTATEQ ORAL SOLUTION TENIVAC INTRAMUSCULAR INJECTABLE 5-2 LFU

101 TETANUS-DIPHTHERIA TOXOIDS TD INTRAMUSCULAR SUSPENSION 2-2 LF/0.5ML TWINRIX INTRAMUSCULAR SUSPENSION TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML (0.5ML SYRINGE) VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML VARIVAX SUBCUTANEOUS INJECTABLE 1350 PFU/0.5ML ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 95 YF-VAX SUBCUTANEOUS INJECTABLE ZOSTAVAX SUBCUTANEOUS SOLUTION RECONSTITUTED UNT/0.65ML INFLAMMATORY BOWEL DISEASE AGENTS AMINOSALICYLATES APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR GM balsalazide disodium oral capsule 750 DIPENTUM ORAL CAPSULE 250 MG LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM mesalamine oral tablet delayed release 800 mesalamine-cleanser kit 4 gm SULFONAMIDES sulfasalazine oral tablet 500 sulfasalazine oral tablet delayed release 500

102 METABOLIC BONE DISEASE AGENTS METABOLIC BONE DISEASE AGENTS alendronate sodium oral tablet 10, 40, 5 alendronate sodium oral tablet 35 ; QL (4 EA per 28 days) alendronate sodium oral tablet 70 ; QL (4 EA per 28 days) calcitonin (salmon) nasal solution 200 unit/act ; BvD calcitriol intravenous solution 1 mcg/ml calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML FOSAMAX PLUS D ORAL TABLET MG-UNIT FOSAMAX PLUS D ORAL TABLET MG-UNIT ; QL (4 EA per 28 days) ibandronate sodium oral tablet 150 MIACALCIN INJECTION SOLUTION 200 UNIT/ML NATPARA SUBCUTANEOUS 100 MCG, 25 MCG, 50 MCG, 75 MCG pamidronate disodium intravenous solution 30 /10ml, 6 /ml, 90 /10ml PA; paricalcitol intravenous solution 2 mcg/ml ; BvD paricalcitol intravenous solution 5 mcg/ml PARICALCITOL ORAL CAPSULE 1 MCG, 2 MCG ; BvD paricalcitol oral capsule 4 mcg ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 96

103 PROLIA SUBCUTANEOUS SOLUTION 60 MG/ML ST; risedronate sodium oral tablet 150 ; QL (1 EA per 28 days) risedronate sodium oral tablet 30, 5 risedronate sodium oral tablet 35 (12 pack) ; QL (12 EA per 84 days) risedronate sodium oral tablet 35, 35 (4 pack) risedronate sodium oral tablet delayed release 35 XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML zoledronic acid intravenous concentrate 4 /5ml ZOLEDRONIC ACID INTRAVENOUS SOLUTION 5 MG/100ML MISCELLANEOUS MISCELLANEOUS ; QL (4 EA per 28 days) ; QL (4 EA per 28 days) PA; ADRENACLICK INJECTION 0.3 MG/0.3ML ; QL (2 EA per 30 days) epinephrine injection 0.15 /0.15ml, 0.3 /0.3ml pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 97 lactated ringers irrigation solution physiolyte irrigation solution physiosol irrigation irrigation solution ringers irrigation irrigation solution OPHTHALMIC AGENTS ; QL (2 EA per 30 days) OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS bimatoprost ophthalmic solution 0.03 % latanoprost ophthalmic solution % LUMIGAN OPHTHALMIC SOLUTION 0.01 %

104 TRAVATAN Z OPHTHALMIC SOLUTION % pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 98 travoprost ophthalmic solution % OPHTHALMIC AGENTS, OTHER atropine sulfate ophthalmic solution 1 % CYSTARAN OPHTHALMIC SOLUTION 0.44 % naphazoline hcl ophthalmic solution 0.1 % RESTASIS OPHTHALMIC EMULSION 0.05 % OPHTHALMIC ANTI INFECTIVES AZASITE OPHTHALMIC SOLUTION 1 % bacitracin ophthalmic ointment 500 unit/gm bacitracin-polymyxin b ophthalmic ointment unit/gm PA; ; QL (60 ML per 30 days) ciprofloxacin hcl ophthalmic solution 0.3 % erythromycin ophthalmic ointment 5 /gm gatifloxacin ophthalmic solution 0.5 % gentamicin sulfate ophthalmic ointment 0.3 % gentamicin sulfate ophthalmic solution 0.3 % XEZA OPHTHALMIC SOLUTION 0.5 % neomycin-bacitracin zn-polymyx ophthalmic ointment neomycin-polymyxin-gramicidin ophthalmic solution ofloxacin ophthalmic solution 0.3 % polymyxin b-trimethoprim ophthalmic solution unit/ml-% sulfacetamide sodium ophthalmic solution 10 %

105 tobramycin ophthalmic solution 0.3 % trifluridine ophthalmic solution 1 % VIGAX OPHTHALMIC SOLUTION 0.5 % ZIRGAN OPHTHALMIC GEL 0.15 % OPHTHALMIC ANTI-ALLERGY AGENTS azelastine hcl ophthalmic solution 0.05 % cromolyn sodium ophthalmic solution 4 % olopatadine hcl ophthalmic solution 0.1 % PATADAY OPHTHALMIC SOLUTION 0.2 % PAZEO OPHTHALMIC SOLUTION 0.7 % OPHTHALMIC ANTIGLAUCOMA AGENTS ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 % apraclonidine hcl ophthalmic solution 0.5 % AZOPT OPHTHALMIC SUSPENSION 1 % betaxolol hcl ophthalmic solution 0.5 % brimonidine tartrate ophthalmic solution 0.15 %, 0.2 % carteolol hcl ophthalmic solution 1 % COMBIGAN OPHTHALMIC SOLUTION % dorzolamide hcl ophthalmic solution 2 % dorzolamide hcl-timolol mal ophthalmic solution /ml levobunolol hcl ophthalmic solution 0.5 % metipranolol ophthalmic solution 0.3 % pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 99

106 PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION RECONSTITUTED % pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 100 pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % SIMBRINZA OPHTHALMIC SUSPENSION % timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % timolol maleate ophthalmic solution 0.25 % timolol maleate ophthalmic solution 0.5 % OPHTHALMIC ANTI-INFLAMMATORIES bacitra-neomycin-polymyxin-hc ophthalmic ointment 1 % BLEPHAMIDE OPHTHALMIC SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT % dexamethasone sodium phosphate ophthalmic solution 0.1 % diclofenac sodium ophthalmic solution 0.1 % DUREZOL OPHTHALMIC EMULSION 0.05 % fluorometholone ophthalmic suspension 0.1 % flurbiprofen sodium ophthalmic solution 0.03 % ILEVRO OPHTHALMIC SUSPENSION 0.3 % ketorolac tromethamine ophthalmic solution 0.4 %, 0.5 % LOTEMAX OPHTHALMIC GEL 0.5 % LOTEMAX OPHTHALMIC OINTMENT 0.5 % LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

107 neomycin-polymyxin-dexameth ophthalmic ointment neomycin-polymyxin-dexameth ophthalmic suspension neomycin-polymyxin-hc ophthalmic suspension pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 101 prednisolone acetate ophthalmic suspension 1 % prednisolone sodium phosphate ophthalmic solution 1 % sulfacetamide-prednisolone ophthalmic solution % TOBRADEX OPHTHALMIC OINTMENT % TOBRADEX OPHTHALMIC SUSPENSION % TOBRADEX ST OPHTHALMIC SUSPENSION % tobramycin-dexamethasone ophthalmic suspension % OTIC AGENTS OTIC AGENTS acetic acid otic solution 2 % CIPRODEX OTIC SUSPENSION % fluocinolone acetonide otic oil 0.01 % neomycin-polymyxin-hc otic solution 1 % neomycin-polymyxin-hc otic suspension ofloxacin otic solution 0.3 % RESPIRATORY TRACT AGENTS

108 ANTIHISTAMINES cetirizine hcl oral syrup 1 /ml cyproheptadine hcl oral tablet 4 PA; ; HR desloratadine oral tablet 5 desloratadine oral tablet dispersible 2.5, 5 diphenhydramine hcl injection solution 50 /ml levocetirizine dihydrochloride oral tablet 5 promethazine hcl injection solution 25 /ml, 50 /ml PA; ; HR promethazine hcl oral tablet 12.5 PA; ; HR promethazine hcl suppository 50 ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS budesonide inhalation suspension 1 /2ml ; BvD FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT, 44 MCG/ACT PULMICORT FLEXHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 180 MCG/ACT, 90 MCG/ACT ANTILEUKOTRIENES montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 zafirlukast oral tablet 10, 20 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 102

109 ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HR 600 MG ZYFLO ORAL TABLET 600 MG BRONCHODILATORS, ANTICHOLINERGIC acetylcysteine inhalation solution 10 % ; BvD ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT ipratropium bromide inhalation solution 0.02 % ; BvD SPIRIVA HANDIHALER INHALATION CAPSULE 18 MCG SPIRIVA RESPIMAT INHALATION AEROSOL, SOLUTION 1.25 MCG/ACT, 2.5 MCG/ACT BRONCHODILATORS, PHOSPHODIESTERASE INHIBITORS (XANTHINES) aminophylline intravenous solution 25 /ml theophylline er oral tablet extended release 12 hr 100, 200, 300, 450 theophylline er oral tablet extended release 24 hr 600 BRONCHODILATORS, SYMPATHOMIMETIC ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT albuterol sulfate er oral tablet extended release 12 hr 4, 8 pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 103

110 albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 /ml) 0.5%, 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED MCG/INH, MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION MCG/ACT ipratropium-albuterol inhalation solution (3) /3ml SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE STIOLTO RESPIMAT INHALATION AEROSOL, SOLUTION MCG/ACT ; BvD ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 104 ; QL (4 GM per 20 days) ; BvD terbutaline sulfate injection solution 1 /ml ventolin hfa inhalation aerosol, solution 108 (90 base) mcg/act MAST CELL STABILIZERS cromolyn sodium inhalation nebulization solution 20 /2ml NASAL AGENTS azelastine hcl nasal solution 0.1 %, 0.15 % budesonide nasal suspension 32 mcg/act flunisolide nasal solution 25 mcg/act (0.025%) fluticasone propionate nasal suspension 50 mcg/act ; BvD

111 ipratropium bromide nasal solution 0.03 % ipratropium bromide nasal solution 0.06 % PULNARY ANTIHYPERTENSIVES ADCIRCA ORAL TABLET 20 MG PA; ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG PA; LETAIRIS ORAL TABLET 10 MG, 5 MG PA; OPSUMIT ORAL TABLET 10 MG PA; ORENITRAM ORAL TABLET EXTENDEDRELEASE MG, 0.25 MG ORENITRAM ORAL TABLET EXTENDEDRELEASE 1 MG, 2.5 MG sildenafil citrate intravenous solution 10 /12.5ml PA; PA; PA; sildenafil citrate oral tablet 20 PA; TRACLEER ORAL TABLET 125 MG, 62.5 MG PA; LA UPTRAVI ORAL 200 & 800 MCG PA; LA UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20 MCG/ML RESPIRATORY TRACT AGENTS, OTHER PA; LA DALIRESP ORAL TABLET 500 MCG PA; ESBRIET ORAL CAPSULE 267 MG PA; KALYDECO ORAL PACKET 50 MG, 75 MG PA; KALYDECO ORAL TABLET 150 MG PA; pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 105

112 NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED 100 MG OFEV ORAL CAPSULE 100 MG PA; ORKAMBI ORAL TABLET MG PA; PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG PULZYME INHALATION SOLUTION 1 MG/ML XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MG SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 106 baclofen oral tablet 10, 20 ; BvD cyclobenzaprine hcl oral tablet 10, 5 PA; ; HR methocarbamol injection solution 1000 /10ml PA; ; HR methocarbamol oral tablet 500, 750 PA; ; HR orphenadrine citrate er oral tablet extended release 12 hr 100 LA PA; ; HR orphenadrine citrate injection solution 30 /ml PA; ; HR tizanidine hcl oral tablet 2 tizanidine hcl oral tablet 4 SLEEP DISORDER AGENTS BARBITURATES BUTISOL SODIUM ORAL TABLET 30 MG PA; ; HR BENZODIAZEPINES estazolam oral tablet 1 ; QL (60 EA per 30 days) estazolam oral tablet 2 ; QL (30 EA per 30 days)

113 flurazepam hcl oral capsule 15 ; QL (60 EA per 30 days) flurazepam hcl oral capsule 30 ; QL (30 EA per 30 days) temazepam oral capsule 15, 22.5, 30 ; QL (30 EA per 30 days) temazepam oral capsule 7.5 ; QL (120 EA per 30 days) triazolam oral tablet ; QL (30 EA per 30 days) triazolam oral tablet 0.25 ; QL (60 EA per 30 days) GABA RECEPTOR DULATORS ROZEREM ORAL TABLET 8 MG ; QL (30 EA per 30 days) zaleplon oral capsule 10, 5 PA; ; HR zolpidem tartrate oral tablet 10, 5 PA; ; HR SLEEP DISORDERS, OTHER HETLIOZ ORAL CAPSULE 20 MG modafinil oral tablet 100, 200 PA; XYREM ORAL SOLUTION 500 MG/ML LA THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES ELECTROLYTE/MINERAL DIFIERS EXJADE ORAL TABLET SOLUBLE 125 MG EXJADE ORAL TABLET SOLUBLE 250 MG, 500 MG pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 107 FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG kionex oral powder SAMSCA ORAL TABLET 15 MG, 30 MG PA; sodium polystyrene sulfonate oral suspension 15 gm/60ml sps oral suspension 15 gm/60ml

114 ELECTROLYTE/MINERAL REPLACEMENT CARBAGLU ORAL TABLET 200 MG dextrose in lactated ringers intravenous solution 5 % dextrose-nacl intravenous solution %, %, %, %, %, % ISOLYTE-P IN D5W INTRAVENOUS SOLUTION pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 108 ISOLYTE-S INTRAVENOUS SOLUTION kcl in dextrose-nacl intravenous solution meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-%, meq/l-%-% kcl-lactated ringers-d5w intravenous solution 20 meq/l klor-con 10 oral tablet extendedrelease 10 meq lactated ringers intravenous solution magnesium sulfate injection solution 50 %, 50 % (10ml syringe) normosol-m in d5w intravenous solution normosol-r in d5w intravenous solution NORSOL-R PH 7.4 INTRAVENOUS SOLUTION PLASMA-LYTE 148 INTRAVENOUS SOLUTION PLASMA-LYTE-56 IN D5W INTRAVENOUS SOLUTION potassium chloride crys er oral tablet extendedrelease 10 meq, 20 meq

115 potassium chloride er oral capsule extended release 10 meq potassium chloride er oral capsule extended release 8 meq potassium chloride er oral tablet extendedrelease 8 meq potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-% potassium chloride in nacl intravenous solution meq/l-%, meq/l-% potassium chloride intravenous solution 10 meq/100ml, 2 meq/ml, 20 meq/100ml, 40 meq/100ml potassium chloride oral solution 20 meq/15ml (10%) potassium citrate er oral tablet extendedrelease 10 meq (1080 ) potassium citrate er oral tablet extendedrelease 5 meq (540 ) ringers intravenous solution sodium chloride injection solution 2.5 meq/ml sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 % sodium fluoride oral tablet 2.2 (1 f) sodium lactate intravenous solution 5 meq/ml tpn electrolytes intravenous solution NUTRIENTS AMINOSYN II INTRAVENOUS SOLUTION 10 %, 7 %, 8.5 % ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 109

116 aminosyn ii/electrolytes intravenous solution 8.5 % AMINOSYN/ELECTROLYTES INTRAVENOUS SOLUTION 7 % ; BvD ; BvD aminosyn/electrolytes intravenous solution 8.5 % ; BvD AMINOSYN-HBC INTRAVENOUS SOLUTION 7 % AMINOSYN-PF INTRAVENOUS SOLUTION 10 %, 7 % AMINOSYN-RF INTRAVENOUS SOLUTION 5.2 % CLINIMIX E/DEXTROSE (2.75/10) INTRAVENOUS SOLUTION 2.75 % CLINIMIX E/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 % CLINIMIX E/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % CLINIMIX E/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX E/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (2.75/5) INTRAVENOUS SOLUTION 2.75 % CLINIMIX/DEXTROSE (4.25/10) INTRAVENOUS SOLUTION 4.25 % ; BvD ; BvD ; BvD ; BvD ; BvD ; BvD ; BvD ; BvD ; BvD ; BvD ; BvD ; BvD ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 110

117 CLINIMIX/DEXTROSE (4.25/20) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/25) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (4.25/5) INTRAVENOUS SOLUTION 4.25 % CLINIMIX/DEXTROSE (5/15) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/20) INTRAVENOUS SOLUTION 5 % CLINIMIX/DEXTROSE (5/25) INTRAVENOUS SOLUTION 5 % dextrose intravenous solution 10 %, 5 % FREAMINE HBC INTRAVENOUS SOLUTION 6.9 % ; BvD ; BvD ; BvD ; BvD ; BvD ; BvD ; BvD hepatamine intravenous solution 8 % ; BvD NEPHRAMINE INTRAVENOUS SOLUTION 5.4 % ; BvD nutrilipid intravenous emulsion 20 % ; BvD plenamine intravenous solution 15 % ; BvD premasol intravenous solution 6 % ; BvD PROCALAMINE INTRAVENOUS SOLUTION 3 % ; BvD PROSOL INTRAVENOUS SOLUTION 20 % ; BvD TRAVASOL INTRAVENOUS SOLUTION 10 % VITAMINS PRENATAL ORAL TABLET 27-1 MG ; BvD pharmacies; HR=High Risk Medication (PA required for ages 65 or over); =Mail Order. For more information call (H) or (PPO). TTY Users call: hours a day, seven 111

118 Alphabetical Listing 8 8-P A abacavir sulfate abacavir-lamivudinezidovudine ABELCET ABILIFY MAINTENA ABRAXANE ACAMPROSATE CALCIUM... 4 acarbose acebutolol hcl acetaminophen-codeine... 2 acetaminophen-codeine # acetaminophen-codeine # acetaminophen-codeine # acetazolamide... 65, 66 acetazolamide er acetic acid acetylcysteine acitretin ACTEMRA ACTHIB ACTIMMUNE acyclovir acyclovir sodium ADACEL ADAGEN ADCIRCA adefovir dipivoxil ADEMPAS ADRENACLICK adrucil ADVAIR DISKUS ADVAIR HFA AFINITOR AFINITOR DISPERZ AKYNZEO ALBENZA albuterol sulfate albuterol sulfate er ALDURAZYME ALECENSA alendronate sodium alfuzosin hcl er ALIMTA ALINIA allopurinol alosetron hcl ALPHAGAN P alprazolam alprazolam er... 49, 50 alprazolam intensol alprazolam xr amantadine hcl AMBISOME amcinonide... 71, 72 amifostine amiloride hcl amiloride-hydrochlorothiazide aminophylline AMINOSYN II aminosyn ii/electrolytes aminosyn/electrolytes AMINOSYN/ELECTROLYT ES AMINOSYN-HBC AMINOSYN-PF AMINOSYN-RF amiodarone hcl AMITIZA amitriptyline hcl amlodipine besy-benazepril hcl amlodipine besylate amlodipine besylate-valsartan amlodipine-atorvastatin amlodipine-valsartan-hctz ammonium lactate amoxapine amoxicillin... 9 amoxicillin-pot clavulanate... 9 amphetaminedextroamphetamine amphotericin b ampicillin... 9 ampicillin sodium... 9, ampicillin-sulbactam sodium 10 AMPYRA ANADROL anagrelide hcl anastrozole ANDRODERM APLENZIN APOKYN apraclonidine hcl apri APRISO APTIOM APTIVUS ARCALYST aripiprazole ARIPIPRAZOLE ARISTADA armodafinil ARRANON ascomp-codeine... 2 aspirin-dipyridamole er assure id insulin safety syr ASTAGRAF XL atenolol atenolol-chlorthalidone ATGAM atorvastatin calcium atovaquone atovaquone-proguanil hcl ATRIPLA atropine sulfate... 78, 98 ATROVENT HFA AUBAGIO AVANDIA AVASTIN AVONEX AVONEX PREFILLED azacitidine AZACTAM IN DEXTROSE. 8 AZASAN AZASITE azathioprine azathioprine sodium azelastine hcl... 99, 104 AZILECT... 40

119 azithromycin AZOPT AZOR aztreonam... 9 B bacitracin... 5, 98 bacitracin-polymyxin b bacitra-neomycin-polymyxinhc baclofen balsalazide disodium BANZEL BARACLUDE BCG VACCINE bekyree BELEODAQ benazepril hcl benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benzoyl peroxide-erythromycin benztropine mesylate betamethasone dipropionate. 72 betamethasone dipropionate aug betamethasone valerate BETASERON betaxolol hcl... 62, 99 bexarotene BEXSERO bicalutamide BICILLIN L-A BICNU bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide BIVIGAM bleomycin sulfate BLEPHAMIDE BLEPHAMIDE S.O.P blisovi 24 fe blisovi fe 1.5/ blisovi fe 1/ BOOSTRIX BOSULIF BREO ELLIPTA BRILINTA brimonidine tartrate BRISDELLE BRIVIACT... 12, 13 bromocriptine mesylate budesonide... 82, 102, 104 bumetanide buprenorphine hcl... 4 buprenorphine hcl-naloxone hcl... 4 buproban... 4 bupropion hcl bupropion hcl er (smoking det)... 4 bupropion hcl er (sr) bupropion hcl er (xl) buspirone hcl BUSULFEX butalbital-apap-caff-cod... 2 butalbital-asa-caff-codeine... 2 BUTISOL SODIUM BYDUREON BYETTA 10 MCG PEN BYETTA 5 MCG PEN C cabergoline CABOMETYX calcipotriene calcitonin (salmon) calcitriol... 72, 96 calcium acetate (phos binder) CANCIDAS candesartan cilexetil candesartan cilexetil-hctz CAPASTAT SULFATE CAPRELSA captopril captopril-hydrochlorothiazide CARAFATE CARBAGLU carbamazepine... 16, 51 carbamazepine er... 16, 51 carbidopa-levodopa carbidopa-levodopa er... 39, carbidopa-levodopaentacapone carboplatin CARIMUNE NF carteolol hcl carvedilol CAYSTON... 9 caziant cefaclor... 7 cefaclor er... 7 cefazolin sodium... 7 cefdinir... 7 cefepime hcl... 7 cefixime... 7 cefoxitin sodium... 7, 8 cefpodoxime proxetil... 8 cefprozil... 8 ceftriaxone sodium... 8 cefuroxime axetil... 8 cefuroxime sodium... 8 celecoxib CELLCEPT INTRAVENOUS CELONTIN cephalexin... 8 CEREZYME CERVARIX cetirizine hcl CHANTIX... 4, 5 CHANTIX CONTINUING NTH PAK... 4 CHANTIX STARTING NTH PAK... 5 chloramphenicol sod succinate... 5 chlordiazepoxide hcl chlordiazepoxide-amitriptyline chlorhexidine gluconate chloroquine phosphate chlorothiazide chlorpromazine hcl chlorpropamide chlorthalidone cholestyramine light chorionic gonadotropin ciclopirox ciclopirox olamine... 72

120 cilostazol CIMZIA CIMZIA PREFILLED CINRYZE CIPRODEX ciprofloxacin ciprofloxacin hcl... 11, 98 ciprofloxacin in d5w ciprofloxacin-ciproflox hcl er cisplatin citalopram hydrobromide cladribine claravis clarithromycin clindamycin hcl... 5 clindamycin palmitate hcl... 5 clindamycin phos-benzoyl perox clindamycin phosphate... 6, 72, 81 clindamycin phosphate in d5w... 6 CLINIMIX E/DEXTROSE (2.75/10) CLINIMIX E/DEXTROSE (2.75/5) CLINIMIX E/DEXTROSE (4.25/10) CLINIMIX E/DEXTROSE (4.25/25) CLINIMIX E/DEXTROSE (4.25/5) CLINIMIX E/DEXTROSE (5/15) CLINIMIX E/DEXTROSE (5/20) CLINIMIX E/DEXTROSE (5/25) CLINIMIX/DEXTROSE (2.75/5) CLINIMIX/DEXTROSE (4.25/10) CLINIMIX/DEXTROSE (4.25/20) CLINIMIX/DEXTROSE (4.25/25) CLINIMIX/DEXTROSE (4.25/5) CLINIMIX/DEXTROSE (5/15) CLINIMIX/DEXTROSE (5/20) CLINIMIX/DEXTROSE (5/25) clobetasol propionate clobetasol propionate e CLOLAR clomipramine hcl clonazepam clonidine hcl CLONIDINE HCL ER clopidogrel bisulfate clorazepate dipotassium clotrimazole... 23, 73 clotrimazole-betamethasone. 73 clozapine COARTEM colchicine colestipol hcl colistimethate sodium... 6 COMBIGAN COMBIVENT RESPIMAT 104 COMETRIQ (100 MG DAILY DOSE) COMETRIQ (140 MG DAILY DOSE) COMETRIQ (60 MG DAILY DOSE) comfort assist insulin syringe COMPLERA compro CONDYLOX COPAXONE COSENTYX COSENTYX SENSOREADY PEN COSMEGEN COTELLIC CREON CRIXIVAN cromolyn sodium... 99, 104 CUBICIN... 6 cvs gauze sterile cyclafem 1/ cyclobenzaprine hcl cyclophosphamide CYCLOSET cyclosporine... 89, 90 cyclosporine modified cyproheptadine hcl CYRAMZA CYSTADANE CYSTAGON CYSTARAN cytarabine cytarabine (pf) D dacarbazine DAKLINZA DALIRESP danazol dapsone... 6 DAPTACEL DARAPRIM DARIFENACIN HYDROBROMIDE ER DARZALEX daunorubicin hcl deblitane decitabine DEMSER DEPEN TITRATABS DEPO-PROVERA DESCOVY desipramine hcl desloratadine desmopressin ace rhinal tube 87 desmopressin ace spray refrig desmopressin acetate desogestrel-ethinyl estradiol. 84 desonide desoximetasone DESVENLAFAXINE ER dexamethasone dexamethasone sodium phosphate... 82, 100 dexmethylphenidate hcl er dexrazoxane dextroamphetamine sulfate... 69

121 dextroamphetamine sulfate er dextrose dextrose in lactated ringers. 108 dextrose-nacl diazepam... 13, 50 diazepam intensol diclofenac potassium diclofenac sodium.. 24, 73, 100 diclofenac sodium er dicloxacillin sodium dicyclomine hcl didanosine DIFICID diflorasone diacetate diflunisal digitek digoxin dihydroergotamine mesylate 26 diltiazem hcl diltiazem hcl er diltiazem hcl er beads diltiazem hcl er coated beads 63 dilt-xr DIPENTUM diphenhydramine hcl diphenoxylate-atropine diphtheria-tetanus toxoids dt 93 dipyridamole disopyramide phosphate disulfiram... 4 divalproex sodium... 14, 26 divalproex sodium er DOCEFREZ DOCETAXEL dofetilide donepezil hcl dorzolamide hcl dorzolamide hcl-timolol mal 99 doxazosin mesylate doxepin hcl doxorubicin hcl DOXORUBICIN HCL LIPOSOMAL doxycycline hyclate doxycycline monohydrate dronabinol drospirenone-ethinyl estradiol duloxetine hcl duramorph... 2 DUREZOL dutasteride dutasteride-tamsulosin hcl E econazole nitrate EDURANT ELAPRASE ELIDEL ELIGARD ELIQUIS ELITEK ELMIRON EMBEDA... 1 EMCYT EMEND... 21, 22 emoquette EMPLICITI EMSAM EMTRIVA EMVERM enalapril maleate enalapril-hydrochlorothiazide ENBREL ENBREL SURECLICK ENGERIX-B enoxaparin sodium enpresse entacapone entecavir enulose ENVARSUS XR epinephrine epitol EPIVIR HBV eplerenone eprosartan mesylate EPZICOM ERAXIS ERBITUX ergoloid mesylates ERGOMAR ERIVEDGE ERWINAZE ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin... 73, 98 erythromycin base erythromycin ethylsuccinate. 11 ESBRIET escitalopram oxalate esomeprazole sodium estazolam estradiol ethambutol hcl ethosuximide etodolac etodolac er ETOPOPHOS etoposide EURAX EVOTAZ EVZIO... 4 exel comfort point pen needle exel pen needles 1/ EXELON exemestane EXJADE F FABRAZYME famciclovir famotidine famotidine premixed FANAPT FANAPT TITRATION PACK FARESTON FARYDAK FASLODEX FAZACLO felbamate felodipine er fenofibrate fenofibrate micronized fenofibric acid fenoprofen calcium fentanyl... 1 FENTORA... 2 FERRIPROX FETZIMA... 19

122 FETZIMA TITRATION finasteride FIRAZYR FIRMAGON FLEBOGAMMA DIF flecainide acetate FLOVENT DISKUS FLOVENT HFA fluconazole fluconazole in sodium chloride flucytosine fludarabine phosphate fludrocortisone acetate flunisolide fluocinolone acetonide. 74, 101 fluocinolone acetonide body 74 fluocinonide fluocinonide-e fluorometholone fluorouracil... 32, 74 fluoxetine hcl FLUOXETINE HCL fluphenazine decanoate fluphenazine hcl flurazepam hcl flurbiprofen flurbiprofen sodium flutamide fluticasone propionate.. 74, 104 fluvastatin sodium fluvastatin sodium er fluvoxamine maleate fluvoxamine maleate er FOLOTYN fondaparinux sodium FORFIVO XL FORTEO FOSAMAX PLUS D fosinopril sodium fosinopril sodium-hctz fosphenytoin sodium FRAGMIN FREAMINE HBC furosemide FUZEON FYAVOLV FYCOMPA G gabapentin GABITRIL galantamine hydrobromide galantamine hydrobromide er GAMMAGARD GAMMAKED GAMMAPLEX ganciclovir sodium GARDASIL GARDASIL gatifloxacin GATTEX GEMCITABINE HCL gemfibrozil generlac gengraf gentamicin in saline... 5 gentamicin sulfate... 5, 74, 98 GENVOYA GEODON gianvi gildess 24 fe GILENYA GILOTRIF GLEEVEC GLEOSTINE glimepiride glipizide glipizide er glipizide-metformin hcl global alcohol prep ease GLUCAGEN HYPOKIT GLUCAGON EMERGENCY glyburide glyburide micronized glyburide-metformin granisetron hcl griseofulvin microsize guanfacine hcl er guanidine hcl H HALAVEN halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX heparin (porcine) in d5w heparin sod (porcine) in d5w 55 heparin sodium (porcine) hepatamine HERCEPTIN HETLIOZ HEXALEN HIBERIX HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN-CROHNS STARTER HUMIRA PEN-PSORIASIS STARTER hydralazine hcl hydrochlorothiazide hydrocodone-acetaminophen.. 2 hydrocodone-ibuprofen... 2 hydrocortisone... 74, 82 hydrocortisone valerate hydromorphone hcl... 2 hydromorphone hcl er... 1 hydroxychloroquine sulfate.. 38 HYDROXYPROGESTERON E CAPROATE hydroxyurea hydroxyzine hcl hydroxyzine pamoate HYPERRAB S/D I ibandronate sodium IBRANCE ibuprofen ICLUSIG idarubicin hcl ifosfamide ILARIS ILEVRO IMBRUVICA imipenem-cilastatin... 9 imipramine hcl imipramine pamoate imiquimod... 74

123 IVAX RABIES INCRELEX indapamide indomethacin indomethacin er INFANRIX INLYTA INTELENCE intron a INTRON A introvale INVANZ... 9 INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKANA IPOL ipratropium bromide , 105 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRESSA irinotecan hcl ISENTRESS ISOLYTE-P IN D5W ISOLYTE-S isoniazid isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er isradipine ISTODAX itraconazole ivermectin IXIARO J JAKAFI jantoven... 55, 56 JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR... 52, 53 JEVTANA juleber junel fe 1/ junel fe JUXTAPID K KADCYLA kaitlib fe KALETRA KALYDECO KANUMA kariva kcl in dextrose-nacl kcl-lactated ringers-d5w KEPIVANCE KETEK ketoconazole... 23, 74, 75 ketoprofen ketoprofen er ketorolac tromethamine 25, 100 KEYTRUDA KIMIDESS KINERET kionex klor-con KORLYM KUVAN KYNAMRO L labetalol hcl lactated ringers... 97, 108 lactulose lamivudine... 44, 46 lamivudine-zidovudine lamotrigine lamotrigine er lansoprazole LANTUS LANTUS SOLOSTAR larin fe 1/ larissia latanoprost LATUDA LAZANDA... 3 leflunomide LENVIMA 10 MG DAILY DOSE LENVIMA 14 MG DAILY DOSE LENVIMA 18 MG DAILY DOSE LENVIMA 20 MG DAILY DOSE LENVIMA 24 MG DAILY DOSE LENVIMA 8 MG DAILY DOSE LETAIRIS letrozole leucovorin calcium LEUKERAN LEUKINE leuprolide acetate LEVEMIR LEVEMIR FLEXTOUCH levetiracetam levetiracetam er LEVETIRACETAM IN NACL levobunolol hcl levocarnitine levocetirizine dihydrochloride levofloxacin levofloxacin in d5w levoleucovorin calcium levonest levonorgest-eth estrad 91-day levonorg-eth estrad triphasic 84 levothyroxine sodium levoxyl LEXIVA LIALDA lidocaine LIDOCAINE lidocaine hcl... 3, 4, 75 lidocaine hcl (pf)... 3 lidocaine viscous lidocaine-prilocaine... 4 lincomycin hcl... 6 lindane linezolid... 6 LINEZOLID... 6 LINZESS liothyronine sodium lisinopril... 59

124 lisinopril-hydrochlorothiazide lithium lithium carbonate lithium carbonate er lithostat LIVALO lomedia 24 fe LONSURF loperamide hcl lorazepam... 50, 51 lorazepam intensol loryna losartan potassium losartan potassium-hctz LOTEMAX lovastatin loxapine succinate LUMIGAN LUMIZYME LUPRON DEPOT... 34, 87 LUPRON DEPOT-PED LYNPARZA LYRICA... 14, 70 LYSODREN lyza M magnesium sulfate MAKENA maprotiline hcl MARPLAN MATULANE meclizine hcl meclofenamate sodium medroxyprogesterone acetate... 85, 86 mefloquine hcl megestrol acetate... 34, 86 MEKINIST meloxicam melphalan hcl memantine hcl MENACTRA menest MENHIBRIX MENOMUNE MENVEO meprobamate mercaptopurine meropenem... 9 mesalamine mesalamine-cleanser mesna MESNEX MESTINON metformin hcl metformin hcl er methadone hcl... 1 METHAZOLAMIDE methimazole methocarbamol methotrexate methotrexate sodium methotrexate sodium (pf) methoxsalen rapid methscopolamine bromide methyclothiazide methyldopa methyldopahydrochlorothiazide methyldopate hcl methylphenidate hcl methylphenidate hcl er methylphenidate hcl er (cd).. 70 methylprednisolone methylprednisolone acetate.. 82 methylprednisolone sodium succ methyltestosterone metipranolol metoclopramide hcl metolazone metoprolol succinate er metoprolol tartrate metoprololhydrochlorothiazide metronidazole... 6, 75, 81 metronidazole in nacl... 6 mexiletine hcl MIACALCIN miconazole microgestin fe 1/ midodrine hcl miglitol minocycline hcl minoxidil MIRCERA mirtazapine misoprostol mitomycin mitoxantrone hcl M-M-R II modafinil moexipril hcl moexipril-hydrochlorothiazide molindone hcl mometasone furoate montelukast sodium morphine sulfate... 3 morphine sulfate (concentrate)... 3 morphine sulfate er... 1 morphine sulfate er beads... 1 VANTIK XEZA moxifloxacin hcl ZOBIL MULTAQ mupirocin mupirocin calcium MUSTARGEN MYCAMINE mycophenolate mofetil mycophenolic acid myorisan MYRBETRIQ N nabumetone nadolol nadolol-bendroflumethiazide 61 nafcillin sodium NAGLAZYME nalbuphine hcl... 3 naloxone hcl... 4 naltrexone hcl... 4 NAMENDA XR NAMENDA XR TITRATION PACK NAMZARIC naphazoline hcl naproxen naproxen dr naproxen sodium... 25

125 nateglinide NATPARA NEBUPENT... 6 necon 1/35 (28) nefazodone hcl neomycin sulfate... 5 neomycin-bacitracin znpolymyx neomycin-polymyxin b gu neomycin-polymyxindexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc NEPHRAMINE NEUPOGEN NEUPRO nevirapine nevirapine er NEXAVAR niacin er (antihyperlipidemic) niacor nicardipine hcl NICOTROL... 5 nifedical xl nifedipine nifedipine er osmotic release 64 nikki NILANDRON nilutamide nimodipine NINLARO nisoldipine er nitrofurantoin macrocrystal... 6 nitrofurantoin monohyd macro... 6 nitroglycerin NITROSTAT NORDITROPIN FLEXPRO 87 norethin ace-eth estrad-fe norethindrone norethindrone acetate norgestim-eth estrad triphasic normosol-m in d5w normosol-r in d5w NORSOL-R PH NORTHERA nortrel 1/35 (21) nortrel 1/35 (28) nortriptyline hcl NORVIR NOVOLIN 70/ NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/ NOVOLOG MIX 70/30 FLEXPEN NOVOLOG PENFILL NOXAFIL NUCALA NUEDEXTA NULOJIX NUPLAZID nutrilipid nystatin... 23, 71, 75 nystatin-triamcinolone O octreotide acetate ODEFSEY ODOMZO OFEV ofloxacin... 11, 98, 101 olanzapine olanzapine-fluoxetine hcl olopatadine hcl omega-3-acid ethyl esters omeprazole ondansetron ondansetron hcl ONFI... 13, 14 OPANA ER... 1 OPDIVO OPSUMIT ORAVIG ORENCIA ORENCIA CLICKJECT ORENITRAM ORFADIN ORKAMBI orphenadrine citrate orphenadrine citrate er oxacillin sodium oxaliplatin oxandrolone oxaprozin oxazepam oxcarbazepine OXTELLAR XR oxybutynin chloride oxybutynin chloride er oxycodone hcl... 3 oxycodone-acetaminophen... 3 oxycodone-aspirin... 3 oxycodone-ibuprofen... 3 OXYCONTIN... 1 oxymorphone hcl... 3 oxymorphone hcl er... 2 P pacerone paclitaxel paliperidone er pamidronate disodium PANRETIN pantoprazole sodium paricalcitol PARICALCITOL paromomycin sulfate... 5 paroxetine hcl paroxetine hcl er PASER PATADAY PAXIL PAZEO PEDVAX HIB peg 3350-kcl-na bicarb-nacl. 79 PEGANONE PEGASYS PEGASYS PROCLICK PEGINTRON PEG-INTRON REDIPEN penicillin g potassium penicillin g sodium penicillin v potassium PENTAM... 6 pentazocine-naloxone hcl... 3 pentoxifylline er perindopril erbumine PERJETA permethrin perphenazine... 41

126 perphenazine-amitriptyline PEXEVA phenelzine sulfate phenobarbital phenytoin phenytoin sodium phenytoin sodium extended.. 16 PHOSPHOLINE IODIDE physiolyte physiosol irrigation PICATO pilocarpine hcl... 71, 100 pimozide pimtrea pindolol pioglitazone hcl pioglitazone hcl-glimepiride 53 pioglitazone hcl-metformin hcl piperacillin sod-tazobactam so pirmella 1/ piroxicam PLASMA-LYTE PLASMA-LYTE-56 IN D5W PLEGRIDY plenamine podofilox polyethylene glycol polymyxin b-trimethoprim POMALYST potassium chloride potassium chloride crys er potassium chloride er potassium chloride in dextrose potassium chloride in nacl potassium citrate er... 81, 109 POTIGA PRADAXA PRALUENT pramipexole dihydrochloride 39 pramipexole dihydrochloride er pravastatin sodium prazosin hcl prednicarbate... 75, 76 prednisolone acetate prednisolone sodium phosphate... 82, 101 prednisone... 82, 83 preferred plus insulin syringe PREMARIN premasol PREMPHASE PREMPRO PRENATAL PREPOPIK PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE PHOSPHATE primidone PRISTIQ probenecid procainamide hcl PROCALAMINE prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT... 56, 57 procto-med hc procto-pak proctozone-hc PROGLYCEM PROGRAF PROLASTIN-C PROLEUKIN PROLIA PROMACTA promethazine hcl propafenone hcl propranolol hcl propranolol hcl er propranolol-hctz propylthiouracil PROQUAD PROSOL protriptyline hcl PULMICORT FLEXHALER PULZYME PURIXAN pyrazinamide pyridostigmine bromide Q QUADRACEL quasense quetiapine fumarate... 42, 43 quinapril hcl quinapril-hydrochlorothiazide quinidine gluconate er quinidine sulfate quinine sulfate R RABAVERT raloxifene hcl ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE RAVICTI reclipsen RECOMBIVAX HB REGRANEX RELENZA DISKHALER reli-on insulin syringe RELISTOR... 78, 79 RELPAX RENVELA repaglinide repaglinide-metformin hcl REPATHA REPATHA PUSHTRONEX SYSTEM REPATHA SURECLICK RESCRIPTOR reserpine RESTASIS RETROVIR REVLIMID REXULTI REYATAZ RHEUMATREX ribasphere ribasphere ribapak ribavirin rifabutin rifampin... 27

127 RIFATER riluzole rimantadine hcl ringers ringers irrigation RIOMET risedronate sodium RISPERDAL CONSTA risperidone RITUXAN rivastigmine tartrate ropinirole hcl rosuvastatin calcium ROTARIX ROTATEQ roweepra ROZEREM S SABRIL... 14, 15 SAMSCA SANCUSO SANDIMMUNE SANDOSTATIN LAR DEPOT SANTYL SAPHRIS SAVELLA SAVELLA TITRATION PACK selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL XR sertraline hcl setlakin SIGNIFOR sildenafil citrate silver sulfadiazine SIMBRINZA SIMPONI SIMPONI ARIA simvastatin sirolimus SIRTURO sodium chloride... 81, 109 sodium fluoride sodium lactate sodium polystyrene sulfonate SOLTAX SOMATULINE DEPOT SOMAVERT sotalol hcl sotalol hcl (af) SOVALDI SPIRIVA HANDIHALER. 103 SPIRIVA RESPIMAT spironolactone spironolactone-hctz SPRITAM SPRYCEL sps stavudine STELARA STIOLTO RESPIMAT STIVARGA STRATTERA streptomycin sulfate... 5 STRIBILD SUBOXONE... 4 sucralfate sulfacetamide sodium... 76, 98 sulfacetamide-prednisolone 101 sulfadiazine sulfamethoxazole-trimethoprim sulfasalazine sulindac sumatriptan sumatriptan succinate SUPRAX... 8 SUSTIVA SUTENT SYLATRON SYMLINPEN SYMLINPEN SYNAGIS SYNAREL SYNERCID... 7 SYNJARDY SYNRIBO synthroid SYPRINE T TABLOID tacrolimus TAFINLAR TAGRISSO TAMIFLU tamoxifen citrate tamsulosin hcl TARCEVA TARGRETIN tarina fe 1/ TASIGNA tazicef... 8 TAZORAC taztia xt TECENTRIQ TECFIDERA TEFLARO... 8 telmisartan telmisartan-amlodipine telmisartan-hctz temazepam tencon TENIVAC terazosin hcl terbinafine hcl terbutaline sulfate terconazole testosterone cypionate testosterone enanthate TETANUS-DIPHTHERIA TOXOIDS TD tetrabenazine THALOMID theophylline er thioridazine hcl THIOTEPA thiothixene THYGLOBULIN tiagabine hcl timolol maleate... 63, 100 TIVICAY tizanidine hcl TOBI PODHALER... 5 TOBRADEX TOBRADEX ST tobramycin... 5, 99 tobramycin sulfate... 5

128 tobramycin-dexamethasone 101 TOLAK tolazamide tolbutamide tolcapone tolmetin sodium... 25, 26 tolterodine tartrate topiramate... 15, 26 topiramate er toposar topotecan hcl TORISEL torsemide TOUJEO SOLOSTAR tpn electrolytes TRACLEER TRADJENTA tramadol hcl... 3 tramadol-acetaminophen... 3 trandolapril trandolapril-verapamil hcl er 62 tranexamic acid transderm-scop (1.5 ) tranylcypromine sulfate TRAVASOL TRAVATAN Z travoprost trazodone hcl TREANDA TRECATOR TRELSTAR MIXJECT TRESIBA FLEXTOUCH tretinoin TREXALL triamcinolone acetonide. 71, 76 triamterene-hctz triazolam TRIBENZOR trifluoperazine hcl trifluridine trihexyphenidyl hcl tri-lo-estarylla tri-lo-sprintec trimethoprim... 7 trimipramine maleate trinessa (28) TRINTELLIX tri-previfem TRISENOX tri-sprintec TRIUMEQ trivora (28) TROKENDI XR TRUVADA TWINRIX TYBOST TYGACIL... 7 TYKERB TYPHIM VI TYSABRI TYZEKA U UCERIS... 76, 83 ULORIC unithroid UPTRAVI ursodiol UVADEX V valacyclovir hcl VALCHLOR valganciclovir hcl valproate sodium valproic acid valsartan valsartan-hydrochlorothiazide vancomycin hcl... 7 VANCOMYCIN HCL... 7 VAQTA VARIVAX VARIZIG VECTIBIX VELCADE VENCLEXTA VENCLEXTA STARTING PACK venlafaxine hcl venlafaxine hcl er VENTAVIS ventolin hfa verapamil hcl verapamil hcl er... 64, 65 VERSACLOZ VESICARE vestura VICTOZA VIDEX vienva VIGAX VIIBRYD VIIBRYD STARTER PACK VIMPAT vinblastine sulfate vincasar pfs vincristine sulfate vinorelbine tartrate VIRACEPT VIRAZOLE VIREAD VITEKTA voriconazole VORICONAZOLE VOTRIENT VPRIV VRAYLAR W warfarin sodium X XALKORI XARELTO XARELTO STARTER PACK XELJANZ XGEVA XIFAXAN... 7 XOLAIR XTANDI XYREM Y YERVOY YF-VAX YONDELIS Z zafirlukast zaleplon ZALTRAP ZANOSAR ZARXIO ZAVESCA zazole ZELBORAF ZENPEP... 78

129 ZEPATIER ZERBAXA... 8 ZETIA ZIAGEN zidovudine ziprasidone hcl ZIRGAN zoledronic acid ZOLEDRONIC ACID ZOLINZA zolpidem tartrate zonisamide ZORTRESS ZOSTAVAX ZYDELIG ZYFLO ZYFLO CR ZYKADIA ZYPREXA RELPREVV ZYTIGA