(List of Covered Drugs)

Transcription

1 Educators Rx Basic (PDP) 208 Formulary (List of Covered s) We have made changes to this formulary, the last update was 06/0/208. For more recent information or other questions, please contact EMI Health Customer Service at or, for TTY users, , 24 hours a day, 7 days a week, or visit Please Read: This document contains information about the drugs we cover in this plan. Version #5 Effective 07/0/208 Last Updated 06/27/208 S5877_F00EDA7A CMS Accepted:090207

2 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B.

3 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 4 B/D PA; MO AMBISOME 4 B/D PA; MO amphotericin b 3 B/D PA; MO CANCIDAS 4 B/D PA; MO caspofungin 4 B/D PA clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL fluconazole fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/00 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml 4 flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole oral MYCAMINE NOXAFIL ORAL nystatin oral suspension Name nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole intravenous voriconazole oral ANTIVIRALS abacavir abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution 3 B/D PA; MO adefovir amantadine hcl APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 50 mg, 200 mg atazanavir oral capsule 300 mg 4 ATRIPLA BARACLUDE ORAL SOLUTION 2

4 Name BIKTARVY cidofovir 4 B/D PA; MO COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY didanosine oral capsule,delayed release(dr/ec) 200 mg, 250 mg, 400 mg EDURANT efavirenz oral capsule 200 mg efavirenz oral capsule 50 mg efavirenz oral tablet EMTRIVA entecavir EPCLUSA (28 per 28 EPIVIR HBV ORAL SOLUTION EVOTAZ famciclovir fosamprenavir FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium intravenous recon soln B/D PA; MO GENVOYA Name HARVONI (28 per 28 INTELENCE ORAL TABLET 00 MG, 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 00 MG ISENTRESS ORAL TABLET,CHEWAB LE 25 MG JULUCA KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine lamivudinezidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET lopinavir-ritonavir moderiba 3

5 Name moderiba dose pack oral tablets,dose pack 200 mg (28)- 400 mg (28), mg (28)-mg (28) moderiba dose pack oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28) nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET 2 ODEFSEY oseltamivir PREVYMIS INTRAVENOUS PREVYMIS ORAL PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 50 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG RELENZA DISKHALER 4 RESCRIPTOR Name RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 200 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 200 mg (7)- 400 mg (7) ribasphere ribapak oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine ritonavir SELZENTRY stavudine oral capsule STRIBILD SUSTIVA ORAL CAPSULE 200 MG 4

6 Name SUSTIVA ORAL CAPSULE 50 MG SUSTIVA ORAL TABLET SYMFI LO SYNAGIS ; LA TAMIFLU tenofovir disoproxil fumarate TIVICAY ORAL TABLET 0 MG TIVICAY ORAL TABLET 25 MG, 50 MG TRIUMEQ TRUVADA valacyclovir oral tablet gram valacyclovir oral tablet 500 mg ; QL (20 ; QL (60 valganciclovir VEMLIDY VIDEX 4 GRAM PEDIATRIC VIDEX EC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 25 MG VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION 3 MO 3 MO VIREAD ZEPATIER (28 per 28 Name ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION 5 3 MO zidovudine CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml cefaclor oral suspension for reconstitution 375 mg/5 ml cefaclor oral tablet extended release 2 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin injection recon soln gram, 500 mg cefazolin injection recon soln 0 gram cefdinir cefepime cefixime cefotaxime injection recon soln gram, 2 gram, 500 mg

7 Name cefotetan injection cefoxitin intravenous recon soln gram, 2 gram cefoxitin intravenous recon soln 0 gram cefpodoxime cefprozil ceftazidime injection recon soln gram, 2 gram ceftazidime injection recon soln 6 gram ceftriaxone injection recon soln gram, 2 gram, 250 mg, 500 mg ceftriaxone injection recon soln 0 gram cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln.5 gram cefuroxime sodium intravenous recon soln 7.5 gram cephalexin SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML 3 MO 3 Name SUPRAX ORAL TABLET,CHEWAB LE 3 MO TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin clarithromycin e.e.s. 400 oral tablet ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES 6

8 Name ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 500 mg/2 ml atovaquone atovaquoneproguanil aztreonam injection recon soln gram baciim bacitracin intramuscular BENZNIDAZOLE 2 BETHKIS 4 B/D PA; MO; QL (224 per 28 BILTRICIDE CAPASTAT 3 CAYSTON ; LA; QL (84 per 28 chloramphenicol sod succinate chloroquine phosphate clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin phosphate injection Name clindamycin phosphate intravenous solution 600 mg/4 ml 7 COARTEM colistin (colistimethate na) dapsone oral daptomycin DARAPRIM 4 PA; MO EMVERM ethambutol gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 80 mg/00 ml gentamicin injection solution 40 mg/ml hydroxychloroquine imipenem-cilastatin INVANZ INJECTION isoniazid injection 3 MO isoniazid oral ivermectin lincomycin linezolid linezolid in dextrose 5% 4

9 Name mefloquine meropenem metronidazole in nacl (iso-os) metronidazole oral NEBUPENT 2 B/D PA; MO; QL ( per 28 neomycin paromomycin 3 MO PASER PENTAM 3 MO polymyxin b sulfate PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin rifampin SIRTURO ; LA SIVEXTRO INTRAVENOUS STREPTOMYCIN SYNERCID 4 tigecycline 4 tinidazole tobramycin in % nacl tobramycin sulfate injection solution 4 4 B/D PA; MO; QL (280 per 28 TRECATOR TYGACIL Name XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate ampicillin oral capsule 500 mg ampicillin sodium injection recon soln gram, 0 gram, 25 mg ampicillin-sulbactam injection recon soln.5 gram, 3 gram ampicillin-sulbactam injection recon soln 5 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML ; QL (9 per 30 ; QL (60 BICILLIN C-R BICILLIN L-A dicloxacillin 8

10 Name nafcillin injection recon soln gram nafcillin injection recon soln 0 gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml oxacillin injection recon soln 0 gram oxacillin injection recon soln 2 gram penicillin g potassium injection recon soln 20 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml 4 penicillin g sodium penicillin v potassium piperacillintazobactam intravenous recon soln 2.25 gram, gram, 4.5 gram, 40.5 gram QUINOLONES BAXDELA INTRAVENOUS ciprofloxacin 4 Name ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/00 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/00 ml, 750 mg/50 ml levofloxacin intravenous levofloxacin oral moxifloxacin oral ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS sulfadiazine 3 MO sulfamethoxazoletrimethoprim TETRACYCLINES demeclocycline 3 MO doxy-00 doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg, 50 mg, 20 mg, 75 mg 9

11 Name doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet minocycline oral tablet extended release 24 hr 5 mg, 65 mg minocycline oral tablet extended release 24 hr 35 mg, 45 mg, 90 mg morgidox oral capsule 50 mg 3 MO 3 MO tetracycline URINARY TRACT AGENTS methenamine hippurate nitrofurantoin nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst trimethoprim VANCOMYCIN Name vancomycin intravenous recon soln,000 mg, 0 gram, 500 mg vancomycin oral capsule 0 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl intravenous recon soln 250 mg ELITEK KEPIVANCE leucovorin calcium injection recon soln 00 mg, 350 mg leucovorin calcium oral levoleucovorin intravenous recon soln 50 mg levoleucovorin intravenous solution 4 mesna MESNEX ORAL 4 4 XGEVA 4 B/D PA; MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 4 B/D PA; MO adriamycin intravenous solution 20 mg/0 ml adrucil intravenous solution 500 mg/0 ml B/D PA B/D PA; MO

12 Name AFINITOR DISPERZ AFINITOR ORAL TABLET 0 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG 4 PA; MO (60 per 30 4 PA; MO ALECENSA (240 per 30 ALIMTA 4 B/D PA; MO ALIQOPA 4 B/D PA; MO; LA ALUNBRIG ORAL TABLET 80 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLET 90 MG ALUNBRIG ORAL TABLETS,DOSE PACK (30 per 30 (80 per 30 (60 per 30 (30 per 30 anastrozole ARRANON 4 B/D PA AVASTIN 4 B/D PA; MO azacitidine 4 B/D PA; MO azathioprine B/D PA; MO azathioprine sodium B/D PA BAVENCIO 4 B/D PA; MO; LA BELEODAQ 4 B/D PA; MO bexarotene bicalutamide Name BICNU 4 B/D PA; MO bleomycin injection recon soln 30 unit B/D PA; MO BORTEZOMIB 4 B/D PA; MO BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 400 MG, 500 MG 4 PA; MO (30 per 30 busulfan 4 B/D PA BUSULFEX 4 B/D PA CABOMETYX 4 PA; MO; LA CALQUENCE 4 PA; MO; LA; QL (60 per 30 CAPRELSA ORAL TABLET 00 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS 4 PA; MO; LA; QL (90 per 30 4 PA; MO; LA; QL (30 per 30 B/D PA; MO 2 B/D PA; MO cisplatin B/D PA; MO cladribine 4 B/D PA; MO clofarabine 4 B/D PA CLOLAR 4 B/D PA COMETRIQ 4 PA; MO COSMEGEN 4 B/D PA; MO COTELLIC 4 PA; MO; LA; QL (63 per 28 cyclophosphamide oral capsule B/D PA; MO

13 Name cyclosporine intravenous cyclosporine modified cyclosporine oral capsule B/D PA B/D PA; MO B/D PA; MO CYRAMZA 4 B/D PA; MO cytarabine B/D PA; MO cytarabine (pf) injection solution 2 gram/20 ml (00 mg/ml) dacarbazine intravenous recon soln 200 mg B/D PA; MO B/D PA; MO dactinomycin B/D PA DARZALEX 4 B/D PA; MO; LA daunorubicin intravenous solution B/D PA decitabine 4 B/D PA; MO docetaxel intravenous solution 60 mg/6 ml (0 mg/ml) docetaxel intravenous solution 80 mg/4 ml (20 mg/ml) doxorubicin intravenous solution 50 mg/25 ml doxorubicin, pegliposomal 4 B/D PA 4 B/D PA; MO B/D PA; MO 4 B/D PA; MO DROXIA EMCYT EMPLICITI 4 B/D PA; MO Name epirubicin intravenous solution 200 mg/00 ml ERBITUX INTRAVENOUS SOLUTION 00 MG/50 ML B/D PA; MO 4 B/D PA; MO ERIVEDGE (30 per 30 ERLEADA 4 PA; MO ERWINAZE 4 B/D PA; MO ETOPOPHOS 3 B/D PA; MO etoposide intravenous B/D PA; MO exemestane FARESTON FARYDAK ORAL CAPSULE 0 MG FARYDAK ORAL CAPSULE 5 MG, 20 MG (2 per 2 (6 per 2 FASLODEX 4 B/D PA; MO FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 20 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln 4 B/D PA; MO 2 B/D PA; MO B/D PA; MO 2

14 Name fluorouracil intravenous solution 5 gram/00 ml B/D PA; MO flutamide FOLOTYN INTRAVENOUS SOLUTION 40 MG/2 ML (20 MG/ML) gemcitabine intravenous recon soln gram gengraf oral capsule 00 mg, 25 mg 4 B/D PA; MO B/D PA; MO B/D PA; MO gengraf oral solution B/D PA; MO GILOTRIF ORAL TABLET 20 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG (60 per 30 (40 per 30 (30 per 30 GLEOSTINE HALAVEN 4 B/D PA; MO HERCEPTIN 4 B/D PA; MO HEXALEN hydroxyurea IBRANCE (2 per 28 ICLUSIG ORAL TABLET 5 MG ICLUSIG ORAL TABLET 45 MG 4 PA; QL (90 (30 per 30 idarubicin B/D PA Name IDHIFA ORAL TABLET 00 MG IDHIFA ORAL TABLET 50 MG ifosfamide intravenous recon soln gram imatinib oral tablet 00 mg imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE 40 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET 40 MG IMBRUVICA ORAL TABLET 280 MG IMBRUVICA ORAL TABLET 420 MG IMBRUVICA ORAL TABLET 560 MG 3 4 PA; MO; LA; QL (30 per 30 4 PA; MO; LA; QL (60 per 30 B/D PA; MO 4 PA; MO (60 per 30 (20 per 30 (240 per 30 (20 per 30 (60 per 30 (40 per 30 (30 per 30 IMFINZI 4 B/D PA; MO; LA INLYTA ORAL TABLET MG INLYTA ORAL TABLET 5 MG 4 PA; MO (20 per 30

15 Name IRESSA (30 per 30 irinotecan intravenous solution 00 mg/5 ml B/D PA; MO ISTODAX 4 B/D PA; MO JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 5 MG JAKAFI ORAL TABLET 25 MG 4 PA; MO (60 per 30 JEVTANA 4 B/D PA; MO KADCYLA 4 PA; MO KEYTRUDA INTRAVENOUS SOLUTION 4 PA; MO KISQALI 4 PA; MO KISQALI FEMARA CO-PACK 4 PA; MO KYPROLIS 4 B/D PA; MO LARTRUVO 4 B/D PA; MO; LA LENVIMA 4 PA; MO letrozole LEUKERAN leuprolide subcutaneous kit LONSURF 4 PA; MO LUPRON DEPOT 4 PA; MO LUPRON DEPOT (3 MONTH) LUPRON DEPOT (NTH) 4 PA; MO 4 PA; MO Name LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED (3 MONTH) INTRAMUSCULA R SYRINGE KIT 30 MG LUPRON DEPOT- PED INTRAMUSCULA R KIT.25 MG, 5 MG 4 PA; MO 4 PA; MO 4 PA; MO LYNPARZA 4 PA; MO LYSODREN MATULANE megestrol oral suspension 400 mg/0 ml (40 mg/ml), 625 mg/5 ml PA; MO megestrol oral tablet PA; MO MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG (20 per 30 (30 per 30 melphalan hcl 4 B/D PA mercaptopurine methotrexate sodium B/D PA; MO methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution mitomycin intravenous recon soln 20 mg, 5 mg B/D PA B/D PA; MO B/D PA; MO 4

16 Name mitomycin intravenous recon soln 40 mg 4 B/D PA; MO mitoxantrone B/D PA; MO MUSTARGEN 3 B/D PA; MO mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium B/D PA B/D PA; MO 4 B/D PA; MO B/D PA; MO B/D PA; MO MYLOTARG 4 B/D PA; MO; LA NERLYNX ; LA NEXAVAR 4 PA; MO; LA; QL (20 per 30 nilutamide NINLARO ORAL CAPSULE 2.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG (6 per 28 (4 per 28 (3 per 28 NULOJIX 4 B/D PA; MO octreotide acetate injection solution,000 mcg/ml, 500 mcg/ml Name octreotide acetate injection solution 00 mcg/ml, 200 mcg/ml, 50 mcg/ml ODOMZO 4 PA; MO; LA; QL (30 per 30 OPDIVO INTRAVENOUS SOLUTION 00 MG/0 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 00 mg oxaliplatin intravenous solution 00 mg/20 ml 4 PA; MO B/D PA; MO B/D PA; MO paclitaxel B/D PA; MO PERJETA 4 B/D PA; MO POMALYST ; LA PROGRAF INTRAVENOUS 2 B/D PA; MO PURIXAN RAPAMUNE ORAL SOLUTION 4 B/D PA; MO REVLIMID 4 PA; MO; LA RITUXAN 4 PA; MO RUBRACA ORAL TABLET 200 MG RUBRACA ORAL TABLET 250 MG RUBRACA ORAL TABLET 300 MG 4 PA; MO; LA; QL (80 per 30 4 PA; MO; LA; QL (50 per 30 4 PA; MO; LA; QL (20 per 30 RYDAPT 4 PA; MO 5

17 Name SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 2 B/D PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 20 MG sirolimus oral tablet 0.5 mg, mg sirolimus oral tablet 2 mg 2 B/D PA; MO B/D PA; MO 4 B/D PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 00 MG, 20 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 40 MG SPRYCEL ORAL TABLET 70 MG 4 PA; MO (30 per 30 (60 per 30 STIVARGA (84 per 28 SUTENT ORAL CAPSULE 2.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG 4 PA; MO (60 per 30 Name SUTENT ORAL CAPSULE 50 MG 6 (30 per 30 SYLVANT 4 B/D PA; MO SYNRIBO 4 B/D PA; MO TABLOID tacrolimus oral B/D PA; MO TAFINLAR ORAL CAPSULE 50 MG TAFINLAR ORAL CAPSULE 75 MG TAGRISSO ORAL TABLET 40 MG TAGRISSO ORAL TABLET 80 MG (80 per 30 (20 per 30 4 PA; MO; LA; QL (60 per 30 4 PA; MO; LA; QL (30 per 30 tamoxifen TARCEVA ORAL TABLET 00 MG, 25 MG TARCEVA ORAL TABLET 50 MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 50 MG, 50 MG TASIGNA ORAL CAPSULE 200 MG 4 PA; MO (30 per 30 4 PA; MO (2 per 28 TECENTRIQ 4 B/D PA; MO; LA THALOMID 4 PA; MO thiotepa 4 B/D PA; MO

18 Name toposar B/D PA; MO topotecan intravenous recon soln 4 B/D PA TORISEL 4 B/D PA; MO TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N.25 MG, 3.75 MG TRELSTAR INTRAMUSCULA R SYRINGE tretinoin (chemotherapy) TRISENOX INTRAVENOUS SOLUTION 2 MG/ML 4 B/D PA; MO 4 B/D PA; MO 4 B/D PA; MO 4 B/D PA; MO TYKERB 4 PA; MO; LA; QL (80 per 30 VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (20 MG/ML) 4 B/D PA; MO VELCADE 4 B/D PA; MO VENCLEXTA ORAL TABLET 0 MG, 50 MG VENCLEXTA ORAL TABLET 00 MG 2 PA; MO; LA 4 PA; MO; LA Name VENCLEXTA STARTING PACK VERZENIO ORAL TABLET 00 MG VERZENIO ORAL TABLET 50 MG VERZENIO ORAL TABLET 200 MG VERZENIO ORAL TABLET 50 MG vinblastine intravenous solution vincasar pfs intravenous solution mg/ml vincristine intravenous solution mg/ml vinorelbine intravenous solution 50 mg/5 ml 4 PA; MO; LA; QL (42 per 80 4 PA; MO; LA; QL (20 per 30 4 PA; MO; LA; QL (80 per 30 4 PA; MO; LA; QL (60 per 30 4 PA; MO; LA; QL (240 per 30 B/D PA; MO B/D PA B/D PA; MO B/D PA; MO VOTRIENT (20 per 30 VYXEOS 4 B/D PA; MO XALKORI ORAL CAPSULE 200 MG XALKORI ORAL CAPSULE 250 MG 4 PA; MO (60 per 30 XATMEP 4 B/D PA; MO XERMELO 4 PA; MO; LA; QL (90 per 30 7

19 Name XTANDI (20 per 30 YERVOY INTRAVENOUS SOLUTION 50 MG/0 ML (5 MG/ML) 4 B/D PA; MO YONDELIS 4 B/D PA; MO ZALTRAP INTRAVENOUS SOLUTION 00 MG/4 ML (25 MG/ML) 4 B/D PA; MO ZANOSAR 3 B/D PA; MO ZEJULA 4 PA; MO; LA; QL (90 per 30 ZELBORAF (240 per 30 ZOLINZA ZORTRESS 4 B/D PA; MO ZYDELIG (90 per 30 ZYKADIA (50 per 30 ZYTIGA ORAL TABLET 250 MG ZYTIGA ORAL TABLET 500 MG (20 per 30 (60 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS Name APTIOM ORAL TABLET 200 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 200 MG BANZEL ORAL TABLET 400 MG BRIVIACT INTRAVENOUS 3 MO BRIVIACT ORAL carbamazepine oral capsule, er multiphase 2 hr carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 2 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG 3 clonazepam PA; MO DIASTAT 3 MO DIASTAT ACUDIAL 3 MO DILANTIN 30 MG divalproex oral capsule, delayed rel sprinkle 8

20 Name divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol ethosuximide felbamate oral suspension felbamate oral tablet fosphenytoin injection solution 00 mg pe/2 ml FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 00 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg GABITRIL ORAL TABLET 2 MG, 6 MG lamotrigine oral tablet lamotrigine oral tablet extended release 24hr ; QL (080 ; QL (360 ; QL (270 ; QL (260 ; QL (80 ; QL (35 3 MO Name lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack levetiracetam in nacl (iso-os) intravenous piggyback,000 mg/00 ml,,500 mg/00 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/00 ml levetiracetam intravenous levetiracetam oral solution 00 mg/ml levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE 00 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 200 MG LYRICA ORAL CAPSULE 225 MG 9 3 MO 2 PA; MO; QL (80 per 30 2 PA; MO; QL (20 per 30 2 PA; MO; QL (90 per 30 2 PA; MO; QL (8 per 30

21 Name LYRICA ORAL CAPSULE 25 MG LYRICA ORAL CAPSULE 300 MG LYRICA ORAL CAPSULE 50 MG LYRICA ORAL CAPSULE 75 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 0 MG, 20 MG 2 PA; MO; QL (720 per 30 2 PA; MO; QL (60 per 30 2 PA; MO; QL (360 per 30 2 PA; MO; QL (240 per 30 2 PA; MO; QL (900 per 30 2 PA; MO 2 PA; MO oxcarbazepine PEGANONE phenobarbital PA; MO phenytoin oral suspension 25 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution primidone roweepra roweepra xr SABRIL ; LA SPRITAM 3 MO Name 20 tiagabine topiramate oral capsule, sprinkle topiramate oral tablet PA; MO PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml vigabatrin ; LA VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 2 zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA benztropine injection benztropine oral PA; MO bromocriptine 3 MO carbidopa carbidopa-levodopa carbidopa-levodopaentacapone 3 MO entacapone NEUPRO 3 MO pramipexole rasagiline ropinirole selegiline hcl tolcapone

22 Name MIGRAINE / CLUSTER HEADACHE THERAPY almotriptan malate oral tablet 2.5 mg almotriptan malate oral tablet 6.25 mg dihydroergotamine injection dihydroergotamine nasal ; QL (24 per 28 ; QL (8 per 28 ; QL (8 per 28 eletriptan ; QL (8 per 28 ergotamine-caffeine frovatriptan ; QL (27 per 28 migergot naratriptan ; QL (8 per 28 rizatriptan ; QL (36 per 28 sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector ; QL (8 per 28 ; QL (36 per 28 ; QL (8 per 28 ; QL (8 per 28 ; QL (8 per 28 Name sumatriptan succinate subcutaneous solution sumatriptannaproxen ; QL (8 per 28 zolmitriptan ; QL (8 per 28 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 4 PA; MO; LA donepezil oral tablet 0 mg, 5 mg donepezil oral tablet 23 mg donepezil oral tablet,disintegrating 3 MO galantamine GILENYA ORAL CAPSULE 0.5 MG glatiramer subcutaneous syringe 20 mg/ml glatiramer subcutaneous syringe 40 mg/ml glatopa subcutaneous syringe 20 mg/ml glatopa subcutaneous syringe 40 mg/ml memantine oral capsule,sprinkle,er 24hr memantine oral solution 4 PA; MO (30 per 30 (2 per 28 (30 per 30 (2 per 28 PA; MO PA; MO 2

23 Name memantine oral tablet PA; MO NAMENDA XR 2 PA; MO NAMZARIC 2 PA; MO NUEDEXTA RADICAVA rivastigmine rivastigmine tartrate TECFIDERA 4 PA; MO; LA tetrabenazine oral tablet 2.5 mg tetrabenazine oral tablet 25 mg (240 per 30 (20 per 30 TYSABRI 4 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral tablet 0 mg, 20 mg cyclobenzaprine oral tablet 3 PA; MO dantrolene LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML MESTINON ORAL SYRUP pyridostigmine bromide 2 B/D PA; MO tizanidine NARCOTIC ANALGESICS Name acetaminophencodeine oral solution 20-2 mg/5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe buprenorphine hcl sublingual codeine sulfate oral tablet duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution mg/ml endocet oral tablet mg, mg, mg 22 ; QL (4500 ; QL (360 ; QL (80 ; QL (266 QL (266 per 30 ; QL (80 ; QL (4000 QL (2000 per 30 ; QL (360 fentanyl citrate (20 per 30 fentanyl transdermal patch 72 hour 00 mcg/hr, 2 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr fentanyl transdermal patch 72 hour 87.5 mcg/hour PA; MO; QL (0 per 30 (0 per 30

24 Name hydrocodoneacetaminophen oral solution mg/5 ml hydrocodoneacetaminophen oral tablet mg, mg, mg hydrocodoneacetaminophen oral tablet mg, mg, mg, mg hydrocodoneibuprofen oral tablet mg, mg, mg ; QL (5550 ; QL (390 ; QL (360 ; QL (50 hydromorphone (pf) ; QL (240 hydromorphone injection syringe 2 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 2 mg, 8 mg hydromorphone oral tablet extended release 24 hr 6 mg, 32 mg QL (200 per 30 ; QL (2400 ; QL (80 PA; MO; QL (60 per 30 (60 per 30 ibuprofen-oxycodone ; QL (28 levorphanol tartrate ; QL (20 lorcet (hydrocodone) ; QL (360 Name 23 lorcet hd ; QL (360 lorcet plus oral tablet mg methadone injection solution methadone oral solution 0 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 0 mg methadone oral tablet 5 mg morphine concentrate oral solution morphine injection syringe 5 mg/ml morphine intravenous syringe 2 mg/ml morphine intravenous syringe 4 mg/ml morphine oral capsule, er multiphase 24 hr morphine oral capsule,extend.relea se pellets morphine oral solution ; QL (360 QL (50 per 30 PA; MO; QL (600 per 30 PA; MO; QL (200 per 30 PA; MO; QL (20 per 30 PA; MO; QL (240 per 30 ; QL (900 QL (400 per 30 QL (000 per 30 QL (500 per 30 PA; MO; QL (60 per 30 PA; MO; QL (90 per 30 ; QL (900 morphine oral tablet ; QL (80

25 Name morphine oral tablet extended release 00 mg morphine oral tablet extended release 5 mg, 200 mg, 30 mg, 60 mg oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 0 mg, 5 mg, 20 mg, 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral tablet mg, mg, mg, mg PA; MO; QL (60 per 30 PA; MO; QL (20 per 30 ; QL (360 ; QL (80 ; QL (200 ; QL (80 ; QL (360 ; QL (360 oxycodone-aspirin ; QL (360 oxymorphone oral tablet 0 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 2 hr ; QL (360 ; QL (80 PA; MO; QL (90 per 30 vicodin ; QL (390 vicodin es ; QL (390 vicodin hp ; QL (390 Name NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet mg buprenorphinenaloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution mg/ml butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal ; QL (360 ; QL (90 ; QL (857 ; QL (428 ; QL (0 per 28 celecoxib diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel % diclofenacmisoprostol ; QL (300 per 28 ; QL (000 per 28 diflunisal etodolac fenoprofen oral tablet flurbiprofen ibu oral tablet 600 mg, 800 mg ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg 24

26 Name ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg meclofenamate mefenamic acid meloxicam oral tablet 5 mg meloxicam oral tablet 7.5 mg ; QL (30 nabumetone nalbuphine injection solution 0 mg/ml nalbuphine injection solution 20 mg/ml ; QL (200 ; QL (00 naloxone naltrexone naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION oxaprozin piroxicam profeno ; QL (2 per 28 Name SUBOXONE SUBLINGUAL FILM 2-3 MG SUBOXONE SUBLINGUAL FILM MG SUBOXONE SUBLINGUAL FILM 4- MG, 8-2 MG 25 ; QL (60 ; QL (360 ; QL (90 sulindac tolmetin oral capsule tolmetin oral tablet 600 mg tramadol oral tablet ; QL (240 tramadol oral tablet extended release 24 hr 00 mg, 200 mg tramadol oral tablet, er multiphase 24 hr tramadolacetaminophen VOLTAREN TOPICAL GEL % PA; MO; QL (30 per 30 PA; MO; QL (30 per 30 ; QL (240 2 ST; MO; QL (000 per 28 PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA amitriptyline PA; MO amoxapine aripiprazole oral solution aripiprazole oral tablet 0 mg aripiprazole oral tablet 5 mg ; QL (90 ; QL (60

27 Name aripiprazole oral tablet 2 mg aripiprazole oral tablet 20 mg aripiprazole oral tablet 30 mg aripiprazole oral tablet 5 mg aripiprazole oral tablet,disintegrating 0 mg aripiprazole oral tablet,disintegrating 5 mg ; QL (450 ; QL (60 ; QL (30 ; QL (80 ; QL (90 ; QL (60 ARISTADA armodafinil 3 PA; MO atomoxetine bupropion hcl oral tablet bupropion hcl oral tablet extended release 2 hr 00 mg bupropion hcl oral tablet extended release 2 hr 50 mg bupropion hcl oral tablet extended release 2 hr 200 mg bupropion hcl oral tablet extended release 24 hr 50 mg bupropion hcl oral tablet extended release 24 hr 300 mg ; QL (20 ; QL (90 ; QL (60 ; QL (90 ; QL (60 buspirone chlorpromazine citalopram oral solution Name citalopram oral tablet 0 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg 26 ; QL (20 ; QL (60 ; QL (30 clomipramine 3 PA; MO clonidine hcl oral tablet extended release 2 hr clorazepate dipotassium PA; MO clozapine oral tablet clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 25 mg desipramine desvenlafaxine succinate oral tablet extended release 24 hr 00 mg desvenlafaxine succinate oral tablet extended release 24 hr 25 mg desvenlafaxine succinate oral tablet extended release 24 hr 50 mg ; QL (20 ; QL (480 ; QL (240 dexmethylphenidate dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamineamphetamine

28 Name diazepam intensol PA; MO diazepam oral solution 5 mg/5 ml ( mg/ml) PA; MO diazepam oral tablet PA; MO doxepin oral 3 PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg ; QL (80 ; QL (20 ; QL (90 ; QL (60 EMSAM ergoloid 3 MO escitalopram oxalate oral solution escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ; QL (60 ; QL (30 ; QL (20 eszopiclone 3 ST; MO; QL (30 per 30 FANAPT ORAL TABLET MG FANAPT ORAL TABLET 0 MG, 8 MG FANAPT ORAL TABLET 2 MG 3 MO; QL (720 ; QL (90 ; QL (60 Name FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 50 MG, 200 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 MG fluoxetine oral capsule 0 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg 27 3 MO; QL (360 3 MO; QL (80 ; QL (20 3 MO; QL (8 per MO; QL (28 per 28 3 MO; QL (30 3 MO; QL (80 3 MO; QL (90 3 MO; QL (45 ; QL (240 ; QL (60

29 Name fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 0 mg fluoxetine oral tablet 20 mg, 60 mg fluphenazine decanoate ; QL (4 per 28 ; QL (240 fluphenazine hcl fluvoxamine oral capsule,extended release 24hr 00 mg fluvoxamine oral capsule,extended release 24hr 50 mg fluvoxamine oral tablet 00 mg fluvoxamine oral tablet 25 mg fluvoxamine oral tablet 50 mg GEODON INTRAMUSCULA R 3 MO; QL (90 3 MO; QL (60 ; QL (90 ; QL (360 ; QL (80 3 MO guanidine haloperidol haloperidol decanoate haloperidol lactate injection haloperidol lactate intramuscular haloperidol lactate oral Name HETLIOZ (30 per 30 imipramine hcl 3 PA; MO imipramine pamoate 3 PA; MO INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 7 MG/0.75 ML, 56 MG/ML, 234 MG/.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.25 ML 3 MO INVEGA TRINZA KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 00 MG KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG, 80 MG 3 MO; QL (20 3 MO; QL (240 ; QL (30 3 MO; QL (240 3 MO; QL (20 3 MO; QL (60 lithium carbonate 28

30 Name lithium citrate oral solution 8 meq/5 ml lorazepam oral PA; MO loxapine succinate maprotiline MARPLAN metadate er methamphetamine PA; MO methylphenidate hcl oral capsule, er biphasic methylphenidate hcl oral capsule,er biphasic methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release methylphenidate hcl oral tablet extended release 24hr 8 mg, 27 mg, 36 mg, 54 mg methylphenidate hcl oral tablet,chewable mirtazapine oral tablet mirtazapine oral tablet,disintegrating modafinil PA; MO nefazodone nortriptyline NUPLAZID Name olanzapine intramuscular olanzapine oral tablet 0 mg olanzapine oral tablet 5 mg, 20 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 0 mg olanzapine oral tablet,disintegrating 5 mg, 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapinefluoxetine paliperidone oral tablet extended release 24hr.5 mg paliperidone oral tablet extended release 24hr 3 mg paliperidone oral tablet extended release 24hr 6 mg paliperidone oral tablet extended release 24hr 9 mg paroxetine hcl oral tablet 0 mg paroxetine hcl oral tablet 20 mg 29 ; QL (60 ; QL (30 ; QL (240 ; QL (20 ; QL (8 ; QL (60 ; QL (30 ; QL (20 ; QL (240 ; QL (20 ; QL (60 ; QL (4 ; QL (80 ; QL (90

31 Name paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 2.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg paroxetine mesylate(menop.sym ) PAXIL ORAL SUSPENSION ; QL (60 ; QL (45 ; QL (80 ; QL (90 ; QL (60 ; QL (30 3 MO perphenazine phenelzine pimozide procentra protriptyline quetiapine oral tablet 00 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg ; QL (240 ; QL (20 ; QL (902 ; QL (8 ; QL (60 ; QL (480 Name quetiapine oral tablet extended release 24 hr 50 mg quetiapine oral tablet extended release 24 hr 200 mg quetiapine oral tablet extended release 24 hr 300 mg quetiapine oral tablet extended release 24 hr 400 mg quetiapine oral tablet extended release 24 hr 50 mg REXULTI ORAL TABLET 0.25 MG REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET MG REXULTI ORAL TABLET 2 MG REXULTI ORAL TABLET 3 MG REXULTI ORAL TABLET 4 MG RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 2.5 MG/2 ML, 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/2 ML, 50 MG/2 ML ; QL (60 ; QL (20 ; QL (8 ; QL (60 ; QL (480 ; QL (480 ; QL (240 ; QL (20 ; QL (60 ; QL (40 ; QL (30 30

32 Name risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ; QL (480 ; QL (920 ; QL (960 ; QL (480 ; QL (240 ; QL (6 ; QL (20 ; QL (920 ; QL (960 ; QL (480 ; QL (240 ; QL (6 ; QL (20 ROZEREM ; QL (30 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG 3 MO; QL (60 Name SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG sertraline oral concentrate sertraline oral tablet 00 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg 3 MO; QL (240 3 MO; QL (20 ; QL (60 ; QL (240 ; QL (20 thioridazine 3 MO thiothixene tranylcypromine 3 MO trazodone trifluoperazine trimipramine 3 PA; MO TRINTELLIX ORAL TABLET 0 MG TRINTELLIX ORAL TABLET 20 MG TRINTELLIX ORAL TABLET 5 MG venlafaxine oral capsule,extended release 24hr 50 mg venlafaxine oral capsule,extended release 24hr 37.5 mg ; QL (60 ; QL (30 ; QL (20 ; QL (60 ; QL (80 3

33 Name venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 00 mg, 75 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg VERSACLOZ 4 VIIBRYD ORAL TABLET 0 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (23) VRAYLAR ORAL CAPSULE.5 MG VRAYLAR ORAL CAPSULE 3 MG VRAYLAR ORAL CAPSULE 4.5 MG VRAYLAR ORAL CAPSULE 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK ; QL (90 ; QL (90 ; QL (270 ; QL (80 ; QL (50 ; QL (20 ; QL (60 ; QL (30 ; QL (30 per 80 ; QL (20 ; QL (60 ; QL (40 ; QL (30 3 MO; QL (7 per 30 XYREM 4 PA; MO; LA zaleplon oral capsule 0 mg 3 ST; MO; QL (60 per 30 Name zaleplon oral capsule 5 mg zenzedi oral tablet 0 mg, 5 mg ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg ziprasidone hcl oral capsule 80 mg 3 ST; MO; QL (30 per 30 ; QL (240 ; QL (20 ; QL (80 ; QL (60 zolpidem oral tablet ST; MO; QL (30 per 30 zolpidem oral tablet,ext release multiphase ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 20 MG 3 ST; MO; QL (30 per 30 CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution B/D PA; MO amiodarone oral dofetilide flecainide mexiletine 32

34 Name pacerone oral tablet 00 mg, 200 mg, 400 mg procainamide injection solution 00 mg/ml procainamide injection solution 500 mg/ml propafenone quinidine gluconate quinidine sulfate oral tablet sorine oral tablet 20 mg, 60 mg, 80 mg sorine oral tablet 240 mg sotalol af oral tablet 20 mg sotalol oral tablet 60 mg, 240 mg, 80 mg SOTYLIZE ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr amiloride amlodipine Name 33 atenolol benazepril betaxolol oral bisoprolol fumarate bumetanide injection bumetanide oral candesartan captopril amiloridehydrochlorothiazide amlodipinebenazepril amlodipineolmesartan amlodipinevalsartan amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide cartia xt carvedilol carvedilol phosphate chlorothiazide chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg clonidine 3 MO; QL (4 per 28 clonidine hcl oral tablet DEMSER diltiazem hcl intravenous

35 Name diltiazem hcl oral capsule,extended release 2 hr diltiazem hcl oral capsule,extended release 24 hr 360 mg, 420 mg diltiazem hcl oral capsule,extended release 24hr 20 mg, 80 mg, 240 mg, 300 mg diltiazem hcl oral tablet dilt-xr doxazosin oral tablet mg, 2 mg, 4 mg doxazosin oral tablet 8 mg ; QL (30 ; QL (60 enalapril maleate eplerenone eprosartan ethacrynate sodium 4 ethacrynic acid felodipine fosinopril furosemide injection furosemide oral solution 0 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet Name hydralazine hydrochlorothiazide indapamide irbesartan isradipine labetalol intravenous solution labetalol oral lisinopril losartan enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide lisinoprilhydrochlorothiazide losartanhydrochlorothiazide matzim la methyclothiazide methyldopa metolazone metoprolol succinate metoprolol tartrate intravenous solution metoprolol tartrate intravenous syringe metoprolol tartrate oral tablet 00 mg, 25 mg, 50 mg minoxidil oral moexipril metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide 34

36 Name nadolol nicardipine intravenous solution nicardipine oral nifedipine oral tablet extended release nifedipine oral tablet extended release 24hr nimodipine nisoldipine olmesartan perindopril erbumine phenoxybenzamine pindolol prazosin propranolol intravenous propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet quinapril Name 35 ramipril REMODULIN 4 PA; MO; LA spironolactone taztia xt TEKTURNA TEKTURNA HCT telmisartan terazosin oral capsule mg, 2 mg, 5 mg terazosin oral capsule 0 mg ; QL (30 ; QL (60 timolol maleate oral torsemide oral trandolapril UPTRAVI 4 PA; MO; LA valsartan nadololbendroflumethiazide olmesartanamlodipin-hcthiazid olmesartanhydrochlorothiazide propranololhydrochlorothiazid quinaprilhydrochlorothiazide spironolactonhydrochlorothiaz telmisartanamlodipine telmisartanhydrochlorothiazid trandolaprilverapamil triamterenehydrochlorothiazid valsartanhydrochlorothiazide verapamil intravenous solution verapamil oral CARDIAC GLYCOSIDES

37 Name digitek digox digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN ORAL TABLET 87.5 MCG, 62.5 MCG COAGULATION THERAPY aspirin-dipyridamole BRILINTA cilostazol clopidogrel oral tablet 75 mg dipyridamole oral ELIQUIS enoxaparin fondaparinux subcutaneous syringe 0 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(00 unit/ml), 25,000 unit/500 ml (50 unit/ml) Name heparin (porcine) injection solution jantoven pentoxifylline PRADAXA 3 MO prasugrel PROMACTA 4 PA; MO; LA tranexamic acid intravenous warfarin XARELTO LIPID/CHOLESTEROL LOWERING AGENTS ; QL (30 atorvastatin ; QL (30 cholestyramine (with sugar) oral powder in packet cholestyramine light oral powder colestipol oral packet colestipol oral tablet ezetimibe amlodipineatorvastatin ezetimibesimvastatin fenofibrate micronized fenofibrate nanocrystallized fenofibrate oral tablet ; QL (30 fenofibric acid 36

38 Name fenofibric acid (choline) fluvastatin oral capsule 20 mg fluvastatin oral capsule 40 mg fluvastatin oral tablet extended release 24 hr ; QL (30 ; QL (60 ; QL (30 gemfibrozil JUXTAPID 4 PA; MO; LA lovastatin oral tablet 0 mg lovastatin oral tablet 20 mg, 40 mg niacin oral tablet extended release 24 hr PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 75 MG/ML ; QL (30 ; QL (60 (2 per 28 (4 per 28 pravastatin ; QL (30 prevalite oral powder in packet REPATHA (3 per 28 REPATHA PUSHTRONEX REPATHA SURECLICK (3.5 per 28 (3 per 28 Name rosuvastatin ; QL (30 simvastatin ; QL (30 VASCEPA 3 MO MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR 2 PA; MO ENTRESTO ; QL (60 RANEXA VECAMYL 4 NITRATES isosorbide dinitrate oral tablet isosorbide dinitrate oral tablet extended release isosorbide mononitrate nitro-bid nitroglycerin intravenous nitroglycerin sublingual nitroglycerin transdermal patch 24 hour nitroglycerin translingual spray,non-aerosol B/D PA DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC 37

39 Name acitretin oral capsule 0 mg acitretin oral capsule 7.5 mg, 25 mg calcipotriene scalp calcipotriene topical cream calcipotriene topical ointment 3 MO calcitriol topical 3 MO selenium sulfide topical lotion BURN THERAPY silver sulfadiazine ssd MISCELLANEOUS DERMATOLOGICALS ammonium lactate diclofenac sodium topical gel 3 % (00 per 28 doxepin topical DUPIXENT 4 PA; MO fluorouracil topical cream 5 % fluorouracil topical solution imiquimod methoxsalen PANRETIN podofilox prudoxin Name REGRANEX tacrolimus topical PA; MO; QL (00 per 30 VALCHLOR THERAPY FOR ACNE adapalene topical cream adapalene topical gel adapalene-benzoyl peroxide 3 PA; MO 3 PA; MO PA; MO amnesteem avita topical cream PA; MO claravis 3 MO clindacin p clindamycin phosphate topical clindamycin-benzoyl peroxide topical gel PA; MO dapsone topical ery pads erygel erythromycin with ethanol topical gel erythromycin with ethanol topical solution calcipotrienebetamethasone clindamycintretinoin erythromycinbenzoyl peroxide isotretinoin metronidazole topical cream 38

40 Name metronidazole topical gel metronidazole topical lotion myorisan oral capsule 0 mg, 20 mg, 40 mg myorisan oral capsule 30 mg neuac tazarotene PA; MO TAZORAC TOPICAL CREAM 0.05 % TAZORAC TOPICAL GEL tretinoin microspheres topical gel 2 PA; MO 2 PA; MO 3 PA; MO tretinoin topical PA; MO zenatane 3 MO TOPICAL ANESTHETICS lidocaine (pf) injection solution 0 mg/ml ( %), 5 mg/ml (0.5 %) lidocaine hcl injection solution 20 mg/ml (2 %) lidocaine hcl mucous membrane jelly lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated ; QL (60 PA; MO Name lidocaine topical ointment 39 3 MO; QL (36 lidocaine viscous lidocaine-prilocaine topical cream ; QL (30 TOPICAL ANTIBACTERIALS gentamicin topical mupirocin mupirocin calcium sulfacetamide sodium (acne) SULFAMYLON TOPICAL ANTIFUNGALS ciclopirox clotrimazole topical econazole ketoconazole topical naftifine nyamyc nystatin topical clotrimazolebetamethasone nystatintriamcinolone nystop oxiconazole TOPICAL ANTIVIRALS acyclovir topical 3 PA; MO; QL (30 per 30 DENAVIR ZOVIRAX TOPICAL CREAM (5 TOPICAL CORTICOSTEROIDS

41 Name ala-cort topical cream alclometasone amcinonide topical cream amcinonide topical lotion amcinonide topical ointment 3 MO 3 MO apexicon e betamethasone dipropionate betamethasone valerate betamethasone, augmented 3 clobetasol scalp ; QL (00 per 28 clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical spray,non-aerosol clobetasol-emollient topical cream ; QL (00 per 28 ; QL (20 per 28 ; QL (8 per 28 ; QL (20 per 28 ; QL (236 per 28 ; QL (25 per 28 ; QL (20 per 28 clodan 3 MO; QL (236 per 28 desonide topical cream 3 MO Name desonide topical lotion desonide topical ointment 3 MO desoximetasone 3 MO diflorasone 3 MO fluocinolone and shower cap fluocinolone topical cream fluocinolone topical ointment fluocinolone topical solution fluocinonide topical cream 0. % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution ; QL (20 ; QL (20 ; QL (20 ; QL (20 fluocinonide-e ; QL (20 flurandrenolide fluticasone topical cream fluticasone topical lotion fluticasone topical ointment halobetasol propionate hydrocortisone butyrate topical cream 3 MO 3 MO 40

42 Name hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone topical cream %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment %, 2.5 % hydrocortisone valerate mometasone topical nolix topical cream nolix topical lotion prednicarbate triamcinolone acetonide topical aerosol triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0. %, 0.5 % trianex triderm topical cream 0. % TOPICAL ENZYMES SANTYL Name 4 TOPICAL SCABICIDES / PEDICULICIDES lindane topical shampoo malathion NATROBA permethrin topical cream DIAGNOSTICS / MISCELLANEOUS AGENTS IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringer's irrigation MISCELLANEOUS AGENTS acamprosate 3 MO ADAGEN alendronate oral tablet 40 mg ; QL (30 anagrelide ARALAST NP INTRAVENOUS RECON SOLN,000 MG BUPHENYL ORAL TABLET ; LA CARBAGLU ; LA cevimeline CHEMET 2 PA; MO CLINIMIX 4.25%/D5W SULFIT FREE 2 B/D PA

43 Name d0 %-0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 0 % and 0.2 % nacl dextrose 0 % in water (d0w) dextrose 5 % in water (d5w) intravenous piggyback dextrose 5 %- lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride disulfiram etidronate disodium EXJADE 4 PA; MO; LA FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET 4 PA 4 PA; MO INCRELEX ; LA JADENU 4 PA; MO JADENU SPRINKLE kionex (with sorbitol) 4 PA; MO Name 42 lanthanum levocarnitine (with sugar) levocarnitine oral tablet midodrine NORTHERA 4 PA; MO ORFADIN ORAL CAPSULE 0 MG, 2 MG, 5 MG ORFADIN ORAL CAPSULE 20 MG ORFADIN ORAL SUSPENSION 4 LA ; LA pilocarpine hcl oral PROLASTIN-C INTRAVENOUS RECON SOLN PROLASTIN-C INTRAVENOUS SOLUTION 4 LA RAVICTI RENVELA ORAL TABLET riluzole risedronate oral tablet 30 mg sevelamer carbonate oral powder in packet sevelamer carbonate oral tablet sodium chloride 0.9 % intravenous piggyback sodium chloride irrigation ; QL (30

44 Name sodium phenylbutyrate sodium polystyrene sulfonate oral powder sps (with sorbitol) oral SYPRINE 4 PA; MO THIOLA trientine 4 PA; MO VELTASSA water for irrigation, sterile XURIDEN SMOKING DETERRENTS bupropion hcl (smoking deter) PA; MO CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX NICOTROL 3 MO NICOTROL NS 3 MO EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal ; QL (60 chlorhexidine gluconate mucous membrane Name ipratropium bromide nasal 43 ; QL (30 olopatadine nasal ; QL (30.5 periogard triamcinolone acetonide dental MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) floxin otic (ear) drops fluocinolone acetonide oil zoledronic acidmannitol-water hydrocortisoneacetic acid ofloxacin otic (ear) OTIC STEROID / ANTIBIOTIC CIPRODEX neomycinpolymyxin-hc otic (ear) ENDOCRINE/DIABETES ADRENAL HORMONES cortisone dexamethasone intensol dexamethasone oral elixir dexamethasone oral tablet dexamethasone sodium phosphate injection solution fludrocortisone

45 Name hydrocortisone oral methylprednisolone acetate methylprednisolone oral tablet methylprednisolone oral tablets,dose pack methylprednisolone sodium succ injection recon soln 25 mg, 40 mg methylprednisolone sodium succ intravenous B/D PA; MO millipred oral tablet 3 B/D PA; MO prednisolone oral solution 5 mg/5 ml prednisolone sodium phosphate oral solution 0 mg/5 ml, 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating B/D PA; MO prednisone intensol B/D PA; MO prednisone oral solution prednisone oral tablet prednisone oral tablets,dose pack triamcinolone acetonide injection suspension 40 mg/ml B/D PA; MO Name veripred 20 ANTITHYROID AGENTS methimazole oral tablet 0 mg, 5 mg propylthiouracil DIABETES THERAPY acarbose oral tablet 00 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg ; QL (90 ; QL (360 ; QL (80 ALCOHOL PADS BYDUREON 2 PA; MO; QL (4 per 28 BYDUREON BCISE BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML).2 ML 2 PA; MO; QL (4 per 28 2 PA; MO; QL (2.4 per 30 2 PA; MO; QL (.2 per 30 CYCLOSET 3 MO; QL (80 GAUZE PADS 2 X 2 glimepiride oral tablet mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg ; QL (240 ; QL (20 ; QL (60 44