2018 Formulary. (List of Covered Prescription and Over-the-Counter Drugs)

Transcription

1 08 Formulary (List of Covered Prescription and Over-the-Counter Drugs) UCare Connect (SNBC) MinnesotaCare Prepaid Medical Assistance Program (PMAP) Minnesota Senior Care Plus (MSC Plus) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THESE PLANS. Other drug coverage: If you have Medicare, you need to get most of your prescription drugs through the Medicare Prescription Drug Program (Medicare Part D). You must be enrolled in a Medicare prescription drug plan to get these services. UCare does not pay for prescriptions that are covered under the Medicare Prescription Drug Program. PMAP MnCare MSC+ SNBC_07_ DHS Approved (707)

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3 Civil Rights Notice Discrimination is against the law. UCare does not discriminate on the basis of any of the following: Race Sex (including sex stereotypes and Color gender identity) National Origin Marital Status Creed Political Beliefs Religion Medical Condition Sexual Orientation Health Status Public Assistance Status Receipt of Health Care Services Age Claims Experience Disability (including physical or Medical History mental impairment) Genetic Information Auxiliary Aids and Services. UCare provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner, to ensure an equal opportunity to participate in our health care programs. Contact UCare at (voice) or (voice), (TTY), or (TTY). Language Assistance Services. UCare provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact UCare at (voice) or (voice), (TTY), or (TTY). Civil Rights Complaints You have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by UCare. You may contact any of the following four agencies directly to file a discrimination complaint. U.S. Department of Health and Human Services Office for Civil Rights (OCR) You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following: Race Color National Origin Age Disability Sex (including sex stereotypes and gender identity)

4 Contact the OCR directly to file a complaint: Director U.S. Department of Health and Human Services Office for Civil Rights 00 Independence Avenue SW Room 509F HHH Building Washington, DC (Voice) (TDD) Complaint Portal Minnesota Department of Human Rights (MDHR) In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following: Race Sex Color Sexual Orientation National Origin Marital Status Religion Public Assistance Status Creed Disability Contact the MDHR directly to file a complaint: Minnesota Department of Human Rights Freeman Building, 65 North Robert Street St. Paul, MN (voice) (toll free) 7 or (MN Relay) (Fax) Info.MDHR@state.mn.us ( ) Minnesota Department of Human Services (DHS) You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following: Race Sex (including sex stereotypes and Color gender identity) National Origin Marital Status Creed Political Beliefs Religion Medical Condition Sexual Orientation Health Status Public Assistance Status Receipt of Health Care Services Age Claims Experience Disability (including physical or Medical History mental impairment) Genetic Information

5 Complaints must be in writing and filed within 80 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint. DHS will notify you in writing of the investigation s outcome. You have a right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome period. Be brief and state why you disagree with the decision. Include additional information you think is important. If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administration actions Contact DHS directly to file a discrimination complaint: ATTN: Civil Rights Coordinator Minnesota Department of Human Services Equal Opportunity and Access Division P.O. Box St. Paul, MN (voice) or use your preferred relay service UCare Complaint Notice You have the right to file a complaint with UCare if you believe you have been discriminated against in our health care programs because of any of the following: Race Color National Origin Creed Religion Sexual Orientation Public Assistance Status Age Disability (including physical or mental impairment) Phone: or toll free TTY: or toll free cag@ucare.org Fax: Sex (including sex stereotypes and gender identity) Marital Status Political Beliefs Medical Condition Health Status Receipt of Health Care Services Claims Experience Medical History Genetic Information Mailing address UCare Attn: Appeals and Grievances PO Box 5 Minneapolis, MN American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral

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7 What is the UCare Formulary? The UCare formulary is a list of prescription and over-the-counter (OTC) drugs that are covered by your health plan. The list is reviewed and updated by a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The most recent version of the formulary can be found on the UCare website at How do I use the Formulary? In the formulary, brand name drugs are capitalized (e.g. EPIPEN) and generic drugs are listed in lowercase italics (e.g. maprotiline tablet). UCare covers both brand name drugs and generic drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs, but work just as well and are equally as safe as the branded product. How to find prescription drugs in the formulary There are two ways to find your prescription drugs in the formulary. You can search by medical condition associated with your drug or by alphabetical listing. Search by Medical Condition Drugs listed by medical condition begin on page. The drugs in this formulary are grouped into categories depending on the type of medical conditions they are used to treat. If you know what your drug is used for, look for the category in the list that begins on page. Then look under the category name for your drug. Search by Alphabetical Listing If you are not sure what category to look under, you can look for your drug in the Index. The Index gives an alphabetical list of all of the drugs included in the formulary. Both brand name 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 within the formulary. Tier (Notes) for prescription drugs The numbers in the Tier (Notes) column on the prescription drug formulary tell you the difference between brand name drug copays and generic drug copays. The number shows that the drug is a generic drug and may have a generic drug copay. The number shows that the drug is a brand name drug and may have a brand name drug copay. For more detailed information about copays, please review your Evidence of Coverage. The abbreviations in the Tier (Notes) column on the formulary tell you if UCare has any special requirements or limits on coverage for that drug. Use the key below to help understand the meaning of each abbreviation. PA = Prior authorization UCare requires you or your doctor to get prior authorization for certain drugs. This means that your provider will need to work with UCare to get coverage approval before you can fill your prescriptions. If you don t get approval, UCare may not cover the drug. ST = Step therapy Even though this drug is on the formulary, UCare requires that you try one or more alternative drugs on the formulary before this drug will be covered. Note: In many cases, if you are already on this drug prior to enrolling in UCare, UCare will pay for your drug and not require you to try other formulary drugs first. QL = Quantity limits For certain drugs, UCare limits the amount of the drug that UCare will cover. i

8 SP = Specialty drugs Fairview Specialty Pharmacy is the exclusive network provider of specialty drugs for UCare State Public Program (Medicaid) members. Specialty drugs are costly injectable or oral drugs that often require special handling or monitoring by a trained pharmacist. Your specialty medication and any needed supplies will be shipped to your home, work, or doctor s office. You can also contact Fairview Specialty Pharmacy and arrange to pick up your medication at one of their retail locations. A Fairview pharmacist is available 4 hours a day, seven days a week, to answer any questions related to your specialty medication. If you use a specialty medication, please have your physician send your prescription to Fairview Specialty Pharmacy via e-prescribing and select FAIRVIEW MAIL ORDER/SPECIALTY PHARMACY or fax it to You can also have your current pharmacy transfer the prescription to Fairview Specialty Pharmacy. For any questions, please contact Fairview at or (toll free), 4 hours a day, seven days a week. How to find OTC drugs in the formulary A list of covered OTC drugs is located in the back of the formulary. Covered OTC drugs are listed by medical condition. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact UCare Customer Services to confirm that your drug is not covered. Call Customer Services at or toll free or, for TTY users, , 8 a.m. - 5 p.m., Monday - Friday, or visit ucare.org. If you learn that UCare does not cover your drug, you can: Take a copy of this formulary to your doctor and ask him or her to prescribe a similar drug that is covered by UCare. Ask your doctor to request a formulary exception.* *Note: Generally, UCare will only approve your doctor s request for a formulary exception if the alternative drugs included on UCare s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects. For more information For more detailed information about your UCare prescription or OTC drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions, please call the UCare Customer Services number on the back of your member ID card. TTY/TDD users should call toll free. Or visit ii

9 UCare Minnesota Health Care Programs Formulary (List of Covered Drugs) Drug Tier Notes ANTIHISTAMINE DRUGS carbinoxamine maleate oral liquid 4 /5 ml carbinoxamine maleate oral tablet 4 clemastine oral tablet.68 cyproheptadine oral syrup /5 ml cyproheptadine oral tablet 4 dimenhydrinate injection solution 50 /ml diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl injection syringe 50 /ml hydroxyzine hcl intramuscular solution 5 /ml, 50 /ml hydroxyzine hcl oral solution 0 /5 ml hydroxyzine hcl oral tablet 0, 5, 50 hydroxyzine pamoate oral capsule 00, 5, 50 meclizine oral tablet.5, 5 meclizine oral tablet,chewable 5 promethazine injection solution 5 /ml, 50 /ml promethazine oral syrup 6.5 /5 ml promethazine oral tablet.5, 5, 50 promethazine rectal suppository.5, 5 ANTI-INFECTIVE AGENTS abacavir oral solution 0 /ml abacavir oral tablet 300 abacavir-lamivudine oral tablet abacavir-lamivudine-zidovudine oral tablet acyclovir oral capsule 00 acyclovir oral suspension 00 /5 ml acyclovir oral tablet 400, 800 acyclovir sodium intravenous recon soln,000, 500 acyclovir sodium intravenous solution 50 /ml adefovir oral tablet 0 SP ALBENZA ORAL TABLET 00 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML Updated: October, 08

10 ALINIA ORAL TABLET 500 MG amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 00 amikacin injection solution,000 /4 ml, 500 / ml amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 5 /5 ml, 00 /5 ml, 50 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 5, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet 50-5, 500-5, amoxicillin-pot clavulanate oral tablet extended release hr, amoxicillin-pot clavulanate oral tablet,chewable , amphotericin b injection recon soln 50 ampicillin oral capsule 50, 500 ampicillin sodium injection recon soln gram, 0 gram, 5, gram, 50, 500 ampicillin sodium intravenous recon soln gram, gram ampicillin-sulbactam injection recon soln.5 gram, 5 gram, 3 gram ampicillin-sulbactam intravenous recon soln.5 gram, 3 gram APTIVUS ORAL CAPSULE 50 MG APTIVUS ORAL SOLUTION 00 MG/ML atazanavir oral capsule 50, 00, 300 atovaquone oral suspension 750 /5 ml atovaquone-proguanil oral tablet 50-00, ATRIPLA ORAL TABLET MG azithromycin intravenous recon soln 500 azithromycin oral packet gram azithromycin oral suspension for reconstitution 00 /5 ml, 00 /5 ml Updated: October, 08

11 azithromycin oral tablet 50, 500, 600 BACIIM INTRAMUSCULAR RECON SOLN 50,000 UNIT bacitracin intramuscular recon soln 50,000 unit BARACLUDE ORAL SOLUTION 0.05 MG/ML SP BENZNIDAZOLE ORAL TABLET 00 MG,.5 MG SP BIKTARVY ORAL TABLET MG CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML SP; QL (84 per 30 days) cefaclor oral capsule 50, 500 cefaclor oral tablet extended release hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet gram cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, gram/50 ml cefazolin injection recon soln gram, 0 gram, 00 gram, 0 gram, 300 g, 500 cefazolin intravenous recon soln gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 5 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefepime in dextrose,iso-osm intravenous piggyback gram/50 ml, gram/00 ml cefepime injection recon soln gram, gram cefotaxime injection recon soln gram cefotetan injection recon soln gram, gram cefotetan intravenous recon soln 0 gram cefoxitin in dextrose, iso-osm intravenous piggyback gram/50 ml, gram/50 ml cefoxitin intravenous recon soln gram, 0 gram, gram cefpodoxime oral suspension for reconstitution 00 /5 ml, 50 /5 ml cefpodoxime oral tablet 00, 00 cefprozil oral suspension for reconstitution 5 /5 ml, 50 /5 ml Updated: October, 08 3

12 cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram, gram, 6 gram ceftriaxone in dextrose,iso-os intravenous piggyback gram/50 ml, gram/50 ml ceftriaxone injection recon soln gram, 0 gram, gram, 50, 500 ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln.5 gram, 7.5 gram cephalexin oral capsule 50, 500 cephalexin oral suspension for reconstitution 5 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 chloramphenicol sod succinate intravenous recon soln gram chloroquine phosphate oral tablet 50, 500 CIMDUO ORAL TABLET MG ciprofloxacin (mixture) oral tablet, er multiphase 4 hr,000, 500 ciprofloxacin hcl oral tablet 00, 50, 500, 750 ciprofloxacin in 5 % dextrose intravenous piggyback 00 /00 ml, 400 /00 ml ciprofloxacin oral suspension,microcapsule recon 50 /5 ml, 500 /5 ml clarithromycin oral suspension for reconstitution 5 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release 4 hr 500 clindamycin hcl oral capsule 50, 300 clindamycin palmitate hcl oral recon soln 75 /5 ml CLINDAMYCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML clindamycin phosphate injection solution 50 /ml Updated: October, 08 4

13 clindamycin phosphate intravenous solution 300 / ml, 600 /4 ml, 900 /6 ml COARTEM ORAL TABLET 0-0 MG colistin (colistimethate na) injection recon soln 50 COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 00 MG, 400 MG dapsone oral tablet 00, 5 daptomycin intravenous recon soln 500 DARAPRIM ORAL TABLET 5 MG PA DESCOVY ORAL TABLET 00-5 MG dicloxacillin oral capsule 50, 500 didanosine oral capsule,delayed release(dr/ec) 5, 00, 50, 400 doxycycline hyclate oral capsule 00, 50 doxycycline hyclate oral tablet 00 doxycycline monohydrate oral capsule 00, 50, 50 EDURANT ORAL TABLET 5 MG efavirenz oral capsule 00, 50 EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLUTION 0 MG/ML entecavir oral tablet 0.5, SP EPIVIR HBV ORAL SOLUTION 5 MG/5 ML (5 MG/ML) SP EPIVIR ORAL SOLUTION 0 MG/ML ertapenem injection recon soln gram ERYTHROCIN (AS STEARATE) ORAL TABLET 50 MG erythromycin ethylsuccinate oral tablet 400 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 ethambutol oral tablet 00, 400 EVOTAZ ORAL TABLET MG famciclovir oral tablet 5, 500 QL ( per 30 days) famciclovir oral tablet 50 QL (60 per 30 days) fluconazole in dextrose(iso-o) intravenous piggyback 00 /00 ml, 400 /00 ml Updated: October, 08 5

14 fluconazole in nacl (iso-osm) intravenous piggyback 00 /50 ml, 00 /00 ml, 400 /00 ml fluconazole oral suspension for reconstitution 0 /ml, 40 /ml fluconazole oral tablet 00, 00, 50 fluconazole oral tablet 50 QL; QL ( Max Qty Per Fill Retail) fosamprenavir oral tablet 700 FUZEON SUBCUTANEOUS RECON SOLN 90 MG SP gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 60 /50 ml, 70 /50 ml, 80 /00 ml, 80 /50 ml, 90 /00 ml gentamicin injection solution 0 / ml, 40 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 00 /0 ml GENVOYA ORAL TABLET MG griseofulvin microsize oral suspension 5 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 5, 50 hydroxychloroquine oral tablet 00 HYOPHEN ORAL TABLET MG INTELENCE ORAL TABLET 00 MG, 00 MG, 5 MG INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), SP 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML SP INVANZ INTRAVENOUS RECON SOLN GRAM INVIRASE ORAL CAPSULE 00 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 00 MG, 5 MG Updated: October, 08 6

15 isoniazid injection solution 00 /ml isoniazid oral solution 50 /5 ml isoniazid oral tablet 00, 300 itraconazole oral capsule 00 QL (30 per 30 days) ivermectin oral tablet 3 JULUCA ORAL TABLET 50-5 MG KALETRA ORAL TABLET 00-5 MG, MG ketoconazole oral tablet 00 lamivudine oral solution 0 /ml lamivudine oral tablet 00, 50, 300 lamivudine-zidovudine oral tablet levofloxacin oral solution 50 /0 ml levofloxacin oral tablet 50, 500, 750 LEXIVA ORAL SUSPENSION 50 MG/ML linezolid in dextrose 5% intravenous piggyback 600 /300 ml linezolid oral suspension for reconstitution 00 /5 ml linezolid oral tablet 600 linezolid-0.9% sodium chloride intravenous parenteral solution 600 /300 ml lopinavir-ritonavir oral solution /5 ml LUGOLS ORAL SOLUTION 5 % MAVYRET ORAL TABLET MG PA; SP mefloquine oral tablet 50 meropenem intravenous recon soln gram, 500 methenamine hippurate oral tablet gram methenamine mandelate oral tablet 0.5 g, gram metronidazole in nacl (iso-os) intravenous piggyback 500 /00 ml metronidazole oral capsule 375 metronidazole oral tablet 50, 500 minocycline oral capsule 00, 50, 75 MYCAMINE INTRAVENOUS RECON SOLN 00 MG, 50 MG nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml, gram/00 ml Updated: October, 08 7

16 nafcillin injection recon soln gram, 0 gram, gram nafcillin intravenous recon soln gram, gram NEBUPENT INHALATION RECON SOLN 300 MG SP neomycin oral tablet 500 nevirapine oral suspension 50 /5 ml nevirapine oral tablet 00 nitrofurantoin macrocrystal oral capsule 00, 50 nitrofurantoin monohyd/m-cryst oral capsule 00 nitrofurantoin oral suspension 5 /5 ml NORVIR ORAL CAPSULE 00 MG NORVIR ORAL SOLUTION 80 MG/ML nystatin oral powder 50 million unit, 500 million unit nystatin oral suspension 00,000 unit/ml nystatin oral tablet 500,000 unit ODEFSEY ORAL TABLET MG ofloxacin oral tablet 300, 400 oseltamivir oral capsule 30 QL; QL (40 per 30 days) oseltamivir oral capsule 45, 75 QL; QL (30 per 30 days) oseltamivir oral suspension for reconstitution 6 /ml QL (360 per 73 days) oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml, gram/50 ml oxacillin injection recon soln gram, 0 gram, gram oxacillin intravenous recon soln gram, gram paromomycin oral capsule 50 PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 35 MCG/0.5 ML, 80 MCG/0.5 ML SP; QL (4 per 30 days) PEGASYS SUBCUTANEOUS SOLUTION 80 MCG/ML SP; QL (4 per 30 days) PEGASYS SUBCUTANEOUS SYRINGE 80 MCG/0.5 ML SP; QL (4 per 30 days) penicillin g potassium injection recon soln 0 million unit, 5 million unit penicillin g procaine intramuscular syringe. million unit/ ml, 600,000 unit/ml Updated: October, 08 8

17 penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 5 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 piperacillin-tazobactam intravenous recon soln.5 gram, gram, 4.5 gram, 40.5 gram polymyxin b sulfate injection recon soln 500,000 unit praziquantel oral tablet 600 PREVYMIS INTRAVENOUS SOLUTION 40 MG/ ML, 480 MG/4 ML SP PREVYMIS ORAL TABLET 40 MG, 480 MG SP PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 00 MG/ML PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG PRIFTIN ORAL TABLET 50 MG PYLERA ORAL CAPSULE MG pyrazinamide oral tablet 500 quinidine gluconate injection solution 80 /ml quinidine gluconate oral tablet extended release 34 quinidine sulfate oral tablet 00, 300 quinine sulfate oral capsule 34 RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION QL (40 per 73 days) RESCRIPTOR ORAL TABLET 00 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 00 MG RETROVIR INTRAVENOUS SOLUTION 0 MG/ML ribavirin oral capsule 00 SP ribavirin oral tablet 00 SP rifabutin oral capsule 50 rifampin intravenous recon soln 600 rifampin oral capsule 50, 300 RIFATER ORAL TABLET MG rimantadine oral tablet 00 ritonavir oral tablet 00 SELZENTRY ORAL SOLUTION 0 MG/ML Updated: October, 08 9

18 SELZENTRY ORAL TABLET 50 MG, 300 MG SIRTURO ORAL TABLET 00 MG stavudine oral capsule 5, 0, 30, 40 STRIBILD ORAL TABLET MG STRONG IODINE ORAL SOLUTION 5 % sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim oral tablet , sulfasalazine oral tablet 500 sulfasalazine oral tablet,delayed release (dr/ec) 500 SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SP SYMFI LO ORAL TABLET MG SYMFI ORAL TABLET MG SYNAGIS INTRAMUSCULAR SOLUTION 00 MG/ML, 50 MG/0.5 ML SP TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML QL (360 per 73 days) tenofovir disoproxil fumarate oral tablet 300 terbinafine hcl oral tablet 50 tetracycline oral capsule 50, 500 TIVICAY ORAL TABLET 0 MG, 5 MG, 50 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 300 /5 ml SP; QL (80 per 30 days) tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection recon soln. gram tobramycin sulfate injection solution 0 /ml, 40 /ml trimethoprim oral tablet 00 TRIUMEQ ORAL TABLET MG TROGARZO INTRAVENOUS SOLUTION 00 MG/.33 ML (50 MG/ML) TRUVADA ORAL TABLET MG UR N-C ORAL TABLET MG Updated: October, 08 0

19 URIMAR-T ORAL TABLET MG UROGESIC-BLUE ORAL TABLET MG valacyclovir oral tablet gram, 500 QL (30 per 30 days) valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 450 vancomycin in dextrose 5 % intravenous piggyback gram/00 ml, 500 /00 ml vancomycin intravenous recon soln,000, 0 gram, 5 gram, 500, 750 vancomycin oral capsule 5, 50 VEMLIDY ORAL TABLET 5 MG SP VIDEX GRAM PEDIATRIC ORAL RECON SOLN 0 MG/ML (FINAL) VIRACEPT ORAL TABLET 50 MG, 65 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) SP VIREAD ORAL TABLET 50 MG, 00 MG, 50 MG SP voriconazole intravenous solution 00 voriconazole oral suspension for reconstitution 00 /5 ml (40 /ml) voriconazole oral tablet 00, 50 VOSEVI ORAL TABLET MG PA; SP XIFAXAN ORAL TABLET 00 MG, 550 MG zidovudine oral capsule 00 zidovudine oral syrup 0 /ml zidovudine oral tablet 300 ANTINEOPLASTIC AGENTS ADRUCIL INTRAVENOUS SOLUTION.5 GRAM/50 ML, 5 GRAM/00 ML, 500 MG/0 ML AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, 3 MG, 5 MG PA; SP AFINITOR ORAL TABLET 0 MG,.5 MG, 5 MG, 7.5 MG PA; SP ALECENSA ORAL CAPSULE 50 MG PA; SP; QL (40 per 30 days) ALIQOPA INTRAVENOUS RECON SOLN 60 MG SP ALUNBRIG ORAL TABLET 80 MG, 90 MG PA; SP ALUNBRIG ORAL TABLET 30 MG PA; SP; QL (80 per 30 days) Updated: October, 08

20 ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 80 MG (3) PA; SP anastrozole oral tablet azacitidine injection recon soln 00 SP BAVENCIO INTRAVENOUS SOLUTION 0 MG/ML BELEODAQ INTRAVENOUS RECON SOLN 500 MG BESPONSA INTRAVENOUS RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) SP bexarotene oral capsule 75 bicalutamide oral tablet 50 bleomycin injection recon soln 5 unit, 30 unit BLINCYTO INTRAVENOUS KIT 35 MCG BORTEZOMIB INTRAVENOUS RECON SOLN 3.5 MG BOSULIF ORAL TABLET 00 MG, 400 MG, 500 MG PA; SP CABOMETYX ORAL TABLET 0 MG, 40 MG, 60 MG PA; SP CALQUENCE ORAL CAPSULE 00 MG PA; SP capecitabine oral tablet 50, 500 SP CAPRELSA ORAL TABLET 00 MG, 300 MG PA; SP carboplatin intravenous recon soln 50 carboplatin intravenous solution 0 /ml cisplatin intravenous solution /ml cladribine intravenous solution 0 /0 ml COMETRIQ ORAL CAPSULE 00 MG/DAY(80 MG X-0 MG X), 40 MG/DAY(80 MG X-0 PA; SP MG X3), 60 MG/DAY (0 MG X 3/DAY) COTELLIC ORAL TABLET 0 MG PA; SP; QL (63 per 30 days) cyclophosphamide intravenous recon soln gram, gram, 500 CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG CYRAMZA INTRAVENOUS SOLUTION 0 MG/ML SP cytarabine (pf) injection solution 00 /5 ml (0 /ml), gram/0 ml (00 /ml), 0 /ml cytarabine injection solution 0 /ml dacarbazine intravenous recon soln 00, 00 Updated: October, 08

21 daunorubicin intravenous recon soln 0 daunorubicin intravenous solution 5 /ml diclofenac sodium topical gel 3 % PA DOCETAXEL INTRAVENOUS SOLUTION 60 MG/6 ML (0 MG/ML), 60 MG/8 ML (0 MG/ML), 0 MG/ ML (0 MG/ML), 0 MG/ML, 0 MG/ML ( ML), 80 MG/4 ML (0 MG/ML), 80 MG/8 ML (0 MG/ML) doxorubicin intravenous recon soln 0, 50 doxorubicin intravenous solution 0 /5 ml, /ml, 0 /0 ml, 50 /5 ml DROXIA ORAL CAPSULE 00 MG, 300 MG, 400 MG EMCYT ORAL CAPSULE 40 MG epirubicin intravenous recon soln 00, 50 epirubicin intravenous solution 50 /5 ml ERIVEDGE ORAL CAPSULE 50 MG PA; SP ERLEADA ORAL TABLET 60 MG PA; SP etoposide intravenous solution 0 /ml etoposide oral capsule 50 exemestane oral tablet 5 FARESTON ORAL TABLET 60 MG FARYDAK ORAL CAPSULE 0 MG, 5 MG, 0 MG PA; SP FASLODEX INTRAMUSCULAR SYRINGE 50 MG/5 ML SP floxuridine injection recon soln 0.5 gram SP FLUOROPLEX TOPICAL CREAM % fluorouracil intravenous solution gram/0 ml,.5 gram/50 ml, 5 gram/00 ml, 500 /0 ml fluorouracil topical cream 5 % fluorouracil topical solution %, 5 % flutamide oral capsule 5 GILOTRIF ORAL TABLET 0 MG, 30 MG, 40 MG PA; SP; QL (30 per 30 days) HEXALEN ORAL CAPSULE 50 MG hydroxyurea oral capsule 500 IBRANCE ORAL CAPSULE 00 MG, 5 MG, 75 MG PA; SP ICLUSIG ORAL TABLET 5 MG PA; SP; QL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG PA; SP; QL (30 per 30 days) Updated: October, 08 3

22 idarubicin intravenous solution /ml IDHIFA ORAL TABLET 00 MG, 50 MG PA; SP ifosfamide intravenous recon soln gram, 3 gram ifosfamide intravenous solution gram/0 ml, 3 gram/60 ml ifosfamide-mesna intravenous kit - gram imatinib oral tablet 00 PA; SP imatinib oral tablet 400 PA; SP; QL (60 per 30 days) IMBRUVICA ORAL CAPSULE 40 MG, 70 MG PA; SP IMBRUVICA ORAL TABLET 40 MG, 80 MG, 40 MG, 560 MG PA; SP IMFINZI INTRAVENOUS SOLUTION 50 MG/ML SP INLYTA ORAL TABLET MG, 5 MG PA; SP INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), SP 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML SP IRESSA ORAL TABLET 50 MG PA; SP irinotecan intravenous solution 00 /5 ml, 40 / ml JAKAFI ORAL TABLET 0 MG, 5 MG, 0 MG, 5 MG, 5 MG PA; SP KADCYLA INTRAVENOUS RECON SOLN 00 MG, 60 MG PA; SP KEYTRUDA INTRAVENOUS SOLUTION 5 MG/ML LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (0 MG X -4 MG X), 0 MG/DAY (0 MG X ), 4 MG/DAY(0 MG X -4 MG X ), 8 MG/DAY (4 MG X ) PA LENVIMA ORAL CAPSULE MG/DAY (4 MG X 3), 4 MG PA; SP letrozole oral tablet.5 LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit /0. ml SP LONSURF ORAL TABLET MG, MG PA; SP LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG,.5 MG PA; SP Updated: October, 08 4

23 LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG PA; SP LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG PA; SP LUPRON DEPOT-PED INTRAMUSCULAR KIT.5 MG, 5 MG, 7.5 MG (PED) PA; SP LYNPARZA ORAL TABLET 00 MG, 50 MG PA; SP MATULANE ORAL CAPSULE 50 MG SP megestrol oral suspension 400 /0 ml (0 ml), 400 /0 ml (40 /ml), 800 /0 ml (0 ml) PA megestrol oral tablet 0, 40 PA MEKINIST ORAL TABLET 0.5 MG, MG PA; SP melphalan hcl intravenous recon soln 50 mercaptopurine oral tablet 50 methotrexate sodium (pf) injection recon soln gram methotrexate sodium (pf) injection solution 5 /ml methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 mitomycin intravenous recon soln 0, 40, 5 mitoxantrone intravenous concentrate /ml SP MYLERAN ORAL TABLET MG NERLYNX ORAL TABLET 40 MG PA; SP NEXAVAR ORAL TABLET 00 MG PA; SP nilutamide oral tablet 50 NINLARO ORAL CAPSULE.3 MG, 3 MG, 4 MG PA; SP; QL (3 per 30 days) OPDIVO INTRAVENOUS SOLUTION 00 MG/0 ML, 40 MG/4 ML oxaliplatin intravenous recon soln 00, 50 oxaliplatin intravenous solution 00 /0 ml, 50 /0 ml (5 /ml) paclitaxel intravenous concentrate 6 /ml PICATO TOPICAL GEL 0.05 %, 0.05 % POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG SP PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT SP REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG PA; SP Updated: October, 08 5

24 RITUXAN HYCELA SUBCUTANEOUS SOLUTION 400 MG/.7 ML (0 MG/ML), PA 600 MG/3.4 ML (0 MG/ML) RUBRACA ORAL TABLET 00 MG, 50 MG, 300 MG PA; SP RYDAPT ORAL CAPSULE 5 MG PA; SP SIKLOS ORAL TABLET 00 MG SPRYCEL ORAL TABLET 00 MG, 40 MG, 0 MG, 50 MG, 70 MG, 80 MG PA; SP STIVARGA ORAL TABLET 40 MG PA; SP SUTENT ORAL CAPSULE.5 MG, 5 MG, 37.5 MG, 50 MG PA; SP SYLATRON SUBCUTANEOUS KIT 00 MCG, 300 MCG, 600 MCG SP SYLVANT INTRAVENOUS RECON SOLN 00 MG, 400 MG SP TABLOID ORAL TABLET 40 MG TAFINLAR ORAL CAPSULE 50 MG, 75 MG PA; SP; QL (0 per 30 days) TAGRISSO ORAL TABLET 40 MG, 80 MG PA; SP; QL (30 per 30 days) tamoxifen oral tablet 0, 0 TARCEVA ORAL TABLET 00 MG, 50 MG, 5 MG PA; SP TARGRETIN TOPICAL GEL % TASIGNA ORAL CAPSULE 50 MG, 00 MG, 50 MG PA; SP TECENTRIQ INTRAVENOUS SOLUTION,00 MG/0 ML (60 MG/ML) SP TEMODAR INTRAVENOUS RECON SOLN 00 MG SP temozolomide oral capsule 00, 40, 80, 0, 50, 5 SP TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG TOPOSAR INTRAVENOUS SOLUTION 0 MG/ML tretinoin (chemotherapy) oral capsule 0 TYKERB ORAL TABLET 50 MG PA; SP UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML VALCHLOR TOPICAL GEL 0.06 % SP Updated: October, 08 6

25 VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (0 MG/ML), 400 MG/0 ML (0 SP MG/ML) VELCADE INJECTION RECON SOLN 3.5 MG SP VENCLEXTA ORAL TABLET 0 MG, 00 MG, 50 MG PA; SP VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 0 MG-50 MG- 00 MG PA; SP VERZENIO ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG PA; SP vinblastine intravenous solution /ml VINCASAR PFS INTRAVENOUS SOLUTION MG/ ML vincristine intravenous solution /ml, / ml vinorelbine intravenous solution 0 /ml, 50 /5 ml VOTRIENT ORAL TABLET 00 MG PA; SP XALKORI ORAL CAPSULE 00 MG, 50 MG PA; SP XTANDI ORAL CAPSULE 40 MG PA; SP YONDELIS INTRAVENOUS RECON SOLN MG PA ZEJULA ORAL CAPSULE 00 MG PA; QL (90 per 30 days) ZELBORAF ORAL TABLET 40 MG PA; SP ZOLINZA ORAL CAPSULE 00 MG SP ZYDELIG ORAL TABLET 00 MG, 50 MG PA ZYKADIA ORAL CAPSULE 50 MG PA; SP ZYTIGA ORAL TABLET 50 MG, 500 MG PA; SP ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES ACTHIB (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE LF-( MCG)-5LF/0.5 ML BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML Updated: October, 08 7

26 BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF- MCG-LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML GAMASTAN S/D INTRAMUSCULAR SOLUTION 5-8 % RANGE SP GAMMAGARD LIQUID INJECTION SOLUTION 0 % SP GAMMAGARD S-D (IGA < MCG/ML) INTRAVENOUS RECON SOLN 0 GRAM, 5 SP GRAM GAMUNEX-C INJECTION SOLUTION GRAM/0 ML (0 %), 0 GRAM/00 ML (0 %),.5 GRAM/5 ML (0 %), 0 GRAM/00 ML (0 %), 5 GRAM/50 ML (0 %) SP GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HAVRIX (PF) INTRAMUSCULAR SYRINGE,440 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HEPLISAV-B (PF) INTRAMUSCULAR SOLUTION 0 MCG/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML HIZENTRA SUBCUTANEOUS SOLUTION GRAM/5 ML (0 %), 0 GRAM/50 ML (0 %), GRAM/0 ML (0 %), 4 GRAM/0 ML (0 %) HYPERHEP B S/D INTRAMUSCULAR SOLUTION 0 UNIT/ML, 0 UNIT/ML (5 ML) HYPERHEP B S/D INTRAMUSCULAR SYRINGE 0 UNIT/ML HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE 0 UNIT/0.5 ML SP SP SP SP Updated: October, 08 8

27 HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 50 UNIT/ML SP HYPERRHO S/D INTRAMUSCULAR SYRINGE,500 UNIT (300 MCG), 50 UNIT (50 MCG) SP IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 5 LF-58 MCG-0 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 5 LF-58 MCG-0 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML MENVEO A-C-Y-W-35-DIP (PF) INTRAMUSCULAR KIT 0-5 MCG/0.5 ML MENVEO MENA COMPONENT (PF) INTRAMUSCULAR RECON SOLN 0 MCG /0.5 ML (FINAL) MENVEO MENCYW-35 COMPNT (PF) INTRAMUSCULAR RECON SOLN 5 MCG X 3/ 0.5 ML (FINAL) M-M-R II (PF) SUBCUTANEOUS RECON SOLN,000-,500 TCID50/0.5 ML ODACTRA SUBLINGUAL TABLET SQ-HDM PA PEDIARIX (PF) INTRAMUSCULAR SYRINGE 0 MCG-5LF-5 MCG-0LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML PENTACEL (PF) INTRAMUSCULAR KIT 5 LF UNIT-0 MCG-5 LF/0.5 ML PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN 0 MCG/0.5 ML PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML Updated: October, 08 9

28 PNEUMOVAX 3 INJECTION SOLUTION 5 MCG/0.5 ML PNEUMOVAX 3 INJECTION SYRINGE 5 MCG/0.5 ML PREVNAR 3 (PF) INTRAMUSCULAR SYRINGE 0.5 ML PRIVIGEN INTRAVENOUS SOLUTION 0 % SP PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 5 LF-48 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML, 40 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 0EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION ML SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,000 UNIT/0.5 ML TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5- LF UNIT/0.5 ML tetanus,diphtheria tox ped(pf) intramuscular suspension 5-5 lf unit/0.5 ml tetanus-diphtheria toxoids-td intramuscular suspension - lf unit/0.5 ml TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION 50 MG TRUMENBA INTRAMUSCULAR SYRINGE 0 MCG/0.5 ML Updated: October, 08 0

29 TWINRIX (PF) INTRAMUSCULAR SYRINGE 70 ELISA UNIT- 0 MCG/ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 5 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 5 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION,350 UNIT/0.5 ML VARIZIG INTRAMUSCULAR SOLUTION 5 UNIT/. ML VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X0EXP8 TO X 0EXP9 CF UNIT VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC) BILLION UNIT WINRHO SDF INJECTION SOLUTION,500 UNIT/.3 ML, 5,000 UNIT/3 ML,,500 SP UNIT/. ML, 5,000 UNIT/4.4 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 0 EXP4.74 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 9,400 UNIT/0.65 ML AUTONOMIC DRUGS acebutolol oral capsule 00, 400 albuterol sulfate inhalation solution for nebulization 0.63 /3 ml,.5 /3 ml,.5 /3 ml (0.083 %),.5 /0.5 ml, 5 /ml albuterol sulfate oral syrup /5 ml albuterol sulfate oral tablet, 4 albuterol sulfate oral tablet extended release hr 4, 8 ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION atenolol oral tablet 00, 5, 50 atenolol-chlorthalidone oral tablet 00-5, 50-5 atropine injection solution 0.4 /ml, /ml atropine injection syringe 0.05 /ml, 0. /ml baclofen oral tablet 0, 0 benztropine injection solution / ml Updated: October, 08

30 benztropine oral tablet 0.5,, betaxolol oral tablet 0, 0 bethanechol chloride oral tablet 0, 5, 5, 50 bisoprolol fumarate oral tablet 0, 5 bisoprolol-hydrochlorothiazide oral tablet 0-6.5,.5-6.5, BOTOX INJECTION RECON SOLN 00 UNIT, 00 UNIT PA; SP brompheniramine-pseudoeph-dm oral syrup /5 ml bupivacaine-epinephrine (pf) injection solution 0.5 %-:00,000, 0.5 %-:00,000 bupivacaine-epinephrine injection solution 0.5 %-:00,000, 0.5 %-:00,000 carvedilol oral tablet.5, 5, 3.5, 6.5 cevimeline oral capsule 30 CHANTIX ORAL TABLET 0.5 MG, MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG ()- MG (4) chlorzoxazone oral tablet 50, 500 clonidine (pf) epidural solution,000 mcg/0 ml (00 mcg/ml) clonidine hcl oral tablet 0., 0., 0.3 clonidine transdermal patch weekly 0. /4 hr, 0. /4 hr, 0.3 /4 hr QL (4 per 30 days) COMBIVENT RESPIMAT INHALATION MIST 0-00 MCG/ACTUATION QL (8 per 30 days) cyclobenzaprine oral tablet 0, 5 dantrolene oral capsule 00, 5, 50 dicyclomine oral capsule 0 dicyclomine oral solution 0 /5 ml dicyclomine oral tablet 0 dihydroergotamine injection solution /ml diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet dobutamine in d5w intravenous parenteral solution,000 /50 ml (4,000 mcg/ml), 50 /50 ml ( /ml), 500 /50 ml (,000 mcg/ml) Updated: October, 08

31 dobutamine intravenous solution 50 /0 ml (.5 /ml), 500 /40 ml (.5 /ml) donepezil oral tablet 0, 5 donepezil oral tablet,disintegrating 0, 5 dopamine in 5 % dextrose intravenous solution 00 /50 ml (800 mcg/ml), 400 /50 ml (,600 mcg/ml), 400 /500 ml (800 mcg/ml), 800 /50 ml (3,00 mcg/ml), 800 /500 ml (,600 mcg/ml) dopamine intravenous solution 00 /5 ml (40 /ml), 400 /0 ml (40 /ml), 400 /5 ml (80 /ml), 800 /0 ml (80 /ml), 800 /5 ml (60 /ml) doxazosin oral tablet, QL; QL (30 per 30 days) doxazosin oral tablet 4 QL (30 per 30 days) doxazosin oral tablet 8 QL; QL (60 per 30 days) DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION QL (3 per 30 days) DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION QL DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT, 500 UNIT PA; SP ED-SPAZ ORAL TABLET,DISINTEGRATING 0.5 MG ephedrine sulfate injection solution 50 /ml epinephrine injection solution /ml, /ml ( ml) epinephrine injection syringe 0. /ml EPIPEN -PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML QL ( per 30 days) EPIPEN INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML QL ( per 30 days) EPIPEN JR -PAK INJECTION AUTO- INJECTOR 0.5 MG/0.3 ML QL ( per 30 days) EPIPEN JR INJECTION AUTO-INJECTOR 0.5 MG/0.3 ML QL ( per 30 days) ergoloid oral tablet galantamine oral capsule,ext rel. pellets 4 hr 6, 4, 8 galantamine oral solution 4 /ml galantamine oral tablet, 4, 8 glycopyrrolate injection solution 0. /ml glycopyrrolate oral tablet, Updated: October, 08 3

32 guanidine oral tablet 5 hyoscyamine sulfate oral elixir 0.5 /5 ml hyoscyamine sulfate oral tablet 0.5 hyoscyamine sulfate oral tablet extended release hr hyoscyamine sulfate oral tablet,disintegrating 0.5 hyoscyamine sulfate sublingual tablet 0.5 ipratropium bromide inhalation solution 0.0 % ipratropium-albuterol inhalation solution for nebulization (.5 base)/3 ml labetalol intravenous solution 5 /ml labetalol intravenous syringe 0 /4 ml (5 /ml) labetalol oral tablet 00, 00, 300 lidocaine-epinephrine injection solution 0.5 %- :00,000, %-:00,000, %-:00,000 metaproterenol oral syrup 0 /5 ml metaproterenol oral tablet 0, 0 metaxalone oral tablet 800 methocarbamol oral tablet 500, 750 methscopolamine oral tablet.5, 5 methyldopa oral tablet 50, 500 methyldopa-hydrochlorothiazide oral tablet 50-5, 50-5 methyldopate intravenous solution 50 /5 ml metoprolol succinate oral tablet extended release 4 hr 00, 00, 5, 50 metoprolol ta-hydrochlorothiaz oral tablet 00-5, 00-50, 50-5 metoprolol tartrate intravenous solution 5 /5 ml metoprolol tartrate intravenous syringe 5 /5 ml metoprolol tartrate oral tablet 00, 5, 50 midodrine oral tablet 0,.5, 5 nadolol oral tablet 0, 40, 80 nadolol-bendroflumethiazide oral tablet 40-5, 80-5 NICOTROL INHALATION CARTRIDGE 0 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 0 MG/ML Updated: October, 08 4

33 norepinephrine bitartrate intravenous solution /ml orphenadrine citrate injection solution 30 /ml orphenadrine citrate oral tablet extended release 00 phenylephrine hcl injection solution 0 /ml physostigmine salicylate injection solution /ml pilocarpine hcl oral tablet 5, 7.5 pindolol oral tablet 0, 5 prazosin oral capsule,, 5 propantheline oral tablet 5 propranolol intravenous solution /ml propranolol oral capsule,extended release 4 hr 0, 60, 60, 80 propranolol oral solution 0 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 0, 40, 60, 80 propranolol-hydrochlorothiazid oral tablet 40-5, 80-5 pyridostigmine bromide oral tablet 60 REVONTO INTRAVENOUS RECON SOLN 0 MG rivastigmine tartrate oral capsule.5, 3, 4.5, 6 rivastigmine transdermal patch 4 hour 3.3 /4 hour, 4.6 /4 hr, 9.5 /4 hr SORINE ORAL TABLET 0 MG, 60 MG, 40 MG, 80 MG SOTALOL AF ORAL TABLET 0 MG, 60 MG, 80 MG sotalol oral tablet 0, 60, 40, 80 SPIRIVA RESPIMAT INHALATION MIST.5 MCG/ACTUATION,.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG QL (90 per 30 days) STRIVERDI RESPIMAT INHALATION MIST.5 MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, QL MCG/ACTUATION Updated: October, 08 5

34 tamsulosin oral capsule 0.4 terazosin oral capsule,, 5 QL (30 per 30 days) terazosin oral capsule 0 QL (60 per 30 days) terbutaline oral tablet.5, 5 terbutaline subcutaneous solution /ml timolol maleate oral tablet 0, 0, 5 tizanidine oral capsule, 4, 6 tizanidine oral tablet, 4 TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG trihexyphenidyl oral elixir 0.4 /ml trihexyphenidyl oral tablet, 5 VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION QL (36 per 30 days) XEOMIN INTRAMUSCULAR RECON SOLN 00 UNIT, 50 UNIT PA; SP BLOOD DERIVATIVES albumin, human 5 % intravenous parenteral solution 5 % ALBURX (HUMAN) 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % ALBUTEIN 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % ALBUTEIN 5 % INTRAVENOUS PARENTERAL SOLUTION 5 % BLOOD FORMATION, COAGULATION, THROMBOSIS ADVATE INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT SP ADYNOVATE INTRAVENOUS SOLUTION,000 (+/-) UNIT,,500 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT AFSTYLA INTRAVENOUS RECON SOLN,000 (+/-) UNIT RANGE,,500 (+/-) UNIT RANGE,,000 (+/-) UNIT RANGE,,500 (+/-) UNIT RANGE, 50 (+/-) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE SP Updated: October, 08 6

35 ALPHANATE INTRAVENOUS RECON SOLN,000 (400 VWF) UNIT/0 ML,,500 (600 VWF) UNIT/0 ML,,000 (800 VWF) UNIT/0 ML, 50 (00 VWF) UNIT/5 ML, 500 (00 VWF) UNIT/5 ML SP ALPHANINE SD INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT, 500 (+/-) SP UNIT ALPROLIX INTRAVENOUS RECON SOLN,000 UNIT,,000 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT ALPROLIX INTRAVENOUS RECON SOLN 50 UNIT SP aminocaproic acid intravenous solution 50 /ml anagrelide oral capsule 0.5, ARANESP (IN POLYSORBATE) INJECTION SOLUTION 00 MCG/ML, 50 MCG/0.75 ML, 00 MCG/ML, 5 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML PA; SP ARANESP (IN POLYSORBATE) INJECTION SYRINGE 00 MCG/0.5 ML, 50 MCG/0.3 ML, 00 MCG/0.4 ML, 5 MCG/0.4 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML PA; SP aspirin-dipyridamole oral capsule, er multiphase hr 5-00 BAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR MG BEBULIN INTRAVENOUS RECON SOLN 700 (+/-) UNIT SP BENEFIX INTRAVENOUS RECON SOLN,000 UNIT,,000 UNIT, 50 UNIT, 3,000 UNIT, 500 SP UNIT butalbital-aspirin-caffeine oral capsule butalbital-aspirin-caffeine oral tablet CATHFLO ACTIVASE INTRA-CATHETER RECON SOLN MG cilostazol oral tablet 00, 50 clopidogrel oral tablet 300, 75 COAGADEX INTRAVENOUS RECON SOLN 50 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE Updated: October, 08 7

36 CORIFACT INTRAVENOUS RECON SOLN,000-,600 UNIT SP desmopressin injection solution 4 mcg/ml PA desmopressin nasal spray,non-aerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0., 0. PA dipyridamole intravenous solution 5 /ml dipyridamole oral tablet 5, 50, 75 ELITE-OB 400 ORAL CAPSULE MG ELOCTATE INTRAVENOUS RECON SOLN,000 UNIT,,500 UNIT,,000 UNIT, 50 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT SP enoxaparin subcutaneous solution 300 /3 ml SP enoxaparin subcutaneous syringe 00 /ml, 0 /0.8 ml, 50 /ml, 30 /0.3 ml, 40 SP /0.4 ml, 60 /0.6 ml, 80 /0.8 ml EPOGEN INJECTION SOLUTION 0,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PA; SP FEIBA NF INTRAVENOUS RECON SOLN,750-3,50 UNIT, UNIT, 65-,00 SP UNIT FOLIVANE-OB ORAL CAPSULE 85- MG HELIXATE FS INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) SP UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT HEMLIBRA SUBCUTANEOUS SOLUTION 05 MG/0.7 ML, 50 MG/ML, 30 MG/ML, 60 MG/0.4 PA; SP ML HEMOFIL M HIGH INTRAVENOUS RECON SOLN 80-,500 UNIT SP HEMOFIL M LOW INTRAVENOUS RECON SOLN UNIT SP HEMOFIL M MID INTRAVENOUS RECON SOLN UNIT SP HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN,50-,000 UNIT SP HEP FLUSH-0 (PF) INTRAVENOUS SOLUTION 0 UNIT/ML Updated: October, 08 8

37 heparin (porcine) in 5 % dex intravenous parenteral solution 0,000 unit/500 ml (40 unit/ml), 5,000 unit/50 ml(00 unit/ml), 5,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml,,000 unit/,000 ml heparin (porcine) injection cartridge 5,000 unit/ml ( ml) heparin (porcine) injection solution,000 unit/ml, 0,000 unit/ml, 0,000 unit/ml, 5,000 unit/ml heparin flush(porcine)-0.9nacl intravenous kit 00 unit/ml heparin lock flush (porcine) intravenous syringe 00 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 0 UNIT/ML HEPARIN LOCK INTRAVENOUS SOLUTION 00 UNIT/ML HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 0 UNIT/ML, 00 UNIT/ML heparin(porcine) in 0.45% nacl intravenous parenteral solution 5,000 unit/50 ml, 5,000 unit/500 ml heparin, porcine (pf) injection solution,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml heparin, porcine (pf) intravenous syringe unit/ml, 00 unit/ml HUMATE-P INTRAVENOUS RECON SOLN,000-,400 UNIT, UNIT, 500-,00 SP UNIT IDELVION INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, SP 3,500 (+/-) UNIT, 500 (+/-) UNIT INFED INJECTION SOLUTION 50 MG/ML IXINITY INTRAVENOUS RECON SOLN,000 UNIT,,500 UNIT,,000 UNIT, 50 UNIT, 3,000 SP UNIT, 500 UNIT JANTOVEN ORAL TABLET MG, 0 MG, MG,.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG KOATE INTRAVENOUS RECON SOLN,000 (+/-) UNIT, 50 (+/-) UNIT, 500 (+/-) UNIT SP Updated: October, 08 9

38 KOGENATE FS INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) SP UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT KOVALTRY INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) SP UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT LEUKINE INJECTION RECON SOLN 50 MCG SP MONOCLATE-P INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT SP MONONINE INTRAVENOUS RECON SOLN,000 (+/-) UNIT SP MOZOBIL SUBCUTANEOUS SOLUTION 4 MG/. ML (0 MG/ML) SP MYNATAL ADVANCE ORAL TABLET MG MYNATAL ORAL CAPSULE 65 MG IRON- MG MYNATAL PLUS ORAL TABLET 65 MG IRON- MG MYNATAL-Z ORAL TABLET 65 MG IRON- MG NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML PA; SP; QL ( per 30 days) NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML PA; SP; QL ( per 30 days) NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/.6 ML PA; SP NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PA; SP NOVOEIGHT INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT NOVOSEVEN RT INTRAVENOUS RECON SOLN MG (,000 MCG), MG (,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG) NUWIQ INTRAVENOUS RECON SOLN 000 (+/-) UNIT,,000 (+/-) UNIT,,500 UNIT, 50 (+/- ) UNIT, 3,000 UNIT, 4,000 UNIT, 500 (+/-) UNIT OBIZUR INTRAVENOUS RECON SOLN 500 (+/- ) UNIT RANGE pentoxifylline oral tablet extended release 400 PNV OB+DHA ORAL COMBO PACK MG SP SP Updated: October, 08 30

39 PNV-DHA + DOCUSATE ORAL CAPSULE MG PNV-DHA ORAL CAPSULE 7 MG IRON- MG MG PNV-OMEGA ORAL CAPSULE MG PNV-SELECT ORAL TABLET 7- MG PR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 400 ORAL COMBO PACK MG PR NATAL 430 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 430 ORAL COMBO PACK 9 MG IRON- MG -430 MG PRADAXA ORAL CAPSULE 0 MG, 50 MG, 75 MG prasugrel oral tablet 0, 5 PRENAISSANCE ORAL CAPSULE MG PRENAISSANCE PLUS ORAL CAPSULE MG PRENATABS FA ORAL TABLET 9- MG PRENATABS RX ORAL TABLET 9 MG IRON- MG PRENATAL LOW IRON ORAL TABLET 7 MG IRON- MG PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 7 MG IRON- MG PRENATAL PLUS ORAL TABLET 9 MG IRON- MG PROCRIT INJECTION SOLUTION 0,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML PA; SP PROFILNINE INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT, 500 (+/-) UNIT PROMACTA ORAL TABLET.5 MG, 5 MG, 50 MG, 75 MG REBINYN INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,000 (+/-) UNIT, 500 (+/-) UNIT RECOMBINATE INTRAVENOUS RECON SOLN,000 (+/-) UNIT,,500 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 500 (+/-) UNIT Updated: October, 08 SP PA; SP SP SP 3

40 RIXUBIS INTRAVENOUS RECON SOLN,000 UNIT,,000 UNIT, 50 UNIT, 3,000 UNIT, 500 SP UNIT SE-NATAL 9 (WITH DOCUSATE) ORAL TABLET 9 MG IRON- MG-5 MG SE-NATAL 9 ORAL TABLET,CHEWABLE 9 MG IRON- MG TARON-C DHA ORAL CAPSULE MG TARON-PREX PRENATAL-DHA ORAL CAPSULE 30 MG IRON-. MG-55 MG-65 MG TL-SELECT ORAL CAPSULE MG TRETTEN INTRAVENOUS RECON SOLN,500 UNIT SP TRIADVANCE ORAL TABLET MG TRINATAL RX ORAL TABLET 60 MG IRON- MG TRINATE ORAL TABLET 8 MG IRON- MG TRIVEEN-DUO DHA ORAL COMBO PACK MG TRIVEEN-ONE ORAL CAPSULE 7 MG IRON- MG -50 MG TRIVEEN-PRX RNF ORAL CAPSULE MG VENA-BAL DHA ORAL COMBO PACK,TABLET AND CAP,DR MG VENOFER INTRAVENOUS SOLUTION 00 MG IRON/5 ML, 00 MG IRON/0 ML, 50 MG IRON/.5 ML VINACAL ORAL TABLET MG VINATE CARE ORAL TABLET,CHEWABLE 40 MG IRON- MG VINATE GT ORAL TABLET MG VINATE M ORAL TABLET 7 MG IRON- MG VINATE ONE ORAL TABLET 60 MG IRON- MG VINATE ULTRA ORAL TABLET MG VIRT-PN DHA ORAL CAPSULE 7 MG IRON- MG -300 MG VIRT-PN ORAL TABLET 7- MG VIRT-PN PLUS ORAL CAPSULE MG VIRT-SELECT ORAL CAPSULE MG Updated: October, 08 3

41 VITAFOL-OB ORAL TABLET 65- MG VOL-NATE ORAL TABLET 8 MG IRON- MG VOL-TAB RX ORAL TABLET 9 MG IRON- MG VONVENDI INTRAVENOUS RECON SOLN,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE warfarin oral tablet, 0,,.5, 3, 4, 5, 6, 7.5 WILATE INTRAVENOUS RECON SOLN,000-,000 UNIT, UNIT, UNIT, 900- SP 900 UNIT XARELTO ORAL TABLET 0 MG, 5 MG, 0 MG XARELTO ORAL TABLETS,DOSE PACK 5 MG (4)- 0 MG (9) XYNTHA INTRAVENOUS SOLUTION,000 (+/-) UNIT,,000 (+/-) UNIT, 50 (+/-) UNIT, 500 (+/-) SP UNIT XYNTHA SOLOFUSE INTRAVENOUS SYRINGE,000 (+/-) UNIT,,000 (+/-) UNIT, SP 50 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PA; SP ZATEAN-PN DHA ORAL CAPSULE 7 MG IRON- MG -300 MG ZATEAN-PN PLUS ORAL CAPSULE MG CARDIOVASCULAR DRUGS acebutolol oral capsule 00, 400 acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 5, 50 acetazolamide sodium injection recon soln 500 adenosine (diagnostic) intravenous solution 3 /ml adenosine intravenous solution 3 /ml alprostadil injection solution 500 mcg/ml amiloride-hydrochlorothiazide oral tablet 5-50 amiodarone intravenous solution 50 /ml amiodarone oral tablet 00, 00, 400 amlodipine oral tablet 0,.5, 5 Updated: October, 08 33

42 amlodipine-benazepril oral capsule 0-0, 0-40,.5-0, 5-0, 5-0, 5-40 aspirin-dipyridamole oral capsule, er multiphase hr 5-00 atenolol oral tablet 00, 5, 50 atenolol-chlorthalidone oral tablet 00-5, 50-5 atorvastatin oral tablet 0, 0, 40, 80 QL; QL (60 per 30 days) benazepril oral tablet 0, 0, 40, 5 benazepril-hydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5, betaxolol oral tablet 0, 0 bisoprolol fumarate oral tablet 0, 5 bisoprolol-hydrochlorothiazide oral tablet 0-6.5,.5-6.5, bumetanide injection solution 0.5 /ml bumetanide oral tablet 0.5,, captopril oral tablet 00,.5, 5, 50 captopril-hydrochlorothiazide oral tablet 5-5, 5-5, 50-5, 50-5 CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 4HR 0 MG, 80 MG, 40 MG, 300 MG carvedilol oral tablet.5, 5, 3.5, 6.5 chlorothiazide oral tablet 50, 500 chlorthalidone oral tablet 5, 50 cholestyramine (with sugar) oral powder 4 gram cholestyramine (with sugar) oral powder in packet 4 gram CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM cilostazol oral tablet 00, 50 clonidine (pf) epidural solution,000 mcg/0 ml (00 mcg/ml) clonidine hcl oral tablet 0., 0., 0.3 clonidine transdermal patch weekly 0. /4 hr, 0. /4 hr, 0.3 /4 hr QL (4 per 30 days) Updated: October, 08 34

43 colesevelam oral powder in packet 3.75 gram colesevelam oral tablet 65 colestipol oral granules 5 gram colestipol oral packet 5 gram colestipol oral tablet gram CORLANOR ORAL TABLET 5 MG, 7.5 MG PA DIGOX ORAL TABLET 5 MCG, 50 MCG digoxin injection solution 50 mcg/ml digoxin injection syringe 50 mcg/ml digoxin oral solution 50 mcg/ml digoxin oral tablet 5 mcg, 50 mcg DILANTIN ORAL CAPSULE 30 MG diltiazem hcl intravenous recon soln 00 diltiazem hcl intravenous solution 5 /ml diltiazem hcl oral capsule,ext.rel 4h degradable 0, 80, 40 diltiazem hcl oral capsule,extended release hr 0, 60, 90 diltiazem hcl oral capsule,extended release 4 hr 0, 80, 40, 300, 360, 40 diltiazem hcl oral capsule,extended release 4hr 0, 80, 40, 300, 360 diltiazem hcl oral tablet 0, 30, 60, 90 DILT-XR ORAL CAPSULE,EXT.REL 4H DEGRADABLE 0 MG, 80 MG, 40 MG dipyridamole intravenous solution 5 /ml dipyridamole oral tablet 5, 50, 75 disopyramide phosphate oral capsule 00, 50 dobutamine in d5w intravenous parenteral solution,000 /50 ml (4,000 mcg/ml), 50 /50 ml ( /ml), 500 /50 ml (,000 mcg/ml) dobutamine intravenous solution 50 /0 ml (.5 /ml), 500 /40 ml (.5 /ml) dofetilide oral capsule 5 mcg, 50 mcg, 500 mcg Updated: October, 08 35

44 dopamine in 5 % dextrose intravenous solution 00 /50 ml (800 mcg/ml), 400 /50 ml (,600 mcg/ml), 400 /500 ml (800 mcg/ml), 800 /50 ml (3,00 mcg/ml), 800 /500 ml (,600 mcg/ml) dopamine intravenous solution 00 /5 ml (40 /ml), 400 /0 ml (40 /ml), 400 /5 ml (80 /ml), 800 /0 ml (80 /ml), 800 /5 ml (60 /ml) doxazosin oral tablet, QL; QL (30 per 30 days) doxazosin oral tablet 4 QL (30 per 30 days) doxazosin oral tablet 8 QL; QL (60 per 30 days) enalapril maleate oral tablet 0,.5, 0, 5 enalaprilat intravenous solution.5 /ml enalapril-hydrochlorothiazide oral tablet 0-5, 5-.5 ENTRESTO ORAL TABLET 4-6 MG, 49-5 MG, MG eplerenone oral tablet 5, 50 epoprostenol (glycine) intravenous recon soln 0.5,.5 SP ezetimibe oral tablet 0 QL (30 per 30 days) felodipine oral tablet extended release 4 hr 0,.5, 5 fenofibrate micronized oral capsule 30, 34, 00, 43, 67 fenofibrate nanocrystallized oral tablet 45, 48 fenofibrate oral tablet 60, 54 fenofibric acid (choline) oral capsule,delayed release(dr/ec) 35, 45 FISH OIL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0 MG-80 MG- 60 MG-,00 MG flecainide oral tablet 00, 50, 50 fosinopril oral tablet 0, 0, 40 fosinopril-hydrochlorothiazide oral tablet 0-.5, 0-.5 furosemide injection solution 0 /ml furosemide injection syringe 0 /ml furosemide oral solution 0 /ml, 40 /5 ml (8 /ml) Updated: October, 08 36

45 furosemide oral tablet 0, 40, 80 gemfibrozil oral tablet 600 guanfacine oral tablet, guanfacine oral tablet extended release 4 hr,, 3, 4 hydralazine injection solution 0 /ml hydralazine oral tablet 0, 00, 5, 50 hydrochlorothiazide oral capsule.5 hydrochlorothiazide oral tablet.5, 5, 50 indapamide oral tablet.5,.5 irbesartan oral tablet 50, 300, 75 irbesartan-hydrochlorothiazide oral tablet 50-.5, isosorbide dinitrate oral tablet 0, 0, 30, 5 isosorbide dinitrate oral tablet extended release 40 isosorbide mononitrate oral tablet 0, 0 isosorbide mononitrate oral tablet extended release 4 hr 0, 30, 60 isradipine oral capsule.5, 5 labetalol intravenous solution 5 /ml labetalol intravenous syringe 0 /4 ml (5 /ml) labetalol oral tablet 00, 00, 300 LETAIRIS ORAL TABLET 0 MG, 5 MG PA; SP lidocaine (pf) intravenous solution 0 /ml ( %) lidocaine (pf) intravenous syringe 00 /5 ml ( %), 50 /5 ml ( %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 /ml (0.8 %) lisinopril oral tablet 0,.5, 0, 30, 40, 5 lisinopril-hydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5 losartan oral tablet 00, 5, 50 losartan-hydrochlorothiazide oral tablet 00-.5, 00-5, lovastatin oral tablet 0 QL (30 per 30 days) Updated: October, 08 37

46 lovastatin oral tablet 0, 40 QL (60 per 30 days) magnesium sulfate in water intravenous parenteral solution 0 gram/500 ml (4 %), 40 gram/,000 ml (4 %) magnesium sulfate in water intravenous piggyback gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml mannitol 0 % intravenous parenteral solution 0 % mannitol 0 % intravenous parenteral solution 0 % mannitol 5 % intravenous solution 5 % mannitol 5 % intravenous parenteral solution 5 % methyldopa oral tablet 50, 500 methyldopa-hydrochlorothiazide oral tablet 50-5, 50-5 methyldopate intravenous solution 50 /5 ml metolazone oral tablet 0,.5, 5 metoprolol succinate oral tablet extended release 4 hr 00, 00, 5, 50 metoprolol ta-hydrochlorothiaz oral tablet 00-5, 00-50, 50-5 metoprolol tartrate intravenous solution 5 /5 ml metoprolol tartrate intravenous syringe 5 /5 ml metoprolol tartrate oral tablet 00, 5, 50 mexiletine oral capsule 50, 00, 50 milrinone in 5 % dextrose intravenous piggyback 0 /00 ml (00 mcg/ml), 40 /00 ml (00 mcg/ml) milrinone intravenous solution /ml minoxidil oral tablet 0,.5 moexipril oral tablet 5, 7.5 moexipril-hydrochlorothiazide oral tablet 5-.5, 5-5, nadolol oral tablet 0, 40, 80 nadolol-bendroflumethiazide oral tablet 40-5, 80-5 nicardipine intravenous solution 5 /0 ml Updated: October, 08 38

47 nicardipine oral capsule 0, 30 nifedipine oral capsule 0, 0 nifedipine oral tablet extended release 4hr 30, 60, 90 nifedipine oral tablet extended release 30, 60, 90 nimodipine oral capsule 30 NITRO-BID TRANSDERMAL OINTMENT % nitroglycerin in 5 % dextrose intravenous solution 00 /50 ml (400 mcg/ml), 00 /500 ml (400 mcg/ml), 50 /50 ml (00 mcg/ml) nitroglycerin intravenous solution 50 /0 ml (5 /ml) nitroglycerin sublingual tablet 0.3, 0.4, 0.6 nitroglycerin transdermal patch 4 hour 0. /hr, 0. /hr, 0.4 /hr, 0.6 /hr nitroglycerin translingual spray,non-aerosol 400 mcg/spray omega-3 acid ethyl esters oral capsule gram PA papaverine injection solution 30 /ml perindopril erbumine oral tablet, 4, 8 phenytoin oral suspension 00 /4 ml, 5 /5 ml phenytoin oral tablet,chewable 50 phenytoin sodium extended oral capsule 00, 00, 300 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml pindolol oral tablet 0, 5 PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML, 75 MG/ML PA; SP pravastatin oral tablet 0 QL (60 per 30 days) pravastatin oral tablet 0, 40, 80 QL; QL (60 per 30 days) prazosin oral capsule,, 5 procainamide injection solution 00 /ml, 500 /ml propafenone oral tablet 50, 5, 300 propranolol intravenous solution /ml propranolol oral capsule,extended release 4 hr 0, 60, 60, 80 Updated: October, 08 39

48 propranolol oral solution 0 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 0, 40, 60, 80 propranolol-hydrochlorothiazid oral tablet 40-5, 80-5 quinapril oral tablet 0, 0, 40, 5 quinapril-hydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5 quinidine gluconate injection solution 80 /ml quinidine gluconate oral tablet extended release 34 quinidine sulfate oral tablet 00, 300 ramipril oral capsule.5, 0,.5, 5 REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 40 MG/3.5 ML PA REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 40 MG/ML PA; SP REPATHA SYRINGE SUBCUTANEOUS SYRINGE 40 MG/ML PA rosuvastatin oral tablet 0, 0, 40, 5 ST; QL (30 per 30 days) sildenafil (antihypertensive) intravenous solution 0 /.5 ml PA; SP sildenafil (antihypertensive) oral tablet 0 PA; SP; QL simvastatin oral tablet 0, 0, 40, 5, 80 QL; QL (60 per 30 days) SORINE ORAL TABLET 0 MG, 60 MG, 40 MG, 80 MG SOTALOL AF ORAL TABLET 0 MG, 60 MG, 80 MG sotalol oral tablet 0, 60, 40, 80 spironolactone oral tablet 00, 5, 50 spironolacton-hydrochlorothiaz oral tablet 5-5 tadalafil (antihypertensive) oral tablet 0 PA; SP; QL (60 per 30 days) terazosin oral capsule,, 5 QL (30 per 30 days) terazosin oral capsule 0 QL (60 per 30 days) THEOCHRON ORAL TABLET EXTENDED RELEASE HR 00 MG, 00 MG, 300 MG Updated: October, 08 40

49 theophylline oral elixir 80 /5 ml theophylline oral solution 80 /5 ml theophylline oral tablet extended release hr 00, 00, 300, 450 theophylline oral tablet extended release 4 hr 400, 600 timolol maleate oral tablet 0, 0, 5 torsemide oral tablet 0, 00, 0, 5 TRACLEER ORAL TABLET 5 MG, 6.5 MG PA; SP TRACLEER ORAL TABLET FOR SUSPENSION 3 MG PA; SP trandolapril oral tablet,, 4 triamterene-hydrochlorothiazid oral capsule , 50-5 triamterene-hydrochlorothiazid oral tablet , UPTRAVI ORAL TABLET,000 MCG,,00 MCG,,400 MCG,,600 MCG, 00 MCG, 400 PA MCG, 600 MCG, 800 MCG UPTRAVI ORAL TABLETS,DOSE PACK 00 MCG (40)- 800 MCG (60) PA valsartan oral tablet 60, 30, 40, 80 valsartan-hydrochlorothiazide oral tablet 60-.5, 60-5, 30-.5, 30-5, VELETRI INTRAVENOUS RECON SOLN 0.5 MG,.5 MG SP verapamil intravenous solution.5 /ml verapamil intravenous syringe.5 /ml verapamil oral capsule, 4 hr er pellet ct 00, 00, 300 verapamil oral capsule,ext rel. pellets 4 hr 0, 80, 40, 360 verapamil oral tablet 0, 40, 80 verapamil oral tablet extended release 0, 80, 40 CENTRAL NERVOUS SYSTEM AGENTS ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG Updated: October, 08 4

50 ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG acamprosate oral tablet,delayed release (dr/ec) 333 acetaminophen-codeine oral solution 0 - /5 ml (5 ml), 0- /5 ml, QL (4500 per 30 days) /.5 ml acetaminophen-codeine oral tablet 300-5, QL (360 per 30 days) acetaminophen-codeine oral tablet QL (80 per 30 days) AIMOVIG AUTOINJECTOR ( PACK) SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML PA AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 MG/ML PA alprazolam oral tablet 0.5, 0.5,, amantadine hcl oral capsule 00 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 00 amitriptyline oral tablet 0, 00, 50, 5, 50, 75 amitriptyline-chlordiazepoxide oral tablet.5-5, 5-0 amoxapine oral tablet 00, 50, 5, 50 aripiprazole oral solution /ml ST aripiprazole oral tablet 0, 5,, 0, 30 ST; QL (30 per 30 days) aripiprazole oral tablet 5 ST; QL (60 per 30 days) aripiprazole oral tablet,disintegrating 0, 5 ST; QL (60 per 30 days) ASCOMP WITH CODEINE ORAL CAPSULE MG QL (80 per 30 days) aspirin-dipyridamole oral capsule, er multiphase hr 5-00 atomoxetine oral capsule 0 QL (300 per 30 days) atomoxetine oral capsule 00 QL (30 per 30 days) atomoxetine oral capsule 8 QL (66 per 30 days) atomoxetine oral capsule 5 QL (0 per 30 days) atomoxetine oral capsule 40 QL (75 per 30 days) atomoxetine oral capsule 60 QL (50 per 30 days) Updated: October, 08 4

51 atomoxetine oral capsule 80 QL (37 per 30 days) AUSTEDO ORAL TABLET MG, 6 MG, 9 MG PA; SP BANZEL ORAL SUSPENSION 40 MG/ML PA BANZEL ORAL TABLET 00 MG, 400 MG PA belladonna alkaloids-opium rectal suppository QL (0 per 30 days) BELLADONNA-OPIUM RECTAL SUPPOSITORY MG QL (0 per 30 days) benztropine injection solution / ml benztropine oral tablet 0.5,, bromocriptine oral tablet.5 buprenorphine hcl injection syringe 0.3 /ml buprenorphine hcl sublingual tablet QL (360 per 30 days) buprenorphine hcl sublingual tablet 8 QL (90 per 30 days) buprenorphine-naloxone sublingual tablet -0.5 QL (360 per 30 days) buprenorphine-naloxone sublingual tablet 8- QL (90 per 30 days) bupropion hcl (smoking deter) oral tablet extended release hr 50 QL (60 per 30 days) bupropion hcl oral tablet 00, 75 bupropion hcl oral tablet extended release 4 hr 50 QL (30 per 30 days) bupropion hcl oral tablet extended release 4 hr 300 QL; QL (30 per 30 days) bupropion hcl oral tablet sustained-release hr 00, 50 QL; QL (60 per 30 days) bupropion hcl oral tablet sustained-release hr 00 QL (60 per 30 days) buspirone oral tablet 0, 5, 30, 5, 7.5 BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE MG QL (80 per 30 days) butalbital-acetaminop-caf-cod oral capsule QL (80 per 30 days) butalbital-acetaminophen oral tablet QL (80 per 30 days) butalbital-acetaminophen-caff oral capsule QL (80 per 30 days) butalbital-acetaminophen-caff oral tablet QL (80 per 30 days) butalbital-aspirin-caffeine oral capsule cabergoline oral tablet 0.5 Updated: October, 08 43

52 caffeine citrate intravenous solution 60 /3 ml (0 /ml) caffeine citrate oral solution 60 /3 ml (0 /ml) carbamazepine oral capsule, er multiphase hr 00, 00, 300 carbamazepine oral suspension 00 /5 ml carbamazepine oral tablet 00 carbamazepine oral tablet extended release hr 00, 00, 400 carbamazepine oral tablet,chewable 00 carbidopa-levodopa oral tablet 0-00, 5-00, 5-50 carbidopa-levodopa oral tablet extended release 5-00, carbidopa-levodopa oral tablet,disintegrating 0-00, 5-00, 5-50 carbidopa-levodopa-entacapone oral tablet , , , , , celecoxib oral capsule 00, 00, 400, 50 ST CELONTIN ORAL CAPSULE 300 MG chlordiazepoxide hcl oral capsule 0, 5, 5 chlorpromazine injection solution 5 /ml chlorpromazine oral tablet 0, 00, 00, 5, 50 choline,magnesium salicylate oral liquid 500 /5 ml citalopram oral solution 0 /5 ml citalopram oral tablet 0, 0, 40 QL (30 per 30 days) clomipramine oral capsule 5, 50, 75 clonazepam oral tablet 0.5,, clonazepam oral tablet,disintegrating 0.5, 0.5, 0.5,, clonidine (pf) epidural solution,000 mcg/0 ml (00 mcg/ml) clorazepate dipotassium oral tablet 5, 3.75, 7.5 clozapine oral tablet 00, 00, 5, 50 Updated: October, 08 44

53 clozapine oral tablet,disintegrating 00,.5, 5 ST codeine sulfate oral tablet 5, 30, 60 QL (80 per 30 days) COMPRO RECTAL SUPPOSITORY 5 MG desipramine oral tablet 0, 00, 50, 5, 50, 75 desvenlafaxine succinate oral tablet extended release 4 hr 00, 5, 50 ST; QL (30 per 30 days) dexmethylphenidate oral tablet 0,.5, 5 QL dextroamphetamine oral capsule, extended release 0 QL (80 per 30 days) dextroamphetamine oral capsule, extended release 5 QL (0 per 30 days) dextroamphetamine oral capsule, extended release 5 QL (360 per 30 days) dextroamphetamine oral tablet 0 QL (80 per 30 days) dextroamphetamine oral tablet 5 QL (360 per 30 days) dextroamphetamine-amphetamine oral capsule,extended release 4hr 0 QL (80 per 30 days) dextroamphetamine-amphetamine oral capsule,extended release 4hr 5 QL (0 per 30 days) dextroamphetamine-amphetamine oral capsule,extended release 4hr 0 QL (90 per 30 days) dextroamphetamine-amphetamine oral capsule,extended release 4hr 5 QL (7 per 30 days) dextroamphetamine-amphetamine oral capsule,extended release 4hr 30 QL (60 per 30 days) dextroamphetamine-amphetamine oral capsule,extended release 4hr 5 QL (360 per 30 days) dextroamphetamine-amphetamine oral tablet 0 QL (80 per 30 days) dextroamphetamine-amphetamine oral tablet.5 QL (44 per 30 days) dextroamphetamine-amphetamine oral tablet 5 QL (0 per 30 days) dextroamphetamine-amphetamine oral tablet 0 QL (90 per 30 days) dextroamphetamine-amphetamine oral tablet 30 QL (60 per 30 days) dextroamphetamine-amphetamine oral tablet 5 QL (360 per 30 days) Updated: October, 08 45

54 dextroamphetamine-amphetamine oral tablet 7.5 QL (40 per 30 days) diazepam injection solution 5 /ml diazepam injection syringe 5 /ml DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML diazepam oral solution 5 /5 ml ( /ml), 5 /5 ml ( /ml, 5 ml) diazepam oral tablet 0,, 5 diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended release 4 hr 00 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical gel % diflunisal oral tablet 500 dihydroergotamine injection solution /ml DILANTIN ORAL CAPSULE 30 MG DISKETS ORAL TABLET,SOLUBLE 40 MG QL (30 per 30 days) divalproex oral capsule, delayed rel sprinkle 5 divalproex oral tablet extended release 4 hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 5, 50, 500 doxepin oral capsule 0, 00, 50, 5, 50, 75 doxepin oral concentrate 0 /ml droperidol injection solution.5 /ml duloxetine oral capsule,delayed release(dr/ec) 0 QL (60 per 30 days) duloxetine oral capsule,delayed release(dr/ec) 30, 60 QL; QL (30 per 30 days) duloxetine oral capsule,delayed release(dr/ec) 40 ENDOCET ORAL TABLET 0-35 MG, 5-35 MG, MG QL (360 per 30 days) entacapone oral tablet 00 EPITOL ORAL TABLET 00 MG escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 0, 0, 5 QL (30 per 30 days) Updated: October, 08 46

55 estazolam oral tablet, eszopiclone oral tablet,, 3 ST; QL (30 per 30 days) ethosuximide oral capsule 50 ethosuximide oral solution 50 /5 ml etodolac oral capsule 00, 300 etodolac oral tablet 400, 500 etodolac oral tablet extended release 4 hr 400, 500, 600 EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML felbamate oral suspension 600 /5 ml felbamate oral tablet 400, 600 FELBATOL ORAL SUSPENSION 600 MG/5 ML fentanyl citrate buccal lozenge on a handle,00 mcg PA; QL (39 per 30 days) fentanyl citrate buccal lozenge on a handle,600 mcg PA; QL (9 per 30 days) fentanyl citrate buccal lozenge on a handle 00 mcg PA; QL (0 per 30 days) fentanyl citrate buccal lozenge on a handle 400 mcg PA; QL (6 per 30 days) fentanyl citrate buccal lozenge on a handle 600 mcg PA; QL (77 per 30 days) fentanyl citrate buccal lozenge on a handle 800 mcg PA; QL (58 per 30 days) fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr QL (0 per 30 days) FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK 0 MG ()- 40 MG (6) ST FETZIMA ORAL CAPSULE,EXTENDED RELEASE 4 HR 0 MG, 0 MG, 40 MG, 80 ST MG flumazenil intravenous solution 0. /ml fluoxetine oral capsule 0 QL (30 per 30 days) fluoxetine oral capsule 0 fluoxetine oral capsule 40 QL (60 per 30 days) fluoxetine oral solution 0 /5 ml (4 /ml) fluphenazine decanoate injection solution 5 /ml fluphenazine hcl injection solution.5 /ml fluphenazine hcl oral concentrate 5 /ml Updated: October, 08 47

56 fluphenazine hcl oral elixir.5 /5 ml fluphenazine hcl oral tablet, 0,.5, 5 flurazepam oral capsule 5, 30 flurbiprofen oral tablet 00, 50 fluvoxamine oral tablet 00 QL (90 per 30 days) fluvoxamine oral tablet 5 QL (30 per 30 days) fluvoxamine oral tablet 50 QL (60 per 30 days) fosphenytoin injection solution 00 pe/ ml, 500 pe/0 ml FYCOMPA ORAL TABLET 0 MG, MG, MG, 4 MG, 6 MG, 8 MG PA gabapentin oral capsule 00, 300, 400 gabapentin oral solution 50 /5 ml, 50 /5 ml (5 ml), 300 /6 ml (6 ml) gabapentin oral tablet 600, 800 GABITRIL ORAL TABLET MG, 6 MG guanfacine oral tablet, haloperidol decanoate intramuscular solution 00 /ml, 50 /ml haloperidol lactate injection solution 5 /ml haloperidol lactate oral concentrate /ml haloperidol oral tablet 0.5,, 0,, 0, 5 hydrocodone-acetaminophen oral solution /5 ml QL (5550 per 30 days) hydrocodone-acetaminophen oral tablet 0-300, 0-35,.5-35, 5-300, 5-35 QL (360 per 30 days), , hydrocodone-ibuprofen oral tablet 0-00, 5-00, QL (50 per 30 days) hydromorphone oral liquid /ml QL (500 per 30 days) hydromorphone oral tablet, 4, 8 QL (80 per 30 days) hydromorphone rectal suppository 3 QL (0 per 30 days) hydroxyzine hcl intramuscular solution 5 /ml hydroxyzine hcl oral solution 0 /5 ml hydroxyzine hcl oral tablet 0, 5, 50 hydroxyzine pamoate oral capsule 00, 5, 50 ibuprofen oral tablet 400, 600, 800 Updated: October, 08 48

57 imipramine hcl oral tablet 0, 5, 50 imipramine pamoate oral capsule 00, 5, 50, 75 indomethacin oral capsule 5, 50 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 7 MG/0.75 ML, 56 MG/ML, 34 MG/.5 ML, 39 MG/0.5 ML, 78 MG/0.5 ML ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets 4 hr 00 ketorolac injection cartridge 5 /ml, 30 /ml ketorolac injection solution 5 /ml, 30 /ml, 30 /ml ( ml) ketorolac intramuscular solution 60 / ml ketorolac oral tablet 0 QL (0 per 30 days) lamotrigine oral tablet 00, 50, 00, 5 lamotrigine oral tablet, chewable dispersible 5, 5 LATUDA ORAL TABLET 0 MG, 0 MG, 40 MG, 60 MG ST; QL (30 per 30 days) LATUDA ORAL TABLET 80 MG ST; QL (60 per 30 days) levetiracetam intravenous solution 500 /5 ml levetiracetam oral solution 00 /ml, 500 /5 ml (5 ml) levetiracetam oral tablet,000, 50, 500, 750 levetiracetam oral tablet extended release 4 hr 500, 750 levorphanol tartrate oral tablet QL (0 per 30 days) lithium carbonate oral capsule 50, 300, 600 lithium carbonate oral tablet 300 lithium carbonate oral tablet extended release 300, 450 lithium citrate oral solution 8 meq/5 ml lorazepam injection solution /ml, 4 /ml lorazepam injection syringe /ml, 4 /ml LORAZEPAM INTENSOL ORAL CONCENTRATE MG/ML lorazepam oral concentrate /ml lorazepam oral tablet 0.5,, Updated: October, 08 49

58 LORCET (HYDROCODONE) ORAL TABLET 5-35 MG QL (360 per 30 days) LORCET HD ORAL TABLET 0-35 MG QL (360 per 30 days) loxapine succinate oral capsule 0, 5, 5, 50 LYRICA ORAL CAPSULE 00 MG, 50 MG, 00 MG, 5 MG, 5 MG, 300 MG, 50 MG, 75 MG PA magnesium chloride injection solution 00 /ml (0 %) magnesium sulfate in water intravenous parenteral solution 0 gram/500 ml (4 %), 40 gram/,000 ml (4 %) magnesium sulfate in water intravenous piggyback gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml maprotiline oral tablet 5, 50, 75 meclofenamate oral capsule 00, 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 5 meloxicam oral tablet 7.5 QL (30 per 30 days) memantine oral solution /ml memantine oral tablet 0, 5 memantine oral tablets,dose pack 5-0 meperidine oral solution 50 /5 ml QL (00 per 30 days) meperidine oral tablet 00 QL (0 per 30 days) meperidine oral tablet 50 QL (40 per 30 days) meprobamate oral tablet 00, 400 METADATE ER ORAL TABLET EXTENDED RELEASE 0 MG QL methadone oral concentrate 0 /ml QL (0 per 30 days) methadone oral solution 0 /5 ml QL (600 per 30 days) methadone oral solution 5 /5 ml QL (00 per 30 days) methadone oral tablet 0 QL (0 per 30 days) methadone oral tablet 5 QL (40 per 30 days) methadone oral tablet,soluble 40 QL (30 per 30 days) METHADOSE ORAL CONCENTRATE 0 MG/ML QL (0 per 30 days) METHADOSE ORAL TABLET,SOLUBLE 40 MG QL (30 per 30 days) Updated: October, 08 50

59 METHYLIN ORAL SOLUTION 0 MG/5 ML, 5 MG/5 ML QL methylphenidate hcl oral capsule, er biphasic QL (80 per 30 days) methylphenidate hcl oral capsule, er biphasic QL (90 per 30 days) methylphenidate hcl oral capsule, er biphasic QL (60 per 30 days) methylphenidate hcl oral capsule, er biphasic QL (45 per 30 days) methylphenidate hcl oral capsule, er biphasic QL (36 per 30 days) methylphenidate hcl oral capsule, er biphasic QL (30 per 30 days) methylphenidate hcl oral capsule,er biphasic , 60 methylphenidate hcl oral capsule,er biphasic , 30, 40 QL methylphenidate hcl oral solution 0 /5 ml QL (80 per 30 days) methylphenidate hcl oral solution 5 /5 ml QL (360 per 30 days) methylphenidate hcl oral tablet 0, 0, 5 QL methylphenidate hcl oral tablet extended release 0 QL (80 per 30 days) methylphenidate hcl oral tablet extended release 0 QL (90 per 30 days) methylphenidate hcl oral tablet extended release 4hr 8 QL (0 per 30 days) methylphenidate hcl oral tablet extended release 4hr 7 QL (80 per 30 days) methylphenidate hcl oral tablet extended release 4hr 36 QL (60 per 30 days) methylphenidate hcl oral tablet extended release 4hr 54 QL (40 per 30 days) methylphenidate hcl oral tablet,chewable 0 QL (80 per 30 days) methylphenidate hcl oral tablet,chewable.5 QL (70 per 30 days) methylphenidate hcl oral tablet,chewable 5 QL (360 per 30 days) mirtazapine oral tablet 5, 30, 45, 7.5 mirtazapine oral tablet,disintegrating 5, 30, 45 modafinil oral tablet 00, 00 PA Updated: October, 08 5

60 morphine concentrate oral solution 00 /5 ml (0 /ml) QL (300 per 30 days) morphine oral solution 0 /5 ml, 0 /5 ml (4 /ml) QL (900 per 30 days) morphine oral tablet 5, 30 QL (80 per 30 days) morphine oral tablet extended release 00 QL (60 per 30 days) morphine oral tablet extended release 5, 30 QL (0 per 30 days) morphine oral tablet extended release 00 QL (30 per 30 days) morphine oral tablet extended release 60 QL (00 per 30 days) morphine rectal suppository 0, 0, 5 QL (360 per 30 days) morphine rectal suppository 30 QL (0 per 30 days) nabumetone oral tablet 500, 750 nalbuphine injection solution 0 /ml, 0 /ml naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 naproxen oral suspension 5 /5 ml naproxen oral tablet 50, 375, 500 naproxen oral tablet,delayed release (dr/ec) 375, 500 naproxen sodium oral tablet 75, 550 NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION nortriptyline oral capsule 0, 5, 50, 75 nortriptyline oral solution 0 /5 ml NUEDEXTA ORAL CAPSULE 0-0 MG PA; QL (60 per 30 days) olanzapine intramuscular recon soln 0 olanzapine oral tablet 0, 0 QL (30 per 30 days) olanzapine oral tablet 5,.5, 5, 7.5 QL; QL (30 per 30 days) olanzapine oral tablet,disintegrating 0, 5, 0, 5 ST; QL; QL (30 per 30 days) oxaprozin oral tablet 600 oxazepam oral capsule 0, 5, 30 oxcarbazepine oral suspension 300 /5 ml (60 /ml) oxcarbazepine oral tablet 50, 300, 600 oxycodone oral capsule 5 QL (360 per 30 days) Updated: October, 08 5

61 oxycodone oral concentrate 0 /ml QL (80 per 30 days) oxycodone oral solution 5 /5 ml QL (00 per 30 days) oxycodone oral tablet 0, 5, 0 QL (80 per 30 days) oxycodone oral tablet 30 QL (0 per 30 days) oxycodone oral tablet 5 QL (360 per 30 days) OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL. HR 0 MG, 5 MG, 0 MG, ST; QL (90 per 30 days) 30 MG, 40 MG OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL. HR 60 MG ST; QL (67 per 30 days) OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL. HR 80 MG ST; QL (50 per 30 days) oxycodone-acetaminophen oral tablet 0-35,.5-35, 5-35, QL (360 per 30 days) oxycodone-aspirin oral tablet QL (408 per 30 days) OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL. HR 0 MG, 5 MG, 0 MG, ST; QL (90 per 30 days) 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL. HR 80 MG ST; QL (50 per 30 days) paliperidone oral tablet extended release 4hr.5, 3, 9 ST; QL (30 per 30 days) paliperidone oral tablet extended release 4hr 6 ST; QL (60 per 30 days) paroxetine hcl oral tablet 0, 40 QL (30 per 30 days) paroxetine hcl oral tablet 0, 30 QL (60 per 30 days) paroxetine hcl oral tablet extended release 4 hr.5, 5, 37.5 QL (60 per 30 days) PEGANONE ORAL TABLET 50 MG pentazocine-naloxone oral tablet perphenazine oral tablet 6,, 4, 8 perphenazine-amitriptyline oral tablet -0, - 5, 4-0, 4-5, 4-50 phenelzine oral tablet 5 phenobarbital oral elixir 0 /5 ml (4 /ml) phenobarbital oral tablet 00, 5, 6., 30, 3.4, 60, 64.8, 97. phenobarbital sodium injection solution 30 /ml, 65 /ml phenytoin oral suspension 00 /4 ml, 5 /5 ml Updated: October, 08 53

62 phenytoin oral tablet,chewable 50 phenytoin sodium extended oral capsule 00, 00, 300 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml piroxicam oral capsule 0, 0 pramipexole oral tablet 0.5, 0.5, 0.5, 0.75,,.5 primidone oral tablet 50, 50 prochlorperazine edisylate injection solution 0 / ml (5 /ml) prochlorperazine maleate oral tablet 0, 5 prochlorperazine rectal suppository 5 promethazine injection solution 5 /ml, 50 /ml promethazine oral syrup 6.5 /5 ml promethazine oral tablet.5, 5, 50 promethazine rectal suppository.5, 5 propranolol intravenous solution /ml propranolol oral capsule,extended release 4 hr 0, 60, 60, 80 propranolol oral solution 0 /5 ml (4 /ml), 40 /5 ml (8 /ml) propranolol oral tablet 0, 0, 40, 60, 80 protriptyline oral tablet 0, 5 quetiapine oral tablet 00, 00, 5, 50 QL (90 per 30 days) quetiapine oral tablet 300, 400 QL (60 per 30 days) quetiapine oral tablet extended release 4 hr 50, 00, 300, 400, 50 ST; QL; QL (60 per 30 days) REXULTI ORAL TABLET 0.5 MG, 0.5 MG, MG, MG, 3 MG, 4 MG ST riluzole oral tablet 50 RISPERDAL CONSTA INTRAMUSCULAR SYRINGE.5 MG/ ML, 5 MG/ ML, 37.5 MG/ ML, 50 MG/ ML risperidone oral solution /ml risperidone oral tablet 0.5, 0.5,,, 3, 4 QL (60 per 30 days) risperidone oral tablet,disintegrating 0.5, 0.5,,, 3, 4 ST; QL (60 per 30 days) Updated: October, 08 54

63 rizatriptan oral tablet 0, 5 QL rizatriptan oral tablet,disintegrating 0, 5 QL ropinirole oral tablet 0.5, 0.5,,, 3, 4, 5 salsalate oral tablet 500, 750 SAVELLA ORAL TABLET 00 MG,.5 MG, 5 MG, 50 MG PA; QL (60 per 30 days) SAVELLA ORAL TABLETS,DOSE PACK.5 MG (5)-5 MG(8)-50 MG(4) PA; QL (55 per 30 days) SECONAL SODIUM ORAL CAPSULE 00 MG selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 sertraline oral concentrate 0 /ml sertraline oral tablet 00 QL (60 per 30 days) sertraline oral tablet 5 QL; QL (60 per 30 days) sertraline oral tablet 50 QL SUBOXONE SUBLINGUAL FILM -3 MG QL (60 per 30 days) SUBOXONE SUBLINGUAL FILM -0.5 MG QL (360 per 30 days) SUBOXONE SUBLINGUAL FILM 4- MG QL (80 per 30 days) SUBOXONE SUBLINGUAL FILM 8- MG QL (90 per 30 days) sulindac oral tablet 50, 00 sumatriptan nasal spray,non-aerosol 0 /actuation QL; QL (8 per 30 days) sumatriptan nasal spray,non-aerosol 5 /actuation QL; QL (36 per 30 days) sumatriptan succinate oral tablet 00, 5 QL; QL (8 per 30 days) sumatriptan succinate oral tablet 50 QL sumatriptan succinate subcutaneous cartridge 4 /0.5 ml, 6 /0.5 ml QL; QL (8 per 30 days) sumatriptan succinate subcutaneous pen injector 4 /0.5 ml, 6 /0.5 ml QL (8 per 30 days) sumatriptan succinate subcutaneous solution 6 /0.5 ml QL (8 per 30 days) temazepam oral capsule 5,.5, 30, 7.5 tetrabenazine oral tablet.5, 5 PA; SP thioridazine oral tablet 0, 00, 5, 50 thiothixene oral capsule, 0,, 5 tiagabine oral tablet, 6,, 4 timolol maleate oral tablet 0, 0, 5 Updated: October, 08 55

64 tolmetin oral capsule 400 tolmetin oral tablet 00, 600 topiramate oral capsule, sprinkle 5, 5 topiramate oral tablet 00, 00, 5, 50 tramadol oral tablet 50 QL (40 per 30 days) tramadol-acetaminophen oral tablet QL (40 per 30 days) tranylcypromine oral tablet 0 trazodone oral tablet 00, 50, 300, 50 triazolam oral tablet 0.5, 0.5 trifluoperazine oral tablet, 0,, 5 trihexyphenidyl oral elixir 0.4 /ml trihexyphenidyl oral tablet, 5 TRINTELLIX ORAL TABLET 0 MG, 0 MG, 5 MG ST; QL (30 per 30 days) valproate sodium intravenous solution 500 /5 ml (00 /ml) valproic acid (as sodium salt) oral solution 50 /5 ml, 50 /5 ml (5 ml), 500 /0 ml (0 ml) valproic acid oral capsule 50 venlafaxine oral capsule,extended release 4hr 50, 37.5 QL; QL (30 per 30 days) venlafaxine oral capsule,extended release 4hr 75 QL venlafaxine oral tablet 00, 5, 37.5, 50, 75 QL (90 per 30 days) venlafaxine oral tablet extended release 4hr 50, 5, 37.5, 75 QL (30 per 30 days) VIIBRYD ORAL TABLET 0 MG, 0 MG, 40 MG ST; QL (30 per 30 days) VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 0 MG (3) ST; QL (30 per 30 days) VIMPAT INTRAVENOUS SOLUTION 00 MG/0 ML VIMPAT ORAL SOLUTION 0 MG/ML VIMPAT ORAL TABLET 00 MG, 50 MG, 00 MG, 50 MG VYVANSE ORAL CAPSULE 0 MG QL (0 per 30 days) VYVANSE ORAL CAPSULE 0 MG QL (05 per 30 days) VYVANSE ORAL CAPSULE 30 MG QL (70 per 30 days) Updated: October, 08 56

65 VYVANSE ORAL CAPSULE 40 MG QL (5 per 30 days) VYVANSE ORAL CAPSULE 50 MG QL (4 per 30 days) VYVANSE ORAL CAPSULE 60 MG QL (35 per 30 days) VYVANSE ORAL CAPSULE 70 MG QL (30 per 30 days) zaleplon oral capsule 0 QL (60 per 30 days) zaleplon oral capsule 5 QL (30 per 30 days) ziprasidone hcl oral capsule 0, 40, 60, 80 QL; QL (60 per 30 days) zolmitriptan oral tablet.5, 5 QL (8 per 30 days) zolmitriptan oral tablet,disintegrating.5, 5 QL (8 per 30 days) zolpidem oral tablet 0, 5 QL; QL (30 per 30 days) zolpidem oral tablet,ext release multiphase.5 QL; QL (30 per 30 days) zolpidem oral tablet,ext release multiphase 6.5 QL (30 per 30 days) zonisamide oral capsule 00, 5, 50 ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 0 MG, 300 MG, 405 MG DEVICES ACE AEROSOL CLOUD ENHANCER SPACER BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE CLEO 90 INFUSION SET 4" INFUSION SET COMFORT SHORT INFUSION SET 3" INFUSION SET ECLIPSE SYRINGE SYRINGE 3 ML GAUGE X " FREESTYLE LIBRE 0 DAY READER FREESTYLE LIBRE 0 DAY SENSOR KIT HEP FLUSH-0 (PF) INTRAVENOUS SOLUTION 0 UNIT/ML heparin (porcine) in nacl (pf) intravenous parenteral solution,000 unit/500 ml,,000 unit/,000 ml heparin flush(porcine)-0.9nacl intravenous kit 00 unit/ml heparin lock flush (porcine) intravenous syringe 00 unit/ml HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 0 UNIT/ML Updated: October, 08 57

66 HEPARIN LOCK INTRAVENOUS SOLUTION 00 UNIT/ML HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 0 UNIT/ML, 00 UNIT/ML heparin, porcine (pf) intravenous syringe unit/ml, 00 unit/ml MONOJECT MAGELLAN SYRINGE SYRINGE 3 ML 0 GAUGE X " MONOJECT SYRINGE SYRINGE / ML 8 GAUGE NORMAL SALINE FLUSH INJECTION SYRINGE POLYFIN QR INFUSION SET sodium chloride 0.9 % injection syringe SYREX SODIUM CHLORIDE 0.9 % INJECTION SYRINGE syringe with needle, safety syringe ml 5 gauge x 5/8" T:SLIM SUBCUTANEOUS CARTRIDGE DIAGNOSTIC AGENTS CANDIN INTRADERMAL ALLERGEN FDA STANDARD cosyntropin injection recon soln 0.5 cosyntropin intravenous solution 0.5 /ml E-Z-CAT DRY ORAL POWDER IN PACKET % (W/W) E-Z-HD BARIUM ORAL SUSPENSION FOR RECONSTITUTION 98 % E-Z-PAQUE ORAL SUSPENSION FOR RECONSTITUTION 96 % (W/W) fluorescein-proparacaine ophthalmic (eye) drops % GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN MG/ML GLUCAGON HCL INJECTION RECON SOLN MG ISOVUE-300 INTRAVENOUS SOLUTION 6 % ISOVUE-M 300 INTRATHECAL SOLUTION 6 % LIQUID E-Z PAQUE ORAL SUSPENSION 60 % (W/V) Updated: October, 08 58

67 mannitol 0 % intravenous parenteral solution 0 % mannitol 0 % intravenous parenteral solution 0 % mannitol 5 % intravenous solution 5 % mannitol 5 % intravenous parenteral solution 5 % OMNIPAQUE 40 INTRAVENOUS SOLUTION 40 MG IODINE/ML OMNIPAQUE 40 INTRAVENOUS SOLUTION 40 MG IODINE/ML OMNIPAQUE 300 INTRAVENOUS SOLUTION 300 MG IODINE/ML ONETOUCH VERIO STRIP READI-CAT ORAL SUSPENSION. % (W/V),.0 % (W/W) TAGITOL V ORAL SUSPENSION 40 % (W/V) thallous chloride tl-0 intravenous solution 37 mbq/ml ( mci/ml) THYROGEN INTRAMUSCULAR RECON SOLN. MG SP VARIBAR THIN HONEY ORAL SUSPENSION 40 % (W/V) 9% (W/W) VARIBAR THIN LIQUID ORAL POWDER 40 % (W/V) VISIPAQUE INTRAVENOUS SOLUTION 70 MG IODINE/ML VOLUMEN ORAL SUSPENSION 0. % ELECTROLYTIC, CALORIC, AND WATER BALANCE acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 5, 50 acetazolamide sodium injection recon soln 500 acetic acid irrigation solution 0.5 % amiloride-hydrochlorothiazide oral tablet 5-50 ammonium chloride intravenous solution 5 meq/ml atenolol-chlorthalidone oral tablet 00-5, 50-5 BAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR MG Updated: October, 08 59

68 BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE benazepril-hydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5, bisoprolol-hydrochlorothiazide oral tablet 0-6.5,.5-6.5, bumetanide injection solution 0.5 /ml bumetanide oral tablet 0.5,, calcium acetate oral capsule 667 calcium acetate oral tablet 667 calcium chloride intravenous solution 00 /ml (0 %) calcium chloride intravenous syringe 00 /ml (0 %) calcium gluconate intravenous solution 00 /ml (0%) captopril-hydrochlorothiazide oral tablet 5-5, 5-5, 50-5, 50-5 CARBAGLU ORAL TABLET, DISPERSIBLE 00 MG SP chlorothiazide oral tablet 50, 500 chlorthalidone oral tablet 5, 50 chromium chloride intravenous solution 4 mcg/ml CONSTULOSE ORAL SOLUTION 0 GRAM/5 ML COPPER CHLORIDE INTRAVENOUS SOLUTION 0.4 MG/ML CYTRA K CRYSTALS ORAL PACKET 3,300-,00 MG CYTRA- ORAL SOLUTION MG/5 ML CYTRA-3 ORAL SOLUTION MG/5 ML CYTRA-K ORAL SOLUTION, MG/5 ML DELFLEX-LC/.5% DEXTROSE INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L DELFLEX-LC/.5% DEXTROSE INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L DELFLEX-LC/4.5% DEXTROSE INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L Updated: October, 08 60

69 DELFLEX-SM WITH.5% DEXTROSE INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG.5 MEQ/L dextrose 5 % in ringer's intravenous parenteral solution 5 % dextrose 5 %-lactated ringers intravenous parenteral solution DIANEAL LOW CALCIUM/.5% DEX INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L DIANEAL PD- WITH.5 % DEX INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG 0.5 MEQ/L DIANEAL PD- WITH 4.5 % DEX INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG 0.5 MEQ/L DIANEAL PD-/.5% DEXTROSE INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG 0.5 MEQ/L DIANEAL WITH.5 % DEXTROSE INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L DIANEAL WITH 4.5 % DEXTROSE INTRAPERITONEAL SOLUTION CA.5 MEQ/L- MG 0.5 MEQ/L EFFER-K ORAL TABLET, EFFERVESCENT 5 MEQ electrolyte-48 in d5w intravenous parenteral solution ELIPHOS ORAL TABLET 667 MG enalapril-hydrochlorothiazide oral tablet 0-5, 5-.5 ENULOSE ORAL SOLUTION 0 GRAM/5 ML fosinopril-hydrochlorothiazide oral tablet 0-.5, 0-.5 FOSRENOL ORAL TABLET,CHEWABLE,000 MG, 500 MG, 750 MG furosemide injection solution 0 /ml furosemide injection syringe 0 /ml furosemide oral solution 0 /ml, 40 /5 ml (8 /ml) furosemide oral tablet 0, 40, 80 GENERLAC ORAL SOLUTION 0 GRAM/5 ML glycine urologic solution irrigation solution.5 % Updated: October, 08 6

70 hetastarch 6 % in 0.9 % nacl intravenous solution 6 % hydrochlorothiazide oral capsule.5 hydrochlorothiazide oral tablet.5, 5, 50 indapamide oral tablet.5,.5 IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION K-EFFERVESCENT ORAL TABLET, EFFERVESCENT 5 MEQ KIONEX (WITH SORBITOL) ORAL SUSPENSION GRAM/60 ML KLOR-CON 0 ORAL TABLET EXTENDED RELEASE 0 MEQ KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ KLOR-CON M0 ORAL TABLET,ER PARTICLES/CRYSTALS 0 MEQ KLOR-CON M5 ORAL TABLET,ER PARTICLES/CRYSTALS 5 MEQ KLOR-CON M0 ORAL TABLET,ER PARTICLES/CRYSTALS 0 MEQ KLOR-CON ORAL PACKET 0 MEQ KLOR-CON/EF ORAL TABLET, EFFERVESCENT 5 MEQ lactated ringers intravenous parenteral solution lactated ringers irrigation solution lactulose oral solution 0 gram/5 ml, 0 gram/5 ml (5 ml), 0 gram/30 ml lanthanum oral tablet,chewable,000, 500, 750 lisinopril-hydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5 losartan-hydrochlorothiazide oral tablet 00-.5, 00-5, Updated: October, 08 6

71 manganese chloride intravenous solution 0. /ml mannitol 0 % intravenous parenteral solution 0 % mannitol 0 % intravenous parenteral solution 0 % mannitol 5 % intravenous solution 5 % mannitol 5 % intravenous parenteral solution 5 % methyldopa-hydrochlorothiazide oral tablet 50-5, 50-5 metolazone oral tablet 0,.5, 5 metoprolol ta-hydrochlorothiaz oral tablet 00-5, 00-50, 50-5 moexipril-hydrochlorothiazide oral tablet 5-.5, 5-5, MYNATAL ADVANCE ORAL TABLET MG MYNATAL ORAL CAPSULE 65 MG IRON- MG MYNATAL PLUS ORAL TABLET 65 MG IRON- MG MYNATAL-Z ORAL TABLET 65 MG IRON- MG nadolol-bendroflumethiazide oral tablet 40-5, 80-5 NORMAL SALINE FLUSH INJECTION SYRINGE NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION NUTRILYTE INTRAVENOUS SOLUTION MEQ/0 ML PHOSPHA 50 NEUTRAL ORAL TABLET 50 MG PHYSIOLYTE IRRIGATION SOLUTION MEQ/L PHYSIOSOL IRRIGATION IRRIGATION SOLUTION MEQ/L PLASMA-LYTE 48 INTRAVENOUS PARENTERAL SOLUTION Updated: October, 08 63

72 PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION PNV OB+DHA ORAL COMBO PACK MG PNV-DHA + DOCUSATE ORAL CAPSULE MG PNV-OMEGA ORAL CAPSULE MG potassium acetate intravenous solution meq/ml potassium bicarb and chloride oral tablet, effervescent 5 meq potassium bicarb-citric acid oral tablet, effervescent 5 meq potassium chlorid-d5-0.45%nacl intravenous parenteral solution 0 meq/l, 0 meq/l, 30 meq/l, 40 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride in water intravenous piggyback 0 meq/00 ml, 0 meq/50 ml, 0 meq/00 ml, 0 meq/50 ml, 30 meq/00 ml, 40 meq/00 ml potassium chloride intravenous solution meq/ml potassium chloride oral capsule, extended release 0 meq, 8 meq potassium chloride oral liquid 0 meq/5 ml, 40 meq/5 ml potassium chloride oral tablet extended release 0 meq, 8 meq potassium chloride oral tablet,er particles/crystals 0 meq, 0 meq potassium chloride-0.45 % nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium chloride-d5-0.3%nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 0 meq/l, 40 meq/l potassium citrate oral tablet extended release 0 meq (,080 ), 5 meq (540 ) Updated: October, 08 64

73 potassium citrate-citric acid oral solution, /5 ml potassium phosphate m-/d-basic intravenous solution 3 mmol/ml PR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 400 ORAL COMBO PACK MG PR NATAL 430 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 430 ORAL COMBO PACK 9 MG IRON- MG -430 MG PRENAISSANCE ORAL CAPSULE MG PRENAISSANCE PLUS ORAL CAPSULE MG PRENATABS FA ORAL TABLET 9- MG PRENATABS RX ORAL TABLET 9 MG IRON- MG PRENATAL LOW IRON ORAL TABLET 7 MG IRON- MG PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 7 MG IRON- MG PRENATAL PLUS ORAL TABLET 9 MG IRON- MG probenecid oral tablet 500 probenecid-colchicine oral tablet propranolol-hydrochlorothiazid oral tablet 40-5, 80-5 quinapril-hydrochlorothiazide oral tablet 0-.5, 0-.5, 0-5 RAVICTI ORAL LIQUID. GRAM/ML SP RENAGEL ORAL TABLET 800 MG RENVELA ORAL TABLET 800 MG ringer's intravenous parenteral solution ringer's irrigation solution selenium intravenous solution 40 mcg/ml sevelamer carbonate oral powder in packet 0.8 gram,.4 gram sodium acetate intravenous solution meq/ml, 4 meq/ml Updated: October, 08 65

74 sodium bicarbonate intravenous solution meq/ml (8.4 %), 4. % sodium bicarbonate intravenous syringe 0 meq/0 ml (8.4 %), 4. % (0.5 meq/ml), 7.5 % (0.9 meq/ml), 8.4 % ( meq/ml) sodium chlor 0.9% bacteriostat injection solution 0.9 % sodium chloride 0.45 % intravenous parenteral solution 0.45 % sodium chloride 0.45 % intravenous piggyback 0.45 % sodium chloride 0.9 % injection solution sodium chloride 0.9 % injection syringe sodium chloride 0.9 % intravenous parenteral solution sodium chloride 0.9 % intravenous piggyback sodium chloride 3 % intravenous parenteral solution 3 % sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution.5 meq/ml, 4 meq/ml sodium chloride irrigation solution 0.9 % sodium citrate-citric acid oral solution /5 ml sodium lactate intravenous solution 5 meq/ml sodium phenylbutyrate oral powder 0.94 gram/gram sodium phenylbutyrate oral tablet 500 sodium phosphate intravenous solution 3 mmol/ml SODIUM POLYSTYRENE (SORB FREE) ORAL SUSPENSION 5 GRAM/60 ML sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate rectal enema 30 gram/0 ml spironolactone oral tablet 00, 5, 50 spironolacton-hydrochlorothiaz oral tablet 5-5 SPS (WITH SORBITOL) ORAL SUSPENSION 5-0 GRAM/60 ML SPS (WITH SORBITOL) RECTAL ENEMA GRAM/0 ML Updated: October, 08 66

75 SYREX SODIUM CHLORIDE 0.9 % INJECTION SYRINGE THEOCHRON ORAL TABLET EXTENDED RELEASE HR 00 MG, 00 MG, 300 MG theophylline oral elixir 80 /5 ml theophylline oral solution 80 /5 ml theophylline oral tablet extended release hr 00, 00, 300, 450 TL-SELECT ORAL CAPSULE MG torsemide oral tablet 0, 00, 0, 5 TRIADVANCE ORAL TABLET MG triamterene-hydrochlorothiazid oral capsule , 50-5 triamterene-hydrochlorothiazid oral tablet , TRICITRATES ORAL SOLUTION MG/5 ML TRINATAL RX ORAL TABLET 60 MG IRON- MG TRINATE ORAL TABLET 8 MG IRON- MG TRIVEEN-DUO DHA ORAL COMBO PACK MG TRIVEEN-ONE ORAL CAPSULE 7 MG IRON- MG -50 MG TRIVEEN-PRX RNF ORAL CAPSULE MG valsartan-hydrochlorothiazide oral tablet 60-.5, 60-5, 30-.5, 30-5, VELTASSA ORAL POWDER IN PACKET 6.8 GRAM, 5. GRAM, 8.4 GRAM SP VENA-BAL DHA ORAL COMBO PACK,TABLET AND CAP,DR MG VINACAL ORAL TABLET MG VINATE ONE ORAL TABLET 60 MG IRON- MG VINATE ULTRA ORAL TABLET MG VIRT-PN PLUS ORAL CAPSULE MG VIRT-SELECT ORAL CAPSULE MG VITAFOL-OB ORAL TABLET 65- MG Updated: October, 08 67

76 water for irrigation, sterile irrigation solution ZATEAN-PN PLUS ORAL CAPSULE MG zinc chloride intravenous solution /ml zinc sulfate intravenous solution 5 /ml ENZYMES CATHFLO ACTIVASE INTRA-CATHETER RECON SOLN MG ELELYSO INTRAVENOUS RECON SOLN 00 UNIT PA; SP FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG PA; SP LUMIZYME INTRAVENOUS RECON SOLN 50 MG PA; SP PULMOZYME INHALATION SOLUTION MG/ML SP STRENSIQ SUBCUTANEOUS SOLUTION 00 MG/ML, 40 MG/ML PA SUCRAID ORAL SOLUTION 8,500 UNIT/ML SP VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML ( MG/ML) SP VPRIV INTRAVENOUS RECON SOLN 400 UNIT PA; SP EYE, EAR, NOSE AND THROAT (EENT) PREPS. acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 5, 50 acetazolamide sodium injection recon soln 500 acetic acid otic (ear) solution % apraclonidine ophthalmic (eye) drops 0.5 % atropine ophthalmic (eye) drops % atropine ophthalmic (eye) ointment % azelastine nasal aerosol,spray 37 mcg (0. %) QL (60 per 30 days) azelastine nasal spray,non-aerosol 0.5 % (05.5 mcg) QL (60 per 30 days) azelastine ophthalmic (eye) drops 0.05 % bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment 500-0,000 unit/gram BACTROBAN NASAL NASAL OINTMENT % Updated: October, 08 68

77 BALANCED SALT INTRAOCULAR SOLUTION betaxolol ophthalmic (eye) drops 0.5 % BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 0-0. % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 0-0. % brimonidine ophthalmic (eye) drops 0.5 %, 0. % carteolol ophthalmic (eye) drops % chlorhexidine gluconate mucous membrane mouthwash 0. % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic (eye) drops 0.3 % cocaine topical solution 4 % cromolyn ophthalmic (eye) drops 4 % cyclopentolate ophthalmic (eye) drops %, % CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % SP dexamethasone sodium phosphate ophthalmic (eye) drops 0. % diclofenac sodium ophthalmic (eye) drops 0. % dorzolamide ophthalmic (eye) drops % dorzolamide-timolol ophthalmic (eye) drops /ml doxycycline hyclate oral tablet 0 erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) QL (50 per 30 days) fluorescein-proparacaine ophthalmic (eye) drops % fluorometholone ophthalmic (eye) drops,suspension 0. % flurbiprofen sodium ophthalmic (eye) drops 0.03 % GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) gentamicin ophthalmic (eye) drops 0.3 % gentamicin ophthalmic (eye) ointment 0.3 % (3 /gram) Updated: October, 08 69

78 HOMATROPAIRE OPHTHALMIC (EYE) DROPS 5 % hydrocortisone-acetic acid otic (ear) drops - % ipratropium bromide nasal spray,non-aerosol 0.03 %, 4 mcg (0.06 %) QL (30 per 30 days) ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % latanoprost ophthalmic (eye) drops % levobunolol ophthalmic (eye) drops 0.5 % lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane jelly in applicator % lidocaine hcl mucous membrane solution 4 % (40 /ml) LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % metipranolol ophthalmic (eye) drops 0.3 % moxifloxacin ophthalmic (eye) drops 0.5 % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 -unit/g-% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5/ml-0,000 unit/ml- 0. % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 /g-0,000 unit/g-0. % neomycin-polymyxin-gramicidin ophthalmic (eye) drops.75-0,000 unit-0.05/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-0, unit-/ml neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-0,000- /ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution 3.5-0,000- /ml-unit/ml-% NEO-POLYCIN HC OPHTHALMIC (EYE) OINTMENT ,000 MG-UNIT/G-% ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin otic (ear) drops 0.3 % Updated: October, 08 70

79 olopatadine ophthalmic (eye) drops 0. %, 0. % PERIOGARD MUCOUS MEMBRANE MOUTHWASH 0. % phenylephrine hcl ophthalmic (eye) drops 0 %,.5 % PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.5 % pilocarpine hcl ophthalmic (eye) drops %, %, 4 % POLYCIN OPHTHALMIC (EYE) OINTMENT 500-0,000 UNIT/GRAM polymyxin b sulf-trimethoprim ophthalmic (eye) drops 0,000 unit- /ml PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % prednisolone acetate ophthalmic (eye) drops,suspension % prednisolone sodium phosphate ophthalmic (eye) drops % proparacaine ophthalmic (eye) drops 0.5 % RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS 0.05 % PA RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % PA; QL (60 per 30 days) sulfacetamide sodium ophthalmic (eye) drops 0 % sulfacetamide sodium ophthalmic (eye) ointment 0 % sulfacetamide-prednisolone ophthalmic (eye) drops 0 %-0.3 % (0.5 %) TETCAINE OPHTHALMIC (EYE) DROPS 0.5 % tetracaine hcl (pf) ophthalmic (eye) drops 0.5 % tetracaine hcl ophthalmic (eye) drops 0.5 % timolol maleate ophthalmic (eye) drops 0.5 %, 0.5 % timolol maleate ophthalmic (eye) gel forming solution 0.5 %, 0.5 % tobramycin ophthalmic (eye) drops 0.3 % tobramycin-dexamethasone ophthalmic (eye) drops,suspension % tropicamide ophthalmic (eye) drops 0.5 %, % XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % Updated: October, 08 7

80 ZIRGAN OPHTHALMIC (EYE) GEL 0.5 % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % GASTROINTESTINAL DRUGS alosetron oral tablet 0.5, aprepitant oral capsule 5, 40 QL; QL ( per 30 days) aprepitant oral capsule 80 QL; QL ( per 30 days) aprepitant oral capsule,dose pack 5 ()- 80 () QL; QL (3 per 30 days) ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG balsalazide oral capsule 750 CANASA RECTAL SUPPOSITORY,000 MG CARAFATE ORAL SUSPENSION 00 MG/ML CESAMET ORAL CAPSULE MG cimetidine hcl oral solution 300 /5 ml cimetidine oral tablet 300, 400, 800 COMPRO RECTAL SUPPOSITORY 5 MG CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC),000-38,000-60,000 UNIT, 4,000-76,000-0,000 UNIT, 3,000-9,500-5,000 UNIT, 36,000-4,000-80,000 UNIT, 6,000-9,000-30,000 UNIT dimenhydrinate injection solution 50 /ml diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet dronabinol oral capsule 0,.5, 5 famotidine (pf) intravenous solution 0 / ml famotidine (pf)-nacl (iso-os) intravenous piggyback 0 /50 ml famotidine intravenous solution 0 /ml famotidine oral tablet 0, 0, 40 GAVILYTE-C ORAL RECON SOLN GRAM GAVILYTE-G ORAL RECON SOLN GRAM GAVILYTE-N ORAL RECON SOLN 40 GRAM granisetron (pf) intravenous solution /ml ( ml), 00 mcg/ml Updated: October, 08 7

81 granisetron hcl intravenous solution /ml, /ml ( ml) granisetron hcl oral tablet QL (6 per 30 days) HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML PA; SP; QL ( per 30 days) HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, PA; SP; QL (3 per 30 days) 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL; QL ( per 30 days) MG/0.8 ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 80 PA; SP; QL (3 per 30 days) MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL; QL ( per 30 days) MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 80 PA; SP; QL (3 per 30 days) MG/0.8 ML-40 MG/0.4 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML PA; SP; QL ( per 30 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0. ML, 0 MG/0. ML, 0 MG/0. ML, 0 PA; SP; QL ( per 30 days) MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML lansoprazole oral capsule,delayed release(dr/ec) 30 QL (30 per 30 days) LINZESS ORAL CAPSULE 45 MCG, 90 MCG, 7 MCG meclizine oral tablet.5, 5 meclizine oral tablet,chewable 5 mesalamine oral tablet,delayed release (dr/ec). gram, 800 mesalamine rectal enema 4 gram/60 ml metoclopramide hcl injection solution 5 /ml metoclopramide hcl injection syringe 5 /ml metoclopramide hcl oral solution 5 /5 ml metoclopramide hcl oral tablet 0, 5 misoprostol oral tablet 00 mcg, 00 mcg nizatidine oral capsule 50, 300 nizatidine oral solution 50 /0 ml OCALIVA ORAL TABLET 0 MG, 5 MG PA; SP Updated: October, 08 73

82 omeprazole oral capsule,delayed release(dr/ec) 0 QL (30 per 30 days) omeprazole oral capsule,delayed release(dr/ec) 0 omeprazole oral capsule,delayed release(dr/ec) 40 QL ondansetron hcl (pf) injection solution 4 / ml ondansetron hcl (pf) injection syringe 4 / ml ondansetron hcl intravenous solution /ml ondansetron hcl oral solution 4 /5 ml QL (50 per 30 days) ondansetron hcl oral tablet 4 QL ( per 30 days) ondansetron hcl oral tablet 4 QL ( per 30 days) ondansetron hcl oral tablet 8 QL ondansetron oral tablet,disintegrating 4, 8 QL palonosetron intravenous solution 0.5 / ml, 0.5 /5 ml pantoprazole oral tablet,delayed release (dr/ec) 0 QL (30 per 30 days) pantoprazole oral tablet,delayed release (dr/ec) 40 peg 3350-electrolytes oral recon soln gram, gram peg-electrolyte soln oral recon soln 40 gram PENTASA ORAL CAPSULE, EXTENDED RELEASE 50 MG, 500 MG PNV OB+DHA ORAL COMBO PACK MG PNV-DHA + DOCUSATE ORAL CAPSULE MG PRENAISSANCE ORAL CAPSULE MG PRENAISSANCE PLUS ORAL CAPSULE MG prochlorperazine edisylate injection solution 0 / ml (5 /ml) prochlorperazine maleate oral tablet 0, 5 prochlorperazine rectal suppository 5 PYLERA ORAL CAPSULE MG ranitidine hcl oral syrup 5 /ml ranitidine hcl oral tablet 50, 300, 75 SE-NATAL 9 (WITH DOCUSATE) ORAL TABLET 9 MG IRON- MG-5 MG Updated: October, 08 74

83 sucralfate oral suspension 00 /ml sucralfate oral tablet gram sulfasalazine oral tablet 500 sulfasalazine oral tablet,delayed release (dr/ec) 500 TARON-PREX PRENATAL-DHA ORAL CAPSULE 30 MG IRON-. MG-55 MG-65 MG TL-SELECT ORAL CAPSULE MG trimethobenzamide oral capsule 300 TRIVEEN-PRX RNF ORAL CAPSULE MG ursodiol oral capsule 300 ursodiol oral tablet 50, 500 VIBERZI ORAL TABLET 00 MG, 75 MG VINACAL ORAL TABLET MG VINATE ULTRA ORAL TABLET MG VIRT-SELECT ORAL CAPSULE MG XERMELO ORAL TABLET 50 MG PA HEAVY METAL ANTAGONISTS CHEMET ORAL CAPSULE 00 MG CUPRIMINE ORAL CAPSULE 50 MG deferoxamine injection recon soln gram, 500 EXJADE ORAL TABLET, DISPERSIBLE 5 MG, 50 MG, 500 MG PA; SP FERRIPROX ORAL TABLET 500 MG PA; SP HORMONES AND SYNTHETIC SUBSTITUTES acarbose oral tablet 00, 5, 50 ALTAVERA (8) ORAL TABLET MG QL ALYACEN /35 (8) ORAL TABLET -35 MG- MCG QL ALYACEN 7/7/7 (8) ORAL TABLET 0.5/0.75/ MG- 35 MCG QL AMETHIA LO ORAL TABLETS,DOSE PACK,3 MONTH 0.0 MG-0 MCG (84)/0 MCG (7) QL AMETHIA ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG (84)/0 MCG (7) QL AMETHYST ORAL TABLET 90-0 MCG QL anastrozole oral tablet Updated: October, 08 75

84 ANDRODERM TRANSDERMAL PATCH 4 HOUR MG/4 HOUR, 4 MG/4 HR PA ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 0.5 MG/.5 GRAM PA (.6 %) ANDROGEL TRANSDERMAL GEL IN PACKET % (5 MG/.5GRAM), % (50 MG/5 GRAM),.6 % (0.5 MG/.5 GRAM),.6 % (40.5 MG/.5 GRAM) PA APRI ORAL TABLET MG QL ARANELLE (8) ORAL TABLET 0.5// MG-MCG QL ARMOUR THYROID ORAL TABLET 0 MG, 80 MG, 40 MG, 30 MG, 300 MG, 60 MG, 90 MG AUBRA ORAL TABLET 0.-0 MG-MCG QL AVIANE ORAL TABLET 0.-0 MG-MCG QL AZURETTE (8) ORAL TABLET MGX /0.0 MG X 5 QL BALZIVA (8) ORAL TABLET MG-MCG QL BASAGLAR KWIKPEN U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) betamethasone acet,sod phos injection suspension 6 /ml BLISOVI 4 FE ORAL TABLET MG-0 MCG (4)/75 MG (4) BLISOVI FE.5/30 (8) ORAL TABLET.5 MG- 30 MCG ()/75 MG (7) BLISOVI FE /0 (8) ORAL TABLET MG-0 MCG ()/75 MG (7) BRIELLYN ORAL TABLET MG-MCG QL budesonide inhalation suspension for nebulization 0.5 / ml, 0.5 / ml, / ml budesonide oral capsule,delayed,extend.release 3 BYDUREON BCISE SUBCUTANEOUS AUTO- INJECTOR MG/0.85 ML PA BYDUREON SUBCUTANEOUS PEN INJECTOR MG/0.65 ML PA BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON MG PA; QL (4 per 30 days) Updated: October, 08 76

85 BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(50 MCG/ML).4 ML PA; QL (3 per 30 days) BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (50 MCG/ML). ML PA; QL ( per 30 days) calcitonin (salmon) nasal spray,non-aerosol 00 unit/actuation CAMILA ORAL TABLET 0.35 MG CAMRESE LO ORAL TABLETS,DOSE PACK,3 MONTH 0.0 MG-0 MCG (84)/0 MCG (7) QL (84 per 84 days) CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG (84)/0 MCG (7) QL CAZIANT (8) ORAL TABLET 0./.5/.5-5 MG-MCG QL CHATEAL ORAL TABLET MG QL chlorpropamide oral tablet 00, 50 colesevelam oral tablet 65 cortisone oral tablet 5 CRYSELLE (8) ORAL TABLET MG- MCG QL CYCLAFEM /35 (8) ORAL TABLET -35 MG- MCG QL CYCLAFEM 7/7/7 (8) ORAL TABLET 0.5/0.75/ MG- 35 MCG QL cyred oral tablet danazol oral capsule 00, 00, 50 DASETTA /35 (8) ORAL TABLET -35 MG- MCG QL DASETTA 7/7/7 (8) ORAL TABLET 0.5/0.75/ MG- 35 MCG QL DAYSEE ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG (84)/0 MCG (7) QL DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML desmopressin injection solution 4 mcg/ml PA desmopressin nasal spray,non-aerosol 0 mcg/spray (0. ml) desmopressin oral tablet 0., 0. PA desogestrel-ethinyl estradiol oral tablet QL DEXAMETHASONE INTENSOL ORAL DROPS MG/ML dexamethasone oral elixir 0.5 /5 ml Updated: October, 08 77

86 dexamethasone oral solution 0.5 /5 ml dexamethasone oral tablet 0.5, 0.75,,.5,, 4, 6 dexamethasone sodium phos (pf) injection solution 0 /ml dexamethasone sodium phosphate injection solution 0 /ml, 4 /ml drospirenone-ethinyl estradiol oral tablet QL DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION QL (3 per 30 days) DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION QL ELINEST ORAL TABLET MG-MCG QL ELLA ORAL TABLET 30 MG QL ( per 30 days) EMOQUETTE ORAL TABLET MG QL ENPRESSE ORAL TABLET (6)/75-40 (5)/5-30(0) QL ENSKYCE ORAL TABLET MG QL ERRIN ORAL TABLET 0.35 MG ESTARYLLA ORAL TABLET MG-MCG QL estradiol oral tablet 0.5,, estradiol transdermal patch semiweekly 0.05 /4 hr, /4 hr, 0.05 /4 hr, QL (8 per 8 days) /4 hr, 0. /4 hr estradiol vaginal cream 0.0 % (0. /gram) estradiol valerate intramuscular oil 0 /ml, 40 /ml estradiol-norethindrone acet oral tablet , -0.5 ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP.5 QL (50 per 30 days) GRAM/ACTUATION estropipate oral tablet 0.75 EVAMIST TRANSDERMAL SPRAY,NON- AEROSOL.53 MG/SPRAY (.7%) QL (7 per 30 days) exemestane oral tablet 5 FALMINA (8) ORAL TABLET 0.-0 MG-MCG QL FARESTON ORAL TABLET 60 MG FEMHRT LOW DOSE ORAL TABLET MG-MCG QL FEMYNOR ORAL TABLET MG-MCG Updated: October, 08 78

87 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 QL (60 per 30 days) MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/ACTUATION QL (4 per 30 days) FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION QL ( per 30 days) FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION QL (4 per 30 days) FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QL ( per 30 days) fludrocortisone oral tablet 0. GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0. MG/0.5 ML, 0.4 MG/0.5 ML, 0.6 MG/0.5 ML, 0.8 MG/0.5 ML, MG/0.5 ML,. MG/0.5 ML,.4 MG/0.5 ML,.6 MG/0.5 ML,.8 MG/0.5 ML, MG/0.5 ML PA; SP GENOTROPIN SUBCUTANEOUS CARTRIDGE MG/ML (36 UNIT/ML), 5 MG/ML (5 PA; SP UNIT/ML) GIANVI (8) ORAL TABLET MG QL glimepiride oral tablet QL; QL (40 per 30 days) glimepiride oral tablet QL (0 per 30 days) glimepiride oral tablet 4 QL (60 per 30 days) glipizide oral tablet 0 QL (80 per 30 days) glipizide oral tablet 5 QL glipizide oral tablet extended release 4hr 0, 5 QL (60 per 30 days) glipizide oral tablet extended release 4hr.5 QL (300 per 30 days) glipizide-metformin oral tablet.5-50 QL (40 per 30 days) glipizide-metformin oral tablet.5-500, QL (0 per 30 days) GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN MG/ML GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN MG GLUCAGON HCL INJECTION RECON SOLN MG glyburide micronized oral tablet.5, 3 QL glyburide micronized oral tablet 6 QL (60 per 30 days) glyburide oral tablet.5,.5, 5 QL Updated: October, 08 79

88 glyburide-metformin oral tablet.5-50 QL (40 per 30 days) glyburide-metformin oral tablet QL (80 per 30 days) glyburide-metformin oral tablet QL; QL (0 per 30 days) HEATHER ORAL TABLET 0.35 MG HUMALOG U-00 INSULIN SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMATROPE INJECTION CARTRIDGE MG (36 UNIT), 4 MG (7 UNIT), 6 MG (8 UNIT) PA; SP HUMATROPE INJECTION RECON SOLN 5 (5 UNIT) MG PA; SP HUMULIN 70/30 U-00 INSULIN SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) HUMULIN 70/30 U-00 KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (3 ML) HUMULIN N NPH U-00 INSULIN SUBCUTANEOUS SUSPENSION 00 UNIT/ML HUMULIN R REGULAR U-00 INSULN INJECTION SOLUTION 00 UNIT/ML HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML hydrocortisone oral tablet 0, 0, 5 hydroxyprogest(pf)(preg presv) intramuscular oil 50 /ml ( ml) PA hydroxyprogesterone capr(bulk) powder 00 % hydroxyprogesterone caproate intramuscular oil 50 /ml PA INTROVALE ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG QL INVOKAMET ORAL TABLET 50-,000 MG, MG, 50-,000 MG, MG INVOKANA ORAL TABLET 00 MG, 300 MG QL (30 per 30 days) JANUMET ORAL TABLET 50-,000 MG, MG QL (60 per 30 days) JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 00-,000 MG, MG QL (30 per 30 days) JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 50-,000 MG QL (60 per 30 days) Updated: October, 08 80

89 JANUVIA ORAL TABLET 00 MG, 5 MG, 50 MG QL (30 per 30 days) JENCYCLA ORAL TABLET 0.35 MG JINTELI ORAL TABLET -5 MG-MCG QL JOLESSA ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG QL JOLIVETTE ORAL TABLET 0.35 MG JULEBER ORAL TABLET MG JUNEL.5/30 () ORAL TABLET.5-30 MG- MCG QL JUNEL /0 () ORAL TABLET -0 MG-MCG QL JUNEL FE.5/30 (8) ORAL TABLET.5 MG-30 MCG ()/75 MG (7) QL JUNEL FE /0 (8) ORAL TABLET MG-0 MCG ()/75 MG (7) QL JUNEL FE 4 ORAL TABLET MG-0 MCG (4)/75 MG (4) KAITLIB FE ORAL TABLET,CHEWABLE 0.8MG- 5MCG(4) AND 75 MG (4) KARIVA (8) ORAL TABLET MGX /0.0 MG X 5 QL KELNOR /35 (8) ORAL TABLET -35 MG- MCG QL KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 4 HR.5-,000 MG QL (60 per 30 days) KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 4 HR 5-,000 MG, MG QL (30 per 30 days) KURVELO ORAL TABLET MG QL l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month mcg (84)/0 mcg (7), QL mcg (84)/0 mcg (7) larin.5/30 () oral tablet mcg LARIN /0 () ORAL TABLET -0 MG-MCG LARIN 4 FE ORAL TABLET MG-0 MCG (4)/75 MG (4) LARIN FE.5/30 (8) ORAL TABLET.5 MG-30 MCG ()/75 MG (7) QL LARIN FE /0 (8) ORAL TABLET MG-0 MCG ()/75 MG (7) QL LARISSIA ORAL TABLET 0.-0 MG-MCG LAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG-5MCG(4) AND 75 MG (4) Updated: October, 08 8

90 LEENA 8 ORAL TABLET 0.5// MG-MCG QL LESSINA ORAL TABLET 0.-0 MG-MCG QL letrozole oral tablet.5 leuprolide subcutaneous kit /0. ml SP LEVONEST (8) ORAL TABLET (6)/75-40 (5)/5-30(0) QL levonorgestrel-ethinyl estrad oral tablet mcg, QL levonorgestrel-ethinyl estrad oral tablet 90-0 mcg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month mcg QL levonorg-eth estrad triphasic oral tablet (6)/75-40 (5)/5-30(0) LEVORA-8 ORAL TABLET MG QL levothyroxine intravenous recon soln 00 mcg, 500 mcg levothyroxine oral tablet 00 mcg, mcg, 5 mcg, 37 mcg, 50 mcg, 75 mcg, 00 mcg, 5 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg LEVOXYL ORAL TABLET 00 MCG, MCG, 5 MCG, 37 MCG, 50 MCG, 75 MCG, 00 MCG, 5 MCG, 50 MCG, 75 MCG, 88 MCG LILETTA INTRAUTERINE INTRAUTERINE DEVICE 9.5 MCG/4 HOUR (4 YEARS) liothyronine intravenous solution 0 mcg/ml liothyronine oral tablet 5 mcg, 5 mcg, 50 mcg LORYNA (8) ORAL TABLET MG QL LOW-OGESTREL (8) ORAL TABLET MG-MCG QL LUGOLS ORAL SOLUTION 5 % LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT.5 MG, PA; SP.5 MG LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG PA; SP LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG PA; SP LUPRON DEPOT-PED INTRAMUSCULAR KIT.5 MG, 5 MG, 7.5 MG (PED) PA; SP LUTERA (8) ORAL TABLET 0.-0 MG-MCG QL LYZA ORAL TABLET 0.35 MG Updated: October, 08 8

91 MAKENA (PF) SUBCUTANEOUS AUTO- INJECTOR 75 MG/. ML PA; SP MARLISSA ORAL TABLET MG QL medroxyprogesterone intramuscular suspension 50 /ml QL medroxyprogesterone intramuscular syringe 50 /ml QL ( per 30 days) medroxyprogesterone oral tablet 0,.5, 5 megestrol oral suspension 400 /0 ml (0 ml), 400 /0 ml (40 /ml), 800 /0 ml (0 ml) PA megestrol oral tablet 0, 40 PA metformin oral tablet,000 QL metformin oral tablet 500 QL; QL (50 per 30 days) metformin oral tablet 850 QL (90 per 30 days) metformin oral tablet extended release 4 hr 500 QL; QL (50 per 30 days) metformin oral tablet extended release 4 hr 750 QL metformin oral tablet extended release 4hr 500 QL (50 per 30 days) methimazole oral tablet 0, 5 METHITEST ORAL TABLET 0 MG methylprednisolone acetate injection suspension 40 /ml, 80 /ml methylprednisolone oral tablet 6, 3, 4, 8 methylprednisolone oral tablets,dose pack 4 methylprednisolone sodium succ injection recon soln 5, 40 methylprednisolone sodium succ intravenous recon soln,000 MICROGESTIN.5/30 () ORAL TABLET.5-30 MG-MCG QL MICROGESTIN /0 () ORAL TABLET -0 MG-MCG QL MICROGESTIN FE.5/30 (8) ORAL TABLET.5 MG-30 MCG ()/75 MG (7) QL MICROGESTIN FE /0 (8) ORAL TABLET MG-0 MCG ()/75 MG (7) QL MIMVEY ORAL TABLET -0.5 MG Updated: October, 08 83

92 MONO-LINYAH ORAL TABLET MG- MCG QL MONONESSA (8) ORAL TABLET MG- MCG QL MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.) PA MYZILRA ORAL TABLET (6)/75-40 (5)/5-30(0) QL nateglinide oral tablet 0, 60 NATPARA SUBCUTANEOUS CARTRIDGE 00 MCG/DOSE, 5 MCG/DOSE, 50 MCG/DOSE, 75 PA MCG/DOSE NATURE-THROID ORAL TABLET 30 MG, 46.5 MG, 6.5 MG, 95 MG, 3.5 MG, MG, 65 MG, 8.5 MG NECON 0.5/35 (8) ORAL TABLET MG- MCG QL NEXPLANON SUBDERMAL IMPLANT 68 MG SP nikki (8) oral tablet NORA-BE ORAL TABLET 0.35 MG noreth-ethinyl estradiol-iron oral tablet,chewable mcg() and 75 (7), 0.8-5mcg(4) and 75 (4) norethindrone (contraceptive) oral tablet 0.35 norethindrone acetate oral tablet 5 norethindrone ac-eth estradiol oral tablet mcg, -0 -mcg, -5 -mcg norethindrone-e.estradiol-iron oral tablet -0 mcg ()/75 (7), -0 mcg (4)/75 (4) norgestimate-ethinyl estradiol oral tablet 0.8/0.5/0.5-5 mcg norgestimate-ethinyl estradiol oral tablet 0.8/0.5/ mcg (8), mcg QL NORTREL 0.5/35 (8) ORAL TABLET MG-MCG QL NORTREL /35 () ORAL TABLET -35 MG- MCG QL NORTREL /35 (8) ORAL TABLET -35 MG- MCG QL NORTREL 7/7/7 (8) ORAL TABLET 0.5/0.75/ MG- 35 MCG QL Updated: October, 08 84

93 NOVOLIN 70/30 U-00 INSULIN SUBCUTANEOUS SUSPENSION 00 UNIT/ML (70-30) NOVOLIN N NPH U-00 INSULIN SUBCUTANEOUS SUSPENSION 00 UNIT/ML NOVOLIN R REGULAR U-00 INSULN INJECTION SOLUTION 00 UNIT/ML NOVOLOG FLEXPEN U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML NOVOLOG MIX U-00 INSULN SUBCUTANEOUS SOLUTION 00 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U-00 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (70-30) NOVOLOG PENFILL U-00 INSULIN SUBCUTANEOUS CARTRIDGE 00 UNIT/ML NOVOLOG U-00 INSULIN ASPART SUBCUTANEOUS SOLUTION 00 UNIT/ML NP THYROID ORAL TABLET 0 MG, 5 MG, 30 MG, 60 MG, 90 MG NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 0 MG/ ML (5 MG/ML), 0 MG/ ML PA; SP (0 MG/ML), 5 MG/ ML (.5 MG/ML) NUVARING VAGINAL RING MG/4 HR OCELLA ORAL TABLET MG QL octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml, 00 mcg/ml, 50 mcg/ml, SP 500 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 50 mcg/ml ( ml), 500 mcg/ml ( ml) SP OGESTREL (8) ORAL TABLET MG- MCG QL ONGLYZA ORAL TABLET.5 MG, 5 MG QL (30 per 30 days) ORSYTHIA ORAL TABLET 0.-0 MG-MCG QL oxandrolone oral tablet 0,.5 PA PHILITH ORAL TABLET MG-MCG QL PIMTREA (8) ORAL TABLET MGX /0.0 MG X 5 QL pioglitazone oral tablet 5, 30, 45 QL (30 per 30 days) pioglitazone-metformin oral tablet 5-500, QL (90 per 30 days) Updated: October, 08 85

94 PIRMELLA ORAL TABLET 0.5/0.75/ MG- 35 MCG, -35 MG-MCG QL PORTIA ORAL TABLET MG QL prednisolone oral solution 5 /5 ml prednisolone sodium phosphate oral solution 5 /5 ml (3 /ml), 5 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 /5 ml prednisone oral tablet, 0,.5, 0, 5, 50 prednisone oral tablets,dose pack 0, 5 PREMARIN INJECTION RECON SOLN 5 MG PREMARIN VAGINAL CREAM 0.65 MG/GRAM PREMPHASE ORAL TABLET 0.65 MG (4)/ 0.65MG-5MG(4) PREMPRO ORAL TABLET MG, MG, MG, MG PREVIFEM ORAL TABLET MG-MCG QL progesterone intramuscular oil 50 /ml progesterone micronized oral capsule 00, 00 PROGLYCEM ORAL SUSPENSION 50 MG/ML propylthiouracil oral tablet 50 QUASENSE ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG QL QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION raloxifene oral tablet 60 RECLIPSEN (8) ORAL TABLET MG QL repaglinide oral tablet 0.5,, repaglinide-metformin oral tablet -500, -500 QL SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SP SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG PA; SP SETLAKIN ORAL TABLETS,DOSE PACK,3 MONTH 0.5 MG-30 MCG QL Updated: October, 08 86

95 SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML ( ML), 0.6 MG/ML ( ML), 0.9 MG/ML ( SP ML) SOLU-CORTEF (PF) INJECTION RECON SOLN,000 MG/8 ML, 00 MG/ ML, 50 MG/ ML, 500 MG/4 ML SOLU-CORTEF INJECTION RECON SOLN 00 MG SOLU-MEDROL (PF) INJECTION RECON SOLN 5 MG/ ML, 40 MG/ML SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN,000 MG/8 ML, 500 MG/4 ML SOLU-MEDROL INTRAVENOUS RECON SOLN,000 MG SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 0 MG/0.5 ML, 60 MG/0. ML, 90 SP MG/0.3 ML SPRINTEC (8) ORAL TABLET MG- MCG QL SRONYX ORAL TABLET 0.-0 MG-MCG QL STRONG IODINE ORAL SOLUTION 5 % SYEDA ORAL TABLET MG QL SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, QL MCG/ACTUATION SYMLINPEN 0 SUBCUTANEOUS PEN INJECTOR,700 MCG/.7 ML PA SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR,500 MCG/.5 ML PA SYNAREL NASAL SPRAY,NON-AEROSOL MG/ML tamoxifen oral tablet 0, 0 tarina fe /0 (8) oral tablet -0 mcg ()/75 (7) testosterone cypionate intramuscular oil 00 /ml, 00 /ml testosterone enanthate intramuscular oil 00 /ml TESTOSTERONE TRANSDERMAL GEL 50 MG/5 GRAM ( %) testosterone transdermal gel in metered-dose pump 0 /0.5 gram /actuation,.5 /.5 gram ( %) PA Updated: October, 08 87

96 testosterone transdermal gel in packet % (5 /.5gram), % (50 /5 gram) PA THYROLAR- ORAL TABLET.5-50 MCG THYROLAR-/ ORAL TABLET MCG THYROLAR-/4 ORAL TABLET MCG THYROLAR- ORAL TABLET 5-00 MCG THYROLAR-3 ORAL TABLET MCG TILIA FE ORAL TABLET -0(5)/-30(7) /MG- 35MCG (9) tolazamide oral tablet 50 QL (0 per 30 days) tolazamide oral tablet 500 QL (60 per 30 days) tolbutamide oral tablet 500 TRI-ESTARYLLA ORAL TABLET 0.8/0.5/0.5 MG-35 MCG (8) QL TRI-LEGEST FE ORAL TABLET -0(5)/-30(7) /MG-35MCG (9) QL TRI-LINYAH ORAL TABLET 0.8/0.5/0.5 MG-35 MCG (8) QL tri-lo-estarylla oral tablet 0.8/0.5/0.5-5 mcg tri-lo-sprintec oral tablet 0.8/0.5/0.5-5 mcg TRINESSA (8) ORAL TABLET 0.8/0.5/0.5 MG-35 MCG (8) QL trinessa lo oral tablet 0.8/0.5/0.5-5 mcg TRI-PREVIFEM (8) ORAL TABLET 0.8/0.5/0.5 MG-35 MCG (8) QL TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 MG PA TRI-SPRINTEC (8) ORAL TABLET 0.8/0.5/0.5 MG-35 MCG (8) QL TRIVORA (8) ORAL TABLET (6)/75-40 (5)/5-30(0) QL TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,0 MCG/.56 ML) PA; SP UNITHROID ORAL TABLET 00 MCG, MCG, 5 MCG, 50 MCG, 75 MCG, 00 MCG, 5 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG unithroid oral tablet 37 mcg vasopressin injection solution 0 unit/ml VELIVET TRIPHASIC REGIMEN (8) ORAL TABLET 0./.5/.5-5 MG-MCG QL Updated: October, 08 88

97 VICTOZA -PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0. ML (8 MG/3 ML) PA; QL; QL (6 per 30 days) VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0. ML (8 MG/3 ML) PA; QL (9 per 30 days) VIENVA ORAL TABLET 0.-0 MG-MCG VIORELE (8) ORAL TABLET MGX /0.0 MG X 5 QL WELCHOL ORAL POWDER IN PACKET 3.75 GRAM WERA (8) ORAL TABLET MG-MCG QL WESTHROID ORAL TABLET 30 MG, 3.5 MG, 65 MG WYMZYA FE ORAL TABLET,CHEWABLE 0.4MG-35MCG() AND 75 MG (7) QL XULANE TRANSDERMAL PATCH WEEKLY MCG/4 HR QL yuvafem vaginal tablet 0 mcg ZARAH ORAL TABLET MG QL ZENCHENT (8) ORAL TABLET MG- MCG QL ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG PA; SP ZOVIA /35E (8) ORAL TABLET -35 MG-MCG QL LOCAL ANESTHETICS (PARENTERAL) bupivacaine (pf) injection solution 0.5 % (.5 /ml), 0.5 % (5 /ml), 0.75 % (7.5 /ml) bupivacaine injection solution 0.5 % (.5 /ml), 0.5 % (5 /ml) bupivacaine-dextrose-water(pf) injection solution 0.75 % (7.5 /ml) bupivacaine-epinephrine (pf) injection solution 0.5 %-:00,000, 0.5 %-:00,000 bupivacaine-epinephrine injection solution 0.5 %-:00,000, 0.5 %-:00,000 lidocaine (pf) in d7.5w intrathecal solution 50 /ml (5 %) lidocaine (pf) injection solution 0 /ml ( %), 5 /ml (.5 %), 0 /ml ( %), 40 /ml (4 %), 5 /ml (0.5 %) lidocaine hcl injection solution 0 /ml ( %), 0 /ml ( %) lidocaine-epinephrine injection solution 0.5 %- :00,000, %-:00,000, %-:00,000 Updated: October, 08 89

98 MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine solution 00 /ml (0 %), 00 /ml (0 %) ACTEMRA INTRAVENOUS SOLUTION 00 MG/0 ML (0 MG/ML), 400 MG/0 ML (0 PA; SP MG/ML), 80 MG/4 ML (0 MG/ML) ACTEMRA SUBCUTANEOUS SYRINGE 6 MG/0.9 ML PA; SP alendronate oral solution 70 /75 ml QL (300 per 30 days) alendronate oral tablet 0, 40, 5 QL (30 per 30 days) alendronate oral tablet 35, 70 QL (4 per 30 days) allopurinol oral tablet 00, 300 amifostine crystalline intravenous recon soln 500 AMPYRA ORAL TABLET EXTENDED RELEASE HR 0 MG PA; SP; QL ATGAM INTRAVENOUS SOLUTION 50 MG/ML SP AUBAGIO ORAL TABLET 4 MG, 7 MG PA; SP AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG PA; SP; QL (4 per 30 days) AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML PA; SP; QL (4 per 30 days) AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML PA; SP; QL (4 per 30 days) azathioprine oral tablet 50 BETASERON SUBCUTANEOUS KIT 0.3 MG PA; SP; QL BOTOX INJECTION RECON SOLN 00 UNIT, 00 UNIT PA; SP calcitonin (salmon) nasal spray,non-aerosol 00 unit/actuation CERDELGA ORAL CAPSULE 84 MG CHEMET ORAL CAPSULE 00 MG colchicine oral capsule 0.6 colchicine oral tablet 0.6 CUPRIMINE ORAL CAPSULE 50 MG cyclophosphamide intravenous recon soln gram, gram, 500 CYCLOPHOSPHAMIDE ORAL CAPSULE 5 MG, 50 MG cyclosporine intravenous solution 50 /5 ml cyclosporine modified oral capsule 00, 5, 50 SP Updated: October, 08 90

99 cyclosporine modified oral solution 00 /ml SP cyclosporine oral capsule 00, 5 CYSTAGON ORAL CAPSULE 50 MG, 50 MG SP deferoxamine injection recon soln gram, 500 DENTA 5000 PLUS DENTAL CREAM. % DENTAGEL DENTAL GEL. % dexrazoxane hcl intravenous recon soln 50, 500 disulfiram oral tablet 50, 500 dutasteride oral capsule 0.5 ST dutasteride-tamsulosin oral capsule, er multiphase 4 hr ST DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT, 500 UNIT PA; SP ELIDEL TOPICAL CREAM % PA ELMIRON ORAL CAPSULE 00 MG ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (0.98 ML) PA; SP; QL (4 per 30 days) ENBREL SUBCUTANEOUS RECON SOLN 5 MG ( ML) PA; SP; QL (8 per 30 days) ENBREL SUBCUTANEOUS SYRINGE 5 MG/0.5ML (0.5) PA; SP; QL (5 per 30 days) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) PA; SP; QL (4 per 30 days) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) PA; SP; QL (4 per 30 days) etidronate disodium oral tablet 00, 400 EVOTAZ ORAL TABLET MG EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML EXTAVIA SUBCUTANEOUS KIT 0.3 MG PA; SP; QL finasteride oral tablet 5 FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML PA; SP flumazenil intravenous solution 0. /ml fluoride (sodium) oral drops 0.5 (. sod.fluorid)/ml fluoride (sodium) oral tablet,chewable 0.5 (0.55 sod. fluoride), 0.5 (. sodium fluorid), (. sod. fluoride) Updated: October, 08 9

100 FLUORITAB ORAL TABLET,CHEWABLE 0.5 MG (. MG SODIUM FLUORID), MG (. MG SOD. FLUORIDE) fomepizole intravenous solution gram/ml FOSRENOL ORAL TABLET,CHEWABLE,000 MG, 500 MG, 750 MG GILENYA ORAL CAPSULE 0.5 MG PA; SP; QL glatiramer subcutaneous syringe 0 /ml PA; SP; QL (30 per 30 days) glatiramer subcutaneous syringe 40 /ml PA; SP; QL ( per 30 days) GLATOPA SUBCUTANEOUS SYRINGE 0 MG/ML PA; SP; QL; QL (30 per 30 days) GLATOPA SUBCUTANEOUS SYRINGE 40 MG/ML PA; SP; QL ( per 30 days) GLUCAGEN HYPOKIT INJECTION RECON SOLN MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN MG HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML PA; SP; QL ( per 30 days) HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, PA; SP; QL (3 per 30 days) 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL; QL ( per 30 days) MG/0.8 ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 80 PA; SP; QL (3 per 30 days) MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL; QL ( per 30 days) MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 80 PA; SP; QL (3 per 30 days) MG/0.8 ML-40 MG/0.4 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML PA; SP; QL ( per 30 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0. ML, 0 MG/0. ML, 0 MG/0. ML, 0 PA; SP; QL ( per 30 days) MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML hydroxychloroquine oral tablet 00 ibandronate intravenous solution 3 /3 ml SP ibandronate intravenous syringe 3 /3 ml SP ibandronate oral tablet 50 ST; QL; QL ( per 30 days) Updated: October, 08 9

101 indomethacin oral capsule 5, 50 INTRON A INJECTION RECON SOLN 0 MILLION UNIT ( ML), 8 MILLION UNIT ( ML), SP 50 MILLION UNIT ( ML) INTRON A INJECTION SOLUTION 0 MILLION UNIT/ML, 6 MILLION UNIT/ML SP KIONEX (WITH SORBITOL) ORAL SUSPENSION GRAM/60 ML KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML PA; SP lanthanum oral tablet,chewable,000, 500, 750 leflunomide oral tablet 0, 0 QL; QL (30 per 30 days) LEMTRADA INTRAVENOUS SOLUTION MG/. ML PA leucovorin calcium injection recon soln 00, 00, 350, 50, 500 SP leucovorin calcium oral tablet 0, 5, 5, 5 SP levocarnitine (with sugar) oral solution 00 /ml levocarnitine oral tablet 330 levoleucovorin intravenous recon soln 75 SP LUDENT FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG(0.55 MG SOD. FLUORIDE), 0.5 MG (. MG SODIUM FLUORID), MG (. MG SOD. FLUORIDE) LUGOLS ORAL SOLUTION 5 % magnesium sulfate in water intravenous parenteral solution 0 gram/500 ml (4 %), 40 gram/,000 ml (4 %) magnesium sulfate in water intravenous piggyback gram/50 ml (4 %), 4 gram/00 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection solution 4 meq/ml (50 %) magnesium sulfate injection syringe 4 meq/ml mercaptopurine oral tablet 50 mesna intravenous solution 00 /ml MESNEX ORAL TABLET 400 MG SP methotrexate sodium (pf) injection recon soln gram methotrexate sodium (pf) injection solution 5 /ml Updated: October, 08 93

102 methotrexate sodium injection solution 5 /ml methotrexate sodium oral tablet.5 methylene blue (antidote) intravenous solution % (0 /ml) miglustat oral capsule 00 MITIGARE ORAL CAPSULE 0.6 MG MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG, 0.5 MG, MG MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG, MG mycophenolate mofetil hcl intravenous recon soln 500 SP mycophenolate mofetil oral capsule 50 SP mycophenolate mofetil oral suspension for reconstitution 00 /ml SP mycophenolate mofetil oral tablet 500 SP mycophenolate sodium oral tablet,delayed release (dr/ec) 80, 360 SP naloxone injection solution 0.4 /ml naloxone injection syringe 0.4 /ml, /ml naltrexone oral tablet 50 naproxen oral suspension 5 /5 ml naproxen oral tablet 50, 375, 500 naproxen oral tablet,delayed release (dr/ec) 375, 500 naproxen sodium oral tablet 75, 550 OCREVUS INTRAVENOUS SOLUTION 30 MG/ML PA octreotide acetate injection solution,000 mcg/ml, 00 mcg/ml, 00 mcg/ml, 50 mcg/ml, SP 500 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 50 mcg/ml ( ml), 500 mcg/ml ( ml) SP ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 5 MG/ML PA; SP ORENCIA SUBCUTANEOUS SYRINGE 5 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML PA; SP ORFADIN ORAL CAPSULE 0 MG, MG, 5 MG SP OTEZLA ORAL TABLET 30 MG PA; SP; QL (60 per 30 days) Updated: October, 08 94

103 OTEZLA STARTER ORAL TABLETS,DOSE PACK 0 MG (4)-0 MG (4)-30 MG (47), 0 MG PA; SP; QL ( per 73 days) (4)-0 MG (4)-30 MG(9) pamidronate intravenous recon soln 30, 90 pamidronate intravenous solution 30 /0 ml (3 /ml), 60 /0 ml (6 /ml), 90 /0 ml (9 /ml) physostigmine salicylate injection solution /ml phytonadione (vitamin k) oral tablet 5 PLEGRIDY SUBCUTANEOUS PEN INJECTOR 5 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 PA; SP ML PLEGRIDY SUBCUTANEOUS SYRINGE 5 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML PA; SP POMALYST ORAL CAPSULE MG, MG, 3 MG, 4 MG SP PREZCOBIX ORAL TABLET MG-MG probenecid oral tablet 500 probenecid-colchicine oral tablet PROLEUKIN INTRAVENOUS RECON SOLN MILLION UNIT SP PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML PA; SP raloxifene oral tablet 60 RAPAMUNE ORAL SOLUTION MG/ML SP REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE MCG/0.5 ML, 44 MCG/0.5 ML PA; SP; QL (6 per 30 days) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR MCG/0.5 ML, 44 MCG/0.5 ML PA; SP; QL (6 per 30 days) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.ML- MCG/0.5ML (6) PA; SP; QL (5 per 30 days) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.ML- MCG/0.5ML (6) PA; SP; QL (5 per 30 days) REMICADE INTRAVENOUS RECON SOLN 00 MG SP RENAGEL ORAL TABLET 800 MG RENVELA ORAL TABLET 800 MG REVLIMID ORAL CAPSULE 0 MG, 5 MG,.5 MG, 0 MG, 5 MG, 5 MG PA; SP SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG SP Updated: October, 08 95

104 SF 5000 PLUS DENTAL CREAM. % SF DENTAL GEL. % sirolimus oral tablet 0.5,, SODIUM POLYSTYRENE (SORB FREE) ORAL SUSPENSION 5 GRAM/60 ML sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate rectal enema 30 gram/0 ml sodium thiosulfate intravenous solution.5 gram/50 ml (50 /ml) SPS (WITH SORBITOL) ORAL SUSPENSION 5-0 GRAM/60 ML SPS (WITH SORBITOL) RECTAL ENEMA GRAM/0 ML STRONG IODINE ORAL SOLUTION 5 % sulfasalazine oral tablet 500 sulfasalazine oral tablet,delayed release (dr/ec) 500 tacrolimus oral capsule 0.5,, 5 SP TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 0 MG, 0 MG (4)- 40 PA; SP MG (46), 40 MG THALOMID ORAL CAPSULE 00 MG, 50 MG, 00 MG, 50 MG PA; SP TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.5 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (. MG)/ML VISTOGARD ORAL GRANULES IN PACKET 0 GRAM VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.5 MG FLUOR. (0.55 MG)/ML XELJANZ ORAL TABLET 0 MG, 5 MG PA; SP; QL (60 per 30 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 4 HR MG PA; SP; QL (30 per 30 days) XEOMIN INTRAMUSCULAR RECON SOLN 00 UNIT, 50 UNIT PA; SP XGEVA SUBCUTANEOUS SOLUTION 0 MG/.7 ML (70 MG/ML) SP ZORTRESS ORAL TABLET 0.5 MG, 0.5 MG, 0.75 MG SP OXYTOCICS oxytocin injection solution 0 unit/ml Updated: October, 08 96

105 PHARMACEUTICAL AIDS DILUENT FOR ACTHIB INTRAMUSCULAR SOLUTION 0.4 % DILUENT FOR IMOVAX INTRAMUSCULAR SYRINGE DILUENT FOR RABAVERT INTRAMUSCULAR SYRINGE DILUENT FOR ROTARIX ORAL SYRINGE SHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION RESPIRATORY TRACT AGENTS acetylcysteine solution 00 /ml (0 %), 00 /ml (0 %) albuterol sulfate inhalation solution for nebulization 0.63 /3 ml,.5 /3 ml,.5 /3 ml (0.083 %),.5 /0.5 ml, 5 /ml albuterol sulfate oral syrup /5 ml albuterol sulfate oral tablet, 4 albuterol sulfate oral tablet extended release hr 4, 8 aminophylline intravenous solution 50 /0 ml, 500 /0 ml atropine injection solution 0.4 /ml, /ml atropine injection syringe 0.05 /ml, 0. /ml ATROVENT HFA INHALATION HFA AEROSOL INHALER 7 MCG/ACTUATION QL (6 per 30 days) brompheniramine-pseudoeph-dm oral syrup /5 ml budesonide inhalation suspension for nebulization 0.5 / ml, 0.5 / ml, / ml carbinoxamine maleate oral liquid 4 /5 ml carbinoxamine maleate oral tablet 4 clemastine oral tablet.68 codeine sulfate oral tablet 5, 30, 60 QL (80 per 30 days) COMBIVENT RESPIMAT INHALATION MIST 0-00 MCG/ACTUATION QL (8 per 30 days) cromolyn ophthalmic (eye) drops 4 % cromolyn oral concentrate 00 /5 ml cyproheptadine oral syrup /5 ml cyproheptadine oral tablet 4 dimenhydrinate injection solution 50 /ml Updated: October, 08 97

106 diphenhydramine hcl injection solution 50 /ml diphenhydramine hcl injection syringe 50 /ml diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION QL (3 per 30 days) DULERA INHALATION HFA AEROSOL INHALER 00-5 MCG/ACTUATION QL ephedrine sulfate injection solution 50 /ml epinephrine injection auto-injector 0.5 /0.3 ml, 0.3 /0.3 ml QL ( per 30 days) epinephrine injection solution /ml, /ml ( ml) epinephrine injection syringe 0. /ml EPIPEN -PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML QL ( per 30 days) EPIPEN JR -PAK INJECTION AUTO- INJECTOR 0.5 MG/0.3 ML QL ( per 30 days) epoprostenol (glycine) intravenous recon soln 0.5,.5 SP ESBRIET ORAL CAPSULE 67 MG PA; SP; QL (70 per 30 days) ESBRIET ORAL TABLET 67 MG PA; SP; QL (70 per 30 days) ESBRIET ORAL TABLET 80 MG PA; SP; QL (90 per 30 days) FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML PA; SP FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 QL (60 per 30 days) MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/ACTUATION QL (4 per 30 days) FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION QL ( per 30 days) FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION QL (4 per 30 days) FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QL ( per 30 days) flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) QL (50 per 30 days) fluticasone nasal spray,suspension 50 mcg/actuation QL (6 per 30 days) Updated: October, 08 98

107 FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDR BREATH ACTIVATED 3-4 MCG/ACTUATION, 3-4 MCG/ACTUATION, 55-4 MCG/ACTUATION GASTROCROM ORAL CONCENTRATE 00 MG/5 ML ipratropium bromide inhalation solution 0.0 % ipratropium-albuterol inhalation solution for nebulization (.5 base)/3 ml KALYDECO ORAL TABLET 50 MG PA; SP LETAIRIS ORAL TABLET 0 MG, 5 MG PA; SP LUGOLS ORAL SOLUTION 5 % metaproterenol oral syrup 0 /5 ml metaproterenol oral tablet 0, 0 montelukast oral granules in packet 4 montelukast oral tablet 0 montelukast oral tablet,chewable 4, 5 NUCALA SUBCUTANEOUS RECON SOLN 00 MG PA NUEDEXTA ORAL CAPSULE 0-0 MG PA; QL (60 per 30 days) OFEV ORAL CAPSULE 00 MG, 50 MG PA; SP; QL (60 per 30 days) ORKAMBI ORAL GRANULES IN PACKET 00-5 MG, MG PA; SP ORKAMBI ORAL TABLET 00-5 MG, 00-5 MG PA; SP PROLASTIN-C INTRAVENOUS RECON SOLN,000 MG SP PROLASTIN-C INTRAVENOUS SOLUTION,000 MG (+/-)/0 ML promethazine injection solution 5 /ml, 50 /ml promethazine oral syrup 6.5 /5 ml promethazine oral tablet.5, 5, 50 PULMOZYME INHALATION SOLUTION MG/ML SP QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION sildenafil (antihypertensive) intravenous solution 0 /.5 ml PA; SP sildenafil (antihypertensive) oral tablet 0 PA; SP; QL Updated: October, 08 99

108 SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MCG QL (90 per 30 days) STRIVERDI RESPIMAT INHALATION MIST.5 MCG/ACTUATION STRONG IODINE ORAL SOLUTION 5 % SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, QL MCG/ACTUATION SYMDEKO ORAL TABLETS, SEQUENTIAL MG (D)/ 50 MG (N) PA; SP tadalafil (antihypertensive) oral tablet 0 PA; SP; QL (60 per 30 days) terbutaline oral tablet.5, 5 terbutaline subcutaneous solution /ml THEOCHRON ORAL TABLET EXTENDED RELEASE HR 00 MG, 00 MG, 300 MG theophylline oral elixir 80 /5 ml theophylline oral solution 80 /5 ml theophylline oral tablet extended release hr 00, 00, 300, 450 TRACLEER ORAL TABLET 5 MG, 6.5 MG PA; SP TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 QL ( per 30 days) MCG/ACTUATION VELETRI INTRAVENOUS RECON SOLN 0.5 MG,.5 MG SP VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION QL (36 per 30 days) XOLAIR SUBCUTANEOUS RECON SOLN 50 MG PA; SP zafirlukast oral tablet 0, 0 QL SKIN AND MUCOUS MEMBRANE AGENTS acitretin oral capsule 0, 7.5, 5 SP acyclovir topical ointment 5 % adapalene topical cream 0. % adapalene topical gel 0. %, 0.3 % adapalene topical gel with pump 0.3 % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % AZELEX TOPICAL CREAM 0 % Updated: October, 08 00

109 benzoyl peroxide topical cleanser 7 % betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone valerate topical cream 0. % betamethasone valerate topical lotion 0. % betamethasone valerate topical ointment 0. % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical ointment 0.05 % BP 0- TOPICAL CLEANSER 0- % calcipotriene topical cream % ciclopirox topical cream 0.77 % ciclopirox topical solution 8 % ciclopirox topical suspension 0.77 % CLARAVIS ORAL CAPSULE 0 MG, 0 MG, 30 MG, 40 MG CLEANSING WASH TOPICAL CLEANSER % CLINDACIN ETZ TOPICAL SWAB % CLINDACIN P TOPICAL SWAB % clindamycin phosphate topical foam % clindamycin phosphate topical gel % clindamycin phosphate topical lotion % clindamycin phosphate topical solution % clindamycin phosphate topical swab % clindamycin phosphate vaginal cream % clindamycin-tretinoin topical gel % clobetasol scalp solution 0.05 % clobetasol topical cream 0.05 % clobetasol topical foam 0.05 % clobetasol topical gel 0.05 % clobetasol topical ointment 0.05 % clobetasol-emollient topical cream 0.05 % clobetasol-emollient topical foam 0.05 % clotrimazole mucous membrane troche 0 Updated: October, 08 0

110 clotrimazole-betamethasone topical cream % CORMAX SCALP SOLUTION 0.05 % COSENTYX ( SYRINGES) SUBCUTANEOUS SYRINGE 50 MG/ML PA; SP COSENTYX PEN ( PENS) SUBCUTANEOUS PEN INJECTOR 50 MG/ML PA; SP COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 50 MG/ML PA; SP COSENTYX SUBCUTANEOUS SYRINGE 50 MG/ML PA; SP CROTAN TOPICAL LOTION 0 % desonide topical cream 0.05 % desonide topical lotion 0.05 % desonide topical ointment 0.05 % diclofenac sodium topical gel % diclofenac sodium topical gel 3 % PA diflorasone topical cream 0.05 % diflorasone topical ointment 0.05 % DOVONEX TOPICAL CREAM % DRITHOCREME HP TOPICAL CREAM % DRYSOL TOPICAL SOLUTION 0 % DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/ ML PA; SP econazole topical cream % ELIDEL TOPICAL CREAM % PA ERY PADS TOPICAL SWAB % erythromycin with ethanol topical gel % erythromycin with ethanol topical solution % erythromycin with ethanol topical swab % ethyl chloride topical aerosol,spray 00 % EURAX TOPICAL CREAM 0 % FEM PH VAGINAL GEL % FINACEA TOPICAL GEL 5 % fluocinolone topical cream 0.0 %, 0.05 % fluocinolone topical ointment 0.05 % fluocinolone topical solution 0.0 % fluocinonide topical cream 0.05 %, 0. % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % Updated: October, 08 0

111 fluocinonide topical solution 0.05 % FLUOCINONIDE-E TOPICAL CREAM 0.05 % FLUOROPLEX TOPICAL CREAM % fluorouracil topical cream 5 % fluorouracil topical solution %, 5 % fluticasone topical cream 0.05 % fluticasone topical ointment % FORMADON TOPICAL SOLUTION 0 % FORMADON TOPICAL SOLUTION WITH APPLICATOR 0 % gentamicin topical cream 0. % gentamicin topical ointment 0. % halobetasol propionate topical cream 0.05 % halobetasol propionate topical ointment 0.05 % HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML PA; SP; QL ( per 30 days) HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML PA; SP; QL (3 per 30 days) HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL; QL ( per 30 days) MG/0.8 ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 80 PA; SP; QL (3 per 30 days) MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 PA; SP; QL; QL ( per 30 days) MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 80 PA; SP; QL (3 per 30 days) MG/0.8 ML-40 MG/0.4 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML, 40 MG/0.8 ML PA; SP; QL ( per 30 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0. ML, 0 MG/0. ML, 0 MG/0. ML, 0 PA; SP; QL ( per 30 days) MG/0.4 ML, 40 MG/0.4 ML, 40 MG/0.8 ML hydrocortisone butyrate topical cream 0. % hydrocortisone butyrate topical ointment 0. % hydrocortisone butyrate topical solution 0. % hydrocortisone rectal enema 00 /60 ml hydrocortisone topical cream.5 % hydrocortisone topical lotion.5 % hydrocortisone topical ointment.5 % Updated: October, 08 03

112 hydrocortisone valerate topical cream 0. % hydrocortisone valerate topical ointment 0. % imiquimod topical cream in packet 5 % KEPIVANCE INTRAVENOUS RECON SOLN 6.5 MG ketoconazole topical cream % ketoconazole topical shampoo % lidocaine hcl laryngotracheal solution 4 % lidocaine hcl topical cream 3 % lidocaine hcl topical lotion 3 % lidocaine hcl-hydrocortison ac rectal cream % lidocaine hcl-hydrocortison ac rectal kit %, 3- % (7 gram) lidocaine hcl-hydrocortison ac topical cream % lidocaine topical ointment 5 % lidocaine-hydrocortisone-aloe rectal gel % lidocaine-hydrocortisone-aloe rectal kit - %, 3-.5 % (7 gram) lidocaine-prilocaine topical cream.5-.5 % lidocaine-prilocaine topical kit.5-.5 % LTA PRE-ATTACHED LARYNGOTRACHEAL SOLUTION 4 % malathion topical lotion 0.5 % methoxsalen oral capsule,liqd-filled,rapid rel 0 SP metronidazole topical cream 0.75 % metronidazole topical gel 0.75 % metronidazole topical lotion 0.75 % metronidazole vaginal gel 0.75 % MICONAZOLE-3 VAGINAL SUPPOSITORY 00 MG QL (3 per 30 days) mometasone topical cream 0. % mometasone topical ointment 0. % mometasone topical solution 0. % mupirocin calcium topical cream % mupirocin topical ointment % MYORISAN ORAL CAPSULE 0 MG, 0 MG, 30 MG, 40 MG Updated: October, 08 04

113 neomycin-polymyxin b gu irrigation solution 40-00,000 unit/ml NYAMYC TOPICAL POWDER 00,000 UNIT/GRAM nystatin topical cream 00,000 unit/gram nystatin topical ointment 00,000 unit/gram nystatin topical powder 00,000 unit/gram nystatin-triamcinolone topical cream 00, unit/g-% nystatin-triamcinolone topical ointment 00, unit/gram-% NYSTOP TOPICAL POWDER 00,000 UNIT/GRAM OTEZLA ORAL TABLET 30 MG PA; SP; QL (60 per 30 days) OTEZLA STARTER ORAL TABLETS,DOSE PACK 0 MG (4)-0 MG (4)-30 MG (47), 0 MG PA; SP; QL ( per 73 days) (4)-0 MG (4)-30 MG(9) permethrin topical cream 5 % phenazopyridine oral tablet 00, 00 PICATO TOPICAL GEL 0.05 %, 0.05 % podofilox topical solution 0.5 % prednicarbate topical cream 0. % prednicarbate topical ointment 0. % PROCTOFOAM HC RECTAL FOAM - % PROCTO-PAK TOPICAL CREAM WITH PERINEAL APPLICATOR % PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR.5 % RECTIV RECTAL OINTMENT 0.4 % (W/W) REMICADE INTRAVENOUS RECON SOLN 00 MG SP ROSADAN TOPICAL CREAM 0.75 % ROSADAN TOPICAL GEL 0.75 % salicylic acid er-ceramides topical kit,cleanser and cream er 6 % salicylic acid topical cream 6 % salicylic acid topical cream,extended release 6 % salicylic acid topical gel 6 % salicylic acid topical lotion 6 % salicylic acid topical lotion,extended release 6 % salicylic acid topical shampoo 6 % Updated: October, 08 05

114 SANTYL TOPICAL OINTMENT 50 UNIT/GRAM SEB-PREV TOPICAL CLEANSER 0 % selenium sulfide topical shampoo.5 % silver nitrate topical ointment 0 % silver nitrate topical solution 0.5 %, 0 %, 5 %, 50 % silver sulfadiazine topical cream % spinosad topical suspension 0.9 % SSD TOPICAL CREAM % SSS 0-5 TOPICAL CREAM 0-5 % (W/W) STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML PA; SP STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML PA; SP sulfacetamide sodium (acne) topical suspension 0 % sulfacetamide sodium topical cleanser 0 % sulfacetamide sodium-sulfur topical cleanser 0-5 % (w/w) sulfacetamide sodium-sulfur topical cream 0-5 % (w/w) sulfacetamide sodium-sulfur topical lotion 0-5 % (w/v), 0-5 % (w/w) sulfacetamide sodium-sulfur topical pads, medicated 0-4 % sulfacetamide sodium-sulfur topical suspension 0-5 % sulfacetamide sod-sulfur-urea topical cleanser % sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream 9 %-4.5 % -spf 5 tacrolimus topical ointment 0.03 % PA tacrolimus topical ointment 0. % TARGRETIN TOPICAL GEL % tazarotene topical cream 0. % PA TAZORAC TOPICAL CREAM 0.05 % PA TAZORAC TOPICAL GEL 0.05 %, 0. % PA terconazole vaginal cream 0.4 %, 0.8 % QL terconazole vaginal suppository 80 QL (3 per 30 days) tretinoin topical cream 0.05 %, 0.05 %, 0. % tretinoin topical gel 0.0 %, 0.05 % Updated: October, 08 06

115 triamcinolone acetonide topical cream 0.05 %, 0. %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0. % triamcinolone acetonide topical ointment 0.05 %, 0. %, 0.5 % UREA NAIL STICK TOPICAL SOLUTION 50 % urea topical cream 50 % urea topical lotion 40 % VALCHLOR TOPICAL GEL 0.06 % SP VANDAZOLE VAGINAL GEL 0.75 % ZENATANE ORAL CAPSULE 0 MG, 0 MG, 30 MG, 40 MG ZYCLARA TOPICAL CREAM IN METERED- DOSE PUMP.5 %, 3.75 % ZYCLARA TOPICAL CREAM IN PACKET 3.75 % SMOOTH MUSCLE RELAXANTS aminophylline intravenous solution 50 /0 ml, 500 /0 ml oxybutynin chloride oral syrup 5 /5 ml oxybutynin chloride oral tablet 5 oxybutynin chloride oral tablet extended release 4hr 0, 5 oxybutynin chloride oral tablet extended release 4hr 5 QL THEOCHRON ORAL TABLET EXTENDED RELEASE HR 00 MG, 00 MG, 300 MG theophylline oral elixir 80 /5 ml theophylline oral solution 80 /5 ml theophylline oral tablet extended release hr 00, 00, 300, 450 tolterodine oral capsule,extended release 4hr, 4 tolterodine oral tablet, VITAMINS ascorbic acid (vitamin c) injection solution 500 /ml B COMPLEX 00 INJECTION SOLUTION MG/ML BAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR MG Updated: October, 08 07

116 calcitriol intravenous solution mcg/ml calcitriol oral capsule 0.5 mcg, 0.5 mcg calcitriol oral solution mcg/ml COMPLETE NATAL DHA ORAL COMBO PACK MG COMPLETENATE ORAL TABLET,CHEWABLE 9 MG IRON- MG cyanocobalamin (vitamin b-) injection solution,000 mcg/ml ELITE OB WITH DHA ORAL CAPSULE MG ELITE-OB 400 ORAL CAPSULE MG ergocalciferol (vitamin d) oral capsule 50,000 unit folic acid injection solution 5 /ml FOLIVANE-OB ORAL CAPSULE 85- MG HECTOROL INTRAVENOUS SOLUTION MCG/ML hydroxocobalamin intramuscular solution,000 mcg/ml M.V.I. ADULT INTRAVENOUS SOLUTION 3,300 UNIT- 50 MCG/0 ML MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG, 0.5 MG, MG MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG, MG MYNATAL ADVANCE ORAL TABLET MG MYNATAL ORAL CAPSULE 65 MG IRON- MG MYNATAL ORAL TABLET MG MYNATAL PLUS ORAL TABLET 65 MG IRON- MG MYNATAL-Z ORAL TABLET 65 MG IRON- MG MYNATE 90 PLUS ORAL TABLET EXTENDED RELEASE 90 MG IRON- MG MYNEPHROCAPS ORAL CAPSULE MG phytonadione (vitamin k) oral tablet 5 PNV OB+DHA ORAL COMBO PACK MG Updated: October, 08 08

117 PNV-DHA + DOCUSATE ORAL CAPSULE MG PNV-DHA ORAL CAPSULE 7 MG IRON- MG MG PNV-OMEGA ORAL CAPSULE MG PNV-SELECT ORAL TABLET 7- MG PR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 400 ORAL COMBO PACK MG PR NATAL 430 EC ORAL COMBO PACK,TABLET AND CAP,DR MG PR NATAL 430 ORAL COMBO PACK 9 MG IRON- MG -430 MG PRENAISSANCE ORAL CAPSULE MG PRENAISSANCE PLUS ORAL CAPSULE MG PRENATABS FA ORAL TABLET 9- MG PRENATABS RX ORAL TABLET 9 MG IRON- MG PRENATAL LOW IRON ORAL TABLET 7 MG IRON- MG PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 7 MG IRON- MG PRENATAL PLUS ORAL TABLET 9 MG IRON- MG PRENATAL-U ORAL CAPSULE MG pyridoxine (vitamin b6) injection solution 00 /ml RENAL CAPS ORAL CAPSULE MG RENA-VITE RX ORAL TABLET MG- MG-MCG RENO CAPS ORAL CAPSULE MG SE-NATAL 9 (WITH DOCUSATE) ORAL TABLET 9 MG IRON- MG-5 MG SE-NATAL 9 ORAL TABLET,CHEWABLE 9 MG IRON- MG TARON-C DHA ORAL CAPSULE MG TARON-PREX PRENATAL-DHA ORAL CAPSULE 30 MG IRON-. MG-55 MG-65 MG TL-SELECT ORAL CAPSULE MG Updated: October, 08 09

118 TRIADVANCE ORAL TABLET MG TRINATAL RX ORAL TABLET 60 MG IRON- MG TRINATE ORAL TABLET 8 MG IRON- MG TRIVEEN-DUO DHA ORAL COMBO PACK MG TRIVEEN-ONE ORAL CAPSULE 7 MG IRON- MG -50 MG TRIVEEN-PRX RNF ORAL CAPSULE MG TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.5 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (. MG)/ML VENA-BAL DHA ORAL COMBO PACK,TABLET AND CAP,DR MG VINACAL ORAL TABLET MG VINATE CARE ORAL TABLET,CHEWABLE 40 MG IRON- MG VINATE GT ORAL TABLET MG VINATE II ORAL TABLET 9 MG IRON- MG VINATE M ORAL TABLET 7 MG IRON- MG VINATE ONE ORAL TABLET 60 MG IRON- MG VINATE PN CARE ORAL TABLET MG VINATE ULTRA ORAL TABLET MG VIRT-PN DHA ORAL CAPSULE 7 MG IRON- MG -300 MG VIRT-PN ORAL TABLET 7- MG VIRT-PN PLUS ORAL CAPSULE MG VIRT-SELECT ORAL CAPSULE MG VITAFOL-OB ORAL TABLET 65- MG VITAMIN D ORAL CAPSULE 50,000 UNIT VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.5 MG FLUOR. (0.55 MG)/ML VOL-NATE ORAL TABLET 8 MG IRON- MG VOL-TAB RX ORAL TABLET 9 MG IRON- MG ZATEAN-PN DHA ORAL CAPSULE 7 MG IRON- MG -300 MG ZATEAN-PN PLUS ORAL CAPSULE MG Updated: October, 08 0

119 Index abacavir... abacavir-lamivudine... abacavir-lamivudine-zidovudine... ABILIFY MAINTENA... 4, 4 acamprosate... 4 acarbose ACE AEROSOL CLOUD ENHANCER acebutolol..., 33 acetaminophen-codeine...4 acetazolamide... 33, 59, 68 acetazolamide sodium...33, 59, 68 acetic acid... 59, 68 acetylcysteine...90, 97 acitretin...00 ACTEMRA...90 ACTHIB (PF)... 7 acyclovir..., 00 acyclovir sodium... ADACEL(TDAP ADOLESN/ADULT)(PF)... 7 adapalene adefovir... adenosine...33 adenosine (diagnostic) ADRUCIL... ADVATE...6 ADYNOVATE... 6 AFINITOR... AFINITOR DISPERZ... AFSTYLA... 6 AIMOVIG AUTOINJECTOR...4 AIMOVIG AUTOINJECTOR ( PACK)... 4 ALBENZA... albumin, human 5 %...6 ALBURX (HUMAN) 5 %... 6 ALBUTEIN 5 %...6 ALBUTEIN 5 %...6 albuterol sulfate..., 97 alclometasone ALECENSA... alendronate ALINIA..., ALIQOPA... allopurinol...90 alosetron... 7 ALPHANATE...7 ALPHANINE SD...7 alprazolam...4 ALPROLIX...7 alprostadil...33 Updated: October, 08 ALTAVERA (8) ALUNBRIG..., ALYACEN /35 (8) ALYACEN 7/7/7 (8) amantadine hcl..., 4 AMETHIA AMETHIA LO...75 AMETHYST...75 amifostine crystalline...90 amikacin... amiloride-hydrochlorothiazide...33, 59 aminocaproic acid... 7 aminophylline... 97, 07 amiodarone amitriptyline... 4 amitriptyline-chlordiazepoxide... 4 amlodipine...33 amlodipine-benazepril ammonium chloride...59 amoxapine...4 amoxicillin... amoxicillin-pot clavulanate... amphotericin b... ampicillin... ampicillin sodium... ampicillin-sulbactam... AMPYRA anagrelide... 7 anastrozole..., 75 ANDRODERM...76 ANDROGEL ANORO ELLIPTA... apraclonidine...68 aprepitant... 7 APRI...76 APTIVUS... ARANELLE (8) ARANESP (IN POLYSORBATE)... 7 aripiprazole...4 ARMOUR THYROID ASACOL HD...7 ASCOMP WITH CODEINE... 4 ascorbic acid (vitamin c)...07 aspirin-dipyridamole... 7, 34, 4 atazanavir... atenolol..., 34 atenolol-chlorthalidone..., 34, 59 ATGAM atomoxetine...4, 43 atorvastatin...34 atovaquone... atovaquone-proguanil... ATRIPLA... atropine..., 68, 97 ATROVENT HFA...97 AUBAGIO...90 AUBRA...76 AUSTEDO...43 AVIANE AVONEX AVONEX (WITH ALBUMIN)...90 azacitidine... azathioprine...90 azelastine AZELEX azithromycin..., 3 AZURETTE (8)...76 B COMPLEX BACIIM...3 bacitracin...3, 68 bacitracin-polymyxin b...68 baclofen... BACTROBAN NASAL BALANCED SALT...69 BAL-CARE DHA...7, 59, 07 balsalazide... 7 BALZIVA (8) BANZEL BARACLUDE... 3 BASAGLAR KWIKPEN U-00 INSULIN BAVENCIO... BD PRE-FILLED NORMAL SALINE... 57, 60 BEBULIN...7 BELEODAQ... belladonna alkaloids-opium...43 BELLADONNA-OPIUM benazepril...34 benazepril-hydrochlorothiazide...34, 60 BENEFIX...7 BENZNIDAZOLE...3 benzoyl peroxide... 0 benztropine...,, 43 BESPONSA... betamethasone acet,sod phos betamethasone dipropionate...0 betamethasone valerate...0 betamethasone, augmented... 0 BETASERON betaxolol..., 34, 69

120 bethanechol chloride... bexarotene... BEXSERO...7 bicalutamide... BIKTARVY... 3 bisoprolol fumarate..., 34 bisoprolol-hydrochlorothiazide..., 34, 60 bleomycin... BLEPHAMIDE BLEPHAMIDE S.O.P...69 BLINCYTO... BLISOVI 4 FE...76 BLISOVI FE.5/30 (8) BLISOVI FE /0 (8) BOOSTRIX TDAP... 7, 8 BORTEZOMIB... BOSULIF... BOTOX..., 90 BP BRIELLYN...76 brimonidine...69 bromocriptine...43 brompheniramine-pseudoephdm..., 97 budesonide...76, 97 bumetanide... 34, 60 bupivacaine bupivacaine (pf)...89 bupivacaine-dextrose-water(pf)..89 bupivacaine-epinephrine..., 89 bupivacaine-epinephrine (pf), 89 buprenorphine hcl buprenorphine-naloxone bupropion hcl...43 bupropion hcl (smoking deter)...43 buspirone BUTALBITAL COMPOUND W/CODEINE...43 butalbital-acetaminop-caf-cod butalbital-acetaminophen butalbital-acetaminophen-caff butalbital-aspirin-caffeine... 7, 43 BYDUREON...76 BYDUREON BCISE BYETTA cabergoline...43 CABOMETYX... caffeine citrate...44 calcipotriene... 0 calcitonin (salmon)... 77, 90 calcitriol calcium acetate Updated: October, 08 calcium chloride...60 calcium gluconate...60 CALQUENCE... CAMILA...77 CAMRESE...77 CAMRESE LO...77 CANASA... 7 CANDIN...58 capecitabine... CAPRELSA... captopril...34 captopril-hydrochlorothiazide34, 60 CARAFATE... 7 CARBAGLU...60 carbamazepine...44 carbidopa-levodopa...44 carbidopa-levodopaentacapone carbinoxamine maleate..., 97 carboplatin... carteolol...69 CARTIA XT...34 carvedilol..., 34 CATHFLO ACTIVASE...7, 68 CAYSTON...3 CAZIANT (8)...77 cefaclor...3 cefadroxil...3 cefazolin... 3 cefazolin in dextrose (iso-os)...3 cefdinir...3 cefditoren pivoxil...3 cefepime...3 cefepime in dextrose,iso-osm...3 cefotaxime...3 cefotetan... 3 cefoxitin... 3 cefoxitin in dextrose, iso-osm...3 cefpodoxime...3 cefprozil...3, 4 ceftazidime... 4 ceftriaxone...4 ceftriaxone in dextrose,iso-os...4 cefuroxime axetil... 4 cefuroxime sodium... 4 celecoxib CELONTIN cephalexin... 4 CERDELGA...90 CESAMET...7 cevimeline... CHANTIX... CHANTIX STARTING MONTH BOX... CHATEAL...77 CHEMET... 75, 90 chloramphenicol sod succinate... 4 chlordiazepoxide hcl...44 chlorhexidine gluconate...69 chloroquine phosphate...4 chlorothiazide... 34, 60 chlorpromazine...44 chlorpropamide...77 chlorthalidone...34, 60 chlorzoxazone... cholestyramine (with sugar) CHOLESTYRAMINE LIGHT choline,magnesium salicylate...44 chromium chloride...60 ciclopirox... 0 cilostazol... 7, 34 CIMDUO...4 cimetidine... 7 cimetidine hcl...7 CIPRODEX...69 ciprofloxacin... 4 ciprofloxacin (mixture)... 4 ciprofloxacin hcl...4, 69 ciprofloxacin in 5 % dextrose...4 cisplatin... citalopram...44 cladribine... CLARAVIS... 0 clarithromycin... 4 CLEANSING WASH...0 clemastine..., 97 CLEO 90 INFUSION SET 4" CLINDACIN ETZ... 0 CLINDACIN P...0 clindamycin hcl...4 clindamycin palmitate hcl... 4 CLINDAMYCIN PEDIATRIC... 4 clindamycin phosphate...4, 5, 0 clindamycin-tretinoin...0 clobetasol... 0 clobetasol-emollient...0 clomipramine...44 clonazepam...44 clonidine..., 34 clonidine (pf)..., 34, 44 clonidine hcl..., 34 clopidogrel...7 clorazepate dipotassium...44 clotrimazole... 0 clotrimazole-betamethasone... 0

121 clozapine... 44, 45 COAGADEX...7 COARTEM... 5 cocaine...69 codeine sulfate... 45, 97 colchicine colesevelam... 35, 77 colestipol colistin (colistimethate na)...5 COMBIVENT RESPIMAT..., 97 COMETRIQ... COMFORT SHORT INFUSION SET 3" COMPLERA... 5 COMPLETE NATAL DHA COMPLETENATE...08 COMPRO... 45, 7 CONSTULOSE...60 COPPER CHLORIDE...60 CORIFACT...8 CORLANOR...35 CORMAX...0 cortisone...77 COSENTYX...0 COSENTYX ( SYRINGES)...0 COSENTYX PEN... 0 COSENTYX PEN ( PENS)...0 cosyntropin...58 COTELLIC... CREON... 7 CRIXIVAN... 5 cromolyn...69, 97 CROTAN... 0 CRYSELLE (8) CUPRIMINE... 75, 90 cyanocobalamin (vitamin b-) 08 CYCLAFEM /35 (8) CYCLAFEM 7/7/7 (8) cyclobenzaprine... cyclopentolate cyclophosphamide..., 90 CYCLOPHOSPHAMIDE..., 90 cyclosporine... 90, 9 cyclosporine modified...90, 9 cyproheptadine..., 97 CYRAMZA... cyred CYSTAGON... 9 CYSTARAN...69 cytarabine... cytarabine (pf)... CYTRA K CRYSTALS...60 CYTRA Updated: October, 08 CYTRA CYTRA-K...60 dacarbazine... danazol...77 dantrolene... dapsone... 5 DAPTACEL (DTAP PEDIATRIC) (PF)...8 daptomycin...5 DARAPRIM... 5 DASETTA /35 (8) DASETTA 7/7/7 (8) daunorubicin...3 DAYSEE...77 deferoxamine... 75, 9 DELFLEX-LC/.5% DEXTROSE...60 DELFLEX-LC/.5% DEXTROSE...60 DELFLEX-LC/4.5% DEXTROSE...60 DELFLEX-SM WITH.5% DEXTROSE...6 DENTA 5000 PLUS...9 DENTAGEL...9 DEPO-PROVERA DESCOVY...5 desipramine...45 desmopressin...8, 77 desogestrel-ethinyl estradiol...77 desonide...0 desvenlafaxine succinate dexamethasone...77, 78 DEXAMETHASONE INTENSOL dexamethasone sodium phos (pf)...78 dexamethasone sodium phosphate... 69, 78 dexmethylphenidate dexrazoxane hcl... 9 dextroamphetamine...45 dextroamphetamineamphetamine... 45, 46 dextrose 5 % in ringer's...6 dextrose 5 %-lactated ringers...6 DIANEAL LOW CALCIUM/.5% DEX...6 DIANEAL PD- WITH.5 % DEX...6 DIANEAL PD- WITH 4.5 % DEX...6 DIANEAL PD-/.5% DEXTROSE...6 DIANEAL WITH.5 % DEXTROSE...6 DIANEAL WITH 4.5 % DEXTROSE...6 diazepam...46 DIAZEPAM INTENSOL...46 diclofenac potassium...46 diclofenac sodium...3, 46, 69, 0 dicloxacillin... 5 dicyclomine... didanosine...5 diflorasone...0 diflunisal DIGOX...35 digoxin...35 dihydroergotamine..., 46 DILANTIN...35, 46 diltiazem hcl...35 DILT-XR DILUENT FOR ACTHIB DILUENT FOR IMOVAX DILUENT FOR RABAVERT...97 DILUENT FOR ROTARIX dimenhydrinate..., 7, 97 diphenhydramine hcl..., 98 diphenoxylate-atropine..., 7, 98 dipyridamole...8, 35 DISKETS...46 disopyramide phosphate disulfiram...9 divalproex...46 dobutamine... 3, 35 dobutamine in d5w..., 35 DOCETAXEL...3 dofetilide...35 donepezil...3 dopamine... 3, 36 dopamine in 5 % dextrose...3, 36 dorzolamide...69 dorzolamide-timolol DOVONEX... 0 doxazosin... 3, 36 doxepin...46 doxorubicin...3 doxycycline hyclate... 5, 69 doxycycline monohydrate...5 DRITHOCREME HP...0 dronabinol... 7 droperidol drospirenone-ethinyl estradiol DROXIA

122 DRYSOL... 0 DULERA...3, 78, 98 duloxetine...46 DUPIXENT... 0 dutasteride... 9 dutasteride-tamsulosin... 9 DYSPORT...3, 9 ECLIPSE SYRINGE...57 econazole...0 ED-SPAZ...3 EDURANT...5 efavirenz...5 EFFER-K...6 electrolyte-48 in d5w... 6 ELELYSO...68 ELIDEL...9, 0 ELINEST ELIPHOS...6 ELITE OB WITH DHA ELITE-OB , 08 ELLA ELMIRON...9 ELOCTATE... 8 EMCYT...3 EMOQUETTE...78 EMTRIVA... 5 enalapril maleate...36 enalaprilat...36 enalapril-hydrochlorothiazide36, 6 ENBREL...9 ENBREL MINI... 9 ENBREL SURECLICK... 9 ENDOCET...46 ENGERIX-B (PF)...8 ENGERIX-B PEDIATRIC (PF)... 8 enoxaparin... 8 ENPRESSE...78 ENSKYCE entacapone entecavir...5 ENTRESTO...36 ENULOSE... 6 ephedrine sulfate...3, 98 epinephrine... 3, 98 EPIPEN... 3 EPIPEN -PAK...3, 98 EPIPEN JR...3 EPIPEN JR -PAK... 3, 98 epirubicin...3 EPITOL EPIVIR... 5 EPIVIR HBV... 5 eplerenone Updated: October, 08 4 EPOGEN...8 epoprostenol (glycine)...36, 98 ergocalciferol (vitamin d) ergoloid... 3 ERIVEDGE...3 ERLEADA... 3 ERRIN ertapenem... 5 ERY PADS... 0 ERYTHROCIN (AS STEARATE)... 5 erythromycin...5, 69 erythromycin ethylsuccinate...5 erythromycin with ethanol...0 ESBRIET...98 escitalopram oxalate ESTARYLLA estazolam...47 estradiol...78 estradiol valerate...78 estradiol-norethindrone acet...78 ESTROGEL...78 estropipate eszopiclone ethambutol... 5 ethosuximide ethyl chloride... 0 etidronate disodium...9 etodolac...47 etoposide...3 EURAX...0 EVAMIST EVOTAZ...5, 9 EVZIO... 47, 9 exemestane...3, 78 EXJADE EXTAVIA... 9 E-Z-CAT DRY...58 ezetimibe...36 E-Z-HD BARIUM E-Z-PAQUE...58 FABRAZYME FALMINA (8) famciclovir... 5 famotidine...7 famotidine (pf)... 7 famotidine (pf)-nacl (iso-os)...7 FARESTON...3, 78 FARYDAK... 3 FASENRA FASLODEX... 3 FEIBA NF... 8 felbamate FELBATOL...47 felodipine...36 FEM PH...0 FEMHRT LOW DOSE...78 FEMYNOR fenofibrate fenofibrate micronized...36 fenofibrate nanocrystallized...36 fenofibric acid (choline) fentanyl...47 fentanyl citrate...47 FERRIPROX FETZIMA...47 FINACEA...0 finasteride...9 FIRAZYR...9 FISH OIL flecainide FLOVENT DISKUS... 79, 98 FLOVENT HFA...79, 98 floxuridine...3 fluconazole... 6 fluconazole in dextrose(iso-o)... 5 fluconazole in nacl (iso-osm)...6 fludrocortisone...79 flumazenil... 47, 9 flunisolide... 69, 98 fluocinolone... 0 fluocinonide... 0, 03 FLUOCINONIDE-E...03 fluorescein-proparacaine...58, 69 fluoride (sodium)...9 FLUORITAB... 9 fluorometholone FLUOROPLEX... 3, 03 fluorouracil...3, 03 fluoxetine...47 fluphenazine decanoate fluphenazine hcl... 47, 48 flurazepam flurbiprofen flurbiprofen sodium...69 flutamide...3 fluticasone... 98, 03 FLUTICASONE-SALMETEROL.99 fluvoxamine folic acid FOLIVANE-OB... 8, 08 fomepizole...9 FORMADON fosamprenavir...6 fosinopril...36

123 fosinopril-hydrochlorothiazide...36, 6 fosphenytoin...48 FOSRENOL...6, 9 FREESTYLE LIBRE 0 DAY READER FREESTYLE LIBRE 0 DAY SENSOR furosemide... 36, 37, 6 FUZEON...6 FYCOMPA...48 gabapentin GABITRIL...48 galantamine...3 GAMASTAN S/D... 8 GAMMAGARD LIQUID... 8 GAMMAGARD S-D (IGA < MCG/ML)...8 GAMUNEX-C... 8 GARDASIL 9 (PF)... 8 GASTROCROM GAVILYTE-C...7 GAVILYTE-G...7 GAVILYTE-N...7 gemfibrozil...37 GENERLAC...6 GENOTROPIN GENOTROPIN MINIQUICK GENTAK gentamicin...6, 69, 03 gentamicin in nacl (iso-osm)...6 gentamicin sulfate (ped) (pf)...6 gentamicin sulfate (pf)...6 GENVOYA... 6 GIANVI (8)...79 GILENYA...9 GILOTRIF...3 glatiramer... 9 GLATOPA... 9 glimepiride...79 glipizide glipizide-metformin GLUCAGEN DIAGNOSTIC KIT...58, 79 GLUCAGEN HYPOKIT... 79, 9 GLUCAGON EMERGENCY KIT (HUMAN)... 79, 9 GLUCAGON HCL...58, 79 glyburide...79 glyburide micronized glyburide-metformin...80 glycine urologic solution... 6 glycopyrrolate...3 Updated: October, 08 granisetron (pf)...7 granisetron hcl...73 griseofulvin microsize...6 griseofulvin ultramicrosize...6 guanfacine...37, 48 guanidine...4 halobetasol propionate...03 haloperidol...48 haloperidol decanoate...48 haloperidol lactate HAVRIX (PF)...8 HEATHER HECTOROL HELIXATE FS... 8 HEMLIBRA...8 HEMOFIL M HIGH... 8 HEMOFIL M LOW... 8 HEMOFIL M MID...8 HEMOFIL M SUPER HIGH...8 HEP FLUSH-0 (PF)...8, 57 heparin (porcine)... 9 heparin (porcine) in 5 % dex... 9 heparin (porcine) in nacl (pf) 9, 57 heparin flush(porcine)-0.9nacl...9, 57 HEPARIN LOCK...9, 58 HEPARIN LOCK FLUSH...9, 57 heparin lock flush (porcine).. 9, 57 HEPARIN LOCKFLUSH(PORCINE)(PF)...9, 58 heparin(porcine) in 0.45% nacl...9 heparin, porcine (pf)... 9, 58 HEPLISAV-B (PF)... 8 hetastarch 6 % in 0.9 % nacl...6 HEXALEN... 3 HIBERIX (PF)...8 HIZENTRA... 8 HOMATROPAIRE HUMALOG U-00 INSULIN HUMATE-P...9 HUMATROPE HUMIRA... 73, 9, 03 HUMIRA PEDIATRIC CROHN'S START... 73, 9, 03 HUMIRA PEN...73, 9, 03 HUMIRA PEN CROHN'S-UC- HS START...73, 9, 03 HUMIRA PEN PSORIASIS- UVEITIS... 73, 9, 03 HUMULIN 70/30 U-00 INSULIN HUMULIN 70/30 U-00 KWIKPEN...80 HUMULIN N NPH INSULIN KWIKPEN...80 HUMULIN N NPH U-00 INSULIN HUMULIN R REGULAR U-00 INSULN HUMULIN R U-500 (CONC) INSULIN hydralazine...37 hydrochlorothiazide... 37, 6 hydrocodone-acetaminophen...48 hydrocodone-ibuprofen hydrocortisone...80, 03 hydrocortisone butyrate...03 hydrocortisone valerate...04 hydrocortisone-acetic acid...70 hydromorphone hydroxocobalamin hydroxychloroquine... 6, 9 hydroxyprogest(pf)(preg presv).. 80 hydroxyprogesterone capr(bulk).80 hydroxyprogesterone caproate...80 hydroxyurea... 3 hydroxyzine hcl..., 48 hydroxyzine pamoate..., 48 HYOPHEN...6 hyoscyamine sulfate...4 HYPERHEP B S/D... 8 HYPERHEP B S-D NEONATAL.8 HYPERRAB S/D (PF)...9 HYPERRHO S/D...9 ibandronate... 9 IBRANCE... 3 ibuprofen ICLUSIG...3 idarubicin...4 IDELVION... 9 IDHIFA... 4 ifosfamide...4 ifosfamide-mesna...4 imatinib...4 IMBRUVICA... 4 IMFINZI... 4 imipramine hcl imipramine pamoate...49 imiquimod...04 IMOVAX RABIES VACCINE (PF)... 9 indapamide...37, 6 indomethacin...49, 93 INFANRIX (DTAP) (PF)...9 5

124 INFED... 9 INLYTA...4 INTELENCE... 6 INTRON A... 6, 4, 93 INTROVALE...80 INVANZ... 6 INVEGA SUSTENNA INVIRASE... 6 INVOKAMET INVOKANA...80 IONOSOL-B IN D5W...6 IONOSOL-MB IN D5W...6 IPOL... 9 ipratropium bromide... 4, 70, 99 ipratropium-albuterol... 4, 99 irbesartan irbesartan-hydrochlorothiazide IRESSA... 4 irinotecan...4 ISENTRESS...6 ISENTRESS HD...6 ISOLYTE S PH ISOLYTE-P IN 5 % DEXTROSE...6 ISOLYTE-S... 6 isoniazid... 7 isosorbide dinitrate isosorbide mononitrate...37 ISOVUE ISOVUE-M isradipine...37 itraconazole...7 ivermectin...7 IXIARO (PF)... 9 IXINITY...9 JAKAFI... 4 JANTOVEN... 9 JANUMET JANUMET XR JANUVIA... 8 JENCYCLA...8 JINTELI... 8 JOLESSA... 8 JOLIVETTE... 8 JULEBER... 8 JULUCA... 7 JUNEL.5/30 ()...8 JUNEL /0 ()...8 JUNEL FE.5/30 (8)...8 JUNEL FE /0 (8)...8 JUNEL FE KADCYLA... 4 KAITLIB FE... 8 Updated: October, 08 6 KALETRA...7 KALYDECO...99 KARIVA (8)...8 K-EFFERVESCENT...6 KELNOR /35 (8)... 8 KEPIVANCE...04 ketoconazole... 7, 04 ketoprofen ketorolac...49, 70 KEYTRUDA...4 KINRIX (PF)... 9 KIONEX (WITH SORBITOL) 6, 93 KLOR-CON... 6 KLOR-CON KLOR-CON KLOR-CON M KLOR-CON M KLOR-CON M KLOR-CON/EF...6 KOATE... 9 KOGENATE FS...30 KOMBIGLYZE XR...8 KOVALTRY KRYSTEXXA...93 KURVELO... 8 l norgest/e.estradiol-e.estrad...8 labetalol...4, 37 lactated ringers...6 lactulose... 6 lamivudine... 7 lamivudine-zidovudine...7 lamotrigine...49 lansoprazole...73 lanthanum... 6, 93 larin.5/30 ()... 8 LARIN /0 ()... 8 LARIN 4 FE... 8 LARIN FE.5/30 (8)...8 LARIN FE /0 (8)...8 LARISSIA... 8 latanoprost LATUDA LAYOLIS FE...8 LEENA leflunomide...93 LEMTRADA...93 LENVIMA... 4 LESSINA... 8 LETAIRIS... 37, 99 letrozole...4, 8 leucovorin calcium...93 LEUKERAN...4 LEUKINE...30 leuprolide...4, 8 levetiracetam...49 levobunolol levocarnitine levocarnitine (with sugar) levofloxacin... 7 levoleucovorin LEVONEST (8)...8 levonorgestrel-ethinyl estrad... 8 levonorg-eth estrad triphasic... 8 LEVORA levorphanol tartrate levothyroxine... 8 LEVOXYL...8 LEXIVA...7 lidocaine lidocaine (pf) in d7.5w lidocaine (pf)...37, 89 lidocaine hcl... 70, 89, 04 lidocaine hcl-hydrocortison ac.. 04 lidocaine in 5 % dextrose (pf)...37 lidocaine-epinephrine... 4, 89 lidocaine-hydrocortisone-aloe.. 04 lidocaine-prilocaine...04 LILETTA... 8 linezolid... 7 linezolid in dextrose 5%...7 linezolid-0.9% sodium chloride...7 LINZESS liothyronine...8 LIQUID E-Z PAQUE...58 lisinopril lisinopril-hydrochlorothiazide 37, 6 lithium carbonate...49 lithium citrate LONSURF... 4 lopinavir-ritonavir...7 lorazepam LORAZEPAM INTENSOL LORCET (HYDROCODONE)...50 LORCET HD...50 LORYNA (8)... 8 losartan losartan-hydrochlorothiazide 37, 6 LOTEMAX lovastatin... 37, 38 LOW-OGESTREL (8)...8 loxapine succinate...50 LTA PRE-ATTACHED...04 LUDENT FLUORIDE...93 LUGOLS...7, 8, 93, 99 LUMIZYME...68 LUPRON DEPOT...5, 8

125 LUPRON DEPOT (3 MONTH)...4, 8 LUPRON DEPOT (4 MONTH)...5, 8 LUPRON DEPOT-PED... 5, 8 LUTERA (8)...8 LYNPARZA... 5 LYRICA LYZA... 8 M.V.I. ADULT magnesium chloride magnesium sulfate... 38, 50, 93 magnesium sulfate in water...38, 50, 93 MAKENA (PF) malathion...04 manganese chloride...63 mannitol 0 %... 38, 59, 63 mannitol 0 %... 38, 59, 63 mannitol 5 %... 38, 59, 63 mannitol 5 %... 38, 59, 63 maprotiline...50 MARLISSA MATULANE...5 MAVYRET...7 meclizine..., 73 meclofenamate...50 medroxyprogesterone mefloquine...7 megestrol... 5, 83 MEKINIST... 5 meloxicam melphalan hcl... 5 memantine MENACTRA (PF)... 9 MENVEO A-C-Y-W-35-DIP (PF)... 9 MENVEO MENA COMPONENT (PF)...9 MENVEO MENCYW-35 COMPNT (PF)...9 meperidine meprobamate mercaptopurine... 5, 93 meropenem... 7 mesalamine...73 mesna MESNEX METADATE ER...50 metaproterenol... 4, 99 metaxalone...4 metformin methadone Updated: October, 08 METHADOSE...50 methenamine hippurate...7 methenamine mandelate...7 methimazole...83 METHITEST...83 methocarbamol...4 methotrexate sodium...5, 94 methotrexate sodium (pf)... 5, 93 methoxsalen...04 methscopolamine... 4 methyldopa...4, 38 methyldopa-hydrochlorothiazide...4, 38, 63 methyldopate...4, 38 methylene blue (antidote)...94 METHYLIN... 5 methylphenidate hcl... 5 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ...83 metipranolol...70 metoclopramide hcl metolazone...38, 63 metoprolol succinate... 4, 38 metoprolol ta-hydrochlorothiaz...4, 38, 63 metoprolol tartrate... 4, 38 metronidazole...7, 04 metronidazole in nacl (iso-os)... 7 mexiletine MICONAZOLE MICROGESTIN.5/30 ()...83 MICROGESTIN /0 ()...83 MICROGESTIN FE.5/30 (8).. 83 MICROGESTIN FE /0 (8)...83 midodrine... 4 miglustat...94 milrinone...38 milrinone in 5 % dextrose...38 MIMVEY minocycline...7 minoxidil mirtazapine...5 misoprostol...73 MITIGARE...94 mitomycin... 5 mitoxantrone... 5 M-M-R II (PF)... 9 modafinil...5 moexipril...38 moexipril-hydrochlorothiazide...38, 63 mometasone MONOCLATE-P...30 MONOJECT MAGELLAN SYRINGE MONOJECT SYRINGE...58 MONO-LINYAH...84 MONONESSA (8)...84 MONONINE...30 montelukast...99 morphine... 5 morphine concentrate...5 moxifloxacin...70 MOZOBIL MULTIVITAMIN WITH FLUORIDE... 94, 08 MULTI-VITAMIN WITH FLUORIDE... 94, 08 MULTIVITAMINS WITH FLUORIDE... 94, 08 mupirocin...04 mupirocin calcium...04 MYALEPT MYCAMINE...7 mycophenolate mofetil mycophenolate mofetil hcl...94 mycophenolate sodium MYLERAN...5 MYNATAL... 30, 63, 08 MYNATAL ADVANCE.. 30, 63, 08 MYNATAL PLUS...30, 63, 08 MYNATAL-Z...30, 63, 08 MYNATE 90 PLUS...08 MYNEPHROCAPS...08 MYORISAN MYZILRA...84 nabumetone... 5 nadolol...4, 38 nadolol-bendroflumethiazide...4, 38, 63 nafcillin... 8 nafcillin in dextrose iso-osm... 7 nalbuphine...5 naloxone...5, 94 naltrexone... 5, 94 naproxen... 5, 94 naproxen sodium...5, 94 NARCAN... 5 NATACYN nateglinide...84 NATPARA NATURE-THROID

126 NEBUPENT...8 NECON 0.5/35 (8)...84 neomycin...8 neomycin-bacitracin-poly-hc...70 neomycin-bacitracin-polymyxin.. 70 neomycin-polymyxin b gu...05 neomycin-polymyxin b- dexameth neomycin-polymyxin-gramicidin.70 neomycin-polymyxin-hc...70 NEO-POLYCIN HC NERLYNX... 5 NEULASTA NEUPOGEN...30 nevirapine...8 NEXAVAR... 5 NEXPLANON nicardipine...38, 39 NICOTROL...4 NICOTROL NS...4 nifedipine...39 nikki (8)...84 nilutamide...5 nimodipine...39 NINLARO... 5 NITRO-BID...39 nitrofurantoin... 8 nitrofurantoin macrocrystal...8 nitrofurantoin monohyd/m-cryst...8 nitroglycerin...39 nitroglycerin in 5 % dextrose nizatidine NORA-BE...84 norepinephrine bitartrate... 5 noreth-ethinyl estradiol-iron...84 norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol...84 norethindrone-e.estradiol-iron norgestimate-ethinyl estradiol NORMAL SALINE FLUSH... 58, 63 NORMOSOL-M IN 5 % DEXTROSE...63 NORMOSOL-R...63 NORMOSOL-R IN 5 % DEXTROSE...63 NORMOSOL-R PH NORTREL 0.5/35 (8)...84 NORTREL /35 ()...84 NORTREL /35 (8)...84 NORTREL 7/7/7 (8)...84 nortriptyline...5 NORVIR... 8 Updated: October, 08 8 NOVOEIGHT...30 NOVOLIN 70/30 U-00 INSULIN NOVOLIN N NPH U-00 INSULIN NOVOLIN R REGULAR U-00 INSULN NOVOLOG FLEXPEN U-00 INSULIN NOVOLOG MIX U-00 INSULN NOVOLOG MIX 70-30FLEXPEN U NOVOLOG PENFILL U-00 INSULIN NOVOLOG U-00 INSULIN ASPART...85 NOVOSEVEN RT...30 NP THYROID NUCALA...99 NUEDEXTA...5, 99 NUTRILYTE NUTROPIN AQ NUSPIN...85 NUVARING NUWIQ...30 NYAMYC...05 nystatin...8, 05 nystatin-triamcinolone NYSTOP OBIZUR...30 OCALIVA...73 OCELLA OCREVUS...94 octreotide acetate...85, 94 ODACTRA...9 ODEFSEY... 8 OFEV ofloxacin... 8, 70 OGESTREL (8) olanzapine...5 olopatadine...7 omega-3 acid ethyl esters omeprazole OMNIPAQUE OMNIPAQUE OMNIPAQUE ondansetron ondansetron hcl...74 ondansetron hcl (pf) ONETOUCH VERIO...59 ONGLYZA OPDIVO... 5 ORENCIA...94 ORENCIA CLICKJECT ORFADIN ORKAMBI...99 orphenadrine citrate... 5 ORSYTHIA...85 oseltamivir... 8 OTEZLA... 94, 05 OTEZLA STARTER...95, 05 oxacillin... 8 oxacillin in dextrose(iso-osm)...8 oxaliplatin... 5 oxandrolone oxaprozin...5 oxazepam...5 oxcarbazepine...5 oxybutynin chloride...07 oxycodone...5, 53 OXYCODONE...53 oxycodone-acetaminophen oxycodone-aspirin OXYCONTIN...53 oxytocin paclitaxel... 5 paliperidone...53 palonosetron pamidronate pantoprazole papaverine paromomycin...8 paroxetine hcl...53 PEDIARIX (PF)...9 PEDVAX HIB (PF)...9 peg 3350-electrolytes...74 PEGANONE...53 PEGASYS... 8 PEGASYS PROCLICK...8 peg-electrolyte soln penicillin g potassium... 8 penicillin g procaine...8 penicillin g sodium...9 penicillin v potassium... 9 PENTACEL (PF)... 9 PENTACEL ACTHIB COMPONENT (PF)...9 PENTACEL DTAP-IPV COMPNT (PF)...9 PENTASA pentazocine-naloxone pentoxifylline perindopril erbumine...39 PERIOGARD...7 permethrin perphenazine... 53

127 perphenazine-amitriptyline phenazopyridine...05 phenelzine...53 phenobarbital phenobarbital sodium...53 phenylephrine hcl... 5, 7 phenytoin...39, 53, 54 phenytoin sodium... 39, 54 phenytoin sodium extended. 39, 54 PHILITH PHOSPHA 50 NEUTRAL...63 PHOSPHOLINE IODIDE...7 PHYSIOLYTE...63 PHYSIOSOL IRRIGATION...63 physostigmine salicylate...5, 95 phytonadione (vitamin k).. 95, 08 PICATO...5, 05 pilocarpine hcl... 5, 7 PIMTREA (8)...85 pindolol...5, 39 pioglitazone pioglitazone-metformin...85 piperacillin-tazobactam...9 PIRMELLA piroxicam...54 PLASMA-LYTE PLASMA-LYTE A PLEGRIDY PNEUMOVAX PNV OB+DHA... 30, 64, 74, 08 PNV-DHA... 3, 09 PNV-DHA + DOCUSATE...3, 64, 74, 09 PNV-OMEGA... 3, 64, 09 PNV-SELECT...3, 09 podofilox...05 POLYCIN... 7 POLYFIN QR INFUSION SET polymyxin b sulfate...9 polymyxin b sulf-trimethoprim...7 POMALYST...5, 95 PORTIA...86 potassium acetate potassium bicarb and chloride...64 potassium bicarb-citric acid...64 potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl..64 potassium chloride in 5 % dex...64 potassium chloride in lr-d potassium chloride in water...64 potassium chloride-0.45 % nacl.64 Updated: October, 08 potassium chloride-d5-0.%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid...65 potassium phosphate m-/dbasic...65 PR NATAL , 65, 09 PR NATAL 400 EC...3, 65, 09 PR NATAL , 65, 09 PR NATAL 430 EC...3, 65, 09 PRADAXA... 3 PRALUENT PEN...39 pramipexole...54 prasugrel... 3 pravastatin...39 praziquantel...9 prazosin...5, 39 PRED MILD...7 prednicarbate prednisolone...86 prednisolone acetate...7 prednisolone sodium phosphate...7, 86 prednisone PREDNISONE INTENSOL...86 PREMARIN PREMPHASE...86 PREMPRO PRENAISSANCE... 3, 65, 74, 09 PRENAISSANCE PLUS...3, 65, 74, 09 PRENATABS FA...3, 65, 09 PRENATABS RX...3, 65, 09 PRENATAL LOW IRON...3, 65, 09 PRENATAL PLUS...3, 65, 09 PRENATAL PLUS (CALCIUM CARB)... 3, 65, 09 PRENATAL-U...09 PREVIFEM...86 PREVNAR 3 (PF)...0 PREVYMIS...9 PREZCOBIX...9, 95 PREZISTA...9 PRIFTIN... 9 primidone PRIVIGEN... 0 probenecid... 65, 95 probenecid-colchicine...65, 95 procainamide...39 prochlorperazine...54, 74 prochlorperazine edisylate... 54, 74 prochlorperazine maleate...54, 74 PROCRIT... 3 PROCTOFOAM HC PROCTO-PAK...05 PROCTOZONE-HC...05 PROFILNINE...3 progesterone progesterone micronized...86 PROGLYCEM PROLASTIN-C PROLEUKIN...5, 95 PROLIA PROMACTA...3 promethazine..., 54, 99 propafenone propantheline... 5 proparacaine... 7 propranolol... 5, 39, 40, 54 propranolol-hydrochlorothiazid...5, 40, 65 propylthiouracil PROQUAD (PF)... 0 protriptyline...54 PULMOZYME...68, 99 PYLERA... 9, 74 pyrazinamide...9 pyridostigmine bromide... 5 pyridoxine (vitamin b6) QUADRACEL (PF)...0 QUASENSE quetiapine...54 quinapril...40 quinapril-hydrochlorothiazide40, 65 quinidine gluconate... 9, 40 quinidine sulfate... 9, 40 quinine sulfate... 9 QVAR REDIHALER...86, 99 RABAVERT (PF)...0 raloxifene...86, 95 ramipril...40 ranitidine hcl RAPAMUNE...95 RAVICTI READI-CAT...59 REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK...95 REBINYN... 3 RECLIPSEN (8)...86 RECOMBINATE...3 9

128 RECOMBIVAX HB (PF)... 0 RECTIV RELENZA DISKHALER... 9 REMICADE... 95, 05 RENAGEL... 65, 95 RENAL CAPS...09 RENA-VITE RX RENO CAPS RENVELA... 65, 95 repaglinide...86 repaglinide-metformin...86 REPATHA PUSHTRONEX REPATHA SURECLICK...40 REPATHA SYRINGE RESCRIPTOR...9 RESTASIS... 7 RESTASIS MULTIDOSE...7 RETROVIR...9 REVLIMID... 5, 95 REVONTO...5 REXULTI ribavirin...9 rifabutin... 9 rifampin... 9 RIFATER...9 riluzole...54 rimantadine... 9 ringer's...65 RISPERDAL CONSTA...54 risperidone ritonavir... 9 RITUXAN HYCELA... 6 rivastigmine... 5 rivastigmine tartrate...5 RIXUBIS...3 rizatriptan ropinirole ROSADAN...05 rosuvastatin...40 ROTARIX... 0 ROTATEQ VACCINE...0 RUBRACA...6 RYDAPT...6 salicylic acid salicylic acid er-ceramides salsalate SANTYL SAVELLA SEB-PREV SECONAL SODIUM...55 selegiline hcl...55 selenium...65 selenium sulfide...06 Updated: October, 08 0 SELZENTRY... 9, 0 SE-NATAL 9...3, 09 SE-NATAL 9 (WITH DOCUSATE)... 3, 74, 09 SENSIPAR... 86, 95 SEROSTIM...86 sertraline SETLAKIN...86 sevelamer carbonate...65 SF...96 SF 5000 PLUS SHINGRIX (PF)...0 SHINGRIX ADJUVANT COMPONENT-PF SHINGRIX GE ANTIGEN COMPONENT...0 SIGNIFOR...87 SIKLOS... 6 sildenafil (antihypertensive)..40, 99 silver nitrate...06 silver sulfadiazine...06 simvastatin sirolimus SIRTURO... 0 sodium acetate...65 sodium bicarbonate...66 sodium chlor 0.9% bacteriostat.. 66 sodium chloride sodium chloride 0.45 %...66 sodium chloride 0.9 %...58, 66 sodium chloride 3 %...66 sodium chloride 5 %...66 sodium citrate-citric acid...66 sodium lactate sodium phenylbutyrate sodium phosphate...66 SODIUM POLYSTYRENE (SORB FREE)... 66, 96 sodium polystyrene sulfonate...66, 96 sodium thiosulfate SOLU-CORTEF...87 SOLU-CORTEF (PF)...87 SOLU-MEDROL...87 SOLU-MEDROL (PF)...87 SOMATULINE DEPOT...87 SORINE... 5, 40 sotalol...5, 40 SOTALOL AF... 5, 40 spinosad...06 SPIRIVA RESPIMAT...5 SPIRIVA WITH HANDIHALER...5, 00 spironolactone...40, 66 spironolacton-hydrochlorothiaz...40, 66 SPRINTEC (8)...87 SPRYCEL... 6 SPS (WITH SORBITOL)... 66, 96 SRONYX SSD...06 SSS STAMARIL (PF)... 0 stavudine...0 STELARA...06 STIVARGA... 6 STRENSIQ...68 STRIBILD... 0 STRIVERDI RESPIMAT...5, 00 STRONG IODINE...0, 87, 96, 00 SUBOXONE...55 SUCRAID sucralfate...75 sulfacetamide sodium...7, 06 sulfacetamide sodium (acne) sulfacetamide sodium-sulfur...06 sulfacetamide sod-sulfur-urea.. 06 sulfacetamide-prednisolone... 7 sulfact na-sul-avobnz-otn-ocsa 06 sulfadiazine... 0 sulfamethoxazole-trimethoprim.. 0 sulfasalazine... 0, 75, 96 sulindac sumatriptan sumatriptan succinate SUTENT...6 SYEDA SYLATRON...0, 6 SYLVANT...6 SYMBICORT...5, 87, 00 SYMDEKO SYMFI... 0 SYMFI LO... 0 SYMLINPEN SYMLINPEN SYNAGIS... 0 SYNAREL SYREX SODIUM CHLORIDE 0.9 %... 58, 67 syringe with needle, safety...58 T:SLIM...58 TABLOID...6 tacrolimus...96, 06 tadalafil (antihypertensive). 40, 00

129 TAFINLAR...6 TAGITOL V TAGRISSO...6 TAMIFLU...0 tamoxifen...6, 87 tamsulosin... 6 TARCEVA... 6 TARGRETIN...6, 06 tarina fe /0 (8)...87 TARON-C DHA... 3, 09 TARON-PREX PRENATAL- DHA...3, 75, 09 TASIGNA... 6 tazarotene TAZORAC TECENTRIQ...6 TECFIDERA...96 temazepam TEMODAR... 6 temozolomide...6 TENIVAC (PF)...0 tenofovir disoproxil fumarate... 0 terazosin...6, 40 terbinafine hcl...0 terbutaline... 6, 00 terconazole...06 TESTOSTERONE...87 testosterone... 87, 88 testosterone cypionate testosterone enanthate tetanus,diphtheria tox ped(pf)...0 tetanus-diphtheria toxoids-td... 0 TETCAINE...7 tetrabenazine tetracaine hcl...7 tetracaine hcl (pf)...7 tetracycline... 0 thallous chloride tl THALOMID...96 THEOCHRON... 40, 67, 00, 07 theophylline... 4, 67, 00, 07 thioridazine...55 thiothixene...55 THYROGEN...59 THYROLAR THYROLAR-/...88 THYROLAR-/ THYROLAR THYROLAR tiagabine...55 TICE BCG... 6, 0 TILIA FE timolol maleate... 6, 4, 55, 7 Updated: October, 08 TIVICAY... 0 tizanidine... 6 TL-SELECT...3, 67, 75, 09 tobramycin...7 tobramycin in 0.5 % nacl... 0 tobramycin in 0.9 % nacl... 0 tobramycin sulfate... 0 tobramycin-dexamethasone...7 tolazamide...88 tolbutamide...88 tolmetin...56 tolterodine topiramate TOPOSAR...6 torsemide... 4, 67 TRACLEER... 4, 00 tramadol tramadol-acetaminophen...56 trandolapril... 4 tranylcypromine...56 trazodone TRELEGY ELLIPTA... 6, 00 tretinoin tretinoin (chemotherapy)... 6 TRETTEN...3 TRIADVANCE... 3, 67, 0 triamcinolone acetonide triamterene-hydrochlorothiazid...4, 67 triazolam...56 TRICITRATES...67 TRI-ESTARYLLA...88 trifluoperazine...56 trihexyphenidyl... 6, 56 TRI-LEGEST FE...88 TRI-LINYAH tri-lo-estarylla...88 tri-lo-sprintec...88 trimethobenzamide...75 trimethoprim... 0 TRINATAL RX...3, 67, 0 TRINATE...3, 67, 0 TRINESSA (8)...88 trinessa lo...88 TRINTELLIX...56 TRI-PREVIFEM (8)...88 TRIPTODUR TRI-SPRINTEC (8)...88 TRIUMEQ...0 TRIVEEN-DUO DHA... 3, 67, 0 TRIVEEN-ONE...3, 67, 0 TRIVEEN-PRX RNF...3, 67, 75, 0 TRI-VITAMIN WITH FLUORIDE...96, 0 TRIVORA (8)...88 TROGARZO...0 tropicamide...7 TRUMENBA... 0 TRUVADA... 0 TUDORZA PRESSAIR...00 TWINRIX (PF)... TYKERB...6 TYMLOS UNITHROID unithroid UNITUXIN... 6 UPTRAVI...4 UR N-C...0 urea UREA NAIL STICK...07 URIMAR-T... UROGESIC-BLUE... ursodiol...75 valacyclovir... VALCHLOR...6, 07 valganciclovir... valproate sodium...56 valproic acid valproic acid (as sodium salt) valsartan...4 valsartan-hydrochlorothiazide...4, 67 vancomycin... vancomycin in dextrose 5 %... VANDAZOLE...07 VAQTA (PF)... VARIBAR THIN HONEY VARIBAR THIN LIQUID VARIVAX (PF)... VARIZIG... vasopressin VAXCHORA VACCINE... VECTIBIX...7 VELCADE... 7 VELETRI... 4, 00 VELIVET TRIPHASIC REGIMEN (8) VELTASSA...67 VEMLIDY... VENA-BAL DHA...3, 67, 0 VENCLEXTA...7 VENCLEXTA STARTING PACK... 7

130 venlafaxine VENOFER...3 VENTOLIN HFA... 6, 00 verapamil...4 VERZENIO...7 VIBERZI VICTOZA -PAK VICTOZA 3-PAK VIDEX GRAM PEDIATRIC... VIENVA VIIBRYD...56 VIMIZIM...68 VIMPAT...56 VINACAL...3, 67, 75, 0 VINATE CARE... 3, 0 VINATE GT... 3, 0 VINATE II... 0 VINATE M... 3, 0 VINATE ONE...3, 67, 0 VINATE PN CARE... 0 VINATE ULTRA...3, 67, 75, 0 vinblastine... 7 VINCASAR PFS...7 vincristine... 7 vinorelbine...7 VIORELE (8) VIRACEPT... VIREAD... VIRT-PN...3, 0 VIRT-PN DHA... 3, 0 VIRT-PN PLUS...3, 67, 0 VIRT-SELECT...3, 67, 75, 0 VISIPAQUE...59 VISTOGARD VITAFOL-OB...33, 67, 0 VITAMIN D... 0 VITAMINS A,C,D AND FLUORIDE... 96, 0 VIVOTIF... VOL-NATE... 33, 0 VOL-TAB RX...33, 0 VOLUMEN...59 VONVENDI...33 voriconazole... VOSEVI... VOTRIENT... 7 VPRIV VYVANSE... 56, 57 warfarin water for irrigation, sterile...68 WELCHOL...89 WERA (8) WESTHROID Updated: October, 08 WILATE...33 WINRHO SDF... WYMZYA FE...89 XALKORI...7 XARELTO XELJANZ XELJANZ XR...96 XEOMIN... 6, 96 XERMELO...75 XGEVA...96 XIFAXAN... XIIDRA... 7 XOLAIR XTANDI... 7 XULANE...89 XYNTHA...33 XYNTHA SOLOFUSE YF-VAX (PF)... YONDELIS... 7 yuvafem...89 zafirlukast zaleplon...57 ZARAH ZARXIO...33 ZATEAN-PN DHA... 33, 0 ZATEAN-PN PLUS...33, 68, 0 ZEJULA...7 ZELBORAF... 7 ZENATANE ZENCHENT (8) zidovudine... zinc chloride zinc sulfate ziprasidone hcl ZIRGAN...7 ZOLINZA... 7 zolmitriptan...57 zolpidem...57 zonisamide ZORBTIVE ZORTRESS...96 ZOSTAVAX (PF)... ZOVIA /35E (8)...89 ZYCLARA...07 ZYDELIG...7 ZYKADIA...7 ZYLET... 7 ZYPREXA RELPREVV ZYTIGA... 7

131 UCARE STATE PUBLIC PROGRAM OTC DRUG FORMULARY 08 The following list of over-the-counter (OTC) medications are covered by UCare for State Public Program members. The formulary only includes the generic version of products. Some brand products are listed in parentheses for reference purposes only. This list is subject to change. ANALGESICS AND ANTI-INFLAMMATORY DRUGS acetaminophen (TYLENOL) acetaminophen / pyrilamine / caffeine aspirin (BAYER) aspirin / acetaminophen/ caffeine (EXCEDRIN) aspirin / buffers (BUFFERIN) aspirin / sodium bicarb / citric acid (ALKA-SELTZER) ibuprofen (MOTRIN) naproxen (ALEVE) COUGH AND COLD MEDICATIONS ANTIHISTAMINES cetirizine (ZYRTEC) clemastine fumurate diphenhydramine (BENADRYL) loratadine (CLARITIN) DECONGESTANTS phenylephrine (SUDAFED PE) pseudoephedrine (SUDAFED) ANTIHISTAMINE / DECONGESTANT COMBINATIONS brompheniramine / pseudoephedrine brompheniramine / phenylephrine cetirizine / pseudoephedrine (ZYRTEC - D) chlorpheniramine / phenylephrine chlorpheniramine / phenylephrine / acetaminophen chlorpheniramine / phenylephrine / dextromethorphan / acetaminophen chlorpheniramine / pseudoephedrine chlorpheniramine / pseudoephedrine / acetaminophen chlorpheniramine / pseudoephedrine / dextrometorphah / acetaminophen diphenhyydramine / pseudoephedrine / acetaminophen diphenydramine / pseudoephedrine loratadine / pseudoephedrine (CLARITIN - D) phenylephrine / acetaminophen phenylephrine / guaifenesin UCare State Public Program OTC Drug Formulary 08