What is the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary?

Transcription

1 CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 019 Comprehensive Formulary PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID , Version Number 8. This formulary was updated on 0/7/019. For more recent information or other questions, please contact CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Member Services, at or, for TTY users, 711, 8 a.m. 8 p.m. local time, seven days a week, from October 1 March 31, and 8 a.m. 8 p.m. local time, Monday Friday, from April 1- September 30, or visit christushealthplan.org. H1189_MC131_C 0/8/019 1

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO). When it refers to plan or our plan, it means CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 03/01/019. For a complete updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 00, and from time to time during the year. What is the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary? A formulary is a list of covered drugs selected by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 019 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

3 o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary? s removed from the market. If the Food and Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance: we may add a new generic drug to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different costsharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier], we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. The enclosed formulary is current as of 03/01/019. To get updated information about the drugs covered by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO), please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 9. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, antihypertensive therapy. If you know what your drug is used for, look for the category name in the list that begins on page number 9. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 83. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. 3

4 What are generic drugs? CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) may not cover the drug. Quantity Limits: For certain drugs, CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) limits the amount of the drug that we will cover. For example, we provide 31 tablets per prescription for AFINITOR. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line a document that explain our prior authorization restriction, step therapy restriction, prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus HMO) to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) formulary? on page 5 for information about how to request an exception. 4

5 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that we do not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by us. You can ask CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary? You can ask CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level [if this drug is not on the specialty tier]. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, we will only approve your request for an exception if the alternative drugs included on the plan s formulary, [the lower cost-sharing drug] or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give 5

6 you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. Enrollees whose transition window has expired and are either being admitted to a LTC setting or being discharged from a long term care setting are provided an additional transition fill due to that level of care change. While the claim will initially reject as the member is no longer transition eligible according to plan enrollment dates, the pharmacist is instructed to enter an override code to allow the transition supply to process accordingly. Early refill edits are not applied in a long term care setting. For more information For more detailed information about your CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call 711. Or, visit 6

7 CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary The formulary below provides coverage information about some of the drugs covered by CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on page 83. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AFINITOR) and generic drugs are listed in lower-case italics (e.g., atorvastatin). The information in the column tells you if we have any special requirements for coverage of your drug. 7

8 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. List of Abbreviations B/D PA: This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. MO: Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. Number Name Copay for a one-month supply filled at a network pharmacy with standard cost-sharing 1 Preferred Generic $4 Generic $10 3 Preferred Brand $35 4 Non-Preferred Brand $90 5 Specialty You pay 9% of the total cost 8

9 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 5 B/D PA; MO AMBISOME 5 B/D PA; MO amphotericin b 4 B/D PA; MO caspofungin 5 B/D PA clotrimazole mucous membrane CRESEMBA INTRAVENOUS MO CRESEMBA ORAL fluconazole MO fluconazole in dextrose(iso-o) fluconazole in nacl (iso-osm) piggyback 00 mg/100 ml fluconazole in nacl (iso-osm) piggyback 400 mg/00 ml 5 MO flucytosine griseofulvin microsize griseofulvin ultramicrosize MO MO itraconazole MO ketoconazole oral MO MYCAMINE NOXAFIL ORAL nystatin oral suspension MO nystatin oral tablet MO SPORANOX ORAL SOLUTION terbinafine hcl oral MO voriconazole MO voriconazole oral ANTIVIRALS abacavir MO abacavir-lamivudine abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 00 mg/5 ml MO MO acyclovir oral tablet MO acyclovir sodium recon soln 500 mg acyclovir sodium solution B/D PA 4 B/D PA; MO adefovir amantadine hcl MO APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 150 mg, 00 mg atazanavir oral capsule 300 mg 5 MO ATRIPLA 9

10 BARACLUDE ORAL SOLUTION BIKTARVY cidofovir 5 B/D PA; MO CIMDUO COMPLERA CRIXIVAN ORAL CAPSULE 00 MG, 400 MG DELSTRIGO DESCOVY didanosine oral capsule,delayed release(dr/ec) 00 mg, 50 mg, 400 mg MO EDURANT efavirenz oral capsule 00 mg efavirenz oral capsule 50 mg MO efavirenz oral tablet EMTRIVA entecavir EPCLUSA (8 per 8 EPIVIR HBV ORAL SOLUTION EVOTAZ famciclovir MO fosamprenavir FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium B/D PA; MO GENVOYA HARVONI (8 per 8 INTELENCE ORAL TABLET 100 MG, 00 MG INTELENCE ORAL TABLET 5 MG INVIRASE ORAL TABLET ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWAB LE 100 MG ISENTRESS ORAL TABLET,CHEWAB LE 5 MG JULUCA KALETRA ORAL TABLET MG KALETRA ORAL TABLET MG lamivudine MO lamivudinezidovudine LEXIVA ORAL SUSPENSION MO lopinavir-ritonavir MO moderiba MO 10

11 moderiba oral tablets,dose pack 600 mg (7)- 600 mg (7) moderiba oral tablets,dose pack mg (8)-mg (8) nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 4 hr NORVIR ORAL POWDER IN PACKET NORVIR ORAL SOLUTION 5 MO MO ODEFSEY oseltamivir MO PIFELTRO PREVYMIS INTRAVENOUS PREVYMIS ORAL ; QL (30 per 30 PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 600 MG, 800 MG RELENZA DISKHALER 5 11 RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL POWDER IN PACKET ribasphere oral capsule ribasphere oral tablet 00 mg, 400 mg ribasphere oral tablet 600 mg ribasphere ribapak oral tablets,dose pack 00 mg (7)- 400 mg (7) ribasphere ribapak oral tablets,dose pack mg (8)-mg (8), mg (8)-mg (8), mg (8)-mg (8) ribasphere ribapak oral tablets,dose pack 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) ribavirin oral capsule ribavirin oral tablet 00 mg MO MO 5 MO MO rimantadine MO ritonavir MO SELZENTRY stavudine oral capsule MO STRIBILD

12 SYMFI SYMFI LO SYMTUZA SYNAGIS ; LA tenofovir disoproxil fumarate TIVICAY ORAL TABLET 10 MG TIVICAY ORAL TABLET 5 MG, 50 MG TRIUMEQ TROGARZO ; LA TRUVADA valacyclovir oral tablet 1 gram valacyclovir oral tablet 500 mg MO; QL (10 per 30 MO; QL (60 per 30 valganciclovir VEMLIDY VIDEX GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIDEX EC ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 15 MG VIRACEPT ORAL TABLET VIRAMUNE ORAL SUSPENSION VIREAD ORAL POWDER 4 MO 4 MO VIREAD ORAL TABLET 150 MG, 00 MG, 50 MG XOFLUZA zidovudine MO CEPHALOSPORINS cefaclor oral capsule MO cefaclor oral suspension for reconstitution 15 mg/5 ml, 50 mg/5 ml cefaclor oral suspension for reconstitution 375 mg/5 ml cefaclor oral tablet extended release 1 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 50 mg/5 ml, 500 mg/5 ml MO MO MO MO cefadroxil oral tablet MO cefazolin in dextrose (iso-os) piggyback 1 gram/50 ml, gram/50 ml cefazolin injection recon soln 1 gram, 500 mg cefazolin injection recon soln 10 gram, 100 gram, 0 gram, 300 g MO MO 1

13 cefazolin cefdinir MO cefepime in dextrose,iso-osm piggyback 1 gram/50 ml cefepime in dextrose,iso-osm piggyback gram/100 ml MO cefepime injection MO cefixime MO cefotaxime injection recon soln 1 gram, 500 mg cefotetan cefoxitin in dextrose, iso-osm cefoxitin recon soln 1 gram, gram cefoxitin recon soln 10 gram MO cefpodoxime MO cefprozil MO ceftazidime injection recon soln 1 gram, gram ceftazidime injection recon soln 6 gram ceftriaxone in dextrose,iso-os MO MO ceftriaxone injection recon soln 1 gram, gram, 50 mg, 500 mg ceftriaxone injection recon soln 10 gram ceftriaxone cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 750 mg cefuroxime sodium recon soln 1.5 gram cefuroxime sodium recon soln 7.5 gram MO MO MO MO MO cephalexin MO SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 4 MO 4 4 MO TEFLARO ERYTHROMYCINS / OTHER MACROLIDES azithromycin azithromycin oral packet MO MO 13

14 azithromycin oral suspension for reconstitution azithromycin oral tablet 50 mg, 50 mg (6 pack), 500 mg, 600 mg azithromycin oral tablet 500 mg (3 pack) MO MO clarithromycin MO e.e.s. 400 oral tablet MO ery-tab oral tablet,delayed release (dr/ec) 50 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 50 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MO MO MO MO MO MO MISCELLANEOUS ANTIINFECTIVES albendazole ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTIO N ALINIA ORAL TABLET amikacin injection solution 1,000 mg/4 ml, 500 mg/ ml MO ARIKAYCE 5 PA; MO; LA atovaquone atovaquoneproguanil MO aztreonam MO baciim bacitracin intramuscular BENZNIDAZOLE 3 MO BETHKIS 5 B/D PA; MO; QL (4 per 8 CAPASTAT 4 CAYSTON ; LA; QL (84 per 8 chloramphenicol sod succinate chloroquine phosphate MO clindamycin hcl MO clindamycin in 5 % dextrose MO 14

15 clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate injection clindamycin phosphate MO MO MO COARTEM colistin (colistimethate na) MO dapsone oral MO DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG daptomycin recon soln 500 mg 3 DARAPRIM 5 PA; MO EMVERM ertapenem MO ethambutol MO gentamicin in nacl (iso-osm) piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50 ml gentamicin in nacl (iso-osm) piggyback 80 mg/100 ml MO gentamicin injection MO gentamicin sulfate (ped) (pf) MO hydroxychloroquine MO imipenem-cilastatin MO IMPAVIDO INVANZ INJECTION isoniazid injection 4 MO isoniazid oral MO ivermectin MO lincomycin linezolid linezolid in dextrose 5% linezolid-0.9% sodium chloride mefloquine MO meropenem MO metro i.v. MO metronidazole in nacl (iso-os) 5 5 MO metronidazole oral MO NEBUPENT 3 B/D PA; MO; QL (1 per 8 neomycin MO paromomycin 4 MO PASER PENTAM 4 MO polymyxin b sulfate MO praziquantel MO PRIFTIN PRIMAQUINE pyrazinamide MO quinine sulfate MO 15

16 rifabutin MO rifampin MO SIRTURO ; LA STREPTOMYCIN SYNERCID 5 tigecycline 5 tinidazole MO tobramycin in 0.5 % nacl tobramycin sulfate injection recon soln tobramycin sulfate injection solution 5 B/D PA; MO; QL (80 per 8 MO TRECATOR VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK vancomycin recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg vancomycin oral capsule 15 mg vancomycin oral capsule 50 mg XIFAXAN ORAL TABLET 00 MG XIFAXAN ORAL TABLET 550 MG PENICILLINS amoxicillin oral capsule 3 MO MO ; QL (9 per 30 ; QL (90 per 30 MO amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 15 mg, 50 mg amoxicillin-pot clavulanate ampicillin oral capsule 500 mg ampicillin sodium injection ampicillin sodium ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam recon soln 1.5 gram ampicillin-sulbactam recon soln 3 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML MO MO MO MO MO MO MO MO BICILLIN C-R BICILLIN L-A dicloxacillin MO 16

17 nafcillin in dextrose iso-osm piggyback 1 gram/50 ml nafcillin in dextrose iso-osm piggyback gram/100 ml nafcillin injection recon soln 1 gram, gram nafcillin injection recon soln 10 gram MO MO nafcillin MO oxacillin in dextrose(iso-osm) piggyback 1 gram/50 ml oxacillin in dextrose(iso-osm) piggyback gram/50 ml oxacillin injection recon soln 1 gram oxacillin injection recon soln 10 gram oxacillin injection recon soln gram penicillin g potassium penicillin g procaine intramuscular syringe 1. million unit/ ml penicillin g procaine intramuscular syringe 600,000 unit/ml MO 5 MO MO MO 17 penicillin g sodium MO penicillin v potassium pfizerpen-g piperacillintazobactam recon soln.5 gram, gram, 4.5 gram, 40.5 gram QUINOLONES ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose levofloxacin in d5w piggyback 50 mg/50 ml levofloxacin in d5w piggyback 500 mg/100 ml, 750 mg/150 ml levofloxacin MO MO MO MO MO MO MO levofloxacin oral MO moxifloxacin in nacl (iso-osm) moxifloxacin oral MO ofloxacin oral tablet 300 mg ofloxacin oral tablet 400 mg MO

18 SULFA'S / RELATED AGENTS sulfadiazine 4 MO sulfamethoxazoletrimethoprim MO sulfatrim MO TETRACYCLINES demeclocycline 4 MO doxy-100 MO doxycycline hyclate doxycycline hyclate oral capsule doxycycline hyclate oral tablet 100 mg, 150 mg, 0 mg, 75 mg doxycycline hyclate oral tablet 50 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet MO MO MO MO MO MO MO mondoxyne nl MO morgidox MO okebo oral capsule 75 mg MO tetracycline MO 18 URINARY TRACT AGENTS methenamine hippurate methenamine mandelate MO MO nitrofurantoin MO nitrofurantoin macrocrystal nitrofurantoin monohyd/m-cryst MO MO trimethoprim MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl recon soln 50 mg dexrazoxane hcl recon soln 500 mg 5 B/D PA 5 B/D PA; MO ELITEK KEPIVANCE KHAPZORY 5 B/D PA leucovorin calcium injection recon soln 100 mg, 00 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg leucovorin calcium oral B/D PA; MO B/D PA MO

19 LEVOLEUCOVORI N CALCIUM INTRAVENOUS RECON SOLN 175 MG levoleucovorin calcium recon soln 50 mg levoleucovorin calcium solution 5 B/D PA 5 B/D PA 5 B/D PA mesna B/D PA; MO MESNEX ORAL VISTOGARD XGEVA 5 B/D PA; MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS abiraterone (10 per 30 ABRAXANE 5 B/D PA; MO adriamycin recon soln 10 mg adriamycin solution adrucil solution.5 gram/50 ml adrucil solution 5 gram/100 ml, 500 mg/10 ml B/D PA B/D PA B/D PA B/D PA; MO AFINITOR (30 per 30 AFINITOR DISPERZ 5 PA; MO ALECENSA (40 per 30 ALIMTA 5 B/D PA; MO ALIQOPA 5 B/D PA; MO; LA ALUNBRIG ORAL TABLET 180 MG, 90 MG ALUNBRIG ORAL TABLET 30 MG ALUNBRIG ORAL TABLETS,DOSE PACK (30 per 30 (60 per 30 (30 per 30 anastrozole MO ARRANON 5 B/D PA ARSENIC TRIOXIDE 5 B/D PA ARZERRA 5 B/D PA; MO AVASTIN 5 B/D PA; MO azacitidine 5 B/D PA; MO azathioprine B/D PA; MO azathioprine sodium B/D PA BAVENCIO 5 B/D PA; MO; LA BELEODAQ 5 B/D PA; MO BENDEKA 5 B/D PA; MO BESPONSA 5 B/D PA; MO; LA bexarotene 5 PA; MO bicalutamide MO BICNU 5 B/D PA; MO bleomycin B/D PA; MO 19

20 BLINCYTO INTRAVENOUS KIT 5 B/D PA; MO BORTEZOMIB 5 B/D PA; MO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 400 MG, 500 MG BRAFTOVI ORAL CAPSULE 50 MG BRAFTOVI ORAL CAPSULE 75 MG (90 per 30 (30 per 30 5 PA; MO; LA; QL (10 per 30 5 PA; MO; LA; QL (180 per 30 busulfan 5 B/D PA CABOMETYX 5 PA; MO; LA CALQUENCE 5 PA; MO; LA; QL (60 per 30 CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin solution 5 PA; MO; LA; QL (60 per 30 5 PA; MO; LA; QL (30 per 30 B/D PA; MO carmustine 5 B/D PA; MO cisplatin B/D PA; MO cladribine 5 B/D PA; MO clofarabine 5 B/D PA COMETRIQ 5 PA; MO COPIKTRA 5 PA; MO; LA COSMEGEN 5 B/D PA; MO COTELLIC 5 PA; MO; LA; QL (63 per 8 cyclophosphamide cyclophosphamide oral capsule cyclosporine cyclosporine modified cyclosporine oral capsule B/D PA; MO B/D PA; MO B/D PA B/D PA; MO B/D PA; MO CYRAMZA 5 B/D PA; MO cytarabine B/D PA; MO cytarabine (pf) injection solution 100 mg/5 ml (0 mg/ml), gram/0 ml (100 mg/ml) cytarabine (pf) injection solution 0 mg/ml B/D PA; MO B/D PA dacarbazine B/D PA; MO dactinomycin B/D PA DARZALEX 5 B/D PA; MO; LA daunorubicin solution B/D PA DAURISMO 5 PA; MO decitabine 5 B/D PA; MO docetaxel solution 160 mg/16 ml (10 mg/ml), 0 mg/ ml (10 mg/ml) 5 B/D PA 0

21 docetaxel solution 160 mg/8 ml (0 mg/ml), 0 mg/ml (1 ml), 80 mg/4 ml (0 mg/ml), 80 mg/8 ml (10 mg/ml) DOCETAXEL INTRAVENOUS SOLUTION 0 MG/ML doxorubicin recon soln 10 mg doxorubicin recon soln 50 mg doxorubicin solution doxorubicin, pegliposomal 5 B/D PA; MO 5 B/D PA B/D PA B/D PA; MO B/D PA; MO 5 B/D PA; MO DROXIA EMCYT EMPLICITI 5 B/D PA; MO epirubicin solution B/D PA; MO ERBITUX 5 B/D PA; MO ERIVEDGE (30 per 30 ERLEADA 5 PA; MO ERWINAZE 5 B/D PA; MO ETOPOPHOS 4 B/D PA; MO etoposide B/D PA; MO exemestane MO FARESTON FARYDAK ORAL CAPSULE 10 MG FARYDAK ORAL CAPSULE 15 MG, 0 MG (1 per 1 (6 per 1 FASLODEX 5 B/D PA; MO FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG 5 B/D PA; MO 3 B/D PA; MO floxuridine B/D PA fludarabine recon soln fludarabine solution fluorouracil B/D PA; MO B/D PA B/D PA; MO flutamide MO FOLOTYN 5 B/D PA; MO GAZYVA 5 B/D PA; MO gemcitabine recon soln 1 gram, 00 mg gemcitabine recon soln gram B/D PA; MO B/D PA 1

22 gemcitabine solution 1 gram/6.3 ml (38 mg/ml), 00 mg/5.6 ml (38 mg/ml) GEMCITABINE INTRAVENOUS SOLUTION 100 MG/ML gemcitabine solution gram/5.6 ml (38 mg/ml) gengraf oral capsule 100 mg, 5 mg B/D PA; MO 3 B/D PA B/D PA B/D PA; MO gengraf oral solution B/D PA; MO GILOTRIF (30 per 30 GLEOSTINE HALAVEN 5 B/D PA; MO HERCEPTIN 5 B/D PA; MO hydroxyurea MO IBRANCE (1 per 8 ICLUSIG ORAL TABLET 15 MG ICLUSIG ORAL TABLET 45 MG (60 per 30 (30 per 30 idarubicin B/D PA IDHIFA 5 PA; MO; LA; QL (30 per 30 ifosfamide recon soln B/D PA; MO ifosfamide solution 1 gram/0 ml ifosfamide solution 3 gram/60 ml imatinib oral tablet 100 mg imatinib oral tablet 400 mg IMBRUVICA ORAL CAPSULE 140 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET B/D PA; MO B/D PA (180 per 30 (60 per 30 (10 per 30 (30 per 30 (30 per 30 IMFINZI 5 B/D PA; MO; LA INLYTA ORAL TABLET 1 MG INLYTA ORAL TABLET 5 MG (180 per 30 (10 per 30 IRESSA (30 per 30 irinotecan solution 100 mg/5 ml irinotecan solution 40 mg/ ml B/D PA; MO 5 B/D PA; MO

23 irinotecan solution 500 mg/5 ml 5 B/D PA ISTODAX 5 B/D PA; MO IXEMPRA 5 B/D PA; MO JAKAFI (60 per 30 JEVTANA 5 B/D PA; MO KADCYLA 5 PA; MO KEYTRUDA INTRAVENOUS SOLUTION 5 PA; MO KISQALI 5 PA; MO KISQALI FEMARA CO-PACK 5 PA; MO KYPROLIS 5 B/D PA; MO LARTRUVO 5 B/D PA; MO; LA LENVIMA 5 PA; MO letrozole MO LEUKERAN leuprolide subcutaneous kit LIBTAYO 5 PA; MO; LA LONSURF 5 PA; MO LORBRENA 5 PA; MO LUMOXITI 5 PA; MO; LA LUPRON DEPOT 5 PA; MO LUPRON DEPOT (NTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) 5 PA; MO 5 PA; MO 5 PA; MO LUPRON DEPOT- PED LUPRON DEPOT- PED (NTH) LYNPARZA ORAL TABLET 5 PA; MO 5 PA; MO (10 per 30 LYSODREN MARQIBO 3 B/D PA; MO MATULANE megestrol oral suspension 400 mg/10 ml (10 ml) megestrol oral suspension 400 mg/10 ml (40 mg/ml), 65 mg/5 ml PA PA; MO megestrol oral tablet PA; MO MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET MG (90 per 30 (30 per 30 MEKTOVI 5 PA; MO; LA; QL (180 per 30 melphalan B/D PA; MO melphalan hcl 5 B/D PA mercaptopurine MO methotrexate sodium B/D PA; MO methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution B/D PA B/D PA; MO 3

24 mitomycin recon soln 0 mg, 5 mg mitomycin recon soln 40 mg B/D PA; MO 5 B/D PA; MO mitoxantrone B/D PA; MO mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium B/D PA B/D PA; MO 5 B/D PA; MO B/D PA; MO B/D PA; MO MYLOTARG 5 B/D PA; MO; LA NERLYNX 5 PA; MO; LA NEXAVAR 5 PA; MO; LA; QL (10 per 30 nilutamide NINLARO ORAL CAPSULE.3 MG NINLARO ORAL CAPSULE 3 MG NINLARO ORAL CAPSULE 4 MG (6 per 8 (4 per 8 (3 per 8 NULOJIX 5 B/D PA; MO octreotide acetate injection solution 1,000 mcg/ml, 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 00 mcg/ml, 50 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml) octreotide acetate injection syringe 500 mcg/ml (1 ml) MO MO ODOMZO 5 PA; MO; LA; QL (30 per 30 ONCASPAR 5 B/D PA; MO ONIVYDE 5 B/D PA; MO OPDIVO 5 PA; MO oxaliplatin recon soln 100 mg oxaliplatin recon soln 50 mg oxaliplatin solution B/D PA; MO B/D PA B/D PA; MO paclitaxel B/D PA; MO PERJETA 5 B/D PA; MO POMALYST 5 PA; MO; LA PORTRAZZA 5 B/D PA; MO POTELIGEO 5 PA; MO PROGRAF INTRAVENOUS 3 B/D PA; MO PURIXAN RAPAMUNE ORAL SOLUTION 5 B/D PA; MO 4

25 REVLIMID 5 PA; MO; LA; QL (8 per 8 RITUXAN 5 PA; MO RITUXAN HYCELA 5 PA; MO ROMIDEPSIN 5 B/D PA RUBRACA 5 PA; MO; LA; QL (10 per 30 RYDAPT 5 PA; MO SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON 3 B/D PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet mg 3 B/D PA 3 B/D PA; MO B/D PA; MO 5 B/D PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 0 MG SPRYCEL ORAL TABLET 70 MG (30 per 30 (90 per 30 (60 per 30 STIVARGA (84 per 8 SUTENT (30 per 30 SYLVANT 5 B/D PA; MO SYNRIBO 5 B/D PA; MO TABLOID tacrolimus oral B/D PA; MO TAFINLAR (10 per 30 TAGRISSO 5 PA; MO; LA; QL (30 per 30 TALZENNA 5 PA; MO tamoxifen MO TARCEVA ORAL TABLET 100 MG, 150 MG TARCEVA ORAL TABLET 5 MG TARGRETIN TOPICAL (30 per 30 (60 per 30 5 PA; MO 5

26 TASIGNA ORAL CAPSULE 150 MG, 00 MG TASIGNA ORAL CAPSULE 50 MG (11 per 8 (10 per 30 TECENTRIQ 5 B/D PA; MO; LA TEMODAR INTRAVENOUS 5 B/D PA; MO temsirolimus 5 B/D PA; MO THALOMID 5 PA; MO thiotepa 5 B/D PA; MO TIBSOVO 5 PA; MO toposar B/D PA; MO topotecan recon soln topotecan solution 5 B/D PA 5 B/D PA; MO TORISEL 5 B/D PA; MO TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N tretinoin (chemotherapy) TRISENOX INTRAVENOUS SOLUTION MG/ML 5 B/D PA; MO 5 B/D PA; MO 5 B/D PA; MO TYKERB 5 PA; MO; LA; QL (180 per 30 UNITUXIN 5 B/D PA; MO VALSTAR 5 B/D PA; MO VANTAS 4 B/D PA; MO VECTIBIX 5 B/D PA; MO VELCADE 5 B/D PA; MO VENCLEXTA ORAL TABLET 10 MG, 50 MG VENCLEXTA ORAL TABLET 100 MG VENCLEXTA STARTING PACK 3 PA; MO; LA 5 PA; MO; LA 5 PA; MO; LA; QL (4 per 180 VERZENIO 5 PA; MO; LA; QL (60 per 30 vinblastine solution vincasar pfs solution 1 mg/ml vincasar pfs solution mg/ ml B/D PA; MO B/D PA B/D PA; MO vincristine B/D PA; MO vinorelbine B/D PA; MO VITRAKVI 5 PA; MO; LA VIZIMPRO (30 per 30 VOTRIENT (10 per 30 6

27 VYXEOS 5 B/D PA; MO XALKORI (60 per 30 XATMEP 5 B/D PA; MO XERMELO 5 PA; MO; LA; QL (90 per 30 XOSPATA 5 PA; MO; LA XTANDI (10 per 30 YERVOY 5 B/D PA; MO YONDELIS 5 B/D PA; MO YONSA (10 per 30 ZALTRAP 5 B/D PA; MO ZANOSAR 4 B/D PA; MO ZEJULA 5 PA; MO; LA; QL (90 per 30 ZELBORAF (40 per 30 ZOLADEX 4 B/D PA; MO ZOLINZA ZORTRESS 5 B/D PA; MO ZYDELIG (60 per 30 ZYKADIA (150 per 30 ZYTIGA ORAL TABLET 50 MG (10 per 30 ZYTIGA ORAL TABLET 500 MG (60 per 30 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 00 MG, 400 MG, 800 MG APTIOM ORAL TABLET 600 MG 4 MO BANZEL BRIVIACT INTRAVENOUS BRIVIACT ORAL carbamazepine oral capsule, er multiphase 1 hr carbamazepine oral suspension 100 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 1 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clobazam oral suspension 4 MO MO 1 MO MO 1 MO PA; MO; QL (480 per 30 clobazam oral tablet PA; MO; QL (60 per 30 7

28 clonazepam oral tablet 0.5 mg, 1 mg clonazepam oral tablet mg clonazepam oral tablet,disintegrating 0.15 mg, 0.5 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating mg PA; MO; QL (90 per 30 PA; MO; QL (300 per 30 PA; MO; QL (90 per 30 PA; MO; QL (300 per 30 DIASTAT 4 MO DIASTAT ACUDIAL 4 MO diazepam rectal MO DILANTIN 30 MG divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 4 hr divalproex oral tablet,delayed release (dr/ec) MO MO 1 MO EPIDIOLEX 5 PA; MO; LA epitol MO ethosuximide MO felbamate oral suspension felbamate oral tablet MO fosphenytoin MO FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET gabapentin oral capsule 100 mg gabapentin oral capsule 300 mg gabapentin oral capsule 400 mg gabapentin oral solution 50 mg/5 ml gabapentin oral solution 50 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) gabapentin oral tablet 600 mg gabapentin oral tablet 800 mg lamotrigine oral tablet lamotrigine oral tablet extended release 4hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating lamotrigine oral tablets,dose pack 1 PA; MO; QL (1080 per 30 1 PA; MO; QL (360 per 30 1 PA; MO; QL (70 per 30 PA; MO; QL (160 per 30 PA; QL (160 per 30 1 PA; MO; QL (180 per 30 1 PA; MO; QL (10 per 30 1 MO 4 MO MO 4 MO MO 8

29 levetiracetam in nacl (iso-os) piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) piggyback 500 mg/100 ml levetiracetam levetiracetam oral solution 100 mg/ml levetiracetam oral solution 500 mg/5 ml (5 ml) levetiracetam oral tablet levetiracetam oral tablet extended release 4 hr LYRICA ORAL CAPSULE 100 MG, 150 MG, 00 MG, 5 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 5 MG, 300 MG LYRICA ORAL SOLUTION ONFI ORAL SUSPENSION ONFI ORAL TABLET 10 MG, 0 MG MO MO MO MO MO 3 PA; MO; QL (90 per 30 3 PA; MO; QL (60 per 30 3 PA; MO; QL (900 per 30 (480 per 30 (60 per 30 oxcarbazepine MO 9 PEGANONE phenobarbital PA; MO phenobarbital sodium injection solution 130 mg/ml phenobarbital sodium injection solution 65 mg/ml phenytoin oral suspension 100 mg/4 ml phenytoin oral suspension 15 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium solution MO MO MO MO MO primidone MO roweepra MO roweepra xr MO SABRIL ORAL TABLET ; LA SPRITAM 4 MO subvenite MO subvenite starter (blue) kit subvenite starter (green) kit subvenite starter (orange) kit SYMPAZAN ORAL FILM 10 MG, 0 MG MO MO MO 5 PA; QL (60 per 30 tiagabine 4 MO

30 topiramate oral capsule, sprinkle topiramate oral tablet PA; MO 1 PA; MO valproate sodium MO valproic acid MO valproic acid (as sodium salt) oral solution 50 mg/5 ml valproic acid (as sodium salt) oral solution 50 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) vigabatrin oral powder in packet MO ; LA vigadrone ; LA VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 3 zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA benztropine injection MO benztropine oral PA; MO bromocriptine 4 MO carbidopa MO carbidopa-levodopa MO carbidopa-levodopaentacapone 4 MO entacapone MO NEUPRO 4 MO pramipexole MO rasagiline MO ropinirole MO selegiline hcl MO tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY dihydroergotamine injection dihydroergotamine nasal MO MO; QL (8 per 8 eletriptan MO; QL (18 per 8 ergotamine-caffeine MO migergot MO naratriptan MO; QL (18 per 8 rizatriptan MO; QL (36 per 8 sumatriptan nasal spray,non-aerosol 0 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector MO; QL (18 per 8 MO; QL (36 per 8 MO; QL (18 per 8 MO; QL (8 per 8 MO; QL (8 per 8 30

31 sumatriptan succinate subcutaneous solution sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml sumatriptannaproxen MO; QL (8 per 8 MO; QL (8 per 8 MO; QL (18 per 8 zolmitriptan MO; QL (18 per 8 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 5 PA; MO; LA dalfampridine 5 PA; MO donepezil oral tablet 10 mg, 5 mg donepezil oral tablet 3 mg donepezil oral tablet,disintegrating 1 MO 4 MO 1 MO galantamine MO GILENYA ORAL CAPSULE 0.5 MG glatiramer subcutaneous syringe 0 mg/ml glatiramer subcutaneous syringe 40 mg/ml glatopa subcutaneous syringe 0 mg/ml glatopa subcutaneous syringe 40 mg/ml 5 PA; MO (30 per 30 (1 per 8 (30 per 30 (1 per 8 LEMTRADA 5 PA; MO memantine oral capsule,sprinkle,er 4hr memantine oral solution memantine oral tablet 31 PA; MO PA; MO PA; MO NAMZARIC 3 PA; MO NUEDEXTA 3 PA; MO OCREVUS 5 PA; MO; LA RADICAVA 5 PA; MO rivastigmine MO rivastigmine tartrate MO TECFIDERA 5 PA; MO; LA tetrabenazine oral tablet 1.5 mg tetrabenazine oral tablet 5 mg (40 per 30 (10 per 30 TYSABRI 5 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral tablet 10 mg, 0 mg cyclobenzaprine oral tablet MO 4 PA; MO dantrolene MO LIORESAL INTRATHECAL SOLUTION,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML 3 B/D PA; MO 3 B/D PA

32 MESTINON ORAL SYRUP neostigmine methylsulfate solution 0.5 mg/ml neostigmine methylsulfate solution 1 mg/ml pyridostigmine bromide regonol revonto MO MO tizanidine MO NARCOTIC ANALGESICS acetaminophen-caffdihydrocod oral capsule acetaminophencodeine oral solution 10 mg-1 mg /5 ml (5 ml), 300 mg-30 mg /1.5 ml acetaminophencodeine oral solution 10-1 mg/5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg buprenorphine hcl injection solution buprenorphine hcl injection syringe MO; QL (300 per 30 QL (4500 per 30 MO; QL (4500 per 30 MO; QL (360 per 30 MO; QL (180 per 30 MO buprenorphine hcl sublingual buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution 1 mg/ml endocet oral tablet mg,.5-35 mg, 5-35 mg, mg MO PA; MO; QL (4 per 8 MO; QL (4000 per 30 QL (000 per 30 MO; QL (360 per 30 fentanyl citrate (10 per 30 fentanyl citrate (pf) injection FENTANYL CITRATE (PF) INTRAVENOUS SYRINGE 100 MCG/ ML (50 MCG/ML) fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 6.5 mcg/hour, 75 mcg/hr fentanyl transdermal patch 7 hour 87.5 mcg/hour MO; QL (400 per 30 3 QL (400 per 30 PA; MO; QL (10 per 30 (10 per 30 3

33 hydrocodoneacetaminophen oral solution mg/15 ml(15 ml) hydrocodoneacetaminophen oral solution mg/15 ml hydrocodoneacetaminophen oral tablet mg, mg, mg hydrocodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg hydrocodoneibuprofen oral tablet mg, 5-00 mg, mg hydromorphone (pf) injection solution 10 (mg/ml) (5 ml), 10 mg/ml hydromorphone (pf) injection solution mg/ml hydromorphone injection solution 1 mg/ml hydromorphone injection solution mg/ml hydromorphone injection solution 4 mg/ml hydromorphone injection syringe 1 mg/ml QL (5550 per 30 MO; QL (5550 per 30 MO; QL (390 per 30 MO; QL (360 per 30 MO; QL (50 per 30 MO; QL (40 per 30 QL (100 per 30 QL (400 per 30 MO; QL (100 per 30 MO; QL (600 per 30 MO; QL (400 per 30 hydromorphone injection syringe mg/ml hydromorphone injection syringe 4 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 4 hr 1 mg, 8 mg hydromorphone oral tablet extended release 4 hr 16 mg, 3 mg QL (100 per 30 MO; QL (600 per 30 MO; QL (400 per 30 MO; QL (180 per 30 PA; MO; QL (60 per 30 (60 per 30 ibuprofen-oxycodone MO; QL (8 per 30 levorphanol tartrate oral tablet mg MO; QL (10 per 30 lorcet (hydrocodone) MO; QL (360 per 30 lorcet hd MO; QL (360 per 30 lorcet plus oral tablet mg methadone injection solution MO; QL (360 per 30 QL (150 per 30 methadone intensol PA; MO; QL (90 per 30 methadone oral concentrate methadone oral solution 10 mg/5 ml PA; MO; QL (90 per 30 PA; MO; QL (600 per 30 33

34 methadone oral solution 5 mg/5 ml methadone oral tablet 10 mg methadone oral tablet 5 mg methadose oral concentrate morphine (pf) injection solution 0.5 mg/ml morphine (pf) injection solution 1 mg/ml morphine (pf) patient control.analgesia soln 150 mg/30 ml morphine (pf) patient control.analgesia soln 30 mg/30 ml morphine concentrate oral solution morphine injection solution 8 mg/ml morphine injection syringe 10 mg/ml morphine injection syringe mg/ml morphine injection syringe 4 mg/ml morphine injection syringe 5 mg/ml PA; MO; QL (100 per 30 PA; MO; QL (10 per 30 PA; MO; QL (40 per 30 PA; MO; QL (90 per 30 QL (4000 per 30 MO; QL (000 per 30 B/D PA; MO; QL (400 per 30 B/D PA; QL (000 per 30 MO; QL (900 per 30 QL (50 per 30 MO; QL (00 per 30 MO; QL (1000 per 30 MO; QL (500 per 30 QL (400 per 30 morphine injection syringe 8 mg/ml morphine solution 10 mg/ml morphine syringe 10 mg/ml morphine syringe mg/ml morphine syringe 4 mg/ml morphine oral capsule, er multiphase 4 hr morphine oral capsule,extend.relea se pellets morphine oral solution QL (50 per 30 MO; QL (00 per 30 QL (00 per 30 QL (1000 per 30 QL (500 per 30 PA; MO; QL (60 per 30 PA; MO; QL (90 per 30 MO; QL (900 per 30 morphine oral tablet MO; QL (180 per 30 morphine oral tablet extended release oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 10 mg, 15 mg, 0 mg, 30 mg oxycodone oral tablet 5 mg PA; MO; QL (10 per 30 MO; QL (360 per 30 MO; QL (180 per 30 MO; QL (100 per 30 MO; QL (180 per 30 MO; QL (360 per 30 34

35 oxycodoneacetaminophen oral tablet mg,.5-35 mg, 5-35 mg, mg MO; QL (360 per 30 oxycodone-aspirin MO; QL (360 per 30 oxymorphone oral tablet 10 mg oxymorphone oral tablet 5 mg MO; QL (360 per 30 MO; QL (180 per 30 vicodin MO; QL (390 per 30 vicodin es MO; QL (390 per 30 vicodin hp MO; QL (390 per 30 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual film 8- mg buprenorphinenaloxone sublingual tablet -0.5 mg buprenorphinenaloxone sublingual tablet 8- mg butorphanol tartrate injection solution 1 mg/ml butorphanol tartrate injection solution mg/ml butorphanol tartrate nasal QL (90 per 30 MO; QL (360 per 30 MO; QL (90 per 30 MO; QL (857 per 30 MO; QL (48 per 30 MO; QL (10 per 8 celecoxib MO clonidine (pf) epidural solution 5,000 mcg/10 ml diclofenac potassium MO diclofenac sodium oral diclofenac sodium topical drops diclofenac sodium topical gel 1 % diclofenacmisoprostol MO MO; QL (300 per 8 MO; QL (1000 per 8 MO diflunisal MO etodolac MO fenoprofen oral tablet MO flurbiprofen MO ibu 1 MO ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule 5 mg ketoprofen oral capsule,ext rel. pellets 4 hr 00 mg MO 1 MO MO meclofenamate MO mefenamic acid MO meloxicam oral tablet 15 mg meloxicam oral tablet 7.5 mg 1 MO 1 MO; QL (30 per 30 nabumetone MO 35

36 nalbuphine injection solution 10 mg/ml nalbuphine injection solution 0 mg/ml MO; QL (00 per 30 MO; QL (100 per 30 naloxone MO naltrexone MO naproxen oral suspension MO naproxen oral tablet 1 MO naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 75 mg, 550 mg naproxen sodium oral tablet, er multiphase 4 hr NARCAN NASAL SPRAY,NON- AEROSOL 4 MG/ACTUATION MO MO MO oxaprozin MO piroxicam MO profeno salsalate 1 MO SUBOXONE SUBLINGUAL FILM 1-3 MG SUBOXONE SUBLINGUAL FILM -0.5 MG SUBOXONE SUBLINGUAL FILM 4-1 MG, 8- MG ; QL ( per 8 ; QL (60 per 30 ; QL (360 per 30 ; QL (90 per 30 sulindac 1 MO tolmetin MO tramadol oral tablet MO; QL (40 per 30 tramadolacetaminophen MO; QL (40 per 30 VIVITROL PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA ADASUVE 3 LA amitriptyline PA; MO amoxapine PA; MO aripiprazole oral solution aripiprazole oral tablet aripiprazole oral tablet,disintegrating MO; QL (30 per 30 ; QL (60 per 30 ARISTADA ARISTADA INITIO armodafinil 4 PA; MO atomoxetine MO bupropion hcl oral tablet bupropion hcl oral tablet extended release 4 hr 150 mg bupropion hcl oral tablet extended release 4 hr 300 mg bupropion hcl oral tablet sustainedrelease 1 hr 1 MO MO; QL (90 per 30 MO; QL (30 per 30 MO; QL (60 per 30 buspirone MO chlorpromazine MO 36

37 citalopram oral solution citalopram oral tablet MO 1 MO; QL (30 per 30 clomipramine 4 PA; MO clonidine hcl oral tablet extended release 1 hr clorazepate dipotassium oral tablet 15 mg clorazepate dipotassium oral tablet 3.75 mg clorazepate dipotassium oral tablet 7.5 mg MO PA; MO; QL (180 per 30 PA; MO; QL (90 per 30 PA; MO; QL (360 per 30 clozapine oral tablet MO clozapine oral tablet,disintegrating 100 mg, 1.5 mg, 5 mg desipramine PA; MO desvenlafaxine succinate dextroamphetamine oral solution dextroamphetamineamphetamine diazepam injection solution diazepam injection syringe MO; QL (30 per 30 MO MO PA PA; MO diazepam intensol PA; MO; QL (40 per 30 diazepam oral concentrate diazepam oral solution 5 mg/5 ml (1 mg/ml) PA; MO; QL (40 per 30 PA; MO; QL (100 per 30 diazepam oral tablet PA; MO; QL (10 per 30 doxepin oral 4 PA; MO duloxetine oral capsule,delayed release(dr/ec) 0 mg, 30 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg MO; QL (60 per 30 MO; QL (90 per 30 EMSAM ergoloid 4 MO escitalopram oxalate oral solution escitalopram oxalate oral tablet MO 1 MO; QL (30 per 30 eszopiclone 4 ST; MO; QL (30 per 30 FANAPT ORAL TABLET 1 MG, MG, 4 MG FANAPT ORAL TABLET 10 MG, 1 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 150 MG, 00 MG 4 MO; QL (60 per 30 ; QL (60 per 30 4 MO; QL (8 per

38 FETZIMA ORAL CAPSULE,EXT REL 4HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 4 HR 4 MO; QL (8 per 8 4 MO; QL (30 per 30 flumazenil MO fluoxetine oral capsule 10 mg fluoxetine oral capsule 0 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg fluoxetine oral tablet 0 mg, 60 mg fluphenazine decanoate 1 MO; QL (30 per 30 1 MO 1 MO; QL (60 per 30 MO; QL (4 per 8 MO MO; QL (30 per 30 MO MO fluphenazine hcl MO fluvoxamine oral capsule,extended release 4hr fluvoxamine oral tablet 100 mg fluvoxamine oral tablet 5 mg fluvoxamine oral tablet 50 mg 4 MO; QL (60 per 30 MO; QL (90 per 30 MO; QL (30 per 30 MO; QL (60 per 30 GEODON INTRAMUSCULA R 4 MO guanidine MO haloperidol 1 MO haloperidol decanoate haloperidol lactate injection haloperidol lactate intramuscular haloperidol lactate oral MO MO MO HETLIOZ (30 per 30 imipramine hcl 4 PA; MO imipramine pamoate 4 PA; MO INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 117 MG/0.75 ML, 156 MG/ML, 34 MG/1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULA R SYRINGE 39 MG/0.5 ML 4 MO INVEGA TRINZA KHEDEZLA ORAL TABLET EXTENDED RELEASE 4HR 100 MG 4 MO; QL (10 per 30 38

39 KHEDEZLA ORAL TABLET EXTENDED RELEASE 4HR 50 MG LATUDA ORAL TABLET 10 MG, 0 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG 4 MO; QL (30 per 30 ; QL (30 per 30 ; QL (60 per 30 lithium carbonate 1 MO lithium citrate oral solution 8 meq/5 ml lorazepam injection solution lorazepam injection syringe MO PA; MO PA lorazepam intensol PA; MO; QL (150 per 30 lorazepam oral concentrate lorazepam oral tablet 0.5 mg, 1 mg lorazepam oral tablet mg PA; MO; QL (150 per 30 PA; MO; QL (90 per 30 PA; MO; QL (150 per 30 loxapine succinate MO maprotiline MO MARPLAN metadate er MO methylphenidate hcl oral capsule,er biphasic MO methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet extended release methylphenidate hcl oral tablet,chewable mirtazapine oral tablet mirtazapine oral tablet,disintegrating MO MO MO MO 1 MO MO modafinil PA; MO molindone nefazodone MO nortriptyline PA; MO NUPLAZID 5 PA; MO olanzapine intramuscular MO olanzapine oral MO; QL (30 per 30 olanzapinefluoxetine paliperidone oral tablet extended release 4hr 1.5 mg, 3 mg paliperidone oral tablet extended release 4hr 6 mg paliperidone oral tablet extended release 4hr 9 mg paroxetine hcl oral tablet 10 mg, 0 mg, 40 mg MO MO; QL (30 per 30 MO; QL (60 per 30 ; QL (30 per 30 1 MO; QL (30 per 30 39

40 paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet extended release 4 hr paroxetine mesylate(menop.sym ) PAXIL ORAL SUSPENSION 1 MO; QL (60 per 30 MO; QL (60 per 30 MO; QL (30 per 30 4 MO perphenazine MO PERSERIS phenelzine MO pimozide MO procentra MO protriptyline MO quetiapine oral tablet 100 mg, 00 mg, 5 mg, 50 mg quetiapine oral tablet 300 mg, 400 mg quetiapine oral tablet extended release 4 hr 150 mg, 00 mg quetiapine oral tablet extended release 4 hr 300 mg, 400 mg, 50 mg MO; QL (90 per 30 MO; QL (60 per 30 MO; QL (30 per 30 MO; QL (60 per 30 REXULTI ; QL (30 per 30 RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 1.5 MG/ ML, 5 MG/ ML RISPERDAL CONSTA INTRAMUSCULA R SYRINGE 37.5 MG/ ML, 50 MG/ ML risperidone oral solution risperidone oral tablet 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg risperidone oral tablet 4 mg risperidone oral tablet,disintegrating 0.5 mg, 0.5 mg, 1 mg, mg, 3 mg risperidone oral tablet,disintegrating 4 mg MO 1 MO; QL (60 per 30 1 MO; QL (10 per 30 MO; QL (60 per 30 MO; QL (10 per 30 ROZEREM ; QL (30 per 30 SAPHRIS 4 MO; QL (60 per 30 sertraline oral concentrate sertraline oral tablet 100 mg, 50 mg sertraline oral tablet 5 mg MO 1 MO; QL (60 per 30 1 MO; QL (30 per 30 thioridazine 4 MO thiothixene 1 MO tranylcypromine 4 MO trazodone 1 MO trifluoperazine MO trimipramine 4 PA; MO 40

41 TRINTELLIX ; QL (30 per 30 venlafaxine oral capsule,extended release 4hr 150 mg, 37.5 mg venlafaxine oral capsule,extended release 4hr 75 mg venlafaxine oral tablet venlafaxine oral tablet extended release 4hr VERSACLOZ 5 VIIBRYD ORAL TABLET VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 0 MG (3) VRAYLAR ORAL CAPSULE VRAYLAR ORAL CAPSULE,DOSE PACK MO; QL (30 per 30 MO; QL (90 per 30 MO; QL (90 per 30 MO; QL (30 per 30 ; QL (30 per 30 ; QL (30 per 180 ; QL (30 per 30 4 MO; QL (7 per 30 XYREM 5 PA; MO; LA zaleplon oral capsule 10 mg zaleplon oral capsule 5 mg 4 ST; MO; QL (60 per 30 4 ST; MO; QL (30 per 30 ziprasidone hcl MO; QL (60 per 30 zolpidem oral tablet ST; MO; QL (30 per 30 ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 10 MG ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 300 MG, 405 MG CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS adenosine amiodarone solution amiodarone syringe B/D PA; MO B/D PA amiodarone oral MO dofetilide MO flecainide MO ibutilide fumarate MO lidocaine (pf) in d7.5w lidocaine (pf) solution lidocaine (pf) syringe lidocaine in 5 % dextrose (pf) parenteral solution 4 mg/ml (0.4 %), 8 mg/ml (0.8 %) MO MO 41

42 mexiletine MO pacerone oral tablet 100 mg, 00 mg, 400 mg procainamide injection solution 100 mg/ml procainamide injection solution 500 mg/ml MO MO propafenone MO quinidine gluconate MO quinidine sulfate oral tablet sorine oral tablet 10 mg, 160 mg, 80 mg sorine oral tablet 40 mg MO MO sotalol af MO sotalol oral MO SOTYLIZE ANTIHYPERTENSIVE THERAPY acebutolol MO amiloride MO MO amlodipine 1 MO 1 MO MO MO MO atenolol 1 MO MO benazepril 1 MO MO betaxolol oral MO bisoprolol fumarate MO 1 MO bumetanide MO candesartan MO MO captopril MO amiloridehydrochlorothiazide amlodipinebenazepril amlodipineolmesartan amlodipinevalsartan amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide MO cartia xt MO carvedilol 1 MO carvedilol phosphate MO chlorothiazide MO chlorothiazide sodium chlorthalidone oral tablet 5 mg, 50 mg MO 1 MO clonidine 4 MO; QL (4 per 8 clonidine (pf) epidural solution 1,000 mcg/10 ml (100 mcg/ml) clonidine hcl oral tablet 1 MO DEMSER 5 PA; MO 4

43 diltiazem hcl diltiazem hcl oral capsule,ext.rel 4h degradable diltiazem hcl oral capsule,extended release 1 hr diltiazem hcl oral capsule,extended release 4 hr diltiazem hcl oral capsule,extended release 4hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 4 hr MO MO MO MO 1 MO MO dilt-xr MO doxazosin oral tablet 1 mg, mg, 4 mg doxazosin oral tablet 8 mg 1 MO; QL (30 per 30 1 MO; QL (60 per 30 enalapril maleate 1 MO enalaprilat solution 1 MO eplerenone MO epoprostenol (glycine) B/D PA; MO eprosartan MO esmolol solution ethacrynate sodium 5 ethacrynic acid felodipine MO fosinopril 1 MO MO furosemide injection MO furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) furosemide oral tablet MO 1 MO hydralazine MO hydrochlorothiazide 1 MO indapamide MO irbesartan 1 MO 1 MO isradipine MO labetalol solution labetalol syringe 0 mg/4 ml (5 mg/ml) MO labetalol oral MO lisinopril 1 MO 1 MO losartan 1 MO enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide lisinoprilhydrochlorothiazide losartanhydrochlorothiazide mannitol 0 % mannitol 5 % solution 1 MO MO matzim la MO 43

44 methyclothiazide MO methyldopa MO metolazone MO metoprolol succinate 1 MO metoprolol tartrate solution metoprolol tartrate syringe metoprolol tartrate oral MO MO 1 MO minoxidil oral MO moexipril 1 MO MO nadolol MO nicardipine solution MO MO nicardipine oral MO nifedipine oral tablet extended release nifedipine oral tablet extended release 4hr MO MO nimodipine MO nisoldipine MO olmesartan 1 MO osmitrol 15 % MO 1 MO osmitrol 0 % perindopril erbumine 1 MO phenoxybenzamine 5 PA; MO phentolamine injection recon soln pindolol MO prazosin MO propranolol propranolol oral capsule,extended release 4 hr propranolol oral solution propranolol oral tablet MO MO 1 MO MO quinapril 1 MO MO ramipril 1 MO REMODULIN 5 PA; MO; LA spironolactone 1 MO MO taztia xt MO TEKTURNA TEKTURNA HCT telmisartan MO metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide nadololbendroflumethiazide olmesartanamlodipin-hcthiazid olmesartanhydrochlorothiazide propranololhydrochlorothiazid quinaprilhydrochlorothiazide spironolactonhydrochlorothiaz telmisartanamlodipine telmisartanhydrochlorothiazid MO MO 44

45 terazosin oral capsule 1 mg, mg, 5 mg terazosin oral capsule 10 mg 1 MO; QL (30 per 30 1 MO; QL (60 per 30 timolol maleate oral MO torsemide oral MO trandolapril 1 MO MO 1 MO UPTRAVI 5 PA; MO; LA valsartan 1 MO trandolaprilverapamil triamterenehydrochlorothiazid valsartanhydrochlorothiazide 1 MO veletri B/D PA; MO verapamil solution verapamil syringe verapamil oral capsule, 4 hr er pellet ct verapamil oral capsule,ext rel. pellets 4 hr 10 mg, 180 mg, 40 mg verapamil oral capsule,ext rel. pellets 4 hr 360 mg MO MO MO 1 MO verapamil oral tablet 1 MO verapamil oral tablet extended release MO COAGULATION THERAPY AMICAR aminocaproic acid aminocaproic acid oral tablet 45 MO MO aspirin-dipyridamole MO BRILINTA CEPROTIN (BLUE BAR) CEPROTIN (GREEN BAR) cilostazol MO clopidogrel oral tablet 300 mg clopidogrel oral tablet 75 mg dipyridamole MO 1 MO PA dipyridamole oral MO DOPTELET (10 TAB PACK) DOPTELET (15 TAB PACK) 5 PA; MO; LA 5 PA; MO; LA ELIQUIS enoxaparin MO fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml fondaparinux subcutaneous syringe.5 mg/0.5 ml heparin (porcine) in 5 % dex parenteral solution 0,000 unit/500 ml (40 unit/ml) MO

46 heparin (porcine) in 5 % dex parenteral solution 5,000 unit/50 ml(100 unit/ml), 5,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) heparin (porcine) injection cartridge heparin (porcine) injection solution heparin (porcine) injection syringe 5,000 unit/ml HEPARIN(PORCIN E) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 1,500 UNIT/50 ML heparin(porcine) in 0.45% nacl parenteral solution 5,000 unit/50 ml, 5,000 unit/500 ml heparin, porcine (pf) injection MO MO MO MO 3 MO MO jantoven 1 MO MULPLETA 5 PA; MO NPLATE pentoxifylline MO PRADAXA 4 MO prasugrel MO PROMACTA ORAL TABLET protamine 5 PA; MO; LA 46 warfarin 1 MO XARELTO LIPID/CHOLESTEROL LOWERING AGENTS MO; QL (30 per 30 atorvastatin 1 MO; QL (30 per 30 cholestyramine (with sugar) MO cholestyramine light MO colesevelam MO colestipol MO ezetimibe MO amlodipineatorvastatin ezetimibesimvastatin fenofibrate micronized fenofibrate nanocrystallized oral tablet 145 mg, 48 mg fenofibrate oral tablet MO; QL (30 per 30 MO MO MO fenofibric acid MO fenofibric acid (choline) fluvastatin oral capsule 0 mg fluvastatin oral capsule 40 mg fluvastatin oral tablet extended release 4 hr MO MO; QL (30 per 30 MO; QL (60 per 30 MO; QL (30 per 30 gemfibrozil 1 MO JUXTAPID 5 PA; MO; LA

47 lovastatin oral tablet 10 mg lovastatin oral tablet 0 mg, 40 mg niacin oral tablet extended release 4 hr PRALUENT SUBCUTANEOUS PEN INJECTOR 150 MG/ML PRALUENT SUBCUTANEOUS PEN INJECTOR 75 MG/ML 1 MO; QL (30 per 30 1 MO; QL (60 per 30 MO ( per 8 (4 per 8 pravastatin 1 MO; QL (30 per 30 prevalite MO REPATHA (3 per 8 REPATHA PUSHTRONEX REPATHA SURECLICK (3.5 per 8 (3 per 8 rosuvastatin 1 MO; QL (30 per 30 simvastatin 1 MO; QL (30 per 30 VASCEPA 4 MO MISCELLANEOUS CARDIOVASCULAR AGENTS cardioplegic soln CORLANOR 3 PA; MO digitek MO digox MO digoxin oral solution 50 mcg/ml MO digoxin oral tablet MO dobutamine B/D PA dobutamine in d5w parenteral solution 1,000 mg/50 ml (4,000 mcg/ml), 50 mg/50 ml (1 mg/ml) dobutamine in d5w parenteral solution 500 mg/50 ml (,000 mcg/ml) dopamine in 5 % dextrose solution 00 mg/50 ml (800 mcg/ml), 400 mg/50 ml (1,600 mcg/ml), 400 mg/500 ml (800 mcg/ml), 800 mg/500 ml (1,600 mcg/ml) dopamine in 5 % dextrose solution 800 mg/50 ml (3,00 mcg/ml) dopamine solution 00 mg/5 ml (40 mg/ml), 800 mg/5 ml (160 mg/ml) dopamine solution 400 mg/10 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml) B/D PA; MO B/D PA B/D PA B/D PA; MO B/D PA B/D PA; MO ENTRESTO ; QL (60 per 30 47

48 LANOXIN ORAL TABLET MCG, 6.5 MCG milrinone B/D PA; MO milrinone in 5 % dextrose norepinephrine bitartrate B/D PA; MO RANEXA sodium nitroprusside VECAMYL 5 NITRATES isosorbide dinitrate oral tablet isosorbide dinitrate oral tablet extended release isosorbide mononitrate MO 1 MO nitro-bid MO nitroglycerin in 5 % dextrose solution 100 mg/50 ml (400 mcg/ml), 50 mg/50 ml (00 mcg/ml) nitroglycerin in 5 % dextrose solution 5 mg/50 ml (100 mcg/ml) nitroglycerin nitroglycerin sublingual nitroglycerin transdermal patch 4 hour B/D PA B/D PA; MO B/D PA MO MO nitroglycerin translingual spray,non-aerosol 48 MO DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 10 mg acitretin oral capsule 17.5 mg, 5 mg MO calcipotriene scalp MO; QL (10 per 30 calcipotriene topical cream calcipotriene topical ointment calcipotrienebetamethasone 4 MO; QL (10 per 30 MO; QL (10 per 30 MO; QL (400 per 30 calcitrene MO; QL (10 per 30 calcitriol topical 4 MO selenium sulfide topical lotion MISCELLANEOUS DERMATOLOGICALS MO ammonium lactate MO carbocaine (pf) injection solution 15 mg/ml (1.5 %) chloroprocaine (pf) diclofenac sodium topical gel 3 % (100 per 8 doxepin topical ; QL (45 per 30

49 DUPIXENT 5 PA; MO fluorouracil topical cream 5 % fluorouracil topical solution MO MO glydo MO; QL (60 per 30 imiquimod topical cream in packet lidocaine (pf) injection solution 10 mg/ml (1 %), 0 mg/ml ( %), 40 mg/ml (4 %), 5 mg/ml (0.5 %) lidocaine (pf) injection solution 15 mg/ml (1.5 %) lidocaine hcl injection solution lidocaine hcl laryngotracheal lidocaine hcl mucous membrane jelly lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine topical adhesive patch,medicated lidocaine topical ointment MO MO MO MO MO; QL (60 per 30 MO; QL (60 per 30 MO PA; MO; QL (90 per 30 4 MO; QL (36 per 30 lidocaine viscous MO lidocaineepinephrine injection solution 0.5 %-1:00,000, 1.5 %- 1:00,000, %- 1:00,000 lidocaineepinephrine injection solution 1 %-1:100,000, %- 1:100,000 lidocaine-prilocaine topical cream MO MO; QL (30 per 30 methoxsalen PANRETIN podofilox MO polocaine injection solution 1 % (10 mg/ml) polocaine-mpf prudoxin MO; QL (45 per 30 REGRANEX SANTYL silver sulfadiazine MO ssd MO tacrolimus topical PA; MO; QL (100 per 30 UVADEX 4 B/D PA VALCHLOR THERAPY FOR ACNE amnesteem MO azelaic acid MO claravis 4 MO 49

50 clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution MO MO MO dapsone topical MO erythromycin with ethanol topical solution erythromycin with ethanol topical swab isotretinoin metronidazole topical MO MO MO myorisan MO rosadan topical cream MO rosadan topical gel MO tazarotene PA; MO TAZORAC TOPICAL CREAM 0.05 % TAZORAC TOPICAL GEL 3 PA; MO 3 PA; MO tretinoin topical PA; MO zenatane 4 MO TOPICAL ANTIBACTERIALS gentamicin topical MO mafenide acetate MO mupirocin MO mupirocin calcium MO sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM SULFAMYLON TOPICAL PACKET MO TOPICAL ANTIFUNGALS ciclodan topical solution ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension clotrimazole topical cream clotrimazole topical solution clotrimazolebetamethasone topical cream clotrimazolebetamethasone topical lotion MO MO; QL (90 per 8 MO; QL (45 per 8 MO; QL (10 per 8 MO MO; QL (60 per 8 MO; QL (45 per 8 MO; QL (30 per 8 MO; QL (45 per 8 MO; QL (60 per 8 econazole MO; QL (85 per 8 ketoconazole topical cream ketoconazole topical foam ketoconazole topical shampoo MO; QL (60 per 8 MO; QL (100 per 8 MO; QL (10 per 8 50

51 naftifine MO; QL (60 per 8 nyamyc MO nystatin topical cream nystatin topical ointment nystatin topical powder MO; QL (30 per 8 MO; QL (30 per 8 MO MO; QL (60 per 8 nystop MO oxiconazole MO TOPICAL ANTIVIRALS acyclovir topical ointment 4 PA; MO; QL (30 per 30 DENAVIR ZOVIRAX TOPICAL CREAM (5 per 30 TOPICAL CORTICOSTEROIDS ala-cort topical cream MO alclometasone MO betamethasone dipropionate betamethasone valerate betamethasone, augmented MO MO MO clobetasol scalp MO; QL (100 per 8 clobetasol topical cream clobetasol topical foam MO; QL (10 per 8 MO; QL (100 per 8 clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical spray,non-aerosol clobetasol-emollient topical cream clobetasol-emollient topical foam 51 MO; QL (10 per 8 MO; QL (118 per 8 MO; QL (10 per 8 MO; QL (36 per 8 MO; QL (15 per 8 MO; QL (10 per 8 MO; QL (100 per 8 desonide 4 MO fluocinolone MO fluocinolone and shower cap MO fluocinonide MO; QL (10 per 30 fluocinonide-e MO; QL (10 per 30 nystatintriamcinolone fluocinonideemollient halobetasol propionate topical cream halobetasol propionate topical ointment hydrocortisone butyrate topical lotion hydrocortisone topical cream 1 %,.5 % hydrocortisone topical lotion.5 % QL (10 per 30 MO MO MO MO MO

52 hydrocortisone topical ointment 1 %,.5 % hydrocortisone-min oil-wht pet MO MO mometasone topical MO nolix topical cream prednicarbate MO triamcinolone acetonide topical aerosol triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.05 %, 0.1 %, 0.5 % MO MO MO MO trianex MO triderm topical cream TOPICAL SCABICIDES / PEDICULICIDES crotan lindane topical shampoo MO MO malathion MO permethrin topical cream MO DIAGNOSTICS / MISCELLANEOUS AGENTS ANTIDOTES acetylcysteine MO IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu MO MO ringer's irrigation MO MISCELLANEOUS AGENTS acamprosate 4 MO acetic acid irrigation MO ADAGEN alendronate oral tablet 40 mg 1 MO; QL (30 per 30 anagrelide MO ARALAST NP ; LA caffeine citrate caffeine citrate oral MO CARBAGLU ; LA cevimeline MO CHEMET 3 PA; MO CLINIMIX 4.5%/D5W SULFIT FREE d10 %-0.45 % sodium chloride d.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride 3 B/D PA MO MO deferoxamine B/D PA; MO 5

53 dextrose 10 % and 0. % nacl dextrose 10 % in water (d10w) dextrose 0 % in water (d0w) dextrose 5 % in water (d5w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w) dextrose 5 %- lactated ringers dextrose 5%-0. % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride MO MO MO MO MO disulfiram MO etidronate disodium MO EXJADE 5 PA; MO; LA FERRIPROX ORAL SOLUTION FERRIPROX ORAL TABLET 5 PA 5 PA; MO INCRELEX ; LA kionex (with sorbitol) MO lanthanum MO levocarnitine (with sugar) levocarnitine oral tablet MO MO LOKELMA midodrine MO NORTHERA 5 PA; MO ORFADIN ORAL CAPSULE 10 MG, MG, 5 MG ORFADIN ORAL CAPSULE 0 MG ORFADIN ORAL SUSPENSION 5 LA ; LA ; LA pilocarpine hcl oral MO PROLASTIN-C INTRAVENOUS RECON SOLN PROLASTIN-C INTRAVENOUS SOLUTION 5 LA ; LA RAVICTI REVCOVI 5 PA; MO; LA riluzole MO risedronate oral tablet 30 mg sevelamer carbonate oral powder in packet sevelamer carbonate oral tablet sodium benzoate-sod phenylacet sodium chloride 0.9 % MO; QL (30 per 30 MO 5 MO 53

54 sodium chloride irrigation sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate oral sodium polystyrene sulfonate rectal enema 30 gram/10 ml MO MO MO SOLIRIS 5 PA; MO sps (with sorbitol) oral sps (with sorbitol) rectal MO THIOLA trientine 5 PA; MO VELTASSA water for irrigation, sterile MO XIAFLEX XURIDEN zoledronic acidmannitol-water piggyback 5 mg/100 ml SMOKING DETERRENTS bupropion hcl (smoking deter) PA; MO MO CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX NICOTROL 4 MO NICOTROL NS 4 MO EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal MO; QL (60 per 30 chlorhexidine gluconate mucous membrane MO denta 5000 plus MO dentagel MO ipratropium bromide nasal MO; QL (30 per 30 olopatadine nasal MO; QL (30.5 per 30 oralone MO paroex oral rinse MO periogard MO sf MO sf 5000 plus MO triamcinolone acetonide dental MISCELLANEOUS OTIC PREPARATIONS MO acetic acid otic (ear) MO ciprofloxacin hcl otic (ear) fluocinolone acetonide oil hydrocortisoneacetic acid MO MO MO 54

55 ofloxacin otic (ear) MO OTIC STEROID / ANTIBIOTIC CIPRODEX neomycinpolymyxin-hc otic (ear) MO ENDOCRINE/DIABETES ADRENAL HORMONES betamethasone acet,sod phos MO cortisone MO decadron deltasone oral tablet 0 mg dexamethasone intensol dexamethasone oral elixir dexamethasone oral solution dexamethasone oral tablet dexamethasone oral tablets,dose pack dexamethasone sodium phos (pf) dexamethasone sodium phosphate injection B/D PA; MO MO MO MO 1 MO MO MO MO fludrocortisone MO hydrocortisone oral MO methylprednisolone acetate methylprednisolone oral tablet MO B/D PA; MO methylprednisolone oral tablets,dose pack methylprednisolone sodium succ injection recon soln 15 mg, 40 mg methylprednisolone sodium succ MO MO MO millipred dp MO millipred oral tablet 4 B/D PA; MO prednisolone oral solution 15 mg/5 ml prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 0 mg/5 ml (4 mg/ml), 5 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating MO MO B/D PA; MO prednisone intensol B/D PA; MO prednisone oral solution prednisone oral tablet prednisone oral tablets,dose pack triamcinolone acetonide injection veripred 0 ANTITHYROID AGENTS MO 1 B/D PA; MO 1 MO MO 55

56 methimazole oral tablet 10 mg, 5 mg MO propylthiouracil MO DIABETES THERAPY acarbose oral tablet 100 mg acarbose oral tablet 5 mg acarbose oral tablet 50 mg MO; QL (90 per 30 MO; QL (360 per 30 MO; QL (180 per 30 ALCOHOL PADS BYDUREON BCISE BYDUREON SUBCUTANEOUS PEN INJECTOR BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(50 MCG/ML).4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (50 MCG/ML) 1. ML 3 PA; MO; QL (4 per 8 3 PA; MO; QL (4 per 8 3 PA; MO; QL (.4 per 30 3 PA; MO; QL (1. per 30 CYCLOSET 4 MO; QL (180 per 30 FREESTYLE FREEDOM FREESTYLE FREEDOM LITE FREESTYLE INSULINX FREESTYLE INSULINX TEST STRIPS 3 FREESTYLE LITE METER FREESTYLE LITE STRIPS FREESTYLE TEST GAUZE PADS X glimepiride oral tablet 1 mg glimepiride oral tablet mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 4hr 10 mg glipizide oral tablet extended release 4hr.5 mg glipizide oral tablet extended release 4hr 5 mg glipizide-metformin oral tablet.5-50 mg glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) 1 MO; QL (40 per 30 1 MO; QL (10 per 30 1 MO; QL (60 per 30 1 MO; QL (10 per 30 1 MO; QL (40 per 30 1 MO; QL (60 per 30 1 MO; QL (40 per 30 1 MO; QL (10 per 30 1 MO; QL (40 per 30 1 MO; QL (10 per 30 56

57 HUMALOG JUNIOR KWIKPEN U-100 HUMALOG KWIKPEN INSULIN HUMALOG MIX INSULN U- 100 HUMALOG MIX KWIKPEN HUMALOG MIX 75-5 KWIKPEN HUMALOG MIX 75-5(U- 100)INSULN HUMALOG U-100 INSULIN HUMULIN 70/30 U-100 INSULIN HUMULIN 70/30 U-100 KWIKPEN HUMULIN N NPH INSULIN KWIKPEN HUMULIN N NPH U-100 INSULIN HUMULIN R REGULAR U-100 INSULN HUMULIN R U-500 (CONC) INSULIN HUMULIN R U-500 (CONC) KWIKPEN INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML, 1 ML, 1/ ML INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG INVOKAMET ORAL TABLET MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 4HR 150-1,000 MG, MG, 50-1,000 MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 4HR MG INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG ; QL (60 per 30 ; QL (10 per 30 ; QL (60 per 30 ; QL (10 per 30 ; QL (90 per 30 ; QL (30 per 30 JANUMET ; QL (60 per 30 JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 100-1,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 4 HR 50-1,000 MG ; QL (30 per 30 ; QL (60 per 30 JANUVIA ; QL (30 per 30 57

58 JARDIANCE ; QL (30 per 30 JENTADUETO ; QL (60 per 30 JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 4HR.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 4HR 5-1,000 MG LANTUS SOLOSTAR U-100 INSULIN LANTUS U-100 INSULIN metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 4 hr 500 mg metformin oral tablet extended release 4 hr 750 mg miglitol oral tablet 100 mg miglitol oral tablet 5 mg miglitol oral tablet 50 mg nateglinide oral tablet 10 mg nateglinide oral tablet 60 mg ; QL (60 per 30 ; QL (30 per 30 1 MO; QL (75 per 30 1 MO; QL (150 per 30 1 MO; QL (90 per 30 1 MO; QL (10 per 30 1 MO; QL (75 per 30 MO; QL (90 per 30 MO; QL (360 per 30 MO; QL (180 per 30 MO; QL (90 per 30 MO; QL (180 per 30 NEEDLES, INSULIN DISP.,SAFETY 58 NOVOFINE 3 OMNIPOD INSULIN MANAGEMENT OMNIPOD INSULIN REFILL ONETOUCH ULTRA BLUE TEST STRIP ONETOUCH ULTRA ONETOUCH ULTRAMINI ONETOUCH VERIO ONETOUCH VERIO IQ METER ONETOUCH VERIO SYSTEM OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.5 MG OR 0.5 MG( MG/1.5 ML) OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE ( MG/1.5 ML) 3 PA; MO; QL (1.5 per 8 3 PA; MO; QL (3 per 8 pioglitazone 1 MO; QL (30 per 30 pioglitazoneglimepiride pioglitazonemetformin MO; QL (30 per 30 MO; QL (90 per 30

59 PRECISION PCX PLUS TEST PRECISION PCX TEST PRECISION XTRA MONITOR 3 PROGLYCEM repaglinide oral tablet 0.5 mg repaglinide oral tablet 1 mg repaglinide oral tablet mg repaglinidemetformin MO; QL (960 per 30 MO; QL (480 per 30 MO; QL (40 per 30 MO; QL (150 per 30 RIOMET ; QL (765 per 30 SYMLINPEN 10 (10.8 per 30 SYMLINPEN 60 (6 per 30 SYNJARDY ORAL TABLET 1.5-1,000 MG, MG, 5-1,000 MG SYNJARDY ORAL TABLET MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 4HR 10-1,000 MG, 1.5-1,000 MG, 5-1,000 MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 4HR 5-1,000 MG ; QL (60 per 30 ; QL (10 per 30 ; QL (60 per 30 ; QL (30 per 30 tolazamide oral tablet 50 mg tolazamide oral tablet 500 mg MO; QL (10 per 30 MO; QL (60 per 30 tolbutamide MO; QL (180 per 30 TOUJEO MAX U- 300 SOLOSTAR TOUJEO SOLOSTAR U-300 INSULIN TRADJENTA ; QL (30 per 30 TRULICITY 4 PA; MO; QL ( per 8 V-GO 0 V-GO 30 V-GO 40 VICTOZA -PAK 3 PA; MO; QL (9 per 30 VICTOZA 3-PAK 3 PA; MO; QL (9 per 30 MISCELLANEOUS HORMONES ALDURAZYME ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 0.5 MG/1.5 GRAM (1.6 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (0.5 MG/1.5 GRAM) 3 PA; MO; QL (150 per 30 3 PA; MO; QL (37.5 per 30 59

60 ANDROGEL TRANSDERMAL GEL IN PACKET 1.6 % (40.5 MG/.5 GRAM) 3 PA; MO; QL (150 per 30 cabergoline MO calcitonin (salmon) MO calcitriol solution 1 mcg/ml MO calcitriol oral MO CERDELGA CEREZYME INTRAVENOUS RECON SOLN 400 UNIT clomiphene citrate PA; MO danazol 4 MO desmopressin injection desmopressin nasal spray with pump desmopressin nasal spray,non-aerosol MO MO MO desmopressin oral MO doxercalciferol doxercalciferol oral MO ELAPRASE FABRAZYME KANUMA KORLYM 5 PA; MO KUVAN 5 PA; MO LUMIZYME methyltestosterone oral capsule MIACALCIN INJECTION 60 4 MO miglustat ; LA MYALEPT 5 PA; MO; LA NAGLAZYME ; LA NATPARA 5 PA; MO; LA oxandrolone oral tablet 10 mg oxandrolone oral tablet.5 mg PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG/0.5 ML PALYNZIQ SUBCUTANEOUS SYRINGE.5 MG/0.5 ML PALYNZIQ SUBCUTANEOUS SYRINGE 0 MG/ML 5 PA; MO PA; MO 5 PA; MO; LA; QL (15 per 30 5 PA; MO; LA; QL (4 per 30 5 PA; MO; LA; QL (60 per 30 pamidronate MO paricalcitol solution mcg/ml paricalcitol solution 5 mcg/ml MO paricalcitol oral 4 MO SAMSCA 5 PA; MO SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 MG SOMAVERT

61 STIMATE STRENSIQ ; LA SYNAREL testosterone cypionate testosterone enanthate testosterone transdermal gel testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation testosterone transdermal gel in metered-dose pump 1.5 mg/ 1.5 gram (1 %) testosterone transdermal gel in metered-dose pump 0.5 mg/1.5 gram (1.6 %) testosterone transdermal gel in packet 1 % (5 mg/.5gram), 1 % (50 mg/5 gram) testosterone transdermal gel in packet 1.6 % (0.5 mg/1.5 gram) testosterone transdermal gel in packet 1.6 % (40.5 mg/.5 gram) PA; MO PA; MO PA; MO; QL (300 per 30 PA; MO; QL (10 per 30 PA; MO; QL (300 per 30 PA; MO; QL (150 per 30 PA; MO; QL (300 per 30 PA; MO; QL (37.5 per 30 PA; MO; QL (150 per 30 testosterone transdermal solution in metered pump w/app PA; MO; QL (180 per 30 VIMIZIM ; LA zoledronic acid solution THYROID HORMONES levothyroxine B/D PA; MO MO levothyroxine oral 1 MO levoxyl oral tablet 100 mcg, 11 mcg, 15 mcg, 137 mcg, 150 mcg, 175 mcg, 00 mcg, 5 mcg, 50 mcg, 75 mcg, 88 mcg 1 MO liothyronine MO unithroid 1 MO GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection solution 0.4 mg/ml atropine injection syringe 0.05 mg/ml atropine injection syringe 0.1 mg/ml dicyclomine intramuscular dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet MO MO MO MO MO MO 61

62 diphenoxylateatropine glycopyrrolate injection glycopyrrolate oral tablet 1 mg, mg glycopyrrolate oral tablet 1.5 mg loperamide oral capsule MO MO MO MO opium tincture MO paregoric MO MISCELLANEOUS GASTROINTESTINAL AGENTS alosetron aprepitant B/D PA; MO balsalazide MO budesonide oral CHENODAL 5 PA; LA CHOLBAM ORAL CAPSULE 50 MG CHOLBAM ORAL CAPSULE 50 MG 5 PA; MO (10 per 30 CINVANTI colocort MO compro MO constulose MO CORTIFOAM CREON cromolyn oral MO CYSTADANE dimenhydrinate injection solution MO DIPENTUM dronabinol oral capsule 10 mg dronabinol oral capsule.5 mg, 5 mg droperidol injection solution EMEND ORAL SUSPENSION FOR RECONSTITUTIO N 5 B/D PA; MO 4 B/D PA; MO MO 3 B/D PA; MO ENTYVIO 5 PA; MO enulose MO GATTEX 30-VIAL 5 PA; MO GATTEX ONE- VIAL 5 PA; MO gavilyte-c MO gavilyte-g MO gavilyte-n MO generlac MO granisetron (pf) MO granisetron hcl MO granisetron hcl oral B/D PA; MO hydrocortisone rectal hydrocortisone topical cream with perineal applicator hydrocortisonepramoxine rectal cream 1-1 % lactulose oral solution MO MO MO MO LINZESS 6

63 meclizine oral tablet 1.5 mg, 5 mg MO mesalamine MO mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl injection syringe metoclopramide hcl oral solution metoclopramide hcl oral tablet metoclopramide hcl oral tablet,disintegrating MO MO MO 1 MO MO MOVANTIK OCALIVA 5 PA; MO; LA; QL (30 per 30 ondansetron B/D PA; MO ondansetron hcl (pf) MO ondansetron hcl ondansetron hcl oral solution ondansetron hcl oral tablet 4 mg ondansetron hcl oral tablet 4 mg, 8 mg palonosetron solution 0.5 mg/5 ml peg electrolytes oral recon soln gram MO B/D PA; MO B/D PA B/D PA; MO MO MO peg electrolytes oral recon soln gram 63 peg-electrolyte PENTASA ORAL CAPSULE, EXTENDED RELEASE 50 MG PENTASA ORAL CAPSULE, EXTENDED RELEASE 500 MG polyethylene glycol 3350 MO prochlorperazine MO prochlorperazine edisylate prochlorperazine maleate oral MO 1 MO procto-med hc MO procto-pak MO proctosol hc topical MO proctozone-hc MO RECTIV RELISTOR SUBCUTANEOUS SOLUTION RELISTOR SUBCUTANEOUS SYRINGE REMICADE 5 PA; MO scopolamine base MO SUCRAID sulfasalazine MO

64 trilyte with flavor packets MO ursodiol MO VARUBI ORAL 3 B/D PA; MO VIBERZI VIOKACE ULCER THERAPY amoxicilclarithromylansopraz MO; QL (11 per 30 cimetidine MO cimetidine hcl oral MO esomeprazole magnesium oral capsule,delayed release(dr/ec) 0 mg esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg esomeprazole sodium recon soln 0 mg esomeprazole sodium recon soln 40 mg MO; QL (30 per 30 MO MO famotidine (pf) MO famotidine (pf)-nacl (iso-os) famotidine solution famotidine oral suspension famotidine oral tablet 0 mg, 40 mg MO MO MO 1 MO lansoprazole oral capsule,delayed release(dr/ec) 15 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg 64 MO; QL (30 per 30 MO misoprostol MO nizatidine MO omeprazole oral capsule,delayed release(dr/ec) 10 mg, 0 mg omeprazole oral capsule,delayed release(dr/ec) 40 mg pantoprazole pantoprazole oral tablet,delayed release (dr/ec) 0 mg pantoprazole oral tablet,delayed release (dr/ec) 40 mg ranitidine hcl injection ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg 1 MO; QL (30 per 30 1 MO MO 1 MO; QL (30 per 30 1 MO MO 1 MO MO 1 MO sucralfate oral tablet MO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS

65 ACTIMMUNE 5 B/D PA; MO ARCALYST 5 PA; MO AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULA R PEN INJECTOR KIT AVONEX INTRAMUSCULA R SYRINGE KIT BETASERON SUBCUTANEOUS KIT (4 per 8 (4 per 8 (4 per 8 (15 per 8 FULPHILA 5 PA; MO GRANIX 5 PA; MO ILARIS (PF) SUBCUTANEOUS SOLUTION INTRON A INJECTION RECON SOLN INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML LEUKINE INJECTION RECON SOLN 5 PA; MO; LA 5 B/D PA; MO 3 B/D PA; MO 5 B/D PA; MO MOZOBIL 5 B/D PA; MO NEULASTA 5 PA; MO NEUPOGEN 5 PA; MO OMNITROPE 5 PA; MO PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION PEGASYS SUBCUTANEOUS SYRINGE PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 15 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 15 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML ; QL ( per 8 ; QL (4 per 8 ; QL ( per 8 ; QL (4 per 8 (1 per 8 (1 per 180 (1 per 8 (1 per

66 PROCRIT INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 40,000 UNIT/ML 3 PA; MO 5 PA; MO PROLEUKIN 5 B/D PA; MO REBIF (WITH ALBUMIN) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.ML- MCG/0.5ML (6) REBIF TITRATION PACK RETACRIT INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML RETACRIT INJECTION SOLUTION 40,000 UNIT/ML (6 per 8 (6 per 8 (4. per 180 (4. per PA; MO 5 PA; MO SYLATRON 66 ZARXIO 5 PA; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT )(PF) BCG VACCINE, LIVE (PF) BEXSERO BOOSTRIX TDAP BOTOX 3 PA; MO DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) 3 B/D PA; MO ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE fomepizole 3 B/D PA; MO GAMASTAN GAMASTAN S/D GARDASIL 9 (PF) GRASTEK 3 PA; MO HAVRIX (PF) INTRAMUSCULA R SUSPENSION HAVRIX (PF) INTRAMUSCULA R SYRINGE 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULA R SYRINGE 70 ELISA UNIT/0.5 ML HIBERIX (PF) 3

67 HIZENTRA 5 B/D PA; MO HYPERHEP B S/D INTRAMUSCULA R SOLUTION 0 UNIT/ML HYPERHEP B S/D INTRAMUSCULA R SOLUTION 0 UNIT/ML (5 ML) HYPERHEP B S/D INTRAMUSCULA R SYRINGE HYPERHEP B S-D NEONATAL 3 HYQVIA 5 B/D PA; MO IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) 3 3 IPOL IXIARO (PF) KINRIX (PF) INTRAMUSCULA R SUSPENSION KINRIX (PF) INTRAMUSCULA R SYRINGE MENACTRA (PF) INTRAMUSCULA R SOLUTION MENVEO A-C-Y- W-135-DIP (PF) 3 M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PRIVIGEN 5 PA; MO 67 PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) RAGWITEK RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 5 MCG/0.5 ML ROTARIX 3 ROTATEQ VACCINE 3 B/D PA; MO 3 B/D PA; MO 3 B/D PA SHINGRIX (PF) STAMARIL (PF) 3 TENIVAC (PF) TETANUS,DIPHTH ERIA TOX PED(PF) TETANUS- DIPHTHERIA TOXOIDS-TD TICE BCG 3 B/D PA; MO TRUMENBA TWINRIX (PF) INTRAMUSCULA R SYRINGE TYPHIM VI INTRAMUSCULA R SOLUTION 3

68 TYPHIM VI INTRAMUSCULA R SYRINGE VAQTA (PF) VARIVAX (PF) VARIZIG INTRAMUSCULA R SOLUTION YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol 1 MO allopurinol sodium aloprim COLCRYS 4 ST; MO KRYSTEXXA MITIGARE probenecid MO probenecidcolchicine MO ULORIC 3 ST; MO OSTEOPOROSIS THERAPY alendronate oral solution alendronate oral tablet 10 mg, 5 mg alendronate oral tablet 35 mg, 70 mg MO; QL (186 per 30 1 MO; QL (30 per 30 1 MO; QL (4 per 8 FORTEO (.4 per 8 ibandronate PA; MO 68 ibandronate oral MO; QL (1 per 30 PROLIA 3 PA; MO raloxifene MO risedronate oral tablet 150 mg risedronate oral tablet 35 mg, 35 mg (1 pack), 35 mg (4 pack) risedronate oral tablet 5 mg risedronate oral tablet,delayed release (dr/ec) MO; QL (1 per 30 MO; QL (4 per 8 MO; QL (30 per 30 MO; QL (4 per 8 TYMLOS (1.56 per 30 OTHER RHEUMATOLOGICALS ACTEMRA 5 PA; MO ACTEMRA ACTPEN (4 per 8 BENLYSTA 5 PA; MO CUPRIMINE DEPEN TITRATABS ENBREL MINI (8 per 8 ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE ENBREL SURECLICK (16 per 8 (8 per 8 (8 per 8

69 HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (6 PACK) (3 per 180 (6 per 180 HUMIRA PEN (4 per 8 HUMIRA PEN CROHNS-UC-HS START HUMIRA PEN PSOR-UVEITS- ADOL HS HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0. ML, 0 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML (6 per 180 (4 per 180 ( per 8 (4 per 8 (3 per 180 HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML HUMIRA(CF) PEN CROHNS-UC-HS HUMIRA(CF) PEN PSOR-UV-ADOL HS HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.4 ML HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 0 MG/0. ML HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG/0.4 ML ( per 180 (3 per 180 (3 per 180 (4 per 8 ( per 8 (4 per 8 leflunomide MO; QL (30 per 30 ORENCIA 5 PA; MO ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT 5 PA; MO 5 PA; MO OTEZLA 5 PA; MO OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)- 0 MG (4)-30 MG (47) 5 PA; MO 69

70 OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)- 0 MG (4)-30 MG(19) 5 PA RIDAURA OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila MO deblitane MO DEPO-PROVERA INTRAMUSCULA R SUSPENSION 400 MG/ML errin MO estradiol oral 4 PA; MO estradiol transdermal patch semiweekly estradiol transdermal patch weekly estradiol vaginal MO estradiol valerate intramuscular oil 0 mg/ml, 40 mg/ml estradiolnorethindrone acet PA; MO; QL (8 per 8 PA; MO; QL (4 per 8 MO PA; MO heather MO hydroxyprogesterone caproate incassia jencycla MO jolivette MO lyza MO medroxyprogesteron e MENEST ORAL TABLET 0.3 MG, 0.65 MG, 1.5 MG MO 3 PA; MO nora-be MO norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol oral tablet mg-mcg, 1-5 mg-mcg MO MO 4 PA; MO norlyda MO norlyroc progesterone MO progesterone in oil MO progesterone micronized MO sharobel MO tulana yuvafem MO MISCELLANEOUS OB/GYN clindamycin phosphate vaginal metronidazole vaginal miconazole-3 vaginal suppository MO MO MO MIRENA ; LA NEXPLANON terconazole MO tranexamic acid oral MO vandazole MO 70

71 xulane MO ORAL CONTRACEPTIVES / RELATED AGENTS altavera (8) MO alyacen 1/35 (8) MO alyacen 7/7/7 (8) MO amethyst (8) MO apri MO aranelle (8) MO aubra MO aubra eq aviane MO azurette (8) MO bekyree (8) MO camrese MO caziant (8) MO chateal (8) MO cryselle (8) MO cyclafem 1/35 (8) MO cyclafem 7/7/7 (8) MO cyred MO cyred eq dasetta 1/35 (8) MO dasetta 7/7/7 (8) MO daysee MO delyla (8) desoge.estradiol/e.estradio l desogestrel-ethinyl estradiol MO drospirenonee.estradiol-lm.fa oral tablet mg (1) (7) drospirenone-ethinyl estradiol MO MO elinest MO emoquette MO enpresse MO enskyce MO estarylla MO ethynodiol diac-eth estradiol falmina (8) MO fayosim MO femynor MO gianvi (8) MO introvale MO isibloom MO jolessa MO juleber MO kariva (8) MO kelnor 1/35 (8) MO kelnor 1-50 MO kurvelo (8) MO l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.10 mg-0 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7) MO 71

72 l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.15 mg-0 mcg/ 0.15 mg-5 mcg larin 1.5/30 (1) MO larin 1/0 (1) MO larin 4 fe MO larin fe 1.5/30 (8) MO larin fe 1/0 (8) MO larissia MO lessina MO levonest (8) MO levonorgestrelethinyl estrad levonorg-eth estrad triphasic MO MO levora-8 MO lillow (8) MO loryna (8) MO low-ogestrel (8) MO lutera (8) MO marlissa (8) MO microgestin 1.5/30 (1) microgestin 1/0 (1) microgestin fe 1.5/30 (8) microgestin fe 1/0 (8) MO MO MO MO mili MO mono-linyah MO myzilra MO 7 nikki (8) MO norethindrone ac-eth estradiol oral tablet 1-0 mg-mcg norethindronee.estradiol-iron oral tablet 1 mg-0 mcg (1)/75 mg (7) norgestimate-ethinyl estradiol MO MO MO nortrel 0.5/35 (8) MO nortrel 1/35 (1) MO nortrel 1/35 (8) MO nortrel 7/7/7 (8) MO ogestrel (8) MO orsythia MO philith MO pimtrea (8) MO pirmella MO portia 8 MO previfem MO quasense MO rajani MO reclipsen (8) MO setlakin MO sprintec (8) MO sronyx MO syeda MO tarina fe 1/0 (8) MO tarina fe 1-0 eq (8) tilia fe MO tri femynor MO

73 tri-estarylla MO tri-legest fe MO tri-linyah MO tri-lo-estarylla MO tri-lo-marzia MO tri-lo-sprintec MO trinessa (8) MO tri-previfem (8) MO tri-sprintec (8) MO trivora (8) MO velivet triphasic regimen (8) MO vienva MO viorele (8) MO wera (8) MO zarah MO zovia 1/35e (8) MO OXYTOCICS methergine methylergonovine injection methylergonovine oral oxytocin injection solution OPHTHALMOLOGY ANTIBIOTICS MO MO ak-poly-bac MO bacitracin ophthalmic (eye) bacitracinpolymyxin b ophthalmic (eye) MO MO ciprofloxacin hcl ophthalmic (eye) erythromycin ophthalmic (eye) MO MO gatifloxacin MO gentak ophthalmic (eye) ointment gentamicin ophthalmic (eye) drops levofloxacin ophthalmic (eye) moxifloxacin ophthalmic (eye) MO MO MO MO NATACYN neomycinbacitracinpolymyxin neomycinpolymyxingramicidin MO MO neo-polycin MO ofloxacin ophthalmic (eye) MO polycin MO polymyxin b sulftrimethoprim MO tobramycin MO ANTIVIRALS trifluridine MO ZIRGAN 4 MO BETA-BLOCKERS betaxolol ophthalmic (eye) MO carteolol MO 73

74 levobunolol ophthalmic (eye) drops 0.5 % timolol maleate ophthalmic (eye) drops timolol maleate ophthalmic (eye) drops, once daily timolol maleate ophthalmic (eye) gel forming solution MISCELLANEOUS OPHTHALMOLOGICS atropine ophthalmic (eye) drops azelastine ophthalmic (eye) balanced salt MO 1 MO MO MO MO MO BLEPHAMIDE 4 MO BLEPHAMIDE S.O.P. 4 MO bss MO cromolyn ophthalmic (eye) MO CYSTARAN epinastine MO EYLEA JETREA (PF) INTRAVITREAL SOLUTION 0.15 MG/0.1 ML (1.5 MG/ML) ; LA LUCENTIS olopatadine ophthalmic (eye) MO OXERVATE 5 PA; MO PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic (eye) drops 1 %, %, 4 % sulfacetamide sodium ophthalmic (eye) sulfacetamideprednisolone 4 MO MO MO MO XIIDRA ; QL (60 per 30 NON-STEROIDAL ANTI- INFLAMMATORY AGENTS bromfenac MO diclofenac sodium ophthalmic (eye) MO flurbiprofen sodium MO ketorolac ophthalmic (eye) MO ORAL DRUGS FOR GLAUCOMA acetazolamide MO acetazolamide sodium MO methazolamide MO OTHER GLAUCOMA DRUGS bimatoprost ophthalmic (eye) MO dorzolamide MO dorzolamide-timolol MO dorzolamide-timolol (pf) ophthalmic (eye) dropperette MO latanoprost MO miostat 74

75 STEROID-ANTIBIOTIC COMBINATIONS neomycin-polymyxin b-dexameth neomycinbacitracin-poly-hc neomycinpolymyxin-hc ophthalmic (eye) MO MO MO neo-polycin hc MO tobramycindexamethasone STEROIDS dexamethasone sodium phosphate ophthalmic (eye) MO MO fluorometholone MO OZURDEX prednisolone acetate MO prednisolone sodium phosphate ophthalmic (eye) SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % MO apraclonidine MO brimonidine MO RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS adrenalin injection solution 1 mg/ml adrenalin injection solution 1 mg/ml (1 ml) cetirizine oral solution 1 mg/ml diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral elixir EPINEPHRINE INJECTION AUTO- INJECTOR 0.15 MG/0.3 ML, 0.3 MG/0.3 ML (MANUFACTURE D BY MYLAN SPECIALTY) MO MO MO MO PA ; QL (4 per 30 EPIPEN ; QL (4 per 30 EPIPEN -PAK ; QL (4 per 30 EPIPEN JR ; QL (4 per 30 EPIPEN JR -PAK ; QL (4 per 30 hydroxyzine hcl oral tablet levocetirizine oral solution levocetirizine oral tablet promethazine injection solution PA; MO MO MO; QL (30 per 30 4 MO promethazine oral 4 PA; MO PULMONARY AGENTS 75

76 acetylcysteine B/D PA; MO ADEMPAS 5 PA; MO; LA albuterol sulfate inhalation solution for nebulization albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release 1 hr aminophylline solution 500 mg/0 ml ARCAPTA NEOHALER B/D PA; MO MO 4 MO 4 MO ; QL (30 per 30 ASMANEX HFA ; QL (13 per 30 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 0 MCG (30 DOSES), 0 MCG (60 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (10 DOSES) ; QL (1 per 30 ; QL ( per 30 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (14 DOSES) 3 QL ( per 8 ATROVENT HFA ; QL (5.8 per 30 budesonide inhalation B/D PA; MO CINRYZE 5 PA; MO COMBIVENT RESPIMAT ; QL (8 per 30 cromolyn inhalation B/D PA; MO DALIRESP 4 PA; MO DULERA ; QL (13 per 30 ESBRIET ORAL CAPSULE ESBRIET ORAL TABLET 67 MG ESBRIET ORAL TABLET 801 MG (70 per 30 (70 per 30 (90 per 30 FASENRA 5 PA; MO FIRAZYR 5 PA; MO flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) MO; QL (50 per 30 fluticasone nasal MO; QL (16 per 30 HAEGARDA 5 PA; MO; LA INCRUSE ELLIPTA ; QL (30 per 30 76

77 ipratropium bromide inhalation ipratropiumalbuterol KALYDECO ORAL GRANULES IN PACKET KALYDECO ORAL TABLET B/D PA; MO B/D PA; MO (56 per 8 (60 per 30 LETAIRIS 5 PA; MO; LA levalbuterol hcl B/D PA; MO metaproterenol MO mometasone nasal MO; QL (34 per 30 montelukast MO OFEV (60 per 30 OPSUMIT 5 PA; MO; LA ORKAMBI ORAL GRANULES IN PACKET ORKAMBI ORAL TABLET (56 per 8 (11 per 8 PERFOROMIST 3 B/D PA; MO PROAIR HFA ; QL (17 per 30 PROAIR RESPICLICK ; QL ( per 30 PULMOZYME 5 B/D PA; MO QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 80 MCG/ACTUATION SEREVENT DISKUS sildenafil (pulmonary arterial hypertension) solution 10 mg/1.5 ml sildenafil (pulmonary arterial hypertension) oral tablet 0 mg SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT STRIVERDI RESPIMAT ; QL (10.6 per 30 ; QL (1. per 30 ; QL (60 per 30 5 PA PA; MO; QL (90 per 30 ; QL (4 per 30 ; QL (90 per 90 ; QL (4 per 30 ; QL (4 per 30 SYMBICORT ; QL (10. per 30 SYMDEKO (56 per 8 77

78 tadalafil (pulmonary arterial hypertension) oral tablet 0 mg (60 per 30 terbutaline MO THEO-4 theophylline in dextrose 5 % parenteral solution 400 mg/500 ml theophylline oral elixir theophylline oral solution theophylline oral tablet extended release 1 hr theophylline oral tablet extended release 4 hr TRACLEER ORAL TABLET MO MO MO 5 PA; MO; LA TYVASO 5 B/D PA; MO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT XOLAIR SUBCUTANEOUS RECON SOLN XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML 5 B/D PA 5 B/D PA; MO 5 B/D PA; MO 5 PA; MO; LA; QL (6 per 8 5 PA; MO; LA; QL (6 per 8 XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML 78 5 PA; MO; LA; QL (5 per 8 zafirlukast MO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS flavoxate MO MYRBETRIQ oxybutynin chloride MO tolterodine MO trospium MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin MO dutasteride MO dutasteridetamsulosin finasteride oral tablet 5 mg MO MO silodosin MO tamsulosin 1 MO MISCELLANEOUS UROLOGICALS alprostadil MO bethanechol chloride MO CYSTAGON ; LA ELMIRON glycine urologic glycine urologic solution K-PHOS NO K-PHOS ORIGINAL

79 potassium citrate MO RENACIDIN IRRIGATION SOLUTION MG-59.4 MG MG/30ML tadalafil oral tablet.5 mg, 5 mg PA; MO; QL (30 per 30 VITAMINS, HEMATINICS / ELECTROLYTES BLOOD DERIVATIVES albumin, human 5 % albuminar 5 % MO alburx (human) 5 % alburx (human) 5 % albutein 5 % albutein 5 % buminate 5 % MO plasbumin 5 % MO plasbumin 5 % ELECTROLYTES calcium acetate oral capsule calcium acetate oral tablet 667 mg calcium chloride calcium gluconate effer-k oral tablet, effervescent 5 meq MO MO MO MO klor-con MO klor-con 10 MO klor-con 8 MO klor-con m10 MO klor-con m15 MO klor-con m0 MO klor-con sprinkle MO klor-con/ef MO k-tab oral tablet extended release 8 meq lactated ringers magnesium chloride injection MAGNESIUM SULFATE IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/100 ML magnesium sulfate in water parenteral solution magnesium sulfate in water piggyback gram/50 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate in water piggyback 4 gram/100 ml (4 %) magnesium sulfate injection solution magnesium sulfate injection syringe MO MO MO 3 MO MO NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE 3 79

80 potassium acetate solution meq/ml potassium chloridd5-0.45%nacl parenteral solution 10 meq/l, 30 meq/l, 40 meq/l potassium chloride in water piggyback 0 meq/100 ml, 0 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml potassium chloride solution MO potassium chloridd5-0.45%nacl parenteral solution 0 meq/l potassium chloride in 0.9%nacl parenteral solution 0 meq/l, 40 meq/l potassium chloride in 5 % dex parenteral solution 0 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 parenteral solution 0 meq/l potassium chloride in lr-d5 parenteral solution 40 meq/l potassium chloride in water piggyback 10 meq/100 ml, 10 meq/50 ml MO MO MO potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral packet potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals potassium chloride % nacl potassium chlorided5-0.%nacl parenteral solution 0 meq/l potassium chlorided5-0.%nacl parenteral solution 30 meq/l, 40 meq/l potassium chlorided5-0.3%nacl parenteral solution 0 meq/l 1 MO MO MO 1 MO 1 MO MO 80

81 potassium chlorided5-0.9%nacl parenteral solution 0 meq/l potassium chlorided5-0.9%nacl parenteral solution 40 meq/l potassium phosphate m-/d-basic ringer's sodium acetate sodium bicarbonate solution 1 meq/ml (8.4 %) sodium bicarbonate syringe 10 meq/10 ml (8.4 %), 7.5 % (0.9 meq/ml) sodium bicarbonate syringe 8.4 % (1 meq/ml) sodium chloride 0.45 % parenteral solution sodium chloride 0.45 % piggyback MO MO MO MO sodium chloride 3 % MO sodium chloride 5 % sodium chloride sodium lactate MO sodium phosphate MO 81 MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 10 % 3 B/D PA AMINOSYN 7 % WITH ELECTROLYTES 3 B/D PA AMINOSYN 8.5 % 3 B/D PA AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE- FREE) AMINOSYN-RF 5. % CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE CLINIMIX 4.5%/D10W SULF FREE 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA 3 B/D PA

82 CLINIMIX 4.5%- D0W SULF-FREE CLINIMIX 4.5%- D5W SULF-FREE CLINIMIX 5%- D0W(SULFITE- FREE) cysteine (l-cysteine) solution electrolyte-48 in d5w 3 B/D PA 3 B/D PA 3 B/D PA B/D PA freamine iii 10 % B/D PA HEPATAMINE 8% 3 B/D PA intralipid emulsion 0 % IONOSOL-MB IN D5W ISOLYTE S PH ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 3 NEPHRAMINE 5.4 % B/D PA B/D PA NORMOSOL-R PH 7.4 PLASMA-LYTE 148 PLASMA-LYTE A 3 plasmanate 3 3 plenamine B/D PA premasol 10 % B/D PA; MO PREMASOL 6 % 3 B/D PA travasol 10 % 4 B/D PA; MO TROPHAMINE 10 % 3 B/D PA; MO TROPHAMINE 6% 3 B/D PA VITAMINS / HEMATINICS fluoride (sodium) oral tablet fluoride (sodium) oral tablet,chewable 1 mg (. mg sod. fluoride) prenatal vitamin oral tablet 4 MO MO 4 MO 8

83 Index A abacavir... 9 abacavir-lamivudine... 9 abacavir-lamivudinezidovudine... 9 ABELCET... 9 ABILIFY MAINTENA abiraterone ABRAXANE acamprosate... 5 acarbose acebutolol... 4 acetaminophen-caffdihydrocod... 3 acetaminophen-codeine... 3 acetazolamide acetazolamide sodium acetic acid... 5, 54 acetylcysteine... 5, 76 acitretin ACTEMRA ACTEMRA ACTPEN ACTHIB (PF) ACTIMMUNE acyclovir... 9, 51 acyclovir sodium... 9 ADACEL(TDAP ADOLESN/ADULT)(PF) 66 ADAGEN... 5 ADASUVE adefovir... 9 ADEMPAS adenosine adrenalin adriamycin adrucil AFINITOR AFINITOR DISPERZ ak-poly-bac ala-cort albendazole ALBENZA albumin, human 5 % albuminar 5 % alburx (human) 5 % alburx (human) 5 % albutein 5 % albutein 5 % albuterol sulfate alclometasone ALCOHOL PADS ALDURAZYME ALECENSA alendronate... 5, 68 alfuzosin ALIMTA ALINIA ALIQOPA allopurinol allopurinol sodium aloprim alosetron... 6 ALPHAGAN P alprostadil altavera (8) ALUNBRIG alyacen 1/35 (8) alyacen 7/7/7 (8) amantadine hcl... 9 AMBISOME... 9 amethyst (8) AMICAR amikacin amiloride... 4 amiloride-hydrochlorothiazide... 4 aminocaproic acid aminophylline AMINOSYN 10 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5. % amiodarone amitriptyline amlodipine... 4 amlodipine-atorvastatin amlodipine-benazepril... 4 amlodipine-olmesartan... 4 amlodipine-valsartan... 4 amlodipine-valsartan-hcthiazid... 4 ammonium lactate amnesteem amoxapine amoxicil-clarithromy-lansopraz amoxicillin amoxicillin-pot clavulanate.. 16 amphotericin b... 9 ampicillin ampicillin sodium ampicillin-sulbactam AMPYRA anagrelide... 5 anastrozole ANDROGEL... 59, 60 APOKYN apraclonidine aprepitant... 6 apri APTIOM... 7 APTIVUS... 9 ARALAST NP... 5 aranelle (8) ARCALYST ARCAPTA NEOHALER ARIKAYCE aripiprazole ARISTADA ARISTADA INITIO armodafinil ARRANON

84 ARSENIC TRIOXIDE ARZERRA ASMANEX HFA ASMANEX TWISTHALER 76 aspirin-dipyridamole atazanavir... 9 atenolol... 4 atenolol-chlorthalidone... 4 atomoxetine atorvastatin atovaquone atovaquone-proguanil ATRIPLA... 9 atropine... 61, 74 ATROVENT HFA aubra aubra eq AUGMENTIN AVASTIN aviane AVONEX AVONEX (WITH ALBUMIN) azacitidine azathioprine azathioprine sodium azelaic acid azelastine... 54, 74 azithromycin... 13, 14 aztreonam azurette (8) B baciim bacitracin... 14, 73 bacitracin-polymyxin b baclofen balanced salt balsalazide... 6 BANZEL... 7 BARACLUDE BAVENCIO BCG VACCINE, LIVE (PF) 66 bekyree (8) BELEODAQ benazepril... 4 benazepril-hydrochlorothiazide... 4 BENDEKA BENLYSTA BENZNIDAZOLE benztropine BESPONSA betamethasone acet,sod phos 55 betamethasone dipropionate. 51 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 4, 73 bethanechol chloride BETHKIS bexarotene BEXSERO bicalutamide BICILLIN C-R BICILLIN L-A BICNU BIKTARVY bimatoprost bisoprolol fumarate... 4 bisoprolol-hydrochlorothiazide... 4 bleomycin BLEPHAMIDE BLEPHAMIDE S.O.P BLINCYTO... 0 BOOSTRIX TDAP BORTEZOMIB... 0 BOSULIF... 0 BOTOX BRAFTOVI... 0 BRILINTA brimonidine BRIVIACT... 7 bromfenac bromocriptine bss budesonide... 6, 76 bumetanide... 4 buminate 5 % buprenorphine... 3 buprenorphine hcl... 3 buprenorphine-naloxone bupropion hcl bupropion hcl (smoking deter) buspirone busulfan... 0 butorphanol tartrate BYDUREON BYDUREON BCISE BYETTA C cabergoline CABOMETYX... 0 caffeine citrate... 5 calcipotriene calcipotriene-betamethasone 48 calcitonin (salmon) calcitrene calcitriol... 48, 60 calcium acetate calcium chloride calcium gluconate CALQUENCE... 0 camila camrese candesartan... 4 candesartan-hydrochlorothiazid... 4 CAPASTAT CAPRELSA... 0 captopril... 4 captopril-hydrochlorothiazide... 4 CARBAGLU... 5 carbamazepine... 7 carbidopa carbidopa-levodopa carbidopa-levodopaentacapone carbocaine (pf) carboplatin... 0 cardioplegic soln carmustine... 0 carteolol cartia xt... 4 carvedilol... 4 carvedilol phosphate... 4 caspofungin... 9 CAYSTON caziant (8) cefaclor... 1 cefadroxil... 1 cefazolin... 1, 13 84

85 cefazolin in dextrose (iso-os) 1 cefdinir cefepime cefepime in dextrose,iso-osm cefixime cefotaxime cefotetan cefoxitin cefoxitin in dextrose, iso-osm cefpodoxime cefprozil ceftazidime ceftriaxone ceftriaxone in dextrose,iso-os cefuroxime axetil cefuroxime sodium celecoxib CELONTIN... 7 cephalexin CEPROTIN (BLUE BAR) CEPROTIN (GREEN BAR) 45 CERDELGA CEREZYME cetirizine cevimeline... 5 CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX chateal (8) CHEMET... 5 CHENODAL... 6 chloramphenicol sod succinate chlorhexidine gluconate chloroprocaine (pf) chloroquine phosphate chlorothiazide... 4 chlorothiazide sodium... 4 chlorpromazine chlorthalidone... 4 CHOLBAM... 6 cholestyramine (with sugar). 46 cholestyramine light ciclodan ciclopirox cidofovir cilostazol CIMDUO cimetidine cimetidine hcl CINRYZE CINVANTI... 6 CIPRODEX ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl... 17, 54, 73 ciprofloxacin in 5 % dextrose cisplatin... 0 citalopram cladribine... 0 claravis clarithromycin clindamycin hcl clindamycin in 5 % dextrose 14 clindamycin palmitate hcl clindamycin pediatric clindamycin phosphate.. 15, 50, 70 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE CLINIMIX 4.5%/D10W SULF FREE CLINIMIX 4.5%/D5W SULFIT FREE... 5 CLINIMIX 4.5%-D0W SULF-FREE... 8 CLINIMIX 4.5%-D5W SULF-FREE... 8 CLINIMIX 5%- D0W(SULFITE-FREE).. 8 clobazam... 7 clobetasol clobetasol-emollient clofarabine... 0 clomiphene citrate clomipramine clonazepam... 8 clonidine... 4 clonidine (pf)... 35, 4 clonidine hcl... 37, 4 clopidogrel clorazepate dipotassium clotrimazole... 9, 50 clotrimazole-betamethasone. 50 clozapine COARTEM COLCRYS colesevelam colestipol colistin (colistimethate na) colocort... 6 COMBIVENT RESPIMAT.. 76 COMETRIQ... 0 COMPLERA compro... 6 constulose... 6 COPIKTRA... 0 CORLANOR CORTIFOAM... 6 cortisone COSMEGEN... 0 COTELLIC... 0 CREON... 6 CRESEMBA... 9 CRIXIVAN cromolyn... 6, 74, 76 crotan... 5 cryselle (8) CUPRIMINE cyclafem 1/35 (8) cyclafem 7/7/7 (8) cyclobenzaprine cyclophosphamide... 0 CYCLOSET cyclosporine... 0 cyclosporine modified... 0 CYRAMZA... 0 cyred cyred eq CYSTADANE... 6 CYSTAGON CYSTARAN cysteine (l-cysteine)... 8 cytarabine... 0 cytarabine (pf)

86 D d10 %-0.45 % sodium chloride... 5 d.5 %-0.45 % sodium chloride... 5 d5 % and 0.9 % sodium chloride... 5 d5 %-0.45 % sodium chloride... 5 dacarbazine... 0 dactinomycin... 0 dalfampridine DALIRESP danazol dantrolene dapsone... 15, 50 DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin DAPTOMYCIN DARAPRIM DARZALEX... 0 dasetta 1/35 (8) dasetta 7/7/7 (8) daunorubicin... 0 DAURISMO... 0 daysee deblitane decadron decitabine... 0 deferoxamine... 5 DELSTRIGO deltasone delyla (8) demeclocycline DEMSER... 4 DENAVIR denta 5000 plus dentagel DEPEN TITRATABS DEPO-PROVERA DESCOVY desipramine desmopressin desog-e.estradiol/e.estradiol. 71 desogestrel-ethinyl estradiol. 71 desonide desvenlafaxine succinate dexamethasone dexamethasone intensol dexamethasone sodium phos (pf) dexamethasone sodium phosphate... 55, 75 dexrazoxane hcl dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0. % nacl dextrose 10 % in water (d10w) dextrose 0 % in water (d0w) dextrose 5 % in water (d5w) dextrose 30 % in water (d30w) dextrose 40 % in water (d40w) dextrose 5 % in water (d5w). 53 dextrose 5 %-lactated ringers53 dextrose 5%-0. % sod chloride dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride DIASTAT... 8 DIASTAT ACUDIAL... 8 diazepam... 8, 37 diazepam intensol diclofenac potassium diclofenac sodium... 35, 48, 74 diclofenac-misoprostol dicloxacillin dicyclomine didanosine diflunisal digitek digox digoxin dihydroergotamine DILANTIN 30 MG... 8 diltiazem hcl dilt-xr dimenhydrinate... 6 DIPENTUM... 6 diphenhydramine hcl diphenoxylate-atropine... 6 dipyridamole disulfiram divalproex... 8 dobutamine dobutamine in d5w docetaxel... 0, 1 DOCETAXEL... 1 dofetilide donepezil dopamine dopamine in 5 % dextrose DOPTELET (10 TAB PACK) DOPTELET (15 TAB PACK) dorzolamide dorzolamide-timolol dorzolamide-timolol (pf) doxazosin doxepin... 37, 48 doxercalciferol doxorubicin... 1 doxorubicin, peg-liposomal.. 1 doxy doxycycline hyclate doxycycline monohydrate dronabinol... 6 droperidol... 6 drospirenone-e.estradiol-lm.fa drospirenone-ethinyl estradiol DROXIA... 1 DULERA duloxetine DUPIXENT duramorph (pf)... 3 dutasteride dutasteride-tamsulosin

87 E e.e.s econazole EDURANT efavirenz effer-k ELAPRASE electrolyte-48 in d5w... 8 eletriptan elinest ELIQUIS ELITEK ELMIRON EMCYT... 1 EMEND... 6 emoquette EMPLICITI... 1 EMSAM EMTRIVA EMVERM enalapril maleate enalaprilat enalapril-hydrochlorothiazide ENBREL ENBREL MINI ENBREL SURECLICK endocet... 3 ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse enskyce entacapone entecavir ENTRESTO ENTYVIO... 6 enulose... 6 EPCLUSA EPIDIOLEX... 8 epinastine EPINEPHRINE EPIPEN EPIPEN -PAK EPIPEN JR EPIPEN JR -PAK epirubicin... 1 epitol... 8 EPIVIR HBV eplerenone epoprostenol (glycine) eprosartan ERBITUX... 1 ergoloid ergotamine-caffeine ERIVEDGE... 1 ERLEADA... 1 errin ertapenem ERWINAZE... 1 ery-tab ERY-TAB ERYTHROCIN erythrocin (as stearate) erythromycin... 14, 73 erythromycin ethylsuccinate. 14 erythromycin with ethanol ESBRIET escitalopram oxalate esmolol esomeprazole magnesium esomeprazole sodium estarylla estradiol estradiol valerate estradiol-norethindrone acet. 70 eszopiclone ethacrynate sodium ethacrynic acid ethambutol ethosuximide... 8 ethynodiol diac-eth estradiol 71 etidronate disodium etodolac ETOPOPHOS... 1 etoposide... 1 EVOTAZ exemestane... 1 EXJADE EYLEA ezetimibe ezetimibe-simvastatin F FABRAZYME falmina (8) famciclovir famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 64 FANAPT FARESTON... 1 FARYDAK... 1 FASENRA FASLODEX... 1 fayosim FAZACLO felbamate... 8 felodipine femynor fenofibrate fenofibrate micronized fenofibrate nanocrystallized. 46 fenofibric acid fenofibric acid (choline) fenoprofen fentanyl... 3 fentanyl citrate... 3 fentanyl citrate (pf)... 3 FENTANYL CITRATE (PF)... 3 FERRIPROX FETZIMA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE... 1 flavoxate flecainide floxuridine... 1 fluconazole... 9 fluconazole in dextrose(iso-o) 9 fluconazole in nacl (iso-osm). 9 flucytosine... 9 fludarabine... 1 fludrocortisone flumazenil flunisolide fluocinolone fluocinolone acetonide oil fluocinolone and shower cap 51 fluocinonide fluocinonide-e fluocinonide-emollient

88 fluoride (sodium)... 8 fluorometholone fluorouracil... 1, 49 fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide... 1 fluticasone fluvastatin fluvoxamine FOLOTYN... 1 fomepizole fondaparinux FORTEO fosamprenavir fosinopril fosinopril-hydrochlorothiazide fosphenytoin... 8 freamine iii 10 %... 8 FREESTYLE FREEDOM FREESTYLE FREEDOM LITE FREESTYLE INSULINX FREESTYLE INSULINX TEST STRIPS FREESTYLE LITE METER 56 FREESTYLE LITE STRIPS 56 FREESTYLE TEST FULPHILA furosemide FUZEON FYCOMPA... 8 G gabapentin... 8 galantamine GAMASTAN GAMASTAN S/D ganciclovir sodium GARDASIL 9 (PF) gatifloxacin GATTEX 30-VIAL... 6 GATTEX ONE-VIAL... 6 GAUZE PAD gavilyte-c... 6 gavilyte-g... 6 gavilyte-n... 6 GAZYVA... 1 gemcitabine... 1, GEMCITABINE... gemfibrozil generlac... 6 gengraf... gentak gentamicin... 15, 50, 73 gentamicin in nacl (iso-osm) 15 gentamicin sulfate (ped) (pf) 15 GENVOYA GEODON gianvi (8) GILENYA GILOTRIF... glatiramer glatopa GLEOSTINE... glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glycine urologic glycine urologic solution glycopyrrolate... 6 glydo granisetron (pf)... 6 granisetron hcl... 6 GRANIX GRASTEK griseofulvin microsize... 9 griseofulvin ultramicrosize... 9 guanidine H HAEGARDA HALAVEN... halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI HAVRIX (PF) heather heparin (porcine) heparin (porcine) in 5 % dex... 45, 46 heparin (porcine) in nacl (pf) 46 heparin(porcine) in 0.45% nacl HEPARIN(PORCINE) IN 0.45% NACL heparin, porcine (pf) HEPATAMINE 8%... 8 HERCEPTIN... HETLIOZ HIBERIX (PF) HIZENTRA HUMALOG JUNIOR KWIKPEN U HUMALOG KWIKPEN INSULIN HUMALOG MIX INSULN U HUMALOG MIX KWIKPEN HUMALOG MIX 75-5 KWIKPEN HUMALOG MIX 75-5(U- 100)INSULN HUMALOG U-100 INSULIN HUMIRA HUMIRA PEDIATRIC CROHNS START HUMIRA PEN HUMIRA PEN CROHNS-UC- HS START HUMIRA PEN PSOR- UVEITS-ADOL HS HUMIRA(CF) HUMIRA(CF) PEDI CROHNS STARTER HUMIRA(CF) PEN HUMIRA(CF) PEN CROHNS-UC-HS HUMIRA(CF) PEN PSOR- UV-ADOL HS HUMULIN 70/30 U-100 INSULIN HUMULIN 70/30 U-100 KWIKPEN

89 HUMULIN N NPH INSULIN KWIKPEN HUMULIN N NPH U-100 INSULIN HUMULIN R REGULAR U- 100 INSULN HUMULIN R U-500 (CONC) INSULIN HUMULIN R U-500 (CONC) KWIKPEN hydralazine hydrochlorothiazide hydrocodone-acetaminophen 33 hydrocodone-ibuprofen hydrocortisone... 51, 5, 55, 6 hydrocortisone butyrate hydrocortisone-acetic acid hydrocortisone-min oil-wht pet... 5 hydrocortisone-pramoxine... 6 hydromorphone hydromorphone (pf) hydroxychloroquine hydroxyprogesterone caproate hydroxyurea... hydroxyzine hcl HYPERHEP B S/D HYPERHEP B S-D NEONATAL HYQVIA I ibandronate IBRANCE... ibu ibuprofen ibuprofen-oxycodone ibutilide fumarate ICLUSIG... idarubicin... IDHIFA... ifosfamide... ILARIS (PF) imatinib... IMBRUVICA... IMFINZI... imipenem-cilastatin imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES VACCINE (PF) IMPAVIDO incassia INCRELEX INCRUSE ELLIPTA indapamide INFANRIX (DTAP) (PF) INLYTA... INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U INTELENCE intralipid... 8 INTRON A introvale INVANZ INVEGA SUSTENNA INVEGA TRINZA INVIRASE INVOKAMET INVOKAMET XR INVOKANA IONOSOL-MB IN D5W... 8 IPOL ipratropium bromide... 54, 77 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide IRESSA... irinotecan..., 3 ISENTRESS ISENTRESS HD isibloom ISOLYTE S PH ISOLYTE-P IN 5 % DEXTROSE... 8 ISOLYTE-S... 8 isoniazid isosorbide dinitrate isosorbide mononitrate isotretinoin isradipine ISTODAX... 3 itraconazole... 9 ivermectin IXEMPRA... 3 IXIARO (PF) J JAKAFI... 3 jantoven JANUMET JANUMET XR JANUVIA JARDIANCE jencycla JENTADUETO JENTADUETO XR JETREA (PF) JEVTANA... 3 jolessa jolivette juleber JULUCA JUXTAPID K KADCYLA... 3 KALETRA KALYDECO KANUMA kariva (8) kelnor 1/35 (8) kelnor KEPIVANCE ketoconazole... 9, 50 ketoprofen ketorolac KEYTRUDA... 3 KHAPZORY KHEDEZLA... 38, 39 KINRIX (PF) kionex (with sorbitol) KISQALI... 3 KISQALI FEMARA CO- PACK... 3 klor-con klor-con klor-con klor-con m klor-con m klor-con m klor-con sprinkle klor-con/ef

90 KORLYM K-PHOS NO K-PHOS ORIGINAL KRYSTEXXA k-tab kurvelo (8) KUVAN KYPROLIS... 3 L l norgest/e.estradiol-e.estrad 71, 7 labetalol lactated ringers... 5, 79 lactulose... 6 lamivudine lamivudine-zidovudine lamotrigine... 8 LANOXIN lansoprazole lanthanum LANTUS SOLOSTAR U-100 INSULIN LANTUS U-100 INSULIN.. 58 larin 1.5/30 (1)... 7 larin 1/0 (1)... 7 larin 4 fe... 7 larin fe 1.5/30 (8)... 7 larin fe 1/0 (8)... 7 larissia... 7 LARTRUVO... 3 latanoprost LATUDA leflunomide LEMTRADA LENVIMA... 3 lessina... 7 LETAIRIS letrozole... 3 leucovorin calcium LEUKERAN... 3 LEUKINE leuprolide... 3 levalbuterol hcl levetiracetam... 9 levetiracetam in nacl (iso-os) 9 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine levofloxacin... 17, 73 levofloxacin in d5w levoleucovorin calcium LEVOLEUCOVORIN CALCIUM levonest (8)... 7 levonorgestrel-ethinyl estrad 7 levonorg-eth estrad triphasic 7 levora levorphanol tartrate levothyroxine levoxyl LEXIVA LIBTAYO... 3 lidocaine lidocaine (pf) in d7.5w lidocaine (pf)... 41, 49 lidocaine hcl lidocaine in 5 % dextrose (pf) lidocaine viscous lidocaine-epinephrine lidocaine-prilocaine lillow (8)... 7 lincomycin lindane... 5 linezolid linezolid in dextrose 5% linezolid-0.9% sodium chloride LINZESS... 6 LIORESAL liothyronine lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate LOKELMA LONSURF... 3 loperamide... 6 lopinavir-ritonavir lorazepam lorazepam intensol LORBRENA... 3 lorcet (hydrocodone) lorcet hd lorcet plus loryna (8)... 7 losartan losartan-hydrochlorothiazide 43 lovastatin low-ogestrel (8)... 7 loxapine succinate LUCENTIS LUMIZYME LUMOXITI... 3 LUPRON DEPOT... 3 LUPRON DEPOT (3 MONTH)... 3 LUPRON DEPOT (4 MONTH)... 3 LUPRON DEPOT (6 MONTH)... 3 LUPRON DEPOT-PED... 3 LUPRON DEPOT-PED (3 MONTH)... 3 lutera (8)... 7 LYNPARZA... 3 LYRICA... 9 LYSODREN... 3 lyza M mafenide acetate magnesium chloride magnesium sulfate MAGNESIUM SULFATE IN D5W magnesium sulfate in water.. 79 malathion... 5 mannitol 0 % mannitol 5 % maprotiline marlissa (8)... 7 MARPLAN MARQIBO... 3 MATULANE... 3 matzim la meclizine meclofenamate medroxyprogesterone mefenamic acid mefloquine megestrol... 3 MEKINIST

91 MEKTOVI... 3 meloxicam melphalan... 3 melphalan hcl... 3 memantine MENACTRA (PF) MENEST MENVEO A-C-Y-W-135-DIP (PF) mercaptopurine... 3 meropenem mesalamine mesalamine with cleansing wipe mesna MESNEX MESTINON... 3 metadate er metaproterenol metformin methadone... 33, 34 methadone intensol methadose methazolamide methenamine hippurate methenamine mandelate methergine methimazole methotrexate sodium... 3 methotrexate sodium (pf)... 3 methoxsalen methyclothiazide methyldopa methylergonovine methylphenidate hcl methylprednisolone methylprednisolone acetate.. 55 methylprednisolone sodium succ methyltestosterone metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metro i.v metronidazole... 15, 50, 70 metronidazole in nacl (iso-os) mexiletine... 4 MIACALCIN miconazole microgestin 1.5/30 (1)... 7 microgestin 1/0 (1)... 7 microgestin fe 1.5/30 (8)... 7 microgestin fe 1/0 (8)... 7 midodrine migergot miglitol miglustat mili... 7 millipred millipred dp milrinone milrinone in 5 % dextrose minocycline minoxidil miostat MIRENA mirtazapine misoprostol MITIGARE mitomycin... 4 mitoxantrone... 4 M-M-R II (PF) modafinil moderiba moderiba dose pack moexipril moexipril-hydrochlorothiazide molindone mometasone... 5, 77 mondoxyne nl mono-linyah... 7 montelukast morgidox morphine morphine (pf) morphine concentrate MOVANTIK moxifloxacin... 17, 73 moxifloxacin in nacl (iso-osm) MOZOBIL MULPLETA mupirocin mupirocin calcium MYALEPT MYCAMINE... 9 mycophenolate mofetil... 4 mycophenolate mofetil hcl... 4 mycophenolate sodium... 4 MYLOTARG... 4 myorisan MYRBETRIQ myzilra... 7 N nabumetone nadolol nadolol-bendroflumethiazide 44 nafcillin nafcillin in dextrose iso-osm 17 naftifine NAGLAZYME nalbuphine naloxone naltrexone NAMZARIC naproxen naproxen sodium naratriptan NARCAN NATACYN nateglinide NATPARA NEBUPENT NEEDLES, INSULIN DISP.,SAFETY nefazodone neomycin neomycin-bacitracin-poly-hc 75 neomycin-bacitracinpolymyxin neomycin-polymyxin b gu... 5 neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc. 55, 75 neo-polycin neo-polycin hc neostigmine methylsulfate

92 NEPHRAMINE 5.4 %... 8 NERLYNX... 4 NEULASTA NEUPOGEN NEUPRO nevirapine NEXAVAR... 4 NEXPLANON niacin nicardipine NICOTROL NICOTROL NS nifedipine nikki (8)... 7 nilutamide... 4 nimodipine NINLARO... 4 nisoldipine nitro-bid nitrofurantoin nitrofurantoin macrocrystal.. 18 nitrofurantoin monohyd/mcryst nitroglycerin nitroglycerin in 5 % dextrose 48 nizatidine nolix... 5 nora-be norepinephrine bitartrate norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol... 70, 7 norethindrone-e.estradiol-iron... 7 norgestimate-ethinyl estradiol... 7 norlyda norlyroc NORMOSOL-R NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortrel 0.5/35 (8)... 7 nortrel 1/35 (1)... 7 nortrel 1/35 (8)... 7 nortrel 7/7/7 (8)... 7 nortriptyline NORVIR NOVOFINE NOXAFIL... 9 NPLATE NUEDEXTA NULOJIX... 4 NUPLAZID nyamyc nystatin... 9, 51 nystatin-triamcinolone nystop O OCALIVA OCREVUS octreotide acetate... 4 ODEFSEY ODOMZO... 4 OFEV ofloxacin... 17, 55, 73 ogestrel (8)... 7 okebo olanzapine olanzapine-fluoxetine olmesartan olmesartan-amlodipinhcthiazid olmesartanhydrochlorothiazide olopatadine... 54, 74 omeprazole OMNIPOD INSULIN MANAGEMENT OMNIPOD INSULIN REFILL OMNITROPE ONCASPAR... 4 ondansetron ondansetron hcl ondansetron hcl (pf) ONETOUCH ULTRA BLUE TEST STRIP ONETOUCH ULTRA ONETOUCH ULTRAMINI. 58 ONETOUCH VERIO ONETOUCH VERIO IQ METER ONETOUCH VERIO SYSTEM ONFI... 9 ONIVYDE... 4 OPDIVO... 4 opium tincture... 6 OPSUMIT oralone ORENCIA ORENCIA (WITH MALTOSE) ORENCIA CLICKJECT ORFADIN ORKAMBI orsythia... 7 oseltamivir osmitrol 15 % osmitrol 0 % OTEZLA OTEZLA STARTER... 69, 70 oxacillin oxacillin in dextrose(iso-osm) oxaliplatin... 4 oxandrolone oxaprozin oxcarbazepine... 9 OXERVATE oxiconazole oxybutynin chloride oxycodone oxycodone-acetaminophen oxycodone-aspirin oxymorphone oxytocin OZEMPIC OZURDEX P pacerone... 4 paclitaxel... 4 paliperidone palonosetron PALYNZIQ pamidronate PANRETIN pantoprazole paregoric... 6 paricalcitol

93 paroex oral rinse paromomycin paroxetine hcl... 39, 40 paroxetine mesylate(menop.sym) PASER PAXIL PEDIARIX (PF) PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE... 9 PEGASYS PEGASYS PROCLICK peg-electrolyte PEGINTRON penicillin g potassium penicillin g procaine penicillin g sodium penicillin v potassium PENTACEL (PF) PENTAM PENTASA pentoxifylline PERFOROMIST perindopril erbumine periogard PERJETA... 4 permethrin... 5 perphenazine PERSERIS pfizerpen-g phenelzine phenobarbital... 9 phenobarbital sodium... 9 phenoxybenzamine phentolamine phenytoin... 9 phenytoin sodium... 9 phenytoin sodium extended.. 9 philith... 7 PHOSPHOLINE IODIDE PIFELTRO pilocarpine hcl... 53, 74 pimozide pimtrea (8)... 7 pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam pirmella... 7 piroxicam plasbumin 5 % plasbumin 5 % PLASMA-LYTE PLASMA-LYTE A... 8 plasmanate... 8 PLEGRIDY plenamine... 8 podofilox polocaine polocaine-mpf polycin polyethylene glycol polymyxin b sulfate polymyxin b sulf-trimethoprim POMALYST... 4 portia PORTRAZZA... 4 potassium acetate potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride in water.. 80 potassium chloride-0.45 % nacl potassium chloride-d5-0.%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate potassium phosphate m-/dbasic POTELIGEO... 4 PRADAXA PRALUENT PEN pramipexole prasugrel pravastatin praziquantel prazosin PRECISION PCX PLUS TEST PRECISION PCX TEST PRECISION XTRA MONITOR prednicarbate... 5 prednisolone prednisolone acetate prednisolone sodium phosphate... 55, 75 prednisone prednisone intensol premasol 10 %... 8 PREMASOL 6 %... 8 prenatal vitamin oral tablet... 8 prevalite previfem... 7 PREVYMIS PREZCOBIX PREZISTA PRIFTIN PRIMAQUINE primidone... 9 PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid probenecid-colchicine procainamide... 4 procentra prochlorperazine prochlorperazine edisylate prochlorperazine maleate oral PROCRIT procto-med hc procto-pak proctosol hc proctozone-hc profeno progesterone progesterone in oil progesterone micronized PROGLYCEM PROGRAF

94 PROLASTIN-C PROLEUKIN PROLIA PROMACTA promethazine propafenone... 4 propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) protamine protriptyline prudoxin PULMOZYME PURIXAN... 4 pyrazinamide pyridostigmine bromide... 3 Q QUADRACEL (PF) quasense... 7 quetiapine quinapril quinapril-hydrochlorothiazide quinidine gluconate... 4 quinidine sulfate... 4 quinine sulfate QVAR REDIHALER R RABAVERT (PF) RADICAVA RAGWITEK rajani... 7 raloxifene ramipril RANEXA ranitidine hcl RAPAMUNE... 4 rasagiline RAVICTI REBIF (WITH ALBUMIN). 66 REBIF REBIDOSE REBIF TITRATION PACK 66 reclipsen (8)... 7 RECOMBIVAX HB (PF) RECTIV regonol... 3 REGRANEX RELENZA DISKHALER RELISTOR REMICADE REMODULIN RENACIDIN repaglinide repaglinide-metformin REPATHA REPATHA PUSHTRONEX 47 REPATHA SURECLICK RESCRIPTOR RETACRIT RETROVIR REVCOVI REVLIMID... 5 revonto... 3 REXULTI REYATAZ ribasphere ribasphere ribapak ribavirin RIDAURA rifabutin rifampin riluzole rimantadine ringer's... 5, 81 RIOMET risedronate... 53, 68 RISPERDAL CONSTA risperidone ritonavir RITUXAN... 5 RITUXAN HYCELA... 5 rivastigmine rivastigmine tartrate rizatriptan ROMIDEPSIN... 5 ropinirole rosadan rosuvastatin ROTARIX ROTATEQ VACCINE roweepra... 9 roweepra xr... 9 ROZEREM RUBRACA... 5 RYDAPT... 5 S SABRIL... 9 salsalate SAMSCA SANDIMMUNE... 5 SANDOSTATIN LAR DEPOT... 5 SANTYL SAPHRIS scopolamine base selegiline hcl selenium sulfide SELZENTRY SENSIPAR SEREVENT DISKUS sertraline setlakin... 7 sevelamer carbonate sf 54 sf 5000 plus sharobel SHINGRIX (PF) SIGNIFOR... 5 sildenafil (pulmonary arterial hypertension) silodosin silver sulfadiazine SIMULECT... 5 simvastatin sirolimus... 5 SIRTURO sodium acetate sodium benzoate-sod phenylacet sodium bicarbonate sodium chloride... 54, 81 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium lactate sodium nitroprusside sodium phenylbutyrate sodium phosphate sodium polystyrene (sorb free)

95 sodium polystyrene sulfonate SOLIRIS SOLTAMOX... 5 SOMATULINE DEPOT... 5 SOMAVERT sorine... 4 sotalol... 4 sotalol af... 4 SOTYLIZE... 4 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX... 9 sprintec (8)... 7 SPRITAM... 9 SPRYCEL... 5 sps (with sorbitol) sronyx... 7 ssd STAMARIL (PF) stavudine STIMATE STIOLTO RESPIMAT STIVARGA... 5 STRENSIQ STREPTOMYCIN STRIBILD STRIVERDI RESPIMAT SUBOXONE subvenite... 9 subvenite starter (blue) kit... 9 subvenite starter (green) kit.. 9 subvenite starter (orange) kit 9 SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne) 50 sulfacetamide-prednisolone.. 74 sulfadiazine sulfamethoxazole-trimethoprim SULFAMYLON sulfasalazine sulfatrim sulindac sumatriptan sumatriptan succinate... 30, 31 sumatriptan-naproxen SUPRAX SUTENT... 5 syeda... 7 SYLATRON SYLVANT... 5 SYMBICORT SYMDEKO SYMFI... 1 SYMFI LO... 1 SYMLINPEN SYMLINPEN SYMPAZAN... 9 SYMTUZA... 1 SYNAGIS... 1 SYNAREL SYNERCID SYNJARDY SYNJARDY XR SYNRIBO... 5 T TABLOID... 5 tacrolimus... 5, 49 tadalafil tadalafil (pulmonary arterial hypertension) oral tablet 0 mg TAFINLAR... 5 TAGRISSO... 5 TALZENNA... 5 tamoxifen... 5 tamsulosin TARCEVA... 5 TARGRETIN... 5 tarina fe 1/0 (8)... 7 tarina fe 1-0 eq (8)... 7 TASIGNA... 6 tazarotene TAZORAC taztia xt TECENTRIQ... 6 TECFIDERA TEFLARO TEKTURNA TEKTURNA HCT telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid TEMODAR... 6 temsirolimus... 6 TENIVAC (PF) tenofovir disoproxil fumarate... 1 terazosin terbinafine hcl... 9 terbutaline terconazole testosterone testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetrabenazine tetracycline THALOMID... 6 THEO theophylline theophylline in dextrose 5 % 78 THIOLA thioridazine thiotepa... 6 thiothixene tiagabine... 9 TIBSOVO... 6 TICE BCG tigecycline tilia fe... 7 timolol maleate... 45, 74 tinidazole TIVICAY... 1 tizanidine... 3 tobramycin tobramycin in 0.5 % nacl.. 16 tobramycin sulfate tobramycin-dexamethasone.. 75 tolazamide tolbutamide tolcapone tolmetin tolterodine

96 topiramate toposar... 6 topotecan... 6 TORISEL... 6 torsemide TOUJEO MAX U-300 SOLOSTAR TOUJEO SOLOSTAR U-300 INSULIN TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril trandolapril-verapamil tranexamic acid tranylcypromine travasol 10 %... 8 trazodone TREANDA... 6 TRECATOR TRELSTAR... 6 tretinoin (chemotherapy)... 6 tretinoin topical tri femynor... 7 triamcinolone acetonide 5, 54, 55 triamterene-hydrochlorothiazid trianex... 5 triderm... 5 trientine tri-estarylla trifluoperazine trifluridine tri-legest fe tri-linyah tri-lo-estarylla tri-lo-marzia tri-lo-sprintec trilyte with flavor packets trimethoprim trimipramine trinessa (8) TRINTELLIX tri-previfem (8) TRISENOX... 6 tri-sprintec (8) TRIUMEQ... 1 trivora (8) TROGARZO... 1 TROPHAMINE 10 %... 8 TROPHAMINE 6%... 8 trospium TRULICITY TRUMENBA TRUVADA... 1 tulana TWINRIX (PF) TYKERB... 6 TYMLOS TYPHIM VI... 67, 68 TYSABRI TYVASO TYVASO INSTITUTIONAL START KIT TYVASO REFILL KIT TYVASO STARTER KIT U ULORIC unithroid UNITUXIN... 6 UPTRAVI ursodiol UVADEX V valacyclovir... 1 VALCHLOR valganciclovir... 1 valproate sodium valproic acid valproic acid (as sodium salt) valsartan valsartan-hydrochlorothiazide VALSTAR... 6 vancomycin VANCOMYCIN IN 0.9 % SODIUM CHL vandazole VANTAS... 6 VAQTA (PF) VARIVAX (PF) VARIZIG VARUBI VASCEPA VECAMYL VECTIBIX... 6 VELCADE... 6 veletri velivet triphasic regimen (8) VELTASSA VEMLIDY... 1 VENCLEXTA... 6 VENCLEXTA STARTING PACK... 6 venlafaxine verapamil veripred VERSACLOZ VERZENIO... 6 V-GO V-GO V-GO VIBERZI vicodin vicodin es vicodin hp VICTOZA -PAK VICTOZA 3-PAK VIDEX GRAM PEDIATRIC... 1 VIDEX 4 GRAM PEDIATRIC... 1 VIDEX EC... 1 vienva vigabatrin vigadrone VIIBRYD VIMIZIM VIMPAT vinblastine... 6 vincasar pfs... 6 vincristine... 6 vinorelbine... 6 VIOKACE viorele (8) VIRACEPT... 1 VIRAMUNE... 1 VIREAD... 1 VISTOGARD VITRAKVI

97 VIVITROL VIZIMPRO... 6 voriconazole... 9 VOTRIENT... 6 VRAYLAR VYXEOS... 7 W warfarin water for irrigation, sterile wera (8) X XALKORI... 7 XARELTO XATMEP... 7 XERMELO... 7 XGEVA XIAFLEX XIFAXAN XIIDRA XOFLUZA... 1 XOLAIR XOSPATA... 7 XTANDI... 7 xulane XURIDEN XYREM Y YERVOY... 7 YF-VAX (PF) YONDELIS... 7 YONSA... 7 yuvafem Z zafirlukast zaleplon ZALTRAP... 7 ZANOSAR... 7 zarah ZARXIO ZEJULA... 7 ZELBORAF... 7 zenatane zidovudine... 1 ziprasidone hcl ZIRGAN ZOLADEX... 7 zoledronic acid zoledronic acid-mannitol-water ZOLINZA... 7 zolmitriptan zolpidem zonisamide ZORTRESS... 7 ZOSTAVAX (PF) zovia 1/35e (8) ZOVIRAX ZYDELIG... 7 ZYKADIA... 7 ZYPREXA RELPREVV ZYTIGA

98 This formulary was updated on 0/7/019. For more recent information or other questions, please contact CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Member Services, at or, for TTY users, 711, 8 a.m. 8 p.m. local time, seven days a week, from October 1 March 31, and 8 a.m. 8 p.m. local time, Monday Friday, from April 1- September 30, or visit christushealthplan.org. 98