Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Gain Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO)

Transcription

1 HP19FORM05 Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Gain Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) 019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary File ID# 197, Version Number 9 This formulary was updated on //19. For more recent information or other questions, please contact Harvard Pilgrim Stride SM (HMO) Member Services at or, for TTY users 711, October 1 - March 1, 8 a.m. - 8 p.m. 7 days a week, and April 1 - September 0, 8 a.m. - 8 p.m. Monday - Friday, or visit Y0098_1907_C

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 Harvard Pilgrim Health Care, Inc.. When it refers to plan or our plan, it means Stride Basic Rx (HMO), Stride Value Rx (HMO), Stride Value Rx Plus (HMO), and Stride Gain Rx (HMO). This document includes the list of the drugs (formulary) for our plan which is current as of //019. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 019, and from time to time during the year. What is the Stride Basic Rx (HMO), Stride Value Rx (HMO), Stride Value Rx Plus (HMO), and Stride Gain Rx (HMO) Formulary? A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Plan 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: Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. 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 cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 0 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 0-day supply of the drug. The enclosed formulary is current as of //19. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. 018 Formulary I

3 In the event of a mid-year, non-maintenance formulary change, we will notify you in your monthly Explanation of Benefits and on our website, You may ask us for a copy of the most recent formulary by contacting 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 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. 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. What are generic drugs? Our plans cover 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: Our plans require 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, our plans may not cover the drug. Quantity Limits: For certain drugs, our plans limit the amount of the drug that we will cover. For example, our plans provide tablets per prescription for alendronate 70 (generic Fosamax). This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plans require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plans will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. II

4 You can ask us 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 Stride Basic Rx (HMO), Stride Value Rx (HMO), Stride Value Rx Plus (HMO), and Stride Gain Rx (HMO) formulary? below for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our plans do not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by our plans. 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 us 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 Stride Basic Rx (HMO), Stride Value Rx (HMO), Stride Value Rx Plus (HMO), and Stride Gain Rx (HMO) s Formulary? You can ask our plans 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, our plans 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, our plans 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, tier, or utilization restriction exception. When you request a formulary, tier 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 you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. 018 Formulary III

5 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 0-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 0-day supply of medication. After your first 0-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 1-day emergency supply of that drug while you pursue a formulary exception. If during your membership you experience a change in your level of care, including being admitted to, or discharged from, a hospital or long-term care facility, we will cover a 1-day emergency supply of a drug that is either not on our formulary or has requirements or limits. This temporary supply will give you time to talk to your doctor about other treatment options or to request an exception. For more information about our Transition Policy, visit our website, For more information For more detailed information about your Stride Basic Rx (HMO), Stride Value Rx (HMO), Stride Value Rx Plus (HMO), and Stride Gain Rx (HMO) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plans, 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 ( ) hours a day/7 days a week. TTY users should call Or, visit IV (HMO)

6 Stride Basic Rx (HMO), Stride Value Rx (HMO), Stride Value Rx Plus (HMO), and Stride Gain Rx (HMO) s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Stride Basic Rx (HMO), Stride Value Rx (HMO), Stride Value Rx Plus (HMO), and Stride Gain Rx (HMO). If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., XARELTO) and generic drugs are listed in lower-case italics (e.g., simvastatin). For generic drugs, we have listed the brand name equivalent in parentheses for your reference only e.g. (Lipitor). If the brand name drug is not also listed in capital letters, it is not covered by our plan. The information in the Requirements/Limits column tells you if our plans have any special requirements for coverage of your drug. Coverage Notes Coverage of Excluded Drugs Our plans cover certain drugs that are excluded from coverage under Medicare Part D. Please refer to the table on page VII that describes Other Special Requirements for Coverage for important information about these drugs. Of these drugs, the most commonly used are those for the treatment of erectile dysfunction, such as Viagra. Our plans do not cover the lower daily dose of Cialis (.5 and 5) for the treatment of erectile dysfunction. Those strengths are only covered under Part D with prior authorization for diagnoses other than erectile dysfunction. Diabetic Testing Supplies Diabetic testing supplies, including test strips, lancets, and glucose meters, are covered under the plan s medical benefit at participating retail or mail-order pharmacies. Coverage of test strips and glucose meters is limited to those made by Abbott Diabetes Care and to quantities of 0 test strips per 0 days and 1 glucose meter per 65 days. Authorization is required for coverage of other brand test strips or glucose meters or for quantities of Abbott Diabetes Care brand test strips or glucose meters in excess of the limits stated above when purchased at a retail or mail-order pharmacy. First Fill Limit The first time you fill a drug covered on Tier 5, the Specialty Drug Tier, our plans will only cover up to a 0-day supply. This provides you an opportunity to try the new drug and see if it is working or is causing unwanted side effects. After your first fill of a Tier 5 drug, your future fills will be available for an extended days supply. Programs to Support the Safe Use of Opioids Harvard Pilgrim Health Care is committed to supporting the safe and appropriate use of opioid pain medications, such as oxycodone and hydrocodone. To help with these efforts, we use a variety of programs and safeguards at the pharmacy when you fill your medications. The edits below will stop your prescription from being approved at the pharmacy when the conditions described are met. In these situations, we ask the pharmacist to consult with your prescriber to verify the appropriateness of the prescribed medication(s). If you or your prescriber do not think these limitations are right for your situation, you can ask us to cover your drug by contacting our Member Services. Opioid Care Coordination Safety Edit Quantity limits apply to most of the individual opioid medications on our formulary. For example, we might limit coverage of an opioid to 60 tablets per 0 days. In addition to quantity limits 018 Formulary V

7 applying to individual drugs, we apply additional quantity limits across all drugs in the opioid class when members fill prescriptions for high doses of opioids. The Opioid Care Coordination Safety Edit calculates the total dose of opioid drugs prescribed for you on the date you fill a prescription for an opioid medication. If your provider(s) prescribes more than 90 morphine milligram equivalents (MME) per day, your claim will not approve without an override. Opioid Benzodiazepine Concurrent Use Edit If you are prescribed both an opioid and benzodiazepine (e.g. lorazepam, diazepam) written by two different prescribers, your claim will not approve without an override. Opioid Naïve Day Supply Limitation When you fill a prescription for an opioid medication for the first time (you have not filled a prescription for an opioid in the previous 60, we will limit your fill to a 7-day supply. Duplicative Long-Acting Opioid Edit When you fill prescriptions for two or more long-acting opioids written by two or more prescribers, your claim will not approve without an override. To obtain an override, your pharmacist can contact our Pharmacy Help Desk, or you or your prescriber can call our Member Services and a representative will be happy to assist you. Specialty Pharmacy As a Harvard Pilgrim Stride member you have the flexibility of filling your medications at the network pharmacy of your choice. If you pay a coinsurance for your specialty medication, your out of pocket costs may be lower should you choose to fill your specialty medication with CVS Specialty Pharmacy. Medications available Pharmacy are identified in our drug list with the following note: Available ( ). Other Pharmacies are available in our network. Information about what other pharmacies are available in our network can be accessed from the Harvard Pilgrim Health Care Pharmacy Directory (available on our website or by request), or by calling our Medicare Advantage Member Services department at or TTY 711. Representatives are available from October 1 - March 1, from 8 a.m. to 8 p.m., 7 days a week and from April 1 - September 0, from 8 a.m. to 8 p.m., Monday through Friday. Topical Compounds Prescriptions for compounded medications that are applied topically, or to the skin, are not covered by our plans. Just as with other drugs not included in this formulary (list of covered drugs), you can ask us to make an exception and cover your drug by calling our Member Services. The following symbols and abbreviations describing utilization management restrictions and other special requirements may be found within the body of this document. SYMBOL DESCRIPTION EXPLANATION Utilization Management Restrictions AGE (Max 6 Years) Age Restriction If you are 65 years of age or older, you (or your physician) are required to get prior authorization from our plan before we will cover this drug. This requirement is in place due to safety concerns with using this drug in people over that age. Prior authorization is not required for members 6 years of age or younger. VI Stride Basic Rx (HMO), Stride Value Rx (HMO), and Stride Value Rx Plus (HMO)

8 SYMBOL DESCRIPTION EXPLANATION Utilization Management Restrictions AGE (Min 65 Years) Age Restriction If you are under the age of 65, you (or your physician) are required to get prior authorization from our plan before we will cover this drug. PA PA BvD PA NSO Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction New Starts Only You (or your physician) are required to get prior authorization from our plans before we will cover this drug. This drug may be eligible for payment under Medicare Part B or Part D depending on the circumstances. You (or your physician) may need to submit information describing the use and setting of the drug to make the determination. If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from our plans before you fill your prescription for this drug. Without prior approval, we may not cover this drug. QL ST Quantity Limit Restriction Step Therapy Restriction Our plans limit the amount of this drug that is covered within a specific time frame, or per prescription. Before we will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. Other Special Requirements for Coverage CB Capped Benefit Quantity Limit Restriction Our plans limit the amount of this drug that is covered within a specific time frame, or per prescription. We will not cover a temporary supply of this drug greater than this quantity limit. EX Excluded Part D Drug This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. GC Gap Coverage We provide additional coverage of this prescription drug in the coverage gap for members of the Stride Value Rx Plus (HMO) plans. Please refer to our Evidence of Coverage for more information about this coverage. 018 Formulary VII

9 SYMBOL DESCRIPTION EXPLANATION Utilization Management Restrictions LA Limited Availability This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Member Services at TTY users should call 711. We are here to assist you October 1 to March 1, from 8 a.m. 8 p.m., 7 days a week and April 1 to September 0, from 8 a.m. 8 p.m., Monday through Friday. NM Non-Mail Order Drugs This drug is not available through your mail order benefit. What you pay for your Part D prescription drugs The costs below are for a 0-day supply at a plan s network pharmacy. For more information about what costs determine when you move from one coverage stage to the next, refer to your Evidence of Coverage. Stride SM Basic Rx (HMO) MAINE MASSACHUSETTS NEW HAMPSHIRE Deductible Tiers 5 only $15 $15 $15 Initial Coverage Tier 1 $0 $0 $0 Tier $15 $15 $15 Tier $7 $7 $7 Tier $100 $100 $100 Tier 5 5% 5% 5% Coverage Gap All Tiers You pay 5% of the price for covered brand-name drugs (plus a portion of the dispensing fee) and 7% of the price for covered generic drugs until your costs total $5,100. Catastrophic Coverage All Tiers You pay the greater of either: coinsurance of 5% of the cost or the drug, or $.0 for a generic drug of a drug that is treated like a generic and $8.50 for all other drugs Our plan pays the rest of the cost VIII Stride Basic Rx (HMO), Stride Value Rx (HMO), and Stride Value Rx Plus (HMO)

10 Stride SM Value Rx (HMO) MAINE MASSACHUSETTS NEW HAMPSHIRE Deductible Tiers 5 only $00 $50 $70 Initial Coverage Tier 1 $0 $0 $0 Tier $10 $10 $10 Tier $7 $7 $7 Tier $100 $100 $100 Tier 5 7% 7% 7% Coverage Gap All Tiers You pay 5% of the price for covered brand-name drugs (plus a portion of the dispensing fee) and 7% of the price for covered generic drugs until your costs total $5,100. Catastrophic Coverage All Tiers You pay the greater of either: coinsurance of 5% of the cost or the drug, or $.0 for a generic drug of a drug that is treated like a generic and $8.50 for all other drugs Our plan pays the rest of the cost 018 Formulary IX

11 Stride SM Value Rx Plus (HMO) MASSACHUSETTS NEW HAMPSHIRE Deductible Tiers 5 only $0 $00 Initial Coverage Tier 1 $0 $0 Tier $10 $10 Tier $7 $7 Tier $100 $100 Tier 5 % 9% Coverage Gap Tier 1 $0 Tiers 5 You pay 5% of the price for covered brand-name drugs (plus a portion of the dispensing fee) and 7% of the price for covered generic drugs until your costs total $5,100. Catastrophic Coverage All Tiers You pay the greater of either: coinsurance of 5% of the cost or the drug, or $.0 for a generic drug of a drug that is treated like a generic and $8.50 for all other drugs Our plan pays the rest of the cost X

12 Stride SM Gain Rx (HMO) NEW HAMPSHIRE Deductible Tiers 5 only $15 Initial Coverage Tier 1 $0 Tier 5% Tier 5% Tier 5% Tier 5 5% Coverage Gap All Tiers You pay 5% of the plan s cost for covered brand name drugs and 7% of the plan s cost for covered generic drugs. Catastrophic Coverage All Tiers You pay the greater of either: coinsurance of 5% of the cost or the drug, or $.0 for a generic drug of a drug that is treated like a generic and $8.50 for all other drugs Our plan pays the rest of the cost XI

13 Table of Contents Analgesics... Anesthetics... 8 Anti-Addiction/Substance Abuse Treatment Agents...9 Antianxiety Agents...10 Antibacterials... 1 Anticancer Agents... 1 Anticholinergic Agents... Anticonvulsants... Antidementia Agents...6 Antidepressants... 7 Antidiabetic Agents... 0 Antifungals...6 Antigout Agents... 8 Antihistamines...9 Anti-Infectives (Skin And Mucous Membrane)...9 Antimigraine Agents...50 Antimycobacterials...51 Antinausea Agents...51 Antiparasite Agents...5 Antiparkinsonian Agents...5 Antipsychotic Agents...55 Antivirals (Systemic)...59 Blood Products/Modifiers/Volume Expanders Caloric Agents...69 Cardiovascular Agents... 7 Central Nervous System Agents... 8 Contraceptives...88 Cough And Cold Products Dental And Oral Agents...95 Dermatological Agents...96 Devices Enzyme Replacement/Modifiers Eye, Ear, Nose, Throat Agents Gastrointestinal Agents Genitourinary Agents Heavy Metal Antagonists

14 Hormonal Agents, Stimulant/Replacement/Modifying...11 Immunological Agents...11 Inflammatory Bowel Disease Agents Irrigating Solutions...10 Metabolic Bone Disease Agents...10 Miscellaneous Therapeutic Agents...1 Ophthalmic Agents...1 Replacement Preparations Respiratory Tract Agents Skeletal Muscle Relaxants... 1 Sleep Disorder Agents... 1 Vasodilating Agents...15 Vitamins And Minerals...16

15 Analgesics Analgesics, Miscellaneous ABSTRAL SUBLINGUAL TABLET 100 MCG ABSTRAL SUBLINGUAL TABLET 00 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG acetaminophen-codeine oral solution 10-1 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet 00-0 acetaminophen-codeine oral tablet ARYMO ER ORAL TABLET,ORAL ONLY,EXTND RELEASE 15 MG, 0 MG, 60 MG buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule butalbital-acetaminophen oral capsule butalbital-acetaminophen oral tablet butalbital-acetaminophen oral tablet 50-5 butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral capsule PA; QL (10 per 0 5 PA; QL (10 per 0 QL (5000 per 0 QL (60 per 0 (Tylenol-Codeine #) QL (60 per 0 (Tylenol-Codeine #) QL (180 per 0 QL (60 per 0 (Butrans) QL ( per 8 PA; QL (180 per 0 ; AGE (Max 6 Years) PA; QL (180 per 0 ; AGE (Max 6 Years) QL (180 per 0 (Bupap) PA; QL (180 per 0 ; AGE (Max 6 Years) (Tencon) PA; QL (180 per 0 ; AGE (Max 6 Years) (Fioricet) PA; QL (180 per 0 ; AGE (Max 6 Years) (Capacet) PA; QL (180 per 0 ; AGE (Max 6 Years)

16 butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule (Esgic) PA; QL (180 per 0 ; AGE (Max 6 Years) (Fiorinal) PA; QL (180 per 0 ; AGE (Max 6 Years) QL (5 per 8 butorphanol tartrate nasal spray,nonaerosol 10 /ml capacet oral capsule QL (180 per 0 codeine sulfate oral tablet 15, 0, QL (180 per 0 60 EMBEDA ORAL CAPSULE,ORAL QL (60 per 0 ONLY,EXT.REL PELL 100- MG, MG, 0-1. MG, 50- MG, 60-. MG, 80-. MG endocet oral tablet 10-5,.5-5, 5-5, fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr fentanyl transdermal patch 7 hour 7.5 mcg/hour, 6.5 mcg/hour, 87.5 mcg/hour FENTORA BUCCAL TABLET, EFFERVESCENT 100 MCG, 00 MCG, 00 MCG, 600 MCG, 800 MCG hydrocodone-acetaminophen oral solution 10-5 /15 ml(15 ml), /15 ml hydrocodone-acetaminophen oral tablet hydrocodone-acetaminophen oral tablet 10-5 hydrocodone-acetaminophen oral tablet.5-5 hydrocodone-acetaminophen oral tablet 5-00 hydrocodone-acetaminophen oral tablet 5-5 QL (60 per 0 (Actiq) 5 PA; QL (10 per 0 (Duragesic) QL (10 per 0 QL (10 per 0 5 PA; QL (10 per 0 QL (700 per 0 (Vicodin HP) QL (90 per 0 (Lorcet HD) QL (60 per 0 (Verdrocet) QL (60 per 0 (Vicodin) QL (90 per 0 (Lorcet (hydrocodone)) QL (60 per 0

17 hydrocodone-acetaminophen oral tablet (Vicodin ES) QL (90 per hydrocodone-acetaminophen oral tablet (Lorcet Plus) QL (60 per hydrocodone-ibuprofen oral tablet (Ibudone) QL (150 per 0, 5-00 hydrocodone-ibuprofen oral tablet 7.5- QL (150 per 0 00 hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 0 hydromorphone oral tablet, (Dilaudid) QL (180 per 0 hydromorphone oral tablet 8 (Dilaudid) QL (0 per 0 hydromorphone oral tablet extended (Exalgo ER) QL (0 per 0 release hr 1, 16, 8 hydromorphone oral tablet extended (Exalgo ER) QL (60 per 0 release hr ibuprofen-oxycodone oral tablet 00-5 QL (8 per 0 KADIAN ORAL QL (60 per 0 CAPSULE,EXTEND.RELEASE PELLETS 00 MG, 0 MG levorphanol tartrate oral tablet QL (180 per 0 lorcet (hydrocodone) oral tablet 5-5 QL (60 per 0 lorcet hd oral tablet 10-5 QL (60 per 0 lorcet plus oral tablet QL (60 per 0 marten-tab oral tablet 50-5 PA; QL (180 per 0 ; AGE (Max 6 Years) methadone oral concentrate 10 /ml (Methadone Intensol) QL (60 per 0 methadone oral solution 10 /5 ml, 5 QL (100 per 0 /5 ml methadone oral tablet 10, 5 (Dolophine) QL (0 per 0 methadose oral tablet,soluble 0 QL (90 per 0 MORPHABOND ER ORAL QL (60 per 0 TABLET,ORAL ONLY,EXT.REL.1 HR 100 MG, 15 MG, 0 MG, 60 MG morphine concentrate oral solution 100 /5 ml (0 /ml) QL (00 per 0 5

18 morphine oral capsule, er multiphase QL (60 per 0 hr 60, 75 morphine oral solution 10 /5 ml QL (700 per 0 morphine oral solution 0 /5 ml ( QL (00 per 0 /ml) MORPHINE ORAL TABLET 15 MG, QL (180 per 0 0 MG morphine oral tablet extended release 100 (MS Contin) QL (10 per 0, 15, 00, 0, 60 oxycodone oral capsule 5 QL (180 per 0 oxycodone oral concentrate 0 /ml QL (180 per 0 oxycodone oral solution 5 /5 ml QL (100 per 0 oxycodone oral tablet 10, 0 QL (180 per 0 oxycodone oral tablet 15, 0, 5 (Roxicodone) QL (180 per 0 oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (10 per 0 hr 10, 15, 0, 0, 0, 60, 80 oxycodone-acetaminophen oral solution QL (1800 per /5 ml oxycodone-acetaminophen oral tablet 10- (Endocet) QL (60 per 0 5,.5-5, 5-5, oxycodone-aspirin oral tablet QL (60 per 0 OXYCONTIN ORAL QL (10 per 0 TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG oxymorphone oral tablet 10, 5 (Opana) QL (180 per 0 oxymorphone oral tablet extended release QL (60 per 0 1 hr 10, 15, 0, 0, 0, 5, 7.5 phrenilin forte(with caffeine) oral capsule PA; QL (180 per 0 ; AGE (Max 6 Years) tramadol oral tablet 50 (Ultram) QL (0 per 0 tramadol oral tablet extended release QL (90 per 0 hr 100 tramadol oral tablet extended release hr 00, 00 QL (0 per 0 6

19 tramadol oral tablet, er multiphase hr QL (90 per tramadol oral tablet, er multiphase hr QL (0 per 0 00, 00 tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (0 per 0 5 vicodin es oral tablet QL (90 per 0 vicodin hp oral tablet QL (90 per 0 vicodin oral tablet 5-00 QL (90 per 0 xylon 10 oral tablet QL (150 per 0 Nonsteroidal Anti-Inflammatory Agents celecoxib oral capsule 100, 00, 50 (Celebrex) PA; QL (60 per 0 ; AGE (Min 65 Years) celecoxib oral capsule 00 (Celebrex) PA; QL (0 per 0 ; AGE (Min 65 Years) diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac sodium topical drops 1.5 % diclofenac sodium topical gel 1 % (Voltaren) diclofenac sodium topical gel % (Solaraze) 5 diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 etodolac oral capsule 00, 00 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release hr 00, 500, 600 fenoprofen oral tablet 600 (Nalfon) FLECTOR TRANSDERMAL PATCH 1 HOUR 1. % PA 7

20 flurbiprofen oral tablet 100, 50 ibu oral tablet 00, 600, 800 ibuprofen lysine (pf) intravenous solution (NeoProfen (ibuprofen 0 / ml lysn)(pf)) ibuprofen oral suspension 100 /5 ml (Child Ibuprofen) ibuprofen oral tablet 00, 600, (IBU) 800 INDOCIN RECTAL SUPPOSITORY 50 MG indomethacin oral capsule 5, 50 PA; AGE (Max 6 Years) indomethacin oral capsule, extended release 75 PA; AGE (Max 6 Years) indomethacin sodium intravenous recon soln 1 PA; AGE (Max 6 Years) ketoprofen oral capsule 5, 50, 75 ketoprofen oral capsule,ext rel. pellets hr 00 meclofenamate oral capsule 100, 50 meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 naproxen oral tablet 500 (Naprosyn) naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75, 500 naproxen sodium oral tablet 75 naproxen sodium oral tablet 550 (Anaprox DS) oxaprozin oral tablet 600 (Daypro) piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet 150, 00 Anesthetics Local Anesthetics lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %), 15 /ml (1.5 %), 0 /ml ( %) 8

21 lidocaine (pf) injection solution 0 /ml ( %) lidocaine hcl injection solution 10 /ml (Xylocaine) (1 %), 5 /ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution % (0 /ml) lidocaine topical adhesive (Lidoderm) PA patch,medicated 5 % lidocaine topical ointment 5 % PA lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) buprenorphine hcl sublingual tablet, QL (90 per 0 8 buprenorphine-naloxone sublingual film (Suboxone) QL (90 per 0 8- buprenorphine-naloxone sublingual tablet -0.5, 8- QL (90 per 0 bupropion hcl (smoking deter) oral tablet (Zyban) extended release 1 hr 150 CHANTIX CONTINUING MONTH QL (6 per 65 BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (6 per 65 MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG () QL (6 per 65 disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0. /ml naloxone injection syringe 0. /ml, 1 /ml naltrexone oral tablet 50 9

22 NARCAN NASAL SPRAY,NON- AEROSOL MG/ACTUATION NICOTROL INHALATION CARTRIDGE 10 MG NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML SUBOXONE SUBLINGUAL FILM 1- MG, -0.5 MG, -1 MG, 8- MG VIVITROL INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 80 MG ZUBSOLV SUBLINGUAL TABLET MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG, MG Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 QL ( per 0 QL (00 per 65 QL (90 per 0 5 NM; Available through CVS Specialty ( ) QL (90 per 0 QL (60 per 0 (Xanax) QL (10 per 0 alprazolam oral tablet (Xanax) QL (150 per 0 buspirone oral tablet 10, 15, 0, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 5, 5 clobazam oral suspension.5 /ml (Onfi) clobazam oral tablet 10, 0 (Onfi) clonazepam oral tablet 0.5 (Klonopin) QL (100 per 0 clonazepam oral tablet 1 (Klonopin) QL (600 per 0 clonazepam oral tablet (Klonopin) QL (00 per 0 clonazepam oral tablet,disintegrating QL (800 per clonazepam oral tablet,disintegrating QL (00 per clonazepam oral tablet,disintegrating 0.5 QL (100 per 0 clonazepam oral tablet,disintegrating 1 QL (600 per 0 clonazepam oral tablet,disintegrating QL (00 per 0 10

23 clorazepate dipotassium oral tablet 15,.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) DIASTAT ACUDIAL RECTAL KIT MG diazepam injection solution 5 /ml diazepam injection syringe 5 /ml diazepam intensol oral concentrate 5 QL (0 per 0 /ml diazepam oral solution 5 /5 ml (1 QL (100 per 0 /ml) diazepam oral tablet 10 (Valium) QL (10 per 0 diazepam oral tablet, 5 (Valium) QL (90 per 0 diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml, (Ativan) /ml lorazepam injection syringe /ml, /ml lorazepam oral concentrate /ml (Lorazepam Intensol) QL (150 per 0 lorazepam oral tablet 0.5, 1 (Ativan) QL (90 per 0 lorazepam oral tablet (Ativan) QL (150 per 0 midazolam (pf) injection cartridge / ml (1 /ml) midazolam (pf) injection solution 1 /ml, 5 /ml midazolam (pf) injection syringe / ml (1 /ml), 5 /ml midazolam injection solution 1 /ml, 5 /ml ONFI ORAL SUSPENSION.5 5 MG/ML ONFI ORAL TABLET 10 MG, 0 MG 5 oxazepam oral capsule 10, 15, 0 temazepam oral capsule 15,.5, (Restoril) QL (0 per 0 0, 7.5 triazolam oral tablet

24 triazolam oral tablet 0.5 (Halcion) Antibacterials Aminoglycosides amikacin injection solution 1,000 / ml, 500 / ml ARIKAYCE INHALATION SUSPENSION FOR NEBULIZATION 590 MG/8. ML BETHKIS INHALATION SOLUTION FOR NEBULIZATION 00 MG/ ML gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 10 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 0 / ml, 0 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml, 60 /6 ml, 80 /8 ml 5 PA; QL (8 per 8 5 PA BvD; NM; Available through CVS Specialty ( ) neomycin oral tablet 500 streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG 5 NM; Available through CVS Specialty ( ) tobramycin in 0.5 % nacl inhalation solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 0 /ml Antibacterials, Miscellaneous clindamycin hcl oral capsule 150, 00, 75 (Tobi) 5 PA BvD; NM; Available through CVS Specialty ( ) (Cleocin HCl) 1

25 clindamycin in 5 % dextrose intravenous piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml clindamycin palmitate hcl oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution 150 /ml clindamycin phosphate intravenous solution 600 / ml colistin (colistimethate na) injection recon soln 150 DALVANCE INTRAVENOUS SOLUTION 500 MG daptomycin intravenous recon soln 50 daptomycin intravenous recon soln 500 FIRVANQ ORAL RECON SOLN 5 MG/ML, 50 MG/ML linezolid 600 /00 ml-0.9% nacl 600 /00 ml linezolid in dextrose 5% intravenous piggyback 600 /00 ml linezolid oral suspension for reconstitution 100 /5 ml (Cleocin Pediatric) (Cleocin) (Cleocin) (Coly-Mycin M Parenteral) (Cubicin) 5 (Zyvox) 5 (Zyvox) 5 linezolid oral tablet 600 (Zyvox) 5 methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) (Metro I.V.) intravenous piggyback 500 /100 ml metronidazole oral capsule 75 (Flagyl) metronidazole oral tablet 50, 500 (Flagyl) MONUROL ORAL PACKET GRAM nitrofurantoin macrocrystal oral capsule (Macrodantin) 100, 5, 50 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrobid) nitrofurantoin oral suspension 5 /5 ml (Furadantin)

26 polymyxin b sulfate injection recon soln 500,000 unit PRIMSOL ORAL SOLUTION 50 MG/5 ML SIVEXTRO INTRAVENOUS 5 RECON SOLN 00 MG SIVEXTRO ORAL TABLET 00 MG 5 trimethoprim oral tablet 100 vancomycin in dextrose 5 % intravenous piggyback 1 gram/00 ml, 500 /100 ml, 750 /150 ml vancomycin intravenous recon soln 1,000, 1.5 gram, 10 gram, 50, 5 gram, 500, 750 VANCOMYCIN INTRAVENOUS RECON SOLN 1.5 GRAM vancomycin oral capsule 15 (Vancocin) vancomycin oral capsule 50 (Vancocin) 5 VIBATIV INTRAVENOUS RECON SOLN 750 MG XIFAXAN ORAL TABLET 00 MG 5 QL (9 per 0 XIFAXAN ORAL TABLET 550 MG 5 PA; QL (60 per 0 Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefaclor oral tablet extended release 1 hr 500 cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin injection recon soln 1 gram, 10 gram, 500 cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 00 (Spectracef) 1

27 cefepime injection recon soln 1 gram, (Maxipime) gram cefixime oral suspension for (Suprax) reconstitution 100 /5 ml, 00 /5 ml cefotaxime injection recon soln 1 gram, 500 cefotaxime injection recon soln 10 gram, (Claforan) gram cefotetan injection recon soln 1 gram, (Cefotan) gram cefotetan intravenous recon soln 10 gram cefoxitin intravenous recon soln 1 gram, 10 gram, gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram, 6 (TAZICEF) gram ceftriaxone injection recon soln 1 gram, 10 gram, gram, 50, 500 cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln 750 cefuroxime sodium intravenous recon soln 1.5 gram, 7.5 gram cephalexin oral capsule 50, 500, (Keflex) 750 cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 DAXBIA ORAL CAPSULE MG SUPRAX ORAL CAPSULE 00 MG SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 100 MG, 00 MG 15

28 tazicef injection recon soln gram, 6 gram TEFLARO INTRAVENOUS RECON 5 SOLN 00 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (6 pack), 500 ( pack), 600 azithromycin oral tablet 50, 500 (Zithromax) clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release hr 500 DIFICID ORAL TABLET 00 MG 5 QL (0 per 10 e.e.s. 00 oral tablet 00 E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 50 ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral (E.E.S. Granules) suspension for reconstitution 00 /5 ml erythromycin ethylsuccinate oral tablet 00 (E.E.S. 00) 16

29 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 ZMAX ORAL SUSPENSION,EXTENDED REL RECON GRAM/60 ML Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram (Azactam) CAYSTON INHALATION 5 LA SOLUTION FOR NEBULIZATION 75 MG/ML doripenem intravenous recon soln 50, 500 imipenem-cilastatin intravenous recon soln 50 imipenem-cilastatin intravenous recon soln 500 (Primaxin IV) INVANZ INJECTION RECON SOLN 1 GRAM PA BvD meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, 500 amoxicillin oral suspension for reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 15, 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet

30 amoxicillin-pot clavulanate oral tablet (Augmentin) , amoxicillin-pot clavulanate oral tablet (Augmentin XR) extended release 1 hr 1, amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, 500 ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML BICILLIN C-R INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin 1 gm/ 50 ml inj 1 gram/50 ml nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram 5 nafcillin injection recon soln gram nafcillin intravenous recon soln gram oxacillin 1 gm add-vantage vl addvantage, inner 1 gram oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 1 gram, gram oxacillin injection recon soln 10 gram 5 18

31 penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 0 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml penicillin g sodium injection recon soln 5 million unit penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous (Zosyn) recon soln.5 gram,.75 gram,.5 gram, 0.5 gram Quinolones BAXDELA ORAL TABLET 50 MG 5 QL (8 per 1 ciprofloxacin (mixture) oral tablet, er (Cipro XR) multiphase hr 1,000, 500 ciprofloxacin hcl oral tablet 100, 750 ciprofloxacin hcl oral tablet 50, 500 (Cipro) ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 00 /00 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50 19

32 levofloxacin oral tablet 500, 750 (Levaquin) moxifloxacin 00 /50 ml bag 00 /50 ml moxifloxacin in nacl (iso-osm) (Avelox in NaCl (isoosmotic)) intravenous piggyback 00 /50 ml moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 00, 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim oral (Sulfatrim) suspension 00-0 /5 ml sulfamethoxazole-trimethoprim oral (Bactrim) tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) tablet sulfatrim oral suspension 00-0 /5 ml Tetracyclines demeclocycline oral tablet 150, 00 doxy-100 intravenous recon soln 100 doxycycline hyclate oral capsule 100, (Morgidox) 50 doxycycline hyclate oral tablet 100, 0 doxycycline hyclate oral tablet 150, (Acticlate) 75 doxycycline hyclate oral tablet 50 (Targadox) doxycycline monohydrate oral capsule (Mondoxyne NL) 100, 50, 75 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral capsule,ir (Oracea) - delay rel,biphase 0 doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 150, 50, 75 minocycline oral capsule 100, 75 minocycline oral capsule 50 (Minocin) 0

33 minocycline oral tablet 100, 50, 75 tetracycline oral capsule 50, 500 tigecycline intravenous recon soln 50 (Tygacil) VIBRAMYCIN ORAL SYRUP 50 MG/5 ML Anticancer Agents Anticancer Agents adriamycin intravenous recon soln 10, PA BvD 50 adriamycin intravenous solution 10 /5 PA BvD ml, /ml, 0 /10 ml, 50 /5 ml adrucil intravenous solution.5 gram/50 ml PA BvD AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION MG, MG, 5 MG AFINITOR ORAL TABLET 10 MG,.5 MG, 5 MG, 7.5 MG ALECENSA ORAL CAPSULE 150 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (60 per 0 5 PA NSO; NM; Available through CVS Specialty ( ); QL (0 per 0 5 PA NSO; NM; Available through CVS Specialty ( ) ALUNBRIG ORAL TABLET 180 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (0 per 0 ALUNBRIG ORAL TABLET 0 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (180 per 0 1

34 ALUNBRIG ORAL TABLET 90 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (60 per 0 ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG () 5 PA NSO; NM; Available through CVS Specialty ( ); QL (0 per 0 anastrozole oral tablet 1 (Arimidex) ARZERRA INTRAVENOUS 5 SOLUTION 1,000 MG/50 ML, 100 MG/5 ML BENDEKA INTRAVENOUS 5 SOLUTION 5 MG/ML BESPONSA INTRAVENOUS 5 RECON SOLN 0.9 MG (0.5 MG/ML INITIAL) bexarotene oral capsule 75 (Targretin) 5 bicalutamide oral tablet 50 (Casodex) bleomycin injection recon soln 15 unit PA BvD BLINCYTO INTRAVENOUS KIT 5 5 PA BvD MCG BOSULIF ORAL TABLET 100 MG, 00 MG, 500 MG 5 PA NSO; NM; Available through CVS Specialty ( ) BRAFTOVI ORAL CAPSULE 50 MG 5 PA NSO; QL (10 per 0 BRAFTOVI ORAL CAPSULE 75 MG 5 PA NSO; QL (180 per 0 CABOMETYX ORAL TABLET 0 MG, 0 MG, 60 MG CALQUENCE ORAL CAPSULE 100 MG CAPRELSA ORAL TABLET 100 MG, 00 MG carmustine intravenous recon soln 100 (BiCNU) 5 PA NSO; NM; Available through CVS Specialty ( ) 5 PA NSO; QL (60 per 0 5 PA NSO

35 COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-0 MG X1), 10 MG/DAY(80 MG X1-0 MG X), 60 MG/DAY (0 MG X /DAY) COPIKTRA ORAL CAPSULE 15 MG, 5 MG 5 PA NSO 5 PA NSO; QL (56 per 8 COTELLIC ORAL TABLET 0 MG 5 PA NSO; NM; LA; Available through CVS Specialty ( ) cyclophosphamide intravenous recon soln PA BvD 1 gram, gram, 500 CYCLOPHOSPHAMIDE ORAL PA BvD CAPSULE 5 MG, 50 MG dacarbazine intravenous recon soln 100 DARZALEX INTRAVENOUS 5 LA SOLUTION 0 MG/ML daunorubicin intravenous recon soln 0 daunorubicin intravenous solution 5 /ml DOCEFREZ INTRAVENOUS 5 RECON SOLN 0 MG, 80 MG docetaxel intravenous solution 0 /ml 5 doxorubicin intravenous recon soln 10 (Adriamycin) PA BvD, 50 doxorubicin intravenous solution 10 /5 (Adriamycin) PA BvD ml, /ml, 0 /10 ml doxorubicin, peg-liposomal intravenous (Doxil) 5 PA BvD suspension /ml DROXIA ORAL CAPSULE 00 MG, 00 MG, 00 MG EMCYT ORAL CAPSULE 10 MG 5 epirubicin intravenous recon soln 00, 50 epirubicin intravenous solution 50 /5 (Ellence) ml ERBITUX INTRAVENOUS SOLUTION 00 MG/100 ML 5

36 ERIVEDGE ORAL CAPSULE 150 MG 5 PA NSO; NM; Available through CVS Specialty ( ) ERLEADA ORAL TABLET 60 MG 5 PA NSO; NM; Available through CVS Specialty ( ) exemestane oral tablet 5 (Aromasin) FARESTON ORAL TABLET 60 MG 5 FARYDAK ORAL CAPSULE 10 MG, 15 MG, 0 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 10 MG, 80 MG 5 PA NSO; NM; Available through CVS Specialty ( ) floxuridine injection recon soln 0.5 gram PA BvD fludarabine intravenous solution 50 / ml fluorouracil intravenous solution 1 PA BvD gram/0 ml fluorouracil intravenous solution 500 (Adrucil) PA BvD /10 ml flutamide oral capsule 15 FOLOTYN INTRAVENOUS 5 SOLUTION 0 MG/ML (1 ML) GAZYVA INTRAVENOUS 5 SOLUTION 1,000 MG/0 ML gemcitabine intravenous recon soln 5 gram, 00 gemcitabine intravenous solution 1 5 gram/6. ml (8 /ml), 100 /ml, gram/5.6 ml (8 /ml), 00 /5.6 ml (8 /ml) GILOTRIF ORAL TABLET 0 MG, 5 PA NSO 0 MG, 0 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 0 MG, 5 MG HERCEPTIN INTRAVENOUS RECON SOLN 150 MG 5 PA BvD

37 HEXALEN ORAL CAPSULE 50 MG 5 hydroxyurea oral capsule 500 (Hydrea) IBRANCE ORAL CAPSULE 100 MG, 15 MG, 75 MG 5 PA NSO; NM; Available through CVS Specialty ( ) ICLUSIG ORAL TABLET 15 MG, 5 MG 5 PA NSO idarubicin intravenous solution 1 /ml (Idamycin PFS) IDHIFA ORAL TABLET 100 MG, 50 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (0 per 0 ifosfamide intravenous recon soln gram (Ifex) PA BvD ifosfamide intravenous solution 1 gram/0 PA BvD ml, gram/60 ml ifosfamide-mesna intravenous kit 1-1 gram ifosfamide-mesna intravenous kit,000-5 PA BvD 1,000 ifosfamide-mesna kit 5 PA BvD ifs=5x1gm,msn=x1gm 1-1 gram imatinib oral tablet 100, 00 (Gleevec) 5 PA NSO; NM; Available through CVS Specialty ( ) IMBRUVICA ORAL CAPSULE 10 MG 5 PA NSO; QL (10 per 0 IMBRUVICA ORAL CAPSULE 70 MG 5 PA NSO; QL (0 per 0 IMBRUVICA ORAL TABLET 10 MG, 560 MG 5 PA NSO; QL (10 per 0 IMBRUVICA ORAL TABLET 80 MG 5 PA NSO; QL (60 per 0 IMBRUVICA ORAL TABLET 0 MG 5 PA NSO; QL (0 per 0 IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML, 10EXP8 (100 MILLION) PFU/ML 5 5

38 INLYTA ORAL TABLET 1 MG, 5 MG 5 NM; Available through CVS Specialty ( ) IRESSA ORAL TABLET 50 MG 5 PA NSO; NM; Available through CVS Specialty ( ) irinotecan intravenous solution 0 / (Camptosar) ml irinotecan intravenous solution 500 /5 ml IXEMPRA INTRAVENOUS RECON SOLN 15 MG, 5 MG 5 JAKAFI ORAL TABLET 10 MG, 15 MG, 0 MG, 5 MG, 5 MG KISQALI FEMARA CO-PACK ORAL TABLET 00 MG/DAY(00 MG X 1)-.5 MG, 00 MG/DAY(00 MG X )-.5 MG, 600 MG/DAY(00 MG X )-.5 MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X 1), 00 MG/DAY (00 MG X ), 600 MG/DAY (00 MG X ) LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 1 MG/DAY ( MG X ), 1 MG/DAY(10 MG X 1- MG X 1), 18 MG/DAY (10 MG X 1- MG X), 0 MG/DAY (10 MG X ), MG/DAY(10 MG X - MG X 1), MG, 8 MG/DAY ( MG X ) 5 PA NSO; NM; Available through CVS Specialty ( ) 5 PA NSO; NM; Available through CVS Specialty ( ) 5 PA NSO; NM; Available through CVS Specialty ( ) 5 PA NSO letrozole oral tablet.5 (Femara) LEUKERAN ORAL TABLET MG leuprolide subcutaneous kit 1 /0. ml NM; Available through CVS Specialty ( ) LONSURF ORAL TABLET MG, MG 5 PA NSO; NM; Available through CVS Specialty ( ) 6

39 LORBRENA ORAL TABLET 100 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (0 per 0 LORBRENA ORAL TABLET 5 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (90 per 0 LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 11.5 MG,.5 MG LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT 0 MG LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT 5 MG LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT.75 MG, 7.5 MG LYNPARZA ORAL CAPSULE 50 MG LYNPARZA ORAL TABLET 100 MG, 150 MG 5 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) 5 PA NSO; QL (8 per 8 5 PA NSO; QL (10 per 0 LYSODREN ORAL TABLET 500 MG MARQIBO INTRAVENOUS KIT 5 5 PA BvD MG/1 ML(0.16 MG/ML) FINAL MATULANE ORAL CAPSULE 50 5 MG megestrol oral tablet 0, 0 PA NSO; AGE (Max 6 Years) MEKINIST ORAL TABLET 0.5 MG, MG 5 PA NSO; NM; Available through CVS Specialty ( ) MEKTOVI ORAL TABLET 15 MG 5 PA NSO; QL (180 per 0 mercaptopurine oral tablet 50 7

40 methotrexate sodium (pf) injection PA BvD solution 5 /ml methotrexate sodium injection solution 5 PA BvD /ml methotrexate sodium oral tablet.5 PA BvD mutamycin intravenous recon soln 0, 0, 5 NERLYNX ORAL TABLET 0 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (180 per 0 NEXAVAR ORAL TABLET 00 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (10 per 0 nilutamide oral tablet 150 (Nilandron) 5 NINLARO ORAL CAPSULE. MG, MG, MG 5 PA NSO; NM; Available through CVS Specialty ( ) ODOMZO ORAL CAPSULE 00 MG 5 PA NSO; NM; LA; Available through CVS Specialty ( ) ONCASPAR INJECTION 5 SOLUTION 750 UNIT/ML ONIVYDE INTRAVENOUS 5 DISPERSION. MG/ML OPDIVO INTRAVENOUS 5 PA BvD SOLUTION 0 MG/ ML oxaliplatin intravenous recon soln 50 oxaliplatin intravenous solution 50 /10 ml (5 /ml) POMALYST ORAL CAPSULE 1 MG, MG, MG, MG 5 PA NSO; NM; Available through CVS Specialty ( ) 8

41 PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) PURIXAN ORAL SUSPENSION 0 MG/ML REVLIMID ORAL CAPSULE 10 MG, 15 MG,.5 MG, 0 MG, 5 MG, 5 MG RITUXAN HYCELA SUBCUTANEOUS SOLUTION 100 MG/11.7 ML (10 MG/ML), 1600 MG/1. ML (10 MG/ML) romidepsin intravenous recon soln 10 / ml RUBRACA ORAL TABLET 00 MG, 50 MG, 00 MG (Istodax) PA NSO; NM; LA; Available through CVS Specialty ( ) 5 5 PA NSO; NM; Available through CVS Specialty ( ) RYDAPT ORAL CAPSULE 5 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (0 per 0 SOLTAMOX ORAL SOLUTION 10 MG/5 ML SPRYCEL ORAL TABLET 100 MG, 10 MG, 0 MG, 50 MG, 70 MG, 80 MG 5 PA NSO; NM; Available through CVS Specialty ( ) STIVARGA ORAL TABLET 0 MG 5 PA NSO; NM; Available through CVS Specialty ( ) SUTENT ORAL CAPSULE 1.5 MG, 5 MG, 7.5 MG, 50 MG SYNRIBO SUBCUTANEOUS RECON SOLN.5 MG TABLOID ORAL TABLET 0 MG 5 PA NSO; NM; Available through CVS Specialty ( ) 5 9

42 TAFINLAR ORAL CAPSULE 50 MG, 75 MG TAGRISSO ORAL TABLET 0 MG, 80 MG TALZENNA ORAL CAPSULE 0.5 MG 5 PA NSO; NM; Available through CVS Specialty ( ) 5 PA NSO; LA 5 PA NSO; NM; Available through CVS Specialty ( ); QL (90 per 0 TALZENNA ORAL CAPSULE 1 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (0 per 0 tamoxifen oral tablet 10, 0 TARCEVA ORAL TABLET 100 MG, 150 MG, 5 MG 5 PA NSO; NM; Available through CVS Specialty ( ) TARGRETIN TOPICAL GEL 1 % 5 TASIGNA ORAL CAPSULE 150 MG, 00 MG, 50 MG 5 PA NSO; NM; Available through CVS Specialty ( ) TEMODAR INTRAVENOUS RECON SOLN 100 MG 5 NM; Available through CVS Specialty ( ) TIBSOVO ORAL TABLET 50 MG 5 PA NSO; QL (60 per 0 topotecan intravenous solution / ml 5 (1 /ml) TRELSTAR INTRAMUSCULAR 5 SUSPENSION FOR RECONSTITUTION 11.5 MG,.5 MG,.75 MG tretinoin (chemotherapy) oral capsule 10 5 TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG PA BvD 0

43 TYKERB ORAL TABLET 50 MG 5 PA NSO; NM; Available through CVS Specialty ( ) UNITUXIN INTRAVENOUS 5 SOLUTION.5 MG/ML VECTIBIX INTRAVENOUS 5 SOLUTION 00 MG/0 ML (0 MG/ML) VENCLEXTA ORAL TABLET 10 PA NSO; LA MG, 50 MG VENCLEXTA ORAL TABLET PA NSO; LA MG VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG 5 PA NSO VERZENIO ORAL TABLET 100 MG, 150 MG, 00 MG, 50 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (56 per 8 PA BvD vincasar pfs intravenous solution / ml vincristine intravenous solution / ml (Vincasar PFS) PA BvD vinorelbine intravenous solution 10 /ml (Navelbine) VIZIMPRO ORAL TABLET 15 MG, 5 PA NSO; QL (0 per 0 0 MG, 5 MG VOTRIENT ORAL TABLET 00 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (10 per 0 XALKORI ORAL CAPSULE 00 MG, 50 MG XATMEP ORAL SOLUTION.5 MG/ML 5 PA NSO; NM; Available through CVS Specialty ( ); QL (60 per 0 PA BvD 1

44 XTANDI ORAL CAPSULE 0 MG 5 PA NSO; NM; Available through CVS Specialty ( ) YERVOY INTRAVENOUS 5 PA NSO SOLUTION 00 MG/0 ML (5 MG/ML), 50 MG/10 ML (5 MG/ML) YONSA ORAL TABLET 15 MG 5 PA NSO ZALTRAP INTRAVENOUS 5 SOLUTION 00 MG/8 ML (5 MG/ML) ZEJULA ORAL CAPSULE 100 MG 5 PA NSO; QL (90 per 0 ZELBORAF ORAL TABLET 0 MG 5 PA NSO; NM; Available through CVS Specialty ( ) ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG,.6 MG ZOLINZA ORAL CAPSULE 100 MG 5 PA NSO; NM; Available through CVS Specialty ( ) ZYDELIG ORAL TABLET 100 MG, 5 PA NSO 150 MG ZYKADIA ORAL CAPSULE 150 MG 5 PA NSO; NM; Available through CVS Specialty ( ) ZYTIGA ORAL TABLET 50 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (10 per 0 ZYTIGA ORAL TABLET 500 MG 5 PA NSO; NM; Available through CVS Specialty ( ); QL (60 per 0

45 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection syringe 0.1 /ml chlordiazepoxide-clidinium oral capsule (Librax (with 5-.5 clidinium)) propantheline oral tablet 15 Anticonvulsants Anticonvulsants APTIOM ORAL TABLET 00 MG, 5 PA NSO 00 MG, 600 MG, 800 MG BANZEL ORAL SUSPENSION 0 5 MG/ML BANZEL ORAL TABLET 00 MG, 5 00 MG BRIVIACT ORAL SOLUTION 10 5 MG/ML BRIVIACT ORAL TABLET 10 MG 5 BRIVIACT ORAL TABLET 100 MG, 5 MG, 50 MG, 75 MG 5 PA NSO carbamazepine oral capsule, er (Carbatrol) multiphase 1 hr 100, 00, 00 carbamazepine oral suspension 100 /5 (Tegretol) ml carbamazepine oral tablet 00 (Epitol) carbamazepine oral tablet extended (Tegretol XR) release 1 hr 100, 00, 00 carbamazepine oral tablet,chewable 100 CELONTIN ORAL CAPSULE 00 MG DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, delayed rel sprinkle 15 (Depakote Sprinkles) divalproex oral tablet extended release (Depakote ER) hr 50, 500 divalproex oral tablet,delayed release (dr/ec) 15, 50, 500 (Depakote)

46 EPIDIOLEX ORAL SOLUTION 100 MG/ML epitol oral tablet 00 ethosuximide oral capsule 50 (Zarontin) ethosuximide oral solution 50 /5 ml (Zarontin) felbamate oral suspension 600 /5 ml (Felbatol) 5 felbamate oral tablet 00, 600 (Felbatol) fosphenytoin injection solution 500 (Cerebyx) pe/10 ml FYCOMPA ORAL SUSPENSION 0.5 MG/ML FYCOMPA ORAL TABLET 10 MG, 1 MG, MG, MG, 6 MG, 8 MG gabapentin oral capsule 100, 00, (Neurontin) 00 gabapentin oral solution 50 /5 ml (Neurontin) gabapentin oral tablet 600, 800 (Neurontin) lamotrigine oral tablet 100, 150, (Lamictal) 00, 5 lamotrigine oral tablet disintegrating, dose pk 5 (1) -50 (7) (Lamictal ODT Starter (Blue)) lamotrigine oral tablet disintegrating, dose pk 5 (1)-50 (1)-100 (7) lamotrigine oral tablet disintegrating, dose pk 50 () -100 (1) lamotrigine oral tablet extended release hr 100, 00, 5, 50, 00, 50 lamotrigine oral tablet, chewable dispersible 5, 5 lamotrigine oral tablet,disintegrating 100, 00, 5, 50 lamotrigine oral tablets,dose pack 5 (5) lamotrigine oral tablets,dose pack 5 () -100 (7) lamotrigine oral tablets,dose pack 5 (8) -100 (1) (Lamictal ODT Starter (Orange)) (Lamictal ODT Starter (Green)) (Lamictal XR) (Lamictal) (Lamictal ODT) (Lamictal Starter (Blue) Kit) (Lamictal Starter (Orange) Kit) (Lamictal Starter (Green) Kit) 5 PA NSO; NM; Available through CVS Specialty ( )

47 levetiracetam oral solution 100 /ml (Keppra) levetiracetam oral tablet 1,000, 50 (Keppra), 500, 750 levetiracetam oral tablet extended release hr 500, 750 (Keppra XR) LYRICA ORAL CAPSULE 100 MG, QL (90 per MG, 00 MG, 5 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 5 MG, QL (60 per 0 00 MG LYRICA ORAL SOLUTION 0 MG/ML QL (900 per 0 oxcarbazepine oral suspension 00 /5 (Trileptal) ml (60 /ml) oxcarbazepine oral tablet 150, 00 (Trileptal), 600 PEGANONE ORAL TABLET 50 MG phenobarbital oral elixir 0 /5 ml ( /ml) PA NSO; AGE (Max 6 Years) phenobarbital oral tablet 100, 15, 16., 0,., 60, 6.8, 97. PA NSO; AGE (Max 6 Years) phenytoin oral suspension 15 /5 ml (Dilantin-15) phenytoin oral tablet,chewable 50 (Dilantin Infatabs) phenytoin sodium extended oral capsule (Dilantin Extended) 100 phenytoin sodium extended oral capsule (Phenytek) 00, 00 phenytoin sodium intravenous solution 50 /ml phenytoin sodium intravenous syringe 50 /ml primidone oral tablet 50, 50 (Mysoline) SABRIL ORAL TABLET 500 MG 5 NM; Available through CVS Specialty ( ) SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG, 50 MG, 500 MG, 750 MG ST 5

48 subvenite oral tablet 100, 150, 00, 5 subvenite starter (blue) kit oral tablets,dose pack 5 (5) subvenite starter (green) kit oral tablets,dose pack 5 (8) -100 (1) subvenite starter (orange) kit oral tablets,dose pack 5 () -100 (7) tiagabine oral tablet 1, 16,, (Gabitril) topiramate oral capsule, sprinkle 15, (Topamax) 5 topiramate oral capsule,sprinkle,er hr (Qudexy XR) 100, 150, 00, 5, 50 topiramate oral tablet 100, 00, (Topamax) 5, 50 valproic acid (as sodium salt) oral (Depakene) solution 50 /5 ml valproic acid oral capsule 50 (Depakene) vigabatrin oral powder in packet 500 (Sabril) 5 NM; Available through CVS Specialty ( ) vigadrone oral powder in packet NM; Available through CVS Specialty ( ) VIMPAT ORAL SOLUTION 10 PA NSO MG/ML VIMPAT ORAL TABLET 100 MG, PA NSO 150 MG, 00 MG, 50 MG zonisamide oral capsule 100, 5 (Zonegran) zonisamide oral capsule 50 Antidementia Agents Antidementia Agents donepezil oral tablet 10,, 5 (Aricept) donepezil oral tablet,disintegrating 10, 5 galantamine oral capsule,ext rel. pellets (Razadyne ER) hr 16,, 8 galantamine oral solution /ml 6

49 galantamine oral tablet 1,, 8 (Razadyne) memantine oral capsule,sprinkle,er hr (Namenda XR) 1, 1, 8, 7 memantine oral solution /ml memantine oral tablet 10, 5 (Namenda) memantine oral tablets,dose pack 5-10 (Namenda Titration Pak) NAMENDA XR ORAL CAP,SPRINKLE,ER HR DOSE PACK MG NAMZARIC ORAL CAP,SPRINKLE,ER HR DOSE PACK 7/1/1/8 MG-10 MG NAMZARIC ORAL CAPSULE,SPRINKLE,ER HR 1-10 MG, 1-10 MG, 8-10 MG, 7-10 MG rivastigmine tartrate oral capsule 1.5,,.5, 6 rivastigmine transdermal patch hour (Exelon) QL (0 per 0 1. / hour,.6 / hr, 9.5 / hr Antidepressants Antidepressants amitriptyline oral tablet 10, 100, 150, 5, 50, 75 amitriptyline-chlordiazepoxide oral tablet 1.5-5, 5-10 amoxapine oral tablet 100, 150, 5, 50 bupropion hcl oral tablet 100, 75 QL (180 per 0 bupropion hcl oral tablet extended release (Wellbutrin XL) QL (90 per 0 hr 150 bupropion hcl oral tablet extended release (Wellbutrin XL) QL (60 per 0 hr 00 bupropion hcl oral tablet extended release (Forfivo XL) hr 50 bupropion hcl oral tablet sustainedrelease 1 hr 100 (Wellbutrin SR) QL (10 per 0 7

50 bupropion hcl oral tablet sustainedrelease (Wellbutrin SR) QL (90 per 0 1 hr 150 bupropion hcl oral tablet sustainedrelease (Wellbutrin SR) QL (60 per 0 1 hr 00 citalopram oral solution 10 /5 ml citalopram oral tablet 10, 0 (Celexa) 1 GC; QL (0 per 0 citalopram oral tablet 0 (Celexa) 1 GC; QL (60 per 0 clomipramine oral capsule 5, 50, (Anafranil) 75 desipramine oral tablet 10, 5 (Norpramin) desipramine oral tablet 100, 150, 50, 75 DESVENLAFAXINE ORAL QL (0 per 0 TABLET EXTENDED RELEASE HR 100 MG, 50 MG desvenlafaxine succinate oral tablet (Pristiq) QL (0 per 0 extended release hr 100, 5, 50 doxepin oral capsule 10, 100, 150, 5, 50, 75 doxepin oral concentrate 10 /ml duloxetine oral capsule,delayed (Cymbalta) QL (60 per 0 release(dr/ec) 0, 0, 60 duloxetine oral capsule,delayed QL (60 per 0 release(dr/ec) 0 EMSAM TRANSDERMAL PATCH 5 HOUR 1 MG/ HR, 6 MG/ HR, 9 MG/ HR escitalopram oxalate oral solution 5 /5 QL (600 per 0 ml escitalopram oxalate oral tablet 10 (Lexapro) QL (5 per 0 escitalopram oxalate oral tablet 0, 5 (Lexapro) QL (0 per 0 FETZIMA ORAL CAPSULE,EXT ST; QL (8 per 8 REL HR DOSE PACK 0 MG ()- 0 MG (6) FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 10 MG, 0 MG, 0 MG, 80 MG ST; QL (0 per 0 8

51 fluoxetine oral capsule 10 (Prozac) 1 GC; QL (60 per 0 fluoxetine oral capsule 0 (Prozac) 1 GC; QL (10 per 0 fluoxetine oral capsule 0 (Prozac) QL (60 per 0 fluoxetine oral capsule,delayed QL ( per 8 release(dr/ec) 90 fluoxetine oral solution 0 /5 ml ( /ml) fluoxetine oral tablet 10 (Sarafem) 1 GC fluoxetine oral tablet 0 (Sarafem) fluvoxamine oral capsule,extended QL (60 per 0 release hr 100, 150 fluvoxamine oral tablet 100, 5, QL (90 per 0 50 imipramine hcl oral tablet 10, 5, (Tofranil) 50 imipramine pamoate oral capsule 100, 15, 150, 75 maprotiline oral tablet 5, 50, 75 MARPLAN ORAL TABLET 10 MG mirtazapine oral tablet 15, 0 (Remeron) QL (0 per 0 mirtazapine oral tablet 5 QL (0 per 0 mirtazapine oral tablet 7.5 mirtazapine oral tablet,disintegrating 15 (Remeron SolTab) QL (0 per 0, 0, 5 nefazodone oral tablet 100, 150, 00, 50, 50 nortriptyline oral capsule 10, 5, (Pamelor) 50, 75 nortriptyline oral solution 10 /5 ml paroxetine hcl oral tablet 10, 0, (Paxil) QL (5 per 0 0 paroxetine hcl oral tablet 0 (Paxil) QL (60 per 0 paroxetine hcl oral tablet extended (Paxil CR) QL (60 per 0 release hr 1.5, 7.5 paroxetine hcl oral tablet extended (Paxil CR) QL (90 per 0 release hr 5 PAXIL ORAL SUSPENSION 10 MG/5 ML ST 9

52 perphenazine-amitriptyline oral tablet - 10, -5, -10, -5, -50 phenelzine oral tablet 15 (Nardil) protriptyline oral tablet 10, 5 sertraline oral concentrate 0 /ml (Zoloft) sertraline oral tablet 100 (Zoloft) 1 GC; QL (60 per 0 sertraline oral tablet 5, 50 (Zoloft) 1 GC; QL (90 per 0 tranylcypromine oral tablet 10 (Parnate) trazodone oral tablet 100, 150, 00, 50 trimipramine oral capsule 100, 5, (Surmontil) 50 TRINTELLIX ORAL TABLET 10 ST; QL (0 per 0 MG, 0 MG, 5 MG venlafaxine oral capsule,extended release (Effexor XR) QL (60 per 0 hr 150 venlafaxine oral capsule,extended release (Effexor XR) QL (0 per 0 hr 7.5 venlafaxine oral capsule,extended release (Effexor XR) QL (90 per 0 hr 75 venlafaxine oral tablet 100, 5, 7.5, 50, 75 VIIBRYD ORAL TABLET 10 MG, 0 ST; QL (0 per 0 MG, 0 MG VIIBRYD ORAL TABLETS,DOSE ST PACK 10 MG (7)- 0 MG () Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose oral tablet 100, 5, 50 (Precose) GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN 1 MG INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG, MG QL (60 per 0 0

53 INVOKAMET XR ORAL TABLET, QL (60 per 0 IR - ER, BIPHASIC HR 150-1,000 MG, MG, 50-1,000 MG, MG INVOKANA ORAL TABLET 100 QL (60 per 0 MG INVOKANA ORAL TABLET 00 QL (0 per 0 MG JANUMET ORAL TABLET 50-1,000 QL (60 per 0 MG, MG JANUMET XR ORAL TABLET, ER QL (0 per 0 MULTIPHASE HR 100-1,000 MG JANUMET XR ORAL TABLET, ER QL (60 per 0 MULTIPHASE HR 50-1,000 MG, MG JANUVIA ORAL TABLET 100 MG QL (0 per 0 JANUVIA ORAL TABLET 5 MG QL (10 per 0 JANUVIA ORAL TABLET 50 MG QL (60 per 0 JARDIANCE ORAL TABLET 10 QL (0 per 0 MG, 5 MG JENTADUETO ORAL TABLET.5- QL (60 per 0 1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, QL (60 per 0 IR - ER, BIPHASIC HR.5-1,000 MG JENTADUETO XR ORAL TABLET, QL (0 per 0 IR - ER, BIPHASIC HR 5-1,000 MG KORLYM ORAL TABLET 00 MG 5 PA; QL (11 per 8 metformin oral solution 500 /5 ml (Riomet) QL (765 per 0 metformin oral tablet 1,000 (Glucophage) 1 GC; QL (60 per 0 metformin oral tablet 500 (Glucophage) 1 GC; QL (150 per 0 metformin oral tablet 850 (Glucophage) 1 GC; QL (90 per 0 metformin oral tablet extended release hr 500 (Glucophage XR) 1 GC; QL (10 per 0 metformin oral tablet extended release hr 750 (Glucophage XR) 1 GC; QL (60 per 0 1

54 metformin oral tablet extended release (Fortamet) QL (60 per 0 hr 1,000 metformin oral tablet extended release hr 500 (Fortamet) 1 GC; QL (150 per 0 nateglinide oral tablet 10, 60 (Starlix) 1 GC OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.5 MG OR 0.5 MG( MG/1.5 ML), 1 MG/0.75 ML ( MG/1.5 ML) pioglitazone oral tablet 15 (Actos) 1 GC; QL (90 per 0 pioglitazone oral tablet 0 (Actos) 1 GC; QL (5 per 0 pioglitazone oral tablet 5 (Actos) 1 GC; QL (0 per 0 pioglitazone-glimepiride oral tablet 0-, 0- (DUETACT) 1 GC; QL (5 per 0 pioglitazone-metformin oral tablet , (Actoplus MET) 1 GC; QL (90 per 0 repaglinide oral tablet GC repaglinide oral tablet 1, (Prandin) 1 GC repaglinide-metformin oral tablet QL (150 per 0, -500 RIOMET ORAL SOLUTION 500 QL (765 per 0 MG/5 ML SYNJARDY ORAL TABLET 1.5-1,000 MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC HR 10-1,000 MG, 1.5-1,000 MG, 5-1,000 MG, 5-1,000 MG TRADJENTA ORAL TABLET 5 MG QL (0 per 0 TRULICITY SUBCUTANEOUS PEN QL ( per 8 INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/ ML) QL (9 per 0

55 Insulins HUMALOG JUNIOR KWIKPEN U- 100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 00 UNIT/ML ( ML) HUMALOG MIX INSULN U- 100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX 75-5 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-5) HUMALOG MIX 75-5(U- 100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-5) HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMULIN 70/0 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-0) HUMULIN 70/0 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML

56 HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML ( ML) LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/0 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-0) NOVOLIN 70-0 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX 70-0 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-0) NOVOLOG MIX 70-0FLEXPEN U- 100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-0) NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML

57 NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML TOUJEO MAX U-00 SOLOSTAR SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) TOUJEO SOLOSTAR U-00 INSULIN SUBCUTANEOUS INSULIN PEN 00 UNIT/ML (1.5 ML) TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML ( ML) TRESIBA FLEXTOUCH U-00 SUBCUTANEOUS INSULIN PEN 00 UNIT/ML ( ML) TRESIBA U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML Sulfonylureas glimepiride oral tablet 1 (Amaryl) 1 GC; QL (0 per 0 glimepiride oral tablet (Amaryl) 1 GC; QL (10 per 0 glimepiride oral tablet (Amaryl) 1 GC; QL (60 per 0 glipizide oral tablet 10 (Glucotrol) 1 GC; QL (10 per 0 glipizide oral tablet 5 (Glucotrol) 1 GC; QL (0 per 0 glipizide oral tablet extended release hr 10 (Glucotrol XL) 1 GC; QL (60 per 0 glipizide oral tablet extended release hr.5 (Glucotrol XL) 1 GC; QL (0 per 0 glipizide oral tablet extended release hr 5 (Glucotrol XL) 1 GC; QL (10 per 0 glipizide-metformin oral tablet GC; QL (0 per 0 glipizide-metformin oral tablet.5-500, GC; QL (10 per 0 5

58 glyburide micronized oral tablet 1.5 (Glynase) 1 PA; GC; QL (0 per 0 ; AGE (Max 6 Years) glyburide micronized oral tablet (Glynase) 1 PA; GC; QL (10 per 0 ; AGE (Max 6 Years) glyburide micronized oral tablet 6 (Glynase) 1 PA; GC; QL (60 per 0 ; AGE (Max 6 Years) glyburide oral tablet PA; GC; QL (80 per 0 ; AGE (Max 6 Years) glyburide oral tablet.5 1 PA; GC; QL (0 per 0 ; AGE (Max 6 Years) glyburide oral tablet 5 1 PA; GC; QL (10 per 0 ; AGE (Max 6 Years) glyburide-metformin oral tablet glyburide-metformin oral tablet.5-500, PA; GC; QL (0 per 0 ; AGE (Max 6 Years) 1 PA; GC; QL (10 per 0 ; AGE (Max 6 Years) tolazamide oral tablet 50 1 GC; QL (10 per 0 tolazamide oral tablet GC; QL (60 per 0 tolbutamide oral tablet GC; QL (180 per 0 Antifungals Antifungals ABELCET INTRAVENOUS 5 PA BvD SUSPENSION 5 MG/ML AMBISOME INTRAVENOUS 5 PA BvD SUSPENSION FOR RECONSTITUTION 50 MG amphotericin b injection recon soln 50 PA BvD caspofungin intravenous recon soln 50 (Cancidas), 70 ciclopirox topical cream 0.77 % (Ciclodan) 6

59 ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % (Loprox) ciclopirox topical solution 8 % (Ciclodan) ciclopirox topical suspension 0.77 % (Loprox (as olamine)) clotrimazole mucous membrane troche 10 clotrimazole topical cream 1 % (Antifungal (clotrimazole)) clotrimazole topical solution 1 % clotrimazole-betamethasone topical (Lotrisone) cream % clotrimazole-betamethasone topical lotion % CRESEMBA ORAL CAPSULE MG econazole topical cream 1 % ERAXIS(WATER DILUENT) 5 INTRAVENOUS RECON SOLN 100 MG, 50 MG EXELDERM TOPICAL CREAM 1 % EXELDERM TOPICAL SOLUTION 1 % fluconazole in nacl (iso-osm) intravenous piggyback 100 /50 ml, 00 /100 ml, 00 /00 ml fluconazole oral suspension for (Diflucan) reconstitution 10 /ml, 0 /ml fluconazole oral tablet 100, 150, (Diflucan) 00, 50 flucytosine oral capsule 50, 500 (Ancobon) 5 griseofulvin microsize oral suspension 15 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 15, 50 itraconazole oral capsule 100 (Sporanox) ketoconazole oral tablet 00 ketoconazole topical cream % ketoconazole topical shampoo % (Nizoral) MENTAX TOPICAL CREAM 1 % 7

60 miconazole- vaginal suppository 00 MYCAMINE INTRAVENOUS 5 RECON SOLN 100 MG, 50 MG naftifine topical cream 1 % naftifine topical cream % (Naftin) NOXAFIL INTRAVENOUS 5 PA BvD SOLUTION 00 MG/16.7 ML NOXAFIL ORAL SUSPENSION 00 5 MG/5 ML (0 MG/ML) NOXAFIL ORAL 5 TABLET,DELAYED RELEASE (DR/EC) 100 MG nyamyc topical powder 100,000 unit/gram nystatin oral powder 150 million unit nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 (Nyamyc) unit/gram nystatin-triamcinolone topical cream 100, unit/g-% nystatin-triamcinolone topical ointment 100, unit/gram-% nystop topical powder 100,000 unit/gram ONMEL ORAL TABLET 00 MG oxiconazole topical cream 1 % (Oxistat) terbinafine hcl oral tablet 50 voriconazole intravenous solution 00 (Vfend IV) voriconazole oral suspension for (Vfend) 5 reconstitution 00 /5 ml (0 /ml) voriconazole oral tablet 00, 50 (Vfend) 5 Antigout Agents Antigout Agents, Other allopurinol oral tablet 100, 00 (Zyloprim) colchicine oral capsule 0.6 (Mitigare) QL (60 per 0 colchicine oral tablet 0.6 (Colcrys) QL (60 per 0 probenecid oral tablet 500 8

61 probenecid-colchicine oral tablet ULORIC ORAL TABLET 0 MG, 80 ST MG ZURAMPIC ORAL TABLET 00 MG PA; QL (0 per 0 Antihistamines Antihistamines cetirizine oral solution 1 /ml (All Day Allergy (cetirizine)) cyproheptadine oral syrup /5 ml PA; AGE (Max 6 Years) cyproheptadine oral tablet PA; AGE (Max 6 Years) desloratadine oral tablet 5 (Clarinex) desloratadine oral tablet,disintegrating.5, 5 diphenhydramine hcl injection solution 50 /ml PA; AGE (Max 6 Years) diphenhydramine hcl injection syringe 50 /ml PA; AGE (Max 6 Years) diphenhydramine hcl oral elixir 1.5 /5 (Children's Allergy PA; AGE (Max 6 ml (diphenhyd)) Years) hydroxyzine hcl intramuscular solution 50 /ml PA; AGE (Max 6 Years) hydroxyzine hcl oral solution 10 /5 ml PA; AGE (Max 6 Years) hydroxyzine hcl oral tablet 10, 5, 50 PA; AGE (Max 6 Years) levocetirizine oral tablet 5 (HR Allergy Relief) promethazine oral syrup 6.5 /5 ml PA; AGE (Max 6 Years) Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL VAGINAL CREAM 15 % clindamycin phosphate vaginal cream % (Cleocin) metronidazole vaginal gel 0.75 % (Metrogel Vaginal) 9

62 terconazole vaginal cream 0. %, 0.8 % terconazole vaginal suppository 80 Antimigraine Agents Antimigraine Agents AIMOVIG 70 MG/ML AUTOINJECTOR 70 MG/ML AIMOVIG AUTOINJECTOR ( PACK) SUBCUTANEOUS AUTO- INJECTOR 70 MG/ML AJOVY SUBCUTANEOUS SYRINGE 5 MG/1.5 ML PA; NM; Available ( ); QL ( per 0 PA; NM; Available ( ); QL ( per 0 PA; NM; Available ( ); QL (1.5 per 0 (Migranal) dihydroergotamine nasal spray,nonaerosol 0.5 /pump act. ( /ml) eletriptan oral tablet 0, 0 (Relpax) QL (1 per 8 EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 10 MG/ML EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 10 MG/ML PA; NM; Available ( ); QL (1 per 0 PA; NM; Available ( ); QL (1 per 0 ergotamine-caffeine oral tablet (Cafergot) frovatriptan oral tablet.5 (Frova) QL (1 per 8 naratriptan oral tablet 1,.5 (Amerge) QL (18 per 8 rizatriptan oral tablet 10 (Maxalt) QL (1 per 8 rizatriptan oral tablet 5 QL (1 per 8 rizatriptan oral tablet,disintegrating 10 (Maxalt-MLT) QL (1 per 8, 5 sumatriptan nasal spray,non-aerosol 0 (Imitrex) QL (1 per 8 /actuation, 5 /actuation sumatriptan succinate oral tablet 100, 5, 50 (Imitrex) QL (18 per 8 sumatriptan succinate subcutaneous cartridge /0.5 ml, 6 /0.5 ml (Imitrex STATdose Refill) QL ( per 8 50

63 sumatriptan succinate subcutaneous pen (Imitrex STATdose QL ( per 8 injector /0.5 ml, 6 /0.5 ml Pen) sumatriptan succinate subcutaneous (Imitrex) QL ( per 8 solution 6 /0.5 ml sumatriptan succinate subcutaneous QL ( per 8 syringe 6 /0.5 ml zolmitriptan oral tablet.5, 5 (Zomig) QL (1 per 8 zolmitriptan oral tablet,disintegrating.5 (Zomig ZMT) QL (1 per 8, 5 ZOMIG NASAL SPRAY,NON- QL (18 per 8 AEROSOL.5 MG ZOMIG NASAL SPRAY,NON- QL (1 per 8 AEROSOL 5 MG Antimycobacterials Antimycobacterials cycloserine oral capsule 50 dapsone oral tablet 100, 5 ethambutol oral tablet 100 ethambutol oral tablet 00 (Myambutol) isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, 00 PASER ORAL GRANULES DR FOR SUSP IN PACKET GRAM PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 rifabutin oral capsule 150 (Mycobutin) RIFAMATE ORAL CAPSULE MG rifampin intravenous recon soln 600 (Rifadin) rifampin oral capsule 150, 00 (Rifadin) RIFATER ORAL TABLET MG SIRTURO ORAL TABLET 100 MG 5 PA TRECATOR ORAL TABLET 50 MG Antinausea Agents Antinausea Agents ANZEMET ORAL TABLET 100 MG 5 PA BvD ANZEMET ORAL TABLET 50 MG PA BvD aprepitant oral capsule 15, 0, 80 (Emend) PA BvD 51

64 aprepitant oral capsule,dose pack 15 (Emend) PA BvD (1)- 80 () compro rectal suppository 5 dronabinol oral capsule 10,.5, 5 (Marinol) PA BvD; QL (10 per 0 granisetron hcl oral tablet 1 PA BvD meclizine oral tablet 1.5 meclizine oral tablet 5 (Dramamine Less Drowsy) ondansetron hcl oral solution /5 ml (Zofran) PA BvD ondansetron hcl oral tablet PA BvD ondansetron hcl oral tablet, 8 (Zofran) PA BvD ondansetron oral tablet,disintegrating PA BvD, 8 prochlorperazine maleate oral tablet 10 (Compazine), 5 prochlorperazine rectal suppository 5 (Compazine) promethazine oral tablet 1.5, 5, 50 PA; AGE (Max 6 Years) promethazine rectal suppository 1.5, 5 (Phenadoz) PA; AGE (Max 6 Years) promethazine rectal suppository 50 (Phenergan) PA; AGE (Max 6 Years) scopolamine base transdermal patch (Transderm-Scop) QL (10 per 0 day 1 over days SYNDROS ORAL SOLUTION 5 5 PA BvD MG/ML Antiparasite Agents Antiparasite Agents albendazole oral tablet 00 (Albenza) 5 ALBENZA ORAL TABLET 00 MG 5 ALINIA ORAL SUSPENSION FOR 5 RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG 5 atovaquone oral suspension 750 /5 ml (Mepron) 5 atovaquone-proguanil oral tablet (Malarone) atovaquone-proguanil oral tablet (Malarone Pediatric) 5

65 benznidazole oral tablet 100, 1.5 chloroquine phosphate oral tablet 50, 500 COARTEM ORAL TABLET 0-10 MG DARAPRIM ORAL TABLET 5 MG PA EMVERM ORAL TABLET,CHEWABLE 100 MG 5 hydroxychloroquine oral tablet 00 (Plaquenil) IMPAVIDO ORAL CAPSULE 50 MG 5 ivermectin oral tablet (Stromectol) mefloquine oral tablet 50 NEBUPENT INHALATION RECON PA BvD SOLN 00 MG paromomycin oral capsule 50 PENTAM INJECTION RECON SOLN 00 MG praziquantel oral tablet 600 (Biltricide) PRIMAQUINE ORAL TABLET 6. MG quinine sulfate oral capsule (Qualaquin) tinidazole oral tablet 50, 500 Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl oral capsule 100 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 100 APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML 5 benztropine oral tablet 0.5, 1, PA; AGE (Max 6 Years) bromocriptine oral capsule 5 (Parlodel) bromocriptine oral tablet.5 (Parlodel) cabergoline oral tablet 0.5 carbidopa oral tablet 5 (Lodosyn) carbidopa-levodopa oral tablet (Sinemet), 5-100, 5-50 carbidopa-levodopa oral tablet extended release 5-100, (Sinemet CR) 5

66 carbidopa-levodopa oral tablet,disintegrating , 5-100, 5-50 carbidopa-levodopa-entacapone oral (Stalevo 50) tablet carbidopa-levodopa-entacapone oral (Stalevo 75) tablet carbidopa-levodopa-entacapone oral (Stalevo 100) tablet carbidopa-levodopa-entacapone oral (Stalevo 15) tablet carbidopa-levodopa-entacapone oral (Stalevo 150) tablet carbidopa-levodopa-entacapone oral (Stalevo 00) tablet entacapone oral tablet 00 (Comtan) NEUPRO TRANSDERMAL PATCH HOUR 1 MG/ HOUR, MG/ HOUR, MG/ HOUR, MG/ HOUR, 6 MG/ HOUR, 8 MG/ HOUR pramipexole oral tablet 0.15, 0.5 (Mirapex), 0.5, 0.75, 1, 1.5 pramipexole oral tablet extended release (Mirapex ER) hr 0.75, 0.75, 1.5,.5,,.75,.5 rasagiline oral tablet 0.5, 1 (Azilect) ropinirole oral tablet 0.5, 0.5, 1 (Requip),,, 5 ropinirole oral tablet ropinirole oral tablet extended release (Requip XL) hr 1,,, 6, 8 selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 tolcapone oral tablet 100 (Tasmar) 5 trihexyphenidyl oral elixir 0. /ml PA; AGE (Max 6 Years) trihexyphenidyl oral tablet, 5 PA; AGE (Max 6 Years) 5

67 ZELAPAR ORAL TABLET,DISINTEGRATING 1.5 MG Antipsychotic Agents Antipsychotic Agents ABILIFY MAINTENA 5 QL (1 per 8 INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 00 MG, 00 MG ABILIFY MAINTENA 5 QL (1 per 8 INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 00 MG, 00 MG ADASUVE INHALATION 5 QL (0 per 0 AEROSOL POWDR BREATH ACTIVATED 10 MG aripiprazole oral solution 1 /ml QL (750 per 0 aripiprazole oral tablet 10, 15, (Abilify) QL (0 per 0, 0, 0, 5 aripiprazole oral tablet,disintegrating 10 5 QL (60 per 0, 15 ARISTADA INTRAMUSCULAR 5 QL (.9 per 56 SUSPENSION,EXTENDED REL SYRING 1,06 MG/.9 ML ARISTADA INTRAMUSCULAR 5 QL (1.6 per 8 SUSPENSION,EXTENDED REL SYRING 1 MG/1.6 ML ARISTADA INTRAMUSCULAR 5 QL (. per 8 SUSPENSION,EXTENDED REL SYRING 66 MG/. ML ARISTADA INTRAMUSCULAR 5 QL (. per 8 SUSPENSION,EXTENDED REL SYRING 88 MG/. ML chlorpromazine injection solution 5 /ml chlorpromazine oral tablet 10, 100, 00, 5, 50 clozapine oral tablet 100, 5 (Clozaril) clozapine oral tablet 00, 50 clozapine oral tablet,disintegrating 100, 1.5, 150, 00, 5 (FazaClo) 55

68 FANAPT ORAL TABLET 1 MG, 10 ST; QL (60 per 0 MG, 1 MG, MG, MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE ST; QL (60 per 0 PACK 1MG()-MG()- MG()- 6MG() fluphenazine decanoate injection solution 5 /ml fluphenazine hcl injection solution.5 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir.5 /5 ml fluphenazine hcl oral tablet 1, 10,.5, 5 GEODON INTRAMUSCULAR RECON SOLN 0 MG/ML (FINAL CONC.) haloperidol dec 50 /ml vial mdv 50 (Haldol Decanoate) /ml haloperidol decanoate intramuscular (Haldol Decanoate) solution 100 /ml haloperidol decanoate intramuscular solution 100 /ml (1 ml) haloperidol decanoate intramuscular (Haldol Decanoate) solution 50 /ml haloperidol lactate injection solution 5 (Haldol) /ml haloperidol lactate intramuscular syringe 5 /ml haloperidol lactate oral concentrate /ml haloperidol oral tablet 0.5, 1, 10,, 0, 5 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, MG/1.5 ML, 78 MG/0.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML 5 NM; Available through CVS Specialty ( ); QL (1.5 per 8 5 NM; Available through CVS Specialty ( ); QL (1 per 8 56

69 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 9 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 7 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 10 MG/1.15 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 56 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/.65 ML LATUDA ORAL TABLET 10 MG, 0 MG, 0 MG, 60 MG, 80 MG loxapine succinate oral capsule 10, 5, 5, 50 NM; Available through CVS Specialty ( ); QL (1.5 per 8 5 QL (0.875 per 90 5 QL (1.95 per 90 5 QL (1.75 per 90 5 QL (.65 per 90 ST; QL (0 per 0 molindone oral tablet 10, 5, 5 NUPLAZID ORAL CAPSULE MG 5 PA NSO; QL (0 per 0 NUPLAZID ORAL TABLET 10 MG, 17 MG 5 PA NSO; QL (60 per 0 olanzapine intramuscular recon soln 10 (Zyprexa) NM; Available through CVS Specialty ( ) (Zyprexa) QL (0 per 0 olanzapine oral tablet 10,.5, 5, 7.5 olanzapine oral tablet 15, 0 (Zyprexa) QL (60 per 0 olanzapine oral tablet,disintegrating 10 (Zyprexa Zydis) QL (0 per 0, 5 olanzapine oral tablet,disintegrating 15 (Zyprexa Zydis) QL (60 per 0, 0 paliperidone oral tablet extended release (Invega) QL (0 per 0 hr 1.5, paliperidone oral tablet extended release (Invega) QL (60 per 0 hr 6 paliperidone oral tablet extended release (Invega) 5 QL (0 per 0 hr 9 57

70 perphenazine oral tablet 16,,, 8 pimozide oral tablet 1, (Orap) quetiapine oral tablet 100, 00, (Seroquel) QL (90 per 0 00 quetiapine oral tablet 00, 5, 50 (Seroquel) QL (10 per 0 quetiapine oral tablet extended release (Seroquel XR) QL (90 per 0 hr 150 quetiapine oral tablet extended release (Seroquel XR) QL (0 per 0 hr 00 quetiapine oral tablet extended release (Seroquel XR) QL (60 per 0 hr 00, 00 quetiapine oral tablet extended release (Seroquel XR) QL (10 per 0 hr 50 REXULTI ORAL TABLET 0.5 MG, 5 ST; QL (0 per MG, 1 MG, MG, MG, MG RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 1.5 MG/ ML, 5 MG/ ML, 7.5 MG/ ML, 50 MG/ ML NM; Available through CVS Specialty ( ); QL ( per 8 risperidone oral solution 1 /ml (Risperdal) risperidone oral tablet 0.5, 1, (Risperdal) QL (60 per 0,, risperidone oral tablet 0.5 (Risperdal) QL (10 per 0 risperidone oral tablet,disintegrating 0.5 QL (60 per 0, 1,, risperidone oral tablet,disintegrating 0.5 QL (10 per 0 risperidone oral tablet,disintegrating SAPHRIS SUBLINGUAL TABLET ST; QL (60 per 0 10 MG,.5 MG, 5 MG thioridazine oral tablet 10, 100, 5, 50 PA NSO; AGE (Max 6 Years) thiothixene oral capsule 1, 10,, 5 trifluoperazine oral tablet 1, 10,, 5 VERSACLOZ ORAL SUSPENSION 50 MG/ML 5 QL (50 per 0 58

71 VRAYLAR ORAL CAPSULE ST; QL (0 per 0 MG, MG,.5 MG, 6 MG ziprasidone hcl oral capsule 0, 0 (Geodon) QL (60 per 0, 60, 80 ZYPREXA RELPREVV QL ( per 8 INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 10 MG ZYPREXA RELPREVV 5 QL ( per 8 INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 00 MG ZYPREXA RELPREVV 5 QL (1 per 8 INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 05 MG Antivirals (Systemic) Antiretrovirals abacavir oral solution 0 /ml (Ziagen) abacavir oral tablet 00 (Ziagen) abacavir-lamivudine oral tablet (Epzicom) abacavir-lamivudine-zidovudine oral (Trizivir) 5 tablet APTIVUS ORAL CAPSULE 50 MG 5 APTIVUS ORAL SOLUTION MG/ML atazanavir oral capsule 150, 00 (Reyataz) 5 QL (60 per 0 atazanavir oral capsule 00 (Reyataz) 5 QL (0 per 0 ATRIPLA ORAL TABLET QL (0 per 0 00 MG BIKTARVY ORAL TABLET MG CIMDUO ORAL TABLET MG COMPLERA ORAL TABLET QL (0 per 0 00 MG CRIXIVAN ORAL CAPSULE 00 QL (50 per 0 MG CRIXIVAN ORAL CAPSULE 00 QL (70 per 0 MG DELSTRIGO ORAL TABLET MG 5 59

72 DESCOVY ORAL TABLET 00-5 MG 5 QL (0 per 0 didanosine oral capsule,delayed (Videx EC) release(dr/ec) 15, 00, 50, 00 EDURANT ORAL TABLET 5 MG 5 efavirenz oral capsule 00 (Sustiva) QL (10 per 0 efavirenz oral capsule 50 (Sustiva) QL (80 per 0 efavirenz oral tablet 600 (Sustiva) 5 QL (0 per 0 EMTRIVA ORAL CAPSULE 00 MG EMTRIVA ORAL SOLUTION 10 MG/ML EPIVIR HBV ORAL SOLUTION 5 MG/5 ML (5 MG/ML) EVOTAZ ORAL TABLET QL (0 per 0 MG fosamprenavir oral tablet 700 (Lexiva) 5 QL (10 per 0 FUZEON SUBCUTANEOUS RECON SOLN 90 MG 5 NM; Available through CVS Specialty ( ) GENVOYA ORAL TABLET QL (0 per MG INTELENCE ORAL TABLET QL (10 per 0 MG INTELENCE ORAL TABLET 00 5 QL (60 per 0 MG INTELENCE ORAL TABLET 5 MG QL (10 per 0 INVIRASE ORAL CAPSULE 00 MG 5 QL (00 per 0 INVIRASE ORAL TABLET 500 MG 5 QL (10 per 0 ISENTRESS HD ORAL TABLET QL (60 per 0 MG ISENTRESS ORAL POWDER IN QL (00 per 0 PACKET 100 MG ISENTRESS ORAL TABLET 00 MG 5 QL (10 per 0 ISENTRESS ORAL 5 QL (180 per 0 TABLET,CHEWABLE 100 MG ISENTRESS ORAL QL (180 per 0 TABLET,CHEWABLE 5 MG JULUCA ORAL TABLET 50-5 MG 5 QL (0 per 0 KALETRA ORAL TABLET MG QL (00 per 0 60

73 KALETRA ORAL TABLET MG 5 QL (150 per 0 lamivudine oral solution 10 /ml (Epivir) lamivudine oral tablet 100 (Epivir HBV) lamivudine oral tablet 150, 00 (Epivir) lamivudine-zidovudine oral tablet (Combivir) LEXIVA ORAL SUSPENSION 50 MG/ML QL (1575 per 8 lopinavir-ritonavir oral solution (Kaletra) /5 ml nevirapine oral suspension 50 /5 ml (Viramune) nevirapine oral tablet 00 (Viramune) nevirapine oral tablet extended release hr 100, 00 (Viramune XR) NORVIR ORAL CAPSULE 100 MG QL (60 per 0 NORVIR ORAL POWDER IN PACKET 100 MG NORVIR ORAL SOLUTION 80 QL (80 per 0 MG/ML NORVIR ORAL TABLET 100 MG QL (60 per 0 ODEFSEY ORAL TABLET QL (0 per 0 MG PIFELTRO ORAL TABLET 100 MG 5 PREZCOBIX ORAL TABLET QL (0 per 0 MG-MG PREZISTA ORAL SUSPENSION QL (60 per 0 MG/ML PREZISTA ORAL TABLET 150 MG 5 QL (0 per 0 PREZISTA ORAL TABLET 600 MG 5 QL (60 per 0 PREZISTA ORAL TABLET 75 MG 5 QL (80 per 0 PREZISTA ORAL TABLET 800 MG 5 QL (0 per 0 RESCRIPTOR ORAL TABLET 00 QL (180 per 0 MG RESCRIPTOR ORAL TABLET, QL (60 per 0 DISPERSIBLE 100 MG REYATAZ ORAL POWDER IN PACKET 50 MG 5 ritonavir oral tablet 100 (Norvir) 61

74 SELZENTRY ORAL SOLUTION 0 5 QL (1800 per 0 MG/ML SELZENTRY ORAL TABLET QL (0 per 0 MG SELZENTRY ORAL TABLET 5 MG QL (0 per 0 SELZENTRY ORAL TABLET 00 5 QL (10 per 0 MG, 75 MG stavudine oral capsule 15, 0, 0, 0 stavudine oral recon soln 1 /ml STRIBILD ORAL TABLET QL (0 per MG SYMFI LO ORAL TABLET MG SYMFI ORAL TABLET MG SYMTUZA ORAL TABLET MG 5 tenofovir disoproxil fumarate oral tablet 00 (Viread) TIVICAY ORAL TABLET 10 MG QL (60 per 0 TIVICAY ORAL TABLET 5 MG, 50 5 QL (60 per 0 MG TRIUMEQ ORAL TABLET QL (0 per 0 00 MG TRUVADA ORAL TABLET QL (0 per 0 MG, 1-00 MG, MG, MG VEMLIDY ORAL TABLET 5 MG 5 QL (0 per 0 VIDEX GM PEDIATRIC SOLN 10 MG/ML (FINAL) VIDEX GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15 MG VIRACEPT ORAL TABLET 50 MG, 5 65 MG VIRAMUNE ORAL SUSPENSION 50 MG/5 ML 6

75 VIREAD ORAL POWDER 0 5 MG/SCOOP (0 MG/GRAM) VIREAD ORAL TABLET 150 MG, 5 00 MG, 50 MG ZERIT ORAL RECON SOLN 1 MG/ML zidovudine oral capsule 100 (Retrovir) zidovudine oral syrup 10 /ml (Retrovir) zidovudine oral tablet 00 Antivirals, Miscellaneous foscarnet intravenous solution /ml (Foscavir) PA BvD oseltamivir oral capsule 0, 5, 75 (Tamiflu) oseltamivir oral suspension for (Tamiflu) reconstitution 6 /ml RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 (Flumadine) SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML 5 NM; Available through CVS Specialty ( ) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML XOFLUZA ORAL TABLET 0 MG, 0 MG Hcv Antivirals EPCLUSA ORAL TABLET MG HARVONI ORAL TABLET MG ledipasvir-sofosbuvir oral tablet PA; NM; Available ( ); QL (8 per 8 5 PA; NM; Available ( ); QL (8 per 8 (Harvoni) 5 PA; NM; Available ( ); QL (8 per 8 6

76 MAVYRET ORAL TABLET MG sofosbuvir-velpatasvir oral tablet VOSEVI ORAL TABLET MG Interferons INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 15 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML SYLATRON SUBCUTANEOUS KIT 00 MCG, 00 MCG, 600 MCG 5 PA; NM; Available ( ); QL (8 per 8 (Epclusa) 5 PA; NM; Available ( ); QL (8 per 8 5 PA; NM; Available ( ); QL (8 per NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) Nucleosides And Nucleotides acyclovir oral capsule 00 (Zovirax) acyclovir oral suspension 00 /5 ml (Zovirax) acyclovir oral tablet 00, 800 (Zovirax) acyclovir sodium intravenous recon soln 500 PA BvD 6

77 acyclovir sodium intravenous solution 50 /ml PA BvD adefovir oral tablet 10 (Hepsera) 5 BARACLUDE ORAL SOLUTION MG/ML entecavir oral tablet 0.5, 1 (Baraclude) 5 famciclovir oral tablet 15, 50, 500 ribasphere oral capsule 00 NM; Available through CVS Specialty ( ) ribasphere oral tablet 00, 00, 600 NM; Available through CVS Specialty ( ) ribasphere ribapak (7)- 00 (7) ribasphere ribapak (7)- 00 (7) ribasphere ribapak oral tablets,dose pack 00 (7)- 00 (7), (8)- (8), (8)- (8) 5 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) ribavirin inhalation recon soln 6 gram (Virazole) 5 PA BvD; NM; Available through CVS Specialty ( ) ribavirin oral capsule 00 (Ribasphere) NM; Available through CVS Specialty ( ) ribavirin oral tablet 00 (Moderiba) NM; Available through CVS Specialty ( ) valacyclovir oral tablet 1 gram, 500 (Valtrex) valganciclovir oral recon soln 50 /ml (Valcyte) valganciclovir oral tablet 50 (Valcyte) 5 65

78 Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) INTRAVENOUS RECON SOLN 500 UNIT ELIQUIS ORAL TABLET.5 MG, 5 MG ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (7 TABS) enoxaparin subcutaneous syringe 100 /ml, 150 /ml enoxaparin subcutaneous syringe 10 /0.8 ml, 80 /0.8 ml enoxaparin subcutaneous syringe 0 /0. ml enoxaparin subcutaneous syringe 0 /0. ml enoxaparin subcutaneous syringe 60 /0.6 ml fondaparinux subcutaneous syringe 10 /0.8 ml,.5 /0.5 ml, 5 /0. ml, 7.5 /0.6 ml heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml,,000 unit/1,000 ml heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 0,000 unit/ml, 5,000 unit/ml 5 (Lovenox) NM; Available through CVS Specialty ( ); QL (60 per 0 (Lovenox) NM; Available through CVS Specialty ( ); QL (8 per 0 (Lovenox) NM; Available through CVS Specialty ( ); QL (18 per 0 (Lovenox) NM; Available through CVS Specialty ( ); QL ( per 0 (Lovenox) NM; Available through CVS Specialty ( ); QL (6 per 0 (Arixtra) NM; Available through CVS Specialty ( ) 66

79 heparin (porcine) injection syringe 5,000 unit/ml HEPARIN(PORCINE) IN 0.5% NACL INTRAVENOUS PARENTERAL SOLUTION 1,500 UNIT/50 ML heparin, porcine (pf) injection solution 1,000 unit/ml, 5,000 unit/0.5 ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml jantoven oral tablet 1, 10,,.5,,, 5, 6, 7.5 PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1, 10,,.5,,, 5, 6, 7.5 XARELTO ORAL TABLET 10 MG, 15 MG,.5 MG, 0 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG ()- 0 MG (9) Blood Formation Modifiers ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 00 MCG/ML, 5 MCG/ML, 00 MCG/ML, 0 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0. ML, 00 MCG/0. ML, 0 MCG/0. ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 150 MCG/0. ML, 60 MCG/0. ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 5 MCG/0. ML 1 GC (Coumadin) 1 GC PA; NM; Available ( ); QL ( per 8 PA; NM; Available ( ); QL (1.6 per 8 PA; NM; Available ( ); QL ( per 8 PA; NM; Available ( ); QL (1. per 8 PA; NM; Available ( ); QL (1.68 per 8 67

80 ARANESP (IN POLYSORBATE) INJECTION SYRINGE 00 MCG/0.6 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 500 MCG/ML CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) GRANIX SUBCUTANEOUS SOLUTION 00 MCG/ML, 80 MCG/1.6 ML GRANIX SUBCUTANEOUS SYRINGE 00 MCG/0.5 ML, 80 MCG/0.8 ML HAEGARDA SUBCUTANEOUS RECON SOLN,000 UNIT,,000 UNIT LEUKINE INJECTION RECON SOLN 50 MCG PA; NM; Available ( ); QL (. per 8 PA; NM; Available ( ); QL ( per 8 5 PA; NM; Available ( ); QL (0 per 0 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) 5 PA; NM; Available ( ) 5 MULPLETA ORAL TABLET MG 5 PA; NM; Available ( ) NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEUPOGEN INJECTION SOLUTION 00 MCG/ML, 80 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 00 MCG/0.5 ML, 80 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML,,000 UNIT/ML, 0,000 UNIT/ ML, 0,000 UNIT/ML,,000 UNIT/ML,,000 UNIT/ML 5 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) 5 NM; Available through CVS Specialty ( ) PA; NM; Available ( ); QL (1 per 8 68

81 PROCRIT INJECTION SOLUTION 0,000 UNIT/ML PROMACTA ORAL POWDER IN PACKET 1.5 MG PROMACTA ORAL TABLET 1.5 MG, 5 MG, 50 MG, 75 MG PA; NM; Available ( ); QL (6 per 8 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) Hematologic Agents, Miscellaneous aminocaproic acid intravenous solution 50 /ml anagrelide oral capsule 0.5 (Agrylin) anagrelide oral capsule 1 protamine intravenous solution 10 /ml tranexamic acid oral tablet 650 (Lysteda) QL (0 per 0 Platelet-Aggregation Inhibitors aspirin-dipyridamole oral capsule, er (Aggrenox) multiphase 1 hr 5-00 BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100, 50 clopidogrel oral tablet 00 clopidogrel oral tablet 75 (Plavix) 1 GC pentoxifylline oral tablet extended release 00 prasugrel oral tablet 10, 5 (Effient) ZONTIVITY ORAL TABLET.08 MG Caloric Agents Caloric Agents AMINOSYN 10 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 10 % AMINOSYN 7 % WITH PA BvD ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % PA BvD 69

82 AMINOSYN 8.5 %-ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN II 7 % INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN II 8.5 % INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES INTRAVENOUS PARENTERAL SOLUTION 8.5 % AMINOSYN M.5 % INTRAVENOUS PARENTERAL SOLUTION.5 % AMINOSYN-HBC 7% INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-PF 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % AMINOSYN-PF 7 % (SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 7 % AMINOSYN-RF 5. % INTRAVENOUS PARENTERAL SOLUTION 5. % CLINIMIX 5%/D15W SULFITE FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX 5%/D5W SULFITE- FREE INTRAVENOUS PARENTERAL SOLUTION 5 % CLINIMIX.75%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION.75 % CLINIMIX.5%/D10W SULF FREE INTRAVENOUS PARENTERAL SOLUTION.5 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 70

83 CLINIMIX.5%/D5W SULFIT FREE INTRAVENOUS PARENTERAL SOLUTION.5 % CLINIMIX.5%-D0W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION.5 % CLINIMIX.5%-D5W SULF-FREE INTRAVENOUS PARENTERAL SOLUTION.5 % CLINIMIX 5%-D0W(SULFITE- FREE) INTRAVENOUS PARENTERAL SOLUTION 5 % dextrose 10 % in water (d10w) intravenous parenteral solution 10 % dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 5 % in water (d5w) intravenous syringe dextrose 0 % in water (d0w) intravenous parenteral solution 0 % dextrose 5 % in ringer's intravenous parenteral solution 5 % dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous piggyback 5 % dextrose 50 % in water (d50w) intravenous parenteral solution dextrose 50 % in water (d50w) intravenous syringe dextrose 70 % in water (d70w) intravenous parenteral solution FREAMINE HBC 6.9 % INTRAVENOUS PARENTERAL SOLUTION 6.9 % FREAMINE III 10 % INTRAVENOUS PARENTERAL SOLUTION 10 % HEPATAMINE 8% INTRAVENOUS PARENTERAL SOLUTION 8 % PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 71

84 INTRALIPID INTRAVENOUS PA BvD EMULSION 0 %, 0 % KABIVEN INTRAVENOUS PA BvD EMULSION % NEPHRAMINE 5. % PA BvD INTRAVENOUS PARENTERAL SOLUTION 5. % OMEGAVEN INTRAVENOUS PA BvD EMULSION 10 % PERIKABIVEN INTRAVENOUS PA BvD EMULSION % PLENAMINE INTRAVENOUS PA BvD PARENTERAL SOLUTION 15 % PREMASOL 10 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 10 % PREMASOL 6 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 6 % PROCALAMINE % PA BvD INTRAVENOUS PARENTERAL SOLUTION % PROSOL 0 % INTRAVENOUS PA BvD PARENTERAL SOLUTION smoflipid intravenous emulsion 0 % PA BvD TRAVASOL 10 % INTRAVENOUS PA BvD PARENTERAL SOLUTION 10 % TROPHAMINE 10 % PA BvD INTRAVENOUS PARENTERAL SOLUTION 10 % TROPHAMINE 6% INTRAVENOUS PA BvD PARENTERAL SOLUTION 6 % Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet 0.1, 0., (Catapres) 1 GC 0. clonidine transdermal patch weekly 0.1 (Catapres-TTS-1) / hr clonidine transdermal patch weekly 0. (Catapres-TTS-) / hr clonidine transdermal patch weekly 0. / hr (Catapres-TTS-) 7

85 clorpres oral tablet , 0.-15, doxazosin oral tablet 1,,, 8 (Cardura) guanfacine oral tablet 1, PA; AGE (Max 6 Years) midodrine oral tablet 10,.5, 5 NORTHERA ORAL CAPSULE 100 MG, 00 MG, 00 MG 5 PA; NM; Available ( ) phenoxybenzamine oral capsule 10 (Dibenzyline) 5 phenylephrine hcl injection solution 10 (Vazculep) /ml prazosin oral capsule 1,, 5 (Minipress) Angiotensin Ii Receptor Antagonists candesartan oral tablet 16,, (Atacand) 1 GC, 8 candesartan-hydrochlorothiazid oral (Atacand HCT) 1 GC tablet , -1.5, -5 ENTRESTO ORAL TABLET -6 MG, 9-51 MG, MG PA; QL (60 per 0 eprosartan oral tablet GC irbesartan oral tablet 150, 00, 75 (Avapro) 1 GC irbesartan-hydrochlorothiazide oral (Avalide) 1 GC tablet , losartan oral tablet 100, 5, 50 (Cozaar) 1 GC losartan-hydrochlorothiazide oral tablet (Hyzaar) 1 GC , 100-5, olmesartan oral tablet 0, 0, 5 (Benicar) olmesartan-amlodipin-hcthiazid oral (Tribenzor) tablet , , , , olmesartan-hydrochlorothiazide oral (Benicar HCT) tablet 0-1.5, 0-1.5, 0-5 telmisartan oral tablet 0, 0, 80 (Micardis) 1 GC 7

86 telmisartan-amlodipine oral tablet 0-10, 0-5, 80-10, 80-5 (Twynsta) 1 GC; QL (0 per 0 telmisartan-hydrochlorothiazid oral (Micardis HCT) 1 GC tablet 0-1.5, , 80-5 valsartan oral tablet 160, 0, 0 (Diovan) 1 GC, 80 valsartan-hydrochlorothiazide oral tablet (Diovan HCT) 1 GC , 160-5, 0-1.5, 0-5, Angiotensin-Converting Enzyme Inhibitors benazepril oral tablet 10, 0, 0 (Lotensin) 1 GC benazepril oral tablet 5 1 GC benazepril-hydrochlorothiazide oral (Lotensin HCT) 1 GC tablet , 0-1.5, 0-5 benazepril-hydrochlorothiazide oral 1 GC tablet captopril oral tablet 100, 1.5, 5 1 GC, 50 captopril-hydrochlorothiazide oral tablet 1 GC 5-15, 5-5, 50-15, 50-5 enalapril maleate oral tablet 10,.5 (Vasotec) 1 GC, 0, 5 enalapril-hydrochlorothiazide oral tablet (Vaseretic) 1 GC 10-5 enalapril-hydrochlorothiazide oral tablet 1 GC EPANED ORAL SOLUTION 1 MG/ML fosinopril oral tablet 10, 0, 0 1 GC fosinopril-hydrochlorothiazide oral tablet 1 GC , lisinopril oral tablet 10, 0, 5 (Prinivil) 1 GC lisinopril oral tablet.5, 0, 0 (Zestril) 1 GC lisinopril-hydrochlorothiazide oral tablet (Zestoretic) 1 GC , 0-1.5, 0-5 moexipril oral tablet 15, GC moexipril-hydrochlorothiazide oral tablet , 15-5, GC 7

87 perindopril erbumine oral tablet, 1 GC, 8 quinapril oral tablet 10, 0, 0 (Accupril) 1 GC, 5 quinapril-hydrochlorothiazide oral tablet (Accuretic) 1 GC , 0-1.5, 0-5 ramipril oral capsule 1.5, 10,.5 (Altace) 1 GC, 5 trandolapril oral tablet 1,, 1 GC trandolapril-verapamil oral tablet, ir - er, 1 GC biphasic hr 1-0 trandolapril-verapamil oral tablet, ir - er, (Tarka) 1 GC biphasic hr -180, -0, -0 Antiarrhythmic Agents amiodarone oral tablet 100, 00, (Pacerone) 00 dofetilide oral capsule 15 mcg, 50 mcg, (Tikosyn) 500 mcg flecainide oral tablet 100, 150, 50 lidocaine (pf) intravenous syringe 100 PA BvD /5 ml ( %), 50 /5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution /ml (0. %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 /ml (0.8 %) mexiletine oral capsule 150, 00, 50 MULTAQ ORAL TABLET 00 MG pacerone oral tablet 100, 00, 00 propafenone oral capsule,extended (Rythmol SR) release 1 hr 5, 5, 5 propafenone oral tablet 150, 5, 00 quinidine gluconate oral tablet extended release 75

88 quinidine sulfate oral tablet 00, 00 Beta-Adrenergic Blocking Agents acebutolol oral capsule 00, 00 atenolol oral tablet 100, 5, 50 (Tenormin) 1 GC atenolol-chlorthalidone oral tablet (Tenoretic 100) atenolol-chlorthalidone oral tablet 50-5 (Tenoretic 50) betaxolol oral tablet 10, 0 bisoprolol fumarate oral tablet 10, 5 bisoprolol-hydrochlorothiazide oral tablet ,.5-6.5, (Ziac) BREVIBLOC IN NACL (ISO-OSM) PA BvD INTRAVENOUS PARENTERAL SOLUTION,000 MG/100 ML,,500 MG/50 ML (10 MG/ML) BYSTOLIC ORAL TABLET 10 MG,.5 MG, 0 MG, 5 MG carvedilol oral tablet 1.5, 5, (Coreg).15, 6.5 carvedilol phosphate oral capsule, er (Coreg CR) multiphase hr 10, 0, 0, 80 esmolol intravenous solution 100 /10 (Brevibloc) PA BvD ml (10 /ml) labetalol oral tablet 100, 00, 00 LEVATOL ORAL TABLET 0 MG metoprolol succinate oral tablet extended (Toprol XL) release hr 100, 00, 5, 50 metoprolol ta-hydrochlorothiaz oral tablet 100-5, metoprolol ta-hydrochlorothiaz oral tablet 50-5 (Lopressor HCT) metoprolol tartrate oral tablet 100, 50 (Lopressor) 1 GC metoprolol tartrate oral tablet 5 1 GC 76

89 metoprolol tartrate oral tablet 7.5, 75 nadolol oral tablet 0, 0, 80 (Corgard) nadolol-bendroflumethiazide oral tablet (Corzide) 0-5, 80-5 pindolol oral tablet 10, 5 propranolol oral capsule,extended release (Inderal LA) hr 10, 160, 60, 80 propranolol oral solution 0 /5 ml ( /ml), 0 /5 ml (8 /ml) propranolol oral tablet 10, 0, 0 1 GC, 80 propranolol oral tablet 60 propranolol-hydrochlorothiazid oral tablet 0-5, 80-5 sorine oral tablet 10, 160, 0, 80 sotalol af oral tablet 10, 160, 80 sotalol oral tablet 10, 160, 0 (Betapace), 80 timolol maleate oral tablet 10, 0, 5 Calcium-Channel Blocking Agents CARDIZEM LA ORAL TABLET EXTENDED RELEASE HR 10 MG cartia xt oral capsule,extended release hr 10, 180, 0, 00 diltiazem hcl intravenous solution 5 /ml diltiazem hcl oral capsule,extended release 1 hr 10, 60, 90 diltiazem hcl oral capsule,extended (Taztia XT) release hr 60 diltiazem hcl oral capsule,extended (Tiazac) release hr 0 diltiazem hcl oral capsule,extended release hr 10, 180, 0, 00 (Cardizem CD) 77

90 diltiazem hcl oral tablet 10, 0, (Cardizem) 60 diltiazem hcl oral tablet 90 diltiazem hcl oral tablet extended release (Cardizem LA) hr 180, 0, 00, 60, 0 dilt-xr oral capsule,ext.rel h degradable 10, 180, 0 matzim la oral tablet extended release hr 180, 0, 00, 60, 0 taztia xt oral capsule,extended release hr 10, 180, 0, 00, 60 verapamil intravenous solution.5 /ml verapamil intravenous syringe.5 /ml verapamil oral capsule, hr er pellet ct (Verelan PM) 100, 00, 00 verapamil oral capsule,ext rel. pellets (Verelan) hr 10, 180, 0, 60 verapamil oral tablet 10, 80 (Calan) verapamil oral tablet 0 verapamil oral tablet extended release (Calan SR) 10, 180, 0 Cardiovascular Agents, Miscellaneous CORLANOR ORAL TABLET 5 MG, 7.5 MG PA; QL (60 per 0 DEMSER ORAL CAPSULE 50 MG 5 digitek oral tablet 15 mcg, 50 mcg QL (0 per 0 digox oral tablet 15 mcg, 50 mcg 1 GC; QL (0 per 0 DIGOXIN ORAL SOLUTION 50 QL (00 per 0 MCG/ML digoxin oral tablet 15 mcg (Digitek) 1 GC; QL (0 per 0 digoxin oral tablet 50 mcg (Digitek) 1 GC; QL (0 per 0 dobutamine in d5w intravenous parenteral solution 1,000 /50 ml (,000 mcg/ml), 50 /50 ml (1 /ml), 500 /50 ml (,000 mcg/ml) PA BvD 78

91 dobutamine intravenous solution 50 /0 ml (1.5 /ml), 500 /0 ml (1.5 /ml) dopamine in 5 % dextrose intravenous solution 00 /50 ml (800 mcg/ml), 00 /50 ml (1,600 mcg/ml), 00 /500 ml (800 mcg/ml), 800 /50 ml (,00 mcg/ml), 800 /500 ml (1,600 mcg/ml) dopamine intravenous solution 00 /5 ml (0 /ml), 00 /10 ml (0 /ml), 00 /5 ml (80 /ml), 800 /10 ml (80 /ml), 800 /5 ml (160 /ml) epinephrine injection auto-injector 0.15 /0.15 ml, 0. /0. ml epinephrine injection auto-injector 0.15 /0. ml FIRAZYR SUBCUTANEOUS SYRINGE 0 MG/ ML (Auvi-Q) (EpiPen Jr) PA BvD PA BvD PA BvD 5 PA; NM; Available ( ) hydralazine oral tablet 10, 100, 5, 50 milrinone intravenous solution 1 /ml 5 PA BvD norepinephrine bitartrate intravenous (Levophed (bitartrate)) PA BvD solution 1 /ml RANEXA ORAL TABLET EXTENDED RELEASE 1 HR 1,000 MG, 500 MG VECAMYL ORAL TABLET.5 MG 5 Dihydropyridines afeditab cr oral tablet extended release 0, 60 amlodipine oral tablet 10,.5, 5 (Norvasc) 1 GC amlodipine-benazepril oral capsule 10-0 (Lotrel) 1 GC, 10-0, 5-10, 5-0, 5-0 amlodipine-benazepril oral capsule GC 79

92 amlodipine-olmesartan oral tablet 10-0 (Azor), 10-0, 5-0, 5-0 amlodipine-valsartan oral tablet (Exforge) 1 GC, 10-0, 5-160, 5-0 amlodipine-valsartan-hcthiazid oral (Exforge HCT) 1 GC tablet , , , , CLEVIPREX INTRAVENOUS EMULSION 5 MG/50 ML, 50 MG/100 ML felodipine oral tablet extended release hr 10,.5, 5 isradipine oral capsule.5, 5 nicardipine oral capsule 0, 0 nifedipine oral tablet extended release (Procardia XL) hr 0, 60, 90 nifedipine oral tablet extended release 0 (Adalat CC), 60, 90 nimodipine oral capsule 0 5 NYMALIZE 60 MG/0 ML 5 SOLUTION 60 MG/0 ML NYMALIZE ORAL SOLUTION 0 5 MG/10 ML Diuretics amiloride oral tablet 5 amiloride-hydrochlorothiazide oral tablet 5-50 bumetanide injection solution 0.5 /ml bumetanide oral tablet 0.5, 1, chlorothiazide oral tablet 50, 500 chlorthalidone oral tablet 5 1 GC chlorthalidone oral tablet 50 ethacrynic acid oral tablet 5 (Edecrin) 5 furosemide injection solution 10 /ml furosemide injection syringe 10 /ml furosemide oral solution 10 /ml, 0 /5 ml (8 /ml) furosemide oral tablet 0, 0, 80 (Lasix) 1 GC 80

93 hydrochlorothiazide oral capsule 1.5 (Microzide) 1 GC hydrochlorothiazide oral tablet 1.5, 1 GC 5, 50 indapamide oral tablet 1.5,.5 1 GC JYNARQUE ORAL TABLETS, SEQUENTIAL 5 MG (AM)/ 15 MG 5 PA; QL (56 per 8 (PM), 60 MG (AM)/ 0 MG (PM), 90 MG (AM)/ 0 MG (PM) methyclothiazide oral tablet 5 metolazone oral tablet 10,.5, 5 spironolactone oral tablet 100, 5, (Aldactone) 50 spironolacton-hydrochlorothiaz oral (Aldactazide) tablet 5-5 torsemide oral tablet 10, 0 (Demadex) torsemide oral tablet 100, 5 triamterene-hydrochlorothiazid oral (Dyazide) capsule triamterene-hydrochlorothiazid oral capsule 50-5 triamterene-hydrochlorothiazid oral (Maxzide-5) 1 GC tablet triamterene-hydrochlorothiazid oral tablet (Maxzide) 1 GC Dyslipidemics amlodipine-atorvastatin oral tablet 10-10, 10-0, 10-0, 10-80, 5-10, 5-0, 5-0, 5-80 amlodipine-atorvastatin oral tablet.5-10,.5-0,.5-0 atorvastatin oral tablet 10, 0, 0, 80 cholestyramine (with sugar) oral powder in packet gram (Caduet) 1 GC; QL (0 per 0 1 GC; QL (0 per 0 (Lipitor) 1 GC (Questran) cholestyramine light oral powder gram cholestyramine light packet gram colesevelam oral powder in packet.75 (WelChol) gram colesevelam oral tablet 65 (WelChol) colestipol oral packet 5 gram (Colestid) 81

94 colestipol oral tablet 1 gram (Colestid) ezetimibe oral tablet 10 (Zetia) ezetimibe-simvastatin oral tablet (Vytorin 10-10) ezetimibe-simvastatin oral tablet 10-0 (Vytorin 10-0) ezetimibe-simvastatin oral tablet 10-0 (Vytorin 10-0) ezetimibe-simvastatin oral tablet (Vytorin 10-80) fenofibrate micronized oral capsule 10, 1, 00,, 67 fenofibrate nanocrystallized oral tablet (Tricor) 15, 8 fenofibrate oral capsule 150, 50 (Lipofen) fenofibrate oral tablet 10, 0 (Fenoglide) fenofibrate oral tablet 160, 5 fenofibric acid (choline) oral (Trilipix) capsule,delayed release(dr/ec) 15, 5 fenofibric acid oral tablet 105, 5 (Fibricor) gemfibrozil oral tablet 600 (Lopid) JUXTAPID ORAL CAPSULE 10 MG, 0 MG, 0 MG, 0 MG, 5 MG, 60 MG 5 PA; ST; QL (0 per 0 LIVALO ORAL TABLET 1 MG, QL (0 per 0 MG, MG lovastatin oral tablet 10, 0, 0 1 GC niacin oral tablet extended release hr (Niaspan Extended- 1,000, 500, 750 Release) niacor oral tablet 500 omega- acid ethyl esters oral capsule 1 gram (Lovaza) pravastatin oral tablet 10 1 GC pravastatin oral tablet 0, 0, 80 (Pravachol) 1 GC prevalite oral powder in packet gram REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 0 MG/.5 ML 5 PA; NM; Available ( ); QL (.5 per 8 8

95 REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 10 MG/ML REPATHA SYRINGE SUBCUTANEOUS SYRINGE 10 MG/ML 5 PA; NM; Available ( ); QL ( per 8 5 PA; NM; Available ( ); QL ( per 8 (Crestor) 1 GC rosuvastatin oral tablet 10, 0, 0, 5 simvastatin oral tablet 10, 0, 0 (Zocor) 1 GC, 80 simvastatin oral tablet 5 1 GC VASCEPA ORAL CAPSULE 0.5 GRAM, 1 GRAM WELCHOL ORAL POWDER IN PACKET.75 GRAM Renin-Angiotensin-Aldosterone System Inhibitors eplerenone oral tablet 5, 50 (Inspra) TEKTURNA HCT ORAL TABLET QL (5 per MG, MG TEKTURNA HCT ORAL TABLET QL (0 per MG, 00-5 MG TEKTURNA ORAL TABLET 150 QL (5 per 0 MG TEKTURNA ORAL TABLET 00 QL (0 per 0 MG Vasodilators BIDIL ORAL TABLET MG isosorbide dinitrate oral tablet 10, 0, 0 isosorbide dinitrate oral tablet 5 (Isordil Titradose) isosorbide dinitrate oral tablet extended (ISOCHRON) release 0 isosorbide mononitrate oral tablet 10, 0 isosorbide mononitrate oral tablet extended release hr 10, 0, 60 8

96 minitran transdermal patch hour 0.1 /hr, 0. /hr, 0. /hr, 0.6 /hr minoxidil oral tablet 10,.5 NITRO-BID TRANSDERMAL OINTMENT % nitroglycerin in 5 % dextrose intravenous solution 100 /50 ml (00 mcg/ml), 5 /50 ml (100 mcg/ml), 50 /50 ml (00 mcg/ml), 50 /500 ml (100 mcg/ml) nitroglycerin sublingual tablet 0., 0. (Nitrostat), 0.6 nitroglycerin transdermal patch hour (Minitran) 0.1 /hr, 0. /hr, 0. /hr, 0.6 /hr nitroglycerin translingual spray,nonaerosol 00 mcg/spray (Nitrolingual) Central Nervous System Agents Central Nervous System Agents AMPYRA ORAL TABLET EXTENDED RELEASE 1 HR 10 MG atomoxetine oral capsule 10, 100, 18, 5, 0, 60, 80 AUBAGIO ORAL TABLET 1 MG, 7 MG AUSTEDO ORAL TABLET 1 MG, 9 MG 5 PA; NM; Available ( ); QL (60 per 0 (Strattera) 5 PA; NM; Available ( ); QL (8 per 8 5 PA; NM; Available ( ); QL (10 per 0 AUSTEDO ORAL TABLET 6 MG 5 PA; NM; Available ( ); QL (60 per 0 AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 0 MCG 5 PA; NM; Available ( ); QL ( per 8 8

97 AVONEX INTRAMUSCULAR PEN INJECTOR KIT 0 MCG/0.5 ML AVONEX INTRAMUSCULAR SYRINGE KIT 0 MCG/0.5 ML clonidine hcl oral tablet extended release 1 hr 0.1 dalfampridine oral tablet extended release 1 hr 10 dexmethylphenidate oral capsule,er biphasic , 15, 0, 5 dexmethylphenidate oral capsule,er biphasic , 0 dexmethylphenidate oral tablet 10,.5, 5 dextroamphetamine oral capsule, extended release 10, 15, 5 dextroamphetamine oral tablet 10, 5 dextroamphetamine-amphetamine oral capsule,extended release hr 10, 15, 5 dextroamphetamine-amphetamine oral capsule,extended release hr 0, 5, 0 dextroamphetamine-amphetamine oral tablet 10, 1.5, 15, 0, 0, 5, 7.5 GILENYA ORAL CAPSULE 0.5 MG, 0.5 MG glatiramer subcutaneous syringe 0 /ml 5 PA; NM; Available ( ); QL ( per 8 5 PA; NM; Available ( ); QL ( per 8 (Kapvay) (Ampyra) 5 PA; NM; Available ( ); QL (60 per 0 (Focalin XR) QL (60 per 0 (Focalin XR) QL (0 per 0 (Focalin) QL (60 per 0 (Dexedrine Spansule) QL (10 per 0 (Zenzedi) QL (180 per 0 (Adderall XR) QL (0 per 0 (Adderall XR) QL (60 per 0 (Adderall) QL (60 per 0 5 PA; NM; Available ( ); QL (8 per 8 (Copaxone) 5 PA; NM; Available ( ); QL (0 per 0 85

98 glatiramer subcutaneous syringe 0 /ml (Copaxone) 5 PA; NM; Available ( ); QL (1 per 8 glatopa subcutaneous syringe 0 /ml 5 PA; NM; Available ( ); QL (0 per 0 glatopa subcutaneous syringe 0 /ml 5 PA; NM; Available ( ); QL (1 per 8 INGREZZA ORAL CAPSULE 0 MG 5 PA; QL (60 per 0 INGREZZA ORAL CAPSULE 80 MG 5 PA; QL (0 per 0 lithium carbonate oral capsule 150, 00, 600 lithium carbonate oral tablet 00 lithium carbonate oral tablet extended (Lithobid) release 00 lithium carbonate oral tablet extended release 50 lithium citrate oral solution 8 meq/5 ml methylphenidate er 18 tab 18 (Concerta) QL (0 per 0 methylphenidate er 7 tab 7 (Concerta) QL (0 per 0 methylphenidate er 6 tab 6 (Concerta) QL (60 per 0 methylphenidate er 5 tab 5 (Concerta) QL (0 per 0 methylphenidate hcl oral capsule, er QL (60 per 0 biphasic , 0, 0 methylphenidate hcl oral capsule, er QL (0 per 0 biphasic , 50, 60 methylphenidate hcl oral capsule,er (Ritalin LA) QL (60 per 0 biphasic , 0, 0 methylphenidate hcl oral capsule,er (Ritalin LA) QL (0 per 0 biphasic methylphenidate hcl oral tablet 10, 0 (Ritalin) QL (90 per 0, 5 methylphenidate hcl oral tablet extended release 10 QL (90 per 0 86

99 methylphenidate hcl oral tablet extended (Metadate ER) QL (90 per 0 release 0 methylphenidate hcl oral tablet extended (Concerta) QL (0 per 0 release hr 18, 7, 5 methylphenidate hcl oral tablet extended (Concerta) QL (60 per 0 release hr 6 methylphenidate hcl oral tablet extended (Relexxii) QL (0 per 0 release hr 7 methylphenidate la 0 cap 0 (Ritalin LA) QL (0 per 0 NUEDEXTA ORAL CAPSULE 0-10 MG PA; QL (60 per 0 OCREVUS INTRAVENOUS SOLUTION 0 MG/ML 5 PA; NM; Available ( ); QL (0 per 180 REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE MCG/0.5 ML, MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR MCG/0.5 ML, MCG/0.5 ML, 8.8MCG/0.ML- MCG/0.5ML (6) REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.ML- MCG/0.5ML (6) 5 PA; NM; Available ( ); QL (1 per 8 5 PA; NM; Available ( ); QL (1 per 8 5 PA; NM; Available ( ); QL (1 per 8 riluzole oral tablet 50 (Rilutek) SAVELLA ORAL TABLET 100 MG, 1.5 MG, 5 MG, 50 MG SAVELLA ORAL TABLETS,DOSE PACK 1.5 MG (5)-5 MG(8)-50 MG() TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10 MG (1)- 0 MG (6) 5 PA; NM; Available ( ); QL (10 per 65 TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10 MG, 0 MG 5 PA; NM; Available ( ); QL (60 per 0 87

100 tetrabenazine oral tablet 1.5, 5 (Xenazine) 5 PA; NM; Available ( ) VYVANSE ORAL CAPSULE 10 MG, 0 MG PA; QL (60 per 0 VYVANSE ORAL CAPSULE 0 MG, 0 MG, 50 MG, 60 MG, 70 MG Contraceptives Contraceptives altavera (8) oral tablet alyacen 1/5 (8) oral tablet 1-5 mcg alyacen 7/7/7 (8) oral tablet 0.5/0.75/1-5 mcg amethia lo oral tablets,dose pack, month mcg (8)/10 mcg (7) amethia oral tablets,dose pack, month mcg (8)/10 mcg (7) apri oral tablet aranelle (8) oral tablet 0.5/1/0.5-5 mcg ashlyna oral tablets,dose pack, month mcg (8)/10 mcg (7) aubra oral tablet mcg aviane oral tablet mcg azurette (8) oral tablet x1 /0.01 x 5 balziva (8) oral tablet mcg bekyree (8) oral tablet x1 /0.01 x 5 blisovi fe oral tablet 1-0 mcg ()/75 () blisovi fe 1.5/0 (8) oral tablet mcg (1)/75 (7) blisovi fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) briellyn oral tablet mcg camila oral tablet 0.5 camrese lo oral tablets,dose pack, month mcg (8)/10 mcg (7) PA; QL (0 per 0 88

101 camrese oral tablets,dose pack, month mcg (8)/10 mcg (7) caziant (8) oral tablet 0.1/.15/ mcg chateal (8) oral tablet cryselle (8) oral tablet mcg cyclafem 1/5 (8) oral tablet 1-5 mcg cyclafem 7/7/7 (8) oral tablet 0.5/0.75/1-5 mcg cyred 8 day tablet outer cyred eq oral tablet dasetta 1/5 (8) oral tablet 1-5 mcg dasetta 7/7/7 (8) oral tablet 0.5/0.75/1-5 mcg daysee oral tablets,dose pack, month mcg (8)/10 mcg (7) deblitane oral tablet 0.5 delyla (8) oral tablet mcg desog-e.estradiol/e.estradiol oral tablet (Azurette (8)) x1 /0.01 x 5 desogestrel-ethinyl estradiol oral tablet (Apri) drospirenone-e.estradiol-lm.fa oral tablet (Beyaz) () () drospirenone-e.estradiol-lm.fa oral tablet (Safyral) (1) (7) drospirenone-ethinyl estradiol oral tablet (Gianvi (8)) -0.0 drospirenone-ethinyl estradiol oral tablet (Ocella) -0.0 elinest oral tablet mcg ELLA ORAL TABLET 0 MG QL (6 per 65 emoquette oral tablet enpresse oral tablet 50-0 (6)/75-0 (5)/15-0(10) enskyce oral tablet errin oral tablet 0.5 estarylla oral tablet mcg 89

102 ethynodiol diac-eth estradiol oral tablet (Kelnor 1/5 (8)) 1-5 -mcg ethynodiol diac-eth estradiol oral tablet (Kelnor 1-50) mcg falmina (8) oral tablet mcg fayosim oral tablets,dose pack, month mcg/ mcg femynor oral tablet mcg gianvi (8) oral tablet -0.0 hailey fe oral tablet 1-0 mcg ()/75 () heather oral tablet 0.5 incassia oral tablet 0.5 introvale oral tablets,dose pack, month mcg isibloom oral tablet jencycla oral tablet 0.5 jolessa oral tablets,dose pack, month mcg jolivette oral tablet 0.5 juleber oral tablet junel 1.5/0 (1) oral tablet mcg junel 1/0 (1) oral tablet 1-0 -mcg junel fe 1.5/0 (8) oral tablet mcg (1)/75 (7) junel fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) junel fe oral tablet 1-0 mcg ()/75 () kaitlib fe oral tablet,chewable 0.8-5mcg() and 75 () kariva (8) oral tablet x1 /0.01 x 5 kelnor 1/5 (8) oral tablet 1-5 -mcg kelnor 1-50 oral tablet mcg kimidess (8) oral tablet x1 /0.01 x 5 kurvelo (8) oral tablet

103 l norgest/e.estradiol-e.estrad oral (Amethia Lo) tablets,dose pack, month mcg (8)/10 mcg (7) l norgest/e.estradiol-e.estrad oral (Fayosim) tablets,dose pack, month mcg/ mcg l norgest/e.estradiol-e.estrad oral (Amethia) tablets,dose pack, month mcg (8)/10 mcg (7) larin 1.5/0 (1) oral tablet mcg larin 1/0 (1) oral tablet 1-0 -mcg larin fe oral tablet 1-0 mcg ()/75 () larin fe 1.5/0 (8) oral tablet mcg (1)/75 (7) larin fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) larissia oral tablet mcg leena 8 oral tablet 0.5/1/ mcg lessina oral tablet mcg levonest (8) oral tablet 50-0 (6)/75-0 (5)/15-0(10) levonorgestrel-ethinyl estrad oral tablet (Aubra) mcg levonorgestrel-ethinyl estrad oral tablet (Altavera (8)) levonorgestrel-ethinyl estrad oral tablet (Amethyst (8)) 90-0 mcg (8) levonorgestrel-ethinyl estrad oral (Introvale) tablets,dose pack, month mcg levonorg-eth estrad triphasic oral tablet (Enpresse) 50-0 (6)/75-0 (5)/15-0(10) levora-8 oral tablet lillow (8) oral tablet loryna (8) oral tablet -0.0 low-ogestrel (8) oral tablet 0.-0 mcg lutera (8) oral tablet mcg lyza oral tablet

104 marlissa (8) oral tablet melodetta fe oral tablet,chewable 1-0 mcg() /75 () mibelas fe oral tablet,chewable 1-0 mcg() /75 () microgestin 1.5/0 (1) oral tablet mcg microgestin 1/0 (1) oral tablet 1-0 -mcg microgestin fe 1.5/0 (8) oral tablet mcg (1)/75 (7) microgestin fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) mili oral tablet mcg mono-linyah oral tablet mcg mononessa (8) oral tablet mcg myzilra oral tablet 50-0 (6)/75-0 (5)/15-0(10) necon 0.5/5 (8) oral tablet mcg necon 7/7/7 (8) oral tablet 0.5/0.75/1-5 mcg nikki (8) oral tablet -0.0 nora-be oral tablet 0.5 noreth-ethinyl estradiol-iron oral (Wymzya Fe) tablet,chewable 0.-5mcg(1) and 75 (7) noreth-ethinyl estradiol-iron oral (Generess Fe) tablet,chewable 0.8-5mcg() and 75 () norethindrone (contraceptive) oral tablet (Camila) 0.5 norethindrone ac-eth estradiol oral tablet (Junel 1/0 (1)) 1-0 -mcg norethindrone-e.estradiol-iron oral tablet (Blisovi Fe 1/0 (8)) 1-0 mcg (1)/75 (7) norethindrone-e.estradiol-iron oral tablet 1-0 mcg ()/75 () (Blisovi Fe) 9

105 norethindrone-e.estradiol-iron oral (Melodetta Fe) tablet,chewable 1-0 mcg() /75 () norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen LO 0.18/0.15/0.5-5 mcg (8)) norgestimate-ethinyl estradiol oral tablet (Ortho Tri-Cyclen (8)) 0.18/0.15/0.5-5 mcg (8) norgestimate-ethinyl estradiol oral tablet (Estarylla) mcg norlyda oral tablet 0.5 norlyroc oral tablet 0.5 nortrel 0.5/5 (8) oral tablet mcg nortrel 1/5 (1) oral tablet 1-5 mcg nortrel 1/5 (8) oral tablet 1-5 mcg nortrel 7/7/7 (8) oral tablet 0.5/0.75/1-5 mcg NUVARING VAGINAL RING MG/ HR ocella oral tablet -0.0 ogestrel (8) oral tablet mcg orsythia oral tablet mcg philith oral tablet mcg pimtrea (8) oral tablet x1 /0.01 x 5 pirmella oral tablet 0.5/0.75/1-5 mcg, 1-5 -mcg portia 8 oral tablet previfem oral tablet mcg quasense oral tablets,dose pack, month mcg rajani oral tablet () () reclipsen (8) oral tablet rivelsa oral tablets,dose pack, month mcg/ mcg setlakin oral tablets,dose pack, month mcg sharobel oral tablet 0.5 9

106 sprintec (8) oral tablet mcg sronyx oral tablet mcg syeda oral tablet -0.0 tarina fe 1/0 (8) oral tablet 1-0 mcg (1)/75 (7) TAYTULLA ORAL CAPSULE 1 MG- 0 MCG ()/75 MG () tilia fe oral tablet 1-0(5)/1-0(7) /1-5mcg (9) tri femynor oral tablet 0.18/0.15/0.5-5 mcg (8) tri-estarylla oral tablet 0.18/0.15/0.5-5 mcg (8) tri-legest fe oral tablet 1-0(5)/1-0(7) /1-5mcg (9) tri-linyah oral tablet 0.18/0.15/0.5-5 mcg (8) tri-lo-estarylla oral tablet 0.18/0.15/0.5-5 mcg tri-lo-marzia oral tablet 0.18/0.15/0.5-5 mcg tri-lo-sprintec oral tablet 0.18/0.15/0.5-5 mcg tri-mili oral tablet 0.18/0.15/0.5-5 mcg (8) trinessa (8) oral tablet 0.18/0.15/0.5-5 mcg (8) tri-previfem (8) oral tablet 0.18/0.15/0.5-5 mcg (8) tri-sprintec (8) oral tablet 0.18/0.15/0.5-5 mcg (8) trivora (8) oral tablet 50-0 (6)/75-0 (5)/15-0(10) tri-vylibra lo oral tablet 0.18/0.15/0.5-5 mcg tri-vylibra oral tablet 0.18/0.15/0.5-5 mcg (8) tulana oral tablet 0.5 tydemy oral tablet (1) (7) 9

107 velivet triphasic regimen (8) oral tablet 0.1/.15/ mcg vestura (8) oral tablet -0.0 vienva oral tablet mcg viorele (8) oral tablet x1 /0.01 x 5 vyfemla (8) oral tablet mcg vylibra oral tablet mcg wera (8) oral tablet mcg wymzya fe oral tablet,chewable 0.- 5mcg(1) and 75 (7) xulane transdermal patch weekly mcg/ hr zarah oral tablet -0.0 zenchent (8) oral tablet mcg zovia 1/5e (8) oral tablet 1-5 -mcg Cough And Cold Products Cough And Cold Products benzonatate oral capsule 100 (Tessalon Perles) EX benzonatate oral capsule 150, 00 EX hydrocodone-chlorpheniramine oral (Tussionex Pennkinetic EX suspension,extended rel 1 hr 10-8 /5 ml ER) hydrocodone-homatropine oral tablet 5- EX 1.5 promethazine-codeine oral syrup EX /5 ml promethazine-phenyleph-codeine oral EX syrup /5 ml Dental And Oral Agents Dental And Oral Agents cevimeline oral capsule 0 (Evoxac) chlorhexidine gluconate mucous (Paroex Oral Rinse) membrane mouthwash 0.1 % denta 5000 plus dental cream 1.1 % dentagel dental gel 1.1 % oralone dental paste 0.1 % paroex oral rinse mucous membrane mouthwash 0.1 % 95

108 periogard mucous membrane mouthwash 0.1 % pilocarpine hcl oral tablet 5, 7.5 (Salagen (pilocarpine)) PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE 1.1 % sf 5000 plus dental cream 1.1 % triamcinolone acetonide dental paste 0.1 (Oralone) % Dermatological Agents Dermatological Agents, Other acitretin oral capsule 10, 17.5, 5 (Soriatane) 5 acyclovir topical ointment 5 % (Zovirax) ALCOHOL PADS TOPICAL PADS, MEDICATED ammonium lactate topical cream 1 % (Geri-Hydrolac) ammonium lactate topical lotion 1 % (AmLactin) amnesteem oral capsule 10, 0, 0 azelaic acid topical gel 15 % (Finacea) calcipotriene scalp solution % calcipotriene topical cream % (Dovonex) calcipotriene topical ointment % (Calcitrene) calcipotriene-betamethasone topical (Taclonex) ointment % calcitrene topical ointment % calcitriol topical ointment mcg/gram (Vectical) claravis oral capsule 10, 0, 0, 0 COSENTYX ( SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML COSENTYX PEN ( PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML dapsone topical gel 5 % (Aczone) DENAVIR TOPICAL CREAM 1 % 5 doxepin topical cream 5 % (Prudoxin) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 96

109 DUPIXENT SUBCUTANEOUS SYRINGE 00 MG/ ML 5 PA; NM; Available ( ) FINACEA TOPICAL FOAM 15 % FINACEA TOPICAL GEL 15 % fluorouracil topical cream 0.5 % (Carac) 5 fluorouracil topical cream 5 % (Efudex) fluorouracil topical solution %, 5 % imiquimod topical cream in packet 5 % (Aldara) isotretinoin oral capsule 10, 0, 0 (Absorica), 0 methoxsalen oral capsule,liqd-filled,rapid (Oxsoralen Ultra) 5 rel 10 myorisan oral capsule 10, 0, 0, 0 PANRETIN TOPICAL GEL 0.1 % 5 PICATO TOPICAL GEL %, % podofilox topical solution 0.5 % REGRANEX TOPICAL GEL 0.01 % 5 SANTYL TOPICAL OINTMENT 50 UNIT/GRAM SULFAMYLON TOPICAL CREAM 85 MG/G TACLONEX TOPICAL SUSPENSION % UVADEX INJECTION SOLUTION 0 MCG/ML VALCHLOR TOPICAL GEL % 5 QL (60 per 0 zenatane oral capsule 10, 0, 0, 0 ZOVIRAX TOPICAL CREAM 5 % Dermatological Antibacterials ALTABAX TOPICAL OINTMENT 1 % BACTROBAN NASAL NASAL OINTMENT % clindamycin phosphate topical foam 1 % (Evoclin) clindamycin phosphate topical gel 1 % (Cleocin T) clindamycin phosphate topical lotion 1 % (Cleocin T) 97

110 clindamycin phosphate topical solution 1 (Cleocin T) % clindamycin phosphate topical swab 1 % (Cleocin T) clindamycin-benzoyl peroxide topical gel (Duac) 1. %(1 % base) -5 % clindamycin-benzoyl peroxide topical gel (Benzaclin) 1-5 % clindamycin-benzoyl peroxide topical gel (Acanya) with pump % CORTISPORIN TOPICAL CREAM.5-10, MG/G-UNIT/G-% CORTISPORIN TOPICAL OINTMENT 1 % ery pads topical swab % erythromycin with ethanol topical gel % (Erygel) erythromycin with ethanol topical solution % erythromycin with ethanol topical swab (Ery Pads) % erythromycin-benzoyl peroxide topical (Aktipak) gel -5 % gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % metronidazole topical cream 0.75 % (MetroCream) metronidazole topical gel 0.75 % (Rosadan) metronidazole topical gel 1 % (Metrogel) metronidazole topical lotion 0.75 % (MetroLotion) mupirocin calcium topical cream % (Bactroban) mupirocin topical ointment % (Centany) selenium sulfide topical lotion.5 % silver sulfadiazine topical cream 1 % (Silvadene) ssd topical cream 1 % sulfacetamide sodium (acne) topical (Klaron) suspension 10 % Dermatological Anti-Inflammatory Agents ala-cort topical cream 1 %,.5 % ala-scalp topical lotion % alclometasone topical cream 0.05 % alclometasone topical ointment 0.05 % 98

111 betamethasone dipropionate topical cream 0.05 % betamethasone dipropionate topical lotion 0.05 % betamethasone dipropionate topical ointment 0.05 % betamethasone valerate topical cream 0.1 % betamethasone valerate topical lotion 0.1 % betamethasone valerate topical ointment 0.1 % betamethasone, augmented topical cream 0.05 % betamethasone, augmented topical gel 0.05 % betamethasone, augmented topical lotion 0.05 % betamethasone, augmented topical (Diprolene) ointment 0.05 % clobetasol scalp solution 0.05 % (Cormax) clobetasol topical cream 0.05 % (Temovate) clobetasol topical foam 0.05 % (Olux) clobetasol topical gel 0.05 % clobetasol topical lotion 0.05 % (Clobex) clobetasol topical ointment 0.05 % (Temovate) clobetasol topical shampoo 0.05 % (Clobex) clobetasol topical spray,non-aerosol 0.05 (Clobex) % clobetasol-emollient topical cream 0.05 % clobetasol-emollient topical foam 0.05 % (Olux-E) clocortolone pivalate topical cream 0.1 % (Cloderm) CORDRAN TAPE LARGE ROLL TOPICAL TAPE MCG/CM cormax scalp solution 0.05 % CORTIFOAM RECTAL FOAM 10 % (80 MG) DESONATE TOPICAL GEL 0.05 % desonide topical cream 0.05 % (DesOwen) desonide topical lotion 0.05 % (DesOwen) 99

112 desonide topical ointment 0.05 % desoximetasone topical cream 0.05 %, (Topicort) 0.5 % desoximetasone topical gel 0.05 % (Topicort) desoximetasone topical ointment 0.05 %, (Topicort) 0.5 % diflorasone topical cream 0.05 % (Psorcon) diflorasone topical ointment 0.05 % ELIDEL TOPICAL CREAM 1 % fluocinolone 0.01% body oil 0.01 % (Derma-Smoothe/FS Body Oil) fluocinolone and shower cap scalp oil 0.01 (Derma-Smoothe/FS % Scalp Oil) fluocinolone topical cream 0.01 % fluocinolone topical cream 0.05 % (Synalar) fluocinolone topical ointment 0.05 % (Synalar) fluocinolone topical solution 0.01 % (Synalar) fluocinonide topical cream 0.05 % fluocinonide topical gel 0.05 % fluocinonide topical ointment 0.05 % fluocinonide topical solution 0.05 % fluocinonide-e topical cream 0.05 % flurandrenolide topical lotion 0.05 % (Cordran) 5 flurandrenolide topical ointment 0.05 % (Cordran) fluticasone topical cream 0.05 % (Cutivate) fluticasone topical lotion 0.05 % (Cutivate) fluticasone topical ointment % halobetasol propionate topical cream 0.05 (Ultravate) % halobetasol propionate topical ointment (Ultravate) 0.05 % hydrocort buty 0.1% lipo cream 0.1 % (Locoid Lipocream) hydrocortisone butyrate topical cream 0.1 (Locoid) % hydrocortisone butyrate topical ointment 0.1 % hydrocortisone butyrate topical solution (Locoid) 0.1 % hydrocortisone topical cream 1 %,.5 % (Ala-Cort) hydrocortisone topical lotion.5 % 100

113 hydrocortisone topical ointment 1 % (Anti-Itch (HC)) hydrocortisone topical ointment.5 % hydrocortisone valerate topical cream 0. % hydrocortisone valerate topical ointment 0. % hydrocortisone-pramoxine rectal cream (Analpram-HC) 1-1 % mometasone topical cream 0.1 % (Elocon) mometasone topical ointment 0.1 % (Elocon) mometasone topical solution 0.1 % pimecrolimus topical cream 1 % (Elidel) prednicarbate topical cream 0.1 % prednicarbate topical ointment 0.1 % (Dermatop) procto-med hc topical cream with perineal applicator.5 % procto-pak topical cream with perineal applicator 1 % proctosol hc topical cream with perineal applicator.5 % proctozone-hc topical cream with perineal applicator.5 % tacrolimus topical ointment 0.0 %, 0.1 (Protopic) % TEXACORT TOPICAL SOLUTION.5 % triamcinolone acetonide topical cream 0.05 % triamcinolone acetonide topical cream 0.1 (Triderm) %, 0.5 % triamcinolone acetonide topical lotion 0.05 %, 0.1 % triamcinolone acetonide topical ointment 0.05 %, 0.1 %, 0.5 % triderm topical cream 0.1 %, 0.5 % Dermatological Retinoids adapalene 0.% gel pump 0. % (Differin) PA adapalene topical cream 0.1 % (Differin) PA adapalene topical gel 0.1 %, 0. % (Differin) PA 101

114 adapalene-benzoyl peroxide topical gel with pump % (Epiduo) avita topical cream 0.05 % PA avita topical gel 0.05 % PA tazarotene topical cream 0.1 % (Avage) PA TAZORAC TOPICAL CREAM 0.05 % PA TAZORAC TOPICAL GEL 0.05 %, PA 0.1 % tretinoin microspheres topical gel 0.0 %, (Retin-A Micro) PA 0.1 % tretinoin topical cream 0.05 % (Avita) PA tretinoin topical cream 0.05 %, 0.1 % (Retin-A) PA Scabicides And Pediculicides EURAX TOPICAL CREAM 10 % EURAX TOPICAL LOTION 10 % lindane topical shampoo 1 % malathion topical lotion 0.5 % (Ovide) permethrin topical cream 5 % (Elimite) spinosad topical suspension 0.9 % (Natroba) Devices Devices ASSURE ID INSULIN SAFETY SYRINGE 1 ML 9 GAUGE X 1/" BD UF NANO PEN NEEDLE QL (00 per 0 MMXG GAUGE X 5/" BD VEO INS 0. ML 6MMX1G (1/) QL (00 per 0 0. ML 1 GAUGE X 15/6" BD VEO INS SYRING 1 ML QL (00 per 0 6MMX1G 1 ML 1 GAUGE X 15/6" BD VEO INS SYRN 0.5 ML QL (00 per 0 6MMX1G 1/ ML 1 GAUGE X 15/6" GAUZE PAD TOPICAL BANDAGE X " INSULIN SYRINGE-NEEDLE U-100 (Ultilet Insulin Syringe) QL (00 per 0 SYRINGE 0. ML 9 GAUGE INSULIN SYRINGE-NEEDLE U-100 (Advocate Syringes) QL (00 per 0 SYRINGE 1 ML 9 GAUGE X 1/" INSULIN SYRINGE-NEEDLE U-100 SYRINGE 1/ ML 8 GAUGE (Lite Touch Insulin Syringe) QL (00 per 0 10

115 PEN NEEDLE, DIABETIC NEEDLE 9 GAUGE X 1/" SURE COMFORT 0.5 ML SYRINGE 0.5 ML 9 GAUGE X 1/" Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers CERDELGA ORAL CAPSULE 8 MG CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 1,000-8,000-60,000 UNIT,,000-76,000-10,000 UNIT,,000-9,500-15,000 UNIT, 6,000-11, ,000 UNIT, 6,000-19,000-0,000 UNIT CYSTAGON ORAL CAPSULE 150 MG, 50 MG FABRAZYME INTRAVENOUS RECON SOLN 5 MG GALAFOLD ORAL CAPSULE 1 MG KUVAN ORAL POWDER IN PACKET 100 MG, 500 MG (1st Tier Unifine Pentips) QL (00 per 0 5 PA; NM; Available ( ); QL (56 per 8 5 PA 5 PA; QL (1 per 8 5 PA; NM; Available ( ) KUVAN ORAL TABLET,SOLUBLE 5 PA; NM; Available 100 MG ( ) miglustat oral capsule 100 (Zavesca) 5 PA; QL (90 per 0 ORFADIN ORAL CAPSULE 10 MG, 5 PA MG, 0 MG, 5 MG ORFADIN ORAL SUSPENSION 5 PA MG/ML PULMOZYME INHALATION SOLUTION 1 MG/ML 5 PA BvD; NM; Available through CVS Specialty ( ) 10

116 REVCOVI INTRAMUSCULAR 5 PA SOLUTION. MG/1.5 ML (1.6 MG/ML) STRENSIQ SUBCUTANEOUS 5 PA; LA SOLUTION 100 MG/ML, 0 MG/ML SUCRAID ORAL SOLUTION 8,500 5 UNIT/ML VIMIZIM INTRAVENOUS 5 SOLUTION 5 MG/5 ML (1 MG/ML) ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-,000 -,000 UNIT, 10,000-,000-55,000 UNIT, 15,000-51,000-8,000 UNIT, 0,000-6,000-8,000 UNIT, 5,000-79, ,000 UNIT, 5,000-85,000-16,000 UNIT,,000-10,000-1,000- UNIT,,000-10,000-16,000 UNIT, 5,000-17,000-,000 UNIT ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 15,000-7,000-6,000 UNIT, 0,000-16, ,000 UNIT Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous apraclonidine ophthalmic (eye) drops 0.5 (Iopidine) % atropine ophthalmic (eye) drops 1 % (Isopto Atropine) azelastine nasal aerosol,spray 17 mcg (0.1 %) azelastine nasal spray,non-aerosol 0.15 % (Astepro) (05.5 mcg) azelastine ophthalmic (eye) drops 0.05 % cromolyn ophthalmic (eye) drops % cyclopentolate ophthalmic (eye) drops (Cyclogyl) 0.5 %, 1 %, % CYSTARAN OPHTHALMIC (EYE) DROPS 0. % 5 epinastine ophthalmic (eye) drops 0.05 % (Elestat) 10

117 ipratropium bromide nasal spray,nonaerosol 0.0 %, mcg (0.06 %) LASTACAFT OPHTHALMIC (EYE) DROPS 0.5 % olopatadine ophthalmic (eye) drops 0.1 (Patanol) % olopatadine ophthalmic (eye) drops 0. (Pataday) % phenylephrine hcl ophthalmic (eye) drops 10 %,.5 % proparacaine ophthalmic (eye) drops 0.5 % tropicamide ophthalmic (eye) drops 0.5 % tropicamide ophthalmic (eye) drops 1 % (Mydriacyl) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (ear) solution % AZASITE OPHTHALMIC (EYE) DROPS 1 % bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) (AK-Poly-Bac) ointment ,000 unit/gram BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT % CILOXAN OPHTHALMIC (EYE) OINTMENT 0. % CIPRO HC OTIC (EAR) DROPS,SUSPENSION 0.-1 % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % ciprofloxacin hcl ophthalmic (eye) drops 0. % (Ciloxan) 105

118 ciprofloxacin hcl otic (ear) dropperette (Cetraxal) 0. % COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION MG/ML erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) gentak ophthalmic (eye) ointment 0. % ( /gram) gentamicin ophthalmic (eye) drops 0. % hydrocortisone-acetic acid otic (ear) drops 1- % levofloxacin ophthalmic (eye) drops 0.5 % moxifloxacin ophthalmic (eye) drops 0.5 (Vigamox) % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % neomycin-bacitracin-poly-hc ophthalmic (Neo-Polycin HC) (eye) ointment ,000 unit/g-1% neomycin-bacitracin-polymyxin (Neo-Polycin) ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) drops,suspension.5/ml-10,000 unit/ml-0.1 % neomycin-polymyxin b-dexameth (Maxitrol) ophthalmic (eye) ointment.5 /g- 10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops ,000 unit-0.05/ml neomycin-polymyxin-hc ophthalmic (eye) drops,suspension.5-10, unit-/ml neomycin-polymyxin-hc otic (ear) drops,suspension.5-10,000-1 /mlunit/ml-% neomycin-polymyxin-hc otic (ear) solution.5-10,000-1 /ml-unit/ml-% 106

119 neo-polycin hc ophthalmic (eye) ointment ,000 -unit/g-1% neo-polycin ophthalmic (eye) ointment ,000 -unit-unit/g ofloxacin ophthalmic (eye) drops 0. % (Ocuflox) ofloxacin otic (ear) drops 0. % polycin ophthalmic (eye) ointment ,000 unit/gram polymyxin b sulf-trimethoprim (Polytrim) ophthalmic (eye) drops 10,000 unit- 1 /ml PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION 0.-1 % PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT % sulfacetamide sodium ophthalmic (eye) (Bleph-10) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0. % (0.5 %) TOBRADEX OPHTHALMIC (EYE) OINTMENT % TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION % tobramycin ophthalmic (eye) drops 0. (Tobrex) % tobramycin-dexamethasone ophthalmic (TobraDex) (eye) drops,suspension % TOBREX OPHTHALMIC (EYE) OINTMENT 0. % trifluridine ophthalmic (eye) drops 1 % (Viroptic) ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % Eye, Ear, Nose, Throat Anti-Inflammatory Agents bromfenac ophthalmic (eye) drops 0.09 % 107

120 dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % DUREZOL OPHTHALMIC (EYE) DROPS 0.05 % flunisolide nasal spray,non-aerosol 5 mcg (0.05 %) fluocinolone acetonide oil otic (ear) (DermOtic Oil) drops 0.01 % fluorometholone ophthalmic (eye) (FML Liquifilm) drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops 0.0 % fluticasone nasal spray,suspension 50 ( Hour Allergy mcg/actuation Relief) FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % ILEVRO OPHTHALMIC (EYE) DROPS,SUSPENSION 0. % ketorolac ophthalmic (eye) drops 0. % (Acular LS) ketorolac ophthalmic (eye) drops 0.5 % (Acular) LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 0.5 % LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 % LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 % mometasone nasal spray,non-aerosol 50 (Nasonex) mcg/actuation NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.1 % prednisolone acetate ophthalmic (eye) (Omnipred) drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % 108

121 PROLENSA OPHTHALMIC (EYE) DROPS 0.07 % RESTASIS OPHTHALMIC (EYE) QL (6 per 0 DROPPERETTE 0.05 % XIIDRA OPHTHALMIC (EYE) QL (60 per 0 DROPPERETTE 5 % Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz oral combo pack CARAFATE ORAL SUSPENSION 100 MG/ML cimetidine hcl oral solution 00 /5 ml cimetidine oral tablet 00 (Acid Reducer (cimetidine)) cimetidine oral tablet 00, 00, 800 esomeprazole magnesium oral (Heartburn Treatment) capsule,delayed release(dr/ec) 0 esomeprazole magnesium oral (Nexium) capsule,delayed release(dr/ec) 0 famotidine intravenous solution 10 /ml famotidine oral suspension 0 /5 ml (8 /ml) famotidine oral tablet 0 (Acid Controller) famotidine oral tablet 0 (Pepcid) lansoprazole oral capsule,delayed (Heartburn Treatment release(dr/ec) 15 Hour) lansoprazole oral capsule,delayed (Prevacid) release(dr/ec) 0 misoprostol oral tablet 100 mcg, 00 mcg (Cytotec) omeprazole oral capsule,delayed release(dr/ec) 10, 0, 0 pantoprazole oral tablet,delayed release (Protonix) (dr/ec) 0, 0 ranitidine hcl injection solution 5 /ml (Zantac) ranitidine hcl oral capsule 150, 00 ranitidine hcl oral syrup 15 /ml 109

122 ranitidine hcl oral tablet 150 (Acid Control (ranitidine)) ranitidine hcl oral tablet 00 (Zantac) sucralfate oral tablet 1 gram (Carafate) Gastrointestinal Agents, Other AMITIZA ORAL CAPSULE MCG, 8 MCG CARBAGLU ORAL TABLET, 5 PA DISPERSIBLE 00 MG CHOLBAM ORAL CAPSULE 50 5 PA MG, 50 MG constulose oral solution 10 gram/15 ml cromolyn oral concentrate 100 /5 ml (Gastrocrom) dicyclomine oral capsule 10 dicyclomine oral solution 10 /5 ml dicyclomine oral tablet 0 diphenoxylate-atropine oral liquid /5 ml diphenoxylate-atropine oral tablet.5- (Lomotil) 0.05 enulose oral solution 10 gram/15 ml GATTEX 0-VIAL SUBCUTANEOUS KIT 5 MG 5 PA; NM; Available ( ) generlac oral solution 10 gram/15 ml glycopyrrolate injection solution 0. /ml glycopyrrolate oral tablet 1, glycopyrrolate oral tablet 1.5 (Glycate) kionex (with sorbitol) oral suspension gram/60 ml lactulose oral solution 10 gram/15 ml (Constulose) LINZESS ORAL CAPSULE 15 MCG, 90 MCG, 7 MCG loperamide oral capsule (Anti-Diarrheal (loperamide)) methscopolamine oral tablet.5, 5 metoclopramide hcl oral solution 5 /5 ml 110

123 metoclopramide hcl oral tablet 10, 5 MOVANTIK ORAL TABLET 1.5 MG, 5 MG MYTESI ORAL TABLET,DELAYED RELEASE (DR/EC) 15 MG OCALIVA ORAL TABLET 10 MG, 5 MG RAVICTI ORAL LIQUID 1.1 GRAM/ML (Reglan) sod polystyren sulf 15 g/60 ml sorbitol free 15 gram/60 ml sodium phenylbutyrate oral tablet 500 (Buphenyl) sodium polystyrene sulfonate oral powder 5 PA; NM; Available ( ); QL (0 per 0 5 PA; NM; Available ( ) sps (with sorbitol) oral suspension 15-0 gram/60 ml TRULANCE ORAL TABLET MG ursodiol oral capsule 00 (Actigall) ursodiol oral tablet 50 (URSO 50) ursodiol oral tablet 500 (URSO Forte) VELTASSA ORAL POWDER IN QL (0 per 0 PACKET 16.8 GRAM, 5. GRAM, 8. GRAM VIBERZI ORAL TABLET 100 MG, 75 5 MG XERMELO ORAL TABLET 50 MG 5 PA; QL (90 per 0 Laxatives CLENPIQ ORAL SOLUTION 10 MG-.5 GRAM -1 GRAM/160 ML gavilyte-c oral recon soln gram gavilyte-g oral recon soln gram gavilyte-n oral recon soln 0 gram MOVIPREP ORAL POWDER IN PACKET GRAM 111

124 peg 50-electrolytes oral recon soln 6- (GaviLyte-G) gram peg 50-electrolytes oral recon soln 0- (Colyte with Flavor gram Packs) peg-electrolyte soln oral recon soln 0 (GaviLyte-N) gram polyethylene glycol 50 oral powder 17 (ClearLax) gram/dose PREPOPIK ORAL POWDER IN PACKET 10 MG-.5 GRAM-1 GRAM SUPREP BOWEL PREP KIT ORAL RECON SOLN GRAM trilyte with flavor packets oral recon soln 0 gram Phosphate Binders AURYXIA ORAL TABLET 10 MG IRON 5 PA; QL (60 per 0 calcium acetate oral capsule 667 calcium acetate oral tablet 667 (Calphron) eliphos oral tablet 667 FOSRENOL ORAL POWDER IN PACKET 1,000 MG, 750 MG lanthanum oral tablet,chewable 1,000, (Fosrenol) 500, 750 sevelamer carbonate oral powder in (Renvela) 5 packet 0.8 gram,. gram sevelamer carbonate oral tablet 800 (Renvela) VELPHORO ORAL 5 TABLET,CHEWABLE 500 MG Genitourinary Agents Antispasmodics, Urinary bethanechol chloride oral tablet 10, (Urecholine) 5, 5, 50 darifenacin oral tablet extended release (Enablex) hr 15, 7.5 flavoxate oral tablet 100 MYRBETRIQ ORAL TABLET EXTENDED RELEASE HR 5 MG, 50 MG oxybutynin chloride oral syrup 5 /5 ml 11

125 oxybutynin chloride oral tablet 5 oxybutynin chloride oral tablet extended (Ditropan XL) release hr 10, 5 oxybutynin chloride oral tablet extended release hr 15 tolterodine oral capsule,extended release (Detrol LA) hr, tolterodine oral tablet 1, (Detrol) TOVIAZ ORAL TABLET EXTENDED RELEASE HR MG, 8 MG trospium oral capsule,extended release hr 60 trospium oral tablet 0 VESICARE ORAL TABLET 10 MG, 5 MG Genitourinary Agents, Miscellaneous alfuzosin oral tablet extended release (Uroxatral) QL (0 per 0 hr 10 dutasteride oral capsule 0.5 (Avodart) dutasteride-tamsulosin oral capsule, er (Jalyn) multiphase hr finasteride oral tablet 5 (Proscar) RAPAFLO ORAL CAPSULE MG, 8 MG silodosin oral capsule, 8 (Rapaflo) tamsulosin oral capsule 0. (Flomax) terazosin oral capsule 1, 10,, 5 Heavy Metal Antagonists Heavy Metal Antagonists CHEMET ORAL CAPSULE 100 MG DEPEN TITRATABS ORAL TABLET 50 MG 5 EXJADE ORAL TABLET, DISPERSIBLE 15 MG, 50 MG, 500 MG FERRIPROX ORAL SOLUTION 100 MG/ML FERRIPROX ORAL TABLET 500 MG 5 NM; Available through CVS Specialty ( )

126 trientine oral capsule 50 (Syprine) 5 Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANADROL-50 ORAL TABLET 50 MG 5 ANDRODERM TRANSDERMAL QL (60 per 0 PATCH HOUR MG/ HOUR ANDRODERM TRANSDERMAL QL (0 per 0 PATCH HOUR MG/ HR ANDROGEL TRANSDERMAL GEL QL (150 per 0 IN METERED-DOSE PUMP 0.5 MG/1.5 GRAM (1.6 %) ANDROGEL TRANSDERMAL GEL QL (7.5 per 0 IN PACKET 1.6 % (0.5 MG/1.5 GRAM) ANDROGEL TRANSDERMAL GEL QL (150 per 0 IN PACKET 1.6 % (0.5 MG/.5 GRAM) danazol oral capsule 100, 00, 50 methyltestosterone oral capsule 10 (Android) 5 oxandrolone oral tablet 10,.5 (Oxandrin) testosterone cypionate intramuscular oil (Depo-Testosterone) 100 /ml testosterone cypionate intramuscular oil 00 /ml (Depo-Testosterone) testosterone enanthate intramuscular oil QL (5 per 0 00 /ml testosterone transdermal gel in metereddose (Fortesta) QL (10 per 0 pump 10 /0.5 gram /actuation testosterone transdermal gel in metereddose (Vogelxo) QL (00 per 0 pump 1.5 / 1.5 gram (1 %) testosterone transdermal gel in metereddose (AndroGel) QL (150 per 0 pump 0.5 /1.5 gram (1.6 %) testosterone transdermal gel in packet 1 % (5 /.5gram), 1 % (50 /5 gram), 1.6 % (0.5 /1.5 gram), 1.6 % (0.5 /.5 gram) (AndroGel) QL (00 per 0 11

127 Estrogens And Antiestrogens amabelz oral tablet , PA; AGE (Max 6 Years) CLIMARA PRO TRANSDERMAL PATCH WEEKLY MG/ HR DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML DEPO-ESTRADIOL INTRAMUSCULAR OIL 5 MG/ML DUAVEE ORAL TABLET MG ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP 0.87 GRAM/ACTUATION PA; AGE (Max 6 Years) PA; AGE (Max 6 Years) PA; AGE (Max 6 Years) estradiol oral tablet 0.5, 1, (Estrace) PA; AGE (Max 6 Years) estradiol transdermal patch semiweekly 0.05 / hr, 0.05 / hr, (Alora) PA; AGE (Max 6 Years) / hr, 0.1 / hr estradiol transdermal patch semiweekly / hr (Minivelle) PA; AGE (Max 6 Years) estradiol transdermal patch weekly 0.05 / hr, / hr, 0.05 / hr, 0.06 / hr, / hr, 0.1 / hr estradiol vaginal cream 0.01 % (0.1 /gram) (Climara) PA; AGE (Max 6 Years) (Estrace) estradiol vaginal tablet 10 mcg (Vagifem) estradiol valerate intramuscular oil 0 (Delestrogen) /ml, 0 /ml estradiol-norethindrone acet oral tablet , (Activella) PA; AGE (Max 6 Years) estropipate oral tablet 0.75, 1.5, PA; AGE (Max 6 Years) jinteli oral tablet 1-5 -mcg PA; AGE (Max 6 Years) lopreeza oral tablet , PA; AGE (Max 6 Years) mimvey lo oral tablet PA; AGE (Max 6 Years) 115

128 mimvey oral tablet PA; AGE (Max 6 Years) norethindrone ac-eth estradiol oral tablet (Femhrt Low Dose) mcg norethindrone ac-eth estradiol oral tablet 1-5 -mcg (Fyavolv) OSPHENA ORAL TABLET 60 MG PA PREMARIN ORAL TABLET 0. MG, 0.5 MG, 0.65 MG, 0.9 MG, 1.5 MG PA; AGE (Max 6 Years) PREMARIN VAGINAL CREAM 0.65 MG/GRAM PREMPHASE ORAL TABLET 0.65 MG (1)/ 0.65MG-5MG(1) PA; AGE (Max 6 Years) PREMPRO ORAL TABLET MG, MG, MG, MG PA; AGE (Max 6 Years) raloxifene oral tablet 60 (Evista) yuvafem vaginal tablet 10 mcg Glucocorticoids/Mineralocorticoids a-hydrocort injection recon soln 100 PA BvD betamethasone acet,sod phos injection (Celestone Soluspan) PA BvD suspension 6 /ml cortisone oral tablet 5 deltasone oral tablet 0 PA BvD DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML dexamethasone oral elixir 0.5 /5 ml (Decadron) PA BvD dexamethasone oral tablet 0.5, 0.75 (Decadron) PA BvD,, 6 dexamethasone oral tablet 1, 1.5, PA BvD dexamethasone oral tablets,dose pack 1.5 (DexPak 6 Day) (1 tabs) dexamethasone oral tablets,dose pack 1.5 (DexPak 10 day) (5 tabs) dexamethasone oral tablets,dose pack 1.5 (DexPak 1 Day) (51 tabs) dexamethasone sodium phos (pf) PA BvD injection solution 10 /ml dexamethasone sodium phosphate injection solution 10 /ml, /ml PA BvD 116

129 dexamethasone sodium phosphate PA BvD injection syringe /ml fludrocortisone oral tablet 0.1 hydrocortisone oral tablet 10, 0, (Cortef) 5 methylprednisolone acetate injection (Depo-Medrol) PA BvD suspension 0 /ml, 80 /ml methylprednisolone oral tablet 16, (Medrol) PA BvD,, 8 methylprednisolone oral tablets,dose pack (Medrol (Pak)) methylprednisolone sodium succ injection PA BvD recon soln 15, 0 methylprednisolone sodium succ (Solu-Medrol) PA BvD intravenous recon soln 1,000 prednisolone 15 /5 ml soln a/f, d/f 15 PA BvD /5 ml ( /ml) prednisolone oral solution 15 /5 ml PA BvD prednisolone sodium phosphate oral PA BvD solution 10 /5 ml, 5 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) prednisolone sodium phosphate oral (Veripred 0) PA BvD solution 0 /5 ml ( /ml) PREDNISONE INTENSOL ORAL PA BvD CONCENTRATE 5 MG/ML prednisone oral solution 5 /5 ml PA BvD prednisone oral tablet 1,.5, 5 PA BvD, 50 prednisone oral tablet 10 PA BvD prednisone oral tablet 0 (Deltasone) PA BvD prednisone oral tablets,dose pack 10, 10 (8 pack), 5, 5 (8 pack) SOLU-CORTEF (PF) INJECTION PA BvD RECON SOLN 1,000 MG/8 ML, 100 MG/ ML, 50 MG/ ML, 500 MG/ ML SOLU-MEDROL (PF) INJECTION RECON SOLN 15 MG/ ML, 0 MG/ML PA BvD 117

130 SOLU-MEDROL (PF) PA BvD INTRAVENOUS RECON SOLN 1,000 MG/8 ML, 500 MG/ ML SOLU-MEDROL INTRAVENOUS RECON SOLN 1,000 MG, GRAM PA BvD triamcinolone acetonide injection (Kenalog) suspension 0 /ml zonacort oral tablets,dose pack 1.5 (7 tabs), 1.5 (1 tabs) Pituitary desmopressin 10 mcg/0.1 ml spr 10 (DDAVP) mcg/spray (0.1 ml) desmopressin nasal solution 0.1 /ml (DDAVP) (refrigerate) desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml) desmopressin oral tablet 0.1, 0. (DDAVP) EGRIFTA SUBCUTANEOUS RECON SOLN 1 MG INCRELEX SUBCUTANEOUS SOLUTION 10 MG/ML LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET.75 MG -5 MG (0) LUPANETA PACK ( MONTH) KIT. SYRINGE AND TABLET 11.5 MG - 5 MG (90) NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML), 0 MG/ ML (10 MG/ML), 5 MG/1.5 ML (. MG/ML) octreotide acetate injection solution 1,000 mcg/ml octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml, 500 mcg/ml PA; NM; Available ( ) 5 PA; NM; Available ( ) PA; NM; Available ( ) 5 NM; Available through CVS Specialty ( ) (Sandostatin) NM; Available through CVS Specialty ( ) 118

131 octreotide acetate injection solution 00 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml) OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5 MG/1.5 ML (. MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN 5.8 MG SEROSTIM SUBCUTANEOUS RECON SOLN MG, 5 MG, 6 MG SIGNIFOR SUBCUTANEOUS SOLUTION 0. MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 10 MG/0.5 ML, 60 MG/0. ML, 90 MG/0. ML SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 0 MG, 5 MG, 0 MG STIMATE NASAL SPRAY,NON- AEROSOL 150 MCG/SPRAY (0.1 ML) SYNAREL NASAL SPRAY,NON- AEROSOL MG/ML TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 MG ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG Progestins DEPO-PROVERA INTRAMUSCULAR SUSPENSION 00 MG/ML NM; Available through CVS Specialty ( ) NM; Available through CVS Specialty ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA 5 NM; Available through CVS Specialty ( ) 5 PA; NM; Available ( ) PA; NM; Available ( ) 119

132 DEPO-SUBQ PROVERA 10 SUBCUTANEOUS SYRINGE 10 MG/0.65 ML MAKENA (PF) SUBCUTANEOUS AUTO-INJECTOR 75 MG/1.1 ML MAKENA INTRAMUSCULAR OIL 50 MG/ML 5 NM; Available through CVS Specialty ( ) 5 PA; NM; Available ( ) (Depo-Provera) medroxyprogesterone intramuscular suspension 150 /ml medroxyprogesterone intramuscular (Depo-Provera) syringe 150 /ml medroxyprogesterone oral tablet 10, (Provera).5, 5 megestrol oral suspension 00 /10 ml PA NSO; AGE (Max (0 /ml) 6 Years) megestrol oral suspension 65 /5 ml (Megace ES) PA NSO; AGE (Max 6 Years) norethindrone acetate oral tablet 5 (Aygestin) progesterone in oil intramuscular oil 50 /ml progesterone micronized oral capsule 100 (Prometrium), 00 Thyroid And Antithyroid Agents levothyroxine oral tablet 100 mcg, 11 (Euthyrox) 1 GC mcg, 15 mcg, 17 mcg, 150 mcg, 5 mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine oral tablet 175 mcg, 00 (Euthyrox) mcg levothyroxine oral tablet 00 mcg (Levo-T) LEVOXYL ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 17 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 50 MCG, 75 MCG, 88 MCG liothyronine oral tablet 5 mcg, 5 mcg, 50 (Cytomel) mcg methimazole oral tablet 10, 5 (Tapazole) propylthiouracil oral tablet 50 10

133 SYNTHROID ORAL TABLET 100 MCG, 11 MCG, 15 MCG, 17 MCG, 150 MCG, 175 MCG, 00 MCG, 5 MCG, 00 MCG, 50 MCG, 75 MCG, 88 MCG Immunological Agents Immunological Agents ACTEMRA SUBCUTANEOUS SYRINGE 16 MG/0.9 ML 5 PA; NM; Available ( ) 5 PA ARCALYST SUBCUTANEOUS RECON SOLN 0 MG azathioprine oral tablet 50 (Imuran) PA BvD BIVIGAM INTRAVENOUS 5 PA BvD SOLUTION 10 % CARIMUNE NF NANOFILTERED 5 PA BvD INTRAVENOUS RECON SOLN 1 GRAM, 6 GRAM CUVITRU SUBCUTANEOUS 5 PA BvD SOLUTION 1 GRAM/5 ML (0 %), GRAM/10 ML (0 %), GRAM/0 ML (0 %), 8 GRAM/0 ML (0 %) cyclosporine modified oral capsule 100 (Gengraf) PA BvD, 5 cyclosporine modified oral capsule 50 PA BvD cyclosporine modified oral solution 100 (Gengraf) PA BvD /ml cyclosporine oral capsule 100, 5 (Sandimmune) PA BvD CYTOGAM INTRAVENOUS SOLUTION 50 MG/ML 5 DUPIXENT SUBCUTANEOUS SYRINGE 00 MG/1.1 ML ENBREL SUBCUTANEOUS RECON SOLN 5 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 5 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 11

134 ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %, 5 % GAMASTAN S/D INTRAMUSCULAR SOLUTION % RANGE GAMMAGARD LIQUID INJECTION SOLUTION 10 % GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM GAMMAKED INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %),.5 GRAM/5 ML (10 %), 0 GRAM/00 ML (10 %), 5 GRAM/50 ML (10 %) GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5 % GAMMAPLEX INTRAVENOUS SOLUTION 10 %, 10 % (100 ML), 10 % (00 ML) GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %),.5 GRAM/5 ML (10 %), 0 GRAM/00 ML (10 %), 0 GRAM/00 ML (10 %), 5 GRAM/50 ML (10 %) gengraf oral capsule 100, 5, 50 5 PA; NM; Available ( ) 5 PA BvD PA BvD 5 PA BvD 5 PA BvD 5 PA BvD 5 PA BvD 5 PA BvD 5 PA BvD PA BvD gengraf oral solution 100 /ml PA BvD HIZENTRA SUBCUTANEOUS 5 PA BvD SOLUTION 1 GRAM/5 ML (0 %), 10 GRAM/50 ML (0 %), GRAM/10 ML (0 %), GRAM/0 ML (0 %) HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS SYRINGE KIT 0 MG/0.8 ML, 0 MG/0.8 ML (6 PACK) 5 PA; NM; Available ( ) 1

135 HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0.8 ML HUMIRA PEN PSOR-UVEITS- ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0. ML, 0 MG/0. ML, 0 MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML, 80 MG/0.8 ML-0 MG/0. ML HUMIRA(CF) PEN CROHNS-UC- HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG/0.8 ML-0 MG/0. ML HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 0 MG/0. ML HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG/0.1 ML, 0 MG/0. ML, 0 MG/0. ML HYPERHEP B S/D INTRAMUSCULAR SOLUTION 0 UNIT/ML, 0 UNIT/ML (5 ML) HYPERHEP B S/D INTRAMUSCULAR SYRINGE 0 UNIT/ML HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE 110 UNIT/0.5 ML HYPERRAB (PF) INTRAMUSCULAR SOLUTION 00 UNIT/ML 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 1

136 HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM /100 ML (10 %),.5 GRAM /5 ML (10 %), 0 GRAM /00 ML (10 %), 0 GRAM /00 ML (10 %), 5 GRAM /50 ML (10 %) ILARIS (PF) SUBCUTANEOUS RECON SOLN 150 MG/ML ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MG/ML 5 PA BvD 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) KEDRAB (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10, 0 (Arava) mycophenolate mofetil oral capsule 50 (CellCept) PA BvD mycophenolate mofetil oral suspension (CellCept) 5 PA BvD for reconstitution 00 /ml mycophenolate mofetil oral tablet 500 (CellCept) PA BvD mycophenolate sodium oral (Myfortic) PA BvD tablet,delayed release (dr/ec) 180, 60 5 PA; QL (18.76 per 8 OCTAGAM INTRAVENOUS 5 PA BvD SOLUTION 10 %, 5 % ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 15 MG/ML 5 PA; NM; Available ( ) ORENCIA SUBCUTANEOUS SYRINGE 15 MG/ML, 50 MG/0. ML, 87.5 MG/0.7 ML 5 PA; NM; Available ( ) OTEZLA ORAL TABLET 0 MG 5 PA; NM; Available ( ); QL (60 per 0 OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG ()-0 MG ()-0 MG (7) 5 PA; NM; Available ( ); QL (110 per 65 1

137 PANZYGA INTRAVENOUS 5 PA BvD SOLUTION 10 %, 10 % (100 ML), 10 % (00 ML), 10 % (5 ML), 10 % (00 ML), 10 % (50 ML) PRIVIGEN INTRAVENOUS 5 PA BvD SOLUTION 10 % RAPAMUNE ORAL SOLUTION 1 5 PA BvD MG/ML RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0. ML, 1.5 MG/0.5 ML, 15 MG/0. ML, 17.5 MG/0.5 ML, 0 MG/0. ML,.5 MG/0.5 ML, 5 MG/0.5 ML, 0 MG/0.6 ML, 7.5 MG/0.15 ML RIDAURA ORAL CAPSULE MG 5 SANDIMMUNE ORAL SOLUTION PA BvD 100 MG/ML sirolimus oral tablet 0.5, 1, (Rapamune) PA BvD STELARA SUBCUTANEOUS SOLUTION 5 MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 5 MG/0.5 ML, 90 MG/ML tacrolimus oral capsule 0.5, 1, 5 VARIZIG INTRAMUSCULAR SOLUTION 15 UNIT/1. ML XELJANZ ORAL TABLET 10 MG, 5 MG XELJANZ XR ORAL TABLET EXTENDED RELEASE HR 11 MG ZORTRESS ORAL TABLET 0.5 MG, 0.5 MG, 0.75 MG, 1 MG Vaccines ACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) (Prograf) PA BvD 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 5 PA BvD 15

138 ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION LF-( MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE LF- ( MCG)-5LF/0.5 ML BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG BEXSERO INTRAMUSCULAR SYRINGE MCG/0.5 ML BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML BOOSTRIX TDAP INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION LF-MCG- LF/0.5ML ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 0 MCG/ML ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 0 MCG/ML ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,0 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML PA BvD PA BvD PA BvD 16

139 HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,0 ELISA UNIT/ML, 70 ELISA UNIT/0.5 ML HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN.5 UNIT INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION LF-MCG-LF/0.5ML INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE LF-MCG-LF/0.5ML IPOL INJECTION SUSPENSION 0-8- UNIT/0.5 ML IPOL INJECTION SYRINGE 0-8- UNIT/0.5 ML IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG/0.5 ML KINRIX (PF) INTRAMUSCULAR SUSPENSION 5 LF-58 MCG-10 LF/0.5 ML KINRIX (PF) INTRAMUSCULAR SYRINGE 5 LF-58 MCG-10 LF/0.5 ML MENACTRA (PF) INTRAMUSCULAR SOLUTION MCG/0.5 ML MENVEO A-C-Y-W-15-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG/0.5 ML M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1,000-1,500 TCID50/0.5 ML PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-5LF-5 MCG- 10LF/0.5 ML PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 7.5 MCG/0.5 ML 17

140 PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-0 MCG-5 LF/0.5 ML PENTACEL DTAP-IPV COMPNT (PF) INTRAMUSCULAR SUSPENSION 15 LF-8 MCG- 5 LF UNIT/0.5ML PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP TCID50/0.5 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-8 MCG- 5 LF UNIT/0.5ML RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.5 UNIT RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 0 MCG/ML, 5 MCG/0.5 ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML, 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50/ML ROTATEQ VACCINE ORAL SOLUTION ML SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- LF UNIT/0.5ML TENIVAC (PF) INTRAMUSCULAR SYRINGE 5- LF UNIT/0.5 ML TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-5 LF UNIT/0.5 ML PA BvD PA BvD QL ( per 65 18

141 TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION - LF UNIT/0.5 ML TRUMENBA INTRAMUSCULAR SYRINGE 10 MCG/0.5 ML TWINRIX (PF) INTRAMUSCULAR SYRINGE 70 ELISA UNIT- 0 MCG/ML TYPHIM VI INTRAMUSCULAR SOLUTION 5 MCG/0.5 ML TYPHIM VI INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML VAQTA (PF) INTRAMUSCULAR SUSPENSION 5 UNIT/0.5 ML, 50 UNIT/ML VAQTA (PF) INTRAMUSCULAR SYRINGE 5 UNIT/0.5 ML, 50 UNIT/ML VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,50 UNIT/0.5 ML YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP.7 UNIT/0.5 ML ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,00 UNIT/0.65 ML Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron oral tablet 0.5, 1 (Lotronex) 5 APRISO ORAL CAPSULE,EXTENDED RELEASE HR 0.75 GRAM balsalazide oral capsule 750 (Colazal) budesonide oral (Entocort EC) 5 capsule,delayed,extend.release budesonide oral tablet,delayed and ext.release 9 (Uceris) 5 19

142 CANASA RECTAL SUPPOSITORY 1,000 MG colocort rectal enema 100 /60 ml DELZICOL ORAL CAPSULE (WITH DEL REL TABLETS) 00 MG DIPENTUM ORAL CAPSULE 50 MG hydrocortisone rectal enema 100 /60 (Colocort) ml mesalamine oral tablet,delayed release (Lialda) (dr/ec) 1. gram mesalamine oral tablet,delayed release (Asacol HD) (dr/ec) 800 mesalamine rectal enema gram/60 ml (Rowasa) mesalamine rectal suppository 1,000 (Canasa) PENTASA ORAL CAPSULE, EXTENDED RELEASE 50 MG, 500 MG sulfasalazine oral tablet 500 (Azulfidine) sulfasalazine oral tablet,delayed release (Azulfidine EN-tabs) (dr/ec) 500 Irrigating Solutions Irrigating Solutions acetic acid irrigation solution 0.5 % sodium chloride irrigation solution 0.9 % (Aqua Care Sodium Chloride) Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution 70 /75 ml alendronate oral tablet 10, 0, 5 QL (0 per 0 alendronate oral tablet 5 1 GC; QL ( per 8 alendronate oral tablet 70 (Fosamax) 1 GC; QL ( per 8 calcitonin (salmon) nasal spray,nonaerosol 00 unit/actuation calcitriol oral capsule 0.5 mcg, 0.5 mcg (Rocaltrol) calcitriol oral solution 1 mcg/ml (Rocaltrol) 10

143 cinacalcet oral tablet 0 (Sensipar) NM; Available through CVS Specialty ( ); QL (60 per 0 cinacalcet oral tablet 60 (Sensipar) 5 NM; Available through CVS Specialty ( ); QL (60 per 0 cinacalcet oral tablet 90 (Sensipar) 5 NM; Available through CVS Specialty ( ); QL (10 per 0 etidronate disodium oral tablet 00, 00 FORTEO SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE MCG/. ML ibandronate intravenous syringe / ml PA; NM; Available ( ) (Boniva) NM; Available through CVS Specialty ( ) ibandronate oral tablet 150 (Boniva) QL (1 per 8 NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 5 MCG/DOSE, 50 MCG/DOSE, 75 5 PA; NM; Available ( ) MCG/DOSE pamidronate intravenous recon soln 0, 90 paricalcitol oral capsule 1 mcg, mcg (Zemplar) paricalcitol oral capsule mcg PROLIA SUBCUTANEOUS PA SYRINGE 60 MG/ML risedronate oral tablet 150 (Actonel) QL (1 per 8 risedronate oral tablet 5 (Actonel) QL ( per 8 risedronate oral tablet 5 (1 pack), QL ( per 8 5 ( pack) risedronate oral tablet 5 (Actonel) QL (0 per 0 risedronate oral tablet,delayed release (dr/ec) 5 (Atelvia) QL ( per 8 11

144 SENSIPAR ORAL TABLET 0 MG NM; Available through CVS Specialty ( ); QL (60 per 0 SENSIPAR ORAL TABLET 60 MG 5 NM; Available through CVS Specialty ( ); QL (60 per 0 SENSIPAR ORAL TABLET 90 MG 5 NM; Available through CVS Specialty ( ); QL (10 per 0 TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (,10 MCG/1.56 ML) XGEVA SUBCUTANEOUS SOLUTION 10 MG/1.7 ML (70 MG/ML) zoledronic acid intravenous recon soln Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTHAR H.P. INJECTION GEL 80 UNIT/ML ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML amifostine crystalline intravenous recon soln 500 BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 00 MG/ML BENLYSTA SUBCUTANEOUS SYRINGE 00 MG/ML CETYLEV ORAL TABLET, EFFERVESCENT.5 GRAM, 500 MG PA; NM; Available ( ) 5 PA NSO; NM; Available through CVS Specialty ( ) 5 PA; NM; Available ( ) 5 NM; Available through CVS Specialty ( ) (Ethyol) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ) 1

145 CYSTADANE ORAL POWDER 1 5 GRAM/1.7 ML dexrazoxane hcl intravenous recon soln (Zinecard (as HCl)) 500 droperidol injection solution.5 /ml ELMIRON ORAL CAPSULE 100 MG ENDARI ORAL POWDER IN PACKET 5 GRAM 5 PA; QL (180 per 0 guanidine oral tablet 15 hydroxyzine pamoate oral capsule 100 PA; AGE (Max 6 Years) hydroxyzine pamoate oral capsule 5, 50 (Vistaril) PA; AGE (Max 6 Years) KEVEYIS ORAL TABLET 50 MG 5 PA leucovorin calcium injection recon soln 50 leucovorin calcium injection solution 10 /ml leucovorin calcium oral tablet 10, 15, 5, 5 levocarnitine (with sugar) oral solution (Carnitor) 100 /ml levocarnitine oral tablet 0 (Carnitor) LEVOLEUCOVORIN CALCIUM 5 INTRAVENOUS RECON SOLN 175 MG levoleucovorin calcium intravenous recon (Fusilev) 5 soln 50 levoleucovorin calcium intravenous 5 solution 10 /ml LITHOSTAT ORAL TABLET 50 MG MESNEX ORAL TABLET 00 MG 5 MESTINON ORAL SYRUP 60 MG/5 ML methylergonovine injection solution 0. /ml (1 ml) methylergonovine oral tablet 0. (Methergine) 1

146 MYOBLOC INTRAMUSCULAR SOLUTION 10,000 UNIT/ ML,,500 UNIT/0.5 ML, 5,000 UNIT/ML PA BvD; NM; Available through CVS Specialty ( ) (Brisdelle) paroxetine mesylate(menop.sym) oral capsule 7.5 PROGLYCEM ORAL SUSPENSION 50 MG/ML pyridostigmine bromide oral tablet 60 (Mestinon) pyridostigmine bromide oral tablet (Mestinon Timespan) extended release 180 SIMULECT INTRAVENOUS 5 PA BvD RECON SOLN 10 MG, 0 MG TEGSEDI SUBCUTANEOUS 5 PA; QL (6 per 8 SYRINGE 8 MG/1.5 ML THALOMID ORAL CAPSULE 100 MG, 150 MG, 00 MG, 50 MG TYBOST ORAL TABLET 150 MG XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT, 00 UNIT Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release 500 acetazolamide oral tablet 15, 50 ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % betaxolol ophthalmic (eye) drops 0.5 % ST BETIMOL OPHTHALMIC (EYE) DROPS 0.5 %, 0.5 % bimatoprost ophthalmic (eye) drops 0.0 % brimonidine ophthalmic (eye) drops 0.15 (Alphagan P) % brimonidine ophthalmic (eye) drops 0. % 5 NM; Available through CVS Specialty ( ) PA BvD; NM; Available through CVS Specialty ( ) 1

147 carteolol ophthalmic (eye) drops 1 % COMBIGAN OPHTHALMIC (EYE) DROPS % COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE -0.5 % dorzolamide ophthalmic (eye) drops % (Trusopt) dorzolamide-timolol (pf) ophthalmic (Cosopt (PF)) (eye) dropperette -0.5 % dorzolamide-timolol ophthalmic (eye) drops.-6.8 /ml (Cosopt) latanoprost ophthalmic (eye) drops (Xalatan) % levobunolol ophthalmic (eye) drops 0.5 % LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % metipranolol ophthalmic (eye) drops 0. % PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.15 % pilocarpine hcl ophthalmic (eye) drops 1 (Isopto Carpine) %, %, % SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION 1-0. % timolol maleate ophthalmic (eye) drops (Timoptic) 0.5 %, 0.5 % timolol maleate ophthalmic (eye) drops, (Istalol) once daily 0.5 % timolol maleate ophthalmic (eye) gel (Timoptic-XE) ST forming solution 0.5 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) DROPS 0.00 % ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE % Replacement Preparations Replacement Preparations calcium chloride intravenous syringe 100 /ml (10 %) d10 %-0.5 % sodium chloride intravenous parenteral solution PA BvD 15

148 d.5 %-0.5 % sodium chloride intravenous parenteral solution d5 % and 0.9 % sodium chloride intravenous parenteral solution d5 %-0.5 % sodium chloride intravenous parenteral solution dextrose 10 % and 0. % nacl intravenous parenteral solution dextrose 5%-0. % sod chloride intravenous parenteral solution dextrose 5%-0. % sod.chloride intravenous parenteral solution dextrose with sodium chloride intravenous parenteral solution 5-0. % electrolyte-8 in d5w intravenous parenteral solution IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 % ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ klor-con m10 oral tablet,er particles/crystals 10 meq klor-con m15 oral tablet,er particles/crystals 15 meq klor-con m0 oral tablet,er particles/crystals 0 meq KLOR-CON ORAL PACKET 0 MEQ klor-con sprinkle oral capsule, extended release 10 meq, 8 meq PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 16

149 magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml magnesium sulfate in water intravenous parenteral solution 0 gram/500 ml ( %), 0 gram/1,000 ml ( %) magnesium sulfate in water intravenous piggyback gram/50 ml ( %), gram/100 ml ( %) magnesium sulfate injection solution meq/ml (50 %) magnesium sulfate injection syringe meq/ml NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION NORMOSOL-R IV SOLUTION L/F, SINGLE-USE NORMOSOL-R PH 7. INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE 18 INTRAVENOUS PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION potassium chlorid-d5-0.5%nacl intravenous parenteral solution 10 meq/l, 0 meq/l, 0 meq/l potassium chlorid-d5-0.5%nacl intravenous parenteral solution 0 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 0 meq/l, 0 meq/l potassium chloride in 5 % dex intravenous parenteral solution 0 meq/l, 0 meq/l, 0 meq/l potassium chloride in lr-d5 intravenous parenteral solution 0 meq/l, 0 meq/l potassium chloride in water intravenous piggyback 10 meq/100 ml, 10 meq/50 ml, 0 meq/100 ml, 0 meq/50 ml, 0 meq/100 ml, 0 meq/100 ml PA BvD 17

150 potassium chloride intravenous solution meq/ml potassium chloride intravenous solution meq/ml (0 ml) potassium chloride oral capsule, extended release 10 meq potassium chloride oral capsule, extended (Klor-Con Sprinkle) release 8 meq potassium chloride oral liquid 0 meq/15 ml, 0 meq/15 ml potassium chloride oral packet 0 meq (Klor-Con) potassium chloride oral tablet extended (K-Tab) release 10 meq, 0 meq, 8 meq potassium chloride oral tablet,er (Klor-Con M10) particles/crystals 10 meq potassium chloride oral tablet,er (Klor-Con M0) particles/crystals 0 meq potassium chloride-0.5 % nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.%nacl intravenous parenteral solution 10 meq/l, 0 meq/l, 0 meq/l, 0 meq/l potassium chloride-d5-0.%nacl intravenous parenteral solution 0 meq/l potassium chloride-d5-0.9%nacl intravenous parenteral solution 0 meq/l, 0 meq/l potassium citrate oral tablet extended (Urocit-K 10) release 10 meq (1,080 ) potassium citrate oral tablet extended (Urocit-K 15) release 15 meq potassium citrate oral tablet extended (Urocit-K 5) release 5 meq (50 ) sodium chloride 0.5 % intravenous parenteral solution 0.5 % sodium chloride 0.5 % intravenous piggyback 0.5 % sodium chloride 0.9 % intravenous parenteral solution sodium chloride % intravenous parenteral solution % 18

151 sodium chloride 5 % intravenous parenteral solution 5 % sodium chloride intravenous parenteral solution.5 meq/ml sodium lactate intravenous solution 5 meq/ml TPN ELECTROLYTES II IV SOLN 5'S,0ML/50ML FTV MEQ/0 ML TPN ELECTROLYTES INTRAVENOUS SOLUTION MEQ/0 ML Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, 0-1 MCG/ACTUATION, 5-1 MCG/ACTUATION AEROSPAN INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 00 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, 00-5 MCG/DOSE budesonide inhalation suspension for nebulization 0.5 / ml, 0.5 / ml, 1 / ml FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION QL (60 per 0 QL (1 per 0 QL (60 per 0 (Pulmicort) PA BvD 19

152 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 0 MCG/ACTUATION, MCG/ACTUATION fluticasone-salmeterol inhalation aerosol (AirDuo RespiClick) powdr breath activated 11-1 mcg/actuation, -1 mcg/actuation, 55-1 mcg/actuation PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION QVAR INHALATION AEROSOL 0 MCG/ACTUATION, 80 MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 0 MCG/ACTUATION, 80 MCG/ACTUATION SYMBICORT INHALATION HFA QL (10. per 0 AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION Antileukotrienes montelukast oral granules in packet (Singulair) montelukast oral tablet 10 (Singulair) montelukast oral tablet,chewable, 5 (Singulair) zafirlukast oral tablet 10, 0 (Accolate) Bronchodilators albuterol sulfate inhalation solution for PA BvD nebulization 0.6 / ml, 1.5 / ml,.5 / ml (0.08 %), 5 /ml albuterol sulfate oral syrup /5 ml albuterol sulfate oral tablet, 10

153 albuterol sulfate oral tablet extended release 1 hr, 8 aminophylline intravenous solution 500 /0 ml ANORO ELLIPTA INHALATION QL (60 per 0 BLISTER WITH DEVICE MCG/ACTUATION ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION BROVANA INHALATION PA BvD SOLUTION FOR NEBULIZATION 15 MCG/ ML COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION elixophyllin oral elixir 80 /15 ml INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 6.5 MCG/ACTUATION ipratropium bromide inhalation solution PA BvD 0.0 % ipratropium-albuterol inhalation solution PA BvD for nebulization (.5 base)/ ml levalbuterol hcl inhalation solution for (Xopenex) PA BvD nebulization 0.1 / ml, 0.6 / ml, 1.5 / ml levalbuterol hcl inhalation solution for (Xopenex Concentrate) PA BvD nebulization 1.5 /0.5 ml levalbuterol tartrate inhalation hfa (Xopenex HFA) aerosol inhaler 5 mcg/actuation metaproterenol oral syrup 10 /5 ml metaproterenol oral tablet 10, 0 PERFOROMIST INHALATION PA BvD SOLUTION FOR NEBULIZATION 0 MCG/ ML PROAIR HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION 11

154 PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION SEREVENT DISKUS INHALATION QL (60 per 0 BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION QL ( per 0 MIST 1.5 MCG/ACTUATION SPIRIVA RESPIMAT INHALATION QL ( per 0 MIST.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER QL (0 per 0 INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION MIST.5-.5 MCG/ACTUATION STRIVERDI RESPIMAT QL ( per 0 INHALATION MIST.5 MCG/ACTUATION terbutaline oral tablet.5, 5 theophylline in dextrose 5 % intravenous parenteral solution 00 /100 ml, 00 /50 ml, 00 /50 ml, 00 /500 ml, 800 /50 ml theophylline oral solution 80 /15 ml theophylline oral tablet extended release (Theochron) 1 hr 100, 00, 00 theophylline oral tablet extended release 1 hr 50 theophylline oral tablet extended release hr 00, 600 TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Respiratory Tract Agents, Other acetylcysteine intravenous solution 00 /ml (0 %) (Acetadote) PA BvD 1

155 acetylcysteine solution 100 /ml (10 PA BvD %), 00 /ml (0 %) cromolyn inhalation solution for PA BvD nebulization 0 / ml DALIRESP ORAL TABLET 50 MCG, 500 MCG ESBRIET ORAL CAPSULE 67 MG 5 PA; NM; Available ( ) ESBRIET ORAL TABLET 67 MG, 801 MG 5 PA; NM; Available ( ) GLASSIA INTRAVENOUS 5 SOLUTION 1 GRAM/50 ML ( %) KALYDECO ORAL GRANULES IN 5 PA PACKET 50 MG, 75 MG KALYDECO ORAL TABLET PA MG NUCALA SUBCUTANEOUS RECON SOLN 100 MG 5 PA; LA; QL (1 per 8 OFEV ORAL CAPSULE 100 MG, 150 MG ORKAMBI ORAL GRANULES IN PACKET MG, MG ORKAMBI ORAL TABLET MG, MG PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG SYMDEKO ORAL TABLETS, SEQUENTIAL MG (D)/ 150 MG (N) XOLAIR SUBCUTANEOUS RECON SOLN 150 MG XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML, 75 MG/0.5 ML Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen oral tablet 10, 0, 5 5 PA NSO; NM; Available through CVS Specialty ( ) 5 PA 5 PA 5 5 PA; QL (56 per 8 5 PA 5 1

156 carisoprodol oral tablet 50, 50 (Soma) PA; AGE (Max 6 Years) chlorzoxazone oral tablet 50, 500 PA; AGE (Max 6 Years) cyclobenzaprine oral tablet 10, 5 PA; AGE (Max 6 Years) cyclobenzaprine oral tablet 7.5 (Fexmid) PA; AGE (Max 6 Years) dantrolene oral capsule 100 dantrolene oral capsule 5, 50 (Dantrium) metaxalone oral tablet 00 PA; AGE (Max 6 Years) metaxalone oral tablet 800 (Metaxall) PA; AGE (Max 6 Years) methocarbamol oral tablet 500 (Robaxin) PA; AGE (Max 6 Years) methocarbamol oral tablet 750 (Robaxin-750) PA; AGE (Max 6 Years) tizanidine oral capsule,, 6 (Zanaflex) tizanidine oral tablet tizanidine oral tablet (Zanaflex) Sleep Disorder Agents Sleep Disorder Agents armodafinil oral tablet 150, 00, (Nuvigil) PA 50, 50 BELSOMRA ORAL TABLET 10 MG, ST 15 MG, 0 MG, 5 MG eszopiclone oral tablet 1,, (Lunesta) QL (0 per 0 HETLIOZ ORAL CAPSULE 0 MG 5 PA; QL (0 per 0 modafinil oral tablet 100, 00 (Provigil) PA ROZEREM ORAL TABLET 8 MG ST XYREM ORAL SOLUTION LA MG/ML zaleplon oral capsule 10, 5 QL (0 per 0 zolpidem oral tablet 10, 5 (Ambien) QL (0 per 0 zolpidem oral tablet,ext release (Ambien CR) QL (0 per 0 multiphase 1.5, 6.5 ZOLPIMIST ORAL SPRAY,NON- AEROSOL 5 MG/SPRAY (0.1 ML) ST; QL (8 per 0 1

157 Vasodilating Agents Vasodilating Agents ADCIRCA ORAL TABLET 0 MG 5 PA; NM; Available ( ) ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, MG,.5 MG CIALIS ORAL TABLET 10 MG, 0 MG CIALIS ORAL TABLET.5 MG, 5 MG epoprostenol (glycine) intravenous recon soln 0.5 epoprostenol (glycine) intravenous recon soln 1.5 LETAIRIS ORAL TABLET 10 MG, 5 MG 5 PA; NM; Available ( ) EX; CB ( EA per 0 PA; QL (0 per 0 (Flolan) PA BvD (Flolan) 5 PA BvD 5 PA; NM; Available ( ) EX; CB ( EA per 0 LEVITRA ORAL TABLET 10 MG,.5 MG, 0 MG, 5 MG OPSUMIT ORAL TABLET 10 MG 5 PA; NM; Available ( ) REVATIO ORAL SUSPENSION FOR RECONSTITUTION 10 MG/ML sildenafil (antihypertensive) oral tablet 0 sildenafil oral tablet 100, 5, 50 STAXYN ORAL TABLET,DISINTEGRATING 10 MG tadalafil (antihypertensive) oral tablet 0 5 PA; NM; Available ( ) (Revatio) PA (Viagra) EX; CB ( EA per 0 EX; CB ( EA per 0 (Adcirca) 5 PA; NM; Available ( ) tadalafil oral tablet 10, 0 (Cialis) EX; CB ( EA per 0 tadalafil oral tablet.5, 5 (Cialis) PA 15

158 TRACLEER ORAL TABLET 15 MG, 6.5 MG TRACLEER ORAL TABLET FOR SUSPENSION MG UPTRAVI ORAL TABLET 1,000 MCG, 1,00 MCG, 1,00 MCG, 1,600 MCG, 00 MCG, 600 MCG, 800 MCG 5 PA; NM; LA; Available through CVS Specialty ( ) 5 PA; NM; Available ( ) 5 PA; NM; Available ( ); QL (60 per 0 UPTRAVI ORAL TABLET 00 MCG 5 PA; NM; Available ( ); QL (0 per 0 UPTRAVI ORAL TABLETS,DOSE PACK 00 MCG (10)- 800 MCG (60) vardenafil oral tablet 10,.5, 0, 5 vardenafil oral tablet,disintegrating 10 VENTAVIS INHALATION SOLUTION FOR NEBULIZATION 10 MCG/ML, 0 MCG/ML Vitamins And Minerals Vitamins And Minerals cyanocobalamin (vitamin b-1) injection solution 1,000 mcg/ml ergocalciferol (vitamin d) oral capsule 50,000 unit FLUORIDE (SODIUM) ORAL TABLET 1 MG (. MG SOD. FLUORIDE) 5 PA; NM; Available ( ); QL (00 per 65 (Levitra) EX; CB ( EA per 0 (Staxyn) EX; CB ( EA per 0 5 PA; NM; Available ( ) EX 1 GC; EX; QL ( per 8 folic acid oral tablet 1 1 GC; EX LUDENT FLUORIDE 1 MG TAB CHEW D/F, S/F, CHEWABLE (OTC) 1 MG (. MG SOD. FLUORIDE) pnv prenatal plus multivit tab s/f, glutenfree 7 iron- 1 16

159 prenatal vitamin plus low iron oral tablet 7 iron- 1 17

160 18

161 INDEX Index abacavir...59 abacavir-lamivudine abacavir-lamivudine-zidovudine 59 ABELCET... 6 ABILIFY MAINTENA ABSTRAL... acamprosate... 9 acarbose... 0 acebutolol acetaminophen-codeine... acetazolamide... 1 acetic acid , 10 acetylcysteine... 1, 1 acitretin ACTEMRA ACTHAR H.P... 1 ACTHIB (PF) ACTIMMUNE...1 acyclovir... 6, 96 acyclovir sodium...6, 65 ADACEL(TDAP ADOLESN/ADULT)(PF)...16 adapalene adapalene-benzoyl peroxide...10 ADASUVE...55 ADCIRCA...15 adefovir ADEMPAS...15 adriamycin...1 adrucil... 1 ADVAIR DISKUS...19 ADVAIR HFA AEROSPAN...19 afeditab cr AFINITOR... 1 AFINITOR DISPERZ... 1 a-hydrocort Index AIMOVIG AUTOINJECTOR AIMOVIG AUTOINJECTOR ( PACK) 50 AJOVY ala-cort...98 ala-scalp albendazole...5 ALBENZA... 5 albuterol sulfate...10, 11 alclometasone ALCOHOL PADS...96 ALECENSA... 1 alendronate alfuzosin ALINIA...5 allopurinol... 8 alosetron...19 ALPHAGAN P... 1 alprazolam...10 ALTABAX altavera (8) ALUNBRIG... 1, alyacen 1/5 (8) alyacen 7/7/7 (8) amabelz amantadine hcl...5 AMBISOME... 6 amethia...88 amethia lo...88 amifostine crystalline... 1 amikacin...1 amiloride amiloride-hydrochlorothiazide..80 aminocaproic acid aminophylline...11 AMINOSYN 10 % Index AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 10 %...70 AMINOSYN II 7 %...70 AMINOSYN II 8.5 %...70 AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M.5 %...70 AMINOSYN-HBC 7%...70 AMINOSYN-PF 10 %...70 AMINOSYN-PF 7 % (SULFITE-FREE)...70 AMINOSYN-RF 5. %...70 amiodarone...75 AMITIZA amitriptyline... 7 amitriptyline-chlordiazepoxide. 7 amlodipine amlodipine-atorvastatin amlodipine-benazepril amlodipine-olmesartan...80 amlodipine-valsartan...80 amlodipine-valsartan-hcthiazid.80 ammonium lactate...96 amnesteem...96 amoxapine... 7 amoxicil-clarithromy-lansopraz amoxicillin...17 amoxicillin-pot clavulanate.17, 18 amphotericin b... 6 ampicillin...18 ampicillin sodium ampicillin-sulbactam AMPYRA...8 I-1

162 Index ANADROL anagrelide...69 anastrozole... ANDRODERM ANDROGEL ANORO ELLIPTA ANZEMET APOKYN...5 apraclonidine aprepitant... 51, 5 apri...88 APRISO...19 APTIOM... APTIVUS aranelle (8) ARANESP (IN POLYSORBATE)...67, 68 ARCALYST...11 ARIKAYCE...1 aripiprazole ARISTADA armodafinil... 1 ARNUITY ELLIPTA ARYMO ER... ARZERRA... ashlyna aspirin-dipyridamole ASSURE ID INSULIN SAFETY...10 atazanavir...59 atenolol...76 atenolol-chlorthalidone...76 atomoxetine...8 atorvastatin atovaquone... 5 atovaquone-proguanil...5 ATRIPLA...59 atropine..., 10 ATROVENT HFA AUBAGIO... 8 Index aubra AUGMENTIN...18 AURYXIA AUSTEDO... 8 AVC VAGINAL... 9 aviane avita AVONEX AVONEX (WITH ALBUMIN)...8 AZASITE azathioprine azelaic acid azelastine...10 azithromycin...16 AZOPT... 1 aztreonam...17 azurette (8) bacitracin bacitracin-polymyxin b baclofen... 1 BACTROBAN NASAL balsalazide balziva (8)...88 BANZEL... BARACLUDE BAXDELA...19 BCG VACCINE, LIVE (PF) 16 BD ULTRA-FINE NANO PEN NEEDLE BD VEO INSULIN SYR HALF UNIT BD VEO INSULIN SYRINGE UF...10 bekyree (8)...88 BELSOMRA... 1 benazepril... 7 benazepril-hydrochlorothiazide.7 BENDEKA... BENLYSTA... 1 Index benznidazole... 5 benzonatate benztropine... 5 BESIVANCE BESPONSA... betamethasone acet,sod phos betamethasone dipropionate betamethasone valerate betamethasone, augmented...99 betaxolol... 76, 1 bethanechol chloride...11 BETHKIS...1 BETIMOL... 1 bexarotene... BEXSERO bicalutamide... BICILLIN C-R...18 BICILLIN L-A BIDIL... 8 BIKTARVY bimatoprost...1 bisoprolol fumarate...76 bisoprolol-hydrochlorothiazide. 76 BIVIGAM bleomycin... BLEPHAMIDE BLEPHAMIDE S.O.P BLINCYTO... blisovi fe...88 blisovi fe 1.5/0 (8)...88 blisovi fe 1/0 (8) BOOSTRIX TDAP...16 BOSULIF... BRAFTOVI... BREO ELLIPTA BREVIBLOC IN NACL (ISO-OSM) briellyn BRILINTA...69 brimonidine...1 I-

163 Index BRIVIACT... bromfenac bromocriptine... 5 BROVANA budesonide...19, 19 bumetanide buprenorphine... buprenorphine hcl... 9 buprenorphine-naloxone...9 bupropion hcl... 7, 8 bupropion hcl (smoking deter)...9 buspirone butalbital compound w/codeine... butalbital-acetaminop-caf-cod... butalbital-acetaminophen... butalbital-acetaminophen-caff, butalbital-aspirin-caffeine... butorphanol tartrate... BYSTOLIC...76 cabergoline... 5 CABOMETYX... calcipotriene calcipotriene-betamethasone calcitonin (salmon)...10 calcitrene calcitriol...96, 10 calcium acetate calcium chloride CALQUENCE... camila...88 camrese camrese lo...88 CANASA...10 candesartan... 7 candesartan-hydrochlorothiazid7 capacet... CAPRELSA... captopril... 7 captopril-hydrochlorothiazide...7 CARAFATE Index CARBAGLU carbamazepine... carbidopa...5 carbidopa-levodopa... 5, 5 carbidopa-levodopa-entacapone 5 CARDIZEM LA CARIMUNE NF NANOFILTERED...11 carisoprodol... 1 carmustine... carteolol...15 cartia xt...77 carvedilol carvedilol phosphate...76 caspofungin...6 CAYSTON caziant (8) cefaclor...1 cefadroxil... 1 cefazolin... 1 cefdinir... 1 cefditoren pivoxil... 1 cefepime cefixime...15 cefotaxime...15 cefotetan...15 cefoxitin cefpodoxime cefprozil...15 ceftazidime ceftriaxone cefuroxime axetil cefuroxime sodium celecoxib... 7 CELONTIN... cephalexin...15 CEPROTIN (BLUE BAR)...66 CERDELGA cetirizine...9 CETYLEV...1 Index cevimeline CHANTIX... 9 CHANTIX CONTINUING MONTH BOX...9 CHANTIX STARTING MONTH BOX...9 chateal (8) CHEMET chlordiazepoxide hcl...10 chlordiazepoxide-clidinium... chlorhexidine gluconate...95 chloroquine phosphate...5 chlorothiazide chlorpromazine chlorthalidone chlorzoxazone...1 CHOLBAM cholestyramine (with sugar) cholestyramine light...81 CIALIS ciclopirox...6, 7 cilostazol CILOXAN CIMDUO cimetidine cimetidine hcl cinacalcet...11 CINRYZE CIPRO HC CIPRODEX ciprofloxacin...19 ciprofloxacin (mixture) ciprofloxacin hcl... 19, 105, 106 ciprofloxacin in 5 % dextrose citalopram... 8 claravis clarithromycin CLENPIQ CLEVIPREX...80 CLIMARA PRO I-

164 Index clindamycin hcl... 1 clindamycin in 5 % dextrose... 1 clindamycin palmitate hcl...1 clindamycin phosphate... 1, 9, 97, 98 clindamycin-benzoyl peroxide.. 98 CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D5W SULFITE-FREE CLINIMIX.75%/D5W SULFIT FREE...70 CLINIMIX.5%/D10W SULF FREE...70 CLINIMIX.5%/D5W SULFIT FREE...71 CLINIMIX.5%-D0W SULF-FREE CLINIMIX.5%-D5W SULF-FREE CLINIMIX 5%- D0W(SULFITE-FREE) clobazam clobetasol...99 clobetasol-emollient clocortolone pivalate clomipramine... 8 clonazepam...10 clonidine... 7 clonidine hcl... 7, 85 clopidogrel...69 clorazepate dipotassium clorpres...7 clotrimazole...7 clotrimazole-betamethasone... 7 clozapine...55 COARTEM... 5 codeine sulfate... colchicine...8 colesevelam...81 Index colestipol...81, 8 colistin (colistimethate na)... 1 colocort...10 COLY-MYCIN S COMBIGAN COMBIVENT RESPIMAT. 11 COMETRIQ... COMPLERA...59 compro... 5 constulose COPIKTRA... CORDRAN TAPE LARGE ROLL CORLANOR cormax CORTIFOAM...99 cortisone CORTISPORIN COSENTYX ( SYRINGES).96 COSENTYX PEN ( PENS).. 96 COSOPT (PF)...15 COTELLIC... CREON CRESEMBA... 7 CRIXIVAN cromolyn...10, 110, 1 cryselle (8)...89 CUVITRU...11 cyanocobalamin (vitamin b-1) cyclafem 1/5 (8) cyclafem 7/7/7 (8) cyclobenzaprine...1 cyclopentolate...10 cyclophosphamide... CYCLOPHOSPHAMIDE... cycloserine...51 cyclosporine cyclosporine modified...11 cyproheptadine...9 Index cyred cyred eq CYSTADANE...1 CYSTAGON CYSTARAN CYTOGAM...11 d10 %-0.5 % sodium chloride 15 d.5 %-0.5 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.5 % sodium chloride..16 dacarbazine... dalfampridine...85 DALIRESP...1 DALVANCE...1 danazol dantrolene...1 dapsone...51, 96 DAPTACEL (DTAP PEDIATRIC) (PF) daptomycin... 1 DARAPRIM... 5 darifenacin...11 DARZALEX... dasetta 1/5 (8)...89 dasetta 7/7/7 (8)...89 daunorubicin... DAXBIA daysee...89 deblitane...89 DELESTROGEN DELSTRIGO deltasone delyla (8) DELZICOL demeclocycline...0 DEMSER DENAVIR denta 5000 plus I-

165 Index dentagel...95 DEPEN TITRATABS...11 DEPO-ESTRADIOL DEPO-PROVERA DEPO-SUBQ PROVERA DESCOVY desipramine... 8 desloratadine... 9 desmopressin desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol DESONATE...99 desonide... 99, 100 desoximetasone DESVENLAFAXINE...8 desvenlafaxine succinate... 8 dexamethasone DEXAMETHASONE INTENSOL dexamethasone sodium phos (pf) dexamethasone sodium phosphate...108, 116, 117 dexmethylphenidate dexrazoxane hcl... 1 dextroamphetamine dextroamphetamineamphetamine dextrose 10 % and 0. % nacl. 16 dextrose 10 % in water (d10w) 71 dextrose 0 % in water (d0w) 71 dextrose 5 % in water (d5w) 71 dextrose 0 % in water (d0w) 71 dextrose 5 % in ringer's dextrose 5 % in water (d5w) dextrose 5%-0. % sod chloride dextrose 5%-0. % sod.chloride Index dextrose 50 % in water (d50w) 71 dextrose 70 % in water (d70w) 71 dextrose with sodium chloride.16 DIASTAT ACUDIAL diazepam diazepam intensol...11 diclofenac potassium...7 diclofenac sodium... 7, 108 diclofenac-misoprostol... 7 dicloxacillin dicyclomine didanosine...60 DIFICID diflorasone diflunisal...7 digitek digox DIGOXIN digoxin dihydroergotamine DILANTIN... diltiazem hcl...77, 78 dilt-xr DIPENTUM...10 diphenhydramine hcl... 9 diphenoxylate-atropine disulfiram... 9 divalproex... dobutamine dobutamine in d5w DOCEFREZ... docetaxel... dofetilide...75 donepezil...6 dopamine dopamine in 5 % dextrose...79 doripenem...17 dorzolamide dorzolamide-timolol dorzolamide-timolol (pf)...15 Index doxazosin... 7 doxepin... 8, 96 doxorubicin... doxorubicin, peg-liposomal... doxy doxycycline hyclate...0 doxycycline monohydrate...0 dronabinol... 5 droperidol... 1 drospirenone-e.estradiol-lm.fa.. 89 drospirenone-ethinyl estradiol.. 89 DROXIA... DUAVEE duloxetine...8 DUPIXENT...97, 11 DUREZOL dutasteride dutasteride-tamsulosin e.e.s E.E.S. GRANULES econazole...7 EDURANT efavirenz EGRIFTA electrolyte-8 in d5w ELESTRIN eletriptan ELIDEL elinest eliphos ELIQUIS elixophyllin ELLA...89 ELMIRON... 1 EMBEDA... EMCYT... EMGALITY PEN...50 EMGALITY SYRINGE emoquette EMSAM... 8 I-5

166 Index EMTRIVA EMVERM... 5 enalapril maleate... 7 enalapril-hydrochlorothiazide...7 ENBREL ENBREL SURECLICK...1 ENDARI... 1 endocet... ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF)...16 enoxaparin...66 enpresse enskyce...89 entacapone...5 entecavir ENTRESTO... 7 enulose EPANED...7 EPCLUSA... 6 EPIDIOLEX... epinastine...10 epinephrine epirubicin... epitol... EPIVIR HBV...60 eplerenone...8 epoprostenol (glycine) eprosartan... 7 ERAXIS(WATER DILUENT)...7 ERBITUX... ergocalciferol (vitamin d) ergotamine-caffeine ERIVEDGE... ERLEADA... errin ery pads ERYPED ery-tab...16 Index ERY-TAB...16 ERYTHROCIN erythrocin (as stearate) erythromycin...17, 106 erythromycin ethylsuccinate...16 erythromycin with ethanol...98 erythromycin-benzoyl peroxide 98 ESBRIET...1 escitalopram oxalate...8 esmolol esomeprazole magnesium estarylla...89 estradiol estradiol valerate estradiol-norethindrone acet estropipate eszopiclone...1 ethacrynic acid...80 ethambutol...51 ethosuximide... ethynodiol diac-eth estradiol...90 etidronate disodium...11 etodolac...7 EURAX...10 EVOTAZ EXELDERM...7 exemestane... EXJADE...11 ezetimibe... 8 ezetimibe-simvastatin...8 FABRAZYME falmina (8)...90 famciclovir...65 famotidine FANAPT...56 FARESTON... FARYDAK... fayosim...90 felbamate... felodipine...80 Index femynor fenofibrate... 8 fenofibrate micronized... 8 fenofibrate nanocrystallized... 8 fenofibric acid...8 fenofibric acid (choline)...8 fenoprofen... 7 fentanyl... fentanyl citrate... FENTORA... FERRIPROX FETZIMA... 8 FINACEA finasteride...11 FIRAZYR FIRMAGON KIT W DILUENT SYRINGE... FIRVANQ...1 flavoxate...11 FLEBOGAMMA DIF... 1 flecainide FLECTOR... 7 FLOVENT DISKUS...19, 10 FLOVENT HFA floxuridine... fluconazole... 7 fluconazole in nacl (iso-osm)... 7 flucytosine... 7 fludarabine... fludrocortisone flunisolide fluocinolone fluocinolone acetonide oil fluocinolone and shower cap fluocinonide fluocinonide-e FLUORIDE (SODIUM)...16 fluorometholone fluorouracil..., 97 fluoxetine...9 I-6

167 Index fluphenazine decanoate fluphenazine hcl flurandrenolide flurbiprofen... 8 flurbiprofen sodium flutamide... fluticasone , 108 fluticasone-salmeterol fluvoxamine... 9 FML FORTE FML S.O.P folic acid FOLOTYN... fondaparinux FORTEO fosamprenavir foscarnet...6 fosinopril... 7 fosinopril-hydrochlorothiazide..7 fosphenytoin... FOSRENOL...11 FREAMINE HBC 6.9 %...71 FREAMINE III 10 %...71 frovatriptan furosemide FUZEON FYCOMPA... gabapentin... GALAFOLD...10 galantamine... 6, 7 GAMASTAN S/D... 1 GAMMAGARD LIQUID... 1 GAMMAGARD S-D (IGA < 1 MCG/ML)... 1 GAMMAKED... 1 GAMMAPLEX...1 GAMMAPLEX (WITH SORBITOL)... 1 GAMUNEX-C... 1 GARDASIL 9 (PF)...16 Index GATTEX 0-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n GAZYVA... gemcitabine... gemfibrozil...8 generlac gengraf... 1 gentak gentamicin... 1, 98, 106 gentamicin in nacl (iso-osm)...1 gentamicin sulfate (ped) (pf).. 1 gentamicin sulfate (pf)... 1 GENVOYA GEODON...56 gianvi (8) GILENYA...85 GILOTRIF... GLASSIA... 1 glatiramer... 85, 86 glatopa GLEOSTINE... glimepiride...5 glipizide... 5 glipizide-metformin...5 GLUCAGEN HYPOKIT... 0 GLUCAGON EMERGENCY KIT (HUMAN)...0 glyburide...6 glyburide micronized...6 glyburide-metformin... 6 glycopyrrolate granisetron hcl... 5 GRANIX...68 griseofulvin microsize...7 griseofulvin ultramicrosize... 7 guanfacine... 7 Index guanidine... 1 HAEGARDA...68 hailey fe halobetasol propionate haloperidol...56 haloperidol decanoate haloperidol lactate HARVONI... 6 HAVRIX (PF)...16, 17 heather heparin (porcine)...66, 67 heparin (porcine) in nacl (pf)..66 HEPARIN(PORCINE) IN 0.5% NACL heparin, porcine (pf)...67 HEPATAMINE 8%...71 HERCEPTIN... HETLIOZ...1 HEXALEN...5 HIBERIX (PF) HIZENTRA... 1 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... 1 HUMIRA PEDIATRIC CROHNS START...1 HUMIRA PEN... 1 I-7

168 Index HUMIRA PEN CROHNS- UC-HS START... 1 HUMIRA PEN PSOR- UVEITS-ADOL HS... 1 HUMIRA(CF)...1 HUMIRA(CF) PEDI CROHNS STARTER...1 HUMIRA(CF) PEN...1 HUMIRA(CF) PEN CROHNS-UC-HS... 1 HUMIRA(CF) PEN PSOR- UV-ADOL HS...1 HUMULIN 70/0 U-100 INSULIN... HUMULIN 70/0 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... hydralazine hydrochlorothiazide hydrocodone-acetaminophen.., 5 hydrocodone-chlorpheniramine.95 hydrocodone-homatropine...95 hydrocodone-ibuprofen... 5 hydrocortisone.100, 101, 117, 10 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydrocortisone-acetic acid hydrocortisone-pramoxine hydromorphone...5 Index hydromorphone (pf)... 5 hydroxychloroquine... 5 hydroxyurea... 5 hydroxyzine hcl...9 hydroxyzine pamoate... 1 HYPERHEP B S/D... 1 HYPERHEP B S-D NEONATAL...1 HYPERRAB (PF)... 1 HYQVIA... 1 ibandronate...11 IBRANCE... 5 ibu...8 ibuprofen... 8 ibuprofen lysine (pf)...8 ibuprofen-oxycodone...5 ICLUSIG...5 idarubicin...5 IDHIFA...5 ifosfamide...5 ifosfamide-mesna... 5 ILARIS (PF)...1 ILEVRO imatinib... 5 IMBRUVICA...5 imipenem-cilastatin...17 imipramine hcl... 9 imipramine pamoate...9 imiquimod...97 IMLYGIC... 5 IMOVAX RABIES VACCINE (PF) IMPAVIDO...5 incassia...90 INCRELEX INCRUSE ELLIPTA indapamide INDOCIN... 8 indomethacin... 8 indomethacin sodium...8 Index INFANRIX (DTAP) (PF) INGREZZA INLYTA...6 INSULIN SYRINGE- NEEDLE U INTELENCE INTRALIPID...7 INTRON A... 6 introvale INVANZ INVEGA SUSTENNA...56, 57 INVEGA TRINZA INVIRASE INVOKAMET... 0 INVOKAMET XR...1 INVOKANA... 1 IONOSOL-B IN D5W...16 IONOSOL-MB IN D5W IPOL ipratropium bromide , 11 ipratropium-albuterol...11 irbesartan... 7 irbesartan-hydrochlorothiazide.7 IRESSA... 6 irinotecan...6 ISENTRESS ISENTRESS HD isibloom ISOLYTE-P IN 5 % DEXTROSE...16 ISOLYTE-S isoniazid isosorbide dinitrate...8 isosorbide mononitrate... 8 isotretinoin isradipine...80 itraconazole... 7 ivermectin... 5 IXEMPRA... 6 IXIARO (PF)...17 I-8

169 Index JAKAFI...6 jantoven...67 JANUMET...1 JANUMET XR... 1 JANUVIA... 1 JARDIANCE... 1 jencycla JENTADUETO...1 JENTADUETO XR...1 jinteli jolessa...90 jolivette...90 juleber JULUCA junel 1.5/0 (1)...90 junel 1/0 (1)...90 junel fe 1.5/0 (8) junel fe 1/0 (8)...90 junel fe JUXTAPID... 8 JYNARQUE KABIVEN...7 KADIAN... 5 kaitlib fe KALETRA... 60, 61 KALYDECO...1 kariva (8)...90 KEDRAB (PF)... 1 kelnor 1/5 (8) kelnor ketoconazole...7 ketoprofen... 8 ketorolac KEVEYIS... 1 kimidess (8) KINERET... 1 KINRIX (PF) kionex (with sorbitol) KISQALI...6 Index KISQALI FEMARA CO- PACK... 6 KLOR-CON KLOR-CON KLOR-CON klor-con m klor-con m klor-con m klor-con sprinkle KORLYM... 1 kurvelo (8) KUVAN l norgest/e.estradiol-e.estrad...91 labetalol...76 lactulose lamivudine lamivudine-zidovudine lamotrigine... lansoprazole lanthanum...11 LANTUS SOLOSTAR U-100 INSULIN... LANTUS U-100 INSULIN... larin 1.5/0 (1) larin 1/0 (1)...91 larin fe larin fe 1.5/0 (8) larin fe 1/0 (8) larissia...91 LASTACAFT latanoprost...15 LATUDA ledipasvir-sofosbuvir... 6 leena leflunomide... 1 LENVIMA... 6 lessina...91 LETAIRIS letrozole...6 leucovorin calcium...1 Index LEUKERAN...6 LEUKINE...68 leuprolide...6 levalbuterol hcl...11 levalbuterol tartrate LEVATOL...76 LEVEMIR FLEXTOUCH U- 100 INSULN... LEVEMIR U-100 INSULIN.. levetiracetam... 5 LEVITRA...15 levobunolol...15 levocarnitine... 1 levocarnitine (with sugar)... 1 levocetirizine...9 levofloxacin... 19, 0, 106 levofloxacin in d5w LEVOLEUCOVORIN CALCIUM... 1 levoleucovorin calcium...1 levonest (8) levonorgestrel-ethinyl estrad...91 levonorg-eth estrad triphasic levora levorphanol tartrate... 5 levothyroxine LEVOXYL LEXIVA lidocaine... 9 lidocaine (pf)...8, 9, 75 lidocaine hcl...9 lidocaine in 5 % dextrose (pf).. 75 lidocaine viscous... 9 lidocaine-prilocaine...9 lillow (8) lindane...10 linezolid... 1 linezolid in dextrose 5%... 1 linezolid-0.9% sodium chloride. 1 LINZESS I-9

170 Index liothyronine...10 lisinopril... 7 lisinopril-hydrochlorothiazide...7 lithium carbonate lithium citrate LITHOSTAT...1 LIVALO... 8 LONSURF... 6 loperamide lopinavir-ritonavir...61 lopreeza lorazepam...11 LORBRENA... 7 lorcet (hydrocodone)...5 lorcet hd... 5 lorcet plus...5 loryna (8)...91 losartan... 7 losartan-hydrochlorothiazide...7 LOTEMAX lovastatin...8 low-ogestrel (8)...91 loxapine succinate...57 LUDENT FLUORIDE...16 LUMIGAN LUPANETA PACK (1 MONTH) LUPANETA PACK ( MONTH) LUPRON DEPOT... 7 LUPRON DEPOT ( MONTH)...7 LUPRON DEPOT ( MONTH)...7 LUPRON DEPOT (6 MONTH)...7 lutera (8)...91 LYNPARZA... 7 LYRICA...5 LYSODREN... 7 Index lyza magnesium sulfate...17 magnesium sulfate in d5w...17 magnesium sulfate in water MAKENA MAKENA (PF) malathion...10 maprotiline... 9 marlissa (8)...9 MARPLAN...9 MARQIBO...7 marten-tab...5 MATULANE... 7 matzim la...78 MAVYRET... 6 meclizine...5 meclofenamate...8 medroxyprogesterone...10 mefloquine... 5 megestrol... 7, 10 MEKINIST... 7 MEKTOVI... 7 melodetta fe... 9 meloxicam... 8 memantine... 7 MENACTRA (PF) MENTAX... 7 MENVEO A-C-Y-W-15-DIP (PF)...17 mercaptopurine...7 meropenem mesalamine MESNEX... 1 MESTINON... 1 metaproterenol...11 metaxalone... 1 metformin... 1, methadone... 5 methadose...5 methenamine hippurate... 1 Index methimazole...10 methocarbamol... 1 methotrexate sodium...8 methotrexate sodium (pf)... 8 methoxsalen...97 methscopolamine methyclothiazide...81 methylergonovine... 1 methylphenidate hcl...86, 87 methylprednisolone methylprednisolone acetate methylprednisolone sodium succ methyltestosterone metipranolol...15 metoclopramide hcl...110, 111 metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz 76 metoprolol tartrate...76, 77 metronidazole... 1, 9, 98 metronidazole in nacl (iso-os)..1 mexiletine mibelas fe...9 miconazole-...8 microgestin 1.5/0 (1)... 9 microgestin 1/0 (1)... 9 microgestin fe 1.5/0 (8)...9 microgestin fe 1/0 (8)...9 midazolam midazolam (pf) midodrine...7 miglustat...10 mili...9 milrinone mimvey mimvey lo minitran...8 minocycline... 0, 1 minoxidil... 8 I-10

171 Index mirtazapine...9 misoprostol M-M-R II (PF) modafinil... 1 moexipril... 7 moexipril-hydrochlorothiazide..7 molindone mometasone...101, 108 mono-linyah...9 mononessa (8)...9 montelukast MONUROL... 1 MORPHABOND ER...5 morphine... 6 MORPHINE... 6 morphine concentrate...5 MOVANTIK MOVIPREP moxifloxacin... 0, 106 moxifloxacin in nacl (iso-osm) 0 moxifloxacin-sod.ace,sul-water 0 MULPLETA MULTAQ mupirocin...98 mupirocin calcium...98 mutamycin...8 MYCAMINE... 8 mycophenolate mofetil... 1 mycophenolate sodium... 1 MYOBLOC... 1 myorisan...97 MYRBETRIQ MYTESI myzilra... 9 nabumetone... 8 nadolol...77 nadolol-bendroflumethiazide nafcillin nafcillin in dextrose iso-osm naftifine...8 Index naloxone...9 naltrexone... 9 NAMENDA XR... 7 NAMZARIC... 7 naproxen... 8 naproxen sodium...8 naratriptan NARCAN...10 NATACYN nateglinide... NATPARA...11 NEBUPENT...5 necon 0.5/5 (8)... 9 necon 7/7/7 (8)... 9 nefazodone...9 neomycin... 1 neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc neo-polycin neo-polycin hc NEPHRAMINE 5. %... 7 NERLYNX... 8 NEULASTA...68 NEUPOGEN...68 NEUPRO... 5 NEVANAC nevirapine NEXAVAR... 8 niacin...8 niacor... 8 nicardipine...80 NICOTROL NICOTROL NS nifedipine...80 Index nikki (8)...9 nilutamide...8 nimodipine NINLARO... 8 NITRO-BID... 8 nitrofurantoin... 1 nitrofurantoin macrocrystal... 1 nitrofurantoin monohyd/mcryst... 1 nitroglycerin... 8 nitroglycerin in 5 % dextrose...8 nora-be... 9 NORDITROPIN FLEXPRO norepinephrine bitartrate...79 noreth-ethinyl estradiol-iron...9 norethindrone (contraceptive)..9 norethindrone acetate...10 norethindrone ac-eth estradiol...9, 116 norethindrone-e.estradiol-iron... 9, 9 norgestimate-ethinyl estradiol.. 9 norlyda... 9 norlyroc...9 NORMOSOL-M IN 5 % DEXTROSE...17 NORMOSOL-R NORMOSOL-R PH NORTHERA... 7 nortrel 0.5/5 (8)...9 nortrel 1/5 (1)...9 nortrel 1/5 (8)...9 nortrel 7/7/7 (8)...9 nortriptyline...9 NORVIR NOVOLIN 70/0 U-100 INSULIN... NOVOLIN 70-0 FLEXPEN U I-11

172 Index NOVOLIN N NPH U-100 INSULIN... NOVOLIN R REGULAR U- 100 INSULN... NOVOLOG FLEXPEN U- 100 INSULIN... NOVOLOG MIX 70-0 U- 100 INSULN... NOVOLOG MIX 70-0FLEXPEN U NOVOLOG PENFILL U-100 INSULIN... NOVOLOG U-100 INSULIN ASPART...5 NOXAFIL...8 NUCALA... 1 NUEDEXTA...87 NUPLAZID NUVARING...9 nyamyc...8 NYMALIZE...80 nystatin...8 nystatin-triamcinolone... 8 nystop...8 OCALIVA ocella...9 OCREVUS OCTAGAM...1 octreotide acetate , 119 ODEFSEY...61 ODOMZO... 8 OFEV...1 ofloxacin... 0, 107 ogestrel (8)... 9 olanzapine olmesartan...7 olmesartan-amlodipin-hcthiazid7 olmesartan-hydrochlorothiazide7 olopatadine omega- acid ethyl esters... 8 Index OMEGAVEN...7 omeprazole OMNITROPE ONCASPAR... 8 ondansetron... 5 ondansetron hcl...5 ONFI ONIVYDE... 8 ONMEL... 8 OPDIVO...8 OPSUMIT oralone ORENCIA...1 ORENCIA CLICKJECT... 1 ORFADIN ORKAMBI...1 orsythia... 9 oseltamivir...6 OSPHENA OTEZLA... 1 OTEZLA STARTER...1 oxacillin...18 oxacillin in dextrose(iso-osm)..18 oxaliplatin... 8 oxandrolone...11 oxaprozin... 8 oxazepam oxcarbazepine...5 oxiconazole...8 oxybutynin chloride... 11, 11 oxycodone... 6 oxycodone-acetaminophen... 6 oxycodone-aspirin...6 OXYCONTIN...6 oxymorphone...6 OZEMPIC... pacerone paliperidone pamidronate...11 PANRETIN Index pantoprazole PANZYGA...15 paricalcitol...11 paroex oral rinse...95 paromomycin... 5 paroxetine hcl... 9 paroxetine mesylate(menop.sym)...1 PASER PAXIL... 9 PEDIARIX (PF)...17 PEDVAX HIB (PF)...17 peg 50-electrolytes...11 PEGANONE...5 PEGASYS... 6 PEGASYS PROCLICK... 6 peg-electrolyte soln PEGINTRON... 6 PEN NEEDLE, DIABETIC.10 penicillin g pot in dextrose...19 penicillin g potassium penicillin g procaine penicillin g sodium...19 penicillin v potassium PENTACEL (PF) PENTACEL DTAP-IPV COMPNT (PF) PENTAM... 5 PENTASA pentoxifylline...69 PERFOROMIST...11 PERIKABIVEN...7 perindopril erbumine periogard permethrin perphenazine...58 perphenazine-amitriptyline...0 pfizerpen-g...19 phenelzine...0 phenobarbital...5 I-1

173 Index phenoxybenzamine...7 phenylephrine hcl...7, 105 phenytoin...5 phenytoin sodium... 5 phenytoin sodium extended...5 philith... 9 PHOSPHOLINE IODIDE phrenilin forte(with caffeine)...6 PICATO PIFELTRO...61 pilocarpine hcl... 96, 15 pimecrolimus pimozide pimtrea (8)...9 pindolol...77 pioglitazone... pioglitazone-glimepiride... pioglitazone-metformin... piperacillin-tazobactam...19 pirmella... 9 piroxicam... 8 PLASMA-LYTE PLASMA-LYTE A...17 PLENAMINE... 7 podofilox polycin polyethylene glycol polymyxin b sulfate...1 polymyxin b sulf-trimethoprim107 POMALYST... 8 portia PORTRAZZA...9 potassium chlorid-d5-0.5%nacl potassium chloride...18 potassium chloride in 0.9%nacl potassium chloride in 5 % dex.17 potassium chloride in lr-d potassium chloride in water Index potassium chloride-0.5 % nacl potassium chloride-d5-0.%nacl...18 potassium chloride-d5-0.%nacl...18 potassium chloride-d5-0.9%nacl...18 potassium citrate...18 PRADAXA pramipexole...5 prasugrel...69 pravastatin...8 praziquantel...5 prazosin...7 PRED MILD PRED-G PRED-G S.O.P prednicarbate prednisolone prednisolone acetate prednisolone sodium phosphate...108, 117 prednisone PREDNISONE INTENSOL 117 PREMARIN PREMASOL 10 %...7 PREMASOL 6 %...7 PREMPHASE PREMPRO prenatal plus (calcium carb).. 16 prenatal vitamin plus low iron.17 PREPOPIK...11 prevalite...8 PREVIDENT 5000 BOOSTER PLUS previfem...9 PREZCOBIX...61 PREZISTA PRIFTIN...51 Index PRIMAQUINE... 5 primidone...5 PRIMSOL... 1 PRIVIGEN...15 PROAIR HFA...11 PROAIR RESPICLICK...1 probenecid... 8 probenecid-colchicine... 9 PROCALAMINE %...7 prochlorperazine... 5 prochlorperazine maleate... 5 PROCRIT...68, 69 procto-med hc procto-pak proctosol hc proctozone-hc progesterone in oil...10 progesterone micronized...10 PROGLYCEM...1 PROLASTIN-C...1 PROLENSA PROLIA PROMACTA promethazine...9, 5 promethazine-codeine...95 promethazine-phenylephcodeine propafenone propantheline... proparacaine propranolol propranolol-hydrochlorothiazid 77 propylthiouracil PROQUAD (PF) PROSOL 0 %...7 protamine protriptyline...0 PULMICORT FLEXHALER PULMOZYME I-1

174 Index PURIXAN...9 pyrazinamide pyridostigmine bromide... 1 QUADRACEL (PF)...18 quasense... 9 quetiapine quinapril quinapril-hydrochlorothiazide...75 quinidine gluconate quinidine sulfate...76 quinine sulfate...5 QVAR...10 QVAR REDIHALER RABAVERT (PF) rajani...9 raloxifene ramipril RANEXA...79 ranitidine hcl , 110 RAPAFLO RAPAMUNE rasagiline...5 RASUVO (PF)...15 RAVICTI REBIF (WITH ALBUMIN).. 87 REBIF REBIDOSE...87 REBIF TITRATION PACK..87 reclipsen (8)... 9 RECOMBIVAX HB (PF)...18 REGRANEX RELENZA DISKHALER... 6 repaglinide... repaglinide-metformin... REPATHA PUSHTRONEX. 8 REPATHA SURECLICK...8 REPATHA SYRINGE... 8 RESCRIPTOR RESTASIS REVATIO REVCOVI Index REVLIMID...9 REXULTI REYATAZ ribasphere...65 ribasphere ribapak ribavirin...65 RIDAURA rifabutin...51 RIFAMATE...51 rifampin...51 RIFATER riluzole rimantadine... 6 RIOMET... risedronate...11 RISPERDAL CONSTA...58 risperidone...58 ritonavir...61 RITUXAN HYCELA... 9 rivastigmine... 7 rivastigmine tartrate... 7 rivelsa...9 rizatriptan romidepsin... 9 ropinirole...5 rosuvastatin... 8 ROTARIX...18 ROTATEQ VACCINE...18 ROZEREM... 1 RUBRACA... 9 RYDAPT...9 SABRIL...5 SANDIMMUNE...15 SANTYL SAPHRIS SAVELLA scopolamine base... 5 selegiline hcl... 5 selenium sulfide...98 SELZENTRY...6 Index SENSIPAR... 1 SEREVENT DISKUS... 1 SEROSTIM sertraline... 0 setlakin...9 sevelamer carbonate...11 sf 5000 plus...96 sharobel...9 SHINGRIX (PF) SIGNIFOR sildenafil sildenafil (antihypertensive)...15 silodosin...11 silver sulfadiazine...98 SIMBRINZA...15 SIMULECT...1 simvastatin... 8 sirolimus SIRTURO SIVEXTRO... 1 smoflipid...7 sodium chloride...10, 19 sodium chloride 0.5 %...18 sodium chloride 0.9 % sodium chloride % sodium chloride 5 % sodium lactate...19 sodium phenylbutyrate sodium polystyrene (sorb free) sodium polystyrene sulfonate..111 sofosbuvir-velpatasvir...6 SOLTAMOX...9 SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF). 117, 118 SOMATULINE DEPOT SOMAVERT sorine...77 sotalol...77 I-1

175 Index sotalol af...77 spinosad...10 SPIRIVA RESPIMAT...1 SPIRIVA WITH HANDIHALER...1 spironolactone...81 spironolacton-hydrochlorothiaz 81 sprintec (8)... 9 SPRITAM... 5 SPRYCEL... 9 sps (with sorbitol) sronyx... 9 ssd stavudine...6 STAXYN...15 STELARA STIMATE STIOLTO RESPIMAT...1 STIVARGA...9 STRENSIQ...10 streptomycin... 1 STRIBILD...6 STRIVERDI RESPIMAT...1 SUBOXONE subvenite...6 subvenite starter (blue) kit...6 subvenite starter (green) kit...6 subvenite starter (orange) kit...6 SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne)...98 sulfacetamide-prednisolone sulfadiazine...0 sulfamethoxazole-trimethoprim 0 SULFAMYLON sulfasalazine sulfatrim...0 sulindac... 8 sumatriptan Index sumatriptan succinate...50, 51 SUPRAX...15 SUPREP BOWEL PREP KIT SURE COMFORT INS. SYR. U SUTENT... 9 syeda... 9 SYLATRON... 6 SYMBICORT...10 SYMDEKO... 1 SYMFI... 6 SYMFI LO... 6 SYMTUZA... 6 SYNAGIS...6 SYNAREL SYNDROS... 5 SYNJARDY... SYNJARDY XR... SYNRIBO... 9 SYNTHROID TABLOID... 9 TACLONEX tacrolimus , 15 tadalafil tadalafil (antihypertensive)...15 TAFINLAR... 0 TAGRISSO... 0 TALZENNA... 0 TAMIFLU... 6 tamoxifen... 0 tamsulosin...11 TARCEVA... 0 TARGRETIN... 0 tarina fe 1/0 (8)... 9 TASIGNA... 0 TAYTULLA... 9 tazarotene...10 tazicef...16 TAZORAC Index taztia xt...78 TECFIDERA TEFLARO TEGSEDI... 1 TEKTURNA...8 TEKTURNA HCT...8 telmisartan... 7 telmisartan-amlodipine...7 telmisartan-hydrochlorothiazid.7 temazepam TEMODAR...0 TENIVAC (PF) tenofovir disoproxil fumarate... 6 terazosin terbinafine hcl...8 terbutaline... 1 terconazole testosterone...11 testosterone cypionate testosterone enanthate...11 TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD...19 tetrabenazine tetracycline...1 TEXACORT THALOMID... 1 theophylline... 1 theophylline in dextrose 5 %...1 thioridazine...58 thiothixene...58 tiagabine...6 TIBSOVO... 0 tigecycline...1 tilia fe...9 timolol maleate...77, 15 tinidazole...5 TIVICAY... 6 tizanidine... 1 I-15

176 Index TOBI PODHALER...1 TOBRADEX TOBRADEX ST tobramycin tobramycin in 0.5 % nacl... 1 tobramycin in 0.9 % nacl...1 tobramycin sulfate... 1 tobramycin-dexamethasone TOBREX tolazamide... 6 tolbutamide...6 tolcapone... 5 tolterodine topiramate... 6 topotecan...0 torsemide...81 TOUJEO MAX U-00 SOLOSTAR... 5 TOUJEO SOLOSTAR U-00 INSULIN... 5 TOVIAZ TPN ELECTROLYTES...19 TPN ELECTROLYTES II TRACLEER...16 TRADJENTA... tramadol... 6, 7 tramadol-acetaminophen...7 trandolapril...75 trandolapril-verapamil tranexamic acid tranylcypromine...0 TRAVASOL 10 %... 7 TRAVATAN Z...15 trazodone...0 TRECATOR TRELEGY ELLIPTA... 1 TRELSTAR... 0 TRESIBA FLEXTOUCH U Index TRESIBA FLEXTOUCH U TRESIBA U-100 INSULIN... 5 tretinoin...10 tretinoin (chemotherapy)...0 tretinoin microspheres TREXALL... 0 tri femynor...9 triamcinolone acetonide... 96, 101, 118 triamterene-hydrochlorothiazid 81 triazolam...11, 1 triderm trientine tri-estarylla...9 trifluoperazine trifluridine trihexyphenidyl...5 tri-legest fe... 9 tri-linyah...9 tri-lo-estarylla...9 tri-lo-marzia... 9 tri-lo-sprintec...9 trilyte with flavor packets...11 trimethoprim...1 tri-mili... 9 trimipramine...0 trinessa (8)...9 TRINTELLIX...0 tri-previfem (8)... 9 TRIPTODUR tri-sprintec (8)...9 TRIUMEQ... 6 trivora (8)... 9 tri-vylibra... 9 tri-vylibra lo...9 TROPHAMINE 10 %... 7 TROPHAMINE 6%... 7 tropicamide trospium Index TRULANCE TRULICITY... TRUMENBA TRUVADA... 6 tulana... 9 TWINRIX (PF) TYBOST...1 tydemy...9 TYKERB...1 TYMLOS...1 TYPHIM VI ULORIC...9 UNITUXIN... 1 UPTRAVI ursodiol UVADEX...97 valacyclovir...65 VALCHLOR valganciclovir...65 valproic acid... 6 valproic acid (as sodium salt).. 6 valsartan...7 valsartan-hydrochlorothiazide.. 7 vancomycin...1 VANCOMYCIN... 1 vancomycin in dextrose 5 %... 1 VAQTA (PF) vardenafil...16 VARIVAX (PF)...19 VARIZIG VASCEPA... 8 VECAMYL VECTIBIX... 1 velivet triphasic regimen (8)...95 VELPHORO...11 VELTASSA VEMLIDY... 6 VENCLEXTA...1 VENCLEXTA STARTING PACK... 1 I-16

177 Index venlafaxine... 0 VENTAVIS VENTOLIN HFA... 1 verapamil...78 VERSACLOZ...58 VERZENIO...1 VESICARE...11 vestura (8) VIBATIV...1 VIBERZI VIBRAMYCIN...1 vicodin...7 vicodin es...7 vicodin hp... 7 VICTOZA... VIDEX GRAM PEDIATRIC... 6 VIDEX GRAM PEDIATRIC... 6 VIDEX EC... 6 vienva vigabatrin... 6 vigadrone...6 VIIBRYD... 0 VIMIZIM VIMPAT...6 vincasar pfs...1 vincristine... 1 vinorelbine... 1 viorele (8) VIRACEPT... 6 VIRAMUNE...6 VIREAD...6 VIVITROL VIZIMPRO... 1 voriconazole...8 VOSEVI...6 VOTRIENT...1 VRAYLAR vyfemla (8) Index vylibra VYVANSE warfarin...67 WELCHOL... 8 wera (8) wymzya fe...95 XALKORI... 1 XARELTO XATMEP... 1 XELJANZ XELJANZ XR...15 XEOMIN...1 XERMELO XGEVA... 1 XIFAXAN... 1 XIIDRA XOFLUZA...6 XOLAIR...1 XTANDI... xulane...95 xylon XYREM... 1 YERVOY... YF-VAX (PF) YONSA... yuvafem zafirlukast...10 zaleplon... 1 ZALTRAP... zarah ZEJULA... ZELAPAR...55 ZELBORAF... zenatane zenchent (8) ZENPEP ZERIT... 6 zidovudine...6 ZIOPTAN (PF)...15 ziprasidone hcl Index ZIRGAN ZMAX ZOLADEX... zoledronic acid... 1 ZOLINZA... zolmitriptan zolpidem... 1 ZOLPIMIST...1 ZOMIG zonacort zonisamide...6 ZONTIVITY ZORBTIVE ZORTRESS...15 ZOSTAVAX (PF)...19 zovia 1/5e (8) ZOVIRAX...97 ZUBSOLV...10 ZURAMPIC...9 ZYDELIG... ZYKADIA... ZYLET ZYPREXA RELPREVV...59 ZYTIGA... I-17

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