Express Scripts Prescription Information

Transcription

1 Express Scripts Prescription Information For Concordia Health Plan Medicare Supplement Members - Premium Plan Express Scripts Preferred Formulary... 2 Express Scripts Preferred List Exclusions Specialty s. 24 s/supplies Not Covered by the Concordia Health Plan (CHP)

2 Express Scripts Medicare (PDP) 206 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN Formulary ID Number: 6033, v6 This formulary was updated on 09/04/205. For more recent information or other questions, please contact Express Scripts Medicare (PDP) Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at Note to current members: This formulary has changed since last year. Please review this document to understand your plan s drug coverage. When this drug list (formulary) refers to we, us or our, it means Medco Containment Life Insurance Company. When it refers to plan or our plan, it means Express Scripts Medicare. This document includes the list of the covered drugs (formulary) for our plan, which is current as of September 4, 205. For more recent information, please contact us. Our contact information, along with the date we last updated the formulary, appears above and on the back cover. You must use network pharmacies to fill your prescriptions to get the most from your benefit. Benefits, premium and/or copayments/coinsurance may change on January, 207. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. This information is available for free in other languages. Please call Express Scripts Medicare Customer Service at the numbers on the back of your member ID card for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Llame al Servicio al cliente de Express Scripts Medicare a los números que figuran al dorso de su tarjeta de identificación de miembro para obtener información adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana. This document is available in braille. Please contact Customer Service if you need plan information in another format. EME969 CRP5_06 F0PP3C6A

3 What is the Express Scripts Medicare formulary? The list of drugs covered by the plan is also known as the formulary. It contains a list of covered Medicare Part D drugs selected by Express Scripts Medicare 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. The formulary also includes information on requirements or limits for some covered drugs that are part of Express Scripts Medicare s standard formulary rules. Your specific plan may provide coverage of additional drugs that are not listed in this formulary, and your plan may have different plan rules and coverage. For more information on your plan s specific drug coverage, please review your other plan materials, visit us on the Web at or contact Customer Service. Express Scripts Medicare will cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Express Scripts Medicare network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your other plan materials. Can my drug coverage change? Generally, if you are taking a drug on our 206 formulary that was covered at the beginning of the year, Express Scripts Medicare will not discontinue or reduce coverage of the drug during the 206 coverage year, except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our plan s formulary, will not affect members who are currently taking the drug. It will remain available at the same copayment or coinsurance amount for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If Express Scripts Medicare removes drugs from our formulary, adds prior authorization, quantity limits, and/or step therapy restrictions on a drug, or moves a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective. If the Food and Administration (FDA) determines that a drug on our formulary is unsafe, or if 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 are taking the drug. This enclosed formulary is current as of the date indicated on the front cover. To get updated information about the drugs covered, please visit us on the Web or contact our Customer Service department using the information provided on the front and back covers of this formulary. If there are any additional changes made to the formulary that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time after the changes take effect. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. 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, Hypertension/Lipids. EME969 CRP5_06 i

4 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 68. 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 Name column of the list. What are generic drugs? Both brand-name drugs and generic drugs are covered under this plan. A generic drug is approved by the FDA as having the same active ingredient(s) 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: You or your doctor is required to get prior authorization for certain drugs. This means that you will need to get approval from the plan before you fill your prescriptions. If you don t get approval, the drugs may not be covered. These drugs are noted with PA next to them in the formulary. Some drugs may be covered under Part B or under Part D, depending on your medical condition. Your doctor will need to get a prior authorization for these drugs as well, so your pharmacy can process your prescription correctly. Quantity Limits: For certain drugs, the amount of the drug that will be covered by the plan is limited. The plan may limit how much of a drug you can get each time you fill your prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. These drugs are noted with QL next to them in the formulary. Step Therapy: In some cases, you are required to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. These drugs are noted with ST next to them in the formulary. You may be able to find out if your drug has any additional requirements or limits by looking in the drug list that begins on page. Note: This drug list includes all possible restrictions and limits on coverage. The requirements and limits may not apply to your plan s specific coverage. To confirm whether a particular drug is covered, visit us on the Web at or contact Customer Service. You can ask us to make an exception to these restrictions or limits. See the section How do I request an exception to the formulary? on the following page for information about how to request an exception. EME969 CRP5_06 ii

5 What if my drug is not on the formulary? If your drug is not included in this list of covered drugs, you should first contact Customer Service and ask if your drug is covered. If you learn that your drug is not covered, you have two options: You can ask our Customer Service department for a list of similar drugs that are covered. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers or request a formulary exception so that the plan will cover the drug you are taking. How do I request an exception to the formulary? You can ask us 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 your drug even if it is not on our formulary. If approved, the drug will be covered at a pre-determined cost-sharing level, and you will 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 your drug is contained in our Non-Preferred Brand tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in our Preferred Brand tier instead. 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, Express Scripts Medicare limits the amount of the drug it will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. You should contact us to ask for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting an exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. Generally, your request for an exception will only be approved if the alternative drugs that are included in the plan formulary, the lower-tiered drugs or the additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. EME969 CRP5_06 iii

6 How do I request an appeal? If we make a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. To start an appeal, you, your doctor or your representative must contact us. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review, we give you our decision. For more information about the appeals process, you may contact Customer Service using the information provided on the front and back covers of this document. Can I get a temporary transition supply while I wait for an exception decision? As a new or continuing member in our plan, you may be taking drugs that are not covered from one year to the next. Or, you may be taking a drug that is covered 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, or while you wait for a coverage decision from us, we may cover a temporary transition supply of your drug in certain cases during the first 90 days that you are enrolled in the plan or at the start of a new coverage year. For each of your drugs that is not on our formulary, or if your ability to get drugs is limited, we will cover a temporary transition supply when you go to a network pharmacy. This temporary transition supply will be for at least 30 days, or less if your prescription is written for fewer days. In that case, you will be allowed multiple fills to provide up to a total of at least a 30-day supply of the medication. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer. We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your ability to get your drug is limited but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency transition supply of that drug (unless you have a prescription written for fewer while you pursue an exception. Other times when we will cover at least a temporary 30-day transition supply (or less, if you have a prescription written for fewer include: When you enter a long-term care facility When you leave a long-term care facility When you are discharged from a hospital When you leave a skilled nursing facility When you cancel hospice care When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized Express Scripts Medicare will send you a letter within 3 business days of your filling a temporary transition supply notifying you that this was a temporary supply and explaining your options. EME969 CRP5_06 iv

7 Other coverage that your plan may provide Your plan may also cover categories of excluded drugs that are not normally covered by a Medicare prescription drug plan and are not listed in the formulary. s in the following categories may be covered subject to the rules and limitations of your specific plan: Prescription drugs when used for anorexia, weight loss or weight gain Prescription drugs when used to promote fertility Prescription drugs when used for cosmetic purposes or to promote hair growth Prescription drugs when used for the symptomatic relief of cough or colds Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are considered Part D drugs) s, such as CAVERJECT, CIALIS, EDEX, LEVITRA, MUSE and VIAGRA, when used for the treatment of sexual or erectile dysfunction Over-the-counter (OTC) diabetic supplies Federal Legend Part B medications for example, oral chemotherapy agents (e.g., TEMODAR, XELODA ) Non-prescription drugs, also known as over-the-counter (OTC) drugs Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale. Please contact Customer Service for additional information about your plan s specific drug coverage and your cost-sharing amount. Please note: Costs for excluded drugs not normally covered by a Medicare prescription drug plan will not count toward your Medicare prescription drug yearly deductible (if applicable), total drug costs or yearly out-of-pocket expenses. Formulary The formulary that begins on page provides coverage information about some of the drugs covered by this plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 68. The Name column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., CRESTOR ) and generic drugs are listed in lowercase italics (e.g., atorvastatin). The information in the column tells you if there are any special requirements for coverage of that particular drug. If you are not sure whether your drug is covered, please visit our website or contact Customer Service using the information provided on the front and back covers of this formulary. Your Costs The amount you pay for a covered drug will depend on: Your coverage stage. Your plan has different stages of coverage. In each stage, the amount you pay for a drug may change. Please refer to your other plan documents for more information about your specific prescription drug benefit. The drug tier for your drug. Each covered drug is in one of three drug tiers. Each tier may have a different cost-sharing amount. The s chart on the following page explains what types of drugs are included in each tier and shows how costs may change with each tier. Your other plan materials have more information about your plan s coverage stages and list the specific cost-sharing amounts for each tier. EME969 CRP5_06 v

8 s Includes Helpful tips : Generic s 2: Preferred Brand s 3: Non-Preferred Brand s This tier includes many commonly prescribed generic drugs and may include other low-cost drugs. This tier includes preferred brand-name drugs as well as some generic drugs. This tier includes non-preferred brand-name drugs as well as some generic drugs. Use drugs for the lowest cost-sharing amount. s in this tier will generally have lower cost-sharing amounts than non-preferred brand drugs. Many non-preferred drugs have lower-cost alternatives in s and 2. Ask your doctor if switching to a lower-cost generic or preferred brand-name drug may be right for you. If you qualify for Extra Help If you qualify for Extra Help from Medicare to help pay for your prescription drugs, your cost-sharing amounts may be lower than your plan s standard benefit. Members who qualify for Extra Help will receive a notice called Important Information for Those Who Receive Extra Help Paying for Their Prescription s ( Low Income Rider or LIS Rider ). Please read it to find out what your costs are. You can also contact Customer Service with any questions using the information listed on the front and back covers of this formulary. For more information For more detailed information about your Medicare prescription drug coverage and your plan s specific costs, please review your other plan materials. If you need additional information on network pharmacies or if you have any other questions, please contact our Customer Service department using the information provided on the front and back covers of this formulary. If you have general questions about Medicare prescription drug coverage, please call Medicare at.800.medicare ( ), 24 hours a day, 7 days a week. TTY users should call Or visit EME969 CRP5_06 vi

9 Below is a list of abbreviations that may appear on the following pages in the column that tells you if there are any special requirements for coverage of your drug. Note: The following drug list includes all possible restrictions and limitations. Depending on your plan s specific benefit, you may not experience every restriction or limit indicated in the list. To confirm your plan s specific coverage, contact Customer Service using the information provided on the front and back covers of this List of abbreviations LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For more information, contact Customer Service using the information provided on the front and back covers of this formulary. MO: Mail-Order. This prescription drug is available through our home delivery service, as well as through our retail network pharmacies. Consider using home delivery for your long-term (maintenance) medications, such as high blood pressure medications. Retail network pharmacies may be more appropriate for short-term prescriptions, such as antibiotics. PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don t get approval, we may not cover this drug. QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. EME969 CRP5_06 vii

10 Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 2 PA; MO AMBISOME 2 PA; MO amphotericin b PA; MO CANCIDAS 2 PA; MO clotrimazole mucous membrane CRESEMBA INTRAVENOUS CRESEMBA ORAL ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN 00 MG 2 fluconazole fluconazole in dextrose(iso-o) intravenous piggyback 400 mg/200 ml flucytosine griseofulvin microsize griseofulvin ultramicrosize itraconazole ketoconazole oral LAMISIL ORAL GRANULES IN PACKET MYCAMINE Name NOXAFIL ORAL nystatin oral suspension nystatin oral tablet SPORANOX ORAL SOLUTION terbinafine hcl oral voriconazole ANTIVIRALS abacavir abacavirlamivudinezidovudine acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution PA; MO adefovir amantadine hcl oral APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA BARACLUDE ORAL SOLUTION 2 cidofovir PA; MO COMPLERA

11 Name CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine EDURANT EMTRIVA entecavir EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ 3 MO famciclovir foscarnet PA; MO FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium HARVONI 3 PA; MO; QL (28 per 28 INTELENCE ORAL TABLET 00 MG, 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ISENTRESS KALETRA lamivudine lamivudinezidovudine 2 LEXIVA Name moderiba moderiba dose pack oral tablets,dose pack 400 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7) nevirapine NORVIR OLYSIO 3 PA; MO; QL (28 per 28 PREZCOBIX 3 MO PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG REBETOL ORAL SOLUTION RELENZA DISKHALER RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 50 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET ribasphere 2

12 Name ribasphere ribapak oral tablets,dose pack mg (28)-mg (28), mg (28)-mg (28), mg (28)-mg (28) ribavirin oral capsule ribavirin oral tablet 200 mg rimantadine SELZENTRY SOVALDI (28 per 28 stavudine STRIBILD SUSTIVA SYNAGIS INTRAMUSCULA R SOLUTION 50 MG/0.5 ML ; LA TAMIFLU TIVICAY TRIUMEQ TRUVADA TYZEKA valacyclovir ; QL (30 VALCYTE ORAL RECON SOLN valganciclovir Name VIDEX 2 GRAM PEDIATRIC VIEKIRA PAK (2 per 28 VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 00 MG VIRAZOLE VIREAD VITEKTA 3 MO ZIAGEN ORAL SOLUTION zidovudine CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 2 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 3

13 Name cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml cefazolin injection recon soln gram, 500 mg cefazolin injection recon soln 0 gram cefdinir cefditoren pivoxil oral tablet 200 mg cefepime cefixime cefotaxime injection recon soln gram, 2 gram, 500 mg cefotetan cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln gram cefoxitin intravenous recon soln 0 gram, 2 gram cefpodoxime cefprozil ceftazidime injection recon soln gram, 2 gram ceftazidime injection recon soln 6 gram Name ceftriaxone injection recon soln 0 gram ceftriaxone injection recon soln 250 mg, 500 mg ceftriaxone intravenous recon soln cefuroxime axetil oral tablet cefuroxime sodium injection recon soln.5 gram, 750 mg cefuroxime sodium intravenous cephalexin FORTAZ INTRAVENOUS RECON SOLN GRAM SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTIO N 500 MG/5 ML SUPRAX ORAL TABLET,CHEWAB LE 2 3 MO 3 3 MO TEFLARO 3 MO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 500 mg 4

14 Name azithromycin intravenous recon soln 500 mg (2 mg/ml) azithromycin oral clarithromycin e.e.s. 400 oral tablet E.E.S. GRANULES ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg ERY-TAB ORAL TABLET,DELAYE D RELEASE (DR/EC) 500 MG erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral tablet erythromycin oral tablet 2 ZMAX MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin injection solution 500 mg/2 ml Name atovaquone atovaquoneproguanil AZACTAM IN DEXTROSE (ISO- OSM) aztreonam injection recon soln gram baciim bacitracin intramuscular 2 BETHKIS (224 per 28 BILTRICIDE CAPASTAT 3 CAYSTON ; LA; QL (84 per 28 chloramphenicol sod succinate chloroquine phosphate oral clindamycin hcl clindamycin in 5 % dextrose clindamycin pediatric clindamycin phosphate intravenous solution 600 mg/4 ml COARTEM 5

15 Name colistin (colistimethate na) CUBICIN DAPSONE DARAPRIM ethambutol gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml gentamicin in nacl (iso-osm) intravenous piggyback 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml gentamicin injection solution 40 mg/ml gentamicin sulfate (pf) intravenous solution 80 mg/8 ml hydroxychloroquine oral imipenem-cilastatin INVANZ INJECTION isoniazid injection 3 MO isoniazid oral ivermectin oral KETEK linezolid intravenous Name linezolid oral mefloquine meropenem intravenous recon soln 500 mg metronidazole in nacl (iso-os) metronidazole oral NEBUPENT (6 per 28 neomycin paromomycin PASER PENTAM 3 MO polymyxin b sulfate PRIFTIN PRIMAQUINE pyrazinamide quinine sulfate rifabutin rifampin intravenous rifampin oral SIRTURO ; LA STREPTOMYCIN INTRAMUSCULA R SYNERCID 2 tinidazole 6

16 Name TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in % nacl tobramycin in 0.9 % nacl intravenous piggyback 80 mg/00 ml tobramycin sulfate injection solution ; QL (224 per 28 PA; MO; QL (280 per 28 TRECATOR TYGACIL XIFAXAN ZYVOX ORAL SUSPENSION FOR RECONSTITUTIO N PENICILLINS amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate ampicillin Name ampicillin sodium injection recon soln gram, 0 gram, 25 mg ampicillin-sulbactam injection recon soln 5 gram ampicillin-sulbactam injection recon soln 3 gram ampicillin-sulbactam intravenous recon soln.5 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTIO N MG/5 ML BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin in dextrose iso-osm intravenous piggyback gram/50 ml nafcillin injection recon soln gram, 0 gram oxacillin in dextrose(iso-osm) intravenous piggyback gram/50 ml 7

17 Name oxacillin in dextrose(iso-osm) intravenous piggyback 2 gram/50 ml oxacillin injection recon soln 0 gram oxacillin intravenous recon soln 2 gram PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK 2 MILLION UNIT/50 ML, 3 MILLION UNIT/50 ML penicillin g potassium injection recon soln 5 million unit penicillin g procaine intramuscular syringe.2 million unit/2 ml 2 penicillin g sodium penicillin v potassium piperacillintazobactam intravenous recon soln gram, 4.5 gram Name ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML ZOSYN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK GRAM/50 ML QUINOLONES ciprofloxacin ciprofloxacin (mixture) ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/00 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback 500 mg/00 ml levofloxacin intravenous 2 levofloxacin oral moxifloxacin ofloxacin oral tablet 400 mg SULFA'S / RELATED AGENTS 8

18 Name sulfadiazine oral sulfamethoxazoletrimethoprim TETRACYCLINES demeclocycline oral doxy-00 doxycycline hyclate intravenous doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00 mg, 20 mg doxycycline hyclate oral tablet 50 mg doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral tetracycline VIBRAMYCIN ORAL SYRUP URINARY TRACT AGENTS Name MACRODANTIN ORAL CAPSULE 25 MG methenamine hippurate nitrofurantoin macrocrystal oral capsule 00 mg, 50 mg nitrofurantoin monohyd/m-cryst nitrofurantoin oral PRIMSOL 3 MO trimethoprim VANCOMYCIN vancomycin intravenous recon soln,000 mg, 0 gram, 500 mg vancomycin oral capsule ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline dexrazoxane hcl intravenous recon soln 250 mg ELITEK INTRAVENOUS RECON SOLN.5 MG 2 9

19 Name FUSILEV KEPIVANCE 2 leucovorin calcium injection recon soln 00 mg, 350 mg leucovorin calcium oral mesna MESNEX ORAL XGEVA ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE adrucil intravenous solution 500 mg/0 ml AFINITOR DISPERZ AFINITOR ORAL TABLET 0 MG AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALIMTA INTRAVENOUS RECON SOLN 500 MG 2 PA; MO (60 per 30 2 PA; MO anastrozole ARRANON 2 ARZERRA INTRAVENOUS SOLUTION 00 MG/5 ML 2 PA; MO Name AVASTIN azacitidine azathioprine PA; MO BELEODAQ bicalutamide BICNU 3 MO bleomycin injection recon soln 30 unit BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 500 MG BUSULFEX 2 CAPRELSA ORAL TABLET 00 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS CELLCEPT ORAL SUSPENSION FOR RECONSTITUTIO N 2 PA; MO (30 per 30 2 PA; MO; LA; QL (90 per 30 2 PA; MO; LA; QL (30 per 30 2 PA; MO 2 PA; MO cisplatin cladribine CLOLAR COMETRIQ 2 PA; MO 0

20 Name CYCLOPHOSPHA MIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified cyclosporine oral capsule 2 PA; MO PA PA; MO PA; MO cytarabine cytarabine (pf) injection solution 2 gram/20 ml (00 mg/ml) dacarbazine intravenous recon soln 200 mg daunorubicin intravenous solution DAUNOXOME decitabine DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (0 mg/ml) doxorubicin intravenous solution 50 mg/25 ml 2 DROXIA EMCYT Name epirubicin intravenous solution 50 mg/25 ml ERBITUX INTRAVENOUS SOLUTION 00 MG/50 ML ERIVEDGE (30 per 30 ERWINAZE ETOPOPHOS 3 MO etoposide intravenous exemestane FARESTON FARYDAK ORAL CAPSULE 0 MG FARYDAK ORAL CAPSULE 5 MG, 20 MG 3 PA; MO; QL (2 per 2 FASLODEX FIRMAGON KIT W DILUENT SYRINGE fludarabine intravenous recon soln fluorouracil intravenous solution 2.5 gram/50 ml 3 PA; MO; QL (6 per 2 flutamide

21 Name FOLOTYN INTRAVENOUS SOLUTION 40 MG/2 ML (20 MG/ML) gemcitabine intravenous recon soln gram gengraf PA; MO GILOTRIF ORAL TABLET 20 MG GILOTRIF ORAL TABLET 30 MG GILOTRIF ORAL TABLET 40 MG GLEEVEC ORAL TABLET 00 MG GLEEVEC ORAL TABLET 400 MG (60 per 30 (40 per 30 (30 per 30 2 PA; MO (60 per 30 HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE (2 per 28 ICLUSIG ORAL TABLET 5 MG ICLUSIG ORAL TABLET 45 MG (90 per 30 (30 per 30 Name idarubicin ifosfamide intravenous recon soln gram IMBRUVICA (20 per 30 INLYTA ORAL TABLET MG INLYTA ORAL TABLET 5 MG irinotecan intravenous solution 00 mg/5 ml 2 PA; MO (20 per 30 ISTODAX IXEMPRA INTRAVENOUS RECON SOLN 45 MG JAKAFI ORAL TABLET 0 MG, 5 MG, 20 MG, 5 MG JAKAFI ORAL TABLET 25 MG 2 PA; MO (60 per 30 JEVTANA KADCYLA INTRAVENOUS RECON SOLN 00 MG KEYTRUDA INTRAVENOUS RECON SOLN LENVIMA 2 PA; MO letrozole 2

22 Name LEUKERAN leuprolide LOMUSTINE LUPRON DEPOT 2 PA; MO LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT- PED INTRAMUSCULA R KIT.25 MG, 5 MG 2 PA; MO 2 PA; MO 2 PA; MO 2 PA; MO LYNPARZA 2 PA; MO LYSODREN MATULANE MEGACE ES megestrol oral suspension 400 mg/0 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG MEKINIST ORAL TABLET 2 MG melphalan hcl (20 per 30 (30 per 30 mercaptopurine methotrexate sodium (pf) injection recon soln PA Name methotrexate sodium (pf) injection solution methotrexate sodium oral mitomycin intravenous recon soln 20 mg PA; MO PA; MO mitoxantrone MUSTARGEN 3 MO mycophenolate mofetil mycophenolate sodium PA; MO PA; MO NEORAL 3 PA; MO NEXAVAR 2 PA; MO; LA; QL (20 per 30 NILANDRON NIPENT NULOJIX 2 PA; MO octreotide acetate injection solution ONCASPAR OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 00 mg/20 ml paclitaxel PERJETA POMALYST 3

23 Name PROGRAF INTRAVENOUS 2 PA; MO PURIXAN RAPAMUNE ORAL SOLUTION 2 PA; MO REVLIMID 2 PA; MO; LA RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 MG RHEUMATREX ORAL TABLETS,DOSE PACK 2.5 MG (DOSE PACK 2), 2.5 MG (DOSE PACK 6), 2.5 MG (DOSE PACK 20), 2.5 MG (DOSE PACK 8) 3 PA; MO 3 PA RITUXAN 2 PA; MO SANDIMMUNE INTRAVENOUS SANDIMMUNE ORAL CAPSULE SANDIMMUNE ORAL SOLUTION SANDOSTATIN LAR DEPOT INTRAMUSCULA R KIT 3 PA; MO 3 PA; MO 2 PA; MO SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 20 MG 2 PA; MO Name sirolimus PA; MO SOLTAMOX SOMATULINE DEPOT SPRYCEL ORAL TABLET 00 MG, 20 MG, 50 MG, 80 MG SPRYCEL ORAL TABLET 40 MG SPRYCEL ORAL TABLET 70 MG 2 PA; MO (30 per 30 (60 per 30 STIVARGA (84 per 28 SUTENT ORAL CAPSULE 2.5 MG SUTENT ORAL CAPSULE 25 MG, 37.5 MG SUTENT ORAL CAPSULE 50 MG SYLVANT INTRAVENOUS RECON SOLN 00 MG 2 PA; MO (60 per 30 (30 per 30 SYNRIBO TABLOID tacrolimus oral PA; MO TAFINLAR ORAL CAPSULE 50 MG (80 per 30 4

24 Name TAFINLAR ORAL CAPSULE 75 MG (20 per 30 tamoxifen TARCEVA ORAL TABLET 00 MG, 25 MG TARCEVA ORAL TABLET 50 MG 2 PA; MO (30 per 30 TARGRETIN TASIGNA ORAL CAPSULE 50 MG TASIGNA ORAL CAPSULE 200 MG 2 PA; MO (2 per 28 THALOMID 2 PA; MO toposar topotecan intravenous recon soln TORISEL TREANDA INTRAVENOUS RECON SOLN 00 MG TREANDA INTRAVENOUS SOLUTION 45 MG/0.5 ML TRELSTAR DEPOT 2 Name TRELSTAR INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N TRELSTAR INTRAMUSCULA R SYRINGE.25 MG/2 ML, 3.75 MG/2 ML TRELSTAR LA 2 tretinoin (chemotherapy) TRISENOX TYKERB 2 PA; MO; LA; QL (80 per 30 VECTIBIX INTRAVENOUS SOLUTION 00 MG/5 ML (20 MG/ML) 2 PA; MO VELCADE vinblastine intravenous solution vincasar pfs intravenous solution mg/ml vincristine intravenous solution mg/ml vinorelbine intravenous solution 50 mg/5 ml 5

25 Name VOTRIENT (20 per 30 XALKORI ORAL CAPSULE 200 MG XALKORI ORAL CAPSULE 250 MG 2 PA; MO (60 per 30 XTANDI (20 per 30 YERVOY INTRAVENOUS SOLUTION 50 MG/0 ML (5 MG/ML) ZALTRAP INTRAVENOUS SOLUTION 00 MG/4 ML (25 MG/ML) ZANOSAR 3 MO ZELBORAF (240 per 30 ZOLINZA ZORTRESS 2 PA; MO ZYDELIG (90 per 30 ZYKADIA (50 per 30 ZYTIGA (20 per 30 Name AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM 3 MO BANZEL carbamazepine oral capsule, er multiphase 2 hr carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 2 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG clonazepam PA; MO diazepam rectal PA; MO DILANTIN 30 MG divalproex epitol ethosuximide felbamate fosphenytoin injection solution 00 mg pe/2 ml FYCOMPA gabapentin oral capsule 6

26 Name gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 2 MG, 6 MG GRALISE 2 PA; MO GRALISE 30-DAY STARTER PACK lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablet,disintegrating LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK,000 MG/00 ML,,500 MG/00 ML LEVETIRACETAM IN NACL (ISO-OS) INTRAVENOUS PIGGYBACK 500 MG/00 ML levetiracetam intravenous levetiracetam oral solution 00 mg/ml 2 PA; MO 2 Name levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA 2 PA; MO ONFI ORAL SUSPENSION ONFI ORAL TABLET 0 MG, 20 MG 2 PA; MO 2 PA; MO oxcarbazepine PEGANONE phenobarbital oral elixir phenobarbital oral tablet 00 mg phenobarbital oral tablet 5 mg, 6.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenytoin oral suspension 25 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended phenytoin sodium intravenous solution POTIGA primidone SABRIL ; LA 7

27 Name TEGRETOL XR ORAL TABLET EXTENDED RELEASE 2 HR 00 MG tiagabine topiramate oral capsule, sprinkle topiramate oral tablet PA; MO PA; MO valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET 2 zonisamide PA; MO ANTIPARKINSONISM AGENTS APOKYN ; LA AZILECT benztropine bromocriptine carbidopa carbidopa-levodopa carbidopa-levodopaentacapone entacapone NEUPRO Name pramipexole oral tablet pramipexole oral tablet extended release 24 hr 0.75 mg,.5 mg ropinirole selegiline hcl tolcapone MIGRAINE / CLUSTER HEADACHE THERAPY CAFERGOT dihydroergotamine injection dihydroergotamine nasal migergot ; QL (8 per 28 naratriptan ; QL (8 per 28 RELPAX ; QL (8 per 28 rizatriptan ; QL (36 per 28 sumatriptan nasal spray,non-aerosol 20 mg/actuation sumatriptan nasal spray,non-aerosol 5 mg/actuation sumatriptan succinate oral sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml ; QL (8 per 28 ; QL (36 per 28 ; QL (8 per 28 ; QL (6 per 28 8

28 Name sumatriptan succinate subcutaneous solution ; QL (6 per 28 zolmitriptan ; QL (8 per 28 MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 2 PA; MO; LA AUBAGIO 3 PA; MO COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML (2 per 28 donepezil EXELON TRANSDERMAL galantamine GILENYA 2 PA; MO glatopa PA; MO; QL (30 per 30 NAMENDA ORAL SOLUTION 2 PA; MO NAMENDA XR 2 PA; MO NUEDEXTA rivastigmine tartrate TECFIDERA 2 PA; MO TYSABRI 2 PA; MO; LA XENAZINE 2 PA; MO; LA MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen Name dantrolene LIORESAL INTRATHECAL SOLUTION 2,000 MCG/ML, 500 MCG/ML LIORESAL INTRATHECAL SOLUTION 50 MCG/ML MESTINON ORAL SYRUP MESTINON TIMESPAN pyridostigmine bromide oral tablet 2 PA; MO 2 PA tizanidine NARCOTIC ANALGESICS acetaminophencodeine oral solution 300 mg-30 mg /2.5 ml acetaminophencodeine oral tablet mg, mg acetaminophencodeine oral tablet mg QL (4500 per 30 ; QL (360 ; QL (80 BUPRENEX ; QL (267 buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet 2 mg QL (267 per 30 ; QL (300 9

29 Name buprenorphine hcl sublingual tablet 8 mg ; QL (75 BUTRANS ; QL (4 per 28 codeine sulfate oral tablet duramorph (pf) injection solution 0.5 mg/ml duramorph (pf) injection solution mg/ml endocet oral tablet mg, mg, mg ; QL (80 ; QL (4000 QL (2000 per 30 ; QL (360 endodan ; QL (360 fentanyl citrate buccal lozenge on a handle,200 mcg fentanyl citrate buccal lozenge on a handle,600 mcg fentanyl citrate buccal lozenge on a handle 200 mcg fentanyl citrate buccal lozenge on a handle 400 mcg fentanyl citrate buccal lozenge on a handle 600 mcg fentanyl citrate buccal lozenge on a handle 800 mcg PA; MO; QL (39 per 30 PA; MO; QL (29 per 30 PA; MO; QL (20 per 30 PA; MO; QL (6 per 30 PA; MO; QL (77 per 30 PA; MO; QL (58 per 30 Name fentanyl transdermal patch 72 hour 00 mcg/hr fentanyl transdermal patch 72 hour 2 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodoneacetaminophen oral solution mg/5 ml hydrocodoneacetaminophen oral tablet mg, mg, mg, mg, mg, mg, mg hydrocodoneibuprofen oral tablet mg hydromorphone (pf) injection solution 0 mg/ml hydromorphone oral liquid hydromorphone oral tablet hydromorphone oral tablet extended release 24 hr 2 mg, 6 mg, 8 mg hydromorphone oral tablet extended release 24 hr 32 mg ; QL (9 per 30 ; QL (0 ; QL (5550 ; QL (360 ; QL (50 ; QL (20 ; QL (500 ; QL (80 ; QL (60 ; QL (47 ibuprofen-oxycodone ; QL (28 20

30 Name levorphanol tartrate ; QL (20 lorcet (hydrocodone) ; QL (360 lorcet hd ; QL (360 lorcet plus oral tablet mg ; QL (360 lortab ; QL (360 lortab ; QL (360 lortab ; QL (360 methadone injection QL (60 per 30 methadone oral solution 0 mg/5 ml methadone oral solution 5 mg/5 ml methadone oral tablet 0 mg methadone oral tablet 5 mg morphine concentrate oral solution morphine intravenous syringe 2 mg/ml morphine intravenous syringe 4 mg/ml ; QL (600 ; QL (200 ; QL (20 ; QL (240 ; QL (300 QL (000 per 30 QL (500 per 30 Name morphine oral capsule, er multiphase 24 hr 20 mg morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.relea se pellets 0 mg, 20 mg, 30 mg, 50 mg, 60 mg morphine oral capsule,extend.relea se pellets 00 mg morphine oral capsule,extend.relea se pellets 80 mg morphine oral solution ; QL (50 ; QL (60 ; QL (90 ; QL (60 ; QL (75 ; QL (900 morphine oral tablet ; QL (80 morphine oral tablet extended release 00 mg morphine oral tablet extended release 5 mg, 30 mg morphine oral tablet extended release 200 mg morphine oral tablet extended release 60 mg ; QL (60 ; QL (20 ; QL (30 ; QL (00 2

31 Name oxycodone oral capsule oxycodone oral concentrate oxycodone oral solution oxycodone oral tablet 0 mg, 5 mg, 20 mg oxycodone oral tablet 30 mg oxycodone oral tablet 5 mg oxycodoneacetaminophen oral tablet mg, mg, mg, mg ; QL (360 ; QL (80 ; QL (200 ; QL (80 ; QL (34 ; QL (360 ; QL (360 oxycodone-aspirin ; QL (360 OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 0 MG, 5 MG, 20 MG, 30 MG, 40 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.2 HR 80 MG ; QL (90 ; QL (67 ; QL (50 Name oxymorphone oral tablet 0 mg oxymorphone oral tablet 5 mg oxymorphone oral tablet extended release 2 hr 0 mg, 5 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 2 hr 30 mg oxymorphone oral tablet extended release 2 hr 40 mg ; QL (200 ; QL (80 ; QL (90 ; QL (67 ; QL (50 reprexain ; QL (50 vicodin es oral tablet mg vicodin hp oral tablet mg vicodin oral tablet mg ; QL (360 ; QL (360 ; QL (360 zamicet QL (5550 per 30 NON-NARCOTIC ANALGESICS buprenorphinenaloxone sublingual tablet mg buprenorphinenaloxone sublingual tablet 8-2 mg butorphanol tartrate injection solution mg/ml PA; MO; QL (360 per 30 PA; MO; QL (90 per 30 ; QL (720 22

32 Name butorphanol tartrate injection solution 2 mg/ml butorphanol tartrate nasal ; QL (360 celecoxib diclofenac potassium diclofenac sodium oral diclofenac sodium topical drops diclofenacmisoprostol ; QL (5 per 28 diflunisal etodolac fenoprofen oral tablet FLECTOR 3 PA; MO; QL (60 per 30 flurbiprofen ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg meclofenamate oral mefenamic acid Name meloxicam oral suspension meloxicam oral tablet 5 mg meloxicam oral tablet 7.5 mg ; QL (30 nabumetone nalbuphine injection solution 0 mg/ml nalbuphine injection solution 20 mg/ml naloxone injection syringe mg/ml ; QL (200 ; QL (00 naltrexone oral naproxen naproxen sodium oral tablet 275 mg, 550 mg naproxen sodium oral tablet, er multiphase 24 hr 500 mg oxaprozin piroxicam SUBOXONE SUBLINGUAL FILM 2-3 MG SUBOXONE SUBLINGUAL FILM MG SUBOXONE SUBLINGUAL FILM 4- MG, 8-2 MG (60 per 30 (360 per 30 (90 per 30 sulindac oral 23

33 Name tolmetin oral capsule tolmetin oral tablet 600 mg tramadol oral tablet ; QL (240 tramadol oral tablet extended release 24 hr 00 mg, 200 mg tramadol oral tablet, er multiphase 24 hr 300 mg tramadolacetaminophen VOLTAREN GEL TOPICAL GEL % ; QL (30 ; QL (30 ; QL (240 PSYCHOTHERAPEUTIC DRUGS ABILIFY DISCMELT ORAL TABLET,DISINTE GRATING 0 MG ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL RECON ABILIFY MAINTENA INTRAMUSCULA R SUSPENSION,EXT ENDED REL SYRING 3 MO; QL (90 amitriptyline PA; MO amoxapine 2 Name amphetamine salt combo aripiprazole oral tablet 0 mg aripiprazole oral tablet 5 mg, 20 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet 30 mg aripiprazole oral tablet 5 mg BRINTELLIX ORAL TABLET 0 MG BRINTELLIX ORAL TABLET 20 MG BRINTELLIX ORAL TABLET 5 MG bupropion hcl oral tablet bupropion hcl oral tablet extended release 00 mg bupropion hcl oral tablet extended release 50 mg bupropion hcl oral tablet extended release 200 mg bupropion hcl oral tablet extended release 24 hr 50 mg ; QL (90 ; QL (60 ; QL (450 ; QL (30 ; QL (80 3 MO; QL (60 3 MO; QL (30 3 MO; QL (20 ; QL (20 ; QL (90 ; QL (60 ; QL (90 24

34 Name bupropion hcl oral tablet extended release 24 hr 300 mg ; QL (60 buspirone chlorpromazine citalopram oral solution citalopram oral tablet 0 mg citalopram oral tablet 20 mg citalopram oral tablet 40 mg ; QL (20 ; QL (60 ; QL (30 clomipramine PA; MO clonidine hcl oral tablet extended release 2 hr clorazepate dipotassium clozapine oral tablet 00 mg, 25 mg, 50 mg clozapine oral tablet 200 mg clozapine oral tablet,disintegrating 00 mg, 2.5 mg, 25 mg PA; MO desipramine oral dexedrine dexmethylphenidate dextroamphetamine oral capsule, extended release Name dextroamphetamine oral tablet dextroamphetamineamphetamine oral capsule,extended release 24hr diazepam intensol PA; MO diazepam oral solution 5 mg/5 ml PA; MO diazepam oral tablet PA; MO doxepin oral PA; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg duloxetine oral capsule,delayed release(dr/ec) 60 mg ; QL (80 ; QL (20 ; QL (90 ; QL (60 EMSAM 3 MO ergoloid escitalopram oxalate oral solution escitalopram oxalate oral tablet 0 mg escitalopram oxalate oral tablet 20 mg escitalopram oxalate oral tablet 5 mg ; QL (60 ; QL (30 ; QL (20 25

35 Name eszopiclone ST; MO; QL (30 per 30 FANAPT ORAL TABLET MG FANAPT ORAL TABLET 0 MG, 8 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 2 MG FANAPT ORAL TABLET 4 MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLETS,DOSE PACK FAZACLO ORAL TABLET,DISINTE GRATING 50 MG, 200 MG FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 20 MG 3 MO; QL (720 3 MO; QL (90 3 MO; QL (60 3 MO; QL (360 3 MO; QL (80 3 MO; QL (20 3 MO; QL (8 per ST; MO; QL (28 per 28 2 ST; MO; QL (30 per 30 2 ST; MO; QL (80 per 30 Name FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 40 MG FETZIMA ORAL CAPSULE,EXTEN DED RELEASE 24 HR 80 MG fluoxetine oral capsule 0 mg fluoxetine oral capsule 20 mg fluoxetine oral capsule 40 mg fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 0 mg fluoxetine oral tablet 20 mg fluphenazine decanoate 2 ST; MO; QL (90 per 30 2 ST; MO; QL (45 per 30 ; QL (240 ; QL (60 ; QL (4 per 28 ; QL (240 fluphenazine hcl fluvoxamine oral capsule,extended release 24hr 00 mg fluvoxamine oral capsule,extended release 24hr 50 mg fluvoxamine oral tablet 00 mg fluvoxamine oral tablet 25 mg ; QL (90 ; QL (60 ; QL (90 ; QL (360 26

36 Name fluvoxamine oral tablet 50 mg ; QL (80 FORFIVO XL 3 MO; QL (30 GEODON INTRAMUSCULA R 3 MO guanidine haloperidol haloperidol decanoate haloperidol lactate HETLIOZ 3 PA; MO imipramine hcl PA; MO imipramine pamoate PA; MO INVEGA ORAL TABLET EXTENDED RELEASE 24HR.5 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG 3 MO; QL (240 3 MO; QL (20 3 MO; QL (60 3 MO; QL (4 Name INVEGA SUSTENNA LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 20 MG LATUDA ORAL TABLET 40 MG LATUDA ORAL TABLET 60 MG, 80 MG 3 MO ; QL (30 ; QL (240 ; QL (20 ; QL (60 lithium carbonate lithium citrate oral solution 8 meq/5 ml lorazepam intensol PA; MO lorazepam oral tablet PA; MO loxapine succinate maprotiline MARPLAN metadate er methamphetamine methylphenidate oral capsule, er biphasic mg, 50 mg, 60 mg methylphenidate oral capsule,er biphasic methylphenidate oral solution methylphenidate oral tablet 27

37 Name methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr methylphenidate oral tablet,chewable mirtazapine modafinil PA; MO nefazodone nortriptyline olanzapine intramuscular olanzapine oral tablet 0 mg olanzapine oral tablet 5 mg, 20 mg olanzapine oral tablet 2.5 mg olanzapine oral tablet 5 mg olanzapine oral tablet 7.5 mg olanzapine oral tablet,disintegrating 0 mg olanzapine oral tablet,disintegrating 5 mg, 20 mg olanzapine oral tablet,disintegrating 5 mg olanzapinefluoxetine ; QL (60 ; QL (30 ; QL (240 ; QL (20 ; QL (8 ; QL (60 ; QL (30 ; QL (20 Name ORAP oxazepam PA; MO paroxetine hcl oral tablet 0 mg paroxetine hcl oral tablet 20 mg paroxetine hcl oral tablet 30 mg paroxetine hcl oral tablet 40 mg paroxetine hcl oral tablet extended release 24 hr 2.5 mg paroxetine hcl oral tablet extended release 24 hr 25 mg paroxetine hcl oral tablet extended release 24 hr 37.5 mg PAXIL ORAL SUSPENSION ; QL (80 ; QL (90 ; QL (60 ; QL (45 ; QL (80 ; QL (90 ; QL (60 3 MO perphenazine phenelzine PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 00 MG PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 2 ST; MO; QL (20 per 30 2 ST; MO; QL (480 per 30 28

38 Name PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 50 MG 2 ST; MO; QL (240 per 30 procentra protriptyline quetiapine oral tablet 00 mg quetiapine oral tablet 200 mg quetiapine oral tablet 25 mg quetiapine oral tablet 300 mg quetiapine oral tablet 400 mg quetiapine oral tablet 50 mg RISPERDAL CONSTA risperidone oral solution risperidone oral tablet 0.25 mg risperidone oral tablet 0.5 mg risperidone oral tablet mg risperidone oral tablet 2 mg risperidone oral tablet 3 mg risperidone oral tablet 4 mg ; QL (240 ; QL (20 ; QL (902 ; QL (8 ; QL (60 ; QL (480 ; QL (480 ; QL (920 ; QL (960 ; QL (480 ; QL (240 ; QL (6 ; QL (20 Name risperidone oral tablet,disintegrating 0.25 mg risperidone oral tablet,disintegrating 0.5 mg risperidone oral tablet,disintegrating mg risperidone oral tablet,disintegrating 2 mg risperidone oral tablet,disintegrating 3 mg risperidone oral tablet,disintegrating 4 mg ; QL (920 ; QL (960 ; QL (480 ; QL (240 ; QL (6 ; QL (20 ROZEREM ; QL (30 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 0 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG ; QL (60 ; QL (240 ; QL (20 ; QL (6 29

39 Name SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG sertraline oral concentrate sertraline oral tablet 00 mg sertraline oral tablet 25 mg sertraline oral tablet 50 mg ; QL (20 ; QL (8 ; QL (60 ; QL (480 ; QL (60 ; QL (240 ; QL (20 STRATTERA SURMONTIL 3 PA; MO temazepam PA; MO thioridazine thiothixene tranylcypromine trazodone Name trifluoperazine venlafaxine oral capsule,extended release 24hr 50 mg venlafaxine oral capsule,extended release 24hr 37.5 mg venlafaxine oral capsule,extended release 24hr 75 mg venlafaxine oral tablet 00 mg, 75 mg venlafaxine oral tablet 25 mg venlafaxine oral tablet 37.5 mg venlafaxine oral tablet 50 mg ; QL (60 ; QL (80 ; QL (90 ; QL (90 VERSACLOZ 2 LA VIIBRYD ORAL TABLET 0 MG VIIBRYD ORAL TABLET 20 MG VIIBRYD ORAL TABLET 40 MG VIIBRYD ORAL TABLETS,DOSE PACK 0 MG (7)- 20 MG (7)-40 MG (6) ; QL (270 ; QL (80 ; QL (50 ; QL (20 ; QL (60 ; QL (30 ; QL (30 XYREM ; LA zaleplon oral capsule 0 mg ST; MO; QL (60 per 30 30

40 Name zaleplon oral capsule 5 mg zenzedi oral tablet 0 mg, 5 mg ZENZEDI ORAL TABLET 5 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG ziprasidone hcl oral capsule 20 mg ziprasidone hcl oral capsule 40 mg ziprasidone hcl oral capsule 60 mg ziprasidone hcl oral capsule 80 mg ST; MO; QL (30 per 30 3 MO ; QL (240 ; QL (20 ; QL (80 ; QL (60 zolpidem ST; MO; QL (30 per 30 ZYPREXA RELPREVV INTRAMUSCULA R SUSPENSION FOR RECONSTITUTIO N 20 MG 2 LA CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution amiodarone oral tablet 200 mg, 400 mg PA; MO flecainide Name mexiletine pacerone oral tablet 00 mg, 200 mg, 400 mg procainamide injection solution 00 mg/ml procainamide injection solution 500 mg/ml propafenone quinidine gluconate quinidine sulfate oral tablet sorine oral tablet 20 mg, 60 mg, 80 mg sorine oral tablet 240 mg sotalol af oral tablet 20 mg sotalol oral tablet 60 mg, 240 mg, 80 mg SOTYLIZE 2 3 TIKOSYN ANTIHYPERTENSIVE THERAPY acebutolol oral afeditab cr amiloride oral amiloridehydrochlorothiazide amlodipine

41 Name atenolol AZOR 2 ST; MO benazepril BENICAR 2 ST; MO BENICAR HCT 2 ST; MO betaxolol oral BIDIL bisoprolol fumarate bumetanide BYSTOLIC candesartan captopril amlodipinebenazepril amlodipinevalsartan amlodipinevalsartan-hcthiazid atenololchlorthalidone benazeprilhydrochlorothiazide bisoprololhydrochlorothiazide candesartanhydrochlorothiazid captoprilhydrochlorothiazide cartia xt carvedilol chlorothiazide Name chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg clonidine ; QL (4 per 28 clonidine hcl oral tablet clorpres oral tablet 0.-5 mg, mg COREG CR DEMSER diltiazem hcl intravenous diltiazem hcl oral capsule, extended release 80 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 2 hr diltiazem hcl oral capsule,extended release 24hr 20 mg, 240 mg, 300 mg diltiazem hcl oral tablet 32 dilt-xr doxazosin oral tablet mg, 2 mg, 4 mg doxazosin oral tablet 8 mg ; QL (30 ; QL (60 EDARBI 3 ST; MO EDARBYCLOR 3 ST; MO

42 Name EDECRIN enalapril maleate eplerenone eprosartan felodipine fosinopril furosemide injection furosemide oral solution 0 mg/ml, 40 mg/5 ml furosemide oral tablet hydralazine hydrochlorothiazide indapamide irbesartan isradipine labetalol intravenous solution labetalol oral lisinopril losartan enalaprilhydrochlorothiazide fosinoprilhydrochlorothiazide irbesartanhydrochlorothiazide lisinoprilhydrochlorothiazide losartanhydrochlorothiazide Name matzim la methyclothiazide methyldopa metolazone metoprolol succinate metoprolol tartrate intravenous solution metoprolol tartrate oral minoxidil oral moexipril nadolol metoprolol tahydrochlorothiaz moexiprilhydrochlorothiazide nadololbendroflumethiazide nicardipine nifedical xl nifedipine oral tablet extended release 24hr nimodipine nisoldipine perindopril erbumine pindolol prazosin oral propranolol intravenous propranolol oral 33

43 Name quinapril ramipril REMODULIN 2 PA; MO; LA spironolactone taztia xt telmisartan terazosin oral capsule mg, 2 mg, 5 mg terazosin oral capsule 0 mg ; QL (30 ; QL (60 timolol maleate oral torsemide oral trandolapril TRIBENZOR 2 ST; MO valsartan propranololhydrochlorothiazid quinaprilhydrochlorothiazide spironolactonhydrochlorothiaz telmisartanamlodipine telmisartanhydrochlorothiazid trandolaprilverapamil triamterenehydrochlorothiazid valsartanhydrochlorothiazide Name verapamil intravenous solution verapamil oral CARDIAC GLYCOSIDES digitek digoxin oral solution 50 mcg/ml digoxin oral tablet LANOXIN ORAL TABLET 87.5 MCG, 62.5 MCG COAGULATION THERAPY AGGRENOX 3 MO BRILINTA cilostazol clopidogrel dipyridamole oral EFFIENT ELIQUIS enoxaparin fondaparinux heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(00 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) 34

44 Name heparin (porcine) injection solution jantoven pentoxifylline PRADAXA PROMACTA 2 PA; MO; LA tranexamic acid intravenous warfarin XARELTO ZONTIVITY LIPID/CHOLESTEROL LOWERING AGENTS amlodipineatorvastatin ; QL (30 atorvastatin ; QL (30 cholestyramine light oral powder in packet colestipol oral granules colestipol oral tablet CRESTOR ; QL (30 fenofibrate micronized fenofibrate nanocrystallized fenofibrate oral tablet 60 mg, 54 mg fenofibric acid (choline) Name fluvastatin oral capsule 20 mg fluvastatin oral capsule 40 mg ; QL (30 ; QL (60 gemfibrozil oral JUXTAPID ; LA LIPOFEN 3 MO lovastatin oral tablet 0 mg lovastatin oral tablet 20 mg, 40 mg niacin oral tablet extended release 24 hr ; QL (30 ; QL (60 pravastatin ; QL (30 prevalite oral powder simvastatin ; QL (30 VASCEPA ZETIA MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR 2 PA; MO RANEXA VECAMYL 3 NITRATES isosorbide dinitrate oral isosorbide mononitrate nitro-bid 35

45 Name nitroglycerin intravenous nitroglycerin transdermal patch 24 hour nitroglycerin translingual spray,non-aerosol PA NITROSTAT DERMATOLOGICALS/TOPICA L THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin calcipotriene calcipotrienebetamethasone calcitriol topical COSENTYX PEN 2 PA; MO COSENTYX PEN (2 PENS) selenium sulfide topical suspension STELARA SUBCUTANEOUS SYRINGE BURN THERAPY 2 PA; MO 2 PA; MO silver sulfadiazine ssd MISCELLANEOUS DERMATOLOGICALS 8-MOP Name ammonium lactate topical CARAC CONDYLOX TOPICAL GEL diclofenac sodium topical gel FLUOROURACIL TOPICAL CREAM 0.5 % fluorouracil topical cream 5 % fluorouracil topical solution PA; MO 3 ST; MO imiquimod methoxsalen rapid PANRETIN podofilox prudoxin REGRANEX tacrolimus topical PA; MO UVADEX 3 VALCHLOR ZYCLARA 3 ST; MO THERAPY FOR ACNE adapalene topical cream adapalene topical gel PA; MO PA; MO amnesteem avita topical cream PA; MO AZELEX 36

46 Name claravis clindamycin phosphate topical clindamycin-benzoyl peroxide topical gel -5 % ery pads erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycinbenzoyl peroxide metronidazole topical cream metronidazole topical gel metronidazole topical lotion myorisan neuac TAZORAC 2 PA; MO tretinoin microspheres topical gel with pump PA; MO tretinoin topical PA; MO zenatane TOPICAL ANESTHETICS lidocaine (pf) injection solution 5 mg/ml (0.5 %) Name lidocaine hcl injection solution 20 mg/ml (2 %) lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl urethral lidocaine topical adhesive patch,medicated lidocaine topical ointment lidocaine-prilocaine topical cream PA; MO TOPICAL ANTIBACTERIALS ALTABAX gentamicin topical mupirocin mupirocin calcium sulfacetamide sodium (acne) SULFAMYLON TOPICAL CREAM TOPICAL ANTIFUNGALS ciclopirox 37

47 Name clotrimazole topical econazole topical ketoconazole topical cream ketoconazole topical shampoo NAFTIN nyamyc nystatin topical clotrimazolebetamethasone nystatintriamcinolone nystop TOPICAL ANTIVIRALS acyclovir topical DENAVIR XERESE 3 MO ZOVIRAX TOPICAL CREAM 3 MO TOPICAL CORTICOSTEROIDS ala-cort topical cream alclometasone amcinonide apexicon e betamethasone dipropionate betamethasone valerate betamethasone, augmented Name CAPEX clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution clobetasol topical spray,non-aerosol clobetasol-emollient topical cream clodan CORDRAN TAPE LARGE ROLL cormax topical solution desonide desoximetasone diflorasone fluocinolone fluocinonide topical cream 0. % fluocinonide topical gel fluocinonide topical ointment 38

48 Name fluocinonide topical solution fluocinonide-e fluticasone topical halobetasol propionate hydrocortisone butyrate topical ointment hydrocortisone butyrate topical solution hydrocortisone butyr-emollient hydrocortisone topical cream %, 2.5 % hydrocortisone topical lotion 2.5 % hydrocortisone topical ointment %, 2.5 % hydrocortisone valerate LOCOID TOPICAL LOTION mometasone PANDEL prednicarbate triamcinolone acetonide topical aerosol triamcinolone acetonide topical cream Name triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment %, 0. %, 0.5 % trianex triderm topical cream TOPICAL ENZYMES SANTYL TOPICAL SCABICIDES / PEDICULICIDES EURAX 3 MO lindane malathion permethrin topical cream SKLICE DIAGNOSTICS / MISCELLANEOUS AGENTS IRRIGATING SOLUTIONS lactated ringers irrigation neomycin-polymyxin b gu ringers irrigation MISCELLANEOUS AGENTS acamprosate ADAGEN 39

49 Name alendronate oral tablet 40 mg ; QL (30 anagrelide ARALAST NP INTRAVENOUS RECON SOLN 500 MG ; LA CARBAGLU ; LA cevimeline CHEMET CLINIMIX 4.25%/D5W SULFIT FREE d0 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 0 % and 0.2 % nacl dextrose 0 % in water (d0w) intravenous parenteral solution dextrose 5 % in water (d5w) intravenous parenteral solution dextrose 5 %- lactated ringers dextrose 5%-0.2 % sod chloride 2 PA Name dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride disulfiram etidronate disodium EXJADE ; LA FERRIPROX INCRELEX ; LA JADENU kionex oral powder levocarnitine (with sugar) levocarnitine intravenous levocarnitine oral tablet midodrine NORTHERA 3 MO ORFADIN 2 LA pilocarpine hcl oral PROLASTIN-C ; LA RAVICTI RENVELA riluzole risedronate oral tablet 30 mg sodium chloride 0.9 % intravenous parenteral solution sodium chloride irrigation ; QL (30 40

50 Name sodium phenylbutyrate sodium polystyrene (sorb free) SYPRINE THIOLA water for irrigation, sterile zoledronic acidmannitol-water intravenous solution SMOKING DETERRENTS PA; MO buproban CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX STARTING MONTH BOX NICOTROL 3 MO NICOTROL NS 3 MO EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal ; QL (60 BACTROBAN NASAL chlorhexidine gluconate mucous membrane Name ipratropium bromide nasal ; QL (30 olopatadine ; QL (30.5 periogard triamcinolone acetonide dental TYZINE NASAL DROPS 0.05 % MISCELLANEOUS OTIC PREPARATIONS acetasol hc acetic acid otic fluocinolone acetonide oil hydrocortisoneacetic acid ofloxacin otic OTIC STEROID / ANTIBIOTIC CIPRODEX COLY-MYCIN S CORTISPORIN-TC neomycinpolymyxin-hc otic ENDOCRINE/DIABETES ADRENAL HORMONES a-hydrocort cortisone DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML 4

51 Name dexamethasone intensol dexamethasone oral elixir dexamethasone oral tablet dexamethasone sodium phosphate injection fludrocortisone hydrocortisone oral methylprednisolone acetate methylprednisolone oral tablet methylprednisolone oral tablets,dose pack methylprednisolone sodium succ injection recon soln 25 mg, 40 mg PA; MO millipred oral tablet PA; MO prednisolone sodium phosphate oral solution 5 mg/5 ml, 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral tablet,disintegrating PA; MO prednisone intensol PA; MO prednisone oral solution Name prednisone oral tablet SOLU-CORTEF (PF) INJECTION RECON SOLN 00 MG/2 ML, 250 MG/2 ML SOLU-MEDROL (PF) INJECTION SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 500 MG/4 ML SOLU-MEDROL INTRAVENOUS RECON SOLN 2 GRAM veripred 20 ANTITHYROID AGENTS methimazole oral tablet 0 mg, 5 mg PA; MO propylthiouracil DIABETES THERAPY acarbose oral tablet 00 mg acarbose oral tablet 25 mg acarbose oral tablet 50 mg ; QL (90 ; QL (360 ; QL (80 ALCOHOL PADS APIDRA 3 ST; MO APIDRA SOLOSTAR 3 ST; MO 42

52 Name BYDUREON (4 per 28 BYETTA SUBCUTANEOUS PEN INJECTOR 0 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML).2 ML (2.4 per 30 (.2 per 30 CYCLOSET 3 MO; QL (80 FARXIGA ORAL TABLET 0 MG FARXIGA ORAL TABLET 5 MG ; QL (30 ; QL (60 GAUZE PADS 2X2 glimepiride oral tablet mg glimepiride oral tablet 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 0 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 0 mg glipizide oral tablet extended release 24hr 2.5 mg ; QL (240 ; QL (20 ; QL (60 ; QL (20 ; QL (240 ; QL (60 ; QL (240 Name glipizide oral tablet extended release 24hr 5 mg glipizide-metformin oral tablet mg glipizide-metformin oral tablet mg, mg GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG SUBCUTANEOUS CARTRIDGE HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 00 UNIT/ML (PREFILLED SYRINGE) ; QL (20 ; QL (240 ; QL (

53 Name HUMULIN 70/30 HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U-500 "CONCENTRATED " INSULIN PEN NEEDLE INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U-00 ML INSULIN SYRINGE (DISP) U-00 /2 ML INVOKAMET ; QL (60 INVOKANA ; QL (30 JANUMET ; QL (60 JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 00-,000 MG, MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-,000 MG ; QL (30 ; QL (60 Name JANUVIA ; QL (30 JENTADUETO 3 ST; MO; QL (60 per 30 KAZANO 3 ST; MO; QL (60 per 30 KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-,000 MG KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-,000 MG, MG ; QL (60 ; QL (30 LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH metformin oral tablet,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg ; QL (75 ; QL (50 ; QL (90 ; QL (20 ; QL (75 44

54 Name metformin oral tablet extended release 24hr,000 mg nateglinide oral tablet 20 mg nateglinide oral tablet 60 mg NEEDLES, INSULIN DISP.,SAFETY ; QL (75 ; QL (90 ; QL (80 NESINA 3 ST; MO; QL (30 per 30 NOVOFINE 32 NOVOLOG 3 ST; MO NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL 3 ST; MO 3 ST; MO 3 ST; MO 3 ST; MO ONGLYZA ; QL (30 pioglitazone ; QL (30 pioglitazoneglimepiride pioglitazonemetformin ; QL (30 ; QL (90 PROGLYCEM repaglinide oral tablet 0.5 mg ; QL (960 Name repaglinide oral tablet mg repaglinide oral tablet 2 mg ; QL (480 ; QL (240 RIOMET ; QL (765 SYMLINPEN 20 (8.9 per 30 SYMLINPEN 60 (0.5 per 30 tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg ; QL (20 ; QL (60 tolbutamide ; QL (80 TOUJEO SOLOSTAR TRADJENTA 3 ST; MO; QL (30 per 30 VGO 20 VGO 30 VGO 40 VICTOZA 3-PAK (9 XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR 0-,000 MG ; QL (30 45

55 Name XIGDUO XR ORAL TABLET, IR & ER, BIPHASIC 24HR MG, 5-,000 MG, MG ; QL (60 MISCELLANEOUS HORMONES ALDURAZYME ANADROL-50 2 PA; MO ANDRODERM 2 PA; MO ANDROGEL 2 PA; MO AXIRON 3 PA; MO cabergoline calcitonin (salmon) calcitriol intravenous solution mcg/ml calcitriol oral CERDELGA CEREZYME INTRAVENOUS RECON SOLN 400 UNIT chorionic gonadotropin, human PA; MO danazol oral desmopressin injection desmopressin nasal solution desmopressin nasal spray,non-aerosol desmopressin oral Name doxercalciferol intravenous doxercalciferol oral ELAPRASE FABRAZYME INTRAVENOUS RECON SOLN 35 MG 46 FORTESTA 3 PA; MO fortical KORLYM 3 MO KUVAN ORAL POWDER IN PACKET 500 MG KUVAN ORAL TABLET,SOLUBL E ; LA LUMIZYME MIACALCIN INJECTION 3 MO MYALEPT 2 PA; MO; LA MYOZYME NAGLAZYME ; LA NATPARA 2 PA; MO; LA novarel PA; MO oxandrolone PA; MO pamidronate intravenous solution paricalcitol oral SAMSCA 2 PA; MO SENSIPAR SOMAVERT

56 Name STIMATE SYNAREL TESTIM 3 PA; MO testosterone cypionate testosterone enanthate ZAVESCA ; LA ZEMPLAR INTRAVENOUS zoledronic acid intravenous solution THYROID HORMONES levothyroxine oral levoxyl oral tablet 00 mcg, 2 mcg, 25 mcg, 37 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine unithroid oral tablet 00 mcg, 2 mcg, 25 mcg, 50 mcg, 75 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection syringe 0.05 mg/ml, 0. mg/ml Name diphenoxylateatropine glycopyrrolate injection glycopyrrolate oral loperamide oral capsule MISCELLANEOUS GASTROINTESTINAL AGENTS AKYNZEO 2 PA; MO alosetron ALOXI AMITIZA APRISO 3 MO ASACOL HD balsalazide budesonide oral CHENODAL 2 PA; MO; LA CIMZIA 3 PA; MO CIMZIA POWDER FOR RECONST 3 PA; MO colocort compro constulose CREON cromolyn oral CYSTADANE DELZICOL DIPENTUM 3 MO dronabinol PA; MO 47

57 Name EMEND INTRAVENOUS EMEND ORAL 2 PA; MO enulose GATTEX ONE- VIAL 3 MO gavilyte-c gavilyte-g gavilyte-n generlac granisetron (pf) intravenous solution 00 mcg/ml granisetron hcl intravenous solution mg/ml ( ml) granisetron hcl oral PA; MO hydrocortisone rectal enema lactulose oral solution 0 gram/5 ml LIALDA LINZESS meclizine oral tablet 2.5 mg, 25 mg mesalamine with cleansing wipe metoclopramide hcl injection solution metoclopramide hcl oral MOVANTIK Name MOVIPREP 3 MO ondansetron PA; MO ondansetron hcl (pf) injection solution ondansetron hcl (pf) injection syringe ondansetron hcl oral solution ondansetron hcl oral tablet 24 mg ondansetron hcl oral tablet 4 mg, 8 mg peg electrolytes oral recon soln gram PA; MO PA PA; MO PENTASA polyethylene glycol 3350 oral powder prochlorperazine prochlorperazine edisylate injection solution 0 mg/2 ml (5 mg/ml) prochlorperazine maleate oral procto-pak proctosol hc proctozone-hc RECTIV RELISTOR SUBCUTANEOUS SOLUTION 48

58 Name RELISTOR SUBCUTANEOUS SYRINGE REMICADE 2 PA; MO SANCUSO SUCLEAR SUCRAID sulfasalazine oral tablet sulfazine ec SUPREP BOWEL PREP KIT TRANSDERM- SCOP trilyte with flavor packets 3 MO UCERIS ORAL ursodiol VIOKACE ZENPEP ORAL CAPSULE,DELAY ED RELEASE(DR/EC) 0,000-34,000-55,000 UNIT, 5,000-5,000-82,000 UNIT, 20,000-68,000-09,000 UNIT, 25,000-85,000-36,000 UNIT, 3,000-0,000-6,000 UNIT, 40,000-36,000-28,000 UNIT ULCER THERAPY Name amoxicilclarithromylansopraz carafate oral suspension ; QL (2 cimetidine cimetidine hcl oral DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 30 MG DEXILANT ORAL CAPSULE,BIPHAS E DELAYED RELEAS 60 MG esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg esomeprazole sodium 3 MO; QL (30 3 MO ; QL (30 famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine oral suspension famotidine oral tablet 20 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) 5 mg lansoprazole oral capsule,delayed release(dr/ec) 30 mg 49 ; QL (30 misoprostol

59 Name NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 0 MG, 2.5 MG, 20 MG, 5 MG NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 40 MG ; QL (30 nizatidine omeprazole oral capsule,delayed release(dr/ec) 0 mg, 20 mg omeprazole oral capsule,delayed release(dr/ec) 40 mg omeprazole-sodium bicarbonate oral capsule 20-. mggram omeprazole-sodium bicarbonate oral capsule 40-. mggram pantoprazole oral tablet,delayed release (dr/ec) 20 mg pantoprazole oral tablet,delayed release (dr/ec) 40 mg ; QL (30 ; QL (30 ; QL (30 PYLERA rabeprazole Name ranitidine hcl injection solution 25 mg/ml ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 50 mg, 300 mg sucralfate oral tablet IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARANESP (IN POLYSORBATE) 3 PA; MO ARCALYST 2 PA; MO AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULA R PEN INJECTOR KIT AVONEX INTRAMUSCULA R SYRINGE KIT BETASERON SUBCUTANEOUS KIT (4 per 28 (4 per 28 (4 per 28 (5 per 28 50

60 Name EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML EXTAVIA SUBCUTANEOUS KIT 3 PA; MO 3 PA; MO; QL (5 per 28 ILARIS (PF) 2 PA; MO; LA INTRON A INJECTION RECON SOLN INTRON A INJECTION SOLUTION 6 MILLION UNIT/ML LEUKINE INJECTION RECON SOLN MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE 2 PA; MO NEUMEGA NEUPOGEN 2 PA; MO NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 0 MG/.5 ML (6.7 MG/ML), 5 MG/.5 ML (0 MG/ML), 5 MG/.5 ML (3.3 MG/ML) 2 PA; MO Name NORDITROPIN NORDIFLEX 2 PA; MO OMNITROPE 2 PA; MO PEGASYS ; QL (4 per 28 PEGASYS PROCLICK ; QL (4 per 28 PEGINTRON ; QL (4 per 28 PEGINTRON REDIPEN PLEGRIDY SUBCUTANEOUS PEN INJECTOR 25 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 25 MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 MCG/0.5 ML- 94 MCG/0.5 ML PROCRIT INJECTION SOLUTION 0,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML ; QL (4 per 28 ( per 28 ( per 80 ( per 28 ( per 80 2 PA; MO 5

61 Name PROLEUKIN REBIF (WITH ALBUMIN) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) REBIF TITRATION PACK (6 per 28 (6 per 28 (4.2 per 80 (2 per 28 SYLATRON VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT )(PF) INTRAMUSCULA R SUSPENSION BCG VACCINE, LIVE (PF) BEXSERO (PF) 2 BOOSTRIX TDAP BOTOX 2 PA; MO CERVARIX VACCINE (PF) 2 COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) Name ENGERIX-B (PF) INTRAMUSCULA R SYRINGE ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SUSPENSION ENGERIX-B PEDIATRIC (PF) INTRAMUSCULA R SYRINGE 2 PA; MO 2 PA; MO 2 PA fomepizole GAMASTAN S/D GARDASIL (PF) GARDASIL 9 (PF) GRASTEK 2 PA; MO HAVRIX (PF) INTRAMUSCULA R SUSPENSION,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULA R SYRINGE 720 ELISA UNIT/0.5 ML IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULA R SUSPENSION 2 IPOL IXIARO (PF) 52

62 Name MENACTRA (PF) INTRAMUSCULA R SOLUTION MENOMUNE - A/C/Y/W-35 (PF) MENVEO A-C-Y- W-35-DIP (PF) M-M-R II (PF) PEDVAX HIB (PF) PRIVIGEN 2 PA; MO PROQUAD (PF) 2 QUADRACEL (PF) 2 RABAVERT (PF) RAGWITEK RECOMBIVAX HB (PF) INTRAMUSCULA R SUSPENSION 0 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 0 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULA R SYRINGE 5 MCG/0.5 ML ROTARIX 2 ROTATEQ VACCINE 2 PA; MO 2 PA; MO 2 PA Name TENIVAC (PF) INTRAMUSCULA R SYRINGE TETANUS,DIPHTH ERIA TOX PED(PF) TETANUS- DIPHTHERIA TOXOIDS-TD THYMOGLOBULI N TRUMENBA 2 TWINRIX (PF) INTRAMUSCULA R SUSPENSION TYPHIM VI INTRAMUSCULA R SOLUTION TYPHIM VI INTRAMUSCULA R SYRINGE VAQTA (PF) INTRAMUSCULA R SYRINGE 2 PA 2 VARIVAX (PF) VARIZIG INTRAMUSCULA R SOLUTION YF-VAX (PF) ZOSTAVAX (PF) MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol

63 Name aloprim colchicineprobenecid COLCRYS probenecid ULORIC 2 ST; MO OSTEOPOROSIS THERAPY alendronate oral solution alendronate oral tablet 0 mg, 5 mg alendronate oral tablet 35 mg, 70 mg ; QL (286 ; QL (30 ; QL (4 per 28 FORTEO (2.4 per 28 FOSAMAX PLUS D ibandronate intravenous solution 3 ST; MO; QL (4 per 28 PA; MO ibandronate oral ; QL ( per 30 PROLIA 2 PA; MO raloxifene risedronate oral tablet 50 mg risedronate oral tablet 35 mg risedronate oral tablet 35 mg (2 pack) risedronate oral tablet 5 mg ; QL ( per 30 ; QL (4 per 28 QL (4 per 28 ; QL (30 Name risedronate oral tablet,delayed release (dr/ec) ; QL (4 per 28 OTHER RHEUMATOLOGICALS ACTEMRA 2 PA; MO BENLYSTA INTRAVENOUS RECON SOLN 20 MG CUPRIMINE DEPEN TITRATABS ENBREL SUBCUTANEOUS RECON SOLN ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.5) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK HUMIRA CROHN'S DIS START PCK HUMIRA SUBCUTANEOUS SYRINGE KIT 0 MG/0.2 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML 3 MO (8 per 28 (8 per 28 (4 per 28 (4 per 28 (4.8 per 80 (0.4 per 28 (2 per 28 54

64 Name HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML (3.2 per 28 leflunomide ; QL (30 ORENCIA 2 PA; MO ORENCIA (WITH MALTOSE) 2 PA; MO OTEZLA 2 PA; MO OTEZLA STARTER 2 PA; MO RIDAURA 3 MO SAVELLA ORAL TABLET SAVELLA ORAL TABLETS,DOSE PACK ; QL (60 ; QL (55 SIMPONI 3 PA; MO SIMPONI ARIA 3 PA; MO XELJANZ 3 PA; MO OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila CRINONE VAGINAL GEL 4 % CRINONE VAGINAL GEL 8 % 3 MO 3 PA; MO deblitane DEPO-PROVERA INTRAMUSCULA R SOLUTION Name DEPO-SUBQ PROVERA 04 3 MO DUAVEE errin ESTRACE VAGINAL estradiol oral estradiol transdermal patch semiweekly estradiol transdermal patch weekly estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml estradiolnorethindrone acet ; QL (8 per 28 ; QL (4 per 28 ESTRING 3 MO estropipate jolivette lyza medroxyprogesteron e intramuscular suspension medroxyprogesteron e oral MENEST 3 MO mimvey mimvey lo nora-be norethindrone (contraceptive) 55

65 Name norethindrone acetate norethindrone ac-eth estradiol oral tablet mg-mcg, -5 mg-mcg norlyroc PREMARIN ORAL progesterone micronized sharobel MISCELLANEOUS OB/GYN CLEOCIN VAGINAL SUPPOSITORY clindamycin phosphate vaginal metronidazole vaginal miconazole-3 vaginal suppository NUVARING 3 MO terconazole tranexamic acid oral vandazole xulane ORAL CONTRACEPTIVES / RELATED AGENTS amethia amethyst apri aranelle (28) Name ashlyna aubra aviane balziva (28) briellyn cryselle (28) cyclafem /35 (28) cyclafem 7/7/7 (28) delyla (28) desoge.estradiol/e.estradio l drospirenone-ethinyl estradiol emoquette enpresse falmina (28) gianvi (28) gildagia gildess 24 fe gildess oral tablet.5-30 mg-mcg introvale junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe 24 kariva (28) kelnor /35 (28) 56

66 Name l norgest/e.estradiole.estrad oral tablets,dose pack,3 month 0.5 mg-30 mcg (84)/0 mcg (7) larin.5/30 (2) larin /20 (2) larin fe leena 28 lessina levonest (28) levonorgestrelethinyl estrad oral tablet mgmcg levonorgestrelethinyl estrad oral tablet mcg levonorgestrelethinyl estrad oral tablets,dose pack,3 month levora-28 lomedia 24 fe loryna (28) lutera (28) marlissa microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28) Name microgestin fe /20 (28) mononessa (28) necon 0.5/35 (28) necon /35 (28) necon /50 (28) necon 0/ (28) necon 7/7/7 (28) nikki (28) noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4) norethindronee.estradiol-iron oral tablet mg-20 mcg (24)/75 mg (4) nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/7 (28) ocella ogestrel (28) orsythia pimtrea (28) pirmella oral tablet -35 mg-mcg portia previfem quasense reclipsen (28) 57

67 Name sprintec (28) sronyx tarina fe tri-legest fe trinessa (28) tri-previfem (28) tri-sprintec (28) trivora (28) velivet triphasic regimen (28) vestura (28) vyfemla (28) wymzya fe zenchent (28) zenchent fe zovia /35e (28) zovia /50e (28) OXYTOCICS methylergonovine oral OPHTHALMOLOGY ANTIBIOTICS bacitracin ophthalmic bacitracinpolymyxin b ophthalmic BESIVANCE CILOXAN OPHTHALMIC OINTMENT Name ciprofloxacin hcl ophthalmic erythromycin ophthalmic garamycin ophthalmic drops gatifloxacin gentak ophthalmic ointment gentamicin ophthalmic levofloxacin ophthalmic NATACYN neomycinbacitracinpolymyxin neomycinpolymyxingramicidin ofloxacin ophthalmic polymyxin b sulftrimethoprim tobramycin TOBREX OPHTHALMIC OINTMENT ANTIVIRALS trifluridine ZIRGAN 3 MO BETA-BLOCKERS betaxolol ophthalmic carteolol 58

68 Name levobunolol ophthalmic drops 0.5 % metipranolol timolol maleate ophthalmic CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE 3 MO CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops DIRECT ACTING MIOTICS pilocarpine hcl ophthalmic drops %, 2 %, 4 % MISCELLANEOUS OPHTHALMOLOGICS azelastine ophthalmic BEPREVE cromolyn ophthalmic CYSTARAN epinastine LACRISERT LASTACAFT PATADAY PAZEO RESTASIS ; QL (60 Name NON-STEROIDAL ANTI- INFLAMMATORY AGENTS bromfenac diclofenac sodium ophthalmic flurbiprofen sodium ILEVRO ketorolac ophthalmic NEVANAC PROLENSA ORAL DRUGS FOR GLAUCOMA acetazolamide oral acetazolamide sodium methazolamide oral OTHER GLAUCOMA DRUGS bimatoprost COMBIGAN dorzolamide dorzolamide-timolol latanoprost LUMIGAN OPHTHALMIC DROPS 0.0 % SIMBRINZA 3 MO TRAVATAN Z travoprost (benzalkonium) ZIOPTAN (PF) 3 ST; MO 59

69 Name STEROID-ANTIBIOTIC COMBINATIONS neomycin-polymyxin b-dexameth neomycinbacitracin-poly-hc neomycinpolymyxin-hc ophthalmic ZYLET STEROIDS ALREX dexamethasone sodium phosphate ophthalmic fluorometholone FML S.O.P. LOTEMAX prednisolone acetate prednisolone sodium phosphate ophthalmic STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE 3 MO BLEPHAMIDE S.O.P. tobramycindexamethasone sulfacetamideprednisolone SULFONAMIDES 3 MO Name sulfacetamide sodium ophthalmic SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0. % apraclonidine brimonidine IOPIDINE OPHTHALMIC DROPPERETTE VASOCONSTRICTOR DECONGESTANTS 3 MO naphazoline RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS adrenalin injection solution mg/ml (:,000) (ml) cetirizine oral solution mg/ml desloratadine ; QL (30 diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl oral elixir epinephrine injection autoinjector PA ; QL (4 per 30 60

70 Name EPIPEN 2-PAK ; QL (4 per 30 EPIPEN JR 2-PAK ; QL (4 per 30 hydroxyzine hcl oral tablet levocetirizine oral solution levocetirizine oral tablet promethazine injection solution PA; MO ; QL (30 promethazine oral PA; MO PULMONARY AGENTS acetylcysteine solution PA; MO ADCIRCA (60 per 30 ADEMPAS 2 PA; MO; LA ADVAIR DISKUS ; QL (60 ADVAIR HFA ; QL (2 AEROSPAN ; QL (7.8 albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml,.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 5 mg/ml PA; MO albuterol sulfate oral Name aminophylline intravenous solution 250 mg/0 ml ANORO ELLIPTA ; QL (60 ARCAPTA NEOHALER ARNUITY ELLIPTA ; QL (30 ; QL (30 ASMANEX HFA ; QL (3 ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 0 MCG (30 DOSES), 220 MCG (30 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (20 DOSES) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (60 DOSES) ; QL (30 ; QL (240 ; QL (60 ATROVENT HFA ; QL (25.8 BREO ELLIPTA ; QL (60 6

71 Name budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml PA; MO budesonide nasal ; QL (7.2 CINRYZE 2 PA; MO COMBIVENT RESPIMAT ; QL (8 per 30 cromolyn inhalation PA; MO DALIRESP 2 PA; MO DULERA ; QL (3 DYMISTA ; QL (23 ELIXOPHYLLIN ORAL ELIXIR 80 MG/5 ML 3 MO ESBRIET (270 per 30 FIRAZYR 2 PA; MO FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 00 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION ; QL (60 ; QL (240 Name FLOVENT HFA INHALATION HFA AEROSOL INHALER 0 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) ; QL (2 ; QL (24 ; QL (0.6 ; QL (50 fluticasone nasal ; QL (6 FORADIL AEROLIZER ipratropium bromide inhalation ipratropiumalbuterol ; QL (60 PA; MO PA; MO KALBITOR KALYDECO ORAL GRANULES IN PACKET KALYDECO ORAL TABLET (56 per 28 (60 per 30 LETAIRIS 2 PA; MO; LA 62

72 Name levalbuterol hcl inhalation solution for nebulization 0.3 mg/3 ml, 0.63 mg/3 ml,.25 mg/0.5 ml PA; MO metaproterenol oral montelukast NASONEX ; QL (34 OFEV (60 per 30 OPSUMIT 2 PA; MO; LA PERFOROMIST 2 PA; MO PROAIR HFA ; QL (7 PROAIR RESPICLICK PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 80 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCG/ACTUATION PULMICORT INHALATION SUSPENSION FOR NEBULIZATION MG/2 ML ; QL (7 ; QL (2 per 30 ; QL ( per 30 2 PA; MO Name PULMOZYME 2 PA; MO QVAR ; QL (7.4 SEREVENT DISKUS sildenafil intravenous ; QL (60 PA sildenafil oral PA; MO; QL (90 per 30 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STRIVERDI RESPIMAT ; QL (60 ; QL (90 per 90 3 MO; QL (4 per 30 SYMBICORT ; QL (0.2 terbutaline oral terbutaline subcutaneous THEO-24 3 MO theophylline oral solution theophylline oral tablet extended release theophylline oral tablet extended release 2 hr TRACLEER 2 PA; MO; LA triamcinolone acetonide nasal ; QL (6.5 63

73 Name TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION (30 ACTUAT) ; QL ( per 30 2 QL ( per 30 TYVASO 2 PA; MO XOLAIR 2 PA; MO; LA; QL (6 per 28 zafirlukast ZYFLO 3 MO ZYFLO CR 3 MO UROLOGICALS ANTICHOLINERGICS / ANTISPASMODICS ENABLEX flavoxate MYRBETRIQ oxybutynin chloride oral tolterodine TOVIAZ trospium VESICARE Name BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin AVODART finasteride oral tablet 5 mg JALYN RAPAFLO 2 ST; MO tamsulosin CHOLINERGIC STIMULANTS bethanechol chloride MISCELLANEOUS UROLOGICALS CIALIS ORAL TABLET 2.5 MG, 5 MG (30 per 30 CYSTAGON ; LA ELMIRON potassium citrate VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES calcium acetate oral capsule dextrose-kcl-nacl eliphos klor-con 0 klor-con 8 klor-con m5 klor-con m20 64

74 Name Name K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ 3 MO potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l k-tab oral tablet extended release 8 meq lactated ringers intravenous magnesium sulfate injection solution magnesium sulfate injection syringe NORMOSOL-R IN 5 % DEXTROSE potassium chloridd5-0.45%nacl intravenous parenteral solution 0 meq/l, 30 meq/l, 40 meq/l potassium chloridd5-0.45%nacl intravenous parenteral solution 20 meq/l potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l 2 potassium chloride intravenous piggyback 0 meq/00 ml, 20 meq/00 ml, 40 meq/00 ml potassium chloride intravenous solution potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral tablet extended release 8 meq potassium chloride oral tablet,er particles/crystals potassium chloride % nacl potassium chlorided5-0.2%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.3%nacl intravenous parenteral solution 20 meq/l 65

75 Name potassium chlorided5-0.9%nacl intravenous parenteral solution 20 meq/l potassium chlorided5-0.9%nacl intravenous parenteral solution 40 meq/l ringers intravenous sodium chloride 0.45 % intravenous parenteral solution sodium chloride 3 % sodium chloride 5 % sodium chloride intravenous parenteral solution 2.5 meq/ml sodium lactate intravenous solution MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % 2 PA 2 PA 2 PA 2 PA AMINOSYN II 7 % 2 PA AMINOSYN II 8.5 % 2 PA Name AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE- FREE) AMINOSYN-RF 5.2 % CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%- D20W SULF-FREE CLINIMIX 4.25%- D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE- FREE) FREAMINE HBC 6.9 % 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA 2 PA HEPATAMINE 8% 2 PA 66

76 Name intralipid intravenous emulsion 20 % INTRALIPID INTRAVENOUS EMULSION 30 % IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S 2 NEPHRAMINE 5.4 % NORMOSOL-R PH 7.4 PLASMA-LYTE 48 PLASMA-LYTE A 2 PLASMA-LYTE-56 IN 5 % DEXTROSE PA; MO 2 PA PA premasol 0 % PA; MO PREMASOL 6 % 2 PA travasol 0 % PA; MO TROPHAMINE 0 % PA; MO TROPHAMINE 6% 2 PA VITAMINS / HEMATINICS prenatal vitamin oral tablet sodium fluoride oral tablet 67

77 Index 8 8-MOP A abacavir... abacavir-lamivudinezidovudine... ABELCET... ABILIFY DISCMELT ABILIFY MAINTENA ABRAXANE... 0 acamprosate acarbose acebutolol... 3 acetaminophen-codeine... 9 acetasol hc... 4 acetazolamide acetazolamide sodium acetic acid... 4 acetylcysteine... 6 acitretin ACTEMRA ACTHIB (PF) ACTIMMUNE acyclovir..., 38 acyclovir sodium... ADACEL(TDAP ADOLESN/ADULT)(PF) 52 ADAGEN adapalene ADCIRCA... 6 adefovir... ADEMPAS... 6 adrenalin adrucil... 0 ADVAIR DISKUS... 6 ADVAIR HFA... 6 AEROSPAN... 6 afeditab cr... 3 AFINITOR... 0 AFINITOR DISPERZ... 0 AGGRENOX a-hydrocort... 4 AKYNZEO ala-cort ALBENZA... 5 albuterol sulfate... 6 alclometasone ALCOHOL PADS ALDURAZYME alendronate... 40, 54 alfuzosin ALIMTA... 0 ALINIA... 5 allopurinol aloprim alosetron ALOXI ALPHAGAN P ALREX ALTABAX amantadine hcl... AMBISOME... amcinonide amethia amethyst amifostine crystalline... 9 amikacin... 5 amiloride... 3 amiloride-hydrochlorothiazide... 3 aminophylline... 6 AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 %- ELECTROLYTES AMINOSYN II 0 % AMINOSYN II 5 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %- ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 0 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % amiodarone... 3 AMITIZA amitriptyline amlodipine... 3 amlodipine-atorvastatin amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid ammonium lactate amnesteem amoxapine amoxicil-clarithromy-lansopraz amoxicillin... 7 amoxicillin-pot clavulanate... 7 amphetamine salt combo amphotericin b... ampicillin... 7 ampicillin sodium... 7 ampicillin-sulbactam... 7 AMPYRA... 9 ANADROL anagrelide anastrozole... 0 ANDRODERM ANDROGEL ANORO ELLIPTA... 6 apexicon e APIDRA APIDRA SOLOSTAR APOKYN... 8 apraclonidine apri APRISO APTIOM... 6 APTIVUS... ARALAST NP aranelle (28) ARANESP (IN POLYSORBATE) ARCALYST

78 ARCAPTA NEOHALER... 6 aripiprazole ARNUITY ELLIPTA... 6 ARRANON... 0 ARZERRA... 0 ASACOL HD ashlyna ASMANEX HFA... 6 ASMANEX TWISTHALER 6 atenolol atenolol-chlorthalidone atorvastatin atovaquone... 5 atovaquone-proguanil... 5 ATRIPLA... atropine... 47, 59 ATROVENT HFA... 6 AUBAGIO... 9 aubra AUGMENTIN... 7 AVASTIN... 0 aviane avita AVODART AVONEX AVONEX (WITH ALBUMIN) AXIRON azacitidine... 0 AZACTAM IN DEXTROSE (ISO-OSM)... 5 azathioprine... 0 azelastine... 4, 59 AZELEX AZILECT... 8 azithromycin... 4, 5 AZOR aztreonam... 5 B baciim... 5 bacitracin... 5, 58 bacitracin-polymyxin b baclofen... 9 BACTROBAN NASAL... 4 balsalazide balziva (28) BANZEL... 6 BARACLUDE... BCG VACCINE, LIVE (PF) 52 BELEODAQ... 0 benazepril benazepril-hydrochlorothiazide BENICAR BENICAR HCT BENLYSTA benztropine... 8 BEPREVE BESIVANCE betamethasone dipropionate. 38 betamethasone valerate betamethasone, augmented BETASERON betaxolol... 32, 58 bethanechol chloride BETHKIS... 5 BEXSERO (PF) bicalutamide... 0 BICILLIN C-R... 7 BICILLIN L-A... 7 BICNU... 0 BIDIL BILTRICIDE... 5 bimatoprost bisoprolol fumarate bisoprolol-hydrochlorothiazide bleomycin... 0 BLEPHAMIDE BLEPHAMIDE S.O.P BOOSTRIX TDAP BOSULIF... 0 BOTOX BREO ELLIPTA... 6 briellyn BRILINTA brimonidine BRINTELLIX bromfenac bromocriptine... 8 budesonide... 47, 62 bumetanide BUPRENEX... 9 buprenorphine hcl... 9, 20 buprenorphine-naloxone buproban... 4 bupropion hcl... 24, 25 buspirone BUSULFEX... 0 butorphanol tartrate... 22, 23 BUTRANS BYDUREON BYETTA BYSTOLIC C cabergoline CAFERGOT... 8 calcipotriene calcipotriene-betamethasone 36 calcitonin (salmon) calcitriol... 36, 46 calcium acetate camila CANCIDAS... candesartan candesartan-hydrochlorothiazid CAPASTAT... 5 CAPEX CAPRELSA... 0 captopril captopril-hydrochlorothiazide CARAC carafate CARBAGLU carbamazepine... 6 carbidopa... 8 carbidopa-levodopa... 8 carbidopa-levodopaentacapone... 8 carboplatin... 0 carteolol cartia xt carvedilol

79 CAYSTON... 5 cefaclor... 3 cefadroxil... 3, 4 cefazolin... 4 cefazolin in dextrose (iso-os). 4 cefdinir... 4 cefditoren pivoxil... 4 cefepime... 4 cefixime... 4 cefotaxime... 4 cefotetan... 4 cefoxitin... 4 cefoxitin in dextrose, iso-osm 4 cefpodoxime... 4 cefprozil... 4 ceftazidime... 4 ceftriaxone... 4 cefuroxime axetil... 4 cefuroxime sodium... 4 celecoxib CELLCEPT... 0 CELLCEPT INTRAVENOUS... 0 CELONTIN... 6 cephalexin... 4 CERDELGA CEREZYME CERVARIX VACCINE (PF) cetirizine cevimeline CHANTIX... 4 CHANTIX CONTINUING MONTH BOX... 4 CHANTIX STARTING MONTH BOX... 4 CHEMET CHENODAL chloramphenicol sod succinate... 5 chlorhexidine gluconate... 4 chloroquine phosphate... 5 chlorothiazide chlorothiazide sodium chlorpromazine chlorthalidone cholestyramine light chorionic gonadotropin, human CIALIS ciclopirox cidofovir... cilostazol CILOXAN cimetidine cimetidine hcl CIMZIA CIMZIA POWDER FOR RECONST CINRYZE CIPRODEX... 4 ciprofloxacin... 8 ciprofloxacin (mixture)... 8 ciprofloxacin hcl... 8, 58 ciprofloxacin in 5 % dextrose. 8 ciprofloxacin lactate... 8 cisplatin... 0 citalopram cladribine... 0 claravis clarithromycin... 5 CLEOCIN clindamycin hcl... 5 clindamycin in 5 % dextrose.. 5 clindamycin pediatric... 5 clindamycin phosphate... 5, 37, 56 clindamycin-benzoyl peroxide CLINIMIX 5%/D5W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D0W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%- D20W(SULFITE-FREE).. 66 clobetasol clobetasol-emollient clodan CLOLAR... 0 clomipramine clonazepam... 6 clonidine clonidine hcl... 25, 32 clopidogrel clorazepate dipotassium clorpres clotrimazole..., 38 clotrimazole-betamethasone. 38 clozapine COARTEM... 5 codeine sulfate colchicine-probenecid COLCRYS colestipol colistin (colistimethate na)... 6 colocort COLY-MYCIN S... 4 COMBIGAN COMBIVENT RESPIMAT.. 62 COMETRIQ... 0 COMPLERA... compro COMVAX (PF) CONDYLOX constulose COPAXONE... 9 CORDRAN TAPE LARGE ROLL COREG CR CORLANOR cormax cortisone... 4 CORTISPORIN-TC... 4 COSENTYX PEN

80 COSENTYX PEN (2 PENS) 36 CREON CRESEMBA... CRESTOR CRINONE CRIXIVAN... 2 cromolyn... 47, 59, 62 cryselle (28) CUBICIN... 6 CUPRIMINE cyclafem /35 (28) cyclafem 7/7/7 (28) CYCLOPHOSPHAMIDE... CYCLOSET cyclosporine... cyclosporine modified... CYSTADANE CYSTAGON CYSTARAN cytarabine... cytarabine (pf)... D d0 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dacarbazine... DALIRESP danazol dantrolene... 9 DAPSONE... 6 DAPTACEL (DTAP PEDIATRIC) (PF) DARAPRIM... 6 daunorubicin... DAUNOXOME... deblitane decitabine... delyla (28) DELZICOL demeclocycline... 9 DEMSER DENAVIR DEPEN TITRATABS DEPO-MEDROL... 4 DEPO-PROVERA DEPO-SUBQ PROVERA desipramine desloratadine desmopressin desog-e.estradiol/e.estradiol. 56 desonide desoximetasone dexamethasone dexamethasone intensol dexamethasone sodium phosphate... 42, 60 dexedrine DEXILANT dexmethylphenidate dexrazoxane hcl... 9 dextroamphetamine dextroamphetamineamphetamine dextrose 0 % and 0.2 % nacl dextrose 0 % in water (d0w) dextrose 5 % in water (d5w). 40 dextrose 5 %-lactated ringers40 dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride dextrose-kcl-nacl diazepam... 6, 25 diazepam intensol diclofenac potassium diclofenac sodium... 23, 36, 59 diclofenac-misoprostol dicloxacillin... 7 didanosine... 2 diflorasone diflunisal digitek digoxin dihydroergotamine... 8 DILANTIN 30 MG... 6 diltiazem hcl dilt-xr DIPENTUM diphenhydramine hcl diphenoxylate-atropine dipyridamole disulfiram divalproex... 6 DOCEFREZ... docetaxel... donepezil... 9 dorzolamide dorzolamide-timolol doxazosin doxepin doxercalciferol doxorubicin... doxy doxycycline hyclate... 9 doxycycline monohydrate... 9 dronabinol drospirenone-ethinyl estradiol DROXIA... DUAVEE DULERA duloxetine duramorph (pf) DYMISTA E e.e.s E.E.S. GRANULES... 5 econazole EDARBI EDARBYCLOR EDECRIN EDURANT... 2 EFFIENT ELAPRASE eliphos

81 ELIQUIS ELITEK... 9 ELIXOPHYLLIN ELMIRON EMCYT... EMEND emoquette EMSAM EMTRIVA... 2 ENABLEX enalapril maleate enalapril-hydrochlorothiazide ENBREL ENBREL SURECLICK endocet endodan ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) enoxaparin enpresse entacapone... 8 entecavir... 2 enulose epinastine epinephrine EPIPEN 2-PAK... 6 EPIPEN JR 2-PAK... 6 epirubicin... epitol... 6 EPIVIR HBV... 2 eplerenone EPOGEN... 5 eprosartan EPZICOM... 2 ERAXIS(WATER DILUENT)... ERBITUX... ergoloid ERIVEDGE... errin ERWINAZE... ery pads ery-tab... 5 ERY-TAB... 5 ERYTHROCIN... 5 erythrocin (as stearate)... 5 erythromycin... 5, 58 erythromycin ethylsuccinate... 5 erythromycin with ethanol erythromycin-benzoyl peroxide ESBRIET escitalopram oxalate esomeprazole magnesium esomeprazole sodium ESTRACE estradiol estradiol valerate estradiol-norethindrone acet. 55 ESTRING estropipate eszopiclone ethambutol... 6 ethosuximide... 6 etidronate disodium etodolac ETOPOPHOS... etoposide... EURAX EVOTAZ... 2 EXELON... 9 exemestane... EXJADE EXTAVIA... 5 F FABRAZYME falmina (28) famciclovir... 2 famotidine famotidine (pf) famotidine (pf)-nacl (iso-os) 49 FANAPT FARESTON... FARXIGA FARYDAK... FASLODEX... FAZACLO felbamate... 6 felodipine fenofibrate fenofibrate micronized fenofibrate nanocrystallized. 35 fenofibric acid (choline) fenoprofen fentanyl fentanyl citrate FERRIPROX FETZIMA finasteride FIRAZYR FIRMAGON KIT W DILUENT SYRINGE... flavoxate flecainide... 3 FLECTOR FLOVENT DISKUS FLOVENT HFA fluconazole... fluconazole in dextrose(iso-o) flucytosine... fludarabine... fludrocortisone flunisolide fluocinolone fluocinolone acetonide oil... 4 fluocinonide... 38, 39 fluocinonide-e fluorometholone fluorouracil..., 36 FLUOROURACIL fluoxetine fluphenazine decanoate fluphenazine hcl flurbiprofen flurbiprofen sodium flutamide... fluticasone... 39, 62 fluvastatin fluvoxamine... 26, 27 FML S.O.P FOLOTYN... 2 fomepizole fondaparinux

82 FORADIL AEROLIZER FORFIVO XL FORTAZ... 4 FORTEO FORTESTA fortical FOSAMAX PLUS D foscarnet... 2 fosinopril fosinopril-hydrochlorothiazide fosphenytoin... 6 FREAMINE HBC 6.9 % furosemide FUSILEV... 0 FUZEON... 2 FYCOMPA... 6 G gabapentin... 6, 7 GABITRIL... 7 galantamine... 9 GAMASTAN S/D ganciclovir sodium... 2 garamycin GARDASIL (PF) GARDASIL 9 (PF) gatifloxacin GATTEX ONE-VIAL GAUZE PAD gavilyte-c gavilyte-g gavilyte-n gemcitabine... 2 gemfibrozil generlac gengraf... 2 gentak gentamicin... 6, 37, 58 gentamicin in nacl (iso-osm).. 6 gentamicin sulfate (pf)... 6 GEODON gianvi (28) gildagia gildess gildess 24 fe GILENYA... 9 GILOTRIF... 2 glatopa... 9 GLEEVEC... 2 glimepiride glipizide glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) glycopyrrolate GRALISE... 7 GRALISE 30-DAY STARTER PACK... 7 granisetron (pf) granisetron hcl GRASTEK griseofulvin microsize... griseofulvin ultramicrosize... guanidine H HALAVEN... 2 halobetasol propionate haloperidol haloperidol decanoate haloperidol lactate HARVONI... 2 HAVRIX (PF) heparin (porcine) heparin (porcine) in 5 % dex 34 HEPATAMINE 8% HERCEPTIN... 2 HETLIOZ HEXALEN... 2 HUMALOG HUMALOG KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMALOG MIX HUMALOG MIX KWIKPEN HUMIRA... 54, 55 HUMIRA CROHN'S DIS START PCK HUMULIN 70/ HUMULIN 70/30 KWIKPEN HUMULIN N HUMULIN N KWIKPEN HUMULIN R HUMULIN R U hydralazine hydrochlorothiazide hydrocodone-acetaminophen 20 hydrocodone-ibuprofen hydrocortisone... 39, 42, 48 hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone valerate hydrocortisone-acetic acid... 4 hydromorphone hydromorphone (pf) hydroxychloroquine... 6 hydroxyurea... 2 hydroxyzine hcl... 6 I ibandronate IBRANCE... 2 ibuprofen ibuprofen-oxycodone ICLUSIG... 2 idarubicin... 2 ifosfamide... 2 ILARIS (PF)... 5 ILEVRO IMBRUVICA... 2 imipenem-cilastatin... 6 imipramine hcl imipramine pamoate imiquimod IMOVAX RABIES VACCINE (PF) INCRELEX indapamide INFANRIX (DTAP) (PF) INLYTA... 2 INSULIN PEN NEEDLE

83 INSULIN SYRINGE (DISP) U ML INSULIN SYRINGE (DISP) U-00 ML INSULIN SYRINGE (DISP) U-00 /2 ML INTELENCE... 2 intralipid INTRALIPID INTRON A... 5 introvale INVANZ... 6 INVEGA INVEGA SUSTENNA INVIRASE... 2 INVOKAMET INVOKANA IONOSOL-B IN D5W IONOSOL-MB IN D5W IOPIDINE IPOL ipratropium bromide... 4, 62 ipratropium-albuterol irbesartan irbesartan-hydrochlorothiazide irinotecan... 2 ISENTRESS... 2 ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S isoniazid... 6 isosorbide dinitrate isosorbide mononitrate isradipine ISTODAX... 2 itraconazole... ivermectin... 6 IXEMPRA... 2 IXIARO (PF) J JADENU JAKAFI... 2 JALYN jantoven JANUMET JANUMET XR JANUVIA JENTADUETO JEVTANA... 2 jolivette junel.5/30 (2) junel /20 (2) junel fe.5/30 (28) junel fe /20 (28) junel fe JUXTAPID K KADCYLA... 2 KALBITOR KALETRA... 2 KALYDECO kariva (28) KAZANO kelnor /35 (28) KEPIVANCE... 0 KETEK... 6 ketoconazole..., 38 ketoprofen ketorolac KEYTRUDA... 2 kionex klor-con klor-con klor-con m klor-con m KOMBIGLYZE XR KORLYM k-tab K-TAB KUVAN L l norgest/e.estradiol-e.estrad. 57 labetalol LACRISERT lactated ringers... 39, 65 lactulose LAMISIL... lamivudine... 2 lamivudine-zidovudine... 2 lamotrigine... 7 LANOXIN lansoprazole LANTUS LANTUS SOLOSTAR larin.5/30 (2) larin /20 (2) larin fe LASTACAFT latanoprost LATUDA leena leflunomide LENVIMA... 2 lessina LETAIRIS letrozole... 2 leucovorin calcium... 0 LEUKERAN... 3 LEUKINE... 5 leuprolide... 3 levalbuterol hcl LEVEMIR LEVEMIR FLEXTOUCH levetiracetam... 7 LEVETIRACETAM IN NACL (ISO-OS)... 7 levobunolol levocarnitine levocarnitine (with sugar) levocetirizine... 6 levofloxacin... 8, 58 levofloxacin in d5w... 8 levonest (28) levonorgestrel-ethinyl estrad 57 levora levorphanol tartrate... 2 levothyroxine levoxyl LEXIVA... 2 LIALDA lidocaine lidocaine (pf) lidocaine hcl lidocaine-prilocaine

84 lindane linezolid... 6 LINZESS LIORESAL... 9 liothyronine LIPOFEN lisinopril lisinopril-hydrochlorothiazide lithium carbonate lithium citrate LOCOID lomedia 24 fe LOMUSTINE... 3 loperamide lorazepam lorazepam intensol lorcet (hydrocodone)... 2 lorcet hd... 2 lorcet plus... 2 lortab lortab lortab loryna (28) losartan losartan-hydrochlorothiazide 33 LOTEMAX lovastatin loxapine succinate LUMIGAN LUMIZYME LUPRON DEPOT... 3 LUPRON DEPOT (3 MONTH)... 3 LUPRON DEPOT (4 MONTH)... 3 LUPRON DEPOT (6 MONTH)... 3 LUPRON DEPOT-PED... 3 lutera (28) LYNPARZA... 3 LYRICA... 7 LYSODREN... 3 lyza M MACRODANTIN... 9 magnesium sulfate malathion maprotiline marlissa MARPLAN MATULANE... 3 matzim la meclizine meclofenamate medroxyprogesterone mefenamic acid mefloquine... 6 MEGACE ES... 3 megestrol... 3 MEKINIST... 3 meloxicam melphalan hcl... 3 MENACTRA (PF) MENEST MENOMUNE - A/C/Y/W-35 (PF) MENVEO A-C-Y-W-35-DIP (PF) mercaptopurine... 3 meropenem... 6 mesalamine with cleansing wipe mesna... 0 MESNEX... 0 MESTINON... 9 MESTINON TIMESPAN... 9 metadate er metaproterenol metformin... 44, 45 methadone... 2 methamphetamine methazolamide methenamine hippurate... 9 methimazole methotrexate sodium... 3 methotrexate sodium (pf)... 3 methoxsalen rapid methyclothiazide methyldopa methylergonovine methylphenidate... 27, 28 methylprednisolone methylprednisolone acetate.. 42 methylprednisolone sodium succ metipranolol metoclopramide hcl metolazone metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate metronidazole... 6, 37, 56 metronidazole in nacl (iso-os) 6 mexiletine... 3 MIACALCIN miconazole microgestin.5/30 (2) microgestin /20 (2) microgestin fe.5/30 (28) microgestin fe /20 (28) midodrine migergot... 8 millipred mimvey mimvey lo minocycline... 9 minoxidil mirtazapine misoprostol mitomycin... 3 mitoxantrone... 3 M-M-R II (PF) modafinil moderiba... 2 moderiba dose pack... 2 moexipril moexipril-hydrochlorothiazide mometasone mononessa (28) montelukast morphine

85 morphine concentrate... 2 MOVANTIK MOVIPREP moxifloxacin... 8 MOZOBIL... 5 mupirocin mupirocin calcium MUSTARGEN... 3 MYALEPT MYCAMINE... mycophenolate mofetil... 3 mycophenolate sodium... 3 myorisan MYOZYME MYRBETRIQ N nabumetone nadolol nadolol-bendroflumethiazide 33 nafcillin... 7 nafcillin in dextrose iso-osm.. 7 NAFTIN NAGLAZYME nalbuphine naloxone naltrexone NAMENDA... 9 NAMENDA XR... 9 naphazoline naproxen naproxen sodium naratriptan... 8 NASONEX NATACYN nateglinide NATPARA NEBUPENT... 6 necon 0.5/35 (28) necon /35 (28) necon /50 (28) necon 0/ (28) necon 7/7/7 (28) NEEDLES, INSULIN DISP.,SAFETY nefazodone neomycin... 6 neomycin-bacitracin-poly-hc 60 neomycin-bacitracinpolymyxin neomycin-polymyxin b gu neomycin-polymyxin b- dexameth neomycin-polymyxingramicidin neomycin-polymyxin-hc 4, 60 NEORAL... 3 NEPHRAMINE 5.4 % NESINA neuac NEULASTA... 5 NEUMEGA... 5 NEUPOGEN... 5 NEUPRO... 8 NEVANAC nevirapine... 2 NEXAVAR... 3 NEXIUM PACKET niacin nicardipine NICOTROL... 4 NICOTROL NS... 4 nifedical xl nifedipine nikki (28) NILANDRON... 3 nimodipine NIPENT... 3 nisoldipine nitro-bid nitrofurantoin... 9 nitrofurantoin macrocrystal... 9 nitrofurantoin monohyd/mcryst... 9 nitroglycerin NITROSTAT nizatidine nora-be NORDITROPIN FLEXPRO 5 NORDITROPIN NORDIFLEX... 5 noreth-ethinyl estradiol-iron. 57 norethindrone (contraceptive) norethindrone acetate norethindrone ac-eth estradiol norethindrone-e.estradiol-iron norlyroc NORMOSOL-R IN 5 % DEXTROSE NORMOSOL-R PH NORTHERA nortrel 0.5/35 (28) nortrel /35 (2) nortrel /35 (28) nortrel 7/7/7 (28) nortriptyline NORVIR... 2 novarel NOVOFINE NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX NOVOLOG MIX FLEXPEN NOVOLOG PENFILL NOXAFIL... NUEDEXTA... 9 NULOJIX... 3 NUVARING nyamyc nystatin..., 38 nystatin-triamcinolone nystop O ocella octreotide acetate... 3 OFEV ofloxacin... 8, 4, 58 ogestrel (28) olanzapine olanzapine-fluoxetine olopatadine... 4 OLYSIO

86 omeprazole omeprazole-sodium bicarbonate OMNITROPE... 5 ONCASPAR... 3 ondansetron ondansetron hcl ondansetron hcl (pf) ONFI... 7 ONGLYZA OPDIVO... 3 OPSUMIT ORAP ORENCIA ORENCIA (WITH MALTOSE) ORFADIN orsythia OTEZLA OTEZLA STARTER oxacillin... 8 oxacillin in dextrose(iso-osm)... 7, 8 oxaliplatin... 3 oxandrolone oxaprozin oxazepam oxcarbazepine... 7 oxybutynin chloride oxycodone oxycodone-acetaminophen oxycodone-aspirin OXYCONTIN oxymorphone P pacerone... 3 paclitaxel... 3 pamidronate PANDEL PANRETIN pantoprazole paricalcitol paromomycin... 6 paroxetine hcl PASER... 6 PATADAY PAXIL PAZEO PEDVAX HIB (PF) peg 3350-electrolytes PEGANONE... 7 PEGASYS... 5 PEGASYS PROCLICK... 5 PEGINTRON... 5 PEGINTRON REDIPEN... 5 PENICILLIN G POT IN DEXTROSE... 8 penicillin g potassium... 8 penicillin g procaine... 8 penicillin g sodium... 8 penicillin v potassium... 8 PENTAM... 6 PENTASA pentoxifylline PERFOROMIST perindopril erbumine periogard... 4 PERJETA... 3 permethrin perphenazine phenelzine phenobarbital... 7 phenytoin... 7 phenytoin sodium... 7 phenytoin sodium extended.. 7 PHOSPHOLINE IODIDE pilocarpine hcl... 40, 59 pimtrea (28) pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin piperacillin-tazobactam... 8 pirmella piroxicam PLASMA-LYTE PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE PLEGRIDY... 5 podofilox polyethylene glycol polymyxin b sulfate... 6 polymyxin b sulf-trimethoprim POMALYST... 3 portia potassium chlorid-d5-0.45%nacl potassium chloride potassium chloride in 0.9%nacl potassium chloride in 5 % dex potassium chloride in lr-d potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl potassium chloride-d5-0.9%nacl potassium citrate POTIGA... 7 PRADAXA pramipexole... 8 pravastatin prazosin prednicarbate prednisolone acetate prednisolone sodium phosphate... 42, 60 prednisone prednisone intensol PREMARIN premasol 0 % PREMASOL 6 % prenatal vitamin oral tablet prevalite previfem PREZCOBIX... 2 PREZISTA... 2 PRIFTIN... 6 PRIMAQUINE

87 primidone... 7 PRIMSOL... 9 PRISTIQ... 28, 29 PRIVIGEN PROAIR HFA PROAIR RESPICLICK probenecid procainamide... 3 procentra prochlorperazine prochlorperazine edisylate prochlorperazine maleate PROCRIT... 5 procto-pak proctosol hc proctozone-hc progesterone micronized PROGLYCEM PROGRAF... 4 PROLASTIN-C PROLENSA PROLEUKIN PROLIA PROMACTA promethazine... 6 propafenone... 3 propranolol propranolol-hydrochlorothiazid propylthiouracil PROQUAD (PF) protriptyline prudoxin PULMICORT PULMICORT FLEXHALER PULMOZYME PURIXAN... 4 PYLERA pyrazinamide... 6 pyridostigmine bromide... 9 Q QUADRACEL (PF) quasense quetiapine quinapril quinapril-hydrochlorothiazide quinidine gluconate... 3 quinidine sulfate... 3 quinine sulfate... 6 QVAR R RABAVERT (PF) rabeprazole RAGWITEK raloxifene ramipril RANEXA ranitidine hcl RAPAFLO RAPAMUNE... 4 RAVICTI REBETOL... 2 REBIF (WITH ALBUMIN). 52 REBIF REBIDOSE REBIF TITRATION PACK. 52 reclipsen (28) RECOMBIVAX HB (PF) RECTIV REGRANEX RELENZA DISKHALER... 2 RELISTOR... 48, 49 RELPAX... 8 REMICADE REMODULIN RENVELA repaglinide reprexain RESCRIPTOR... 2 RESTASIS RETROVIR... 2 REVLIMID... 4 REYATAZ... 2 RHEUMATREX... 4 ribasphere... 2 ribasphere ribapak... 3 ribavirin... 3 RIDAURA rifabutin... 6 rifampin... 6 riluzole rimantadine... 3 ringers... 39, 66 RIOMET risedronate... 40, 54 RISPERDAL CONSTA risperidone RITUXAN... 4 rivastigmine tartrate... 9 rizatriptan... 8 ropinirole... 8 ROTARIX ROTATEQ VACCINE ROZEREM S SABRIL... 7 SAMSCA SANCUSO SANDIMMUNE... 4 SANDOSTATIN LAR DEPOT... 4 SANTYL SAPHRIS (BLACK CHERRY) SAVELLA selegiline hcl... 8 selenium sulfide SELZENTRY... 3 SENSIPAR SEREVENT DISKUS SEROQUEL XR... 29, 30 sertraline sharobel SIGNIFOR... 4 sildenafil silver sulfadiazine SIMBRINZA SIMPONI SIMPONI ARIA SIMULECT... 4 simvastatin sirolimus... 4 SIRTURO... 6 SKLICE

88 sodium chloride... 40, 66 sodium chloride 0.45 % sodium chloride 0.9 % sodium chloride 3 % sodium chloride 5 % sodium fluoride sodium lactate sodium phenylbutyrate... 4 sodium polystyrene (sorb free)... 4 SOLTAMOX... 4 SOLU-CORTEF (PF) SOLU-MEDROL SOLU-MEDROL (PF) SOMATULINE DEPOT... 4 SOMAVERT sorine... 3 sotalol... 3 sotalol af... 3 SOTYLIZE... 3 SOVALDI... 3 SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER spironolactone spironolacton-hydrochlorothiaz SPORANOX... sprintec (28) SPRYCEL... 4 sronyx ssd stavudine... 3 STELARA STIMATE STIVARGA... 4 STRATTERA STREPTOMYCIN... 6 STRIBILD... 3 STRIVERDI RESPIMAT SUBOXONE SUCLEAR SUCRAID sucralfate sulfacetamide sodium sulfacetamide sodium (acne) 37 sulfacetamide-prednisolone.. 60 sulfadiazine... 9 sulfamethoxazole-trimethoprim... 9 SULFAMYLON sulfasalazine sulfazine ec sulindac sumatriptan... 8 sumatriptan succinate... 8, 9 SUPRAX... 4 SUPREP BOWEL PREP KIT SURMONTIL SUSTIVA... 3 SUTENT... 4 SYLATRON SYLVANT... 4 SYMBICORT SYMLINPEN SYMLINPEN SYNAGIS... 3 SYNAREL SYNERCID... 6 SYNRIBO... 4 SYPRINE... 4 T TABLOID... 4 tacrolimus... 4, 36 TAFINLAR... 4, 5 TAMIFLU... 3 tamoxifen... 5 tamsulosin TARCEVA... 5 TARGRETIN... 5 tarina fe TASIGNA... 5 TAZORAC taztia xt TECFIDERA... 9 TEFLARO... 4 TEGRETOL XR... 8 telmisartan telmisartan-amlodipine telmisartan-hydrochlorothiazid temazepam TENIVAC (PF) terazosin terbinafine hcl... terbutaline terconazole TESTIM testosterone cypionate testosterone enanthate TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD tetracycline... 9 THALOMID... 5 THEO theophylline THIOLA... 4 thioridazine thiothixene THYMOGLOBULIN tiagabine... 8 TIKOSYN... 3 timolol maleate... 34, 59 tinidazole... 6 TIVICAY... 3 tizanidine... 9 TOBI PODHALER... 7 tobramycin tobramycin in % nacl... 7 tobramycin in 0.9 % nacl... 7 tobramycin sulfate... 7 tobramycin-dexamethasone.. 60 TOBREX tolazamide tolbutamide tolcapone... 8 tolmetin tolterodine topiramate... 8 toposar... 5 topotecan... 5 TORISEL

89 torsemide TOUJEO SOLOSTAR TOVIAZ TRACLEER TRADJENTA tramadol tramadol-acetaminophen trandolapril trandolapril-verapamil tranexamic acid... 35, 56 TRANSDERM-SCOP tranylcypromine travasol 0 % TRAVATAN Z travoprost (benzalkonium) trazodone TREANDA... 5 TRECATOR... 7 TRELSTAR... 5 TRELSTAR DEPOT... 5 TRELSTAR LA... 5 tretinoin tretinoin (chemotherapy)... 5 tretinoin microspheres triamcinolone acetonide 39, 4, 63 triamterene-hydrochlorothiazid trianex TRIBENZOR triderm trifluoperazine trifluridine tri-legest fe trilyte with flavor packets trimethoprim... 9 trinessa (28) tri-previfem (28) TRISENOX... 5 tri-sprintec (28) TRIUMEQ... 3 trivora (28) TROPHAMINE 0 % TROPHAMINE 6% trospium TRUMENBA TRUVADA... 3 TUDORZA PRESSAIR TWINRIX (PF) TYGACIL... 7 TYKERB... 5 TYPHIM VI TYSABRI... 9 TYVASO TYZEKA... 3 TYZINE... 4 U UCERIS ULORIC unithroid ursodiol UVADEX V valacyclovir... 3 VALCHLOR VALCYTE... 3 valganciclovir... 3 valproate sodium... 8 valproic acid... 8 valproic acid (as sodium salt)... 8 valsartan valsartan-hydrochlorothiazide vancomycin... 9 vandazole VAQTA (PF) VARIVAX (PF) VARIZIG VASCEPA VECAMYL VECTIBIX... 5 VELCADE... 5 velivet triphasic regimen (28) venlafaxine verapamil veripred VERSACLOZ VESICARE vestura (28) VGO VGO VGO VIBRAMYCIN... 9 vicodin vicodin es vicodin hp VICTOZA 3-PAK VIDEX 2 GRAM PEDIATRIC... 3 VIEKIRA PAK... 3 VIIBRYD VIMPAT... 8 vinblastine... 5 vincasar pfs... 5 vincristine... 5 vinorelbine... 5 VIOKACE VIRACEPT... 3 VIRAMUNE XR... 3 VIRAZOLE... 3 VIREAD... 3 VITEKTA... 3 VOLTAREN GEL voriconazole... VOTRIENT... 6 vyfemla (28) W warfarin water for irrigation, sterile... 4 wymzya fe X XALKORI... 6 XARELTO XELJANZ XENAZINE... 9 XERESE XGEVA... 0 XIFAXAN... 7 XIGDUO XR... 45, 46 XOLAIR XTANDI... 6 xulane XYREM

90 Y YERVOY... 6 YF-VAX (PF) Z zafirlukast zaleplon... 30, 3 ZALTRAP... 6 zamicet ZANOSAR... 6 ZAVESCA ZELBORAF... 6 ZEMPLAR zenatane zenchent (28) zenchent fe ZENPEP zenzedi... 3 ZENZEDI... 3 ZETIA ZIAGEN... 3 zidovudine... 3 ZIOPTAN (PF) ziprasidone hcl... 3 ZIRGAN ZMAX... 5 zoledronic acid zoledronic acid-mannitol-water... 4 ZOLINZA... 6 zolmitriptan... 9 zolpidem... 3 zonisamide... 8 ZONTIVITY ZORTRESS... 6 ZOSTAVAX (PF) ZOSYN IN DEXTROSE (ISO- OSM)... 8 zovia /35e (28) zovia /50e (28) ZOVIRAX ZYCLARA ZYDELIG... 6 ZYFLO ZYFLO CR ZYKADIA... 6 ZYLET ZYPREXA RELPREVV... 3 ZYTIGA... 6 ZYVOX

91 With Express Scripts Medicare, you will have access to over 68,000 network pharmacies nationally. You may fill your prescriptions at a retail, home infusion, long-term care or Indian Health Service / Tribal / Urban Indian Health Program (I/T/U) pharmacy, or through our convenient home delivery service. You must use network pharmacies to fill your prescriptions to get the most out of your benefit. However, there are emergency circumstances under which you may be reimbursed for a covered prescription that is not filled at a network pharmacy. Limitations, copayments and restrictions may apply. This formulary was updated on 09/04/205. For more recent information or other questions, please contact Express Scripts Medicare Customer Service at the numbers located on the back of your member ID card. Customer Service is available 24 hours a day, 7 days a week. You can also visit us on the Web at Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal. 205 Express Scripts Holding Company. All Rights Reserved. Express Scripts and E Logo are trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the property of their respective owners. F0PP3C6A